ABSTRACT
Objective:
This study aimed to evaluate the effect of various sugary drinks and a denture cleanser on the color stability and surface roughness of two tested denture teeth materials (3D printed and CAD/CAM milled).
Materials and Methods:
CAD/CAM additive and subtractive techniques were used to fabricate 160 custom disc-shaped specimens from two commercially available denture teeth resins. Specimens were randomly divided into 16 groups (n = 10) based on the immersion media used: a control group (artificial salivary substitute), sugary drinks groups (Pepsi, Gatorade, and ice tea), and denture cleanser groups after exposure to sugary drinks. These immersion cycles were repeated for 180 days, and the changes in color and surface roughness measurements were recorded. The data related to change in color and surface roughness was tabulated, and the statistical analysis was performed.
Results:
When exposed to sugary drinks, the change in color for both milled and 3D-printed materials was maximum when tested specimens were exposed to ice tea (ΔE = 3.548 and 4.055), followed by a carbonated drink (Pepsi) (ΔE = 2.334 and 3.503) and sports drink (Gatorade) (ΔE = 1.272 and 1.443), respectively. Whereas the change in surface roughness was highest after exposure to carbonated drink (ΔRa = 0.052 μm and 0.074 μm), followed by ice tea (ΔRa = 0.043 μm and 0.061 μm) and sports drink (ΔRa = 0.039 μm and 0.049 μm) for milled and 3D-printed materials, respectively.
Conclusion:
The 3D-printed denture tooth resins have poor color stability and are prone to more changes in surface roughness when exposed to different sugary drinks as compared to CAD/CAM milled denture teeth.
KEYWORDS: CAD–CAM, color stability, complete dentures, denture cleansers, denture teeth, subtractive manufacturing, sugary drinks, surface roughness, 3D-printing
INTRODUCTION
With the advent of new technologies and materials in the dental field, dentists have transformed the ways of providing high-quality treatments to patients.[1] The amalgamation of knowledge, proficiency, modern materials, and advanced technical tools has considerably improved the treatment outcomes.[2] Dentists can provide such high-quality treatments in a shorter duration of time. CAD/CAM milling technology is utilized for the fabrication of dental prostheses and demonstrates a high success rate. This technique has led to the fabrication of prostheses with accuracy, meeting high standards.[3,4] The advantage of CAD/CAM milled materials is their superior mechanical and surface properties.[4] Another technology commonly used nowadays for manufacturing prostheses is 3D printing which is an additive process. This technique involves printing structures in layers.[5,6] In addition to various advantages of subtractive manufacturing, additive manufacturing saves the material and therefore reduces the overall cost of manufacturing.[7] These prostheses have shown high success and excellent physical and mechanical properties.[3,4,5,6,7]
Conventional complete dentures are made using the compression molding technique, which has its inherent disadvantage of incorporating errors during denture processing.[8] The implementation of CAD/CAM technology effectively eliminates many problems associated with conventional denture construction.[3,4,5,6,7]
These denture materials are exposed to various food products the patients consume, which may alter some of their physical and mechanical properties in the long run. As per the published data, a good percentage of older people consume sugary drinks daily.[9] This high consumption may be related to the inability of older people to consume solid food products adequately due to poor masticatory ability. As per the reports, the most commonly consumed sugary drinks by people above the age of 50 years are carbonated drinks, followed by fruit drinks, coffee, tea, sports drinks, and energy drinks.[9] These drinks are acidic in nature and contain various pigments that may affect the color and surface roughness of dentures. Change in the color of the denture teeth may instill a negative impact on the patient, who may doubt the dentist’s treatment and serviceability of the denture.[10]
Denture cleansers are commonly prescribed and are effective for routine cleaning of the dentures. These denture cleansers have carbonates and peroxides as active ingredients, which help in cleaning action.[11,12] Studies have reported that these cleansers have the potential to bring changes in color and surface roughness of these materials. So, for dentures to be successful, the denture teeth materials should exhibit superior physical properties to prevent patent dissatisfaction.[11,12]
There are no published studies that provide information related to the influence of sugary drinks and denture cleansers on denture teeth fabricated using 3D printing and CAD/CAM milling techniques. Thus, the present study aims to evaluate the influence of various sugary drinks and a denture cleanser on the color and surface roughness of tested denture teeth materials (3D printed and CAD/CAM milled). The tested null hypothesis is that there is no difference in color stability and surface roughness of the two tested denture teeth materials (3D printed and CAD/CAM milled) after exposure to different sugary drinks and denture cleansers.
MATERIALS AND METHODS
Materials
Custom disc-shaped specimens were fabricated using CAD/CAM additive and subtractive techniques from two commercially available denture teeth resins. These discs were exposed to different immersion media, followed by a denture cleanser solution. Alteration of color and surface roughness was assessed.
Specimen designing and fabrication
One hundred and sixty disc-shaped specimens (10 mm diameter and 2 mm height) were manufactured using two techniques: CAD/CAM additive (n = 80); CAD/CAM subtractive (n = 80). The sample size was determined using a software program (G * Power) after taking into consideration the results of the pilot study (n = 3, per group).
CAD software (Microsoft 3D builder) was utilized to design the specimens virtually. For the CAD/CAM milling, the Opera Pro-Expert-5 milling machine was used to mill the Telio CAD PMMA disc using the stereolithography file (STL), to obtain 80 disc-shaped specimens. For the CAD/CAM additive group, the same STL file was uploaded to the slicing software (CHITUBOX). The printer employed in the study was a direct light processing (DLP) 3D printer (NextDent™ 5100). The printer was set to a layer thickness of 50 μm, with the printing direction at 45°. The specimens were cleaned in an ultrasonic bath and were later polymerized as per manufacturer’s guidelines [Figure 1].
Figure 1.
(a-f) Steps involved in fabrication of CAD/CAM milled and 3D-printed denture tooth specimens
Specimens were finished and polished using wet abrasive silicon carbide discs (P1500, P2500, and P4000 grits) and polishing paste. Specimens were cleaned ultrasonically and were inspected using dental loupes. Specimens with surface defects were replaced with new ones. A straight fissure bur mounted on a low-speed handpiece was used to mark coding on the unpolished surface of each specimen. Single-trained operator was performed all the procedures.
Initial color and surface roughness testing
To measure the change in color, we utilized the CIE L * a * b* color space before and after the immersion procedure. To record the color coordinates, colorimeter (CS-10) was configured based on manufacturer’s guidelines. All the recordings were made by placing the specimen against a standard white background to prevent possible absorption effects on the evaluated parameters.[13] Three readings from the center of each specimen were averaged to determine its initial color. Initial surface roughness was recorded for the polished surface of each specimen using a 3D optical non-contact surface profiler. The average of three readings recorded from each specimen’s center was considered as initial surface roughness Ra (μm).
Immersion protocol
Specimens fabricated by each technique were randomly divided into 16 groups (n = 10) using MS Excel, based on the immersion media used: A control group (artificial salivary substitute), sugary drinks groups (Pepsi, Gatorade, and ice tea), and denture cleanser groups after exposure to sugary drinks. This random allocation was kept confidential from the data analyst and researchers involved in assessing the result. Details of each subgroup are mentioned in Table 1.
Table 1.
Details of various groups
| Group | Fabrication technique and immersion media | n |
|---|---|---|
| Group 1 | Milled + Artificial salivary substitute | 10 |
| Group 2 | Milled + Pepsi | 10 |
| Group 3 | Milled + Ice tea | 10 |
| Group 4 | Milled + Sport drink | 10 |
| Group 5 | 3D printed + Artificial salivary substitute | 10 |
| Group 6 | 3D printed + Pepsi | 10 |
| Group 7 | 3D printed + Ice tea | 10 |
| Group 8 | 3D printed + Sport drink | 10 |
| Group 9 | Milled + Artificial salivary substitute + Denture cleanser | 10 |
| Group 10 | Milled + Pepsi + Denture cleanser | 10 |
| Group 11 | Milled + Ice tea + Denture cleanser | 10 |
| Group 12 | Milled + Sport drink + Denture cleanser | 10 |
| Group 13 | 3D printed + Artificial salivary substitute + Denture cleanser | 10 |
| Group 14 | 3D printed + Pepsi + Denture cleanser | 10 |
| Group 15 | 3D printed + Ice tea + Denture cleanser | 10 |
| Group 16 | 3D printed + Sport drink + Denture cleanser | 10 |
| Total | 160 |
Specimens of Groups 1 to 8 were immersed in the tested solution for 15 minutes daily. Subsequently, specimens were rinsed in running water and kept in distilled water in an incubator at 37°C for the remainder of the day. The artificial salivary substitute was fabricated in the Substance Abuse and Toxicology Research Centre, Jazan University. A total of 20 mL of each sugary drink is used to immerse each specimen at room temperature (27 ± 2°C). A fresh container of each sugary drink was used every day. Specimens in Groups 9 to 16 were immersed for 15 minutes in tested solutions daily. Later, they were rinsed with water and kept in a denture cleanser solution for 5 minutes. For making denture cleanser solution, the manufacturer’s guidelines were followed (One tablet is dissolved in 250 mL of warm water 40°C).[12,14] Later, the specimens were washed and stored in distilled water for the rest of the day in an incubator at 37°C. These immersion cycles were repeated for 180 days for all the groups thus simulating denture teeth use and cleaning with denture cleanser by the patient.[12]
Final color and surface roughness testing
After the immersion cycles, the final color and surface roughness measurements were recorded using the same protocols as the initial ones. For calculating the change in color (ΔE), the formula Equation (1) used was as follows:
ΔE = [(ΔL*)2 + (Δa*)2 + (Δb*)2]1/2 (1)
ΔL*, Δa*, and Δb* are the differences in L*, a*, and b* values, measured before and after immersion. L*, a*, and b* represent the color’s lightness, red/green intensity, and yellow/blue intensity, respectively.
For calculating the change in surface roughness (ΔRa), the formula Equation (2) was used as follows:
ΔRa = Raf – Rai (2)
Rai and Raf measure the surface roughness values before and after immersion. One trained operator conducted all the measurements without knowing the specimen allocation.
Data analysis
Tabulation of the data was performed using the Microsoft Excel spreadsheet. Statistical analysis was performed using SPSS version 24.0. Data analysis was conducted using ANOVA and the t-test, followed by post-analysis with the Bonferroni test.
RESULTS
Descriptive statistics discussing the mean variation in color and surface roughness of specimens after exposure to sugary drinks and denture cleansers were presented in Table 2 and Figures 2 and 3. When exposed to sugary drinks, the change in color for both milled and 3D-printed materials was maximum when tested specimens were exposed to ice tea (ΔE = 3.548 and 4.055), followed by carbonated drink (Pepsi) (ΔE = 2.334 and 3.503) and sports drink (Gatorade) (ΔE = 1.272 and 1.443), respectively, whereas the change in surface roughness was highest after exposure to carbonated drink (Pepsi) (ΔRa = 0.052 μm and 0.074 μm), followed by ice tea (ΔRa = 0.043 μm and 0.061 μm) and sports drink (Gatorade) (ΔRa = 0.039 μm and 0.049 μm) for milled and 3D-printed materials, respectively. The changes in color and surface roughness were found to be statistically significant.
Table 2.
Mean change in color (ΔE) and surface roughness (ΔRa) among the tested groups
| Group | Mean change in color (ΔE) | Change in surface roughness (ΔRa) (μm) | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|
|
|
|
|||||||||
| n | Mean | SD | 95% confidence interval for mean | n | Mean | SD | 95% confidence interval for mean | |||
|
|
|
|||||||||
| Lower bound | Upper bound | Lower bound | Upper bound | |||||||
| Group 1 – milled and artificial saliva | 10 | 0.403 | 0.000 | 0.403 | 0.403 | 10 | −0.002 | 0.001 | −0.003 | −0.001 |
| Group 2 – milled and Pepsi | 10 | 2.334 | 0.241 | 2.162 | 2.506 | 10 | 0.052 | 0.007 | 0.047 | 0.057 |
| Group 3 – milled and ice tea | 10 | 3.548 | 0.173 | 3.425 | 3.672 | 10 | 0.043 | 0.004 | 0.040 | 0.046 |
| Group 4 – milled and gatorade | 10 | 1.272 | 0.098 | 1.202 | 1.343 | 10 | 0.039 | 0.004 | 0.036 | 0.041 |
| Group 5 – print and artificial saliva | 10 | 0.506 | 0.009 | 0.499 | 0.513 | 10 | −0.003 | 0.001 | −0.004 | −0.001 |
| Group 6 – print and Pepsi | 10 | 3.503 | 0.131 | 3.409 | 3.597 | 10 | 0.074 | 0.009 | 0.067 | 0.080 |
| Group 7 – print and ice tea | 10 | 4.055 | 0.104 | 3.980 | 4.129 | 10 | 0.061 | 0.003 | 0.058 | 0.063 |
| Group 8 – print and gatorade | 10 | 1.443 | 0.081 | 1.385 | 1.500 | 10 | 0.049 | 0.005 | 0.046 | 0.053 |
| Group 9 – milled and artificial saliva and denture cleanser | 10 | 0.282 | 0.024 | 0.264 | 0.299 | 10 | 0.036 | 0.003 | 0.034 | 0.038 |
| Group 10 – milled and Pepsi and denture cleanser | 10 | 0.715 | 0.032 | 0.692 | 0.738 | 10 | 0.115 | 0.005 | 0.112 | 0.118 |
| Group 11 – milled and ice tea and denture cleanser | 10 | 1.018 | 0.049 | 0.983 | 1.054 | 10 | 0.106 | 0.005 | 0.103 | 0.109 |
| Group 12 – milled and gatorade and denture cleanser | 10 | 0.481 | 0.041 | 0.451 | 0.510 | 10 | 0.099 | 0.005 | 0.096 | 0.102 |
| Group 13 – print and artificial saliva and denture cleanser | 10 | 0.305 | 0.014 | 0.295 | 0.315 | 10 | 0.070 | 0.004 | 0.068 | 0.073 |
| Group 14 – print and Pepsi and denture cleanser | 10 | 1.131 | 0.128 | 1.039 | 1.223 | 10 | 0.192 | 0.004 | 0.189 | 0.195 |
| Group 15 – print and ice tea and denture cleanser | 10 | 1.539 | 0.1096 | 1.461 | 1.618 | 10 | 0.166 | 0.004 | 0.164 | 0.169 |
| Group 16 – print and Gatorade and denture cleanser | 10 | 0.566 | 0.0453 | 0.534 | 0.598 | 10 | 0.157 | 0.0039 | 0.155 | 0.160 |
| ANOVA | P<0.001 | |||||||||
SD: standard deviation
Figure 2.
Comparison of mean change in the color of milled and 3D-printed specimens
Figure 3.
Comparison of mean change in the surface roughness of milled and 3D-printed specimens
Multiple comparisons were performed between the groups using the Bonferroni post hoc test regarding the alteration in color and surface roughness of materials after exposure to sugary drinks. A statistically significant (P < 0.05) relation was observed in most of the tested groups. t-test was used to compare the change in color and surface roughness of tested materials with and without immersion in denture cleansers. There were significant differences (P < 0.001) between the two groups. Tested materials displayed higher changes in surface roughness and lower changes in color when exposed to denture cleansers as compared to non-denture cleanser groups [Table 3 and Figures 4 and 5].
Table 3.
Comparison of effect of denture cleansers on change in color and surface roughness using t-test
| n | Mean | Std. deviation | Std. error | P value | |
|---|---|---|---|---|---|
| Mean change in color (ΔE) | |||||
| No denture cleanser | 80 | 2.1330 | 1.35901 | 0.15194 | t-test: P<0.001 |
| Denture cleanser | 80 | 0.7546 | 0.42085 | 0.04705 | |
| Mean change in surface roughness (ΔRa) | |||||
| No denture cleanser | 80 | 0.0391 | 0.02651 | 0.00296 | |
| Denture cleanser | 80 | 0.1178 | 0.04906 | 0.00548 |
Figure 4.
Comparison of effect of immersion in denture cleansers on change in color of tested materials
Figure 5.
Comparison of effect of immersion in denture cleansers on change in surface roughness of tested materials
DISCUSSION
The current research assessed the effect of sugary drinks and denture cleansers on the color stability and surface roughness of denture teeth fabricated by CAD/CAM milling and 3D printing techniques. The tested null hypothesis was rejected as significant alterations in color, and surface roughness was detected when tested resins were exposed to sugary drinks alone and along with denture cleansers.
Color stability and surface smoothness are important properties when selecting a material for fabricating a dental prosthesis in esthetic zones. Denture teeth replace missing natural teeth and are important for esthetics. Any noticeable change in their color will affect the patient’s assessment of the denture’s serviceability and longevity.
Exposure to sugary drinks can cause extrinsic staining of the denture teeth due to the absorption and adsorption of the staining agents present in these drinks. The amount of extrinsic stains that will get deposited on the surface of the specimen is associated with the degradation and solubility of its surface.[12,13,14]
The current study used a colorimeter, an objective method that provides numerical data to evaluate the properties of color effectively. Classical CIE L * a * b * color space was used to calculate the change in color (ΔE). Different studies have reported varying values for clinically perceptible range for color change (ΔE).[15,16] Studies have also reported that sensitivity in perception also varied according to the evaluator. For the current study, ΔE > 3.7 was considered to be clinically perceptible or relevant.[16]
The current study selected four commonly consumed sugary drinks.[9] The samples were kept in the solution for 15 minutes every day for 180 days, assuming that exposure to these sugary drinks is for an average of 5–10 minutes twice daily. Overall, 3D-printed denture tooth resins have displayed higher changes in color than CAD/CAM milled denture tooth resins. The highest changes were observed when specimens of both the tested materials were immersed in ice tea (ΔE 3D printed: 4.5, DE CAD/CAM milled: 3.55), followed by Pepsi (ΔE 3D printed: 3.5, ΔE CAD/CAM milled: 2.33), whereas control group displayed the least change in color. High discoloration after immersion in ice tea might be due to a higher percentage of yellow color pigments, the molecular size of the pigments, and their chemical composition. Although Pepsi has a more acidic pH (pH of Pepsi: 2.5, pH of ice tea: 3.1) as compared to ice tea, but it ranked second in causing discoloration.[17,18]
Our results are in agreement with the results of studies conducted by Shim et al.[18] and Tasin et al.,[19] who evaluated the stainability of 3D printed and CAM/CAM milled resin materials after exposure to different staining liquids. The high stainability of 3D-printed resins could be due to several factors. Compared to 3D-printed resins, CAD/CAM milled resins are denser as they are highly cross-linked and undergo industrial-grade processing.[20,21] Secondly, the monomers used in 3D-printed resins are hydrophilic in nature when compared to hydrophobic monomers in CAD/CAM milled PMMA resins.[20,21,22,23] Some other factors that make 3D-printed resins more prone to discoloration include their high solubility,[18] the presence of a non-polymerized layer on the surface high water sorption, and the presence of layers on the surface microstructure.[16]
In the present research, significant color changes were observed in stained specimens immersed in denture cleansing solutions. The changes in color differed according to the staining solution and type of resin material tested. Denture cleanser effectively reduced the color change for all the tested resins. These values were well below the clinically perceptible limits. Our results were in agreement with the previously published studies, which reported similar results when denture cleansers were used on other materials.[24,25]
Another important property evaluated in the current research is the alteration in surface roughness of the specimens. The rough surface of the prosthesis can lead to easy accumulation of plaque and food elements. Thus, it is vital that prosthetic material undergo minimal changes in surface roughness. Regarding the effect of sugary drinks and denture cleansers on surface roughness, overall 3D-printed denture tooth resins have displayed higher changes in surface roughness when compared to CAD/CAM milled denture tooth resins. The highest changes were observed when specimens of both the tested materials were exposed to Pepsi and denture cleansers (ΔRa 3D printed: 0.192, ΔRa CAD/CAM milled: 0.052), followed by ice tea and denture cleansers (ΔRa 3D printed: 0.166, ΔRa CAD/CAM milled: 0.043), whereas control group displayed the least change in surface roughness. For all the tested groups, the values were below the acceptable threshold of 0.2 μm.[26] Higher change in surface roughness after immersion in a carbonated soft drink (Pepsi) may be attributed to its acidic pH (2.5) when compared to other tested sugary drinks. In general, immersion of specimens in denture cleansers had an additive effect on increasing the surface roughness of the tested specimens. For all the tested groups, change in surface roughness values was higher for groups immersed in denture cleansers than non-denture cleansers groups. As the authors could not find any study comparing the effect of denture cleansers on tested denture teeth materials, it is not feasible to precisely compare our study outcomes with other studies. Previously published studies have varied results on the effect of denture cleansers on the surface roughness of tested materials. Studies by Polychronakis et al.[27] and Jain et al.[12] reported an increase in surface roughness when tested denture resins were exposed to denture cleansers. In contrast, studies by Ma et al.[28] and Davi et al.[29] reported non-significant changes in surface roughness. Differences in the composition and degree of crosslinking may be the primary factor for variation in change in surface roughness of 3D printed and CAD/CAM milled specimens.[18,19]
The primary limitation of this study is its in vitro nature. It is not possible to create the same atmosphere as for patient study, and the effect of other confounding factors cannot be simulated and evaluated. Additionally, the study period was limited to immersion for 180 days only. More clinical studies with longer durations using a variety of denture cleansers should be conducted in future.
CONCLUSIONS
Within the limitations of the study, it can be concluded that as follows:
The 3D-printed denture tooth resins have poor color stability and are prone to more changes in surface roughness when exposed to different sugary drinks.
The maximum change in color was with the ice tea drink, while the carbonated drink (Pepsi) caused the maximum change in surface roughness of all the tested specimens.
Denture cleansers effectively reduce are effective in reducing the discolorations caused by the tested sugary drinks but can lead to an additional increase in the surface roughness of these denture teeth materials.
Ethical approval
The research protocol used in this study was approved by the scientific research committee at the College of Dentistry, Jazan University (Reference number: CODJU-2106I).
Conflicts of interest
The authors confirm that there is no conflict of interest related to the manuscript.
Data availability statement
The data that support the findings of this study are available from the corresponding author on special request.
Funding Statement
None.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author on special request.