journal of dentistry 38 (2010) 16–22

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A preliminary evaluation of the structural integrity

and fracture mode of minimally prepared resin bonded
CAD/CAM crowns

Effrosyni A. Tsitrou a,*, Maria Helvatjoglu-Antoniades b, Richard van Noort a

a
Department of Adult Dental Care, School of Clinical Dentistry, University of Sheffield, Claremont Crescent, S10 2TA, Sheffield, UK
b
Department of Operative Dentistry, School of Dentistry, Aristotle University of Thessaloniki, Thessaloniki, Greece

article info abstract

Article history: Purpose: This study was a preliminary evaluation of two minimal preparation designs
Received 3 November 2008 proposed for ceramic and composite resin bonded CAD/CAM crowns. It compared the
Received in revised form structural integrity and fracture mode of teeth restored with traditionally and minimally
5 July 2009 prepared resin bonded CAD/CAM crowns fabricated from the same material hypothesizing
Accepted 10 July 2009 that teeth restored with minimal resin bonded crowns would demonstrate the same
fracture strength to teeth restored with traditional resin bonded crowns.
Materials and methods: Forty intact maxillary molar teeth were used and divided in four
Keywords: groups. Two groups were prepared according to a traditional crown preparation design and
Fracture strength two groups were prepared according to minimal preparation designs. A resin composite
Minimal designs (Paradigm MZ100, 3M ESPE) and a leucite glass–ceramic (ProCAD, Ivoclar Vivadent) were
Ceramic crowns used for the fabrication of the crowns using CEREC Scan. Crowns of ceramic were cemented
Composite crowns using Variolink II (Ivoclar Vivadent) and crowns of composite with Rely X Unicem AplicapTM
Structural integrity (3M ESPE) and loaded until fracture. Load data was analysed using ANOVA comparing
CAD/CAM crowns of the same restorative material. The mode of fracture was also recorded and
CEREC analysed (Kruskal–Wallis).
Results: For the composite system the mean fracture load and SD was 1682 N (315) for the
traditional and 1751 N (338) for the minimal crowns. For the ceramic system the mean
fracture load and SD was 1512 N (373) for the traditional and 1837 (356) for the minimal
crowns. No statistically significant difference was found between the two designs for each
system. Nonparametric analysis (Kruskal–Wallis) of the fracture mode showed no statistical
significant difference between designs for either material ( p > .05).
Conclusion: Within the limitations of this experimental design, it was found that minimally
prepared resin bonded CEREC crowns demonstrated equal fracture resistance and mode of
fracture to that of crowns bonded to traditionally prepared teeth.
# 2009 Elsevier Ltd. All rights reserved.

1. Introduction ques, and the scientific developments in cariology, have

changed the way that dental diseases are treated and have led
The continuous evolution in the dental materials industry to the development of minimal invasive/ultraconservative
with the introduction of new adhesive materials and techni- dentistry.1 Minimally invasive approaches were first applied

* Corresponding author. Tel.: +44 0114 271 7962; fax: +44 0114 266 5326.
E-mail address: e.tsitrou@gmail.com (E.A. Tsitrou).
0300-5712/$ – see front matter # 2009 Elsevier Ltd. All rights reserved.
doi:10.1016/j.jdent.2009.07.003
 journal of dentistry 38 (2010) 16–22
for the treatment of direct restorations. However, lately these
principles are beginning to be applied to indirect restorations
as well.2 The preservation of tooth tissue is very important,
especially for cases where gross amount of tooth substance
have already been lost for various reasons (e.g. tooth wear,
trauma, etc.) or simply when the gross removal of tooth tissue
cannot be justified for the replacing of the missing anatomy
(i.e. hypoplastic defects).2,3 Further to that an increasing
demand from patients for aesthetic restorations and some
wariness of amalgam hazards and mercury poisoning, have
also increased the use of aesthetic restorations.4
All-ceramic restorations are some of the most aesthetically
pleasing restorations. Due to the lack of metal core which
blocks light transmission all-ceramic restorations can resem-
ble natural tooth structure in terms of colour and light
translucency better than any other restorative option. In that
way restorations can be more easily ‘‘integrated’’ with tooth
structure, since the bonding mechanism can establish optical
continuity from tooth structure to restoration.5–7 In addition
metal-free polymer crowns have been introduced as an
alternative and inexpensive option offering restorations with
high functional and aesthetic ratings.8,9 The introduction of
new ceramic and resin composite materials has improved
some of the properties of both materials offering a new
dimension to the application of aesthetic indirect restora-
tions.2,3,10–15
Another possible advantage of these restorations is the
potential for a more conservative preparation due to the lack of
a metal substructure.5 The use of materials that can be
adhesively bonded to the tooth can make possible the
application of even more minimal intervention procedures.
Many in vitro and in vivo studies exist in the literature evaluating
the fracture strength and clinical performance of dentine
bonded crowns.2,3,8,10–17 These provide enough evidence to
support the premise that the fracture strength of teeth restored
with these restorations is increased significantly when the
restoration is bonded to the tooth tissue.16,18–20
Sintered feldspathic and leucite reinforced ceramic and
filled polymers are used for the fabrication of metal-free
restorations using traditional laboratory based fabrication
techniques However, with the introduction of CAD/CAM
technology, machinable versions of these materials can
now be used for these applications.
Whilst there is evidence of the clinical application of resin
bonded indirect restorations with promising results,2,8,10,11,21–
23
the work published so far on the fracture strength of resin
bonded crowns has been carried out with traditional labora-
tory made crowns. It was therefore of interest to investigate
the strength of these restorations when they are CAD/CAM
fabricated. Previous studies indicate that the CEREC system is
able to produce designs more conservative to that suggested
by the manufacturer. However, the brittleness index of the
materials and the software and hardware of the system can be
determinant factors on the application of minimal designs.24–
26
As a result minimal preparation designs were proposed for
materials available for the CEREC 3 chairside system
(Table 1).26
The aim of the present investigation was to evaluate the
immediate post-operative structural integrity and the mode of
fracture of CAD/CAM fabricated resin composite and ceramic
17
Table 1 – Proposed minimal preparation designs for
CEREC 3 chairside materials.
Composite material Leucite reinforced
(Paradigm MZ100) ceramic (ProCAD)
0.4 mm chamfer margin 0.8 mm round shoulder margin
0.6 mm occlusal reduction 1.2 mm occlusal reduction
68 taper 68 taper
crowns using minimal preparation designs, and compare this
with traditionally prepared resin bonded CAD/CAM crowns.
The null hypothesis was that the structural integrity of teeth
restored with resin bonded CAD/CAM crowns using minimal
preparation designs, whether made of ceramic or composite,
is not compromised compared to teeth that have been
restored using a traditional crown design.
2. Materials and methods
Two restorative materials were tested; namely a resin
composite material (Paradigm MZ100, 3M/ESPE AG, ESPE Platz,
Seefeld, Germany) and a leucite reinforced glass–ceramic
(ProCAD, Ivoclar Vivadent Bendererstrasse 2, Schaan, Liech-
tenstein). Forty extracted caries-free and crack-free maxillary
first molar teeth were used for this study. Four groups (A, B, C
and D) of ten teeth in each were formed. Care was taken that
all teeth had similar bucco-palatal widths (BPW—the distance
from the maximum convexity on the buccal and palatal
surfaces). The mean BPW of each group did not varied more
than 2.5% from the other groups. All teeth were cleaned of any
calculus deposits and soft tissues with a hand scaler and
stored in a thymol solution (0.5%).
A blue die stone was used to fix each tooth, crown
uppermost and long axis vertical, in a plastic mould that
had a central cylindrical diameter of 30 mm. The die stone was
placed 1.0 mm from the cemento-enamel junction of each
tooth.
The resin composite group (Paradigm MZ100) consisted of
Groups A and C. A traditional crown preparation design for a
full coverage crown was performed for Group A with a circular
flat butt shoulder of 1.5 mm, a 68 convergence angle between
tooth axis and lateral wall and a 2.0 mm occlusal reduction. A
minimal crown preparation design was performed for Group C
and the teeth were prepared with a circular minimal chamfer
of 0.4 mm, a 68 convergence angle and a 0.6 mm occlusal
reduction (Fig. 1).
The ceramic (ProCAD) group consisted of Groups B and D. A
traditional crown preparation design for a full coverage crown
was performed for Group B as described above for Group A. For
Group D the teeth were prepared with a circular minimal
round shoulder of 0.8 mm, a 68 convergence angle and 1.2 mm
occlusal reduction (Fig. 1).
For all preparations a paralleling device and gauged burs
were used to standardise the preparation procedures (Mei-
singer; Intensiv Advanced CEREC Kit). An air-rotor hand piece
attached to the paralleling device was used for the tooth
preparations.
Impressions of the prepared teeth were taken using a one
stage impression technique following the manufacturer’s
18 journal of dentistry 38 (2010) 16–22
Fig. 1 – A diagram of the three designs: the traditional
crown preparation used for both systems (a), the minimal
crown design for the ceramic system (b) and the minimal
crown design for the composite system (c) (not to scale).
instructions (3M Express STD-Putty, 3M-ESPE Imprint-light
body). All impressions were cleaned and sprayed with a
surface tension reduction agent (Tensilab, Zehnmack, Italy),
which was then air-dried gently, to permit a more accurate
flow of the die stone and to inhibit any bubble formation. Forty
casts were fabricated using a special die stone for the CEREC
system (CAM-base1, Dentona).
The preparations were scanned using the CEREC Scan
system and the crowns were designed using the software
CEREC 3D v.2.10 R1500. The milling mode used was the Endo
mode and the cutting tool for the milling of the internal
surface of the crowns was the 1.2 mm diamond bur. A slower
milling process (Endo milling mode) and a smaller cutting bur
(1.2 mm) were used as it was found previously that these
parameters had an effect on the marginal integrity of
minimally prepared CEREC crowns.26 Ten crowns of the same
wall thickness were milled for each group using 20 Paradigm
MZ100 and 20 ProCAD blocks.
Before cementation a fast cure acrylic (Sampl-Kwick Fast
Cure Acrylic, Buehler, Kit No. 20-3560) was used to mount all
specimens. For the cementation process the cement recom-
mended for each material was used following the manufac-
turers’ instructions. For the resin composite system (Groups A
and C) the cement recommended by the manufacturer was
RelyX Unicem AplicapTM 3M/ESPE, which is a self-adhesive
dual cured resin cement. The internal surface of the crowns
was rinsed and dried thoroughly. No etching of the intaglio
surface was performed as it was reported that the as-milled
surface provide excellent bond strength.27 The cementation
procedure followed was according to the manufacturer’s
instructions. The restorations were polished with fine dia-
monds and polishing wheels (Intensiv Advanced CEREC
Finishing Kit, 3M ESPE Sof-Lex Finishing and Polishing
System).
For the ceramic system (Groups B and D) the crowns were
glazed prior cementation in a vacuum (Vacumat 200, VITA)
according to the manufacturer’s instructions. The fit of the
crowns was checked again and then the outer surface was
covered in wax to protect it from the pre-treatment of the
internal surface. The crowns were cleaned and etched with
hydrofluoric acid (IPS Ceramic etching gel, Ivoclar Vivadent) for
60 s and then silanised (Monobond-S, Ivoclar Vicadent) for 60 s.
A thin layer of a light-curing bonding agent (Heliobond, Ivoclar
Vicadent) was applied on the etched and silanised ceramic
surface. To avoid premature setting of the resin, the crown was
stored in a dark place to protect it from light. The prepared teeth
were also pre-treated before cementation. The preparations
Fig. 2 – Universal test machine with the special holder for
the specimen and the rubber dam in place.
were cleaned with water and dried with water- and oil-free air,
taking care not to cause over-drying of the tooth surface. The
bonding area was etched with phosphoric acid gel (total etch
37 wt.%, Ivoclar Vivadent) for 30 s. A two-phase adhesive
system (Syntac, Primer and Adhesive, Ivoclar Vivadent) was
used and applied according to the instructions. The bonding
agent (Heliobond, Ivoclar Vivadent) was brushed and air-
thinned on the pre-treated enamel and dentin. A dual curing
luting composite system (Variolink II, Ivoclar Vivadent) was
used for the cementation of the crowns. The restorations were
seated into place with slight pressure, any excess of the cement
was removed with a brush, and then the pressure was increased
and maintained for 15 s. Any further excess of the cement was
removed with a brush. The resin cement was then polymerized
with a light-curing unit (EliparTM 2500, 3M ESPE) for 40 s per axial
quadrant and occlusally.
After cementation of the crowns all specimens were stored
in water for 24 h. Before performing the fracture strength test
an acrylic resin (Sampl-Kwick Fast Cure Acrylic, Buehler, Kit
No. 20-3560) was used to mount all specimens. The occlusal
part of each tooth was affixed on a glass slide using sticky wax
and then the roots were embedded in acrylic resin.
For the fracture strength test each crown was loaded axially
to their occlusal surface at a crosshead speed of 0.5 mm/min in
a universal test machine (Loyds Instruments Model LRX.). In
order to keep the specimen firmly in place a special holder was
made and placed on the test machine (Fig. 2). A plunger with a
steel ball (4.24 mm diameter) was used to transmit the
compressive force until fracture occurred. The ball was
positioned on the occlusal plane with the contact area
oriented toward natural antagonistic tooth contacts. A piece
of rubber dam was placed as a stress breaker between each
crown sample and the steel ball. Fracture loads (N) were
recorded. The mode of fracture was also recorded for both
systems.
The load data recorded for the traditional and minimal
crowns of both restorative systems were entered into the
statistical package SPSS v.14 for statistical analysis. One-way
analysis of variance (ANOVA) was performed to identify
significant differences between the two designs for each
restorative material.
 journal of dentistry 38 (2010) 16–22 19

Fig. 3 – A type II mode of fracture.

Fig. 4 – Mean fracture strength and SD of traditional and

The mode of fracture of the crowns was detected after
minimal design for the composite system.
failure using a classification previously described by Burke15
(Fig. 3). According to this specimens were classified to the
following categories based on the pattern of crown failure:

I Minimal fracture or crack in crown

II Less than half of crown lost
III Crown fracture through midline; half of crown displaced or
lost
IV More than half of crown lost
V Severe fracture of tooth and/or crown

Kruskal–Wallis nonparametric test was performed to

identify any statistical differences between the mode of
fracture detected for the minimal and traditional preparation
designs.

3. Results

For the resin composite system the mean fracture loads and
standard deviations (SD) reported were 1682 N (315) for the
traditional crowns (Group A) and 1751 N (338) for the
minimal crowns (Group C). One-way analysis of variance
showed that there is no statistically significant difference
between traditional/minimal preparation designs ( p > .05). A
bar graph of the mean fracture load and SD for the two designs
is shown in Fig. 4.
For the ceramic system the mean fracture loads and
standard deviations recorded were 1512 N (373) for the
traditional crowns (Group B) and 1837 (356) for the minimal
crowns (Group D). One-way analysis of variance showed that
there is no statistically significant difference between tradi-
tional/minimal preparation designs ( p > .05). A bar graph of
the mean fracture load and SD for the two designs is shown in
Fig. 5.
The mode of fracture of the specimens is reported in
Tables 2 and 3 for each material respectively. Nonparametric
tests (Kruskal–Wallis) of the mode of fracture showed that
there was no statistically significant difference between
traditionally and minimally prepared crowns for either
restorative system ( p > .05).
Fig. 5 – Mean fracture strength and SD of traditional and
minimal designs for the ceramic system.
4. Discussion
This study was designed to compare the structural integrity of
minimally prepared resin bonded CEREC crowns with tradi-
tional designs, in order to determine if there is any change in
the fracture strength immediately post-operatively when a
minimal intervention technique is employed. Crowns fabri-
cated from the same restorative material were compared. Two
materials, a resin composite (MZ100) and a ceramic (ProCAD),
with the respective cementation technique proposed by their
manufacturers were used, forming in that way two restorative
systems, the MZ100 system and the ProCAD system. It was not
the intention of the study to compare the effect of a different
cementation technique or restorative material on the fracture
strength of the crowns and for that reason no direct
comparisons between the two restorative systems were
20 journal of dentistry 38 (2010) 16–22
Table 2 – Mode of fracture detected for the composite
groups.
Restorative systems Mode of fracture
I II III IV
MZ100 traditional 1 3 0 3
MZ100 minimal 0 2 2 3
Table 3 – Mode of fracture detected for the ceramic
groups.
Restorative systems Mode of fracture
I II III IV
ProCAD traditional 0 5 1 0
ProCAD minimal 0 2 1 2
performed. Besides for the different materials used, the
designs were also different and thus any direct comparison
would be invalid due to multiple variables.
This study examined the immediate post-operative struc-
tural integrity of the restored teeth, whereas dental restora-
tions usually fail as a result of many loading cycles or from an
accumulation of damage from stress and water.28 In the oral
environment restorations may be loaded during their life-time
up to 107 cycles,29 which can cause up to 50% reduction in
strength of the ceramic due to fatigue.28–30 In terms of in vivo
loading, the masticatory cycle consists of a combination of
vertical and lateral forces, subjecting the restoration to a
variety of off-axis loading forces.31 In the current investigation
the cemented crowns were subjected to a static loading test
after storage in water for 24 h, without any thermal or load
cycling fatigue. The intention was to give a primary indication
as to whether or not the proposed minimal designs would
provide crowns with a similar structural integrity to tradi-
tionally prepared CEREC crowns.
Before engaging any time-consuming durability tests it was
necessary first to establish that the structural integrity of the
restored tooth had not been fatally compromised by the use of
a minimal and untested design. This study has shown that this
is not the case.
The mean fracture load reported in this study for the MZ100
system ranged from 1682 to 1751 N. No statistically significant
differences were found between traditional and minimal
crowns for this restorative system. For the ProCAD system the
mean fracture load reported ranged from 1512 to 1837 N. No
statistically significant differences were found between tradi-
tional and minimal crowns for this restorative system.
A large variability in fracture load of the crowns was
observed which was consistent with other studies for fracture
strength tests.13–15,32,33 This is consistent with a brittle fracture
system with a dispersion of flaws of different sizes,34 and
despite procedures of collecting, storing, and preparing the
teeth and the conditions of milling the crowns had been
standardised, it is impossible to control the size and distribu-
tion of internal flaws of each tooth structure or milling block.
To our knowledge the structural integrity of minimal
preparation designs is tested for the first time in this study for
two restorative materials used with the CEREC system, thus no
direct comparison to previous studies was possible. Still, when
comparing the fracture loads obtained in this study for
traditional CEREC crowns, with the fracture loads of tradi-
tionally prepared CEREC crowns reported in other studies it
V
can be seen that the current results are higher and almost
3 double to that reported previously for the same material.32,35
3 By contrast, Bindl et al. have reported the mean fracture
strength of adhesively cemented leucite glass–ceramic crowns
(ProCAD) prepared with a more traditional design to be over
2000 N.36 A possible explanation to that could be the fact that
in the present study natural teeth were used, whilst in the
study of Bindl et al. composite abutments were made, which
could have a better adhesive bond to the cement and crown.
V With regard to the fracture pattern of the crowns
4 nonparametric analysis showed that there was no statistically
5 significant difference between traditional and minimal
crowns for either restorative system. A potential drawback
of minimal resin bonded crowns could be the number of
severe fractures of the restored teeth. However, fracture
strength of minimal resin bonded crowns exhibited in the
present study occurs at loads well above the maximum loads
that can occur in the mouth. The mean masticatory forces
during mastication and swallowing reported in humans are
approximately 40 N, whilst the average maximum posterior
masticatory forces vary from 200 to 540 N.33,37
The main point to emphasize is that the use of minimal
preparation designs did not compromise the immediate post-
operative structural integrity of the restored teeth. Also this
finding applies to both composite and ceramic system. Even
though there was no statistically significant difference
between the traditional and minimal design for both restora-
tive systems, the mean fracture loads reported for the minimal
designs were higher to those reported for the traditional
designs. A possible explanation of this finding could be the fact
that more enamel was left with the minimal preparation
designs which improved the bond between the material
(ceramic or composite) and the tooth tissue. It is possible that
the conservation of more residual tooth structure and more
enamel may contribute to an improved structural integrity.
The next plan of the work in assessing the strength of the
proposed minimal preparation designs for crowns is to
undertake more complex durability tests. To undertake such
tests prior to checking the initial structural integrity of the
crowns would have been redundant if the immediate post-
operative structural integrity had been found severely
compromised.
The clinical significance of these results was that they gave
an indication of the strength of such restorations when are
CAD/CAM fabricated. According to these results the structural
integrity of minimally prepared teeth for crown restorations
was similar to traditionally prepared teeth. If the structural
integrity had been seriously compromised as indicated by a
significant reduction in fracture strength, it would have been
logical to expect this to be reflected in clinical performance.
However, this was not the case.
Within the limitations of this experimental design, the null
hypothesis was met, showing that minimally prepared resin
bonded CEREC crowns demonstrated a fracture resistance
equal to that of traditionally prepared resin bonded crowns,
offering a viable alternative to traditional tooth preparation
 journal of dentistry 38 (2010) 16–22
designs. Whilst the knowledge that the initial structural
integrity of the crowns is not compromised by the application
of a minimal preparation design, further studies are needed to
assess the durability of such restorations before applying
them in clinical practice.
5. Conclusions
The application of minimal intervention procedures for
indirect restorations is another treatment modality, with
the dentine bonded crowns being one representative. Recently
CAD/CAM systems are also employed for the fabrication of
indirect restorations. The structural integrity of teeth mini-
mally prepared for crowns was compared to that of tradi-
tionally prepared teeth. Two restorative systems, a composite
and a ceramic, and the CEREC system were used for the
fabrication of the crowns. Within the limitations of this
experimental design, it was found that minimally prepared
resin bonded CEREC crowns demonstrated equal fracture
resistance and mode of fracture to that of crowns bonded to
traditionally prepared teeth regardless of the material used.
Acknowledgements
The authors wish to thank Mrs. J. Russell, Department of
Corporate Information and Computing Services, for her
assistance in the statistical analysis of the results. The authors
would also wish to thank 3M ESPE and Ivoclar Vivadent for
supplying the materials.
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