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Available online at www.sciencedirect.com

ScienceDirect

journal homepage: www.intl.elsevierhealth.com/journals/dema

Influence of restoration thickness and dental

bonding surface on the fracture resistance of
full-coverage occlusal veneers made from lithium
disilicate ceramic

Martin Sasse ∗ , Anna Krummel, Karsten Klosa, Matthias Kern

Department of Prosthodontics, Propaedeutics and Dental Materials, School of Dentistry, Christian-Albrechts
University, Arnold-Heller-Str. 16, 24105 Kiel, Germany

a r t i c l e i n f o a b s t r a c t

Article history: Objectives. The purpose of this in-vitro study was to evaluate the influence of ceramic
Received 9 September 2014 thickness and type of dental bonding surface on the fracture resistance of non-retentive
Received in revised form full-coverage adhesively retained occlusal veneers made from lithium disilicate ceramic.
4 March 2015 Methods. Seventy-two extracted molars were divided into three test groups (N = 24) depend-
Accepted 28 April 2015 ing on the location of the occlusal veneer preparation: solely within enamel, within enamel
Available online xxx and dentin or within enamel and an occlusal composite resin filling. For each test group,
occlusal all-ceramic restorations were fabricated from lithium disilicate ceramic blocks (IPS
Keywords: e.max CAD) in three subgroups with different thicknesses ranging from 0.3 to 0.7 mm in the
Fracture resistance fissures and from 0.6 to 1.0 mm at the cusps. The veneers were etched (5% HF), silanated
Ceramic thickness and adhesively luted using a self etching primer and a composite luting resin (Multilink
Dental bonding surface Primer A/B and Multilink Automix). After water storage at 37 ◦ C for 3 days and thermal
Full-coverage molar restoration cycling for 7500 cycles at 5–55 ◦ C, specimens were subjected to dynamic loading in a chewing
All-ceramic simulator with 600,000 loading cycles at 10 kg combined with thermal cycling. Unfractured
Self etching primer specimens were loaded until fracture using a universal testing machine. Statistical analysis
was performed using Kruskal–Wallis and Wilcoxon tests with Bonferroni–Holm correction
for multiple testing.
Results. Only specimens in the group with the thickest dimension (0.7 mm in fissure, 1.0 mm
at cusp) survived cyclic loading without any damage. Survival rates in the remaining sub-
groups ranged from 50 to 100% for surviving with some damage and from 12.5 to 75%
for surviving without any damage. Medians of final fracture resistance ranged from 610
to 3390 N. In groups with smaller ceramic thickness, luting to dentin or composite provided
statistically significant (p ≤ 0.05) higher fracture resistance than luting to enamel only. The
thickness of the occlual ceramic veneers had a statistically significant (p ≤ 0.05) influence
on fracture resistance.
Significance. The results suggest to use a thickness of 0.7–1 mm for non-retentive full-
coverage adhesively retained occlusal lithium disilicate ceramic restorations.
© 2015 Academy of Dental Materials. Published by Elsevier Ltd. All rights reserved.

∗
Corresponding author. Tel.: +49 431 597 2874; fax: +49 431 597 2860.
E-mail address: msasse@proth.uni-kiel.de (M. Sasse).
http://dx.doi.org/10.1016/j.dental.2015.04.017
0109-5641/© 2015 Academy of Dental Materials. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Sasse M, et al. Influence of restoration thickness and dental bonding surface on the fracture resistance of
full-coverage occlusal veneers made from lithium disilicate ceramic. Dent Mater (2015), http://dx.doi.org/10.1016/j.dental.2015.04.017
DENTAL-2557; No. of Pages 9
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1. Introduction
The prosthodontic treatment of severly abraded teeth or
patients with a lateral open bite after orthodontic treatment is
an important aspect in dental therapy. Modern dental ceram-
ics such as lithium disilicate nowadays offer the option of
minimally invasive replacement of lost tooth substance [1]
while having a high fracture resistance [2,3]. Failures of all-
ceramic restorations are mainly based on fractures of the
ceramic material [3–6].
Fracture resistance of all-ceramic restorations is influ-
enced by different factors. The adhesive technique used plays
an important role in this regard since adhesively bonded
all-ceramic restorations show a higher fracture resistance
than conventionally cemented restorations [7–14]. Today resin
cements based on the Bisphenol A glycidylmethacrylate com-
pound are being used primarily. In order to bond to the
surfaces of the different components (tooth structure as well
as restoration) they need to be conditioned specifically; since
each interface quality influences the fracture resistance of the
restoration [2,7].
The type of bonding surface and the type of surface con-
ditioning affects the bond strength of the ceramic to the
tooth structure. Restorations bonded to teeth using the total
etch technique achieved a bond strength of up to 28 MPa [15]
within the enamel and 13 to 20 MPa within the dentin (depend-
ing on the adhesive system used) [16,17]. An improved bond
strength to dentin can be reached when an immediate seal-
ing of the dentin after the preparation is done [18]. Today
many manufacturers offer self-etching primers which are sup-
posed to simplify the adhesive bonding procedure. Different
bond strength values have been reported in the literature
regarding these self-etching primers. The bond strength of
ceramic bonded to enamel was about 26 MPa regardless of the
manufacturer while the bond strength of ceramic bonded to
dentin was 15 to 29 MPa depending on the adhesive system
used [17,19,20]. In these studies specimens were not subjected
to thermal cycling, water storage or masticatory simulation
though. For example a study of Zhang et al. [21] reported a
bond strength to dentin of up to 36 MPa using a self-etching
primer.
A further factor influencing the fracture resistance of all-
ceramic restorations is the design of the preparation. For
all-ceramic restorations the preparation has to be rounded
carefully and no sharp angles should exist [4,22–25]. The
thickness of the ceramic restoration is another factor influ-
encing its fracture resistance [26]. Scientific data on the
minimum thickness of lithium disilicate ceramic partial
crowns or occlusal veneers is rare. In vitro studies on bonded
occlusal veneers made of emax CAD showed that restora-
tions with a thickness of 1.2–1.8 mm withstood forces of
up to 1000 N and thicknesses of 0.6–1.0 mm withstood 800 N
[27,28]. A study of Guess et al. [29] investigated the influ-
ence of the thickness and the extension of different premolar
partial crowns made of a pressed lithium disilicate ceramic.
No significant effect on the fracture resistance of pressable
lithium disilicate ceramic onlay restorations was found in
this study when the preparation depth was reduced down to
0.5 mm.
Please cite this article in press as: Sasse M, et al. Influence of restoration thickness and dental bonding surface on the fracture resistance of
full-coverage occlusal veneers made from lithium disilicate ceramic. Dent Mater (2015), http://dx.doi.org/10.1016/j.dental.2015.04.017
The success of all-ceramic restorations is related to multi-
ple factors. The purpose of this study was to evaluate the effect
of varying thicknesses of non-retentive full-coverage adhe-
sively retained occlusal lithium disilicate ceramic restorations
(further on referred to as occlusal veneers) bonded to differ-
ent surfaces using a bonding system based on a self-etching
primer.
2. Materials and methods
2.1. Specimen fabrication
Seventy two human molars without any caries or fillings
were cleaned and stored in a 0.1% thymol solution. They
were embedded in a technique which proved to be effec-
tive in previous studies [2,30–32]. The root portion apically of
the cemento-enamel junction was coated with an artificial
periodontal membrane made of gum resin (Anti-Rutsch-
Lack, Wenko-Wenselaar, Hilden, Germany). The roots of the
teeth were then embedded in custom made standard brass
cylinders (Ø 15 mm) positioned along their long axis with auto-
polymerizing acrylic resin material (Technovit 4000, Heraeus
Kulzer, Wehrheim, Germany). The enamel-cement junction
was located 2 mm above the level of the embedded resin. The
roots were retained in the resin by a thin steel bar (Ø 0.9 mm)
inserted in the apical third of the root.
Specimens were divided into three groups (n = 24 each). In
the first group the preparation was only within the enamel
(group EN), in the second group the preparation was not
limited to the enamel but extended into the dentin (group
ED) and in the third group the preparation extended into the
dentin also but the dentin core was reduced by 1.5 mm and a
composite filling (Tetric EvoCeram, Ivoclar Vivadent, Schaan,
Liechtenstein) was placed into the cavity (group EC) using a
three-step bonding system (Optibond FL, Kerr, Charlotte, NC,
USA). Finally all preparations and all composite fillings were
smoothed and sharp edges were rounded. In all three groups
the circumferential outline of the preparation was strictly
within the enamel. An angle of 150 degrees was prepared
between the cusps (Fig. 1). After tooth preparation, impres-
sions were made using a simultaneous dual-mix technique
with polyether material (Permadyne Penta H und L, 3 M ESPE,
Seefeld, Germany). The impressions were cast with die stone
type 4 (Hydrobase300, Dentona, Dortmund, Germany). The
teeth were stored in a 0.1% thymol solution until adhesive
luting.
In order to achieve a constant ceramic thickness the
occlusal surface received a semi-anatomic shaping. In the
CAD/CAM software the occlusal surface of the tooth was vir-
tually elevated and then reduced again in the fissure area
until the desired thickness was obtained. The master casts
were sent to a commercial milling center (Biodentis, Leipzig,
Germany). The unsintered ceramic occlusal veneers were then
milled out of lithium disilicate blocks (IPS e.max.CAD, Ivoclar
Vivadent, Schaan, Liechtenstein) in accordance to the planned
design using CAD/CAM technique. They were fitted to the
master casts and sintered according to the manufacturers’
directions. Test groups are summarized in Table 1.
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Fig. 1 – Preparation design of the test groups (E = enamel, D = dentin, C = composite resin filling).

2.2. Bonding procedure at each temperature in a computerized masticatory simulator

A self-etching primer (Multilink Primer A and B, Ivoclar
Vivadent, Schaan, Liechtenstein) was mixed for 10 s with a
ratio of 1:1. The teeth were then pretreated according to the
following protocol: in groups EN and EC the primer was applied
onto the bonding surface of the tooth with a brush for 15 s and
after another 15 s the surface was gently air dried. In group
ED the primer was first applied to the enamel surface for 15 s
before it was applied to the dentin surface for 15 s, followed
by gentle air drying of the surface.
The bonding surfaces of the restorations were etched for
20 s using 5% hydrofluoric acid etching gel (IPS Ceramic Ätzgel,
Ivoclar Vivadent). The etched ceramic surface was thoroughly
cleaned using water spray for 60 s. After airdrying a silane cou-
pling agent (Monobond Plus, Ivoclar Vivadent) was applied and
air dried again after 60 s.
A self-curing luting composite (Multilink Automix, Ivoclar
Vivadent) was dispensed from the automix syringe onto the
bonding surface of the restoration and onto the fissure area
of the tooth. The restoration was positioned by hand and kept
in place by a special loading apparatus with a constant force
of 50 N. Subsequently, all margins were light-cured for 20 s
according to the manufacturer’s instructions.
After a curing period of 5 min the specimens were removed
from the loading apparatus, the margins were polished and
the specimens were stored in water for 3 days at 37 ◦ C in order
to achieve complete curing.
2.3. Cyclic loading and fracture load
After water storage all specimens were first thermocycled 7500
times between 5 and 55 ◦ C in tap water with a 30 s dwell time
(Willytec, Munich, Germany), followed by combined thermo-
cycling (60 s dwell time) and dynamic loading for another
600,000 cycles with a weight of 10 kg. A loading cycle frequency
of 2.0 Hz with a lateral sliding component of 0.3 mm towards
the central fissure was chosen to simulate conditions in the
oral cavity. The descending velocity was 30 mm/s, the ascend-
ing velocity was 55 mm/s and the vertical motion was 6 mm.
The antagonistic tooth was simulated by a steatite ceramic ball
5 mm in diameter (Hoechst Ceram Tec, Wunsiedel, Germany)
which was positioned so that it first contacted the supporting
cusp when moving down.
Following masticatory simulation all unfractured spec-
imens were examined using a stereomicroscope (Wild,
Heerbrugg, Switzerland) and they were photographed (Leica
DC 100, Leica Microsystems, Cambridge, UK) in order to record
possible damage.
The specimens were then loaded until fracture in a univer-
sal testing machine (Zwick Z010/TN2A, Ulm, Germany). A steel
bar with a 6 mm ball end was centered on the main fissure of
each specimen in order to apply the load evenly to the triangu-
lar ridges of the oral and buccal cusps. Additionally a 0.6 mm
tin foil was placed between the ball end and the specimen
in order to distribute the load homogenously. The steel bar
descended at a cross-head speed of 2 mm/min while a com-
puter software (testXpert II, Zwick, Ulm, Germany) recorded
the maximum load until fracture in Newton.
After static loading all specimens underwent a stere-
omicroscopic evaluation again and were photographed. In
addition sampled fragments of specimens that did not with-
stand dynamic loading as well as sampled fragments of
specimens after static loading were evaluated using a scan-
ning electron microscope (XL 30 CP, Philips, Eindhoven,

Table 1 – Allocation of test groups.

Preparation (group code) Ceramic thickness

0.3–0.6 mm (n = 24) 0.5–0.8 mm (n = 24) 0.7–1.0 mm (n = 24)

Restricted to enamel (EN) (n = 24) EN1 (n = 8) EN2 (n = 8) EN3 (n = 8)
Enamel and dentin (ED) (n = 24) ED1 (n = 8) ED2 (n = 8) ED3 (n = 8)
Enamel and dentin with composite filling (EC) (n = 24) EC1 (n = 8) EC2 (n = 8) EC3 (n = 8)

Please cite this article in press as: Sasse M, et al. Influence of restoration thickness and dental bonding surface on the fracture resistance of
full-coverage occlusal veneers made from lithium disilicate ceramic. Dent Mater (2015), http://dx.doi.org/10.1016/j.dental.2015.04.017
DENTAL-2557; No. of Pages 9
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Fig. 2 – Overview and SEM image at ×50 magnification of the occlusal surface of a restoration showing micro crack
formation after dynamic loading.

Netherlands) in order to gain information on the failure mode Stereomacroscopic and scanning electron microscopic
of the adhesive bond. Some specimens which already showed evaluation of the fractured surfaces within group EN (prepa-
damage after dynamic loading were also inspected using the ration restricted to enamel) showed a failure of the adhesive
scanning electron microscope. interface between the enamel surface and the luting com-
posite (Fig. 3). Within group ED (preparation extended into
the dentin) failure of the adhesive interface occurred between
2.4. Analysis of results and statistics the restoration surface and the luting composite as well as
in the adhesive interface of the hybrid layer (Figs. 4 and 5).
The Shapiro–Wilk test was performed on all groups and Within group EC the fractures occurred at the adhesive inter-
revealed, that some groups were not distributed normally. face between the restoration surface and the luting composite
Hence the Kruskal–Wallis test was performed on all groups (Fig. 6).
and revealed statistically significant differences. This test was
followed by multi-pairwise comparisons of all groups using
the Wilcoxon rank sum test and the risk of an alpha error was 4. Discussion
reduced by performing the procedure of Bonferroni–Holm on
each resulting p-value. The influence of the thickness of non-retentive full-coverage
adhesively retained occlusal ceramic veneers on their frac-
ture resistance and the influence of the underlying bonding
substrate were evaluated in this study. For this study the
3. Results design of the preparation was chosen based on a study of
Clausen et al. [2] and based on general preparation guidelines
Some specimens did not withstand dynamic loading [25,33]. Specimens were thermal cycled in order to simu-
unscathed. They were rated as failure when chippings late the physical stress dental restorations are exposed in
occurred. As partial failure they were rated when crack the oral cavity. Thermocycling stress and tensions occur at
formation took place (Fig. 2) and specimens were rated as a
success when they did not show any macroscopic damage
after masticatory simulation. The results regarding survival
after dynamic loading are shown in Table 2 and the results for Table 2 – Survival rates for dynamic loading including
median loads until fracture of the different groups are shown partial failures (A) and regarding complication-free
in Table 3. restorations only (B).
Statistical analysis of the data regarding thickness of the Ceramic thickness (mm) Survival rates (%)
restorations showed statistically significant differences when
A B
comparing groups EC1 and EC3 (p = 0.01041) as well as when
EN 0.3–0.6 50 50
comparing groups EC2 and EC3 (p = 0.00193). Regarding the
0.5–0.7 75 75
different bonding surfaces statistically significant differences
0.7–1.0 100 100
could be found within grouping factor 1 when testing groups
ED 0.3–0.6 100 50
EN1 vs ED1 (p = 0.005253) and groups EN1 vs EC1 (p = 0.002567).
0.5–0.7 50 50
Within grouping factor 3 statistically significant differences
0.7–1.0 100 100
could be found when testing groups EN3 vs ED3 (p = 0.006993)
and EN3 vs EC3 (p = 0.0001554). So for grouping factor 1 and 3 EC 0.3–0.6 100 12.5
0.5–0.7 100 37.5
luting on dentin or composite provided statistically significant
0.7–1.0 100 100
higher fracture resistance values than luting on enamel.

Please cite this article in press as: Sasse M, et al. Influence of restoration thickness and dental bonding surface on the fracture resistance of
full-coverage occlusal veneers made from lithium disilicate ceramic. Dent Mater (2015), http://dx.doi.org/10.1016/j.dental.2015.04.017
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Table 3 – Median fracture resistance (N) of groups, minima, maxima for static loading and influence of the ceramic
thickness and the bonding substrate. Medians with the same upper case superscript letter within the same row
(=different thicknesses) are not statistically different (p > 0.05). Medians with the same lower case subscript letter within
the same column (=different bonding substrate) are not statistically different (p > 0.05).
Preparation (group code) Thickness

0.3–0.6 mm (n = 24) 0.5–0.8 mm (n = 24) 0.7–1.0 mm (n = 24)

A A
Restricted to enamel Med 610 a 2355 a 2070A a
(EN) (n = 24) Min 0 0 1450
Max 2230 3170 2570

Enamel and dentin Med 2370A b 1105A a 3000A b

(ED) (n = 24) Min 1530 0 1880
Max 2700 3800 3780

Enamel and dentin Med 2765A b 2270A a 3390B b

with composite Min 1400 1520 2860
filling (EC) n = 24 Max 3940 3000 4080

Fig. 3 – Overview of a sample of group EN after static loading showing no visible composite leftovers on the tooth surface
and SEM image of the basal surface of a chipped fragment at ×50 magnification. It shows a homogenous surface of the
luting composite mirroring the grinded tooth surface.

Fig. 4 – Overview and stereomicroscopic view at ×8 magnification of a sample of group ED. No visible composite leftovers
can be found on the enamel surface (E) while partial leftovers can be found on the dentin surface (D).

Please cite this article in press as: Sasse M, et al. Influence of restoration thickness and dental bonding surface on the fracture resistance of
full-coverage occlusal veneers made from lithium disilicate ceramic. Dent Mater (2015), http://dx.doi.org/10.1016/j.dental.2015.04.017
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Fig. 5 – SEM images of another sample of group ED. View on the basal surface of a chipped fragment at ×50, ×125 and
×2000 magnification. Areas of different underlying tooth substance can be distinguished (D-dentin, E-enamel, T-transition
zone). A distinct shift in surface structure can be found within the transition zone at ×2000 magnification. In the lower part
(enamel zone) composite leftovers indicate a failure in between the enamel and the luting composite and in the upper part
(dentin zone) a failure within the hybrid layer is indicated by the ripped out areas of the dentinal tubules.

the adhesive interface due to the different thermal expan-
sion coefficients of the materials [34], which affect the
bond strength. The intent of the thermocycling process
before dynamic loading in combination with thermocycling
was to artificially preage the specimen with an increased
frequency of thermocycling even before mechanical load-
ing. During thermocycling without mechanical loading, the
specimen was thermal cycled between 5 and 55 ◦ C in tap
water with a 30 s dwell time at each temperature and a
6 s switch time. While during cyclic loading, the specimen
was thermal cycled with a 60 s dwell time and a 15 s switch
time.
Further on specimens were dynamically loaded in order to
simulate the mechanical stress while chewing as well. Accord-
ing to a previous study [2] specimens were loaded with a force
of 10 kg and an additional lateral sliding movement of 0.3 mm
was applied to simulate the sliding movement of the antago-
nistic tooth while chewing [2,30].
The number of cycles in the masticatory simulator was
set to 600,000 as in previous studies [2,30,32] which equals a
clinical use of 2.5 years [35,36]. Specimens that did not frac-
ture during dynamic loading were quasi-static loaded until
fracture as in previous studies [2,30,32] again. Analog to clin-
ical studies [37–40] and one in vitro study [41] all restorations
that did not show a loss of function were regarded as success
or partial success even if crack formation took place. Spec-
imens that fractured or showed chippings were regarded as
failure and selected fragments were analyzed concerning the
type of failure.
The statistical analysis revealed that a thickness of the
ceramic restoration of 0.7–1 mm lead to a significant higher
fracture resistance compared to thinner restorations within
the group bonded to enamel and composite filling (EC). In
the two remaining groups no significant influence of the
thickness could be shown. When analyzing the results, the
survival rate of the dynamic loading should not be neglected
though. In all three groups only the restorations with a thick-
ness of 0.7–1 mm completely withstood the dynamic loading
unharmed. Regarding the partial success rate (restorations
with crack formation included) all restorations in the group
bonded to enamel and composite filling (EC) and in the group
bonded to enamel and dentin (ED) except the ones with a
thickness of 0.5–0.8 mm withstood the dynamic loading com-
plete.

Please cite this article in press as: Sasse M, et al. Influence of restoration thickness and dental bonding surface on the fracture resistance of
full-coverage occlusal veneers made from lithium disilicate ceramic. Dent Mater (2015), http://dx.doi.org/10.1016/j.dental.2015.04.017
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Fig. 6 – Overview, stereomicroscopic view at ×8 and at ×50 magnification of samples of group EC. Clearly recognizable
leftovers can be found on the surface of the composite filling (C) while no luting composite leftovers can be found on the
enamel surface (E). On the basal surface of the chipped fragment areas of different underlying tooth substance can be
distinguished (C-composite filling, E-enamel, T-transition zone). Clearly visible is the definite shift in surface structure from
the enamel zone to the zone of the underlying composite filling where no leftovers of the luting composite can be found on
the ceramic restorations surface.

A prediction on the remaining longevity of such restora-
tions already showing crack formation, cannot be made since
no studies on this subject have been published so far. It has to
be noted that the lowest values of fracture resistance within
any group did not necessarily occur at restorations with cracks
present.
The statistical analysis of the groups with a thickness of
0.3–0.6 mm and 0.7–1.0 mm concerning the influence of the
bonding surface on the fracture resistance revealed a signif-
icant difference comparing the enamel bonded restorations
(EN) to the dentin (ED) and composite resin filling (EC) bonded
restorations with the loading values until fracture being lower
for the enamel bonded restorations than for the other two
groups.
The values measured in group EN3 ranged from 1450 to
2570 N and thereby exceeded the recommended minimum
fracture strength for posterior restorations of 500–700 N [42]
by far. The fracture resistance observed for these restorations
was in the same range as for untreated human molars [41,43].
A thickness of 0.7–1.0 mm can therefore be recommended for
clinical use, since in this group neither a failure nor a partial
failure occurred.
The restorations that were bonded solely to enamel showed
inferior results which is in contradiction to the results of other
studies [41,44] in which the bond strength of luting compos-
ite was investigated and also to results of studies [2,7,45,46] in
which the fracture resistance of restorations either bonded to
enamel or dentin was investigated. The assumed reason for
this difference is the utilized adhesive luting system applied
to the tooth surfaces. In the studies mentioned above, the
tooth surfaces were conditioned using the total-etch tech-
nique while in the current study a self-etching primer only
was used for conditioning of the tooth surfaces.
The significantly higher fracture resistance when bonding
to dentin in the current study is in accordance to a study
of Zhang et al. [21]. They found that regarding the bond
strength to dentin, conditioning with a self-etching primer
lead to higher bond strength values as compared to the total-
etch technique. A further option for the improvement of the
bond strength to dentin is the immediate dentin sealing tech-
nique as described by Magne et al. [18]. Another study on the
marginal quality of restorations bonded to enamel and dentin
found a significantly decreased marginal quality after mas-
ticatory simulation for specimen bonded to enamel using a
self-etching primer [47]. This again is in accordance to the
current study.
The highest values of fracture resistance and the high-
est survival rates in our study were found with restorations
which were partly bonded to composite fillings. Few studies
were found regarding the bond strength of composite fillings
to the luting resin and the ceramic restoration in dependence
of the applied surface conditioning method. A study of Saba-
tini et al. [48] investigated the shear bond strength of luting
resins to various prosthodontic substrates. They found that
the bond strength values of Multilink Automix to compos-
ite fillings using A/B primer achieved 32 MPa which is in the

Please cite this article in press as: Sasse M, et al. Influence of restoration thickness and dental bonding surface on the fracture resistance of
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DENTAL-2557; No. of Pages 9
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same range as the bond strength to dentin found in one other
study [21]. There is a major difference though to other stud-
ies investigating the bond strength of Multilink Automix to
dentin [49–51]. In these studies bond strength values in the
range of 18.5 MPa or even lower were reported. Since some of
these studies involved thermocycling and artificial aging while
others did not, comparisms to other studies are difficult due
to the different designs of the studies. This also explains the
wide range of the resulting values.
Comparing the current results to other studies on the frac-
ture resistance of lithium disilicate restorations it is noticeable
that the values of fracture resistance were significantly higher
than in a similar study of Guess et al. [29]. In their work they
evaluated the relationship of the design and extension of the
preparation and the thickness of occlusal veneers made of a
pressed lithium disilicate ceramic bonded to human premo-
lars. No influence on the fracture resistance was found in that
study when comparing pressable lithium disilicate ceramic
onlay restorations with different occlusal thicknesses. The
preparation design used in that study was different to the one
used in our study though and the specimen were bonded using
the total-etch technique.
However, the results of the above study [29] suggest that
within our study the group bonded solely to enamel would
have shown better results when the total-etch technique
would have been choosen as conditioning method for the
enamel. Overall the fracture resistance values achieved in
the study of Guess et al. [29] were in a lower range (median
729–1300 N) than in our study (median 610–3390 N) which
might be due to the different type of teeth that were restored
(premolars vs molars) and to the different preparation designs
used. In addition the results suggest to conduct a follow-
up study to evaluate wether the fracture resistance and the
survival rate will increase when the total-etch technique is
used as pretreatment of the enamel. This follow-up study
would also clarify wether even further decreased thicknesses
of the occlusal veneers might be recommended for clinical
use.
In a study of Yildiz et al. [52] the fracture resistance of
pressed and CAD/CAM manufactured lithium disilicate par-
tial crowns with an occlusal thickness of 1.5 mm (according
to the manufacturer’s recommendation) was compared and a
lower fracture resistance for the CAD/CAM restorations was
revealed. They also investigated the influence of the bonding
technique on the fracture resistance by bonding some spec-
imen using the total-etch technique and the others by using
Multilink primer A/B as conditioning method. Specimens con-
ditioned with Multilink primer showed a significantly lower
fracture resistance than specimens conditioned with the total-
etch technique. The overall values of fracture resistance were
again lower (1584 ± 238 MPa) as compared to our study. Again
this might also be due to a different preparation and study
design.
5. Conclusion
The results of the current study support the treatment of
occlusal abrasion or malpositioned teeth with non-retentive
lithium disilicate ceramic occlusal veneers.
Please cite this article in press as: Sasse M, et al. Influence of restoration thickness and dental bonding surface on the fracture resistance of
full-coverage occlusal veneers made from lithium disilicate ceramic. Dent Mater (2015), http://dx.doi.org/10.1016/j.dental.2015.04.017
They suggest that a minimum thickness of 0.7–1.0 mm
should not be deceeded when a self-etching primer is used
for conditioning of the tooth substrate.
Acknowledgement
The authors gratefully acknowledge the support of this study
by Ivoclar-Vivadent, Schaan, Liechtenstein, by providing their
materials free of charge, as well as by Absolute Ceramics,
Biodentis GmbH, Leipzig, Germany, by manufacturing the
restorations free of charge.
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