Effect of Minimally Invasive Posterior Veneer Preparation Designs on Failure Load and Mode After Fatigue (in-vitro Study)

doi:10.21203/rs.3.rs-4618159/v1

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Effect of Minimally Invasive Posterior Veneer Preparation Designs on Failure Load and Mode After Fatigue (in-vitro Study)

https://doi.org/10.21203/rs.3.rs-4618159/v1

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Introduction:

Ceramic veneers are considered one of the most essential demands in dental aesthetics. It provides high accuracy and efficiency in restoring tooth shape, shade, form, and function. Preparation design is considered a critical factor in the success of dental veneers, as it influences the failure load and fatigue survival of posterior minimally invasive ceramic veneer restorations.

Objective

To assess how various preparation designs affect the minimally invasive posterior ceramic veneer restorations' fatigue survival and failure load.

Materials and methods

64 human premolars were divided into four groups of equal size. Group 1 had a buccal preparation depth of 0.7 mm; group 2 had an additional reduction of the buccal cusp, group 3 had a mesio-occluso distal box. The occlusal box preparation has a vertical dimension of three mm and a horizontal dimension of 2 mm, while sound teeth serve as control. Monolithic lithium disilicate restorations were cemented in adhesive cement and then exposed to dynamic fatigue while thermocycling. Each specimen underwent a single load-to-failure test, and the discrepancy in failure load before and after fatigue was computed.

Results

no significant differences in initial fracture resistance were observed among the four groups evaluated (p < .075). Nevertheless, after fatigue, significant differences were detected (p < .013) as fatigue caused a substantial drop in fracture resistance among all groups.

Conclusion

Within the limitations of this study, minimally invasive preparation designs are recommended compared to full coverage aggressive preparation designs.

Ceramic Veneer

minimally invasive treatment

premolar

Fatigue test

esthetics

Esthetic dentistry and cosmetics rehabilitation are considered one of the most challenging procedures. An esthetic smile is achieved through dental veneers, inlays, and Onlays. Furthermore, combining Veneer and inlay or Onlay is necessary to restore esthetics and function.⁽¹⁾ Recently, the "minimally invasive concept" allows the preservation of tooth structure whenever possible. This will permit shifting from full veneer restorations to less invasive choices, which are currently accessible due to the newly introduced adhesive systems & high strength ceramics that lead to gaining the same effectiveness as complete coverage restoration. VOnlay is a unique concept that combines an Onlay with an extended buccal veneer. It is specifically designed for usage in bicuspid regions rather than for full-coverage restorations.⁽²⁾

There has been a substantial increase in the loss of dental hard tissue due to wear and erosion in recent years. Consequently, there is a demand for the creation of minimally invasive methods for restoring damaged areas, with a specific emphasis on rectifying these imperfections.^(5–7) Dental ceramic laminate veneers are a reliable, functional, and esthetic treatment option in the anterior dentition.⁽⁸⁾ occlusal veneers and onlays aim to replace the occlusal tooth material absent in the posterior region.^(9–11) Since 92–97% of people can see maxillary premolars when they smile, restorations for these teeth must meet the strictest aesthetic standards.^(12,13) Preserving the remaining tooth structure is essential to achieving outstanding esthetics and less invasive restorative therapy.^(14–16)

The dental literature extensively explains the strong connection between the deterioration of strength and the reduction of tooth structure.⁽¹⁷⁾ Full-veneer restorations are now being utilized as a less intrusive alternative to full-coverage crowns. They effectively cover the occlusal, labial, and proximal areas, addressing any defects that may be present.^(18,19) Lithium disilicate (LDS) glass-ceramic, produced using press or CAD/CAM technologies, exhibits favorable aesthetic and mechanical properties appropriate for single-tooth restorations.^(20,21) Furthermore, there have been publications suggesting positive clinical outcomes and high rates of long-term survival and success for various dental procedures, such as posterior inlays, anterior veneers, onlays, overlays, and crown restorations.^(22,23)

Due to the favorable clinical results, the manufacturer has revised the recommendation for adhesively cemented lithium disilicate glass (LDS) crown restorations to a thickness of 1 mm.⁽²⁴⁾ Recently, occlusal veneers or table tops have been developed for the molar region. These veneers are extremely thin, comparable to Onlays, and feature a non-retentive pattern. They provide a conservative alternative to traditional full-coverage crowns.^(25,26) Nevertheless, there is currently a lack of clinical and in vitro evidence regarding posterior defect-oriented preparation forms, such as full-veneer restorations with reduced restoration thickness.⁽²⁷⁾

The preparation geometry for all-ceramic restorations often adheres to the conventional principles employed for metal-cast gold preparations. These criteria encompass integrating retentive features, such as an occlusal box preparation.⁽²⁸⁾ The recommended ceramic thicknesses for the occlusal surface range from 1.0 to 2.0 mm, while for the buccal aspect, they range from 0.3 to 1.0 mm. The specific all-ceramic system will determine the exact thickness within these ranges.⁽²⁴⁾ For the premolars, the guidelines for the preparation of defect-oriented posterior full-veneer restorations remain scarce. Based on dental studies, the likelihood of failure for all-ceramic veneers is notably higher when the preparations reveal dentin or a lack of enamel in the cervical area.^(29,30)

The current in-vitro study aims to evaluate the failure load and mode after fatigue of different minimally invasive preparation designs. The null hypothesis proposed no significant differences in fracture resistance among the suggested preparation designs.

Specimens' preparation

A total of sixty-four recently extracted intact human maxillary premolars were obtained from patients who sought treatment at the Oral Surgery Department of the Faculty of Dentistry, Alexandria University. The teeth were thoroughly cleansed and preserved in distilled water. The teeth were first cleaned using an ultrasonic scaler. They were then immersed in a Chloramines-B-hydrate solution for seven days, eliminating all types of microorganisms without affecting the hardness or microstructure of the enamel or dentin. Afterward, the teeth were preserved for 90 days in distilled water.⁽³¹⁾ The periodontal ligament was simulated in compliance with tooth specimen preparation. A thin layer of approximately 0.2 to 0.3 mm was created by immersing the roots of all teeth in molten utility wax. Each specimen was embedded in a self-curing acrylic resin 2mm below the cementoenamel junction using a split metallic copper mold of 20 mm in length and 14 mm in diameter.⁽³²⁾ The wax spacer was removed from the root surface, and then polyether adhesive was coated on the roots until thoroughly dried. Polyether impression material coated the roots entirely for the simulation of the periodontal ligament, and then they were returned to their acrylic resin space (alveolus) and allowed to be set. The surplus polyether material was excised using a scalpel blade to create a level surface for each tooth.⁽³³⁾ The blocks were removed from the split mold after the acrylic resin was set on each tooth.

To standardize the preparation, a dental imprint of all the teeth was taken using vinyl polysiloxane material (what brand). Before starting the procedure, accurate silicon indices of each tooth were collected to evaluate the degree of reduction. The indices were engraved in both bucco-palatal and meso-distal orientations to function as a silicon index or guide for restoring the tooth to its natural anatomical form. The indices protruded a minimum of 3 mm beyond the cervical region of the tooth's crown to guarantee precise placement of the mold during each substitution. ^(34,35)

For all groups, designs were created using a diamond stone for veneer preparation (Microdont, Brazil).

For the first group, a chamfer finish line was created on the outer side of the object with a depth of 0.5 mm. The finish line closest to the origin was positioned 1mm above the cementoenamel junction. The specimens were randomly sorted into four primary groups, each consisting of 16 specimens, based on distinct patterns of tooth surface preparations. The endpoint of the proximal box was positioned 1mm superior to the cementoenamel junction. The initial set of premolars underwent buccal reduction at a depth of 0.7 mm (Fig. 1). The second Group was prepared with a 0.7 mm buccal reduction and buccal cusp reduction with a depth of 1.5 mm occluso-cervical and extension bucco-palatally to the central groove (Fig. 2). The third Group was prepared with a 0.7 mm depth of buccal reduction, buccal cusp reduction with a depth of 1.5 mm occluso-cervically, and Mesio-Occluso-Distal (MOD) box preparation. The occlusal box is prepared with 3 mm depth and 2 mm width. The proximal box had a depth of 1.5 mm from the pulpal wall to the cervical wall and 3 mm width from the buccal wall to the palatal wall (Fig. 3). The fourth Group was sound unprepared premolars.

A dental laboratory scanner (Medit i710) digitized the prepared teeth to capture digital impressions. The teeth were sprayed (Cerec optispray) to improve the precision of the digital impression. The precision of the scan ensures the generation of a faultless digital representation of the tooth.

A CAD software (Exocad, Exocad GmbH in Darmstadt, Germany) was utilized to design the lithium disilicate restorations (IPS e.max CAD, Ivoclar Vivadent in Schaan, Liechtenstein). The design was sent to CAM milling equipment ( CEREC 3, Sirona Dental Systems, GmbH in Bensheim, Germany). CAD-CAM blocks, A3 in the shade and C14 in size, were inserted into the machine and subjected to wet milling followed by crystallization heat treatment (Programmat P310, Ivoclar Vivadent, Schaan, Liechtenstein).

Adhesive cementation:

A dual cure cement (Bisco DUO-LINK, Bisco USA) was selected for the cementation of the restorations. Before applying adhesive cement, the inner surfaces of the restorations were exposed to 9.5% hydrofluoric acid (Ceramic Etchant; Bisco, USA) for 30 seconds. Subsequently, they were rinsed entirely using an air-water spray for 30 seconds, followed by air drying. The fitting surface was coated with a precise application of a single layer of silane coupling agent (Bisco, USA) using fine brushes for 60 seconds, followed by air drying.

The tooth surface was etched with a 37% phosphoric acid solution for 20 seconds, washed, and then softly dried using air. A layer of adhesive was applied and subjected to light curing for 20 seconds. A thin layer of dual-cure resin cement was applied, and the restorations were seated gently with finger pressure. Any surplus cement was eliminated, and the Veneer was briefly exposed to a low-intensity light source for 2 seconds to facilitate removing any remaining excess cement. The cement was lightly polymerized for 40 seconds.

Initial and residual fracture strength test:

Half the restorations received one cycle load to failure using axial loading in a universal testing machine (Tinius Olsen, 5 ST, England) (Fig. 4). The experiment was performed with a steel ball of five mm in diameter, with the crosshead speed set at 1.5 mm/min. The indenter was positioned at the central fossa with a plastic stress breaker. The specimens were subjected to axial stress until they fractured, and the highest load at which failure occurred was measured and analyzed using appropriate software.

The other half of the specimens underwent cyclic loading (1.2 mil cycles, with a force range of 100–150 N, at 5 sec contact time) using an ACTA-type pneumatic fatigue tester.⁽³⁶⁾ To replicate the natural chewing process, we subjected the palatal cusp to cyclic fatigue directed toward the central fissure. Cracks, fractures, or debonding were examined in the specimens during fatigue testing. The test was performed in a water bath under a 5–55 degree Celsius temperature cycle.

Failure analysis: The specimens were visually inspected using a light stereomicroscope (model SZ1145TR, Olympus Japan 1990) at magnifications of 5 and 10 times (Fig. 5), and failure modes were categorized as follows: Type I: minimal repairable crack propagation in the ceramic material; Type II: Cohesive unrepairable fracture in the ceramic material, leaving the tooth intact; Type III: Catastrophic fracture of restoration involving part of the tooth structures, Type IV Catastrophic fracture of the tooth and root.⁽¹⁷⁾

Statistical analysis

The data were collected and entered into the computer system using ( SPSS 22 Statistical Package for Social Science) software, specifically version 25, to do statistical .(37) Shapiro–Wilk normality test was used to assess the distribution of the quantitative variables.^(38,39) Due to the lack of normal distribution in the data, non-parametric statistics were utilized.⁽⁴⁰⁾ The data were characterized by their lowest, maximum, median, 95% confidence interval of the median, and the interquartile range (25th to 75th percentiles). The Kruskal-Wallis test evaluated differences in fracture resistance and percent change. This was followed by Dunn's post hoc test with Bonferroni adjustment. The tests were two-tailed, with a significance level set at a p-value of < .05.

There were no statistically significant differences in initial fracture resistance (p = .075) among the tested groups. However, after fatigue, significant differences were detected (p = .013). Significant reduction in fracture resistance was observed after fatigue among the four studied groups (Control: p = .014), (Group I: p = .012), (Group II: p = .018), (group III: p = .021) (Fig. 6).

The percentage change (%) of fracture resistance after fatigue was statistically significantly different among the studied groups (p = .026). Group III showed the least change compared with Group I (p = .028) and Group II (p = .039). All other pairwise inter-group comparisons were not statistically significant (p > .05).

There were no significant differences in the failure mode between the tested groups (p < 0.069). The predominant failure mode was class II, characterized by cohesive fracture inside the ceramic material while keeping the tooth intact. This kind of failure occurred in 50% of cases in group I, 37.5% in group II, and 81.25% in group III. Type IV failure, characterized by root fracture, and was detected in 18.75% of group I, 12.5% of group II, and 12.5% of group III (Fig. 7).

There is a lack of comprehensive preclinical and clinical evidence regarding premolar restorations. Vonlay restorations are highlighted for their superior esthetic outcomes and preservation of tooth structure, making them an advantageous choice for posterior teeth afflicted with extensive caries-induced cavities.

Data analysis revealed a significant difference in fracture load but no significant difference in the failure type among the tested designs after fatigue. Anita Schwendimann and Mutlu Özcan (2019)⁽⁴¹⁾ discovered that root fractures, among various types of failures, had minimal or no clinical significance. This phenomenon could be ascribed to pre-existing fissures in the excised teeth or may have transpired under repetitive stress in the chewing simulator. These findings should be considered alongside the results of this study's mode of failure analysis.⁽⁴¹⁾ The restored teeth were also subjected to 1,200,000 loading cycles. It was found that applying cyclic loading combined with thermal gradient enhances the simulation of clinical conditions. Future research should include advanced fatigue components in the experimental design to obtain more clinically significant information about the material's ultimate strength after fatigue, which is also relevant to this study.⁽⁴¹⁾

Nevertheless, this study did not use acidic stimuli encountered in the oral cavity, human saliva, or synthetic saliva as a medium. The adhesion of the veneers can vary based on the demineralization of dental tissues or the depth of dentin. This variability could be seen as a drawback of the study and should be specifically addressed in future research endeavors.⁽⁴¹⁾ Regarding the preparation design, it was recommended to decrease the incisal part to evenly distribute the load and lower the stress levels on the veneer material.⁽⁴¹⁾

In their study, Hassan et al. (2020)⁽⁴²⁾ employed the Thermo Mechanical Load Cycling procedure to evaluate the maxillary molars fracture resistance repaired with occlusal veneers constructed of Lithium Disilicate Glass-ceramic. The researchers also compared the outcomes of two distinct preparation designs. The utilization of a minimally invasive occlusal veneer preparation, along with a marginal chamfer, demonstrated encouraging fracture resistance outcomes that were comparable to those achieved with a conventional conservative preparation for the repair of molars utilizing CAD/CAM lithium disilicate occlusal veneers.⁽⁴²⁾ Zhang et al. (2020).⁽¹⁰⁾ analyzed different types of preparation designs in premolars, including occlusal veneers and occlusal veneers with covering on the lingual and proximal surfaces. The study discovered that these designs yielded higher fracture strength values than full-coverage crown restorations.⁽¹⁰⁾ Kim et al. (2017),⁽⁴³⁾ study suggests that Vonlays are a highly suitable option for patients who have big cavities, decay that extends towards the neck of the tooth, or occlusal issues in their premolar or molar teeth. Veneers are regarded as a minimally invasive and visually appealing dental repair. This corresponds to the group III buccal Veneer with MOD restoration design that was mentioned in the study.. ⁽⁴³⁾

According to Al-Akhali et al. (2019),⁽¹³⁾ the VOnlay was chosen as a replacement for full coverage restorations because it combines the benefits of an Onlay with a laminate veneer while requiring less preparation. They are mainly used for back teeth with cavities impairing the chewing and exterior surfaces. This research had a group III buccal veneer with MOD restoration design.⁽¹³⁾ According to Guess et al. (2013),⁽⁴⁴⁾ it was discovered that decreasing the depth of preparation to 1.00 mm and 0.5 mm did not negatively affect the ability of pressable lithium-disilicate ceramic Onlay restorations to withstand fractures. Nevertheless, it led to decreased failure loads in the case of full veneer restorations on premolars. Furthermore, it was found that palatal-Onlay restorations exhibited considerably greater resistance to fractures when they had ultra-thin thicknesses compared to conventional thicknesses (p = .015). Nevertheless, thickness changes did not have an impact on onlay restorations. The fracture stresses of conventional full veneers were significantly greater than those of thin and ultra-thin restorations. This is consistent with the present findings.⁽⁴⁴⁾ The proposed hypothesis was thus rejected.

In the Hazzaa et al. (2023),⁽⁴⁵⁾ study, the clinical efficacy of premolars repaired with ceramic Onlays and VOnlays was evaluated using modified USPHS criteria. The evaluation focused on fracture, marginal integrity, and marginal discoloration. A total of 26 partial coverage restorations were constructed using pressable lithium disilicate ceramic material for vital premolar teeth. The study found no statistically significant disparity in the clinical performance of maxillary premolars, particularly concerning fracture, marginal integrity, and discoloration, throughout one year. Both groups of maxillary premolars were discovered to have been restored using either complete Onlay or VOnlay designs, employing pressable lithium disilicate ceramic material.

The clinical results of premolars treated with ceramic veneer restorations versus Onlay restorations were evaluated in a randomized clinical trial using modified USPHS criteria. Czechowski et al. (2023),⁽⁴⁶⁾ found that occlusal veneers constructed from zirconium oxide ceramic exhibited an average fracture resistance between 1086 and 1640 N. In contrast, those made of lithium disilicate ceramics showed a range of 456 to 1044 N. These findings demonstrate that zirconium oxide ceramics possess superior fracture resistance compared to lithium disilicate ceramic..⁽⁴⁶⁾

According to Schwendimann and Özcan (2019),⁽⁴¹⁾ it was discovered that the elasticity modulus of the indirect resin composite utilized was 6 to 8 GPa, as stated by the manufacturer. The value of this material is significantly lower compared to feldspathic ceramic (60–70 GPa) and pressed lithium disilicate (96 GPa). Indirect resin composite is a superior alternative in terms of mechanical resistance, as it causes less damage to the opposing teeth compared to ceramic restoration.⁽⁴¹⁾

Majed Al-Akhali et al. (2017)⁽⁴⁷⁾ demonstrated that occlusal veneers made from lithium disilicate and zirconia-reinforced lithium silicate demonstrated higher fracture resistance in comparison to those produced from polymer-infiltrated ceramic and PMMA resin..⁽⁴⁷⁾

Further studies are needed to investigate the influence of minimally invasive preparation designs on clinical success under various conditions and using different materials.

Within the limitations of this study, minimally invasive non-retentive preparation designs provided acceptable fatigue and fracture resistance, which justifies further clinical investigations.

Hence, minimally invasive non-retentive LDS full-veneer restorations demonstrated considerable failure loads, particularly those with reduced thicknesses and adhesively cemented and subjected to cyclic mechanical loading with simultaneous thermocycling. They could serve as a viable treatment for addressing buccal mesio-occluso distal MOD defects, particularly in maxillary premolars. However, it's essential to validate the findings of this in vitro study through further clinical investigations.

LIMITATIONS

One limitation of this study is that its findings are only relevant to the specific all-ceramic materials and luting systems examined. Additionally, the use of human teeth introduces some variability due to differences in storage time, hard tissue thickness, and morphological variations among the teeth studied, which may affect the generalizability of the results.

Conflict of Interest:

The authors declare no conflicts of interest.

Funding Statement:

The authors received no specific funding for the conduction of this study.

Author Contribution

M.A. and I.M. conceived of the presented idea. A.E. developed the theory.M.A. and I.M. verified the analytical methods. M.H. encouraged I.M. to andsupervised the findings of this work. All authors discussed the results and contributed to the final manuscript.

Data Availability

Data is available upon request

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Table 1 is available in the Supplementary Files section.

No competing interests reported.

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Editorial decision: Revision requested
27 Jun, 2024
Editor assigned by journal
25 Jun, 2024
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21 Jun, 2024

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Effect of Minimally Invasive Posterior Veneer Preparation Designs on Failure Load and Mode After Fatigue (in-vitro Study)

Status:

Version 1

Abstract

Introduction:

Objective

Materials and methods

Results

Conclusion

Figures

INTRODUCTION

MATERIALS AND METHODS

Specimens' preparation

Adhesive cementation:

Initial and residual fracture strength test:

Statistical analysis

RESULTS

DISCUSSION

CONCLUSIONS

RECOMMENDATIONS

LIMITATIONS

Declarations

Conflict of Interest:

Funding Statement:

Author Contribution

Data Availability

References

Tables

Additional Declarations

Supplementary Files

Status:

Version 1