Grace M. De Souza

The use of MDP-based materials for bonding to zirconia

STATEMENT OF PROBLEM A strong and stable bond between the luting resin and overlying ceramic restoration is critical to longevity, but no technique has been established for how to provide such a bond when the core material is zirconia. PURPOSE The purpose of this study was to evaluate the effect of different materials containing 10-methacryloyloxydecyl dihydrogen phosphate (MDP) on the bond strength to yttria-tetragonal zirconia polycrystal (Y-TZP) ceramic. MATERIAL AND METHODS Forty Y-TZP slices (Lava) were cemented to substrates (8 groups; n=5 in each) with or without the previous application of an experimental primer (0.5% MDP) or an MDP-based adhesive (Clearfil S3 Bond Plus or Scotchbond Universal) with either an MDP (Clearfil SA) or a non-MDP (RelyX Ultimate) luting resin. Specimens were cut, stored in distilled water, and microtensile tested (5 beams per specimen) at 48 hours and again at 6 months after luting procedures. The data were analyzed by 4-way ANOVA (α=.05) and the Tukey test (α=.05). The mode of failure was classified with a stereomicroscope, and the treated surfaces were analyzed with energy-dispersive x-ray spectroscopy. RESULTS Both adhesive (P<.001) and time (P<.001) significantly affected bond strength. The interaction of any of the factors was not significant. The use of an MDP-containing adhesive and the shorter storage time were associated with higher bond strengths. At 48 hours, an overall incidence of 50.5% of Type 1 mode of failure (adhesive at ceramic/resin interface) occurred, as opposed to 68% after 6 months of water storage. Energy-dispersive x-ray spectroscopy results showed peaks of carbon and phosphorus when MDP-based materials were used. CONCLUSIONS The application of an MDP-based adhesive may improve bond strength to zirconia. However, microtensile bond strength results for all groups did not remain stable over 6 months.

Effect of metal primers on microtensile bond strength between zirconia and resin cements

STATEMENT OF PROBLEM There are no established clinical procedures for bonding zirconia to tooth structure using resin cements. PURPOSE The purpose of this study was to evaluate the influence of metal primers, resin cements, and aging on bonding to zirconia. MATERIAL AND METHODS Zirconia was treated with commercial primers developed for bonding to metal alloys (Metaltite, Metal Primer II, Alloy Primer or Totalbond). Non-primed specimens were considered as controls. One-hundred disk-shaped specimens (19 × 4 mm) were cemented to composite resin substrates using Panavia or RelyX Unicem (n=5). Microtensile bond strength specimens were tested after 48 hours and 5 months (150 days), and failure modes were classified as type 1 (between ceramic/cement), 2 (between composite resin/cement) or 3 (mixed). Data were analyzed by 3-way ANOVA and Multiple Comparison Tukey test (α=.05). RESULTS The interactions primer/luting system (P=.016) and luting system/storage time (P=.004) were statistically significant. The use of Alloy Primer significantly improved the bond strength of RelyX Unicem (P<.001), while for Panavia, none of the primers increased the bond strength compared to the control group. At 48 hours, Panavia had statistically higher bond strength (P=.004) than Unicem (13.9 ± 4.4 MPa and 10.2 ± 6.6 MPa, respectively). However, both luting systems presented decreasing, statistically similar, values after aging (Panavia: 3.6 ± 2.2 MPa; Unicem: 6.1 ± 5.3 MPa). At 48 hours, Alloy Primer/Unicem had the lowest incidence of type 1 failure (8%). After aging, all the groups showed a predominance of type 1 failures. CONCLUSIONS The use of Alloy Primer improved bond strength between RelyX Unicem and zirconia. Though the initial values obtained with Panavia were significantly higher than RelyX Unicem, after aging, both luting agents presented statistically similar performances.

Bond strength to high-crystalline content zirconia after different surface treatments

The aim of this study was to evaluate the effect of primers, luting systems and aging on bond strength to zirconium oxide substrates. Eighteen zirconia discs (19.5 x 4 mm) were polished and treated (n = 3) either with a MDP primer (Md) or with a MDP and VBATDT primer (MV). In the control group (n = 3) no surface chemical treatment was performed. Zirconia specimens were cemented to prepolymerized composite discs utilizing resin cements - RelyX Unicem or Panavia 21 (RU and Pa, respectively). After 24 h, samples were sectioned for microtensile testing and returned to water at 37 degrees C for two different periods before being tested: 72 h or 60 days + thermocycling (5-55 degrees C/5000 cycles). Bond strength testing was performed at 1 mm/min. Values in MPa were analyzed through ANOVA and Tukeys Studentized Range (HSD) (p > 0.05). The application of MV primer resulted in the highest bond strength (22.77 MPa), statistically superior to Md primer (12.78 MPa), and control groups presented the lowest values (9.17 MPa). When luting systems were compared, RU promoted the highest bond strength (16.07 MPa) in comparison with Pa (13.75 MPa). The average bond strength decrease after aging (9.35 MPa) when compared with initial values (20.46 MPa). The results presented by this in vitro study suggest that a chemical surface treatment based on the MDP and VBATDT combination may improve bond strength between zirconia and luting system, without any previous mechanical treatment, depending on the luting system used. This chemical treatment may result in a reliable alternative to achieve adequate and durable bond strength.

Correlation between clinical performance and degree of conversion of resin cements: a literature review

Resin-based cements have been frequently employed in clinical practice to lute indirect restorations. However, there are numerous factors that may compromise the clinical performance of those cements. The aim of this literature review is to present and discuss some of the clinical factors that may affect the performance of current resin-based luting systems. Resin cements may have three different curing mechanisms: chemical curing, photo curing or a combination of both. Chemically cured systems are recommended to be used under opaque or thick restorations, due to the reduced access of the light. Photo-cured cements are mainly indicated for translucent veneers, due to the possibility of light transmission through the restoration. Dual-cured are more versatile systems and, theoretically, can be used in either situation, since the presence of both curing mechanisms might guarantee a high degree of conversion (DC) under every condition. However, it has been demonstrated that clinical procedures and characteristics of the materials may have many different implications in the DC of currently available resin cements, affecting their mechanical properties, bond strength to the substrate and the esthetic results of the restoration. Factors such as curing mechanism, choice of adhesive system, indirect restorative material and light-curing device may affect the degree of conversion of the cement and, therefore, have an effect on the clinical performance of resin-based cements. Specific measures are to be taken to ensure a higher DC of the luting system to be used.

Fracture Strength of Aged Monolithic and Bilayer Zirconia-Based Crowns.

The purpose of this study was to evaluate the effect of design and surface finishing on fracture strength of yttria-tetragonal zirconia polycrystal (Y-TZP) crowns in monolithic (1.5 mm thickness) and bilayer (0.8 mm zirconia coping and 0.7 mm porcelain veneer) configuration after artificial aging. Bovine incisors received crown preparation and Y-TZP crowns were manufactured using CAD/CAM technique, according to the following groups (n = 10): Polished monolithic zirconia crowns (PM); Glazed monolithic zirconia crowns (GM); Bi-layer crowns (BL). Crowns were cemented with resin cement, submitted to artificial aging in a chewing simulator (2.5 million cycles/80 N/artificial saliva/37°C), and tested for fracture strength. Two remaining crowns referring to PM and GM groups were submitted to a chemical composition analysis to measure the level of yttrium after aging. One-way ANOVA and Tukeys test (P = .05) indicated that monolithic zirconia crowns presented similar fracture strength (PM = 3476.2 N ± 791.7; GM = 3561.5 N ± 991.6), which was higher than bilayer crowns (2060.4 N ± 810.6). There was no difference in the yttrium content among the three surfaces evaluated in the monolithic crowns. Thus, monolithic zirconia crowns present higher fracture strength than bilayer veneered zirconia after artificial aging and surface finishing does not affect their fracture strength.

Matrix metalloproteinase inhibitor modulates esterase-catalyzed degradation of resin-dentin interfaces.

OBJECTIVE Assess the modulating effect of matrix metalloproteinase (MMP) inhibition on simulated human salivary enzyme (SHSE)-catalyzed degradation of interfacial fracture-toughness (FT) of self-etched and total-etched resin-dentin interfaces. METHODS Miniature short-rod FT specimens (N=10/group) containing a resin composite bonded to human dentin, using a self-etch (Easy Bond, EB) or a total-etch (Scotchbond, SB) adhesives, were prepared with and without application of an MMP inhibitor (galardin). Specimens were non-incubated or incubated in phosphate buffered saline (PBS) or SHSE for 7, 30, 90, or 180-days. FT data were obtained using a universal testing machine. Incubation media were analyzed by high performance liquid chromatography (HPLC) for the presence of a 2,2-bis-[4-2(2-hydroxy-3-methacryloxypropoxy)phenyl]-propane (bisGMA)-derived degradation product, bis-hydroxy-propoxy-phenyl-propane (bisHPPP). Fractographic analysis was performed by scanning electron microscopy and image processing software (ImageJ). Statistical analysis was performed by ANOVA and Tukeys (p<0.05). RESULTS More bisHPPP was detected in SHSE vs. PBS for both adhesive systems (p<0.05). EB specimens yielded no difference in FT and failed preferentially in the resin after >30-days (p<0.05). SB specimens yielded lower FT values after 180-days with SHSE ±galardin vs. 0-days/no-galardin (p<0.05) and failed preferentially in the hybrid-layer after >30-days (p<0.05). Galardin mildly modulated the change in fracture mode for both systems. SIGNIFICANCE Esterase-catalyzed degradation of total-etch interfaces is modulated by MMP-inhibition, however, self-etch interfaces possess greater biostability under simulated intra-oral conditions, regardless of MMP inhibition. This could be related to different chemical compositions and/or mode of adhesion.

Effect of accelerated aging on dental zirconia-based materials

OBJECTIVE To investigate the effect of aging on phase transformation and mechanical properties of yttria-tetragonal zirconia polycrystal (Y-TZP). MATERIALS AND METHODS Fully-sintered Y-TZP slabs, IPS E-max ZirCAD (ZC - Ivoclar) and Z-5 ceramic (Z5 - C5 Medical Werks), were artificially aged in autoclave for: 0, 30, 60 or 90min. Flexural strength (FS), crystalline changes (X-ray diffraction analysis - XRD) and surface topography were analyzed. 0 and 90min-aged samples were evaluated by nanoindentation to measure hardness and modulus, and results were compared using Wilcoxan Mann Whitney rank sum test (p≤0.05). FS results were compared using two-way ANOVA and Tukey HSD (α=0.05). RESULTS Material factor had significant effect (p=0.001) on flexural strength (Z5=966.95MPa; ZC=847.82MPa), but aging did not. Nanoindentation showed incidence of typical load/depth curves combined with some exhibiting features compatible with cracking. When typical curves were considered, aging had no effect on the modulus and hardness, but hardness was dependent on material type. A steady increase in the m phase related to aging time was observed for ZC samples. The maximum incidence of m phase was 6.56% for Z5/60min. SIGNIFICANCE Flexural strength is not affected by surface transformation in dental Y-TZP. Hydrothermal aging has an effect on m content and surface topography of different zirconia brands, but mechanical tests that can precisely characterize surface changes in aged Y-TZP are still missing.

Accuracy of Digital vs Conventional Implant Impression Approach: A Three-Dimensional Comparative In Vitro Analysis

PURPOSE To assess the three-dimensional (3D) accuracy and clinical acceptability of implant definitive casts fabricated using a digital impression approach and to compare the results with those of a conventional impression method in a partially edentulous condition. MATERIALS AND METHODS A mandibular reference model was fabricated with implants in the first premolar and molar positions to simulate a patient with bilateral posterior edentulism. Ten implant-level impressions per method were made using either an intraoral scanner with scanning abutments for the digital approach or an open-tray technique and polyvinylsiloxane material for the conventional approach. 3D analysis and comparison of implant location on resultant definitive casts were performed using laser scanner and quality control software. The inter-implant distances and interimplant angulations for each implant pair were measured for the reference model and for each definitive cast (n = 20 per group); these measurements were compared to calculate the magnitude of error in 3D for each definitive cast. The influence of implant angulation on definitive cast accuracy was evaluated for both digital and conventional approaches. Statistical analysis was performed using t test (α = .05) for implant position and angulation. Clinical qualitative assessment of accuracy was done via the assessment of the passivity of a master verification stent for each implant pair, and significance was analyzed using chi-square test (α = .05). RESULTS A 3D error of implant positioning was observed for the two impression techniques vs the reference model, with mean ± standard deviation (SD) error of 116 ± 94 μm and 56 ± 29 μm for the digital and conventional approaches, respectively (P = .01). In contrast, the inter-implant angulation errors were not significantly different between the two techniques (P = .83). Implant angulation did not have a significant influence on definitive cast accuracy within either technique (P = .64). The verification stent demonstrated acceptable passive fit for 11 out of 20 casts and 18 out of 20 casts for the digital and conventional methods, respectively (P = .01). CONCLUSION Definitive casts fabricated using the digital impression approach were less accurate than those fabricated from the conventional impression approach for this simulated clinical scenario. A significant number of definitive casts generated by the digital technique did not meet clinically acceptable accuracy for the fabrication of a multiple implant-supported restoration.

Surface and Mechanical Characterization of Dental Yttria-Stabilized Tetragonal Zirconia Polycrystals (3Y-TZP) After Different Aging Processes.

Yttria-stabilized tetragonal zirconia polycrystals (3Y-TZP) is a ceramic material used in indirect dental restorations. However, phase transformation at body temperature may compromise the materials mechanical properties, affecting the clinical performance of the restoration. The effect of mastication on 3Y-TZP aging has not been investigated. 3Y-TZP specimens (IPS E-max ZirCAD and Z5) were aged in three different modes (n=13): no aging (control), hydrothermal aging (HA), or chewing simulation (CS). Mechanical properties and surface topography were analyzed. Analysis of variance showed that neither aging protocol (p=0.692) nor material (p=0.283) or the interaction between them (p=0.216) had a significant effect on flexural strength, values ranged from 928.8 MPa (IPSHA) to 1,080.6 MPa (Z5HA). Nanoindentation analysis showed that material, aging protocol, and the interaction between them had a significant effect (p<0.001) on surface hardness and reduced Youngs modulus. The compositional analysis revealed similar yttrium content for all the experimental conditions (aging: p=0.997; material: p=0.248; interaction material×aging: p=0.720). Atomic force microscopy showed an effect of aging protocols on phase transformation, with samples submitted to CS exhibiting features compatible with maximized phase transformation, such as increased volume of the material microstructure at the surface leading to an increase in surface roughness.

Nanoparticles in Restorative Materials

Nanotechnology has made significant progress in the past 20 years. Particles as small as 3 nm are being employed in restorative materials in attempts to improve their functional performance. There are currently many commercial brands with different particle size distribution; some of them are termed nanohybrids, where nanoparticles (minimum size ~3 nm) are associated with particles larger than 100 nm. Materials called nanofill contain nanoparticles with a more even distribution (smaller than 100 nm). Amongst the particles used, some of them are applied to enhance the material’s bioactivity, which may control or reduce viable bacterial count on the tooth surface or on the tooth–restoration interface. Some examples of those particles are titanium dioxide (TiO2), chlorhexedine-hexametaphosphate (CHX-HMP) and silver (Ag). Nanofillers are also used to improve the material’s clinical performance, by either strengthening the restoration or enhancing its aesthetic characteristics, such as translucency and polishability. Zirconium dioxide (ZrO2), colloidal platinum and zirconia–silica nanoparticles are examples in this category of nanofillers. Amongst the desirable characteristics of nano-based restorative materials are higher mechanical properties; enhanced ion release of glass ionomer cements; development of bioactive adhesives, to provide antibacterial effect within the restoration or at the tooth–restoration interface; polishability and stable optical properties of resin composites; phase stability of high–crystalline content ceramics and lesser chipping of dental porcelains. The main goal of this chapter is to provide an overview of the advancements in the field of restorative materials with the application of nanoparticles. Nonetheless, it is worth mentioning that any progress reported here is very novel and has not been fully investigated, and more investigations are required before new restorative materials can be widely disseminated as a permanent solution to a given clinical problem.