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1 TITLE “Clinical and Scientific Aspect of Inlay Fixed Partial Dentures” UNIVERSITY OF SIENA SCHOOL OF DENTAL MEDICINE PHD PROGRAM: “DENTAL MATERIALS AND CLINICAL APPLICATIONS” Ph D THESIS OF: Carlo Monaco TITLE “Clinical and scientific aspect of Inlay Fixed Partial Dentures” 1 ACCADEMIC YEAR 2004/2005 December 2005 Siena Italy Committee: Promoter Prof. Marco Ferrari Co-Promoter Prof. R. Scotti Prof. xxxxxxxxxxxx Prof. xxxxxxxxxxxx Prof. xxxxxxxxxxxx Prof. xxxxxxxxxxxx TITLE “Clinical and scientific aspect of Inlay Fixed Partial Dentures” _____________________________________________________________ CANDIDATE Carlo Monaco December 2005 2 CONTENTS Chapter 1: General introduction 1.1 Tooth structure removal associated with various preparation designs 1.2 Metal-free inlay retainer restorations 1.3 Indication and contraindications of inlay-fixed partial denture Chapter 2: The use of fiber reinforced composites in dentistry 2.1 Fiber-reinforced composite systems 2.2 Properties of the fibers and polymer matrices 2.3 Impregnation of the fibers 2.4 Quantity of fibers 2.5 Direction of the fibers 2.6 Position of fibers 2.7 Water sorption of FRC matrix Chapter 3: Marginal adaptation of IFPDs 3.1 Marginal adaptation of three partial bridges made with different structure material. Chapter 4: Criteria for selecting the materials for IFPDs 4.1 Fracture strength of three partial bridges made with different structure material. Chapter 5: laboratory process for high volume fiber framework 5.1 Fiber reinforced composite with a high volume framework: a technical procedure. Chapter 6: Different structure of the framework 6.1 Clinical Evaluation of Fiber-Reinforced Composite IFPDs. Chapter 7: adhesive procedures 7.1 Inlay Bridge With a New Microfilled Composite: A Clinical Report 3 Chapter 8: Clinical trial 8.1 Randomized controlled trial of Fiber-Reinforced Composite Inlay Fixed Partial Dentures: two-year results. Chapter 9: Alternative materials as regards FRC 9.1 Fatigue test in shear: its effect on bond of a glass-infiltrated alumina ceramic to human dentin, using different luting procedures. Chapter 10 Other clinical application of FRC 11.1 Clinical evaluation of teeth restored with quartz fiber-reinforced epoxy resin posts. Chapter 11 Conclusions Summary 4 Chapter 1 General Introduction When missing tooth structure or teeth are replaced, minimal biologic risk should be involved to reestablish function and esthetics. To proven reliability and durability of complete-crown metal ceramics made them the method of choice for posterior single- tooth restorations and fixed partial denture (FPD). However, this restoration required considerable reduction of tooth structure. The increased use of the adhesive technique and preservation of dental tissues have greatly impacted conservative tooth preparation design. The development of fibre-reinforced composite (FRC) technology and all-ceramic systems has opened the potential for fabrication of metal- free restorations with durability and good aesthetics. This thesis contains a study on several different basic and clinical aspects related to the use of inlay-fixed partial dentures made with fiber-reinforced composites and all ceramic systems. Starting from the assessment of the differences between the amount of tooth structure removed for conventional preparation and various innovative designs for fixed prosthodontics, the next step was to analyse the different materials that can be used when missing tooth must be replaced. Inlay-fixed partial dentures and dental implants are the true alternatives to the conventional metal-ceramic three-unit bridges; for these reason an overview regarding the properties advantages and disadvantages of fiber-reinforced materials is presented. As actually different fiber- reinforced composites are available on the market, it is important for the clinician to know the properties of each system to select the more appropriate for the specific clinical application. The first objective of this thesis was to evaluate before and after fatigue the marginal adaptation of inlay fixed partial dentures made with different materials and establish a connection between the quality of continuous/non-continuous margins and the mechanical properties of different materials. The second was indeed to conduct a study to assess the fracture strength and the dye penetration after fatigue of one fiber- reinforced composite and two all-ceramic systems, and to verify the existence of a correlation between the mechanical resistance and the microleakage. Another goal of this thesis was in fact to evaluate if and how different methods of positioning of the 5 fibers for the framework can increase the fracture strength and reduced the flexibility of the bridges. The design of the fiber framework is an important prerequisite to obtain a durable clinical success when using fiber-reinforced composite. Another step of this thesis was to describe the technical procedure to obtain a framework with a high volume of fiber; for these reason a clinical study comparing the survival rate of inlay fixed partial dentures made with different framework design is presented. Bonding procedures represent the goal for the term of partial restorations. The next step of this thesis was to describe the luting procedures and the surface treatment for the inlay bridges and to compare the clinical performances and the post-operative sensibility of three- and two-step adhesive systems after two-year observation period. Alternative materials to the metal-ceramic restorations went through rapid developments in the last few years, in particular alumina- and zirconia based ceramics. Both these materials represent the future alternatives of the fiber-reinforced composite but their clinical applications in partial restorations are still limited. The next steps of this thesis were the analysis of the bond of a glass-infiltrated alumina ceramic to human dentin, using different luting procedures. Finally the use of fiber-reinforced composite in the reconstruction of the endodontically treated teeth is examined with according to the aim of the minimal intervention philosophy. 1.1 Tooth structure removal associated with various preparation designs The introduction of more invasive complete crown preparation for metal- and all- ceramic crowns has been correlated with an increase in pulpal complications since these restorations require considerable reduction of tooth structure (Creugers et al 1994). For a metal-ceramic shoulder preparation, a facial tooth reduction of about 1.3 to 1.5 mm and an occlusal reduction of 2.0 mm are recommended (McLean JW 1980, Rosenstiel et al 1995). In 1966, only 0.4% to 2% radiographic periapical pathologies were found (Ericsson et al 1966), whereas in 1970, 2.9% was reported (Schwartz et al 1970), and about 10 years later up to 4.0% periapical pathologies were detected (Kerschbaum et at 1981). These results are explained by the use of air turbines () and more invasive shoulder or chamfer preparations compared to the feather-edge design 6 used in the 1960s and 1970s (Klötzer 1984). A lower number of endodontic complications are associated with less invasive preparations. In a literature review, inlay restorations at 10 years showed a lower rate of loss of pulpal vitality (5.5%) compared to complete crowns (14.5%) (Kerschbaum et al 1981). The mechanical reliability and broad range of indications have made complete crowns the preferred denture retainer. However, wing—shaped retainers with retentive elements such as grooves made of metal have demonstrated a remarkable long-term success rate if the clinical protocol is followed carefully (Creugers et al 1992). The gravimetric analysis (Edelhoff et al 2002) showed that for a metal-ceramic crown retainer preparation, almost eight times more tooth structure must be removed compared to an adhesive wing-and groove attachment for a resin-bonded cast-metal fixed partial denture. The “new” half-crown preparation assigned for all ceramic fixed partial dentures (FPDs) required a similar amount of tooth structure removal as the onlay and cost approximately half of the tooth structure of a complete crown design. The percentage of tooth structure removal associated with the different preparation designs for a mandibular premolar was 19.3% for mesial/distal occlusal inlay without transverse ridge or central groove, 30.4% for mesial/distal occlusal inlay with transverse ridge or central groove and 75.9% for mete-ceramic complete crown. Similar percentages of tooth structure removal were found for the same kind of preparation in mandibular molar (19.3%, 25.5%, 73.1%). The inclusion of enamel promotes a superior bond over dentin, lower post- cementation sensitivity, improved support of the materials used for the restorations, and reduced endodontic intervention. The positive influence of tooth structure preservation on the life expectancy of the pulp was reported in the literature. For cast-metal resin- bonded FPDs, a 0.13% rate of loss of pulpal vitality up to 5 years was reported, compared to 9.1% for complete crown abutments in the same period (Paszyna et al 1990). 1.2 Metal-free inlay retainer restorations For the past 30 yr, some dentists have avoided the use of full coverage retainers for fixed partial dentures in order to conserve sound tooth substance. Generally, metal- reinforced systems are the materials of choice for fabricating posterior fixed partial dentures because of their reliability and durability. Inlay-retained FPDs made of 7 metal alloys are been usually seated using the conventional cementation technique and cements (Kopp 1970).
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