Professional Documents
Culture Documents
Supported by Natural Science Foundation of Guangdong Province of China (2018A0303130213) and Clinical Research Startup Program of Southern Medical University by
High-level University Construction Funding of Guangdong Provincial Department of Education (LC2016PY023), as well as Clinical Research Program of Nanfang Hospital
Southern Medical University (2018CR018).
a
Graduate student, Graduate Endodontics, Department of Stomatology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, PR China.
b
Nurse-in-charge, Department of Stomatology, Nanfang Hospital, Guangdong, PR China.
c
Graduate student, Graduate Endodontics, Department of Stomatology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, PR China.
d
Graduate student, Graduate Endodontics, Department of Stomatology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, PR China.
e
Graduate student, Graduate Endodontics, Department of Stomatology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, PR China.
f
Graduate student, Graduate Endodontics, Department of Stomatology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, PR China.
g
Professor, Department of Stomatology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, PR China.
Clinical Implications
The results of this study suggested that GR with a
similar elastic modulus to dentin produced a better
biomechanical behavior, which could achieve
promising long-term outcomes for endocrown
restorations.
Table 1. Material properties Approval for this study was provided by the ethics
Elastic Poisson Characteristic Weibull committee of Nanfang Hospital, Southern Medical
Material Modulus (MPa) Ratio Strength (MPa) Modulus
University, Guangzhou, PR China. Thirty extracted
Vita Suprinity 104 900.00 0.21 537.03 5.20
IPS e.max CAD 102 700.00 0.22 609.80 13.40
intact human mandibular molars with approximately
Vita Enamic 37 800.00 0.24 195.67 17.62
similar size and morphology were collected and stored
Lava Ultimate 12 700.00 0.45 300.64 10.90 in 0.1% thymol solution (Caelo) at room temperature.
Grandio blocs 18 000.00 0.26 281.60 12.07 All teeth received a standard endodontic treatment
Enamel 84 100.00 0.33 42.41 5.53 in vitro and were prepared with a flat endocrown
Dentin 18 600.00 0.31 44.45 3.35 design as previously reported.39 They were vertically
Spongious bone 1370.00 0.30 d d embedded in acrylic resin (Unifast Trad; GC) up to 2
Cortical bone 10 700.00 0.30 d d mm below the cementoenamel junction (CEJ) in a 12-
Periodontal ligament 68.90 0.45 d d mm-diameter polyvinyl chloride (PVC) tube.
Flowable resin 7000.00 0.25 d d A total of 30 molar-endocrowns fabricated from 5
Gutta percha 0.69 0.45 d d CAD-CAM materials (n=6) were designed and milled by
using a CAD-CAM system (CEREC AC; Dentsply Sirona)
(Fig. 2). The luting surfaces of the teeth and endocrowns
values (Table 1).32-37 All structures were assumed to be
were treated as recommended by the manufacturers.
linear-elastic, isotropic, and homogeneously distributed.
Resin cement (NX3; Kerr Corp) was applied to the luting
As the stress distribution varies with the loading di-
surfaces of endocrowns, which were placed on their
rection, 2 situations were examined: a vertical load of 200
corresponding teeth under a load of 9.8 N for 10 minutes
N applied on the buccal and lingual cusps parallel to the
and exposed to a light polymerizing unit (Elipar; 3M
long axis of the tooth and an oblique load of 200 N at 45
ESPE) at 1000 mW/cm2 for 20 seconds. Excess cement
degrees to the long axis of the tooth, applied to the
was removed, followed by finishing and polishing of the
lingually inclined plane of the buccal cusp.26,32,38 Because
margins.
the FE model was linear, 200 N was applied, and the
After storing at 37 C in distilled water for 1 week,
stresses of other loads (200 to 1500 N in 100-N in-
all specimens were thermocycled for 5000 cycles be-
crements) were calculated in proportion to the data of
tween 5 C and 55 C with a dwell time of 30 seconds
200 N. For all designs, the von Mises stress (VMS) and
in each bath.40-42 All specimens were subjected to a
maximum principal stress (MPS) of dental structures and
compressive test until catastrophic failure in a universal
restorations were evaluated in MPa separately by using
testing machine (Instron 5967; Instron LTD). Force was
the FEA software program.
applied with a 6-mm-diameter stainless-steel ball on
According to the normal stress failure criterion, failure
the central fossa of the occlusal surface of the endo-
was assumed to arise from the greatest principal tensile
crown at a crosshead speed of 0.5 mm/min. Tinfoil
stress on stress concentration areas. The Weibull risk of
(0.25 mm) was placed between the restoration surface
rupture analysis, also called the survival probability, Ps ,
and the loading ball to prevent stress concentration.27
was obtained as previously reported.32,33,37 When loaded,
The fracture load of the specimens, defined as the
a restoration will survive until the risk of rupture reaches
maximal load before the load reading dropped sud-
a critical value at any one of the multiple failure sources.
denly on the load-strain curve, was recorded. The 1-
For a system of n=i sources, the overall survival proba-
way ANOVA test was used to analyze the fracture
bility, Ps , is the product of the individual survival prob-
resistance of the 5 groups, and the Tukey post hoc
abilities:
multiple-comparison test was applied to identify sta-
Y
Ps = Psi ; tistically homogeneous subsets (a=.05).
i The fracture specimens were collected and examined
under a stereomicroscope (Stereo Discovery.V20; Zeiss)
where i=1, 2, 3. For each of the 5 test models, the stress for fracture types: Type I, fracture in endocrown material;
concentration regions of the enamel, dentin, and resto- Type II, adhesive failure between endocrown material
ration were observed to be at risk. Hence, the failure and dentin; Type III, fracture in enamel or dentin; Type
probability, Pf , for the total systems is IV, fracture extending to root.25 Fractures above the CEJ
Pf = 1 − ðPS1 × PS2 × PS3 Þ were considered repairable, and fractures below the CEJ
and extending to the root were termed nonrepairable.
The probability of failure versus load curves was Representative fracture specimens were further examined
calculated. The characteristic strengths and Weibull by using a scanning electron microscope (SEM) (SU-70;
moduli of different materials were adopted from the Hitachi) to determine the fracture origin and direction of
literature and testing data for calculation (Table 1). crack propagation.
Figure 2. Specimens designed and fabricated by using computer-aided design and computer-aided manufacturing system. A, Digital scan of specimen.
B, Design of endocrown restoration. C, Fabricate of endocrown restoration. D, Endocrown restoration after milling.
Figure 3. Von Mises stress distribution patterns in endodontically Figure 4. Von Mises stress distributions patterns in endodontically
treated teeth restored by endocrown under axial load of 200 N treated teeth restored by endocrown under oblique load of 200 N
according to restorative material type. A, Restoration. B, Enamel. according to restorative material type. A, Restoration. B, Enamel.
C, Dentin. D, Overall structures in sagittal plane. EMX, IPS e.max CAD; C, Dentin. D, Overall structures in sagittal plane. EMX, IPS e.max CAD;
GR, Grandio blocs; LU, Lava Ultimate; VE, Vita Enamic; VS, Vita Suprinity. GR, Grandio blocs; LU, Lava Ultimate; VE, Vita Enamic; VS, Vita Suprinity.
presented in Figure 8. The fractographic analysis revealed Table 2. Maximum principal stress values in enamel, dentin, and
that the fracture originated in the occlusal loading area restoration under axial and oblique loads (MPa)
where the crack propagated downward through the Enamel Dentin Restoration
endocrown, leading to a bulk fracture (Fig. 9). Compared Model Axial Oblique Axial Oblique Axial Oblique
with VS and EMX groups, more compression curls and VS 4.53 7.70 7.23 18.75 33.87 34.38
EMX 4.54 7.73 7.23 18.74 33.97 34.48
arrest lines occurred in the fracture surface of endocrown
VE 4.91 9.30 7.05 18.25 34.41 34.93
in VE, LU, and GR groups.
LU 6.73 16.36 6.70 17.16 45.10 41.22
GR 5.15 10.79 6.86 17.74 34.73 35.25
DISCUSSION
EMX, IPS e.max CAD; GR, Grandio blocs; LU, Lava Ultimate; VE, Vita Enamic; VS, Vita
The purpose of this FEA and in vitro study was to Suprinity.
100% 100%
Failure Probability
Failure Probability
80% 80%
60% 60%
40% 40%
20% 20%
0% 0%
0 200 400 600 800 1000 1200 1400 0 200 400 600 800 1000 1200 1400
Load (N) Load (N)
VS EMX VE LU GR VS EMX VE LU GR
A B
100% 100%
Failure Probability
Failure Probability
80% 80%
60% 60%
40% 40%
20% 20%
0% 0%
0 200 400 600 800 1000 1200 1400 0 200 400 600 800 1000 1200 1400
Load/N Load (N)
VS EMX VE LU GR VS EMX VE LU GR
C D
Figure 5. Failure probability versus load curves of FEA models under axial load according to Weibull risk of rupture analysis. A, Enamel. B, Dentin.
C, Restorations. D, Overall failure probability. EMX, IPS e.max CAD; GR, Grandio blocs; LU, Lava Ultimate; VE, Vita Enamic; VS, Vita Suprinity.
Table 3. Fracture forces (N), mean ±standard deviations, minimum, and 100%
maximum, of groups after compressive loading
90%
Frequencies of Failure Types (%)
Figure 8. Example of fracture modes. (A-a) Type I, fracture in endocrown material. (B-b) Type III, fracture in enamel or dentin. (C-c) Type IV, fracture
extending to root. Arrows: Origin indicates initial starting zone of failure. Multiple arrest lines and hackles indicate direction of crack propagation.
Compression curl represents curved lip before total fracture inside material. Twist hackles represents final breakthrough of facture crack. CEJ,
cementoenamel junction.
Figure 9. Scanning electron micrographs of fractographic analysis for each group under different magnifications (×25 to ×45). Fracture features
observed in endocrown included compression curl, arrest line, and hackles. EMX, IPS e.max CAD; GR, Grandio blocs; LU, Lava Ultimate; VE, Vita Enamic;
VS, Vita Suprinity.
CONCLUSIONS
Based on the results of this study, the following conclu-
sion was drawn:
1. The endocrown fabricated with GR exhibited the
best monobloc stress distribution and met the me-
chanical requirements for large occlusal areas.
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CRediT authorship contribution statement
maxillary premolar with different crack depths with endodontic treatment by
Ziting Zheng: Conceptualization, Methodology, Investigation, Writing - original
computer-aided design/computer-aided manufacturing ceramic restorations.
draft, Writing - review & editing. Yunyan He: Methodology, Investigation.
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