In vitro fracture strength of teeth restored with different all-ceramic

crown systems
Narong Potiket, DDS, MS,a Gerard Chiche, DDS,b and Israel M. Finger, DDS, MS, MEdc
School of Dentistry, Louisiana State University Health Sciences Center, New Orleans, La
Statement of problem. There is insufficient knowledge of the strength of all-ceramic crowns bonded to
natural teeth to warrant the use of all-ceramic crowns in place of metal-ceramic crowns.
Purpose. The purpose of this study was to evaluate and compare fracture resistance of crowns made of 3
different types of 2 all-ceramic crown systems—0.4-mm and 0.6-mm aluminum oxide coping crowns and
zirconia ceramic coping crowns—and metal-ceramic crowns.
Material and methods. Forty intact, noncarious human maxillary central incisors were divided into 4 groups
(n=10): Group MCC (control), metal-ceramic crown (JRVT High Noble Alloy); Group AC4, crown with
0.4-mm aluminum oxide coping (Procera AllCeram); Group AC6, crown with 0.6-mm aluminum oxide coping
(Procera AllCeram); and Group ZC6, crown with 0.6-mm zirconia ceramic coping (Procera AllZirkon). Teeth
were prepared for complete-coverage all-ceramic crowns so that a final dimension of 5.5 6 0.5 mm was achieved
incisocervically, mesiodistally, and faciolingually. A 1.0-mm deep shoulder finish line was used with a rounded
internal line angle. All restorations were treated with bonding agent (Clearfil SE Bond) and luted with
phosphate-monomer–modified adhesive cement (Panavia 21). Fracture strength was tested with a universal
testing machine at a crosshead speed of 2 mm per minute with an angle of 30 degrees to the long axis of the
tooth after restorations were stored in 100% relative humidity of a normal saline solution for 7 days. The mode
of fracture was examined visually. Means were calculated and analyzed with 1-way ANOVA and Tukey’s HSD
(a=.05).
Results. The means of fracture strength were: Group MCC, 405 6 130 N; Group AC4, 447 6 123 N; Group
AC6, 476 6 174 N; and Group ZC6, 381 6 166 N. There was no significant difference between groups
(P=.501). The mode of failure for all specimens was fracture of the natural tooth.
Conclusions. There was no significant difference in the fracture strength of the teeth restored with all-ceramic
crowns with 0.4- and 0.6-mm aluminum oxide copings, 0.6-mm zirconia ceramic copings, and metal ceramic
crowns. (J Prosthet Dent 2004;92:491-5.)

CLINICAL IMPLICATIONS
There was no significant difference in the fracture strength of teeth restored with all-ceramic and
metal-ceramic restorations in this in vitro study. The all-ceramic crown may be considered to be
an alternative restoration for highly esthetic areas.

R ecent progress in the technology and research of

new dental materials has resulted in an increased number
of materials available for esthetic restorations.
Evaluations of the physical properties of the materials,
biocompatibility, and clinical success are necessary be-
fore these materials can be recommended for standard
treatment. The incorporation of a metal substructure
has been among methods previously used to improve
fracture resistance of ceramic crowns. Increasing aware-
Presented at the 81st General Session of the International and
American Associations for Dental Research in Göteborg, Sweden,
June 2003.
a
Assistant Professor, Department of Prosthodontics.
b
Professor, Chairman, Department of Prosthodontics.
c
Professor, Director, Residency Program in Prosthodontics, De-
partment of Prosthodontics.
ness among patients of dental esthetics had led some to
be dissatisfied with the appearance of metal-ceramic
crowns.1,2 A disadvantage of such restorations is in-
creased light reflectivity, which is due to the opaque por-
celain that is used to mask the metal substrate.3 Previous
investigation of the fracture surfaces of a limited number
of all-ceramic crowns, primarily Dicor ceramic
(Dentsply International Inc, York, Pa), revealed that
most clinical failures initiated from the cement or the in-
ternal surface.4,5 A recent independent study of clinically
failed glass-ceramic crowns confirmed these earlier find-
ings of cement surface failure origin.6 Finite element
modeling of a single-unit glass-ceramic crown demon-
strated the effect of internal surface flaws and cement
voids in increasing internal stresses, and the results
were in agreement with the mode of clinical failure
observed for glass-ceramic crowns.7

NOVEMBER 2004 THE JOURNAL OF PROSTHETIC DENTISTRY 491

THE JOURNAL OF PROSTHETIC DENTISTRY
The influence of different restorative design features
of Dicor glass-ceramic restorations has been studied.
Malament and Socransky found that there was no signif-
icant difference in survival of acid-etched Dicor res-
torations placed on shoulder or chamfer preparations.8
Thickness of the restorations that were evaluated at
the midpoint of the labial, lingual, mesial, distal, and
midocclusal surfaces did not relate to risk of failure.8
Dicor glass-ceramic restorations luted with zinc phos-
phate cement have had poorer success rates than res-
torations cemented and bonded with composite luting
agents.9 The survival of acid-etched Dicor restorations
luted to dentin preparation was significantly higher
than non-acid-etched restorations luted to dentin.9
The observations of restorations fractured during clini-
cal service indicate that failure originated from intaglio
surfaces. These surfaces are the site of critical flaws and
high tensile stress. Etching and polymer coatings of these
surfaces have substantially improved the strength of
ceramic structures.10,11 This strengthening effect may
be caused by the elimination, blunting, or bridging of
cracks, or by coatings that may reduce the transport of
water to the crack tip, lessening the potential for stress
corrosion. Hydrophobic silane treatments have been
shown to significantly increase the strength of feld-
spathic dental porcelain.12
The purpose of this study was to evaluate and
compare the fracture resistance of crowns made of
3 different types of 2 all-ceramic crown systems—
0.4-mm and 0.6-mm aluminum oxide coping crowns
and zirconia ceramic coping crowns—and metal-ceramic
crowns bonded to the human teeth with resin luting
agent. The null hypothesis was that the all-ceramic
restorations have the same fracture resistance as metal-
ceramic restorations after being bonded to the natural
tooth.
MATERIAL AND METHODS
Forty extracted human maxillary central incisors were
collected and stored in a 10% formalin solution.13 The
criteria in choosing the teeth included soundness and
absence of hypoplastic defects, caries, and cracks. The
extracted teeth were examined with a translumination
light (Elipar 2500 curing light; 3M ESPE, St Paul,
Minn) to evaluate the teeth for cracks. Calculus deposits
and soft tissue were removed from the selected
teeth with a scaler. The teeth were embedded in autopo-
lymerizing epoxy resin (Epoxy Fast Set Resin; Precision
Surface International, Houston, Texas) blocks and
placed upright with the long axes positioned perpendic-
ular to the block. The cementoenamel junction (CEJ)
was placed 3 mm above the resin. Teeth were prepared
by hand following the manufacturers’ recom-
mendations for complete-coverage all-ceramic crowns.
The final dimensions of the prepared tooth were 5.5 6
492
POTIKET, CHICHE, AND FINGER
Fig. 1. Tooth preparation.
0.5 mm incisocervically, mesiodistally, and faciolingually.
A 1.0-mm-deep shoulder finish line with a rounded in-
ternal line angle was prepared using a diamond instru-
ment (No. 5850-018; Brasseler USA, Savannah,
Ga).14,15 The teeth were prepared with a taper angle
of 6 to 8 degrees.16 All sharp angles were rounded,
and all cervical margins were located 1.0 mm above
the CEJ (Fig. 1). All teeth were measured after the
preparation using a precision electronic micrometer
(Electronic Micrometer; LS Starrett, Athol, Mass)
with an accuracy of 60.002 mm. A single-stage impres-
sion was made of each prepared tooth using a vinyl poly-
siloxane impression material (Express; 3M ESPE) and
a custom-made impression tray. Master dies were fabri-
cated with Type V improved die stone (Jade Stone;
Whip Mix, Louisville, Ky). The 40 teeth were divided
into 4 groups of 10 specimens each: 3 experimental
groups and 1 control group.
For Group MCC, metal-ceramic crowns, the metal
framework was waxed to a thickness of 0.4 mm and
cast with gold-platinum alloy (JRVT High Noble
Alloy; Jensen, North Haven, Conn). The framework
was then cut back 1.5 mm vertically on the labial surface
to produce a porcelain margin. Feldspathic porcelain
(Vita Omega Metal Ceramics; Vita Zahnfabrik, Bad
Säckingen, Germany) was fired directly on the shoulder
and used to veneer the crown. The restoration was
then polished and glazed. The intaglio surface of the
crowns was airborne-particle abraded with 50-mm alu-
minum oxide at 60 to 100 psi before cementation.
For Group AC4, all-ceramic crowns with 0.4-mm
aluminum oxide coping, the crowns were made with
a densely sintered high-purity aluminum oxide coping
core (Procera AllCeram; Nobel Biocare, Yorba Linda,
Calif). Prior to the scanning procedure, the die was trim-
med below the finish line to clearly define the extent
of the preparation. The die was oriented and mounted
vertically in the die holder of the scanner (Procera
VOLUME 92 NUMBER 5
POTIKET, CHICHE, AND FINGER
Scanner; Nobel Biocare). A sapphire ball at the tip of the
scanner was rotated and probed around the die’s vertical
axis. A light pressure of approximately 20g maintained
the probe in contact with the die as it rotated. One
data point was collected at every degree around the 360-
degree circumference of the die.
When scanning was concluded, the data was evalu-
ated on a computer screen for completeness. After the
evaluation of the data was completed, 2-dimensional
plots were visualized on the computer screen and ro-
tated by 5 or 10 degrees around the vertical axis of the
die. The margin on the 2-dimensional plots was
marked by keystroke computer commands at every 10
degrees of rotation. A 0.4-mm coping thickness was se-
lected for the group. A veneering porcelain (AllCeram;
Degussa-Ney, Bloomfield, Conn) was used.
Crowns in Group AC6, all-ceramic crowns with
0.6-mm aluminum oxide coping, were prepared as Group
AC4 crowns were prepared, except that 0.6-mm was se-
lected as the coping thickness. For Group ZC6, crowns
with 0.6-mm zirconia ceramic coping, industrial yttrium
oxide–partially-stabilized zirconia ceramic (Procera
AllZirkon; Nobel Biocare) was used to fabricate the cop-
ings. A veneering porcelain (Cerabien ZR; Noritake
Dental Supply, Mie, Japan) was used to complete the
crowns.
Cementation
Teeth and restorations underwent the following lut-
ing procedures. For Group MCC, the prepared tooth
surface was cleaned with pumice and rinsed with water.
Primer liquids A and B (Panavia 21 ED Primers; Kuraray
Medical, Tokyo, Japan) were mixed and applied to the
prepared tooth and left for 60 seconds. Air was used to
dry the liquid. The intaglio surface of the metal-ceramic
crown was airborne-particle abraded with 50-mm alu-
mina powder at a pressure of 60-100 psi. Adhesive metal
primer (Alloy Primer; Kuraray Medical) was applied inside
the restoration. All restorations were luted with phos-
phate-monomer–modified adhesive cement (Panavia
21; Kuraray Medical).
For Groups AC4, AC6, and ZC6, the prepared tooth
surface was cleaned with pumice and rinsed with water.
Primer liquids A and B were mixed and applied to the
abutment tooth and left for 60 seconds. Compressed
air was used to sufficiently dry the surfaces. The intaglio
surface of the all-ceramic crown was airborne-particle
abraded with 50-mm alumina powder at a pressure of
14 to 28 psi. Etchant gel (K-Etchant Gel; Kuraray
Medical) was applied inside the restoration for 5 sec-
onds, then the restoration was rinsed with water and
dried with air. Porcelain primer and porcelain
bond activator (Primer of Clearfil SE Bond and
Clearfil Porcelain Bond Activator; Kuraray Medical)
were mixed and applied on the intaglio surface and
NOVEMBER 2004
THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 2. Testing instrument.
left for 5 seconds. The surface was sufficiently dried
using compressed air. All restorations were luted
with phosphate-monomer–modified adhesive cement
(Panavia 21; Kuraray Medical).
During cementation, the crown was secured with
hand-held pressure for 2 minutes. Gross removal of
the cement was done prior to placing the oxygen-barrier
gel (Oxyguard II; Kuraray Medical) around the margin
of the crown. After crown placement, all specimens re-
mained in water at room temperature (20°C) except
when the experimental procedure required isolation
from moisture. After cementation, all specimens were
stored in 100% relative humidity of a normal saline solu-
tion for 7 days.
Fracture strength testing
Fracture strength was tested with a screw-driven
universal testing machine (Instron 4411; Instron,
Canton, Mass) at a crosshead speed of 2 mm/min.17
An axial load was applied to the incisal edge at an
angle of 30 degrees to the long axis of the tooth. To
distribute the force, a piece of tin foil 0.7 mm thick
was placed between the incisal edge and the load
point.17 The load was distributed over a flat surface
on the incisal edge (Fig. 2). All crowns were loaded
until catastrophic fracture of the crown and/or tooth
occurred.
Following the fracture strength testing, an examiner
visually examined the mode of fracture. Fracture mode
of the crown was classified according to a classification
proposed by Burke18: Class I, minimal fracture or crack
in crown; Class II, less than half of crown lost; Class III,
crown fracture through midline, half of crown displaced
or lost; Class IV, more than half of crown lost; Class V,
severe fracture of tooth and/or crown. The data were
subjected to 1-way ANOVA to determine whether sig-
nificant differences between groups existed. Tukey’s
493
THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 3. Control specimens after loading.
Table I. One-way analysis of variance of control group and
experimental groups
Sum of Mean
Source df squares squared F ratio F probability
Between groups 3 53880.5 17960.1 0.80 0.5014
Within groups 36 806971.6 22415.8
Total 39 860852.2
HSD procedure was used to identify different groups.
Significance for all statistical tests was determined at
a=.05.
RESULTS
All 40 specimens were loaded until failure occurred
(Figs. 3 and 4). The curve of failure load on the x-y
plot initially showed a decrease in inclination caused by
the compression of the tin foil between the crown and
the load point. Subsequently, the load was incrementally
increased until fracture occurred. Mean fracture
strength of the control group (metal-ceramic crowns)
was 405 6 130 N. Mean fracture strengths for the ex-
perimental groups, Procera AllCeram 0.4-mm coping
crown, Procera AllCeram 0.6-mm coping crown, and
Procera AllZirkon 0.6-mm zirconia ceramic coping,
were 447 6 123, 476 6 174, and 381 6 166 N, respec-
tively. One-way analysis of variance indicated that there
was no significant difference (P=.501) among the 4
groups (Table I). Visual analysis of the fractured speci-
mens showed that all the specimens (100%) in every
group exhibited a Class V mode of fracture. No crowns
were dislodged from the prepared tooth, and there were
no fractures of the all-ceramic or metal-ceramic crowns.
All fractures occurred through the natural tooth.
494
POTIKET, CHICHE, AND FINGER
Fig. 4. AC6 (left) and ZC6 (right) specimens after loading.
DISCUSSION
This study evaluated the fracture resistance of 3 dif-
ferent crown systems bonded to natural maxillary central
incisors. The hypothesis that all-ceramic restorations
have the same fracture resistance as metal-ceramic resto-
rations after being bonded to the natural tooth was ac-
cepted.
No standard method exists for testing the compres-
sive strength of a clinical ceramic crown. Several factors,
such as preparation design, ceramic material, crown
thickness, method of luting, cyclic preload, and thermal
cycling, can influence results.19 Extracted human maxil-
lary central incisors were used in this study. Natural
teeth show a large variation depending on age, anatomy,
and storage time after extraction and therefore can cause
difficulties in standardization. Several studies used steel
or resin dies for the fracture testing of crowns.13,20
The advantages include standardized preparation and
the identical physical quality of materials used.
However, prepared teeth made of steel or resins do
not reproduce the actual force distribution that occurs
on crowns cemented on natural teeth. Dentin has a lower
elastic modulus than steel. Therefore, the greater defor-
mation of the teeth, the higher the shear stress will be at
the inner crown surface.
The preparation design of the abutments used in this
study included a 6- to 8-degree taper, which was shown
to reveal no statistically significant difference in fracture
resistance.16 In vivo, a 90-degree shoulder with
a rounded internal line angle is recommended for all-ce-
ramic crowns.14,15 Kelly21 showed that in vitro ball-
loading of fixed partial dentures and crowns yielded
blunt indentation damage, which is different from the
crack and failure origins observed clinically. All fracture
forces found in the present study were smaller than those
found in other studies.22,23 The design of the present
study contains several limitations, making it difficult to
VOLUME 92 NUMBER 5
POTIKET, CHICHE, AND FINGER
compare its results with the clinical situation. The pri-
mary limitation is that it is an evaluation of fracture
strength of the restorations under static loading after 7
days of exposure to normal saline solution. Clinically,
restorations are subjected to dynamic complex loading
in saliva, which contains both organic and inorganic
components. These conditions are quite different from
the condition used in this study. To predict the long-
term performance of the restorations, testing utilizing
stress corrosion or corrosion fatigue methodology
should be employed. Another limitation is the large scat-
ter in the data, which makes it difficult to discriminate
between groups studied. Such a large scatter is not un-
common in mechanical testing using a small sample
size.17,24-27 A power analysis of data indicated that to
detect a difference in the means in the 90% confidence
interval (P,.05), 240 specimens were needed. To
clearly ascertain the significance of test data, future test-
ing is planned with a larger sample size.
CONCLUSION
This study evaluated resistance to load in all-ceramic
and metal-ceramic crown specimens. Within the limita-
tions of the study design there was no significant differ-
ence in fracture strength of teeth prepared for all-
ceramic crowns with 0.4- and 0.6-mm aluminum oxide
copings or 0.6-mm zirconia ceramic copings and teeth
prepared for metal-ceramic crowns. Fracture after load-
ing occurred through the teeth, not through the
restorations.
The authors thank Drs Nikil Sarkar and Markus Blatz for valuable
comments, Dr Donald Mercante for statistical consultation, Michael
Higgins for manuscript revision, and Edwin Kee and Julio Zavala for
the laboratory support.
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Reprint requests to:
DR NARONG POTIKET
SCHOOL OF DENTISTRY
LOUISIANA STATE UNIVERSITY HEALTH SCIENCES CENTER
1100 FLORIDA AVE, BOX 222
NEW ORLEANS, LOUISIANA 70119
FAX: 504-619-8741
E-MAIL: npotik@lsuhsc.edu
0022-3913/$30.00
Copyright Ó 2004 by The Editorial Council of The Journal of Prosthetic
Dentistry
doi:10.1016/j.prosdent.2004.09.001
495