journal of the mechanical behavior of biomedical materials 119 (2021) 104485

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Journal of the Mechanical Behavior of Biomedical Materials

journal homepage: http://www.elsevier.com/locate/jmbbm

Influence of material type, thickness and storage on fracture resistance of

CAD/CAM occlusal veneers
Eman Albelasy a, Hamdi H. Hamama a, *, James K.H. Tsoi b, Salah H. Mahmoud a
a
Operative Dentistry Department, Faculty of Dentistry, Mansoura University, Egypt
b
Dental Material Science, Division of Applied Oral Sciences and Community Dental Care, Faculty of Dentistry, The University of Hong Kong, Hong Kong, China

A R T I C L E I N F O A B S T R A C T

Keywords: Objectives: The present study aimed to evaluate the effect of restoration thickness, CAD/CAM material, and 6
Fracture resistance months of artificial saliva storage on the fracture resistance of occlusal veneers.
Aging Materials and methods: A total of 84 intact maxillary molars were sectioned 4.0 mm occlusal to the cementoe­
Non-retentive occlusal veneers
namel junction to expose the dentine. The teeth were assigned into 3 main groups according to the type of
Lithium disilicate glass-ceramic
Polymer-infiltrated ceramic
restorative material (e.max CAD, Vita Enamic, and Lava Ultimate). In each group, the teeth were allocated into 2
CAD/CAM composite subgroups (n = 14) according to restoration thickness (1.0 and 1.5 mm). The veneers were adhesively bonded
using dual-cure self-adhesive luting agent. A total of 42 specimens comprising half the tested subgroups were
stored in distilled water for 24-h before the test. The remaining half was stored in artificial saliva at 37 ± 1 ◦ C in
an incubator for 6 months. All specimens (n = 84) were subjected to 5000 thermal cycles between 5 and 55 ◦ C ±
2 before the fracture resistance test. The maximum force at fracture was recorded in Newton. Failure mode was
analyzed using a stereomicroscope. The results were analyzed using a parametric Three-way ANOVA test.
Results: The results of the Three-way ANOVA test revealed that material type and restoration thickness signifi­
cantly affected fracture resistance values (p < 0.5), while 6 months of storage in artificial saliva had no sig­
nificant effect on mean fracture resistance values (p˃0.5). The most common failure patterns in CAD/CAM resin
composite and polymer-infiltrated ceramics were scores I and score II. For glass ceramic groups, score IV and III
were more dominant.
Conclusions: All the tested CAD/CAM restorations in both thicknesses exhibited fracture resistance values
exceeding normal and parafunctional bite forces. Polymer-infiltrated ceramics and CAD/CAM resin composite
veneers showed more favorable fracture patterns.

1. Introduction significant amount of tooth structure loss, invasive approaches could

The gradual non-carious loss of dental hard tissues has a detrimental
impact on patient’s chewing capacity, overall satisfaction with their
dentition, and quality of life (Al-Omiri et al., 2006). In advanced cases,
degradation of surface and subsurface structures of teeth with impair­
ment to function and esthetics can complicate treatment options (West
and Joiner, 2014). To successfully manage such cases, comprehensive
diagnosis and identification of the aetiological factor are essential and
consequently determining the appropriate treatment protocol (Loomans
et al., 2017). Conventional approaches for managing tooth wear of
posterior teeth particularly in advanced stages might necessitate full
mouth rehabilitation using full-coverage crowns, ceramic onlays, and
overlays (Vailati and Belser, 2008). Taking into consideration the
jeopardize the integrity and vitality of the remaining tooth structure
(Schlichting et al., 2011). Partial coverage restorations such as occlusal
veneers with a reduced thickness could represent a conservative alter­
native to restore vertical dimension in cases of extensive occlusal tooth
loss.
With the technological advancements which allow for a refined
reproduction of details along with new restorative materials, comput­
erized dentistry might provide the optimal solution for combining
conservation of tooth structure along with simple and practical resto­
rations (Johnson et al., 2014). High strength ceramics such as lithium
disilicate have shown promising results in terms of structural integrity
when used anteriorly or posteriorly as veneers, inlays, onlays, crowns,
partial coverage restorations, and 3-unit fixed prosthesis (Attia and

* Corresponding author. Operative Dentistry Department, Faculty of Dentistry, Mansoura University, Algomhoria St, Mansoura, Aldakhlia, 35516, Egypt.
E-mail address: hamdy@connect.hku.hk (H.H. Hamama).

https://doi.org/10.1016/j.jmbbm.2021.104485
Received 12 February 2021; Received in revised form 9 March 2021; Accepted 15 March 2021
Available online 29 March 2021
1751-6161/© 2021 Elsevier Ltd. All rights reserved.
E. Albelasy et al.
Kern, 2004; Guess et al., 2013; Kern et al., 2012; Sasse et al., 2015).
Furthermore, by using lithium disilicate (LDC), posterior loading re­
quirements can be met with a more conservative preparation in com­
parison with porcelain restorations (Ma et al., 2013).
Resin-matrix ceramics form a new group of CAD/CAM restorative
materials that were designed to incorporate the positive attributes of
ceramics and polymers. Based on their internal structure and industrial
polymerization mode, resin-matrix ceramics can be further classified
into high-temperature polymerized resin-based composite with
dispersed ceramic fillers and a predominately organic phase, and high-
temperature/high-pressure polymer-infiltrated ceramics (Spitznagel
et al., 2018).. Previous studies (Magne et al., 2010; Schlichting et al.,
2011), have shown that CAD/CAM resin composite (RC) occlusal ve­
neers may provide better resistance to fatigue loading compared to ce­
ramics. Polymer-infiltrated ceramics (PIC) are obtained by polymer
infiltration of a pre-sintered glass-ceramic network, which is secondarily
polymerized. The presence of a polymer network can mitigate crack
propagation (Stawarczyk et al., 2015). However, concerns regarding the
mechanical performance of polymeric materials when compared with
ceramics need to be further evaluated.
The outcomes of several studies conducted on preparation guidelines
for partial coverage ceramic restorations remain conflicting. While most
manufacturers recommend a minimum thickness of 1.5 for posterior
ceramic restorations, satisfactory long-term clinical results for ceramic
restorations with a thickness of 1.0 mm were reported (Malament and
Socransky, 1999).
Furthermore, changes in humidity, pH, and temperature of the oral
environment may result in changes in the properties of dental materials
depending on their content (Dayan and Mumcu, 2019). Dental ceramics
might be subjected to stress-corrosion-driven slow crack propagation
assisted by moisture. This could result in strength reduction over the
years and cumulative mechanical damage (Zhang and Lawn, 2004;
Zhang et al., 2005). Also, resin composite can be subjected to a drop­
down in flexural strength following storage (Ikeda et al., 2019).
Accordingly, there is a need to analyze the fracture strength of any
restorative material in laboratory studies where target parameters as
restoration thickness and aging techniques can be standardized (Guess
et al., 2013). Therefore, this laboratory study was conducted to evaluate
the effect of thickness and 6-months of artificial saliva storage on frac­
ture resistance of 3 different CAD/CAM occlusal veneers restorations.
The null hypothesis was that fracture resistance of occlusal veneers is
not significantly affected by changes in restoration thickness, material
type, and 6-months of artificial saliva storage.
Table 1
Chemical composition of the materials tested.
Material Specification Manufacturer
IPS e.max Lithium disilicate glass IvoclarVivadentAG, Schaan,
CAD ceramics Liechtenstein
Vita Enamic Polymer-infiltrated VITA Zahnfabrik, Bad Säkingen,
ceramics Germany
Lava Resin nano- ceramic 3M ESPE, St Paul, Minnesota, USA
Ultimate
RelyX Self-adhesive dual cure 3M, GmbH, Germany
Unicem resin luting agent
Bis-GMA: Bisphenol A diglycidyl dimethacrylate, Bis-EMA: Ethoxylated bisphenol A dimethacrylate, TEGDMA: Triethylene glycol dimethacrylate.
Journal of the Mechanical Behavior of Biomedical Materials 119 (2021) 104485
2. Materials and Methods
2.1. Materials
Three different CAD/CAM materials were utilized in this study:
lithium disilicate glass-ceramic (IPS e.max CAD, Ivoclar Vivadent AG,
Schaan, Liechtenstein), polymer-infiltrated ceramics (Vita Enamic, VITA
Zahnfabrik, Bad Säkingen, Germany), and CAD/CAM resin composite
(Lava Ultimate, 3M ESPE, St Paul, Minnesota, USA). The full description
of the materials used is presented in Table 1.
2.2. Specimens preparation
Eighty-four sound maxillary molars extracted from healthy in­
dividuals due to periodontal reasons were collected according to a
protocol approved by the ethical committee of the university
(A04260219). The teeth were thoroughly inspected under a 30x
magnification stereomicroscope (SZ TP, Olympus, Tokyo, Japan). With
the use of a digital caliber, molars that grossly exceeded an average
dimension of 12.5 ± 2 mm buccolingual and 10 ± 2 mm mesiodistal
width were discarded. After the removal of soft tissue remnants with a
hand scaler (Goldman, Illinois, USA), the teeth were stored in a 1%
chloramine-T solution as a disinfectant for 72 h. All chosen teeth were
cleaned using a rubber cup and fine pumice water slurry. The teeth were
stored in distilled water at 37 ◦ C ± 1 ◦ C using an incubator (BTC, Model:
BT1020, Cairo, Egypt) and the water was changed periodically every 5
days throughout the study. The teeth were embedded in a cylindrical
PVC ring (2.0 × 2.4 cm) using self-cure acrylic resin (Acrostone, Egypt)
up to 2.0 mm below cementoenamel junction (CEJ). The teeth were
positioned in the PVC ring with the aid of a custom-made device to
centralize the teeth in the ring. For periodontal simulation, roots of the
teeth were dipped into melted wax to a depth of 2.0 mm below the CEJ
to produce a 0.2–0.3 mm layer approximately equal to the average
thickness of the periodontal ligament (Fig. 1). After setting of the acrylic
resin, each tooth was removed from the cylinder. The wax spacer was
removed from the root surface and the alveolus of the acrylic resin
cylinders. Polyether impression material (Impregum soft, 3M ESPE, St.
Paul, Minnesota, USA) was delivered into the polystyrene resin alveolus,
the tooth was reinserted into the alveolus, and the polyether material
was allowed to set. After setting, excess impression material was
removed with a scalpel blade (Taha et al., 2011). For groups tested after
6-months of storage in artificial saliva, fixation using polyether was
carried out immediately before the fracture resistance test to avoid
water-induced changes in the impression material (Fig. 2).
A standardized teeth preparation simulating worn occlusal table was
performed using a diamond saw (ISOMET 4000, Buehler, Lake Bluff, IL,
USA). Coronal tooth structure 4.0 mm above CEJ was removed leaving
Batch #S Chemical Composition
W35199 SiO2 (57%–80%), Li2O (11. % – 19%), K2O (0.0%–13%), P2O5
(0.0%–11.0%), ZrO2 (0.0%–8.0%) ZnO (0.0%–8.0%), Al2O3
(0.0 %–5. %), MgO (0.0–5.0) and colouring oxides (0.0–8.0)
80,061 Ceramic component: SiO2 (58–63), Al2O3 (20–23), Na2O (6–11), K2O (4–6), B2O3
(0.5–2), CaO(<1) and TiO2(<1)
Polymer component: methacrylate polymer
Ceramic to polymer ratio; 86%–14% by weight
N763594 Silica nanomers (20 nm), zirconia nanomers (4–11 nm), nanocluster particles
derived from the nanomers
(0.6–10 nm), silane coupling agent, resin matrix (Bis-GMA, Bis-EMA, UDMA, and
TEGDMA)
4219302 Powder: Glass powder, initiator, Silica, Substituted pyrimidine, Calcium hydroxide,
Peroxy compound, Pigment.
Liquid: Methacrylated phosphoric ester, Dimethacrylate, Acetate, Stabiliser, and
initiator.
2
E. Albelasy et al. Journal of the Mechanical Behavior of Biomedical Materials 119 (2021) 104485

Fig. 2. Fixation in PVC ring using Impregum. (A) PVC ring filled with Impre­
gum (B) tooth inserted in PVC filled with Impregum and C, After removal
of excess.

Fig. 1. Centralization in PVC ring. (A) a custom-made device used for

centralization of the teeth in PVC ring, (B) root of a molar tooth covered with a
layer of wax 2.0 mm inferior to CEJ, and (C) a molar tooth centralized in
PVC ring.

central exposed dentin and peripheral enamel (Egbert et al., 2015;

Johnson et al., 2014). Two notches were placed in the mesial and distal
finish line of each preparation to facilitate accurate positioning of the
veneers during cementation (Fig. 3). The teeth were visually inspected
using magnifying loupes with 5X magnification (Univet, Italy) to check
for the presence of disqualifying qualities such as cracks and pulpal
exposures. The prepared teeth were randomly assigned into 3 main
groups (n = 28) according to the type of the restorative material (e.max
CAD, Vita Enamic, and Lava Ultimate).
Fig. 3. Teeth preparation. Upper maxillary molar after removal of
occlusal enamel.
2.3. Occlusal veneers manufacturing

Occlusal veneers were manufactured with CAD/CAM technology

3
E. Albelasy et al.
using Ceramill Mind CAD software (AmannGirrbach, Koblach, Austria).
The prepared tooth surface was covered with silver powder (CERCON,
DeguDent GmbH, Germany) to create an opaque surface required for
scanning with CAD scanner (Ceramill Map 400, Amann Girrbach,
Koblach, Austria). In each group, the teeth were randomly assigned into
2 subgroups (n = 14) according to restoration thickness (1.0 and 1.5 mm
measured from the central grove). The thickness of the restorations was
standardized in the software by virtually elevating and reducing the
occlusal surface in the fissure area until the desired thickness was ob­
tained (Fig. 4) (Sasse et al., 2015). Virtual die spacer was standardized in
all groups (46 μm). The restorations were milled in a 5-axis milling
machine (Ceramill motion 2, AmannGirrbach, Koblach, Austria).
Following the milling process, Lithium metasilicate ingots were crys­
talized in a ceramic furnace at 880 ◦ C (Programat p500, Ivoclar Viva­
dent, Schaan, Liechtenstein) for 30 min. After firing, the sprues were
removed, and the veneers were polished with rubber cups and glazed at
700 ◦ C. Polymer-infiltrated ceramics veneers were polished using the
Enamic Polishing set (VITA, VITA Zahnfabrik, Bad Säckingen, Germany)
and CAD/CAM resin composite veneers were polished using silicone tip
and diamond paste.
2.4. Adhesive cementation procedures
The restorations were assessed for adequate fit and cleaned with 99%
Fig. 4. Restoration designing. A; thickness measurement in Ceramill mind
software, (B) occlusal anatomy refining.
4
Journal of the Mechanical Behavior of Biomedical Materials 119 (2021) 104485
isopropanol in an ultrasonic cleaner for 5 min. The prepared teeth were
cleaned with pumice and thoroughly rinsed with water. Lithium dis­
ilicate veneers were etched with 8% hydrofluoric acid (Dentobond Etch,
Itena, France) for 20 s, whereas PIC veneers were etched for 60 s. The
etched surfaces were rinsed with water stream for 60 s and gently air-
dried with oil-free compressed air. Subsequently, the treated surfaces
were silanated (Dentobond Silane, Itena, France). Silane was left to react
for 60 s and then excess silane was air-dried. For CAD/CAM RC, the
intaglio surface of the veneers was sandblasted with 50 μm aluminum
oxide particles at 2 bar pressure followed by silane application.
Enamel margins of all the prepared teeth were selectively etched
with 37% phosphoric acid (N-Etch, Ivoclar Vivadent AG, Schaan,
Liechtenstein) for 15 s (De Munck et al., 2004; Hikita et al., 2007;
Radovic et al., 2008). Dentin was protected with Polytetraflouro­
ethylene (PTFE) tape during this step. Following that, all occlusal ve­
neers were adhesively bonded to their respective teeth preparations
using self-adhesive dual-cure luting agent (Rely X Unicem, 3M ESPE, St
Paul, Minnesota, USA). The veneers were positioned on the preparation
using finger pressure and then a custom-made device was used to apply a
load of 10 N for 5 min (Chieffi et al., 2006, 2007; De Munck et al., 2004).
The restored teeth were initially cured for 5 s using LED-curing unit
(Elipar, 3M ESPE, St Paul, Minnesota, USA) at a distance of 2.0 mm with
a light intensity of 1400 mW/cm2. The light intensity of the LED curing
unit was measured every 5 specimens using a radiometer (Blue phase
Meter, Ivoclar Vivadent, Austria) throughout the experiment. Following
initial light curing, excess luting material was removed using a manual
instrument and an air-inhibiting gel (Glycerine) was applied along the
margins to inhibit the formation of an unpolymerized resin layer. The
restored teeth were light-cured through glycerine from each aspect for
30 s.
2.5. Artificial saliva preparation
The artificial saliva was prepared according to modified method of
Macknight-Hane and Whitford (1992) (McKnight-Hanes and Whitford,
1992). Sorbitol was not used because the artificial saliva would be more
viscous than normal saliva when the sorbitol was mixed with Na CMC
(Levine et al., 1987). Two grams of methyl paraben were dissolved in
800 ml of distilled water under magnetic stirring. After that, 10 g of Na
CMC were sprinkled over the surface of the obtained dispersion to allow
polymer soaking overnight. Then, the remaining components were dis­
solved in the following order: 0.625 g of KCl, 0.059 g of MgCl2.6H2O,
0.166 g of CaCl2.2H2O, 0.804 g of K2HPO4 and 0.326 g of KH2PO4 under
magnetic stirring. The volume was completed to 1 L using distilled water
and magnetically stirred for about 24 h to ensure solubility and homo­
geneity of all components.
2.6. Artificial saliva storage
Following cementation, a total of 42 specimens comprising half the
tested subgroups were subjected to fracture resistance test after 24 h of
storage in distilled water. The remaining specimens (n = 42) were tested
after aging in artificial saliva at 37 ± 1 ◦ C using an incubator for 6
months.
2.7. Thermal cycling
All specimens (n = 84) were thermo-cycled for a total number of
5000 cycles (SD mechatronik thermocycler, Germany) which approxi­
mately represents 6 months of clinical service before fracture resistance
test (Morresi et al., 2014). The specimens were alternated between 5 and
55 ◦ C ± 2 with a dwell time of 5 s (Doerr et al., 1996; Li et al., 2002;
Schmid-Schwap et al., 2011) and 5 s transfer time between each bath
according to ISO 11405 (International Standards Organization) recom­
mendations (Ernst et al., 2004). Afterward, all specimens were carefully
evaluated under an optical microscope to check for cracks or debonding.
E. Albelasy et al.
2.8. Fracture resistance test
Following thermal cycling, axial compression was performed in a
universal testing machine (Instron 3345, Canton, Massachusetts, USA)
using a 6.0-mm metal ball positioned in the central fossa and contact
with the cuspal inclines at 0.5 mm/min crosshead speed. A load cell of
5N was used to deliver the compressive load until fracture. The
maximum force required to break the specimen was recorded in Newton
(N).
2.9. Failure pattern analysis
Failure pattern was assessed using a stereomicroscope (SZ TP,
Olympus, Tokyo, Japan). Assessment criteria were categorized accord­
ing to Guess et al. (2013): score I: extensive crack formation, Score II:
fracture involving only the restoration, score III: fracture involving both
the restoration and tooth structure, and score VI: longitudinal fracture of
the restoration and tooth structure. Failure pattern was assessed using a
stereomicroscope (SZ TP, Olympus, Tokyo, Japan).
2.10. Statistical analysis
Data were tabulated and coded using (Microsoft Excel, 2016). Sta­
tistical Package for Social Science (SPSS 22, SPSS Inc, Chicago, Illinois,
USA) was used for data analysis. The distribution of data was statisti­
cally checked by Kolmogorov–Smirnov and Shapiro-Wilk test. A para­
metric Three-way Analysis of variance (ANOVA) was conducted
followed by Tukey’s HSD post-hoc multiple comparisons.
3. Results
3.1. Fracture resistance test
The results of Kolmogorov–Smirnov and Shapiro-Wilk tests revealed
that all data showed normal distribution. Therefore, a parametric Three-
way analysis of variance test (ANOVA) was conducted. The outcomes of
the Three-way ANOVA test revealed that “type of the restorative ma­
terial” and “thickness of the restoration” significantly affected fracture
resistance mean values (p˂0.05), while aging time did not significantly
affect the mean fracture resistance values of the tested groups. Fracture
resistance mean values in Newton and standard deviations for each
group with Tukey’s HSD post-hoc multiple comparisons between groups
are presented in Table 2.
For groups tested following 24-h storge, Tukey’s HSD post-hoc
multiple comparison test results showed that PIC occlusal veneers
with a thickness of 1.0 mm had a significantly lower mean fracture
resistance value (891.7 ± 259 N) in comparison with all the tested
groups (p˂0.05). At a thickness of 1.5 mm, no significant difference was
Table 2
Means (N) and Standard deviation (SD) values for different groups and multiple
comparisons between means (each, n = 7).
Group 24-h storage 6-months storage
Material Thickness (mm) Mean (N) ±SD Mean (N)±SD
LDC 1 aA
1889.96 ± 175 1267.93 bA ± 279
1.5 2127.09 aA ± 320 1746.37 abA±466
RC 1 1795.00 aA ± 443 2233.19 aA ± 448
1.5 1992.94 aA ± 412 2373.5 aA ± 420
PIC 1 891.71 bA ± 259 1441.71 bA ± 333
1.5 1514.47 aA ± 277 1898 abA±615
Abbreviations; LDC: Lithium disilicate glass ceramics, RC: CAD/CAM resin
composite, PIC: Polymer-infiltrated ceramic.
- Means with the same superscripted capital letters in the same row have no
significant difference. (Tukey HSD; p < 0.05).
- Means with the same superscripted small letters in the same columns have no
significant difference. (Tukey HSD; p˃0.05).
5
Journal of the Mechanical Behavior of Biomedical Materials 119 (2021) 104485
found between the 3 materials. No statistically significant difference
existed between both thicknesses of LDC and RC occlusal veneers
(p˃0.05).
For groups tested after 6-months storage, RC occlusal veneers with a
thickness of 1.5 mm showed the highest mean fracture resistance value
of (2373.5 ± 420 N) that was statistically significant from 1.0 mm LDC
and PIC veneers (p˂0.05). No statistically significant difference was
found between both thicknesses of the same material for all the tested
groups (p˃0.05). No significant difference was found between specimens
stored for 24-h and 6-months for all tested materials (p˃0.05). Mean
fracture resistance values for all the tested groups are illustrated in
Fig. 5.
3.2. Failure pattern analysis
The most common failure patterns in RC and PIC groups were scores I
and score II. For LDC groups, score IV and III were more dominant. For
all the tested groups, score II was the dominating failure pattern with
(38.1%) followed by score III with (22.6%), score I (21.4%), and score IV
(17.85%). Failure patterns distribution among different groups is illus­
trated in Fig. 6. Representative samples from each failure mode are
presented in Fig. 7.
4. Discussion
Based on the results of this study, fracture strength of CAD/CAM
occlusal veneers was significantly affected by changes in thickness and
material type while storage in artificial saliva had no significant impact
on fracture resistance mean values. Thus, the null hypothesis was
rejected.
Fracture strength is a challenging aspect of ceramic restorations as it
is influenced by an array of factors including cavity design, luting agent,
restoration thickness, mechanical properties of the restorative material,
and damage caused by occlusal functions (Cubas et al., 2011; Habekost
Lde et al., 2006; Morimoto et al., 2009; Rekow et al., 2011; Soares et al.,
2006). The inclusion of 2 thicknesses in this study was aimed to compare
the standard recommended thickness by the manufacture for posterior
partial coverage ceramic restorations (1.5 mm) with a minimally inva­
sive and yet a practical thickness of 1.0 mm. In specimens tested
following 24-h water storage, 1.0 mm PIC occlusal veneers exhibited a
significantly lower mean fracture resistance value compared to 1.5
restorations of the same material. However, it still exceeded the
maximum expected bite forces in the posterior region estimated at 850 N
(Waltimo and Kononen, 1993). This outcome is contradictory to the
results of previous studies (Andrade et al., 2018; Johnson et al., 2014),
in which fracture resistance of PIC occlusal veneers was not significantly
affected by changes in thicknesses. The disagreement could be attrib­
uted to variations in methodologies. Static tests are influenced by mul­
tiple factors including cementation procedure, specimen storage, aging
procedures, and test parameters which were different from the current
study.
When PIC and RC veneers were compared in a thickness of 1.0 mm in
both storage times, RC demonstrated a significantly higher fracture
resistance. This could be attributed to the composition of RC which
contains monodispersed, nano-aggregated, and nano-agglomerated
nanoparticles of silica (20 nm) and zirconia (4–11 nm) forming nano­
clusters (0.6–10 nm) which gives structural integrity and allows a high
portion of ceramic to be integrated. Furthermore, the interstitial spaces
between the particles are filled with nanomers leading to high ceramic
content (Egbert et al., 2015). In contrast (Ioannidis et al., 2019), found
no significant difference between fracture resistance of 0.5 and 1.0 mm
occlusal veneers manufactured from RC and PIC. The difference could be
related to variation in the bonding substrate. Restorations in the previ­
ously mentioned study (Ioannidis et al., 2019), were adhesively bonded
to enamel. Confining the substrate surface within enamel likely resulted
in improved adhesion and thus no significant difference existed between
E. Albelasy et al.
Fig. 5. Box plot showing fracture resistance mean values for all the tested groups. Stored for 24-h = U, Stored for 6 months = S.
Fig. 6. Percentage values of failure pattern among all groups.
the two materials. In the current study, the restorations were prepared to
simulate a clinical situation of advanced tooth wear where exposure of
dentine is inevitable.
Furthermore, in specimens tested after 24-h storage, 1.0 mm LDC
veneers exhibited a significantly higher fracture resistance value
compared to 1.0 mm PIC. This comes in agreement with a previous study
by Al-Akhali et al. (2017), who reported that LDC occlusal veneers at a
thickness of 0.8 mm demonstrated significantly higher fracture resis­
tance values compared to PIC with the same thickness. This could be
attributed to the higher mechanical properties of LDC in comparison
with PIC (Bindl et al., 2006). Moreover, it could be related to the
monolithic nature of LDC which facilitated a proper etching pattern with
hydrofluoric acid so that a stronger bond with adhesive resin may be
achieved (Borges et al., 2003). Interestingly, after 6-months storage, no
significant difference was found between 1.0 mm LDC and PIC veneers.
Fracture resistance values for PIC veneers increased after storage which
eliminated the difference between LDC and PIC.
In both 24-h and 6-months storage groups, LDC veneers with a
thickness of 1.5 mm showed mean fracture resistance values not
6
Journal of the Mechanical Behavior of Biomedical Materials 119 (2021) 104485
significant from veneers with 1.0 mm. This result came in agreement
with the results of (Bakeman et al., 2015) who reported that
glass-ceramic thickness in posterior restorations can be effectively
reduced to 1.0 mm when the restoration is adhesively bonded to the
underlying tooth structure. Thus, changes in thickness would only create
minor influences on the overall performance of the restoration (Albelasy
E et al., 2020). Similarly, no significant difference was found between
fracture resistance values for RC at both thicknesses (1.0 and 1.5)
following 24-h and 6 months of storage. This outcome is supported by
the results of (Andrade et al., 2018) and (Johnson et al., 2014) who
concluded that RC occlusal veneers were not significantly affected by
changes in thickness. When restoration thickness was increased to 1.5
mm in both storage times, no significant difference was detected be­
tween all tested materials despite inherent variations in their mechani­
cal properties. This outcome could indicate that fracture resistance
values did not necessarily correlate with the mechanical properties of
the tested materials. Lithium disilicate glass-ceramic exhibits the highest
flexural strength (360 MPa) followed by RC (205 MPa) and PIC
(150–160 MPa) (Egbert et al., 2015). The discrepancies between frac­
ture resistance values and mechanical properties of the tested materials
could be attributed to adhesion between the luting agent and the ma­
terial of the occlusal veneer. Furthermore, it could be an indication that
not only the material itself contributes to fracture resistance but rather
the entire tooth-luting agent-restoration complex. Moreover, it shows
that the mechanical behavior of the restored tooth complex (restorative
materials, adhesive system, and restored tooth) cannot be predicted.
When evaluating the effect of 6-months of artificial saliva storage on
fracture resistance values, no significant difference was observed be­
tween specimens stored for 24-h and those tested after 6-months. This
could be attributed to the controlled industrial process associated with
the manufacturing of CAD/CAM blocks which reduced the risk of po­
rosities and resulted in a more homogenous material that is less sus­
ceptible to water sorption (Czasch and Ilie, 2013). Therefore, higher and
more solid mechanical properties can be expected (Stawarczyk et al.,
2015). On the contrary (Lauvahutanon et al., 2014), had reported hy­
drolysis of polymer materials following storage possibly as a result of
material content. Moreover, it was suggested that water sorption could
E. Albelasy et al.
Fig. 7. Failure patterns under stereomicroscope. A; score I in a specimen from group PIC-1.5-S, B; score II in a specimen from group RC-1.5-S, C; score III in a
specimen from group PIC-1.5-U and D; score IV in a specimen from group LDC-1-S. Stored for 24 = hours = U and stored for 6-months = S.
cause hydrolysis of the interfacial silane coupling agent, especially in the
case of zirconium silicate which is not effectively silanized due to its
high crystalline content (Druck et al., 2015). Accordingly, the mechan­
ical properties of zirconia containing RC could decrease after storage
(Lauvahutanon et al., 2014). However, in the current study, fracture
resistance values for both PIC and RC veneers increased (although not
significantly) following storage. This could be related to the plasticiza­
tion of the resin matrix due to water sorption. Matrix plasticization could
have resulted in an increase in fracture energy of the materials and a
reduction in the yield stress which allowed the development of a larger
yield zone in front of the crack tip. This zone represents an area of plastic
deformation which absorbs the energy from the elastically strained
material (Indrani et al., 1995). Further research is essential to test the
impact of storage media, duration, and temperature on the performance
of CAD/CAM resin-matrix ceramics.
All the tested CAD/CAM occlusal veneers at both thicknesses
demonstrated fracture resistance values exceeding normal masticatory
forces in the posterior region. Moreover, the recorded fracture resistance
values in this study exceeded masticatory forces in individuals with
parafunctional habits ranging from 780 N to 1120 N (Waltimo et al.,
1994). This positive outcome may be accredited to the adhesive tech­
nique which allowed close contact between the dentinal substrate, lut­
ing agent, and restorative material. Thus, the applied force can be
dissipated through the tooth, periodontal ligament, and alveolar bone
(Magne and Cheung, 2017; Magne and Douglas, 1999).
Regarding failure patterns, no correlation with fracture strength
values was observed. This means that higher fracture strength values did
not cause undesirable damage to the tooth structure. The predominant
failure patterns in RC groups were scores I and II which are favorable
fracture patterns with no damage to the tooth structure. Conversely, LDC
veneers showed a prevalence of mode III and IV fractures. This could be
attributed to the composition of RC and its modulus of elasticity of (12.8
GPa) which is similar to that of dentin (5.5–19.3 GPa). Modulus of
elasticity influences the susceptibility of a ceramic restoration to frac­
ture since materials with more compatible elastic modulus tend to bend
under load and distribute stresses more evenly (El-Damanhoury et al.,
2015), whereas more rigid materials like glass-ceramic produce stress
concentration at critical areas that might cause catastrophic fractures
(Al-Omari et al., 2010; Saupe et al., 1996). In PIC groups, the incidence
of favorable fracture patterns (score I and II) was more dominant. Taha
et al. (2018), reported a similar outcome when evaluating the failure
pattern of PIC endocrowns. This could be explained by the presence of
polymer phase within the ceramic network which gives the onset of
7
Journal of the Mechanical Behavior of Biomedical Materials 119 (2021) 104485
plasticity to the bulk material demonstrating the Dugdale cracking
model. In this model, the presence of a polymer chain could spread the
plasticity under the increase of load and hence increase the crack
resistance with the crack length (He et al., 2011; Taha et al., 2018).
In the current study, all efforts were exerted to simulate physiologic
oral conditions including thermal cycling, use of natural teeth rather
than epoxy resin dies, and standardization of thickness measurements.
Thus, the results of this experimental study were assumed to be clinically
relevant. Since artificial saliva aging had no pronounced effect on
fracture resistance values, the survival of occlusal veneers in the oral
environment could be anticipated. However, despite positive outcomes
of minimally invasive occlusal veneers in this study, presumptions of
clinical success might be too early to make due to the limitations of this
work. Inherent morphological variations among extracted teeth might
have resulted in variations in fracture resistance values and a relatively
high standard deviation. Also, the nature of force in the oral cavity is not
strictly compressive. Failure of restorations intraorally usually occurs
under multiple cycles of fatigue rather than a constant axial load.
Therefore, fracture resistance value solely is not indicative of the long-
term success of the restorations.
5. Conclusions
Glass-ceramic, polymer-infiltrated ceramics, and CAD/CAM resin
composite occlusal veneers with a thickness of 1.0 could represent a
conservative alternative for restoring vertical dimensions in patients
with advanced tooth wear. Polymeric materials are a potential alterna­
tive to all-ceramic restorations in terms of favorable fracture patterns
and the possibility of intraoral repair.
Authorship contributions
Category 1.
Conception and design of study: HH HAMAMA, J Tsoi, SH Mahmoud
Acquisition of data: E Albelasy, HH HAMAMA, J Tsoi, SH Mahmoud
Analysis and/or interpretation of data: E Albelasy, HH HAMAMA.
Category 2.
Drafting the manuscript: E Albelasy, HH HAMAMA
Revising the manuscript critically for important intellectual content:
HH HAMAMA, J Tsoi, SH Mahmoud.
Category 3.
Approval of the version of the manuscript to be published (the names
of all authors must be listed): E Albelasy, HH HAMAMA, J Tsoi, SH
E. Albelasy et al.
Mahmoud.
Disclosure statement
None.
Funding source
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Declaration of competing interest
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influence
the work reported in this paper.
Acknowledgments
The authors would like to thank Dr. Noha Saleh, a lecturer at the
pharmaceutical Department, Faculty of Pharmacy, Mansoura Univer­
sity, for the preparation of artificial saliva.
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