# Clinical Effect of Feldspar Glass Ceramics and Lithium Disilicate Reinforced Glass Ceramics

Authors: Chang Liu; Suming Yang; Xiaoyu Chu
Journal: Contrast Media & Molecular Imaging
 (2022)

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## Abstract

The clinical effect of feldspar ceramics and lithium disilicate reinforced glass ceramics was studied. 57 affected teeth with complete root canal treatment and computer aided design/computer aided manufacturing (CAD/CAM) endocrown restoration were reviewed 24-36 months aftercompletion of the restoration. These dimensions including anatomical morphology, proximal contact , color matching, edge integrity, edge coloring, secondary caries, kinesthetic occlusion relationship, and periodontal health of the affected teeth by the modified clinical scoringcriteriafor United States Public Health Service (USPHS) were evaluated, and the patients’ satisfaction was recorded. The 57 affected teeth were divided into feldspar group and lithium disilicate reinforced ceramic group according to the different repair materials, and the statistical results are analyzed. The experimental results show medullary fixation crown can be used to repair a large area of dental defects after root canal treatment.


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## Body

## 1. Introduction

In 1999, Bindl and Mörmann first proposed restoreteeth after root canal treatment [1]. With the development of adhesion technology, the possibility of repairing large dental defects in the posterior teeth has been widely concerned. Compared with pile core crown , the advantages of endocrown include less tooth preparation, which can retain healthier neck and root tooth hard tissue, relatively simple preparation method, and low technical sensitivity, saving chairside operation time; the whole restoration is a whole, reducing the stress between the bonding interfaces, and better dispersing occlusal stress [2].There has been some controversy about a large area of tooth defects. The traditional idea is that the retainer shape used in endocrown will produce tensile stress in the tooth tissue, while dentin is compressive but not tensile, thus increasing the possibility of crown splitting [2]. However, Sedrez-Porto et al. found that there was no significant difference between the endocrown and the full crown and post-and-core nuclear crown by meta-analysis of related in vitro studies [3].At present, there are few clinical studies on endocrowns, and more studies focus on feldspar ceramics [4, 5]. Lithium disilicate reinforced glass ceramics have higher elastic modulus and flexure strength than feldspar ceramics and also have higher bonding properties with dentin. Therefore, this study aims to investigate the clinical efficacy of endocrowns after repairing large dental defects prepared from two porcelain materials.The rest of this paper is organized as follows: Section 2 discusses related work, followed by the therapeutic process and statistical analysis in Section 3. Section 4 shows the experimental results, and Section 5 concludes the full-text primary coverage, key points, and future research directions.


## 2. Related Work

For teeth with large dental defects after root canal treatment, traditional full crowns and post-and-core crowns were often used to repair them in the past. However, clinically,it is common to have a large area of dentin caries inside the tooth, while theperipheral enamel is intact. Due to the small amount of healthy tooth tissue in the neck, these affected teeth will lose a lot of healthy enamel after the traditional full crown preparation, and it is difficult to obtain adequate dentin and neck collars [6]. In addition, there are also common cases where traditional crown and pile nuclear crown repair cannot be used due to short root or root canal bending and insufficient repair space. Medullary crowns can provide an alternative for the preservation of natural teeth. The preparation amount of myeloid space retention crown is less invasive, which can not only retain healthier dental tissue but also avoid the risk of root canal side penetration and contamination of the root canal system caused by traditional pile core preparation [7]. In this study, a total of 57 cases of medullary topic crown restorations prepared by CAD/CAM (computer aided design/computer aided manufacturing) are visited, of which 55 patients had intact tooth function and satisfactory patients, and the survival rate reached 96.49%, which is consistent with the results of other scholars [8]. There was no significant difference in the survival rate of the two porcelain materials.According to in vitro three-dimensional finite element analysis, some researchers pointed out that the V on M used stress of myeloid cavity retention crown is lower to dentin compared to pile core crown [9]. In this study, the residual dental tissue of the myeloid retention crowns prepared from two porcelain materials was clinically examined, and no cracks, collapse, or fractures were found in all the base teeth, suggesting that the myeloid retention crowns had some protective effect on the remaining dental tissue.Ideally, the pulp cavity retention crown should be made from materials with low elastic modulus, high strength, and good adhesion close to dentin [10]. Similar to the elastic modulus (5–19.3GPa a) of tooth tissue can make the restoration better transfer and disperse the occlusal force, and reduce the possibility of tooth fracture. of tooth fracture. High mechanical strength can reduce the risk of repair breaks [11].The elastic modulus and flexure strength of lithium disilicate reinforced glass ceramics are higher than those of feldspar ceramics, so the preparation thickness of tooth tissue is lower, which is more conducive to repairing the posterior teeth with insufficient occlusal space. However, one failed case in this study repaired the second molar, and a local collapse of the distal middle tip of the restoration was reviewed 2 years after the repair. On clinical examination, the adhesive interface was intact without marginal coloring or secondary caries. The remaining dental tissue was intact without defects or cracks. However, the patient has a narrow interjaw distance, it breaks the nonfunctional tip of the restoration, and the fracture site is at the stress concentration of the opposite tooth tip. Therefore, when preparing medullary cavity retention crown teeth and using the CAD/CAM system, the physician should carefully observe the occlusal state of the patient, buffer the lateral force during lateral occlusion, and appropriately increase the thickness of the prosthesis in the stress concentration area.It is secured by mechanical insertion into the pulp cavity and adhesion to the dentin and enamel of the remaining dental tissue. One case of restorative debonding in this study occurred 1 year after the preparation of mandibular premolar restorations using feldspar ceramics. The analysis reason is that the remaining teeth are less machinery and adhesion forces are insufficient, resulting in bonding failure.The durability of the repair body bonding interface is affected by many factors: including the structure of the repair material, elastic modulus, and linear expansion coefficient. Edge microleakage can gradually affect the bonding interface and thus disrupt the repair edge integrity [12]. Previous studies have proved that the bonding strength of lithium disilicate-enhanced ceramics was significantly higher than that of feldspar ceramics due to the particularity of their crystal structure [13]. Zhu et al. indicated that the increased elastic modulus of the restorative material favors the durability of the bonding interface of the prosthesis and abutment [9]. The edge coloring in this study was more frequent in the feldspar ceramic group than in the lithium disilicate reinforced ceramic group, but there was no significant difference, and this result may be limited by the small sample size and observation time of this study. Moreover, in this study, the number of premolars is higher, which may be due to the relatively large depth of the pulp cavity and the adhesive area of the remaining dental tissue is higher than the premolars, and the stress of the bonding interface is more dispersed in the functional state, so the bonding interface destruction speed is relatively slow.


## 3. Therapeutic Process and Statistical Analysis

55 patients presented to the Outpatient Department of Peking University Stomatological Hospital between 2016 and had completed root canal treatment and CAD/DAM. Among them, 10 cases are male and 45 cases are female, aged from 23 to 60 years old. There are 57 posterior teeth, including 32 premolars and 25 molars.


### 3.1. Equipment and Material Selection

The research equipment is CAD/CAM system (Cerec 4.3, Sirona, Germany); the available porcelain blocks are Vita mark II (Vita, Germany), Cerec blocks (Sirona, Germany), and IPS e.max CAD (IVOCLAR VIVADENT, Liechtenstein); restorative adhesive is Rely X Ultimate resin gate (3M, USA).


### 3.2. Grouping

According to different repair materials, the pulp cavity fixation crown is divided into two groups: feldspar ceramic group: the pulp cavity fixation crown prepared by cutting porcelain block Vita mark II or Cerec blocks; lithium disilicate reinforced ceramic group: IPS e. medullary topic crown prepared by max CAD.


### 3.3. Therapeutic Process

#### 3.3.1. Dental Preparation

The affected teeth that meet the inclusion criteria should remove carious tissue and old filling, remove thin walls and weak tips, and have at least one wall of healthy dental tissue with a minimum thickness and height of 1 mm. The canal filling material is removed and the canal is closed using SE-BOND adhesive (CCME, Japan) and AP-X resin (CCME, Japan), and the material thickness is about 1 mm. Dental standard is as follows: 2 mm deep, eliminate concave, hole shaft wall extension 2°∼5°; the adjacent surface is prepared in the self-cleaning area and separated from adjacent teeth; ensure at least 2 mm repair space for feldspar glass ceramic occlusion surface and 1.5 mm for lithium disilicate reinforced glass ceramic group; clear and coherent edges, flat bottom, and rounded inside.


#### 3.3.2. Optical Printing and Preparation of Repair

After blow-drying the scanned area, at least two adjacent teeth and the adjacent side occlusion optical images are scanned to obtain optical printing data.CEREC software system and cut-designed repair with supporting cutting device are used. Lithium disilicate reinforced porcelain block is cut and tried on in the patient's mouth. After grinding, the technician finished sintering the glazed porcelain according to the color of the adjacent teeth. Feldspar porcelain block is worn directly.


#### 3.3.3. Adhesive

The bonding surface of 2 groups of porcelain blocks is eroded with 3% hydrofluoric acid. Under strict wet insulation conditions, the base is disinfected with alcohol cotton, and Rely X Ultimate resin gate is used to bond the restoration according to the instructions. Remove the excess adhesive, adjust the bite, and polish.


### 3.4. Repair Evaluation

Patients returned for a subsequent visit 24 to 36 months after repair, including 30 patients in the feldspar porcelain group and 27 patients in the lithium disilicate reinforced ceramic group. According to the evaluation criteria of the prosthesis, the anatomical morphology, adjacent relationship, color matching, edge integrity, edge coloring, secondary caries, and United States, Public Health Service (USPHS) is shown in Table1. The gingival and periodontal health status of the affected teeth and the tissue integrity of the residual teeth (with microcracks) are recorded, the efficacy of the repair is evaluated, and patient satisfaction is recorded.Table 1
Modified clinical scoring criteria for USPHS.
Inspection itemGradeCode of pointsEdge integrityAThe edges are in close contact with the dental tissueBThe groove is visible at the edge, but not within the enamel dentin boundaryCThe margins have dentine or basal tooth exposureDThe restoration is loose, cracked, or detachedAnatomic formAThe morphology is intact and closely attached to the dental tissueBMild less than or greater than the dental profileCSignificantly less than or greater than the dental profileSecondary cariesAThere were no secondary caries at the edgeBThere are secondary caries on the edgeColor matchingAColor, brightness, and transparency are difficult to distinguish from adjacent teethBThere is no obvious color difference between color, brightness, transparency, and adjacent teethCColor, brightness, and transparency did not match the adjacent teeth but were within normal rangeDColor, brightness, and transparency do not match the adjacent teeth and are not within the normal rangeEdge coloringAThere is no coloration between the restoration and the teethBThere is a coloring between the restoration and the tooth bodyCColoring has penetrated from the restoration and between dental tissues toward the pulpSyntopieABOver loose, metal molding sheet through no resistanceCToo tight, the metal molding sheet cannot pass throughDHyperpine, but no complications in the gums in this areaEOverpine, food impaction, and the repair body must be replacedStatic dynamic occlusal relationAThe interposition was stable and the immediate opening of the anterior teeth was satisfactoryBThe tip is stable, the immediate opening and closing of the anterior teeth are acceptable, the fangs protect the occlusion without early contact, and dental interferenceCThe staggered position of the tip is unstable, there are lateral forces rather than vertical forces on the top and edge of the restoration, and the restoration should be observed regularlyDAs nonfunctional, the restoration needs to be replaced


### 3.5. Statistical Analysis

Data are analyzed by using the SPSS16.0 software. The self-consistency test of 2 examiners is performed with Cohen's kappa with kappa values from 0.81 to 0.92 considered highly consistent. The comparison of clinical effects in 2 groups after the repair is performed by the Chi-square test,P>0.05 as statistically significant.


## 3.1. Equipment and Material Selection

The research equipment is CAD/CAM system (Cerec 4.3, Sirona, Germany); the available porcelain blocks are Vita mark II (Vita, Germany), Cerec blocks (Sirona, Germany), and IPS e.max CAD (IVOCLAR VIVADENT, Liechtenstein); restorative adhesive is Rely X Ultimate resin gate (3M, USA).


## 3.2. Grouping

According to different repair materials, the pulp cavity fixation crown is divided into two groups: feldspar ceramic group: the pulp cavity fixation crown prepared by cutting porcelain block Vita mark II or Cerec blocks; lithium disilicate reinforced ceramic group: IPS e. medullary topic crown prepared by max CAD.


## 3.3. Therapeutic Process

### 3.3.1. Dental Preparation

The affected teeth that meet the inclusion criteria should remove carious tissue and old filling, remove thin walls and weak tips, and have at least one wall of healthy dental tissue with a minimum thickness and height of 1 mm. The canal filling material is removed and the canal is closed using SE-BOND adhesive (CCME, Japan) and AP-X resin (CCME, Japan), and the material thickness is about 1 mm. Dental standard is as follows: 2 mm deep, eliminate concave, hole shaft wall extension 2°∼5°; the adjacent surface is prepared in the self-cleaning area and separated from adjacent teeth; ensure at least 2 mm repair space for feldspar glass ceramic occlusion surface and 1.5 mm for lithium disilicate reinforced glass ceramic group; clear and coherent edges, flat bottom, and rounded inside.


### 3.3.2. Optical Printing and Preparation of Repair

After blow-drying the scanned area, at least two adjacent teeth and the adjacent side occlusion optical images are scanned to obtain optical printing data.CEREC software system and cut-designed repair with supporting cutting device are used. Lithium disilicate reinforced porcelain block is cut and tried on in the patient's mouth. After grinding, the technician finished sintering the glazed porcelain according to the color of the adjacent teeth. Feldspar porcelain block is worn directly.


### 3.3.3. Adhesive

The bonding surface of 2 groups of porcelain blocks is eroded with 3% hydrofluoric acid. Under strict wet insulation conditions, the base is disinfected with alcohol cotton, and Rely X Ultimate resin gate is used to bond the restoration according to the instructions. Remove the excess adhesive, adjust the bite, and polish.


## 3.3.1. Dental Preparation

The affected teeth that meet the inclusion criteria should remove carious tissue and old filling, remove thin walls and weak tips, and have at least one wall of healthy dental tissue with a minimum thickness and height of 1 mm. The canal filling material is removed and the canal is closed using SE-BOND adhesive (CCME, Japan) and AP-X resin (CCME, Japan), and the material thickness is about 1 mm. Dental standard is as follows: 2 mm deep, eliminate concave, hole shaft wall extension 2°∼5°; the adjacent surface is prepared in the self-cleaning area and separated from adjacent teeth; ensure at least 2 mm repair space for feldspar glass ceramic occlusion surface and 1.5 mm for lithium disilicate reinforced glass ceramic group; clear and coherent edges, flat bottom, and rounded inside.


## 3.3.2. Optical Printing and Preparation of Repair

After blow-drying the scanned area, at least two adjacent teeth and the adjacent side occlusion optical images are scanned to obtain optical printing data.CEREC software system and cut-designed repair with supporting cutting device are used. Lithium disilicate reinforced porcelain block is cut and tried on in the patient's mouth. After grinding, the technician finished sintering the glazed porcelain according to the color of the adjacent teeth. Feldspar porcelain block is worn directly.


## 3.3.3. Adhesive

The bonding surface of 2 groups of porcelain blocks is eroded with 3% hydrofluoric acid. Under strict wet insulation conditions, the base is disinfected with alcohol cotton, and Rely X Ultimate resin gate is used to bond the restoration according to the instructions. Remove the excess adhesive, adjust the bite, and polish.


## 3.4. Repair Evaluation

Patients returned for a subsequent visit 24 to 36 months after repair, including 30 patients in the feldspar porcelain group and 27 patients in the lithium disilicate reinforced ceramic group. According to the evaluation criteria of the prosthesis, the anatomical morphology, adjacent relationship, color matching, edge integrity, edge coloring, secondary caries, and United States, Public Health Service (USPHS) is shown in Table1. The gingival and periodontal health status of the affected teeth and the tissue integrity of the residual teeth (with microcracks) are recorded, the efficacy of the repair is evaluated, and patient satisfaction is recorded.Table 1
Modified clinical scoring criteria for USPHS.
Inspection itemGradeCode of pointsEdge integrityAThe edges are in close contact with the dental tissueBThe groove is visible at the edge, but not within the enamel dentin boundaryCThe margins have dentine or basal tooth exposureDThe restoration is loose, cracked, or detachedAnatomic formAThe morphology is intact and closely attached to the dental tissueBMild less than or greater than the dental profileCSignificantly less than or greater than the dental profileSecondary cariesAThere were no secondary caries at the edgeBThere are secondary caries on the edgeColor matchingAColor, brightness, and transparency are difficult to distinguish from adjacent teethBThere is no obvious color difference between color, brightness, transparency, and adjacent teethCColor, brightness, and transparency did not match the adjacent teeth but were within normal rangeDColor, brightness, and transparency do not match the adjacent teeth and are not within the normal rangeEdge coloringAThere is no coloration between the restoration and the teethBThere is a coloring between the restoration and the tooth bodyCColoring has penetrated from the restoration and between dental tissues toward the pulpSyntopieABOver loose, metal molding sheet through no resistanceCToo tight, the metal molding sheet cannot pass throughDHyperpine, but no complications in the gums in this areaEOverpine, food impaction, and the repair body must be replacedStatic dynamic occlusal relationAThe interposition was stable and the immediate opening of the anterior teeth was satisfactoryBThe tip is stable, the immediate opening and closing of the anterior teeth are acceptable, the fangs protect the occlusion without early contact, and dental interferenceCThe staggered position of the tip is unstable, there are lateral forces rather than vertical forces on the top and edge of the restoration, and the restoration should be observed regularlyDAs nonfunctional, the restoration needs to be replaced


## 3.5. Statistical Analysis

Data are analyzed by using the SPSS16.0 software. The self-consistency test of 2 examiners is performed with Cohen's kappa with kappa values from 0.81 to 0.92 considered highly consistent. The comparison of clinical effects in 2 groups after the repair is performed by the Chi-square test,P>0.05 as statistically significant.


## 4. Experimental Results

### 4.1. Self-Consistency Test of the Inspector

The self-consistency tests of the two examiners are shown in Table2. It can be seen from Table 2 that the Kappa values are in the highly consistent range (0.81∼0.92), which indicates that the consistency of the two examiners is good.Table 2
Self-consistency test.
Inspector 1Inspector 2Cohen’s kappa0.850.91


### 4.2. Dental Restorations

Table3 shows the retention rates of different materials and dental restorations. It is evident from Table 3 that, in the follow-up examination from 24 to 36 months, all the affected teeth showed no percussion pain and no loosening, and no abnormalities are found in the periapical tissue of the X-ray ray after completing the repair: one case of premolar feldspar ceramic restoration and one case of lithium disilicate reinforced glass ceramic prosthesis, with a survival rate of 96.49%. There is no significant difference between the groups (Fisher exact test) (P>0.05).Table 3
Retention rates of different materials and dental restorations.
Divide into groupsDental positionExample numberNumber of failed casesFraction surviving (%)Feldspar ceramic groupDentes premolares21196.67Grind one’s teeth in sleep90Lithium disilicate reinforced ceramic groupDentes premolares11096.30Grind one's teeth in sleep161


### 4.3. Clinical Examination according to the Evaluation Criteria of Modified USPHS

Seven teeth in the feldspar group show marginal coloring, all occurring in the premolars. A total of four patients in the lithium disilicate-enhanced ceramic group show marginal coloring, two in premolars and two in molars. Table4 is the comparison of the clinical repair effect of group materials. It can be seen from Table 4 that none of the restorations shows altered adjacency and occlusion, no secondary caries, no gingival and periodontal problems due to the restorations, and no microcracks, local collapse, or fracture of the remaining dental tissue. There is no significant difference in success rate between the 2 groups (Pearson square) (P>0.05).Table 4
Comparison of clinical repair effect of group materials (example).
Inspection itemGradeLong stone porcelain groupLithium disilicate-enhanced ceramic groupEdge integrityA2926B00C00D11Anatomic formA3027B00C00Secondary cariesA3027B00Color matchingA2825B22C00D00Edge coloringA2323B74C00SyntopieA3027B00C00D00E00Static dynamic occlusal relationA3027B00C00D00Mission success rate73.33%81.48%


### 4.4. Patient Satisfaction with the Treatment Effect

Except for the two failed cases, all the patients were very satisfied with the treatment , and the overall satisfaction rate was 96.49%.


## 4.1. Self-Consistency Test of the Inspector

The self-consistency tests of the two examiners are shown in Table2. It can be seen from Table 2 that the Kappa values are in the highly consistent range (0.81∼0.92), which indicates that the consistency of the two examiners is good.Table 2
Self-consistency test.
Inspector 1Inspector 2Cohen’s kappa0.850.91


## 4.2. Dental Restorations

Table3 shows the retention rates of different materials and dental restorations. It is evident from Table 3 that, in the follow-up examination from 24 to 36 months, all the affected teeth showed no percussion pain and no loosening, and no abnormalities are found in the periapical tissue of the X-ray ray after completing the repair: one case of premolar feldspar ceramic restoration and one case of lithium disilicate reinforced glass ceramic prosthesis, with a survival rate of 96.49%. There is no significant difference between the groups (Fisher exact test) (P>0.05).Table 3
Retention rates of different materials and dental restorations.
Divide into groupsDental positionExample numberNumber of failed casesFraction surviving (%)Feldspar ceramic groupDentes premolares21196.67Grind one’s teeth in sleep90Lithium disilicate reinforced ceramic groupDentes premolares11096.30Grind one's teeth in sleep161


## 4.3. Clinical Examination according to the Evaluation Criteria of Modified USPHS

Seven teeth in the feldspar group show marginal coloring, all occurring in the premolars. A total of four patients in the lithium disilicate-enhanced ceramic group show marginal coloring, two in premolars and two in molars. Table4 is the comparison of the clinical repair effect of group materials. It can be seen from Table 4 that none of the restorations shows altered adjacency and occlusion, no secondary caries, no gingival and periodontal problems due to the restorations, and no microcracks, local collapse, or fracture of the remaining dental tissue. There is no significant difference in success rate between the 2 groups (Pearson square) (P>0.05).Table 4
Comparison of clinical repair effect of group materials (example).
Inspection itemGradeLong stone porcelain groupLithium disilicate-enhanced ceramic groupEdge integrityA2926B00C00D11Anatomic formA3027B00C00Secondary cariesA3027B00Color matchingA2825B22C00D00Edge coloringA2323B74C00SyntopieA3027B00C00D00E00Static dynamic occlusal relationA3027B00C00D00Mission success rate73.33%81.48%


## 4.4. Patient Satisfaction with the Treatment Effect

Except for the two failed cases, all the patients were very satisfied with the treatment , and the overall satisfaction rate was 96.49%.


## 5. Conclusions

The clinical effect of endocrowns made from feldspar ceramics and lithium disilicate reinforced glass ceramics was studied. The treatment of large dental defects after root canal treatment can meet clinical needs. In 24–36 months of clinical follow up, lithium disilicate reinforced glass ceramics had comparable clinical efficacy with endocrowns prepared from feldspar ceramics. The durability of the retention crown is related to various factors, including the selection of cases, tooth preparation morphology, the selection of restorative materials and adhesives, and the design of the morphology of the prosthesis. However, due to the limited sample size and observation time in this study, future clinical studies with larger sample sizes and longer observation times are needed to provide evidence to support the clinical application of endocrowns.



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