Posttreatment diagnosis of caries under

fixed restorations: A pilot study

Mehmet Selim Bilgin, DDS, PhD,a Osman Sami Aglarci, DDS, PhD,b
and Ali Erdem, DDS, PhDc
Faculty of Dentistry, Sifa University, Izmir, Turkey
Statement of problem. Conventional radiographic techniques are insufcient for detecting caries under xed restorations or
for acquiring clear images of the disease. Advanced radiographic techniques such as cone beam computerized tomography
may be a solution.
Purpose. The purpose of this study was to assess the viability of detecting and characterizing caries under complete-ceramic
and metal-supported crowns by using cone beam computerized tomography.
Material and methods. A grade 6 carious molar tooth according to the International Caries Detection and Assessment
System criteria was selected. The tooth was prepared, and 3 different crowns were fabricated in a dental laboratory: yttria
tetragonal zirconia polycrystal (Y-TZP) ceramic, lithium disilicate ceramic, and metal ceramic. The crowns were placed on the
prepared tooth, and each specimen was subjected to cone beam computerized tomography. Opacity values were recorded
and evaluated with 2-way ANOVA. Multivariate comparisons (Tukey was performed to assess the mean gray value differences
of the materials between caries and dentin, and the Mann-Whitney U test was performed to assess the mean gray value
differences between caries and dentin for each material (a.05).
Results. Carious borders and cavities were detected under the 3 ceramic crown specimens with a cone beam computerized
tomography radiographic technique. The statistical analysis of the radiopacity mean gray value was at the borderline of
signicance for the specimen radiographies. Signicant differences were found with respect to materials, location, and the
interaction between these 2 factors (P<.001).
Conclusions. Cone beam computerized tomography can be used as a posttreatment diagnostic technique for detecting caries
under high atomic numbered crowns and partial xed dental prostheses. (J Prosthet Dent 2014;112:1364-1369)

Clinical Implication
Without image degradation and metal artifacts, cone beam computerized
tomography can be a solution for diagnosing caries without removal of
partial xed prostheses for diagnosis and is less harmful to patients.
Metal crowns and partial xed dental
prostheses (FDP) have become the
treatment of choice for patients with
esthetic and functional loss. With
rapidly developing technology, several
types of materials, including different
metal alloys and high-strength ceramics,
have been developed. Metal ceramic
crowns continue to be popular but have
esthetic disadvantages, including lack of
transparency, opacity, and the reection
of metal beneath the ceramic at the
cervical zone where the opaque and

ceramic layers are thinner.1,2 Another

disadvantage is the posttreatment diagnosis of abutment teeth.
The radiopacity of materials is related to their levels of absorption and
scattering of x-rays3 and thus has a
signicant effect on the accuracy of
conventional radiographic techniques.4
Because most metals have a high electron density, they are radiopaque in
conventional x-rays and in most other
types of radiographic images,5 which
makes it difcult to diagnose caries

at the crown level of abutment teeth

with light and dark streaks. These metal
artifacts increase in the presence of
greater numbers of metal objects and/
or units.6
In spite of the evolution of the materials and techniques used to fabricate
xed restorations, the need to remove
them still arises, and the most common
reason for their failure is recurrent
caries.7 The 10-year survival rate of
FDPs is between 89.1% and 92.0%.8-10
Dentists need a means of detecting

Assistant Professor, Department of Prosthodontics.

Assistant Professor, Department of Maxillofacial Radiology.
c
Assistant Professor, Department of Prosthodontics.
b

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Bilgin et al

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1365

1 Embedded tooth in arch form mold and positioned by

pouring wax.
caries underneath a xed restoration
without removing it, and cone beam
computed tomography (CBCT) may
represent an alternative radiographic
technique to conventional x-rays. Digital
radiography has been the most widely
used diagnostic technique for caries
detection.11 CBCT has a 2-dimensional
sensor with a cone-shaped beam instead of the fan-shaped x-ray beam used
for conventional computed tomography,12 and comparative studies have
been published with digital radiographic
techniques and conventional lm systems.13,14 In the current study, a CBCT
radiographic technique was used to
detect caries underneath metal ceramic,
lithium disilicate ceramic, and zirconia
ceramic crowns. The null hypothesis was
that the radiographic technique investigated would not detect caries underneath these specimens.

MATERIAL AND METHODS

A permanent mandibular right rst
molar tooth with grade 6 caries according to the International Caries Detection and Assessment System was
selected for use in this study. After the
extracted tooth had been cleaned and
the remaining soft and hard tissues were
removed, it was kept in distilled water
for 24 hours at 37 C. The tooth
was then embedded in a mold in the
form of a dental arch and was xed
by pouring wax (Cavex) and gypsum
(Shera Werkstoff Technologie) into the

Bilgin et al

2 Wax-lled caries cavity.

3 Fixed cast in denture scan apparatus.

mold to maintain clear visualization

(Figs. 1, 2).
The tooth was then prepared with a
shoulder marginal nishing line, and the
carious cavity was lled with wax to a
level in line with the preparation outline,
as if it were still a complete structure
(Fig. 2). Three impressions for each of
the specimens were made with a silicone
impression material (Elite HD; Zhermack
SPA) and sent to a dental technician
for the fabrication a lithium disilicate
ceramic crown, a yttria tetragonal zirconia polycrystal (Y-TZP)ebased zirconia
ceramic crown, and a cobalt (Co) chromium (Cr) metal ceramic crown.
The lithium disilicate (e max; Ivoclar
Vivadent AG) ceramic crown was built
up with ceramic powder (e max ceram;
Ivoclar Vivadent AG) and processed in
a furnace (Programat EP3000; Ivoclar

Vivadent AG). The substructure of the

zirconia restoration was shaped from a
Y-TZPebased block (Zirkon Ice; Zirconzahn GMBH) with a milling machine
(Shera Eco-Mill 5X; Shera Werkstoff
Technologie) and sintered in a ceramic
oven (Keramikofen 1500; Zirconzahn
GMBH). After sintering, ceramic powder
(Zenoex; Wieland DentalTechnik) was
used to complete the specimen. The
metal ceramic restorations metal substructure was built by dental direct metal
laser sintering with a dental direct metal
laser sintering machine (Dentaurum)
with Co-Cr nanopowder (Remanium star
CL, Dentaurum). Ceramic powder
(Reex Dimension; Wieland DentalTechnik) was used for the ceramic
structure.
The wax was removed from the
carious cavity by using hot water. Each

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Volume 112 Issue 6

4 A, Axial slice of metal ceramic crown. B, Coronal slice of metal ceramic crown. C, Sagittal slice of metal ceramic
crown. D, Axial slice of zirconia crown. E, Coronal slice of zirconia crown. F, Sagittal slice of zirconia crown.

specimen was placed on the natural

tooth, which was embedded in a plaster
cast, xed in a denture scan apparatus,
and scanned with a CBCT (NewTom
5G; QR) scanner to evaluate the carious
lesions (Fig. 3). CBCTs were made for
the 3 materials and the prepared tooth
without any restoration. Exposure parameters were kept constant before and
after the placement of the FDPs. An
88-cm eld of view was used in high-

resolution denture scan mode with 36

seconds scanning time and 7.3 seconds
exposure time. Tube potential and tube
current were automatically determined from scout views by the CBCT
machine. The axial slice thickness was
0.1 mm, with a pixel size of 0.1 mm. The
CBCT images of the specimens were
analyzed with software (NNT; NewTom
5G; QR) and a computer (Precision
T5400 workstation; Dell) (Fig. 4).

The Journal of Prosthetic Dentistry

Images of axial slices were evaluated

with photo editing software (Adobe
Photoshop CS3; Softonic International,
S.L.) to determine mean gray values
(MGV). For each image and by using the
photo editing software, 3 locations in
different parts of the carious region and
3 locations in the healthy dentin region,
each 0.2 cm in width and 0.2 cm
in height, were chosen to evaluate
radiopacity. The MGV of each location

Bilgin et al

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1367

4 (continued) G, Axial slice of lithium disilicate crown. H, Coronal slice of lithium disilicate crown. I, Sagittal slice of lithium
disilicate crown. J, Axial slice of teeth without any restoration. K, Coronal slice of teeth without any restoration. L, Sagittal
slice of teeth without any restoration.

was recorded for each group. The

Kolmogorov-Smirnov test was used
to determine the homogeneity of the
data. Because the test showed
normality (P>.05), the data obtained
were analyzed statistically by 2-way
ANOVA. Multivariate comparison
(Tukey) was performed for material
differences between caries and dentin,
and the independent samples t test
was performed for MGV differences

Bilgin et al

between caries and dentin for each

material.

RESULTS
The means (standard deviations) of
the MGVs are shown in Table I. Twoway ANOVA detected signicant differences with respect to materials,
location, and interaction between
these 2 factors (P<.001) (Table II). The

prepared tooth with no restoration

exhibited the lowest radiopacity, and
the zirconia specimen exhibited the
highest for the caries region (Figs. 4, 5).
MGVs statistically differed signicantly
among all materials, together with the
prepared tooth for the caries region
(Table III). For the healthy dentin
region, the MGVs of the prepared
tooth alone differed signicantly from
those of the tooth with the metal

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Volume 112 Issue 6

Table I.

Mean gray values of the materials tested

Caries
Material

(mean SD)

(mean SD)

123.39 4.12

25.29 0.57

144.04 2.46

Prepared teeth
Lithium disilicate

Dentin

Zirconia

69.36 1.50

140.9 1.15

Metal ceramic

37.39 1.76

106.39 2.27

Between groups
P
<.001
<.001
<.001
<.001

SD, standard deviation.

*P < .001.

Table II.

Two-way ANOVA between subjects and effects

Source

Type III Sum of Squares

df

Mean Square

Sig.

Corrected Model

65114 319a

9302 046

2106 034

<.001

Intercept

156870 021

156870 021

35516 233

<.001

Material

6307 021

2102 340

475 981

<.001

Location

54915 537

54915 537

12433 179

<.001

material  location

3891 762

1297 254

293 705

<.001

4 417

Error

70 670

16

Total

222055 010

24

Corrected Total

65184 988

23

Table III.

Tukey test shows material differences

Subset
Material

Prepared teeth

61.6967

Metal ceramic

Lithium disilicate

Zirconia

DISCUSSION
No research has been published
that investigated the possibility of detecting different types of caries under
different types of xed restorations
with CBCT. In the present study,

71.8933
84.6683
105.1300

Sig.

ceramic restoration (P<.001) but not

the lithium disilicate and zirconia
(P.526). A signicant difference was
found between caries and dentin MGVs
for all situations, including the restoration materials and prepared teeth
without restoration (Table I, Fig. 4).

1.000

1.000

ceramic restorations of lithium disilicate and zirconia were assessed and

compared with a metal ceramic crown.
Murat et al12 prepared specimens to
imitate caries cavitation at the cervical
third under different restorations of
composite resin, amalgam, complete
metal crown, and thermoplastic polymer. In the present study, a human
tooth with caries that extended to
dentin, including the pulp cavity and
cavity walls all along the cervical, middle, and occlusal third of the crown,
was used to evaluate whether the
detection of caries with borders was

The Journal of Prosthetic Dentistry

1.000

1.000

possible in all 3 segments of the tooth,

with different opacities and under
different crown systems.
Nummikoski et al4 noted that the
radiopacity of restorative materials,
which depends on the atomic number,
has a primary effect on the ability to
detect caries in the cervical zone. The
current study showed that, with developing digital radiographic techniques,
the middle and occlusal third of the
tooth under a xed restoration could
be diagnosed in addition to the cervical
zone. A previous study showed that the
greater opacity of Y-TZPebased zirconia

Bilgin et al

December 2014

80

1369
Prepared teeth

Lithium disilicate

Metal ceramic

Zirconia

70
60
50
40
30
20
10
0

MGV
5 Radiopacities of materials and prepared
tooth (mean gray values).

restorations is a consequence of the

presence of yttrium and zirconium
because their atomic numbers are 39 and
40.3 In the present study, it was also
conrmed that the zirconia crown had
greater opacity than the lithium
disilicate crown or the metal ceramic
crown. However, the signicance of
the difference between caries and healthy
dentin regions was borderline (P.05).
Metal artifacts and image degradation
(as light streaks) increase with the
number of metal restorations in the oral
cavity.6,12 However, although metal restorations hinder the visualization of caries
under xed restorations, the present
study showed that caries under all 3 types
of restorations can be detected and
characterized, including all the relevant
details of the remineralized tissue of the
cavity walls along the structure.
One of the limitations of this study
was that as it was a pilot study, with
only a single crown evaluated for CBCT
diagnosis. Future studies should evaluate CBCT for the detection of caries
by using a greater number of metal
units (retainers, connectors, and pontics). Another limitation was that it was
an in vitro study, and it was not
possible to imitate oral uids, soft and

Bilgin et al

hard tissues, and surrounding dental

anatomic structures, all of which affect
radiopacity. In addition, no cement was
used to lute the specimens, and cement
may affect radiopacity values.

CONCLUSIONS
CBCT images enabled the detection
of caries under the crowns of all 3 specimens investigated. CBCT can be used as
a posttreatment diagnostic technique
under crowns and FDPs. Further studies
with larger sample sizes and different
tooth groups are needed.

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Corresponding author:
Dr Osman Sami Aglarci
Sifa University
Ankara Cad. No: 45 35100 Bornova
Izmir
TURKEY
E-mail: aglarci@gmail.com
Copyright 2014 by the Editorial Council for
The Journal of Prosthetic Dentistry.