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Masticatory Fatigue, Fracture Resistance, and nt n

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Marginal Discrepancy of Ceramic Partial Crowns With
and Without Coverage of Compromised Cusps
Christian F.J. Stapperta/Pia Abeb/Volker Kurthsc/Thomas Gerdsd/Jörg R. Strube

Purpose: To evaluate preparation designs of compromised cusps and whether or not they influence masticatory fatigue,
fracture resistance, and marginal discrepancy of ceramic partial-coverage restorations (PCRs) luted on mandibular mo-
lars.

Materials and Methods: Sixty-four caries-free molars were equally divided into four groups. Control group NP received
no preparation (NP). Group B-IN received a basic inlay (IN) preparation with buccal (B) cusp conservation and occlusal
reduction of both lingual cusps. Group B-ON was prepared in the same way, except buccal cusps were prepared with an
angle of 45 degrees to the occlusal plane (buccal onlay). Group B-OV preparation was similar to group B-ON, but buccal
cusps received a further shoulder preparation on the buccal aspect (buccal overlap). Forty-eight all-ceramic IPS e.max
Press PCRs were fabricated and luted adhesively. Specimens underwent mouth-motion fatigue (1.2 million cycles, 1.6
Hz, 49 N) and 5500 thermal cycles (5°C/55°C). Fracture patterns were observed. Surviving specimens were loaded un-
til fracture. Marginal discrepancies were examined.

Results: Only one specimen of group B-ON fractured during fatigue. Median fracture loads (N) [IQR=x.25-x.75]: group NP
= 1604 N [1182-1851 N], group B-IN = 1307 N [1262-1587N], group B-ON = 1396 N [817-1750N], group B-OV = 1205
N [1096-1542N]. No significant differences in fracture resistance were found between restored molars and unprepared
teeth (p ≥ 0.18). Different preparation designs showed no significant influence on PCR fracture resistance. Mouth-mo-
tion fatigue caused a significanty decrease of marginal accuracy in groups B-IN (p = 0.009) and B-ON (p = 0.008). Mar-
ginal discrepancy values of groups B-IN and B-OV were significantly different after fatigue (p = 0.045).

Conclusion: Ceramic coverage of compromised cusps did not demonstrate an increase of fracture resistance after fa-
tigue when compared to less invasive partial-coverage restorations. However, enhanced exposure of restoration mar-
gins to occlusal wear could result in more extensive marginal discrepancies.

Keywords: fracture resistance, marginal discrepancy, partial coverage restoration, ceramic, fatigue.

J Adhes Dent 2008; 10: 41-48. Submitted for publication: 12.10.06; accepted for publication: 01.05.07.

D ental ceramics present an interesting option in terms of

a Assistant Professor, Department of Periodontology and Implant Dentistry, De-
partment of Biomaterials and Biomimetics, New York University College of Den-
tistry, New York, NY, USA; Associate Professor, Department of Prosthodontics,
Albert Ludwigs University, Freiburg, Germany.
b Research Associate, Department of Prosthodontics, Albert Ludwigs University,
Freiburg, Germany.
c Research Associate, Department of Prosthodontics, Albert Ludwigs University,
Freiburg, Germany.
d Statistician, Department of Prosthodontics, Albert Ludwigs University, Freiburg,
Germany.
e Professor and Chairman, Department of Prosthodontics, Albert Ludwigs Uni-
versity, Freiburg, Germany.
Correspondence: Dr. Christian Stappert, DDS, Department of Biomaterials and
Biomimetics, New York University College of Dentistry, Arnold and Marie Schwartz
Hall of Dental Sciences, 345 East 24th Street, New York, 10010 NY, USA. Tel: +1-
212-998-9939, Fax: +1-212-995-4244.
e-mail: christian.stappert@nyu.edu
biocompatibility and esthetics for the restoration of lost
tooth structure.47 With improvements in the physical and bio-
mechanical properties of ceramic materials along with the
use of adhesive cementation, the application of all-ceramic
restorations in the anterior and posterior dentition is justi-
fied.3 Fabrication techniques such as heat pressing or com-
puter-assisted machining of prefabricated ceramic ingots or
blocks are used to produce even small-sized all-ceramic
restorations, such as inlays and onlays, with high fracture re-
sistance.18
Long-term clinical studies have well documented the good
performance of all-ceramic inlays, and they are widely ac-
cepted as treatment procedures.16,18,19,31,37,44,45 Mean an-
nual failure rates in posterior stress-bearing preparations of
1.9% for ceramic inlays and 1.7% for CAD/CAM ceramic

Vol 10, No 1, 2008 41


Stappert et al
Fig 1 Control group NP (no preparation). Fig 2 Preparation of group B-IN.
restorations were found.38 Survival rates of ceramic inlays
are described as ranging from 74% to 100% with observa-
tion periods of up to 12 years.3,22 Ceramic onlays also occur
in these investigations, but their numbers are small and fail-
ure rates are not strictly separated from those of inlay
restorations.
Although preparation design is considered one of the im-
portant factors responsible for the success of ceramic
restorations,18 evidence-based preparation guidelines for
posterior ceramic partial-coverage restorations (PCRs) are
hard to find in the literature. Many preparation designs are
based on experience with cast metal partial-coverage
restorations and have been modified to optimize the perfor-
mance of ceramic PCRs.2,39 Guidelines for conventionally
cemented cast metal restorations53 include almost parallel
preparation surfaces or box designs to gain stability by re-
tention against mainly horizontal mastication forces. Due to
strong adhesive bonding,30 preparation design of all-ce-
ramic PCRs is less dependent on retention form, which al-
lows a higher variation in preparation when compared to
conventionally cemented restorations. A general consensus
exists on ceramic preparation standards, such as rounded
line angles17,31,39,58 and passive seating of PCRs by diverg-
ing preparation angles.39,58 Adequate material thicknesses
and ideal extensions of a ceramic restoration, however, are
less well defined.
In the case of a large tooth defect, reduction and over-
lapping of the weakened cusps by a PCR has been recom-
mended to reinforce the compromised tooth structure.5,9 In-
vitro studies demonstrated an improvement of fracture re-
sistance for endodontically treated premolars with amal-
gam41 or conventionally cemented cast-metal cusp cover-
age.59 When restorations were adhesively luted, cusp cov-
erage by cast-metal59 and ceramic restorations55 did not
show a clinically relevant increase of fracture resistance
compared to an inlay restoration. The aim of the present
study was to evaluate different preparation designs of com-
promised cusps and whether or not they influence mastica-
tory fatigue, fracture resistance, and marginal fit of all-ce-
ramic PCRs luted on mandibular molars. A lithium disilicate
press ceramic (IPS e.max Press; Ivoclar Vivadent; Schaan,
Liechtenstein) was used to fabricate the ceramic restora-
tions.
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Fig 3 Preparation of group B-ON.
MATERIALS AND METHODS
Extracted caries-free human mandibular molars were ex-
amined under a reflected light microscope at 10X to 50X
magnification (Stemi 2000 CS; Carl Zeiss; Jena, Germany).
Sixty-four teeth, equal in size (deviation of < 5%) (Digital Mi-
crometer, Protective System IP 65, Mitutoyo; Kyoto, Japan)
and free of hypoplastic defects and cracks, were selected.
Teeth were cleaned by scaling and stored in 0.1% thymol so-
lution at room temperature, for three months maximum. The
molars were divided into 4 groups of 16 specimens each.
Group NP (no preparation) served as a control of natural, un-
prepared teeth (Fig 1). The remaining teeth were prepared.
Tooth Preparation
Forty-eight teeth were prepared according to specific
guidelines (groups B-IN, B-ON and B-OV). Teeth were pre-
pared freehand by one clinician using a high-speed
handpiece and diamond burs under water cooling. Primary
preparation was conducted with 80-μm-grit preparation dia-
monds (837KR.314.012, 847KR.314.016), while finishing
was carried out with finer diamonds (30- to 40-μm grain
size, 8837KR.314.012, 8847KR.314.016, 8390.204.016,
Komet, Brasseler; Lemgo, Germany).
Group B-IN (buccal-inlay preparation) was prepared with
a mesio-occlusal-distal (MOD) inlay cavity with a 3-mm-deep
occlusal box and an isthmus width of 3 mm as well as an
overall preparation angle of 6 degrees towards the occlusal
aspect. Proximal finishing lines were 1 mm above the ce-
mentoenamel junction (Fig 2). Both lingual cusps were re-
duced by 2 mm with an angle of 45 degrees to the occlusal
plane. Teeth of group B-ON (buccal-onlay preparation) were
prepared in the same manner as in group B-IN, except for an
additional reduction of both buccal cusps by 2 mm with an
angle of 45 degrees to the occlusal plane (Fig 3). In group B-
OV (buccal-overlap preparation), the teeth were prepared as
in group B-ON, but with an additional overlapping shoulder
preparation of the buccal cusps by 0.8 mm with rounded in-
ner edges (Fig 4). Prior to preparation, two silicone impres-
sions were taken of each tooth (Formasil Xact, Heraeus Kulz-
er; Wehrheim, Germany). For impression taking and prepa-
ration, pairs of teeth were provisionally secured in a prefab-
ricated plaster mold (GC FujiRock EP, type 4 dental stone, GC
The Journal of Adhesive Dentistry

Fig 4 Preparation of group B-OV.
Europe; Leuven, Belgium). One impression was used as an
orientation aid for the subsequent wax-up of the ceramic
restorations, while the other one was cut in a buccal-oral di-
rection to serve as an aid in the removal of tooth structure
according to the preparation guidelines. Accuracy of prepa-
ration dimensions was re-evaluated (Digital Micrometer, Pro-
tective System IP 65, Mitutoyo) under light microscopy (5X)
(Stemi 2000 CS; Carl Zeiss).
Fabrication of the Ceramic Restorations
Following double-mixing technique impressions with
polyvinyl siloxane material (Dimension Garant L and Per-
magum Putty Soft, 3M-ESPE; Seefeld, Germany), the master
models were poured using dental stone (GC Fujirock type 4,
GC; Tokyo, Japan). Critical line angles along the preparation
margin of the master models were strengthened and en-
hanced by die hardener (Margidur, DUS Dental-U; Richmond,
Canada). Die spacer (Purargent 20ml, DUS Dental-U) was
applied to the cavity surfaces (approximately 10 μm) 1.5 mm
from the marginal areas.
IPS e.max Press (VP 1989/4) PCRs were fabricated by
Ivoclar Vivadent (Schaan, Liechtenstein). Full PCR wax-ups
were made according to the silicone guides of the unpre-
pared teeth. After investment of the wax-up, the investment
cylinders were preheated in a furnace (Type 5636; KaVo
Dental; Biberach, Germany) at 850°C. For the pressing pro-
cedure of the ceramic PCRs, a hot-press furnace (EP 500;
Ivoclar Vivadent) was used. The investment cylinders along
with the glass-ceramic ingots (VP 1989/4, Ivoclar Vivadent)
were placed at the center of the EP 500 press furnace and
pressed at a temperature of 915°C. After divestment, the
pressed PCRs were cut from the sprues with a water-cooled
diamond-coated disk (Diaflex H347, Horico Dental; Berlin,
Germany) and cleaned with a jet steam machine (EV1 SJ, Sil-
fradent Sync; Sofia, Italy). PCR fit was verified on the master
model. Two glazing procedures were performed in a firing
oven (Programat P100; Ivoclar Vivadent) with C27688 Em-
press 2 glazing material (Ivoclar Vivadent). The inner sur-
faces of the PCRs were airborne-particle abraded with a
high-grade alumina (Type 100, KaVo EWL blasting medium,
white, KaVo Dental) at 2 bar pressure for 10 s and cleaned
with a jet steam machine (EV1 SJ, Silfradent Sync).
Vol 10, No 1, 2008
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Adhesive Luting n lte
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Prior to placement of the PCRs, the prepared teeth twere
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es z
cleaned with synthetic rotary brushes and fluoride-free pol-s e n
ishing paste (Pell-ex, Hawe Neos Dental; Bioggio, Switzer-
land). Subsequently, the teeth were etched (enamel for 60 s,
dentin for 15 s) with 37% phosphoric acid (Total Etch, Ivoclar
Vivadent) and conditioned with Syntac Primer for 15 s and
Adhesive for 10 s (Ivoclar Vivadent). Heliobond (Ivoclar Vi-
vadent) was applied onto the preparation surface and dis-
persed as a thin layer using clean, dry air. Pooling or insuffi-
cient coverage of the adhesive was avoided. The layer of He-
liobond (Ivoclar Vivadent) was polymerized with a light-cur-
ing unit (Elipar Free Light 2; 3M ESPE, Seefeld, Germany) for
20 s. IPS e.max Press PCRs were cleaned with 99% iso-
propanol, inner surfaces were etched with 4.9% hydrofluo-
ric acid (IPS Ceramic Etching Gel, Ivoclar Vivadent) for 20 s,
thoroughly rinsed with water for 60 s, and dried with oil-free
compressed air. Afterwards, a single-component bonding
silane (Monobond-S, Ivoclar Vivadent) was applied to the
etched surfaces.
Forty-eight ceramic PCRs were luted with a dual poly-
merizing resin composite (Variolink II, Ivoclar Vivadent). Be-
fore light polymerizing, excess composite was removed us-
ing synthetic pellets. To avoid oxygen inhibition during poly-
merization, glycerine gel (Liquid Strip, Ivoclar Vivadent) was
applied to the marginal area. The PCRs were light polymer-
ized with a minimum of 650 mW/cm2 light intensity (Elipar
Free Light 2; 3M ESPE) in increments from the occlusal to
the buccal, oral, and proximal aspects for at least 40 s each.
Finishing was performed using hand instruments (#15c
scalpel, #371716, Bard-Parker; Becton, Dickinson and Co;
Franklin Lakes, NJ, USA), finishing disks (Sof-Lex Pop-On;
3M; St Paul, MN, USA), and fine silicone ceramic polishers
(#9418.204.030, #9419.204.030, #9547.204.030; Komet
Dental, Brasseler; Lemgo, Germany). Specimens were
stored in 0.1 thymol solution prior to fatigue testing for at
least 30 days.
Mastication Simulator
To simulate the periodontal ligament, roots were coated with
a gum resin (Anti-Rutsch-Lack, Wenko-Wenselaar; Hilden,
Germany) of 0.25 mm thickness, 2 mm below the cemen-
toenamel junction. Afterwards, the molars were embedded
in a self-polymerizing resin at an angle of 90 degrees to the
horizontal plane (Technovit 4000, Heraeus-Kulzer). All spec-
imens were subjected to a dynamic load of 49 N at 1.6 Hz
with synchronized thermal cycling in a dual-axis masticatory
simulator (Willytech; Munich, Germany). A total of 1,200,000
loading cycles was performed, simulating almost 5 years of
clinical service.12,32 The specimens were thermocycled be-
tween 5°C and 55°C 5500 times simultaneously with the
mechanical cycling, with a 60-s dwell time at each temper-
ature. The dynamic load was applied on the occlusal-buccal
edge between the two buccal cusps, using a ceramic an-
tagonist (steatite; Hoechst Ceram Tec; Wunsiedel, Germany)
6 mm in diameter. The invariable load was applied with an
ellipsoidal force profile, with a vertical movement of 6 mm
and a horizontal movement of 0.5 mm. The rising speed was
60 mm/s, the forward speed was 60 mm/s, the descending
speed was 55 mm/s, and the backward speed was 55
43

Stappert et al
Fig 5 PCR of group B-OV loaded until frac-
turein a universal testing machine. To prevent
local force concentrations, a 1-mm-thick
piece of tin foil was placed between the tip of
the punch and the specimen.
mm/s. During dynamic loading, all specimens were exam-
ined twice a day. Failure was defined by bulk fracture of a
specimen, not subcritical crack growth. The real time of
mouth-motion loading and thermal changes per test group
was 10 to 12 days. After the masticatory simulation test, all
specimens were photographed from occlusal and palatal as-
pects with a 4X magnification lens (4T; Nikon F5; Nikon cam-
era systems; Tokyo, Japan), examined for fractures under an
optical microscope (Stemi 2000 CS; Carl Zeiss) at low pow-
er (50X) stereomagnification using incident light.
All specimens which survived the masticatory simulation
were loaded until fracture using a universal testing machine
(Zwick Z010/TN2S; Ulm, Germany). The force was applied
axially to the buccal cusps through a steel wedge, using a
consistent crosshead speed of 1.5 mm/min. A 1-mm-thick
tin foil was placed over the occlusal surface of the tooth to
achieve homogenous stress distribution (Fig 5). After failure,
all specimens were re-examined for fracture modes under
optical light microscopy (Stemi 2000 CS; Carl Zeiss) (50X to
200X) by two independent observers.
Load-to-fracture values were recorded by Zwick testXpert
V 7.1 software. Statistical analysis of data was performed us-
ing the Kruskal-Wallis test (ANOVA) (α = 0.05). For the com-
parison of independent groups, the unpaired Wilcoxon rank
sum test (α = 0.05) (S-PLUS statistics program, version 3.4
release 1 for Sun SPARC, Insightful; Seattle, WA, USA) was
used. A Bonferroni-Holm adjustment of the p-values was
performed.
Marginal Accuracy
Individual impressions (Permagum Putty Soft, Dimension
Garant L, 3M-ESPE; Seefeld, Germany) were made for every
adhesively luted specimen to examine the marginal fit of
each restoration. Further impressions were taken after
mouth-motion fatigue, provided that the specimen did not
fail during masticatory simulation. Impressions were poured
with epoxy resin (Epon 812, Sigma Chemie; Munich, Ger-
many). To produce replicas without bubbles, the impressions
were placed in a furnace at 60°C for 24 h (Type 5636; KaVo
Dental). The epoxy material was mixed according to manu-
facturer’s instructions. For thorough polymerization, im-
pressions were incubated for 24 h at 60°C in the furnace. Af-
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ter taking the replicas out of the molds, they were fixed
n along lte
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t esAd- z
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the center axis on aluminum sample holders with Epoxy
hesive (Epoxy Kit 8778-00; Cole-Parmer Instrument Compa- se n
ny; Vernon Hills, IL, USA). For image acquisition and evalua-
tion of marginal regions with stereo light microscopy (Stemi
2000 CS; Carl Zeiss), replicas were coated with a fine gold
layer (200 Å) using a high-vacuum sputter device (SCD 050,
Bal-Tec; Witten, Germany).
This study adopted the definition of marginal width ("ab-
solute marginal discrepancy") by Diedrich and Erpenstein14
as the space between the restoration margin and the exter-
nal preparation margin. To investigate the restorations’ mar-
ginal fits, a stereo light microscope (Stemi 2000 CS; Carl
Zeiss) at 200X magnification, a 3 CCD color video camera
(Sony; Cologne, Germany), and an IBM compatible PC
equipped with a Microsoft NT 4.0 operating system were
used. The program Analysis 3.0 (Soft-Imaging Software; Mu-
nich, Germany) was applied for image investigation. Mea-
surements of marginal discrepancies were taken at 100-μm
intervals around the circumference of the restoration mar-
gins. Due to discrepancies in shape and size of the human
mandibular molars and preparation design, differing num-
bers of measurements for specimens were taken. To estab-
lish a number range for statistical analysis, marginal dis-
crepancy measurements were averaged from between 400
and 500 points for each tooth. The averaged marginal
widths values were used for computing means and confi-
dence intervals for marginal accuracy assessment for each
group after adhesive cementation and aging process (fa-
tigue and thermocycling). Estimation of confidence intervals
and t-test were based on logarithmically transformed values.
To achieve a global level of significance (α = 0.05), the p-val-
ues resulting from comparisons of unpaired t-tests (between
groups) and paired t-tests (between stages) were corrected
by the Bonferroni-Holm method.
RESULTS
Only one specimen of group B-ON fractured during mastica-
tory fatigue. The following median fracture resistance values
(N) [IQR=x.25-x.75] were recorded: group NP 1604 N [1182-
1851N], group B-IN 1307 N [1262-1587 N], group B-ON
1396 N [817-1750 N], group B-OV 1205 N [1096-1542 N].
Irrespective of the fractured specimen of group B-ON, all
groups demonstrated a minimum fracture resistance above
690 N after fatigue. The highest fracture resistance value
was observed in group B-ON (3048 N) (Table 1). For each
group, statistics were computed for fracture resistance val-
ues after fatigue loading. These results are represented in
box plots (Fig 6). No significant differences in fracture loads
were found between restored molars when compared to nat-
ural teeth (p ≥ 0.18). The different preparation designs
demonstrated no significant influence on the fracture resis-
tance of PCRs (B-IN/B-ON p = 0.61; B-IN/B-OV p = 0.30; B-
ON/B-OV p = 0.89).
In group NP, 10 of the natural mandibular molars demon-
strated fractures exclusively in enamel. Six teeth showed a
participation of dentin. Most of these fractures were coronal;
only one longitudinal fracture occurred. In contrast, most of
The Journal of Adhesive Dentistry
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Table 1 Load-to-fracture test results [N]
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Group Median IQR Minimum Mean Maximum SD e ss e n z
[Q1(x.25)-Q3(x.75)]

NP (n = 16)
no preparation 1604 [1181.9-1851.3] 769 1502 2322 477

B-IN (n = 16)
buccal inlay preparation 1307 [1261.7-1586.9] 699 1440 2138 405

B-ON (n = 15)
buccal onlay preparation 1396 [817.1-1750.2] 49 1326 3048 773

B-OV (n = 16)
buccal overlay preparation 1205 [1095.9-1541.7] 735 1295 2145 372

Interquartile range (IQR) = difference between lower quartile, Q1 (x.25), and upper quartile, Q3 (x.75).

Fig 6 Box plot of fracture resistance results in N. NP = natural
teeth with no preparation; B-IN = PCRs with inlay preparation of
the buccal cusps; B-ON = PCRs with onlay preparation of the buc-
cal cusps; B-OV = PCRs with overlapping preparation of the buc-
cal cusps.
Fig 7 Diagram of geometrical means [95% confidence limits] of
marginal discrepancy analysis; cemented adhesively (luted) and
after mouth-motion simulation (aged). No significant differences
between the groups were found after luting (p ≥ 0.5). Fatigue led
to significantly different marginal width values of groups B-IN and
B-OV (p = 0.045).

Table 2 Absolute marginal discrepancies in μm of PCRs cemented adhesively (luted) and after mouth-motion simula-
tion (aged)

Group Min Mean Max Median IQR Geomean SE CI-95%

[Q1(x.25)-
Q3(x.75)]

B-IN luted 54 81 119 82 67– 92 79 1.1 70– 90

B-IN aged 73 95 124 93 89–101 94 1.1 80– 92
B-ON-luted 42 78 105 76 67– 92 76 1.1 67– 87
B-ON-aged 63 93 122 92 81–100 91 1.1 83–101
B-OV-luted 63 81 109 82 69– 91 80 1.1 73– 88
B-OV-aged 68 86 104 81 79– 97 86 1.1 80– 92

Vol 10, No 1, 2008 45


Stappert et al
the restored specimens of groups B-IN to B-OV fractured in
a different manner. The majority of specimens showed a
combination of coronal and cervical fractures, inducing
damage to tooth structure and ceramic. In groups B-IN, B-
ON, and B-OV, 13 (81%), 13 (81%), and 10 (62.5%) fractures
exceeded the ceramic restorations and propagated into the
natural tooth structure, respectively. No debonding of a ce-
ramic restoration occurred.
Marginal discrepancies (geometrical mean) [95% confi-
dence limits] of luted PCRs were recorded as followed: B-IN
79 μm [70-90], B-ON 76 μm [67-87], and B-OV 80 μm [73-
88]. No significant differences were found between the
groups (p ≥ 0.5). Mouth-motion fatigue and thermocycling
caused a decrease of marginal accuracy (B-IN 94 μm [80-
92], B-ON 91 μm [83-101], and B-OV 86 μm [80-92]; Fig 7);
in groups B-IN (p = 0.009) and B-ON (p = 0.008) the de-
crease was significant. Marginal width values of groups B-IN
and B-OV were significantly different after fatigue (p =
0.045). All values of marginal discrepancy analyses are sum-
marized in Table 2.
DISCUSSION
Extracted human teeth were chosen as substrates because
their modulus of elasticity, thermal conductivity, bonding
characteristics, and strength mimic the clinical situation bet-
ter than plastic, metal, or animal teeth would.48,57 Natural
teeth have been used in various investigations,7,54,56 since
substrate material properties demonstrated a significant in-
fluence on fracture resistance of ceramic restorations.48 To
minimize variation in preparation and restoration dimen-
sions, all teeth were prepared by only one clinician using sil-
icone guides. Accuracy of preparation dimensions was re-
evaluated under light microscopy using a digital micrometer.
Tooth mobility has been reported to be a relevant factor
in the evaluation of fracture strength.25,26,49 When a small
abutment rotation is allowed during testing, failure is more
likely to occur.26 To mimic physiological tooth mobility,42 a
layer of gum resin was applied to the roots.28 The necessity
of applying an artificial periodontium during masticatory
simulation, thermocycling, and fracture testing has recently
been demonstrated by Rosentritt et al49 on all-ceramic fixed
partial dentures. Omitting the artificial periodontium during
mouth-motion fatigue caused fracture results almost twice
the fracture force compared to tests with periodontium. The
influence of the artificial periodontium during fracture test-
ing was more distinct: rigidly embedded teeth withstood
three times the loading force than those with a polyether pe-
riodontium layer did.
The main objective of mouth-motion simulation tests is to
introduce fatigue damage to dental restorations under con-
ditions that are as close as possible to the clinical situa-
tion.27 The parameters used for masticatory simulation were
adjusted to physiological values found in the literature.7,29,33
These in vitro studies have considered a functional loading
force of 49 N, which arises during mastication or swallowing.
Despite higher forces measured in the posterior denti-
tion,11,20 a value of 49 N was considered to be more applic-
able as an average constant force in this investigation. Julien
46
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et al described an average clinical total contact area
n of 52 lte
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mm (female) and 64 mm (male) on posterior teetht during
i
2 2
e ss e n z
maximum intercuspation. In vivo, mastication forces are dis-
tributed to the total contact area, which reduces the simple
contact pressure significantly.27 In consideration of the giv-
en material properties (ESteatite=138 GPa, EIPS e.max
Press=69 GPa), the radius of the Hertzian indenter, and test
conditions (P = 49 N), a stress level of approximately 800
MPa at or near the ceramic contact surface was calculated.
A simple contact pressure of 5 to 890 MPa was reported to
encompass the range of realistic average bite forces.27 De-
pendent on the diameter of the wear facet,27 the applied
load of 49 N was able to induce a contact stress level at the
upper end of this range. Variables such as surface structure,
inclination of the cusps, and wear behavior of the ceramic
and indenter materials35 cause variations in the contact
stress level.
An average of 250,000 masticatory cycles per year was
demonstrated by participants in clinical investigations.12,50
Based on this, an in vivo service time of almost 5 years was
performed.21,32 If ceramic restorations are subjected to pre-
liminary masticatory fatigue and thermocycling, the fracture
resistance may decrease up to 50% compared with the
baseline values.13 Superficial and deep microcracks are re-
sponsible for this decline.35 In this study, only one specimen
did not survive the exposure to the mastication simulator. It
would be ideal to subject a high number of specimens to
mouth-motion fatigue under different loads and time peri-
ods until failure (step-stress profiles). In this way, the relia-
bility of a specific restoration system would be more pre-
dictable.27,35 However, high costs of dental restoration spec-
imens and machine running time restrict this research ap-
proach. Since most of the specimens survived fatigue, load-
to-fracture tests7,28,55,56 were performed to examine the in-
fluence of overlapping the compromised cusps on the frac-
ture resistance of ceramic PCRs.
Load-to-fracture tests require high uni-axial loads which
might cause sharp or blunt indentation stresses on the sur-
face of a ceramic specimen.27 When a pure steel wedge was
applied, contact damage (eg, cone cracks) was observed. To
avoid superficial damage, tin foil was used to distribute the
load. When surface contact stresses are kept low enough,
radial cracks can develop at the bonded ceramic undersur-
face.34 This is reported when a ceramic layer is uniformly
supported by and bonded to a material of lesser stiffness,
since high tensile stresses develop in the ceramic at its in-
terface with the cement directly below the loaded
area.27,35,36 These interfacial stresses arise from strain dif-
ferences in the ceramics, cement, and dentin, because the
ceramic material possesses a higher modulus of elasticity.
This is why cracks usually initiate at the interface level, lead-
ing to a subsequent total failure of the restoration.24,27 Light-
microscopy observation identified bottom radial cracks as
being primarily responsible for the fatal damage of the
restorations under load to failure. Unknown stress patterns
under extreme single loading and collateral damage caused
by overshooting loads after sudden stress release27 limit the
ability to identify the fracture initiation. Failure modes at the
interface and surface are often combined. The intention of
the load to failure test was to compare the fracture resis-
The Journal of Adhesive Dentistry

tance of PCRs with different preparation designs after fa-
tigue under a standardized protocol. The authors did not ex-
pect to mimic clinical failure modes with this method. Fur-
ther investigations could use fractography51 to verify the
crack initiation under single loading.
Adhesive bonding proved to be effective in stabilizing the
all-ceramic material, since recorded fracture patterns of
groups B-IN to B-OV showed no ceramic delamination and in-
volved ceramic and natural tooth structure. In general, it
might be preferable if only the restoration itself fails, and
does not involve the remaining tooth structure.46
Mean marginal discrepancies of 78 to 95 μm were ob-
served on current glass-ceramic PCRs before and after
mouth-motion fatigue. These values met the requirements
of maximally acceptable marginal discrepancies between
25 μm and 120 μm as proposed in the literature.8,30,40,52
Nevertheless, a decrease of marginal accuracy of all-ce-
ramic PCRs due to off-axis mouth-motion fatigue and ther-
mal changes was recorded. Water sorption phenomena of
composite resin cement,43 microleakage,6 degradation of
luting cement as a result of the moist oral environment, and
wear should be considered as decisive factors in these find-
ings. An increase of marginal discrepancies by masticatory
simulation was also demonstrated in a previous investiga-
tion on glass-ceramic PCRs luted to maxillary molars.54 In
contrast to the present study, positioning of the restoration
margins at the occlusal surface did not lead to significantly
higher marginal gap values. In the current investigation, the
steatite antagonist was positioned between the buccal
cusps and crossed the restoration margins of group B-IN dur-
ing occlusal horizontal movement. Therefore, marginal wear
of this group was increased. This was not the case in the pre-
vious study54 when the load was applied vertically onto the
center of the occlusal surface of the partial coverage restora-
tions. According to these findings, occlusal contact points
sliding over all-ceramic restoration margins could compro-
mise the integrity of the marginal seal of a ceramic PCR un-
der clinical conditions.
An in vitro fracture resistance study about restored nat-
ural posterior teeth showed maximum fracture strengths of
2680 N for Vitadur N inlays, 1662 N for Ceramco II inlays,
and 3547 N for unprepared molars.15 Bremer and Geurt-
sen4 also reported an average fracture resistance value of
2102 N for human molars, which was higher than in the pre-
sent study. Under similar load-to-fracture conditions in an
earlier investigation, natural maxillary molars achieved high-
er mean fracture loads (2041 N) than the mandibular mo-
lars in the current study (1502 N).57 Maxillary molars re-
stored with IPS e.max Press PCRs demonstrated higher me-
dian fracture resistance values of 1567 N to 1870 N than
the restored mandibular molars (1205 N to 1396 N).57 IPS
e.max Press PCRs on natural maxillary premolars demon-
strated median fracture resistance values of 776 N to 1300
N after fatigue, depending on the preparation design.55 De-
spite different preparation designs, the statistical analysis
demonstrated neither a significant difference in fracture re-
sistance between restored teeth nor in unprepared mandi-
bular molars in the current study.
Fracture resistance of a natural tooth is described to be
compromised after tooth preparation or caries.10 Adhesive
Vol 10, No 1, 2008
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ceramic partial-coverage restorations demonstrated n
a com- lte
n
t es
i
plete recovery of fracture strength irrespective of the prepa-
ration design. Hence, it may be necessary to reconsider thes e n
z
imminent need of cusp coverage when a margin of an inlay
or onlay approaches within 1.5 mm of a functional cusp.2 An
FEA study examined the loading characteristics of ceramic
onlay restorations and compared their associated stress lev-
els with different designs of marginal preparation.1 It was
concluded in that study that the buccal aspect of a restora-
tion is subjected to high stresses when horizontal forces are
applied. The authors suggested that the restorative materi-
al in this area should be sufficiently thick to withstand these
stresses. In the present study, vertical and horizontal forces
on the buccal aspect did not reveal insufficient material or
tooth structure behavior.
CONCLUSION
Ceramic coverage of compromised cusps did not demon-
strate an increase in fracture resistance after fatigue when
compared to less invasive partial coverage restorations.
However, enhanced exposure of restoration margins to oc-
clusal wear could result in more extensive marginal dis-
crepancies.
ACKNOWLEDGMENTS
We express our appreciation to Wael Att, Visiting Professor, UCLA School
of Dentistry, Weintraub Center for Reconstructive Biotechnology, Los An-
geles, CA, USA for his consistent support, and to Hans-Peter Foser, Mas-
ter Dental Technician, Ivoclar Vivadent, Schaan, Liechtenstein, for his
efforts in the fabrication of the ceramic restorations.
REFERENCES
1. Abu-Hassan MI, Abu-Hammad OA, Harrison A. Stress distribution associ-
ated with loaded ceramic onlay restorations with different designs of mar-
ginal preparation. An FEA study. J Oral Rehabil 2000;27:294-298.
2. Banks RG. Conservative posterior ceramic restorations: a literature review.
J Prosthet Dent 1990;63:619-626.
3. Blatz MB. Long-term clinical success of all-ceramic posterior restorations.
Quintessence Int 2002;33:415-426.
4. Bremer BD, Geurtsen W. Molar fracture resistance after adhesive restora-
tion with ceramic inlays or resin-based composites. Am J Dent
2001;14:216-220.
5. Broderson SP. Complete-crown and partial-coverage tooth preparation de-
signs for bonded cast ceramic restorations. Quintessence Int
1994;25:535-539.
6. Browning WD, Safirstein J. Effect of gap size and cement type on gingival
microleakage in Class V resin composite inlays. Quintessence Int
1997;28:541-544.
7. Chitmongkolsuk S, Heydecke G, Stappert C, Strub JR. Fracture strength of
all-ceramic lithium disilicate and porcelain-fused-to-metal bridges for molar
replacement after dynamic loading. Eur J Prosthodont Restor Dent
2002;10:15-22.
8. Christensen GJ. Marginal fit of gold inlay castings. J Prosthet Dent
1966;16:297-305.
9. Christensen GJ. Alternatives for the restoration of posterior teeth. Int Dent
J 1989;39:155-161.
10. Cotert HS, Sen BH, Balkan M. In vitro comparison of cuspal fracture resis-
tances of posterior teeth restored with various adhesive restorations. Int J
Prosthodont 2001;14:374-378.
11. De Boever JA, Mc Call WD, Holden S, Ash MM. Functional occlusal forces:
an investigation by telemetry. J Prosthet Dent 1978;40:326-333.
47

Stappert et al
12. DeLong R, Douglas WH. Development of an artificial oral environment for
the testing of dental restoratives: bi-axial force and movement control. J
Dent Res 1983;62:32-36.
13. Deng Y, Lawn BR, Lloyd IK. Characterization of damage modes in dental
ceramic bilayer structures. J Biomed Mater Res 2002;63:137-145.
14. Diedrich P, Erpenstein H. Scanning electron optical analysis of the mar-
ginal space of in vivo incorporated shoulder crowns and inlays [in German].
Schweiz Monatsschr Zahnmed 1985;95:575-586.
15. Dietschi D, Maeder M, Meyer JM, Holz J. In vitro resistance to fracture of
porcelain inlays bonded to tooth. Quintessence Int 1990;21:823-831.
16. El-Mowafy O, Brochu JF. Longevity and clinical performance of IPS-Empress
ceramic restorations--a literature review. J Can Dent Assoc 2002;68:233-
237.
17. Federlin M, Schmidt S, Hiller KA, Thonemann B, Schmalz G. Partial ce-
ramic crowns: influence of preparation design and luting material on inter-
nal adaptation. Oper Dent 2004;29:560-570.
18. Felden A, Schmalz G, Federlin M, Hiller KA. Retrospective clinical investiga-
tion and survival analysis on ceramic inlays and partial ceramic crowns: re-
sults up to 7 years. Clin Oral Investig 1998;2:161-167.
19. Frankenberger R, Petschelt A, Krämer N. Leucite-reinforced glass ceramic
inlays and onlays after six years: clinical behavior. Oper Dent 2000;25:
459-465.
20. Gibbs CH, Mahan PE, Lundeen HC, Brehnan K, Walsh EK, Holbrook WB. Oc
clusal forces during chewing and swallowing as measured by sound trans-
mission. J Prosthet Dent 1981;46:443-449.
21. Gibbs CH, Mahan PE, Mauderli A, Lundeen HC, Walsh EK. Limits of human
bite strength. J Prosthet Dent 1986;56:226-229.
22. Hickel R, Manhart J. Longevity of restorations in posterior teeth and rea-
sons for failure. J Adhes Dent 2001;3:45-64.
23. Julien KC, Buschang PH, Throckmorton GS, Dechow PC. Normal mastica-
tory performance in young adults and children. Arch Oral Biol 1996;41:69-
75.
24. Kelly JR, Giordano R, Pober R, Cima MJ. Fracture surface analysis of dental
ceramics: clinically failed restorations. Int J Prosthodont 1990;3:430-440.
25. Kelly JR. Perspectives on strength. Dent Mater 1995;11:103-110.
26. Kelly JR, Tesk JA, Sorensen JA. Failure of all-ceramic fixed partial dentures
in vitro and in vivo: analysis and modeling. J Dent Res 1995;74:1253-
1258.
27. Kelly JR. Clinically relevant approach to failure testing of all-ceramic
restorations. J Prosthet Dent 1999;81:652-661.
28. Kern M, Douglas WH, Fechtig T, Strub JR, DeLong R. Fracture strength of
all-porcelain, resin-bonded bridges after testing in an artificial oral environ-
ment. J Dent 1993;21:117-121.
29. Kern M, Strub JR, Lu XY. Wear of composite resin veneering materials in a
dual-axis chewing simulator. J Oral Rehabil 1999;26:372-378.
30. Krämer N, Lohbauer U, Frankenberger R. Adhesive luting of indirect
restorations. Am J Dent 2000;13:60D-76D.
31. Krämer N, Frankenberger R. Clinical performance of bonded leucite-rein-
forced glass ceramic inlays and onlays after eight years. Dent Mater
2005;21:262-271.
32. Krejci I, Lutz F. In-vitro test results of the evaluation of dental restoration
systems. Correlation with in-vivo results [in German]. Schweiz Monatsschr
Zahnmed 1990;100:1445-1449.
33. Krejci I, Reich T, Lutz F, Albertoni M. In-vitro test procedure to evaluate den-
tal restoration systems. 1. Computer-controlled masticatory simulation [in
German]. Schweiz Monatsschr Zahnmed 1990;100:953-960.
34. Lawn B, Deng Y, Miranda P, Pajares A, Chai H, Kim D. Overview: Damage in
brittle layer structures from concentrated loads J Mater Res 2002;
17:3019-3036.
35. Lawn BR, Deng Y, Thompson VP. Use of contact testing in the characteriza-
tion and design of all-ceramic crownlike layer structures: a review. J Pros-
thet Dent 2001;86:495-510.
36. Lawn BR, Deng Y, Lloyd IK, Janal MN, Rekow ED, Thompson VP. Materials
design of ceramic-based layer structures for crowns. J Dent Res 2002;
81:433-438.
37. Lehener C, Studer S, Brodbeck U, Schärer P. Six-year clinical results of
leucite-reinforced glass ceramic inlays and onlays. Acta Med Dent Helv
1998;3:137-146.
38. Manhart J, Chen H, Hamm G, Hickel R. Buonocore Memorial Lecture. Re-
view of the clinical survival of direct and indirect restorations in posterior
teeth of the permanent dentition. Oper Dent 2004;29:481-508.
48
All C opyrig
eR
ht
ech
te
by
vo
rbe
Qu
ha
39. McDonald A. Preparation guidelines for full and partial coverage ceramic
n lte
n
restorations. Dent Update 2001;28:84-90.
t es
i
40. McLean JW, von Fraunhofer JA. The estimation of cement film thickness by
an in vivo technique. Br Dent J 1971;131:107-111.
se nz
41. Mondelli RF, Barbosa WF, Mondelli J, Franco EB, Carvalho RM. Fracture
strength of weakened human premolars restored with amalgam with and
without cusp coverage. Am J Dent 1998;11:181-184.
42. Mühlemann HR. Physiologic and pathologic dental mobility [in German].
SSO Schweiz Monatsschr Zahnheilkd 1951;61:1-71.
43. Ortengren U, Elgh U, Spasenoska V, Milleding P, Haasum J, Karlsson S.
Water sorption and flexural properties of a composite resin cement. Int J
Prosthodont 2000;13:141-147.
44. Otto T, De Nisco S. Computer-aided direct ceramic restorations: a 10-year
prospective clinical study of Cerec CAD/CAM inlays and onlays. Int J
Prosthodont 2002;15:122-128.
45. Pallesen U, van Dijken JW. An 8-year evaluation of sintered ceramic and
glass ceramic inlays processed by the Cerec CAD/CAM system. Eur J Oral
Sci 2000;108:239-246.
46. Peters MC, de Vree JH, Brekelmans WA. Distributed crack analysis of ce-
ramic inlays. J Dent Res 1993;72:1537-1542.
47. Rosenblum MA, Schulman A. A review of all-ceramic restorations. J Am
Dent Assoc 1997;128:297-307.
48. Rosentritt M, Plein T, Kolbeck C, Behr M, Handel G. In vitro fracture force
and marginal adaptation of ceramic crowns fixed on natural and artificial
teeth. Int J Prosthodont 2000;13:387-391.
49. Rosentritt M, Behr M, Gebhard R, Handel G. Influence of stress simulation
parameters on the fracture strength of all-ceramic fixed-partial dentures.
Dent Mater 2006;22:176-182.
50. Sakaguchi RL, Douglas WH, DeLong R, Pintado MR. The wear of a poste-
rior composite in an artificial mouth: a clinical correlation. Dent Mater
1986;2:235-240.
51. Scherrer SS, Quinn JB, Quinn GD, Kelly JR. Failure analysis of ceramic clini-
cal cases using qualitative fractography. Int J Prosthodont 2006;19:185-
192.
52. Schmalz G, Federlin M, Reich E. Effect of dimension of luting space and
luting composite on marginal adaptation of a class II ceramic inlay. J Pros-
thet Dent 1995;73:392-399.
53. Shillingburg H, Jacobi R, Brackett S. Fundamentals of tooth preparations.
Chicago: Quintessence, 1987:13.
54. Stappert CF, Denner N, Gerds T, Strub JR. Marginal adaptation of different
types of all-ceramic partial coverage restorations after exposure to an arti-
ficial mouth. Br Dent J 2005;199:779-783; discussion 777.
55. Stappert CF, Guess PC, Gerds T, Strub JR. All-ceramic partial coverage pre-
molar restorations. Cavity preparation design, reliability and fracture resis-
tance after fatigue. Am J Dent 2005;18:275-280.
56. Stappert CF, Stathopoulou N, Gerds T, Strub JR. Survival rate and fracture
strength of maxillary incisors, restored with different kinds of full veneers.
J Oral Rehabil 2005;32:266-272.
57. Stappert CF, Att W, Thomas G, Strub JR. Fracture resistance of different
partial-coverage ceramic molar restorations: An in vitro investigation. J Am
Dent Assoc 2006;137:514-522.
58. Van Djiken JWV, Hasselrot L, Örmin A, Olofsson A-L. Restorations with ex-
tensive dentin/enamel-bonded ceramic coverage. A 5-year follow-up. Eur J
Oral Sci 2001;109:222-229.
59. Yamada Y, Tsubota Y, Fukushima S. Effect of restoration method on frac-
ture resistance of endodontically treated maxillary premolars. Int J Prostho-
dont 2004;17:94-98.
Clinical relevance: Since the present ceramic PCRs
achieved, independent of preparation design, fracture re-
sistance values similar to natural mandibular molars, less-
invasive, defect-oriented all-ceramic PCRs should be clin-
ically considered. Prominent occlusal contact points
should be avoided at ceramic restoration margins, since
wear compromises the marginal integrity.
The Journal of Adhesive Dentistry