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Journal of Prosthodontic Research 55 (2011) 53–59

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Technical procedure
Fracture resistance of premolars restored with inlay and onlay ceramic
restorations and luted with two different agents
Gloria Beatriz de Azevedo Cubas DDS MSc, Luciano Habekost DDS MSc,
Guilherme Brião Camacho DDS MSc, PhD, Tatiana Pereira-Cenci DDS MSc PhD*
Department of Restorative Dentistry, School of Dentistry, Federal University of Pelotas, Brazil
Received 10 June 2009; received in revised form 14 June 2010; accepted 1 July 2010
Available online 12 October 2010

Abstract
Purpose: The purpose of this study was to evaluate the fracture resistance of human maxillary premolars restored with 2 ceramic systems (Vitadur
Alpha and In Ceram) comparing 3 preparation designs and 2 luting agents.
Methods: Seventy sound teeth were prepared to receive ceramic restorations (Vitadur Alpha; n = 14) as follows: (1) control, sound premolars, with
no preparation, (2) inlays, (3) partial onlays (palatal cuspid coverage), (4) total onlays (both cuspids coverage), and (5) total onlays with an In
Ceram core. The ceramic restorations were cemented using Enforce or RelyX ARC (half restorations with each cement), placed into the cavity and
held under pressure, except for the control group. The teeth were subjected to compressive axial loading at 0.5 mm min 1 using a 9 mm steel ball
until fracture. Data were analyzed by 3-way ANOVA and post hoc Tukey’s test (a = .05).
Results: There was a significant difference between cements and among preparation designs (P < .05). All restorations cemented with Enforce
exhibited significantly higher fracture resistance (P < .05). Inlay restorations showed similar fracture resistance when compared to control group
(P > .05). Partial and total onlays did not statistically differ and showed the weakest performance. The use of an In Ceram core did not produce
higher fracture resistance.
Conclusions: Within the limitations of this study, the cements tested had different mechanical properties, while cuspid coverage did not result in
improved fracture resistance of the restored teeth.
# 2010 Japan Prosthodontic Society. Published by Elsevier Ireland. Open access under CC BY-NC-ND license.

Keywords: Ceramic; Fracture resistance; Inlays; Onlays

1. Introduction
The loss of dental structure caused by caries, trauma, or
cavity preparation designs drastically diminishes teeth resis-
tance when compared to sound teeth [1–5]. These partially
destructed teeth may be restored using several adhesive systems
and restorative techniques, which aims to reestablish the lost
health [6–11]. However, little is known regarding the amount of
the original resistance restored with dental treatment [1,2,6].
This way, it becomes important to study the factors that
influence the fracture resistance of restored teeth, especially
considering the occurrence of catastrophic fractures as a
recurrent problem [3,11–14]. The main determinants in fracture
* Corresponding author at: School of Dentistry, Federal University of Pelotas,
Rua Gonçalves Chaves, 457, 2nd floor, Pelotas-RS 96015560, Brazil.
Tel.: +55 53 32226690; fax: +55 53 32226690.
E-mail address: tatiana.cenci@ufpel.tche.br (T. Pereira-Cenci).
are the restoring material, the type of cementing agent, and the
extension and conformation of the cavity preparation [2–
5,7,11,15].
There are several designs of cavity preparation of MOD type
proposed for posterior teeth [3,4,16–18]. Indirect restorations
usually consider preparations with or without cuspid reduction,
width and depth of the dental structure reduction increasing the
cuspids height and isthmus width, enhancing the generated
stress to the cuspids base, which increases the fracture risk
[3,19–21]. For this reason, the application of non-adhesive
restorations is not indicated in deep and wide cavity
preparations, such as amalgam or gold base inlays, as they
do not promote reinforcement of the weakened cuspids [19,22].
Some studies also consider the fracture resistance of restored
teeth increment when resin cements are used in detriment to
conventional cements [8,19,23].
The esthetic demand for restoring treatments that reestablish
the natural teeth aspects is rising [8,10,23–25]. Among the

1883-1958 # 2010 Japan Prosthodontic Society. Published by Elsevier Ireland. Open access under CC BY-NC-ND license.
doi:10.1016/j.jpor.2010.07.001
54 G.B.A. Cubas et al. / Journal of Prosthodontic Research 55 (2011) 53–59
Table 1
Composition of materials used in the study.
Material Composition
Single bond Water, alcohol, HEMA, BisGMA, dimethacrylate,
photoinitiator, copolymers of the polyacrylic acid
and polyitaconic acid
RelyX ARC BisGMA, TEGDMA, silica and zirconium
glass (67.5 wt.%)
Enforce BisGMA, BHT, EDAB, TEGDMA, fumed,
silica, silanized barium, aluminum,
borosilicate glass (66 wt.%)
Silane Silane, ethanol and acetic acid
available options, ceramic restorations are an excellent
alternative for the retrieval of posterior teeth with extensive
dental structure losses and aesthetic needs [7,9,23,26]. These
restorations present aesthetical advantages, chemical durabil-
ity, fluorescence, resistance to compression and wear, thermal
expansion coefficient similar to the structure, biocompatibility
and when compared to resin composite restorations, restrain the
polymerization contraction problem to the cement pellicle
[7,10,23,27].
Despite technological advance of resin cements and
adhesive systems, which permitted the increase of the clinical
application of all ceramic restorations [7,15,26,28], there is a
rising concern related to these restorations longevity
[7,9,16,29–33]. Several studies point to a tendency of
catastrophic fractures through time [29,33,34] related to their
brittleness and low resistance to tensions provoked by
antagonistic occlusal forces [10,23,24].
The aim of this study was to evaluate the fracture resistance
of human maxillary premolars restored with two ceramic
systems, comparing three types of cavity preparations and two
different luting cements. Three null hypotheses were tested. (1)
Different conformations of the cavity preparation would not
influence fracture resistance of the restored teeth. (2) The
utilization of different resin-based cementing agents would not
lead to different performances on the fracture resistance of the
restored teeth. (3) An In Ceram core would lead to higher
fracture resistance of a total onlay when compared to a total
onlay without the In Ceram core.
2. Materials and methods
This work was approved by the Ethics Committee of Federal
University of Pelotas. Seventy caries-free human premolars
extracted for orthodontic reasons were used. The removal of
periodontal soft tissues was conducted, and the teeth were
immersed in choramin-T 0.5% during 72 h [36]. Teeth were
examined under magnification (10), to check possible fissures
in the teeth. Teeth were washed in running water for 24 h and
stored in distilled water at 37 8C for 5 days. These teeth were
then randomly divided into five groups (n = 14), according to
the following cavity preparation designs: control group (no
preparation), Vitadur Alpha ceramic (VITA Zahnfabrik, Bad
Säckingen, Germany) MOD inlays, Vitadur Alpha ceramic
partial onlays with palatine cuspid coverage, Vitadur Alpha
Batch # Manufacturer
3HL 3M ESPE, St Paul, MN, USA
BHBH 3M ESPE, St Paul, MN, USA
731 Dentsply, Petrópolis RJ, Brazil
178 3M ESPE, St Paul, MN, USA
ceramic total onlays with both cuspids coverage, and Vitadur
Alpha ceramic total onlay manufactured on an In Ceram (VITA
Zahnfabrik) core. Materials used in this study are described in
Table 1.
The teeth were fixed 1 mm above the cementum–enamel
junction limit and imbedded in autopolymerized acrylic resin
(Artigos Odontológicos, Classico Ltd., São Paulo, Brazil)
blocks, according to previously published protocols [35,36].
Standardized preparations were manufactured with proximal
boxes 1.5 mm at the cervical wall in a proximal–proximal
direction and occlusal boxes at a depth of 2 mm (half of the
intercuspid distance—buccal-lingual dimension). The cervical
walls stayed 1 mm above the cementum–enamel junction limit.
A 1.5 mm cuspid reduction was performed in the protected
cusps (extended 2 mm in the cervical direction at the buccal
surface) and a 2 mm reduction in the functional cuspid
(extended 2 mm in the cervical direction at the lingual surface)
[35] (Figs. 1–3). Diamond rotary cutting instruments (4138;
KG Sorensen, Barueri, Brazil) were used and discarded at every
four preparations. The cavity preparations were copied with
polyvinylsiloxane (Express; 3 M ESPE, St Paul, Minn, USA)
working as a guide and cast with type IV Gypsum (Durone,
Dentsply, RJ, Brazil).
The ceramic restorations were manufactured with the
Vitadur Alpha ceramic using the refractory mould technique,
with three burnings at (600–960 8C). Finishing and polishing
were carried out with Sof-Lex system (Sof-Lex Pop-On, 3 M
ESPE) and glaze at 930 8C. The ceramic restorations were
sprayed with glass particles at 1 bar pressure for the internal
surface cleaning. The acid conditioning of the ceramic surface
was carried out with 10% hydrofluoridric acid during 4 min and
a silane was applied with the assistance of a micro-brush. The
dental surface treatment was conducted using 37% phosphoric
acid (Scotchbond Etchant; 3 M ESPE) applied during 15 s.
Next, the dental cavity was abundantly washed with water
during 15 s, and the tooth was slightly dried with absorbing
paper. The adhesive (Single Bond; 3 M ESPE) was applied in
two layers using a micro-brush with a light air jet after the first
layer followed by one more layer. At the end of the applications,
the adhesive was light polymerized for 20 s with a light curing
unit XL 3000 (3 M ESPE) with energy higher than
450 mW cm 2.
Half of the restorations of each group were cemented with
the Enforce resin cement and the other half with the RelyX
[(Fig._1)TD$IG]
G.B.A. Cubas et al. / Journal of Prosthodontic
Fig. 1. MOD inlays.
[(Fig._2)TD$IG]
Fig. 2. Onlays with palatine cuspid coverage.
ARC cement. Equal portions of base and catalyst of each
cement were proportioned for cementation and after the
overflow of cement excess, the restoration was placed under
pressure (1 kgf charge using a Vicat needle for 2 min). Next the
polymerization was conducted during 30 s. The mesial and
distal polymerizations of each tooth was conducted during 40 s.
Finishing and polishing were done with the Sof-lex system. The
restored teeth were kept in distilled water during seven days at
37 8C. Restorations with a core were manufactured with a
ceramic core of high resistance (In Ceram) through the slip-
casting technique and with the traditional Vitadur Alpha
ceramic, as previously described. The fracture resistance test
[(Fig._3)TD$IG]
Research 55 (2011) 53–59 55
Fig. 3. Total onlays with both cuspids coverage.
was performed on the teeth’s occlusal surfaces in a universal
testing machine MEM-2000 (EMIC Ltd., Sao Jose dos Pinhais,
Brazil) with a 9 mm stainless steel sphere (in diameter) and
0.5 mm min 1 speed (Fig. 4). The sphere was applied in the
center of the occlusal surfaces with a 500 kgf load until
specimen fracture [36].
The failure mode was assessed based on previous
publications [35,36], where mode I was a fracture restrict to
the restoration; mode II was a fracture of the dental structure,
but not through the long axis of the tooth; mode III was a
fracture of the tooth and restoration, but not through the long
axis of the tooth and mode IV was a fracture through the long
axis of the tooth, being in the tooth/restoration or only at the
tooth. Fig. 5 shows the failure mode and its distribution among
the groups tested.
3. Results
With the application of ANOVA for three variation sources,
a significant difference was found among the different cavity
design groups (P < .001) and between the types of cement
studied (P < .05). Mean and standard deviation values of the
fracture strength obtained in the axial compression test are
described in Table 2. Table 3 shows the different performances
among the restored premolars and control group, and cements.
Regarding the type of resin-based cement used, the Enforce
system leaded to a greater pressure of the restorations.
The inlay ceramics had similar resistance when compared to
control group (P > .001), and greater resistance when
compared to the other restored groups (P < .001). The total
onlay restorations with In Ceram core, although presenting
greater resistance to fracture, did not statistically differ
compared to the other groups (total and partial onlays without
the In Ceram core), with P = 0.063.
[(Fig._4)TD$IG]56
G.B.A. Cubas et al. / Journal of Prosthodontic
Fig. 4. Schematic illustration of the stainless steel ball in contact with teeth.
4. Discussion
Tissue reduction drastically reduces the teeth structural
resistance, reaching up to a 50% loss, which increases their
fracture risks [1]. The indication of partial ceramic restorations
such as inlays, when compared to total crowns, save healthy
dental tissue [6], reducing from around 67.5–72.3% to about
5.5–27.2% the tissue loss [25]. Partial ceramic and gold
restorations, when associated to new adhesive systems and resin
cements [6,25,26], develop greater resistance to fracture when
compared to the traditional cements, such as glass ionomer and
zinc phosphate [7,18,22].
The resin cements represent a good option for aesthetic
restorations due to their adhesive capability not only to the
dental structure, but also to the restoring material. Additionally,
resin cements present enhanced properties in relation to
solubility and lack of adhesion, if compared to the traditional
cements [6,14,25,27]. In several studies the properties and
performance of these cements are discussed, showing different
types of cement and application techniques may influence bond
strength of ceramic restorations and fracture resistance of the
restored teeth [7,14,22,25,27,32]. In this study, there was a
different performances between the two cementing agents used,
with Enforce promoting greater values of fracture resistance in
all types of cavity preparation evaluated when compared with
the ones restored with RelyX ARC. Habekost et al. [36]
evaluated 3 cementing agents and reported that cements with
higher flexural modulus exhibits higher values of fracture
resistance for the ceramic/tooth assembly, what may help to
explain the possible reason why there was a difference between
cements in our study.
[(Fig._5)TD$IG]
Research 55 (2011) 53–59
Fig. 5. Failure modes for each group.
Although the teeth cemented with Enforce have shown a
slight increase in fracture resistance varying from 10 to 30%
when compared with RelyX, the various restoration types
showed, in general, similar fracture modes. Only the inlay
group cemented with Enforce presented a prevalence of failure
mode II, when compared with RelyX. There was a similar
performance in the failure mode of the restorations cemented
with the 2 luting agents. In the control group, 57% were failure
mode IV (catastrophic), followed by failure mode II with 44%
of fracture of the palatal cuspid. In the inlay group, teeth
cemented with RelyX presented higher prevalence of failure
modes I and III, while teeth restored with Enforce presented
higher prevalence of failure modes II and III. On the partial
onlay group, teeth presented higher prevalence of mode failure
mode I for both cements, with 70% cohesive and 30% cohesive
and adhesive failure. The total onlay group resulted in failure
mode I mode for both cements, with cohesive failure of the
ceramic. For the In Ceram group, both cements presented 100%
of failure mode I mode with adhesive failure of the ceramic
restoration.
Onlays presented higher prevalence of fracture of the palatal
cuspid. In the partial onlay groups with palatal cuspid coverage,
only one tooth restored with Enforce presented failure mode III
with fracture of the palatine cuspid. The control group
presented 42% of the restored tooth with fracture of the palatal
cuspid with an II failure mode. A higher prevalence of
catastrophic fractures by the failure mode IV occurred in
control teeth. Considering that when fracture occurs in restored
tooth, it is more desirable that it is restricted to the restoration.
In this study, the groups with cuspid coverage presented a
higher prevalence of fractures restricted to the restoration
(failure mode I), in general.
All ceramic restorations are brittle and stiff materials and
have little capacity to deform; therefore they are luted and
supported by less stiff materials such as adhesive resin, dentin
bonding agent, and human dentin [37]. This combination
results in a resin ceramic hybrid layer that acts as an inherent
elastic buffering layer that is able to absorb stress during load
application [38]. Information regarding the role of the resin in
transferring stress from the loaded restoration to the underlying
tooth structure is limited. The elastic modulus is related to the
stress transmission between the restoration and the tooth
 G.B.A. Cubas et al. / Journal of Prosthodontic Research 55 (2011) 53–59
Table 2
Mean  SD (kgf) of fracture resistance for different experimental groups.
Cements Groups
Control Inlays
RelyX 178.2  32.8 158.7  17.0
Enforce 173.9  12.8
Table 3
ANOVA in accordance with fracture resistance results.
Sources of variation df F value
Ceramic system 2 6.18
Cement 4 4.01
Cavity design 4 0.92
Ceramic system  cement 8 2.59
Ceramic system  cavity design 8 2.03
Ceramic system  cement  cavity design 32 0.30
df = degrees of freedom; ns = not significant.
structure. It also indicates the ability of the cement to resist
elastic deformation which could jeopardize the integrity of the
bonded interface [39]. Ceramic strengthening enhancement is
dependent upon the elastic modulus of the resin cement chosen
[38]. Cements with higher flexural modulus exhibits higher
values of fracture resistance for the ceramic inlays/tooth
assembly [36], what may help to explain the reason why there
was a difference between cements in our study. The elastic
modulus of the luting agents RelyX ARC and Enforce were
5.70 and 7.29 GPa respectively [36]. Thus, the increase of
fracture resistance values of the ceramic restorations cemented
with Enforce may be due to its higher elastic modulus.
An intermediary elastic modulus for cements between
dentin and the ceramic has been proposed, because this can
reduce interfacial stress concentrations without causing
excessive strains [40]. Alternatively, it is also argued that as
the cement/tooth interfaces are weaker and of greater biologic
importance than the cement/restoration interfaces, the elastic
modulus of cements should be closer to that of dentin than of
indirect restorative materials. Although neither argument
supports the use of luting cements with elastic modulus lower
than dentin, many commercially available cements presents
elastic modulus ranging from 5 to 12 GPa. In this study, the
cements had elastic modulus below the lower limits of the
elastic modulus of dentin (11–19 GPa).
The clinical longevity of the ceramic restorations is a
concern [6,8,16,23,28,32], since the long-term fracture
resistance is a mandatory quality, as fractures are among the
main flaw causes of these restoring treatments [16,29,
31,33,34]. Taking into account that posterior teeth are exposed
to high occlusal charges when associated to extensive cavity
preparations, the fracture risk becomes critical [3,4]. As
previously described by Bader et al. [11], the incidence of
fracture in previously restored posterior teeth is high. Molin
et al. [29], in a randomized clinical evaluation with 3 ceramic
inlays systems, reported 8% of fractures while 92% of ceramic
57
Partial onlays Total onlays Total onlays + In Ceram
86.0  5.4 84.0  15.7 100.4  14.7
116.5  21.2 104.7  20.4 108.0  41.9
inlays based on CDA criteria were rated as satisfactory after 5
years. In a clinical evaluation of feldspathic inlays, Hayashi
P et al. [34], reported longevity of 80% after eight years, and the
.063 ns majority due the failures were due to bulk fracture. Clinical
<.001 evaluations of leucite-reinforced glass ceramic inlays and
<.05 onlays and CAD/CAM (Cerec) ceramic inlays have reported a
0.55 ns 8–11% failure rate, with fractures as the main reason for failure
0.19 ns
0.20 ns
[31,33]. This way, it becomes important to study fracture
resistance among various preparation designs in order to
identify which preparation would show lower fracture
resistance, which may lead to higher longevity of the
restorations.
It is difficult to determine which restorative material would
be ideal for the restoration of posterior teeth [6–9]. Reviews of
the literature considering ceramic inlays and ceramic compared
with gold inlays concluded that there are few randomized
clinical trials capable of defining which material presents better
performance to restore posterior teeth in a long-term basis
[28,30]. In the past decades, indirect metal or amalgam
restorations were the first choice for the restoration of partially
destructed teeth [18,21], however, many studies have demon-
strated that there is a higher occurrence of fractures in these
types of restoration through time [7], probably because indirect
metal or amalgam restorations provide only primary mechan-
ical retention without increasing dental structure resistance,
which may ultimately result in cuspid fractures [12,21].
Although ceramic restorations present disadvantages in relation
to friability and the antagonist wear [9,22,24], they are
considered a clinically viable option that fulfills the aesthetics
and resistance needs [7,22,26].
Premolar teeth are an interesting option for the indication of
inlays due to their aesthetical necessity, when considering their
occlusal requests, and for representing a frequently used teeth
group in studies, allowing comparisons [1,3,5,10,18]. The
major prevalence of palatine cuspid fractures of upper
premolars has already been reported [1,5,10,13,20], and
justified as it deals with centric contention cuspids that are
subjected to higher masticatory forces. Additionally, functional
cusps of maxillary premolars fracture with greater frequency
than their counterparts probably because in this group of teeth
the functional cusp is significantly smaller than the nonfunc-
tional cusp [20]. Eakle et al. [19], reported in his study that the
lingual cusps (53.1%) of maxillary premolars fractured slightly
more frequently than buccal cusps.
Some authors have previously recommended cuspids
reduction with their inclusion in the cavity preparation in
order to enhance fracture resistance, converting inlays to onlays
to protect cuspids without support, especially to eliminate
58 G.B.A. Cubas et al. / Journal of Prosthodontic Research 55 (2011) 53–59
contacts that occur at the interface between the restoration and
tooth structure [6,12]. For this reason, fracture resistance tests
with designs of cavity preparations involving only the palatine
cuspid are important. Additionally, in order to compare fracture
resistance of preparations that involves one or both cuspids,
studies aiming to evaluate the real need of greater dental loss
are needed. There is no consensus regarding cuspids reduction
in cavity preparation with regard to structural resistance of the
tooth-restoration complex [15,17]. While some studies have
shown that cuspal coverage of posterior teeth with ceramic
partial coverage inlays did not result in increased fracture
resistance [15,17], marginal integrity and longevity were not
affected by cuspal reduction [15,31].
In the present study, inlay restorations were the only
restorations to show resistance performance similar to the
control group, as the less invasive preparation. The more
invasive preparations were incapable of restoring the fracture
resistance of the restored teeth when compared to the control
group. This may explain why neither the inclusion of the
protective cuspid nor the cuspid of support resulted in increased
fracture resistance of restored teeth, corroborating with other
findings [15]. Maintenance of the buccal cuspid contributes to
the maintenance of the restored teeth aesthetic. Therefore, inlay
restorations should be preferred, as they are more conservative
since there is no occlusal reduction and they presented the
highest fracture resistance values.
The evolution of the ceramic systems in the latest years is
overwhelming [22,23,25]. The reinforced ceramics are largely
used in total and partial metal-free crowns, associating both
aesthetic and resistance [7,26]. They present a ceramic core of
high resistance manufactured through the slip-casting techni-
que [25]. Conversely, in this work, the utilization of an In
Ceram core with the total onlay preparation did not differ from
the traditional onlay, except for the inlays. The limited number
of randomized, controlled and well designed longitudinal
studies is a significant problem when evaluating ceramic inlay
and onlay performance in a long-term perspective, turning
difficult to compare and asses the overall effectiveness of
different ceramic inlay systems [30].
Although this work does not recreate the mouth clinical
conditions, this type of test with application of loads is
currently a feasible option for reproduction of the answers in
relation to the charge powers and may be a clue on how these
restorations may perform clinically. It is important to conduct
future studies to determine cavity preparation designs with
minimal tissue reduction, which may help to promote adequate
resistance of the tooth and restoration array, avoiding long-term
restorations flaws.
5. Conclusions
Within the limitations of this study, the following conclu-
sions were drawn:
1. There was a significant difference between the used cements
in fracture resistance of the restored teeth with the different
cavity preparations.
2. The ceramic inlay restorations presented the highest axial
compression resistance values and did not differ from
premolars used as control.
3. The superiority of the specimens restored with partial onlay
restorations when compared to total onlays was not
statistically confirmed.
4. The increase of dental reduction with the cuspids protection
did not result in increased fracture resistance.
5. There were no differences between the total onlays restored
with an In Ceram core compared to those restored with the
traditional ceramic system.
Conflict of interest statement
The authors declare that they have no conflict of interest.
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