RESTORATIVE DENTISTRY

Flexural strength of minimum thickness ceramic veneers

manufactured with different techniques
Fabio A. P. Rizzante, DDS, MSc, PhD/Idiane B. L. Soares-Rusu/Suellen S. Senna, DDS/
Carla M. Ramos-Tonello, DDS, MSc, PhD/Rafael F. L. Mondelli, DDS, MSc, PhD/Sérgio K. Ishikiriama, DDS, MSc, PhD/
Ana Flávia S. Borges, DDS, MSc, PhD/Zvi Gutmacher, DMD

The objective of the present study was to assess
the effect of monolithic and bilayer restorations considering
heat-pressed and milled/CAD/CAM reinforced lithium disili-
cate ceramic veneers, on the flexural strength after cementa-
tion. Method and materials: Thirty-five specimens were di-
vided into five groups (n = 7), according to the restorative
solution: 2-mm thickness composite resin (CR2); heat-pressed
monolithic ceramic 0.6 mm (HPM), CAD/CAM monolithic
ceramics 0.6 mm (CCM); heat-pressed monolithic ceramic
0.4 mm + 0.2 mm glass-ceramic (HPB); CAD/CAM monolithic
ceramic 0.4 mm + 0.2 glass-ceramic (CCB). Specimens were
cemented on composite resin bars and submitted to a three-
point bending test on a Universal Testing Machine, until frac-
ture. Fractured samples were analyzed under stereomicro-
scope and SEM. Flexural strength data were analyzed by
one-way ANOVA and Tukey test. Results: The control group
showed the highest flexural strength results (119.57 ±
19.49 MPa), with values similar to groups HPM (98 ± 25.62 MPa)
and CCM (96.14 ± 20.60 MPa). Groups HPB and CCB showed
lower values when compared with the other groups. Fracture
started from the base on monolithic groups and from ceramic
on bilayer groups. Conclusion: Both ceramic systems (CAD/
CAM and heat-pressed) have similar fracture strength, al-
though bilayer restorations present lower strength when com-
pared with monolithic ceramics. (Quintessence Int 2020;51:
268–273; doi: 10.3290/j.qi.a44147)

Key words: CAD/CAM, ceramics, dental materials, esthetics, operative dentistry, prosthodontics, veneers

The “perfect” smile has become essential, frequently associated
with better social and professional projection. Ceramic veneers
are one of the possible treatments for predictable resolutions of
esthetic cases, allowing excellent esthetic results while preserving
as much as possible of teeth structure, which is consistent with
the concepts of a minimally invasive dentistry.1-3 Ceramic veneers
are considered a well-established treatment option, with longev-
ity of 100% after two years4 and around 90% after over 10 years.5,6
Due to their physico-mechanical and optical properties,
lithium disilicate ceramics are one of the most frequently
used material for ceramic veneers, allowing very conservative
preparations.7-9 In some cases, the marginal edges can be
defined as a feather edge (about 0.3-mm thickness) or even
with no reduction of tooth structures at all.4
This class of ceramics are extremely versatile, allowing mono-
lithic or bilayer restorations, using both heat-pressed (eg, IPS
E-max Press, Ivoclar Vivadent) and computer-aided de-
sign/computer-assisted manufacture (CAD/CAM) tech-
niques (eg, IPS E-max CAD, Ivoclar Vivadent).10-12 CAD/CAM
systems allow restoration manufacturing in reduced time
while reducing production costs.10,13 It has been speculated
that due to better process standardization (less technically
sensitive), they could achieve higher flexural strength val-
ues.14 Nevertheless, this assumption seems controversial since
IPS E-max CAD goes through two crystallization processes (one
during the manufacturing process – lithium metasilicate/Li2SiO3,
and a second one in the laboratory/clinic – lithium disilicate/
Li2Si2O5), resulting in reduced mechanical properties due to a
random distribution of the crystals, and their smaller size when
compared with pressed lithium disilicate ceramics.11,12,15,16
Regarding the number of layers, bilayered ceramics (associ-
ation between lithium disilicate and a feldspathic or nanofluor-

268 QUINTESSENCE INTERNATIONAL | volume 51 • number 4 • April 2020


apatite ceramic) were designed to improve esthetics.9 None-
theless, this restorative solution is associated with higher failure
rates.9,10,15 This said, monolithic restorations usually are associ-
ated with higher flexural strength and success rates.10,14
Considering these aspects, there is a lack of information
about flexural strength of minimally invasive veneers made
with different techniques. The aim of the present study was to
assess the effect of heat-pressed and CAD/CAM reinforced lith-
ium disilicate ceramic veneers, considering monolithic or
bilayer restorations, on the flexural strength after cementation.
The null hypotheses tested were:
■ there would be no difference in flexural strength for mono-
lithic lithium disilicate ceramics between CAD/CAM and
heat-press techniques
■ there would be no difference in flexural strength of bilayer
lithium disilicate ceramics between CAD/CAM and for heat-
press techniques
■ there would be no difference in the flexural strength between
monolithic and bilayer lithium disilicate ceramics veneers.
Method and materials
Thirty-five specimens were prepared following manufacturers’
instructions and were distributed into five groups (n = 7):
■ CTR: 2-mm composite resin (control group)
■ HPM: Heat-pressed monolithic ceramics (IPS e.max) with
0.6-mm thickness
■ CCM: CAD/CAM monolithic ceramics (IPS e.max CAD) with
0.6-mm thickness
■ HPB: Heat-pressed monolithic ceramics (IPS e.max) with
0.4-mm thickness + 0.2-mm fluorapatite glass-ceramic
■ CCB: CAD/CAM monolithic ceramics (IPS e.max CAD) with
0.4-mm thickness + 0.2-mm fluorapatite glass-ceramics.
For heat-pressed ceramics, a 0.4- or 0.6-mm thickness resin pat-
tern (Duralay, Reliance Dental) was obtained through a metallic
matrix (16 × 4 × 2 mm), with the aid of a 1.6- or 1.4-mm thick-
ness shim respectively. The resin pattern was connected to an
injection sprue with wax and the injection was made with aid
of a furnace (Programat EP 3000, Ivoclar Vivadent) using E-Max
Press HT A1 ceramic ingots. Ceramics were divested and
cleaned with aluminum oxide blasting and ceramic excesses
were removed with specific abrasive disks.
For the CAD/CAM groups, HT A1 E-Max CAD blocks were
cut with aid of a diamond disk and a cutting machine (ISOMET
Low Speed Saw, Buehler). The first cut was made separating
QUINTESSENCE INTERNATIONAL | volume 51 • number 4 • April 2020
Rizzante et al
the metal base, followed by cuts parallel to the block long axis
(three slices of 4 mm each), resulting in three smaller blocks
(16 × 4 × 12 mm). Each block was cut again through its long
axis resulting in blocks of 16 × 4 × 0.4 mm or 0.6 mm. CAD/
CAM specimens were crystallized in a ceramic furnace (Ivoclar
3000, Ivoclar Vivadent), using program 81 (850°C for 25 min-
utes), in accordance with manufacturers’ recommendations.
After thickness standardization, glass-ceramic was applied
over the core/base ceramic, in groups HPB and CCB. For this,
the 0.4-mm samples were positioned into the metallic matrix,
with a 1.4-mm shim, and a 0.2-mm veneer layer was applied
and heated on a ceramic furnace (Vulcano, EDG; initial tem-
perature 430°C, final temperature 730°C, with approximately
30 minutes cycle time).
Resin bases of 16 × 4 × 2 mm (Z350XT, 3M ESPE) were ob-
tained with the aid of the metallic matrix, without shim inter-
position. After composite insertion, a mylar strip was pos-
itioned and pressed over the surface with a glass plate to
standardize the surface. After glass plate removal, composite
was light cured with a 1,200 mW/cm2 LED (Radical, SDI) at three
points, for 40 seconds, on both upper and lower surfaces
(240 seconds in total).
For the cementation protocol, the ceramics were etched
with 10% fluoridric acid (Condac Porcelana, FGM), silanized (Pro-
sil, FGM), and the adhesive system (Ambar, FGM) was applied
without light curing. For the resins, they were etched with 37%
phosphoric acid (Condac 37%, FGM) and a thin layer of adhesive
was applied (Ambar, FGM). After that, the light-cured resin ce-
ment (AllCem Veneer, FGM) was applied on the ceramic surface
and the set was positioned over the resin base. The cement line
was standardized applying a 500 KgF weight positioned over
the ceramic surface for 5 seconds. Excesses were removed with
a microbrush and the set was light cured for 40 seconds for each
of the three surface points (120 seconds in total). All specimens
were stored in a 36.5°C incubator, for 24 hours.
A flexural strength test was performed with a three-point
bending device adapted on an Universal Testing Machine with a
500 N loading cell (Instron model 3342, Instron) (Fig 1). The load
was applied in the center between the two bases (with 12 mm
between them) with the ceramic side under tensile stress, with
0.5 mm/minute downward movement, perpendicular to the
composite resin surface, until specimen fracture. Flexural
strength values were converted to MPa using the built-in soft-
ware, having each specimen’s transversal section values as refer-
ence. The fractured samples were analyzed under a stereomicro-
scope (Discovery V20 Zeiss) and representative samples were
gold sputtered and analyzed under a scanning electron micro-
269
 RESTORATIVE DENTISTRY
1 to the milling burs.11,12,15-17 During the crystallization process, at
Fig 1 Three-point bending device adapted on the upper arm of the
Universal Testing Machine, with the specimen in position.
scope (SEM Inspect S50, FEI). The obtained images were qualita-
tively analyzed and described. Flexural strength data were sub-
mitted to the Shapiro-Wilk normality test, one-way analysis of
variance (ANOVA) (different treatments) and Tukey test.
Results
The control group, CCM, and HPM (respectively heat-pressed
and CAD/CAM 0.6-mm ceramics cemented to a 2-mm compos-
ite resin base) showed the highest flexural strength (Table 1).
HPB and CCB (bilayer CAD and heat-pressed ceramics cemented
to a 2-mm composite resin base) showed similar results, but
these were lower in comparison with the other groups (Table 1).
Fractographic analysis demonstrated that bilayer ceramics
showed fracture starting from the ceramic and progressing to
the composite base (Fig 2), whereas for monolithic ceramics,
the fracture pattern started from the composite and progressed
up to the fracture of the ceramic (Fig 3). No debonding was
observed either for the glass-ceramic or for the veneer ceramic.
Discussion
Lithium disilicate ceramics might be the most frequently used
material for minimum thickness veneers, and are associated
with good mechanical properties, chemical stability, biocom-
patibility, reduction in bacterial plaque acumuli, good esthet-
270 QUINTESSENCE INTERNATIONAL | volume 51 • number 4 • April 2020
ics, and adequate marginal fit.7-9 Nevertheless, there are limited
data about mechanical properties comparing minimum thick-
ness ceramic restorations, especially regarding monolithic and
bilayered configurations and different manufacturing tech-
niques (heat pressed or CAD/CAM).
Flexural strength of heat-pressed and CAD/CAM lithium dis-
ilicate ceramics has been discussed, and the results have been
considered based on the manufacturing technique/process.
Blocks of lithium disilicate ceramics consist of a glass-ceramic
with the crystal phase composed by lithium disilicate crystals
(Li2Si2O5), corresponding to 60% of the total ceramic volume.
Blocks before milling present the material partially crystallized
(lithium metasilicate), with particle sizes ranging between 0.2 μm
and 1 μm, and a flexural strength of 130 MPa, to avoid damage
840°C for 25 minutes, particle size increases under control, from
0.5 μm to 5 μm. During this process, prismatic glass-ceramics are
formed and dispersed over the glassy matrix. As the crystal spac-
ing becomes denser, the proportion of fine lithium disilicate
crystals within the glassy matrix increases 70% after crystalliza-
tion, and the flexural strength of the restoration increases to
360 MPa.11,12,15-17 The effects of the crystallization process can be
verified by approximately 0.2% to 0.3% shrinkage.18
It is important to note there is no reported shrinkage for
heat-pressed lithium disilicate, since the whole crystallization
process was performed industrially. In accordance with the pres-
ent results, the crystallization process does not seem to influ-
ence flexural strength, resulting in similar strength values for
both CAD/CAM and heat-pressed techniques (CCM [monolithic
CAD/CAM]: 96.14 ± 20.60 Mpa versus HPM [monolithic heat-
pressed] 98.00 ± 25.62 MPa) (Table 1). Thus, the first null hypoth-
esis was accepted. Such results are in agreement with the litera-
ture,12 despite controversial results.11 Different results can be
explained by differences in method, for example assessing frac-
ture toughness based on a triangular ceramic prism, which can
lead to stress concentration and cracks11 that have different ori-
entations of crystals (random in CAD/CAM ceramics or paral-
lel-oriented and in higher density in heat-pressed ceramic).
There was also no observed difference between monolithic
groups and the CTR group. Control group results are in accor-
dance with the literature using ISO 4049 (119.57 ±19.49 MPa
and 123.29 ± 21.92 MPa).19 In order to simulate clinical condi-
tions, it is important to cement the specimens on tooth- or den-
tin-like substrate (ISO 6872 standard). The option for applying
the flexural force on the resin base surface was made because,
clinically, the fracture origin is often located at the inner surface
of the ceramic restorations.20

Table 1 Results for flexural strength and elastic modulus
CCM: E-max CAD
Group CTR: control 2 mm 0.6 mm
Flexural strength (MPa) 119.57 ± 19.49a 96.14 ± 20.60a
a bc
Elastic modulus (GPa) 6.48 ± 0.44 5.12 ± 0.19
Different letters mean statistically significant difference between columns in the same row (inter-groups) (P ≤ .05).
Associating the demand of patients for esthetics with the
optical properties of lithium disilicate ceramics, a bilayer tech-
nique (lithium disilicate core + glass-ceramic veneer layer) was
developed to achieve better esthetic results, since it becomes
possible to characterize each part of the restoration individually.
There were no differences between flexural strength of bi-
layer lithium disilicate ceramics manufactured using CAD/CAM
or heat-pressed techniques. Those results were expected since
core ceramics from CAD/CAM and heat-pressed techniques
showed the same strength, and the layering process was the
same for the different groups. Accordingly, the second null hy-
pothesis was accepted. Nonetheless, the strength on bilayered
groups decreased severely and the third null hypothesis was
rejected. Bilayer technique reduced the flexural strength of the
set (resin base + resin cement + ceramic restoration) in about
50%, considering both CAD/CAM and heat-pressed techniques
(Table 1). These in vitro results can explain some clinical obser-
vations, in which the literature reports more frequent failures/
insuccess for bilayered ceramic restorations when compared
with the monolithic ones (1.53% versus 1.3% after 4 years),21 as
well as in vitro studies.9,22-24 Reduction of core ceramic thickness
for bilayered ceramics can reduce the strength (a reduction of
0.8 mm to 0.4 mm may double the predicted fracture probabil-
ity).23 Overall, a thicker core ceramic will result in more resistant
restorations.16,23 This is especially true because mechanical
properties of veneer ceramics are considerably lower,22 and
stresses can be generated between the ceramics interface. In-
ner stress development can also happen due to manufacturing
process and physico-mechanical properties mismatch, contrib-
uting to early failures.24 In addition, veneered lithium disilicate
restorations are associated with higher teeth wear rates, due to
an increase in roughness during occlusal contact.25
When comparing the different elastic modulus, it can be
noted that the set dentin/ceramic resulted in lower values, for
both monolithic and bilayer restorations, indicating that cemen-
tation line/material may influence the elastic properties of the set,
mainly when ceramics with lower strength are used (bilayered).
QUINTESSENCE INTERNATIONAL | volume 51 • number 4 • April 2020
Rizzante et al
HPM: Heat pressed CCB: Bi-heat pressed HPB: Bi-CAD
0.6 mm 0.4 mm + 0.2 mm 0.4 mm + 0.2 mm
98.00 (25.62)a 54.85 ± 4.63b 50.86 ± 4.56b
b bc
5.31 (0.38) 4.83 ± 0.35 4.75 ± 0.32c
Considering the fractographic analysis, it was interesting to
observe the fracture pattern change with the different restora-
tive solutions (monolithic and bilayer). For bilayer ceramics, it
was observed that the facture started from the ceramic and pro-
gressed to the composite base, as the compression curl can be
observed at the base of the composite (opposite side from the
cementation line)(Fig 2). This was expected since the fracture
strength decreased for bilayered solutions, resulting in an
“earlier” fracture.22 Interestingly, the fracture pattern for mono-
lithic ceramics was changed. It was possible to observe the
compression curl located next to the cementation line, indicat-
ing that the fracture started from the composite base and pro-
gressed to the ceramic (Fig 3). This might be explained by the
higher flexural strength of the monolithic ceramic, meaning that
the tensile component of the force during the three-point bend-
ing test was not able to fracture the ceramic. In addition, it can
be concluded that the compressive strength of the composite
was exceeded, leading to the beginning of the fracture. The
integrity of the cementation line during all tests is noteworthy,
as this shows the reliability of the adhesive cementation proto-
col.26 No debonding was observed at the interface between
composite and ceramic or core and veneer ceramic. Similar
results regarding the interface between core and veneer
ceramic have been reported.24
The veneering ceramic used in the present study is com-
posed of fluorapatite (E-max Ceram, Ivoclar Vivadent), and is
labeled to have a lower biaxial flexural strength and lower elas-
tic modulus when compared with the lithium disilicate blocks
and ingots. It is important to note that manufacturers test the
material alone, without the interaction with core ceramics as
assessed in the present study.
Despite being a simplistic testing method, use of a flat spec-
imen reduced the possibility of manufacturing-induced errors.
Cementing ceramic veneers on dentin-like substrates (compos-
ite resin) allows close reproduction of clinical configurations
when compared with traditional isolated material bars.16 Further
studies might focus on assessing the influence of the cementa-
271
 RESTORATIVE DENTISTRY

2 3

Fig 2 Broken half of a bilayer ceramic at 35× magnification. The
white arrows indicate the radial hackles surrounding the critical flaw
(origin of the fracture), as well as the direction of crack propagation
(dcp) (from the ceramic to the composite base). The compression curl
can be observed at the composite resin base, indicating the bending
component immediately before the specimen’s total fracture.
Fig 3 Broken half of a monolithic ceramic at 35× magnification.
Typical fracture surface for brittle materials. Radiating hackle lines
can be observed surrounding the origin of the fracture and indicating
the direction of the crack propagation (from the composite base
towards the ceramic). The black arrows indicate the compression curl
located at the cementation line.

tion material on the flexural strength of ceramic veneers, includ-
ing analysis of more complex geometries and stress distribution,
as well as their strength after artificial aging and/or fatigue tests.
That being said, in the present authors’ opinion, the increased
failure risk and the possible increase in tooth wear does not jus-
tify the virtually better esthetic outcomes that a bilayered veneer
could generate when compared with monolithic veneers, espe-
cially considering the current painting and glazing techniques,
allowing the achievement of very natural results. Thus, mono-
lithic veneers are easier and faster to manufacture; at the same
time they provide better mechanical properties and similar
esthetics when compared with bilayered veneers.
of lithium disilicate ceramics. Nonetheless, flexural strength of
bilayered ceramics can be severely reduced when compared
with monolithic solutions.
Acknowledgments
The authors thank Dr José Roberto Pereira Lauris, Professor at
Bauru School of Dentistry, University of São Paulo, for help with the
statistical analysis; and Dr Naiara Araújo de Oliveira, PhD student
at the Department of Operative Dentistry, Endodontics and Dental
Materials at FOB-USP, for her help with the fractographic analysis.

Conclusion
Within the limitations of the present study, it can be concluded
that manufacturing techniques did not change flexural strength
Declaration
The authors declare that they have no conflict of interest. The
present study was supported by FAPESP (The São Paulo
Research Foundation) (grant number 2014/13575-4).

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Fabio A. P. Rizzante Suellen S. Senna Alumni, Bauru School of Dentistry, University

Fabio A. P. Rizzante Assistant Professor,r Department of Compre-
hensive Care, School of Dental Medicine - Case Western Reserve
University, Cleveland, OH, USA
Idiane B. L. Soares-Rusu PhD candidate, Department of Opera-
tive Dentistry, Endodontics and Dental Materials, Bauru School of
Dentistry, University of São Paulo, Bauru, SP, Brazil
of São Paulo, Bauru, São Paulo, Brazil
Carla M. Ramos-Tonello Assistant Professor,r Department of Re-
storative Dentistry – FMU Education Group, São Paulo, SP, Brazil
Rafael F. L. Mondelli Department Chair,r Department of Opera-
tive Dentistry, Endodontics and Dental Materials, Bauru School of
Dentistry, University of São Paulo, Bauru, SP, Brazil
Sérgio K. Ishikiriama Associate Professor,r Department of Oper-
ative Dentistry, Endodontics and Dental Materials, Bauru School of
Dentistry, University of São Paulo, Bauru, SP, Brazil
Ana Flávia S. Borges Associate Professor,r Department of Oper-
ative Dentistry, Endodontics and Dental Materials, Bauru School of
Dentistry, University of São Paulo, Bauru, SP, Brazil
Zvi Gutmacher Department Chair,r Department of Maxillofacial
Rehabilitation, School of Graduate Dentistry, Rambam Healthcare
Campus, Haifa, Israel

Correspondence: Dr Fabio Antonio Piola Rizzante, Department of Comprehensive Care, Case Western Reserve University, School of
Dental Medicine - 9601 Chester Avenue, Room 340, Cleveland, OH 44106, USA. Email: fap17@case.edu

QUINTESSENCE INTERNATIONAL | volume 51 • number 4 • April 2020 273