Karl Lyons

Clinical trials in zirconia: a systematic review

Zirconia is unique in its polymorphic crystalline makeup, reported to be sensitive to manufacturing and handling processes, and there is debate about which processing method is least harmful to the final product. Currently, zirconia restorations are manufactured by either soft or hard-milling processes, with the manufacturer of each claiming advantages over the other. Chipping of the veneering porcelain is reported as a common problem and has been labelled as its main clinical setback. The objective of this systematic review is to report on the clinical success of zirconia-based restorations fabricated by both milling processes, in regard to framework fractures and veneering porcelain chipping. A comprehensive review of the literature was completed for in vivo trials on zirconia restorations in MEDLINE and PubMed between 1950 and 2009. A manual hand search of relevant dental journals was also completed. Seventeen clinical trials involving zirconia-based restorations were found, 13 were conducted on fixed partial dentures, two on single crowns and two on zirconia implant abutments, of which 11 were based on soft-milled zirconia and six on hard-milled zirconia. Chipping of the veneering porcelain was a common occurrence, and framework fracture was only observed in soft-milled zirconia. Based on the limited number of short-term in vivo studies, zirconia appears to be suitable for the fabrication of single crowns, and fixed partial dentures and implant abutments providing strict protocols during the manufacturing and delivery process are adhered to. Further long-term prospective studies are necessary to establish the best manufacturing process for zirconia-based restorations.

Clinical considerations for increasing occlusal vertical dimension: a review.

The purpose of this article is to discuss the clinical considerations related to increasing the occlusal vertical dimension (OVD) when restoring a patients dentition. Thorough extraoral and intraoral evaluations are mandatory to assess the suitability of increasing OVD. In the literature, multiple techniques have been proposed to quantify OVD loss. However, the techniques lack consistency and reliability, which in turn affects the decision of whether to increase the OVD. Therefore, increasing OVD should be determined on the basis of the dental restorative needs and aesthetic demands. In general, a minimal increase in OVD should be applied, though a 5 mm maximum increase in OVD can be justified to provide adequate occlusal space for the restorative material and to improve anterior teeth aesthetics. The literature reflects the safety of increasing the OVD permanently, and although signs and symptoms may develop, these are usually of an interim nature. Whenever indicated, the increase in OVD should be achieved with fixed restorations rather than a removable appliance, due to the predictable patient adaptation. The exception to this is for patients with TMD, where increasing the OVD should still be achieved using removable appliances to control TMD-associated symptoms before considering any form of irreversible procedure.

Trends in computer-aided manufacturing in prosthodontics: A review of the available streams

In prosthodontics, conventional methods of fabrication of oral and facial prostheses have been considered the gold standard for many years. The development of computer-aided manufacturing and the medical application of this industrial technology have provided an alternative way of fabricating oral and facial prostheses. This narrative review aims to evaluate the different streams of computer-aided manufacturing in prosthodontics. To date, there are two streams: the subtractive and the additive approaches. The differences reside in the processing protocols, materials used, and their respective accuracy. In general, there is a tendency for the subtractive method to provide more homogeneous objects with acceptable accuracy that may be more suitable for the production of intraoral prostheses where high occlusal forces are anticipated. Additive manufacturing methods have the ability to produce large workpieces with significant surface variation and competitive accuracy. Such advantages make them ideal for the fabrication of facial prostheses.

Tooth wear and wear investigations in dentistry

Tooth wear has been recognised as a major problem in dentistry. Epidemiological studies have reported an increasing prevalence of tooth wear and general dental practitioners see a greater number of patients seeking treatment with worn dentition. Although the dental literature contains numerous publications related to management and rehabilitation of tooth wear of varying aetiologies, our understanding of the aetiology and pathogenesis of tooth wear is still limited. The wear behaviour of dental biomaterials has also been extensively researched to improve our understanding of the underlying mechanisms and for the development of restorative materials with good wear resistance. The complex nature of tooth wear indicates challenges for conducting in vitro and in vivo wear investigations and a clear correlation between in vitro and in vivo data has not been established. The objective was to critically review the peer reviewed English-language literature pertaining to prevalence and aetiology of tooth wear and wear investigations in dentistry identified through a Medline search engine combined with hand-searching of the relevant literature, covering the period between 1960 and 2011.

Influence of veneering porcelain thickness and cooling rate on residual stresses in zirconia molar crowns

OBJECTIVE The aim of this study was to investigate the influence of increasing veneering porcelain thickness in clinically representative zirconia molar crowns on the residual stresses under fast and slow cooling protocols. METHODS Six veneered zirconia copings (Procera, Nobel Biocare AB, Gothenburg, Sweden) based on a mandibular molar form, were divided into 3 groups with flattened cusp heights that were 1mm, 2mm, or 3mm. Half the samples were fast cooled during final glazing; the other half were slow cooled. Vickers indentation technique was used to determine surface residual stresses. Normality distribution within each sample was done using Kolmogorov-Smirnov & Shapiro-Wilk tests, and one-way ANOVA tests used to test for significance between various cusp heights within each group. Independent t-tests used to evaluate significance between each cusp height group with regards to cooling. RESULTS Compressive stresses were recorded with fast cooling, while tensile stresses with slow cooling. The highest residual compressive stresses were recorded on the fast cooled 1mm cusps which was significantly higher than the 2 and 3mm fast cooled crowns (P<0.05). There was a significant linear trend for residual stress to decrease as veneering porcelain thickness increased in the fast cooled group (P<0.05). No significant differences were found between the various cusp heights during slow cooling (P≥0.05). SIGNIFICANCE Cooling rate and geometric influences in a crown anatomy have substantially different effects on residual stress profiles with increasing veneering porcelain thickness compared to the basic flat plate model.

A comparison of fit of CNC-milled titanium and zirconia frameworks to implants.

BACKGROUND Computer numeric controlled (CNC) milling was proven to be predictable method to fabricate accurately fitting implant titanium frameworks. However, no data are available regarding the fit of CNC-milled implant zirconia frameworks. PURPOSE To compare the precision of fit of implant frameworks milled from titanium and zirconia and relate it to peri-implant strain development after framework fixation. MATERIALS AND METHODS A partially edentulous epoxy resin models received two Branemark implants in the areas of the lower left second premolar and second molar. From this model, 10 identical frameworks were fabricated by mean of CNC milling. Half of them were made from titanium and the other half from zirconia. Strain gauges were mounted close to the implants to qualitatively and quantitatively assess strain development as a result of framework fitting. In addition, the fit of the framework implant interface was measured using an optical microscope, when only one screw was tightened (passive fit) and when all screws were tightened (vertical fit). The data was statistically analyzed using the Mann-Whitney test. RESULTS All frameworks produced measurable amounts of peri-implant strain. The zirconia frameworks produced significantly less strain than titanium. Combining the qualitative and quantitative information indicates that the implants were under vertical displacement rather than horizontal. The vertical fit was similar for zirconia (3.7 µm) and titanium (3.6 µm) frameworks; however, the zirconia frameworks exhibited a significantly finer passive fit (5.5 µm) than titanium frameworks (13.6 µm). CONCLUSIONS CNC milling produced zirconia and titanium frameworks with high accuracy. The difference between the two materials in terms of fit is expected to be of minimal clinical significance. The strain developed around the implants was more related to the framework fit rather than framework material.

Cracking of Porcelain Surfaces Arising from Abrasive Grinding with a Dental Air Turbine

PURPOSE The purpose of this in vitro study was to evaluate porcelain cracking induced by abrasive grinding with a conventional dental air turbine and abrasive diamond burs. MATERIALS AND METHODS Four commercially available porcelains were examined-Wieland ALLUX, Wieland ZIROX, IPS e.max Ceram, and IPS Empress Esthetic Veneering porcelain. Sixty discs of each porcelain type were fabricated according to manufacturer instructions, followed by an auto-glaze cycle. Abrasive grinding using fine, extra-fine, and ultra-fine diamond burs was carried out, using a conventional dental air turbine. The grinding parameters were standardized with regard to the magnitude of the force applied, rotational speed of the diamond bur, and flow rate of the water coolant. A testing apparatus was used to control the magnitude of force applied during the grinding procedure. The ground surfaces were then examined under scanning electron microscope. RESULTS Cracking was seen for all porcelain types when ground with the fine bur. Cracking was not seen for specimens ground with the extra-fine or the ultra-fine bur. CONCLUSION Wet abrasive grinding with a conventional dental air turbine and fine grit diamond burs has the potential to cause cracking in the four porcelain types tested. Similar abrasive grinding with smaller grit size particles does not cause similar observable cracking.

Additive Technology: Update on Current Materials and Applications in Dentistry.

Additive manufacturing or 3D printing is becoming an alternative to subtractive manufacturing or milling in the area of computer-aided manufacturing. Research on material for use in additive manufacturing is ongoing, and a wide variety of materials are being used or developed for use in dentistry. Some materials, however, such as cobalt chromium, still lack sufficient research to allow definite conclusions about the suitability of their use in clinical dental practice. Despite this, due to the wide variety of machines that use additive manufacturing, there is much more flexibility in the build material and geometry when building structures compared with subtractive manufacturing. Overall additive manufacturing produces little material waste and is energy efficient when compared to subtractive manufacturing, due to passivity and the additive layering nature of the build process. Such features make the technique suitable to be used with fabricating structures out of hard to handle materials such as cobalt chromium. The main limitations of this technology include the appearance of steps due to layering of material and difficulty in fabricating certain material generally used in dentistry for use in 3D printing such as ceramics. The current pace of technological development, however, promises exciting possibilities.

A novel in vitro approach to assess the fit of implant frameworks

OBJECTIVE To introduce a new strain gauge approach to assess the fit of fixed implant frameworks. MATERIALS AND METHODS A partially edentulous epoxy resin mandible model received two Straumann implants in the area of the lower left second premolar and second molar. The model was used to fabricate four zirconia and four identical cobalt-chromium alloy frameworks using a laboratory computer-aided design/computer-aided manufacturing (CAD/CAM) system. A total of four linear strain gauges were then bonded around each implant on the peri-implant structure (mesial, distal, buccal, and lingual). The experimental part was composed of two phases: qualitative and quantitative. For the qualitative assessment, the model was verified by recording the response of each strain gauge while applying a near-constant force of known directions on each implant. For the quantitative phase, the frameworks were attached on the implants and the screws were torqued to 15 N cm. RESULTS In the qualitative phase, the strain gauge response to every force direction was recorded. After attaching the frameworks, all frameworks produced measurable strains, but with different strain patterns. Upon correlating the two phases, the zirconia frameworks were found to be slightly smaller than the inter-implant distance, whereas the cobalt-chromium alloy frameworks tended to be slightly larger than the inter-implant distance. CONCLUSIONS The proposed technique is not only valid for detecting implant framework misfit but also for determining the form of inaccuracies. Model verification is an essential informative step to aid the interpretation of the pattern of framework distortion.

Effect of vertical misfit on strain within screw-retained implant titanium and zirconia frameworks

PURPOSE To assess the implication of vertical misfit on strain within implant frameworks manufactured in titanium or zirconia. METHODS A master model was fabricated by inserting a Brånemark implant in left side of a mandibular model in the area of the first premolar and the first molar. This model was used to fabricate identical frameworks, five in titanium and five in zirconia. A single strain gauge was mounted on the occlusal surface of each framework to assess strain development as a result of framework fitting. In addition, the peak-to-peak strain amplitude was measured for each framework to determine the strain pattern fluctuation. The vertical gap of the framework-implant interface was measured using a measuring microscope, when only one screw was tightened (1-screw test) and when both screws were tightened (2-screw test). The vertical fit of the frameworks was altered by adding one to three layers of 30 μm steel shims on one of the implants. RESULTS For all fitting conditions, measurable amount of strains were recorded, however, as the vertical misfit was introduced, linear increase in framework strain was detected. The titanium and zirconia frameworks exhibited similar strain activities. A direct relationship was observed between the framework strain and vertical gap. CONCLUSIONS Framework misfit clearly influenced the framework strain magnitude and pattern. The framework material did not affect the framework strain for a similar level of misfit.