Characterization of mode II-wear particles and cytokine response in a human macrophage-like cell culture.

Informations about wear particles in metallosis (mode II wear) and their effects in vitro and in vivo are limited. The aim of this study was to characterize wear particles obtained intraoperatively and to analyse their effects on cytokine response in an established human macrophage-like cell culture model. METHOD: Wear particles were obtained intraoperatively from four patients with metallosis resulting from CrCoMo/PE/TiAIV-implants (mode II wear) (3 knee, 1 hip prosthesis). After purification, particles were characterized regarding to their composition and size (particle size analyser, electron microscopy, edx-analysis, histological slices). The effects of particles on the release of cytokines (PDGF, IL-1beta, IL-8, TNF alpha) were determined in an established human macrophage-like cell culture system by ELISA-assays. RESULTS: The metal wear particles consisted of TiAIV with a mean size of 0.1 +/- 0.15 microm, independent of the prosthesis location. CrCoMo particles could not be detected. In the cell culture model 1456 x 10(8) particles per 1 x 10(6) macrophages released maximum amounts of TNFalpha (8-fold) and IL-8 and IL-1beta (5-fold) while the survival rate of the cells was more than 90 percent. A particle-dependent increase of PDGF-levels could not be detected. CONCLUSION: As already shown for mode I wear particles (contact between primary bearing surfaces), also mode II wear particles cause release of bone resorbing cytokines in a macrophage-like cell culture model. Because their local and systemic effects in vivo are still not completely understood, we recommend a complete removal of wear particles in cases of metallosis to avoid possible immunological reactions of the body as well as periprosthetic osteolysis.     

Wear Testing of Moderate Activities of Daily Living Using In Vivo Measured Knee Joint Loading

Resumption of daily living activities is a basic expectation for patients provided with total knee replacements. However, there is a lack of knowledge regarding the impact of different activities on the wear performance. In this study the wear performance under application of different daily activities has been analyzed. In vivo load data for walking, walking downstairs/upstairs, sitting down/standing up, and cycling (50 W & 120 W) has been standardized for wear testing. Wear testing of each activity was carried out on a knee wear simulator. Additionally, ISO walking was tested for reasons of comparison. Wear was assessed gravimetrically and wear particles were analyzed. In vivo walking produced the highest overall wear rates, which were determined to be three times higher than ISO walking. Moderate wear rates were determined for walking upstairs and downstairs. Low wear rates were determined for standing up/sitting down and cycling at power levels of 50 W and 120 W. The largest wear particles were observed for cycling. Walking based on in vivo data has been shown to be the most wear-relevant activity. Highly demanding activities (stair climbing) produced considerably less wear. Taking into account the expected number of loads, low-impact activities like cycling may have a greater impact on articular wear than highly demanding activities.     

Biological impact of polyacetal particles on loosening of isoelastic stems

The aim of our study was to identify biological factors responsible for premature loosening of polyacetal hip stems. The results of histological analyses of the tissue around 11 total hip prostheses with loosened polyacetal femoral stems were compared to those obtained in a group of 11 total hip prostheses with loosened metal (CoCr) femoral components. A higher number of polymer wear particles surrounded by giant cells, more bone chips, and a more extensive necrosis were found around loosened polyacetal stems. Histomorphological characteristics of polyacetal wear particles containing BaSO(4) granules in the tissue around loosened polyacetal stems were described. Radiological evaluation of the wear of polyethylene cups suggested that elastic modulus of the stem had no influence on the wear of polyethylene cups. This study indicates that polyacetal wear particles have a great biological potential accelerating the process of loosening.     

Identification of wear particles of joint prostheses in tissues using laser microprobe mass analysis (LAMMA)]

The definite identification of wear particles from joint prostheses is of great importance for the development of joint replacement, as the type and quantity of different wear particles gives information on the wear resistance of implant materials. From the types of prostheses nowadays in use polyethylene wear of the sockets, bone cement wear, metallic and ceramic wear can be generated. Whereas polyethylene wear can be easily identified by its bright luminescence in polarized light and its characteristic configuration, the distinction of the small granular wear particles of the bone cement, metal and ceramic by light microscope is difficult. The laser microprobe mass analysis (LAMMA) is a method, which allows the analysis of single light microscopically detectable wear particles in tissues. Not only contrast medium particles of the bone cements (zirconium oxide or barium sulfate) but also metallic and aluminum oxide particles could be definitely identified within the pseudocapsules as well as in regional lymph nodes by LAMMA-analysis, whereby the bone cement wear predominated. In addition, the distinction between organic substances (as blood degradation products), which may appear similar to wear particles in configuration and colour, and the foreign material is also possible with this method.     

A novel low wearing differential hardness, ceramic-on-metal hip joint prosthesis

Osteolysis and loosening of artificial joints caused by polyethylene wear debris has prompted renewed interest in alternative bearing materials for hip prosthesis designs. Lower wearing metal-on-metal (MOM) and ceramic-on-ceramic prostheses are being used more extensively, and there is considerable interest in further improving on their performance. This study investigated the wear properties and debris morphology of a novel differential hardness ceramic-on-metal (COM) prosthesis, in comparison with MOM articulations in a physiological anatomical hip joint simulator.The COM pairings were found to have wear rates approximately 100-fold lower than the MOM pairings. The MOM pairings showed a higher "bedding in" wear rate (3.09+/-0.46mm(3)/10(6) cycles) in the first million cycles, which then reduced to a steady state wear rate of 1.23+/-0.5mm(3)/10(6) cycles. The wear rate of the COM pairings over the duration of the test was approximately 0.01mm(3)/10(6) cycles with very little wear detected on the surface of the prosthesis components.The wear particles from both articulations were oval to round in shape and in the nanometer size range. After one million cycles the mean maximum diameter of the MOM and COM wear particles were 30+/-2.25 and 17.57+/-1.37nm, respectively. After five million cycles the wear particles were statistically significantly smaller than at one million cycles, 13.9+/-0.72nm for the MOM pairings and 6.11+/-0.40nm for the COM pairings.The wear rates of the MOM prostheses were representative of clinical values. The use of differential hardness COM pairings dramatically reduced the wear rate compared to MOM hip prostheses. The wear particles from the MOM articulation were similar to particles found in retrieved tissues from around MOM prostheses. The extremely low wearing differential hardness COM bearings presented in this study produced far smaller volumetric particle loads compared to MOM prostheses currently used clinically.     

Polyoma-like Virions in Human Demyelinating Brain Disease

Specimens of brain tissue obtained at autopsy from three patients suffering from progressive multifocal leukoencephalopathy (PML) were examined by electron microscopy. In specimens from all three cases particles similar to those of the papova virus group were present, confirming previous observations. By the negative staining method it was possible to define the morphological characteristics of the particles more precisely and it was shown that they are structurally similar to virions of the polyoma-SV40-K type. The need is emphasized for obtaining fresh unfixed diseased tissue from persons suffering from PML in order that the biological properties of the particles can be investigated.     

Alterations in the adhesion behavior of osteoblasts by titanium particle loading: inhibition of cell function and gene expression

Total joint replacement prostheses are required to withstand corrosive environments and sustain millions of loading and articulation cycles during their term of implantation. Wear debris generation has been implicated as one of the primary causes of periprosthetic osteolysis and subsequent implant loosening in total joint replacements. Particulate debris consisting of metals, polyethylene, ceramics, and bone cement have each been shown to provoke a biological response in joint tissues. The major cell types within the interfacial granulomatous fibrous tissues consist of fibroblasts, macrophages, lymphocytes, and foreign-body giant cells. Osteoblasts are one of the principal cell types in the bone tissue adjacent to prostheses, maintaining physiologic bone remodeling through the balanced coordination of bone formation and resorption in concert with osteoclasts. To date the phenomenon of osteoblast phagocytosis of titanium particles has been suggested, but has not been sufficiently studied or confirmed. This study seeks to clarify the influence of titanium particles on osteoblast adhesion, deformability, proliferation, and gene expression profile. These studies were accomplished by performing biorheological testing, Northern blot analysis and RNase protection assay. The uptake of metallic particles by the osteoblast resulted in a particle-filament complex formation, which induced a series of variations in cell function. Understanding these variations is critical to expanding our knowledge of implant loosening and elucidating the nature of prosthetic joint failure. This study suggests that the impact of titanium particles on osteoblast function and subsequent implant loosening may have been previously underestimated.     

Immunogold-silver staining method for light and electron microscopic detection of lymphocyte cell surface antigens with monoclonal antibodies

We used the immunogold-silver staining method (IGSS) for detection of lymphocyte cell surface antigens with monoclonal antibodies in light and electron microscopy and compared this procedure with the immunogold staining method. Two different sizes of colloidal gold particles (5 nm and 15 nm) were used in this study. Immunolabeling on cell surfaces was visualized as fine granules only by IGSS in light microscopy. The labeling density (silver-gold complexes/cell) and diameters of silver-enhanced gold particles on cell surfaces were examined by electron microscopy. Labeling density was influenced not by the enhancement time of the physical developer but by the size of the gold particles. However, the development of shells of silver-enhanced gold particles correlated with the enhancement time of the physical developer rather than the size of the colloidal gold particles. Five-nm gold particles enhanced with the physical developer for 3 min were considered optimal for this IGSS method because of reduced background staining and high specific staining in the cell suspensions in sheep lymph. Moreover, this method may make it possible to show the ultrastructure of identical positive cells detected in 1-micron sections counterstained with toluidine blue by electron microscopy, in addition to the percentage of positive cells by light microscopy.     

Chromium-induced lymph node histiocytic proliferation after hip replacement. A case report

BACKGROUND: Prosthetic joint replacement is frequently used for the treatment of degenerative joint disease, rheumatoid arthritis, bone tumors and traumatic lesions. The prostheses contain such materials as titanium, cobalt and chromium. We describe a patient who, after total hip arthroplasty, developed an inguinal-pelvic mass. Fine needle aspiration revealed metallic particles, also seen on light microscopy in reactive pelvic lymph nodes. Ultrastructure was consistent with the presence of foreign particles, while energy dispersive x-ray microanalysis established the presence of chromium. To our knowledge, this is the first report of chromium-related lymph node metallosis diagnosed by fine needle aspiration. CASE: Eight years after total hip arthroplasty, a 78-year-old woman developed a right pelvic cystic mass. Aspiration drainage was performed. Smears from fine needle aspiration showed numerous macrophages with abundant, foamy cytoplasm and round nuclei without atypia. Small, birefringent particles were seen in the cytoplasm. Histopathology showed fibroconnective tissue with chronic inflammation and marked lymph node sinus histiocytosis. Within histiocytes, numerous particles were present, identical to those seen in the smears. Their nature as "foreign bodies" was confirmed by electron microscopy, and the presence of chromium was shown by energy dispersive x-ray analysis. CONCLUSION: Fine needle aspiration and polarized microscopy are excellent techniques to evaluate foreign materials in lymph nodes draining the sites of joint prostheses, thus precluding confusion with other conditions, such as metastatic carcinoma.     

Development of computational wear simulation of metal-on-metal hip resurfacing replacements

As one of the alternatives to traditional metal-on-polyethylene total hip replacements, metal-on-metal hip resurfacing prostheses demonstrating lower wear have been introduced for younger and more active patients during the past decade. However, in vitro hip simulator testing for the predicted increased lifetime of these surface replacements is time-consuming and costly. Computational wear modelling based on the Archard wear equation and finite element contact analysis was developed in this study for artificial hip joints and particularly applied to metal-on-metal resurfacing bearings under simulator testing conditions to address this issue. Wear factors associated with the Archard wear equation were experimentally determined and based on the short-term hip simulator wear results. The computational wear simulation was further extended to a long-term evaluation up to 50 million cycles assuming that the wear rate stays constant. The prediction from the computational model shows good agreement with the corresponding simulator study in terms of volumetric wear and the wear geometry. The simulation shows the progression of linear wear penetrations, and the complexity of contact stress distribution on the worn bearing surfaces. After 50 million cycles, the maximum linear wear was predicted to be approximately 6 and 8 microm for the cup and head, respectively, and no edge contact was found.     

The use and development of the dynamic light-scattering method to investigate supramolecular structures in aqueous solutions of bacterial lipopolysaccharides

The temperature dependence of the scattering intensity, average size, and size distribution for supramolecular particles in aqueous solutions of lipopolysaccharides from Azospirillum bacteria was investigated by dynamic light scattering. Relationships were obtained that made it possible to comparatively estimate the mass–volume concentration of the biopolymeric substance in suspensions and the number concentration of supramolecular particles with their size and degree of polydispersity taken into account. In the range from 0 to 60°C, two types of the temperature dependence of scattering intensity were found: (a) with an irregular spasmodic change in scattering intensity and with considerable heterogeneity of the systems with respect to particle size and (b) with a smoother character of this dependence with considerably decreased heterogeneity of the suspensions. In the ranges of the latter type, whose location depended on what strain was used to isolate lipopolysaccharides, it proved to be possible to correctly determine the parameters of the supramolecular particles (of the supposedly formed micellar phase) by dynamic light scattering. The revealed statistically significant differences in the size and the concentration of the micellar particles are explained by their dependence on the peculiarities of the chemical structure of lipopolysaccharides. Atomic-force microscopy was used for an independent morphological estimation of the preparations, yielding good agreement with the dynamic light-scattering results.     

A Review of the Potential and Versatility of Colloidal Gold Cytochemical Labeling for Molecular Morphology

In the present article we review several postembedding cytochemical techniques using the colloidal gold marker. Owing to the high atomic number of gold, the colloidal gold particles are electron dense. They are spherical in shape and can be prepared in sizes from 1 to 25 nm, which renders this marker among the best for electron microscopy. In addition, because it can be bound to several molecules, this marker has the advantage of being extremely versatile. Combined to immunoglobulins or immunoglobulin-binding proteins (protein A), it has been applied successfully in immunocytochemistry. Colloidal gold particles 5–15 nm in size are excellent for postembedding cytochemistry. Particles of smaller size, such as 1 nm, must be silver enhanced to be visualized by transmission electron microscopy. We have elected to review the superiority of indirect immunocytochemical approaches using IgG-gold or protein A-gold (protein G-gold and protein AG-gold). Lectins or enzymes can be tagged with colloidal gold particles, and the corresponding lectin-gold and enzyme-gold techniques have specific advantages and great potential. Using an indirect digoxigenin-tagged nucleotide and an antidigoxigenin probe, colloidal gold technology can also be used for in situ hybridization at the electron microscope level. Affinity characteristics lie behind all cytochemical techniques and several molecules displaying high affinity properties can also be beneficial for colloidal gold electron microscopy cytochemistry. All of these techniques can be combined in various ways to produce multiple labelings of several binding sites on the same tissue section. Colloidal gold is particulate and can easily be counted; thus the cytochemical signal can be evaluated quantitatively, introducing further advantages to the use of the colloidal gold marker. Finally, several combinations and multiple step procedures have been designed to amplify the final signal which renders the techniques more sensitive. The approaches reviewed here have been applied successfully in different fields of cell and molecular biology, cell pathology, plant biology and pathology, microbiology and virology. The potential of the approaches is emphasized in addition to different ways to assess specificity, sensitivity and accuracy of results.     

A review of the potential and versatility of colloidal gold cytochemical labeling for molecular morphology.

In the present article we review several postembedding cytochemical techniques using the colloidal gold marker. Owing to the high atomic number of gold, the colloidal gold particles are electron dense. They are spherical in shape and can be prepared in sizes from 1 to 25 nm, which renders this marker among the best for electron microscopy. In addition, because it can be bound to several molecules, this marker has the advantage of being extremely versatile. Combined to immunoglobulins or immunoglobulin-binding proteins (protein A), it has been applied successfully in immunocytochemistry. Colloidal gold particles 5-15 nm in size are excellent for postembedding cytochemistry. Particles of smaller size, such as 1 nm, must be silver enhanced to be visualized by transmission electron microscopy. We have elected to review the superiority of indirect immunocytochemical approaches using IgG-gold or protein A-gold (protein G-gold and protein AG-gold). Lectins or enzymes can be tagged with colloidal gold particles, and the corresponding lectin-gold and enzyme-gold techniques have specific advantages and great potential. Using an indirect digoxigenin-tagged nucleotide and an antidigoxigenin probe, colloidal gold technology can also be used for in situ hybridization at the electron microscope level. Affinity characteristics lie behind all cytochemical techniques and several molecules displaying high affinity properties can also be beneficial for colloidal gold electron microscopy cytochemistry. All of these techniques can be combined in various ways to produce multiple labelings of several binding sites on the same tissue section. Colloidal gold is particulate and can easily be counted; thus the cytochemical signal can be evaluated quantitatively, introducing further advantages to the use of the colloidal gold marker. Finally, several combinations and multiple step procedures have been designed to amplify the final signal which renders the techniques more sensitive. The approaches reviewed here have been applied successfully in different fields of cell and molecular biology, cell pathology, plant biology and pathology, microbiology and virology. The potential of the approaches is emphasized in addition to different ways to assess specificity, sensitivity and accuracy of results.     

FITC-Dextran tracers in microcirculatory and permeability studies using combined fluorescence stereo microscopy,fluorescence light microscopy and electron microscopy

Summary Coupling fluorescein-isothiocyanate to dextrans (FITC-D) extends the usefulness of the dextrans as electron microscopic tracer particles by permitting preceding fluorescence stereo microscopy and high-power light microscopy of the tissue specimens. The fate of the tracer may thus be studied in vivo during the experiment, during fixation, and during the succeeding tissue processing. A study of some simple physicochemical characteristics of the tracer, and the influence, if any, of the fixing agent are also made possible. FITC-D was found to be uncharged in the pH range from 6.5 to 8.5, more rapidly precipitated by acetone than by alcohol, and to react with glutaraldehyde and osmium tetroxide in an unknown way during tissue fixation. FITC-D with molecular weights 70,000 and 150,000 showed no signs of diffusion during tissue preparation with the methods reported in the paper, whereas FITC-D 40,000 did so to a slight degree, when the tissue was kept for several days in the fixative vehicle. Securing the preservation of the lower molecular weight FITC-Ds during tissue fixation and preparation is more difficult and the described methods are not adequate. Dextrans provoke an anaphylactic reaction in most rat strains, but are well tolerated by Wistar Furth rats. The introduction of FITC into the dextran molecule might alter the biological reactions, but was also well tolerated by Wistar Furth rats. Combined fluorescence stereo microscopy, fluorescence microscopy of sections, light microscopy of stained sections and electron microscopy made it possible to follow a particular microcirculatory area, selected in vivo, to the final study in the electron microscope.     

Changes of concentrations of the elements Co,Cr, Sb,and Sc in tissues of persons with joint implants

Elevated levels of Co and Cr were found in several organs of deceased implant bearers (CoCr-alloy/polyethylene joint prostheses) by means of instrumental and radiochemical neutron activation analysis as compared to normal persons. For comparative purposes, concentrations of the elements Co, Cr, Sb, and Sc were measured in heart, kidney, liver, and spleen of the patients and normal persons. For Cr determination, a new radiochemical separation technique with sufficiently low determination limit was employed. The importance of such investigations for studying possible carcinogenic effects of corrosion products and wear particles of metallic prostheses is mentioned.     

Comparison of protein A-gold and ferritin immunoelectron microscopy of Semliki Forest virus in mouse brain using a rapid processing technique

Processing tissue for transmission electron microscopy by standard laboratory methods can take two to three days. This makes the development of new techniques time consuming and generally restricts the use of the electron microscope in routine diagnostic work. The possibility of viewing tissue with the electron microscope five hours after sampling using rapid processing techniques is presented. The morphology of the tissue appears undamaged with cell and organelle ultrastructures being readily recognized, as is the presence of virus and its replicating stages. When combined with immunoelectron microscopy a rapid labeling protocol is possible. We have used the technique to develop protein A-gold (6 and 16 nm particles) and ferritin immunoelectron microscopic techniques to demonstrate viral antigens in brain cell cultures and brain tissue from mice infected with Semliki Forest virus.     

The influence of design, materials and kinematics on the in vitro wear of total knee replacements

Debris-induced osteolysis due to surface wear of ultra high molecular weight polyethylene (UHMWPE) bearings is a potential long-term failure mechanism of total knee replacements (TKR). This study investigated the effect of prosthesis design, kinematics and bearing material on the wear of UHMWPE bearings using a physiological knee simulator. The use of a curved fixed bearing design with stabilised polyethylene bearings reduced wear in comparison to more flat-on-flat components which were sterilised by gamma irradiation in air. Medium levels of crosslinking further improved the wear resistance of fixed bearing TKR due to resistance to strain softening when subjected to multidirectional motion at the femoral-insert articulating interface. Backside motion was shown to be a contributing factor to the overall rate of UHMWPE wear in fixed bearing components. Wear of fixed bearing prostheses was reduced significantly when anterior-posterior displacement and internal-external rotation kinematics were reduced due to decreased cross shear on the articulating surface and a reduction in AP displacement. Rotating platform mobile bearing prostheses exhibited reduced wear rates in comparison to fixed bearing components in these simulator studies due to redistribution of knee motion to two articulating interfaces with more linear motions at each interface. This was observed in two rotating platform designs with different UHMWPE bearing materials. In knee simulator studies, wear of TKR bearings was dependent on kinematics at the articulating surfaces and the prosthesis design, as well as the type of material.     

Strength requirements for internal and external prostheses

Throughout the history of development of joint replacement implants and external prostheses there have been mechanical failures due to a discrepancy between material strength, cross-sectional characteristics and the loads developed in normal or abnormal function by the patient utilising the device. Particularly for internal prostheses attention is being paid at the present time to wear characteristics and the requirements for the articulating surfaces and the volume of wear particles produced during tests simulating the use of the device within the patient. The particular importance of the wear particles is that they seem to be associated with accelerated resorption of bone at areas essential for successful fixation of the implant within it. This article will consider joint replacements at the knee and hip and external prostheses for the leg. If failure due to external trauma is ignored the loads to be considered in testing standards correspond in implants to the muscular and ligamentous forces related to the forces developed between ground and foot and to the bending moments in the structure of leg prostheses. Generally it can be assumed that the treatment of the patient following trauma is more easily accomplished and more likely to be successful if the prosthesis has failed and not the bony structure of the patient. However, the author is unaware that these devices have ever been designed to have lower intrinsic strength than the anatomical structures to which they are connected; indeed in many cases particularly for implants they are much stronger than the bone to which they are connected. The major difficulty in rational design of prosthetic devices has been uncertainty about the importance of occasionally applied loads of a high value relative to those on a frequent basis and also to the frequency of application of these overloads. In this paper consideration is given to methods of determination of load systems relevant to the mechanical performance of implanted joint replacements at the hip and the knee and external prostheses for leg amputees. New data are presented relating to walking, other daily activities and the corresponding frequency of occurrence of these. Loading data on implants obtained by various biomechanical models is compared and related to the loads actually measured by implanted transducers. The philosophy of the standardised test load systems and the performance requirements is reviewed.     

Electrochemical properties of biocompatible material hardness modifications on titanium and steel under mechanical loads]

Friction corrosion may appear between different implant components or between implant and hard tissue. The sliding micro movements induce fretting wear corrosion and have been recently reported as a cause of joint prostheses failure. A surface coating is desirable, that retains the mechanical properties of the substrate, offers good biocompatibility and improves the fretting corrosion resistance. In this study it could be demonstrated that tantalum and niobium coatings fulfill the requirements. On titanium substrates the coating decreases the abrasion against PMMA, an orthopedic relevant material. Furthermore, in the case of medical steel substrates the biocompatibility and the corrosion properties are improved. The better abrasion-resistance is minimizing the release of allergological critical particles like nickel and chromium.     

Investigation on the Tribological Behavior and Wear Mechanism of Five Different Veneering Porcelains

Objectives

The primary aim of this research was to investigate the wear behavior and wear mechanism of five different veneering porcelains.

Methods

Five kinds of veneering porcelains were selected in this research. The surface microhardness of all the samples was measured with a microhardness tester. Wear tests were performed on a ball-on-flat PLINT fretting wear machine, with lubrication of artificial saliva at 37°C. The friction coefficients were recorded by the testing system. The microstructure features, wear volume, and damage morphologies were recorded and analyzed with a confocal laser scanning microscope and a scanning electron microscope. The wear mechanism was then elucidated.

Results

The friction coefficients of the five veneering porcelains differ significantly. No significant correlation between hardness and wear volume was found for these veneering porcelains. Under lubrication of artificial saliva, the porcelain with higher leucite crystal content exhibited greater wear resistance. Additionally, leucite crystal size and distribution in glass matrix influenced wear behavior. The wear mechanisms for these porcelains were similar: abrasive wear dominates the early stage, whereas delamination was the main damage mode at the later stage. Furthermore, delamination was more prominent for porcelains with larger crystal sizes.

Significance

Wear compatibility between porcelain and natural teeth is important for dental restorative materials. Investigation on crystal content, size, and distribution in glass matrix can provide insight for the selection of dental porcelains in clinical settings.