Received: 15 November 2018 Revised: 14 December 2018 Accepted: 27 December 2018

DOI: 10.1111/jerd.12457

RESEARCH ARTICLE

Influence of preparation designs on marginal adaptation and

failure load of full-coverage occlusal veneers after
thermomechanical aging simulation
Daniele Angerame MD, DDS1 | Matteo De Biasi DDS, MS, PhD1 |
Martina Agostinetto DDS2 | Andrea Franzò DDS3 | Giulio Marchesi DDS, MS, PhD1

1
University Clinical Department of Medical,
Surgical, and Health Sciences, University of
Trieste, Trieste, Italy
2
Private Practice, Jesolo, Italy
3
Private Practice, Gorizia, Italy
Correspondence
Daniele Angerame, University Clinical
Department of Medical, Surgical, and Health
Sciences, Piazza Ospedale 1, Trieste, I-34125,
Italy.
Email: d.angerame@fmc.units.it
Abstract
Objectives: To evaluate the fracture resistance and marginal quality of maxillary molars restored
using lithium disilicate glass-ceramic (LDG) occlusal veneers with two preparation designs.
Methods: Sixteen extracted maxillary molars were assigned to two groups (n = 8). In group
1 (G1), the teeth received a preparation for a conservative full-coverage occlusal veneer restora-
tion with a 90 rounded shoulder margin. In group 2 (G2), the teeth underwent a 1-mm cusp
reduction with a marginal chamfer. LDG restorations (IPS e.max CAD) were obtained with the
Cerec 3 CAD/CAM system and luted with Variolink II cement. After thermomechanical aging
(1 250 000 cycles), the specimens were loaded to fracture. A semiquantitative marginal seal
evaluation was performed observing resin replicas of the specimens at the scanning electron
microscope. Cement thickness was assessed at the stereomicroscope on sectioned specimens.
Collected data were statistically analyzed by parametric and nonparametric tests.
Results: The maximum load to fracture was 2395.01 ± 150.96 N in G1 and 2408.39 ± 112.66 N
in G2. Most of the observed specimens exhibited restorable fractures and continuous margins.
Cement thickness was 132 ± 38 μm in G1 and 150 ± 41 μm in G2. No differences between the
groups emerged.
Conclusion: This study demonstrated similar satisfactory performance of the two considered
preparations designs for occlusal veneer with LDG.
Clinical Significance: A new minimally invasive occlusal veneer preparation with marginal cham-
fer exhibited promising fracture resistance and marginal adaptation that were comparable to
those of a standard conservative preparation for the restoration of molars with CAD/CAM lith-
ium disilicate occlusal veneers.

KEYWORDS

CAD/CAM, cement thickness, lithium disilicate, marginal adaptation, occlusal veneers

1 | I N T RO D UC T I O N lead to improved preservation of the residual tooth structures, espe-

Obtaining excellent esthetic results without renouncing to the preser-
vation of the biological structures is one of the main goals of modern
restorative dentistry. In both the clinical and laboratory setting, the
restorative protocols have become simpler, predictable, and capable
of providing satisfactory esthetic and functional results. The use of
new generation all-ceramic restorations and adhesive systems can
cially for the treatment of the single tooth.1,2
Lithium disilicate glass-ceramic (LDG) is a recently introduced
ceramic material composed of quartz, lithium dioxide, phosphor oxide,
alumina, potassium oxide and other components, characterized by
flexural strength up to 440 MPa.3 The mechanical stability of LDG
ceramic is assured by the embedment of lithium disilicate crystals
(SiO2-Li2O) into a matrix of glass that minimizes microcrack

J Esthet Restor Dent. 2019;1–10. wileyonlinelibrary.com/journal/jerd © 2019 Wiley Periodicals, Inc. 1

2 ANGERAME ET AL.
propagation.4,5 The first available and most tested commercial product
belonging to the class of LDG materials is IPS e.max lithium disilicate,
introduced in 2005 by Ivoclar Vivadent. LDG restorations can be man-
ufactured making use of either lost-wax hot-pressing techniques or
computer-aided-design/computer-aided manufacturing (CAD/CAM)
milling procedures. CAD/CAM LDG ceramic blocks, which are avail-
6
able for both the dental laboratory and office milling machines, are
fabricated at the industrial level under controlled conditions, that min-
imize the formation of voids and volume defects within the material.7
Among the several CAD/CAM ceramic materials, IPS e.max CAD
exhibited superior mechanical properties and better internal fit than
that of other ceramic blocks used for all-ceramic restorations.8 The
clinical effectiveness of monolithic LDG CAD/CAM crowns have been
already documented by a considerable amount of studies, attesting
the capability of LDG crowns to maintain their structural integrity
after 2 years of clinical service,9 and to reach a 10-year survival rate
equal to 96.7%.10 Laboratory studies on LDG crowns have shown
their superior reliability after fatigue in comparison with porcelain-
layered Yttrium-tetragonal zirconia polycrystal-based crowns.11,12
Molar crowns made of IPS e.max CAD can withstand mean fracture
loads up to 2500 N, which is approximately 3 to 4 times the maximum
force that can be exerted by the masticatory muscles in the posterior
area.11 The use of monolithic LDG restorations has been advocated
for the rehabilitation of conditions of erosion or abrasion where the
replacement of the damaged enamel is indicated through a “re-enam-
eling” process.13
Different factors play a significant role in determining the fracture
resistance of all-ceramic restorations. The luting technique has an
impact in this regard as adhesively bonded all-ceramic restorations are
characterized by greater fracture resistance than traditionally cemen-
ted restorations. 14,15
Depending on the adhesive system being used,
adhesive restorations bonded making use of total-etch techniques can
16
reach a bond strength up to 28 MPa within enamel and 13 to
17
20 MPa within dentin. Immediate sealing of the freshly cut dentin
has been suggested to improve bond strength.18
The increased thickness of the ceramic restoration is surely
another factor positively affecting its fracture resistance,19 but the
modern minimally invasive concepts of restorative and prosthetic den-
tistry often impose the use of thin occlusal restorations. Scientific evi-
dence on the minimum thickness allowed for LDG ceramic partial
crowns or occlusal veneers is still scarce. Bonded occlusal veneers
made of e.max CAD were found to resist to forces of up to 800 N
and 1000 N, when their thickness was 0.6-1.0 mm or 1.2-1.8 mm,
respectively20,21; these values are only slightly inferior to those of
monolithic full crowns of comparable thickness.22 The use of ultrathin
LDG occlusal veneers (0.6 mm) has been reported to be a promising
and viable restorative procedure.23,24 Further, Guess et al.25 reported
no significant effect on the fracture resistance of pressable LDG
ceramic onlay restorations on premolars reducing the preparation
depth to 1.00 and 0.5 mm.
The preparation design is another factor potentially capable of
influencing the fracture resistance of all-ceramic restorations. Ideally,
the preparation surface of a tooth receiving an all-ceramic restoration
26
should have no sharp angles and be rounded as much as possible.
Nonretentive full-coverage occlusal veneers are becoming a popular
treatment option to restore the shape and anatomy of posterior teeth
affected by occlusal wear and/or advanced erosive lesions.20,21,27–29
Minimally invasive designs or the “no-preparation” approach have
been advocated for teeth where a significant amount of dental tissue
has already been lost by wear and erosion, because further tooth
preparation may be counterproductive in these cases.21 Although
there is some evidence dissuading from the use of LDG single crowns
with feather edge preparation in frontal teeth due to marginal crack
formation,30 little is known about the performance of LDG occlusal
veneers with reduced marginal thickness.
The purpose of this study was to evaluate the influence of two
different occlusal veneer preparations on the fracture load and mar-
ginal quality in maxillary molars restored using monolithic lithium disi-
licate after chewing simulation. A rounded 90 shoulder was
compared to a new minimally invasive chamfer design. The following
hypotheses were tested: (1) there is no difference in the load to frac-
ture, fracture pattern, internal fit, and marginal quality between the
two preparation techniques and (2) the thermomechanical aging simu-
lation has no influence on the marginal adaptation of occlusal veneers.
2 | M A T E R I A L S A N D M ET H O D S
2.1 | Sample selection
The sample size was calculated on the basis of data gathered in prelimi-
nary studies (α = 0.05; β = 0.20; δ = 250.0; σ = 160.0). Sixteen extracted
noncarious human maxillary molars were collected after obtaining the
patients' informed consent to their use for research purposes under a
protocol approved by the institutional review board of the University of
Trieste. The teeth were stored at 4 C in 0.5% chloramine-T solution for
no more than 1 month before use. With the aim of selecting teeth of
comparable size, the teeth to be included in the present experimentation
were measured with a digital caliper and discarded if exceeding the fol-
lowing ranges: crown mesiodistal width, 10.5 ± 1.0 mm; crown buccolin-
gual width, 11.5 ± 1.0 mm; overall length, 20.0 ± 1.0 mm.
The remnants of periodontal ligament and calculus were removed
with a manual scaler. Then, the teeth were immersed into a 5%
sodium hypochlorite solution for 15 minutes and stored in saline.
The teeth were randomly assigned to two test groups of eight
elements each according to the preparation technique to receive a
full-coverage lithium disilicate occlusal veneer. The teeth were pre-
pared either with a rounded 90 shoulder finish line in group 1 (G1),
or a minimally invasive chamfer in group 2 (G2), as described below.
2.2 | Tooth preparation
A single experienced prosthodontist performed all the operative
phases for sample preparation. The occlusal reduction for both groups
was set at 1 mm, following the indications about the minimum occlu-
sal thickness for the final restoration given by the manufacturer of the
lithium disilicate CAD/CAM blocks used in the present study (IPS e.
max, Ivoclar Vivadent, Schaan, Liechtenstein). For each tooth, two sili-
con indexes were obtained to check the occlusal reduction in mesio-
distal and buccolingual direction.
ANGERAME ET AL.
FIGURE 1 Detail of the occlusal veneer preparation criteria in the two experimental groups: 90 rounded shoulder (A) and minimally invasive chamfer (B)
The teeth were prepared with a simple nonretentive full-coverage
geometry with blunt internal edges. Specifically, the step-by-step
preparation protocol for each group was the following:
• G1, rounded 90 shoulder (Figure 1A). Depth grooves were placed
all over the occlusal surface of the tooth following the original anat-
omy with a cylindrical coarse diamond bur (835 KRM 314008,
Komet, Lemgo, Germany) with a 0.8 mm diameter. The guiding
grooves were connected by removing the enamel septa between
the grooves with a conical bur (846 KR 314 016, Komet). The occlu-
sal preparation was finished with a fine-grit diamond bur (8846 KR
314 016, Komet). A wider round-ended cylindrical diamond bur
(836 KR 314 018, Komet) was used to prepare the axial walls creat-

ing a 90 shoulder finish line, which was finished with a fine-grit bur
(88836 KR 314 018, Komet). The prepared surfaces were then
polished with abrasive rubber points (9608 314 030, Komet).
• G2, minimally invasive chamfer technique (Figure 1B). The occlusal
reduction was carried out as described in G1. The marginal chamfer
was prepared on the top of the axial wall with the aid of a specific
tapered bur with a noncutting guide pin at its tip (6856P 314 018,
Komet) and finished with a fine-grit bur (8856 P 314 018, Komet;
Figure 2). The prepared surfaces were polished as described above.
2.3 | Immediate dentin sealing
The dentin surfaces exposed by the tooth preparation process were
immediately treated with a self-etch adhesive system (Clearfil SE Bond
2, Kuraray, Osaka, Japan) by following the principles of the immediate
FIGURE 2 Preparation of the minimally invasive chamfer with coarse (A) and fine grit (B) diamond burs. Note the noncutting pin at the burs' tip
3
dentin sealing.31–33 The adhesive primer was applied on the exposed den-
tine with a light brushing motion for 20 seconds and gently air-dried for
5 seconds. Afterward, the adhesive resin was applied only on dentin and
light-cured with a LED lamp at 1500 mW/cm2 (Radii Plus, SDI Limited,
Bayswater, Australia) for 20 seconds. Excess resin accumulated on the
enamel margins was carefully removed with the aid of an abrasive rubber
point (9608 314 030, Komet) activated at low-speed. The prepared speci-
mens were embedded into self-curing resin blocks (Protemp 4, 3M ESPE,
St. Paul, MN) up to a depth of 3 mm apical to the cementoenamel junc-
tion after the periodontal ligament simulation was obtained by applying a
layer of regular-viscosity vinyl polysiloxane (Express Standard, 3M ESPE)
onto the root portion of each tooth following a previously described pro-
cedure.34 Polytetrafluoroethylene cylinders having an internal diameter of
15 mm were used as mold. The specimens were stored in distilled water
for 24 hours at 37 C before the restorative procedures.
2.4 | Restorations design and manufacturing
Table 1 reports the details of the tested materials. The whole process
of occlusal veneer design and manufacturing was carried out with the
Cerec 3 CAD/CAM system (Cerec software v. 3.03, Sirona Dental
Systems GmbH, Bensheim, Germany). The specimens were subjected
to optical impression to replicate the clinical setting. A stainless-steel
ball with a diameter of 5 mm with similar dimensions of the head of
the stylus used in the fracture resistance test was also scanned. This
approach allowed to plan the occlusal anatomy of the restoration with
the aim of providing an ideal tripod between the central fossa of the
occlusal veneer and the stylus.
4 ANGERAME ET AL.

TABLE 1 Chemical compositions and application procedures of the tested materials

Material Application procedures Composition

Clearfil SE Bond 2,
Kuraray, Osaka, Japan
Fill Etch, Dental World,
Molfetta, Italy
IPS e.max CAD, Ivoclar-Vivadent,
Shaan, Liechtenstein
Variolink II, Ivoclar-Vivadent,
Shaan, Liechtenstein
Etch-and-dry acid primer 20 seconds,
air blow s, bonding for 20 seconds
and light curing for 20 s
Application on enamel for
30 seconds
Primer: 10-methacryloyloxydecyl dihydrogen phosphate,
2-hydroxyethyl methacrylate, hydrophilic aliphatic dimethacrylate,
dl-camphorquinone, water
Bonding: 10-methacryloyloxydecyl dihydrogen phosphate, bisphenol
A diglycidylmethacrylate, 2-hydroxyethyl methacrylate,
hydrophobic aliphatic dimethacrylate, dl-camphorquinone,
initiators, accelerators, silanated colloidal silica.
Phosphoric acid, purified water, thickener, colorant.
SiO2, Li2O, K2O, P2O5, ZrO2, ZnO, other and coloring oxides.
Bisphenol A diglycidylmethacrylate, urethane dimethacrylate,
triethylene glycol dimethacrylate, barium glass, ytterbium
trifluoride, Ba-Al-fluorosilicate glass, spheroid mixed oxide,
catalysts, stabilizers, pigments (particle size: 0.04-3 μm; mean filler
size: 0.7 μm; base: 46.7 vol%, low viscosity catalyst: 43.6 vol%).

Sixteen occlusal veneers were milled from an equal number of
lithium disilicate blocks (IPS e.max CAD) following the same principles
already described by Magne et al.20 After milling, each restoration was
carefully examined and no cracks were observed. After manufacturing,
the internal surface of each restoration was acid-etched with viscous
buffered 9% hydrofluoric acid (HF; Porcelain etch, Ultradent Products,
Inc., South Jordan, Utah) for 20 seconds, which was then rinsed with
water spray for 20 seconds. Postetching cleaning was performed with
37% orthophosphoric acid (Fill Etch, Dental World, Molfetta, Italy).
After 60 seconds, the gel was rinsed with water spray for the same
amount of time and the restoration immersed in an ultrasonic bath
containing absolute ethanol for 3 minutes. Once dried, a silane primer
(Monobond Plus, Ivoclar Vivadent) was applied thrice onto the inner
surface of each veneer and gently dried with air.
St. Paul, Minnesota). The enamel margins were covered with an etchant
gel containing 37% orthophosphoric acid (Fill Etch, Dental World), which
was rinsed after 30 seconds. Both the internal surface of the restoration
and the prepared tooth were covered with adhesive resin (Clearfil SE
Bond 2, Kuraray). The two components of a dual-cure resin luting
cement (Variolink II, shade A3, Ivoclar-Vivadent) were mixed in a 1:1
ratio and placed onto the treated veneer surface. Seating pressure of
20 g/mm2 was applied with a plunger loaded by a box filled with lead
pellets for 5 minutes to the specimens.35. The excess luting cement
extruding at the adhesive interface was removed with a manual instru-
ment and each surface of the restored tooth was exposed to three light-
curing cycles of 20 s each with a LED lamp at 1500 mW/cm2 (Radii
Plus, SDI Limited). The margins were polished with rotary rubber points
(Identoflex Composite Polishers, Kerr, Orange, California) (Figure 3).

2.5 | Adhesive placement 2.6 | Thermomechanical aging

The prepared tooth surfaces were treated with an intraoral sandblaster Specimens were incubated in distilled water at 37 C for 24 hours and
and 35 μm aluminum oxide particles at 30 psi (Cojet System, 3M, then cleaned for 10 minutes by sonication.

FIGURE 3 Representative specimens of the two experimental groups after preparation and occlusal veneer cementation: rounded 90 shoulder
(A and C) and minimally invasive chamfer (B and D)
ANGERAME ET AL.
The restored samples underwent thermomechanical aging by
means of a chewing simulator (CS-4.4, Willytech, Munich, Germany).
A steatite ceramic sphere with a 5-mm diameter (Hoechst Ceram
Tec, Wunsiedel, Germany) was applied with a downward speed of
16 mm/s exerting a force of 50 N, at a frequency of 1 Hz for
1 250 000 cycles.36 At the same time, the device subjected the speci-
mens to thermocycles of 80 seconds each in distilled water at
5 ± 3 C e 55 ± 3 C. Correct thermo-mechanical loading was checked
every 10 000 cycles by monitoring the mechanical action and water
temperature within the chewing chambers.
2.7 | Load-to-fracture test and failure analysis
The resistance to fracture of the specimens was tested with a univer-
sal testing machine (Quasar, Galdabini, Cardano al Campo, Italy),
which was set to exert an increasing force with a round 5 mm wide
stainless steel stylus onto the restored tooth at a speed of
1 mm/min.25 The tip of the stylus was positioned over the central
fossa to achieve tripodization of contacts along the cuspal inclines
(Figure 4). The maximum load to fracture was registered and collected
in a dedicated spreadsheet.
The type of fracture was qualitatively appraised by two indepen-
dent trained examiners, who classified the failure mode distinguishing
between failures above or below the cementoenamel junction and
between fractures and cracks (fracture without fragment detachment).37
2.8 | Marginal quality and internal fit analysis
Making use of custom box-shaped trays, two-phase two-stage preci-
sion impressions (Aquasil Putty and Light, Dentsply Caulk, Milford,
Delaware) of the restored teeth were taken immediately after the
occlusal veneer cementation, at the end of thermomechanical aging
and after the load-to-fracture test.
Epoxy resin was prepared by mixing the two components of a
commercial product in the 5:2 ratio suggested by the manufacturer
FIGURE 4 Load to fracture test in the universal testing machine
5
FIGURE 5 Transillumination of a specimen after testing. Note
“mosaiclike” cracks as a result of force propagation through a brittle,
crystalline, solid material. This type of restorable fracture was the
most frequent under the conditions of the present study
(EpoThin Epoxy Resin and Hardener, Buehler, Lake Bluff, Illinois) and
then poured inside the impressions. After 24 hours, the positive resin
replicas of the restored teeth were removed from the impressions and
sputter-coated with gold (Sputter Coater K550X, Fei Company, Hills-
boro, Nebraska) in order to be observed at the scanning electron
microscope (Quanta 250, Fei Company). A low-magnification image
(50×) of each of the four faces of the restored tooth (mesial, buccal,
distal, and lingual) was acquired for the semiquantitative evaluation of
marginal seal, which was carried out according to a previously
described protocol38 that involves the following categories: continu-
ous margin, gap/irregularity, or not assessable/artifact.
All the specimens were longitudinally sectioned trice with a
microtome (Micromet, Remet, Bologna, Italy; Figure 5), thus creating
four surfaces to be analyzed. Each section was inspected and photo-
graphed at the stereomicroscope (MZ16, Leica, Wetzlar, Germany), to
measure the thickness of the cement layer with the aid of the same
software mentioned above. The cement thickness was measured at
20 equidistant points along the adhesive interface.
2.9 | Statistical analysis
All the data sets were handled with statistical software (Statistical
Package for Social Sciences v.15, SPSS Inc., Chicago, Illinois). Scalar
data were tested for the existence of the assumptions for the use of
parametric tests (Shapiro-Wilk and Levene tests). The differences in
maximum load to fracture between the two groups were carried out
with an independent sample t test. A Chi-squared test served to com-
pare the groups in terms of fracture pattern after the load-to-fracture
test and in terms of margin quality. For the measurement of internal
fit, the average value of the readings obtained for each specimen con-
stituted the statistical unit and the comparisons between groups were
performed by means of independent sample t tests. The value of α
was set at 5%.
6 ANGERAME ET AL.
TABLE 2 Failure types and numbers (crack implies fracture without isolated fragment)
Group Intact specimen Fracture above CEJ
Crack
Chamfer (n = 8) 0 6
Shoulder (n = 8) 0 5
3 | RESULTS
The means of the maximum load to fracture were 2395.01 ± 150.96 N
and 2408.39 ± 112.66 N in shoulder and chamfer groups, respectively;
the difference was not statistically significant (P = 0.844). The fracture
pattern, summarized in Table 2, was also similar in the two groups, with
cracks above the CEJ being the most predominant type of restoration
failure (Figure 6). In both groups, only two specimens were characterized
by fracture below the CEJ.
As to margin quality assessment, the vast majority of the observed
specimens exhibited continuous margins (87.5%-100%), irrespective of
experimental phase or group (P > 0.05) (Table 3 and Figure 7).
The internal fit measurement revealed good adaptation of the
occlusal veneer restoration, with cement thickness values equal to
132 ± 38 μm in G1 and 150 ± 41 μm in G2 (Figure 8). The difference
in internal fit was not statistically significant (P = 0.393).
4 | DISCUSSION
The null hypotheses that the tested types of preparation technique do
not affect load to fracture, fracture pattern, internal fit, and marginal
quality, as well as that thermomechanical loading has no influence on
the marginal adaptation were both accepted.
Occlusal veneers have been demonstrated as a conservative alter-
native to traditional onlays and complete coverage crowns for the treat-
ment of severe abrasive/erosive lesions. Occlusal veneers are essentially
thin overlay restorations with a nonretentive design that allow the
FIGURE 6 Specimen after microtome sectioning before internal fit
assessment
Fracture below CEJ
Fragment Crack Fragment
0 0 2
1 0 2
conservation of coronal structure, often avoiding the root canal treat-
ment. For this reason, the present investigation was conducted on teeth
that intentionally were not endodontically treated. This kind of restora-
tions can be fabricated at a minimal thickness (0.6 mm) even with CAD/-
CAM techniques, such as the Cerec system.21
After thermomechanical loading, all ceramic restorations survived
without fracture or chipping. Masticatory forces during normal func-
tion range from 50 N to 250 N and 500 to 800 N in bruxism in the
posterior region.39,40 Mean fracture loads for both groups (~2300 N)
exceeded those values. Comparing our results to other investigations
on the fracture resistance of LDG restorations, resistance to load was
significantly higher than that reported in a study on premolars
restored with LDG overlays (maximum mean value 1361 ± 333 N).25
Such difference is possibly attributed to the different tooth type. On
the other hand, a recent work on LDG occlusal veneers considering
different molar tooth preparations showed a wide range of fracture
loads among the considered experimental groups (median value
610 N-3390 N),27 which were slightly below or greatly above the
recommended minimum fracture strength for posterior restorations of
500 N-700 N.41 The authors obtained the best results with 0.7 to
1.0 mm-thick restoration in terms of the survival rate after dynamic
loading and fracture resistance regardless of the bonding substrate
(only enamel or enamel and dentin), whereas the performance of thin-
ner restorations depended on the bonding surface, with 0.3 to
0.6 mm-thick restorations bonded only to enamel showing the worst
results.27 In the present study, the restorations were mainly bonded
to enamel, but a certain degree of dentin exposure on the occlusal
surface was unavoidable in all teeth (Figure 8); nonetheless, the occlu-
sal veneers were 1.0 mm thick (with the sole exception of the margin
in the chamfer group) and thus the possible effect of bonding to den-
tin was likely decreased. The findings of the present study corroborate
the evidence in favor of the treatment of occlusal abrasion or malposi-
tioned teeth with nonretentive lithium disilicate ceramic occlusal
veneers with a marginal thickness even inferior to 1 mm.
In our study two finishing lines were chosen, a 90 shoulder and a
minimally invasive chamfer, but the marginal preparation design
showed no significant influence on the fracture resistance (P = 0.844).
Clausen et al. evaluated the influence of different preparation designs
(chamfer finishing line or straight-beveled finishing line) on fracture
resistance of adhesively luted nonretentive full-coverage molar resto-
rations, made of lithium or leucite-reinforced glass ceramic, and found
no statistically significant differences on the fracture resistance.42
These considerations suggest that the finishing line seems not to play
a primary role in the fracture resistance of partial indirect restoration,
provided that the other variables are kept constant. Probably the
results of our study might be explained by the location of point of
loading during the fracture test, which was not near the finishing line.
Enamel and dentin are unique tissues with highly specialized function.
ANGERAME ET AL. 7

TABLE 3 Results for marginal quality of the tested specimens

Number of Continuos Gap/ Not judgeable/ % Continuos

Groupa Margin Time analized surfaces margin irregularity artifact margina
Group 1 Shoulder Baseline 32 31 1 0 96.9%
After aging 32 31 1 0 96.9%
Group 2 Chamfer Baseline 32 32 0 0 100%
After aging 32 30 2 0 93.8%
a
No statically significant differences were found among all groups.

When restoring a tooth one should consider not only the restorative
materials that best emulates enamel and dentin, but also the simula-
tion of the dentin-enamel junction through the restoration-dentin
43
bond, which can be considered a true composite structure. Using
extremely thin “enamel-like” restorations, the bonding strategy
becomes yet more important.27
The clinical success of a ceramic restoration depends on the qual-
ity and durability of the bond between the ceramic and the resin
cement.44 The quality of this bond is determined by the bonding
mechanism, which is controlled in part by specific surface treatment
used to promote micromechanical or chemical retention to the
45
ceramic substrate. In the present study, the ceramic restorations
were etched with 9% HF for 20 seconds and covered with silane.
Etching the ceramic surface with 9% HF promoted dissolution in the
glassy matrix of the specimens to the depth of a few microns,
increased the surface area and facilitated the penetration and reten-
tion of resin cement into the microretentions of the treated surface.46
The ideal HF concentration to maximize the ceramic surface rough-
ness and avoid the potential detrimental effects of over-etching on
the strength of the LDG restorations is still debated. Some authors
have advocated the use of 5% HF acid to reduce the risk of defect
formation on the ceramic surface and their propagation in the bulk
structure of the LDG restoration.47 Some others reported no signifi-
cant differences between 5% and 10% HF etching in terms of bond
strength to LDG ceramic48 and, most importantly, of cyclic load-to-
failure of lithium disilicate crowns.49 Therefore, making use of differ-
ent combinations of HF concentrations and etching times appears
reasonable, provided that over-etching is avoided. As to alternative

FIGURE 7 Representative scanning electron microscope images of the margin quality before and after thermomechanical loading in the 90
rounded shoulder group (A and B) and in the minimally invasive chamfer group (C and D)
8 ANGERAME ET AL.
FIGURE 8 Appearance of two representative sections observed
during the internal fit assessment: 90 rounded shoulder (A) and
minimally invasive chamfer (B)
surface treatments, several studies demonstrated that there is a
decrease in shear bond strength when the ceramic surface was air
abraded with Al2O3 when compared with a ceramic surface etched
with 9%-10% HF.46,50,51 Differently, Panah et al. showed no signifi-
cant differences between a ceramic surface etched with 10 HF% and
one air abraded with Al2O3.52
Specimens were thermo-mechanically cycled with a specific load-
ing machine to simulate in vitro the physical stress to which restored
teeth are exposed in the oral environment. Tensions and thermo-
mechanical stress occur at the adhesive interface due to the different
thermal expansion coefficients of the materials and are able to induce
physicochemical alterations in dental materials.53,54 In the present
 
study, the temperature ranged from 5 C to 55 C in 1 250 000 cycles,
because thermal records in the oral environment ranged between 0 C
and 67 C.55
The coefficient of thermal expansion is defined as a change in
length per unit of the original length when the temperature is changed
by 1 K. It is known that the coefficients of thermal expansion of
enamel and dentin are approximately 17 × 10−6/ C and 11 × 10−6/
C respectively and the coefficients for adhesive and resin cement
range between 20 × 10−6/ C and 80 × 10−6/ C.56 For the restored
tooth, the problem is amplified by the use of composites, because
some of these materials may exhibit high thermal expansion coeffi-
cients when compared with porcelain or ceramics.57 in vitro studies
have shown that oral fluids degrade the resin matrix, and it has been
shown that thermomechanical loading causes the marginal adaptation
of adhesive restorations to break down.58 In this study, no differences
in the margin with two different preparations designs were observed
at time zero and after thermo-mechanical loading. Thus, satisfactory
adhesion to enamel was evident in all groups. This investigation is in
agreement with other studies in which enamel margins demonstrated
a good seal in contrast to the dentin margins because bonding to
enamel produces the smallest degree of microleakage.59
The internal fit measurement revealed good adaptation of the
occlusal veneer restoration, with cement thickness values equal to
0.132 ± 0.038 μm in G1 and 0.150 ± 0.041 μm in G2 (P = 0.393).
These findings attest that the registered internal adaptation is clini-
cally acceptable. To the best of the Authors' knowledge, no previous
study has investigated the internal fit of LDG occlusal veneers. Never-
theless, it is conceivable that the internal fit of such kind of restoration
would not substantially vary from that obtainable with full crowns at
the occlusal level, given the standardization of the scanning and mill-
ing processes. In accordance with this speculation, a recent study
reported internal fit values at the occlusal space of e.max LDG crowns
that were very similar to that found in the present study (median
values 139-166 μm, depending on the intraoral camera used for the
scanning process).60
5 | CONC LU SIONS
In conclusion, the results of the present study support the use of dif-
ferent preparations lines for occlusal veneer with LDG. Further in vivo
studies are needed to validate the clinical performance of the more
conservative preparation design.
ACKNOWLEDGMENTS
The authors thank the staff of the dental laboratory Momic, Via
Nicolò degli Aldegardi 18, Trieste, Italy, for providing their essential
contribution for the occlusal veneer fabrication. The authors declare
that they do not have any financial interest in the companies whose
materials are included in this article.
ORCID
Daniele Angerame https://orcid.org/0000-0003-4345-3790
Matteo De Biasi https://orcid.org/0000-0003-2261-0400
RE FE RE NC ES
1. Edelhoff D, Sorensen JA. Tooth structure removal associated with var-
ious preparation designs for posterior teeth. Int J Periodontics Restor-
ative Dent. 2002;22:241-249.
2. Valenti M, Valenti A. Retrospective survival analysis of 261 lithium dis-
ilicate crowns in a private general practice. Quintessence Int. 2009;40:
573-579.
3. Tysowsky GW. The science behind lithium disilicate: a metal-free
alternative. Dent Today. 2009;28:112-113.
4. Demir N, Ozturk AN, Malkoc MA. Evaluation of the marginal fit of full
ceramic crowns by the microcomputed tomography (micro-CT) tech-
nique. Eur J Dent. 2014;8:437-444.
ANGERAME ET AL.
5. Silva NR, Thompson VP, Valverde GB, et al. Comparative reliability
analyses of zirconium oxide and lithium disilicate restorations in vitro
and in vivo. J Am Dent Assoc. 2011;142(suppl 2):4S-9S.
6. Anadioti E, Aquilino SA, Gratton DG, et al. 3D and 2D marginal fit of
pressed and CAD/CAM lithium disilicate crowns made from digital
and conventional impressions. J Prosthodont. 2014;23:610-617.
7. Giordano R. Materials for chairside CAD/CAM-produced restorations.
J Am Dent Assoc. 2006;137(suppl 1):14S-21S.
8. Goujat A, Abouelleil H, Colon P, et al. Mechanical properties and inter-
nal fit of 4 CAD-CAM block materials. J Prosthet Dent. 2018;119:
384-389.
9. Fasbinder DJ, Dennison JB, Heys D, Neiva G. A clinical evaluation of
chairside lithium disilicate CAD/CAM crowns: a two-year report. J Am
Dent Assoc. 2010;141(suppl 2):10S-14S.
10. Pieger S, Salman A, Bidra AS. Clinical outcomes of lithium disilicate
single crowns and partial fixed dental prostheses: a systematic review.
J Prosthet Dent. 2014;112:22-30.
11. Guess PC, Zavanelli RA, Silva NR, Bonfante EA, Coelho PG,
Thompson VP. Monolithic CAD/CAM lithium disilicate versus
veneered Y-TZP crowns: comparison of failure modes and reliability
after fatigue. Int J Prosthodont. 2010;23:434-442.
12. Silva NR, Bonfante EA, Martins LM, et al. Reliability of reduced-
thickness and thinly veneered lithium disilicate crowns. J Dent Res.
2012;91:305-310.
13. Cortellini D, Parvizi A. Rehabilitation of severely eroded dentition uti-
lizing all-ceramic restorations. Pract Proced Aesthet Dent. 2003;15:
275-282. quiz 284.
14. Piwowarczyk A, Bender R, Ottl P, Lauer HC. Long-term bond between
dual-polymerizing cementing agents and human hard dental tissue.
Dent Mater. 2007;23:211-217.
15. Klosa K, Wolfart S, Lehmann F, Wenz HJ, Kern M. The effect of stor-
age conditions, contamination modes and cleaning procedures on the
resin bond strength to lithium disilicate ceramic. J Adhes Dent. 2009;
11:127-135.
16. Fortin D, Swift EJ Jr, Denehy GE, Reinhardt JW. Bond strength and
microleakage of current dentin adhesives. Dent Mater. 1994;10:
253-258.
17. Sarr M, Mine A, De Munck J, et al. Immediate bonding effectiveness
of contemporary composite cements to dentin. Clin Oral Investig.
2010;14:569-577.
18. Magne P. IDS: Immediate Dentin Sealing (IDS) for tooth preparations.
J Adhes Dent. 2014;16:594.
19. Lima JM, Souza AC, Anami LC, et al. Effects of thickness, processing
technique, and cooling rate protocol on the flexural strength of a
bilayer ceramic system. Dent Mater. 2013;29:1063-1072.
20. Magne P, Schlichting LH, Maia HP, Baratieri LN. In vitro fatigue resis-
tance of CAD/CAM composite resin and ceramic posterior occlusal
veneers. J Prosthet Dent. 2010;104:149-157.
21. Schlichting LH, Maia HP, Baratieri LN, Magne P. Novel-design ultra-
thin CAD/CAM composite resin and ceramic occlusal veneers for the
treatment of severe dental erosion. J Prosthet Dent. 2011;105:
217-226.
22. Sorrentino R, Nagasawa Y, Infelise M, et al. In vitro analysis of the
fracture resistance of CAD-CAM monolithic lithium disilicate molar
crowns with different occlusal thickness. J Osseointegr. 2018;10:
11-17.
23. Al-Akhali M, Chaar MS, Elsayed A, et al. Fracture resistance of ceramic
and polymer-based occlusal veneer restorations. J Mech Behav Biomed
Mater. 2017;74:245-250.
24. Andrade JP, Stona D, Bittencourt HR, Borges GA, Burnett LH Júnior,
Spohr AM. Effect of different computer-aided design/computer-aided
manufacturing (CAD/CAM) materials and thicknesses on the fracture
resistance of occlusal veneers. Oper Dent. 2018;43:539-548.
25. Guess PC, Schultheis S, Wolkewitz M, Zhang Y, Strub JR. Influence of
preparation design and ceramic thicknesses on fracture resistance and
failure modes of premolar partial coverage restorations. J Prosthet
Dent. 2013;110:264-273.
26. Federlin M, Krifka S, Herpich M, Hiller KA, Schmalz G. Partial ceramic
crowns: influence of ceramic thickness, preparation design and luting
material on fracture resistance and marginal integrity in vitro. Oper
Dent. 2007;32:251-260.
9
27. Sasse M, Krummel A, Klosa K, Kern M. Influence of restoration thickness
and dental bonding surface on the fracture resistance of full-coverage
occlusal veneers made from lithium disilicate ceramic. Dent Mater. 2015;
31:907-915.
28. Magne P, Stanley K, Schlichting LH. Modeling of ultrathin occlusal
veneers. Dent Mater. 2012;28:777-782.
29. Schlichting LH, Resende TH, Reis KR, Magne P. Simplified treatment
of severe dental erosion with ultrathin CAD-CAM composite occlusal
veneers and anterior bilaminar veneers. J Prosthet Dent. 2016;116:
474-482.
30. Fuzzi M, Tricarico MG, Ferrari Cagidiaco E, et al. Nanoleakage and
internal adaptation of zirconia and lithium disilicate single crowns with
feather edge preparation. J Osseointegr. 2017;9:250-262.
31. Magne P. Immediate dentin sealing: a fundamental procedure for indi-
rect bonded restorations. J Esthet Restor Dent. 2005;17:144-154. dis-
cussion 155.
32. Magne P, So WS, Cascione D. Immediate dentin sealing supports
delayed restoration placement. J Prosthet Dent. 2007;98:166-174.
33. Oliveira L, Mota EG, Borges GA, Burnett LH Jr, Spohr AM. Influence
of immediate dentin sealing techniques on cuspal deflection and frac-
ture resistance of teeth restored with composite resin inlays. Oper
Dent. 2014;39:72-80.
34. Wafaie RA, Ibrahim Ali A, Mahmoud SH. Fracture resistance of pre-
pared premolars restored with bonded new lab composite and all-
ceramic inlay/onlay restorations: Laboratory study. J Esthet Restor
Dent. 2018;30:229-239.
35. Goracci C, Cury AH, Cantoro A, Papacchini F, Tay FR, Ferrari M.
Microtensile bond strength and interfacial properties of self-etching
and self-adhesive resin cements used to lute composite onlays under
different seating forces. J Adhes Dent. 2006;8:327-335.
36. Kern M, Strub JR, Lu XY. Wear of composite resin veneering materials
in a dual-axis chewing simulator. J Oral Rehabil. 1999;26:372-378.
37. Magne P, Knezevic A. Thickness of CAD-CAM composite resin over-
lays influences fatigue resistance of endodontically treated premolars.
Dent Mater. 2009;25:1264-1268.
38. Spreafico R, Marchesi G, Turco G, et al. Evaluation of the in vitro
effects of cervical marginal relocation using composite resins on the
marginal quality of CAD/CAM crowns. J Adhes Dent. 2016;18:
355-362.
39. Kampe T. Function and dysfunction of the masticatory system in indi-
viduals with intact and restored dentitions. A clinical, psychological
and physiological study. Swed Dent J Suppl. 1987;42:1-68.
40. Kiliaridis S, Kjellberg H, Wenneberg B, Engstrom C. The relationship
between maximal bite force, bite force endurance, and facial morphol-
ogy during growth. A cross-sectional study. Acta Odontol Scand. 1993;
51:323-331.
41. Körber KH, Ludwig K. Maximum biteforces as a basis for the design of
dental restorations. Dent Labor. 1983;31:55-60.
42. Clausen JO, Abou Tara M, Kern M. Dynamic fatigue and fracture resis-
tance of non-retentive all-ceramic full-coverage molar restorations.
Influence of ceramic material and preparation design. Dent Mater.
2010;26:533-538.
43. Magne P, Knezevic A. Influence of overlay restorative materials and
load cusps on the fatigue resistance of endodontically treated molars.
Quintessence Int. 2009;40:729-737.
44. Soares CJ, Soares PV, Pereira JC, Fonseca RB. Surface treatment pro-
tocols in the cementation process of ceramic and laboratory-
processed composite restorations: a literature review. J Esthet Restor
Dent. 2005;17:224-235.
45. Della Bona A, Shen C, Anusavice KJ. Work of adhesion of resin on
treated lithia disilicate-based ceramic. Dent Mater. 2004;20:
338-344.
46. Spohr AM, Sobrinho LC, Consani S, et al. Influence of surface condi-
tions and silane agent on the bond of resin to IPS Empress 2 ceramic.
Int J Prosthodont. 2003;16:277-282.
47. Murillo-Gomez F, Palma-Dibb RG, De Goes MF. Effect of acid etching
on tridimensional microstructure of etchable CAD/CAM materials.
Dent Mater. 2018;34:944-955.
48. Puppin-Rontani J, Sundfeld D, Costa AR, et al. Effect of hydrofluoric
acid concentration and etching time on bond strength to lithium disili-
cate glass ceramic. Oper Dent. 2017;42:606-615.
10
49. Prochnow C, Venturini AB, Guilardi LF, et al. Hydrofluoric acid concen-
trations: Effect on the cyclic load-to-failure of machined lithium disilicate
restorations. Dent Mater. 2018;34:e255-e263.
50. Salvio LA, Correr-Sobrinho L, Consani S, Sinhoreti MAC, de Goes MF,
Knowles JC. Effect of water storage and surface treatments on the
tensile bond strength of IPS Empress 2 ceramic. J Prosthodont. 2007;
16:192-199.
51. Ayad MF, Fahmy NZ, Rosenstiel SF. Effect of surface treatment on
roughness and bond strength of a heat-pressed ceramic. J Prosthet
Dent. 2008;99:123-130.
52. Panah FG, Rezai SM, Ahmadian L. The influence of ceramic surface
treatments on the micro-shear bond strength of composite resin to
IPS Empress 2. J Prosthodont. 2008;17:409-414.
53. DeLong R, Douglas WH. Development of an artificial oral environ-
ment for the testing of dental restoratives: bi-axial force and move-
ment control. J Dent Res. 1983;62:32-36.
54. Oyafuso DK, Ozcan M, Bottino MA, Itinoche MK. Influence of thermal
and mechanical cycling on the flexural strength of ceramics with tita-
nium or gold alloy frameworks. Dent Mater. 2008;24:351-356.
55. Palmer DS, Barco MT, Billy EJ. Temperature extremes produced orally
by hot and cold liquids. J Prosthet Dent. 1992;67:325-327.
56. Anusavice KJ, Brantley WA. Physical properties of dental materials. In:
Anusavice KJ, ed. Phillips' Science of Dental Materials. 11th ed. St.
Louis, MO: Saunders; 2005:52-53.
ANGERAME ET AL.
57. Versluis A, Douglas WH, Sakaguchi RL. Thermal expansion coefficient
of dental composites measured with strain gauges. Dent Mater. 1996;
12:290-294.
58. Roulet JF, Walti C. Influence of oral fluid on composite resin and
glass-ionomer cement. J Prosthet Dent. 1984;52:182-189.
59. Uludag B, Ozturk O, Ozturk AN. Microleakage of ceramic inlays luted
with different resin cements and dentin adhesives. J Prosthet Dent.
2009;102:235-241.
60. de Paula Silveira AC, Chaves SB, Hilgert LA, Ribeiro AP. Marginal and
internal fit of CAD-CAM-fabricated composite resin and ceramic
crowns scanned by 2 intraoral cameras. J Prosthet Dent. 2017;117:
386-392.
How to cite this article: Angerame D, De Biasi M,
Agostinetto M, Franzò A, Marchesi G. Influence of preparation
designs on marginal adaptation and failure load of full-
coverage occlusal veneers after thermomechanical aging simu-
lation. J Esthet Restor Dent. 2019;1–10. https://doi.org/10.
1111/jerd.12457