Retentive strength of CAD/CAM-fabricated all-ceramic crowns luted on titanium implant abutments using different ceramic materials and luting agents.

doi:10.21203/rs.3.rs-1607620/v2

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Retentive strength of CAD/CAM-fabricated all-ceramic crowns luted on titanium implant abutments using different ceramic materials and luting agents.

https://doi.org/10.21203/rs.3.rs-1607620/v2

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Objectives.

This study aimed to determine the retentive strength of monolithic hybrid-all-ceramic crowns luted on titanium implant abutments.

Material and Methods.

In total, 450 crowns (75 each of Mark II, Empress CAD, e.max CAD, Suprinity, Enamic, Celtra Duo) were milled using a CAD/CAM system. The crowns were cemented onto sandblasted titanium implant abutments using five luting agents (Multilink Implant, Variolink II, RelyX Unicem, Fujicem, and Panavia 2.0). After thermocycling, the crowns were removed using a universal testing machine. The location of luting-agent residue on the abutment and inner crown surfaces was evaluated. Analyses of variance (ANOVA) with the Bonferroni correction were performed to evaluate differences of retentive strength depending on the crown material and the kind of the luting agent.

Results.

The retentive strength for the different ceramic materials were Vita Mark II: 652N-759N (SD:134N-146N), Empress CAD: 681N-822N (SD: 89N-146N), e.max CAD: 784N-1044N (SD: 109N-176N), Vita Enamic: 716N-1177N (SD: 132N-220N), Vita Suprinity: 867N-1488N (SD: 202N-278N) and Celtra Duo 772N-1335N (SD:151N-229N). After the removal trials, the visual documentation showed different adhesive residue location depending on the ceramic materials. Furthermore, the pull-off force was dependent on the choice of adhesives

Conclusions.

The ceramic material used seems to influence the retentive strength and the use of certain luting agents result for some ceramic materials in a higher retentive strength.

implant

ceramic

retentive strength

CAD/CAM

luting agent

cement.

The request of ceramic fixed partial dentures is increasing because all-ceramic materials constitute an appropriate option, optimal esthetics, offering excellent biocompatibility and low thermal conductivity. Referring to this, digital workflows have the potential to reach an outcome at the production of ceramic restorations comparable to conventional procedures from the patients point of view (1). Over the years, several ceramic systems have been developed and introduced, using various materials and techniques for CAD/CAM fabrication. In this context CAD/CAM systems were optimized regarding an adequate internal and marginal fitting (2, 3), esthetics and stability and functional aspects as relevant success factors. Regarding this a distinction can be made between screw-retained and cemented restorations and with these systems also the production of monolithic restorations, which offer reduced chipping problems compared with restorations based on a core material layered with a veneering ceramic are possible. At this several ceramic classes, i.e., feldspathic, glass and oxide ceramic materials and further hybrid-ceramics and different luting systems, i.e., adhesive composite materials, non- and self-etching, self and light curing and a glass ionomer cement are used. Those combinations of ceramic restorations and luting agents are not only used on teeth, but also utilized for implant-based restorations. Those implant-based restorations could be screw-retained or consist of ceramic suprastructures cemented on abutments (4, 5). Each retention mode offers advantages, so screw retained implant based restorations avoid cement residues and thus biological implant pathologies (6) and guarantees a fixation when the vertical available space for the suprastructure is limited and thus not offer a sufficiently large cementation surface. However, a fixation concept of a vertical screw retention cannot be implemented in any case. i.e., at a strong divergence between implant length axis and the axis of the prosthetic restoration regarding esthetic aspects, especially in visually exposed regions as the front teeth. In the case of cemented restorations an important aspect for long term success is a sufficient fixation of the ceramic suprastructures on the abutment platforms. In this context data was published regarding the effect of contamination of the bond surface (7–9), the cement type and abutment height (10), abutment platform configuration (11), airborne-particle abrasion by using alumina (12) or silanisation and laser pretreatment (13) on retention force of the restoration. Beyond that it is possibly to be expected that the adhesive interface behavior between the implant surface, the luting agent and the bond surface of the ceramic restoration could be meaningful for the stabilization of the ceramic restoration.

In the present study the focus was primarily placed on the combination effects using different ceramic materials and luting agents on the retentive strength. This target size was accepted as a measure of long-term success using six ceramic materials in combination with five different luting systems clinically regularly used for the fixation of dental restorations.

In total, 450 implant abutments (No. 57120, Bego Implant Systems, Bremen, Germany) were screwed onto implant laboratory analogs (No. 56696, Bego Implant Systems) using a torque driver (No. 55799, Bego Implant Systems) with 25 Ncm. Seventy-five crowns of a mandibular right first premolar, made of ceramic materials (75 each of Vita Mark II; feldspar ceramic [FSC], Ivoclar Empress CAD; Leucite reinforced glass ceramic [LrGC], Ivoclar e.max CAD; Lithium disiclicate [LiDS], Vita Enamic; Polymer reinforced fine-structure feldspar ceramic [PolyFSP], Vita Suprinity; presintered zirconia reinforced lithium silicate ceramic [PSZirLS], Celtra Duo; Fully crystallized zirconia reinforced lithium silicate [FcZirLS]); Table 1), were manufactured using a CAD/CAM system (CEREC inLab version 4.1; Sirona, Bensheim, Germany; CEREC parameters: block size 14 mm, cement space 30 µm, and spacer 0 µm).

Table 1. Ceramic materials and luting agents tested in this study.

	Materials	Manufacturer	Specification
Ceramic materials	Vita Mark II [FSC]	VITA Zahnfabrik H. Rauter GmbH & Co. KG, Bad Säckingen, Germany	Finely structured feldspar ceramic
	Empress CAD [LrGC]	Ivoclar Vivadent, Schaan, Lichtenstein	Leucite-reinforced glass ceramic
	e.max CAD [LiDS]	Ivoclar Vivadent, Schaan, Lichtenstein	Lithium disilicate glass ceramic
	Vita Enamic [PolyFSP]	VITA Zahnfabrik H. Rauter GmbH & Co. KG, Bad Säckingen, Germany	Hybrid dental ceramic with polymer network 86% ceramic network 14% polymer network
	Vita Suprinity [PsZirLS]	VITA Zahnfabrik H. Rauter GmbH & Co. KG, Bad Säckingen, Germany	Zirconia-reinforced lithium silicate presintered 10% zirconia 90% lithium silicate
	Celtra Duo [FcZirLS]	Dentsply Detrey GmbH, Konstanz, Germany	Zirconia-reinforced lithium silicate fully crystallized 10% zirconia 90% lithium silicate
	Multilink Implant	Ivoclar Vivadent, Schaan, Lichtenstein	Self-polymerizing luting composite with light-curing option
	Variolink II	Ivoclar Vivadent, Schaan, Lichtenstein	Dual-/light- polymerizing, resin-based dental luting material
	Rely X Unicem	3M ESPE	Dual-polymerizing, self-adhesive resin cement
	GC Fujicem	GC Corporation	Self-polymerizing, resin-reinforced glass-ionomer luting cement
	Panavia 2.0	Kuraray Europe GmbH	Dual-polymerizing, self-adhesive resin cement

The exterior surfaces of the implant abutments were sandblasted (corundum, 50 µm, ∼10-mm distance, 1 bar, ∼60-s blasting time per abutment), degreased, and bonded with silane (Monobond P; Ivoclar Vivadent Clinical, Schaan, Lichtenstein). The inner surfaces of the crowns were etched with hydrofluoric acid (5%; Ivoclar Vivadent Clinical) and silanized with Monobond P. The abutment and inner crown surfaces were also pretreated with Monobond P. This resulted in 15 different test series. All six ceramic materials and five luting agents used (Table 2) were applied in strict accordance with the manufacturers’ instructions. All cement excesses were immediately removed with a sponge. The proprietary glycerine gel of each luting system was subsequently applied at the crown margin. If no such gel was available from the respective manufacturer, an alternative gel (Airblock) was applied. In the case of dual-curing systems crowns were polymerized using a polymerization light (Bluephase; Ivoclar Vivadent Clinical) for 240 s.

To simulate the oral environment, the implant-abutment-crown complexes were placed in a moist container for 30 min at 37°C in an insulated chamber. After 30 min, specimens were placed in water for 1 week at 37°C. Thereafter, thermocycling was performed for 5000 cycles (5–55°C, 30-s dwell time; Willytec; SD Mechatronik GmbH, Feldkirchen-Westerham, Germany).

To enable the crowns to be pulled off with the testing machine, it was necessary to create a well-fitting construction that would serve as an adapter between the all-ceramic crowns and the universal testing machine (Model 1425; Zwick Roell GmbH & Co. KG, Ulm, Germany). This resulted in an adapter that had an accurate and homogenous contact with the crowns.

All pull-off trials were conducted with the universal testing machine. The specimens were taken from the water bath prior to the pull-off test and mounted in the machine. The testing machine was adjusted so that the two tensile heads holding the abutment respective to the crown moved strictly vertically at a speed of 1 mm/min. After the crowns had been pulled off, the location of luting-agent residue was evaluated by visual observation.

Retentive strength was recorded, using SPSS 25.0 mean, standard deviations, minimum and maximum were calculated (Table 3). Using an analysis of variance comparisons with Bonferroni correction was performed with a level of significance α = 0,00011494.

For this study, two working hypotheses were formulated:

In terms of retentive strength,

(1) all ceramic materials used would behave independently of the type of luting agent applied; and

(2) all luting agents would result in equal values independent of the type of ceramic material.

First no significant differences between the luting agents for the ceramic materials FSC and LrGC were observed (Fig. 1). For the material LiDS a significant higher retentive strength for Unicem compared to Panavia was observed (p < 0.001). For ceramic PolyFSP significant higher retentive strength for the luting agents Multilink implant vs. Panavia 2.0, Fujicem and Unicem vs. Variolink and Unicem and Fujicem vs. Panavia were detected (p < 0.001). The ceramic PsZirLs showed significant higher retentive differences between the luting agents Unicem and Fujicem vs. Multilink implant, Fujicem vs. Variolink and Fujicem vs Panavia (p < 0.001). For ceramic PcZirLS significant higher retentive streength were detected between the luting agents Fujicem vs. Multilink and Variolink, Unicem vs. Panavia and Fujicem vs. Panavia (p < 0.001).

With the focus on the luting agents the agent Multilink Implant showed a higher retentive strength in the combination with PolyFSP and FcZirLS vs. FSC, PolyFSP and FcZirLS vs. LrGC (p < 0.001), the agent Variolink II showed in combination PolyFSP, PsZirlLs and PcZirLS a higher retentive strength compared to FSC, for PsZirLS a higher than for LrGC and for LiDS (p < 0.001), when the agent Unicem was used the combination with LiDS, PolyFSP, PsZirLS and FcZirLS exhibit a higher retentive strength compared to FSC, further the combination of LiDS, PolyFSP, PsZirLS and FcZirLS a higher compared to LrGC (p < 0.001), for the combination of PsZirLS a higher than for LiDS (p < 0.001), for the luting agent Fujicem the combination with PolyFSP, PsZirLS and FcZirLS a higher compared to FSC and LrGC, for PsZirLS and FcZirLS a higher compared LiDS and for PsZirLS compared to PolyFSP, for the luting agent Panavia 2.0 the combination with PSZirLS showed a higher retentive strength compared to FSC, PolyFSP and FcZirLS (p < 0.001). The location of the luting agent’s residue was documented in Table 4.

Table 3

Retentive strength (mean, minimum, maximum, SD in N) divided by ceramic material and luting agent.
Ceramic material	Luting agent	n	mean	sd	min	max
FSC	MI	15	685	142	310	885
	VII	15	657	145	445	970
	RX	15	652	146	430	955
	GC	15	759	134	552	1010
	P	15	715	145	485	946
LrGC	MI	15	681	146	290	887
	VII	15	774	89	642	925
	RX	15	749	175	536	1198
	GC	15	748	98	579	935
	P	15	822	131	635	1068
LiDS	MI	15	842	176	438	1147
	VII	15	859	109	691	1052
	RX	15	1044	173	825	1310
	GC	15	970	135	740	1137
	P	15	784	133	458	945
PolyFSP	MI	15	1017	132	842	1320
	VII	15	919	150	675	1227
	RX	15	1169	142	892	1398
	GC	15	1177	220	787	1518
	P	15	716	169	458	1097
PsZirLS	MI	15	867	278	235	1411
	VII	15	1109	272	521	1569
	RX	15	1332	272	763	1935
	GC	15	1488	214	1104	1737
	P	15	1021	202	686	1407
FcZirLS	MI	15	1004	170	545	1201
	VII	15	969	151	766	1328
	RX	15	1130	204	790	1530
	GC	15	1335	229	974	1647
	P	15	772	209	510	1239

Table 4

Location of luting agents’ residue (MI: Multilink Implant, VII: Variolink II, RX: RelyX Unicem, GC: Fujicem, P: Panavia).
Ceramic material		FSC					LrGC					LiDS
Luting agent		MI	VII	RX	GC	P	MI	VII	RX	GC	P	MI	VII	RX	GC	P
Location of luting agent residue: implantsurface/inner crown surface	0%/ 100%	15	14	15	0	11	15	15	15	2	10	15	14	14	8	9
	25%/ 75%	0	1	0	7	4	0	1	0	8	5	0	1	1	4	6
	50%/ 50%	0	0	0	8	0	0	0	0	3	0	0	0	0	3	0
	75%/ 25%	0	0	0	0	0	0	0	0	2	0	0	0	0	0	0
	100%/ 0%	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0

Ceramic material		PolyFSP					PsZirLS					FcZirLS
Luting agent		MI	VII	RX	GC	P	MI	VII	RX	GC	P	MI	VII	RX	GC	P
Location of luting agent residue: implantsurface/inner crown surface	0%/ 100%	0	1	2	0	1	0	0	0	0	0	0	0	0	0	0
	25%/ 75%	13	6	9	1	9	3	14	5	1	0	2	12	8	5	2
	50%/ 50%	0	0	3	2	2	5	0	2	1	4	2	2	2	3	2
	75%/ 25%	0	2	0	2	1	3	0	1	8	2	1	0	1	2	1
	100%/ 0%	2	6	1	10	2	4	1	7	5	9	10	1	4	5	10

To satisfy patient demand for metal-free fixed partial dentures that provide long-term stability, it is necessary to keep several issues in mind. It is well known that in addition to marginal adaption, high fracture strengths, and sufficient aesthetics, one of the most important aspects for long-term survival of luted fixed partial dentures (i.e., crowns) is the fixation of the restoration achieved as a quality factor for long-term success(14). Thus, in several studies the bond strength was used as a prognostic factor to evaluate clinical suitability, i.e. for veneer restorations on natural teeth (15). However, the question arises how it behaves with ceramic restorations on titanium abutments. Therefore the experimental designs of those studies, just like in this study, are (16, 17) to simulate the clinical situation, i.e. of crowns made of monolithic all-ceramic materials luted on implant abutments, and thus allows a realistic assessment of the retentive strength as a factor for long-term success that can be achieved when frequently used ceramic materials and luting agents are utilized. Regarding this the retentive strength depends on several factors: among other things the texture of the retentive surfaces respective to their pretreatment (18–21), the luting agent or their curing mechanism (22, 23) or the geometry of the retentive surfaces (24–28). So special attention was paid to allow a sufficient dwell time of cemented crowns in 100% humidity before they were placed in water. For some luting agents, placement in water immediately after removing cement excesses can lead to rapid hydrolytic degradation of the bond (for example if the luting agent has not completely cured) and a reduction in the bonding potential of the luting agent (17, 29). This does not absolutely correspond with the clinical situation, in which the cement is in contact with saliva rather than water. However, in this study long-term water storage was not conducted because Ernst et al. (17) has shown that it had no further significant effect on retentive strength, whereas thermocycling was carried out to simulate the thermal stress as a relevant factor for reducing bond strength (20, 30, 31). In this study it was valued that representative and commonly used ceramic materials and luting agents were used. Different classes of ceramic materials, feldspathic, lithium disilicate, a hybrid ceramic and ceramic materials with oxide ceramic components were utilized and regarding the luting agents also different types, which are frequently encountered in everyday clinical practice, such as adhesive composite materials, non- and self-etching, self and light curing and a reinforced glass ionomer cement. Although manufacturers of ceramic materials and professional societies make specific recommendations for the combination of the ceramic materials and luting agents the question arises to what extent other combinations influence the retentive strength. So, the first working hypothesis, that each ceramic material used would behave independently of the type of luting agent regarding the retentive strength, was only accepted for the Mark II and Empress CAD ceramics. For the other ceramic materials used this hypothesis had to be rejected. Regarding the second hypothesis, that all luting agents would result in equal retentive values independent of the type of ceramic material have to be rejected completely.

To explain the results, it is required to analyze the fixation, on the one hand the interface between the ceramic surface and the luting agent and on the other hand between the luting agent and the adhesive surface of the implant abutment. With this regard the location of the residue of the luting agent allows to judge the quality of the bonding and helps to understand the behavior of releasing of the bond during the withdrawal process. Historically dental ceramics first were bonded on natural teeth using and based on this there are already numerous publications and findings on the bonding interface between ceramic material, luting agent and the surface of natural teeth (31). Compared to the experimental setup of those studies further studies were conducted there was a titanium surface instead of human dentin.

The question is if there is a context between the location of the adhesive residue and the used luting agents and ceramic materials.

In this study regarding the feldspar ceramic and glass ceramic no significant differences between the luting agents were detected, the residues of the luting agents were primarily in the adhesive surfaces of the ceramic restoration and thus the prevailing adhesive failure was between the titanium surface and the luting agents and that show the basically good adhesive connection between all luting materials to the feldspathic (Mark II) and glass ceramic (Empress) materials tested. For the lithium disilicate ceramic (LiDS) the luting agent Rely X Unicem shows a significant higher retentive strength compared to Panavia (p < 0.001) whereas the residues were also overwhelmingly in the inner crown surface. For the hybrid dental ceramic PolyFSP more significant differences between the luting agents were detected. So, for the luting agents Multilink implant, Rely X Unicem and Fujicem a higher retentive strength was detected compared to Panavia 2.0, whereas it is noticeable that beside more significant differences between the luting agents for this hybrid ceramic materials more and more residue of the luting agents were located on the titanium abutment surface and less in the inner crown surface. For the presintered zirconia-reinforced lithium silicate ceramic (PsZirLS) and the fully crystalized zirconia-reinforced lithium silicate ceramic (FcZirLS) higher retention values, higher standard deviations for nearly all combinations with the different luting agents were detected and the residue of the luting agents were also increasingly on the abutment surfaces.

With respect to the luting agents the self-polymerizing luting agent Multilink showed significant higher retentive strength for the ceramic materials Enamic and Celtra Duo compared to the ceramics Mark II and Empress. For the luting agent Variolink as a dual-/light- polymerizing, resin-based dental luting material Enamic, Suprinity and Celtra offered higher retentive strength compared to Mark II and Suprinity further to Empress. Regarding the dual-polymerizing, self-adhesive resin cement Unicem the ceramic Empress, Enamic, Suprinity and Celtra offered a significant higher retentive strength compared to Mark II, and Enamic, Suprinity and Celtra are also higher in retentive strength compared to the material Empress. Fujicem as a self-polymerizing, resin-reinforced glass-ionomer luting cement offer a similar situation with a higher strength for Enamic, Suprinity and Celtra in comparison to Mark II and Empress and Suprinity and Celtra higher than e.max and the material Suprinity higher than Enamic. In contrast the dual-polymerizing, self-adhesive resin cement Panavia showed only for Suprinity a higher retentive strength compared to Mark II.

The interpretation of these results is certainly difficult because despite all standardization of the experimental setup various influencing factors must be considered, essentially the different ceramic materials and luting agents. Because of the standardized setup the reason for this must be in the factor ceramic material, luting agent and in the combination of them, the interface of titanium surface, luting agent and adhesive surface of the ceramic material. It is conspicuous that almost no significant difference between the luting agents in retentive strength for the feldspathic (FSC), the glass (LrGC) and the lithium disilicate (LiDS) material were noted. In summary the ceramic materials Enamic, Suprinity and Celtra showed in combination with the different luting agents tested relatively often higher values for retentive strength compared to the feldspathic Mark II and the glass ceramic Empress. Increasingly more differences between the luting agents were detected for the hybrid (PolyFSP), the presintered (PsZirLS) and fully crystalized (FcZirLS) zirconia-reinforced ceramic. Regarding these ceramic materials tested further studies stated also differences in fracture strength (32)with a higher fracture strength of hybrid (PolyFSP), the presintered (PsZirLS) and fully crystalized (FcZirLS) zirconia-reinforced ceramic compared to the feldspathic (FSC), the glass (LrGC) materials. It might indicate that the retentive strength could be related to the stability of the ceramic material. A hypothesis is that loosening of the crowns is caused by a failure of the adhesive connection initiated by microcracks that arises first in ceramic materials with lower stability. This could be an explanation for higher retention forces when ceramics with high a higher stability are used. However, the question is further to explain the observed significant differences of retentive strength between crowns within each ceramic material made of the high stable materials (PolyFSP), (PsZirLS) and (FcZirLS). Those differences were probably caused by the different luting agents which are for the crowns made of these materials mainly responsible for the formation of different adhesive connection patterns between the titanium surface, the layer of the luting agent and the ceramic surface. However, it must be clarified to what extent the results depend on individual components of the several luting agents used.

In summary, the benefit of this study is that in the clinical frequently used numerous ceramic material and luting agent classes were tested in a standardized laboratory setup with corundum abrasion of the titanium abutments and completely identical testing procedure, and an adjacent consistent pull-off setup without the presence of influencing factors like saliva or blood, that could affect the quality of the fixation of the ceramic crowns. Further it is to be expected that the monolithic ceramic crowns made of the ceramic materials und luting agents used will exceed physical masticatory forces, however certain combinations of ceramic materials and luting agents offer higher retentive strength.

Thus, the first hypothesis that all ceramic materials behave independently of the type of luting agent applied must be rejected to the materials LiDS, PolyFSP, PsZirLS and FcZirLS and the second working hypothesis, that the luting agent used would result in equal retentive strength independent of the type of ceramic material was completely rejected.

Within the limitations of this study the following conclusions are drawn:

The ceramic material used influences the retentive strength of all ceramic crowns luted with several luting agents and
the combination of certain ceramic materials with certain luting agents results in higher retentive strength.

Further investigation regarding adhesive residues should be the subject of subsequent studies.

Author Contributions: Conceptualization, K.M.L., M.W., and H.S.; methodology, K.L.M.; software, S.W., validation, M.B., H.S. K.M.L.; formal analysis, K.M.L.; investigation, M.W..; resources, H.S..; data curation, M.B., K.M.L., S.W..; writing—original draft preparation, M.B.; writing—review and editing, M.B. K.M.L., visualization, M.B..; supervision, K.M.L.; project administration, K.M.L.; funding acquisition, M.W. All authors have read and agreed to the published version of the manuscript.

Funding: Please add: This research received no external funding.

Ethics and consent to participate: Not applicable.

Data Availability Statement: Data can be seen in Tables 1-4.

Conflicts of Interest: The authors declare no conflict of interest.

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No competing interests reported.

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Retentive strength of CAD/CAM-fabricated all-ceramic crowns luted on titanium implant abutments using different ceramic materials and luting agents.

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Abstract

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