Clin Oral Invest
DOI 10.1007/s00784-017-2057-7
ORIGINAL ARTICLE
In-vitro performance of CAD/CAM-fabricated
implant-supported temporary crowns
Martin Rosentritt 1 & Philipp Raab 1 & Sebastian Hahnel 1 & Matthias Stöckle 1 &
Verena Preis 1
Received: 14 September 2016 / Accepted: 10 January 2017
# Springer-Verlag Berlin Heidelberg 2017
Abstract
Objectives The aim of this study was to investigate the in-
vitro performance and fracture resistance of a temporary
computer-aided designed and computer-aided manufactured
polymethylmethacrylate (CAD/CAM-PMMA) material as
implant or tooth-supported single crown with respect to the
clinical procedure (permanently bonded/temporarily
cemented).
Materials and methods Sixty-four crowns were fabricated on
implants or human molar teeth simulating (a) labside proce-
dure on prefabricated titanium-bonding base ([TiBase] im-
plant crown bonded in laboratory, screwed chairside), (b)
labside procedure ([LAB] standard abutment and implant
crown bonded in laboratory, screwed chairside), (c) chairside
procedure ([CHAIR] implant crown bonded to abutment), and
(d) reference ([TOOTH] crowns luted on prepared human
teeth). Crowns were made of a CAD/CAM-PMMA tempo-
rary material (TelioCAD, Ivoclar-Vivadent). For investigating
the influence of fixation, half of the crowns were permanently
(P) or temporarily (T) bonded. Combined thermal cycling and
mechanical loading (TCML) was performed simulating a 5-
year clinical situation. Fracture force was determined. Data
were statistically analyzed (Kolmogorov-Smirnov test, one-
way ANOVA; post hoc Bonferroni, α = 0.05).
Results All restorations survived TCML without visible fail-
ures. Fracture results varied between 3034.3 (Tooth-P) and
1602.9 N (Tooth-T) [TOOTH], 1510.5 (TiBase-P) and
963.6 N (TiBase-T) [TiBase], 2691.1 (LAB-P) and
2064.5 N (LAB-T) [LAB], and 1609.4 (Chair-P) and
* Verena Preis
verena.preis@ukr.de
1
Department of Prosthetic Dentistry, University Medical Center
Regensburg, 93042 Regensburg, Germany
1253.0 N (Chair-T) [CHAIR]. Tested groups showed signifi-
cantly (p < 0.001) different fracture values. Failure pattern was
characterized by fractures in mesial-distal, buccal-oral, or
mixed (mesial-distal/buccal-oral) directions, with differences
for the individual groups.
Conclusions Temporary CAD/CAM crowns showed no dif-
ferent in-vitro performance but provided different fracture re-
sults that depended on cementation, screw channel, and type
of abutment.
Clinical relevance All bonded and screwed PMMA crowns
were in a range where clinical application seems not restricted.
Keywords CAD/CAM composites . PMMA, temporary .
Provisional, chewing simulation . Implant crown . Abutment .
Fracture resistance
Introduction
Temporary computer-aided designed and computer-aided
manufactured (CAD/CAM) implant-supported crowns restore
esthetics and guarantee function during the restoration process
or the osseointegration of dental implants. The temporary
crown can be fabricated from polymethylmethacrylate-
(PMMA), composite-, or polyetheretherketone- (PEEK)
based materials and should provide dimensional and marginal
stability and resistance to functional occlusal loading [1–3].
Besides paste/paste bis-acrylate- and powder/liquid MMA-
based materials, multiple polymer-based materials are avail-
able as CAD/CAM blocks [4]. These materials are polymer-
ized under controlled and standardized industrial conditions at
high pressure and temperature, resulting in an improved con-
version and reduced residual monomer content [5]. With the
fabrication process, physical material properties [6, 7] and
wear resistance [8] are improved compared to conventionally

polymerized materials. In return, the high conversion reduced
the ability of bonding to resin-based bonding materials [9–12].
CAD/CAM materials are increasingly used as implant-
supported temporary or as long-term therapeutic restorations
for the pretreatment of complex clinical cases involving the
adjustment of the occlusal plane [3, 13, 14]. Special CAD/
CAM blocks are even manufactured with a prefabricated in-
terface for the direct cementation onto a titanium-adhesive
base allowing a chairside screw-retained fixation of the tem-
porary crown, easy retrievability, and ease of maintenance
[15–17]. The prefabricated interface provides an easy han-
dling and an optimized adaptation to the abutment. Screw-
retained hybrid abutments offer the elimination of deep sub-
mucosal abutment shoulders and avoid excess cement which
may lead to inflammatory reactions of the gingival tissue with
adjacent marginal bone loss.
Implant placement with immediate provisionalization is a
state of the art in implant dentistry, especially in the esthetic
zone, and temporary restorations may be important for control-
ling the osseointegration [18] and may help forming the emer-
gence profile and visualizing the permanent solution [19–23].
To date, only limited scientific in-vivo information is avail-
able for the performance of such restorations. Therefore, in-
vitro aging and tests on the fracture resistance of CAD/CAM-
fabricated implant-supported temporary crowns may provide
the first prediction of their mechanical performance and clin-
ical durability.
The hypothesis of this investigation was that temporary
CAD/CAM crowns show different in-vitro performance and
fracture resistance when:
– Crowns were (I) permanently or (II) temporarily bonded
and
– Crowns were fixed on different abutments ((a) titanium-
adhesive base in the laboratory and screwed onto an im-
plant chairside (group TiBase), (b) abutments bonded in
the laboratory and screwed onto an implant chairside
(group LAB), (c) crowns bonded chairside (group
CHAIR)), or (d) crowns boned on the human teeth (group
TOOTH, reference).
Materials and methods
A total of 64 temporary crowns were fabricated from a
PMMA-based CAD/CAM temporary restorative material
(Telio CAD, Ivoclar Vivadent, Schaan, FL), by the chairside
CAD/CAM-system (Cerec, MCXL, Sirona, G). All crowns
were either permanently bonded (BP^, Multilink Automix,
Ivoclar Vivadent) or temporarily bonded (BT^, Telio CS
Link, Ivoclar Vivadent). Inner sides of the crowns were
Clin Oral Invest
conditioned (SR Connect; Bluephase Style 40s, Ivoclar
Vivadent) prior to cementation as recommended by the
manufacturer.
Four groups (n = 16 per group) were designed to simulate
the following clinical procedures (Fig. 1):
– Group BTOOTH^ (reference): crowns were bonded on
prepared human molar teeth.
– Group BTiBase^ labside procedure: Telio CAD A16—
abutment solutions with a prefabricated interface and
the titanium-adhesive base (Ti Base, Sirona, G) were lut-
ed in the dental laboratory resulting in a temporary hybrid
abutment crown. After the excess material was removed,
the restoration was screwed onto the implant analog. The
screw access channel was sealed with composite
(Monobond Plus, Filtek Supreme; Elipar Trilight 40s,
3M Oral Care, USA).
– Group BLAB^ labside procedure: a screw access channel
was manually drilled into the central fossa of the
prefabricated temporary crown (diamond red, 1.5 mm,
water cooling). The crowns were bonded on the
implant-abutment dummy. Then, the excess material
was removed, and the screw access channel was sealed
with composite.
– Group BCHAIR^ chairside procedure: the crowns were
directly bonded on the implant-abutment dummy and the
excess material was removed.
For group TOOTH, 16 extracted human molars were pre-
pared according to ceramic and CEREC guidelines with a 1.5-
mm axial and occlusal anatomical reduction and a 1-mm cir-
cumferential deep shoulder margin with rounded inner angles
at an equigingival level of the tooth cervix and a convergence
angle of 4°. The teeth were vertically positioned in resin
blocks (Palapress Vario, Heraeus-Kulzer, G), and the roots
of the teeth were coated with a 1-mm polyether layer
(Impregum, 3M Oral Care, USA) simulating the resilience
of the human periodontium. To achieve a similar layer, the
roots were dipped in wax, which was replaced by polyether,
Fig. 1 Scheme of the groups from left to right: TiBase, LAB, CHAIR,
and TOOTH
Clin Oral Invest
as described in previous studies [24, 25]. All teeth were not
conditioned prior to temporary bonding. For permanent bond-
ing, primer was used (Multilink Primer A and B, Ivoclar
Vivadent) according to the instructions of the manufacturer.
To simulate a clinical implant situation, (groups CHAIR,
LAB) 16 × 2 implant-abutment dummies (Straumann, G, titani-
um grad IV, d = 4.1 mm, H = 12 mm, abutment length = 6 mm, 6°)
were vertically positioned in resin blocks (Palapress Vario,
Heraeus-Kulzer). Abutments were pretreated (110 μm Al2O3,
1.5 bar) and activated with coupling agent (Monobond Plus,
60s, Ivoclar-Vivadent) prior to cementation. For group TiBase,
the titanium-adhesive base (Ti Base SBL 4.1 L, Sirona, G) was
mounted on a matching implant laboratory analog (Strauman
analog RC, Ref. 025.4101) using the applied abutment screw.
Implant laboratory analogs with titanium-adhesive base abut-
ments were positioned in resin blocks. Only for permanent bond-
ing, the base was pretreated (50 μm Al2O3, 1.5 bar, Monobond
Plus) (Table 1).
The prepared teeth and implant situations were digitalized
using scanbodies (Cerec Omnicam, Sirona, G). The temporary
molar crowns were designed (SW4.03, Cerec AC, Sirona)
with identical shapes and the default settings for Telio CAD
and fabricated (Cerec, MCXL, Sirona). Inner sides of the
crowns were sandblasted (110 μm Al2O3, 1.5 bar).
A combined thermal cycling and mechanical loading
(TC = 2 × 3000 cycles between 5/55 °C distilled water,
ML = 50 N for 1.2 × 10 6 cycles, f = 1.6 Hz, mouth
opening = 2 mm) with 12-mm steatite balls (CeramTec,
Plochingen, G) as standardized antagonists was performed in a
chewing simulator (EGO, Regensburg, G). Crowns were loaded
with three points of contact in occlusal plane. Tests are equiva-
lent to approximately 5 years of clinical service time [26, 27].
After TCML, all crowns were investigated in detail with
microscope and intact restorations were loaded to fracture.
Fracture force was determined by loading the crowns to
Table 1 Materials
Code Cement Composition
CS Telio CS Link 55–56% DMA, ∼43% inorganic fillers, catalysts, stabilizers,
pigments
MA Multilink Automix 32–33% DMA, HEMA, ∼65% inorganic fillers (barium glass,
ytterbium), Ba-Al-fluorosilicate glass, catalysts, stabilizers, pigments
PMMA Telio CAD/Telio CAD Abutment 99.5% PMMA, pigments
Composite Filtek Supreme XTE flow 10–25% Bisphenol A bis(3-methacryloyloxypropyl)ether DMA
5–10% bisphenol-A-diglycidyl-MA
5–10% 2-propionacid, 2-methyl-, 3-
(trimethoxysilyl)propylester
5–10% 2,2′-ethylendioxydiethylDMA
<5% ytterbiumfluorid
<2% polycaprolacton polymer
50–60% inorganic fillers
Bonding Monobond plus 4% Bonding monomers
96% ethanol
failure in a universal testing machine (1446, Zwick,
v = 1 mm/min). In order to prevent force peaks, a tin foil
(0.25 mm, Dentaurum, G) was positioned between crown
and antagonist. After fracture testing, all crowns were optical-
ly examined and appearing failures were documented.
Statistical analysis was performed with IBM SPSS Software
(v. 20.0, IBM Chicago, IL, USA). Normal distribution of data
was assessed with the Kolmogorov-Smirnov test. Means and
standard deviations were calculated by using one-way analy-
sis of variance (ANOVA) and subsequent posthoc analysis
(Bonferroni test) where appropriate. The level of significance
was set to α = 0.05.
Results
All restorations survived TCML without visible failures. Small
wear traces were found in the occlusal contact areas. After
TCML, fracture results in the six different groups varied be-
tween 3034.3 (Tooth-P) and 1602.9 N (Tooth-T) [TOOTH],
1510.5 (TiBase-P) and 963.6 N (TiBase-T) [TiBase], 2691.1
(LAB-P) and 2064.5 N (LAB-T) [LAB], and 1609.4 (Chair-P)
and 1253.0 N (Chair-T) [CHAIR] (Fig. 2). Significantly
(p < 0.001) different fracture values were found among the
tested groups (Table 2). The predominant failure type was a
central fracture of the crown with partly remaining crown frag-
ments attached to the abutment (Fig. 3). The groups [TOOTH]
showed significantly (p < 0.001) higher fracture values com-
pared to the other groups except from group [LAB]. Fracture
values of crowns with screw channel [LAB] were higher than
those without [CHAIR]. Significantly (p = 0.012) different frac-
ture forces were found for permanent cementation when com-
paring group [LAB-P] and group [CHAIR-P]. If a temporary
cementation was selected, no significant differences were found
(p = 0.187) between group [LAB-T] and group [CHAIR-T].
Manufacturer
Ivoclar Vivadent, Schaan, FL
Ivoclar Vivadent, Schaan, FL
Ivoclar Vivadent, Schaan, FL
3M Oral Care, St. Paul, USA
Ivoclar Vivadent, Schaan, FL
 Clin Oral Invest

Fig. 2 Mean fracture foce [N] as TOOTH

comparison of the individual 3500
groups with permanent (P) or 3000
temporary (T) cementation
2500

2000

1500

1000

500
P
CHAIR 0 TiBASE
T

Fracture values of the crowns with prefabricated screw channel fabricated temporary molar crowns could be partly confirmed.
[TiBase] were significantly (p < 0.009) lower compared to the For all groups, we found no failures during TCML and there-
crowns with a manually drilled one [LAB], independently of the fore no influence of the type of cementation on the in-vitro
type of cementation. Failure pattern was characterized by frac- performance. With permanent bonding, higher fracture values
tures in mesial–distal, buccal–oral or mixed (mesial–distal/buc- in comparison to the temporary bonding were found. This
cal–oral) directions (Figs. 3, 4). Both TOOTH-groups provided may be attributed to the reduced bonding of the temporary
mixed fractures and fractures in buccal-oral direction. Only for adhesive to abutment and crowns. A lower-filled content and
group TOOTH-P, two fractures of the cusps were found. The the lack of hydrophilic monomers (HEMA) (Table 1) contrib-
main type of fracture for both TiBase-groups and group LAB-T ute to the lower fracture results for the temporary bonded
was fracture in the mesial–distal direction. Both CHAIR-groups groups, especially in the TOOTH-group: temporarily
and group LAB-P mainly showed mixed fractures (Fig. 4). cemented crowns on the human teeth showed only about
50% (1400 N) of the fracture results in comparison to their
permanently bonded references. On abutments, the differ-
Discussion ences between permanent and temporary cementation were
smaller, ranging up to 620 N [TiBase]. The smallest differ-
The first part of the hypothesis that the type of cementation ences of about 350 N were found, when the crowns had no
(permanently versus temporarily bonded) influences the in- occlusal screw channel [CHAIR]. The temporarily cemented
vitro performance and fracture resistance of CAD/CAM- crowns provided about 65% [TiBase] and more than 75%
[CHAIR, LAB] of the fracture forces of the comparable per-
Table 2 Fracture force (N) of the different groups (identical letters manent groups. Different failure types between permanent and
indicate no significant differences among the groups (p < 0.05)) temporary cementation were found only for groups LAB and
TOOTH. These results confirm literature data that the type of
Group Cement Fracture force [N] ± SD [N]
cementation significantly influences fracture results of resin-
Tooth-P Adhesive 3034.3 ± 439a,e based restorations [6]. Materials with lower strength (flexural
Tooth-T Temporary 1602.9 ± 407b,c,d,f,g,h strength = Telio CAD 130 MPa) benefit from permanent
TiBase-P Adhesive 1510.5 ± 594b,c,d,f,g,h bonding in comparison to high-strength materials
TiBase-T Temporary 963.6 ± 421b,c,d,g,h (zirconia = 1200 MPa). For materials with higher strength
LAB-P Adhesive 2691.1 ± 1098a,e,f, such as lithium-disilicate or zirconia, no significant different
LAB-T Temporary 2064.5 ± 569b,c,e,f,g fracture results between permanently and conventionally
Chair-P Adhesive 1609.4 ± 393b,c,d,f,g,h cemented restorations were reported [26, 28, 29]. Previous
Chair-T Temporary 1253.0 ± 281b,c,d,f,g,h studies showed that resin-based materials with lower modulus
of elasticity and flexural strength offer a higher resistance
Clin Oral Invest

Fig. 3 Example failure type after

fracture test (TiBase: right
permanent; left temporary)

against catastrophic failure compared to ceramic crowns [30, 4 mm) for a prepared tooth. For the abutments, the support
31]. For resin-based materials, a protective effect due to higher is located straight below the fissure, which is the thinnest
damping and shock-absorbing capacity in comparison to ce- occlusal part of the crown and designed as an occlusal neck.
ramics was confirmed earlier [28, 32]. Sufficient strength with Local stress peaks on the top of the abutment may cause cat-
functional stability and reliable adherence between the resto- astrophic overloading and fracture of a low strength resin-
ration and abutment is a major prerequisite for the clinical based material. Here, further tests are required for investigat-
success of temporary CAD/CAM-fabricated crowns [32]. ing these influences.
Therefore, an adequate pretreatment of the prepared teeth/ Under clinical conditions, chewing forces might be directly
abutments, a sufficient strength of the crown materials and transferred from the crown to the abutment, leading to a higher
good bonding of the cement are found important factors for stress on the screw and the implant-abutment interface [34].
guaranteeing a sufficient cementation [33, 34]. Further, a compromised proprioception of patients with
The results indicate that fracture forces were strongly de- implant-supported restorations can result in a higher bite force
pendent on the type of abutment. During the in-vitro perfor- during functional loading [35]. In this context, it should be
mance, no failures and therefore no influence of the abutment mentioned that a higher stability of the materials might be
could be determined. Thus, the second part of the hypothesis generally required for implant-supported restorations [29].
could be partly confirmed, too. Crowns on the human teeth The presence of a screw channel and the geometry of the
showed the highest fracture data on most groups, besides abutment are also critical factors for the success of a fixed
LAB-T. This is in contrast to earlier data that the crowns on dental restoration. In general, the screw channel is expected
high-modulus (metal-based) abutments showed higher frac- to reduce the stability of screw-retained restorations [36–38],
ture data in comparison to comparable low-modulus teeth but present data show an unexpected influence of the screw
[29, 33]. The damping effects of the artificial periodontium channel. When crowns were bonded under identical condi-
for the tooth groups may have caused a more even force dis- tions on identical abutments, the crowns with a manually in-
tribution and aligning of the crown to the occlusal loading. duced screw channel showed higher stability with values of
This resulted in a different fracture pattern with mixed but also 800 (temporary) and 1000 N (permanent) in comparison to
buccal-oral and cuspal fracture. A small valuation of the load- crowns without screw channel. Reasons might be a local stress
ing areas may help to discuss the results: based on the assump- reduction on top of the abutment. The load is not directly
tion of a molar crown diameter of about 10 mm, less than 10% transferred to the crown material itself but to the restorative
of the occlusal area is supported by the artificial abutment screw channel filling. Another potential explanation would be
(diameter 2 mm) in comparison to about 80% (diameter that the screw channel allows a better flow during cementation
and thus a more homogenous distribution of the cement and a
8
more equal and thinner layer of cement. This drain may also
7
avoid a local cement accumulation. These results are in agree-
6 ment with a recent study, which found that an increased ce-
5 ment layer thickness over 50 μm reduces the fracture strength
m-d/b-o
4 of CAD/CAM ceramic crowns [39]. Present findings are sup-
m-d
3 ported by data that showed that the clinically relevant mechan-
b-o
2 ical stability of all crowns was not negatively influenced by
c
1 the presence of a screw channel [40].
0 A clear effect was observed for the type of screw channel,
which was similar for both types of cementation. About 1100 N
higher fracture results were found for both LAB groups
Fig. 4 Number and type of failure after fracture test (mesial-distal: m-o; (manual screw channel) in comparison to the TiBase-group
buccal-oral: b-o; mixed mesial-distal/buccal-oral: m-d/b-o; fracture cusp: c) (prefabricated channel). Noticeable are the high standard

deviations for three of four groups with screw channels, espe-
cially for the prefabricated channels (TiBase). These results
might be influenced by the design of the Ti-Base abutment
with comparably sharper edges, rotation protection, smaller
diameter, and a steeper preparation angle, whereas the standard
abutment provides round edges, which might show advantages
in case of crack initiation and crack development.
The study design has to be discussed critically; to ensure a
test model as simple as possible and focus on the design of the
crown, clinically occuring screwing joints were partly elimited
by using one-piece implant dummies in groups [LAB] and
[CHAIR]. But under clinical conditions, screwed connections
often represent a critical part in the implant-abutment-crown
combination [41]. However, in the present study, no damage
was observed on titanium-adhesive base, abutment screw, or
the implant dummy after TCML.
Conclusion
Irrespective of the type of cementation and abutment types,
polymeric CAD/CAM restorations showed good mid- or even
long-term resistance to fatigue during TCML. All groups have
the potential to withstand maximum bite forces in the molar
region, which are reported to reach up to 900 N [42].
Permanent bonding resulted in higher fracture data, but even
temporary cementation provided sufficient data for a clinical
application. The design of the screw channel and the type of
abutment contributed to the fracture stability of the crown.
These findings suggest a level of fracture resistance for the
CAD/CAM temporary crowns that may allow their use as
long-term temporary solution on prepared teeth and implants.
Acknowledgements We would like to thank the manufacturers for pro-
viding the materials.
Compliance with ethical standards
Conflict of interest Prof. Dr. Martin Rosentritt declares that he has
third-party research projects with all dental companies.
Dr. Philipp Raab declares that he has no conflict of interest.
Prof. Dr. Sebastian Hahnel declares that he has no conflict of interest.
Dr. Matthias Stöckle declares that he has no conflict of interest.
PD Dr. Verena Preis declares that she has no conflict of interest.
Funding No.
Ethical approval This article does not contain any studies with human
participants or animals performed by any of the authors.
Informed consent For this type of study, formal consent is not
required.
Clin Oral Invest
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