Keywords
CAD/CAM - 3D printing - denture base resin - surface properties -
Candida albicans
- denture stomatitis
Introduction
Polymethyl methacrylate (PMMA) resin was proven satisfactory for the fabrication of
removable dentures due to its mechanical, optical, aesthetic, and biological characteristics.[1]
[2] However, low surface hardness, porosities, surface roughness, and contact angles
could enhance microbial adhesion.[2] Thus, epidemiological studies report a 70% prevalence of denture-associated stomatitis
in patients wearing removable prosthesis, with Candida albicans being the main pathogen.[3]
Candida adhesion to acrylic surface has been correlated with the surface properties (roughness
and hydrophobicity) of the material, the Candida species, and the surrounding environment.[4]
[5] The surface roughness of acrylic resin is dependent on many factors including the
material's structure, manufacturing process such as polymerization, and polishing
procedures.[6] Roughness and grooves on the resin specimen provide more hideout places for microorganisms
away from the normal cleaning process.[4]
Additionally, the microbial adhesion to a material is correlated to its surface hydrophobicity
and free energy.[7] The hydrophobic Candida easily adheres to hydrophobic resin surface. Therefore, increasing the hydrophilicity
and reducing contact angle could lower Candida adhesion.[4] Murat et al[8] described a significant positive association between surface roughness and Candida adhesion with no correlation between hydrophobicity and Candida adhesion. On the contrary, da Silva et al[1] stated that as the hydrophilicity of a denture base material is changed, microbial
colonization is altered. In addition to the impact of surface properties on Candida adhesion, the residual monomer that is released from denture base material over time
may lead to porosity formation and enhance the adhesion of Candida and biofilm formation thereafter.[9]
As surface properties play an essential role in Candida adhesion, altering these characteristics may make the dentures less prone to the
adhesion.[2] These alterations may comprise surface coating of the resin, chemical composition
modification, or the addition of fillers. All of these treatment modalities proved
effective in reducing Candida adhesion when contact angle and surface roughness were reduced.[4] A simpler approach may involve the use of computer-aided designing/computer-aided
manufacturing (CAD/CAM) PMMA as a substitute to heat polymerization. The manufacturing
technique of CAD/CAM milled PMMA creates a highly cross-linked structure that is less
porous with minimal residual monomer.[9] Additionally, milled dentures have a better fit, which reduces dead spaces under
the denture that acts as a Candida reservoir.[8]
[10]
On the other hand, dentures can be made utilizing the 3D-printing technology, where
they are virtually designed using CAD software and then 3D printed using the desired
resin material.[11] Nevertheless, this technology is relatively new to the removable prosthesis field
and has not been extensively investigated. Few studies evaluated the surface characteristics
of various kinds of denture base resins and reported conflicting results. Di Fiore
et al[12] reported insignificant differences between the surface roughness of heat-polymerized
(HP), milled, and 3D-printed denture base resins after regular polishing procedures,
while Gad et al[13] reported lower surface roughness of 3D-printed PMMA compared with HP resin. Other
studies reported significant differences in roughness and contact angle between various
types of 3D-printed resins and in comparison to milled or HP resins.[14]
[15]
The surface roughness and wettability might vary according to the brands of CAD/CAM
PMMA used.[16] Accordingly, the present study assessed the surface roughness, contact angle, and
C. albicans adhesion among different brands of CAD/CAM denture base resins manufactured by different
CAM technologies (milling and 3D printing) in relation to conventional HP denture
base resins. The study's null hypothesis stated that there will be no difference in
surface roughness, contact angles, and C. albicans adhesion between CAD/CAM and conventional HP denture base resins.
Materials and Methods
Sample Size Calculation and Test Groups
The sample size for this study was determined through power analysis. For this purpose,
the formula was adopted from the World Health Organization (WHO), keeping 0.05 as
the level of significance, power at 80%, and marginal error set at 5%, which demonstrated
the need for 10 specimens for each group to estimate the presumed effect size. The
total number of required specimens was 180 divided as follow; 60 specimens per tested
property with 10 specimens of each material. Rectangular acrylic specimens with dimension
of 10 × 12 × 2.5 mm were prepared from different resins: HP acrylic resin, prepolymerized
acrylic disks for milling, AvaDent and IvoCad and 3D-printed resins, ASIGA, FormLabs,
and Denture 3D+ (see [Table 1] for details).
Table 1
Materials used in the present study
|
Group
|
Material/equipment
|
|
Heat-polymerized acrylic resin
|
Major.Base.20, Major Prodotti Dentari, Moncalieri, Italy
|
|
AvaDent
|
AvaDent denture base puck (AvaDent, Global Dental Science Europe, Tilburg, the Netherlands)
|
|
IvoCad
|
IvoBase CAD (Ivoclar Vivadent, Schaan, Liechtenstein)
|
|
ASIGA
|
(Resin) ASIGA DentaBASE (Asiga pty Ltd, Alexandria, NSW, Australia)
(Printer) ASIGA MAX Printer (DLP)
|
|
FormLabs
|
(Resin) FormLabs Denture Base LP (FormLabs, Somerville, MA, United States)
(Printer) Form 2 Printer (SLA)
|
|
NextDent
|
(Resin) Denture 3D+ (NextDent B.V., Soesterberg, the Netherlands)
(Printer) NextDent 5100 3D Printer (SLA)
|
Fabrication of HP, Milled, and 3D-Printed Specimens
HP (control) acrylic resin specimens were fabricated by the use of conventional water
bath method as mentioned in an earlier study.[17] Investing of wax specimens in dental stone was done, followed by wax elimination.
Packing of acrylic resin mix was done at the dough phase following the application
of separating medium on stone surfaces. After that, processing of acrylic resin was
achieved in water bath polymerization unit (KaVo Elektrotechnisches Werk GmbH, Leutkirch,
Germany) at 73°C for 90 minutes, then at 100°C for an additional 30 minutes. Finishing
of specimens was accomplished by the use of tungsten carbide bur (HM 79GX-040 HP;
Meisinger, Centennial, CO, United States) to remove excess resin.
For both milled groups (AvaDent and IvoCad), prepolymerized PMMA pucks were cut to
the required dimensions, where each disk was positioned and fixed in precision cutting
machine (IsoMet 5000 Linear Precision Saw, Buehler, Lake Bluff, IL, United States)
and sliced using diamond disk under constant water coolant.[18]
For the printed specimens, the stereolithography (STL) file of the design was created
using an open software (123D design, Autodesk, version 2.2.14, San Francisco, California,
United States) and sent to each material's corresponding printer ([Table 1]). For ASIGA and NextDent resins, the resin containers were shaken for 30 minutes
and then poured into the resin tank, while for FormLabs, the resin tank was mounted
on the printer directly. The printing orientation of all specimens was set at 90 degrees
to the platform and 50-µm layer thickness. Following the printing procedure, the specimens
were immersed in 99.9% isopropyl alcohol (IPA) to remove uncured resin. To complete
the polymerization of printed specimens, additional postcuring cycle was done according
to manufacturer's recommendations. Specimens were placed in the glycerin path within
the postcuring machine.
All specimens (HP, milled, and 3D printed) were polished using 1,200-grit sandpaper
disks (MicroCut PSA; Buehler) by the use of a polishing machine (MetaServ 250 Grinder
Polisher, Buehler) in wet settings to ensure standardized polishing methods. A single
investigator performed the polishing procedure of all the specimens and reassessed
the specimens' dimensions to 0.01-µm accuracy using a digital caliber. Specimens with
acceptable dimensions were incubated in distilled water at 37°C for 48 hours before
assessing the desired properties.
Measurement of Surface Roughness and Contact Angle
A noncontact optical interferometric profilometer (Contour GT; Bruker Nano GmbH, Berlin,
Germany) was utilized in measuring the surface roughness (Ra
) of each specimen at five distant areas and 0.01-mm resolution. The average Ra
value per specimen was then calculated.[19]
An automated goniometer (DM-501; Kyowa Interface Science Co., Niiza-City, Saitama,
Japan) measured the contact angle (degrees) at four areas on each specimen followed
by mean value calculation per specimen. The sessile drop technique was followed using
an autopipette to dispense (2-μL) droplets of distilled water on the specimen's dry
surface. The images were interpreted using the FAMAS software (Kyowa Interface Science
Co.).[20]
Microbiological Analysis of the Biofilm
Frozen culture of C. albicans reference strain (ATCC 10231) was inoculated onto Sabouraud dextrose agar (SDA; MOLEQULE-ON,
New Lynn, Auckland, New Zealand) for 48 hours at 37°C. Isolated colonies were added
to Sabouraud dextrose broth (SDB; MOLEQULE-ON) for overnight incubation at 37°C and
then the broth was diluted and adjusted to approximately 00.5 McFarland (1 × 107 CFU/mL; DensiCHEK TM Plus, Durham, NC, United States).
The biofilm formation was evaluated using the protocol of colony-forming unit (CFU)
assay according to Gulati et al[21] with a slight modification. Briefly, after sterilization of specimens with 70% IPA,
each specimen was placed in 12-well cell culture plates (Nunclon Delta Surface, Thermo
Fisher Scientific, Roskilde, Denmark), and a volume of 1,000 µL of the adjusted yeast
suspension was added to each well and incubated at 37°C for 48 hours. To remove nonadherent
cells, the specimens were washed three times with phosphate buffer saline (PBS), then
scraped and vortex for 2 minutes at 3,000 rpm to dislodge the adherent cells from
the specimens.[22]
[23]
[24] To enumerate CFU count, 10-fold dilution in PBS was performed, before a volume of
100 µL was directly platted onto SDA plates and incubated at 30°C for 48 hours. The
experiment was performed blindly in triplicates with positive and negative controls
to ensure reproducibility.[25]
[26]
[27]
Statistical Analysis
The normality of the data was evaluated using the Shapiro–Wilk test and p-values greater than 0.05 indicated that the data were normally distributed. Comparison
of means between the groups (HP, AvaDent, IvoCad, ASIGA, FormLabs, and NextDent) for
each tested property was done using one-way analysis of variance (ANOVA). Significant
ANOVA results necessitated the use of Tukey's post hoc test to identify the pairwise
differences. Pearson's correlation analysis was used to correlate C. albicans adhesion and related surface parameters. Statistical package for social science (SPSS,
IBM, New York, United States) version 24 was used for statistical analysis and p-values ≤0.05 were considered statistically significant.
Results
[Table 2] presents the means, standard deviations, and significance of surface roughness (Ra
, µm) between tested materials. ANOVA results for Ra
exhibited a significant difference between the groups (p = 0.001). For pairwise comparisons, no significant differences in surface roughness
were found between any of the groups except with NextDent, which showed the highest
Ra
value (1.68 ± 0.22 µm) among the groups (p < 0.05), whereas ASIGA showed the lowest Ra
value (0.92 ± 0.23 µm).
Table 2
Mean, SD, and significances between groups for all tested properties
|
HP
|
AvaDent
|
IvoCad
|
ASIGA
|
FormLabs
|
NextDent
|
p-value
|
|
Mean ± SD
|
Mean ± SD
|
Mean ± SD
|
Mean ± SD
|
Mean ± SD
|
Mean ± SD
|
|
Ra
(µm)
|
1.09 ± 0.16[a]
|
1.28 ± 0.41[a]
|
1.15 ± 0.12[a]
|
0.92 ± 0.23[a]
|
1.23 ± 0.33[a]
|
1.68 ± 0.22
|
F = 9.931
p = 0.001[b]
|
|
Contact angle (degrees)
|
79.44 ± 3.84[a]
|
70.01 ± 2.61[c]
|
72.4 ± 3.74[c]
|
81.63 ± 3.13[a]
|
80.62 ± 8.35[a]
|
89.91 ± 3.61
|
F = 23.709
p = 0.001[b]
|
|
Candida count (log10 CFU/mL)[d]
|
4.22 ± 0.166
|
4.14 ± 0.089
|
4.11 ± 0.101
|
4.21 ± 0.118
|
4.21 ± 0.066
|
4.27 ± 0.203
|
F = 1.897
p = 0.110
|
Abbreviations: CFU, colony-forming unit; HP, heat-polymerized; SD, standard deviation.
a No statistical difference between the groups.
b Statistically significant at p = 0.05.
c No statistical difference between the groups.
d ANOVA (analysis of variance) results were not statistically significant; therefore,
post hoc was not performed.
For contact angle, the values are summarized in [Table 2], and representative images of contact angles are shown in [Fig. 1]. The ANOVA results showed significant differences between the materials (p = 0.001). For intergroup comparisons, NextDent significantly showed the highest contact
angle (89.91 ± 3.61 degrees; p = 0.001) among the groups. Compared with the control material (HP), the milled groups
(AvaDent/IvoCad) showed significantly lower contact angles (p = 0.001 and 0.015, respectively), while ASIGA and FormLabs showed no significant
differences (p = 0.895 and 0.992, respectively).
Fig. 1 Representative images of contact angle of all tested resins. (A) heat-polymerized (HP), (B) AvaDent, (C) IvoCad, (D) ASIGA, (E) FormLabs, and (F) NextDent.
The C. albicans colony counts per material are presented in [Table 2] and [Fig. 2]. The overall results showed that there was no significant difference in C. albicans count between all tested materials (p = 0.074). The highest CFU (log10 CFU/mL) count of C. albicans adhered to the NextDent-printed specimens (4.27 ± 0.203), while the lowest count
was recorded with IvoCad (4.11 ± 0.101).
Fig. 2 The colony forming unit assay of Candida albicans biofilm recovered from each tested group: (A) heat-polymerized (HP), (B) AvaDent, (C) IvoCad, (D) ASIGA, (E) FormLabs, and (F) NextDent.
[Table 3] displays the level of association between C. albicans count and tested surface parameters that were analyzed using Pearson's correlation.
The analysis showed that C. albicans count was not associated with surface roughness, but was significantly associated
with contact angle.
Table 3
Pearson's correlation among Candida adhesion and surface parameters
|
Candida count
|
Ra
|
Contact angle
|
|
Candida count
|
1
|
r = 0.492
p = 0.149
|
r = 0.825
p = 0.003[a]
|
|
Ra
|
|
1
|
r = 0.230
p = 0.523
|
|
Contact angle
|
|
|
1
|
a Significant at p = 0.05.
Discussion
The present study tested the surface roughness, contact angle, and C. albicans adhesion of HP denture base acrylic resin compared with the CAD/CAM counterparts
fabricated by milling or 3D-printing technologies. The study hypothesis was partly
rejected since the contact angle and surface roughness showed variation between the
tested denture base resins, while C. albicans adhesion showed no significant difference.
The results demonstrated no significant differences between the surface roughness
of HP, milled, and 3D-printed resins, except NextDent specimens, which showed the
highest value among all tested groups. Similarly, Di Fiore et al[12] found that HP and CAD/CAM denture base resins (milled and 3D printed) had similar
surface roughness after polishing, while the milled resin showed lower surface roughness
before polishing. Also, Al-Dwairi et al[15] mentioned that 3D-printed resins showed various surface properties between different
brands where ASIGA exhibited the lowest surface roughness among the studied 3D-printed
resins, which is in agreement with our results. In contrast, previous studies reported
lower surface roughness of milled and 3D-printed resins, in comparison to HP.[4]
[8]
[16]
[18] Also, Helal et al[14] and Alharethi[28] found lower surface roughness of milled resin compared with printed resins. Variation
in surface roughness results might be related to differences between the tested materials,
tested manufacturing techniques, or the polishing methods used in these studies. Also,
some studies did not compare between milled and 3D-printed resins,[15]
[16] or included only one type (brand) of denture base resin for each fabrication technique
(milling or 3D printing).[12] Murat et al[8] subjected the specimens to thermal cycling before testing the surface properties,
which could be the reason for the variation in results when compared with our findings.
In another study by Srinivasan et al,[29] milled (AvaDent) and printed (NextDent) resins exhibited comparable surface roughness,
which is in disagreement with the current study. This might be due to the difference
in polishing techniques, printing orientation, and layer thickness.
The type of printer, printing technologies, and printing resins were the variables
available among the three groups of 3D-printed specimens tested in the current study.
The printing technologies of the three printers used were as follows: the NextDent
and FormLabs printers were based on SLA, and the ASIGA printer was based on digital
light projection (DLP) technology. NextDent specimens exhibited higher surface roughness
than those of FormLabs and ASIGA. Since the printing parameters (layer thickness and
printing orientation) were similar in all 3D-printed groups, and the printing technology
of NextDent and FormLabs was the same (SLA), therefore the variation in surface roughness
might be related to other parameters and limitations within each printer or printing
material.
The contact angles of milled resins were significantly lower than those of HP and
3D-printed resins in the present study. However, Al-Dwairi et al[15]
[16] found that HP had a lower contact angle than milled and 3D-printed resins. Differences
in results could be related to the variations in the study designs and tested materials.
In addition, they compared the properties of milled and 3D-printed resins to HP resins
in two separate studies.[15]
[16] Comparison of contact angle results between our study and previously published research
was difficult due to the low number of studies testing contact angles of CAD/CAM materials.
C. albicans adhesion in the present study was not significantly affected by the manufacturing
technique, as there was no significant difference in Candida adherence to the surfaces of the tested materials. However, the lowest count was
found with milled CAD/CAM resins followed by printed resin, except NextDent specimens,
which showed higher Candida count than HP PMMA. A previous study[12] compared C. albicans adhesion between different CAD/CAM resins (milled and 3D printed) and HP PMMA after
16 hours of incubation and reported similar results. They demonstrated that the time
of incubation affected Candida adhesion. Increasing the incubation time resulted in microbial biofilm formation
and increased Candida adhesion independent of the surface roughness.[12] In the present study, the incubation time was 48 hours. This could explain the results
of no difference between the tested groups regarding C. albicans adhesion. Previous studies reported lower Candida adhesion on milled resin compared with HP resin after short incubation periods (90 minutes
and 2 hours) than the one followed in our study.[8]
[18] Also, the tested materials were different than those tested in the present study.
A recent report noted that the printing technology (SLA and DLP) does not influence
C. albicans adhesion to 3D-printed denture bases, supporting the results in the present study.[30] Shim et al[31] investigated the effect of printing orientation on Candida adhesion and found a significantly lower Candida count when a 90-degree orientation was used in comparison to 0 and 45 degrees. Accordingly,
the vertical printing orientation followed in our study might be the reason for no
differences of C. albicans adhesion among 3D-printed, HP, and milled resins, even in NextDent specimens, which
showed a significantly higher surface roughness.
The results of the present study showed that contact angle was significantly correlated
with C. albicans adhesion, while surface roughness showed no significant correlation. Milled resins
tested in this study had the lowest values of contact angle compared with HP and 3D-printed
resins. In addition, they also had the least number of C. albicans count but without significant difference compared with printed and HP resins. The
correlation between surface hydrophobicity and Candida adhesion has been confirmed previously.[4] It was demonstrated that a decrease in contact angle was associated with less Candida adhesion.[4] Murat et al[8] reported similar findings of lower contact angle and C. albicans adhesion with milled denture base resin than HP. However, contrary to our results,
they reported lower surface roughness of milled resin than HP, and significant correlation
between the increase in surface roughness and the number of attached C. albicans cells, while hydrophobicity (high contact angle) showed no correlation. Variation
in results might be related to differences in the tested materials, polishing techniques,
and then exposing the specimens to thermal cycling. Moreover, printed resins were
not evaluated in their study.
The findings of the current study presented no difference regarding C. albicans adhesion to CAD/CAM and HP denture base resins. However, the lowest count was found
with milled resins. High contact angle was significantly correlated with higher C. albicans adhesion, while surface roughness showed no significant correlation. In between printed
resins and compared with milled and HP resins, NextDent showed the highest surface
roughness and contact angle. However, other tested 3D-printed resins showed similar
properties to HP. Looking at the results of this study, the tested 3D-printed resins
could be used clinically for the construction of complete dentures with similar possibility
of C. albicans adhesion as HP and milled resins. Thus, incidence of denture stomatitis is expected
to be similar among denture base materials manufactured by conventional heat polymerization,
milling, or 3D-printing technologies. Based on the present results, the tested denture
base materials when used clinically for construction of denture bases would show comparable
adhesion of C. albicans irrespective to their method of fabrication (conventional, milled, and 3D printed).
However, the present findings should be interpreted with caution due to its in vitro nature. Exposure to artificial saliva with various pH affects the mechanical and
surface roughness of conventional and CAD/CAM denture base resins.[32] Therefore, clinical studies are required to support the present findings, after
exposing the tested materials to masticatory forces, oral flora, saliva, denture cleansing,
and food and beverages with varying temperatures.
The present study included more than one brand from each CAD/CAM manufacturing techniques,
in addition to the use of two printing technologies, SLA and DLP, which would add
validity to the results reported by each manufacturing technique. The biofilm assay
by determination of CFU is a common microbiological research technique; however, this
process is laborious, tedious, and time-consuming.[23] Future research should focus on studying the biofilm of C. albicans using other methods such as Cell Proliferation Assay Kits. This study is limited
as the effect of aging or denture cleaning routines on the tested properties was not
tested. Further investigations are required to test the effect of aging and beverage
consumption on different characteristics of CAD/CAM resins. The differences between
3D-printed resins tested in the present study require further investigations to understand
the factors causing these variations.
Conclusion
The adhesion of C. albicans to the surfaces of milled, 3D-printed, and HP denture base resins was similar; however,
the lowest count was found in milled resins. Surface roughness of milled and 3D-printed
resins was the same as that of HP, except NextDent, which showed the highest value.
Milled resins had significantly lower contact angles compared with other tested groups.
