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PII: S1751-6161(17)30251-5
DOI: http://dx.doi.org/10.1016/j.jmbbm.2017.06.013
Reference: JMBBM2373
To appear in: Journal of the Mechanical Behavior of Biomedical Materials
Received date: 18 March 2017
Revised date: 5 June 2017
Accepted date: 9 June 2017
Cite this article as: Majed Al-Akhali, Mohamed Sad Chaar, Adham Elsayed,
Abdulaziz Samran and Matthias Kern, Fracture resistance of ceramic and
polymer-based occlusal veneer restorations, Journal of the Mechanical Behavior
of Biomedical Materials, http://dx.doi.org/10.1016/j.jmbbm.2017.06.013
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Fracture resistance of ceramic and polymer-based occlusal veneer
restorations
Majed Al-Akhalia,b1, Mohamed Sad Chaara1, Adham Elsayeda, Abdulaziz Samrana,b,c, Matthias
Kerna
a
Department of Prosthodontics, Propaedeutics and Dental Materials, School of Dentistry,
Christian-Albrechts University, Kiel, Germany
b
Department of prosthodontics, School of Dentistry, Ibb University, Ibb, Yemen
c
Department of Restorative and Prosthetic Dental Sciences, School of Dentistry, Dar Al-Uloom
University, Riyadh, Saudi Arabia
malakhali@proth.uni-kiel.de
schaar@proth.uni-kiel.de
*
Corresponding authors at: Department of Prosthodontics, Propaedeutics and Dental Materials,
School of Dentistry, Christian-Albrechts University, Arnold- Heller-Str. 16, 24105 Kiel,
Germany. Tel.: +49 431 50026440; fax: +49 431 50026404.
ABSTRACT
OBJECTIVES
The purpose of this in vitro study was to evaluate the influence of thermodynamic loading on the
durability and fracture resistance behavior of occlusal veneers fabricated from different
METHODS
The occlusal surfaces of 64 extracted premolars were prepared in the enamel layer and restored
with occlusal veneers with a fissure/cusp thickness of 0.5/0.8 mm made from four different
1
The first and second author contributed equally to this work.
1
dental CAD/CAM materials: group LD lithium disilicate (e.max CAD), group LS zirconia-
reinforced lithium silicate (Vita Suprinity), group PI polymer-infiltrated ceramic (Vita Enamic),
and group PM polymethylmethacrylate PMMA (Telio CAD). The prepared teeth were etched
with phosphoric acid. The occlusal veneers were then bonded using an adhesive luting system
(Multilink Primer A/B and Multilink Automix luting resin). Half of the specimens were
subjected to thermodynamic loading in a chewing simulator (1.2 million cycles at 98 N). All
specimens were quasi-statically loaded until fracture. The statistical analysis was made using the
t test and one-way ANOVA followed by the Tukey HSD test (α=0.05).
RESULTS
All aged specimens survived the thermodynamic loading. Thermodynamic loading significantly
raised the fracture resistance in groups LS, PI, and PM (P˂0.03). Occlusal veneers made from
lithium disilicate and zirconia-reinforced lithium silicate recorded higher fracture resistance than
CONCLUSIONS
All tested dental CAD/CAM biomaterials exhibited a fracture resistance considerably exceeding
the average occlusal force in the posterior dentition. Therefore, they might present a viable long-
Keywords
1. INTRODUCTION
Conservation of tooth structures is the main objective in restorative dentistry. Unfortunately, the
loss of natural occlusal contacts between maxillary and mandibular teeth may occur because of
wear, caries, or malposition. The treatment of such problems is complicated and challenging as
2
removal of undamaged hard dental tissues has to be done to accept conventional restorative
materials (Edelhoff and Sorensen, 2002; Tsitrou and van Noort, 2008). Moreover, loss of
occlusal contact may be compensated by tooth over-eruption (Tsitrou and van Noort, 2008),
which in turn restricts the thickness of the planned restorations. Minimally invasive procedures
in prosthetic dentistry aim to preserve sound tooth substance, maintain the vitality of the tooth,
Lithium disilicate ceramic has been considered the strongest glass-ceramic. The high number of
microstructural, interlocking, needle-like lithium disilicate crystals that are embedded in the
glassy matrix gives this type of ceramic higher mechanical properties than other types of glass-
based ceramic materials (Oh et al., 2000). Lithium disilicate ceramic has shown promising
results in terms of structural integrity when used in the anterior or posterior area as veneers,
inlays, onlays, crowns, partial coverage restorations, and three-unit fixed dental prostheses (Attia
and Kern, 2004a; Guess et al., 2013; Kern et al., 2012; Sasse et al., 2015). In an attempt to
improve the mechanical and optical properties of glass-ceramic restorative materials, new
generations have been developed for computer-aided design and computer-aided manufacturing
(CAD/CAM) technology. For instance, dissolving 10% zirconia into the lithium silicate glass
matrix claimed to be more translucent and stronger material than the conventional lithium
disilicate ceramic (Elsaka and Elnaghy, 2016). In another approach, a ceramic network structure
was infiltrated with a polymer material to combine the advantages of the two materials to obtain
better mechanical properties and better machinability for CAD/CAM than those of glass-
ceramics (Coldea et al., 2013). Likewise, the mechanical and physical properties of CAD/CAM
glass-ceramics, especially when thin restorations with high masticatory loads are required
3
because of their high resistance to dynamic fatigue (Schlichting et al., 2011). For that reason, the
longevity, stability, and behavior of these new biomedical dental materials should be investigated
when they are used for minimally invasive occlusal veneer restorations.
In the current study, the influence of thermodynamic loading on the durability and fracture
resistance of four different dental CAD/CAM occlusal veneer restorative biomaterials with a
fissure/cusp thickness of 0.5/0.8 mm was evaluated. The null hypotheses of this study were as
follows: (1) different dental CAD/CAM occlusal veneers will survive thermodynamic loading
equally; (2) thermodynamic loading will not affect the fracture resistance of each material itself;
and (3) no differences will be found in fracture resistance between the different dental
Sixty four intact, noncarious, unrestored human maxillary first premolars, recently extracted for
orthodontic reasons, were collected anonymously. They were cleaned of both calculus deposits
and soft tissues and then stored at room temperature in 0.1% thymol solution (Caelo, Hilden,
Germany). The teeth in this study were selected to be as similar as possible in dimension. The
mesiodistal and buccolingual as well as the buccal and lingual cusp slopes of the tooth occlusal
surfaces were measured and determined as 5.43 ±0.66 mm, 5.73 ±0.55 mm, 4.22 ±0.46 mm, and
3.18 ±0.34 mm, respectively. Hence, teeth below or above the average ±SD were excluded from
the study. The sample size of this study was justified to follow previous studies which were
carried out by our group with the same study design and sources of variations, and these studies’
sample sizes gave acceptable standard deviations and allowed the statistical differentiation of
4
evaluated factors. In addition, the chewing simulator machine accepts only 8 specimens per test
making this an ideal manageable group size (Attia and Kern, 2004a, b; Clausen et al., 2010;
All teeth were fixed within metallic brass tubes (Ø 15 mm) so that the exposed root portions
Wehrheim, Germany) was used to fix the coated roots inside the metallic brass tubes.
were used to prepare the teeth. The occlusal surfaces of the teeth were prepared in the enamel
layer with the following standardized preparation criteria: 120 degrees was the angle between the
buccal and lingual cusp slopes, mesiobuccal and distobuccal slopes, mesiolingual and
distolingual slopes, and finishing line and lingual cusp slope. All sharp angles were rounded
(Fig. 1).
Impressions were made with the dual-mixed impression technique with polyvinylsiloxane
material (Virtual, Ivoclar Vivadent, Schaan, Liechtenstein). Thereafter, type IV stone (New
Fujirock, GC, Alsip, IL, USA) was used to form working dies, which were scanned using a 3D
scanner (D900 3D scanner, 3shape, Copenhagen, Denmark) to enable the design of the occlusal
veneers with thicknesses of 0.5/0.8 mm at fissures/cusps (Fig. 2). Thereafter, restorations were
milling machine (inLab MC XL, Sirona, Bensheim, Germany) from four different CAD/CAM
5
materials: group LD lithium disilicate ceramic blocks (e.max CAD, Ivoclar Vivadent, Schaan,
Liechtenstein), group LS zirconia-reinforced lithium silicate ceramic blocks (Vita Suprinity, Vita
Zahnfabrik, Bad Säckingen, Germany), group PI polymer-infiltrated ceramic (Vita Enamic, Vita
Zahnfabrik), and group PM PMMA (Telio CAD, Ivoclar Vivadent). The restorations were
The occlusal veneers were cleaned with 99% isopropanol in an ultrasonic cleaner for 3 min,
while the prepared teeth were cleaned with fluoride-free pumice for 15 sec and rinsed thoroughly
with water for 15 sec. A 5% hydrofluoric acid etching gel (IPS Ceramic Etching Gel, Ivoclar
Vivadent) was used to etch the intaglio surfaces of the occlusal veneers of groups LD and LS for
20 sec and group PI for 60 sec. The treated surfaces were cleaned thoroughly with water spray
for 60 sec. Oil-free compressed air was used to dry the intaglio surfaces, and then a silane-
containing primer (Monobond Plus, Ivoclar Vivadent) was applied immediately to the intaglio
surface of each occlusal veneer and left to react for 60 sec. Subsequently, any remaining excess
primer was dispersed with a stream of air. For group PM, the intaglio surfaces were airborne-
particle abraded with 50 µm Al2O3 at a pressure of 0.05 MPa, and then cleaned with 99%
isopropanol in ultrasonic cleaner for 3 min. Subsequently, a PMMA primer (Luxatemp-Glaze &
Bond, DMG, Hamburg, Germany) was applied, and then exposed to curing light for 20 sec using
The prepared teeth were etched with 37% phosphoric acid (Total Etch, Ivoclar Vivadent) for 30
sec, the etchant was rinsed off thoroughly with water spray for 20 sec, and the teeth were dried
with oil-free air. Immediately afterwards, they were conditioned with a tooth primer (Multilink
6
Primer A/B, Ivoclar Vivadent), which was mixed for 10 sec in a ratio of 1:1 and applied for 30
sec to the enamel surface with a microbrush. After that, a gentle stream of air was applied to the
primed surface to evaporate volatiles, leaving the surface appearing glossy. Next, all restorations
were cemented adhesively to their respective prepared teeth with dual-polymerizing composite
resin cement (Multilink Automix, Ivoclar Vivadent). The restorations were placed in position
using gentle finger pressure and then a customized loading apparatus with a 1 kg weight. The
excess luting cement at the margins was removed with sponge pellets, and an air-inhibiting gel
(Liquid Strip, Ivoclar Vivadent) was applied along the margin of the cemented occlusal veneers
to prevent the formation of an oxygen inhibited unpolymerized resin layer. The luting material
was cured using a light-curing unit (Elipar 2500, 3M ESPE) at a distance of 5 mm for 20 sec
from the mesial, distal, buccal, and lingual directions, followed by additional curing with an
external curing unit (UniXS Kulzer, Heraeus Kulzer) for 90 sec. After cementation, the
specimens were stored in a water bath at 37°C for 3 days before testing. Finally, the specimens in
every group (n=16) were assigned randomly into 2 subgroups (n=8) either with or without
thermodynamic loading. The study groups were coded according to CAD/CAM materials as
shown in Table 1.
To mimic intraoral conditions and 5 years of clinical service (Kern et al., 1999; Steiner et al.,
2009), half of the specimens in each group (n=8) were fatigued thermodynamically in a dual-axis
subjected to 1.2 million mechanical chewing cycles with simultaneous thermocycling between 5
and 55°C in distilled water with a 30 sec dwell time at each temperature with a total of 5,500
7
thermal cycles at a loading cycle frequency of 2.4 Hz. Steatite ceramic balls with a 6-mm
diameter (Hoechst Ceram Tec, Wunsiedel, Germany) were used as antagonists to simulate the
opposing teeth. A vertical load of 98 N (10 Kg) was applied with a vertical movement of 6 mm
and a descending speed of 30 mm/sec on the buccal cusp beginning 0.5 mm below the cusp tip
with a lateral sliding component of 0.3 mm towards the central fissure. After the thermodynamic
loading was complete, all specimens were inspected carefully under an LED light source and an
optical microscope (Wild M420, Wild Heerbrugg, Gais, Switzerland) with 5.8× magnification to
detect incipient cracks. Finally, all non-aged and surviving aged specimens were quasi-statically
To determine the specimens’ fracture resistance, a stainless steel bar with a 6-mm-diameter ball-
end mounted in a universal testing machine (Zwick Z010/TN2A, Zwick, Ulm, Germany) was
used to apply a quasi-statical load, which was centered at the fissure along the long axis of the
restored tooth at a cross-head speed of 1 mm/min until fracture (Fig. 3). Additionally 0.5-mm tin
foil was placed between the specimens and the stainless steel bar to avoid local stress
concentration. The fracture loads were recorded automatically in Newtons (N) for each specimen
After the fracture resistance test, all specimens were inspected under an LED light source and an
optical microscope (Wild M420, Wild Heerbrugg) with 20× magnifications to evaluate the mode
of failure. According to Guess et al. (2013), failure mode was classified into four categories in
accordance with the following criteria: (I) Extensive crack formation within the restoration; (II)
cohesive fracture within the restoration; (III) adhesive fracture between the restoration and tooth
structures; (IV) longitudinal fracture of the restoration and tooth (Fig. 4).
8
2.5. Statistical analysis
One-way analysis of variance (ANOVA) was performed to compare the fracture resistance
means among the four groups, followed by multiple comparisons using the Tukey HSD test,
while the t test was used to identify which pairs of groups demonstrated a significant difference
(α=0.05). Statistical analysis was performed using SPSS 20 (IBM SPSS for Windows, Version
3. RESULTS
All aged specimens in all groups survived the thermodynamic loading without fracture, ceramic
chipping, or cracks. The results of the quasi-static load to fracture test of all groups are listed in
Table 1. Thermodynamic loading increased the fracture resistance significantly for groups LS,
Without thermodynamic loading, group LD showed significantly higher fracture resistance than
groups PI and PM (P≤0.015) but not group LS (P=0.051). No statistically significant difference
was found between groups LS, PI, PM when compared with each other (P=1.0). However, after
In the current study, the failure mode after quasi-static loading was evaluated and is represented
descriptively in Figure 5. It was remarkable that the most common failure modes were class I
9
4. DISCUSSION
Little information is available on the reliability and longevity of recent dental CAD/CAM
biomaterials as minimally invasive restorations when bonded to natural tooth structures with
nonretentive preparation designs (Clausen et al., 2010; Guess et al., 2013; Sasse et al., 2015). To
ensure a close simulation of the clinical situations, all procedures in the recent study were
designed to follow clinically applied protocols. In fact, several factors influence the fracture
technique, final preparation design, and luting method (Kern et al., 1994). Natural human teeth
were used in this study to improve clinical relevance. Moreover, physiological tooth mobility
was simulated through the application of 0.2-mm-thick gum resin on the roots of the teeth to
replicate the periodontal membrane, which is important for the absorption and distribution of
stresses generated by masticatory forces over teeth into the alveolar bone (Poiate et al., 2009).
In vitro investigations, including thermocycling and dynamic loading are of great importance in
the testing of new dental materials with accelerated conditions mimicking the actual intraoral
activities. The parameters used for masticatory simulation were adjusted to the reported
physiological values (Kern et al., 1999; Steiner et al., 2009). Tooth morphology and preparation
geometry have been shown to influence the longevity and reliability of prosthetic restorations
(Schmidt et al., 2011). Therefore, premolars used in this current study were selected to be as
similar as possible in dimensions, i.e. mesiodistally and buccolingually. Also, the preparation
design was chosen based on the general guidelines recommended for minimally invasive partial
coverage ceramic restorations (Ahlers et al., 2009; Kern et al., 2015). To standardize the
preparation geometry, the cusp inclinations were designed to have a 120-degree angle with
dental hard tissues. Moreover, minimally invasive restorations provide a better bond strength
when adhesively bonded to enamel than when bonded to dentin (Ozturk et al., 2013). Besides,
thin occlusal veneer restorations bonded to enamel revealed a fracture resistance comparable to
that of thick occlusal veneers when bonded to dentin (Clausen et al., 2010; Guess et al., 2013).
The present study showed that the average final fracture resistance of all groups was higher than
that recorded for the natural unrestored human maxillary premolars, 932 N (Attia and Kern,
2004a, b). Moreover, they were higher than the maximum parafunctional masticatory forces up
to 1,000 N (Floystrand et al., 1982). The fracture resistance of the four tested dental CAD/CAM
biomaterials in this study did not correspond to their respective uniaxial flexural strength of 530,
420, 160, and 130 MPa for lithium disilicate, zirconia-reinforced lithium silicate, polymer-
infiltrated ceramic, and PMMA, respectively. This confirmed that the mechanical behavior of the
restored tooth complex, i.e. restorative material, adhesive system, and restored tooth, cannot be
predicted (Kelly, 1995; Ma et al., 2013). Furthermore, strong adhesive bonding with luting resin
can noticeably strengthen weaker ceramic restorations and balance the inherent strength
No specimens in the present study showed signs of cracks or chipping after thermodynamic
loading. Thus, the first null hypothesis that different dental CAD/CAM occlusal veneers will
survive thermodynamic loading equally was accepted. Sasse et al., (2015) demonstrated that the
surviving occlusal veneers with a fissure/cusp thicknesses of 0.5/0.8 mm luted to enamel showed
cracks after thermodynamic loading. This might be attributed to the use of only self-etching
primer rather than using separate phosphoric acid etching on enamel. Self-etching primer has a
11
lower ability to etch enamel than etching with phosphoric acid. The proper morphological etch
pattern and the positive adhesion effect after using phosphoric acid on enamel has been observed
in previous studies (Erickson et al., 2009; Sheets et al., 2012; Van Landuyt et al., 2006).
In the present study, the fracture resistance was lower than that reported by Yildiz et al. (2013),
who evaluated the fracture resistance of partial coverage crowns made from machinable lithium
disilicate ceramic with an occlusal thickness of 1.5 mm, and they recorded a fracture resistance
of 2,356 ±677 N. Furthermore, Clausen et al. (2010) reported a fracture resistance of 4,070 ±777
N for occlusal veneers with a fissure/cusp thickness of 1.5/2.0 mm. Likewise, Sasse et al. (2015)
showed that occlusal veneers with thicknesses of 0.5 mm at the fissures and 0.8 mm at the cusps
had a median fracture resistance of 2,355 N. The higher overall values of fracture resistance in
the studies of Clausen et al. and Sasse et al. might be related to the less steeply prepared molar
cusp inclination angles of 150 degrees; the prepared premolar cusp inclination angle in our study
was 120 degrees. Previous studies have revealed that the failure load increases when the
prepared cusp angles increase, i.e., the less steep prepared cusp inclinations (Preis et al., 2014;
tooth morphology, and study design might have influenced the fracture resistance.
Guess et al. (2013), measured the fracture resistance of retentive occlusal veneers made from
pressed lithium disilicate. Their occlusal onlays with thicknesses of 0.5, 1.0, and 2.0 mm had a
lower fracture resistance of 997 ±331, 1108 ±340, and 963 ±405 N, respectively, after
thermodynamic loading than the CAD/CAM lithium disilicate occlusal veneers in the current
study with 1,545 ±175 N. The lower mean of fracture resistance in the former study might be due
to the extension of the occlusal onlays to restore the occlusal and the proximal walls of the
premolar teeth. Guess et al. emphasized that occlusal veneers with a 0.5 mm thickness bonded to
12
enamel had a fracture resistance comparable with that of 2.0 mm thick occlusal veneers bonded
to dentin. The improved fracture resistance of the ultrathin occlusal onlay is due to the superior
Thermodynamic loading significantly raised the fracture resistance of groups LS, PI, and PM in
the present study. Therefore, the second null hypothesis that thermodynamic loading will not
affect the fracture resistance of each material was partially rejected. This finding might be
explained by the postcuring effect and stress relaxation because of the warm temperature of the
Regarding the comparison among the different dental CAD/CAM biomaterials without
fracture resistance than groups PI and PM (P≤0.015). As a result, the first part of the third null
hypothesis that there will be no differences in fracture resistance among the different dental
CAD/CAM materials before thermodynamic loading was partially rejected. This might be
attributed to the higher mechanical properties of lithium disilicate ceramic (Bindl et al., 2006) or
it could be related to the monolithic structural property of lithium disilicate ceramic which
facilitates a proper etching pattern using hydrofluoric acid, so that a stronger bond with the
However, after thermodynamic loading, occlusal veneers made from zirconia-reinforced lithium
silicate (group LS) showed significantly higher fracture resistance than occlusal veneers made
from the resin-containing materials (groups PI and PM). Lithium disilicate (group LD) showed
significantly higher fracture resistance than PMMA restorations (group PM). Therefore, the
second part of the third null hypothesis that no differences will be found in fracture resistance
among the different dental CAD/CAM materials after thermodynamic loading was also partially
13
rejected. The reason for this result might be the inherent mechanical properties of the tested
restorative materials (Awada and Nathanson, 2015; Bindl et al., 2006; Elsaka and Elnaghy,
2016). In some studies, CAD/CAM thin composite resin occlusal veneers had significantly high
stepwise loading fatigue resistance when compared with ceramic veneers (Magne et al., 2010;
Schlichting et al., 2011). However, the loading protocols used in these studies were quite
different from that of the current study, as they followed a stepwise loading fatigue from 200 N
up to 1,400 N at a maximum of 185,000 cycles without testing the specimens under static load,
5. CONCLUSION
Considering the survivability and the fracture resistance of the tested occlusal veneers, all
materials may be considered as a viable treatment for restoring the occlusal surfaces of posterior
teeth.
Acknowledgements
The authors gratefully acknowledge Ivoclar Vivadent, Schaan, Liechtenstein, and Vita
Zahnfabrik, Bad Säckingen, Germany for providing their materials free of charge.
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Figures:
Figure 1. Occlusal surface preparation with 120 degrees between the prepared surfaces.
Figure 2. A virtual design of an occlusal veneer for one of the studied specimens.
19
Figure 3. Load to fracture test in the universal testing machine (Zwick) before the placement
20
Figure 4. Failed specimens in occlusal view showing the failure mode: I=Extensive crack
restoration and tooth structures. IV=Longitudinal restoration and tooth fracture involving root.
10 9 6
15
41 26
32 50 57 57
31 47
12 Class IV
16 30
12 23 12 Class III
Class II
42 47 43 43
38 35 31 35 Class I
LD LS PI PM LD LS PI PM
Without thermodynamic loading With thermodynamic loading
Figure 5. Descriptive statistics of failure mode (%). Definition of failure modes class I to IV see
Fig. 4.
21
Table 1 - Fracture resistance of groups in Newtons [N], means, standard deviations (SD), medians,
Groups (Codes) Mean ±SD Median Q1 Min Mean ±SD Median Q1 Min
Q3 Max Q3 Max
Lithium disilicate 1,408.8 1,335.0 1,220.0 1,150.0 1,545.0 1,560.0 1,372.5 1,300.0
(LS)
(PI)
Means with the same upper case superscript letters within the same column are not statistically different (P˃0.05).
Means with the same subscript letters within the same raw are not statistically different (P˃0.05).
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