Cement Thickness of Inlay Restorations Made of Lithium

Disilicate, Polymer-Infiltrated Ceramic and Nano-Ceramic

CAD/CAM Materials Evaluated Using 3D X-Ray
Micro-Computed Tomography
Recep Uzgur, DDS, PhD,1 Ertuğrul Ercan, DDS, PhD,2 Zeynep Uzgur, DDS, PhD,1 Hakan Çolak, DDS, PhD,3
Muhammet Yalçın, DDS, PhD,4 & Mutlu Özcan, DDS, DMD, PhD5
1
Department of Prosthodontics, Faculty of Dentistry, Zirve University, Gaziantep, Turkey
2
Department of Restorative Dentistry, Faculty of Dentistry, Kırıkkale University, Kırıkkale, Turkey
3
Department of Restorative Dentistry, Faculty of Dentistry, Zirve University, Gaziantep, Turkey
4
Department of Restorative Dentistry, Faculty of Dentistry, Inonu University, Malatya, Turkey
5
University of Zurich, Dental Materials Unit, Center for Dental and Oral Medicine, Clinic for Fixed and Removable Prosthodontics and Dental
Materials Science, Zurich, Switzerland

Keywords Abstract
CAD/CAM; cement thickness; micro-CT.
Purpose: To evaluate the marginal and internal cement thicknesses of inlay restora-
Correspondence
tions made of various CAD/CAM materials using 3D X-ray micro-computed tomog-
Recep Uzgur, Department of Prosthodontics, raphy (micro-CT) technique.
Faculty of Dentistry, Zirve University, Materials and Methods: Caries-free extracted mandibular molars (N = 30) with
Şehitkamil, Gaziantep 27000, Turkey. similar size were randomly assigned to three groups (N = 10 per group). Mesio-
E-mail: ruzgur@gmail.com occlusal-distal (MOD) cavities were prepared, and inlay restorations were obtained
by milling out CAD/CAM materials namely, (a) IPS: monolithic lithium disilicate
This study was supported by Kırıkkale (control), (b) VE: polymer-infiltrated ceramic, and (c) CS: nano-ceramic using a CAM
University, Research Center, Turkey. unit. Marginal and internal cement thicknesses were measured using 3D micro-CT.
Data were analyzed using 1-way ANOVA and Tukey’s tests (alpha = 0.05).
Conflict of interest statement: The authors
did not have any commercial interest in any of
Results: The mean marginal and internal cement thickness were not significant in
the materials used in this study.
all inlay materials (p > 0.05). Mean marginal cement thickness (µm) was the lowest
for the IPS group (67.54 ± 10.16) followed by VE (84.09 ± 3.94) and CS (95.18 ±
Accepted May 30, 2016 10.58) (p > 0.05). The internal cement thickness (µm) was the lowest in the CS group
(54.85 ± 6.94) followed by IPS (60.58 ± 9.22) and VE (77.53 ± 12.13) (p > 0.05).
doi: 10.1111/jopr.12521 Conclusion: Marginal and internal cement thicknesses of MOD inlays made of mono-
lithic lithium disilicate, polymer-infiltrated ceramic, and nano-ceramic CAD/CAM
materials were similar and all less than 100 µm, which could be considered clinically
acceptable.
Clinical significance: MOD inlays made of different CAD/CAM materials presented
similar cement thickness, less than 100 µm.

Despite the advances made in modern dentistry, dental caries Several factors could directly influence the longevity of indi-
remains a significant problem and represents one of the main rect ceramic restorations, among which the quality of marginal
causes of tooth loss. In contemporary practice, moderate Class seal and the thickness of the luting agent seems to be most
I and II carious lesions can be restored using inlay or onlay relevant.9 Marginal seal has the most substantial impact on the
restorations1-4 that could be fabricated from a range of mate- longevity, because it ensures resistance to secondary caries and
rials, including alloy, ceramic, or resin composite.5 Long-term microleakage. On the other hand, the gap between the restora-
clinical studies still consider cast gold partial coverage as the tion and the tooth surface, filled with cement in the 3D plane
model of excellence for restoring teeth with caries in poste- is also of significance for the durability of the restorations. To
rior teeth; however, recently, novel materials and techniques function effectively, the restoration needs mechanical support
have been introduced as nonmetallic tooth-colored materials for provided by the tooth substance, which becomes more crucial
posterior restorations. One such material is monolithic lithium in the posterior teeth.8-10 Overall, 3D fit is directly affected
disilicate all-ceramic produced using CAD/CAM technologies by the thickness of the cement layer. In this regard, three fac-
that also present high fracture resistance.6,7 tors need to be considered when placing restorations, namely,

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Micro-CT Evaluation of Inlay Restorations Cement Thickness Uzgur et al

the thickness, chemical structure, and elastic modulus of the Table 1 Brands, abbreviations, manufacturers, and batch numbers of
restoration and the cement.11-13 the inlay materials used in this study
Marginal and internal cement thickness of a restoration
Brand Manufacturer Batch numbers
could be assessed using different methods based on section-
ing, replica, or X-ray micro-computed tomography (micro- IPS e-max CAD Ivoclar Vivadent GmbH U16405
CT) techniques, where the latter two are considered less (IPS) Schaan, Liechtenstein
invasive.14 Among various methods employed to evaluate the fit Vita Enamic VITA Zahnfabrik, GmbH & Co 41960
of dental reconstructions, micro-CT is becoming increasingly (VE) Bad Säckingen, Germany
common.15-22 Cerasmart GC Dental Products, 1412081
Recently introduced CAD/CAM materials combine the dura- (CS) Tokyo, Japan
bility and long-lasting color of ceramics with the benefits
of resin composite materials. Current studies reported opti-
mal marginal and internal cement thickness for such materials
ranging between 20 and 200 µm.8,23-28 The manufacturers, with 30 to 40 µm grit diamond burs (8837KR.314.012*,
however, claim cement thickness within clinically acceptable 8847KR.314.016*, 8390.204.016*, Komet).35
levels.29,30 In fact, cement thickness below 200 µm could more For milling parameters, 40 µm for the spacer and 20 µm
effectively withstand wear of the cement at the restoration for the cement gap were established.36 Inlay cavities were then
margins.31,32 scanned using a laboratory scanner (D710 3D Scanner; 3Shape,
The wide range of cement thickness with recent CAD/CAM Copenhagen, Denmark), and CAD software (3D Dental System
materials also relates to the measurement method. To date, 2015; 3Shape) was used to design the inlays. A CAM unit
micro-CT technique has not been employed to assess the (Coritec 550i; Imes-icor GmbH, Eiterfeld, Germany) milled
internal and marginal cement thickness of partial coverage the inlays out of the test materials for each tooth.
restorations made of recent CAD/CAM materials. Therefore,
the objective of this study was to evaluate the marginal Adhesive cementation
and internal cement thickness of inlay restorations made of
Inlay restorations were adhesively cemented (Panavia F2.0;
monolithic lithium disilicate, polymer-infiltrated ceramic and
Kuraray Noritake Dental Inc., Tokyo, Japan) to the corre-
nano-ceramic CAD/CAM materials. The null hypothesis tested
sponding cavities following the manufacturer‘s instructions.
was that there would be no significant difference in marginal
Initially, intaglio surfaces of the inlays were air-abraded
and internal cement thickness of inlay restorations fabricated
(50 µm Al2 O3 , Microetcher; Danville Engineering, San Ra-
from different CAD/CAM materials.
mon, CA) and then etched with 40% phosphoric acid (K
Etchant gel; Kuraray Noritake Dental Inc.) for 5 seconds. Equal
amounts of silane were mixed (Clearfil SE Bond, Porcelain
Materials and methods Bond Activator; Kuraray Noritake Dental Inc.), and one coat
Specimen preparation was applied with a microbrush. The tooth surface was con-
ditioned using a self-etch primer (ED Primer A and B; Ku-
The Ethics Committee of Kirikkale University, Faculty of
raray) for 30 seconds and air-dried gently with oil-free air.
Medicine, approved this research project. Caries-free extracted
Equal amounts of the base and activator of dual-polymerized
mandibular molars (N = 30) of similar size were selected. The
resin cement was mixed for 20 seconds, and the mixture of
teeth were initially examined under 10x magnification using
paste was applied on the intaglio surface of the inlays. The
loups, and only those deemed to be free from any hypoplastic
inlay was cemented with the aid of a sticky holder (Viva-
defects and cracks were selected. The teeth were thoroughly
stick; Ivoclar Vivadent) under 50 N, and excess cement was
cleaned of soft tissues and stored in 0.1% thymol solution at
removed using a dental probe and microbrush. The inlay
room temperature until the experiment.33 The apical parts of
was then photo-polymerized from the mesial, distal, and oc-
all teeth were embedded in an autopolymerizing resin to the
clusal aspects for 20 seconds per surface using an LED unit
cement-enamel junction (CEJ) (Paladent RR; Heraeus Kulzer
(Bluephase; Ivoclar Vivadent; Light output: 1200 mw/cm2 ).
GmbH, Hanau, Germany).
Glycerine gel was applied at the margins (Oxyguard; Kuraray
The teeth were divided into three groups (n = 10 per group)
Noritake Dental Inc.), left for 60 seconds, and rinsed with
and received an inlay manufactured from one of the following
copious water.
CAD/CAM materials, namely (a) IPS: monolithic lithium dis-
ilicate, (b) VE: polymer-infiltrated ceramic, and (c) CS: nano-
Cement thickness measurement
ceramic (Table 1). A mesio-occlusal-distal (MOD) inlay cav-
ity was prepared in each tooth with 3 mm isthmus width and The cement thickness at the margins and internal surface of
2.5 mm cavity depth. Cavities were prepared 1 mm above the the inlays were measured using high-resolution 3D micro-
CEJ at an overall preparation angle of 10° towards the oc- CT (SkyScan 1172; Bruker-micro-CT, Kontich, Belgium). The
clusal aspect and rounded shoulder.27,33,34 One single operator X-ray tube was operated at 100 kV and 100 µA using a
prepared the cavities using a dental surveyor (Paraflex, BEGO 0.5 mm Al+Cu filter at a resolution of 10 µm pixels. Each
GmbH, Bremen, Germany). The teeth were first prepared using specimen was scanned for a total of 60 minutes at 180° rota-
80 µm grit diamond burs (837KR.314.012*, 847KR.314.016*; tion around the vertical axis. The camera exposure time was
Komet Dental, Brasseler, Lemgo, Germany) and finished 1400 ms, with a rotation step of 0.40, average frame of 3, and

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Uzgur et al Micro-CT Evaluation of Inlay Restorations Cement Thickness

Figure 1 Micro-CT images of cement thick-

ness under the inlays in MOD cavities from
axial, occlusal, and mesial views.

random movement of 20 mm. System reconstruction software Windows v.20 (SPSS, Chicago, IL). Kolmogorov-Smirnov and
(NRecon v.1.6.3, SkyScan; Brucker-micro-CT) was then em- Shapiro-Wilk tests were used to test normal distribution of the
ployed to reconstruct the axial cross-sections of the resulting data. As the data (µm) were normally distributed, one-way
2D images (8-bit TIFF) with a beam hardening correction of ANOVA and Tukey’s tests were used. p-values <0.05 were
55%, smoothing of 3, and an attenuation coefficient range of considered significant in all tests.
0 to 0.064000. Thereafter, 3D reconstructions were developed
using the software to produce the linear and volumetric analysis Results
(CTAn v.1.12 and CT Vol v.2.2.1, Skyscan; Bruker-micro-CT).
Finally, gingival cement thickness was calculated for marginal The mean marginal and internal cement thickness were not sig-
area, and mean axial and pulpal cement thickness were calcu- nificant in all inlay materials (p > 0.05). The marginal cement
lated for internal cement thickness (Fig 1). thickness (µm) was the lowest for the IPS group, followed by
VE and CS (p > 0.05). The internal cement thickness (µm) was
Statistical analysis the lowest in CS group, followed by IPS and VE (p > 0.05)
(Table 2).
Statistical analysis was performed with SPSS Statistics for
Discussion
Table 2 Mean marginal and internal cement thickness and standard
deviations (SD) (µm) for the MOD inlay restorations made of different This study was undertaken to compare the compare the marginal
CAD/CAM materials. For group abbreviations see Table 1 and internal cement thickness of molar inlay restorations made
of a variety of CAD/CAM materials using an X-ray micro-CT.
Experimental Marginal cement Internal cement Based on the results obtained, since there were no significant
groups thickness (±SD) (µm) thickness (±SD) (µm) differences between the measurement areas (marginal vs. inter-
IPS 67.54 ± 10.16 60.58 ± 9.22 nal) in all tested materials, the null hypothesis was accepted.
VE 84.09 ± 3.94 77.53 ± 12.13 The nonsignificant differences between groups could also
CS 95.18 ± 10.58 54.85 ± 6.94 indicate accurate preparation designs. The geometry of the
p > 0.05 p > 0.05 preparation employed in this study was in accordance with
the recommended preparation guidelines for ceramic partial
coverage restorations.27,33,34 In an attempt to standardize the

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Micro-CT Evaluation of Inlay Restorations Cement Thickness Uzgur et al

preparation procedures, the same operator working with the terials, presented mean values less than 100 µm, which could
same settings and using the dental surveyor prepared the cavi- be considered clinically acceptable.
ties. In addition, the same CAM equipment and software were
used to scan the specimens, design the inlays, and mill the
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