Documente Academic
Documente Profesional
Documente Cultură
MARCH 2003
Static Analysis
Distal cantilevers against natural dentition and complete dentures are believed to be subjected to high masticatory forces, which generates relative high bending
moments and stresses, especially in the distal abutments.15 It has been suggested that the use of 2 distal
cantilever pontics (long cantilever) can lead to overstressing and failure of the FPD and abutment teeth.16 A
2-dimensional static analysis was conducted to learn
more about the theoretical shear forces and bending
moments that arise in cantilever prosthetic treatments.
The analysis was established on accepted engineering
principles of beams.17 This is a simulative mathematical
method that is based on statically determinate force systems in equilibrium.18 It provides theoretical qualitative
THE JOURNAL OF PROSTHETIC DENTISTRY 227
Fig. 3. A, Lateral view left side. B, Periapical view showing maxillary first premolar with 2 roots in mesioangulated position.
Fig. 5. A, Prepared teeth. Note small convergence of axial walls. B, Provisional fixed partial denture.
moment diagrams. Theoretically, increasing the interabutment span from l to 2l could possibly reduce the
reactive forces by 25%, from 2 to 1.5 F for C-FPD and
EC-FPD, respectively. Similarly, it can be seen that R1
could possibly be reduced by 50%, from -F to -F/2 for
C-FPD and EC-FPD, respectively. According to the
analysis, in the situation described, increasing the span
between the proximal abutments that support a cantilever FPD could reduce the reactive forces in the abutments between 25% and 50%.
With this simulation, it was decided to reposition the
posterior abutment by moving the tooth distally via
orthodontic means. It was believed that such abutment
repositioning would extend the dental arch with or
without the cantilever prosthesis and theoretically reduce the stresses with a cantilever FPD.
CLINICAL REPORT
A 48-year-old healthy woman was referred for restoration of missing teeth. Her main complaint was a perceived reduced function in 2 quadrants as a result of
missing teeth. An intraoral examination revealed missing
MARCH 2003
229
SUMMARY
Arch extention with a cantilever FPD for a patient
with a shortened dental arch was described. On the basis
of a 2-dimensional static analysis, orthodontic movement of the distal abutment to enlarge the interabutment span was performed before the final restoration. A
4-unit cantilever FPD was cemented to extend and re230
store the shortened dental arch. Four years after cementation, the cantilever shortened arch is in service without
incidence. A prosthetic solution with improved function
and esthetics was achieved.
REFERENCES
1. Kayser AF. Shortened dental arches and oral function. J Oral Rehabil
1981;8:457-62.
2. Witter DJ, Cramwinckel AB, van Rossum GM, Kayser AF. Shortened dental
arches and masticatory ability . J Dent 1990;18:185-9.
3. Witter DJ, van Elteren P, Kayser AF, van Rossum GM. Oral comfort in
shortened dental arches. J Oral Rehabil 1990;17:137-43.
4. Witter DJ, de Haan AF, Kayser AF, van Rossum GM. A 6-year follow-up
study of oral function in shortened dental arches. Part I: Occlusal stability.
J Oral Rehabil 1994; 21:113-25.
5. Witter DJ, van Elteren P, Kayser AF. Migration of teeth in shortened dental
arches. J Oral Rehabil 1987;14:321-9.
6. Budtz-Jorgensen E, Isidor F, Karring T. Cantilevered fixed partial dentures
in a geriatric population: a preliminary report. J Prosthet Dent 1985;54:
467-73.
7. Budtz-Jorgensen E, Isidor F. Cantilever bridges or removable partial dentures
in geriatric patients: a two-year study. J Oral Rehabil 1987;14:239-49.
8. Leempoel PJB, Kayser AF, van Rossum GMJM, de Haan AFJ. The survival
rate of bridges. A study of 1674 bridges in 40 Dutch general practices.
J Oral Rehabil 1995;22:327-30.
9. Jepson NJA, Moynihan PJ, Kelly PJ, Watson GW, Thomason JM. Caries
incidence following restoration of shortened lower dental arches in a
randomized controlled trial. Br Dent J 2001;191:140-4.
10. Sertgoz A, Guvener S. Finite element analysis of the effect of cantilever
and implant length on stress distribution in an implant-supported fixed
prosthesis. J Prosthet Dent 1996;76:165-9.
11. Tashkandi EA, Lang BR, Edge MJ: Analysis of strain at selected bone sites of
cantilevered implant-supported prosthesis. J Prosthetic Dent 1996;76:58-64.
12. Lewinstein, I., Banks-Sills, L. & Eliasi, R. Finite element analysis of a new
system (IL) for an implant-retained cantilever prosthesis. Int J Oral Maxillofac Implants 1995;10:355-66.
13. Himmel R, Pilo R, Assif D, Aviv I. The cantilever fixed partial denture: a
literature review. J Prosthet Dent 1992;67:484-7.
14. Randow K, Glantz PO. On cantilever loading of vital and nonvital teeth:
an experimental clinical study. Acta Odontol Scand 1986; 44:271-7.
15. Falk H, Laurell L, Lunsgern D. Occlusal cantilever forces and cantilever
joint stresses in implant-supported fixed prosthesis occluding with toothsupported fixed prosthesis or complete dentures. Swed Dent J Suppl
1990;69:1-11.
16. Laurell L, Lundgren D. Distribution of occlusal forces along unilateral
posterior two-unit cantilever segments in cross-arch fixed partial dentures.
J Prosthet Dent 1988;60:106-12.
17. Rodriguez AM, Aquilino SA Lund PS. Cantilever and implant biomechanics: A Review of the literature, part 1. J Prosthodont 1994;3:41-6
18. Crandall SH, Dahl NC, Lardner TJ. An introduction to the mechanics of
solids. 2nd ed. New York: McGraw-Hill; 1972. p. 515-41.
VOLUME 89 NUMBER 3
MARCH 2003
OF
DENTAL MEDICINE
TEL: 972-3-6409068
FAX: 972-3-6409250
E-MAIL: lewins@post.tau.ac.il
Copyright 2003 by The Editorial Council of The Journal of Prosthetic
Dentistry.
0022-3913/2003/$35.00 0
doi:10.1067/mpr.2003.44
231
tion. There was no surgical intervention in the remaining 4 clinical reports.1,3,6 Healing was uneventful
without complications, thus it appears that surgical
treatment of these fractures is not mandatory. It has
been suggested that this disability resolves when the
fibers of the genioglossus form a fibrous attachment to
adjacent tissues in the floor of the mouth.7 Thus it seems
reasonable to adopt a conservative treatment approach
and to anticipate full return of function.4,8 This clinical
report describes a situation of fractured genial tubercles
and discusses the pathogenesis and treatment of this
injury.
CLINICAL REPORT
A 70-year-old woman was referred to the Oral and
Maxillofacial clinic at Sheba Medical Center, Tel
Hashomer, Israel, for diagnosis and treatment of a sublingual hematoma. The patient complained of pain and
swelling beneath the mandibular complete denture that
started the previous day. While eating, she heard a cracking sound and felt severe pain at the base of the tongue.
There was no associated bleeding, and her mandibular
denture was undamaged.
Clinical examination revealed a gross atrophy of the
mandible, particularly in the incisor region. A hard,
painful, reddish swelling (2 2 cm) was noted in the
floor of the mouth adjacent to the lingual surface of the
anterior mandible (Fig. 1). Tongue mobility was not
restricted, although the patient experienced pain during
function. Both submandibular ducts were patent with
saliva flowing free of debris.
A panoramic radiograph revealed gross atrophy of the
mandible without other disorders. However, an occlusal
radiograph of the anterior mandible showed a fracture of
the genial tubercles with a marked posterior displacement of the genial segment (approximately 15 mm)
(Fig. 2).
The patient was advised of the finding, and no specific
therapy was recommended other than removal of the
VOLUME 89 NUMBER 3
SUMMARY
There is no evidence in the literature that fracture of
the genial tubercles leads to any major disability. In this
clinical report, a conservative approach to treatment was
advised that resulted in a return to full function.
We thank Ms. Rita Lazar for editorial assistance and Prof. Amos
Buchner, Head of the Department of Oral Pathology, The Maurice
and Gabriela Goldschleger School of Dental Medicine, Tel Aviv
University, Tel Aviv, Israel, for his assistance and advice in the
preparation of this manuscript.
REFERENCES
1. Goebel WM. Fractured genial tubercles. J Prosthet Dent 1978;39:603-4.
2. Reifman S. Genial tubercle fracture. Report of a case. Oral Surg Oral Med
Oral Pathol 1969;27:595-7.
3. Glendinning DE, Hirschmann PN. Fractures of the genial tubercles: two
cases and a review of the literature. Br J Oral Surg 1977;14:217-9.
4. Youngs R, Albert D. Fractured genial tubercles. J Laryngol Otol 1984;98:
1047-8.
5. Santos-Oller JM, Junquera Gutierrez LM, De Vicente Rodriguez JC, Llorente
Pendas S. Spontaneous fracture of hypertrophied genial tubercles. Oral Surg
Oral Med Oral Pathol 1992;74:28-9.
6. Carroll MJ. Spontaneous fracture of the genial tubercles. Br Dent J 1983:
154;47-8.
7. Moore JE, Russell JG. Geniohyoid and genioglossus muscles: effect of
experimental section. Oral Surg Oral Med Oral Pathol 1974;38:2-9.
8. Azaz B, Taicher S. Treatment of abnormal oral anatomical changes in
dentulous patients. Gerodontics 1986;2:32-4.
mandibular denture until discomfort subsided. Follow-up at 1 month revealed resolution of the hematoma,
complete symptomatic recovery, and no loss of normal
mobility of the tongue. Radiographs revealed the frac-
MARCH 2003
233
NABADALUNG
CLINICAL REPORT
NABADALUNG
Fig. 3. A, Tissue-side view of finished nose prosthesis shows type A silicone (white color) replica (matrix) for engagement of
modified part (patrix) of maxillary denture. B, Patient with finished nose prosthesis in place.
PROCEDURE
A mechanical retentive mechanism (a modified
button shape of an auto-polymerizing denture base
resin extending from the maxillary denture to the nasal cavity) was designed and fabricated (Fig. 1, B).
With the modified maxillary denture and definitive
mandibular denture in place, an impression of the
defect was made with irreversible hydrocolloid (Jel236
NABADALUNG
thane sheet, and (3) the mold was packed under pressure (1500 psi) with silicone elastomer MDX-4210
(Dow Corning Corp) mixed with intrinsic colors
(Factor II Inc) and type A silicone material (Dow
Corning Corp). The material was polymerized in water at 165 F for 9 hours. The prosthesis was recovered after polymerization and rinsed with water to
eliminate the residues, and flash was removed with a
pair of surgical scissors (Schiling Forge Co, Syracuse,
N.Y.). The prosthesis was evaluated on the patient.
To engage the nose prosthesis to the mechanical
extension (patrix) on the maxillary denture (Fig. 1,
B), a replica (matrix) on the tissue side of the nose
prosthesis was fabricated. To accomplish this, Type A
adhesive silicone material was applied to the acrylic
button after the maxillary denture was properly
placed. The nose prosthesis was then positioned. Caution was taken to ensure that the amount of silicone
Type A adhesive material was adequate to fill in the
space between the button on the maxillary denture
and the inner surface of the nose prosthesis. The patrix and matrix were separated after the material had
set (15 minutes). The resulting mechanism (Fig. 3, A)
provided additional retention for both nose prosthesis
and the maxillary denture.
The nose prosthesis was delivered (Fig. 3, B) and
retained on the face by a medical adhesive (Secure; Factor II Inc) and the fabricated attachment. The patient
was instructed on home care and prosthesis maintenance. To sanitize the wound, the patient was instructed
to gently remove any exudate with a wet cotton tip with
1% hydrogen peroxide, and to clean the tissue side of the
prosthesis with water once a day. In addition, the application of the medical adhesive and the placement of the
prosthesis were demonstrated. The patient was then
scheduled for the first adjustment (3 days after delivery).
At the first adjustment appointment, the treatment included observation of the surgical wound to ensure the
health of the tissues and report any abnormality to the
surgeon, adjustment of the prosthesis to resolve the
pressure areas on the tissues, and emphasis of hygiene
regarding prosthesis maintenance and home care. After
the first adjustment, the patient was placed on a
3-month recall for evaluation.
SUMMARY
Squamous cell carcinomas of the nasal septum are
rare. Their symptoms are not different from other common rhinologic symptoms. The lesions require combined radiation therapy and aggressive excision of all or
part of the nose. Immediate surgical reconstruction is
very complex for the total rhinectomy, because close
inspection of the lesion is required. This clinical report
describes treatment using a urethane lined prosthesis
with a mechanical retention design for a patient who
MARCH 2003
REFERENCES
1. Harrison LB, Sessions RB, Hong WK. Head and neck cancer: a multidisciplinary approach. Philadelphia: Lippincott-Raven; 1998. p. 11, 411-2.
2. Million RR, Cassissi NJ. Management of head and neck cancer: a multidisciplinary approach. 2nd ed. Philadelphia: Lippincott-Raven; 1993. p.
31.
3. Landis SH, Murray T, Bolden S, Wingo PA. Cancer statistics, 1999. CA
Cancer J Clin 1999;49:8-31, 1.
4. Fradis M, Podoshin L, Gertner R, Sabo E. Squamous cell carcinoma of the
nasal septum mucosa. Ear Nose Throat J 1993;72:217-21.
5. Fornelli RA, Fedok FG, Wilson EP, Rodman SM. Squamous cell carcinoma
of the anterior nasal cavity: a dual institution review. Otolaryngol Head
Neck Surg 2000;123:207-10.
6. DiLeo MD, Miller RH, Rice JC, Butcher RB. Nasal septal squamous cell
carcinoma: a chart review and meta-analysis. Laryngoscope 1996;106:
1218-22.
7. Thawley SE, Panje WR, Batsakis JG, Donley S. Comprehensive management of head and neck tumors. 2nd ed. Philadelphia: WB Saunders; 1998.
p. 526-7.
8. McGuirt WF, Thompson JN. Surgical approaches to malignant tumors of
the nasal septum. Laryngoscope 1984;94:1045-9.
9. Lydiatt WM, Davidson BJ, Shah J, Schantz SP, Chaganti RS. The relationship of loss of heterozygosity to tobacco exposure and early recurrence in
head and neck squamous cell carcinoma. Am J Surg 1994;168:437-40.
10. Brennan JA, Boyle JO, Koch WM, Goodman SN, Hruban RH, Eby YJ, et al.
Association between cigarette smoking and mutation of the p53 gene in
squamous-cell carcinoma of the head and neck. N Engl J Med 1995;332:
712-7.
11. Robbins KT. Advances in head and neck oncology. San Diego: Singular
Publishing Group; 1998. p. 5-24.
12. Jacobs C. Carcinomas of the head and neck. Boston: Kluwer Academic
Publisher; 1990. p. 83-113, 235-7.
13. Harrison DF. Total rhinectomya worthwhile operation? J Laryngol Otol
1982;96:1113-23.
14. Nadeau J. Special prostheses. J Prosthet Dent 1968;20:62-76.
15. Javid N. The use of magnets in a maxillofacial prosthesis. J Prosthet Dent
1971:25;334-41.
16. Udagama A, King GE. Mechanically retained facial prostheses: helpful or
harmful? J Prosthet Dent 1983;49:85-6.
17. Dumbrigue HB, Fyler A. Minimizing prosthesis movement in a midfacial
defect: a clinical report. J Prosthet Dent 1997;78:341-5.
18. Beumer J, Curtis TA, Marunick MT. Maxillofacial rehabilitation: prosthetic
and surgical considerations. St. Louis: Ishiyaku EuroAmerica; 1998. p.
387-408.
19. Parel SM, Branemark PI, Tjellstrom A, Gion G. Osseointegration in maxillofacial prosthetics. Part II: Extraoral applications. J Prosthet Dent 1986;
55:600-6.
20. Tolman DE, Desjardins RP. Extraoral application of osseointegrated implants. J Oral Maxillofac Surg 1991;49:33-45.
21. van Oort RP, Reintsema H, van Dijk G, Raghoebar GM, Roodenburg JL.
Indications for extra-oral implantology. J Invest Surg 1994;7:275-81.
22. Tolman DE, Taylor PF. Bone-anchored craniofacial prosthesis study. Int
J Oral Maxillofac Implants 1996;11:159-68.
23. Nishimura RD, Roumanas E, Moy PK, Sugai T. Nasal defects and osseointegrated implants: UCLA experience. J Prosthet Dent 1996;76:597602.
24. Branemark PI, Tolman DE. Osseointegration in craniofacial reconstruction. Chicago: Quintessence; 1998. p. 95-102.
25. Soutar DS, Tiwari RM. Excision and reconstruction in head and neck
surgery. London: Churchill Livingtone; 1994. p. 254-9.
26. Myers EN, Suen Jy, McGrew L. Cancer of the head and neck. 3rd ed.
Philadelphia: WB Saunders; 1996. p. 712-47.
27. Foster RD, Anthony JP, Singer MI, Kaplan MJ, Pogrel AM, Mathes SJ.
Reconstruction of complex midfacial defects. Plast Reconstr Surg 1997;
99:1555-65.
28. Udagama A. Urethane-lined silicone facial prostheses. J Prosthet Dent
1987;58:351-4.
237
NABADALUNG
SQUIRE HALL-215
BUFFALO, NY 14214
FAX: 716-829-2440
E-MAIL: dn3@buffalo.edu
Copyright 2003 by The Editorial Council of The Journal of Prosthetic
Dentistry.
0022-3913/2003/$30.00 0
doi:10.1067/mpr.2003.45
238
VOLUME 89 NUMBER 3
various system components have been attributed to misfit.8-10,12,13 Additionally, adverse tissue reactions, pain,
tenderness, marginal bone loss, and loss of osseointegration have also been listed as possible sequela of prosthesis misfit.13-18 However, animal studies in which intentional misfits were introduced as well as clinical reports
of nonpassive prostheses do not necessarily demonstrate
bone loss or implant failure.19,20 It is speculated that
misfit coupled with cyclical functional loading rather
than constant strain would cause bone loss, but a discernable relationship between misfit and bone loss has
not been established.9,20 The consensus of many studies
and reports implies that some mode of biologic tolerance seems to exist between the implant and surrounding bone that permits a certain degree of misfit.9 Even
so, the minimal threshold of biologic tolerance to misfit
has yet to be scientifically defined or quantified.8,9 It is
therefore recommended that clinical and laboratory procedures be executed in such a way to optimize the fit of
screw-retained implant prostheses.2,8,9,19
Recommended clinical techniques to improve fit include the use of custom impression trays, rigid impression materials, radiographs, alternate finger pressure, direct vision and tactile sensation, one-screw test, and the
use of disclosing media and various instrumentation.8
Because framework fabrication requires many steps, the
cause of distortion in implant frameworks may be multifactorial.2,3,8 The factors that may introduce errors resulting in distortions include implant alignment, impression technique and materials, framework fabrication
process, design configuration, and clinician and technician experience.2,3,8-10 Also, dimensional changes occur
related to the chemical reactions of impression materials,
dental stones, and investment materials, as well as the
coefficients of thermal expansion (and contraction) for
cast metals and their accompanied investment materials
during the casting and cooling process.
Traditional fixed prosthodontic materials may yield
clinically acceptable dimensional mismatches in shortTHE JOURNAL OF PROSTHETIC DENTISTRY 239
COBB ET AL
CLINICAL REPORT
A 52-year-old white woman was initially seen with an
existing maxillary complete denture opposing the mandibular arch with 5 implant fixtures (Standard Fixtures
3.75 15 mm RP; Nobel Biocare USA, Yorba Linda,
Calif.) and a mandibular denture with an interim resilient liner. The patient had initiated treatment previously
with a general dentist but decided to seek specialty care
for the completion of her treatment.
Fabrication of a fixed-detachable hybrid prosthesis
was planned for the mandibular arch and for a new maxillary complete denture. The treatment options presented to the patient also included the fabrication of an
implant-supported overdenture, but the patients desire
was to eliminate a removable prosthesis in the mandible.
The following clinical and laboratory procedures were
performed.
The healing abutments were removed, and impression copings were connected to the implants (Impression Coping Pick-up Type, 5 mm Profile; 3i Implant
Innovations, Palm Beach Gardens, Fla.) (Fig. 1). A custom tray was used to make the final impression with
heavy-bodied impression material (Exaflex Heavy Body;
GC America Inc, Alsip, Ill.). The maxillary complete
denture impression was made using an acrylic custom
tray that was border molded with modeling plastic impression compound (ISO Functional Compound; GC
America Inc) and poly-sulfide rubber base impression
material (Coe-Flex Injection; GC America Inc). Master
casts were recovered and trimmed, and record bases and
occlusion rims were fabricated. The patient returned for
recording of maxillomandibular relations and tooth selection. Master casts were then mounted on a semiadjustable articulator (Hanau Modular Articulator System, REF: 014110-000; Waterpik Technologies Inc,
Fort Collins, Colo.).
After the arrangement of the denture teeth, a wax/
esthetic try-in was performed to verify the accuracy of
maxillomandibular relations and to obtain patient approval of esthetics. Modifiable (prepable) abutments
(PrepTite Abutment; 3i Implant Innovations) were con240
Fig. 1. A, Impression copings connected to implants. B, Tissue surface of final impression before analog connection.
nected to the implant analogs and evaluated for common path of insertion using a dental surveyor (Ney Surveyor; The JM Ney Company, Bloomfield, Conn.). If
the path of insertion deviates considerably, then castable
abutments may be used to produce the optimal angulations. The abutments were prepared with a 2- to 6-degree taper to develop the path of insertion and create
adequate retention and resistance form (Fig. 2). Clearance of denture teeth was verified with a denture tooth
index. The abutment screw access hole of each of prepared abutment was filled with an interim light-polymerized material (Fermit; Vivadent, Amherst, N.Y.),
and 2 coats of die spacer were painted over the abutments on the master cast.
The framework design was similar to the conventional hybrid prosthesis,4-7 but it did not have screw
access holes. The framework was waxed, cast, recovered,
and fitted to the abutments on the master cast. Disclosing media (Kerrs Disclosing Wax; Kerr, Romulus,
Mich. and Occlude; Pascal Co Inc, Bellevue, Wash.)
were used to evaluate the fit of the framework and to
guide adjustment procedures. The fit was refined until
the framework seated passively on the master cast. ClearVOLUME 89 NUMBER 3
COBB ET AL
ance of the framework with the denture teeth was verified with the tooth index (Fig. 3). The die spacer and
light-polymerized interim material were removed from
the abutments before the abutments were connected to
the implants (Fig. 4). The metal framework was tried in
to evaluate and verify a passive fit intraorally. Disclosing
media was used to discern any fit discrepancies. Adjustments were performed, and abutments were removed
from the implant fixtures and healing abutments reconnected.
The mandibular denture teeth were waxed to the
hybrid framework, and a final wax try-in was performed
to verify and correct maxillomandibular relations. At this
appointment, the customized abutments were connected to the implants for the final wax try-in where they
remained until final delivery of the prosthesis. A new
resilient liner (Coe-Soft; GC America Inc) was placed in
the existing mandibular denture after it was relieved to
accommodate the height of the definitive abutments.
The maxillary complete denture was invested/flasked
and processed by use of the maxillary master cast as any
conventional complete denture. However, the mandibular hybrid prosthesis was invested without the master
cast. The internal aspects of the casting that fit on the
abutments were blocked out with polyvinyl-siloxane impression material, and the prosthesis was invested directly into the lower half of the processing flask. The
investing, flasking, and processing procedures were then
completed (Fig. 5). The prostheses were finished and
polished, a clinical remount was performed to allow for
refinement of occlusal contacts, and the hybrid prosthesis was cemented onto abutments with provisional cement (Temp Bond; Kerr) (Fig. 6). Hygiene techniques
were reviewed, and the patient was scheduled for recall
and maintenance.
DISCUSSION
Producing a passive-fitting substructure for a fixeddetachable hybrid prosthesis is arguably one of the most
MARCH 2003
COBB ET AL
Even then, the framework may not fit passively. Eliminating multiple sectioning, indexing, and soldering procedures may therefore simplify framework fabrication.
Another advantage to this technique is the elimination of screw access holes, which may improve esthetics
and occlusion, yet permit retrievability of the prosthesis
for hygiene and repair procedures. Furthermore, by
eliminating screw-retention, the problems of fatigue,
component fracture, and screw loosening are also eliminated.
There may be several disadvantages of this technique.
First, selection and milling of modification (prepable)
abutments requires an experienced clinician and technician working together with adequate communication.
Implant angulations beyond 15 degrees may require an
angled abutment or a castable abutment to achieve an
acceptable path of insertion. Also, numbering or other
methods of matching the correct abutment and orientation with the correct implant fixture is imperative.
Patients with limited interarch space may present several problems. Inadequate height of abutments may
compromise retention and resistance form for the
framework/abutment interface, or it may result in a
framework with deficient thickness or insufficient space
for setting denture teeth.
With regard to cement retention, provisional cement
should be used for easy retrieval of the prosthesis. However, cement failure may result in a loose prosthesis requiring an unscheduled patient visit. Also, meticulous
removal of excess cement is essential.
Fig. 6. Definitive prostheses. A, Frontal view. B, Occlusal
view demonstrating absence of access holes for optimal occlusion and esthetics.
SUMMARY
A design for a hybrid prosthesis with cement retention rather than screw retention is presented.
REFERENCES
1. Tharp G. Implant update. Miss Dent Assoc J 1998;54:22-3.
2. Misch CE. Contemporary implant dentistry. 2nd ed. St Louis: Mosby;
1999. p. 69, 549-93.
3. Watzek G. Endosseus implants: scientific and clinical aspects. Chicago:
Quintessence: 1996. p. 342-354.
4. Zarb GA, Symington JM. Osseointegrated dental implants: preliminary
report on a replication study. J Prosthet Dent 1983;50:271-6.
5. Lundqvist S, Carlsson GE. Maxillary fixed prostheses on osseointegrated
dental implants. J Prosthet Dent 1983;50:262-70.
6. Goll GE. Production of accurately fitting full-arch implant frameworks:
Part I-Clinical procedures. J Prosthet Dent 1991;66:377-84.
7. Branemark PI, Zarb GA, Albrektsson T. Tissue-integrated prostheses: osseointegration in clinical dentistry. Chicago: Quintessence; 1985. p. 24182.
8. Kan JY, Rungcharassaeng K, Bohsali K, Goodacre CJ, Lang BR. Clinical
methods for evaluating implant framework fit. J Prosthet Dent 1999;81:713.
9. Taylor TD. Prosthodontic problems and limitations associated with osseointegration. J Prosthet Dent 1998;79:74-8.
10. Goodacre CJ, Kan JY, Rungcharassaeng K. Clinical complications of osseointegrated implants. J Prosthet Dent 1999;81:537-52.
11. Skalak R. Biomechanical considerations in osseointegrated prostheses.
J Prosthet Dent 1983;49:843-8.
12. Branemark PI. Osseointegration and its experimental background. J Prosthet Dent 1983;50:399-410.
VOLUME 89 NUMBER 3
COBB ET AL
13. Zarb GA, Schmitt A. The longitudinal clinical effectiveness of osseointegrated dental implants: the Toronto study. Part III: Problems and complications encountered. J Prosthet Dent 1990;64:185-94.
14. Naert I, Quirynen M, van Steenberghe D, Darius P. A study of 589
consecutive implants supporting complete fixed prostheses. Part II: Prosthetic aspects. J Prosthet Dent 1992;68:949-56.
15. Lekholm U, van Steenberghe D, Herrmann I, Bolender C, Folmer T,
Gunne J, et al. Osseointegrated implants in the treatment of partially
edentulous jaws: a prospective 5-year multicenter study. Int J Oral Maxillofac Implants 1994;9:627-35.
16. Bauman GR, Mills M, Rapley JW, Hallmon WW. Plaque-induced inflammation around implants. Int J Oral Maxillofac Implants 1992;7:330-7.
17. Haanaes HR. Implants and infections with special reference to oral bacteria. J Clin Periodontol 1990;17:516-24.
18. Kallus T, Bessing C. Loose gold screws frequently occur in full-arch fixed
prostheses supported by osseointegrated implants after 5 years. Int J Oral
Maxillofac Implants 1994;9:169-78.
19. Carr AB, Gerard DA, Larsen PE. The response of bone in primates around
unloaded dental implants supporting prostheses with different levels of fit.
J Prosthet Dent 1996;76:500-9.
MARCH 2003
20. Jemt T, Book K. Prosthesis misfit and marginal bone loss in edentulous
patients. Int J Oral Maxillofac Implants 1996;11:620-5.
21. Eden GT, Franklin OM, Powell JM, Ohta Y, Dickson G. Fit of porcelain
fused-to-metal crown and bridge castings. J Dent Res 1979;58:2360-8.
22. Rangert B, Jemt T, Jorneus L. Forces and moments on Branemark implants.
Int J Oral Maxillofac Implants 1989;4:241-7.
Reprint requests to:
DR GEORGE W COBB JR
UNIVERSITY OF TEXAS-HOUSTON DENTAL BRANCH
6516 M.D. ANDERSON BLVD
HOUSTON, TX 77030
FAX: 713-500-4353
E-MAIL: George.W.Cobb@uth.tmc.edu
Copyright 2003 by The Editorial Council of The Journal of Prosthetic
Dentistry.
0022-3913/2003/$30.00 0
doi:10.1067/mpr.2003.39
243
CLINICAL IMPLICATIONS
Ideally, to ensure long-term service of mandibular implant-supported screw-retained prostheses,
both anterior and posterior cantilever lengths should be carefully considered during prosthodontic treatment planning. The ratio of posterior cantilever to anteroposterior spread should be kept
less than 2:5 to decrease the risk of prosthetic failure.
Research supported in part by The Minnesota Dental Research Center for Biomaterials and Biomechanics, R01DE12225.
a
Assistant Professor, Division of Prosthodontics, Department of Restorative Sciences.
b
Associate Professor, Department of Restorative Dentistry, Nova
Southeastern University, Fort Lauderdale, Fla.
c
Senior Research Associate, Division of Biostatistics.
244 THE JOURNAL OF PROSTHETIC DENTISTRY
ufacturer. All casts were digitized in a sequential manner, beginning with implants A through E, then the
most posterior left tooth through the most posterior
right tooth. The 3-dimensional coordinates from the
FaroArm were then placed into an algebraic formula to
determine the distance between the 2 points,
P1(x1y1z1) and P2(x2y2z2). A 1-way analysis of variance was used to compare prostheses with loose screws
to prostheses without loose screws for each of the 3
outcome measures: length of the mandibular anterior
cantilever, length of the mandibular posterior cantilever,
and the anteroposterior spread (P.05).
VOLUME 89 NUMBER 3
Patient
Anterior
cantilever
(mm)
Anteroposterior
spread
(mm)
Right
posterior
cantilever
(mm)
Left
posterior
cantilever
(mm)
Posterior
cantilever*/
anteroposterior spread
Anterior
cantilever/
anteroposterior spread
Number
of loose
screws
1
2
3
4
5
6
7
8
9
10
11
12
13
Mean
SD
14.4
11.7
5.9
10.9
5.5
7.5
8.6
11.9
6.5
11.6
7.6
5.9
6.2
8.8
3.0
7.1
7.9
8.1
8.9
10.8
6.6
8.0
8.0
6.9
7.0
5.2
12.3
6.0
7.9
1.9
16.7
14.1
16.9
16.0
20.0
12.8
15.0
18.1
15.6
16.3
18.0
9.2
20.0
16.0
2.9
16.0
13.0
20.9
16.8
19.8
17.0
12.1
18.1
15.1
17.0
18.8
11.4
17.0
16.4
2.9
2.35
1.78
2.58
1.88
1.86
2.58
1.89
2.28
2.26
2.42
3.61
0.93
3.36
2.29
0.69
2.03
1.48
0.73
1.22
0.51
1.14
1.08
1.50
0.94
1.66
1.46
0.48
1.04
1.17
0.45
0
0
2
0
0
0
0
0
0
1
3
0
1
0.54
0.97
*The largest of the 2 mandibular posterior cantilever lengths was used for this calculation.
RESULTS
FaroArm measurements for the lengths of the mandibular anterior cantilevers, right and left mandibular
posterior cantilevers, anteroposterior spread, and the
status of the retaining screws can be found in Table I.
Although there was no apparent correlation between
length of the mandibular anterior cantilever and screw
loosening (P.45), the ratio of posterior cantilever to
the anteroposterior spread was significantly associated
with screw loosening (P.006). Statistically, when the
ratio of mandibular posterior cantilever to anteroposterior spread was approximately 2:4, there appeared to be
a greater risk of screw loosening. On the basis of the
means of this small sample, it seemed that the ratio of the
mandibular anterior cantilever to the anteroposterior
spread to the mandibular posterior cantilever was approximately 1:1:2.
DISCUSSION
Implant cantilevers are often clinically necessary for
occlusal support and esthetics. Numerous investigations2,7-10,18,36 have addressed mandibular posterior
cantilevers, however little information is available on the
mandibular anterior cantilever for an implant-supported
screw-retained prosthesis.
Biomechanical considerations for successful implant
treatment outcomes have been recommended. Theoretically, the anteroposterior spread may dictate the length
of the posterior cantilever for an implant-supported
prosthesis.7-9 In this patient sample, the ratio of the
anteroposterior spread to the posterior cantilever length
fell within the suggested ranges for successful treatment
outcome.8,11-17 The anteroposterior spread and cantileMARCH 2003
CONCLUSIONS
Within the limitations of this study, anterior cantilevers in mandibular implant-supported screw-retained
prostheses seemed common but depended on individual
implant placement and prosthesis design. When restoring edentulous situations to class I dental relationships,
it is possible to create both an anterior and posterior
cantilever with an apparent length ratio of approximately 1:2.
Ideally, to ensure long-term service of mandibular
implant-supported fixed prostheses, both anterior and
posterior cantilevers should be carefully considered during prosthodontic treatment planning.
We thank Colleen Doyen CCRP, CCRC, Clinic Coordinator of the
Oral Health Clinical Research Center, University of Minnesota, for
her help in the coordination of patients throughout the investigation.
REFERENCES
1. Adell R, Lekholm U, Rockler B, Branemark PI. A 15-year study of osseointegrated implants in the treatment of the edentulous jaw. Int J Oral
Surg 1981;10:387-416.
2. Branemark PI, Zarb GA, Albrektsson T. Tissue-integrated prostheses: osseointegration in clinical dentistry. 2nd ed. Chicago: Quintessence; 1985.
p. 51-70.
3. Tallgren A. The continuing reduction of the residual alveolar ridges in
complete denture wearers: a mixed-longitudinal study covering 25 years.
J Prosthet Dent 1972;27:120-32.
4. Zarb GA, Bolender CL, Carlsson GE, Boucher CO. Bouchers prosthodontic treatment for edentulous patients. 11th ed. St. Louis: Mosby; 1997. p.
40.
5. Pietrokovski J. The bony residual ridge in man. J Prosthet Dent 1975;34:
456-62.
6. Misch CE. Contemporary implant dentistry. 2nd ed. St. Louis: Mosby,
1998. p. 113.
7. English CE. Critical A-P spread. Implant Soc 1990;1:2-3.
8. Rangert B, Jemt T, Jorneus L. Forces and moments on Branemark implants.
Int J Oral Maxillofac Implants 1989;4:241-7.
9. Skalak R. Biomechanical considerations in osseointegrated prostheses.
J Prosthet Dent 1983;49:843-8.
10. McAlarney ME, Stavropoulos DN. Determination of cantilever lengthanterior-posterior spread ratio assuming failure criteria to be the compromise of the prosthesis retaining screw-prosthesis joint. Int J Oral Maxillofac
Implants 1996;11:331-9.
11. Chapman RJ. Principles of occlusion for implant prostheses: guidelines for
position, timing, and force of occlusal contacts. Quintessence Int 1989;
20:473-80.
12. Shackleton JL, Carr L, Slabbert JC, Becker PJ. Survival of fixed implantsupported prostheses related to cantilever lengths. J Prosthet Dent 1994;
71:23-6.
13. Beumer J, Lewis SG. The Branemark implant system: clinical and laboratory procedures. St. Louis: Medico Dental Media; 1989. p. 73.
14. Hobo S, Ichida E. Osseointegration and occlusal rehabilitation. Chicago:
Quintessence; 1989. p. 179.
VOLUME 89 NUMBER 3
15. Zarb G, Schmitt A. The longitudinal clinical effectiveness of osseointegrated dental implants: the Toronto study. Part III: Problems and complications encountered. J Prosthet Dent 1990;64:185-94.
16. Hansen CA, DeBoer J, Woolsey GD. Esthetic and biomechanical considerations in reconstructions using dental implants. Dent Clin North Am
1992;36:713-41.
17. Naert I, Quirynen M, van Steenberghe D, Darius P. A study of 589
consecutive implants supporting complete fixed prostheses. Part II: prosthetic aspects. J Prosthet Dent 1992;68:949-56.
18. Lindquist LW, Rockler B, Carlsson GE. Bone resorption around fixtures in
edentulous patients treated with mandibular fixed tissue-integrated prostheses. J Prosthet Dent 1988;59:59-63.
19. White SN, Caputo AA, Anderkvist T. Effect of cantilever length on stress
transfer by implant-supported prostheses. J Prosthet Dent 1994;71:493-9.
20. Adell R, Eriksson B, Lekholm U, Branemark PI, Jemt T. Long-term follow-up study of osseointegrated implants in the treatment of totally edentulous jaws. Int J Oral Maxillofac Implants 1990;5:347-59.
21. Jemt T, Carlsson L, Boss A, Jorneus L. In vivo load measurements on
osseointegrated implants supporting fixed or removable prostheses: a
comparative pilot study. Int J Oral Maxillofac Implants 1991;6:413-7.
22. Zarb G, Schmitt A. Osseointegration and the edentulous predicament: the
10-year-old Toronto study. Br Dent J 1991;170:439-44.
23. Kallus T, Bessing C. Loose gold screws frequently occur in full-arch fixed
prostheses supported by osseointegrated implants after 5 years. Int J Oral
Maxillofac Implants 1994;9:169-78.
24. Walton JN, MacEntee MI. Problems with prostheses on implants: a retrospective study. J Prosthet Dent 1994;71:283-8.
25. Patterson EA, Johns RB. Theoretical analysis of the fatigue life of fixture
screws in osseointegrated dental implants. Int J Oral Maxillofac Implants
1992;7:26-33.
26. McGlumphy EA, Mendel DA, Holloway JA. Implant screw mechanics.
Dent Clin North Am 1998;42:71-89.
27. Hobkirk JA, Schwab J. Mandibular deformation in subjects with osseointegrated implants. Int J Oral Maxillofac Implants 1991;6:319-28.
28. Meijer HJ, Kuiper JH, Starmans FJ, Bosman F. Stress distribution around
dental implants: influence of superstructure, length of implants, and height
of mandible. J Prosthet Dent 1992;68:96-102.
29. Korioth TW, Hannam AG. Deformation of the human mandible during
simulated tooth clenching. J Dent Res 1994;73:56-66.
30. Hobkirk JA, Havthoulas TK. The influence of mandibular deformation,
implant numbers, and loading position on detected forces in abutments
supporting fixed implant superstructures. J Prosthet Dent 1998;80:169-74.
31. DiPietro GJ, Moergeli JR. Significance of the Frankfort-mandibular plane
angle to prosthodontics. J Prosthet Dent 1976;36:624-35.
32. Mercier P, Lafontant R. Residual alveolar ridge atrophy: classification and
influence of facial morphology. J Prosthet Dent 1979;41:90-100.
33. Unger JW, Ellinger CW, Gunsolley JC. An analysis of the relationship
between mandibular alveolar bone loss and a low Frankfort-mandibular
plane angle. J Prosthet Dent 1991;66:513-6.
34. Ericsson I, Glantz PO, Branemark PI. Use of implants in restorative therapy
in patients with reduced periodontal tissue support. Quintessence Int
1988;19:801-7.
35. Cohen SR, Orenstein JH. The use of attachments in combination implant
and natural-tooth fixed partial dentures: a technical report. Int J Oral
Maxillofac Implants 1994;9:230-4.
36. Osier JF. Biomechanical load analysis of cantilevered implant systems.
J Oral Implantol 1991;17:40-7.
37. Quirynen M, Naert I, van Steenberghe D. Fixture design and overload
influence marginal bone loss and fixture success in the Branemark system.
Clin Oral Implant Res 1992;3:104-11.
38. Carr AB, Stewart RB. Full-arch implant framework casting accuracy: preliminary in vitro observations for in vivo testing. J Prosthodont 1993;2:2-8.
39. Worthington P, Bolender CL, Taylor TD. The Swedish system of osseointegrated implants: problems and complications encountered during a 4-year
trial period. Int J Oral Maxillofac Implants 1987;2:77-84.
40. Korioth TW, Johann AR. Influence of mandibular superstructure shape on
implant stresses during simulated posterior biting. J Prosthet Dent 1999;
82:67-72.
41. FaroArm Technologies Inc Manual; 1999.
42. FaroArm Technologies Inc. The FaroArm product page. Available at:
http://faroarm.com. Accessed March 20, 2002.
43. Taylor TD. Prosthodontic problems and limitations associated with osseointegration. J Prosthet Dent 1998;79:74-8.
44. Tulley WJ. Methods of recording patterns of behavior of the oro-facial
muscles using the electromyograph. Trans Brit Soc Study Orthodont 1953;
96:88-95.
Reprint requests to:
DR MARY ELIZABETH BROSKY
DIVISION OF PROSTHODONTICS
DEPARTMENT OF RESTORATIVE SCIENCES
SCHOOL OF DENTISTRY
UNIVERSITY OF MINNESOTA
9-450A MOOS TOWER OFFICE
515 DELAWARE STREET SE
MINNEAPOLIS, MN 55455
FAX: 612-626-1496
E-MAIL: brosk001@tc.umn.edu
Copyright 2003 by The Editorial Council of The Journal of Prosthetic
Dentistry.
0022-3913/2003/$30.00 0
doi:10.1067/mpr.2003.43
MARCH 2003
249
CLINICAL IMPLICATIONS
This in vitro study demonstrated that rigid custom trays produced significantly more accurate
implant fixture-level impressions, as measured by vertical fit discrepancy, than did the polycarbonate stock trays tested.
VOLUME 89 NUMBER 3
BURNS ET AL
Typodont construction
The study used 4 regular platform implant analogs
(DCA 711-0; Nobel Biocare) mounted in an aluminum
typodont. Two channels were milled into the typodont
to retain a flexible bed of silicone material (Gemini 2
part silicone model duplicating material; Bracon Ltd,
Etchingham, Sussex, United Kingdom) (Fig. 1).
The width between the channels corresponded to the
width between the tray walls of a polycarbonate mandibular stock impression tray (Size 12 Solo tray; Davis
Healthcare Services Ltd, Potters Bar, Hertfordshire, England). This allowed the seating of impression trays on a
displaceable bed that could potentially allow tray distortion under load.
Impression protocol
Three impressions were made from each of the 9
impression trays using implant transfer copings (DCA
099-0; Nobel Biocare AB). Polyether impression material (Impregum Penta; 3M Espe Dental AG) was used
and was dispensed using a delivery unit (Pentamix II;
3M Espe Dental AG). A stop clock was used to note the
time to load and level the tray, load the syringe, syringe
the impression material around the copings, seat the tray
on the displaceable bed, and allow for full setting, to
standardize the impression protocol. The material was
allowed to polymerize for twice the manufacturers recommended setting times to allow for room temperature
rather than mouth temperature. A circular piece of steel
weighing 430 gm was used to standardize the seating
252
BURNS ET AL
Measurement protocol
The subsequent measurements performed on the
casts were without the previously described information;
the envelope was opened only after the measurements
and re-measurements had been completed. This allowed
for a single blind study design. All measurements were
made by one operator.
By virtue of the markings on the reference framework
and cast, it was a straightforward procedure to mount
the anterior or posterior reference bar on the appropriate cast in the correct orientation. One end of the bar
was then attached to the cast with the abutment screw
and tightened to 20 Ncm with the restorative torque
indicator (RTI2035; 3i Implant Innovations, Palm
VOLUME 89 NUMBER 3
BURNS ET AL
RESULTS
The results are presented in Tables I and II. The
results showed that the mean fit accuracy, as measured
by vertical fit discrepancy, of casts from the stock trays
(23 20 m) were statistically significantly less
(P.001) than the spaced custom trays (12 10 m) or
close-fit custom trays (11 10 m). A significant difference (P.001) between the stock and the custom
impression trays was found at both anterior and posteMARCH 2003
DISCUSSION
The study showed that custom trays produced more
accurate impressions than stock trays. This finding is in
agreement with a number of other studies with natural
teeth14,16,19,30; however, there are potentially major differences between the natural tooth studies and this
study. In the natural tooth studies, investigators used
closed impression trays that may have been more susceptible to flexion and distortion when seated with impression material. The impression protocol used for implant
fixture-level registration generally uses an open tray,
which may allow impression material subjected to hydrostatic pressure on seating to more readily escape. In
addition, the use of a fixture-level impression technique
(with machined components) only needs to record the
implant head position rather than both its position and
dimensions. Both of these factors would suggest that
253
BURNS ET AL
Stock trays
Spaced custom trays
Close fit custom trays
10
20
30
40
50
6
27
30
39
48
46
32
21
24
7
10
7
8
2
60
70
80
90
100
110
120
Table II. Results showing vertical gap measurements in micrometers Mean, (standard deviation), median and interquartile
range
Tray Type
Stock
Spaced Custom
18
(17)
20
10-40
28
(21)
20
10-40
0.001
9
(8)
10
0-10
14
(11)
10
10-20
0.013
9
(11)
10
0-10
14
(8)
10
10-20
0.001
23
(20)
20
10-30
12
(10)
10
5-30
11
(10)
10
0-20
P value for
comparison of trays*
.001
.001
All Trays
12
(13)
10
10-20
19
16)
20
10-20
0.001
.001
*Kruskal-Wallis ANOVA. Stock trays significantly different from spaced and close fit custom trays at both anterior and posterior sites (P .001), spaced custom
and close fit custom trays not significantly different (P.5). Post-ANOVA contrasts with Mann-Whitney U test.
Mann-Whitney U test
BURNS ET AL
CONCLUSIONS
Within the limits of this in vitro study, it may be
concluded that, as measured by vertical fit discrepancy,
rigid custom close-fit trays and spaced custom trays produce significantly more accurate impressions than flexible polycarbonate stock trays (P.001). Also, for analogs with a 20-mm separation, there was a difference in
medians of 10 m in accuracy between the stock and
custom trays, as measured by vertical fit discrepancy.
REFERENCES
1. Jemt T, Lie A. Accuracy of implant-supported prostheses in the edentulous
jaw: analysis of precision of fit between cast gold-alloy frameworks and
master casts by means of a three-dimensional photogrammetric technique.
Clin Oral Implants Res 1995;6:172-80.
2. Millington ND, Leung T. Inaccurate fit of implant superstructures. Part 1:
Stresses generated on the superstructure relative to the size of fit discrepancy. Int J Prosthodont 1995;8:511-6.
3. Jemt T. In vivo measurements of precision of fit involving implant-supported prostheses in the edentulous jaw. Int J Oral Maxillofac Implants
1996;11:151-8.
4. Riedy SJ, Lang BR, Lang BE. Fit of implant frameworks fabricated by
different techniques. J Prosthet Dent 1997;78:596-604.
5. Jemt T, Lekholm U. Measurements of bone and frame-work deformations
induced by misfit of implant superstructures. A pilot study in rabbits. Clin
Oral Implants Res 1998;9:272-80.
6. Taylor TD, Agar JR, Vogiatzi T. Implant prosthodontics: current perspective and future directions. Int J Oral Maxillofac Implants 2000;15:66-75.
7. Jemt T, Book K. Prosthesis misfit and marginal bone loss in edentulous
implant patients. Int J Oral Maxillofac Implants 1996;11:620-5.
8. Smedberg JI, Nilner K, Rangert B, Svensson SA, Glantz SA. On the influence of superstructure connection on implant preload: a methodological
and clinical study. Clin Oral Implants Res 1996;7:55-63.
9. McLean JW, Frauenhoffer JA. The estimation of cement film thickness by
an in vivo technique. Br Dent J 1971;131:107.
10. Kohavi D. Complications in the tissue integrated prostheses components:
clinical and mechanical evaluation. J Oral Rehabil 1993;20:413-22.
11. Jemt T, Linden B, Lekholm U. Failures and complications in 127 consecutively placed fixed partial prostheses supported by Branemark implants:
MARCH 2003
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
255
CLINICAL IMPLICATIONS
This study suggests that the fit of implant frameworks fabricated by the Procera system were
significantly better than that of frameworks made with cast gold-alloy.
cise fit, the framework was fabricated from cast goldalloy. Implant prosthesis frameworks in cast materials,
such as gold-alloy, involve a certain risk for built-in tension and stress caused by the wax-up and casting procedures.
Recently, frameworks have been milled from pure
titanium and, according to the manufacturer, have been
considered to have a high degree of fit. It has been
reported that Procera machined framework (All-inOne) fits better to the implant abutment than the goldalloy casting framework.11
The purpose of this study was to compare the precision of fit between implant abutments and framework
cylinders in frameworks fabricated by the Procera system
and those fabricated from cast gold-alloy.
Fig. 1. Film thickness was recorded as distance between edge of abutment and edge of cylinder.
Maxilla
Mandible
Total
1
2
Total
6 (29)
3 (13)
9 (42)
8 (41)
2 (12)
10 (53)
14 (70)
5 (25)
19 (95)
Fig. 2. Four measurement points for each abutment. Lc, Line to connect each centric point of implant abutments; L1-L5 cross
Lc at right angles through each centric point of implant abutments.
Table II. Precision of fit (mean and standard deviation [SD] in micrometers) between implant abutment and cylinder of
superstructure for All-in-One frameworks (type 1)
Framework
1
2
3
4
5
6*
7
8
9
10*
11*
12*
13*
14*
Mean
SD
Buccal
Lingual
Right
Left
Mean
SD
No of Implant
49.0
48.2
26.7
26.7
29.0
34.3
22.5
25.5
19.3
22.8
31.3
19.6
20.6
18.5
28.1
9.8
34.8
44.3
27.3
21.6
24.2
51.5
21.9
18.2
15.7
17.9
30.6
14.4
16.4
20.1
25.6
11.2
37.5
43.9
30.9
24.2
29.0
37.5
22.3
21.6
19.7
20.3
30.3
17.7
19.6
17.8
26.6
8.4
39.6
45.5
34.4
25.8
26.5
37.0
22.7
24.3
18.4
22.2
27.8
20.6
17.6
20.6
27.4
8.5
40.2
45.5
29.8
24.6
27.2
40.1
22.4
22.4
18.3
20.8
30.0
18.1
18.6
19.3
All-Mean 26.9
All-SD 9.3
6.2
1.9
3.6
2.2
2.3
7.7
0.3
3.2
1.8
2.2
1.5
2.7
1.9
1.3
4
6
5
5
5
2
6
5
5
6
4
5
6
6
Total 70
RESULTS
The measurements of the 2 types of frameworks are
given in Tables II and III. For type 1, the analyses
showed that the mean values were 28.1 m (SD 9.8) on
258
Table III. Precision of fit (mean and standard deviation [SD] in micrometers) between implant abutment and cylinder of
superstructure for gold-alloy casting frameworks (type 2)
Framework
Buccal
Lingual
Right
Left
Mean
42.4
44.2
42.4
39.3
41.6
42.0
1.8
42.0
39.1
64.6
53.0
59.3
51.6
10.9
45.4
40.8
68.9
48.3
42.6
49.2
11.4
45.4
40.6
55.0
42.8
38.1
44.4
6.5
43.8
1.9
41.2
2.2
57.7
11.8
45.9
6.0
45.4
9.5
All-Mean 46.8
All-SD 8.8
1
2*
3
4*
5*
Mean
SD
SD
No. of implant
5
5
7
3
5
Total 25
DISCUSSION
The Procera system (CAD-CAM technology), which
originated from Andersson,13 was developed14-17 and
modified for fabrication of frameworks for implant-supported restorations. The All-in-One is a framework
milled from a pure titanium block. The reason for the
development of the All-in-One was to create a framework with high biocompatibility, low cost, and a fit precision to the abutment through industrial production
with the latest CAD-CAM technology.
In the clinic, the dentist follows the same routine
procedures as for the fabrication of other types of frameworks. After the final check of design and tooth arrangement, the dental technician fabricates a resin pattern of
the desired framework. The pattern is scanned for computerized handling of the implant positions, abutment
replicas, and framework design. The framework is milled
from the computer data. The accurate position of the
implants and the relation to each other is possible without use of welded joints. After the framework has been
milled, it is carefully measured in a stereomicroscope to
check the fit against the cast. It has been reported that
the gap distance between the gold-alloy casting framework and the implant abutment was 42 to 74 m,5 and
for Procera-machined and laser-welded frameworks it
was less than 25 m.11
Osseointegrated implants present a significantly different mobility compared with the natural teeth supported with periodontal ligaments.19 Therefore minor
distortion of frameworks could invoke a risk of inducing
stress from frameworks connected to osseointegrated
implants. Natural teeth have the ability to adjust to the
misfit because of the mobility of the periodontal ligament. The difference in mobility between implants and
natural teeth means that the precision of fit of the framework is more important when fixed prostheses are connected to implants than to natural teeth.
Several methods for evaluating the implant framework fit have been recommended, such as alternate finger pressure, direct vision and tactile sensation, radiographs, one-screw test, screw resistance test (half a turn),
and disclosing media.12 To quantify the misfit, a comMARCH 2003
puterized coordinate measuring machine,3 a 3-dimensional photogrammetric technique,4,5 and laser videography11 were described. However, most of these
methods need expensive equipment and an advanced
technique. In this experiment, a disclosing medium was
used to measure the gap distance between the implant
abutments and the framework cylinders (All-in-One and
gold-alloy casting) of the master cast. The method is
characterized by simplicity and low cost.
For all specimens, the type 1 framework differed from
the type 2 framework (Table I). Because most of the
frameworks were fabricated with the Procera system, at
the time of this study it was not possible to find more
than 5 treatments with the type 2 framework. However,
the standard deviations were very low for both groups,
and data analysis found both a clinically and a statistically
significant difference between the 2 groups.
As a result, the total means were 26.9 m (SD 9.3)
for type 1 frameworks and 46.8 m (SD 8.8) for type 2
frameworks. For type 1 frameworks, this is in agreement
with the data of Riedy et al.11 The mean value of type 2
frameworks was lower than reported by Jemt and Lie.5
This increase of the precision of fit could be explained by
an improved technique at the dental laboratory derived
from a long experience with the casting method. It is
suggested that the framework with a good precision of
fit will decrease the stress to the implant components
and the surrounding bone, thus avoiding deformation
of the bone and an increase in technical problems.
CONCLUSION
Within the limitations of this study, it was demonstrated that the fit of implant frameworks fabricated by
the Procera system (All-in-One) were significantly better than that of frameworks made with cast gold-alloy.
For any measurement points (buccal, lingual, right, and
left), the fit of the All-in-One frameworks was statistically better than the framework made with cast goldalloy. For the All-in-One frameworks, all mean values of
the thickness of the film at the 4 measurements points
(buccal, lingual, right, and left) were less than 30 m.
Students unpaired t test showed a significant difference
259
12. Kan JYK, Rungcharassaeng K, Bohsali K, Goodacre CJ, Lang BR. Clinical
methods for evaluating implant framework fit. J Prosthet Dent 1999;81:713.
13. Andersson M, Bergman B, Bessing C, Ericson G, Lundquist P, Nilson H..
Clinical results with titanium crowns fabricated with machine duplication
and spark erosion. Acta Odontol Scand 1989;47:279-86.
14. Bergman B, Bessing C, Ericson G, Lundquist P, Nilson H, Andersson M. A
2-year follow-up study of titanium crowns. Acta Odontol Scand 1990;48:
113-7.
15. Karlsson S. The fit of Procera titanium crowns: an in vitro and clinical
study. Acta Odontol Scand 1993;51:129-34.
16. Persson M, Andersson M, Bergman B. The accuracy of a high-precision
digitizer for CAD/CAM of crowns. J Prosthet Dent 1995;74:223-9.
17. Andersson M, Carlsson L, Persson M, Bergman B. Accuracy of machine
milling and spark erosion with a CAD/CAM system. J Prosthet Dent
1996;76:187-93.
18. Satoh K. Experimental study on the influence of various dental luting
cements on the elevation of crown during cementation. Shikwa Gakuho
1989;89:1317-37. [Japanese]
19. Sekine H, Komiyama Y, Hotta H, Yoshida K. Mobility characteristics and
tactile sensitivity of osseointegrated fixture-supporting system. In: van
Steenberghe U, editor. Tissue integration in oral and maxillofacial reconstructions. New York: Elsevier Science; 1987. p. 326-32.
Reprint requests to:
DR TOSHIYUKI TAKAHASHI
DEPARTMENT OF CROWN AND BRIDGE PROSTHODONTICS
TOKYO DENTAL COLLEGE
1-2-2, MASAGO, MIHAMA-KU
CHIBA 261-8502
JAPAN
E-MAIL: totakaha@tdc.ac.jp
Copyright 2003 by The Editorial Council of The Journal of Prosthetic
Dentistry.
0022-3913/2003/$35.00 0
doi:10.1067/mpr.2003.40
260
VOLUME 89 NUMBER 3
Purpose. The purpose of this investigation was to compare the resistance to crack propagation of 9 flowable
composites as measured by the fracture toughness.
Material and methods. The composites studied include AeliteFlo, Crystal Essence, Flow-it, FloRestore,
Permaflo, Revolution, Tetric Flow, VersaFlo, and Wave. Ten specimens of each composite were formed with a
brass mold with a 3-mm preformed notch. The final dimensions of each specimen were 2 4.2 20 mm. All
specimens were light-polymerized to manufacturer specifications and stored in air for 24 hours. The fracture
toughness value, KIC (MNm3/2), for each specimen was measured by use of a 3-point bending mode and a
single-edge notched beam at a crosshead speed of 0.125 mm/min until fracture. The data were analyzed
statistically by use of 1-way analysis of variance, t tests (P.05), and regression analysis.
Results. The flowable composites tested showed a spectrum of fracture toughness values ranging from 1.15
0.10 MNm3/2 for Wave to 1.65 0.13 MNm3/2 for Permaflo (significantly different, P.05). The remaining
materials formed 1 group with intermediate KIC values not different from each other (P.05) but significantly
different from Wave and Permaflo. Comparisons of fracture toughness to the filler content by volume of each
composite revealed no correlation.
Conclusion. This in vitro study concluded that there was no significant difference among 7 of the 9 composites
tested in their resistance to fracture. Permaflo showed the greatest resistance to crack propagation. There was no
correlation between the filler content by volume and the fracture toughness of these flowable composites.
(J Prosthet Dent 2003;89:261-7.)
CLINICAL IMPLICATIONS
The tested flowable composites exhibited a high resistance to crack propagation as measured by
KIC. This characteristic, together with the low elastic modulus, may make these flowable composites suitable for conservative restorations.
were developed in response to requests for special handling properties rather than clinical assessment.2 Flowable composites are characterized by low modulus of
elasticity, low viscosity, and high wettability of tooth
structure.2,3 In addition, the use of these low-viscosity
resins was suggested to reduce the microleakage in different preparation configurations.5,6 However, other
studies found no significant reduction of marginal microleakage of composite restorations tested with or without linings.7-10
The limitations of flowable composite materials are
still unknown. Additional information on the mechanical characteristics is required to fully evaluate their clinical efficacy for posterior restorations in comparison with
nonflowable or packable posterior composites.11
Fracture toughness, KIC, is an intrinsic characteristic
of a material concerning resistance to crack propagation.
It is a measure of the energy required to initiate and
propagate a crack in a material, which may lead to catastrophic failure. In general, the larger the flaw, the lower
the stress needed to cause fracture, because the stresses
normally supported by material are now concentrated at
THE JOURNAL OF PROSTHETIC DENTISTRY 261
Aeliteflo
Crystal Essence
FloRestore
Flow-It
Permaflo
Revolution
Tetric Flow
VersaFlo
Wave SDI
Manufacturer
Resin
Size (m)
wt %
vol %
Bisco Inc.
CONFI-DENTAL Products
Den-Mat Corp.
Jeneric/Pentron
ULTRADENT Products Inc.
Kerr Corp.
IVOCLAR N.A.
Centrix Inc.
Southern Dental Industries
Bis-GMA 35%
Bis-GMA 16%
Bis-GMA 38%
Ethoxylated Bis-GMA TEGDMA 25%
Methacrylate 32.5%
Bis-GMA 47%
Bis-GMA, UDMA, TEDMA 31.1%
Bis-GMA 32%
UDMA 35%
0.7
3.7
0.7
1.5
1.0
1.7
0.7
1.0
1.5
60.0
64.0
50.0
70.5
68.0
52.0
67.8
63.0
65.0
42.0
41.0
48.0
55.0
48.0
41.0
43.8
43.0
50.0
Fig. 1. Diagrammatic representation of aluminum mold used for fabrication of beam specimens.
Society for Testing Materials guidelines for the singleedge notched beam specimen (Standard E-399).18 A
custom-made, brass and aluminum mold with a sharp
steel blade was used to reproducibly form 10 specimens
of each composite (n 10) with a centrally placed notch
(Fig. 1). The dimensions of each specimen used in the
investigation were 2 4.2 20 mm, with a 3-mm long
notch on one edge.
Each composite was placed into the mold in 1-mm
increments by use of prefilled syringes provided by the
manufacturers. Each increment was light-polymerized
for 45 seconds following manufacturers specifications
with a visible light polymerization unit (Coltolux 4; Coltene-Whaledent, Mahwah, N.J.) with an output of 650
mW/cm2 and a wavelength between 450 and 520 nanometers. A dental radiometer (Coltolux light meter; Coltene-Whaledent) was used to verify the light intensity at
each use of the polymerization unit. A glass slab was
placed over the final increment to ensure that the material was flush with the surface of the mold. After polymerization of the last increment, each specimen was
carefully removed from the mold and light- polymerized
on each side for an additional 45 seconds. Any flash
present on the borders of the specimen was then removed by finishing the specimen with 400-grit sandpaper. A typical finished specimen is shown in Figure 2.
Specimens that had noticeable defects around the tested
VOLUME 89 NUMBER 3
Fig. 3. Diagrammatic
notched-beam test.
representation
of
single-edged
PL
a
f
bw 1.5
w
where
f
a
3 a
w
w
0.5
1.99
a
a
1
w
w
2.15 3.93
a
a
2.7
w
w
Fig. 4. Representative notched beam fracture mode perpendicular to vertical and horizontal planes through center of
specimen.
RESULTS
The mean fracture toughness values and standard
deviations for the flowable restorative resin materials
tested are shown in Figure 5. Horizontal lines indicate
means that are not significantly different from each
other (P.05). Intergroup differences were significant
(P.05). The flowable composites exhibited a range of
fracture toughness characteristics; the highest mean KIC
value was for Permaflo (1.65 0.13 MNm3/2), and
the lowest mean KIC value was for Wave (1.15 0.10
MNm3/2). The remaining materials formed 1 group
with intermediate KIC values between these 2 extremes.
The mean values for these materials, ranked in descending order, are Tetric Flow, 1.43 0.09 MNm3/2;
Aelite Flo, 1.39 0.17 MNm3/2; Flow-It, 1.38
263
Fig. 5. Mean fracture toughness values for 9 flowable composites tested. Vertical bars represent 1 standard deviation. The
horizontal bar connects groups of materials that were not statistically significantly different (P.05).
Fig. 6. Fracture toughness values as function of volume concentration of filler. No correlation exists.
The relationship between fracture toughness and volume concentration of fillers (provided by the manufacturers) is shown in Figure 6. Linear regression analysis, with
volume concentration being the independent variable and
VOLUME 89 NUMBER 3
Fig. 7. Fracture toughness values for several packable composite restorative resins. Horizontal lines represent 1 standard
deviation. Groups of materials not statistically significantly different (P.05) are connected by vertical bars. Data adapted from
Bonilla et al.11
KIC the dependent variable revealed a very weak correlation between them (r2 0.101). This weak interdependence of fracture toughness and filler by volume is illustrated by the flowable resins that had the greatest filler
content, Flow it (1.38 MNm3/2) and Wave (1.15
MNm3/2), compared with a KIC for Crystal Essence
(1.31 MNm3/2) and for Revolution (1.32 MNm3/2),
which had the least filler content by volume.
DISCUSSION
Fracture mechanic parameters such as KIC are useful to understand the flaw characteristics of a dental
composites. KIC describes the resistance of flaw propagation of brittle materials, which may lead to catastrophic failure under an applied load. This study reported a range of KIC values of a variety of flowable
composites that have a large resin matrix component
(16% to 47%). The highest KIC value was observed
with the methacrylates (32.5% by volume) as a matrix
(Permaflo). Intermediate values were obtained with
the composites on the basis of Bis GMA (16% to 47%
by volume), whereas the lowest KIC values were seen
with materials having UDMA (35% by volume) as the
major component of the resin matrix. Although the
resin matrix undoubtedly has a strong effect on fracture toughness, filler type, distribution, and concentration also may contribute to the KIC.
MARCH 2003
evaluate the correlation of KIC and elasticity of flowable composites with clinical applications.
Some significant differences in fracture toughness
were determined among the materials tested. A higher
fracture toughness is desirable because it is indicative
of resistance to crack propagation; however, a question may arise with regard to what level of KIC is
optimum. Currently there is no known clinical criterion. With this in mind, selection of a flowable composite should also involve consideration of other mechanical properties such as compressive, flexural, and
fatigue strengths.
CONCLUSIONS
Within the limitations of this in vitro study, the
composite resins ranked in ascending order of mean
KIC values are Wave, VersaFlow, Crystal Essence,
Revolution, FloRestore, Flow-It, Aelite Flo, Tetric
Flow, and Permaflo. Permaflo flowable composite exhibited the significantly highest KIC and showed the
greatest resistance to crack propagation under load,
whereas Wave exhibited the significantly lowest KIC.
The remaining materials formed 1 group with intermediate KIC values not different from each other
(P.05) but significantly different from Wave and
Permaflo. There was no correlation between the fracture toughness value and the filler content by volume
of the flowable composites.
REFERENCES
1. Behle C. Flowable composites: properties and applications. Pract Periodontics Aesthet Dent 1998;10:347, 350-1.
2. Bayne SC, Thompson JY, Swift EJ, Stamatiades P, Wilkerson M. A characterization of first-generation flowable composites. J Am Dent Assoc 1998;
129:567-77.
3. Estafan D, Schulman A, Calamia J. Clinical effectiveness of a Class V
flowable composite resin system. Compend Contin Educ Dent 1999;20:
11-5; quiz 16.
4. Unterbrink GL, Liebenberg WH. Flowable resin composite as filled adhesives: literature review and clinical recommendations. Quintessence
Int 1999;30:249-57.
5. Kemp-Scholte CM, Davidson CL. Marginal sealing of curing contraction
gaps in Class V composite resin restorations. J Dent Res 1988;67:841-5.
6. Kemp-Scholte CM, Davidson CL. Complete marginal seal of Class V resin
composite restorations effected by increased flexibility. J Dent Res 1990;
69:1240-3.
7. Chuang SF, Liu JK, Jin YT. Microleakage and internal voids in class II
composite restorations with flowable composite linings. Operative Dentistry 2001;26:193-200.
8. Jain P, Belcher M. Microleakage of Class II resin-based composite restorations with flowable composite in the proximal box. Am J Dent 2000;
13:235-8.
9. Estafan AM, Estafan D. Microleakage study of flowable composite resin
systems. Compend Contin Educ Dent 2000;21:705-8, 710, 712, quiz
714.
10. Labella R, Lambrechts P, Van Meerbeek B, Vanherle G. Polymerization
shrinkage and elasticity of flowable composites and filled adhesives. Dent
Mater 1999;15:128-37.
11. Bonilla ED, Mardirossian G, Caputo AA. Fracture toughness of posterior
resin composites. Quintessence Int 2001;32:206-10.
VOLUME 89 NUMBER 3
12. Kim KH, Park JH, Imai Y, Kishi T. Microfracture mechanisms of dental
resin composites containing spherically-shaped filler particles. J Dent Res
1994;73:499-504.
13. Drummond JL, Botsis J, Zhao D, Samyn J. Fracture properties of aged and
post-processed dental composites. Eur J Oral Sci 1998:106;661-6.
14. Ferracane JL, Berge HX, Condon JR In vitro aging of dental composites in
water-effect of degree of conversion, filler volume, and filler/matrix coupling. J Biomed Mater Res 1998:42;465-72.
15. Lloyd CH. The fracture toughness of dental composites III. The effect of
environment upon the stress intensification factor (KIC) after extended
storage after extended storage. J Oral Rehabil 1984;11:393-8.
16. Lloyd CH, Adamson H. The development of fracture toughness and
fracture strength in posterior restorative materials. Dent Mater 1987;3:
225-31.
17. Pilliar RM, Vowles R, Williams DF. The effect of environmental aging
on the fracture toughness of dental composites. J Dent Res 1987;66:
722-6.
MARCH 2003
18. Standard test method for plane-strain fracture toughness for metallic materials. Standard E399-90 ASTM. In: 1990 Annual book of ASTM standards. West Conshohocken (PA): ASTM; 1990. p. 13-5.
Reprint requests to:
DR ESTEBAN D. BONILLA
UCLA SCHOOL OF DENTISTRY
SECTION OF DIVISION OF RESTORATIVE DENTISTRY, CHS A0-156
10833 LECONTE AVE
LOS ANGELES, CA 90095-1668
FAX: (310) 206-5539
E-MAIL: edbonilla2@juno.com
Copyright 2003 by The Editorial Council of The Journal of Prosthetic
Dentistry.
0022-3913/2003/$35.00 0
doi:10.1067/mpr.2003.33
267
SILICA-BASED CERAMICS
Silica-based ceramics, such as feldspathic porcelain
and glass ceramic, are frequently used to veneer metal
frameworks (commonly referred to as metal ceramic restorations or PFMs)114 or high-strength ceramic copings
for all-ceramic restorations.97 Their excellent esthetic
properties make them the material of choice for ceramic
laminate veneers115 and inlays/onlays.6 In spite of the
inherent brittleness and limited flexural strength of silica-based ceramics, final adhesive cementation with composite increases the fracture resistance of the ceramic
restoration and the abutment tooth.25,26 Leucite-reinforced feldspathic porcelain (for example: IPS Empress;
Ivoclar-Vivadent, Schaan, Liechtenstein) achieves significantly higher fracture strength and provides the restorative team with the ability to fabricate full-coverage
all-ceramic restorations for both anterior and posterior
teeth if resin bonding techniques are properly applied.6
A lithium-disilicate glass-ceramic core veneered with a
sintered glass-ceramic (for example: IPS Empress 2; Ivoclar-Vivadent) offers further strength that allows for the
fabrication of short-span fixed partial dentures
(FPDs).116
Intraoral porcelain-repair systems for chipped or fractured veneering ceramic also rely on strong resin bonds
and adequate surface treatment.29 These systems may
VOLUME 89 NUMBER 3
Application of a silane coupling agent to the pretreated ceramic surface provides a chemical covalent and
hydrogen bond55,56 and is a major factor for a sufficient
resin bond to silica-based ceramics.36-52,55-70 Silanes are
bifunctional molecules that bond silicone dioxide with
the OH groups on the ceramic surface. They also have a
degradable functional group that copolymerizes with
the organic matrix of the resin.38,71 Silane coupling
agents usually contain a silane coupler and a weak acid,
which enhances the formation of siloxane bonds.38 Silanization also increases wettability of the ceramic surface. In a study by Lacy et al,48 airborne-particle
abraded silica-based ceramic was not retentive unless a
silane coupling agent was applied. Some silane agents
that contained carboxylic acid provided sufficient
bond strengths even without HF acid etching, and
others were successful after acid etching with phosphoric acid.72 Sorensen et al24 showed that ceramic
etching and silanization significantly decreased microleakage, which was not achieved by exclusive silane
treatment.
Studies on the efficacy of silanes after try-in procedures or resilanation of the ceramic restoration show
differing results.73,74 Residual organic contaminants
may decrease bond strengths and should be removed
before bonding, preferably with phosphoric acids or solvents such as acetone or alcohol. Silane primers can be
categorized into 3 main groups: unhydrolyzed singleliquid silane primer, prehydrolized single-liquid silane
primer, and 2- or 3-liquid silane primer. Silane coupling
agents usually contain high amounts of solvents.73 Single-bottle products have a limited shelf life and are susceptible to rapid solvent evaporation and hydrolization,
making the silane solution useless. A good indicator is
the appearance of the liquid; a clear solution is useful,
whereas a milky-looking one should not be used. Many
ceramic-bonding systems require separate silane treatment before the application of a bonding agent and the
composite cement. Some manufacturers add a silane
coupler to their bonding system that, whenever necessary, is mixed with the other bonding-agent components and applied in a single step (for example: Clearfil
Porcelain Bond Activator and Clearfil SE Bond; Kuraray, Osaka, Japan). Silanes may have different chemical
structures (for example: -methacryloxy propyltrimethoxy silane or 3-trialkyloxysilylpropyl methacrylate),
which make it important to stay within 1 bonding system and not interchange components that may not be
compatible.87
269
COMPOSITE CEMENTS
Resin-based composites are the material of choice for
the adhesive luting of ceramic restorations.75 Composite
cements have compositions and characteristics similar to
conventional restorative composites and consist of inorganic fillers embedded in an organic matrix (for example: Bis-GMA, TEGDMA, UDMA). Composite cements can be classified according to their initiation
mode as autopolymerizing (chemically activated), photoactivated, or dual-activated materials.75 Photoactivated composites offer wide varieties of shades, consistencies, and compositions.75 Clinical application is
simplified through long handling times before and rapid
hardening after exposure to light. Shade, thickness, and
transmission coefficient of the bonded ceramic restoration and the composite itself influence the conversion
rate of the photo-activated material and limit its application to thin silica-based ceramics. Blackman et al76
found polymerization beneath ceramic inlays to be safe
up to 3 mm distance from the tip of a standard curing
light. Dual-activated composites offer extended working times and controlled polymerization,75 although
chemical activators ensure a high degree of polymerization. Most dual-activated resin cements still require
photopolymerization and demonstrated inferior hardness when light polymerization was omitted.77,78 Various dual-activated resin cements showed no differences
in resin-bond strengths between glass ceramics and
enamel.79 Autopolymerizing resin cements have fixed
setting times and are generally indicated for resin bonding metal-based or opaque, high-strength ceramic restorations.75
Resin cements with reduced filler contents offer improved flow, increased surface wettability, and optimal
positioning of the restoration.75 However, filler-containing composite cements revealed higher bond
strengths than resins without fillers,51 and hybrid composites showed better results than microfilled composites.58 A study by Hahn et al81 revealed significantly less
microleakage at the dentin/composite interface when
high-viscous instead of low-viscous resin cements were
used for cementation of ceramic inlays. Highly filled
resin cements may improve abrasion resistance at the
marginal area, reduce polymerization shrinkage, and facilitate removal of excess cement.75 Highly filled and
therefore viscous resin cements may require alternative
cementation procedures such as the ultrasonic-insertion
technique, in which application of energy through highfrequency vibrations changes the consistency of the resin
cement to a thinner viscosity for the time of energy
application and allows for optimal seating of the restoration.75 The different viscosities have clinical advantages and disadvantages; whereas removal of excess material of low-viscosity composites may be difficult, high270
ALUMINUM-OXIDE CERAMICS
The need for improved fracture strength of all-ceramic restorations led to the development of ceramics
with an increased alumina content.95 The aluminum oxide serves as reinforcement of the glassy matrix, compaVOLUME 89 NUMBER 3
ZIRCONIUM-OXIDE CERAMICS
Depending on the specific composition, fracture
strength of sintered zirconia can exceed 1000 MPa.100 A
number of zirconium-oxide ceramic systems have been
recently introduced, such as Cercon (Dentsply, Amherst, N.Y.), DCS system (DCS Dental AG, Allschwil,
Switzerland), LAVA (3M ESPE) and Procera AllZirkon
(NobelBiocare). Zirconium-oxide ceramic is indicated
for conventional and resin-bonded FPDs, full-coverage crowns, implant abutments, and endodontic
posts.125-128 Zirconia endodontic posts offer a strong
and esthetic alternative to metal posts and should be
bonded with composite cements.128-132 Full-coverage
zirconium-oxide ceramic restorations and FPDs may
not require adhesive cementation.125 However, a sufficient resin bond has the aforementioned advantages and
may become necessary in some clinical situations, such
as compromised retention and short abutment teeth.133
Conventional acid etching has no positive effect on the
resin bond to zirconium-oxide ceramics. Derand and
Derand111 evaluated different surface treatments and
resin cements and found that an autopolymerizing resin
cement (Superbond C&B; Sun Medical) exhibited the
significantly highest bond strengths regardless of surface
treatment (silica coating, airborne particle abrasion, HF
etching, or grinding with a diamond bur). Water storage
271
272
6. Blatz MB. Long-term clinical success of all-ceramic posterior restorations. Quintessence Int 2002;33:415-26.
7. Felden A, Schmalz G, Federlin M, Hiller KA. Retrospective clinical
investigation and survival analysis on ceramic inlays and partial ceramic
crowns: results up to 7 years. Clin Oral Investig 1998;2:161-7.
8. van Dijken JW, Hoglund-Aberg C, Olofsson AL. Fired ceramic inlays: a
6-year follow up. J Dent 1998;26:219-25.
9. Hayashi M, Tsuchitani Y, Miura M, Takeshige F, Ebisu S. 6-year clinical
evaluation of fired ceramic inlays. Oper Dent 1998;23:318-26.
10. Fuzzi M, Rappelli G. Ceramic inlays: clinical assessment and survival
rate. J Adhesive Dent 1999;1:71-9.
11. Roulet JF. Longevity of glass ceramic inlays and amalgamresults up to
6 years. Clin Oral Invest 1997;1:40-6.
12. Mormann W, Krejci I. Computer-designed inlays after 5 years in situ:
clinical performance and scanning electron microscopic evaluation.
Quintessence Int 1992;23:109-15.
13. Pallesen U. Clinical evaluation of CAD/CAM ceramic restorations: 6-year
report. In: Mormann WH, editor. CAD/CIM in aesthetic dentistry: CEREC
10 year anniversary symposium. Berlin: Quintessence; 1996. p. 241-53.
14. Berg NG, Derand T. A 5-year evaluation of ceramic inlays (CEREC). Swed
Dent J 1997;21:121-7.
15. Sjogren G, Molin M, van Dijken JW. A 5-year clinical evaluation of
ceramic inlays (Cerec) cemented with a dual-cured or chemically cured
resin composite luting agent. Acta Odontol Scand 1998;56:263-7.
16. el-Mowafy O, Rubo MH. Resin-bonded fixed partial denturesa literature review with presentation of a novel approach. Int J Prosthodont
2000;13:460-7.
17. Corrente G, Vergnano L, Re S, Cardaropoli D, Abundo R. Resin-bonded
fixed partial dentures and splints in periodontally compromised patients:
a 10-year follow-up. Int J Periodontics Restorative Dent 2000;20:628-36.
18. Behr M, Leibrock A, Stich W, Rammelsberg P, Rosentritt M, Handel G.
Adhesive-fixed partial dentures in anterior and posterior areas: results of
an on-going prospective study begun in 1985. Clin Oral Investig 1998;
2:31-5.
19. Kern M, Strub JR. Bonding to alumina ceramic in restorative dentistry:
clinical results over up to 5 years. J Dent 1998;26:245-9.
20. Malament KA, Socransky SS. Survival of Dicor glass-ceramic dental
restorations over 14 years: Part I. Survival of Dicor complete coverage
restorations and effect of internal surface acid etching, tooth position,
gender, and age. J Prosthet Dent 1999;81:23-32.
21. Malament KA, Socransky SS. Survival of Dicor glass-ceramic dental
restorations over 14 years. Part II: effect of thickness of Dicor material
and design of tooth preparation. J Prosthet Dent 1999;81:662-7.
22. Malament KA, Socransky SS. Survival of Dicor glass-ceramic dental
restorations over 16 years. Part III: effect of luting agent and tooth or
tooth-substitute core structure. J Prosthet Dent 2001;86:511-9.
23. el-Mowafy O. The use of resin cements in restorative dentistry to overcome retention problems. J Can Dent Assoc 2001;67:97-102.
24. Sorensen JA, Kang SK, Avera SP. Porcelain-composite interface microleakage with various porcelain surface treatments. Dent Mat 1991;7:
118-23.
25. Reference deleted.
26. Jensen ME, Sheth JJ, Tolliver D. Etched-porcelain resin-bonded fullveneer crowns: in vitro fracture resistance. Compendium 1989;10:336-8,
340-1, 344-7.
27. Fradeani M. Anterior maxillary aesthetics utilizing all-ceramic restorations. Pract Periodontics Aesthet Dent 1995;7:53-66.
28. Touati B, Quintas AF. Aesthetic and adhesive cementation for contemporary porcelain crowns. Pract Proced Aesthet Dent 2001;13:611-20.
29. Latta MA, Barkmeier WW. Approaches for intraoral repair of ceramic
restorations. Compend Contin Educ Dent 2000;21:635-9, 642-4.
30. Semmelmann JO, Kulp PR. Silane bonding porcelain teeth to acrylic.
J Am Dent Assoc 1968;76:69-73.
31. Jochen DG, Caputo AA. Composite resin repair of porcelain denture
teeth. J Prosthet Dent 1977;38:673-9.
32. Ferrando JM, Graser GN, Tallents RH, Jarvis RH. Tensile strength and
microleakage of porcelain repair materials. J Prosthet Dent 1983;50:4450.
33. Bailey LF, Bennet RJ. DICOR surface treatments for enhanced bonding. J
Dent Res 1988;67:925-31.
34. Wolf DM, Powers JM, OKeefe KL. Bond strength of composite to porcelain treated with new porcelain repair agents. Dent Mater 1992;8:15861.
VOLUME 89 NUMBER 3
35. Sorensen JA, Engelman MJ, Torres TJ, Avera SP. Shear bond strength of
composite resin to porcelain. Int J Prosthodont 1991;4:17-23.
36. Chen JH, Matsumura H, Atsuta M. Effect of different etching periods on
the bond strength of a composite resin to a machinable porcelain. J Dent
1998;26:53-8.
37. Chen JH, Matsumura H, Atsuta M. Effect of etchant, etching period, and
silane priming on bond strength to porcelain of composite resin. Oper
Dent 1998;23:250-7.
38. Barghi N. To silanate or not to silanate: making a clinical decision.
Compend Contin Educ Dent 2000;21:659-62, 664.
39. Kamada K, Yoshida K, Atsuta M. Effect of ceramic surface treatments on
the bond of four resin luting agents to a ceramic material. J Prosthet Dent
1998;79:508-13.
40. Estafan D, Dussetschleger F, Estafan A, Jia W. Effect of prebonding
procedures on shear bond strength of resin composite to pressable ceramic. Gen Dent 2000;48:412-6.
41. Della Bona A, Anusavice KJ, Shen C. Microtensile strength of composite
bonded to hot-pressed ceramics. J Adhes Dent 2000;2:305-13.
42. Rosentritt M, Behr M, Kolbeck C, Lang R, Handel G. In vitro repair of
all-ceramic and fibre-reinforced composite crowns. Eur J Prosthodont
Restor Dent 2000;8:107-12.
43. Kupiec KA, Wuertz KM, Barkmeier WW, Wilwerding TM. Evaluation of
porcelain surface treatments and agents for composite-to-porcelain repair. J Prosthet Dent 1996;76:119-24.
44. Thurmond JW, Barkmeier WW, Wilwerding TM. Effect of porcelain
surface treatments on bond strengths of composite resin bonded to
porcelain. J Prosthet Dent 1994;72:355-9.
45. Shahverdi S, Canay S, Sahin E, Bilge A. Effects of different surface
treatment methods on the bond strength of composite resin to porcelain.
J Oral Rehabil 1998;25:699-705.
46. Pameijer CH, Louw NP, Fischer D. Repairing fractured porcelain: how
surface preparation affects shear force resistance. J Am Dent Assoc
1996;127:203-9.
47. Szep S, Gerhardt T, Gockel HW, Ruppel M, Metzeltin D, Heidemann D.
In vitro dentinal surface reaction of 9.5% buffered hydrofluoric acid in
repair of ceramic restorations: a scanning electron microscopic investigation. J Prosthet Dent 2000;83:668-74.
48. Lacy AM, LaLuz J, Watanabe LG, Dellinges M. Effect of porcelain surface
treatment on the bond to composite. J Prosthet Dent 1988;60:288-91.
49. Calamia JR. Etched porcelain veneers: the current state of the art. Quintessence Int 1985;16:5-12.
50. Kern M, Thompson VP. Sandblasting and silica coating of a glassinfiltrated alumina ceramic: volume loss, morphology, and changes in
the surface composition. J Prosthet Dent 1994;71:453-61.
51. Kato H, Matsumura H, Atsuta M. Effect of etching and sandblasting on
bond strength to sintered porcelain of unfilled resin. J Oral Rehabil
2000;27:103-10.
52. Frankenberger R, Kramer N, Sindel J. Repair strength of etched vs silicacoated metal-ceramic and all-ceramic restorations. Oper Dent 2000;25:
209-15.
53. Kiatsirirote K, Northeast SE, van Noort R. Bonding procedures for intraoral repair of exposed metal with resin composite. J Adhes Dent
1999;1:315-21.
54. Sun R, Suansuwan N, Kilpatrick N, Swain M. Characterization of tribochemically assisted bonding of composite resin to porcelain and metal.
J Dent 2000;28:441-5.
55. Horn HR. Porcelain laminate veneers bonded to etched enamel. Dent
Clin North Am 1983;27:671-84.
56. Bailey JH. Porcelain-to-composite bond strengths using four organosilane
materials. J Prosthet Dent 1989;61:174-7.
57. Bertolotti RL, Lacy AM, Watanabe LG. Adhesive monomers for porcelain
repair. Int J Prosthodont 1989;2:483-9.
58. Paffenbarger GC, Sweeney WT, Bowen RL. Bonding porcelain teeth to
acrylic resin denture bases. J Am Dent Assoc 1967;74:1018-23.
59. Cooley RL, Tseng EY, Evans JG. Evaluation of 4-META porcelain repair
system. J Esthet Dent 1991;3:11-13.
60. Diaz-Arnold AM, Aquilino SA. An evaluation of the bond strengths of
four organosilane materials in response to thermal stress. J Prosthet Dent
1989;62:257-60.
61. Diaz-Arnold AM, Schneider RL, Aquilino SA. Bond strengths of intraoral
porcelain repair materials. J Prosthet Dent 1989;61:305-9.
62. Diaz-Arnold AM, Wistrom DW, Aquilino SA, Swift EJ Jr. Bond strengths
of porcelain repair adhesive systems. Am J Dent 1993;6:291-4.
MARCH 2003
63. Llobell A, Nicholls JI, Kois JC, Daly CH. Fatigue life of porcelain repair
systems. Int J Prosthodont 1992;5:205-13.
64. Matsumura H, Kawahara M, Tanaka T, Atsuta M. A new porcelain repair
system with a silane coupler, ferric chloride, and adhesive opaque
system. J Dent Res 1989;68:813-8.
65. Pratt RC, Burgess JO, Schwartz RS, Smith JH. Evaluation of bond strength
of six porcelain repair systems. Dent Mat 1992;8:158-61.
66. Stokes AN, Hod JA, Tidmarsh BG. Effect of 6-month water storage on
silane-treated resin/porcelain bonds. J Dent 1988;16:294-6.
67. Suliman AH, Swift EJ Jr, Perdigao J. Effects of surface treatment and
bonding agents on bond strength of composite resin to porcelain. J
Prosthet Dent 1993;70:118-20.
68. Aida M, Hayakawa T, Mizukawa K. Adhesion of composite to porcelain
with various surface conditions. J Prosthet Dent 1995;73:464-70.
69. Tjan AH, Nemetz H. A comparison of the shear bond strength between
two composite resins and two etched ceramic materials. Int J Prosthodont
1988;1:73-9.
70. Braga RR, Ballester RY, Carrilho MR. Pilot study on the early shear
strength of porcelain-dentin bonding using dual-cure cements. J Prosthet
Dent 1999;81:285-9.
71. Soderholm KJ, Shang SW. Molecular orientation of silane at the surface
of colloidal silica. J Dent Res 1993;72:1050-4.
72. Russell DA, Meiers JC. Shear bond strength of resin composite to Dicor
treated with 4-META. Int J Prosthodont 1994;7:7-12.
73. Chen TM, Brauer GM. Solvent effects on bonding organo-silane to silica
surfaces. J Dent Res 1982;61:1439-43.
74. Barghi N, Chung K, Farshchian F, Berry T. Effects of the solvents on bond
strength of resin bonded porcelain. J Oral Rehab 1999;26:853-7.
75. Kramer N, Lohbauer U, Frankenberger R. Adhesive luting of indirect
restorations. Am J Dent 2000;13:60D-76D.
76. Blackman R, Barghi N, Duke E. Influence of ceramic thickness on the
polymerization of light-cured resin cement. J Prosthet Dent 1990;63:295300.
77. Hasegawa EA, Boyer DB, Chan DC. Hardening of dual-cured cements
under composite resin inlays. J Prosthet Dent 1991;66:187-92.
78. el-Badrawy WA, el-Mowafy OM. Chemical versus dual curing of resin
inlay cements. J Prosthet Dent 1995;73:515-24.
79. Chang JC, Nguyen T, Duong JH, Ladd GD. Tensile bond strengths of
dual-cured cements between a glass-ceramic and enamel. J Prosthet
Dent 1998;79:503-7.
80. Gregory WA, Moss SM. Effects of heterogeneous layers of composite and
time on composite repair of porcelain. Oper Dent 1990;15:18-22.
81. Hahn P, Attin T, Grofke M, Hellwig E. Influence of resin cement viscosity
on microleakage of ceramic inlays. Dent Mater 2001;17:191-6.
82. Frazier KB, Sarrett DC. Wear resistance of dual-cured rein luting agents.
Am J Dent 1995;8:161-4.
83. Kawai K, Isenberg BP, Leinfelder KF. Effect of gap dimension on composite resin cement wear. Quintessence Int 1994;25:53-8.
84. Chung CH, Brendlinger EJ, Brendlinger DL, Bernal V, Mante FK. Shear
bond strengths of two resin-modified glass ionomer cements to porcelain.
Am J Orthod Dentofacial Orthop 1999;115:533-5.
85. Berry T, Barghi N, Chung K. Effect of water storage on the silanization in
porcelain repair strength. J Oral Rehabil 1999;26:459-63.
86. Roulet JF, Soderholm KJ, Longmate J. Effects of treatment and storage
conditions on ceramic/composite bond strength. J Dent Res 1995;74:
381-7.
87. Kato H, Matsumura H, Tanaka T, Atsuta M. Bond strength and durability
of porcelain bonding systems. J Prosthet Dent 1996;75:163-8.
88. Matsumura H, Kato H, Atsuta M. Shear bond strength to feldspathic
porcelain of two luting cements in combination with three surface treatments. J Prosthet Dent 1997;78:511-7.
89. Eikenberg S, Shurtleff J. Effect of hydration on bond strength of a silanebonded composite to porcelain after seven months. Gen Dent 1996;44:
58-61.
90. Appeldoorn RE, Wilwerding TM, Barkmeier WW. Bond strength of composite resin to porcelain with newer generation porcelain repair systems.
J Prosthet Dent 1993;70:6-11.
91. Leibrock A, Degenhart M, Behr M, Rosentritt M, Handel G. In vitro study
of the effect of thermo- and load-cycling on the bond strength of porcelain repair systems. J Oral Rehabil 1999;26:130-7.
92. ilo G. Bond strength testingwhat does it mean? Int Dent J 1993;43:
492-8.
273
274
117. Mackert J Jr, Evans Al. Effect of cooling rate on leucite volume fraction in
dental porcelains. J Dent Res 1991;70:137-9.
118. McKinney JE, Wu W. Chemical softening and wear of dental composites.
Dent Res 1985;64:1326-31.
119. Ortengren U, Andersson F, Elgh U, Terselius B, Karlsson S. Influence of
pH and storage time on the sorption and solubility behaviour of three
composite resin materials. J Dent 2001;29:35-41.
120. Palmer DS, Barco MT, Billy EJ. Temperature extremes produced orally by
hot and cold liquids. J Prosthet Dent 1992;67:325-7.
121. Harrison A, Moores GE. Influence of abrasive particle size and contact
stress on the wear rate of dental restorative materials. Dent Mater 1985;
1:14-8.
122. Paul SJ, Pietrobon N, Scharer P. The new In-Ceram Spinell systema
case report. Int J Periodontics Restorative Dent 1995;15:520-7.
123. Piotrowski PR. Comparative studies on the adhesion of a silicone elastomer to a chromium-cobalt dental alloy. Eur J Prosthodont Restor Dent
2001;9:141-6.
124. Wada T. Development of a new adhesive material and its properties. In:
Gettleman L, Vrijhoef M, Uchiyama Y, editors. Proceedings of the international symposium on adhesive prosthodontics, 1986 June 24, Amsterdam, Netherlands. Chicago: Academy of Dental Materials; 1986. p.
9-18.
125. Tinschert J, Natt G, Mautsch W, Augthun M, Spiekermann H. Fracture
resistance of lithium disilicate-, alumina-, and zirconia-based three-unit
fixed partial dentures: a laboratory study. Int J Prosthodont 2001;14:
231-8.
126. McLaren EA. All-ceramic alternatives to conventional metal-ceramic
restorations. Compend Contin Educ Dent 1998;19:307-8, 310, 312.
127. Yildirim M, Edelhoff D, Hanisch O, Spiekermann H. Ceramic abutmentsa new era in achieving optimal esthetics in implant dentistry. Int
J Periodontics Restorative Dent 2000;20:81-91.
128. Koutayas SO, Kern M. All-ceramic posts and cores: the state of the art.
Quintessence Int 1999;30:383-92.
129. Ahmad I. Zirconium oxide post and core system for the restoration of an
endodontically treated incisor. Pract Periodontics Aesthet Dent 1999;11:
197-204.
130. Blatz MB. Comprehensive treatment of traumatic fracture and luxation
injuries in the anterior permanent dentition. Pract Proced Aesthet Dent
2001;13:273-9.
131. Fradeani M, Aquilano A, Barducci G. Aesthetic restoration of endodontically treated teeth. Pract Periodontics Aesthet Dent 1999;11:761-8.
132. Meyenberg KH, Luthy H, Scharer P. Zirconia posts: a new all-ceramic
concept for nonvital abutment teeth. J Esthet Dent 1995;7:73-80.
133. Burke FJ. Fracture resistance of teeth restored with dentin-bonded
crowns: the effect of increased tooth preparation. Quintessence Int 1996;
27:115-21.
Reprint requests to:
DR MARKUS B. BLATZ
LOUISIANA STATE UNIVERSITY HEALTH SCIENCES CENTER
SCHOOL OF DENTISTRY
1100 FLORIDA AVE
NEW ORLEANS, LA 70119
FAX: (504) 619-8741
E-MAIL: mblatz@lsuhsc.edu
Copyright 2003 by The Editorial Council of The Journal of Prosthetic
Dentistry.
0022-3913/2003/$30.00 0
doi:10.1067/mpr.2003.50
VOLUME 89 NUMBER 3
CLINICAL IMPLICATIONS
In this in vitro study, the dentin bonding agent tested, when placed immediately after the
completion of preparation, resulted in better bond strengths to dentin with the cement tested.
MARCH 2003
dentistry, composite restorations have become popular. Composite restorations exhibit problems such as
color stability, wear resistance, polymerization contraction, and microleakage. Ceramic inlays combining
esthetics with wear resistance have been developed for
restoration of posterior teeth.2,4,5-8 Clinical success
with ceramic inlays/onlays has been assisted by the
ability to develop a reliable bond of composite to
dental tissues.9,10
THE JOURNAL OF PROSTHETIC DENTISTRY 275
Preparation design
Standardized box-shaped class I inlay preparations
were made with round burs (no. 6801L.314; Gebr Brasseler, Lemgo, Germany) and 6-degree conical diamond
burs (No. 8959KR.314.016; Gebr Brasseler) in a highspeed handpiece mounted on a parallelometer (Bego
Bremer Goldschagerei Wihl Herbst GmbH & Co, Bremen, Germany). Each preparation had a length of
6 mm, a width of 3 mm, a depth of 2 mm, and 6-degree
convergence of the walls (Fig. 1).
The 120 prepared teeth were randomly assigned to
2 groups of 60, each to 2 ceramic systems, Ceramco II
(Ceramco, Burlington, NJ) (Group I) and IPS Empress 2 (Ivoclar, Schaan, Liechtenstein) (Group II).
Each of the 2 groups were further divided into 3
cementation technique groups of 20 each (Group I A,
B, and C and Group II A, B, and C). The bonding
agent and resin cement used in this study are described in Table I. All the groups were then prepared
as follows.
In Group I A and II A, the dentin bonding agent was
applied immediately after the completion of the inlay
preparation, before making the final impression (DDBA technique). In Group I B and II B, the dentin
bonding agent was applied just before the placement of
the inlays (I-DBA technique). In Group I C and II C,
the ceramic inlay restorations were luted without the
bonding agent (No-DBA technique).
VOLUME 89 NUMBER 3
Fig. 2. A, Specimen preparation for microtensile bond test. B, I-shape sections, top half consisting of ceramic and bottom half
consisting of dentin, for microtensile bond test.
Table 1. Cementation materials used in this study
Material
Manufacturer
Type
Panavia F
Dual-polymerizing adhesive
system
Composition
Table II. Descriptive analysis of bond strength values for Groups I A, B, C, and II A, B, C
Cementation
Technique
Number of
specimens
Mean (MPa)
SD (MPa)
Ceramco II D-DBA
IPS Empress 2 D-DBA
Ceramco II I-DBA
IPS Empress 2 I-DBA
Ceramco II No DBA
IPS Empress 2 No DBA
60
60
60
60
60
60
19.56
20.71
14.77
15.43
15.93
16.50
4.39
4.16
2.68
4.10
3.26
5.32
Groups
IA
II A
IB
II B
IC
II C
df
Sum of squares
Mean square
F value
Ceramic technique
Ceramic
Technique
1
1
2
12110.089
57.192
1686.673
12110.089
57.192
843.337
734.423
3.468
51.145
P value
.000
.063
.000
bonding surface of the ceramic restorations. Finger pressure was used to stabilize the inlays during to the dentin
surface. Excessive cement was removed with an explorer,
and the cement was polymerized for 20 seconds with the
same light polymerizing unit. The margins were covered
with glycerine jelly for 3 minutes and washed.
Microtensile testing
After cementation, specimens were stored in distilled
water at 37C for 24 hours. Acrylic blocks were fixed to
the mounting plate of a slow-speed diamond saw sectioning machine. The roots were removed from the remaining crown approximately 1 to 2 mm below the
cemento-enamel junction. The specimens were prepared for microtensile testing according to previous
studies.20,21 Each tooth was vertically sectioned both
mesial-distally and buccal-lingually along their long axis
into 1.2 1.2 mm wide sections. Three I-shapesectioned longitudinal cuts, the top half consisting of ceramic and the bottom half consisting of dentin, were
made from each tooth (Fig. 2). Therefore there were 60
specimens per group, and a total of 360 specimens were
subjected to tensile forces. The microtensile testing
method permits multiple specimens to be prepared from
each tooth.22
These specimens were then attached to the testing
apparatus (Harvard Apparatus Co. Inc., Dover, Mass.)
with cyanoacrylate adhesive (Zapit; Dental Ventures of
America, Corona, Calif.). The specimens were then subjected to tensile forces at a crosshead speed of 1 mm/
min, and the maximum load at fracture (in kilograms)
was recorded. Preparation of all specimens and completion of the testing were done by the same operator.
Fracture analysis
After the specimens fractured, they were removed
from the testing apparatus and the fractured surfaces
278
were observed with a stereomicroscope (SZ-TP; Olympus, Tokyo, Japan) at original magnification 22 to
identify the mode of fracture. The fractured surface was
classified according to 1 of 3 types: type 1, adhesive
failure between bonding resin and dentin; type 2, cohesive failure in the bonding resin; type 3, cohesive failure
in the dentin.
SEM examination
A tooth from each cementation group was prepared
for SEM analysis. After being stored for 24 hours at 37C,
the teeth were sectioned buccolingually through the restoration. To observe the interface, the specimens were
first polished with 240-, 400-, and 600-grit silicon carbide abrasive paper. The bonding interface was etched
with 35% phosphoric acid for 10 seconds and then
washed and gently air dried for 3 seconds. Specimens
were sputter-coated with gold and interfaces observed
under SEM (435 VP; Leo SEM Products, Cambridge,
United Kingdom).
VOLUME 89 NUMBER 3
Fig. 4. SEM view of demineralized specimen section replica for D-DBA technique. D, Dentin; C, composite; RT, resin tags; H,
hybrid layer. (Original magnification 4540.)
Fig. 5. SEM view of demineralized specimen section replica for I-DBA technique. D, Dentin; C, composite; RT, resin tags; H,
hybrid layer. (Original magnification 5960.)
RESULTS
The means and standard deviations values of the 3
cementation groups of the bond strengths for each ceramic material are given in Table II. As seen in Table III,
2-way analysis of variance indicated that tensile bond
strength was significantly affected by cementation technique (P.001) and that there was no significant interaction between the 2 ceramic materials (P.05). Tukey
honestly significant difference indicated that the D-DBA
groups (Groups I A and II A) had a significantly higher
mean (P.001) than the I-DBA (Groups I B and II B)
279
Fig. 6. SEM view of demineralized specimen section replica for No-DBA technique. D, Dentin; C, composite; RT, resin tags;
H, hybrid layer. (Original magnification 5800.)
DISCUSSION
The cementation technique for ceramic inlays is important, and the properties of the luting agent are crucial
for the longevity of restorations.9,10 The use of ceramic
inlays has gained popularity recently with the combination of dentin bonding agents and resin cements.15 Dentin bonding is designed to produce a hermetic seal between a composite restoration and surrounding
dentin.16 Use of a dual-polymerizing resin cement in
combination with dentin bonding has reduced the problem of loss of retention.17
In spite of encouraging results, the clinical performance of the dentin bond is impaired by the composite
polymerization shrinkage and the stresses resulting from
thermal dimensional changes.8 The choice of the restorative method has a critical impact on the behavior of the
dentin-resin interface. In addition to the cementation
280
CONCLUSIONS
Within the limitations of this study, the tensile bond
strength in the D-DBA technique (40.27 MPa) was significantly higher than both the I-DBA (30.20 MPa) and
No-DBA techniques (32.43 MPa) for 2 different ceramic systems. Also, fracture surfaces of each specimen
examined under stereomicroscopy demonstrated that
98% of the failures were adhesive in nature. In SEM
examination, a distinct and thicker hybrid zone with
longer and more resin tags were found in the D-DBA
technique than in the I-DBA and No-DBA techniques.
REFERENCES
1. Dietschi D, Maeder M, Meyer JM, Holz J. In vitro resistance to fracture of
porcelain inlays bonded to tooth. Quintessence Int 1990;21:823-31.
2. Fradeani M, Aquilano A, Bassein L. Longitudinal study of pressed glass
ceramic inlays for four and a half years. J Prosthet Dent 1997;78:346-53.
3. Krejci I, Lutz F, Reimer M, Heinzmann JL. Wear of ceramic inlays, their
enamel antagonists, and luting cements. J Prosthet Dent 1993;69:425-30.
MARCH 2003
4. Abel MG. In-office inlays with todays new materials. Dent Clin North Am
1998;42:657-64.
5. Gemalmaz D, Ozcan M, Yoruc AB, Alkumru HN. Marginal adaptation of
a sintered ceramic inlay system before and after cementation. J Oral
Rehabil 1997;24:646-51.
6. Mitchem JC. The use and abuse of aesthetic materials in posterior teeth. Int
Dent J 1988;8:119-25.
7. Qualtrough AJ, Wilson NH, Smith GA. Porcelain inlay: a historical view.
Oper Dent 1990;15:61-70.
8. Van Meerbeek B, Perdigao J, Lambrechts P, Vanherle G. The clinical
performance of adhesives. J Dent 1998;26:1-20.
9. Inokoshi S, Willems G, Van Meerbeek B, Lambrechts P, Braem M, Vanherle G. Dual-cure luting composites: Part I: Filler particle distribution.
J Oral Rehabil 1993;20:133-46.
10. Sjogren G, Molin M, Van Dijken J, Bergman M. Ceramic inlays (Cerec)
cemented with either a dual-cured or a chemically cured composite resin
luting agent. A 2-year clinical study. Acta Odontol Scand 1995;53:32530.
11. Buonocore MG. A simple method of increasing the adhesion of acrylic
filling materials to enamel surfaces. J Dent Res 1955;34:849-53.
12. Eliades G. Clinical relevance of the formulation and testing of dentine
bonding systems. J Dent 1994;22:73-81.
13. Frankenberger R, Kramer N, Petschelt A. Technique sensitivitiy of dentin
bonding: Effect of application mistakes on bond strength and marginal
adaptation. Oper Dent 2000;25:324-30.
14. Pashley DH, Sano H, Ciucchi B, Yoshiyama M, Carvalho RM. Adhesion
testing of dentin bonding agents: a review. Dent Mater 1995;11:117-25.
15. El-Mowafy OM, Benmergui C. Radiopacity of resin-based inlay luting
cements. Oper Dent 1994;19:11-5.
16. Oram DA, Pearson GJ. A survey of current practice into the use of
aesthetic inlays. Br Dent J 1994;176:457-62.
17. Milleding P, Ortengren U, Karlsson S. Ceramic inlay systems: some clinical aspects. J Oral Rehabil 1995;22:571-80.
18. Paul SJ, Scharer P. The dual bonding technique: a modified method to
improve adhesive luting procedures. Int J Periodontics Restorative Dent
1997;17:536-45.
19. Magne P, Douglas WH. Porcelain veneers: dentin bonding optimization
and biomimetic recovery of the crown. Int J Prosthodont 1999;12:111-21.
20. Phrukkanon S, Burrow MF, Tyas MJ. The influence of cross-sectional
shape and surface area on the microtensile bond test. Dent Mater 1998;
14:212-21.
21. Tanumiharja M, Burrow MF, Tyas MJ. Microtensile bond strengths of
seven dentin adhesive systems. Dent Mater 2000;16:180-7.
22. Pashley DH, Carvalho RM, Sano H, Nakajima M, Yoshiyama M, Shono Y,
et al. The microtensile bond test: a review. J Adhes Dent 1999;1:299-309.
Reprint requests to:
DR A. NILGU N OZTURK
SELCUK UNIVERSITY
FACULTY OF DENTISTRY
DEPARTMENT OF PROSTHODONTICS
KONYA
TURKEY
FAX: 90-332-2410062
E-MAIL: nilgun25@hotmail.com
Copyright 2003 by The Editorial Council of The Journal of Prosthetic
Dentistry.
0022-3913/2003/$30.00 0
doi:10.1067/mpr.2003.37
281
CLINICAL IMPLICATIONS
The results of this study of a limited population suggest that, the greater the deviation of anterior
tooth and facial midlines, the higher the detection rate. Nearly half of the 10 observers involved
in this investigation were unable to detect midline deviations of 2 mm.
Fig. 2. Slanting dental midline made parallel to facial midline in definitive restoration of patient in Fig. 1.
MARCH 2003
RESULTS
DISCUSSION
In this investigation, deviation of the anterior tooth
and facial midlines of up to 2 mm was not noticeable to
almost half of the observers. It must be noted, however,
that each observers attention was deliberately directed
to the midline. Without this direction, even a large midline deviation (2 mm) might not have been noticed.
Frush and Fisher9 suggested that the vertical long axis
of the midline is more critical than its mediolateral position (Figs. 1 and 2). Provided that the central incisor
midline is parallel to the facial midline, the dentist may
safely place the anterior tooth midline up to 2 mm from
the facial midline in this population.
In a study by Brisman,10 the shape, symmetry, and
proportion of drawings and photographs of maxillary
central incisors were evaluated for esthetics. The author9
found significant differences between evaluations made
by patients and dentists, with the preferences of dental
students falling in between those of the other observers.
In the present study, 5 dentists and 5 nondental personnel were chosen as observers. Initially, it was expected
that the ability of these 2 groups to detect deviations of
VOLUME 89 NUMBER 3
Fig. 4. Percent detection rate of anterior tooth and facial midlines deviations. To determine detection rate, number of
photographs in which deviation of midline was detected by observer was divided by number of photographs in which that
deviation existed. No. of Observers, Number who successfully detected deviation.
Table I. Summary of 1-way analysis of variance for
detection rate of deviation of facial and anterior tooth
midlines
Source of variation
Between groups
Within groups
Total
Sum of
squares
df
Mean
square
9388.0 2 4694.0
28276.4 27 1047.3
37664.4 29
CONCLUSION
4.5
.02
3.3
MARCH 2003
285
Purpose. The purpose of this study was to measure the forces imposed while cutting teeth with tungsten carbide
burs used in high-speed handpieces.
Material and methods. Thirty-one dentists each cut 8 conventional class II MO and DO preparations in
intact extracted third molars, by use of 2 different air turbine handpieces with different torque-speed
characteristics. Two different flat fissure, plain and cross-cut tungsten carbide burs, cutting wet and dry in
each handpiece/bur combination. The teeth were mounted in a custom-made transducer unit that displayed
the forces imposed by the bur. Data were analysed with a 1-way ANOVA ( .05) and Spearman correlation
test.
Results. The results showed that there was no significant difference in the applied force between plain and
cross-cut burs, cutting wet or cutting dry, but there was a significant difference between the high and the lower
torque handpieces. The higher torque handpiece was used at a mean cutting force of 1.44 N and the lower torque
handpiece at 1.20 N (P.002). The overall general mean force observed was 1.30 N.
Conclusion. It was concluded that the forces used in cutting teeth with the tungsten carbide burs tested
related both to the type of the handpiece and to the forces chosen by clinical operators. There was no
difference between the plain and cross-cut burs, there was no difference between the cutting wet or dry, and
the higher torque handpiece required a higher mean cutting force. (J Prosthet Dent 2003;89:286-91.)
CLINICAL IMPLICATIONS
This research illustrates that dentists should be fully aware of the power in the ultra-high speed
handpieces that they use and that the applied force during cutting may become much higher than
dentists anticipate. Such force may seriously damage the structure of tooth tissues and may
compromise the vitality of the human dental pulp. It also introduces the need to a methodologic
approach to cutting hard tooth tissues in dentistry.
lthough dentists use ultra-high speed handpieces every day, the efficiency of the cutting process
has never been optimized. Todays clinically used cutting tools rotate at very high speeds and are subjected
to unknown forces. The force and the direction with
which cutters are pressed against the tooth to achieve
the desired shape of preparation are chosen and adjusted by instinct.1
In previous studies of tooth cutting at high speed,
researchers suggested a maximum force of 3 N.2-4 Others did not explain the rationale behind the selection of
the forces used in their cutting experiments.5-12 Some
assumed that their chosen figures would be clinically
acceptable,4,13-16 whereas others obtained their figures
a
Hon. Clinical Lecturer, Department of Conservative Dentistry, Eastman Dental Institute For Oral Health Care Sciences.
b
Professor of Orthopaedic Biomechanics, Mechanical Engineering
Department, Imperial College.
c
Head of Department, Senior Lecturer/Consultant, Department of
Conservative Dentistry, Eastman Dental Institute For Oral Health
Care Sciences.
286 THE JOURNAL OF PROSTHETIC DENTISTRY
by a subjective means.3,18-20 Many researchers used differing forces to investigate other aspects of the cutting
process2,5,7,10,17,19-26 (Table I).
The aim of this study was to measure the forces
applied by dentists when different types of high-speed
handpieces and tungsten carbide burs are used to cut
teeth under wet and dry conditions. It was hypothesized that different forces would be applied when cutting under each different set of conditions. The experiment was designed to simulate clinical cutting
procedures as realistically as possible and then measure the forces applied while high-speed air rotors are
used. The purpose of this study was to provide data
that could be used when designing experiments intended to accurately reproduce the clinical cutting
process for optimization.
Year
Force (N)
1951
1967
1980
1.96-7.36
0.56-8.83
0.01-2.94
1961
0.88
1973
1978
1978
1.11
0.69
0.29-0.69
Cast iron
Teeth
Teeth
1979
1.96-3.92
1980
0.69
Teeth
1982
1.08
Composite
1983
1973
1977
0.50
1.47
0.69 and 1.44
Teeth
Teeth & glass
Teeth
1996
0.50-1.47
Glass ceramic
1989
1964
0.20-0.78
0.50-0.78
0.88
1.47
Glass ceramic
Dentin
Cast iron
Ceramic
Comparing handpieces
Heat related to tooth structure removal
Effect of geometrical shape of TC burs on cutting
Significant of the blade geometry in the efficiency of
TC burs
1983
Substrate
Ivorene
Dentin
Teeth and
amalgam
Brass
Purpose of study
A specially designed force measuring unit was constructed. It consisted of a cantilevered aluminium rod,
a specimen housing unit and a casing (Imperial College, London, United Kingdom). The rod was machined in the middle to receive 2 pairs of single-element strain gauges (Type TLA 1-11; TechniMeasure,
Worcester, United Kingdom) that were bonded axi287
57
557
ally in 2 pairs at right angles to each other and connected in bridge circuits to give an output proportional to the sideways cutting force in any direction
(Fig. 2). The strain gauges were connected to 2 conditioning amplifiers (Type 031; Solartron, Bognor
Regis, Sussex, United Kingdom) with light-emitting
diode digital displays, whose output was connected to
a computer and to an X-Y plotter. A special software
was prepared for this experiment (Medical Engineering Unit, St. Thomass Hospital, London, United
Kingdom) that allowed simultaneous acquisitions of
data; recorded duration, frequency of force application, and maximum force applied; and computed the
average recorded force. The assembly easily permitted
placement and removal of the teeth, which were used
as cut material, by use of removable metal sockets in
which teeth were secured by plaster of Paris. The unit
provided a firm resting point for operators hands and
allowed good vision and drainage of the cooling water
spray during cutting.
288
KaVo
Midwest
42.4 (15-60)
40.6 (15-60)
39.1 (13-60)
37.6 (14-60)
The transducer was calibrated after every third operator by means of a 100-g weight (0.981 N) attached
by a thread to the tooth mounting. This was taken
over a pulley to provide a horizontal force. The pulley
was moved around the transducer, and the amplifier
outputs were adjusted to ensure equal, calibrated outputs in all directions. The transducer was accurate to
0.01 N.
An X-Y plotter (Bryans 26000A3; Bryans Aeroquipment Ltd, Mitcham, Surrey, United Kingdom) was used
to record the magnitude and direction of the force applied to the tooth. This was computed through a twinchannel amplifier (Gemini; Solartron Ltd) and displayed
on a polar graph, with the radius from the origin representing the force. A limit of 3 N was chosen on the basis
of other studies.2-4
Thirty-one dentists from the Eastman Dental Institute and Hospital and from general practice were
each asked to prepare conventional class II mesioocclusal (MO) and distal-occlusal (DO) cavities in
caries-free fully-erupted third molars. Each operator
prepared 8 cavities, using a new bur for each cavity,
cutting wet and dry and combining plain and crosscut burs with the KaVo and Midwest handpieces.
Teeth were kept in 5% formal saline solution before
being secured with plaster of Paris in a housing, which
locked firmly on the transducer. Only the clinical
crown was visible above the level of the plaster. The
dentists were requested to use their own personal
technique of cutting and were given complete freedom with regard to time, volume of water cooling
spray, size of cavity, and quality of finish. Cutting
force data were collected for up to 60 seconds. Cooling water and cut debris were evacuated with a mobile
Virilium 5A aspirator (Virilium Co Ltd, Watford,
Herts, United Kingdom). Illumination of the operating field was achieved by laboratory spotlights and was
considered by all operators to be adequate.
Data were analyzed statistically by means of 1-way
analysis of variance (SAS/STAT) with a significant level
of .05 and by Spearman correlation test.
RESULTS
A total of 248 cavities were prepared and completed with the KaVo and Midwest handpieces. A
meantime of 39.9 seconds of cutting force data were
VOLUME 89 NUMBER 3
57 Wet
57 Dry
557 Wet
557 Dry
KaVo
Midwest
57 W
557 W
57 v. 557
57 v. 557
Handpiece
Statistics
Significance
M v. K
M v. K
M
K
0.169
0.398
0.648
0.527
0.363
0.027
0.000
0.002
Fig. 3. Mean cutting forces applied by operators for KaVo and Midwest handpieces cutting sound wet and dry teeth.
DISCUSSION
This study presented an original method to measure the force applied during simulated dental cutting. It adopted a realistic approach to conventional
clinical cutting procedures, and it had an original
measuring unit built solely for the study. The force
measuring unit permitted the recording of the direct
lateral force applied between the rotating cutting bur
and the tooth substrate in all directions, and it also
allowed the acquisition and recording of the horizontal directions and the patterns of the movement of the
force vector during the entire cutting procedure. The
pattern of cutting could allow more understanding of the
clinical dental cutting process.
The exclusion of the vertical axis from force measurement in this experiment was not considered critical, because of the absence of the adjacent teeth on
the cutting platform, so that all cutting could take
place laterally with the bur axis almost vertical. The
assembly permitted a direct sideways cutting approach, which can be achieved in clinical practice. The
resilient deflection of the beam carrying the tooth and
the strain gauges was evaluated by all participants as
clinically representative. Therefore the sideways cutting measurements can be considered valid. It was
noted that the cutting force applied by each operator
varied greatly with time, including dropping to zero.
This was speculated to be an intentional part of the
individual operators technique, since there was no
instance of bur stalling in this study. Although there
was a significant difference between the mean forces
applied to the 2 handpieces (Fig. 3), and most operators used higher forces with the KaVo handpiece,
some operators presented an unexplainable reverse
situation.
This study showed that 22 of the 31 operators who
participated in this experiment applied higher peak
lateral cutting forces than the forces chosen by all
previous researchers, and the lower range of all operators was higher than the figures reported in a comparable study.26 However, the means closely confirm
the values chosen by few researchers.13,15,24
The results confirm that the magnitude of force
depended on the power of the handpiece in use rather
than its free running speed and on the operator to a
lesser degree. It is speculated that each operator adjusts the force applied during tooth cutting on the
basis of audible feedback and so intuitively finds an
operating point, which is a compromise between increasing force and decreasing cutting speed. The
mean forces observed in this study of 1.44 N for the
KaVo handpiece and 1.20 N for the Midwest with a
general means of 1.31 N indicate that the forces used
in cutting studies should relate both to the type of the
290
handpiece and to the forces chosen by clinical operators if realistic experimental conditions are desired.
CONCLUSIONS
Within the limitations of this study, it can be concluded that the magnitude of cutting force depends
on the power of the handpiece rather than the free
running speed and on the operator to a lesser degree.
Also, the forces chosen in cutting studies should relate
to the type of handpiece if realistic experimental conditions are desired.
We thank all the dentists who took part in this study and Dr. Ruth
Holt of Eastman Dental Institute for her statistical assistance.
REFERENCES
1. Rosenstiel SF, Land MF, Fujimoto J. Contemporary fixed prosthodontics.
3rd ed. St. Louis: Mosby; 2001. p. 167, 169-70.
2. Henry EE, Peyton FA. A study of the cutting efficiency of dental burs for the
straight handpiece. J Dent Res 1951;30:854-69.
3. Schuchard A, Watkins EC. Cutting effectiveness of tungsten carbide burs
and diamond points at ultra-high rotational speeds. J Prosthet Dent 1967;
18:58-65.
4. Westland IA. The energy requirement of the dental cutting process. J Oral
Rehabil 1980;7:51-63.
5. Semmelman JO, Kulp PR, Kurlansik L. Cutting studies at air-turbine
speeds. J Dent Res 1961;40:404-10.
6. Reisbick MH, Bunshah RF. Wear characteristics of burs. J Dent Res
1973;52:1138-46.
7. Lloyd BA, Rich JA, Brown WS. Effect of cooling techniques on temperature
control and cutting rate for high-speed dental drills. J Dent Res 1978;57:
675-84.
8. Brown WS, Christensen DO, Lloyd BA. Numerical and experimental
evaluation of energy inputs, temperature gradients, and thermal
stresses during restorative procedures. J Am Dent Assoc 1978;96:
451-8.
9. Grajower R, Zeitchick A, Rajstein J. The grinding efficiency of diamond
burs. J Prosthet Dent 1979;42:422-8.
10. Luebke NH, Chan KC, Bramson JB. The cutting effectiveness of carbide
fissure burs on teeth. J Prosthet Dent 1980;43:42-5.
11. King DR, Reitz CD, King AC. Cutting efficiency of carbide burs on two
composite resins. J Can Dent Assoc 1982;48:263-5.
12. Harkness N, Davies EH. The cleaning of dental diamond burs. Br Dent J
1983;154:42-5.
13. Eames WB, Nale JL. A comparison of cutting efficiency of air-driven fissure
burs. J Am Dent Assoc 1973;86:412-5.
14. Eames WB, Reder BS, Smith GA. Cutting efficiency of diamond stones:
effect of technique variables. Oper Dent 1977;2:156-64.
15. von Fraunhofer JA, Givens CD, Overmyer TJ. Lubricating coolants for
high-speed dental handpieces. J Am Dent Assoc 1989;119:291-5.
16. Siegel SC, von Fraunhofer JA. Assessing the cutting efficiency of dental
diamond burs. J Am Den Assoc 1996;127:763-72.
17. Ball JS, Davidson CW. Estimation of the air turbine rotational speed under
clinical condition. Br Dent J 1962;112:208-10.
18. Schuchard A, Watkins CE. Thermal and histologic response to high-speed
and ultrahigh-speed cutting in tooth structure. J Am Dent Assoc 1965;71:
1451-8.
19. Rakow B, Balbo MP, Pines M, Schulman A. An experimental diamond
stone: a preliminary report. J Prosthet Dent 1983;50:216-9.
20. Taira M, Wakasa K, Yamaki M, Matsui A. Comparison of rotational speeds
and torque properties between air-bearing and ball-bearing air-turbine
handpieces. Dent Mater J 1989;8:26-34.
21. Lammie GA. A comparison of the cutting efficiency and heat production
of tungsten carbide and steel burs. Br Dent J 1951;90:251-9.
VOLUME 89 NUMBER 3
22. Sorenson FM, Cantwell KR, Aplin AW. Thermogenices in cavity preparation using air turbine handpieces: the relationship of heat transferred to rate of tooth structure removal. J Prosthet Dent 1964;4:52432.
23. Greener EH, Lindenmeyer EH. Bur geometry and its relation to cutting.
J Dent Res 1968;47:87-97.
24. Atkinson AS. The significance of blade geometry in the cutting efficiency
of tungsten carbide dental burs at ultrahigh speeds. Br Dent J 1983;155:
187-93.
25. Taira M, Wakasa K, Yamaki M, Matsui A. Dental cutting behaviour of
mica-based and apatite-based machinable glass-ceramics. J Oral Rehabil
1990;17:461-72.
26. Ohmoto K, Taira M, Shintani H, Yamaki M. Studies on dental high-speed
cutting with carbide burs used on bovine dentine. J Prosthet Dent 1994;
71:319-23.
27. Walker RT, Morrant GA. Performance characteristics of air turbine handpieces. Br Dent J 1975;139:227-32.
MARCH 2003
291
CLINICAL IMPLICATIONS
Because upper airway sleep disorders are potentially life threatening, the ability to treat patients
with oral devices may be critical. Dentists are recognized as an integral part of the treatment
team for these patients. Even though numerous studies and publications are available, most
dental schools do not include the treatment of upper airway sleep disorders as part of the curriculum. As a result, predoctoral dental students are not being taught to manage these disorders.
IVANHOE ET AL
treatment is judged by a repeat sleep study (after treatment) and a significant reduction in the respiratory distress index.19,20
The diagnosis and treatment of OSA has traditionally
resided with the medical profession; however, oral devices have recently been approved for use, and research
has shown that they are effective in treating patients with
mild to moderate OSA.21 Furthermore, oral devices
were associated with fewer side effects and greater patient satisfaction than more traditional modalities such
as continuous positive air pressure.15,22-26 Although 1
author cites no adverse effects after long-term use of
these devices,27 and another cites side-effects as being
minor, infrequent, and not serious,28 there are
reports of side-effects including excess salivation, xerostomia, temporomandibular joint or myofacial pain,
dental discomfort, and occlusal changes.29,30 These reports illustrate the need for well-prepared, well-trained
dental graduates and therefore more formal instruction
in dental schools. Because the involvement of dentistry
in this area of medicine is well-documented as evidenced
by a recent study listing 129 references,31 the purpose of
this study was to conduct a survey to determine the
extent to which USAD and its treatment is taught in
curricula of North American dental schools.
RESULTS
Two separate mailings to the 64 schools resulted in
the return of 43 questionnaires for a response rate of
67%. Although this return was less than expected, no
geographic region was underrepresented in the sample.
Forty-two percent (18/43) of the responding
schools teach the subject of UASD. Of those 18 schools,
33% teach this only at the predoctoral level, 28% teach
this only at the postdoctoral level, and 39% teach this at
both levels. The average number of didactic hours devoted to instruction in these subjects was 2.5 hours, with
a range of 1 to 8 hours as estimated by the respondents
(mode 2 hours).
The distribution of teaching UASD by departments is
as follows: restorative dentistry/prosthodontics 33%,
oral medicine/oral diagnosis 22%, and oral surgery 17%.
293
IVANHOE ET AL
Restorative dentistry/prosthodontics
Oral medicine/oral diagnosis
Oral surgery
Anatomy
Physiology
Oral facial pain
General practice
AEGD residency
No. of
schools
6
4
3
1
1
1
1
1
33.3
22.2
16.6
5.5
5.5
5.5
5.5
5.5
Reason
No. of
schools
17
8
5
3
2
1
0
0
1
68
32
25
12
8
4
0
0
4
DISCUSSION
It should be noted that the questionnaire was designed to be brief and easy to complete to enhance compliance. The accompanying cover letter requested that
the questionnaire be given to a more knowledgeable
person if the addressee was not the most qualified to
respond. In spite of the authors efforts, the 67% response rate was lower than expected. One reason for the
low response may be a lack of familiarity with a topic that
has only recently been brought to the attention of dental
practitioners. This lack of familiarity is obvious in some
of the responses to the question on reasons for not
teaching UASD. Another reason could be the traditional attitude that OSA care is a medical procedure and
not a dental procedure, as indicated by 12% of responding schools as a reason for not including the subject in
their curriculum.
The schools that are teaching UASD didactically are
nearly evenly divided with regard to the level of instruction (predoctoral, postdoctoral, or both). In addition,
the number of didactic hours devoted to this subject
varied (1 to 8) among the respondents. Both of these
responses could be attributed to the fact that this type of
treatment is new to the dental profession and dental
schools have not yet reached a consensus about how or
where to teach this subject.
Although the oral devices used for treating UASD are
removable, one half of the responding schools taught
VOLUME 89 NUMBER 3
IVANHOE ET AL
as a priority. It is understandable that Insufficient curriculum time available would be reported by approximately 1/3 of the respondents. A hopeful sign is that
1/4 of the respondents reported that the subject is currently being considered for inclusion in the curriculum.
One selection: OSA care is a medical procedure, not a
dental was selected by 12% of the responders. No
school responded with a concern about patient safety;
however, 8% were concerned about temporomandibular
disorder (TMD)-related problems. Although this is a
legitimate concern, it presented a greater problem before the development of adjustable oral devices, which
are patient-titrated until the mandible is sufficiently protruded to minimize or eliminate the snoring problem.
Such adjustability reduces the chance of TMD symptoms and allows for convenient modification as conditions change.
Thirty-two percent of responders indicated that there
is Insufficient research to justify teaching this subject
in the dental school curriculum. Although the relatively
high incidence of OSA has only recently been given
attention, a recent review of the literature on this subject
cited 129 references.31
CONCLUSION
A lack of appreciation for the importance of incorporating UASD in the curriculum is illustrated by the fact
that only 18 of 43 reporting dental schools have included this subject in their curriculum. The importance
of proper diagnosis and treatment of these patients may
also not be fully appreciated as indicated by (1) lack of
using the Epworth scale as a potential diagnostic aid, (2)
acceptance of patients as walk-ins without a referral
from a physician or a sleep study, and (3) the minimum
recall of patients. The fact that the 7 schools providing a
clinical experience averaged only 10 devices being fabricated per school per year suggests that students are
getting minimal exposure to UASD patients. The responses given when requested to provide an explanation
of why this information was not a part of the curriculum
further demonstrates a lack of information among the
schools.
REFERENCES
1. Foresman BH, Sleep and breathing disorders: the genesis of obstructive
sleep apnea. J Am Osteopath Assoc 2000;100:S1-8.
2. Phillipson EA. Sleep apnea-a major public health problem. N Engl J Med
1993;328:1271-3.
3. Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S. The occurrence
of sleep-disordered breathing among middle-aged adults. N Engl J Med
1993;328:1230-5.
4. Bearpark H, Elliott L, Grunstein R, Cullen S, Schneider H, Althaus W, et al.
Snoring and sleep apnea. A population study in Australian men. Am J
Respir Crit Care Med 1995;151:1459-65.
5. Ohayon MM, Guillemenault C, Priest RG, Cauet M. Snoring and breathing
pauses during sleep: telephone interview survey of a United Kingdom
population sample. BMJ 1997;314:860-3.
6. Ferguson KA, Fleetham JA. Sleep-related breathing disorders. 4. Consequences of sleep disordered breathing. Thorax 1995;50:998-1004.
295
7. Hla KM, Young TB, Bidwell T, Palta M, Skatrud JB, Dempsey J. Sleep
apnea and hypertension: a population based study. Ann Intern Med 1994;
120:382-88.
8. Teran-Santos J, Jimenez-Gomez A, Cordero-Guevara J. The association
between sleep apnea and the risk of traffic accidents. N Engl J Med
1999;340:847-51.
9. He J, Kryger MH, Zorick FJ, Conway W, Roth T. Mortality and apnea index
in obstructive sleep apnea. Experience in 385 male patients. Chest 1988;
94:9-14.
10. Young T, Evans L, Finn L, Palta M. Estimation of the clinically diagnosed
proportion of sleep apnea syndrome in middle-aged men and women.
Sleep 1997;20:705-6.
11. Haponik EF, Frye AW, Richards B, Wymer A, Hinds A, Pearce K, et al.
Sleep history is neglected diagnostic information: challenges for primary
care physicians. J Gen Intern Med 1996;11:759-61.
12. Ball EM, Simon RD Jr, Tall AA, Banks MB, Nino-Murcia G, Dement K.
Diagnosis and treatment of sleep apnea within the community: the Walla
Walla project. Arch Intern Med 1997;157:419-24.
13. Friedlander AH, Walker LA, Friedlander IK, Felsenfeld AL. Diagnosing and
comanaging patients with obstructive sleep apnea syndrome. J Am Dent
Assoc 2000;131:1178-84.
14. Piccirillo JF, Duntley S, Schotland H. Obstructive sleep apnea. JAMA
2000;284:1492-4.
15. Practice parameters for the treatment of snoring and obstructive sleep
apnea with oral appliances. American Sleep Disorders Association. Sleep
1995;18:511-3.
16. Practice parameters for the use of portable recording in the assessment of
obstructive sleep apnea. Standards of Practice Committee of the American
Sleep Disorders Association. Sleep 1994;17:372-7.
17. Johns MW. A new method for measuring daytime sleepiness: the Epworth
sleepiness scale. Sleep 1991;14:540-5.
18. Garcia Lopez P, Capote Gil F, Quintana Gallego ME, Fuentes Pradera MA,
Carmona Bernal C, Sanchez Armengol A. Assessment with the Epworth
scale of daytime somnolence in patients with suspected obstructive sleep
apnea syndrome during sleep: differences between patients and their
partners. Arch Bronconeumol 2000;36:608-11. [Spanish].
19. Liu Y, Zeng X, Fu M, Huang X, Lowe AA. Effects of a mandibular
repositioner on obstructive sleep apnea. Am J Orthod Dentofacial Orthop
2000;118:248-56.
20. Barthlen GM, Brown LK, Wiland MR, Sadeh JS, Patwari J, Zimmerman M.
Comparison of three oral appliances for treatment of severe obstructive
sleep apnea syndrome. Sleep Med 2000;1:299-305.
21. Practice parameters for the treatment of snoring and obstructive sleep
apnea with oral appliances. American Sleep Disorders Association. Sleep
1995;18:511-3.
296
IVANHOE ET AL
22. Clark GT, Sohn JW, Hong CN. Treating obstructive sleep apnea and
snoring: assessment of an anterior mandibular positioning device. J Am
Dent Assoc 2000;131:765-71.
23. Lowe AA, Sjoholm TT, Ryan CF, Fleetham JA, Ferguson KA, Remmers JE.
Treatment, airway and compliance effects of a titratable oral appliance.
Sleep 2000;23:S172-8.
24. Petitjean T, Chammas N, Langevin B, Philit F, Robert D. Principles of
mandibular advancement device applied to the treatment of snoring and
sleep apnea syndrome. Sleep 2000;23:166-71.
25. Fritsch K, Bloch KE. Noninvasive alternatives to CPAP in therapy of
obstructive sleep apnea syndrome. Ther Umsch 2000;57:449-53. [German].
26. Walker-Engstrom ML, Wilhelmsson B, Tegelberg A, Dimenas E, Ringqvist
I. Quality of life assessment of treatment with dental appliance or UPPP in
patients with mild to moderate obstructive sleep apnoea: a prospective
randomized 1-year follow-up study. J Sleep Res 2000;9:303-8.
27. Bondemark L, Lindman R. Craniomandibular status and function in patients with habitual snoring and obstructive sleep apnoea after nocturnal
treatment with a mandibular advancement splint: a 2-year follow-up. Eur
J Orthod 2000;22:53-60.
28. Tegelberg A, Wilhelmsson B, Walker-Engstrom ML, Ringqvist M, Andersson L, Krekamanov L, et al. Effects and adverse events of a dental appliance for treatment of obstructive sleep apnoea. Swed Dent J 1999;23:11726.
29. Pantin CC, Hillman DR, Tennant M. Dental side effects of an oral device
to treat snoring and obstructive sleep apnea. Sleep 1999;22:237-40.
30. Clark GT, Arand D, Chung E, Tong D. Effect of anterior mandibular
positioning on obstructive sleep apnea. Am Rev Respir Dis 1993;147:
624-9.
31. Ivanhoe JR, Cibirka RM, Lefebvre CA, Parr GR. Dental considerations in
upper airway sleep disorders: a review of the literature. J Prosthet Dent
1999;82:685-98.
Reprint requests to:
DR JOHN R. IVANHOE
MEDICAL COLLEGE OF GEORGIA
SCHOOL OF DENTISTRY
AUGUSTA, GA 30912-1250
FAX: (706) 721-6276
E-MAIL: jivanhoe@mail.g.edu
Copyright 2003 by The Editorial Council of The Journal of Prosthetic
Dentistry.
0022-3913/2003/$30.00 0
doi:10.1067/mpr.2003.52
VOLUME 89 NUMBER 3
Philosophical mind
These patients anticipate the need for treatment with
complete dentures and are willing to rely on the dentists
advice for diagnosis and treatment. Philosophical patients will follow the dentists advice when advised to
replace their dentures.
Exacting mind
Exacting-mind patients are usually in poor health and
need a great deal of treatment, but they are unwilling to
accommodate suggestions from the dentist or physician
to extract hopeless teeth and become denture wearers.
Exacting-mind patients also doubt the dentists ability
to make dentures that would satisfy their esthetic and
functional needs. Often, the exacting-mind patient demands extraordinary efforts and guarantees of treatment
outcome at no additional cost.
Hysterical mind
These patients are neglectful of their oral health, dentophobic, and unwilling to try to adapt to wearing dentures. Although these patients may try to wear dentures,
they often fail to use the prosthesis because they expect
it to look and function like natural teeth.
Indifferent mind
Indifferent patients tend not to care about their self
image and are not motivated to enjoy eating. They have
managed to survive without wearing dentures.
Patients with an exacting mind, hysterical mind, or
indifferent mind respond to the prospect of becoming
edentulous and the experience of wearing dentures in
less than ideal ways. Houses6 classification was designed
to help clinicians anticipate a variety of patient responses
when faced with specific clinical procedures. The classification system is relatively simple, which is its strength
and its weakness.
Following in Houses path, OShea et al7 and Winkler8 described ideal dental patients. OShea et al7 characterized the ideal dental patient as compliant, sophisticated, and responsive. Winkler8 described 4 traits that
characterize the ideal patients response: (1) realizes the
need for the prosthetic treatment, (2) wants the prosthesis, (3) accepts the prosthesis, and (4) attempts to use
THE JOURNAL OF PROSTHETIC DENTISTRY 297
PROPOSED CLASSIFICATION
Individual adaptation to the role of patient
The proposed classification is based on 2 factors: (1)
the level and quality of the engagement or involvement
of the patient toward the dentist (including such issues
as domination, submission, and idealization and devaluation of the dentist) and (2) the level of willingness to
submit (trust) to the dentist. The ideal patient stance,
which is most likely to lead to the best treatment outcome, is a reasonable amount (versus an excessive
amount) of engagement and willingness to submit
299
Ideal
Submitter
Reluctant
Engagement
Indifferent
Resistant
tients lack discrimination and tend to idealize the dentist, which results in a high degree of engagement and
utter surrender. This renders the submitter incapable of
providing genuine informed consent because he/she
has surrendered the use of critical faculties and therefore
cannot be an active partner in the treatment.
The reluctant patient rates on engagement and
on willingness to submit (trust). He/she is often
leery of the dentist and skeptical of the treatment plan.
The indifferent patient, who corresponds to Houses
indifferent mind, rates on engagement and on willingness to submit (trust). Usually coerced into seeing
the dentist by a concerned family member or friend, the
indifferent patient is minimally engaged and indifferent
to the dentist to the extent that willingness to submit
(trust) is not an issue.
Finally, there is the resistant patient. This patient corresponds to Houses exacting mind and Bouchers critical patient. Resistant patients are skeptical of the dentist
as a person and of being helped by anyone under any
circumstance. The resistant patient is, paradoxically,
very engaged with the dentist but in an adversarial way.
Rather than being dependent, they challenge the dentist. And, like the indifferent patient, there is no trust.
To understand the description of each of the 5 patient
types, it is necessary to know the differences among
patient types in level of shared responsibility between
the patient and the dentist. The best treatment outcome
will result with patients who possess Houses philosophical mind (ideal patient), who rate on engagement
and on willingness to submit (trust). These patients recognize their responsibility, along with the dentists, as an active partner in the treatment. The ideal
patient asks questions, complies without total submission, and challenges the dentist if something does not
seem right.
VOLUME 89 NUMBER 3
Table II. Intersection of particular patient types and particular dentists needs
Patient type
Need to be idealized
Ideal
Submitter
Reluctant
Indifferent
Resistant
Need to dominate
SUMMARY
This article proposes a new classification system built
on Houses original mental classification. With contemporary terminology, the new classification system considers the role of the dentist, as well as the role of the
patient. The value of this new classification is its effectiveness when applied in a clinical environment. If clinicians find the system instructive and helpful in understanding relationships with patients, then it is
worthwhile even if it remains scientifically unproven.
301
302
10. Jamieson CH. Geriatrics and the denture patient. J Prosthet Dent 1958;8:
8-13.
11. Krochak M. The difficult denture patient. Int J Psychosom 1991;38:58-62.
12. Richards LF. Introductory remarks: behavioral sciences in dentistry. AAAS
symposium, December 27, 1965, Berkeley, California. J Dent Res 1966;
45:1584.
13. Kent G. Satisfaction with dental care: Its relationship to utilization and
allegiance. Med Care 1984;22:583-5.
14. Stolorow RD, Atwood GE. Contexts of being: the intersubjective foundations of psychological life. Hillsdale (NJ): The Analytic Press; 1997. p.
7-28.
15. Kohut H, Stepansky P. How does analysis cure? Chicago: University of
Chicago Press; 1984. p. 41.
Reprint requests to:
DR SIMON GAMER
435 N BEDFORD DR
PENTHOUSE
BEVERLY HILLS, CA 90210-4316
FAX: (310) 278-3040
E-MAIL: sgamerdds@aol.com
Copyright 2003 by The Editorial Council of The Journal of Prosthetic
Dentistry.
0022-3913/2003/$30.00 0
doi:10.1067/mpr.2003.49
VOLUME 89 NUMBER 3
CLINICAL IMPLICATIONS
All of the resilient lining materials tested in this study decreased in bond strength with thermocycling except Ufigel C and Mollosil. After thermocycling, all materials tested had satisfactory
bond strength.
MARCH 2003
the denture base.3,4 Adhesion failure between silicone, resilient denture lining materials, and the denture base is
commonly encountered in clinical practice.1,5 Several investigators have microscopically examined the nature of
the interface between the resilient liners and the denture
base materials.1,4,6,7 Some parameters are expected to affect
the bond between the resilient lining materials and the
denture bases. These parameters include aging in water,
use of a primer with the lining material, and the nature of
denture base materials.8
Dentures constructed of 2 different materials can
only be successful if a satisfactory bond between these 2
materials exists. When immersed, resilient denture liners
THE JOURNAL OF PROSTHETIC DENTISTRY 303
Ufigel C
Ufigel P
Mollosil
Molloplast B
Permafix
Permaflex
Type
Auto-polymerized
Auto-polymerized
Auto-polymerized
Heat-polymerized
Auto-polymerized
Heat-polymerized
silicone
silicone
silicone
silicone
silicone
silicone
Manufacturer
rubber
rubber
rubber
rubber
rubber
rubber
Termo (A)
Product (B)
AB
Error
Df
Sum of
square
Mean
square
1
5
5
132
0.41
2.04
1.77
4.83
0.41
0.41
0.35
0.04
P value
11.08
11.16
9.68
.0011
.0001
.0001
Jeol, Peabody, Mass.) and specimens were photographed at original magnification 20.
Results were tested by multiple analysis of variance
(ANOVA) for mode of failure (adhesive, cohesive, and
mix), 2-way ANOVA (storage-products), and 1-way
ANOVA (storage-products interaction, before and after
thermocycling). Duncans test was used to determine
whether significant changes in the tensile bond properties of the materials occurred during thermocycling. All
data were analyzed at a 0.05 level of significance.
RESULTS
The 2-way ANOVA results shown in Table II indicate that significant differences were found between
products and thermocycling for tensile bond properties.
In addition, the significant interaction between prod305
Fig. 4. Graph of mean and standard deviation (SD) of tensile bond strength (kg/cm2) of each group resilient liner tested.
Table III. Mean tensile bond strength values and probability values (p) for changes in tensile bond properties caused by
thermocycling
Before thermocycling (kg/cm2)
Ufigel C
Ufigel P
Mollosil
Permaflex
Permafix
Molloplast B
Min
Max
Mean
SD
Min
Max
Mean
SD
P values
12
12
12
12
12
12
4.5
5.0
6.0
4.0
6.0
8.0
8.9
9.0
10.5
11.9
11.5
15.0
6.64
6.84
8.17
8.48
9.09
10.70
0.10
0.12
0.14
0.24
0.13
0.18
3.8
2.3
8.1
2.5
2.9
4.8
14.0
9.9
11.5
10.2
6.9
11.8
8.99
5.11
9.50
6.95
4.50
8.58
0.32
0.20
0.11
0.25
0.14
0.22
.03
.01
.02
.13
.0001
.01
Molloplast B
Permafix
Permaflex
Mollosil
Ufigel P
S
S
S
S
S
S
S
NS
NS
S
S
NS
S
S
NS
Ufigel C
Ufigel P
Mollosil
Permaflex
Permafix
Molloplast B
Permafix
Permaflex
Mollosil
Ufigel P
NS
S
NS
NS
S
S
NS
S
S
NS
NS
S
NS
S
Ufigel C
Ufigel P
Mollosil
Permaflex
Permafix
Table VI. Comparison mode of failures before and after thermocycling groups for each resilient liner
Before thermocycling (kg/cm2)
Ufigel C
Ufigel P
Mollosil
Permaflex
Permafix
Molloplast B
Total
Type 1
Type 2
Type 3
Type 1
Type 2
Type 3
P values
12
12
12
12
12
12
72
11
12
2
8
1
0
34
1
0
0
2
0
12
15
0
0
10
2
11
0
23
10
11
2
8
10
0
41
1
1
0
1
1
12
16
1
0
10
3
1
0
15
0.492 (NS)
0.328 (NS)
1.000 (NS)
0.810 (NS)
0.005 (S)
1.000 (NS)
Table VII. Multiple ANOVA for failure modes of 6 processed soft denture liners
df
Sum of square
Mean square
F test
Between groups
Within groups
Total
2
141
143
1.412
7.363
9.048
.706
.054
13.035
P .0001
Group
Count
Mean
SD
SE
73
32
39
.668
.889
.843
.237
.271
.186
.028
.048
.030
Adhesive
Cohesive
Mix
Adhesive vs cohesive
Adhesive vs mix
Cohesive vs mix
Mean diff.
Fisher
Scheffe F test
Dunnett t test
.221
.175
.046
.098
.091
.110
9.99
7.18
.338
4.47
3.789
.822
DISCUSSION
In general, debonding of the resilient denture lining
materials is a common problem. Ideally, resilient den307
Fig. 5. SEM microstructure of fracture surface of adhesive failure. (Original magnification 20). Absence of liner material on
fracture surface. A, Ufigel C lining material. B, Ufigel P lining material. C, Permaflex lining material.
Fig 7. SEM microstructure of mixed mode of failure. (Original magnification 20). Area A portion of fracture surface free
of liner. Area B liner material retained on surface. A, Mollosil lining material. B, Permafix lining material.
CONCLUSIONS
Within the limitations of this study, thermocycling
generally decreased the tensile bond strength and
change the mode of failure to adhesive failures in resilient liner materials. The results showed that the force for
failure was 4.5 kg/cm2, which is acceptable for clinical
use. Considering this criterion, all materials tested had
also a satisfactory bond strength to the polymerized
PMMA denture base resin after thermocycling.
Molloplast B soft liner exhibited a cohesive mode of
failure and the highest bond strength values, and Ufigel
C exhibited a adhesive mode of failure and the lowest
bond strength values before thermocycling. Mollosil resilient liner exhibited a mixed mode of failure and the
highest bond strength values after thermocycling. Permafix soft liner showed a significant difference (P.05)
in mode of failure results before and after thermocycling
and showed the lowest bond strength values after thermocycling.
REFERENCES
1. al-Athel MS, Jagger RG. Effect of test method on the bond strength of a
silicone resilient denture lining material. J Prosthet Dent 1996;76:535-40.
2. Kawano F, Dootz ER, Koran A 3rd, Craig RG. Comparison of bond strength
of six soft denture liners to denture base resin. J Prosthet Dent 1992;68:
368-71.
3. Kutay O, Bilgin T, Sakar O, Beyli M. Tensile bond strength of a soft lining
with acrylic denture base resins. Eur J Prosthodont Restor Dent 1994;2:
123-6.
4. Sinobad D, Murphy WM, Huggett R, Brooks S. Bond strength and rupture
properties of some soft denture liners. J Oral Rehabil 1992;19:151-60.
5. Emmer TJ Jr, Emmer TJ Sr, Vaidynathan J, Vaidynathan TK. Bond strength
of permanent soft denture liners bonded to the denture base. J Prosthet
Dent 1995;74:595-601.
310
6. Storer R. Resilient denture base materials. Part I. Introduction and laboratory evaluation. Br Dent J 1962;113:195-203.
7. Amin WM, Fletcher AM, Ritchie GM. The nature of the interface between
polymethyl methacrylate denture base materials and soft lining materials.
J Dent 1981;9:336-46.
8. al-Athel M, Salwa K. Sem assessment on the nature of the interface
between Molloplast B and the denture base materials. Saudia Dent J
1997;9:133-8.
9. Aydin AK, Terzioglu H, Akinay AE, Ulubayram K, Hasirci N. Bond strength
and failure analysis of lining materials to denture resin. Dent Mater
1999;15:211-8.
10. Braden M, Wright PS. Water absorption and water solubility of soft lining
materials for acrylic dentures. J Dent Res 1983;62:764-8.
11. Kazanji MN, Watkinson AC. Soft lining materials: their absorption of, and
solubility in, artificial saliva. Br Dent J 1988;165:91-4.
12. Polyzois GL. Adhesion properties of resilient lining materials bonded to
light-cured denture resins. J Prosthet Dent 1992;68:854-8.
13. Waters MG, Jagger RG. Mechanical properties of an experimental denture
soft lining material. J Dent 1999;27:197-202.
14. Bates JF, Smith DD. Evaluation of indirect resilient liners for dentures.
Laboratory and clinical tests. J Amer Dent Assn. 1965;70:344-53.
15. Khan Z, Martin J, Collard S. Adhesion characteristics of visible light-cured
denture base material bonded to resilient lining materials. J Prosthet Dent
1989;62:196-200.
16. Dootz ER, Koran A, Craig RG. Physical property comparison of 11 soft
denture lining materials as a function of accelerated aging. J Prosthet Dent
1993;69:114-9.
17. Craig RG, Gibbons P. Properties of resilient denture liners. J Amer Dent
Assn 1961;63:382-90.
18. Mack PJ. Denture soft linings: materials available. Aust Dent J 1989;34:
517-21.
Reprint requests to:
DR YASEMIN KULAK OZKAN
UNIVERSITY OF MARMARA
DEPARTMENT OF PROSTHODONTICS
GUZELBAHCE BUYUKCIFTLIK SOK. NO: 6 80200
NISANTASI, ISTANBUL
TURKEY
FAX: 90-0-212-246-5247
E-MAIL: yasyas@superonline.com
Copyright 2003 by The Editorial Council of The Journal of Prosthetic
Dentistry.
0022-3913/2003/$30.00 0
doi:10.1067/mpr.2003.41
VOLUME 89 NUMBER 3
CLINICAL IMPLICATIONS
Because TMJ sounds in this study were consistent, they were analyzed on recordings objectively
and used to evaluate the severity of internal derangements for diagnostic purposes. However,
absence of TMJ sounds alone should not always be regarded as an indication of a normal joint
and will require a gold standard such as magnetic resonance imaging for definitive diagnosis.
MARCH 2003
U
G
TCEN-TOLLER
O
spectral analysis from the TMJ sound recordings. Isberg-Holm and Westesson19,20 correlated the movements of disc and condyle in TMJs with and without
clicking by use of a high-speed cinematography and dissection and with arthrography and cineradiography dissection on autopsy specimens. Osler et al21 depicted
TMJ sound patterns on a moderately high-frequencyresponse strip chart recorder after arthrographic diagnosis.
The TMJ internal derangement is explained as anterior or anteromedial displacement of the disc with or
without reduction. TMJ sounds on either opening and
closing or protrusive and retrusive motions of the mandible have been correlated with anterior displacement of
the TMJ disc and arthrotic degenerative changes.9,23-28
However, the literature lacks any comparative study on
TMJ sounds and disc position and reduction, if existent,
on all mandibular excursions. The aim of this is a comparative TMJ sound evaluation on mandibular openingclosing, protrusion-retrusion, and lateral excursions of
the mandible.
51 TMJs
19
4
6
5
85
TMJs
TMJs
TMJs
TMJs
TMJs
TMJ
38
28
2
37
9
14
22
16
18
70
42
54.28
40.00
52.85
12.85
20.00
31.42
22.85
25.71
RESULTS
Fifty-one TMJs presented with anterior disc displacement with reduction (ADDR) and 19 TMJs had anterior disc displacement with reduction with intermittent
locking. Four TMJs had had acute locking and 11 TMJs
had chronic anterior disc displacement without reduction (ADD), including 5 TMJs with osteodegenerative
arthritis (OA). The remaining 19 TMJs were normal in
the patient group (Table I). The sound characteristics of
TMJ anterior disc displacements with and without reVOLUME 89 NUMBER 3
U
G
TCEN-TOLLER
O
DISCUSSION
duction on various mandibular motions were established (Table II). Silent TMJs were the feature of normal
TMJs, except for the cases of acute lock. Clicking was a
consistent finding of ADDR, whereas crepitation was
found in varying degrees in ADD and OA (Figs. 1
through 4). Although in 29 TMJs opening click was
followed by a closing click (reciprocal clicking), 46
TMJs with opening click also had clicking on protrusion. On the other hand, 19 TMJs with opening click
also had clicking on ipsilateral motion, and 40 TMJs
with opening click had clicking on contralateral motion
of the mandible. The sound patterns were found to be
similar in opening-protrusive clicks and opening-contralateral clicks. The lack of protrusive click in the presence of opening click was considered an indication of
late disc reduction on opening. Crepitation was observed in advanced cases of TMJ internal derangements.
The opening click was observed in 92.95% of ADDR
cases and in 46.66% of TMJs with ADD. The difference
in sound patterns between the TMJs with ADDR and
those with ADD was found to be highly significant statistically by use of 2 test with Yates correction (P.001)
(Table III).
TMJ sounds on protrusion were observed in 64.78%
of the TMJs with ADDR and in only 26.66% of ADD
cases. The difference in sound patterns between the
MARCH 2003
U
G
TCEN-TOLLER
O
Fig. 2. Phonograms of patient with TMJ anterior disc displacement with reduction. A, Opening and closing, reciprocal clicking.
Sharp impact click with high amplitute of short duration on opening is followed by softer closing sound. B, Protrusion and
retrusion. Protrusive click has similar sound characteristics to opening click followed by silent retrusive movement. C, Lateral
excursions of mandible. Ipsilateral and contralateral clicks are noted. Amplitude increases with speed of motion.
314
VOLUME 89 NUMBER 3
U
G
TCEN-TOLLER
O
Fig. 3. Phonograms of patient with advanced TMJ anterior disc displacement with reduction. A, Opening and closing. Two
sharp impact sounds with high amplitute of short duration on opening are followed by softer closing sound. B, Protrusion and
retrusion. Protrusive click has dissimilar sound characteristics to opening click on right. C, Lateral excursions of mandible. Soft
sound signals are noted. The additional signals of short duration with high and low amplitude indicate degenerative changes
of both disc and condylar surface and discal perforation.
MARCH 2003
315
U
G
TCEN-TOLLER
O
ADDR
ADD
Total
TMJ Sounds on
lateral excursions
Silent TMJs on
lateral excursions
Total
42
11
53
29
4
33
71
15
86
ADDR
ADD
Total
TMJ Sounds on
ipsilateral motion
TMJ Sounds on
Contralateral motion
Total
30
9
39
38
8
46
68
17
85
Fig. 4. Phonograms of patient with TMJ anterior disc displacement without reduction. Sound recordings on opening
and closing. Presence of multiple high and low amplitude
signals of long duration (crepitation) indicate osteodegenerative changes in TMJ.
Table III. Comparative statistical data of TMJ sounds on
opening of the TMJs with ADDR and ADD
ADDR
ADD
Total
ADDR
ADD
Total
Silent TMJs
on opening
Total
66
7
73
5
8
13
71
15
86
Total
66
7
73
32
6
38
98
13
111
ADDR
ADD
Total
TMJ Sounds
on protrusion
TMJ Sounds
on retrusion
Total
46
4
50
9
3
12
55
7
62
TMJ Sounds
on protrusion
Silent TMJs on
protrusion
Total
46
4
50
25
11
36
71
15
86
TMJ Sounds
on closing
TMJ Sounds
on opening
ADDR
ADD
Total
TMJ Sounds
on opening
U
G
TCEN-TOLLER
O
ADDR
ADD
Total
Present
Absent
Total
28
4
32
43
11
54
71
15
86
Silent
TMJs
Total
168
27
195
174
69
243
342
96
438
ADDR
ADD
Total
11.89, P.001.
2
or degenerative changes, such as discal hypertrophy. Although sideway displacement of the disc could be demonstrated on coronal sections on MRIs, fine details such
as degenerative changes and fibrous adhesions on articular surfaces were found to be difficult to detect on both
arthrographic and MRIs in this study. Arthroscopic examination could be added to the investigation for detection of degenerative surface changes. Thus further study
is required to detect fine details about the rotational and
sideway disc displacement, articular surface irregularities, and adhesions for the assessment of the relationship
between the TMJ sounds and lateral excursions of the
mandible. On the other hand, lack of clicking or crepitation could be an indication of either normal TMJ or
adhesions in the TMJ.
CONCLUSIONS
The results of the study indicated that TMJ sounds
are consistent and can be analyzed on recordings objectively to evaluate the severity of internal derangements
for diagnostic purposes. Therefore it could be concluded that TMJ sound analysis on various mandibular
excursions is indicative for diagnosis and establishment
of severity of TMJ internal derangements. Clicking and
crepitation may be looked on as signs of abnormal joint
disease, with clicking indicating anterior disc displacement with reduction and crepitation indicating progression from anterior disc displacement without reduction
to osteodegenerative arthritis. However, absence of
TMJ sounds alone should not always be regarded as an
indication of a normal joint and will require a gold standard such as magnetic resonance imaging for definitive
diagnosis. On the other hand, TMJ sound analysis on
mandibular lateral excursions seems rather complicated
to evaluate; further study is required for the assesment of
disc position, as well as degenerative discal and surface
changes in comparison with TMJ sounds on lateral motions. Arthroscopic evaluation could be added for this
purpose.
We thank Professor Hayrettin Ko ymen, Department of Electronic
Engineering, Engineering School of Bilkent University, for his invaluable support in this research project.
REFERENCES
1. Holmlund A, Hellsing G. Arthroscopy of the temporomandibular joint. An
autopsy study. Int J Oral Surg 1985;14:169-75.
2. Wilkes CH. Internal derangements of the temporomandibular joint. Pathological variations. Arch Otolaryngol Head Neck Surg 1989;115:469-77.
3. Farrar WB, McCarty WL Jr. Inferior joint space arthrography and characteristics of condylar paths in internal derangements of the TMJ. J Prosthet
Dent 1979;41:548-55.
4. Roberts CA, Tallents RH, Katzberg RW, Sanchez-Woodworth RE, Manzione JV, Espeland MA, et al. Clinical and arthrographic evaluation of
temporomandibular joint sounds. Oral Surg Oral Med Oral Pathol 1986;
62:373-6.
5. Sutton DI, Sadowsky PL, Bernreuter WK, McCutcheon MJ, Lakshminarayanan AV. Temporomandibular joint sounds and condyle/disk relations on
magnetic resonance images. Am J Ortho Dentofac Orthop 1992;101:70-8.
317
U
G
TCEN-TOLLER
O
6. Kaltzberg RW, Westesson PL, Tallents RH, Anderson R, Kurita K, Manzione JV Jr, et al. Temporomandibular joint: MR assessment of rotational and
sideways disc displacements. Radiology 1988;169:741-8.
7. Miller TL, Katzberg RW, Tallents RH, Bessette RW, Hayakawa K. Temporomandibular joint clicking with nonreducing anterior displacement of
the meniscus. Radiology 1985;154:121-4.
8. Manco LG, Messing SG, Busino LJ, Fasulo CP, Sordill WC. Internal derangements of the temporomandibular joint evaluated with direct sagittal
CT: a prospective study. Radiology 1985;157:407-12.
9. Farrar WB. Characteristics of the condylar path in internal derangements
of the TMJ. J Prosthet Dent 1978;39:319-23.
10. Murakami K, Segami N, Moriya Y, Iizuka T. Correlation between pain and
dysfunction and intra-articular adhesions in patients with internal derangement of the temporomandibular joint. J Oral Maxillofac Surg 1992;
50:705-8.
11. Roberts C, Katzberg RW, Tallents RH, Espeland MA, Handelman SL. The
clinical predictability of internal derangements of the temporomandibular
joint. Oral Surg Oral Med Oral Pathol 1991;71:412-4.
12. Murakami S, Takahashi A, Nishiyama H, Fujishita M, Fuchihata H. Magnetic resonance evaluation of the temporomandibular joint disc position
and configuration. Dentomaxillofac Radiol 1993;22:205-7.
13. Lydiatt D, Kaplan P, Harold TU, Sleder P. Morbidity associated with
temporomandibular joint arthrography in clinically normal joints. J Oral
Maxillof Surg 1986;44:8-10.
14. Paesani D, Westesson PL, Hatala MP, Tallents RH, Brooks SL. Accuracy of
clinical diagnosis for TMJ internal derangement and arthrosis. Oral Surg
Oral Med Oral Pathol 1992;73:360-3.
15. Eriksson L, Westesson PL, Rohlin M. Temporomandibular joint sounds in
patients with disc displacement. Int J Oral Surg 1985;14:428-36.
16. Gay T, Bertolami CN, Donoff RB, Keith DA, Kelly JP. The acoustical
characteristics of the normal and abnormal temporomandibular joint.
J Oral Maxillofac Surg 1987;45:397-407.
17. Heffez L, Blaustein D. Advances in sonography of the temporomandibular
joint. Oral Surg Oral Med Oral Pathol 1986;62:486-95.
18. Hutta JL, Morris TW, Katzberg RW, Tallents RH, Espeland MA. Seperation
of internal derangements of the temporomandibular joint using sound
analysis. Oral Surg Oral Med Oral Pathol 1987;63:151-7.
19. Isberg-Holm AM, Westesson PL. Movement of disc and condyle in temporomandibular joint with and without clicking. A high-speed cinematographic and dissection study on autopsy specimens. Acta Odontol Scand
1982;40:165-77.
20. Isberg-Holm AM, Westesson PL. Movement of disc condyle in temporomandibular with clicking: an arthrographic and cineradiographic study on
autopsy specimens. Acta Odontol Scand 1982;40:151-64.
318
21. Oster C, Katzberg RW, Tallents RH, Morris TW, Bartholomew J, Miller TL,
et al. Characterization of temporomandibular joint sounds. A preliminary
investigation with arthrographic correlation. Oral Surg Oral Med Oral
Pathol 1984;58:10-6.
22. Sigaroudi K, Knap FJ. Analysis of jaw movements in patients with temporomandibular joint click. J Prosthet Dent 1983;50:245-50.
23. Schwartz HC, Kendrick RW. Internal derangements of the temporomandibular joint: description of clinical syndromes. Oral Surg Oral Med Oral
Pathol 1984;58:24-9.
24. Dolwick MF. Intra-articular disc displacement. Part I: Its questionable role
in temporomandibular joint pathology. J Oral Maxillofac Surg 1995:53;
1069-72.
25. Farrar WB. Differentiation of temporomandibular joint dysfunction to
simplify treatment. J Prosthet Dent 1972;28:629-36.
26. Yatani H, Suzuki K, Kuboki T, Matsuka Y, Maekawa K, Yamashita A. The
validity of clinical examination for diagnosing anterior disc displacement
without reduction. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
1998;85:654-60.
27. Yatani H, Sonoyama W, Kuboki T, Matsuka Y, Orsini MG, Yamashita A.
The validity of clinical examination for diagnosing anterior disc displacement with reduction. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
1998;85:647-53.
28. Sato S, Kawamura H, Nagasaka H, Motegi K. The natural course of
anterior disc displacement without reduction in the temporomandibular
joint: follow-up at 6, 12, and 18 months. J Oral Maxillofac Surg 1997;55:
234-8.
Reprint requests to:
G U TCEN-TOLLER
DR MELAHAT O
DIS HEKIMLIG I
NIVERSITESI
ONDOKUZ MAYS U
SAMSUN
TURKEY
FAX: (90)36-2457-6032
E-MAIL: melahato@omu.edu.tr
Copyright 2003 by The Editorial Council of The Journal of Prosthetic
Dentistry.
0022-3913/2003/$35.00 0
doi:10.1067/mpr.2003.18
VOLUME 89 NUMBER 3
TECHNIQUE
A 50-year-old white woman was referred to the Postgraduate Prosthodontic Clinic at the School of Dental
Medicine, State University of New York at Buffalo, for
prosthodontic assessment (Fig. 1). Other than receiving
medication for arthritis, there were no significant medical findings.
Clinical examination revealed partially dentate maxilla and mandible. In the mandibular arch, a Kennedy
THE JOURNAL OF PROSTHETIC DENTISTRY 319
Laboratory Procedures
1. Mount the diagnostic casts in a semi-adjustable articulator with the aid of a facebow registration and
centric relation record.
2. Perform a full contour diagnostic wax-up (Fig. 2) of
the desired new crown contours and the desired
occlusal scheme.
3. Fabricate an open dual-arch custom impression tray
that can be interposed between the upper and lower
members of the articulator without interfering with
pin closure.
4. Raise the pin on the articulator (2 to 3 mm) to
accommodate for the thickness of the impression
material.
5. Coat the tray with silicone adhesive (VPS adhesive;
Kerr, Romulus, Mich.) and load the tray with putty
addition silicone (Extrude XP Putty; Kerr). Simultaneously inject medium-body addition silicone
320
Clinical procedures
1. Remove the existing fixed prostheses and diseased
hard tissues from the treatment arch (Fig. 4).
VOLUME 89 NUMBER 3
accurate way by use of a direct technique. The advantages of this technique include accurate representation
of the diagnostic wax-up in the completed provisional
prosthesis, thereby satisfying the esthetic and occlusal
demands of the treatment. Disadvantages include the
inability to perform this technique when parallelism between the abutments is impossible, thereby necessitating the segmentation of the prosthesis, as well as the
inherent mechanical shortcomings of the necessary
composite type provisional material, mainly concerning
fracture resistance. It is of importance for this technique
to achieve parallelism of the preparations for the entire
arch, otherwise the provisional prosthesis will have to be
segmented. This can be readily accomplished through
the use of contour strips strategically placed intraorally.6
This technique is recommended only when the edentulous areas involve 1 pontic or 2 pontics, when connector size can be large and for patients that do not
exhibit excessive masticatory strength. For patients
with extensive edentulous areas or a strong muscula-
DISCUSSION
This procedure allows for the fabrication of a full-arch
provisional fixed partial denture in an expedient and
MARCH 2003
321
SUMMARY
A procedure is described with a direct approach used
to fabricate a complete-arch provisional fixed partial
denture in an expedient and functional manner, duplicating the diagnostic wax in an accurate manner. Although this procedure requires significant laboratory
preparation for its implementation, it should expedite
chair-side procedures and provide accurate results, both
functionally and esthetically.
We acknowledge the assistance of Dr Alvin G. Wee, Assistant
Professor, Section of Restorative Dentistry, Prosthodontics and Endodontics, The Ohio State University College of Dentistry.
REFERENCES
1. Federick DR. The provisional fixed partial denture. J Prosthet Dent 1975;
34:520-6.
2. Hunter RN. Construction of accurate acrylic resin provisional restorations.
J Prosthet Dent 1983;50:520-1.
3. Weiner S. Fabrication of provisional acrylic resin restorations. J Prosthet
Dent 1983;50:863-4.
4. Passon C, Goldfogel M. Direct technique for the fabrication of a visible
light-curing resin provisional restoration. Quintessence Int 1990;21:699703.
5. Zinner ID, Trachtenberg DI, Miller RD. Provisional restorations in fixed
partial prosthodontics. Dent Clin North Am 1989;33:355-77.
6. Liebenberg WH. Direct pressure provisionalization technique: a new
open-tray technique for complete-arch rehabilitations. Quinetssence Int
2000;31:83-93.
322
AND
ENDODONTICS
doi:10.1067/mpr.2003.53
VOLUME 89 NUMBER 3
Fig. 2. A, Metal bar as handle for facial cast. B, Notice reduced bulk of cast.
MARCH 2003
REFERENCES
1. Kelly JR, Tesk JA, Sorensen JA. Failure of all-ceramic fixed partial dentures
in vitro and in vivo: analysis and modeling. J Dent Res 1995;74:1253-8.
2. Thompson JY, Anusavice KJ, Naman A, Morris HF. Fracture surface characterization of clinically failed all-ceramic crowns. J Dent Res 1994;73:1824-32.
Reprint requests to:
DR YUJI KOKUBO
DEPARTMENT OF FIXED PROSTHODONTICS
TSURUMI UNIVERSITY SCHOOL OF DENTAL MEDICINE
2-1-3 TSURUMI TSURUMI-KU
YOKOHAMA CITY, 230-8501
JAPAN
E-MAIL: kokubo-y@tsurumi-u.ac.jp
a
doi:10.1067/mpr.2003.47
VOLUME 89 NUMBER 3