You are on page 1of 98

Abutment positioning in a cantilevered shortened dental arch: A clinical

report and static analysis


Israel Lewinstein, DMD, PhD,a Yehuda Ganor, DMD,b and Raphael Pilo, DMD,c
The Maurice and Gabriela Goldschleger School of Dental Medicine, Tel Aviv University,
Tel Aviv, Israel
This article describes the extension of a shortened dental arch with a cantilever fixed partial denture in
a patient who refused to be treated with an implant-supported and retained prosthesis. Orthodontic
movement of the distal abutment to enlarge the interabutment span was performed before the final
restoration. The mechanical advantage of the enlarged span in a cantilever fixed partial denture is analyzed, discussed, and demonstrated by 2-dimensional static analysis. (J Prosthet Dent 2003;89:227-31.)

bsence of molar support is a common situation in


dental practice. Patients with missing molars are frequently categorized as subjects with shortened dental
arches (SDA).1 It has been reported that SDAs can provide sufficient oral comfort and function.2,3 In a 6-year
follow-up study,4 subjects with SDAs were compared
with subjects with complete dental arches with respect
to occlusal stability. It was concluded that (1) SDAs
provided durable occlusal stability, (2) extension-base
removable partial dentures (RPD) did not contribute to
occlusal stability, and (3) SDAs with periodontally involved teeth demonstrated continuing periodontal
breakdown. Occlusal stability was assessed by Witter et
al5 with the following 5 parameters used as indicators:
interdental spacing, occlusal contacts, vertical and horizontal overlap, occlusal tooth wear, and periodontal
support. They found that the occlusal changes were selflimiting, suggesting a new occlusal equilibrium, and
they concluded that SDAs can provide long-term occlusal stability. In addition, they stated that precautions to
prevent occlusal collapse by extending SDAs with prosthetic devices as a routine action should be discouraged.5 Nevertheless, in certain situations the SDA can
be extended by a distal cantilever. Budtz-Jorgensen et
al6 reported that extending an SDA with cantilever fixed
partial dentures (FPD) was a favorable prosthetic solution in patients with anterior teeth and 1 or 2 premolars
remaining in the mandible. In this study a pronounced
improvement of chewing function and stability of the
opposing maxillary complete dentures was observed.
Treatment with distally extending cantilever FPDs in the
mandible (against a complete maxillary denture) has
been suggested as a favorable alternative to treatment
with an RPD in elderly patients with reduced dentition.7
In another study of 1674 FPDs,8 no significant difference in the survival rate was found between FPDs with a
conventionally fixed pontic and those with a cantilever
a

Senior lecturer, Department of Oral Rehabilitation.


Research associate, Department of Oral Rehabilitation.
c
Senior lecturer, Department of Oral Rehabilitation.
b

MARCH 2003

pontic. Of the FPDs studied, 86% were fabricated with a


conventionally fixed pontic, and 14% had a cantilever
pontic.
It was also found that there was a significantly greater
incidence of new and recurrent caries lesions in subjects
restored with RPDs compared with cantilever resinbonded FPDs.9 It has been shown, however, that in a
cantilevered FPD the 2 proximal abutments are the most
stressed with large reactive forces.10-12 Therefore the
relationship between biology, mechanics and the stress
distributions of the supporting structures was considered critical with a cantilever FPD.13 Furthermore,
some authors14 have advised clinicians to avoid the use
of a post-core-crown restored tooth as an abutment for
distal extension RPDs or cantilever FPDs.
The purposes of this article were to describe and conduct a static analysis of a shortened dental arch extended by
a cantilever FPD, and to present a clinical report based on
the static analysis extended by a cantilever FPD for a patient
with a shortened dental arch who refused to be treated with
dental implants. Treatment required orthodontic movement to enlarge the span between the 2 distal abutments
prior to the final restoration. This treatment plan was designed to offer the patient an extended functional arch with
an improved mechanical resistance.

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

THE JOURNAL OF PROSTHETIC DENTISTRY

Fig. 1. A, Cantilever FPD retained by 2 adjacent abutments.


F, Applied force; R1 and R2, reactive forces; a, cantilever
length; l, interabutment span. B, Shear forces diagram. C,
Bending moments diagram. R1 -Fa/l and R2 F Fa/l.

LEWINSTEIN, GANOR, AND PILO

Fig. 2. A, Cantilever FPD with enlarged interabutment span.


R1 and R2, Reactive forces; a, cantilever length; l, interabutment span. B, Shear forces diagram. C, Bending moments
diagram. R1 -Fa/2l and R2 F Fa/2l.

Fig. 3. A, Lateral view left side. B, Periapical view showing maxillary first premolar with 2 roots in mesioangulated position.

information about shear forces, bending moments, and


deflections of beams. Because the analysis is a 2-dimensional simulative method, it is limited in its accuracy and
ability to reflect a clinical situation. However, it can still
be considered an important tool to predict the mechanical behavior of FPDs and their various components under loading.19 The analysis was conducted on a cantilever FPD supporeted by 2 abutments.17-19 Figure 1, A,
simulates a cantilever FPD (C-FPD) with a concentrated
load F acting vertically on its edge. In Figure 1, B and
C, the expected shear and moment diagrams are plotted.
A further static analysis suggested that increasing
the span between abutments may reduce the reactive
forces and stresses in the 2 distal abutments. Figure 2
simulates a cantilever FPD with an enlarged interabutment span (EC-FPD) and presents shear and bending
228

Fig. 4. Orthodontic phase.


VOLUME 89 NUMBER 3

LEWINSTEIN, GANOR, AND PILO

THE JOURNAL OF PROSTHETIC DENTISTRY

Fig. 5. A, Prepared teeth. Note small convergence of axial walls. B, Provisional fixed partial denture.

Fig. 6. Final impression.

Fig. 7. Final PFM cantilever 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.

teeth in the maxillary posterior quadrants that resulted


in a loss of the support, thus creating an incomplete
shortened arch. On the maxillary left side, the second
premolar and all molars were missing (Fig 3). The periapical radiograph showed the first premolar with 2 roots,
mesially located and angulated. Proximity of the palatal
root and the maxillary sinus was demonstrated radiographically. The peridontium was normal except for a
5-mm gingival pocket in the mesial aspect of the tooth.
A similar situation was observed on the right side. After
various treatment options were presented, the patient
selected an FPD and rejected treatment with an implantsupported fixed restoration.
The objectives of the treatment were to (1) upright
and reposition the maxillary left first premolar for a more
favorable tooth position, (2) increase the span between
premolar and the canine teeth for a better design of an
FPD, (3) eliminate the existing periodontal pockets, and
(4) restore the missing teeth with a cantilever FPD in an
attempt to reduce reactive forces in the abutment teeth.
After the initial phase of oral hygiene, the maxillary
first premolar was prepared for a crown by removing an
old amalgam restoration and replacing it with a provi-

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

THE JOURNAL OF PROSTHETIC DENTISTRY

LEWINSTEIN, GANOR, AND PILO

Fig. 8. Periapical view left side. A, Before treatment. B, After treatment.

sional crown. In the orthodontic phase, the premolar


was uprighted and distally moved using brackets, arch
wire, and an activated coil spring (straight braided
round coil spring; Dentaflex wire; Dentarum, Pforzheim, Germany) (Fig. 4). Plaque removal and root planning was carried out twice a month during this phase.
The orthodontic movement occurred over 5 months
followed by retention. At the end of the orthodontic
phase, the premolar was repositioned to the location of
the missing second premolar. In the retention phase, the
first premolar and the canine were splinted together for
6 weeks with composite reinforced by a twist-flex wire
(0.018-inch Dentaflex wire; Dentarum, Pforzheim,
Germany). After the retention phase, the teeth were
prepared and received a 4-unit provisional FPD (Fig. 5).
An impression was made to fabricate a cantilever FPD
made of porcelain fused to metal (Fig. 6). After try-in
and occlusal adjustment of the definitive retoration to
assure that the cantilever was free of contacts in lateral
excursions, the FPD was provisionally cemented (Tempbond NE; Kerr, Peterborough, United Kingdom). After
1 month, the restoration, abutment teeth, and periodontium were examined for changes in material properties, mobility, and any disease. There was no evidence
of any change or disease, and the FPD was cemented
permanently with zinc phosphate cement (Harvard cement; Harvard Dental GmbH, Berlin, Germany) (Fig.
7). The interabutment span before and after treatment
are shown in Figure 8. Four years after cementation, the
cantilever shortened arch is in service without incidence,
and the patient remains satisfied. The right side was
similarly restored.

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

LEWINSTEIN, GANOR, AND PILO

THE JOURNAL OF PROSTHETIC DENTISTRY

19. Hobo S, Ichida E, Gracia LT. Osseointegration and occlusal rehabilitation.


2nd ed. Tokyo: Quintessence Int; 1990. p. 267-80.
Reprint requests to:
DR ISRAEL LEWINSTEIN
DEPARTMENT OF ORAL REHABILITATION
THE MAURICE AND GABRIELA GOLDSCHLEGER SCHOOL
TEL AVIV UNIVERSITY
TEL AVIV 69978
ISRAEL

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

Fracture of the genial tubercles associated with a mandibular denture:


A clinical report
Izhar Shohat, DMD,a Yitzhak Shoshani, DMD,b and Shlomo Taicher, DMDc
The Chaim Sheba Medical Center, Tel Hashomer, Israel; and The Maurice and Gabriela
Goldschleger School of Dental Medicine, Tel Aviv University, Tel Aviv, Israel
Fracture of the genial tubercles without an associated mandibular fracture is uncommon. It occurs
mainly in patients wearing a complete mandibular denture when the mandible is atrophied and the genial tubercles are hypertrophied. Only 7 reports have been found in the English-language literature.
An additional situation of a 70-year-old woman is presented along with a review of the literature. A
conservative approach to treatment is advised with this type of fracture. The use of dental implants
should be considered in patients with hypertrophied tubercles to prevent such fracture. (J Prosthet
Dent 2003;89:232-3.)

he genial tubercles are a group of bony extensions


that surround the lingual foramen bilaterally on the lingual surface of the mandible, situated midway between
the superior and inferior borders of the mandible.1,2
They form the sites of origin of the genioglossus muscle
superiorly and geniohyoid muscle inferiorly.3 Hypertrophy of the genial tubercles is common especially in atrophied mandibles.4
Fracture of the genial tubercles without an associated
mandibular fracture is uncommon. A search of MEDLINE between the years 1967 and 2002 revealed only 7
reports of such fractures.1-6 The mean age of the patients
was 67 years, and the male to female ratio was 2:5. All
patients had maxillary complete dentures. It appears that
fracture of the genial tubercles in an atrophied mandible
can occur under normal masticatory forces, which are
delivered through the mandibular denture.
The signs and symptoms associated with the fracture
of the genial tubercles may include pain, swelling and
hematoma in the floor of the mouth, limitation in
tongue mobility, dysphagia, and discomfort while wearing the mandibular denture.4-6 Occlusal and panoramic
radiographs should be made of this region to rule out
additional mandibular fractures.
The treatment of fracture of the genial tubercles is
controversial. Surgical intervention was initiated in 3
clinical reports.2,4,5 With the patient under local anesthetic, the fractured tubercles were removed and the
muscles were repositioned. Bony fragments were removed to confirm the diagnosis and to prevent possible
chronic irritation to the soft tissue caused by the fragments, not because of any complication such as infeca

Resident, Department of Oral and Maxillofacial Surgery, The Chaim


Sheba Medical Center.
b
Attending, Department of Oral and Maxillofacial Surgery, The
Chaim Sheba Medical Center.
c
Associate Professor and Head, Department of Oral and Maxillofacial Surgery, The Maurice and Gabriela Goldschleger School of
Dental Medicine.
232 THE JOURNAL OF PROSTHETIC DENTISTRY

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

SHOHAT, SHOSHANI, AND TAICHER

THE JOURNAL OF PROSTHETIC DENTISTRY

tured portion of the tubercles to be in the same position


as it was immediately after the incident.

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.

Fig. 1. Sublingual hematoma in floor of mouth.

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.

Fig. 2. Occlusal radiograph demonstrating fracture of genial


tubercles.

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

Reprint requests to:


DR IZHAR SHOHAT
DEPARTMENT OF ORAL AND MAXILLOFACIAL SURGERY
THE CHAIM SHEBA MEDICAL CENTER
TEL HASHOMER, 52621
ISRAEL
FAX: 972-3-5341210
E-MAIL: taichs46@sheba.health.gov.il
Copyright 2003 by The Editorial Council of The Journal of Prosthetic
Dentistry.
0022-3913/2003/$30.00 0
doi:10.1067/mpr.2003.46

233

Prosthetic rehabilitation of a total rhinectomy patient resulting from


squamous cell carcinoma of the nasal septum: A clinical report
Darunee P. NaBadalung, DDSa
School of Dental Medicine, SUNY-Buffalo, Buffalo, N.Y.
The clinical characteristics and prosthetic rehabilitation of a patient with squamous cell carcinoma of
the nasal septum after combined radiation therapy and a total rhinectomy is presented. (J Prosthet
Dent 2003;89:234-8.)

ancer of the head and neck is a generic term applied


to a group of malignant tumors that occur in the anatomic regions of the head and neck. Tumors found in
the upper aerodigestive tract account for most of these
head and neck cancers.1 Higher incidences of these malignancies have been noted among elderly patients, with
a prevalence 3 times higher in men than in women.2,3 In
the United States, approximately 60,000 to 61,000 new
head and neck cancers are reported annually with a 27%
mortality rate.3 Early detection increases the chance of a
cure; unfortunately, only about 35% of those diagnosed
have curable diseases at the time of diagnosis.
Malignancies of the nasal septum are rare and account
for only 9% of all cancers of the nasal cavity.4 As of the
year 2000, there had been 300 reported cases of carcinomas of the nasal septum.5 Most of these tumors were
squamous cell carcinoma.5-7 These tumors are considered deadly unless diagnosed and treated early.8
Molecular biology investigations5-7,9-11 have increased knowledge about squamous cell carcinomas of
the head and neck. The mechanism of malignant transformation progresses in 2 stages: initiation and promotion. The process of initiation describes the onset of
permanent cellular DNA damage. Promotion refers to
environmental agents, such as tobacco,9,10 alcohol, and
viruses that stimulate cellular proliferation or alter differentiation. These mechanisms may include dysregulation of the proliferating cell nuclear antigen, transforming growth factor, glycoprotein, loss of tumor
suppressor activity at gene 9p21, amplification of the
cyclin D1 gene, mutations of gene p53, and overexpression of gene bcl-2.
Treatment options for nasal septum carcinomas are
the same as treatments of the other cancers of the head
and neck, including surgery, radiation therapy, and chemotherapy. These treatments, used alone or in conjunction with one another, have been used to satisfactorily
control or even cure the disease.4,8 However, delayed
diagnosis, smoking, alcohol consumption, poor nutrition, and other unknown factors seemed to decrease the
effectiveness of these treatments. In recent years, newer
a

Assistant Professor, Prosthodontics, Department of Restorative Dentistry.

234 THE JOURNAL OF PROSTHETIC DENTISTRY

treatment options such as cryotherapy, immunotherapy,


cytotoxic treatment, photodynamic treatment, and hyperthermal treatment have been used in conjunction
with conventional treatment methods for head and neck
cancers.12 Unfortunately, most of these treatment methods result in unwanted or incapacitating defects requiring immediate short- or long-term management and
rehabilitation procedures.
Reconstruction of head and neck defects after surgical treatment can be accomplished either surgically or
prosthetically.5-8,13 The site, size, etiology, severity, age,
and patients desire are used to determine the methods
of reconstruction. Prosthetic rehabilitation has considerable advantages; for example, a prosthesis offers the
clinician and the patient the means to observe the healing wound for recurrence of disease, esthetic superiority,
technical simplicity, and inexpensive care. Most facial
prostheses are retained with adhesives and mechanisms,
including anatomic undercuts, eyeglasses, and magnets.14-18 In the last 2 decades, osseointegrated implants
have been used for improving support and retention of
the facial prostheses.19-24 Recently developed surgical
reconstruction techniques (microvascular surgery, free
flap)25-27 have been presented as the new treatments of
choice. However, radiation therapy, anatomic complexity, possibility of recurrence, appearance of the area to be
rehabilitated, and complexity of the surgical procedure
may exclude surgical reconstruction as an option as in
the situation of a patient undergoing total rhinectomy.7,13
For the purpose of prosthetic rehabilitation for facial defects, biomaterials such as polymethyl methacrylate, polyvinyl chloride, polyurethane, and silicone
have been used. Silicone materials are the most widely
used for facial prostheses because of their various superior features.18 Silicone preparations with different
chemical and physical properties have provided the
required versatility for industrial applications; however, these silicone materials fall short of an ideal maxillofacial prosthetic material because of their poor adheophilic property, polishing problems, low tear
resistance, and microbial growthpromoting characteristics.18,28
VOLUME 89 NUMBER 3

NABADALUNG

THE JOURNAL OF PROSTHETIC DENTISTRY

Fig. 2. Perforated die stone cast.

cess of using a prefabricated urethane sheet as a lining for


the tissue surface of the silicone materials has been evaluated.28 The urethane sheet has a high tear resistance
and is clear, smooth, easily cleanable, and compatible
with many available adhesives. In addition, the urethane
material can be satisfactorily bonded to metals and silicone materials, producing a superior prosthesis. Such a
prosthesis could be called a composite prosthesis.
This clinical report describes the prosthetic rehabilitation of a patient with nasal septum squamous cell carcinoma after radiation therapy and a total rhinectomy.

CLINICAL REPORT

Fig. 1. A, Patients face with defect after total rhinectomy. B,


Maxillary denture with modified button (patrix) extended to
nasal cavity.

Methods of overcoming these weak properties and


taking advantage of the superior features of the silicone
materials have been introduced. For example, the proMARCH 2003

A 56-year-old white woman with a 5-year history of


treatment for infection and allergic rhinitis noted, over a
2-month period, some swelling and partial obstruction
of her nares. She had a history of smoking 1 or more
packs of cigarettes a day for many years. She reported no
weight loss, difficulty swallowing, headaches, or seizures.
A biopsy revealed a well-differentiated squamous cell
carcinoma involving the anterior portion of the nasal
septum. The patient received Co 60 radiation and a
booster dose to the primary site with an electron beam.
After radiation therapy, the patient complained of difficulty breathing through her nose. A mass obstruction in
her nose was noted; subsequently, in August 1999, the
patient underwent a total rhinectomy followed by radiation therapy. Surgical reconstruction was not recommended at the time due to the need for continued observation. The patient was referred to the clinic for
possible prosthetic restoration of the nasal defect.
The patient reported with post-total rhinectomy
(Fig. 1, A). There was no skin graft lining over the
defect. The patient was completely edentulous with
235

THE JOURNAL OF PROSTHETIC DENTISTRY

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.

healthy oral tissues and wore maxillary and mandibular


dentures. Examination of both dentures in position revealed an acceptable vertical dimension of occlusion.
The posterior teeth were in contact in centric relation,
and there was no interference in eccentric movements.
The mandibular denture showed excellent stability and
retention, but the maxillary denture showed compromised retention due to the existing maxillary defect. Use
of root form osseointegrated implants for retention of
the nose prosthesis was considered; however, after discussing potential problems with this treatment modality21,24 (the patient was in the recurrent observation period), she rejected further surgery. The fabrication of a
nasal prosthesis with modification of the maxillary denture was planned, and the expectation of this treatment
was explained to the patient.

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

trate Plus;LD Caulk Div Dentsply International Inc,


Milford, Del.) supported with polyester fiber (Factor
II Inc, Lakeside, Az.) and a thin layer of dental stone
(Jade Stone; Whip Mix Corp, Louisville, Ky.). To
facilitate the adaptation of a polyurethane sheet, a
perforated cast was made as described by Udagama28
(Fig. 2). To fabricate a hollow prosthesis29,30 that
would reduce the weight of the nose prosthesis and
make a space for breathing, a hole was made through
the defect area and a clay-core of the nose prosthesis
was made on the cast. The prosthesis was sculpted
with generic pink base-plate wax over the core. On
completion and verification of the wax prosthesis via a
trial insertion procedure, the core was replaced with a
vacuum mixed dental stone. The wax sculpture was
flasked on the cast with the room temperature vulcanization silicone material (Dow Corning Corp, Midland, Mich.), and the wax was eliminated. A lining
polyurethane sheet (0.004-inch thick; Factor II Inc)
was prepared and adapted on the perforated master
cast.28 A mold was prepared, packed, and processed in
the following manner: (1) a silicone separating agent
(Dow Corning Corp) was applied over the mold surface, (2) a fresh thin layer of Type A adhesive (Dow
Corning Corp) was applied on the primed lining ureVOLUME 89 NUMBER 3

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

THE JOURNAL OF PROSTHETIC DENTISTRY

received a combined total rhinectomy and irradiation


therapy.
I thank Dr L. Ann Reid for assistance on this manuscript and the
patient for her cooperation.

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

THE JOURNAL OF PROSTHETIC DENTISTRY

29. Brown KE. Fabrication of a nose prosthesis. J Prosthet Dent 1971;26:54354.


30. Taicher S, Bergen SF, Rosen A, Levy M, Lepley JB. Hollow polydimethylsiloxane facial prostheses using anatomic undercuts. J Prosthet Dent 1982;
48:444-7.
Reprint requests to:
DR DARUNEE P. NABADALUNG
PROSTHODONTICS, DEPARTMENT OF RESTORATIVE DENTISTRY
SUNY-BUFFALO SCHOOL OF DENTAL MEDICINE

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

Bound volumes available to subscribers


Bound volumes of The Journal of Prosthetic Dentistry are available to subscribers (only) for
the 2002 issues from the publisher at a cost of $92.00 ($106.00 international) for Vol. 87
(January-June) and Vol. 88 (July-December). Shipping charges are included. Each bound volume
contains a subject and author index, and all advertising is removed. The binding is durable buckram
with the journal name, volume number, and year stamped in gold on the spine. Payment must
accompany all orders. Contact Mosby, Subscription Customer Service, 6277 Sea Harbor Dr, Orlando, FL 32887, or call 800-654-2452 or 407-345-4000.
Subscriptions must be in force to qualify. Bound volumes are not available in place of
a regular Journal subscription.

238

VOLUME 89 NUMBER 3

An alternate treatment method for a fixed-detachable hybrid prosthesis:


A clinical report
George W. Cobb, Jr, DDS,a A. Max Metcalf, DDS,b Douglas Parsell, PhD,c and
Gary W. Reeves, DMDd
Houston Dental Branch, University of Texas, Houston, Texas; School of Dentistry, University of
Mississippi, Jackson, Miss.
The inability to consistently achieve a passive fit with screw-retained implant prostheses is well documented in the literature. Cement-retained implant frameworks have been advocated for implant-retained fixed partial dentures. However, cement retention has not been routinely advocated for fixeddetachable hybrid prostheses. This article describes a method for fabricating a cement-retained fixeddetachable hybrid prosthesis. The advantages and disadvantages are discussed. (J Prosthet Dent 2003;
89:239-43.)

he inability to consistently achieve a passive fit with


a multiple-implant ceramo-metal prosthesis led to the
development of the fixed-detachable hybrid prosthesis.1,2 The high temperatures necessary for firing porcelain onto the metal frameworks may result in warpage
and lack of passivity.2,3 Zarb and Symington4 and Lundquist and Carlsson5 developed the hybrid prosthesis by
attaching denture teeth with heat-polymerized acrylic
resin to a cast metal substructure. Although this technique has been used successfully for a number of years, it
does have shortcomings.3-5 First, passive fit of the metal
substructure may require sectioning and soldering after
initial fabrication. Even then, a completely passive substructure does not always result.6-10 Second, access holes
must be present to allow for screw tightening or retrieval
of the prosthesis. The access holes may compromise esthetics and occlusion, especially when implants are angled or placed labially to the planned tooth position as a
result of severe mandibular resorption.7 Third, the clinical and laboratory techniques are complex and generally
require an experienced clinician and technician.2,3,6-8
The degree of misfit between implant frameworks
and implants that will cause bone loss or failure of osseointegration clinically has yet to be determined.8 It has
generally been accepted that passive seating of a prosthesis is a requirement for maintaining successful longterm osseointegration.6,7,9,10 Furthermore, the literature has implicated ill-fitting implant frameworks as a
significant factor in the cause of mechanical and biologic
complications.9-12,13 Loosening of screws for both prosthetic components and abutments and even fracture of
a

Associate Professor, Department of Prosthodontics, University of


Texas.
b
Assistant Professor, Department of Restorative Dentistry, University
of Mississippi.
c
Associate Professor, Department of Restorative Dentistry, University
of Mississippi.
d
Professor and Chairman, Department of Restorative Dentistry, University of Mississippi.
MARCH 2003

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

THE JOURNAL OF PROSTHETIC DENTISTRY

COBB ET AL

span (2 to 4 teeth) fixed partial dentures.21 But the


criteria for optimal fit of implant abutments to implant
fixtures is 10 m or less,22 which is difficult to achieve
consistently with fixed-detachable hybrid superstructures made with conventional methods and materials.
The clinical/laboratory technique presented explores an
approach appropriate when the previously mentioned
casting size limitation is surpassed and traditional methods may yield clinically unacceptable dimensional mismatches. Furthermore, this report describes a method
for constructing a fixed-detachable hybrid prosthesis
with cement retention and discusses the rationale, advantages, and disadvantages of this technique.

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

Fig. 2. Prepared abutments on master cast.

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

THE JOURNAL OF PROSTHETIC DENTISTRY

Fig. 3. Cast framework fitted to abutments on master cast


with tooth index.

Fig. 4. Intraoral view of prepared abutments connected to


implants.

Fig. 5. Intaglio surface view of processed prosthesis.

technically complex tasks in implant dentistry. In spite of


a number of techniques to prevent or correct distortions
that occur during impression making, cast pouring, waxing, casting, indexing, and soldering, errors in the fit of
241

THE JOURNAL OF PROSTHETIC DENTISTRY

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.

frameworks persist. The gap between an implant fixture


and an abutment should be 10 m or less to be considered passive.22 This degree of fit may be almost impossible with the geometry of most screw-retained fixeddetachable hybrid prostheses. The technique presented
may not initially produce a perfectly passive framework,
but use of disclosing media and adjusting the internal
aspect of the casting can result in nonbinding, fully
seated prostheses.
Disclosing media were used to evaluate the fit of the
framework on the implant abutments in the same manner as are used to ensure complete seating and passivity
for conventional fixed and removable partial dentures.
Adjustments to the internal surfaces of the framework
can then be made to eliminate binding as in conventional prostheses. Although the possibility exists that
sectioning, indexing, and soldering may be required to
obtain a passive-fitting substructure of this design, modification of the internal aspects should be sufficient in the
majority of situations. On the other hand, a screw-retained prosthesis either fits passively or it does not. If it
does not, the only alternative is to section and solder.
242

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

THE JOURNAL OF PROSTHETIC DENTISTRY

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

The anterior cantilever in the implant-supported screw-retained mandibular


prosthesis
M. E. Brosky, DMD,a T. W. P. Korioth, BOd, Cir Dent, PhD,b and J. Hodges, PhDc
School of Dentistry, University of Minnesota, Minneapolis, Minn.; and Nova Southeastern
University, Fort Lauderdale, Fla.
Statement of problem. When implants are placed interforaminally in mandibular implant-supported screwretained prostheses, the most anterior implant is usually positioned lingual to the incisors of the prosthesis. This
creates an anterior cantilever with the entire prosthesis acting as a class I lever and possibly placing the anterior
implant under alternating tension and compression during function.
Purpose. The purpose of this study was to measure the anterior cantilever of randomly chosen patients with
restored mandibular implant-supported fixed prostheses, and to establish the proportions of anterior to posterior
cantilever lengths relative to the anteroposterior spread.
Material and methods. Thirteen edentulous patients were recruited from the University of Minnesotas
dental implant program. Each patient had been restored with a maxillary complete denture and a mandibular
implant-supported screw-retained prosthesis supported by 5 endosseous implants. Each patient had 1 mandibular
impression made with irreversible hydrocolloid, which was poured in type III gypsum. A FaroArm precision 3D
measuring stylus was used to make multiple-axis (X-Y-Z) measurements (mm) on the casts of the dental implants,
of anteroposterior spread, and anterior and posterior cantilevers. Presence or absence of screw loosening was
noted using a screwdriver with finger pressure. Data were analyzed using a 1-way analysis of variance to compare
prostheses with loose screws to prostheses without loose screws, for each of 3 outcome measures: length of
anterior cantilever, length of posterior cantilever, and anteroposterior spread (P.05).
Results. Mandibular anterior cantilever lengths ranged from 5.5 to 14.4 mm with a mean of 8.78 mm.
Combined posterior cantilever lengths ranged from 9.2 to 20.9 mm with a mean of 16.2 mm. Anteroposterior
spread ranged from 5.2 to 12.3 mm with a mean of 7.9 mm. From a total of 65 retaining screws, 7 were found
to be completely loose. No apparent correlation was found between length of mandibular anterior cantilever and
screw loosening (P.45), although the ratio of posterior cantilever to anteroposterior spread (2:4) was significantly associated with screw loosening (P.006).
Conclusion. Within the limitations of this study, anterior cantilevers in mandibular implant-supported screwretained prostheses were frequent and appeared to depend on implant placement and prosthesis design. The ratio
of anterior to posterior cantilever lengths was approximately 1:2. (J Prosthet Dent 2003;89:244-9.)

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.

t appears that the anterior cantilever in mandibular


implant-supported screw-retained prostheses has received little attention in past in vitro or in vivo investigations (Fig. 1). It seems that the cantilever usually develops as a consequence of mandibular implant
placement and resultant prosthetic restoration.

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

For many years, great emphasis was placed on the best


possible intraoral location for dental implants.1 Investigations by Adell et al1 and Branemark et al2 have shown
that the anterior mandible has the best long-term prognosis for implant placement, because the optimal quantity and quality of bone.
Tallgren3 traced anterior mandibular bone loss patterns and noted that subjects displayed not only a vertical but also a marked horizontal loss of bone. Boucher et
al4 described ridge resorption patterns for the maxilla as
superior and medial, whereas the mandible is inferior
and lateral. This is true for the posterior areas of the
mandible, but in the intraforaminal area this is not so.5,6
Histologically and from a gross anatomy perspective, the
VOLUME 89 NUMBER 3

BROSKY, KORIOTH, AND HODGES

Fig. 1. Cast of implant-supported screw-retained prosthesis.


Mandibular anterior cantilever defined as distance from center of most anterior implant (Imp) to incisal edge (Inc) of most
anterior tooth in mandibular implant-supported screw-retained prosthesis.

labial cortical plate of the anterior mandible is thinner


than the lingual cortical plate,5 but both cortical plates
are dense with coarse internal trabecular bone.6 Thus
the resorption pattern seems to be more horizontal or
slightly lingual, as illustrated by Tallgren.3 Because this
resorption pattern, the greatest quantity of available
bone for implant placement is lingual to the natural
tooth position.3,5,6
With optimum placement of mandibular implants intraforaminally, a cantilever is needed to obtain posterior
occlusion when restoring an implant-supported screwretained prosthesis. Historically, investigators have theorized lengths of the posterior cantilever on the basis of
the anteroposterior spread.7-9 English7 recognized the
cantilever magnification and defined a critical anteroposterior spread. He recommended that the length of
the mandibular posterior cantilever for a fixed-detachable prosthesis with 5 implants be 1.5 times the length of
the anteroposterior spread. Recently, however, McAlarney and Stavropoulos10 suggested that a cantilever
length to anteroposterior spread ratio of 2:1 was too
high for 6 implants. Branemarks classic design for a
cantilever prosthesis was to place 4 to 6 implants intraforaminally and cantilever 2 to 3 premolars bilaterally to
obtain posterior occlusion.1,2 Additional literature has
suggested mandibular posterior cantilever lengths of less
than 15 mm,11 15 to 20 mm,8,12 or no greater than 20
mm.13-17
Lindquist et al18 and White et al19 studied the effects
of cantilever length on stresses transferred to bone by
the implant-supported prosthesis. Their findings revealed that cantilever length can influence forces delivered to the implants and bone and can directly affect
marginal bone loss. Rangert et al8 addressed the fundamentals of the mechanical parameters that determine
the load on implant units. They demonstrated that prosthesis design and implant placement have a significant
influence on bone stress, as well as on screw attachment.
MARCH 2003

THE JOURNAL OF PROSTHETIC DENTISTRY

Reports on the frequency of implant screw loosening


in the literature are variable but seem quite high.17,20-24
Many authors have cited implant screw loosening as a
disadvantage, although prosthesis retrievability may be
regarded as an advantage. When a screw is tightened, it
is placed under a tensile force. Patterson et al25 demonstrated that the screw loosens only if the outside forces
trying to separate the components are greater than the
force keeping them together. The length of a cantilever
creates a mechanical advantage to increase the applied
forces and may exacerbate screw loosening.26 As an individual with the fixed detachable prosthesis goes
through the chewing cycle, they incise food (applying
compressive forces to the anterior of the prosthesis and
tensile forces to the posterior) as well as grind (applying
compressive forces to the posterior of the prosthesis and
tensile forces to the anterior). This motion creates alternating tension and compression (see-saw motion) on
the retaining screws, which may tend to loosen the attachment apparatus.
In addition to stresses transferred to bone via cantilever, alveolar ridge resorption in combination with facial musculature have been shown to increase forces
transmitted to the bone via mandibular deformation,27-30 increased masticatory force,31-33 occlusion,34,35 and decreasing intra-arch distance during
movements.27 Increased occlusal loads applied to cantilevers have also produced additional stresses leading to
bone loss and implant failure.19,36,37 One cannot overlook additional stresses transferred to the bone because
of nonpassive castings38 and superstructure design.39,40
A review of the literature revealed a scarcity of publications related to the identification of the mandibular
anterior cantilever. This study defined the mandibular
anterior cantilever as the distance from the center of the
most anterior implant to the incisal edge of the most
anterior tooth in a mandibular implant-supported
screw-retained prosthesis. It was hypothesized that the
frequency of anterior or mid-screw loosening was related to an increased anterior cantilever length.
The objectives of this investigation were therefore to
3-dimensionally digitize dental casts obtained from patients restored with mandibular implant-supported
screw-retained prostheses supported by 5 endosseous
implants, and establish the proportions of anterior to
posterior cantilever lengths relative to the anteroposterior spread. A presence or absence of mandibular implant screw loosening was then correlated with the
above distances.

MATERIAL AND METHODS


A total of 13 edentulous patients were randomly recruited from the University of Minnesotas dental implant program. Of the 13 patients, 10 were female and 3
were male ranging from 56 to 91 years of age. Dental
245

THE JOURNAL OF PROSTHETIC DENTISTRY

implants and prostheses had been placed from 7 to 10


years before, all having been placed and restored by the
same oral maxillofacial surgeon and prosthodontist.
Each patient was restored with a conventional maxillary
complete denture and mandibular implant-supported
screw-retained prosthesis supported by 5 dental implants placed intraforaminally. No attempt was made to
examine the skeletal classification or vertical dimension
of occlusion, and it appeared that all patients had been
restored to a clinical class I dental relationship. Approval
from the Committee for the Use of Human Subjects in
Research, as well as informed consent from all patients
was obtained before enrollment.
Each patient came to the Oral Health Clinical Research Center, medical and dental histories were reviewed and updated, and an oral examination was performed. Resin from the access holes of the mandibular
implant-supported screw-retained prosthesis was removed and an impression was made (Coe Spacer Trays;
GC America Inc, Chicago, Ill.) with an irreversible hydrocolloid (Coe Alginate; GC America Inc). The maxillary denture and mandibular prosthesis were then removed and ultrasonically cleaned. No control was used
to determine whether the screws were loose. Rather,
finger pressure deemed screws loose only if complete
looseness occurred. The prostheses were then reinserted
in the patients mouth, screws were tightened at the
recommended torque level, and the screw access holes
were sealed as they were found.
Each irreversible hydrocolloid impression was poured
with resin die stone (Apex RZ-10; Garreco Inc, Herber
Springs, Ark.), vacuum-mixed in a mechanical spatulator (VAC-U-VESTOR; Whip Mix, Louisville, Ky.) for
15 seconds at low speed, and vibrated into the impression. Poured impressions were allowed to set undisturbed for 1 hour; resultant casts were then removed
from the impression and trimmed. Each cast was then
secured to the platform of the FaroArm (Faro Technologies Inc, Lake Mary, Fla.) and point measurements
were made (Fig. 2).
The FaroArm is a precision 3-dimensional measuring
stylus with a measurement volume of 4 feet, allowing the
operator to make measurements in multiple axes (X-YZ)41 (Fig. 3). It has an accuracy of 75 m and singlepoint repeatability of 0.035 mm.41 It uses integrated
optical encoders, precision bearings, and patented counterbalancing for infinite positioning freedom.42 Measurements were made with a 6-mm-diameter ball probe.
The FaroArms point of measurement on any ball probe
is the center of the ball, whereas quality control software
compensates for the radius of the ball probe. Caliper
3-dimensional software was developed by Faro Industries to analyze the data received from the FaroArm. The
FaroArm was calibrated by the company during installation, and self-calibration procedures were done for this
investigation before use, as recommended by the man246

BROSKY, KORIOTH, AND HODGES

Fig. 2. FaroArm with cast on platform.

Fig. 3. Multiple-axis measurements obtained with FaroArm.

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

BROSKY, KORIOTH, AND HODGES

THE JOURNAL OF PROSTHETIC DENTISTRY

Table 1. FaroArm measurements obtained from the implant-supported screw-retained prosthesis

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

ver length should not be used alone when deciding a


successful treatment outcome; other significant variables
such as craniofacial geometry and its force productive
capabilities, different implant systems, and prosthesis
design should also be taken into account.
Within the design of the implant system, the retaining
screw seems to be the weakest link.2,20,22,24-26 Loosening
of retaining screws results in patient and dentist frustration and, if left untreated, may result in fracture. Several
interrelated factors may play a role in screw loosening.
Ample torque administered with a torque wrench will
provide the desired pretorque value to the retaining
screws. As long as the potential separating forces between the screw and the implant are kept below the
clamping force, the joints will not separate. Cantilever
lengths kept to a minimum will help decrease the chance
of screw loosening, which may lead to fracturing of the
prosthesis or bone loss.9,18,19,36 Passivity and intimate
contact of the superstructure with the abutments is essential but difficult to determine exactly. An inaccurate
fit will produce microscopic flexure, leading to possible
screw fracture, or an overload of the prosthesis, also
leading to fracture.8,39 Material fatigue is a common
occurrence with occlusal materials caused by the increased magnitude of force that the patient is able to
apply in function to either the opposing arch or the
prosthesis.43 These fractures are due in part to prosthesis
design, lack of a periodontal ligament, parafunction, or
additional concentration of stress placed on the prosthesis over the screw access hole.38,43 In addition, English7
emphasized the importance of the distance of the occlusal plane to implant height, or the crown to root ratio.
He suggested that if the height from the top of the
247

THE JOURNAL OF PROSTHETIC DENTISTRY

implant to the top of the occlusal plane was 20 to 28


mm, a 2:1 to 3:1 crown to root ratio would be produced
if 8- to 10-mm dental implants were placed. These vertical layers coupled with long cantilever lengths could
lead to mechanical or osseous failure.7
With the potential decrease in available bone quantity
in the implant patient, there may be a decrease in resistance to mandibular deformation, particularly in the situation of powerful masticatory muscle action. Investigations by Hobkirk and Schwab27 revealed a 0.042-mm
decrease in intra-arch distance during opening and a
16-N force transmission between implants. It has been
suggested that mandibular deformation could impose
complex bending forces between implants and their superstructure, and direct unfavorable forces to the bone,
which may result in implant failure or bone loss.19,27-30
The importance of the Frankfort-mandibular plane angle (FMA) has also been investigated in relation to bone
loss.31-33 DiPietro and Moergeli31 concluded that patients with a low FMA had increased masticatory forces
that resulted in transmittal of more stress to the residual
ridges. This increased stress resulted in greater ridge
resorption in the edentulous32 and a less favorable prognosis for long span and cantilevered fixed partial dentures in the partially edentulous patient.31
Implant-supported prosthodontic reconstruction
should be rigid.40 This would lead one to expect greater
stress in bone surrounding the implants than in bone
surrounding natural teeth during functional movement
of the mandible. Under forces of occlusion, dental implants move approximately 10 m, and natural teeth
move 50 to 200 m under similar forces.34,35 Thus these
implant stresses arise not only from mandibular deformation and low FMA, but also from occlusion and parafunction. It has been suggested in the literature that
excessive marginal bone loss and implant loss be correlated with occlusal overloading and poor oral hygiene.19,37 Skalak9 noted that when the forces placed on
the implant are tensile and compressive, the vitality of
the bone is maintained; however, when the forces are
shear or when there is no force, bone volume begins to
decrease. Occlusal stresses are momentary, whereas
stresses from bending during functional movement are
more long term. If each human chewing cycle lasts approximately 700 to 1000 ms, occlusal forces maybe active for approximately 200 ms of this cycle. However,
stresses from functional movements can be active during
the entire cycle.44 The net effect is that the bone surrounding the implants is subjected to continuous
stresses of varying magnitudes. These stresses could result in remodeling or loss of bone, which could jeopardize long-term success of dental implants.
In using Skalaks rigid model, McAlarney and Stavropoulos10 addressed the posterior cantilever length and
the anteroposterior spread ratio assuming failure of the
prosthesis retaining-screw-prosthesis joint. Different
248

BROSKY, KORIOTH, AND HODGES

spatial arrangements and numbers of implants placed


intraforaminally were used, in addition to force variables
of 143 N (vertical load), 200 N (pretorque value), and
400 N (joint tensile yield strength). Contrary to previous assumptions, these authors suggested that a posterior cantilever length to anteroposterior spread ratio of
2:1 was still too high for all situations except when 6
implants were used. Their results were based on the
theoretically assumed failure forces that were applied.

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

BROSKY, KORIOTH, AND HODGES

THE JOURNAL OF PROSTHETIC DENTISTRY

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

Availability of JOURNAL Back Issues


As a service to our subscribers, copies of back issues of The Journal of Prosthetic Dentistry for
the preceding 5 years are maintained and are available for purchase from the publisher, Mosby, until
inventory is depleted. Please write to Mosby, Subscription Customer Service, 6277 Sea Harbor Dr,
Orlando, FL 32887, or call 800-654-2452 or 407-345-4000 for information on availability of particular issues and prices.

MARCH 2003

249

Accuracy of open tray implant impressions: an in vitro comparison of stock


versus custom trays
Jason Burns, MSc, BDS, LDS, DGDP,a Richard Palmer, PhD, BDS,b Leslie Howe, BDS,c and
Ron Wilson, PhD, MPhild
Guys Hospital, London, England
Statement of problem. The accuracy of an implant fixture-level impression is affected by the type of impression tray used.
Purpose. The purpose of this in vitro study was to investigate the accuracy of open tray implant impressions
comparing polycarbonate stock impression trays and rigid custom-made impression trays to make implant
fixture-level impressions.
Material and methods. Gold cylinder pairs, splinted by gold bars (reference frameworks) were constructed on
an aluminum typodont. Polyether impressions were made of 2 pairs of Brnemark 3.75-mm diameter fixtures
mounted in an aluminium typodont, with 3 stock impression trays, 3 close-fit custom trays, and 3 spaced custom
impression trays, by use of an open tray technique. The casts produced were assessed for accuracy by attaching the
reference frameworks with alternate single screws and measuring the vertical fit discrepancy of these reference
frameworks to the analogs within the working cast using a traveling microscope. Comparison of gap dimensions
by tray type was performed with a nonparametric Kruskal-Wallis analysis of variance (ANOVA) followed by
pair-wise Mann-Whitney U tests. To adjust for multiple comparisons in the post-ANOVA contrasts (P.02).
Comparison of gap dimensions between anterior and posterior regions were performed with Mann-Whitney U
tests (P .05).
Results. 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). The difference in median gap size for analogs with a 20-mm separation
was 10 m.
Conclusion. Within the limits of this in vitro study, rigid custom trays produced significantly more accurate
impressions than the polycarbonate stock trays. The stock trays used in this study could not produce accurate
impressions consistently. For analogs with a 20-mm separation, there was a difference in medians of 10 m in
accuracy between the stock and custom trays. (J Prosthet Dent 2003;89:250-5.)

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.

any clinicians and authors have addressed the


idea that passive fit of implant prostheses is essential to
long-term treatment success.1-5 Although it is assumed
that a misfitting prosthesis between 2 or more implants
may have a negative effect on the long-term stability of
those implants, evidence to support this theory is lacking.6
The statistical correlation between prosthesis misfit
and marginal bone level changes in maxillary implants
with in vivo measurements has been examined.7 This
human retrospective study found that although none of
the prostheses were passively fitting, no evidence of
bone loss was present even after 5 years. One of the
Private practice, London, England.
Professor of Periodontology and Implant Dentistry.
c
Consultant in Restorative Dentistry.
d
Dental Clinical Research.

conclusions from this study was that there must be a


range of prosthesis misfit tolerated by osseointegrated
implants that allows for long-term stability. Work supporting this theory has found that clinically well-fitting
prostheses still produced a considerable amount of misfit
load but no loss of osseointegration.8 Clinically, it is
difficult to measure gaps less than 60 m.9
Although there is some evidence that prosthesis misfit may not affect osseointegration, there is evidence that
prosthesis misfit is likely to increase the incidence of
mechanical component loosening or fracture.10 The
causes of component failure and loosening are multifactorial, but it must be assumed that prosthesis misfit plays
an important role in complications such as occlusal and
abutment screw loosening and fracture in linked implant
restorations.10-13 Because of these concerns, prosthesis
misfit should be minimized.

250 THE JOURNAL OF PROSTHETIC DENTISTRY

VOLUME 89 NUMBER 3

BURNS ET AL

One of the crucial steps for producing a well-fitting


prosthesis is an accurate impression. Most of the available literature evaluating the accuracy of impression materials and comparing accuracy of stock with custom
trays use measurements relating to prepared teeth.14-19
Studies evaluating implant impressions tend to concentrate on comparing different impression techniques by
use of machined components.20-29 The literature suggests that direct impression copings produce more accurate impressions than reseatable impression coping techniques.23-26 It also seems prudent to use a rigid
elastomeric impression material, such as polyether, because it is rigid and maintains impression copings accurately, is dimensionally stable, has a good resistance to
permanent deformation, has a low strain in compression
(flexibility), and has a high initial shear strength.23
Studies with prepared teeth show that custom trays
produce more consistently accurate impressions compared with stock trays.14,16,19,30 This may be because the
tray rigidity does not allow distortion of the impression.19 However, it has been shown that a different
thickness of elastomeric impression material in an impression tray can reduce impression accuracy.31 Comparison of impression accuracy with stock or custom
trays has not been investigated with implants and machined transfer components.
The aim of this in vitro study therefore was to evaluate whether custom trays produce more consistently accurate implant fixture-level impressions than stock trays,
by use of an open tray technique. It was hypothesized
that flexibility in stock impression trays would lead to
less consistently accurate impressions than rigid custom
trays.

MATERIAL AND METHODS


Gold cylinder pairs splinted by gold bars (reference
frameworks) were constructed on a custom constructed
aluminium typodont and tested for fit accuracy using a
1-screw test32 with the aid of a traveling microscope
(Travimed; J Swift and Son, London, United Kingdom).
Three polyether impressions (Impregum Penta; 3M
Espe Dental AG, Seefeld, Germany) were made with
each of 3 stock impression trays, 3 close-fit custom trays,
and 3 spaced custom impression trays. In total, 27 impressions were made of 2 pairs of Brnemark 3.75-mm
diameter implants (Nobel Biocare AB, Goteborg, Sweden) mounted in an aluminium typodont, with an open
tray technique.
The casts produced were assessed for accuracy by attaching the reference frameworks with alternate single
screws and measuring the vertical fit discrepancy of these
reference frameworks to the analogs within the working
cast with the aid of a traveling microscope.32
MARCH 2003

THE JOURNAL OF PROSTHETIC DENTISTRY

Fig. 1. Block with displaceable bed.

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.

Reference bar construction


The typodont retained 4 implant analogs, 2 in the
approximate region corresponding to the mandibular
canine teeth and 2 in the mandibular right premolar/
molar regions. The anterior pair and posterior pair each
had 20 mm of separation, as measured from the center
of each analog.
Four implant-level gold cylinders (DCA 814-0; Nobel Biocare AB) were placed on the typodont abutments
and splinted with a 2-mm diameter gold bar (DCB
077-0; Nobel Biocare AB) using a laser welding machine (Neolaser L; Girrbach, Pforzheim, Germany) to
provide an anterior and posterior reference framework.
Corresponding abutment screws (DCA 778-0; Nobel
Biocare AB) provided the connection between the reference bars and analogs. The analogs were then glued
with epoxy resin adhesive (RS Components, Corby, England) into the typodont with the reference bars still
attached. The accurate fit of the reference bars to the
glued analogs was verified by use of a traveling microscope. These reference bars (Fig. 2) were used to verify
the accuracy of casts produced from impressions.
251

THE JOURNAL OF PROSTHETIC DENTISTRY

Fig. 2. Reference framework (showing orientation markings


to aid positioning of traveling microscope).

Impression tray design


Three types of impression trays were used: mandibular polycarbonate stock trays (Size 12 Solo trays; Davis
Healthcare Services Ltd); close-fit custom trays constructed with a single sheet of rigid visible light-polymerizing material custom tray material (Palatray LC;
Heraeus Kulzer, Wehreim, Germany) polymerized over
a 3-mm wax spacer covering the typodont; and spaced
custom trays constructed with a single sheet of rigid
visible light-polymerizing material custom tray material
(Palatray LC; Hereus Kulzer) polymerized over a plaster
horseshoe to allow for 10 mm of space. This horseshoe
was cast from an impression of one of the stock trays.
This ensured that internal dimensions of the stock trays
and the spaced custom trays were the same.
Three stock trays were selected. In addition, 3 closefit and 3 spaced custom trays were fabricated, and all the
trays were opened with 4 holes cut above the typodont
analogs. This allowed access to the guide pins when
making impressions using an open tray technique. Each
tray within each set of 3 was tested to ensure uniform
construction by measurement of tray thickness at numerous points on each tray.

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

Fig. 3. Measurement casts.

load on the impression tray for each specimen. It was


necessary to construct a 2.5-mm-thick horseshoe of
polymethyl methacrylate (Perspex; Cox Plastics, Gateshead, United Kingdom) to fit between the weight and
impression copings to ensure the weight was acting just
on the tray and was not deflected by the transfer copings.

Cast production protocol


Once polymerized, 4 regular platform implant analogs were screwed onto the impression copings contained within the set impression. Care was taken to ensure that the impression analogs were fully seated against
the impression copings.
The impressions were cast in batches of 9 within the
manufacturers recommended times. The impressions
were cast in a type IV dental stone (GC Fujirock EP; GC
Europe, Leuven, Belgium) according to the manufacturers instructions. Each cast was then trimmed into an
anterior and posterior pair (Fig. 3). Each cast of each
pair was carefully marked A for anterior and P for posterior, and each pair was randomly designated a number
between 1 and 6. This number corresponded to a particular tray type and number, and this information was noted
on a sheet and subsequently placed in a sealed envelope. All
the casts were poured and prepared by one operator.

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

THE JOURNAL OF PROSTHETIC DENTISTRY

Fig. 4. Gap measurement points on stone blocks. A, Anterior


analogues; P, posterior analogues; arrows, points at which
veritcal gaps were measured on each specimen; red arrows,
points that were remeasured 3 days later; dotted lines; each
pair of analogues trimed into a single block specimen.

Beach, Fla.). The accuracy of bar fit was then quantified


by measuring the vertical gap between the other cylinder
and analog with a traveling microscope at 3 points on
each analogue (Fig. 4).
The abutment screw was then removed and tightened onto the other gold cylinder at 20 Ncm, and the
procedure was repeated. The same measurement protocol was used for each cast throughout the study.
Comparison of gap dimensions by tray type was performed with a nonparametric Kruskal-Wallis analysis of
variance (ANOVA) followed by pair-wise Mann-Whitney U tests. To adjust for multiple comparisons in the
post-ANOVA contrasts, statistical significance was assumed where P.02. Comparison of gap dimensions
between anterior and posterior regions were performed
with Mann-Whitney U tests, and P.05 was used to
judge statistical significance.
To test the reproducibility of the measurements
made, 2 of the 6 points on each cast were remeasured
3 days later. The casts had the appropriate reference bars
reattached and were remounted and remeasured by use
of the same standard protocol. The same 2 points were
remeasured throughout (Fig. 4). A summary of the protocol used in the main study is shown in Figure 5.

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

Fig. 5. Summary of main study protocol.

rior sites. However, there was no statistical difference


between the 2 types of custom impression tray (P.5).
The difference in median gap size between stock and
both types of custom trays for analogs with a 20-mm
separation was 10 m.
There were also significant differences (P.05) between anterior and posterior pairs in all tray types, and
the anterior pairs produced smaller vertical fit discrepancies. There was no significant difference in measurements between separate trays of the same description.
Comparisons between sites and between left and right
pairs (the bars were splinted) were not significant.

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

THE JOURNAL OF PROSTHETIC DENTISTRY

BURNS ET AL

Table I. Distribution of gap measurements by tray type


Gap Value in
micrometers

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

Anterior implant sites

Posterior implant sites

P value for comparison of anterior


and posterior implants
All implant sites

Stock

Spaced Custom

Close Fit 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

impression distortion was likely to have less effect than in


conventional fixed prosthodontic impressions.
From examination of the data, there was no statistical
difference in gap measurements between the 2 types of
custom tray. This may have been because the tray rigidity
did not allow distortion of the impression. However, it has
been shown that a different thickness of elastomeric impression material in an impression tray can reduce impression accuracy.31 It was postulated in this study that the
impression material could shrink away from the impression
specimen during setting, because of the impression material preferentially adhering to the tray rather than the specimen. This distorting effect would be magnified with
greater bulks of impression material.
In this study, however, there were no statistically significant differences in vertical gap measurements between the spaced and close fit custom impression trays.
This occurred in spite of a much thicker layer of impression material in the spaced tray (10 mm) than in the
close-fit tray (3 mm). It seems that any influence of the
impression material thickness on the spatial positioning
of the transfer copings was negligible.
There were statistically significant differences in accuracy between the anterior analog pairs and posterior
analog pairs in all trays. For stock trays, the increased accu254

racy in the anterior part of the tray may be accounted for


because the tray is thickest in the midline region and is
therefore more rigid. The differences in gap values between
anterior and posterior pairs in the custom trays are more
difficult to explain. It must be noted for all tray types,
however, that in spite of statistical significance, the actual
differences in anterior and posterior values were small and
may have little clinical significance.
The results of this study showed a difference in medians of 10 m in accuracy between the stock and custom trays, as measured by vertical fit discrepancy. This in
itself is probably of minimal clinical significance, especially when it has been shown that, clinically, it is difficult
to measure gaps less than 60 m.9 Over a larger implant
span or with multiple linked fixtures, these measurement
differences could potentially be magnified to a degree
that is clinically significant. However, any extrapolations
of these results into a clinical environment should be
interpreted with caution.
In view of the ideal bench conditions for making
impressions, one would expect to obtain consistently
accurate results with all trays. However, the stock trays
obviously allowed distortion of the impression. Because
the only discernable difference between the stock and
spaced custom trays were differences in rigidity, this
VOLUME 89 NUMBER 3

BURNS ET AL

must be a contributory factor. One theory derived from


studies on natural teeth is that, under load, the stock tray
flexes and the impression distorts. The other theory of
differing uniform impression thickness may occur, but it
did not appear to influence the results of this study. Why
the stock tray distortions did not occur consistently with
the strict protocol used is difficult to explain, but it is clear
is that an identical but rigid tray eliminated this problem.
The results showed that flexible stock trays were statistically more inaccurate. It was possible to make accurate
stock tray impressions, although the accuracy was not as
consistent compared with custom trays. Provided an accurate impression material and good impression protocol are
used, a rigid stock tray may be a valid alternative to custom
trays for implant fixture-level impressions. This would require further investigation. Even though the difference in
medians of 10 m in accuracy between the stock and custom trays, as measured by vertical fit discrepancy, is statistically significant, this difference may be difficult to identify
and measure if extrapolated clinically.

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

THE JOURNAL OF PROSTHETIC DENTISTRY

12.
13.

14.
15.

16.
17.

18.

19.

20.
21.
22.

23.
24.
25.

26.

27.
28.

29.
30.

31.
32.

from prosthetic treatment to first annual checkup. Int J Oral Maxillofac


Implants 1992;7:40-4.
Tolman DE, Laney WR. Tissue-integrated prosthesis complications. Int
J Oral Maxillofac Implants 1992;7:477-84.
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.
Gordon GE, Johnson GH, Drennon DG. The effect of tray selection on the
accuracy of elastomeric impression materials. J Prosthet Dent 1990;63:12-5.
Boulton JL, Gage JP, Vincent PF, Basford KE. A laboratory study of dimensional changes for three elastomeric impression materials using custom
and stock trays. Aust Dent J 1996;41:398-404.
Millstein P, Maya A, Segura C. Determining the accuracy of stock and
custom tray impression/casts. J Oral Rehabil 1998;25:645-8.
Saunders WP, Sharkey SW, Smith GM, Taylor WG. Effect of impression
tray design and impression technique upon the accuracy of stone casts
produced from a putty-wash polyvinyl siloxane impression material.
J Dent 1991;19:283-9.
Saunders WP, Sharkey SW, Smith GM, Taylor WG. Effect of impression tray
design upon the accuracy of stone casts produced from a single-phase
medium-bodied polyvinyl siloxane impression material. J Dent 1992;20:18992.
Wassell RW, Ibbetson RJ. The accuracy of polyvinyl siloxane impressions
made with standard and reinforced stock trays. J Prosthet Dent 1991;65:
748-57.
Spector MR, Donovan TE, Nicholls JI. An evaluation of impression techniques for osseointegrated implants. J Prosthet Dent 1990;63:444-7.
Barrett MG, de Rijk WG, Burgess JO. The accuracy of six impression
techniques for osseointegrated implants. J Prosthodont 1993;2:75-82.
Humphries RM, Yaman P, Bloem TJ. The accuracy of implant master casts
constructed from transfer impressions. Int J Oral Maxillofac Implants
1990;5:331-6.
Carr AB. Comparison of impression techniques for a five-implant mandibular model. Int J Oral Maxillofac Implants 1991;6:448-55.
Carr AB. Comparison of impression techniques for a two-implant 15degree divergent model. Int J Oral Maxillofac Implants 1992;7:468-75.
Liou AD, Nicholls JI, Yuodelis RA, Brudvik JS. Accuracy of replacing three
tapered transfer impression copings in two elastomeric impression materials. Int J Prosthodont 1993;6:377-83.
Phillips K, Nicholls JI, Tsun M, Rubenstein JE. The accuracy of three
implant impression techniques: a three dimensional analysis. Int J Oral
Maxillofac Implants 1994;9:533-40.
Assif D, Fenton A, Zarb G, Schmitt A. Comparative accuracy of implant
impression procedures. Int J Periodontics Restorative Dent 1992;12:112-21.
Inturregui JA, Aquilino SA, Ryther JS, Lund PS. Evaluation of three impression techniques for osseointegrated oral implants. J Prosthet Dent 1993;
69:503-9.
Assif D, Marshak B, Schmidt A. Accuracy of implant impression techniques. Int J Oral Maxillofac Implants 1996;11:216-22.
Rueda LJ, Sy-Munoz JT, Naylor WP, Goodacre CJ, Swartz ML. The effect
of using custom or stock trays on the accuracy of gypsum casts. Int J
Prosthodont 1996;9:367-73.
Eames WB, Sieweke JC, Wallace SW, Rogers LB. Elastomeric impression
materials: effect of bulk on accuracy. J Prosthet Dent 1979;41:304-7.
Tan KB, Rubenstein JE, Nicholls JI, Yuodelis RA. Three-dimensional analysis of the casting accuracy of one-piece, osseointegrated implant-retained
prostheses. Int J Prosthodont 1993;6:346-63.

Reprint requests to:


DR JASON BURNS
320 KEW ROAD
RICHMOND
SURREY, TW9 3DU
UNITED KINGDOM
E-MAIL: jason@molars.com
Copyright 2003 by The Editorial Council of The Journal of Prosthetic
Dentistry.
0022-3913/2003/$30.00 0
doi:10.1067/mpr.2003.38

255

Fit of implant frameworks: an in vitro comparison between two fabrication


techniques
Toshiyuki Takahashi, DDS, PhD,a and Johan Gunne, DDS, PhDb
Tokyo Dental College, Chiba, Japan; Faculty of Medicine and Odontology, Ume University,
Ume, Sweden.
Statement of problem. It has been suggested that a precise fit between the implant and the framework
cylinder is necessary to ensure a satisfactory long-term clinical outcome.
Purpose. 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.
Material and methods. A total of 19 frameworks, 14 made with the Procera system (type 1) and 5 made of
a cast gold-alloy (type 2), were fabricated. A total of 95 implants, 70 type 1 and 25 type 2 frameworks, were
evaluated. Three replicas of the space between the implant abutments and the framework cylinders of the master
cast were made for each test specimen. The replicas were cut with a scalpel in 2 axial directions: buccal-lingual and
right-left. For the purpose of measurement, a microscope with a precision of 0.5 m was used at original
magnification 30. The Student t test was used to determine whether there were significant differences between
the framework designs.
Results. The buccal-lingual measurements for the type 1 and type 2 frameworks showed mean values of 28.1
m (SD 9.8) and 42.0 m (SD 1.8) on the buccal side, respectively, and 25.6 m (SD 11.2) and 51.6 m (SD
10.9) on the lingual side, respectively. For the right-left view, the mean measurements were 26.6 m (SD 8.4)
and 49.2 m (SD 11.4) on the right side, respectively, and 27.4 m (SD 8.5) and 44.4 m (SD 6.5) on the left
side, respectively. The total mean value for type 1 frameworks was 26.9 m (SD 9.3); that for type 2 frameworks
was 46.8 m (SD 8.8).
Conclusion. Within the limitations of this experiment, it was demonstrated that the fit of frameworks made
with the Procera system was significantly better than that of the frameworks made with cast gold-alloy (P.01).
(J Prosthet Dent 2003;89:256-60.)

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.

t has been suggested that a precise fit between the


implant and the framework cylinder is necessary to ensure a satisfactory long-term clinical outcome. Poor fit of
frameworks connected to implants has been shown to
cause a deformation of the surrounding bone1 and an
increase in technical problems.2
Fit of implant-supported prostheses, correlation to
distortion of the surrounding bone, change of marginal
bone level around the implants, and technical problems
have recently been addressed in several reports.1-12
However, in most of the reports that deal with the preSupported by the Department of Odontology/Faculty of Medicine
and Odontology, Ume University and Ume Dental Laboratory,
Ume, Sweden.
a
Assistant Professor, Department of Crown and Bridge Prosthodontics, Tokyo Dental College. Guest researcher, Department of
Odontology/Prosthetic Dentistry, Faculty of Medicine and Odontology, Ume University.
b
Professor, Department of Odontology/Prosthetic Dentistry, Faculty
of Medicine and Odontology, Ume University.
256 THE JOURNAL OF PROSTHETIC DENTISTRY

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.

MATERIAL AND METHODS


All superstructures were fabricated in the same laboratory but were not fabricated by the same technician.
The 19 frameworks had 2 different shapes. Seventeen
VOLUME 89 NUMBER 3

TAKAHASHI AND GUNNE

THE JOURNAL OF PROSTHETIC DENTISTRY

Fig. 1. Film thickness was recorded as distance between edge of abutment and edge of cylinder.

Table I. Number of frameworks and implants (within


parentheses) in type 1 and type 2
Type

Maxilla

Mandible

Total

1
2
Total

6 (29)
3 (13)
9 (42)

8 (41)
2 (12)
10 (53)

14 (70)
5 (25)
19 (95)

were completely edentulous (cross arch fixed dentures),


and 2 were partially edentulous.
A total of 19 frameworks, 14 made with the Procera
system (Nobel Biocare, Go thenburg, Sweden) (type 1)
and 5 made of a cast gold-alloy (Type 2) were fabricated.
A total of 95 implants, 70 type 1 and 25 type 2 frameworks, were evaluated (Table I). The Procera system is a
new CAD-CAM technology developed to fabricate the
framework for implant-supported prostheses that originates from a technique to make titanium crowns.13-17
After the fabrication of the frameworks at the laboratory, 3 replicas of the space between the implant abutments and the framework cylinders of the master cast
were made for each test specimen. A light-body A-silicon impression material (Provil Novo green; Heraeus
Kulzer, Hanau, Germany) was applied, with the help of
a syringe, on and around the implant abutment of the
master cast. The framework was then placed onto the
implant abutments of the master cast and maximal 4-finger pressure (about 8 to 10 kg18) was applied on the
MARCH 2003

occlusal surfaces of the framework. After the setting of


the impression material, the framework and the impression material were removed from the master cast, resulting in a thin film of light-body material representing the
discrepancy between the framework cylinder and the
implant abutment.
In most situations, a thin film of impression material
resulted on the inside of the cylinder and the part of the
cylinder opposing the abutment. For purposes of stabilization a medium-body material (Provil Novo yellow;
Heraeus Kulzer) was injected into the cylinder and
around the impression material surface, jointing with
the light-body film to form one piece (Fig. 1). With this
procedure it was possible to remove and handle the intermediate replica of light-body material. The replica
adhering to the medium-body material was cut with a
scalpel in 2 axial directions, buccal-lingual side and
right-left side (Fig. 2). In this manner the replica was
divided into 4 pieces.
For purpose of measurement, a microscope (Wild
Leitz Co, Wetzlar, Germany) with a precision of
0.5 m was used at original magnification 30. Measurements of the thickness of the film were performed at
4 points between the abutment and the cylinder, totaling 4 measurements for each implant abutment. The
thickness of the film was recorded as the shortest distance from the cylinder to the abutment at the four
points (Fig. 1). Ninety-five implants, 3 replicas of each
257

THE JOURNAL OF PROSTHETIC DENTISTRY

TAKAHASHI AND GUNNE

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

*Upper jaw case.

implant, with film thickness measured at 4 points on


each specimen, give a total of 1140 measurements. In
most positions there was a thin film of impression
material, but occasionally there was no material between the abutment and cylinder. No material was
measured as zero thickness. Students unpaired t test
was used to determine whether there was a significant
difference of the film thickness between the 2 types of
frameworks.

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

the buccal side, 25.6 m (SD 11.2) on the lingual side,


26.6 m (SD 8.4) on the right side, and 27.4 m (SD
8.5) on the left side. The total mean was 26.9 m (SD
9.3) (Table II).
For type 2, the analyses showed that the mean values
were 42.0 m (SD 1.8) on the buccal side, 51.6 m (SD
10.9) on the lingual side, 49.2 m (SD 11.4) on the
right side, and 44.4 m (SD 6.5) on the left side. The
total mean was 46.8 m (SD 8.8) (Table III).
For any measurement points (buccal, lingual, right,
and left), the fit of type 1 was statistically significantly
better (Students unpaired t test, P.01) than type 2.
For all of type 1, the mean values of the film thickness at
the 4 measurement points were less than 30 m.
VOLUME 89 NUMBER 3

TAKAHASHI AND GUNNE

THE JOURNAL OF PROSTHETIC DENTISTRY

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

*Upper jaw case

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

THE JOURNAL OF PROSTHETIC DENTISTRY

TAKAHASHI AND GUNNE

(P.01) between the frameworks made with Procera


system and the frameworks made with cast gold-alloy.
REFERENCES
1. 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.
2. 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.
3. Tan KB, Rubenstein JE, Nicholls JI, Yuodelis RA. Three-dimensional analysis of the casting accuracy of one-piece, osseointegrated implant-retained
prostheses. Int J Prosthodont 1993;6:346-63.
4. Lie A, Jemt T. Photogrammetric measurements of implant positions. Description of a technique to determine the fit between implants and superstructures. Clin Oral Implants Res 1994;5:30-6.
5. 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.
6. Jemt T. Three-dimensional distortion of gold-alloy casting and welded
titanium frameworks: measurements of the precision of fit between completed implant prostheses and the master casts in routine edentulous
situations. J Oral Rehabil 1995;22:557-64.
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. Lindquist LW, Carlsson GE, Jemt T. A prospective 15-year follow-up study
of mandibular fixed prostheses supported by osseointegrated implants:
clinical results and marginal bone loss. Clin Oral Implants Res 1996;7:
329-36.
9. Jemt T, Rubenstein JE, Carlsson L, Lang BR. Measuring fit at the implant
prosthodontic interface. J Prosthet Dent 1996;75:314-25.
10. 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.
11. Riedy SJ, Lang BR, Lang BE. Fit of implant frameworks fabricated by
different techniques. J Prosthet Dent 1997;78:596-604.

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

New product news


The January and July issues of the Journal carry information regarding new products of interest to prosthodontists. Product information should be sent 1 month prior to ad closing date to:
Dr. Glen P. McGivney, Editor, UNC School of Dentistry, 414C Brauer Hall, CB #7450, Chapel
Hill, NC 27599-7450. Product information may be accepted in whole or in part at the discretion
of the Editor and is subject to editing. A black-and-white glossy photo may be submitted to
accompany product information.
Information and products reported are based on information provided by the manufacturer.
No endorsement is intended or implied by the Editorial Council of The Journal of Prosthetic Dentistry,
the editor, or the publisher.

260

VOLUME 89 NUMBER 3

Fracture toughness of nine flowable resin composites


Esteban D. Bonilla, DDS,a Mahrokh Yashar,b and Angelo A. Caputo, PhDc
School of Dentistry, University of California at Los Angeles, Los Angeles, Calif.
Statement of problem. Flowable composite is used in a variety of clinical applications; however, the capacity
of these materials to resist crack propagation is not well understood.

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.

estorative dentistry is experiencing a dynamic transition in developing adhesive technology. A category of


composite systems known as flowable composites has become an integral part of the restorative process since the
first appearance in 1995 (Revolution, Kerr, Orange,
Calif).1 These restorative dental resins were initially developed to restore Class V lesions,2 but they are now
being incorporated into a variety of clinical applications
such as small carious lesions, pit and fissure sealants,
liners, crown cementation, and other adhesive restorative procedures.1-4
Flowable composite chemistry is based on traditional
hybrid composites, but generally the composites contain
smaller filler concentrations and, in some instances,
modified resin formulations. These restorative materials
Presented in part at the 78th General Session of the International
Association for Dental Research, Washington DC, April 5-8,
2000.
a
Lecturer, Division of Restorative Dentistry.
b
Dental Student.
c
Professor and Chairman, Biomaterials Science Section, Division of
Advanced Prosthodontics, Biomaterials, and Hospital Dentistry.
MARCH 2003

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

THE JOURNAL OF PROSTHETIC DENTISTRY

BONILLA, YASHAR, AND CAPUTO

Table I. Flowable composite resin materials tested


Filler
Product

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.

the edge of the flaw. KIC values may be good predictors


of the clinical performance of composite resin restorations, but values may be affected by different storage
conditions.12-17 There are limited clinical data, however,
supporting a direct relationship between clinical failure
and low fracture toughness. Therefore, in addition to
fracture toughness, the overall clinical load-bearing capacity of composites also depends on other mechanical
properties such as wear resistance and compressive, diametral tensile, flexural, and fatigue strengths.
Although the physical and mechanical properties of
some flowable composites have been tested,2 there is
still insufficient information on the fracture toughness
characteristics of several flowable restorative resin materials. The purpose of this in vitro study was to evaluate and compare the resistance to crack propagation
of 9 flowable composites as measured by the fracture
toughness.

MATERIAL AND METHODS


This study investigated the fracture toughness of 9
flowable composites. The matrix components and the
filler percentages reported by the manufacturers are
summarized in Table I. A single-edge notched beam test
was used to determine the fracture toughness (KIC). The
test specimen configuration conformed to the American
262

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

BONILLA, YASHAR, AND CAPUTO

THE JOURNAL OF PROSTHETIC DENTISTRY

Fig. 2. Typical specimen after removal from mold.

Fig. 3. Diagrammatic
notched-beam test.

representation

of

single-edged

notch area were discarded. Specimens were stored in air


at room temperature for 24 hours before testing.
A universal testing machine (Model 1122; Instron
Corp, Canton, Mass.) was used to apply a central load to
each beam specimen in a 3-point bending mode at a
crosshead speed of 0.125 mm/min until the specimen
fractured (Fig. 3). Visual examination of the fractured
parts was also performed to ensure that the fracture
plane was through the notch and perpendicular to the
vertical and horizontal planes through the center of the
specimen (Fig. 4).
The fracture toughness was calculated with the equation:18
K IC


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

where 2(1 2 a/w)(1 a/w)3/2; KIC stress


intensity factor; P load at fracture; L span, distance
between the supports; w width of the specimen; b
thickness of the specimen; and a crack length.
MARCH 2003

Fig. 4. Representative notched beam fracture mode perpendicular to vertical and horizontal planes through center of
specimen.

The KIC values for the 9 composites were analyzed


and compared by 1-way analysis of variance and t tests
with post hoc corrections for multiple comparisons
(P.05). Linear regression analysis was performed to
assess potential relationship between KIC and volume
concentration of fillers.

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

THE JOURNAL OF PROSTHETIC DENTISTRY

BONILLA, YASHAR, AND CAPUTO

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.

0.20 MNm3/2; FloRestore, 1.35 0.14 MNm3/2;


Revolution, 1.32 0.18 MNm3/2; Crystal Essence,
1.31 0.19 MNm3/2; VersaFlow, 1.26 0.13
MNm3/2.
264

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

BONILLA, YASHAR, AND CAPUTO

THE JOURNAL OF PROSTHETIC DENTISTRY

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

In this experimental study, the KIC values of all


tested flowable composites were determined by use of
a single-edge notched beam test. The results of this
study are consistent with those previously reported by
Bayne et al2 using a different test technique and storage environment. The authors evaluated the KIC of 5
flowable composites with disc-shaped specimens. The
only difference in the results was the KIC value of
FloRestore, which was higher (1.68 MNm3/2) than
the value of 1.35 MNm3/2 found in this study. The
reason for this difference is not clear.
The effect of water storage on the KIC of composites has been considered by a number of investigators.
Varying results have been reported, with some results
indicating a decrease in KIC.12-14 Others show an increase in KIC,15,16 whereas still other results indicated
no significant difference in KIC between composites
stored in air and water.17 Because no clear tendency
has been demonstrated, the specimens in this study
were stored dry at room temperature for 24 hours
before testing.
This study showed that the KIC values of Permaflo
(1.65 MNm3/2) and Tetric Flow (1.43 MNm3/2)
were higher than the hybrid and packable posterior
composites (Fig. 7).11 The testing protocol followed for
the packable materials was identical to that described for
the flowable composites. The explanation of the high
265

THE JOURNAL OF PROSTHETIC DENTISTRY

KIC values of some flowable composites might be related


to the larger amount of plastic matrix in these materials,
which may blunt the high stress at the crack tip through
plastic deformation. Other mechanical properties must
be assessed, however, before a preparation is restored
with these flowable materials alone. For example, the
flowable composites exhibit greater polymerization
shrinkage than the packable and hybrid materials.2,10
Therefore use of flowable materials in a large preparation
may lead to high shrinkage stresses at the margin increasing the potential for marginal leakage. Furthermore, the lower reported strengths of the flowable materials tend to contraindicate their use in high-load
areas. Consequently, the characteristics of the flowable
composites may best be used to restore small lesions in
lower stress regions and as a first increment in a layered
restoration technique.
Historically, clinicians have recommended using
flowable composites as a lining material in a variety of
preparations because of their low viscosity, low modulus of elasticity, and high degree of wettability to
significantly reduce microleakage and postoperative
sensitivity. Kemp-Scholte and Davidson5 tested several restorative materials with low viscosity and
Youngs modulus as a intermediate layer to achieve a
good marginal seal of restorations. They concluded
that these resins undergo plastic deformation to counteract the early interfacial stress build-up that occurs
during the polymerization contraction of the resin
materials to preserve the resin-dentin marginal integrity of the composite restorations.5,6 However, current studies have reported no significant difference
involving the marginal microleakage of the composite
restorations with or without an intermediate layer.7,8
In an in vitro microleakage study, Estafan and Estafan9 compared 4 low-viscosity with a hybrid composite on class V preparation designs. The authors confirmed that no significant difference of marginal
microleakage on composite restorations was found
between the flowable materials and the control composite for the Class V situation.9 In addition, Labella
et al10 evaluated the modulus of elasticity and the
polymerization shrinkage of 13 flowable composites.
They concluded that the higher shrinkage of flowable
composites over hybrids may indicate a potential for
higher interfacial stresses; however, lower rigidity may
be a counteracting factor.
It should be emphasized that the results of this
study also have shown clearly that there is no direct
correlation between KIC and filler content by volume.
The explanation for this observation appears to be
that other features of the filler and matrix were not the
same for the materials tested. A similar finding was
obtained on posterior composites by a previous report.11 Lastly, future studies should be oriented to
266

BONILLA, YASHAR, AND CAPUTO

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

BONILLA, YASHAR, AND CAPUTO

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

THE JOURNAL OF PROSTHETIC DENTISTRY

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

Resin-ceramic bonding: a review of the literature


Markus B. Blatz, DMD, Dr Med Dent,a Avishani Sadan, DMD,b and
Matthias Kern, DMD, PhDc
School of Dentistry, Louisiana State University Health Sciences Center, New Orleans, La.;
School of Dentistry, Christian Albrechts University Kiel, Kiel, Germany
Current ceramic materials offer preferred optical properties for highly esthetic restorations. The inherent brittleness of some ceramic materials, specific treatment modalities, and certain clinical situations
require resin bonding of the completed ceramic restoration to the supporting tooth structures for
long-term clinical success. This article presents a literature review on the resin bond to dental ceramics.
A PubMed database search was conducted for in vitro studies pertaining to the resin bond to ceramic
materials. The search was limited to peer-reviewed articles published in English between 1966 and
2001. Although the resin bond to silica-based ceramics is well researched and documented, few in
vitro studies on the resin bond to high-strength ceramic materials were identified. Available data suggest that resin bonding to these materials is less predictable and requires substantially different bonding methods than to silica-based ceramics. Further in vitro studies, as well as controlled clinical trials,
are needed. (J Prosthet Dent 2003;89:268-74.)

n increasing number of all-ceramic materials and


systems are currently available for clinical use. Multiple
clinical studies document excellent long-term success of
resin-bonded restorations, such as porcelain laminate
veneers,1-5 ceramic inlays and onlays,6-15 resin-bonded
fixed partial dentures,16-19 and all-ceramic crowns.6,20-22
A strong, durable resin bond provides high retention,23
improves marginal adaptation and prevents microleakage,24 and increases fracture resistance of the restored
tooth and the restoration.25,26
Adhesive bonding techniques and modern all-ceramic systems offer a wide range of highly esthetic treatment options.5,6,19,27,28 Bonding to traditional silicabased ceramics is a predictable procedure yielding durable
results when certain guidelines are followed.24-26,29-94
However, the composition and physical properties of
high-strength ceramic materials, such as aluminum oxide-based (Al2O3)95-99 and zirconium oxide-based
(ZrO2) ceramics,100 differ substantially from silica-based
ceramics96,101,102 and require alternative bonding techniques to achieve a strong, long-term, durable resin
bond. Controlled clinical trials are ideal to test specific
treatment modalities and their long-term durability.
However, in vitro investigations are indispensable to
identify superior materials before their clinical evaluation, especially for comparative studies of bonding
agents and cements.
This literature review evaluated and compared in vitro
studies on the resin bond to dental ceramics. A search of
PubMed databases was conducted and limited to peera

Assistant Professor, Department of Prosthodontics, Louisiana State


University.
b
Associate Professor, Department of Prosthodontics, Louisiana State
University.
c
Professor and Chairman, Department of Prosthodontics, Propaedeutics and Dental Materials, Christian Albrechts University Kiel.
268 THE JOURNAL OF PROSTHETIC DENTISTRY

reviewed articles in English that were published between


the years 1966 and 2001. Reference lists of culled articles were screened for additional publications. Of the
retrieved articles, a total of 68 articles were selected on
the resin bond to silica-based ceramics,24-26,29-94 8 on
the bond to aluminum-oxide ceramics,103-110 and 3 on
the bond to zirconium-oxide ceramics.111-113 Additional
references were included to accompany statements of
facts.1-23,27,28,95-102,114-133

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

BLATZ, SADAN, AND KERN

increase the longevity of a failing restoration and may be


a provisional, cost-effective alternative to immediate replacement.29

THE JOURNAL OF PROSTHETIC DENTISTRY

repair composite to the metal surface (for example:


Rocatec System; 3M ESPE, St. Paul, Minn.).52-54

Silane coupling agents


Surface treatment
A strong resin bond relies on micromechanical interlocking and chemical bonding to the ceramic surface,
which requires roughening and cleaning for adequate
surface activation.30-37 Common treatment options are
grinding,30 abrasion with diamond rotary instruments,31,32 airborne particle abrasion with aluminum
oxide,48,49 acid etching,33 and combinations of any of
these methods. Acid etching with solutions of hydrofluoric acid (HF) or ammonium bifluoride can achieve
proper surface texture and roughness.33-37 The glassy
matrix is selectively removed, and crystalline structures
are exposed. HF solutions between 2.5% and 10% applied for 2 to 3 minutes seem to be most successful.35-37
The number, size, and distribution of leucite crystals
influence the formation of microporosities that acid
etching creates.38 Leucite crystals grow during the cooling phase of the ceramic-firing process.117 Some lowfusing ceramics and glass ceramics contain only minimal
amounts of leucite crystals, which may inhibit the formation of highly-retentive microporosities with HF acid
etching.39 For the leucite-reinforced feldspathic porcelain IPS Empress, solutions of 9% HF applied for 60
seconds were most successful.40 The lithium-disilicate
glass-ceramic IPS Empress 2 has a high crystalline content and exhibits significantly higher bond strengths
than IPS Empress independent from surface conditioning.41 It seems that the ceramic microstructure has a
significant influence on the fracture resistance of the
composite-ceramic adhesion zone.41
Current ceramic-repair systems offer various treatment methods for intraoral repair of fractured veneering
porcleain.29,42 A combination of airborne particle abrasion (50 m Al203), etching with HF acid, and application of a silane coupling agent is recommended.43-46
Acid etchants that are less hazardous than HF acid are
preferred intraorally. Szep et al47 found that HF acid
leaves an amorphous precipitate of fluoride on tooth
structures, which may influence caries resistance and
bonding interaction. Sole airborne particle abrasion provides insufficient bond strengths.48,49 Excessive airborne
particle abrasion induced chipping or a high loss of ceramic material49,50 and is therefore not recommended
for cementation of silica-based all-ceramic restorations.
Kato et al51 compared airborne particle abrasion with
different acid-etching agents and found that HF acid
and sulfuric acid-hydrofluoric acid provided the highest
and most durable bond strengths. If a veneering-porcelain fracture extends to the framework, exposed metal
should be pretreated for a sufficient resin bond of the
MARCH 2003

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

THE JOURNAL OF PROSTHETIC DENTISTRY

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

BLATZ, SADAN, AND KERN

viscosity materials may be pulled out of the luting gap


during cleaning.75
Wear and substance loss of composite cements after
final insertion have been extensively studied in laboratory and clinical investigations that demonstrated a correlation of marginal gap width and depth of wear.82,83
However, the effect of cement wear on the clinical longterm success of bonded restorations remains to be determined.
An interesting alternative to resin-based composites
are resin-modified glass-ionomer cements that showed
bond strengths to etched and silanated silica-based ceramics comparable to composite cements.84 Other
properties of these materials need to be investigated before they can be recommended for bonding of ceramic
restorations without reservation.

TESTING CONDITIONS AND


METHODS
The ceramic-composite bond is susceptible to chemical,118,119 thermal,120 and mechanical121 influences under intraoral conditions. The simulation of such influences in the laboratory is compulsory to draw
conclusions on the long-term durability of a specific
bonding procedure and to identify superior materials
and techniques. Long-term water storage85 and thermocycling of bonded specimens are accepted methods to
simulate aging and to stress the bonding interface. Most
studies that apply these methods reveal significant differences between early and late bond strength values.86-90 Application of mechanical cyclic loading (fatigue load) causes significant reduction of bond
strengths.63,91
Material selection and clinical recommendations on
resin bonding to ceramics are based on mechanical laboratory tests that show great variability in materials and
methods.41,94 Preferred bond strength tests are the
3-point bending test, the tensile and micro-tensile test,
and the shear and micro-shear test. ilo92 discussed the
accuracy and clinical relevance of the different testing
methods. The most common testing method is the shear
bond test; however, some researchers prefer modified
tensile tests to eliminate the occurrence of nonuniform
interfacial stresses typical to conventional tensile and
shear bond tests. Their specific fracture pattern may
cause cohesive failure in the ceramic,93 which may lead
to erroneous interpretation of the actual data and taint
an absolute ranking of the tested methods and materials.41,94

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

BLATZ, SADAN, AND KERN

rable to leucite crystals. In general, ceramics containing


less than 15 wt% silica are not regarded as silica-based or
silicate ceramics. In high-strength alumina- or zirconiabased ceramics, the aluminum oxide or zirconium oxide
is not a reinforcement; it forms the matrix.97
High-strength aluminum-oxide ceramics are indicated in all areas of the mouth for copings and frameworks of full-coverage crowns and FPDs.6 Such copings
and frameworks are veneered with feldspathic porcelain
to combine superior physical strength with optimal esthetic properties. Glass-infiltrated aluminum-oxide ceramic (for example: In-Ceram Alumina; Vita Zahnfabrik, Bad Sackingen, Germany) and densely-sintered
high-purity aluminum-oxide ceramic (for example: Procera AllCeram; NobelBiocare, Goteborg, Sweden) are
widely used representatives of this group. In-Ceram
Spinell (Vita Zahnfabrik) is a glass-infiltrated spinel ceramic (containing the spinel oxide MgAl2O4) and is
slightly weaker than In-Ceram Alumina, but it offers
improved optical properties.122 One third of the aluminum oxide is replaced by zirconium oxide in In-Ceram
Zirconia (Vita Zahnfabrik), which is significantly stronger than In-Ceram Alumina.

Glass-infiltrated aluminum-oxide ceramic


In-Ceram Alumina incorporates a dry-sintered aluminum-oxide core that is infused with molten glass. The
all-ceramic core offers a flexural strength of 450 MPa96
after glass infiltration and is veneered with feldspathic
porcelain for enhanced esthetics.
Acid etchants used for silica-based dental ceramics do
not sufficiently roughen the surface of aluminum-oxide
ceramics.109 Airborne particle abrasion with Al2O3 is
effective and practical for creating an activated and
roughened surface on aluminum-oxide ceramic.50 The
application of a tribochemical silica coat that allows for
chemical bonds to a silane coupling agent and to composite has been recommended.50,103,104 The Rocatec
System (3M ESPE) is an effective and user-friendly silica-coating method.123 It includes 2 steps of airborne
particle abrasion and the application of a silane coupling
agent (ESPE-Sil; 3M ESPE) that bonds to the silicacoated surface and to resin. Other silica-coating methods were either ineffective for alumina ceramics or technically very complicated.103-105
Silanization of glass-infiltrated aluminum-oxide ceramic does not provide a chemical bond but may have a
rewetting effect on air-particle-abraded alumina surfaces. Kern and Thompson103 reported that this combination initially provided sufficient bond strengths with
conventional Bis-GMA resin cements. However, bond
strengths decreased significantly below clinically acceptable values after long-term storage and thermocycling.
Silica coating and silane application with the Rocatec
System provided a durable resin bond to glass-infiltrated
MARCH 2003

THE JOURNAL OF PROSTHETIC DENTISTRY

aluminum-oxide ceramic with Bis-GMA composite-cements.103,104,106


A phosphate-monomer-containing resin cement
(Panavia 21; Kuraray) provided strong and long-term
durable resin bonds to air-particle-abraded glass-infiltrated alumina ceramic.19,103,107,108 The adhesive functional phosphate monomer 10-methacryloyloxydecyl
dihydrogen phosphate chemically bonds to metal oxides
such as aluminum and zirconium oxides.124 Some authors recommend Panavia without a silane or bonding
agent,103 whereas others suggest a silane coupling agent
to increase wettability of the ceramic substrate.106,108

Densely-sintered aluminum-oxide ceramic


Densely-sintered high-purity aluminum-oxide ceramic97 (for example: Procera AllCeram) offers a flexural
strength of 610 MPa98,99 and does not contain any silica.
Similar to glass-infiltrated alumina ceramic, the surface
of pure aluminum-oxide ceramic cannot be altered
through conventional acid etching.109 Airborne particle
abrasion with a micro etcher (50 m Al2O3 at 2.5 bar)
revealed significantly higher bond strengths than acid
etching with either 9.6% HF or 37% phosphoric acid,
grinding with a diamond, or no treatment (control).109
Blixt et al110 found tribochemical surface treatment with
the Rocatec System to be superior to other treatments;
however, this study was limited to short-term observations.

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

THE JOURNAL OF PROSTHETIC DENTISTRY

for 60 days had mixed effects on bond strengths. Kern


and Wegner112 evaluated different adhesion methods
and their durability after long-term storage (150 days)
and repeated thermocycling. Airborne particle abrasion,
silane application, and a Bis-GMA resin cement resulted
in an initial bond that failed spontaneously after simulated aging.112 Silica-coating with the Rocatec System
was equally insufficient.112 Only the phosphate-modified resin cement Panavia 21 after airborne particle abrasion (110 m Al2O3 at 2.5 bar) provided a long-term
durable resin bond to zirconium oxide ceramic.112
These findings were confirmed by a long-term study in
which specimens were subject to 2 years water storage
and repeated thermocycling.113

SUMMARY AND SUGGESTED


CLINICAL GUIDELINES
The resin bond to silica-based ceramics is well documented through numerous in vitro investigations. Preferred surface treatment methods are acid etching with
HF acid solutions (2.5% to 10% for 2 to 3 minutes) and
subsequent application of a silane coupling agent. Adhesive cementation may not be required for final insertion of high-strength all-ceramic restorations with
proper mechanical retention. However, some clinical
situations and restorative treatment options mandate
resin bonding and, therefore, adequate ceramic-surface
conditioning. Preferred treatments for glass-infiltrated
aluminum-oxide ceramic are either airborne particle
abrasion with Al2O3 (50 to 110 m at 2.5 bar) and use
of a phosphate-modified resin cement (Panavia 21) or
tribochemical surface treatment (Rocatec System) in
combination with conventional Bis-GMA resin cement.
The small number of long-term in vitro studies on the
bond strength to densely-sintered aluminum-oxide ceramic does not allow for clinical recommendations. The
few available studies on resin bonding to zirconiumoxide ceramics suggest the use of resin cements that
contain special adhesive monomers. Compared with silica-based ceramics, the number of in vitro studies on the
resin bond to high-strength ceramics is small. The rapidly increasing popularity of all-ceramic systems requires
further research. Controlled clinical trials are needed
before clinical recommendations can be given.
REFERENCES
1. Cho GC, Donovan TE, Chee WW. Clinical experiences with bonded
porcelain laminate veneers. J Calif Dent Assoc 1998;26:121-7.
2. Dumfahrt H, Schaffer H. Porcelain laminate veneers. A retrospective
evaluation after 1 to 10 years of service: Part II clinical results. Int J
Prosthodont 2000;13:9-18.
3. Friedman MJ. Ask the experts: porcelain veneers. J Esthet Restor Dent
2001;13:86-7.
4. Fradeani M. Six-year follow-up with Empress veneers. Int J Periodontics
Restorative Dent 1998;18:216-25.
5. Peumans M, Van Meerbeek B, Lambrechts P, Vanherle G. Porcelain
veneers: a review of the literature. J Dent 2000;28:163-77.

272

BLATZ, SADAN, AND KERN

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

BLATZ, SADAN, AND KERN

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

THE JOURNAL OF PROSTHETIC DENTISTRY

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

THE JOURNAL OF PROSTHETIC DENTISTRY

93. Chadwick RG, Mason AG, Sharp W. Attempted evaluation of three


porcelain repair systemswhat are we really testing? J Oral Rehabil
1998;25:610-5.
94. Della Bona A, van Noort R. Shear vs. tensile bond strength of resin
composite bonded to ceramic. J Dent Res 1995;74:1591-6.
95. McLean JW, Hughes TH. The reinforcement of dental porcelain with
ceramic oxides. Br Dent J 1965;119:251-67.
96. Seghi RR, Sorensen JA. Relative flexural strength of six new ceramic
materials. Int J Prosthodont 1995;8:239-46.
97. Andersson M, Oden A. A new all-ceramic crown: a dense-sintered,
high-purity alumina coping with porcelain. Acta Odontol Scand 1993;
51:59-64.
98. Zeng K, Oden A, Rowcliffe D. Flexure tests on dental ceramics. Int J
Prosthodont 1996;9:434-9.
99. Zeng K, Oden A, Rowcliffe D. Evaluation of mechanical properties of
dental ceramic core materials in combination with porcelains. Int J
Prosthodont 1998;11:183-9.
100. Ashizuka M, Kiyohara H, Okuno T, Kubota Y. Fatigue behavior of
tetragonal zirconia polycrystals (Y-TZP) containing 2 and 4 mol% Y2O3
(Part 2). J Ceram Soc Jpn Inter Ed 1988;96:731-6.
101. Taira M, Nomura Y, Wakasa K, Yamaki M, Matsui A. Studies on fracture
toughness of dental ceramics. J Oral Rehabil 1990;17:551-63.
102. Giordano RA 2nd, Pelletier L, Campbell S, Pober R. Flexural strength of
an infused ceramic, glass ceramic, and feldspathic porcelain. J Prosthet
Dent 1995;73:411-8.
103. Kern M, Thompson VP. Bonding to glass infiltrated alumina ceramic:
adhesive methods and their durability. J Prosthet Dent 1995;73:240-9.
104. Sadoun M, Asmussen E. Bonding of resin cements to an aluminous
ceramic: a new surface treatment. Dent Mater 1994;10:185-9.
105. Kern M, Thompson VP. Sandblasting and silica-coating of dental alloys:
volume loss, morphology and changes in the surface composition. Dent
Mater 1993;9:151-61.
106. Ozcan M, Alkumru HN, Gemalmaz D. The effect of surface treatment on
the shear bond strength of luting cement to a glass-infiltrated alumina
ceramic. Int J Prosthodont 2001;14:335-9.
107. Isidor F, Stokholm R, Ravnholt G. Tensile bond strength of resin luting
cement to glass infiltrated porous aluminium oxide cores (In-Ceram). Eur
J Prosthodont Restor Dent 1995;3:199-202.
108. Madani M, Chu FC, McDonald AV, Smales RJ. Effects of surface treatments on shear bond strengths between a resin cement and an alumina
core. J Prosthet Dent 2000;83:644-7.
109. Awliya W, Oden A, Yaman P, Dennison JP, Razzoog ME. Shear bond
strength of a resin cement to densely sintered high-purity alumina with
various surface conditions. Acta Odontol Scand 1998;56:9-13.
110. Blixt M, Adamczak E, Linden LA, Oden A, Arvidson K. Bonding to
densely sintered alumina surfaces: effect of sandblasting and silica coating on shear bond strength of luting cements. Int J Prosthodont 2000;13:
221-6.
111. Derand P, Derand T. Bond strength of luting cements to zirconium oxide
ceramics. Int J Prosthodont 2000;13:131-5.
112. Kern M, Wegner SM. Bonding to zirconia ceramic: adhesion methods
and their durability. Dent Mater 1998;14:64-71.
113. Wegner SM, Kern M. Long-term resin bond strength to zirconia ceramic.
J Adhes Dent 2000;2:139-47.
114. Weinstein M, Katz S, Weinstein AB. Permanent Manufacturing Corporation, assignee. Fused Porcelain-to-Metal Teeth. U.S. Patent No.
3,052,982. September 11, 1962.
115. McLaughlin G. Porcelain veneers. Dent Clin North Am 1998;42:653-6,
ix.
116. Culp L. Empress 2. First year clinical results. J Dent Technol 1999;16:
12-5.

274

BLATZ, SADAN, AND KERN

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

Dentin bond strengths of two ceramic inlay systems after cementation


with three different techniques and one bonding system
Nilgun Ozturk, DDS, PhDa and Filiz Aykent, DDS, PhDb
Faculty of Dentistry, Selcuk University, Konya, Turkey
Statement of problem. Cementation of inlay restoration is critical. Because of its high organic content, dentin
is a less favorable substrate for bonding than enamel. Therefore it is important to improve dentin adhesion when
placing ceramic inlay restorations.
Purpose. The purpose of this study was to compare the dentin bond strengths of 2 different ceramic inlay
systems after cementation with 3 different techniques and 1 bonding system.
Material and methods. One hundred twenty freshly extracted caries- and restoration-free molar teeth used in
this study were stored in saline solution at room temperature. Standardized Class I preparations were made in all
teeth. 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. Teeth were randomly assigned to 2 groups of 60 each to evaluate the bonding of 2 ceramic systems,
Ceramco II (Group I) and IPS Empress 2 (Group II), to dentin. 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). Groups I A and B
and Groups II A and B used dentin bonding agent (DBA) Clearfil Liner Bond 2V, and resin cement (Panavia F).
Groups I C and II C served as control groups and used Panavia F without the dentin-bonding agent. In Groups
I A and II A, the DBA was applied immediately after the completion of the preparations (D-DBA). Impressions
were then made, and the ceramic inlays were fabricated according to the manufacturers guidelines. In Groups I
B and II B the DBA was applied just before luting the inlay restorations (I-DBA). In Groups I C and II C, no
bonding agent was used before the cementation of the inlay restorations (No DBA). Cementation procedures
followed a standard protocol. After cementation, specimens were stored in distilled water at 37 C for 24 hours.
The teeth were sectioned both mesial-distally and buccal-lingually along their long axis into three 1.2 1.2 mm
wide I-shaped sections. The specimens were then subjected to microtensile testing at a crosshead speed of
1 mm/min, and the maximum load at fracture (in kilograms) was recorded. Two-way analysis of variance and
Tukey honestly significant difference tests were used to evaluate the results (P.05). Scanning electron microscopy analysis was used to examine the details of the bonding interface. The fractured surfaces were observed with
a stereomicroscope at original magnification 22 to identify the mode of fracture.
Results. Although no significant difference was found among the 2 ceramic systems with regard to dentin bond
strengths (P.05), the difference between the cementation techniques was found to be significant (P.001).
Comparison among techniques showed that the dentin bond strength in the D-DBA technique had a significantly
higher mean (40.27 8.55 Kg) than the I-DBA (30.20 6.78 Kg) and No DBA techniques (32.43 8.58 Kg).
As a result of scanning electron microscopy analysis, a distinct and thicker hybrid zone with more, and longer resin
tags were found in specimens treated with the D-DBA technique than with the other 2 techniques. Most failures
(353 of 360) were adhesive in nature at the bonding resin/dentin interface. Only 7 specimens showed cohesive
failure within the bonding resin.
Conclusion. Within the limitations of this in vitro study, the cementation of the ceramic inlays tested with the
D-DBA technique used resulted in higher bond strengths to dentin. (J Prosthet Dent 2003;89:275-81.)

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.

atients esthetic expectations have increased for


the posterior, as well as anterior, region.1 Although
amalgam restorations have improved physical and
chemical properties, they provide questionable esthetic results.2,3 With the developments in adhesive

Research Fellow, Department of Prosthodontics.


Associate Professor, Department of Prosthodontics.

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

THE JOURNAL OF PROSTHETIC DENTISTRY

OZTURK AND AYKENT

Fig. 1. Standardized Class I preparation. A, Sagittal view. B, Occlusal view.

Since its introduction, the enamel etch technique11


has provided an ideal surface for reliable bonding performance with adhesive resins. Success with bonding to
dentin, however, has been less reliable because of the
characteristics of the dentin substrates, including high
organic content, tubular structure variations, and the
presence of outward fluid movement.12-14 In spite of
these difficulties, dentin bonding has become more successful with the development of new dentin bonding
systems over the last 10 years.12,13,15-17
Clinically, 2 methods may be used to promote dentin adhesion when placing indirect bonded restorations. The conventional approach consists of delaying
the application of the dentin bonding agent until the
last treatment stage, just before luting the restoration.
To avoid incomplete seating of the restoration, it is
usually recommended to have the adhesive resin in its
nonpolymerized form. It is assumed that the pressure
of the luting composite during the seating of the inlay
may cause a collapse of demineralized collagen fibers
and subsequently affect the adhesive interface cohesiveness.18
Paul and Scharer18 modified the luting procedure and
applied the dentin bonding agent (ART Bond) to freshly
prepared dentin. Similarly, Magne and Douglas19 applied adhesive (Optibond FL) and polymerized it before
making the impression. In both studies this optimized
technique resulted in a considerable increase in the bond
strength values.
The aim of this investigation was to compare the
dentin bond strengths of 2 ceramic inlay systems cemented by use of 1 bonding system and 1 resin cement
with 3 different techniques. In addition, the mode of
fracture was evaluated with scanning electron microscopy (SEM).

MATERIAL AND METHODS


One hundred twenty freshly extracted human maxillary molars were used. Each tooth was free of caries or
276

restorations. The teeth were cleaned and stored in saline


solution at room temperature during the study.
The occlusal surfaces were flattened perpendicular to
the long axis of the teeth with a slow-speed diamond saw
sectioning machine (Isomet Buehler Ltd, Lake Bluff,
Ill.). Teeth were embedded up to 2 mm from the cemento-enamel junction into autopolymerizing resin
(Bayer Ltd, Newbury, United Kingdom).

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

OZTURK AND AYKENT

THE JOURNAL OF PROSTHETIC DENTISTRY

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

Clearfil Liner Bond2V

Kuraray Co, Osaka, Japan

Resin-based adhesive system

Panavia F

Kuraray Co, Osaka, Japan

Dual-polymerizing adhesive
system

Impression making and fabrication of inlay


restorations
Impressions were made of all teeth preparations with
vinyl polysiloxane impression material (Permagum; 3M
ESPE AG, Seefeld, Germany) and poured in a vacuummixed polyurethane die material (Alpha Die MF;
Schu ltz-Dental GmbH, Rosbach, Germany) according
to the manufacturers instructions. To fabricate IPS Empress 2 inlays, polyurethane dies were painted with 3
coats of die spacer (Cement Spacer; Kerr Dental, Orange, Calif.). Inlay restorations were waxed (Yeti Dental
Produkte GmbH, Engen, Germany) and sprued. Ceramic inlays were pressed after investment. All procedures were performed with IPS Empress 2 materials and
protocol. After divestment, ceramic inlays were finished
with diamond burs (no. 863-11-016; Gebr Brasseler)
and glazed.
To fabricate Ceramco II inlays, refractory dies were
duplicated from the polyurethane dies. Ceramic inlays
were built up on these refractory dies, fired in a porcelain furnace (Programat P 90; Ivoclar) and glazed.

Bonding ceramic inlays


Both IPS Empress 2 and Ceramco II inlays were luted
in the same way. Ceramic inlays were etched with phosMARCH 2003

Composition

Primer A: MDP, HEMA, water, photoinitiator,


accelerator
Primer B: HEMA, water, accelerator
Bond liquid A: MDP, demethacrylates,
photoinitiator, accelerator, microfiller
ED Primer A: HEMA, MDP, 5-NMSA
ED Primer B:5-NMSA
Paste A: MDP, bis-GMA, filler, benzoyl
peroxide, photoinitiator
Paste B: Bis-GMA, filler, sodium fluoride, amine

phoric acid gel (K Etchant; Kuraray Co Ltd, Osaka,


Japan) for 5 seconds. A layer of silane coupling agent
combination (Clearfil Porcelain Bond Activator; Clearfil
Liner Bond 2V Primer; Kuraray Co Ltd) was applied to
the ceramic bonding surfaces for 5 seconds and then air
dried.
In Group I A and B and Group II A and B, Clearfil
Liner Bond 2V, the self-etching primer, was applied to
the dentin surface for 30 seconds and gently air dried.
Clearfil Liner Bond 2V bond, an adhesive agent, was
applied to the dentin surface. Panavia F, the dual polymerizing resin cement, was mixed for 20 seconds and
applied to both prepared teeth and the bonding surface
of the ceramic restorations. Finger pressure was used to
stabilize the inlays during bonding to the dentin surface.
Excessive cement was removed with an explorer, and the
cement was polymerized for 20 seconds with the light
polymerizing unit (Hilux 350; Express Dental Products,
Toronto, Canada) at 350 mW/cm2 (with the light tip to
specimen distance of 0 mm). The margins were covered
with glycerine jelly for 3 minutes and washed.
In Groups I C and II C, Panavia F ED, the selfetching primer, was applied to the dentin surface for 60
seconds and gently air dried. Panavia F was mixed for 20
seconds and applied to both prepared teeth and the
277

THE JOURNAL OF PROSTHETIC DENTISTRY

OZTURK AND AYKENT

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

Table III. Analysis of variance tensile bond strength results


Source

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

Fig. 3. Tensile bond strengths of ceramic inlays.

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

OZTURK AND AYKENT

THE JOURNAL OF PROSTHETIC DENTISTRY

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.)

The statistical analysis was performed with SPSS for


windows 2000/V 8.0 (SPSS Inc, Chicago, Ill.). The
means and standard deviations for the 3 different cementation techniques of the bond strengths were calculated for each ceramic material. For each cementation
technique tested, the bond strength values were analyzed with 2-way analysis of variance and Tukey honestly
significant difference tests to determine whether a relationship existed between the cementation techniques
and the ceramic material. Differences were considered
significant at P.05.
MARCH 2003

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

THE JOURNAL OF PROSTHETIC DENTISTRY

OZTURK AND AYKENT

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.)

and No-DBA (Groups I C and II C) groups (Fig. 3). No


statistically significant differences were found between
the bond strengths of I-DBA and No-DBA techniques
(P.05).
Most failures (353 of 360) were adhesive in nature at
the bonding resin/dentin interface (type 1). Only 7
specimens showed cohesive failure within the bonding
resin (type 2). One of these cohesive failures was seen in
Group I A, 2 were seen in Group I C, and the last 4 in
Group II C. In SEM evaluation, D-DBA technique
specimens exhibited a distinct and thicker hybrid zone
with longer and more resin tags (Fig. 4) than the specimens of both I-DBA (Fig. 5) and No-DBA techniques
(Fig. 6).

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

variables, dentin is a heterogeneous substrate, and it is


difficult to predict the overall behavior of the dentinresin interface.14
Paul and Scharer18 modified the luting procedure and
applied the dentin bonding agent (ART Bond, ColteneWhaledent Inc, Mahwah, N.J.) to freshly prepared dentin. This technique resulted in a considerable increase in
the bond strength values.
Magne and Douglas19 evaluated the efficiency of the
2 different application methods of a dentin bonding
agent (Optibond FL) using experimental strain gauges,
finite element analysis, and SEM evaluation. In the first
approach, adhesive was applied in the last treatment
stage. In the second approach, adhesive was applied and
polymerized before making the impression.19 This optimized method showed higher bond strengths than the
conventional technique. The dentin-resin interface
showed notable differences when observed under a
SEM. Both DBA applications generated a well organized hybrid layer. D-DBA technique specimens exhibited longer resin tags and did not show any discontinuity
either in the dentin-resin interface or between the prepolymerized adhesive and the luting composite. However, for I-DBA specimens the hybrid layer systematically presented a partial disruption with the overlying
resin.19
Similar to the previous study by Magne and Douglas,19 the results of this study showed that D-DBA technique demonstrated higher microtensile bond strength
than both I-DBA and No-DBA techniques. Also DDBA specimens exhibited a distinct and thicker hybrid
zone with more, longer resin tags than the specimens of
I-DBA and No-DBA techniques.
VOLUME 89 NUMBER 3

OZTURK AND AYKENT

Because clinical failures result primarily from tensile


forces, the microtensile method is more appropriate for
clinical applications. The number of cohesive fractures
was significantly reduced when a microtensile bond test
was performed with very small surface area specimens.20,21 The small size of the specimens has led to a
more favorable stress distribution and thus the failure of
bonds which are closer to their true ultimate
strengths.20,21 Therefore in this study the microtensile
test method was used to evaluate bond strength of the
specimens. Most of the failures were adhesive in all test
groups, only 7 of them were cohesive, and 6 of these in
the bonding resin were seen in groups I C and II C (No
DBA). However, microcracks and other defects can possibly occur during the production of specimens with
slow-speed diamond saw sectioning machine, which
may cause premature failure of the bond. Therefore meticulous preparation of the specimens is necessary.21
The D-DBA technique showed improved bond
strength in vitro conditions. This technique may also
prevent the development of bacterial leakage and dentin
sensitivity during the provisional phase. Although the
D-DBA technique showed better results in this study
and in previous studies,18,19 this application is not common. Clinical trials are necessary to validate the results of
this in vitro study.

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

THE JOURNAL OF PROSTHETIC DENTISTRY

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

Observable deviation of the facial and anterior tooth midlines


Harold S. Cardash, BDS, LDS,a Zeev Ormanier, DMD,b and Ben-Zion Laufer, DMD, MSDc
The Maurice and Gabriela Goldschleger School of Dental Medicine, Tel Aviv University,
Tel Aviv, Israel
Statement of problem. It has been recommended that the anterior tooth midline be placed coincidently with
the midline of the face (facial midline). The location of the facial midline depends largely on the judgment of the
clinician. The amount of deviation between these 2 midlines that is noticeable to the observer has not been fully
investigated.
Purpose. The observable deviation between the anterior tooth and facial midlines in a limited sample of dentate
subjects was recorded.
Material and methods. Full facial-view, standardized photographs (1/1.5) of 45 subjects, meeting very
limited inclusion/exclusion criteria and undergoing routine dental treatment at Tel Aviv Dental School, were
examined by 10 observers: 5 dentists and 5 nondental personnel who were given only a brief explanation of facial
and tooth midlines. The examiners asked whether the facial and anterior tooth midlines deviated. The photographs then were scanned onto a computer screen, and the facial midline was determined by bisecting the distance
between the medial angles of the eyes. The distance between a line perpendicular to this point and the contact
point of the central incisors was measured by one calibrated examiner. The photographs were grouped according
to the midline deviation: group 1, 1 mm; group 2, 1 to 2 mm; and group 3, 2 mm. Two photographs with
oblique anterior tooth midlines were removed from the study because they were so easily detected. The observers
detection rates for the remaining midline deviation were compared and subjected to 1-way analysis of variance to
identify significant differences at the 95% level of confidence. A post hoc Student t test was performed to identify
significant differences among the groups.
Results. Dentists and nondental personnel demonstrated a similar ability to notice deviations of anterior tooth
and facial midlines. Midline deviations of 1 mm (group 1) were detected by 6 of 10 observers in 4 of 29
photographs (14%). Midline deviations of 1 to 2 mm (group 2) were detected by 6 observers in 3 of 8
photographs (37%). Midline deviations of 2 mm (group 3) were detected by 6 observers in 5 of 6 photographs
(83%). The greater the deviation, the higher the detection rate. Significant differences were found between group
3 and the other 2 groups (P.01).
Conclusion. Within the limitations of this study, 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. (J Prosthet Dent 2003;89:282-5.)

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.

sthetics are enhanced when the mesial surfaces of


the maxillary central incisors (anterior tooth midline)
coincide with the midline of the face (facial midline).
Lombardi1 noted that proper location of the dental midline is necessary for stability of the dental composition,
as improper placement of the midline makes it impossible to balance the elements on either side of it. Tension
is produced because of induced forces that make the
viewer feel that the line must move to its proper place to
produce stability and permanence.2
a

Clinical Associate Professor, Department of Oral Rehabilitation.


Instructor, Department of Oral Rehabilitation.
c
Clinical Lecturer, Department of Oral Rehabilitation.
b

282 THE JOURNAL OF PROSTHETIC DENTISTRY

Standard complete denture textbooks recommend


that the mesial surfaces of maxillary central incisors be in
contact with an imaginary vertical line that bisects the
face.3-5 The midpoint of the interpupillary line, or the
line from the center of the brows, typically is used to
locate the facial midline. The anterior tooth midline is
then determined by dropping an imaginary perpendicular line from the midpoint on the interpupillary line. It is
sometimes difficult to transpose an imaginary point from
the bisection of the interpupillary line to the midline of
the mouth to determine the contact point of the mesial
surfaces of the incisors. Other anatomic landmarks used
to estimate the midline position of the central incisors in
complete denture prostheses are the incisal papilla5 and
VOLUME 89 NUMBER 3

CARDASH, ORMANIER, AND LAUFER

THE JOURNAL OF PROSTHETIC DENTISTRY

Fig. 1. Example of deviation and slanting of dental midline


compared with facial midline in a patient with a provisional
FPD.

Fig. 2. Slanting dental midline made parallel to facial midline in definitive restoration of patient in Fig. 1.

a point midway between the angles of the mouth when


the patient is smiling.3
Using the tubercle of the upper lip as the midline of
the face, Latta6 found that in 70% of 100 patients, the
average distances of the midpalatal suture, nasopalatine
papilla, and labial frenum were 1 mm from the midline. The clinical significance of this finding is minimal,
given that the range varied by as much as 5.5 mm. Tjan
et al7 suggested that, because patients tend to relate the
midline to the upper lip rather than to other facial features that are further from the mouth, an imaginary line
dividing the midline lobe of the philtrum can be used to
establish the midline. Miller et al8 identified the center of
the philtrum as the most reliable guide to the facial
median line (facial midline). They reported that the midline of the maxillary teeth in 75% of 500 subjects examined coincided with the median line of the philtrum.
Because no human face is symmetrical, there can be
no hard and fast rule for determining the facial midline;
the artistic judgment of the individual clinician therefore
must be used. Observation reveals that a lack of exact
coincidence between the location and direction of the 2
midlines is common and not necessarily an esthetic liability. Patients with crowded, spaced, or malposed teeth
who seek oral reconstruction often balk at the idea of
lengthy orthodontic treatment. Figure 1 shows a patient
who complained of deviation of the dental midline. Examination revealed deviation and slanting of the dental
midline compared with the facial midline. The patient
would not consider orthodontic treatment. Figure 2
shows the same patient after the slanting dental midline
was made parallel to the facial midline without correction of the mediolateral deviation; the result was a harmonious appearance with a barely detectable tooth to
facial midline deviation. Where compromise treatment is
advocated, it may be possible to achieve a good esthetic

result even if the anterior tooth midline is not coincident


with the facial midline.
The amount of deviation of the anterior tooth midline from the facial midline that is noticeable to a viewer
is unknown. The purpose of this investigation was to
determine the observable deviation between the anterior tooth and facial midlines in a limited sample of
dentate subjects.

MARCH 2003

MATERIAL AND METHODS


The reproduction ratio of the full facial-view to the
standardized photographs was 11.5, where the photograph was 1 and the face size was 1.5 times the size of
the photograph (1/1.5). Photographs of 45 subjects
undergoing routine dental treatment were taken. Their
ages ranged from 25 to 65 years. None of the subjects
had fixed or removable prostheses on their anterior
teeth. All subjects were clean-shaven and had medium or
high lip lines that easily exposed the complete central
incisors when they smiled. There was no clinical evidence of periodontal disease. Each patient was seated in
a dental chair with the headrest in a fixed position and at
a constant distance from a camera mounted on a tripod.
The crown length of the central incisors in the mouth
and on the photographs was measured to ensure that the
magnification was constant.
The photographs were examined by 10 observers, 5
general dentists and 5 nondental personnel from the
administration department, all of whom worked at the
Tel Aviv Dental School. The nondental personnel were
given a brief explanation of facial and anterior tooth
midlines. Each person was asked whether the anterior
tooth midline was coincident with the facial midline and
was then allowed to view each photograph from any
angle and at any distance for 10 seconds. Oblique anterior tooth midlines were easily detected, even with no
283

THE JOURNAL OF PROSTHETIC DENTISTRY

CARDASH, ORMANIER, AND LAUFER

The coefficient of variation was calculated as 0.26%


and was attributed to the difficulty of locating the exact
points to be measured and placing the cursor on these
points. The image of the midline of the teeth was not
always sharp, and the medial angles of both eyes were
rarely exactly symmetrical. The deviation between the
anterior tooth and facial midlines of the images calculated from the computer ranged from 0 to 3 mm. The
photographs were grouped according to the size of the
deviation: group 1, 1 mm; group 2, 1 to 2 mm; and
group 3, 2 mm. The observers detection rates for
midline deviation in the photographs were compared
and subjected to 1-way analysis of variance to identify
significant differences at the 95% level of confidence. A
post hoc Student t test was performed to identify significant differences among the groups.

RESULTS

Fig. 3. Measurement of midline deviation on computer


screen.

deviation of the midline. Two photographs with oblique


midlines therefore were removed from this study.
The remaining photographs were scanned onto a
computer screen with a specialized program (Image Editor, version 20b; Ulead Systems Inc, Torrance, Calif.)
to magnify the images, which enabled better identification of the anatomic structures and facilitated measurement. The images were aligned with the interpupillary
line parallel to the framework of the screen. The facial
midline often is determined as the midpoint of the interpupillary line.3-5 However, the pupils appeared dark
on the computer screen, and because their margins were
indistinct, their center points were difficult to identify.
The nearby angle of the eye therefore was selected as a
measuring point. The cursor was placed on the medial
angle of one eye and moved horizontally to the medial
angle of the other eye. The distance between them was
recorded. This horizontal line was then bisected by a
vertical line drawn perpendicular to it, down through
the lips. The vertical line represented the midline of the
face. The distance between it and the contact of the
mesial surfaces of the central incisors was read on the
computer (Fig. 3). One examiner made all measurements and determined the experimental error by measuring this distance in a similar manner on 1 photograph
intermittently interposed 10 times among all others
measured.
284

An initial comparison showed little difference in the


ability of the dentists and the nondental personnel to
detect deviations of the midlines in the photographs.
Their results therefore were combined. In group 1 (1
mm deviation), 6 of 10 observers detected the deviation
in 4 of 29 photographs (13%) (Fig. 4). In group 2 (1-2
mm deviations), 6 observers detected the deviation in 3
of 8 photographs (37%). In group 3 (2 mm deviation),
6 observers detected the deviation in 5 of 6 photographs
(83%). The greater the deviation, the higher the detection rate.
Significant differences were found between group 3
and the other groups (P.01) (Table 1). Groups 1 and
2 were not significantly different (P.48).

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

CARDASH, ORMANIER, AND LAUFER

THE JOURNAL OF PROSTHETIC DENTISTRY

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

F value P value F critical

4.5

.02

3.3

the anterior tooth and facial midlines might vary. There


was, however, little difference with regard to their detection rates. The small size of the observer groups rendered statistical comparisons between them impractical.
Attempts were made to use the philtrum and the
tubercle of the upper lip on the computerized image as
the facial midline. The borders of these structures were
indistinct; hence, their midpoints were difficult to identify precisely. Subjective measurements resulted in high
intraobserver error and therefore were abandoned.
The results of this study cannot be compared with
those of others in which anterior tooth midline deviation was measured, as no other investigation measured
the observers ability to detect differences between facial
and anterior tooth midlines. The observable deviation of
these midlines was determined from photographs in the
present study. Detection in the patient would probably
be considered more difficult, as the face is constantly
moving and dynamic movements of the tissues are distracting. Patient input may be critical when features such
as the position of the incisor midline are examined. The
authors experience is that patients often try to view the
dental arrangement in a closer position and lift their lips
and cheeks to better expose the teeth.

MARCH 2003

Within the limitations of this study, a majority of the


10 observers noticed deviations of anterior tooth midlines from facial midlines of 2 mm in magnified photographs. With deviations of 2 mm, the detection rate
decreased.
REFERENCES
1. Lombardi RE. A method for the classification of errors in dental esthetics.
J Prosthet Dent 1974;32:501-13.
2. Lombardi RE. The principles of visual perception and their clinical application to denture esthetics. J Prosthet Dent 1973;29:358-82.
3. Macgregor AR. Fenn, Liddelow, and Gimsons clinical dental prosthetics.
London: Butterworth & Co; 1989. p. 87.
4. Neill DJ, Nairn RI. Complete denture prosthetics. 3rd ed. London; Wright;
1990. p. 83.
5. Zarb GA, Bolender CL, Carlsson GE. Bouchers prosthodontic treatment
for edentulous patients. 11th ed. St. Louis: Mosby; 1997. p. 318.
6. Latta G. The midline and its relation to anatomic landmarks in the edentulous patient. J Prosthet Dent 1988;59:681-3.
7. Tjan AH, Miller GD. The JGP. Some esthetic factors in a smile. J Prosthet
Dent 1984;51:24-8.
8. Miller EL, Bodden WR Jr, Jamison HC. A study of the relationship of the
dental midline to the facial median line. J Prosthet Dent 1979;41:657-60.
9. Frush JP, Fisher RD. The dynesthetic interpretation of the dentogenic
concept. J Prosthet Dent 1958;8:558-81.
10. Brisman AS. Esthetics: a comparison of dentists and patients concepts.
J Am Dent Assoc 1980;100:345-52.
Reprint requests to:
DR HAROLD CARDASH
DEPARTMENT OF ORAL REHABILITATION
GOLDSCHLEGER SCHOOL OF DENTAL MEDICINE
TEL AVIV UNIVERSITY
TEL AVIV 69978
ISRAEL
FAX: (972)3-640-9250
E-MAIL: cardash@inter.net.il
Copyright 2003 by The Editorial Council of The Journal of Prosthetic
Dentistry.
0022-3913/2003/$30.00 0
doi:10.1067/mpr.2003.68

285

The magnitude of cutting forces at high speed


Kanaan Elias, DDS, MSc,a Andrew A. Amis, DSc,b and Derrick J. Setchell, BDS, MSc
Eastman Dental Institute For Oral Health Care Sciences, University College London and Imperial
College, University of London, London, United Kingdom
Statement of the problem. Previous research has used a range of cutting forces for preparing teeth, but there
are no data available on the forces actually imposed while cutting teeth with high-speed handpieces.

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.

MATERIAL AND METHODS


Two different air turbine handpieces were used: a
KaVo super torque 630B (Kaltenbach & Voigt, BiberVOLUME 89 NUMBER 3

ELIAS, AMIS, AND SETCHELL

THE JOURNAL OF PROSTHETIC DENTISTRY

Table I. Summary of some relevant previous studies


Authors

Year

Force (N)

Henry and Peyton


Schuchard and Watkins
Westlans

1951
1967
1980

1.96-7.36
0.56-8.83
0.01-2.94

Semmelman, Kulp, and


Kurlansik
Reisbick and Bunshah
Lloyd, Rich, and Brown
Brown, Christensen, and
Lloyd
Grajower, Zeitchick, and
Rajstein
Luebke, Chan, and
Bramson
King, Reitz, and King

1961

0.88

1973
1978
1978

1.11
0.69
0.29-0.69

Cast iron
Teeth
Teeth

Comparing the efficiency of different burs


Comparing the performance of different handpieces
Measurement of the energy requirement of the cutting
process
The relative function of speed and torque in the
cutting process
Wear characteristics of burs
Effectiveness of cooling techniques
Measurement of energy deposition during cutting

1979

1.96-3.92

Teeth & glass

Cutting efficiency of diamond wheels

1980

0.69

Teeth

Cutting effectiveness of TC burs on teeth

1982

1.08

Composite

Harkness and Davies


Eames and Neal
Von Fraunhofer, Grieves,
and Overmyer
Siegel and Von
Fraunhofer
Tiara et al
Sorenson et al
Greener and Lindenmeyer
Atkinson

1983
1973
1977

0.50
1.47
0.69 and 1.44

Teeth
Teeth & glass
Teeth

Comparison of burs on composite with air coolant


alone and air-water coolant
Effect of cleaning on cutting efficiency
Durability of burs
Effect of lubricating coolants

1996

0.50-1.47

Glass ceramic

Cutting efficiency of diamond burs

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

TC, Tungsten carbide

ach, Germany) with a free running speed of 325,000


rpm and a Midwest 8000I handpiece (Midwest Dental
Supply, Des Plaines, Ill.) with a free running speed of
425,000 rpm. The handpieces possess distinctly different torque/speed characteristics. A maximum torque of
1.75 mNm for the KaVo handpiece and 1.15 mNm for
the Midwest were measured using the methods of
Walker and Morrant.27 The KaVo handpiece was driven
by a Minor driving unit (A-dec Inc, Newberg, Ore.)
with air pressure regulated at 34 psi, while the Midwest
handpiece was driven by a Porta Pacuttnit (A-dec Inc)
with air pressure of 32 psi. Both units had a common air
supply.
Plain and cross-cut tungsten carbide flat fissure
burs (Jet nos. 57 and 557; Beaver Apex Dental Supplies Ltd, Tewkesbury, Gloucester, United Kingdom)
were chosen because of their consistency in manufacture, which was verified by a geometrical survey of a
variety of different makes (K Elias, personal correspondence, 1999). The Jet bur has consistent end-on
features that do not conform to the familiar star or
revelation type, although this feature was assumed not
to be important in the sideways cutting in this experiment (Fig. 1).
MARCH 2003

Fig. 1. End-on view of Jet bur no. 57.

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

THE JOURNAL OF PROSTHETIC DENTISTRY

ELIAS, AMIS, AND SETCHELL

Table II. Cutting times (seconds) with each bur and


handpiece, shown as mean (range), N 31

57
557

Fig. 2. Schematic diagram showing longitudinal section of


force measuring unit. Diagram not to scale. t, Tooth specimen; p, plaster; b, brass well; a, aluminum beam; s, strain
gauges; c, casing.

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

ELIAS, AMIS, AND SETCHELL

THE JOURNAL OF PROSTHETIC DENTISTRY

Table III. Peak cutting forces when cutting wet or dry,


shown as mean standard deviation (range), N 31

57 Wet
57 Dry
557 Wet
557 Dry

KaVo

Midwest

1.48 0.47 (0.64-2.75)


1.51 0.41 (0.81-2.61)
1.40 0.53 (0.43-2.53)
1.36 0.44 (0.35-2.65)

1.19 0.38 (0.25-1.94)


1.25 0.43 (0.20-2.18)
1.12 0.43 (0.22-1.82)
1.22 0.37 (0.25-1.91)

Table IV. Spearman correlation


Bur

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

M, Midwest; K, KaVo; W, wet.

Fig. 3. Mean cutting forces applied by operators for KaVo and Midwest handpieces cutting sound wet and dry teeth.

collected for each cavity (Table II). Although the time


of data collection for each cavity was limited to 60
seconds, all cavities were cut within that time, but
some operators continued with fine adjustment up to
60 seconds. No bur was fractured and no dentist
stalled the bur at any time, although some operators
expressed their desire to run the handpieces at higher
air pressure. The maximum force recorded by each
dentist was assumed to be meaningful in the absence
of stalling. The highest recorded force was 2.75 N and
was achieved with the KaVo handpiece cutting wet
with bur No. 57, whereas one operator completed the
preparation of a cavity with a maximum recorded
force of only 0.20 N using the Midwest handpiece and
cutting dry with bur No. 57 (Table III).
No significant difference (P.05) in cutting forces was
found by analysis of variance between cutting wet rather
than cutting dry or between plain and cross-cut burs
(P.05) in any applications with the KaVo handpiece
group or the Midwest group, but in all situations a significantly higher cutting force was applied with the KaVo
MARCH 2003

handpiece (P.0001). Although the data showed a wide


range of forces applied by the operators, most operators
were consistent in their own force for all applications.
The Spearman correlation test confirmed that there
was no overall correlation between the force applied
to one handpiece and that applied to the other by each
operator. This test also showed that if keeping to one
handpiece, an operator who applied a high force with
one bur did the same with another. With a particular
choice of bur, there was not a significant correlation
between the forces applied with different handpieces
(Table IV). When the No. 57 bur cutting wet was
used in the KaVo handpiece, there was no significant
correlation between the peak force applied and the
time spent to produce the cavity (r0.008, P.97).
With the KaVo handpiece, the mean maximum force
recorded by each operator for all applications was 1.44 N
(range 0.72 to 2.23 N). The Midwest handpiece had a
significantly lower (P.002) mean maximum force of 1.20
N (range 0.66 to 1.69 N). The overall mean force for all
cavities cut was 1.31 N.
289

THE JOURNAL OF PROSTHETIC DENTISTRY

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

ELIAS, AMIS, AND SETCHELL

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

ELIAS, AMIS, AND SETCHELL

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

THE JOURNAL OF PROSTHETIC DENTISTRY

Reprint requests to:


DR KANAAN ELIAS
EASTMAN DENTAL INSTITUTE FOR ORAL HEALTH CARE SCIENCES,
UNIVERSITY COLLEGE LONDON
UNIVERSITY OF LONDON
256 GRAYS INN ROAD
LONDON WC1X 8LD
UNITED KINGDOM
TEL: 00 44 207 915 1027
FAX: 00 44 207 915 1028
E-MAIL: k.elias@eastman.ucl.ac.uk
Copyright 2003 by The Editorial Council of The Journal of Prosthetic
Dentistry.
0022-3913/2003/$35.00 0
doi:10.1067/mpr.2003.35

291

The teaching and treatment of upper airway sleep disorders in North


American dental schools
John R. Ivanhoe, DDS,a Kevin B. Frazier, DMD,b Gregory R. Parr, DDS, MS,c and
Van B. Haywood, DMDd
School of Dentistry, Medical College of Georgia, Augusta, Ga.
Statement of problem. Many dental patients suffer from upper airway sleep disorders (UASD) that affect the
quantity and quality of their sleep. These disorders vary from minor annoyances to life-threatening conditions.
Even though dentists can play a role in the successful treatment of these patients with oral devices, few do. This
lack of participation, in part, may be due to lack of education.
Purpose. The purpose of this study was to determine which North American dental schools include the
treatment of UASD in their curriculum. This information may prove helpful to other schools in determining
whether, and to what degree, they should teach about UASD and its treatment options.
Material and methods. A survey instrument (questionnaire) was mailed to all of the North American dental
schools (n 64) affiliated with the American Association of Dental Schools. The questionnaire consisted of 9
multipart questions. Major categories of questions included the following: (1) Is the subject of UASD a part of
the school curriculum? If so, in what department is it taught? (2) Are oral devices fabricated for patients or is the
experience only at the didactic level? (3) What diagnostic procedures are required? (4) What types of oral devices
are fabricated and what is the success rate/recall frequency? (5) What is the patient source? (6) If this subject area
is not covered either didactically or clinically, why not? The data were analyzed by use of descriptive statistics.
Results. Forty-three of the 64 schools that received the survey responded. Forty-two percent of the schools that
responded are teaching the treatment of UASD with oral devices. There is no apparent consensus with regard to
whether to teach the subject, at what level, or to what degree.
Conclusion. Even though many dental patients suffer from potentially life-threatening sleep disorders, many of
which could be treated with oral devices, fewer than half of the reporting dental schools currently include this area
as part of their curriculum. This lack of inclusion is caused primarily by a lack of familiarity with the information
available and a lack of available curriculum time. (J Prosthet Dent 2003;89:292-6.)

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.

uman beings spend approximately one third of


their lives sleeping. This time is recognized as having an
important physiological role.1 Sleep disruption caused
by breathing disorders is recognized as an important
global health issue because of its prevalence and association with disease development and death.2-9 Among
the various sleep disorders, obstructive sleep apnea
(OSA) is 1 of the most common, affecting approximately 4% and 2% of the middle-aged male and female
population, respectively.3 Unfortunately, many patients
with OSA go unrecognized and are not diagnosed and
treated.10 Lack of physician training has been presented
a

Associate Professor, Department of Oral Rehabilitation.


Associate Professor, Department of Oral Rehabilitation.
c
Professor, Department of Oral Rehabilitation.
d
Professor, Department of Oral Rehabilitation.
b

292 THE JOURNAL OF PROSTHETIC DENTISTRY

as a reason for this problem.11,12 If properly trained, the


dentist, as a frequently consulted health care provider,
could be an important and overlooked source of detection, referral, and treatment of these patients.13
The science of treating upper airway sleep disorders
(UASD) has advanced rapidly in last decade. Current
recommendations are that no clinical intervention, dental or otherwise, be attempted until definitive diagnosis
is performed via a sleep study.14,15 Less costly home tests
are viewed as limited and useful only when all-night
studies are not possible.16 The Epworth scale,17 although not useful when testing for OSA, is a simple
patient-based tool used to assess daytime sleepiness.18
The Epworth scale is valuable for screening purposes
and useful for convincing patients that the time and
expense of a full sleep study is necessary. The objective
success of an oral device or any other method of OSA
VOLUME 89 NUMBER 3

IVANHOE ET AL

Table I. Teaching and treating UASD: survey questionnaire


summary
Subject areas taught
Instructional level (predoctoral, resident)
Curriculum hours
Responsible department
Oral devices-didactic instruction
Instructional level
Lecture hours
Responsible department
Oral devices-clinical experience
Instructional level
Diagnostic procedures
Sleep study / Epworth scale
Type of oral device (prefabricated/custom)
Device source (dental school laboratory/commercial laboratory)
Number of devices completed (per year)
Percentage patients successfully treated
Patient follow-up protocol
Patient sources (referral / walk-in)
Reasons for not teaching these subjects

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.

MATERIAL AND METHODS


A 2-page survey instrument (questionnaire) (Table I)
was mailed to each of the North American dental
schools affiliated with the American Association of Dental Schools (n 64). Specifically, the questionnaires
were sent to individuals selected from the American
Dental Education Association (ADEA) Directory of Institutional Members and Associated Officers who held poMARCH 2003

THE JOURNAL OF PROSTHETIC DENTISTRY

sitions associated with curriculum or academic affairs.


Each questionnaire included a cover letter describing
the purpose of the study and an assurance of confidentiality. The questionnaires were coded to allow for identification for follow-up letters. If, after 6 weeks, there
was no response, a reminder letter and a second copy of
the questionnaire were sent. Return of the questionnaire
was accepted as implied consent to participate in the
study.
The questionnaire consisted of 9 multipart questions
and was developed by the research team to determine if,
and how the subjects of OSA and UASD were being
taught. The first question asked whether the subjects
were taught at all, at what level they were taught (predoctoral or postdoctoral), how many hours were devoted to the subject matter, and what department(s) did
the teaching. The second and third questions asked for
similar information concerning the fitting of oral devices
to address the symptoms of UASD, specifically, whether
this subject was taught in a lecture format only or if
clinical experiences were available as well (fitting of oral
devices). If this service was performed clinically, further
information was requested concerning how patients
were referred to the school, how they were evaluated,
how the oral devices were fabricated (prefabricated or
custom made, fabricated in a dental school or commercial laboratory), and how many patients were treated in
a year. Outcome-related questions such as how often
patients were seen for follow-up and an estimate of the
success rate were included as well. The final question, for
those schools whose curricula did not cover UASD, inquired about reasons for not teaching these subjects.
The information resulting from this survey might
serve as a starting point for those schools not currently
teaching or treating sleep disorders but interested in
developing a teaching or clinical program. The data
were analyzed by use of descriptive statistics.

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

THE JOURNAL OF PROSTHETIC DENTISTRY

IVANHOE ET AL

Table II. Departments that teach OSA or UASD (18


schools)
Department

Restorative dentistry/prosthodontics
Oral medicine/oral diagnosis
Oral surgery
Anatomy
Physiology
Oral facial pain
General practice
AEGD residency

Table III. Reasons for not teaching OSA or UASD (25


schools): (multiple answers possible for each school)

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

Five other departments were listed equally as having a


role in teaching these subjects (Table II).
Sixty-one percent (11/18) of the schools that teach
the subject of UASD offer didactic instruction in the
fitting of oral devices to address the symptoms of snoring and OSA. Instruction in this area occurs only at the
postdoctoral level in 5 schools whereas the remaining 6
schools teach this subject either at the predoctoral level
only or at both levels (3 schools each). The average
number of lecture hours devoted to this subject was 1.8
with a range of 1 to 4 hours marked on the questionnaires (mode 1 hour).
Restorative dentistry/prosthodontics (45%), and oral
medicine/oral diagnosis (36%) provided most of the
instruction in fitting the oral devices. Oral surgery and
general practice residency make up the balance of the
departments that teach this subject (1 school each).
Thirty-eight percent (7/18) of the schools that teach
UASD offer clinical experiences to students in the fitting
of oral devices. Most of these experiences (5/7) are
exclusively at the postdoctoral level (72%), whereas the
rest of the schools offer this experience at the predoctoral level (28%). Forty-three percent (3/7) of the respondents require a sleep study before prescribing an
oral device whereas only 29% (2/7) use the Epworth
scale as part of their evaluation.
Four of 7 schools use custom-made oral devices exclusively whereas 3 schools use either prefabricated or
custom-made devices. Five of the 7 schools offering clinical experiences use an outside (commercial) laboratory
to make oral devices whereas the other 2 use an in-house
(dental school) laboratory. The average number of oral
devices completed in the responding schools (n 6) per
year was estimated to be 10. The respondents were
asked to estimate the percentage of patients that were
treated successfully with oral devices, and the average of
the 4 responses was 86%.
When asked about recall protocols, 44% of schools
used a recall frequency of from 2 to 4 times, 22% saw the
patients more than 4 times, 22% recalled the patients on
a yearly basis, and 11% saw the patients on an as
294

Reason

Has not yet been discussed


Insufficient curriculum time available
Is currently under consideration
OSA care is a medical procedure, not dental
Insufficient research to use oral devices
Concern for TMD problems
Oral devices are not recommended
Concern for patient safety
Other-only if requested by ENT

No. of
schools

17
8
5
3
2
1
0
0
1

68
32
25
12
8
4
0
0
4

needed basis. Most patients treated for UASD were


referred by physicians (50%) or other dentists (31%),
whereas the smallest percentage (19%) was seen without
referral (walk-ins).
The questionnaire contained a list of 8 reasons for not
teaching these subjects in the curriculum (Table III).
The reasons most frequently cited by the 25 responding
schools were Has not yet been discussed (68%), Insufficient curriculum time available (32%), and Is currently under consideration for inclusion (25%). Some
schools selected more than 1 response for this question.

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

this subject with restorative/prosthodontic faculty. This


suggests that the best way of imparting the knowledge
and skills required by the dental health care professional
has not yet been determined. Perhaps creative and even
multidisciplinary approaches are best suited to this topic.
Only 38% of the schools that include didactic information on UASD conditions offer clinical treatment
with oral devices. The reasons for this response may
include those previously mentioned in addition to the
difficulty of finding time to introduce new or advanced
techniques in an already crowded curriculum.
Question 3 related to the clinical performance and
experience of the individual schools. Thirty-eight percent of schools teaching this material performed the
service clinically. Teaching was done mostly at the postdoctoral level (72%). In the opinion of the author(s),
lack of teaching at the predoctoral level may be due to
the fact that new procedures are often viewed as beyond the ability of predoctoral students. More experience at the faculty level is likely needed before this procedure is covered clinically in predoctoral programs to a
larger degree. It was unexpected that only 43% of
schools required a sleep study before an oral device was
prescribed because current recommendations require a
sleep study before initiating patient treatment.14,15
The frequent use (57%) of custom-fabricated oral devices was expected because these devices fit patients with
greater predictability than prefabricated or stock devices. The high use of a commercial laboratory for fabrication of the custom devices (82%) is also not remarkable. This is a newer procedure that is not frequently
performed. It is doubtful if this service will ever be a
standard option of in-house dental school laboratories.
Although a significant reduction in the respiratory
distress index20,21 is the objective criteria indicating success of an oral device, the responders were asked to
subjectively evaluate the success of the oral devices. The
average success rate of 86% reported in response to the
third survey question was presumably related to the ability of the patient to wear the device comfortably while
reporting a decrease in snoring. The average of 2 to 4
return visits (80%) was also not remarkable because adjustments must be made to the fit and occlusion of the
devices and the titration (incremental adjustment) of the
devices must be carefully monitored. Because dentists
have been warned against accepting the role of primary
care provider for patients,31 it is unexpected that 58% of
the schools do not require a referral from a physician.
The last question requested an explanation if the
teaching of this material was not included in the curriculum. Predetermined items could be checked or individualized responses could be written. The most common
response was that the subject has not been considered
for inclusion in the curriculum (Table III). This seems to
indicate a lack of education of the potential importance
of these devices and, hence, a lack of teaching this topic
MARCH 2003

THE JOURNAL OF PROSTHETIC DENTISTRY

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

THE JOURNAL OF PROSTHETIC DENTISTRY

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

M. M. House mental classification revisited: Intersection of particular


patient types and particular dentists needs
Simon Gamer, DDS,a Richard Tuch, MD,b and Lily T. Garcia, DDS, MSc
School of Dentistry, University of Southern California, Los Angeles; University of California at
Los Angeles, Los Angeles, Calif.; and UTHSCSA Dental School, San Antonio, Texas
Fifty-three years ago, M. M. House devised a classification of patients on the basis of how they behaved in response to the prospect of becoming edentulous and on how they subsequently adapted to
wearing complete dentures. Although Houses system was an important contribution, it failed to consider the dentists emotional reaction to a patients behavior as part of an understanding of how the
patient and doctor cope with the dental treatment. This article presents an expansion of the House
classification to include the behavior of the dentist as a codeterminer of the patients behavior. This
expanded classification system is based on empiricism and awaits scientific validation or clinical application to determine its ultimate validity, reliability, and effectiveness. (J Prosthet Dent 2003;89:297-302.)

ixty years ago, the American Association of Dental


Schools (now the American Dental Educators Association) first suggested that behavioral aspects of dentistry
deserved attention within dental school curricula.1 Since
then, many psychiatrists, psychologists, and psychologically minded dentists have contributed to the body of
knowledge about how people react to the experience of
being a dental patient.2-5 Publications have ranged from
empirical observations of experienced clinicians, to theoretical musings of psychoanalysts, to formal studies
conducted by research psychologists.
In 1950, Dr M. M. House,6 whose contributions
advanced the science and art of prosthodontics, devised
a classification system on the basis of patients psychological responses to becoming edentulous and adapting
to dentures. Relying strictly on his clinical impressions,
House6 classified patients into 4 types: philosophical
mind, exacting mind, hysterical mind, and indifferent
mind.

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.

Presented at the Pacific Coast Society of Prosthodontists 61st Annual


Meeting at the El Dorado Hotel, Santa Fe, New Mexico, June
26-29, 1996.
a
Clinical Professor, Department of Restorative Dentistry, University
of Southern California.
b
Assistant Clinical Professor, Department of Psychiatry, University of
California at Los Angeles.
c
Associate Professor and Chair, Department of Prosthodontics, UTHSCSA Dental School.
MARCH 2003

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

THE JOURNAL OF PROSTHETIC DENTISTRY

the prosthesis. This patient corresponds to Houses philosophical-mind patient.


The literature on the dentist/patient relationship has
focused directly on the needs of the patient. Winkler8
discussed the need to fit oneself to the personality of the
patient. Koper9 characterized and typed patients who
have difficulty in adapting to complete dentures as problem patients, difficult denture patients, or difficult denture birds. Jamieson10 stated that fitting the personality
of the aged patient is often more difficult than fitting the
denture to the mouth.
Other authors have also suggested that more than
technical competence is needed to forge a patient dentist
alliance and that interpersonal aspects of the relationship
also require attention. Friedman et al4 noted the significance of the dentist/patient alliance. He wrote that the
clinician has the power to make a significant change in
the patients life. To cross over to adaptability, the patient must have a partnership with the clinician. The
feelings that will emerge may be either positive or negative, depending on the clinicians behavior and attitude. The tone of that relationship will become the feelings toward the denture. If the clinician has not forged a
trusting relationship with the patient, the denture will be
contaminated. However, if a positive relationship develops, the patient accepts both the prosthesis and the clinician.
Krochack,11 recognizing the critical need to understand the behavior of the dental patient, stated that
many patients with favorable anatomy cannot tolerate a
well-fabricated denture and yet other patients with unfavorable anatomy willingly endure dentures that may
be ill-fitting. He asserted that the inconsistencies of patient adaptation in these situations may be related to the
patients psychological state.
When behavioral scientists began to evaluate dentistry from their perspective, Jackson1 noted their surprise at the dental professions inexperience in the area
of human behavior. He further stated that the challenge
in teaching behavioral science is to significantly impact
the clinician to alter his/her interpersonal relationships.
Although most dentists agree that communication is
important, they tend to believe that it is an innate part of
their personality or common sense.
Although dentists may concede the importance of
behavioral skills, these skills are rarely placed at the same
level of importance as the dentists technical abilities.
However, a study that attempted to determine what
patients considered important in a dentist demonstrated
that patients place communication (feeling fully informed) and a sense of being understood of equal importance with the technical competency of the dentist.12
Kent13 demonstrated that use of dental services correlated positively to patient satisfaction. The ability of a
dentist to determine when a patient has unrealistic ex298

GAMER, TUCH, AND GARCIA

pectations and the ability to manage that interaction


effectively may avert a conflict.

WHY THE HOUSE CLASSIFICATION


REQUIRES REEVALUATION
Among the reasons that the House classification requires reevaluation is that some of the terminology is
antiquated, falling out of use, or no longer carries the
same meaning within psychiatry. For instance, the word
hysterical has come to be regarded as derogatory and
judgmental. Although the term has a historical place
within psychoanalysis (hysterics served as the original
psychoanalytic patients), given Houses description of
the type today one might speak more of a narcissistic
patient.
Another more important reason for reevaluation is
that the House classification pertains to the patient in
isolation. House provided little attention to how the
patients reactions and behaviors are codetermined by
the treatment and behavior of the dentist. As part of a
presentation of intersubjectivity theory within the psychoanalytic literature, Stolorow and Atwood14 critiqued
the idea that a patient can be viewed in isolation from the
effect of the psychoanalyst. They called this a mistaken
notion and an example of the myth of the isolated
mind. Thus the patients behavior is codetermined by
the personality and behavior of the psychoanalyst. The
thesis is that it is important to pay close attention to how
the observer affects the observed.15 This interaction is a
logical extension of ecological concepts that developed
in the late 1960s and 1970s that emphasized mutual
interaction of cause and effect. To understand the patients behavior, therefore, the clinicians personality,
subjective responses, and reactions must be considered
as contributing factors.
Few articles have been published that focus on the
needs of the dentist. Although dentists may believe they
are beyond discussing wishes and needs other than those
considered purely professional, the dentist may experience wishes to be liked and admired, to be heard and
respected as an authority, and to feel in control of the
situation. Each of these wishes exists along a continuum.
The wish to be liked and admired can become a need to
be idealized (placed on a pedestal), the wish to be heard
and respected as an authority can become a need to have
ones words be taken as gospel, and the wish to feel in
control can become a need to dominate.
The purpose of this article is to build on Houses
contribution to include an understanding that the practitioners psychology, along with that of the patient,
determines how well the dentist adapts to the patients
needs. The proposed new classification includes both
the patient and the dentist as codeterminers of treatment
outcomes, regardless of whether the patient is edentulous or dentate.
VOLUME 89 NUMBER 3

GAMER, TUCH, AND GARCIA

FACTORS AFFECTING THE DENTIST/


PATIENT RELATIONSHIP
The authors propose that the relationship between
the behavior and reactions of the patient and those of
the dentist are determined by the following factors: (1)
the patients ability to adapt to patienthood (the role of
the patient), (2) the dentists response to the patients
adaptation to patienthood, (3) the patients tendency to
unconsciously react to the dentist as if the dentist were
someone from the patients earlier life (transference),
(4) the dentists tendency to unconsciously react to the
patient as if the patient were someone from the dentists
earlier life (countertransference), and (5) other nonspecific factors.
Patients vary in their levels of submission to recommendations from the dentist and procedures performed
and in their levels of trust for the dentist. This, in turn,
may trigger emotional reactions in dentists. It is difficult
if not impossible for dentists not to react emotionally to
patients who constantly challenge their authority by
questioning and doubting whatever recommendations
the dentist offers. These reactions may not be apparent
to the patient. However, some patients may sense the
dentists frustration, irritation, or impatience, no matter
how hard the dentist tries to disguise his/her feelings.
Other types of patients who adopt a submissive stance
regarding treatment or who seem indifferent toward and
unappreciative of the dentists efforts may likewise create
feelings in the dentist. These, in turn, may trigger additional feelings in the dental patient. When the doctor/
patient relationship has developed, it may become impossible to say who is reacting to whom, much like a
cause-effect cycle in the chicken-and-egg analogy.
Transference is defined as experiencing feelings,
drives, attitudes, fantasies, and defenses toward a person
in the present that are not entirely appropriate, as they
may come to be understood as a repetition of how one
had experienced someone from past. The process by
which an individual adapts to the role of dental patient
can, under certain circumstances, be determined by
transference reactions to the authority of the dentist.
The similarity of the parent-child role to the dentist/
patient role can provoke a patient to regress and to react
as if the dentist were that patients parent. Regardless of
whether the patients parents helped that patient cope
with the dependency of childhood can affect all subsequent relationships that individual has with authority
figures.
Dentists can play one of several roles in the dentist/
patient relationship: (1) a parent who demands unquestioning, even submissive, obedience; (2) a parent who
wishes to be pleased, and when pleased will reward the
child with praise, approval, and love; (3) a parent who is
covertly defied, even frustrated; and (4) a parent with
whom one anticipates having a cooperative partnership
MARCH 2003

THE JOURNAL OF PROSTHETIC DENTISTRY

in which each player satisfies the requirements of their


particular role.
Often, the dental patient finds something in the dentists behavior on which to hang the transference. Accordingly, the transference-based reaction does not
seem completely off-base to the patient. The dentists
traits and behaviors can therefore cause emotional reactions in the patient that revive and resemble unresolved
relationships from the past. For example, the patient
may react to the dentist as an authoritarian who demands unquestioning submission as the patients parents did.
Additionally, dental patients may react to the needs
that the dentist brings to the situation. Just as parents
look to their children to satisfy a host of narcissistic
(self-centered) needs, dentists look to their patients for
the same satisfaction.
Although some people may be inclined to think only
in terms of patients transference reactions to the dentist, dentists react with transference as well. For example,
the patient can remind the dentist of someone from the
dentists past toward whom the dentist still has strong
feelings, either positive or negative. These feelings may
affect the treatment provided by the dentist.
Unconscious transference reactions by the dentist
may include an emotional reaction toward another person or previous situation that affects the present relationship with the patient. In many instances, the dentists emotional reactions to a patient may be repressed.
Inevitably, when patients are particularly frustrating or
difficult for the dentist, transferential feelings may break
through and determine the dentists behavior toward
the patient. In turn, if the patient becomes unconsciously aware that the dentist is overreacting to some
aspect of the patients behavior, the patient may react
unconsciously to the dentists behavior.
Because professionalism dictates that dentists maintain emotional control to avoid negative impact on
treatment, dentists may contend that any emotional reaction toward a patient constitutes unprofessional behavior. This attitude is unrealistic because it creates false
expectations. Furthermore, it blinds dentists to subtle
and perhaps unconscious ways in which they may be
reacting to patients.

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

THE JOURNAL OF PROSTHETIC DENTISTRY

GAMER, TUCH, AND GARCIA

Table I. Behavioral profile of patients


Patient type

Ideal
Submitter

Reluctant

Engagement

Willingness to submit (trust)

: I see you as a professional who is in a position to help


me, and willingly, I accept you in that capacity.
: You are the best dentist Ive ever had. No, you are the
best dentist around. I admire you, idealize you, and think of
you in the most glowing terms.
: Please dont take this personally, but I just dont think you,
or any other dentist, is going to be able to help me.

: What you say makes sense, but there are


some questions Id appreciate being answered.
: You know everything and will never make
an error. Therefore I will submit to whatever you
suggest without question.
: It isnt you I distrust, but my destiny. Nothing
ever works out in my life. Therefore I will
reluctantly follow your instructions, but I doubt
this will work.
: You are a dentist like any dentist, what does it
matter whom I see. I will listen and follow
instructions, I guess, for now.
: Youve got to be crazy if you think Im going to
do just what you say. I need to grill you to
determine that you are not a charlatan!

Indifferent

: I wouldnt even give you a second thought.

Resistant

: You authority-types are all the same. You expect us


patients to just accept what you say. If you think Im one of
those types of patients, you are sadly mistaken. Prepare to be
challenged!

(trust). The level of patient engagement with the dentist


and treatment process exists along a continuum from
completely overinvolved () to disengaged ().
The level of the patients willingness to submit (trust)
also exists along a continuum from willingness to submit
to the dentists recommendations without a second
thought () to intense reluctance to do anything
the dentist recommends ().

Behavioral profiles of patients


Table I summarizes 5 patient types: ideal, submitter,
reluctant, indifferent, and resistant. Each type is characterized by a rating on engagement and willingness to
submit (trust) and by the stance the patient types are
likely to take in reaction to being a dental patient.
The ideal patient, which corresponds to Houses
philosophical mind, is reasonably engaged () and
reasonably willing to submit (trust) () to the dentist. This type of patient is not ranked in either
category, because these patients are considered mature
with a healthy life balance. They are not vulnerable to
regression or excessive dependence on authority figures.
Therefore they are not prone to fixate on and be overly
absorbed with their particular dental treatment. They
have worked through whatever childhood conflicts and
animosities they held for authority figures. Furthermore,
the ideal patient has a healthy level of distrust. Any reasonable patient should have some skepticism; they
should permit themselves to have questions and doubts.
Patients deserve explanations for professional dental recommendations to understand the situation and arrive at
a final decision regarding treatment. Therefore the ideal
patient tends to be neither overly suspicious nor blindly
accepting of the dentists recommendations.
The submitter patient rates on engagement
and on willingness to submit (trust). Such pa300

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

GAMER, TUCH, AND GARCIA

THE JOURNAL OF PROSTHETIC DENTISTRY

Table II. Intersection of particular patient types and particular dentists needs
Patient type

Need to be idealized

Ideal

The dentist may be offended by the


patients reasonable attitude that
falls short of the dentists need to
be idealized.

Submitter

The dentist may be flattered and


potentially seduced into
providing treatment aimed at
perpetuating the idealization.

Reluctant

The dentist may either feel offended


by the patients attitude or the
dentist may feel challenged by
the patients pessimistic
expectations.
The dentist may feel offended by
the patients disengaged attitude,
taking it as a personal failure.

Indifferent

Resistant

The dentist may become angry or


disappointed with a patient who
persistently distrusts. The dentist
may compromise the treatment in
an effort to please the patient.

Need to have the dentists word taken


as gospel

The dentist may be offended by the


patients attitude that falls short
of the dentists need for
unquestioning acceptance of his/
her recommendations.
The dentist may feel highly
respected, but the patients
unquestioning acceptance of the
dentists word means the patient
is not exercising his/her
responsibility to be a partner in
the process.
The dentist may feel either
offended by the patients attitude
or challenged by the patients
pessimistic expectations.

The dentist may be less than enthused


by the patients wish to be treated
as a partner in the process.

The dentist may feel frustrated


when the patient remains
disengaged, treating the dentists
recommendations with disregard.
The dentist may feel disrespected
and may invite the patient to
turn elsewhere for help.

The dentist may feel irritated with an


uninvolved patient and may
disengage.

This sense of shared responsibility does not exist in


the other types of patients defined in this article. The
submitter, reluctant, and indifferent patients do not get
involved as active partners in the treatment. The resistant patient, although actively involved, will neither allow a cooperative relationship or share responsibility
with the dentist.

Dentist/patient conjunctions and disjunctions


Table II summarizes the 5 patient types in relation to
3 types of dentists needs: (1) to be liked and admired,
(2) to be heard and respected, and (3) to feel in control.
When considering what both dentist and patient bring
to the clinical setting, it becomes clear how the interaction affects the ultimate treatment outcome. A conjunction of needs or traits occurs when a dentists personality
and needs are well suited to a given patients engagement and willingness to submit (trust). If the dentists
personality and needs are poorly suited to a given patients profile, however, it is referred to as a disjunction.
A better understanding of what may occur between the
patient and dentist may come from studying conjunctive
and disjunctive interactions from a behavioral perspective.
Consider the dominating and controlling dentist an
example of a disjunctive interaction. The dominating
MARCH 2003

Need to dominate

The dentist may judge these patients


as ideal, insofar as they submit to
the dentists domination.

The dentist may win over the patients


confidence or he/she may become
frustrated at the patients continuous
failure to comply.

The dentist-patient relationship may


become irresolvably confrontational
as each tries to gain the upper
hand.

dentist is an effective match with the submitter patient,


who is willing to totally submit and relinquish authority.
However, the dominating dentist will get into a control
battle with a resistant patient. A resistant patient will also
create problems for a dentist who wants approval and
acceptance to such an extent that the dentist may compromise the treatment in pursuit of winning the patients love. A dentist who seeks approval and acceptance
can also encounter difficulties with the submitter patient
because, sensing that the dentist enjoys being idealized,
this type of patient may initially idealize the dentist only
to become vastly disappointed and angry should problems develop during the treatment. Such an evolution of
feelings can lead the patient to pursue legal action
against the dentist.

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

THE JOURNAL OF PROSTHETIC DENTISTRY

The authors encourage studies to evaluate the validity,


reliability, and effectiveness of this classification.
REFERENCES
1. Jackson E. The role of behavioral science in dental education. Behav Educ
Dent 1986;8:23-6.
2. Friedman N, Landesman HM, Wexler M. The influences of fear, anxiety,
and depression on the patients adaptive responses to complete dentures.
Part I. J Prosthet Dent 1987;58:687-9.
3. Friedman N, Landesman HM, Wexler M. The influences of fear, anxiety,
and depression on the patients adaptive responses to complete dentures.
Part II. J Prosthet Dent 1988;59:45-8.
4. Friedman N, Landesman HM, Wexler M. The influences of fear, anxiety,
and depression on the patients adaptive responses to complete dentures.
Part III. J Prosthet Dent 1988;59:169-73.
5. Hirsch B, Levin B, Tiber N. Effects of dentist authoritarianism on patient
evaluation of dentures. J Prosthet Dent 1973;30:745-8.
6. House MM. Full denture technique. In: Conley FJ, Dunn AL, Quesnell AJ,
Rogers RM, editors. Classic prosthodontic articles: a collectors item. Vol
III. Chicago: American College of Prosthodontists; 1978. p. 2-24.
7. OShea RM, Corah NL, Ayer WA. Dentists perceptions of the good adult
patient: an exploratory study. J Am Dent Assoc 1983;106:813-6.
8. Winkler S. Psychological aspects of treating complete denture patients:
their relation to prosthodontic success. J Geriatr Psychiatry Neurol 1989;
2:48-51.
9. Koper A. Difficult denture birds. J Prosthet Dent 1967;17:532-9.

302

GAMER, TUCH, AND GARCIA

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

Effect of thermocycling on tensile bond strength of six silicone-based,


resilient denture liners
Yasemin Kulak-Ozkan, PhD,a Atilla Sertgoz, PhD,b and Hale Gedik, BDSc
University of Marmara, Istanbul, Turkey
Statement of problem. Adhesion failure between silicone resilient denture lining materials and denture base
resin is commonly encountered in clinical practice. Adhesion failure results in localized unhygienic conditions at
the debonded regions and often causes functional failure of the prosthesis.
Purpose. The purpose of this study was to investigate the effect of thermocycling on the tensile bond strength of
6 soft lining materials.
Material and methods. Six commonly used silicone-based resilient denture liners (Ufigel C, Ufigel P, Mollosil,
Molloplast B, Permafix, and Permaflex) were chosen for the investigation. The bond strength was determined, in
tension, after processing to PMMA. The resilient denture liners for each group (n 24) were 10 10 3 mm
and were processed between 2 polymethyl methacrylate specimens according to manufacturers instructions. Two
PMMA specimens were prepared by investing brass dies with a 3-mm-thick spacer in a denture flask. Specimens
were made by processing the resilient denture liners against the polymerized PMMA block. After polymerization,
the brass spacer was removed from the mold, the 2 PMMA resin specimens were trimmed, and the surfaces to be
bonded were smoothed. The PMMA block was placed back into the molds and the resilient denture liners were
packed into the space made by brass spacer, trial packed, and polymerized according to the manufacturers
instructions. Half of the specimens for each group were stored in water for 24 hours, and the other half were
thermocycled (5000 cycles) between baths of 5 and 55C. All specimens were placed under tension until failure
in a universal testing machine at a crosshead speed of 5 mm/min. The maximum tensile stress before failure and
mode of failure were recorded. The mode of failure was characterized as cohesive, adhesive, or mixed mode,
depending on whether the fracture surface was in the soft liner only, at the denture base-soft liner interface only,
or in both. Failure strength was recorded in kg/cm2. 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.
Results. Varying degrees of bond strengths were found for soft lining materials and were significantly different
(P.05). Results of this study also indicated that the bond strengths of soft lining materials had significantly
decreased after thermocycling except Ufigel C and Mollosil.
Conclusions. Because the adequate adhesive value for soft lining materials is given 4.5 kg/cm2, all of the
materials were acceptable for clinical use. (J Prosthet Dent 2003;89:303-10.)

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.

enture lining materials have become important in


dental prosthetic treatment. The favorable properties of
denture liners are long-term resiliency and good adhesion
to denture base materials.1 Resilient denture liners have
several problems associated with their use, such as loss of
softness, colonization by Candida albicans, porosity, poor
tear strength, and various degrees of softness.2 One of the
most serious problems with resilient denture liners is the
failure of adhesion between the resilient denture liner and

Associate Professor, Department of Prosthodontics.


Associate Professor, Department of Prosthodontics.
c
Research Assistant, Department of Prosthodontics.
b

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

THE JOURNAL OF PROSTHETIC DENTISTRY

KULAK-OZKAN, SERTGOZ, AND GEDIK

Table I. Resilient liner and denture base material used


Product

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

undergo 2 processes: leaching out of plasticizers and


other soluble materials and absorption of water and
saliva. The balance between these 2 processes affects
the compliance and dimensional stability of the denture.9-11 When the material swells, stress builds between bonding surfaces and the viscoelastic properties
of resilient liners change.12 The tensile properties are
regarded as a general guide to the quality of the rubbers. Hardness and tensile properties therefore give a
general guide to the suitability of a material; for example, a hard material with poor tensile properties
and elongation would be of little use as a soft lining
material. An adequate bond between the denture base
and denture lining material is essential. Failure of soft
lining materials is often attributed to a breakdown of
this bond; thus the measurement of bond strength is
very important.13
The bond properties of resilient lining materials have
been evaluated by several investigators using tensile,2,14,15 tensile and tear,16 and peeling tests.10,17 Several investigators have evaluated the effect of water on
bonding strength of resilient materials.10,12,14,17 Dootz
et al16 have shown that accelerated aging dramatically
affects the physical and mechanical properties of many of
the elastomers. It has been reported that RTV silicones
had inadequate strength10,14 and that HTV silicones and
acrylic resins had adequate strength.10
Siloxane polymers have been used as resilient liners
for denture bases since the early 1960s. Their resilience
at mouth temperature is not derived from the use of
plasticizers but from an intrinsic property of this type of
polymer; therefore they retain their resilience throughout their working life. The bond between the acrylic
denture base and the silicone liners is aided by the use of
a silicone polymer (such as methyl siloxane) in a volatile
solvent or by the use of alkylsilane bonding agents. The
result is a marked change in both physical properties and
the dimensions of the soft polymer, as well as loss of
adhesion from the acrylic to which the soft denture lining materials is bonded. Therefore the bond strength of
silicone denture base liners depends on the tensile strength
of the materials and the adhesive used.18 The purpose of
this study was to measure the effects of thermocycling on
tensile bond strength of 6 silicone-based resilient lining
materials currently used as denture base linings.
304

VOCO, Cuxhaven, Germany


VOCO, Cuxhaven, Germany
Coolike Regnery, Bensheim, Germany
Coolike Regnery, Bensheim, Germany
Kohler, Neuhausen, Germany
Kohler, Neuhausen, Germany

Fig. 1. Brass dies and spacers invested in silicone rubber.

MATERIAL AND METHODS


In this study, a tensile bond test method was used to
examine the bond strengths and types of failure in tensile
bond test methods before and after thermocycling. The
resilient denture liners tested in this study are shown in
Table I.
Twenty-four specimens measuring 3 mm thick, 10 mm
wide, and 10 mm long were prepared for each soft liner
tested. Two PMMA specimens were prepared by investing brass dies with a 3-mm thick spacer in a denture
flask. The dies and spacers were invested in silicone rubber to allow for easy removal of processed specimens
from the flask (Fig. 1). Specimens were made by processing the resilient denture liners against polymerized
PMMA block. The heat-polymerized acrylic resin
(Trevalon; De Trey, Konstanz, Germany) was processed
according to the manufacturers instructions. After poVOLUME 89 NUMBER 3

KULAK-OZKAN, SERTGOZ, AND GEDIK

Fig. 2. Prepared PMMA specimens reset in mold with spacer


removed.

lymerization, 2 PMMA resin specimens were trimmed


and the surfaces to be bonded were smoothed on 240grit aluminum oxide paper, cleaned, and dried. The
PMMA blocks were placed back into the molds (Fig. 2),
and the resilient denture liners were then packed into the
space made by the brass spacer, trial packed, and polymerized according to the manufacturers instructions.
After polymerization, the specimens were removed
from the flask and trimmed with a sharp blade. Half of
the specimens for each group (n 12) were stored in
water for 24 hours, and the other half were thermocycled (5000) cycles between baths of 5 and 55 C.
All specimens were placed under tension until failure
in a universal testing machine (Instron; Instron Corp,
Canton, Mass.) at a crosshead speed of 5 mm/min (Fig.
3). The maximum tensile stress before failure was recorded for each specimen. Tensile bond strength values
were calculated as the force at debonding divided by the
cross-sectional area of the interface. Tensile bond
strength values were recorded in kg/cm2. Then the
mode of failure was evaluated and characterized as
adhesive (type 1), cohesive (type 2), or mixed mode
(type 3). Adhesive failure refers to total separation at
the interface between the resilient liner material and
acrylic resin, cohesive failure refers to tear within the
resilient liner material, and mixed failure refers to
both. The type of failure was observed by use of a
scanning electron microscope (SEM) (JSM-5200;
MARCH 2003

THE JOURNAL OF PROSTHETIC DENTISTRY

Fig. 3. Tensile specimen in universal testing machine.

Table II. Two-way ANOVA for tensile bond strength of 6


processed resilient denture liners

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

THE JOURNAL OF PROSTHETIC DENTISTRY

KULAK-OZKAN, SERTGOZ, AND GEDIK

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

ucts and thermocycling indicates that some materials


were more affected by thermocycling.
The mean and standard deviation (SD) values of tensile bond strength of specimens are shown in Figure 4
and Table III. The mean bond strength to PMMA resin
ranged from 6.64 to 10.7 kg/cm2 before thermocycling
and from 4.5 to 9.5 kg/cm2 after thermocycling. Before
thermocycling, the lowest bond strength was seen with
Ufigel C (6.64 kg/cm2) and the highest was seen with
Molloplast B (10.7 kg/cm2). Tensile bond strength varied significantly among resilient liners except between
Ufigel C and Ufigel P, Permafix and Permaflex, and
Permaflex and Mollosil liners (Table IV).
306

After thermocycling (kg/cm2)

After thermocycling, the lowest bond strength was


seen with Permafix (4.5 kg/cm2), and the highest was
seen with Mollosil (9.5 kg/cm2) (Table V). Most lining
materials demonstrated a decrease in tensile strength
after thermocycling. Ufigel P, Molloplast B, and Permafix liners showed a significant decrease in tensile bond
strength after thermocycling (P.01, P.01, and
P.0001, respectively). The tensile bond strength of
Permaflex also decreased after thermocycling, but this
decrease was not found to be statistically significant
(P.13). Mollosil and Ufigel C liners showed a significant increase in tensile bond strength after thermocycling (P.02 and P.03, respectively).
VOLUME 89 NUMBER 3

KULAK-OZKAN, SERTGOZ, AND GEDIK

THE JOURNAL OF PROSTHETIC DENTISTRY

Table IV. Significance as determined by Duncans tests


between tensile bond values for resilient denture liners
before thermocycling

Table V. Significance as determined by Duncans tests


between tensile bond values for resilient denture liners
after thermocycling

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

S, Significantly different at this level.

S, Significantly different at this level.

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

After thermocycling (kg/cm2)

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

The mode of failure results and the statistical analysis


of these results are shown in Tables VI and VII. Different failure types were observed among the groups. Before thermocycling (n 72), 34 showed adhesive failure, 15 showed cohesive failure, and 23 showed mixed
failures. After thermocycling (n 72), 31 showed adhesive failure, 16 showed cohesive failure, and 15
showed mixed failures.
Ufigel C, Ufigel P, and Permaflex liners showed
mostly adhesive failures, Mollosil and Permafix resilient
lining materials showed adhesive and cohesive failures,
and Molloplast B lining material showed cohesive failures before thermocycling. Among the 6 resilient liners
MARCH 2003

tested, Permafix showed a difference in the mode of


failure after thermocycling, which was found to be statistically significant (P.05). According to ANOVA
comparisons of adhesive and cohesive failures, adhesive
and mixed failures are found to be significantly different
(P.001). SEM evaluation revealed typical microstructures of failure surfaces as presented in Figure 5 (adhesive failure), Figure 6 (cohesive failure), and Figure 7
(mixed failure).

DISCUSSION
In general, debonding of the resilient denture lining
materials is a common problem. Ideally, resilient den307

THE JOURNAL OF PROSTHETIC DENTISTRY

KULAK-OZKAN, SERTGOZ, AND GEDIK

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. 6. SEM microstructure of typical cohesive failure for


Molloplast B lining material. (Original magnification 20).
Entire fracture surface covered with liner.

ture liners should bond sufficiently well to the PMMA


denture base resin to avoid failure of the interface during
308

the life of the prosthesis. Several factors 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 the denture base material. The effect of water
on the adhesive properties of the resilient lining material
to denture base material is of utmost importance in final
clinical success. When immersed, resilient denture liners
undergo 2 processes; leaching out of plasticizers and
other soluble materials and absorption on water and
saliva.9 The balance between these 2 processes affects
both the compliance and dimensional stability of the
denture.10,11 When the material swells, stress builds between bonding surfaces and the viscoelastic properties of
the resilient liners change.12 The material becomes brittle and transfers the external loads to the bond area.9
After thermocycling, all materials except Ufigel C and
Mollosil showed a significant reduction in bond
strength. The reduction in the bond strength is the result of swelling and stress buildup at the bond interface
or of the changed viscoelastic properties of the resilient
VOLUME 89 NUMBER 3

KULAK-OZKAN, SERTGOZ, AND GEDIK

THE JOURNAL OF PROSTHETIC DENTISTRY

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.

lining material, which renders the material stiffer and


transmits the external loads to the bond site. The results
of this study contradict Emmer et al,5 Dootz et al,16 and
Craig and Gibbons,17 who reported that tensile strength
of resilient lining materials increased after storage in water. This study agreed with Polyzois,12 who reported
that water storage reduced the bond strength of resilient
liner. However, a direct comparison of these studies
cannot be made because of the different mechanical tests
and research protocols used.
It has been reported that resilient denture lining materials with 10 pounds per inch (4.5 kg/cm2) bond
strength are acceptable for clinical use.15,17 Considering
this criterion, all materials tested had a satisfactory bond
strength to polymerized PMMA denture base resin.
The heat-polymerized silicone Molloplast B showed
the highest bond strength of all materials before thermocycling. This value was higher than that observed by
Kutay et al3 and lower than observed by Bates and
Smith,14 and Khan et al.15 However, this difference may
be the result of the different denture bases used, the
shape of the specimens, and the cross-head speed of the
tensile testing machine. The bond strength of Molloplast B decreased after thermocycling, which may be
attributed to high water uptake caused by the filler content. Molloplast B showed cohesive failure, indicating
that this material bonded strongly to the denture base
and that the tensile strength of resilient liner was weaker
than the bond strength to PMMA.
For silicone-based resilient lining materials, an adhesive is supplied to aid in bonding to the denture base
resin because silicone denture base liners have little or no
chemical adhesion to PMMA resin. But the heat-polymerized silicone Permaflex forms a durable bond to the
hard acrylic denture base without adhesive. When processed to PMMA, the bond strength was 8.48 kg/cm2.
This bond strength is obviously higher than 4.5 kg/
MARCH 2003

cm2, the clinically acceptable bond strength. Permaflex


showed mostly adhesive failure, which indicates that the
tensile strength of resilient liner was higher than the
bond strength to PMMA.
The lowest bond strength was seen with Permafix as
4.5 kg/cm2 after thermocycling, which may be due to
filler content. Absorption of water by the filler could lead
to decreased tensile strength. Among the 6 resilient liners tested, Permafix showed different modes of failure
before and after thermocycling. It showed mixed failures
before thermocycling but adhesive failures after thermocycling. An adhesive or cohesive mode of failure indicates that the bond strength is almost the same as the
tensile strength of the material. The tensile strength of
the resilient liner may be affected by thermocycling.
The tensile strength of Ufigel P also decreased after
thermocycling, but it still had sufficient tensile bonding
strength (5.11 kg/cm2) for prosthetic applications.
These test results contradicted Aydin et al,9 who reported that the tensile strength of Ufigel P was inadequate. After thermocycling, Ufigel C and Mollosil
showed a significant increase in bond strength, which
may indicate that the materials become more brittle and
less viscoelastic. The strength of the filler-polymer bond
will also have an influence on tensile properties.
Clinically, the ability of denture lining materials to
resist debonding and internal fracture under masticatory
stresses is extremely important. On the basis of the mode
of failure results shown in Table VI, several conclusions
can be drawn. Under multidirectional forces exerted in
the mouth, Ufigel C, Ufigel P, and Permaflex liners
could show interfacial separation. In Mollosil and Permafix liners, both tear and interfacial separation are possible. Molloplast B liner could tear rather than separate
from the denture base. Kutay et al3 stated that adhesion
of Molloplast B liner to PMMA was found, tensile bond
values were lower, and the mode of failure was different.
309

THE JOURNAL OF PROSTHETIC DENTISTRY

However, differences in specimen size, acrylic resin type,


and processing technique might have affected these results.

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

KULAK-OZKAN, SERTGOZ, AND GEDIK

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

Sound analysis of temporomandibular joint internal derangements with


phonographic recordings
gutcen-Toller, DDS, MSc, PhDa
Melahat O
Faculty of Dentistry, Ondokuz Mays University, Samsun, Turkey
Statement of problem. Temporomandibular joint (TMJ) sound recordings could be analyzed to assess the
state of TMJ internal derangements.
Purpose. The aim of the study was to assess the value of sound analysis in the diagnosis of the type of the TMJ
internal derangements.
Material and methods. After clinical and radiologic examinations, phonographic sound recordings on mandibular excursions were obtained in 52 patients with TMJ internal derangements and 12 control individuals.
Sound correlations were made on the basis of opening-closing, protrusive-retrusive, and lateral excursions of the
mandible.
Results. Clicking was a consistent finding of anterior disc displacement with reduction, whereas crepitation was
found in varying degrees in anterior disc displacement and osteodegenerative arthritis. Silent TMJs were the
feature of normal TMJs, except for the situations of acute lock. 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 openingprotrusive clicks and opening-contralateral clicks. The lack of protrusive clicking 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.
Conclusion. Within the limitations of this study, the results suggest that TMJ sound analysis on mandibular
excursions was indicative for diagnosis and establishment of severity of TMJ internal derangements. Clicking and
crepitation may be looked on as signs of abnormal joint disorder, clicking indicating anterior disc displacement
with reduction, and crepitation, indicating progression from anterior disc displacement without reduction to
osteodegenerative arthritis. (J Prosthet Dent 2003;89:311-8.)

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.

he advances in diagnostic techniques have led to a


better understanding of the temporomandibular joint
(TMJ) internal derangements. These techniques include
arthrography, arthrotomography, arthroscopy, computed tomography, and magnetic resonance imaging
(MRI).1-8 Arthrography and arthrotomography as invasive techniques under fluoroscopic guidence have been
most successful in the diagnosis of TMJ disc displacements and perforations, as well as follow-up of the patients.4,9-13 Computed tomography as a noninvasive
technique provides superior imaging of bone changes
but gives poor soft tissue images.8 As a noninvasive technique, MRI has been an established diagnostic tool in
TMJ internal derangements, but it is not useful in displaying disc perforations and adhesions.14 To investigate
a

Professor and Head, Department of Oral and Maxillofacial Surgery.

MARCH 2003

the diagnostic role of the TMJ sounds as a noninvasive


technique, various studies have been performed.15-22 Sigaroudi and Knap22 drew attention to clinical evaluation
of clicking TMJs. They used a tracing apparatus to locate
and mark the TMJ clicks visually. TMJ sounds have been
displayed as signs of different states of the disc position
in the literature.15-21 The TMJ sounds were recorded
with a stethoscope, and the disc position was studied
with inferior joint space arthrography and fluoroscopy
simultaneously and classified as with or without reduction to indicate the severity of the TMJ internal derangement.15 Gay et al16 recorded acoustic signals from each
joint simultaneously with 2 separate vibration transducers whose outputs were connected to a high-quality cassette recorder. They also tracked jaw movements in 3-dimensional space with a magnetometer system used for
correlation. Heffez and Blaustein17 and Hutta et al18
developed a software package to perform sound-power
THE JOURNAL OF PROSTHETIC DENTISTRY 311

U
G
TCEN-TOLLER
O

THE JOURNAL OF PROSTHETIC DENTISTRY

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.

MATERIAL AND METHODS


A total of 64 patients, including 12 control subjects,
was included in the study. Patients ranged in age between 15 and 43 years. The number of female patients
with TMJ internal derangement was 34, which constituted 65.38% of the patients. The control subjects were
chosen to match the patient group in terms of age and
sex ratio. The diagnostic criteria was depended on the
patient history, extraoral and intraoral examination results, and panoramic radiographs, as well as arthrography (15 patients) and MRI (49 patients). Preauricular
pain, muscular tenderness on palpation, restriction or
deviation on opening, and TMJ sounds were all noted.
The diagnosis of the TMJ internal derangements was
based on clinical and radiologic examinations according
to the clinical criteria in the literature.9,14,23-25 The anterior position of the disc from the superior position,
indicating the top position of the posterior band of the
disc over the condyle on centric occlusion, was regarded
as anterior disc displacement in MRI. The accumulation
of contrast matter in the inferior joint space in anterior
aspect of the condyle on centric occlusion was regarded
as anterior disc displacement on arthrogram. The resumption of the normal relationship between the disc
and the condyle on opening was regarded as disc reduction in both MRI and arthrography. Nonreducing discs
were observed to persist in anterior aspect of the condyle
on maximum opening. The patient group consisted only
of arthrography- or MRI-proven TMJ internal derangements, such as TMJ disc displacements with and without
reduction, as study cases for TMJ sound analysis. Patients with systemic involvement and congenital deformities were excluded from the study. The 2 test, 2 test
312

Table I. Clinical evaluation of patients with TMJ internal


derangements
ADDR

51 TMJs

ADDR intermittent locking


Closed-lock
Chronic ADD
Osteodegenerative arthritis
Total number of internal derangements

19
4
6
5
85

TMJs
TMJs
TMJs
TMJs
TMJs

Table II. The evaluation of sound patterns in the ADDR


subgroup of patients

Clicking on opening only


Reciprocal clicking
Silent on protrusion retrusion
Clicking on protrusion only
Clicking on both protrusion and retrusion
TMJ sounds towards the ipsilateral side
TMJ sound towards the contralateral side
Sounds on bilateral excursions
Silent on lateral excursions
Total number of TMJs with ADDR
Total number of patients with ADDR

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

with Fishers exact, and 2 test with Yates correction


were applied to the statistical data.
TMJ sounds were recorded through phonomicrophones placed over the TMJ of both right and left sides
simultaneously. The phonomicrophones were connected to a phonocardiograph/DC amplifier (model
V2207; Honeywell Inc, Morristown, N.J.) with 3 dB
cutoff frequencies measured to be 164 and 570 Hz, and
with 12 dB/octave falloff beyond passband. The phonocardiograph transducer was of piezoelectric type and
had flat response in the range of frequencies mentioned
above. The TMJ sounds were recorded on a Kohden
Data recorder (DTR-1204; Kohden, Ikegami, Japan).
The TMJ sounds on each movement of the mandible
were repeated at least 20 times to gain repetitive sound
patterns to study the consistency of the sounds. The
sound patterns were then classified as silent, clicking, or
crepitation, similar to the literature.15,19-21

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

Fig. 1. Phonogram of one control subject. Soft sound signals


with low amplitude and frequecy are noted on opening and
closing movements of mandible. R, right; L, left sides of
mandible. Phonographic sound patterns were found to be
consistent on repetition of same motions of mandible.

THE JOURNAL OF PROSTHETIC DENTISTRY

ADDR and ADD cases was not found to be statistically


significant with Fishers exact test (P.05) (Table IV).
TMJ sounds on lateral excursions were observed in
59.15% of the TMJs with ADDR and in 73.33% of ADD
cases. The difference in sound patterns between the
ADDR and ADD cases was not found to be statistically
significant with Fishers exact test (P.05) (Table V).
The difference in sound patterns on ipsilateral and contralateral excursions between the ADDR and ADD cases
was not found to be statistically significant with Yates
correction (P.05) (Table VI). The difference in sound
patterns on opening and closing between the ADDR
and ADD cases was found to be statistically significant
with Yates correction (P.01) (Table VII). The difference in sound patterns on protrusion and retrusion between the ADDR and ADD cases was not found to be
statistically significant with Yates correction (P.05)
(Table VIII). The difference in sound patterns on the
presence of reciprocal TMJ sounds between the ADDR
and ADD cases was not found to be statistically significant with Fishers exact test (P.05) (Table IX). When
the sum of TMJ sounds on every motion of the mandible was taken into account, the difference in sound patterns on the basis of the presence of the TMJ sounds
between the TMJs with ADDR and with ADD was
found to be highly significant statistically with 2 test
(P.001) (Table X).

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

TMJ sounds have been viewed as signs of different


pathologic changes.5,15 Eriksson et al15 demonstrated
that joints with reciprocal clicking consistently showed
disc displacement with reduction and that silent and
crepitating joints showed disc displacement without reduction. All joints with reciprocal clicking, as well as
most silent joints, demonstrated nonarthrotic articular
surfaces, whereas crepitation was recorded in both arthrotic and nonarthrotic joints. They concluded that
reciprocal clicking could be considered an accurate sign
of reduction of anteriorly displaced discs but that crepitation was a rather unreliable sign of arthrosis. Sutton et
al5 found that the group of patients with clinically discernible TMJ sounds was far more likely to have a
change in the relationship between the condyle and the
intermediate zone of the disc than the clinically silent
group. Yatani et al26 reported that the sensitivity and
specificity of historical and clinical findings were 58%
and 87%, respectively, for positive history of clicking and
15.6% and 96.7% for positive history of crepitation.
Roberts et al11 also reported high sensitivity (80.3%) and
specificity (84.4%) for clicking test in TMJ internal derangements. This is in accord with previous studies in
which clicking sounds were considered an accurate sign
of reduction of an anteriorly displaced disc.2,3,19,23-25 On
the other hand, various methods have been used in TMJ
313

THE JOURNAL OF PROSTHETIC DENTISTRY

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

THE JOURNAL OF PROSTHETIC DENTISTRY

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

THE JOURNAL OF PROSTHETIC DENTISTRY

Table V. Comparative statistical data of TMJ sounds on


lateral excursions for the TMJs with ADDR and ADD

ADDR
ADD
Total

TMJ Sounds on
lateral excursions

Silent TMJs on
lateral excursions

Total

42
11
53

29
4
33

71
15
86

20.40, P.05 (with Fishers exact test).

Table VI. Comparative statistical data of TMJ sounds on


ipsilateral and contralateral motions for the TMJs with
ADDR and ADD included in the study

ADDR
ADD
Total

TMJ Sounds on
ipsilateral motion

TMJ Sounds on
Contralateral motion

Total

30
9
39

38
8
46

68
17
85

20.85, P.05 (with Yates correction).

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

Table VII. Comparative statistical data of TMJ sounds on


opening and closing for the TMJs with ADDR and ADD
included in the study

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

Table VIII. Comparative statistical data of TMJ sounds on


protrusion and retrusion for the TMJs with ADDR and ADD
included in the study

ADDR
ADD
Total

Table IV. Comparative statistical data of protrusive TMJ


sounds for the TMJs with ADDR and ADD

TMJ Sounds
on protrusion

TMJ Sounds
on retrusion

Total

46
4
50

9
3
12

55
7
62

20.70, P.05 (with Yates correction).

TMJ Sounds
on protrusion

Silent TMJs on
protrusion

Total

46
4
50

25
11
36

71
15
86

20.44, P.05 (with Fishers exact test).

sound analyses in the literature to provide diagnostic


value for TMJ internal derangements.4,5,15-21 However,
the literature lacks a study on comparative TMJs sound
analysis for 3 types of mandibular motions: opening and
closing, protrusion and retrusion, and lateral as ipsilateral and contralateral excursions. In this study, the value
of phonograhic TMJ sound recordings on 3 types of
mandibular excursions was investigated in patients with
TMJ internal derangements.
316

TMJ Sounds
on closing

28.91, P.01 (with Yates correction).

TMJ Sounds
on opening

217.23, P.001 (with Yates correction).

ADDR
ADD
Total

TMJ Sounds
on opening

Paesani et al14 reported that the overall diagnostic


accuracy of a standardized clinical examination to determine the status of the joint was approximately 43% and
that sensitivity and specificity values of clinical examination for TMJ internal derangements were 0.78 and 0.52,
respectively. Yatani et al27 showed that the sensitivity
values of clinical parameters in ADD were considerably
low in contrast with their high specificity, concluding
that it would cause false-positive diagnoses. Sato et al28
argued that TMJ disc displacement without reduction
did not always cause clinical signs and symptoms. Although Eriksson et al15 reported that neither the degree
of disc displacement nor the degree of deformation of
VOLUME 89 NUMBER 3

U
G
TCEN-TOLLER
O

THE JOURNAL OF PROSTHETIC DENTISTRY

Table IX. Comparative statistical data of reciprocal TMJ


sounds on opening and closing for the TMJs with ADDR
and ADD included in the study
Reciprocal TMJ Sounds

ADDR
ADD
Total

Present

Absent

Total

28
4
32

43
11
54

71
15
86

20.40, P.05 (with Fishers exact).

Table X. The statistical data of sum of TMJ sounds on


every motion of the mandible
TMJ Sounds on
mandibular excursions

Silent
TMJs

Total

168
27
195

174
69
243

342
96
438

ADDR
ADD
Total
11.89, P.001.
2

the disc could be disclosed by analysis of the sound, the


original results of the study showed that when a combination of comparative sound analyses was made, sound
recordings provided a lot of information on the internal
status of the TMJ. With the guidance of arthrography
and MRI as gold standards for the definitive diagnosis of
the disc position, the presence or absence of TMJ
sounds in combination with 3 types of mandibular motions could provide additional information for the state
of the TMJ disc in most cases.
The original results of the study showed that the
opening click in ADDR cases was observed in 92.95% of
the cases and in 46.66% of TMJs with ADD and that the
difference in sound patterns between the TMJs with
ADDR and those with ADD was found to be highly
significant statistically. The sound characteristics were
found to be different when the TMJ phonograms of 3
types of mandibular motions were recorded. Therefore
it could be concluded that TMJ phonography could be
diagnostic as a tool for anterior disc displacement with
reduction at a lower cost than other techniques, such as
MRI.
TMJ clicks on protrusion were observed in 64.78% of
the TMJs with ADDR. The protrusive clicks were almost identical to opening clicks in TMJs with ADDR in
the study. This could be explained by the the fact that
disc reduction on condylar translation occurred in a similar way in both opening and protrusion. However, the
analysis of lateral sounds seemed to be more complicated, because TMJ sounds on lateral excursions were
observed in 59.15% of the TMJs with ADDR and in
73.33% of ADD cases. The higher percentage of TMJ
sounds on lateral excursions in the ADD cases could
indicate rotational and sideway displacements of the disc
MARCH 2003

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

THE JOURNAL OF PROSTHETIC DENTISTRY

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

Expedient direct approach for esthetic and functional provisional


restorations
Panagiotis C. Psichogios, DDS,a and Edward J. Monaco, DDSb
College of Dentistry, The Ohio State University, Columbus, Ohio; State University of New York
at Buffalo, Buffalo, N.Y.
This article describes a direct procedure for the expeditious fabrication of provisional restorations for
extensive fixed prosthodontic applications. Customary indirect or indirect-direct approaches require
extensive clinical time as well as laboratory support for their successful application. Provided that the
necessary preoperative steps are followed precisely, this treatment method allows for excellent clinical
results while being less time consuming. (J Prosthet Dent 2003;89:319-22.)

he importance of provisional restorations as an integral part of fixed prosthodontic treatment is evident


from the abundance of literature pertaining to their importance regarding margin fidelity, function, occlusion,
and esthetics. There are a variety of techniques available
to suit the individual needs of the clinician and of the
clinical situation, from a single unit to a complete-arch
provisional fixed prostheses.1-8
The indirect technique has been proven superior8 to
other techniques because the resulting provisional restorations have improved marginal fit, density, fracture9
and wear resistance, especially laboratory heat-processed
provisional prostheses. Additionally, potential pulpal
damage is diminished9,10 since polymerization is performed extraorally. Known disadvantages of this approach include extended time and the need for laboratory support.11 Because of these disadvantages,
clinicians might be inclined to choose the direct techniques for fabrication of provisional fixed partial dentures.
The challenge arises in situations of extensive fixed
prosthodontic treatment, specifically complete-arch rehabilitations, where the direct techniques fall short of
expectations because of shrinkage and polymerization
heat.12,13 Liebenberg6 presented a direct technique for
provisionalization of complete-arch rehabilitations that
overcomes this problem and allows for excellent clinical
results by using composite type (BIS-GMA) provisional
resins. These products exhibit minimal shrinkage and
are easily manipulated, but the resins used for this technique should be of a dual-polymerized nature. Liedenberg6 recommended these resins in conjunction with an
accurate dual-arch impression of the patients existing
crown contours and opposing arch before any tooth
Presented as a table clinic in the 50th Annual Meeting of the American Academy of Fixed Prosthodontics in Chicago, Ill., March
2-3, 2001.
a
Assistant Professor, Section of Restorative Dentistry, Prosthodontics
and Endodontics, The Ohio State University.
b
Assistant Professor and Director, Advanced Education Program in
Prosthodontics, State University of New York at Buffalo.
MARCH 2003

Fig. 1. Frontal view of existing failing rehabilitation of maxillary arch.

preparation is begun. The major disadvantage of this


technique is that the existing tooth structure is essentially duplicated, which does not permit the advantage of
incorporating improvements from diagnostic wax-up
procedures.
Treatment situations requiring an extensive reconstructive effort, such as complete-arch rehabilitations,
usually require major alterations in occlusion and crown
contours, making the diagnostic wax-up procedure an
imperative step.14 The purpose of this article is to
present a direct technique for fabrication of completearch provisional restorations on the basis of a detailed
diagnostic-preoperative laboratory procedure when significant changes in esthetics and occlusion are desired.

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

THE JOURNAL OF PROSTHETIC DENTISTRY

Fig. 2. Full contour diagnostic wax-up.

Class I removable partial denture replaced the bilaterally


missing first and second molars. The partially dentate maxillary arch had been restored with metal-ceramic fixed prostheses, replacing the maxillary first premolars, and in the
anterior region the 4 incisors were restored with individual
metal ceramic crowns. This rehabilitation had been present
for a period of 10 years. Periodontal, clinical, and radiographic examination revealed advanced loss of the periodontal attachment of the maxillary anterior teeth. The
patient reported that the diastema between the central incisors developed during the last year and that she disapproved of the esthetics of the existing crown restorations
and desired their replacement.
The comprehensive treatment plan for the maxillary
arch agreed upon with the patient involved extraction of
the left lateral incisor, comprehensive periodontal treatment, and replacement of the existing crowns, with the
intention to provide a complete-arch maxillary fixed partial
denture. The following procedures summarize the laboratory and clinical steps followed for the successful implementation of this direct complete-arch provisionalization.

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

PSICHOGIOS AND MONACO

Fig. 3. Impression of both arches, with articulator in closure


(pin touching).

Fig. 4. Removal of existing restorations and establishment of


new finish lines.

(Extrude Medium; Kerr) around the diagnostic


wax-up, interpose the tray between the upper and
lower members, close the articulator, and verify that
the pin is touching the incisal table (Fig. 3).
6. Remove and inspect the accuracy of the impression
for both the treatment and opposing arches. A detailed representation of the diagnostic wax-up, as
well as the cusp tips and incisal edges of the opposing arch is required.
7. On the treatment arch, trim the impression material so that it extends 3 to 4 mm apical from the
gingival portion of the diagnostic wax-up. Repeat
on the opposing arch so that only the cusp tips
and incisal edges are represented. Leave the impression of the hard palate to assist in the accurate
seating of the impression tray after tooth preparation. The tray is now ready for the clinical part
of the technique.

Clinical procedures
1. Remove the existing fixed prostheses and diseased
hard tissues from the treatment arch (Fig. 4).
VOLUME 89 NUMBER 3

PSICHOGIOS AND MONACO

THE JOURNAL OF PROSTHETIC DENTISTRY

Fig. 5. Tray try-in.

Fig. 6. Injection of BIS-GMA resin provisional material in


custom tray.

Fig. 7. Retracted view of complete-arch provisional fixed


partial denture.

Fig. 8. Labial view of provisional complete-arch fixed partial


denture.

2. Try-in the custom impression tray (verify repeated


closure) (Fig. 5). Lightly coat the preparations with
lubricant (Petroleum Jelly; Quality King Inc,
Ronkonkoma, N.Y.).
3. Inject BisGMA provisional material (Luxatemp,
DMG Hamburg, Englewood, N.J.) in the corresponding part of the treatment arch (Fig. 6), seat
the tray, and instruct the patient to close with firm
pressure. Remove the tray after 2 minutes. Remove
provisional restoration material and trim excess with
sharp scissors.
4. Return the provisional restoration to the impression
tray and bench-polymerize for 2 minutes.
5. Complete final trimming and polishing, and cement
with temporary luting agent (Temp-Bond Non-Eugenol; Kerr) (Figs. 7, 8).

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

THE JOURNAL OF PROSTHETIC DENTISTRY

ture, the use of customary indirect or direct-indirect


procedures is advocated.

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

PSICHOGIOS AND MONACO

7. Galindo D, Soltys JL, Graser GN. Long-term reinforced fixed provisional


restorations. J Prosthet Dent 1998;79:698-701.
8. Rosenstiel SF, Land MF, Fujimoto J. Contemporary fixed prosthodontics.
3rd ed. St Louis: Mosby; 2000. p. 381-416.
9. Ogawa T, Tanaka M., Koyano K. Effect of water temperature during
polymerization on strength of autopolymerizing resin. J Prosthet Dent
2000;84:222-4.
10. Castelnuovo J, Tjan AH. Temperature rise in pulpal chamber during
fabrication of provisional resinous crowns. J Prosthet Dent 1997;78:441-6
11. Rosenstiel SF, Land MF, Fujimoto J. Contemporary fixed prosthodontics.
3rd ed. St. Louis: Mosby; 2000. p. 390.
12. Grajower R, Shaharbani S, Kaufman E. Temperature rise in pulp chamber
during fabrication of temporary self-curing resin crowns. J Prosthet Dent
1979;41:535-40.
13. Moulding MB, Teplitsky PE. Intrapulpal temperature during direct fabrication of provisional restorations. Int J Prosthodont 1990;3:299-304.
14. Okeson JP. Management of temporomandibular disorders and occlusion.
5th ed. St. Louis: Mosby; 2002. p. 569-71.
Reprint requests to:
DR PANAGIOTIS C. PSICHOGIOS
SECTION OF RESTORATIVE DENTISTRY, PROSTHODONTICS
COLLEGE OF DENTISTRY
THE OHIO STATE UNIVERSITY
POSTLE HALL
305 W 12TH AVE
COLUMBUS, OH 43218-2357
FAX: (614) 292-9422
E-MAIL: psichogios.1@osu.edu

AND

ENDODONTICS

Copyright 2003 by The Editorial Council of The Journal of Prosthetic


Dentistry.
0022-3913/2003/$30.00 0

doi:10.1067/mpr.2003.53

VOLUME 89 NUMBER 3

A handle for facial casts


Hakimeh Siadat, DDS, MSc,a and Ali Mirfazaelian, DDS, MScb
School of Dentistry, Kerman University of Medical Sciences, Kerman, Iran; School of Dentistry,
Tehran University of Medical Sciences, Tehran, Iran

After making an impression of a large region of the


face, one must pour the impression with dental stone or
plaster to make a cast.1,2 The conventional method of
pouring may result in distortion because of the high
weight of the stone material, especially when one uses
visual light-polymerized (VLC) custom-made impression trays,3 or when the impression material is thick. In
addition, large stone facial casts are heavy and difficult to
handle. To prevent distortion, a thin layer of stone
should be poured into the impression (Fig. 1). Mechanical retention must be provided for retention of the next
a

Assistant Professor, Department of Prosthodontics, Kerman University of Medical Sciences.


b
Assistant Professor, Department of Prosthodontics, Tehran University of Medical Sciences.
J Prosthet Dent 2003;89:323.

layer(s). Inserting a metal bar (handle of a dental mirror)


into the stone before stone setting is complete is recommended. The bar will serve as a handle during laboratory
procedures and can strengthen the cast so the bulk of
dental stone can be reduced (Fig. 2). The resulting cast
will be lighter and easier to handle during laboratory
procedures.
REFERENCES
1. Pflughoeft FA, Shearer HH. Fabrication of a plastic facial moulage. J Prosthet Dent 1971; 25:567-71.
2. Aquilino SA, White J, Taylor TD, Jordan RD. Thermoplastic custom trays for
making regional facial impressions. J Prosthet Dent 1985;53:686-8.
3. Shifman A. Clinical applications of visible light-cured resin in maxillofacial
prosthetics. Part II: tray material. J Prosthet Dent 1990;64:695-9.
Reprint requests to:
DR ALI MIRFAZAELIAN
DEPARTMENT OF PROSTHODONTICS
SCHOOL OF DENTISTRY
TEHRAN UNIVERSITY OF MEDICAL SCIENCES
TEHRAN, IRAN
FAX: (9821) 6401132
E-MAIL: mir-ali@nrcgeb.ac.ir or mir_ali@hbi.dmr.or.ir
Copyright 2003 by The Editorial Council of The Journal of Prosthetic
Dentistry.
0022-3913/2003/$30.00 0
doi:10.1067/mpr.2003.34

Fig. 1. First layer of dental stone must be thin.

Fig. 2. A, Metal bar as handle for facial cast. B, Notice reduced bulk of cast.
MARCH 2003

THE JOURNAL OF PROSTHETIC DENTISTRY 323

Nondestructive examination of all-ceramic fixed partial denture with


microcomputed tomography
Yuji Kokubo, DDS, PhD,a and Shinji Shimoda, DDS, PhDb
School of Dental Medicine, Tsurumi University, Yokohama, Japan

All-ceramic crowns and fixed partial dentures (FPDs)


are widely fabricated in dental practice because of the
high mechanical strength of their core materials. These
all-ceramic restorations have occasionally been noted to
have fracture problems after loading. Fractures are suspected to start adjacent to small flaws inside the porcelain, especially at points of high stress concentration.1,2
Before delivery of the prostheses to the dental office,
microcomputed tomography (MCT-CB100MFZ; Hitachi Co, Tokyo, Japan) can quickly obtain slice images
at a minimum of 14-m resolution, facilitating the detection of small bubbles and cracks before and after firing the porcelain on the coping frame. The completed
Procera FPD (Nobel Biocare AB, Gothenburg, Sweden)
(Fig. 1, A) was returned from the dental laboratory, and
a nondestructive examination with microcomputed tomography was used. There were bubbles between the
retainer and the pontic, and the approximate bubble size
was 100 100 m (Fig. 1, B).
We acknowledge Dr Yoshihiro Yamada for his technical assistance.

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

Instructor, Department of Fixed Prosthodontics.


Associate Professor, Department of Oral Anatomy.
J Prosthet Dent 2003;89:324.

Fig. 1. A, Occlusal view of completed Procera FPD. Marking


shows buccolingually sliced area. B, Cross-sectional view of
connector of Procera FPD with microcomputed tomography.
Bubbles are shown with black in upper view and white in
lower view.

Copyright 2003 by The Editorial Council of The Journal of Prosthetic


Dentistry.
0022-3913/2003/$30.00 0

324 THE JOURNAL OF PROSTHETIC DENTISTRY

doi:10.1067/mpr.2003.47

VOLUME 89 NUMBER 3