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Back to Journal »Clinical, Aesthetic and Research Dentistry» Volume 13
The effect of ceramic and substrate type on the microleakage of aged porcelain veneer
Author Alnakib Y, Alsaady A
Published on March 11, 2021, Volume 2021: 13 pages, 67-76
DOI https://doi.org/10.2147/CCIDE.S280280
Single anonymous peer review
Editor approved for publication: Professor Christopher E. Okunseri
Yasir Alnakib,1 Ammar Alsaady2 1 Department of Conservative Dentistry, Faculty of Dentistry, Amid University, Karbala, Iraq; 2 Department of Conservative Dentistry, Faculty of Dentistry, Mustansiriya University, Baghdad, Iraq Mailing address: Yasir Alnakib 164/42 Almokhayam District, Karbala, 56001, Israel Tel 9647702784555 Email [email protected] Purpose: To evaluate the effect of ceramic types, ceramic effects and cervical substrate types on the microleakage of aged porcelain veneers (PLV). Materials and methods: 48 healthy human maxillary premolars were randomly divided into two groups (n=24), group A: lithium disilicate PLV; group B: zirconia reinforced lithium silicate PLV. These groups are further subdivided into four subgroups (n=12): (A1, B1): the finish line is placed in the V-grade composite filler; (A2, B2): the finish line is placed in the sound enamel. In subgroups A1 and B1, standardized class V cavities were prepared and repaired using nanocomposites. Standardized PLV tooth preparation was performed on specimens from all subgroups. The bonding of PLV is done with light-curing resin adhesive, and the samples are stored in distilled water for 2 weeks. Completed mechanical load cycles (45,000 cycles, 49 N at 2.5 Hz) and thermal cycling programs (500 cycles, 5–55°C). Use dye penetration (2% methylene blue) for microleakage test, and use stereo microscope and ImageJ program to record and calculate the percentage of microleakage. Results: The average percentages of microleakage in the subgroups were: A1 (6.6075%), A2 (4.6058%), B1 (7.3158%) and B2 (6.105%). Two-way analysis of variance showed the significant influence of ceramic type and cervical composite material Matrix. According to the sample t-test, the A2 subgroup is significantly lower than A1 and B2, while the B2 subgroup is significantly lower than B1. A P value ≤ 0.05 is considered statistically significant. Conclusion: Both the type of ceramic and the type of substrate will affect PLV micro-leakage. Compared with zirconia-reinforced lithium silicate PLV, lithium disilicate PLV has significantly lower micro-leakage. Compared with teeth with enamel matrix, teeth with cervical composite matrix have significantly higher microleakage. Keywords: dental leakage, dental restoration, dental veneers, VITA Suprinity, IPS e.max CAD
Porcelain veneer (PLV) as an aesthetic treatment has attracted more and more interest around the world, which is attributed to the combination of excellent aesthetic effects and the strength of dental porcelain with more conservative types of tooth preparation. 1 PLV is used to change the shape, color and position of teeth. According to a systematic review evaluating the main clinical manifestations of glass-ceramic and feldspar PLV, the estimated survival rate of glass-ceramic PLV was 94% and the estimated survival rate of feldspar PLV was 87% during the 9-year median follow-up period. 2 The main reasons for failure are fracture and fragmentation 4%, debonding 2%, severe edge discoloration 2%, secondary caries 1%, and pulp failure 2%.
In the past ten years, the computer-aided design/computer-aided manufacturing (CAD/CAM) of dental restorations has become an established manufacturing process, especially the manufacturing process of PLV. PLVs are traditionally made of glass ceramics because these materials have excellent optical properties that can mimic the shadows and translucency of natural dentition. Over the years, the composition, physical properties and processing technology of glass ceramics have been continuously developed. The original feldspar porcelain had no crystal phase, and later evolved into a better leucite crystal phase and later lithium disilicate crystal phase ceramics (L2S)3. Recently, a new material, zirconia reinforced lithium silicate ceramics (ZLS) has been introduced. The idea is that zirconia can serve as the center of the crystal phase core and can reinforce glass ceramic materials. 4 This material was created to combine the physical properties of polycrystalline ceramics with the aesthetics of glass ceramics in CAD/CAM integral restorations. However, this material is relatively new and there is little public evidence of its performance.
The use of PLV with dentin or composite filling edges has always been controversial. 5-7 Although researchers suggest that the veneer should be extended to reach the inner edge of tooth enamel, 8 this is not always the case in clinical practice. According to a clinical study, it is reported that 60% of laminated veneers will cover existing composite restorations. 9
PLV edge discoloration has caused patient dissatisfaction in clinical studies. 2,10,11 It holds evidence of edge defects, partial debonding and micro-leakage. 12 It is suggested that the shrinkage layer of the resin cement will generate internal stress and cause micro-leakage. -Crack formation, 13 This can be accelerated by mechanical loads, which further slightly propagate the cracks and cause micro leaks and possible future fractures. Another suggestion is the difference in the coefficient of thermal expansion (CTE) of the bonding surfaces (enamel, resin cement, ceramics, and composites). The difference in the behavior of such surfaces under oral thermal cycling may lead to edge openings and eventually micro-leakage . 8
There is little information in the literature on the effect of ceramic materials on PLV microleakage. In addition, there is almost no evidence to show the effect of V-type composite filling as a bonding substrate on PLV micro-leakage. The purpose of this study is to evaluate the effect of ceramic materials and cervical composite substrates on the microleakage of aged PLV.
Forty-eight human maxillary first premolars were selected for the study. As part of the orthodontic treatment plan, all patients signed a consent form in the clinic of the Orthodontics Department of the School of Dentistry, Mustansiriya University. The study was approved by the Scientific and Ethical Research Committee of the School of Dentistry, Mustansiriya University.
All teeth are free of caries and are carefully inspected by light transmission (Diagnostic LED Attachment, Radii-Plus, SDI, Australia) to detect any cracks. Use a fluorine-free pumice stone with a preventive rubber cup (Produits Dentaires SA, Switzerland) to clean the teeth, and then store it in a 0.1% thymol solution for 1 week. In all subsequent steps of the study, the samples were stored in distilled water.
According to the type of ceramic materials used, the samples were randomly divided into two groups (n=24). Group A: Lithium disilicate PLV (IPS e.max CAD, A1 HT, C14, Ivoclar/Vivadent, Germany); Group B: Zirconia reinforced lithium silicate PLV (VITA Suprinity PC, A1 HT, LS14, Vita Zahnfabrick, Germany). These groups are further subdivided into four subgroups (n = 12): (A1, B1): Cervical spine finishing lines placed in a Class V composite filler (Filtek Z350 XT, 3M ESPE, Germany); (A2, B2 ): The finish line is placed in the sound enamel.
Bone support and periodontal ligament are very important for the stress distribution mechanism of teeth. Dip the tooth root surface in molten dipping wax (GEO Dip, Renfert, Germany) to 2 mm below the enamel junction (CEJ), 14 resulting in a 0.2-0.3 mm thick wax layer, by measuring the width of the enamel to ensure the use of digital display The caliper (InSize, Austria) starts from three facing points before and after dipping (Figure 1A and B). A dental surveyor (Paraline, Dentaurum GmbH, Germany) was used to individually install the teeth in a custom mold made of rubber silicon material (20×20×25 mm) and pink cold-curing acrylic resin (Paladur, Kulzer GmbH, Germany) , To ensure the vertical positioning of each tooth in the mold. At the first polymerization mark, remove each tooth from the acrylic block, then remove the wax, then inject the A-silicone lightweight impression material (Elite HD, Zhermack SpA, Italy) and reinsert the tooth. Therefore, a standard silica gel layer of 0.2-0.3 mm was created to simulate the periodontal ligament and the thickness of the wax layer was taken. Figure 1 (A) Measure the width of the roots before dipping in wax. (B) Measure the width of the root after wax immersion.
Figure 1 (A) Measure the width of the roots before dipping in wax. (B) Measure the width of the root after wax immersion.
All specimens in the A1 and B1 subgroups received a standardized Class V cavity on the cheek. Initially, a square-edged diamond wheel bur (ISO No. 806 314 043 524 040, NTI-Kahla GmbH, Germany) and a high-speed water-cooled handpiece (Kavo Dental GmbH, Germany) were used to make a V-level cavity preparation template, which was fixed in the modified dental measurement The vertical arm of the instrument is prepared with a standardized cavity perpendicular to the long axis of the tooth. Then, the tungsten carbide crack bur did not. 256 (Komet, Germany) is used to standardize cavity depth and correct cavity bottom. Color markings (Stabilo, China) and digital calipers (InSize, Austria) are used to mark the burs to provide a visual reference of 1.5 mm depth.
In order to keep the restoration within the enamel boundary, all V-level cavities are prepared 1 mm above the enamel junction. 15,16 The dimensions of the prepared cavity are: occlusal gingiva (2 mm) and axial depth (1.5 mm). Wipe the excess color marks with a cotton ball dipped in alcohol.
According to the manufacturer's instructions, use 35% phosphoric acid etchant gel (Scotchbond™ Universal Etchant, 3M ESPE, Germany) to etch class V cavity acid, then wash and expand with cotton balls. Apply the 5th generation adhesive (Adper Single Bond 2 Adhesive, 3M ESPE, USA) and light cure (Radii-Plus, SDI, Australia) for 40 seconds. The repair procedure is done using nano-filled composite material (Filtek Z350 XT, 3M ESPE, Germany) in two horizontal layers, each layer is light cured (Radii-Plus, SDI, Australia) for 20 seconds. Use the finishing polishing kit (Super-Snap Kit, SHOFU INC., Japan) to finish finishing and polishing the composite filler.
For standardization purposes, all specimens were prepared by the same operator at 4x magnification (ZEISS EyeMag Pro S, ZEISS Medical Technology, Germany). The ceramic veneer system was used to prepare the bur set (Keramik-veneers.de, Komet, Germany) for standardized preparation of all teeth. At first, a silicon mold was constructed with Ormadent Putty with Ormactivator Gel (Major Prodotti Dentari Spa, Italy) to provide a visual reference during tooth preparation (Figure 2A). Use a waterproof color marker (Stabilo, China) to draw the outline of the preparation on the tooth to provide a visual reference for the preparation area. The preparation is 1.5 mm above the CEJ, 1.5 mm buccal palate and 1.5 mm bite-neck. The face prepared using occlusal butt joints is reduced to 0.4 mm in the third of the neck and 0.5 mm in the middle and third of the occlusal (Figure 2B). Figure 2 (A) Silicon index used for visual reference during the manufacturing process. (B) Final tooth preparation.
Figure 2 (A) Silicon index used for visual reference during the manufacturing process. (B) Final tooth preparation.
First, a customized impression tray is manufactured by a pressure forming machine (Biostar, Scheu-Dental GmbH, Germany). The perforation size of the custom pallet is 20x20x25 mm. The final impressions of all groups of teeth are made of added silicone impression material (Elite HD, Zhermack SpA, Italy), using two-stage putty cleaning technology, cast IV type tartar (elite model, Zhermack SpA, Italy).
The PLV was designed with (inLab SW, Sirona Dental Systems, Bensheim, Germany) and then milled with a 5-axis milling machine (CEREC inLab MC XL, Sirona Dental Systems, Bensheim, Germany). According to the manufacturer's instructions, PLV is fired in a ceramic firing furnace (Programat CS, Ivoclar Vivadent/technical, Liechtenstein, Germany) under vacuum at 840°C.
In the A1 and A2 groups of the composite substrate, the composite surface is sandblasted to promote the bonding process. A sandblasting machine (AquaCare, Velex, UK) was blasted with 29 μm alumina (Al2O3) particles for 10 seconds. 17 The custom protective cover is made of additional silicon (Zhermack SpA, Italy). The custom protective cover contains an opening only in the area of the composite restoration to prevent the adverse effects of sandblasting on the tooth structure.
The teeth of all subgroups were etched with 35% phosphoric acid etching gel (Scotchbond™ Universal Etchant, 3M ESPE, Germany) for 20 seconds, rinsed for 20 seconds, and then gently dried with excess water for 5 seconds. Immediately after drying, apply two consecutive layers of the fifth-generation adhesive (Single Bond 2 Adhesive, 3M ESPE, USA) on the etched tooth surface for 15 seconds, stir gently with a fully saturated brush, and then lightly dilute with air for 5 seconds to evaporate Solvent, does not cure. 18,19
According to the manufacturer's instructions, 5% hydrofluoric acid gel (IPS ceramic etching gel, 3M ESPE, Germany) was used to etch the inner surface of the PLV manufactured by all groups for 20 seconds. Then the finish is thoroughly cleaned with air/water spray for 30 seconds and air dried. The veneer was silanized by applying a ceramic primer (RelyX ceramic primer, 3M ESPE, USA) to the inner surface of the veneer and letting it dry for 1 minute. A layer of 5th generation adhesive (Single Bond 2 Adhesive, 3M ESPE, USA) was applied to the inner surface of the veneer, and it was not cured.
Dispense a small amount of translucent lampshade light-curing resin cement (RelyX Veneer cement, 3M ESPE, USA) directly from the syringe onto the inner surface of the veneer. Use a placement tool with a sticky tip (Optrastick, Ivoclar/Vivadent, Germany) to hold the veneer in place with light pressure, and then light cure (Radii-Plus, SDI, Australia) for 40 seconds. The edges are finished and polished with a finishing and polishing kit (Super-Snap Kit, SHOFU INC., Japan). Then, store the sample in distilled water at 37°C for 2 weeks.
In order to simulate clinical situations (for example, chewing and oral environments), all samples were subjected to mechanical load cycling and thermal cycling procedures. A customized device is used for the duty cycle program (Figure 3A). The sample is subjected to 50,000 cycles of 49 N at a frequency of 2.5 Hz. The specimen is kept moist during the operation by using a cannula attached with a container of distilled water, which continuously drops distilled water on the specimen (Figure 3B). Use a customized automatic thermal cycle device to complete the thermal cycle program. According to the specifications of the International Organization for Standardization (ISO/TS 11405:2015), the sample has undergone 500 water cycles between 5°C and 55°C with a residence time of at least 30 seconds. Then, all samples were air-dried. Figure 3 (A) Customized cyclic loading device. (B) The cyclic loading tip in contact with the tooth.
Figure 3 (A) Customized cyclic loading device. (B) The cyclic loading tip in contact with the tooth.
Soak the sample in 2% methylene blue dye in the container at 37°C for 48 hours. Then, the crown of the sample was sealed with a transparent cold-curing acrylic resin (Paladur, Kulzer GmbH, Germany) with a customized round mold (diameter 15 mm), and a microtome (MT-4 diamond cutting saw, USA) was used to round The thickness of the disc is 0.35 mm, and it is cut at high speed with water coolant.
The presence of microleakage was confirmed by observing the blue dye range in the adhesive interface (occlusion and neck) using a stereo microscope (Meiji Techno Co. Ltd, Japan). Microleakage measurement is done by using an image processing program (ImageJ software, National Institutes of Health, https://imagej.nih.gov). Measurement calibration uses millimeter graph paper as a guide to measure the length in micrometers (Mm) (Figure 4A). First, record the total measurement value of the adhesive interface (Figure 4B), and then record the occlusion and neck microleakage measurements (Figure 4C and D). Figure 4 (A) Length measurement calibration. (B) Measurement of total adhesive interface (Mm). (C) Occlusal microleakage (Mm). (D) Cervical microleakage (mm).
Figure 4 (A) Length measurement calibration. (B) Measurement of total adhesive interface (Mm). (C) Occlusal microleakage (Mm). (D) Cervical microleakage (mm).
The following mathematical formula is used to calculate the percentage of micro-leakage:
Microleakage %=[bite reading (Mm) cervical spine reading (Mm)/total measurement value of adhesive interface (Mm)] x 100% (take the average of the two halves of each sample as a record).
The workflow of the current research is shown in Figure 5. Figure 5 Flow chart of the research protocol workflow.
Figure 5 Flow chart of the research protocol workflow.
Use IBM SPSS Statistics (Social Science Statistics Package, Version 24.0; IBM Corp., Armonk, NY, USA) for statistical analysis to calculate descriptive statistics and inferential statistics. Initially, the distribution of the data was checked statistically by using the Kolmogorov-Smirnov and Shapiro-Wilk tests. The analysis of variance (two-way analysis of variance) was performed because we wanted to evaluate the impact of two factors (ceramic type and substrate type) on the microleakage of aged PLV. Use a separate analysis (independent sample t test) under each condition. P value ≤0.05 is considered statistically significant. P value ≤ 0.01 is considered statistically significant. A P value> 0.05 is considered statistically insignificant.
The results of this study showed that the average percentage of microleakage in the A2 subgroup was the lowest, followed by the B2 and A1 subgroups, and the B1 group had the highest average. Kolmoyrov-Smirnov and Shapiro-Wilk tests are used to test the data distribution in statistical methods. Based on the results of these two tests, it is assumed that the data are normally distributed (Table 1). Table 1 Descriptive statistics (mean and standard deviation of microleakage percentage) and normality of statistical method distribution test
Table 1 Descriptive statistics (mean and standard deviation of microleakage percentage) and normality of statistical method distribution test
The two-way analysis of variance test showed a significant influence of ceramic type. Likewise, the type of substrate has a very significant impact. However, the interaction between these two factors had no significant effect on the percentage of microleakage (Table 2). Table 2 Binary analysis of variance of the average value of the percentage of micro-leakage related to ceramic type and substrate type
Table 2 Binary analysis of variance of the average value of the percentage of micro-leakage related to ceramic type and substrate type
According to the sample t-test, compared with the enamel matrix, the PLVs group (A1 and A2) repaired with L2S ceramics showed that the presence of the cervical composite matrix had a significant effect on the increase in the percentage of microleakage. Similarly, the PLV group recovered with ZLS (B1 and B2) showed the same significant effect. In the PLVs group with cervical composite base (A1 and B1), the effect between the two ceramics was not significant. On the other hand, in the PLV group with enamel substrates (A2 and B2), the microleakage percentage of L2S PLV was significantly lower than that of ZLS PLV (Table 3). Table 3 Independent sample t test of the four research groups
Table 3 Independent sample t test of the four research groups
Although the ideal environment for experimental research on dental materials and restorations is the oral cavity, clinical trials are time-consuming and not always cost-effective. 20,21 To test materials and restorations in vitro, the test conditions should match the oral environment.22 Therefore, periodontal simulation, thermal cycling, and mechanical load cycling were used in this study. Human teeth were used in this study because of their unique properties, such as adhesive properties, elasticity, strength, thermal conductivity, ion transfer in the dentin tubules, and enamel thickness. twenty three
Bone support and periodontal ligament are very important for the stress distribution mechanism of teeth. 14,24,25 When a load is applied, the periodontal fibers are compressed, the teeth are slightly displaced, and the bone in the direction of the root movement is deformed. 26 The mechanical response of the periodontal ligament to external stress is nonlinear and viscous, 27 which is similar to the properties of elastic impression materials. In this study, the simulation of the periodontal ligament was done by creating a layer of 0.2-03 mm silicon impression material between the tooth root and the acrylic block. 14,28
When placing the edge of the porcelain veneer on an existing composite material, it is important to consider that weak bonding may lead to micro-leakage and fracture. The difference in bending and thermal expansion between teeth and ceramic or resin composite materials may cause micro-leakage. 1,8,10 In order to avoid the weak bonding of the existing composite material area, the surface of the composite material was treated with alumina sandblasting. Cementation time. 29
Microleakage is measured by measuring the microleakage at the cut end and neck in millimeters, then dividing them by the total adhesive surface of the veneer and multiplying by 100% to get the microleakage percentage. All measurements are performed digitally by computer software. 18 Compared with the scoring method that relies on the subjective decision of the observer, this microleakage measurement method is considered to be more objective, more accurate, and less likely to be biased.
According to the results of the two-way analysis of variance, it is found that the type of ceramic restoration has a significant impact on the microleakage rate of the porcelain veneer. This finding disagrees with the views of Zaimoglu and Karaagaclioglu, 30 who believe that porcelain materials have no significant effect on the microleakage of porcelain veneers. This may be attributed to the different ceramics used, different restoration manufacturing methods, and different microleakage data recording methods.
According to the results of the sample's t test, the average value of the microleakage percentage of the L2S veneer A2 group was significantly lower than that of the ZLS B2 group. When comparing the A1 and B1 subgroups (though not significant), the same finding was also noted, with the ZLS group B1 recording the highest percentage of microleakage. There has been no previous study to compare the micro-leakage of the two ceramic materials.
The coefficient of thermal expansion (CTE) is considered to be an important factor affecting micro-leakage, 31-33 it is affected by the composition of the repair material. The large difference in CTE between the tooth and the restoration material can cause excessive stress along with temperature fluctuations, which can lead to micro-cracks that propagate along the bonding interface, leading to the formation of gaps and ultimately to micro-leakage. Compared with ZLS ceramics (CTE=11.6×10-6 K-1), the lower CTE of L2S ceramics (CTE=10.25×10-6 K-1) may be the reason for the lower percentage of reported micro-leakage of L2S veneer This translates into better material performance during thermal stress. 34
On the other hand, one of the methods reported in the literature to reduce the microleakage of dental restoration materials is to use materials with a low modulus of elasticity (MOE). 35,36 According to Elsaka and Elnaghy, 37 L2S ceramic has a significantly lower modulus of elasticity (60.61 GPa) compared to ZLS ceramic (70.44 GPa). Compared with ZLS ceramics, the combination of lower MOE and lower strength of L2S ceramics translates into higher resilience. 38 This leads to better elastic cushioning and compensation of resin cement shrinkage stress, which is another explanation for the lower average percentage of micro-leakage in the L2S veneer.
This study shows that the cervical composite substrate has a very significant impact on the microleakage rate of the porcelain veneer. This finding is consistent with Sadighpour et al. 7 who concluded that the ceramic veneer with grade 4 composite filler has significantly higher microleakage compared to the control. The results of the study also agree with the views of Lacy et al. 39 They proved that there is complete leakage between the GIC restoration and the porcelain veneer. "However, in our study, the microleakage record was low, which may be due to the bonding behavior of different filling materials and/or surface treatments.
According to the sample t-test results, compared with the enamel matrix group A2, the cervical composite matrix group A1 has a significantly higher average value of the percentage of microleakage. When comparing the B1 group and the B2 group, the same significant effect can be seen, the first one is significantly higher than the latter. These findings are consistent with the views of Metz et al. They concluded that the composite material, as a finishing line for interaction with resin cement and ceramic crowns, has significantly higher microleakage than the control group. 40
The increase in the percentage of microleakage in the cervical composite base group (A1 and B1) may be due to the difference in curvature between the tooth structure and the ceramic material, which may cause gap formation and increase microleakage. 7 Another reason may be due to the difference in coefficients. The thermal expansion between the tooth structure, composite filling and ceramic veneer reveals the different behavior of various materials during thermal cycling and load cycling, which may lead to larger gaps and increase Of micro-leakage.
The microleakage data recorded in this study is consistent with other similar studies that use the percentage of microleakage as the recording method. 18,41,42 Compared with the acceptable microleakage score for porcelain crowns, there is no acceptable microleakage rating for porcelain veneers.
It is necessary to further study the microleakage between the indirect restoration and the composite substrate, which may use different surface treatments, different bonding procedures or different adhesives, because there is a lack of such research in the current literature.
Within the limits of this study, the conclusions reached are:
-The type of ceramic material and the presence of type V fillers as the bonding substrate have a significant impact on the micro-leakage percentage of the porcelain laminate veneer.
-Compared with ZLS veneer, L2S veneer significantly reduces micro-leakage.
-Compared with the PLV on the teeth without the type V composite filling, the PLV on the teeth using the type V composite filling in the cervical finishing line has a significantly higher microleakage.
-There is no significant difference in microleakage between the two types of ceramic veneers when using Class V composite fillings to bond to teeth.
The authors report no conflicts of interest in this work.
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