Influence of cavity preparation design on fracture resistance of posterior

Leucite-reinforced ceramic restorations

Carlos Jose Soares, DDS, MS, PhD,a Luis Roberto Marcondes Martins, DDS, MS, PhD,b
Rodrigo Borges Fonseca, DDS, MS, PhD,c Lourenco Correr-Sobrinho, DDS, MS, PhD,d
and Alfredo Julio Fernandes Neto, DDS, MS, PhDe
School of Dentistry, Federal University of Uberlandia, Minas Gerais, Brazil; Piracicaba School of
Dentistry, State Univerty of Campinas, Sao Paulo, Brazil
Statement of problem. Controversy exists concerning the preferred cavity design for posterior ceramic res-
torations to improve their resistance to fracture under occlusal load.
Purpose. The aim of this study was to assess the resistance to fracture of leucite-reinforced ceramic restorations
placed on molars with different cavity preparation designs.
Material and methods. Ninety noncarious molars were selected, stored in 0.2% thymol solution, and divided
into 9 groups (n=10): IT, intact teeth; CsI, conservative inlay; ExI, extensive inlay; CsO/mb, conservative onlay
with mesio-buccal cusp coverage; ExO/mb, entensive onlay with mesio-buccal cusp coverage; CsO/b, conser-
vative onlay with buccal cusp coverage; ExO/b, entensive onlay with buccal cusp coverage; CsO/t, conservative
onlay with total cusp coverage; ExO/t, extensive onlay with total cusp coverage. Teeth were restored with a
Leucite-reinforced ceramic (Cergogold). The fracture resistance (N) was assessed under compressive load in a
universal testing machine. The data were analyzed with 1-way and 2-way analyses of variance, followed by
the Tukey HSD test (a=.05). Fracture modes were recorded, based on the degree of tooth structure and
restoration damage.
Results. One-way analysis showed that intact teeth had the highest fracture resistance values. Two-way analyses
showed no significant differences for the isthmus extention factor, but showed a significant difference for the
preparation design type of fracture (P=.03), and also for the interaction between both factors (P=.013). The
fracture mode observed in all groups tended to involve only restorations.
Conclusion. Within the limitations of this study, it was observed that cuspal coverage does not increase frac-
ture resistance of the posterior tooth-restoration complex restored with leucite-reinforced ceramics. (J Prosthet
Dent 2006;95:421-9.)

CLINICAL IMPLICATIONS
In this in vitro study, the cavity preparation involving cuspal reduction for restoration with
Leucite-reinforced ceramic did not improve the resistance to fracture. The fracture modes
observed were predominantly restricted to the restorative material.

T he presence of extensive carious lesions, unsatisfac-

tory restorations, and tooth fracture results in contro-
versy regarding the optimal restorative procedure.
Choosing between use of a direct or indirect technique
Presented at the IADR Meeting, Hawaii, March 10-13, 2004.
Supported by Fundacao de Amparo a Pesquisa do Estado de Minas
Gerais (FAPEMIG), Grant 1987-03.
a
Professor, Operative Dentistry and Dental Materials, Dental School
of Federal University of Uberlandia.
b
Professor, Operative Dentistry, Dental School of Piracicaba, State
University of Campinas.
c
Professor, Operative Dentistry and Dental Materials, Dental School
of Federal University of Uberlandia.
d
Professor, Dental Materials, Dental School of Piracicaba, State Uni-
versity of Campinas.
e
Professor, Prosthodontic and Dental Materials, Dental School of
Federal University of Uberlandia.
when placing a posterior restoration is difficult and in-
volves esthetic, biomechanical, anatomical, and financial
considerations. When an indirect restoration is determined
to be the best treatment option, the clinician must then
determine the geometric configuration of the cavity
preparation.1-3 Several designs have been proposed for
preparing posterior resin-bonded all-ceramic restora-
tions,4-7 due to the particular mechanical and struc-
tural characteristics presented by ceramic restorative
materials.8-10
For cast metal restorations, nonfunctional and func-
tional cusps tend to be reduced during cavity prepara-
tion, producing better stress distribution.11 Since
metal restorations are generally cemented with a non-
adhesive cement, such as zinc-phosphate cement, com-
plete cusp coverage is indicated to increase dental
structure resistance.12 Tooth preparation designs

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THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 1. Cavity preparation designs of different experimental groups.
advocated for posterior ceramic restorations have been
based on traditional cast metal restoration designs, but
with more occlusal tooth reduction and a slightly in-
creased taper.3 These preparations can involve the re-
moval of considerable tooth structure,13 and as more
structure is removed, a tooth will have less resistance
to fracture.14 However, in preparations for posterior ce-
ramic restorations, some authors have demonstrated
that occlusal reduction results in a reduced chance of res-
toration failure, likely increasing longevity of the restora-
tion.4,6,15 Fracture resistance tests have been used to
determine the forces that may induce fracture of such
restorations, and thus enable a preparation design to
be suggested for providing greatest resistance to frac-
ture.10,16-26
Dental ceramics are considered to be esthetic restor-
ative materials with desirable characteristics, such as
translucence, fluorescence, and chemical stability.17,27
They are also biocompatible, have high compressive
strength, and their thermal expansion coefficient is sim-
ilar to that of the tooth structure.27 In spite of their
many advantages, ceramics are fragile under tensile
strain, making them susceptible to fracture during the
luting procedure and under occlusal force.28-31 This
dichotomy raises an important question as to which is
the best cavity preparation design for posterior teeth
restored with ceramic restorations.
Therefore, the aim of this study was to assess the
in vitro resistance to fracture of Leucite-reinforced
ceramic-restored posterior teeth, and to analyze the
modes of fracture with various preparation designs.
The null hypothesis was that different preparation
designs have no effect on the fracture resistance of teeth
restored with Leucite-reinforced ceramics.
MATERIAL AND METHODS
Ninety freshly extracted, sound, caries-free human
mandibular molars of similar size and shape were
422
SOARES ET AL
selected by measuring the buccolingual and mesiodistal
widths in millimeters, allowing a maximum deviation of
10% from the determined mean. Teeth were stored in
0.2% thymol solution. Calculus and soft-tissue deposits
were removed with a hand scaler. The teeth were cleaned
using a rubber cup and fine pumice water slurry and then
stored in 0.9% saline solution at 4°C until completion of
the experiment. The roots were covered with a 0.3-mm
layer of a polyether impression material (Impregum; 3M
ESPE, St Paul, Minn) to simulate the periodontal liga-
ment, and embedded in a polystyrene resin (Cristal,
Piracicaba, Sao Paulo, Brazil) up to 2 mm below
the cementoenamel junction to simulate the alveolar
bone.17,24 The teeth were divided into 9 groups
(n=10) as follows: IT, intact teeth (control group);
CsI, conservative inlay; ExI, extensive inlay; CsO/mb,
onlay with conservative isthmus covering the mesio-
buccal cusp; ExO/mb, onlay with extensive isthmus
covering the mesio-buccal cusp; CsO/b, onlay with
conservative isthmus covering all buccal cusps; ExO/
b, onlay with extensive isthmus covering all buccal
cusps; CsO/t, onlay with conservative isthmus covering
all cusps; ExO/t, onlay with extensive isthmus covering
all cusps (Fig. 1).
Using a 6-degree taper diamond rotary cutting
instrument (3131; KG Sorensen, Barueri, Sao Paulo,
Brazil), 8 different preparations, with internal rounded
angles, were defined. A preparation machine (Federal
University of Uberlandia, Uberlandia, Minas Gerais,
Brazil) was used to standardize preparation dimensions
(Fig. 2).17 This device consists of a high-speed handpiece
(KaVodo Brasil Ltd, Joinville, SC, Brazil) coupled to a
mobile base. The mobile base moves vertically and hor-
izontally with the aid of 3 micrometers (Mitutoyo,
Tokyo, Japan) with a 0.1-mm level of accuracy. The isth-
mus floor of the mesio-occluso-distal (MOD) cavities
was prepared following principles for ceramic and indi-
rect composite resin preparations.32 The pulpal floor
was prepared to a depth of 2.5 mm from the occlusal
VOLUME 95 NUMBER 6
SOARES ET AL
Fig. 2. Cavity preparation instrument. (A) Micrometer con-
trols quantity of vertical movement, which is moved by con-
necting rod, B; (C) metal device allows 180-degree
movement around its longitudinal axis and 360-degree move-
ment around its transverse axis; (D) high-speed handpiece
with diamond rotary cutting instrument; (E) specimen being
prepared; (F) micrometer.
cavosurface margin of the preparation; the occlusal
isthmus was 5 mm wide for extensive isthmus groups
and 2.5 mm wide for conservative isthmus groups.
The buccolingual widths on mesial and distal boxes
were similar to the occlusal isthmus width. Each box
had a gingival floor depth of 1.5 mm mesiodistally and
an axial wall height of 2 mm. Margins were prepared
with 90-degree cavosurface angles.
A single-stage impression was made of each pre-
pared tooth using a double-viscosity vinyl polysiloxane
(Panasil; Kettenbach GmbH, Eschenburg, Germany)
in a stock plastic tray (Tigre, Sao Paulo, Brazil).
After 2 hours, the impressions were poured with
Type IV stone (Velmix; Kerr Italia SpA, Scafati,
Italy). One technician fabricated all restorations using
a standardized technique and following the manufac-
turer’s instructions.27 Restorations were made with a
leucite-reinforced ceramic (Cergogold; Degussa Dental,
Hanau, Germany). A spacer (Isolit; Degussa Dental)
was applied over the high-density stone dies, and a
0.7-mm-thick wax coping (Plastodent; Degussa
Dental) was fabricated. The wax coping was invested
(Cergofit Investment; Degussa Dental) and placed in
a burnout furnace (F1800 1P; EDG, Sao Paulo,
Brazil) to eliminate the wax. The burnout furnace
was preheated to 270°C, and the temperature was
gradually increased to approximately 850°C for 40
minutes with the alumina plunger kept inside the
furnace. Ingots (Cergogold, shade A3; Degussa Dental)
were pressed in an automatic press furnace (Ceram-
press Qex; Dentsply Ceramco, York, Pa). After cool-
ing, the specimens were divested using 50-mm glass
JUNE 2006
THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 3. Compressive loading using 6-mm-diameter steel
sphere placed in center of occlusal leucite-reinforced
ceramic molar restoration.
beads at 4-bar pressure, followed by airborne-particle
abrasion with 100-mm aluminum oxide at 2-bar pres-
sure to remove the refractory material. Finally, the
specimens were treated with 100-mm aluminum oxide
airborne-particle abrasion at 1-bar pressure.
The ceramic restorations were then luted (RelyX
ARC; 3M ESPE), following the manufacturer’s instruc-
tions. Ceramic inlays were etched with 10% hydrofluoric
acid (Condicionador de Porcelanas; Dentsply, Sao
Paulo, Brazil) for 60 seconds, and then a silane agent
(Rely-X ceramic primer; 3M ESPE) was applied for
60 seconds and dried.27 The cavity preparations (enamel
and dentin) were etched using 37% phosphoric acid for
15 seconds, rinsed, and blotted dry with absorbent pa-
per. With a fully saturated brush tip, 2 consecutive coats
of an adhesive system (Adper Single Bond; 3M ESPE)
were applied to the tooth, gently dried for 5 seconds
with compressed air, and polymerized with a halogen
light-polymerization unit (XL 3000; 3M ESPE) for 20
seconds at an intensity of 800 mW/cm2 and a source-
to-specimen distance of 1 cm. The resin luting agent was
dispensed onto a mixing pad and mixed for 10 seconds.
A thin layer of the material was applied to the ceramic
restoration, which was seated in place. Excess luting
agent was removed with a brush. The luting agent was
polymerized (800 mw/cm2, XL 3000; 3M ESPE)
from the facial, lingual, and occlusal directions for 40
seconds in each direction. Finishing rotary cutting in-
struments (#2135 F and #2135 FF; KG Sorensen)
were used to remove excess luting agent.
The teeth were subjected to axial compressive loading
with a metal sphere 6 mm in diameter (Fig. 3) at a cross-
head speed of 0.5 mm/min in a universal testing
machine (Model DL2000; EMIC, Sao Jose dos Pinhais,
Brazil). The force required (N) to cause fracture was
423
THE JOURNAL OF PROSTHETIC DENTISTRY SOARES ET AL

Fig. 4. Fracture modes: (I) isolated fracture of restoration; (II) restoration fractures involving small portion of tooth; (III) fracture
involving more than half of tooth, without root involvement; (IV) fracture with root involvement.

Table I. One-way ANOVA of mechanical compression test Table II. Mean fracture resistance values (SDs) and statistical
values categories of all experimental groups (n=10)
Source Sum of Mean Calculated Critical Statistical Tukey
of variation df squares square F P F Groups Failure load mean (N) category

Types of 8 184925.4 23115.7 11.444 .001 2.055 IT 3143.1 (635.5) A

preparations CsI 2465.4 (318.7) B
Error 81 163606.9 2019.8 ExI 2278.1 (586.4) B
Total 89 348532.2 ExO/b 2204.5 (353.0) BC
CsO/b 2158.4 (321.7) BCD
Variation coefficient = 199.76.
CsO/t 2062.3 (488.4) BCD
ExO/mb 2001.5 (337.3) BCD
CsO/mb 1612.2 (349.1) CD
ExO/t 1551.4 (443.3) D
Table III. Two-way ANOVA (4 3 2) for mechanical
compression test of ceramic restored groups IT, Intact teeth.
Minimum significant difference = 628.4; different letters indicate significant
Sum of Mean Calculated differences (P,.05).
Source of variation df squares square F P

Type of preparation 3 49541.5 16513.8 9.454 .003

Buccolingual extent 1 899.8 899.8 0.515 .095
Table IV. Mean fracture resistance (SD) values and
Interaction 3 22482.3 7494.1 4.290 .013
statistical categories defined by Tukey HSD test for
Treatments 7 72923.6 10417.7
interaction between isthmus extension and cavity
Error 72 125770.7 1746.8
preparation design factors (n=10)
Total 79
Variation coefficient 196.8; significant difference P,.05. Groups Failure load mean values General mean values

Conservative
CsI 2465.4 (318.7)A 2074.6 (369.5)A
recorded by a 5-kN load cell hardwired to software CsO/b 2158.4 (321.7)A
(TESC; EMIC), which was able to detect any sudden CsO/t 2062.3 (488.4)AB
load drop during compression. CsO/mb 1612.2 (349.1)B
The fractured specimens were evaluated to determine Extensive
fracture patterns using a modified classification system ExI 2278.1 (586.4)a 2008.9 (430.0)A
ExO/b 2204.5 (353.0)a
based on the classification system proposed by Burke
Ex/Omb 2001.5 (337.3)ab
et al8: (I) isolated fracture of the restoration; (II) resto-
ExO/t 1551.4 (443.3)b
ration fracture involving a small tooth portion; (III)
fracture involving more than half of the tooth, without Minimum significant difference = 482.59.
Different uppercase (conservative groups) or lowercase (extensive groups)
periodontal involvement; and (IV) fracture with perio- letters indicate significant differences (P,.05). General mean values are
dontal involvement (Fig. 4). compared by uppercase letters (P..05).

424 VOLUME 95 NUMBER 6

SOARES ET AL THE JOURNAL OF PROSTHETIC DENTISTRY

Fig. 5. Mean fracture resistance values and distribution by statistical categories. Different letters represent significant differences
identified by Tukey test for preparations characterized by conservative occlusal isthmus (P,.05).

Fig. 6. Mean fracture resistance values and distribution by statistical categories. Different letters represent significant differences
identified by Tukey test for preparations characterized by extensive occlusal isthmus (P,.05).

In the initial analysis, the fracture resistance data of
the 9 groups were submitted to statistical analysis by
1-way analysis of variance (ANOVA) and the Tukey
Honestly Significant Difference (HSD) test. In the
second analysis, the aim was to determine the influence
of 2 factors involved in this study, the dimension of the
isthmus floor and cuspal coverage. Therefore, the data
were analyzed with a 2-way ANOVA (4 3 2) and the
Tukey HSD test. For all tests, groups were considered
statistically different at a=.05.
RESULTS
The 1-way ANOVA showed that there were signifi-
cant differences (P=.001) among all groups with respect
to resistance to fracture (Table I). The Tukey HSD test
showed that intact teeth presented a higher resistance to
fracture under occlusal load, which was significant when
compared to the other groups (P,.05). The mean and
SD of the forces applied to cause failure in each tested
group are shown in Table II. Two-way ANOVA showed
that there were significant differences (P=.013) for the
interaction between occlusal isthmus floor dimension
and cuspal coverage procedure (Table III). The Tukey
test was applied to determine the significance of the in-
teraction of the 2 factors (Table IV) and indicated that
the cuspal coverage did not result in higher fracture re-
sistance (Figs. 5 and 6). The fracture mode analysis indi-
cated that all groups tended to demonstrate only
fractures of restorations, rather than tooth structure
(Fig. 7).
DISCUSSION
Performing in vitro experiments that aim to analyze
indirect restoration failures, characterized by the

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THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 7. Representative fracture modes observed after compressive loading test. A, Inlay. B, Onlay covering 1 cusp. C, Onlay
covering all buccal cusps. D, Onlay covering all cusps.
fracture of either the restorative material or dental struc-
ture, is an important method for improving restorative
procedures.1,2,10,12,16,17,28 There are a number of fac-
tors that may interfere with resistance to fracture, such
as the tooth embedment method, type of load applica-
tion device, and crosshead speed.8 Thus, the experimen-
tal methods used for in vitro analyses do not faithfully
represent real clinical conditions, in which failures occur
primarily due to fatigue.18 To minimize the discrepancy
between experimental assessments and clinical failures,
different methods have been used, such as the joint
use of mechanical tests and fracture mode analysis ac-
cording to predefined scales.8,17,19
Mechanical fracture tests are performed to numeri-
cally quantify the influence of restorative material
types,2,10,16,17,19,20 luting procedures,12,21 and prep-
aration characteristics14,22 for resistance to fracture
when submitted to a concentrated and increasing load.
These tests usually produce failure loads that exceed
the load limit exerted by normal stomatognathic system
movements.33 In spite of this fact, higher loading situa-
tions can be compared to the situation in which the
individual grinds a solid body of small dimensions and
the force that would be distributed over the occlusal
surfaces of posterior teeth is concentrated over a single
tooth. If this tooth is structurally debilitated or prepared
with an inadequate cavity design, the result may be
fracture of the tooth, the restoration, or both.
When performing mechanical tests, some factors are
important to more closely approximate the clinical situ-
ation, such as the root embedment method to simulate
426
SOARES ET AL
the periodontal membrane, the loading apparatus, and
the mode of load transmission.8 The simulation of the
periodontal ligament should be done with an elasto-
meric material that is able to undergo elastic deforma-
tion and reproduce the accommodation of the tooth
in the alveolus, providing the nonconcentration of
stresses in the cervical region of the tooth. Moreover, a
simulated periodontal ligament is highly influential on
the fracture pattern.23 In this experiment, a polyether
impression material was used in association with a poly-
styrene resin as an adequate method for fracture resis-
tance tests.17,24
Occlusal loading is another important factor. Burke
et al8 and Burke and Watts9 concluded that the best
method for measuring the resistance of premolars to
fracture is the use of a cylinder of a defined diameter.19
The use of a 6-mm steel sphere for resistance to fracture
testing by Dietschi et al25 and Soares et al17 was shown
to be ideal for molars because it contacts the functional
and nonfunctional cusps in positions close to those
found clinically.
The results of the present study showed that the mean
resistance to load of healthy teeth (IT:3143.1 6 635.5
N) was significantly higher than the resistance to load
of teeth prepared with different types of preparations
and restored with a Leucite-reinforced ceramic; thus,
the null hypothesis was rejected. This demonstrates
that the restorative process, even when adhesive tech-
niques are associated with cuspal coverage, is not able
to restore the total resistance to load of healthy molars.
This result is in agreement with the studies of Morin
VOLUME 95 NUMBER 6
SOARES ET AL
et al,1 St-Georges et al,26 and particularly with that of
Mondelli et al,14 who showed a reduction in the resis-
tance to fracture for teeth that had been prepared with
greater removal of dental structure. Since ceramics
have high elastic moduli and tend to concentrate stress
inside the body of the restoration,4,18,31 they have lower
resistance to fracture than healthy teeth, even though
the ceramic is reinforced by the inclusion of oxides.27
This is because ceramics are not capable of undergoing
elastic deformation at the same rate as tooth structure
and resinous materials. Thus, stress concentrations are
dependent on the geometry of the specimen material,
loading conditions, and presence of intrinsic or extrinsic
flaws. In addition, the resin luting agent under a ceramic
restoration may act as a soft layer and could reduce the
effects of stress concentration. In spite of the adhesive
process being fundamental for luting a leucite-rein-
forced ceramic restoration,12,27 the cushioning effect
of the resinous cement did not seem to be sufficient
to absorb the stresses, which remain inside the ceramic
restoration and demand deformation; if deformation
does not exist, fracture may occur.
Analyses of the different types of preparations in this
study showed that preparations resulting in a greater loss
of tooth structure appear to decrease the resistance to
fracture of the tooth-restoration complex. Assif et al22
analyzed the extent of preparation for amalgam restora-
tions and found that endodontically treated teeth with a
small amount of structure removed (conservative occlu-
sal isthmus) and total cuspal coverage produced better
resistance values. The discrepancies between the results
of Assif et al22 and the findings of the present study are
likely due to the differences in the mechanical properties
and adhesive characteristics of the respective restorative
materials used. Amalgam, as a metal, can undergo elastic
deformation; however, ceramics cannot due to their
ionic and covalent bonds. Moreover, amalgam adhesion
to the tooth structure is minimal; thus, extensive amal-
gam restorations demand cuspal coverage to protect
teeth from fracture when the restorative material is un-
dergoing deformation. Ceramics, in general, present a
high elastic modulus and low strain capacity, so the
stress tends to concentrate inside the material since
stress can not be relieved by deformation the material
fractures before stresses are transferred to the tooth.
Leucite-reinforced ceramics have good adhesion to
tooth structures, and according to St-Georges et al,26
this enables an internal rather than an external splinting
with cuspal coverage10 to be created in some instances.
Thus, the adhesive strength should be enough to sup-
port cusp deflection. With respect to the fracture resis-
tance of all tested groups, the conservative inlay
preparation showed the highest numerical value
(2465.4 6 318.7 N), but was statistically similar to
the extensive inlay group, in which a greater amount
of tooth structure had been removed during preparation
JUNE 2006
THE JOURNAL OF PROSTHETIC DENTISTRY
(2278.1 6 586.4 N). The ceramic restoration presented
less resistance to fracture when more tooth structure was
removed during preparation, and the effect of cuspal
coverage was not a benefit.
In addition to discussing fracture resistance values, it
may be important to analyze the fracture modes in each
experimental group. For all groups, fracture was ob-
served in the restoration itself. Similar findings were
reported by Soares et al17 when the authors tested feld-
spathic ceramic in extensive inlays, and also by Burke,21
who affirmed that the ceramic fractures before the
tooth. For the CsI group, it was found that the majority
of the fractures occurred exclusively in the restoration,
probably because of the larger volume of dental struc-
ture in the cusps, which resulted in a greater capacity
for undergoing deformation rather than fracture.
Cuspal coverage with an onlay apparently does not
produce a clear benefit to the fracture resistance of the
restored tooth, as has been shown for metal restora-
tions.11 This is related to the fact that the failure, as
seen by the fracture modes, occurs almost exclusively
in ceramics. If the restoration is expected to fail irrespec-
tive of the preparation design, then extending prepara-
tions will not change this behavior, as seen in this
study.
The clinician may encounter a situation in which the
tooth presents loss of a cusp or fracture of a portion of it.
It is not advisable to establish an occlusal contact at the
tooth-restoration interface, due to the difference in the
mechanical behavior of the 2 structures. In this situation
the need for cuspal coverage must be determined.
Another concern is the need for covering nonfunctional
cusps, which may be observed by comparing the groups
of teeth with onlay preparations covering just the func-
tional cusps (CsO/b, 2158.4 6 321.7 N and ExO/b,
2204.5 6 353.0 N), and the onlay preparations with
total cusp coverage (CsO/t, 2062.3 6 488.4 N and
ExO/t, 1551.4 6 443.3 N). According to the results
of this study, it appears that there is no advantage in
covering nonfunctional cusps.
The comparison of the behavior of groups with great
volumes of ceramic in occlusal isthmus (CsO/t and
ExO/t) requires discussion. In spite of being statistically
similar, ExO/t was almost 500 N less resistant than
CsO/t, and it may be that the volume of ceramic material
in the occlusal box and the thickness of remaining tooth
structure in prepared cusps are responsible for this find-
ing. Ceramic thickness, when either very thin or very
thick, seems to be detrimental with regard to fracture.34
In addition, sharp angles and knife-edge–prepared
cusps tend to concentrate stress, resulting in greater sus-
ceptibility to ceramic restoration fracture32; therefore,
rounded internal angles are preferred for ceramic resto-
rations. When tooth structure loss results in an extensive
occlusal isthmus, this may necessitate coverage of all the
cusps, a feasible alternative for restoration in the occlusal
427
THE JOURNAL OF PROSTHETIC DENTISTRY
isthmus and also to eliminate the knife-edge form in
the prepared cusps. However, further investigation is
needed to determine the effect of this procedure.
This study has several limitations. The compressive
load applied to the restored tooth was increased until
failure; however, dental ceramics typically fail as a result
of many loading cycles or from an accumulation of dam-
age from stress and water.35 In terms of in vivo loading,
the masticatory cycle consists of a combination of vertical
and lateral forces, subjecting the ceramic to a variety of
off-axis loading forces.36 Cyclic loading may be more
adequate to reproduce fatigue failures verified clinically.
Future analyses should involve both methods of load ap-
plications. Destructive tests are important for predicting
and comparing the behavior of a restored tooth under
specific situations; however, future studies should per-
haps use nondestructive methodologies such as finite el-
ement analysis or structural deformation by employment
of strain gauges, enabling not only analysis at the mo-
ment of failure but also the possible causes for the failure.
In addition, because only one material type was used in
the current study, it is not possible to apply these results
to other esthetic materials.17 The results of this study
suggest guidelines when preparing teeth for ceramic
restorations, but more analyses are required before ex-
trapolating these results to other ceramic restorative
systems.
CONCLUSION
Within the limitations of this in vitro study, the fol-
lowing conclusions were drawn:
1. Intact teeth are more resistant to fracture than teeth
prepared and restored with Leucite-reinforced ce-
ramics, irrespective of the cavity preparation design.
2. Specific designs of different preparations facilitate the
occurrence of fractures of ceramic restorations, with
fracture modes generally restricted to the restoration.
3. The cuspal coverage did not increase fracture resis-
tance of the posterior tooth-restoration complex
restored with Leucite-reinforced ceramics.
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3. Etemadi S, Smales RJ, Drummond PW, Goodhart JR. Assessment of tooth
preparation designs for posterior resin-bonded porcelain restorations.
J Oral Rehabil 1999;26:691-7.
4. Banks RG. Conservative posterior ceramic restorations: a literature
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VOLUME 95 NUMBER 6
SOARES ET AL THE JOURNAL OF PROSTHETIC DENTISTRY

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DR CARLOS JOSE SOARES Copyright Ó 2006 by The Editorial Council of The Journal of Prosthetic
FACULDADE DE ODONTOLOGIA Dentistry.
UNIVERSIDADE FEDERAL DE UBERLÂNDIA
AV. PARÁ, N.1720, BLOCO 2B, SALA 24
CAMPUS UMUARAMA
CEP: 38400-902
UBERLÂNDIA, MINAS GERAIS, BRAZIL
FAX: 55 34 32182279
E-MAIL: carlosjsoares@umuarama.ufu.br doi:10.1016/j.prosdent.2006.03.022

A confocal microscopic evaluation of resin-dentin interface using

Noteworthy Abstracts adhesive systems with three different solvents bonded to dry and
of the moist dentin—An in vitro study
Current Literature Mohan B, Kandaswamy D. Quintessence Int 2005;36:511-21.

Objective: Total dehydration of acid-etched dentin is known to cause the collapse of collagen fiber, which leads
to poor hybridization. Dentin-bonding systems with water as a solvent are found to rehydrate the collapsed
collagen. Acetone-based adhesives are found to compete with moisture, and the acetone carries the resin
deep into the dentin. The question arises whether to dry the dentin and use a water-based adhesive, or to
keep the dentin moist and use an acetone- or alcohol-based adhesive. The aim of this study was to compare
different bonding systems and techniques to assess which is most successful. A confocal microscope was
used to evaluate the amount of hybrid layer formation and the depth of resin tag formation.
Method and Materials: Superficial occlusal dentin specimens from 120 noncarious, freshly extracted human
premolars were used for the study. The dentin was etched using 36% phosphoric acid for 15 seconds and then
rinsed. The specimens were then randomly divided into 4 groups for different drying procedures; group I:
air-dried for 30 seconds; group II: air-dried for 3 seconds; group III: blotted dry; group IV: overwet.
The specimens were further subdivided into 3 groups to be tested with different bonding systems: sub-
group A: acetone-based adhesive (Prime & Bond NT); subgroup B: water-based adhesive (Syntac Single
Component); subgroup C: water- and ethanol-based adhesive (Single Bond). The resulting resin-dentin
interfaces were then examined and categorized via confocal microscopy, and relative values were assigned to
each specimen.
Results: Group IV (overwet) showed the lowest values, and the highest values were obtained in group III. The
highest values were seen in group III, subgroup A (blotted dry, acetone-based bonding agent, Prime & Bond
NT).
Conclusion: Under these conditions, using these three bonding systems, maximum hybridization and resin
tag formation were achieved using acetone-based adhesive on etched dentin kept moist by blot drying.—
Reprinted with permission of Quintessence Publishing.

JUNE 2006 429