Journal of Dental Sciences (2012) 7, 159e164

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ORIGINAL ARTICLE

Fracture strength and bending of all-ceramic and

fiber-reinforced composites in inlay-retained fixed
partial dentures
Serkan Saridag a*, Atilla Gokhan Ozyesil b, Gurel Pekkan c**

a
Department of Prosthodontics, Faculty of Dentistry, Kocaeli University, Kocaeli, Turkey
b
Department of Prosthodontics, Faculty of Dentistry, Selcuk University, Konya, Turkey
c
Department of Prosthodontics, Faculty of Dentistry, Dumlupinar University, Kutahya, Turkey

Final revision received 12 December 2011; accepted 26 March 2012

Available online 22 May 2012

KEYWORDS Abstract Background/purpose: In the most recent decade, the use of all-ceramic and fiber-
inlay-retained fixed reinforced composites as inlay-retained fixed partial dentures has increased. There are limited
partial dentures; studies of comparisons of the mechanical strength and bending of these restorations. The aim
all-ceramic; of this in vitro study was to compare the fracture strength and the amount of bending in all-
fiber-reinforced ceramic and fiber-reinforced composite inlay-retained fixed partial dentures.
composite; Materials and methods: Forty mandibular premolars and 40 mandibular molars were collected.
fracture strength; The specimens were randomly divided into four groups of 10 molars and premolars within each
bending group, each with box-shaped proximal preparations. Two different all-ceramic systems (IPS
e.max Press and ICE Zirkon) and two different fiber-reinforced composite systems (EverStick
and Vectris) with a connector size of 16 mm2 were used to restore prepared abutment teeth.
After thermal cycling (5 and 55 C  5000), a vertical force was loaded to the center of the
inlay-retained fixed partial dentures at a crosshead speed of 0.5 mm/min. Failure types of
specimens were examined with a stereomicroscope and radiography. Statistical analysis was
performed using one-way analysis of variance (ANOVA) and Mann-Whitney-U tests (a Z 0.05).
Results: Fracture strengths were significantly higher in the ICE Zirkon (1540 N) and EverStick
specimens (1057 N) than in the Vectris (794 N) and IPS e.max Press specimens (606 N)
(P < 0.001). The amount of bending was significantly greater in the EverStick (1.94 mm) and
Vectris (1.87 mm) specimens than in the ICE Zirkon (1.07 mm) and IPS e.max Press specimens
(1.18 mm) (P < 0.001).

* Corresponding author. Department of Prosthodontics, Faculty of Dentistry, Kocaeli University, Kocaeli 41190, Turkey.
** Corresponding author. Faculty of Dentistry, Dumlupinar University, Tavsanli Yolu 10. Km., Kutahya 43270, Turkey.
E-mail addresses: ssaridag@hotmail.com (S. Saridag), gurelp@gmail.com (G. Pekkan).

1991-7902/$36 Copyright ª 2012, Association for Dental Sciences of the Republic of China. Published by Elsevier Taiwan LLC. All rights reserved.
doi:10.1016/j.jds.2012.03.013
160
Conclusions: Zirconia-based ceramic inlay-retained fixed partial dentures demonstrated the
highest fracture strength. The fiber-reinforced composite inlay-retained fixed partial dentures
demonstrated higher bending values than did the all-ceramic inlay-retained fixed partial
dentures.
Copyright ª 2012, Association for Dental Sciences of the Republic of China. Published by
Elsevier Taiwan LLC. All rights reserved.
Introduction
In current dental practice, the treatment philosophy is
based on the least invasive approach, whereby intact tooth
tissues are conserved as much as possible.1 The traditional
method of molar replacement is either with a fixed partial
denture (FPD) or an implant-retained crown.2e4 Irre-
spective of the type of FPD, the clinician uses a crown
preparation that is a risk to pulp vitality and may lead to
pulpal reactions in the long term.5 Approximately 63%w73%
of the coronal tooth structure is removed when teeth are
prepared for crowns.6 In light of these facts, it seems
desirable to adapt the type of abutment preparation to the
extent of sound tooth structure after caries removal, not
only for single-tooth restorations, but also for abutment
preparations for FPDs. Therefore, if a patient rejects
implant treatment, and enough sound tooth structure is
available, it would be desirable to restore a missing tooth
with an inlay-retained FPD (IRFPD) instead of a crown-
retained FPD.4
Clinical evaluations of IRFPDs showed a failure rate of
10% after 9 months for IPS Empress II (Ivoclar Vivadent AG,
Schaan, Liechtenstein).7 However, Kaplan-Meier survival
rates of 57% after 5 years and 38% after 8 years for IPS
e.max Press (Ivoclar Vivadent AG), were recently repor-
ted.2 In those studies, failure was by debonding or
a combination of debonding and fracture. Despite those
failure rates, IRFPDs can be a favorable treatment option
for biological and economic reasons.4e6
Partial-coverage restorations may have an increased risk
of fracture, because the restorations are relatively small
compared to complete-coverage restorations.2,7,8 Recent
progress in material production and processing technology
of high-strength dental ceramics may have overcome this
disadvantage.3 Recently, yttria-stabilized tetragonal
zirconia (Y-TZP) became available to dentistry through
computer-aided design and computer-aided manufacturing
or copy-milling techniques, and provides excellent
mechanical performance, superior strength, and fracture
resistance compared to other ceramics.3,9 However, the
use of some types of ceramics is still limited in the posterior
region where extensive masticatory forces are pre-
sent.3,9e11 For example, a new lithium-disilicate glass-
ceramic, IPS e.max Press (Ivoclar Vivadent AG) features
good wear resistance and excellent aesthetics, but limited
strength.2
Alternatives combining the good flexural strength values
of fiber-reinforced composite (FRC) materials with the
superior esthetic properties of ceramics were suggested for
dental applications.4,12e15 These prostheses are composed
of two types of composite materials: fiber composites to
S. Saridag et al
build the framework, and hybrid or microfill particulate
composites to create the external veneer surface.1 Effec-
tive pre-impregnation also allows the matrix to increase the
surface wetting property of the fibers and helps keep the
fibers in close contact within a fiber bundle.4,14,15
Furthermore, good impregnation of fibers with the
surrounding monomer matrix is important, since fiber
reinforcement is successful only when the loading force can
be transferred from the resin matrix to the fibers.16 Some
manufacturers produce dry fibers that require hand
impregnation by a technician or dentist, e.g., Ribbond
(Ribbond, Seattle, WA, USA), GlasSpan (GlasSpan, Exton,
PA, USA), and Construct (Kerr, Orange, CA, USA). Some
commercially available FRC materials are machine
impregnated with resin by the manufacturer, e.g., Ever-
Stick (Stick Tech, Turku, Finland), FiberKor (Pentron Labo-
ratory Technologies, Wallingford, CT, USA), and Vectris
(Ivoclar Vivadent AG). These machine-impregnated mate-
rials are also known as pre-impregnated FRC materials. The
mechanical and handling properties of machine-
impregnated FRCs are better than those of hand-
impregnated FRCs. The rigidity and strength of dental
appliances made from FRCs are dependent on the polymer
matrix of the FRC and the type of fiber reinforcement.4,14,15
Therefore, proper selection of restorative materials is
essential, especially in the posterior region.17
The aim of this in vitro study was to determine and
compare the fracture strength and bending amount of
IRFPDs made of two different all-ceramics, IPS e.max Press
(Ivoclar Vivadent AG) and ICE Zirkon (Zirkonzahn, Bruneck,
Italy) and two glass fiber-reinforced composites, EverStick
(Stick Tech) and Vectris (Ivoclar Vivadent AG). The
hypotheses were that: (1) all-ceramic IRFPDs have higher
fracture strength than FRCs; and (2) FRCs have higher
bending than all-ceramic IRFPDs.
Materials and methods
Eighty freshly extracted intact and caries-free human teeth
of similar size (40 mandibular molars and 40 mandibular
premolars) were collected. The teeth were cleaned by
curettage and stored in a saline solution at room temper-
ature. Before the experiment, the roots of the teeth were
covered with a 0.2 mm-thick layer of polyether material
(Impregum Garant L Duosoft, 3M ESPE, Seefeld, Germany)
to simulate the human periodontium. Each sample included
a premolar and molar embedded 1.0 mm apical to the
cementoenamel junction in an autopolymerizing acrylic
resin block (Meliodent, Heraeus Kulzer, Hanau, Germany).
The distance between the abutments was 11 mm, to
Fracture strength and bending of inlay partial dentures
represent the loss of a mandibular first molar. Artificial
tooth mobility was evaluated in the horizontal and vertical
directions using a periotest instrument (Periotest, Siemens
AG, Bensheim, Germany). Periotest values of the
embedded teeth were standardized at a value of < 7 to
simulate the natural dentition.18
Specimens were randomly divided into four groups
(n Z 10) with proximal preparations on each abutment
adjacent to the edentulous area. For molars, the isthmus in
the box-shaped proximal preparation was 4 mm wide, 6 mm
long, and 2 mm deep, and the proximal box extending
1.5 mm apical to the isthmus floor was 1.5 mm wide. The
difference in the tooth preparation for the premolar was
only in the isthmus length (4 mm) (Fig. 1). Tooth prepara-
tions were made by the same operator with the same
sequence of specific diamond burs (Inlay Preparations Set
4261, Komet, Lemgo, Germany) and constant water cool-
ing. To ensure standardized preparation of the abutments,
a milling machine (Paraskop, Bego, Bremen, Germany) was
used to evaluate the preparation dimensions.
Lithium-disilicate glass ceramic IRFPDs (IPS e.max Press,
Ivoclar Vivadent AG) and zirconia ceramic IRFPDs (ICE Zir-
kon, Zirkonzahn GmbH) were fabricated according to the
manufacturers’ instructions. The lithium-disilicate glass
ceramic IRFPD frameworks were manufactured by
a conventional press technique.3 The veneering ceramic for
the lithium-disilicate-based IRFPDs was its specific glass
ceramic (IPS e.max Ceram, Ivoclar Vivadent AG). ICE Zirkon
frameworks were milled in a “green” ceramic condition and
sintered to the final dimensions (Fig. 2). The veneering
ceramic for the zirconia-based IRFPDs was the glass ceramic
of the same company (ICE Ceramik, Zirkonzahn). The glass-
fiber frameworks (Vectris, Ivoclar Vivadent AG) and stick
glass-fiber frameworks (EverStick, Stick Tech) were made
using an indirect technique according to the manufac-
turers’ recommendations (Figs. 3,4). In both groups, the
pontics were built up layer by layer, with different
composite materials (Fig. 5). The layering material for the
EverStick framework was indirect resin composite (Solidex,
Shofu, Ratingen, Germany), whereas the layering material
for the Vectris framework was another indirect resin
composite (Adora, Ivoclar Vivadent AG). The dimensions of
the connector were 4  4 mm, to enhance an optimum
mechanical stress distribution, provide mechanical reten-
tive features, and allow fabrication of accurate inlay
Figure 1 Preparation of abutment teeth.
161
Figure 2 The ICE Zirkon framework.
restorations, with good adaptation and strength of the
restorative material.7,19
Zirconia-based specimens were etched for 180 seconds
with a priming agent (Metal/Zirconia Primer, Ivoclar Viva-
dent AG). The interior surfaces of all specimens were sila-
nated with porcelain primer (Monobond S, Ivoclar Vivadent
AG) for 60 s and then air-dried. A bonding agent (Heliobond,
Ivoclar Vivadent AG) was applied to the ceramic surfaces,
air-dried for 3 seconds, and left under a light-resistant box.
Before luting of the IRFPDs, the enamel portions of the
preparations were etched for 30 seconds and the dentin
surfaces of the teeth for 15 seconds with 37% phosphoric
acid (Total Etch, Ivoclar Vivadent AG). Following this, all
etchant gel was removed with water spray for 5 seconds.
Excess moisture was removed leaving the dentin surface
with a slightly glossy wet appearance. The Syntac Primer
and Adhesive (Ivoclar Vivadent AG) were consecutively
applied and thoroughly air-dried. Heliobond (Ivoclar Viva-
dent AG) was applied and blown to a thin layer. It was
polymerized with the cementation material. The IRFPDs
were adhesively luted using a dual polymerizing composite
luting agent (Variolink II, Ivoclar Vivadent AG). Dual poly-
merizing resin cement (Variolink II base transparent, Ivoclar
Vivadent AG) was mixed with its catalyst (Variolink II
transparent high viscosity, Ivoclar Vivadent AG) in equal
parts for 15 seconds and applied to the IRFPD bonding
surface and cemented with finger pressure, and the spec-
imen was exposed to polymerizing light from two opposite
directions for 40 seconds each.
Figure 3 The Vectris framework.
162
Figure 4 The EverStick framework.
Specimens were stored for 24 hours in distilled water at
37 C, then thermocycled for 5000 cycles in two water baths
at 5 and 55 C. The dwell time at each temperature was 30
seconds, and the transfer time from one bath to the other
was 2 seconds. After thermal cycling, the IRFPDs were
loaded until fracture occurred, using a universal testing
machine (TSTM 02500, Elista, Istanbul, Turkey) with
a crosshead speed of 0.5 mm/minute. A vertical force was
applied to the central fossa of the pontic with a round-
ended steel rod 5 mm in diameter. In order to reduce the
local force peaks, 0.5 mm-thick tinfoil was inserted
between the steel rod and pontic. The amount of bending
(mm) was also evaluated by measuring the distance the
test rod moved from the 10-Newton (N) preload to
fracture.
Specimens were examined for the type of failure with
a stereomicroscope (SZTP, Olympus, Tokyo, Japan) and
radiography (Heliodent DS, Siemens, Munich, Germany).
The statistical analyses consisted of a nonparametric one-
way analysis of variance (ANOVA, Kruskal-Wallis) and
a Mann-Whitney U-test, to determine differences between
groups (a Z 0.05).
Results
The mean and standard deviations for fracture strength and
bending amounts were recorded in N and mm, respectively,
for the three groups (Table 1).
Figure 5 The veneered FRC IRFPD.
S. Saridag et al
Table 1 Mean fracture strength and bending for each
experimental group.
Fracture strength Bending Mean
Mean (SD) (N) (SD) (mm)
IPS e.max Press 606.20a (129.36) 1.077d (0.170)
ICE Zirkon 1539.82c (191.16) 1.189d (0.224)
EverStick 1056.90b (243.84) 1.941e (0.198)
Vectris 793.64a (157.31) 1.870e (0.192)
mm Z millimeter; N Z Newton; SD Z standard deviation Within
the same column means with different uppercase superscript
letters differ statistically according to Kruskal-Wallis and Mann
Whitney U tests (P < 0.001).
a,b,c,d,e
Within the same column means different superscript
letters are significantly different (P < 0.05).
For fracture strength, there were significant differences
between all groups (P < 0.001) except between the IPS
e.max Press (606 N) and Vectris (794 N) specimens. The
highest median fracture resistance was recorded for ICE
Zirkon specimens (1540 N). Significantly lower fracture
results were determined for Vectris specimens (794 N) than
EverStick specimens (1057 N). Additionally, the results
showed that the bending amounts were significantly greater
in the FRC groups than the all-ceramic groups (P < 0.001).
The IPS e.max Press specimens displayed equal numbers of
failures in both connectors and retainer areas. The ICE Zirkon
specimens predominantly demonstrated connector failure.
In addition, only one ICE Zirkon specimen was observed to
have adhesive failure (Fig. 6). The predominant fracture
behavior of the FRC specimens was delamination of the
veneering composite, whereas the framework stayed intact.
Discussion
New dental materials with new preparation designs have to
be tested before they can be recommended for clinical
use.3,20 It is not known what fracture resistance is required
to achieve good long-term outcomes of IRFPDs in the molar
region. Many authors investigated maximum bite forces
during mastication, and mean values for the maximum bite
force level varied (216w847 N).8,21 The highest bite force
Figure 6 Radiographic view of the connector fracture and
adhesive failure.
Fracture strength and bending of inlay partial dentures
was found in the first molar region.21 Körber and Ludwig22
summarized that posterior FPDs should be strong enough
to withstand a load of 500 N. Additionally, cyclic fatigue
loading caused by mastication can considerably weaken the
fracture resistance of dental restorations.23 Under condi-
tions of the oral environment, inherent flaws of restorative
materials act as the origin of crack propagation which can
grow to critical sizes.24 The endurance limit for fatigue
cycling that can be applied to dental ceramics is approxi-
mately 50% of the maximal fracture strength.9,25 There-
fore, it seems reasonable to assume that an initial fracture
resistance of 1000 N should be required for a favorable
clinical prognosis of posterior IRFPDs.
The preparation designs for partial-coverage restora-
tions are not standardized, in contrast to those for
complete-coverage restorations.11,19 Various preparation
designs have been proposed such as grooves, tube- or box-
shaped proximal preparations, retentive-slot preparations,
use of a rest seat on the occlusal surface, long chamfers,
and lingual tooth reduction.6,19,26e28 However, in most
studies, the cavity design appears insufficient.7,19,28 Behr
et al.26 conducted an in vitro study comparing tube-shaped
and box-shaped preparation techniques for IRFPDs using
the Vectris/Targis system (Ivoclar Vivadent AG). In their
study, the frameworks were composed only of pontic
prepreg fibers, and showed fracture strength values of 696
N (531w958 N) for box-shaped preparations and 722 N
(665w818 N) for tube-shaped preparations. Results of the
current study demonstrated that FRC IRFPDs with box-
shaped preparation designs revealed mean fracture
strengths of approximately 794 N for the Vectris and 1057 N
for the EverStick groups. Zirconia-framework IRFPDs (ICE
Zirkon 1540 N) had significantly higher fracture strength
than other all-ceramic (606 N for IPS e.max Press) and FRCs.
The results support the first hypothesis that all-ceramic
IRFPDs have higher fracture strength and than FRCs. The
zirconia frameworks of the IRFPDs were industrially manu-
factured from Y-TZP, the superior material characteristics
of which were proven in various studies.9,20 These particles
are densely sintered, resulting in a final microstructure in
which voids, flaws, and cracks are reduced to a minimum.24
For this reason and because of the transformation-
toughening mechanism, Y-TZP frameworks offer remark-
able fracture strengths.20,24 Kiliçarslan et al19 concluded
that zirconia-framework IRFPDs exhibit the highest resis-
tance to fracture compared to metal-ceramic and glass-
ceramic ones. Failures of all-ceramic IRFPDs were always
cohesive and were located at the connector areas that
represent the weakest parts of the IRFPDs.
Several factors may effect fracture resistance of FPDs
fabricated from glass-fiber-reinforced materials sys-
tems.1,4,13e16,27,29,30 In addition to the type of fibers used,
their quantity, toughness, position, and type of impregna-
tion may considerably influence the fracture resistance.31
Data from this study also showed that the difference in
fracture strengths between the two FRC groups was
statistically significant (P < 0.001). FRC IRFPDs made with
EverStick had greater fracture strengths than FRC IRFPDs
made with Vectris. While both of these materials use
continuous, unidirectional E-glass fiber reinforcement, the
method of fabrication differs.30,32 Fibers are usually
impregnated with monomers, polymers, or a combination
163
of both, in order to achieve good adhesion with the
veneering composite resin.1,33,34 For the Vectris group,
a prepreg of fibers in a dimethacrylate matrix is used to
create the substructure.30 For the EverStick group, the
prepreg of fibers is contained within a bi-phase matrix
consisting of dimethacrylate and poly (methyl methacry-
late) (PMMA) polymers.4,13e15 The PMMA matrix is highly
viscous compared to the dimethacrylate system, hence
improving both the handling properties and bonding prop-
erties of the FRC after it is polymerized.33e35 In this study,
the different matrix compositions of FRCs may have
affected the fracture strength values.
Fiber-reinforced materials have higher bending tenden-
cies because of their lower moduli compared to all-ceramic
materials. Therefore, the second hypothesis, that FRCs
have higher bending than all-ceramic IRFPDs, was also
accepted. In this study, data showed that the difference in
bending amounts between the two FRC groups was not
statistically significant (P > 0.05), although FRC IRFPDs
made with glass-fiber-reinforced Vectris exhibited a lower
bending amount than those made with EverStick.
Vallittu13 evaluated the survival rate of 29 resin-bonded
glass-fiber-reinforced composite FPDs in a clinical study for
periods of up to 42 months, and the Kaplan-Meier survival
probability at 63 months was 75%. Three of the failed FPDs
were rebonded or repaired in situ, producing a functional
survival rate of 93% after rebounding or repair of the veneer
composites. Van Heuman et al14,15 evaluated 5-year
survival of three-unit FRC fixed partial dentures in poste-
rior and anterior areas. They found a success rate of 71%
and survival rate of 78% after 5 years for posterior areas and
a success rate of 45% and survival rate of 64% after 5 years
for anterior areas. However, Behr et al29 concluded in
a clinical report that the veneering composites of FRC
restorations need further improvement because of the
increasing wear, discoloration, and fractures of the facings,
and fiber exposure. Visually, the main weak point of FRC
IRFPDs is the veneering material, as veneer fractures are
initiated before debonding of the fibers under load. This
finding is in accordance with Cho et al,27 who reported
cracking and chipping of the veneering resin that was fol-
lowed by adhesive failure between the veneering
composite and fiber framework. For most specimens, the
displaced fragment was not completely detached from the
fiber framework. In the present study, the fracture analysis
supported this statement.
This study attempted to simulate oral conditions,
particularly in terms of simulating physiological tooth
movement with a polyether coating. Despite wide varia-
tions present among human teeth, they were used in this
study because the fracture strength is critically dependent
on the elastic modulus of the abutment materials.
Furthermore, it was demonstrated that abutment mobility
is a decisive factor when evaluating fracture strength, and
when a small amount of abutment rotation is allowed,
failure is more likely.10 One limitation of this study was the
non-inclusion of an artificial aging process, such as
mechanical loading, which would have simulated its nega-
tive effects on fracture strength.
In conclusion, yttrium-oxide partially stabilized zirconia-
based ceramic IRFPDs demonstrated the highest fracture
strength compared to FRC IRFPDs and lithium-disilicate
164
glass ceramic IRFPDs. FRC IRFPDs had higher bending values
than all-ceramic IRFPDs. The predominant fracture
behavior of the all-ceramic IRFPDs was in the connectors
and retainer areas; however, FRC specimens exhibited
delamination of the veneering composite.
Acknowledgments
The authors thank Associate Prof. Dr. Nilgün Öztürk for
scholarly advice, Associate Prof. Dr. Ali Murat Sümbül for
_
statistical assistance, and As Dental Konya, Den-tek A.S‚ Izmir,
and Anıl Dental _Izmir for materials and laboratory support.
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