RESEARCH AND EDUCATION

Comparison of mechanical properties of three machinable

ceramics with an experimental fluorophlogopite glass ceramic
Brian T. W. Leung, BDS, MDS, MSc,a James K. H. Tsoi, BSc, PhD,b Jukka P. Matinlinna, BSc, MSc, PhD,c
and Edmond H. N. Pow, BDS, MDS, PhDd

Ceramic materials are widely ABSTRACT

used in dentistry because of
their biocompatibility, chemi-
cal inertness, good compres-
sive strength and abrasion
resistance, low plaque accu-
mulation, superior esthetics,
and color stability.1 However,
their low tensile and flexural
strength make the material
brittle and sensitive to flaws
and defects.2,3 With the ad-
vancement in computer-aided
design/computer-aided man-
4
ufacturing technology, cer-
amic dental restorations can be
milled from a solid ceramic
block instead of made with
conventional multiple firings
of feldspathic porcelain. Be-
cause the millable ceramic
material has minimal defects
or flaws compared with con-
ventional feldspathic porce-
lain, its mechanical properties
are superior.5-7
Many millable ceramic sys-
tems have been developed and
evaluated,8-15 including glass ceramics and oxide ce-
ramics.16 Zirconia, ZrO2, one of the millable oxide ceramic
Statement of problem. Fluorophlogopite glass ceramic (FGC) is a biocompatible, etchable, and
millable ceramic with fluoride releasing property. However, its mechanical properties and reliability
compared with other machinable ceramics remain undetermined.
Purpose. The purpose of this in vitro study was to compare the mechanical properties of 3
commercially available millable ceramic materials, IPS e.max CAD, Vitablocs Mark II, and Vita Enamic,
with an experimental FGC.
Material and methods. Each type of ceramic block was sectioned into beams (n=15) of standard
dimensions of 2×2×15 mm. Before mechanical testing, specimens of the IPS e.max CAD group were
further fired for final crystallization. Flexural strength was determined by the 3-point bend test with
a universal loading machine at a cross head speed of 1 mm/min. Hardness was determined with a
hardness tester with 5 Vickers hardness indentations (n=5) using a 1.96 N load and a dwell time of
15 seconds. Selected surfaces were examined by scanning electron microscopy and energy-
dispersive x-ray spectroscopy. Data were analyzed by the 1-way ANOVA test and Weibull analysis
(a=.05). Weibull parameters, including the Weibull modulus (m) as well as the characteristic
strength at 63.2% (h) and 10.0% (B10), were obtained.
Results. A significant difference in flexural strength (P<.001) was found among groups, with IPS
e.max CAD (341.88 ±40.25 MPa)>Vita Enamic (145.95 ±12.65 MPa)>Vitablocs Mark II (106.67 ±18.50
MPa), and FGC (117.61 ±7.62 MPa). The Weibull modulus ranged from 6.93 to 18.34, with FGC
showing the highest Weibull modulus among the 4 materials. The Weibull plot revealed that IPS
e.max CAD>Vita Enamic>FGC>Vitablocs Mark II for the characteristic strength at both 63.2% (h) and
10.0% (B10). Significant difference in Vickers hardness among groups (P<.001) was found with IPS
e.max CAD (731.63 ±30.64 HV)>Vitablocs Mark II (594.74 ±25.22 HV)>Vita Enamic (372.29 ±51.23 HV)
>FGC (153.74 ±23.62 HV).
Conclusions. The flexural strength and Vickers hardness of IPS e.max CAD were significantly higher
than those of the 3 materials tested. The FGC’s flexural strength was comparable with Vitablocs
Mark II. The FGC’s Weibull modulus was the highest, while its Vickers hardness was the lowest
among the materials tested. (J Prosthet Dent 2015;114:440-446)
materials, shows excellent mechanical properties,
biocompatibility, and radiopacity.17 However, it is difficult

This work was done in partial fulfillment of the requirements of the degree of Advanced Diploma in Prosthodontics for Brian T. W. Leung at the Faculty of Dentistry,
The University of Hong Kong.
a
Postgraduate student, Oral Rehabilitation, Faculty of Dentistry, The University of Hong Kong, Hong Kong, PR China.
b
Assistant Professor, Dental Materials Science, The University of Hong Kong, Hong Kong, PR China.
c
Associate Professor, Dental Materials Science, The University of Hong Kong, Hong Kong, PR China.
d
Clinical Associate Professor, Oral Rehabilitation, The University of Hong Kong, Hong Kong, PR China.

440 THE JOURNAL OF PROSTHETIC DENTISTRY

September 2015 441

Table 1. Ceramics used

Clinical Implications Ceramic Manufacturer Composition Shade
Lot
No.
Experimental fluorophlogopite glass ceramic is a IPS e.max CAD Ivoclar SiO2, Li2O, K2O, P2O5, ZrO2, LTA2 K11235
less abrasive material with minimal variation in Vivadent ZnO, Al2O3, MgO, coloring
oxides
flexural strength compared with 3 commercial Vitablocs Mark II Vita SiO2, Al2O3, Na2O, K2O, CaO, 2M1C 7728
machinable dental ceramics. Zahnfabrik TiO2, coloring oxides
Vita Enamic Vita SiO2, Al2O3, Na2O, K2O, B2O3, 2M2T 32960
Zahnfabrik CaO, TiO2, coloring oxides,
methacrylate polymer
to bond with composite resin cements18 and veneering Experimental Hing Lung K2SiF6, Al2O3, MgO, SiO2, NA T001
porcelain.19 Although surface treatments such as tri- fluorophlogopite Engineering B2O3
glass ceramic
bochemical silica coating have been thought to enhance
the bonding to resin,18 airborne-particle abrasion could
make the material more susceptible to low temperature patients,33 patients with amelogenesis imperfecta,34 or
degradation. Therefore, other pretreatment methods, patients with bruxism or dental erosion.35 However,
including laser,19 and infiltration coating,20 and other long-term in vivo studies are still lacking.34
coupling agents,21 have been investigated. Other ceramics The formation of cracks in materials usually starts
can be etched with hydrofluoric acid, resulting in a rough from the flaws and/or voids at a surface or internally and
surface for bonding, and the bond on such an etched then penetrates to the interface of the grains or weaker
surface has been shown to be strong and reliable.22,23 phases in the material. In machinable materials, surface
Because the etching procedure can be easily performed flaws could be generated during the milling process or
either in the dental laboratory or chairside, etchable glass during the hydrofluoric acid etching process. In partic-
ceramics are popular in clinical practice.24-26 ular, Vita Enamic contains heterogeneous phases of resin
A variety of millable ceramics are available.27,28 IPS and ceramics that might be dislocated (phase separation)
e.max CAD (Ivoclar Vivadent AG) is a lithium disilicate, during any mechanical challenges, for example,
Li2Si2O5 containing 35 to 45 vol% of evenly dispersed compression and bending.36 The other 2 ceramics, IPS
1 to 5 mm leucite crystals. Vitablocs Mark II (Vita Zahn- e.max CAD and Vitablocs Mark II, have homogeneous
fabrik) is a fine-particle (4 mm) feldspathic porcelain phases; once the crack starts, it will propagate promptly,
involving a sintering process at 1170 C under vacuum and no diversion of the crack would occur within the
that can produce a homogenous microstructure ceramic ceramic matrix. To arrest the crack propagation, an
block for the milling process. Vita Enamic (Vita Zahn- effective method is to introduce crystals or flakes with the
fabrik) was recently introduced as a polymer-infiltrated- same chemical composition to interlock and thus rein-
ceramic-network material.29,30 This material is claimed force the phases.36
to be a hybrid ceramic material comprising a structure- Fluorophlogopite glass ceramic (FGC) is a glass
sintered ceramic matrix with space in between ceramic ceramic that contains such flake components.37 In addi-
substrates filled with resin material to form a so-called tion, FGC has been shown to release fluoride ions
double network hybrid. Although the processing is not slowly.38 A recent study showed that fluoride-releasing
disclosed by the manufacturer, the mass percentage of restorative materials could inhibit the drop of pH value
the inorganic ceramic part is stated to be 86 wt% and the at the bacteria-material interface after glucose challenge,
organic polymer part 14 wt%. As claimed by the manu- which seemed to correspond to the fluoride level.39
facturer, the dominant basic ceramic network provides Therefore, FGC might be a suitable machinable dental
stability, and the polymer network provides elasticity.31 ceramic. However, limited data are available on the
The material is claimed to absorb masticatory forces mechanical properties of FGC.40
and stop crack formation.32 Studies suggest this material Flexural strength is considered to be an essential
is strong in thin layers and suitable for treating young mechanical parameter when brittle materials such as

Table 2. Flexural strength and Vickers hardness of tested specimens

Characteristic Experimental FGC (1) Vitablocs Mark II (2) Vita Enamic (3) IPS e.max CAD (4) Groupa P Multiple Comparisonb
Flexural strength (MPa), mean (SD) 117.61 (7.62) 106.67 (18.50) 145.95 (12.65) 341.88 (40.25) <.001 (1), (2)<(3)<(4)
Flexural strength (MPa)c NA 113-154 150-160 360 NA NA
Vickers hardness (Hv), mean (SD) 153.74 (23.62) 594.74 (25.22) 372.29 (51.23) 731.63 (30.64) <.001 <(3)<(2)<(4)
Vickers hardness [Hv]c NA 640 254 591.4 NA NA

FGC, fluorophlogopite glass ceramic.

a
Comparing difference in flexural strengths or Vickers hardness among 4 groups.
b
Significant difference in flexural strengths or Vickers hardness between 2 groups.
c
Data quoted from manufacturer’s technical documents.

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Table 3. Weibull parameters of different ceramics (n=15) 30

Specimen m h B10 IPS e.max CAD
25 Vitablocs Mark II
IPS e.max CAD 10.01 359.17 286.85 Vita Enamic
20 FGC
Vitablocs Mark II 6.93 114.12 82.46
Vita Enamic 12.87 151.85 127.49 15

In(In(1/(1-F)))
Experimental FGC 18.34 121.00 107.03 10
m, Weibull modulus parameter; h, 63.2% of investigated populations expected to fail; B10, 5
10% of investigated populations expected to fail; FGC, fluorophlogopite glass ceramic.
0
–5
100 –10
IPS e.max CAD
90 Vitablocs Mark II –15
Vita Enamic
Probability of Failure (%)

80 FGC
70
60
50
40
30
20
10
0
0 50 100 150 200 250
Flexural Strength (MPa)
Figure 1. Probability of failure versus flexural strength.
ceramics are being evaluated. The 3-point bending test
has been used as a standard test for measuring flexural
strength. However, the strength of ceramic is a complex
parameter that cannot be fully described by a single
value. The maximum flexural strength varies greatly from
specimen to specimen because of the distribution of flaws
present in the specimen.36 When flaws are consistent
and evenly distributed, the flexural strength of a spec-
imen will behave more consistently than when flaws are
clustered inconsistently.36 Thus, the Weibull theory could
provide a useful description of the intrinsic statistical
variation in the fracture stress behavior of ceramic.36
The Weibull distribution is a generalization of the
exponential distribution that describes the survival and
failures times of brittle materials. Analyzing failure
probability with the Weibull distribution could help to
understand the life time of the materials better than
using the material strength alone.41,42 The Weibull
modulus (m) is not a material constant but reflects the
shape of the defect population present in the material.43
It is understood that the higher the Weibull modulus, the
less variation. The Weibull scale parameter is known as
the characteristic life or characteristic strength that could
estimate or reflect the failure statistically. In particular, 2
failure percentages are usually used: h denotes the esti-
mated 63.2% of investigated population that would fail,
and B10 denotes the 10% of the investigated population
that could fail. B10 is a parameter that might be able to
–20
4.2 4.4 4.6 4.8 5 5.2 5.4 5.6 5.8 6
In(δδ)
Figure 2. Weibull plots of 4 ceramics tested.
reflect an early clinical failure. The aim of this study was
to compare the mechanical properties of 3 commercially
available ceramics with an experimental FGC.
300 350 400 450 MATERIAL AND METHODS
The ceramic specimens, batch numbers, and manufac-
turers are listed in Table 1. All the ceramic materials were
used as supplied.
A 3-point bend test was used to evaluate flexural
strength. Ceramic blocks were sectioned into dimension of
approximately 2×2×15 mm with a cutting machine (Micro
Slice; Metals Research) using an alloy blade. Fifteen
specimens were prepared for each ceramic. Each specimen
was further polished with 180-, 400-, 600- and 1200-grit
SiC papers and a polishing machine (ECOMET 5; Bueh-
ler) under running water for 10 minutes. For IPS e.max
CAD, final sintering was carried out in a furnace (Pro-
gramat CS; Ivoclar Vivadent AG) according to the manu-
facturer’s instructions. The specimens were stored dry for 1
week until tested. The final dimensions of each specimen
were measured with a digital caliper (Digimatic Caliper;
Mitutoyo). Then the specimens were mounted on a uni-
versal loading machine (ElectroPuls E3000; Instron In-
dustrial Products). The specimen was placed centrally on a
3-point bending stand with a supporting distance of 10
mm. A testing load was applied at a crosshead speed of 1
mm/min until the specimen fracture.
For surface hardness testing, ceramic blocks of approx-
imately 14×12×4 mm were sectioned, polished, and sin-
tered as described in the first experiment. Five Vickers
hardness indentations were made per specimen with a
hardness tester (microhardness tester; Leitz) and analyzed
by software (Leica QGo; Leica Microsystems Imaging So-
lution) using a 1.96 N load and a dwell time of 15 seconds.
The mean hardness value was calculated for each specimen.
After the 3-point bending test, all fractured specimens
were examined by using scanning electron microscopy

THE JOURNAL OF PROSTHETIC DENTISTRY Leung et al

September 2015
Figure 3. Scanning electron microscope images of specimens at fractured surface after flexural strength test (×100). A, IPS e.max CAD. B, Vitablocs Mark
II. C, Vita Enamic. D, Experimental fluorophlogopite glass ceramic.
(SEM) (Hitachi S-3400N VP-SEM; Hitachi High-
Technologies). Energy-dispersive x-ray analysis was
also performed to investigate the elemental composition
of the tested specimen.
Data were analyzed by statistical software (SPSS
Statistics v20 for Windows; IBM Corp). Differences in
flexural strength and hardness among groups were
analyzed by 1-way ANOVA with the Bonferroni correc-
tion to adjust for multiple comparisons (a=.05). The
Weibull modulus and the Weibull characteristic strength,
which is the strength that occurs at a probability that a
specimen would fail, were determined with a spread-
sheet (Excel 2010 for Windows; Microsoft Corp).
RESULTS
Table 2 represents the flexural strength and Vickers
hardness of each ceramic type. A significant difference in
flexural strength was found among the groups (P<.001).
After adjusting for multiple comparisons, the flexural
strength of the IPS e.max CAD group (341.88 ±40.25
MPa) was found to be significantly higher (P<.001) than
the Vita Enamic group (145.95 ±12.65 MPa), which was
also significantly higher (P<.001) than the Vitablocs Mark
Leung et al
443
II group (106.67 ±18.50 MPa) and the FGC group (117.61
±7.62 MPa). However, no significant difference in flexural
strength was found between the Vitablocs Mark II group
and FGC group (P=.577).
A significant difference in Vickers hardness was found
among the groups (P<.001). After adjusting for multiple
comparisons, the Vickers hardness of the ceramics was found
to be of the following order: IPS e.max CAD (731.63 ±30.64
HV)>Vitablocs Mark II (594.74 ±25.22 HV)>Vita Enamic
(372.29 ±51.23 HV)>FGC (153.74 ±23.62 HV) (P<.05).
The data of the Weibull parameters, including the
Weibull modulus (m), the 63.2% of the specimens ex-
pected to fail (h), and the 10.0% of the specimens ex-
pected to fail (B10), are presented in Table 3. The Weibull
plots are shown in Figures 1, 2. The Weibull plot revealed
that IPS e.max CAD>Vita Enamic>FGC>Vitablocs Mark
II for a characteristic strength at both 63.2% (h) and
10.0% (B10). The Weibull modulus ranged from 6.925 to
18.338, and the FGC showed the highest Weibull
modulus among the 4 studied ceramic materials.
Figure 3 shows the SEM images of different ceramic
materials after the 3-point bend test. The fracture sur-
faces of Vita Enamic and experimental FGC appeared
rougher compared with Vitablocs Mark II and IPS e.max
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444 Volume 114 Issue 3

Table 4. Energy-dispersive x-ray analysis The Weibull modulus (m) of all groups was larger than 1,
App Intensity Weight% which indicates that the failure rate increases with time.
Element Conc Correlation Weight% Sigma Atomic%
Although the flexural strength of FGC is lower than that
IPS e.max CAD
CK 4.68 0.26 6.71 1.21 10.79
of Vita Enamic and IPS e.max CAD, it presented with the
OK 122.03 0.87 51.63 0.71 62.34
highest Weibull modulus among the 4 materials, sug-
Al K 8.43 1.51 2.03 0.07 1.47 gesting that the FGC material has less quality variability
Si K 81.92 0.94 32.31 0.46 22.22 than other tested ceramics. To improve the flexural
PK 4.25 0.93 1.68 0.08 1.05 strength of FGC, previous studies had shown that by
KK 10.02 0.97 3.81 0.08 1.88 varying the chemical composition, such as the fluoride
Ce L 3.8 0.78 1.80 0.14 0.25 content,38 addition of zirconia,37 heat treatment condi-
Totals 100.00 tions,37 the flexural strength can be increased up to
Vitablocs Mark II 228.11 MPa. Furthermore, Vita Enamic, a polymer-
CK 3.28 0.25 4.91 3.80 8.17 containing ceramic, also has a higher Weibull modulus
OK 99.21 0.83 44.88 1.81 56.08 than Vitablocs Mark II and IPS e.max CAD. Brittle
Na K 13.95 0.92 5.66 0.25 4.92 materials, such as the traditional dental ceramics, can
Al K 48.72 1.51 12.07 0.50 8.94
usually be described by the Griffith behavior theory.44
Si K 57.97 0.82 26.38 1.07 18.78
However, the existence of the polymer phase within
KK 14.79 0.98 5.65 0.24 2.89
the ceramic phase gives the onset of plasticity to the bulk
Ca K 1.12 0.92 0.45 0.06 0.23
Totals 100.00
material and thus can demonstrate another possible
Vita Enamic
model: the Dugdale cracking model.31 In brief, polymer
CK 46.26 0.40 35.55 2.04 47.76 chains in the polymer phase in Vita Enamic could spread
OK 67.10 0.58 35.10 1.15 35.41 the plasticity under the increase of load and hence
Na K 9.36 0.91 3.12 0.12 2.19 increase the crack resistance with the crack length. This
Al K 36.36 1.53 7.20 0.24 4.31 could give a higher observable Weibull modulus, rather
Si K 44.30 0.88 15.32 0.50 8.80 than toughening itself.32 Thus, the Vita Enamic might not
KK 11.68 1.00 3.53 0.13 1.46 have a higher toughness than others; rather the Dugdale
Ca K 0.55 0.94 0.18 0.04 0.07 behavior lowered the scattering in flexural strength
Totals 100.00 values for a given sampling population and therefore
Experimental FGC increased the Weibull modulus. Nevertheless, further
CK 12.77 0.32 13.59 1.09 20.98 clarification of the behavior and the material relationship
OK 90.99 0.75 41.48 0.61 48.10
is necessary.
FK 3.080 0.20 5.31 0.29 5.19
Hardness is defined as the resistance to a permanent
Mg K 17.21 0.79 7.44 0.14 5.68
surface indentation. In ceramics, hardness affects the
Al K 32.16 1.37 8.06 0.15 5.55
Si K 38.76 0.81 16.47 0.25 10.88
polishability, wear resistance, and ease of milling.45
KK 22.31 1.00 7.65 0.14 3.63
Because an ideal dental restorative material should not
Totals 100.00 wear the opposing dental tissues, a ceramic with a high
hardness value might not be desirable. Although the
App Conc: apparent concentration; FGC, fluorophlogopite glass ceramic.
Vickers hardness values of FGC and Vita Enamic were
low compared with other tested ceramics, their values are
comparable with enamel (611.8 Hv) and dentin (102
CAD. Energy-dispersive x-ray analysis confirmed that
Hv).46-48 Therefore, FGC and Vita Enamic might be
the chemical components were the same as those
considered as nonaggressive to opposing tooth structure,
claimed by the manufacturers, except that Ti was not
although wear is a complicated process and is not
found in Vitablocs Mark II or Vita Enamic, and Zr was
determined by material hardness only.
not detected in IPS e.max CAD (Table 4, Fig. 4).
The majority of the results in this study are compa-
Furthermore, the carbon weight percentage was higher in
rable with the data from manufacturers (Table 2) and
Vita Enamic than others, which might be explained by
other in vitro studies,27,28 except the IPS e.max CAD
the methacrylate polymer component, and fluoride was
flexural strength (137.51 MPa) in 1 study.28 The observed
present in the experimental FGC. Ce was also found in
discrepancy might be due to the differences in the
IPS e.max CAD (Table 4, Fig. 4).
preparation of the materials. For example, Charlton
et al28 tested specimens of size 4×3×18 mm with sup-
DISCUSSION
porting rollers set at 14 mm apart, which is different from
This study compared the flexural strength, Vickers the present study (specimen size of 2×2×15 mm with the
hardness, and Weibull parameters of 3 commercially supports set at 10 mm apart). Data for FGC are still
available millable ceramics against an experimental FGC. limited. Studies37,38 have shown variations in flexural

THE JOURNAL OF PROSTHETIC DENTISTRY Leung et al

September 2015 445

Si
Si

Al
O O
Ca

C C Na K
Al P K Ce
K Ce Ce Ce Ce K Ca

0 2 4 6 8 10 0 2 4 6 8 10
Full Scale 13903 cts Cursor: 0.000 keV' Full Scale 10106 cts Cursor: 0.000 keV'
A B

Si Si

O O Al
C Al Mg
K K
F
Ca
Na K C
Ca K

0 2 4 6 8 10 0 2 4 6 8 10
Full Scale 7572 cts Cursor: 0.000 keV' Full Scale 6684 cts Cursor: 0.000 keV'
C D
Figure 4. Energy-dispersive x-ray spectroscopic analysis of representative specimens. A, IPS e.max CAD. B, Vitablocs Mark II. C, Vita Enamic. D,
Experimental FGC.

strength from 80.6 MPa to 228.11 MPa, compared with
117.61 MPa obtained in the current study. Vickers
hardness also varies among studies37,38,40 from 0.58 Hv
to 836.1 Hv, compared with 153.74 Hv in the current
study. Thus, varying the composition and conditions,
such as heat treatment, may produce different materials
with various properties, and therefore no direct com-
parison can be made.
The SEM images of the fractured slot surfaces
revealed differences among the materials. Depending on
the differences in the microstructure, the appearance of
the fracture pattern and fracture surfaces differ. The
fracture surfaces of Vita Enamic and experimental FGC
were rougher compared with Vitablocs Mark II and IPS
e.max CAD. The smooth fractured surfaces imply crack
propagation with a limited deflection. Coldea et al30
suggested that “propagating cracks are deflected and
experience a more tortuous path . resulting in rough
surfaces.” This suggests that cracks induced by stress run
through the ceramic parts in Vitablocs and IPS e.max
CAD ceramic but deflect more at the polymer-ceramic
interfaces in Vita Enamic30 or by the flake component
in FGC.37 This behavior is an indication of the damage
tolerance of Vita Enamic and FGC. Clinically, local
damage deriving from milling or clinical adjustment may
be less likely to result in chipping.30
In summary, the experimental FGC is the least
abrasive ceramic with the highest Weibull modulus
compared with the other tested ceramics. Because it is
etchable and possesses a fluoride-releasing property,
FGC might be an alternative to dental ceramic. However,
further development is needed to improve its flexural
strength and optical properties.
CONCLUSIONS
The flexural strength and Vickers hardness of IPS e.max
CAD were significantly higher than that of the 3 mate-
rials tested. FGC’s flexural strength was comparable with
Vitablocs Mark II. FGC’s Weibull modulus was the
highest, while its Vickers hardness was the lowest among
the materials tested.

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REFERENCES 27. Bindl A, Luthy H, Mormann WH. Fracture load of CAD/CAM-generated

slot-inlay FPDs. Int J Prosthodont 2003;16:653-60.
28. Charlton DG, Roberts HW, Tiba A. Measurement of select physical and
1. Kelly JR, Nishimura I, Campbell SD. Ceramics in dentistry: historical roots
mechanical properties of 3 machinable ceramic materials. Quintessence Int
and current perspectives. J Prosthet Dent 1996;75:18-32.
2008;39:573-9.
2. van Dijken JW. All-ceramic restorations: classification and clinical evalua-
29. Coldea A, Swain MV, Thiel N. In-vitro strength degradation of dental ce-
tions. Compend Contin Educ Dent 1999;20:1115-24.
ramics and novel PICN material by sharp indentation. J Mech Behav Biomed
3. Hayashi M, Tsuchitani Y, Kawamura Y, Miura M, Takeshige F, Ebisu S. Eight-
Mater 2013;26:34-42.
year clinical evaluation of fired ceramic inlays. Oper Dent 2000;25:473-81.
30. Coldea A, Swain MV, Thiel N. Mechanical properties of polymer-infiltrated-
4. Mormann WH. The evolution of the CEREC system. J Am Dent Assoc
ceramic-network materials. Dent Mater 2013;29:419-26.
2006;137(suppl):7S-13S.
31. Dugdale DS. Yielding of steel sheets containing slits. J Mechan Phys Solids
5. Schultheis S, Strub JR, Gerds TA, Guess PC. Monolithic and bi-layer CAD/
1960;8:100-4.
CAM lithium-disilicate versus metal-ceramic fixed dental prostheses: com-
32. Kendall K, Alford NM, Tan SR, Birchall JD. Influence of toughness on
parison of fracture loads and failure modes after fatigue. Clin Oral Investig
Weibull modulus of ceramic bending strength. J Mater Res 1986;1:120-3.
2013;17:1407-13.
33. Alonso V, Caserio M. A clinical study of direct composite full-coverage
6. Griffin JD Jr. Combining monolithic zirconia crowns, digital impressioning,
crowns: long-term results. Oper Dent 2012;37:432-41.
and regenerative cement for a predictable restorative alternative to PFM.
34. Preissner S, Kostka E, Blunck U. A noninvasive treatment of amelogenesis
Compend Contin Educ Dent 2013;34:212-22.
imperfecta. Quintessence Int 2013;44:303-5.
7. Zesewitz TF, Knauber AW, Northdurft FP. Fracture resistance of a selection of full-
35. Guth JF, Almeida ESJS, Ramberger M, Beuer F, Edelhoff D. Treatment
contour all-ceramic crowns: an in vitro study. Int J Prosthodont 2014;27:264-6.
concept with CAD/CAM-fabricated high-density polymer temporary resto-
8. Molin MK, Karlsson SL. A randomized 5-year clinical evaluation of 3 ceramic
rations. J Esthet Restor Dent 2012;24:310-8.
inlay systems. Int J Prosthodont 2000;13:194-200.
36. Della Bona A, Borba M. All-ceramic restorations on implants. In:
9. Pallesen U, van Dijken JW. An 8-year evaluation of sintered ceramic and
Matinlinna JP, editor. Handbook of oral biomaterials. Singapore: Pan Stan-
glass ceramic inlays processed by the Cerec CAD/CAM system. Eur J Oral Sci
ford; 2014. p. 517-34.
2000;108:239-46.
37. Li H, You DQ, Zhou CR, Ran JG. Study on machinable glass-ceramic con-
10. Otto T, De Nisco S. Computer-aided direct ceramic restorations: a 10-year
taining fluorophlogopite for dental CAD/CAM system. J Mater Sci Mater
prospective clinical study of Cerec CAD/CAM inlays and onlays. Int J Pros-
Med 2006;17:1133-7.
thodont 2002;15:122-8.
38. Molla AR, Basu B. Microstructure, mechanical, and in vitro properties of mica
11. Sjogren G, Molin M, van Dijken JW. A 10-year prospective evaluation of
glass-ceramics with varying fluorine content. J Mater Sci Mater Med 2009;20:
CAD/CAM-manufactured (Cerec) ceramic inlays cemented with a chemically
869-82.
cured or dual-cured resin composite. Int J Prosthodont 2004;17:241-6.
39. Mayanagi G, Igarashi K, Washio J, Domon-Tawaraya H, Takahashi N.
12. Fasbinder DJ, Dennison JB, Heys DR, Lampe K. The clinical performance of
Effect of fluoride-releasing restorative materials on bacteria-induced pH
CAD/CAM-generated composite inlays. J Am Dent Assoc 2005;136:1714-23.
fall at the bacteria-material interface: an in vitro model study. J Dent
13. Fasbinder DJ. Clinical performance of chairside CAD/CAM restorations. J Am
2014;42:15-20.
Dent Assoc 2006;137(suppl):22S-31S.
40. Roy S, Basu B. Hardness properties and microscopic investigation of crack-
14. Pjetursson BE, Sailer I, Zwahlen M, Hammerle CH. A systematic review of
crystal interaction in SiO(2)-MgO-Al(2)O(3)-K(2)O-B(2)O(3)-F glass ceramic
the survival and complication rates of all-ceramic and metal-ceramic re-
system. J Mater Sci Mater Med 2010;21:109-22.
constructions after an observation period of at least 3 years. Part I: single
41. Ritter JE. Predicting lifetimes of materials and material structures. Dent Mater
crowns. Clin Oral Implants Res 2007;18(suppl 3):73-85.
1995;11:142-6.
15. Sailer I, Pjetursson BE, Zwahlen M, Hammerle CH. A systematic review of
42. Kelly JR. Perspectives on strength. Dent Mater 1995;11:103-10.
the survival and complication rates of all-ceramic and metal-ceramic re-
43. van der Zwaag S. The concept of filament strength and the Weibull modulus.
constructions after an observation period of at least 3 years. Part II: fixed
J Test Eval 1989;17:292-8.
dental prostheses. Clin Oral Implants Res 2007;18(suppl 3):86-96.
44. Darvell BW. Materials science for dentistry. 9th ed. Cambridge: Woodhead;
16. Tian T, Tsoi JK, Matinlinna JP, Burrow MF. Aspects of bonding between resin
2009. p. 1-36.
luting cements and glass ceramic materials. Dent Mater 2014;30:e147-62.
45. Etman MK. Wear properties of dental ceramics. In: Vallittu PK, editor. Non-
17. Liu D, Matinlinna JP, Pow EHN. Insights into porcelain to zirconia bonding.
metallic biomaterials for tooth repair and replacement. Cambridge: Wood-
J Adhes Sci Technol 2012;26:1249-65.
head; 2013. p. 161-93.
18. Matinlinna JP, Choi AH, Tsoi JK. Bonding promotion of resin composite to
46. Xu HH, Smith DT, Jahanmir S, Romberg E, Kelly JR, Thompson VP, et al.
silica-coated zirconia implant surface using a novel silane system. Clin Oral
Indentation damage and mechanical properties of human enamel and
Implants Res 2013;24:290-6.
dentin. J Dent Res 1998;77:472-80.
19. Liu D, Matinlinna JP, Tsoi JK, Pow EH, Miyazaki T, Shibata Y, et al. A new modified
47. Cuy JL, Mann AB, Livi KJ, Teaford MF, Weihs TP. Nanoindentation mapping
laser pretreatment for porcelain zirconia bonding. Dent Mater 2013;29:559-65.
of the mechanical properties of human molar tooth enamel. Arch Oral Biol
20. Liu D, Pow EH, Tsoi JK, Matinlinna JP. Evaluation of four surface coating
2002;47:281-91.
treatments for resin to zirconia bonding. J Mech Behav Biomed Mater
48. Mahoney E, Holt A, Swain M, Kilpatrick N. The hardness and modulus of
2014;32:300-9.
elasticity of primary molar teeth: an ultra-micro-indentation study. J Dent
21. Cheng HC, Tsoi JK, Zwahlen RA, Matinlinna JP. Effects of silica-coating and
2000;28:589-94.
zirconate coupling agent on shear bond strength of flowable resin-zirconia
bonding. Int J Adhes Adhes 2014;50:11-6.
22. Guarda GB, Correr AB, Goncalves LS, Costa AR, Borges GA, Sinhoreti MA,
et al. Effects of surface treatments, thermocycling, and cyclic loading on the Corresponding author:
bond strength of a resin cement bonded to a lithium disilicate glass ceramic. Dr Edmond H. N. Pow
Oper Dent 2013;38:208-17. Oral Rehabilitation
23. Borges GA, Sophr AM, de Goes MF, Sobrinho LC, Chan DC. Effect of Faculty of Dentistry
etching and airborne particle abrasion on the microstructure of different The University of Hong Kong
dental ceramics. J Prosthet Dent 2003;89:479-88. 34 Hospital Road
24. Hopp CD, Land MF. Considerations for ceramic inlays in posterior teeth: a HONG KONG
review. Clin Cosmet Investig Dent 2013;5:21-32. Email: ehnpow@hku.hk
25. Pini NP, Aguiar FH, Lima DA, Lovadino JR, Terada RS, Pascotto RC. Ad-
vances in dental veneers: materials, applications, and techniques. Clin Cos- Acknowledgments
met Investig Dent 2012;4:9-16. The authors thank Ehsan Homaei for Weibull analysis and Dr Dan Liu for
26. Pieger S, Salman A, Bidra AS. Clinical outcomes of lithium disilicate single technical support.
crowns and partial fixed dental prostheses: a systematic review. J Prosthet
Dent 2014;112:22-30. Copyright © 2015 by the Editorial Council for The Journal of Prosthetic Dentistry.

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