Clinical Oral Investigations

https://doi.org/10.1007/s00784-019-03190-7

ORIGINAL ARTICLE

Estimation of stress distribution and risk of failure

for maxillary premolar restored by occlusal veneer with different
CAD/CAM materials and preparation designs
Xiao-qiong Huang 1 & Nan-rui Hong 1,2 & Lei-yan Zou 1 & Shu-yi Wu 1 & Yan Li 1

Received: 23 October 2018 / Accepted: 26 December 2019

# Springer-Verlag GmbH Germany, part of Springer Nature 2020

Abstract
Objectives To compare stress distribution and failure probability in maxillary premolars restored by simple occlusal veneer
(SOV) and buccal-occlusal veneer (BOV) with 3 different CAD/CAM materials.
Materials and methods A maxillary premolar was digitized by a micro-CT scanner. Three-dimensional dynamic scan data were
transformed, and finite element models of 2 different models (SOVand BOV restored teeth) were designed. Three different CAD/
CAM materials, including lithium disilicate glass ceramic (LD) IPS e.max CAD, polymer-infiltrated ceramic-network (PICN)
Vita Enamic, and resin nano-ceramic (RNC) Lava Ultimate, were designated to both veneers. Maximum principle stresses were
determined by applying a 300-N axial load to the occlusal surface. Weibull analyses were performed to calculate the failure
probability of the models.
Results LD-restored teeth showed the highest stress in the veneer, lowest stress in substrate teeth, and lowest failure probability
for the overall system; RNC-restored teeth showed the lowest stress in the veneer, highest stress in substrate teeth, and highest
failure probability. No significant differences were found in the cement layer among the different models. No significant
differences of stress and failure probability existed between SOV and BOV preparations.
Conclusions CAD/CAM composite resin occlusal veneers bear lower maximum stress than ceramic veneers. Teeth restored by
composite veneers are more prone to failure than those restored by ceramic veneers. Additional reduction of the buccal surface
did not increase the stress on the occlusal veneer under axial load.
Clinical relevance Both occlusal veneers could be used under physiological masticatory force. CAD/CAM glass ceramic was
safer than composite resins.

Keywords Occlusal veneer . CAD/CAM . Preparation design . Finite element analysis . Weibull analysis

Introduction

Yan Li and Shu-yi Wu contributed equally to this work.
Electronic supplementary material The online version of this article
(https://doi.org/10.1007/s00784-019-03190-7) contains supplementary
material, which is available to authorized users.
* Shu-yi Wu
shuyiwu@21cn.com
* Yan Li
dliyan2004@126.com
1 crown) of premolars typically results in excessive reduc-
Department of Prosthodontics, Guanghua School of Stomatology,
Guangdong Provincial Key Laboratory of Stomatology, Sun Yat-sen
University, No. 56 Lingyuan West Road, Guangzhou 510055, China
2
Department of Stomatology, The First Affiliated Hospital of
Guangzhou University of Chinese Medicine, Guangzhou, China
With the development of adhesive bonding techniques,
minimally invasive dentistry is currently a popular topic
in clinical restorative dentistry. Preserving tooth structure
is critical for the longevity of teeth and restorations [1].
Previous studies have shown that molars restored with
occlusal veneers showed satisfactory mechanics, which
supports the treatment of occlusal abrasion and erosion
with non-retentive occlusal veneers [2, 3]. The special
anatomic form (narrower in the cervical one third of the
tion of tooth structure during preparation for a complete
crown [4]. However, there is a lack of data regarding
premolars restored by ceramic and composite resin occlu-
sal veneers.

Computer-aided design and computer-aided manufacturing
(CAD/CAM) technology has been widely used in prosthodon-
tics [5, 6]. Most materials are now fully produced under in-
dustrial conditions, ensuring quality standards hardly
achieved in laboratory-based processing [7]. The industrial
environment of CAD/CAM fabrication remarkably reduces
possible origins of defects or flaws, and it supports testing of
the mechanical strength of the produced blocks because of its
accurate quality control [8].
Lithium disilicate (LD) is a synthetic glass ceramic that has
been used for many years for tooth restoration; it exhibits good
esthetics and mechanical properties, as well as excellent ad-
hesion to dental tissues [9]. It demonstrates an ideal survival
rate in posterior teeth in clinical practice [10, 11]. Compared to
ceramic blocks, resin composite blocks are more easily adjust-
ed, milled, and repaired; they even show greater bond strength
to resin-based adhesive materials [5, 12]. Recently, polymer-
infiltrated ceramic-network (PICN) material and resin nano-
ceramics (RNC) blocks have been introduced as alternatives
to ceramic blocks [13]. The PICN material VITA Enamic
(VITA Zahnfabrik, Bad Säckingen, Germany) comprises
two continuous interpenetrating networks and is formed by
penetration of the presintered ceramic phase into a polymer
with capillary activity [14–16]. The flexural strength, elastic
modulus, hardness, and strain at failure of PICN structures
showed similar properties to tooth structure [15]. The RNC
blocks (Lava Ultimate, 3M ESPE, Bad Seefeld, Germany)
consist of nano-ceramic particles deep-seated in a highly
crosslinked resin network [16]. Both newly developed com-
posite resin blocks can be used for inlays, onlays, and veneers,
in accordance with the manufacturers’ instructions. The com-
bination of CAD/CAM technologies and bonding protocol
development contributes to and promotes the application of
innovative non-retentive occlusal veneer for posterior
restoration.
Occlusal reduction is considered a fundamental step for
providing uniform space and adequate bonding for posterior
prosthesis. There is controversy regarding the preparation, de-
sign, and selection of the restorative material used for occlusal
veneer. In our study, the buccal-occlusal veneer (BOV) de-
sign, involving tooth reduction of both buccal and occlusal
surfaces, is compared to the simple occlusal veneer (SOV),
which involves reduction of the occlusal surface only. There
are three reasons for introducing the BOV design: (1) Dental
defects, including occlusal wear and cervical wedge-shaped
defects on the buccal surface, are a major clinical manifesta-
tion of occlusal disease [17]. (2) The maxillary first premolars
are in the aesthetic region while laughing. Thus, restoration of
the buccal and occlusal surfaces could simultaneously meet
the patients’ aesthetic and functional demands for the affected
tooth. (3) The bond strength of the enamel-cement interface is
superior to that of the dentin-cement interface [18]. Buccal
surface reduction in our study was restricted to the enamel
Clin Oral Invest
layer, which may increase the bond strength between the ve-
neer and tooth.
Finite element analysis (FEA) has gained increasing popu-
larity in dental research because it facilitates the investigation
of complex geometries and helps to study the influence of
geometry or stiffness of different materials [19]. By simulating
occlusal loading conditions in finite element models, the stress
distribution of each component can be predicted, and the ef-
fect of material or preparation design on the biomechanical
performance of occlusal veneers can be revealed [5].
However, predicting the risk of failure and longevity of tooth
restorations cannot be achieved simply by FEA; this requires
Weibull analyses [20], which can be used to calculate the
probability of fracture in brittle materials and to predict cumu-
lative failure probability at different levels of stress [21].
The aim of this study was to investigate the effect of CAD/
CAM restorative materials and tooth preparation designs
(SOV and BOV) on the mechanical behavior and risk of fail-
ure for a maxillary premolar restored by occlusal veneers. The
first null hypothesis was that no differences exist in stress
distribution and failure probability among multiple restorative
materials (LD, PICN, and RNC). The second null hypothesis
was that no differences exist in stress distribution and failure
probability between two preparation designs (SOVand BOV).
Material and methods
Finite element (FE) model generation
This study was approved by the appropriate ethics review
committee. An intact human maxillary premolar, extracted
for orthodontic reasons, was scanned by using micro-
computed tomography (micro-CT) (μCT50, SCANCO
Medical AG, Bassersdorf, Switzerland) with a voxel dimen-
sion of 15.8 μm and an operating voltage of 70 kV. From 1358
slices obtained after scanning, 136 slices were used for model-
ing. Informed consent was obtained from the patient who
provided the test tooth.
Micro-CT images were processed by using an interactive
medical image control system (Mimics 16.0, Materialise,
Leuven, Belgium), which converted the 2-dimensional images
into a 3-dimensional (3D) model. Masks were created by
growing threshold regions, based on image density, to sepa-
rate and identify enamel and dentin portions of the tooth. The
pulp chamber and root canals were generated as an empty
space. Each mask (enamel, dentin) was separately converted
into stereolithography (STL) files and then further manipulat-
ed with Geomagic Studio 2013 (Geomagic GmbH, Stuttgart,
Germany) to establish perfect congruence of the interface be-
tween different objects. The polygon objects were repaired,
smoothened, and prepared for the process of exact surface.
After fitting surfaces, the polygon objects were exported to
Clin Oral Invest
step (STP) file format as CAD objects. In Solidworks 2017
(SolidWorks Corp., Concord, MA, USA), a preparation pro-
cedure for restoration was simulated and other CAD objects
were created by performing multiple Boolean and other oper-
ations on the intact tooth model. Two occlusal veneer prepa-
rations were modeled as follows:
(1) SOV: occlusal surface height was reduced by 1.0–
1.2 mm in this preparation type;
(2) BOV: occlusal surface height was reduced by 1.0–
1.2 mm and buccal surface thickness was reduced by
0.3–0.8 mm in this preparation type.
The thicknesses of occlusal surface reduction of the two
models were consistent with each other. All angles were
rounded. Veneers were designed with an external morphology
corresponding to that of the original tooth. Three CAD/CAM
materials were used for each type of preparation design:
(1) IPS e.max CAD (Ivoclar Vivadent AG, Schaan,
Liechtenstein): this ceramic block was selected as the
representative for lithium disilicate glass ceramic blocks
and was coded as LD;
(2) VITA Enamic: this composite resin block was selected as
the representative for polymer-infiltrated ceramic-net-
work material and was coded as PICN;
(3) Lava Ultimate: this composite resin block was selected
as the representative for resin nano-ceramic blocks and
was coded as RNC.
The cement layer was set as 50 μm thick. Periodontal liga-
ment (PDL) was modeled at 0.2 mm thickness, starting from
approximately 1 mm apically to the cementoenamel junction
and surrounding the tooth root. Surrounding bone was modeled
based on PDL geometry, with 2-mm thick cortical bone and 10-
mm thick spongious bone. The buccal-lingual and anterior-
posterior dimensions of the bone were designated as 13 and
10 mm, respectively. A simulated food layer (0.2 mm thick-
ness) was created based on the geometry of the occlusal sur-
face. A simulated indenter (stainless steel dome), with a
semisphere of Ф = 5.5 mm, was used to simultaneously apply
the load on 2 cusps of the veneers. Figure 1 shows the 2 model
assemblies with different tooth preparations in an expanded
view, displaying each individual material component.
FE analyses
The constructed model elements were assembled into a whole
model with Solidworks and imported to the FE analysis soft-
ware of ANSYS 17.0 Workbench (ANSYS, Canonsburg, PA,
USA). All models consisted of 10-node tetrahedral structural
solid elements with quadratic displacement behavior. These
elements are suitable for modeling irregular meshes [22].
The accuracy and efficiency of numerical simulations was
checked by convergence tests [5, 22]. Stresses in critical re-
gions were compared at different mesh refinements to ensure
that the solution converged on a limiting value for each case.
We used maximum principal stress of the occlusal veneers,
which constituted our main results, as a representative index
for convergence test of the whole models.
All materials were assumed to be linear elastic, homoge-
neous, and isotropic. The material properties (including
Young’s modulus and Poisson’s ratio) are quoted from other
literature (Table 1).
For boundary conditions, the external surface of surround-
ing bone was fixed in all directions, and the indenter was
restricted to movement along the Z-axis. A surface-to-
surface sliding contact, without separation, was defined be-
tween the indenter and food layer to simulate tooth and food
contact while chewing, whereas all other interfaces were as-
sumed to be completely bonded.
Average normal biting force is approximately 322.5 N for
the maxillary premolar clinically [23, 28]; therefore, an ap-
proximate value of 300 N was adopted in our research. The
load was applied to the indenter along the Z-axis, and the
indenter contacted the food layer on both cusps of the restored
maxillary premolar simultaneously, in order to simulate phys-
iologic loads during occlusion.
Since the FE model was linear, stresses of other loads
(100–1500 N, in 100 N increments) were calculated in pro-
portion to the data of the 300-N load; results were validated in
FEA. For each combination of experimental factor levels at
300 N, maximum principal stress values were determined for
veneer, cement layer, enamel, and dentin separately and the
results are presented as bar graphs.
Weibull analyses
All materials in our analyses were assumed to be linear elastic,
and their failure was assumed to follow the normal stress failure
criterion in Weibull risk-of-rupture analysis. Failures were pre-
sumed to occur from the highest principal tensile stress on stress
concentration areas. Therefore, the survival probability, Ps, is
given as follows in Weibull analysis [20, 21]:
  m 
σ
Ps ðσÞ ¼ exp − ;
σ0
where Ps represents the survival probability of a node at stress σ
(for load F), σ represents the failure stress (maximum principal
stress), σ0 represents the characteristic strength, which is a nor-
malizing parameter corresponding to the stress at which 63% of
specimens fail, and m represents the Weibull modulus, which is
a material parameter determined by the flaw size distribution
[21, 29]. When loaded, a restoration will survive until the risk-
 Clin Oral Invest

Fig. 1 Material components of

simulation models. Model simple
occlusal veneer (SOV) at the left
side and model buccal-occlusal
veneer (BOV) at the right side

of-rupture reaches a critical value at any one of the multiple

Ps ¼ ∏i Psi ;
failure sources. For a system of n = i sources, the overall sur-
vival probability, Ps, is the product of individual survival prob- where i = 1, 2, 3, 4 in the case of the occlusal veneer restored
abilities [21, 23]: tooth with different restorations; the stress concentration

Table 1 Mechanical properties of materials used in finite element and Weibull analyses

Material Young’s modulus (MPa) Poisson’s ratio Characteristic strength (MPa) Weibull modulus

Enamel [23, 24] 84,100 0.30 42.41 5.53

Dentin [23, 24] 18,600 0.30 44.45 3.35
Food layer (polyethylene) [25] 900 0.46
Indenter (structural steel)a 200,000 0.30
PDL [26] 68.9 0.45
Spongious bone [26] 1370 0.30
Cortical bone [26] 13,700 0.30
Resin cement [23, 27] 8300 0.35 453.8 4.02
IPS e.max CAD [7, 8] 102,700 0.215 609.80 13.40
Vita Enamic [7, 8] 37,800 0.244 193.45 18.80
Lava Ultimate [7, 8] 12,700 0.45 300.64 10.90
a
From database in ANSYS
Clin Oral Invest
regions of enamel, dentin, cement layer, and occlusal veneer
were observed to be at risk. Thus, the failure probability, Pf, for
the total system is determined by:
P f ¼ 1−Ps1  Ps2  Ps3  Ps4 :
Curves reflecting failure probability versus load for each
occlusal veneer itself and each overall system in the restored
premolar were calculated and compared. σ0 and m of different
materials were obtained from the literature (Table 1).
Results
Two basic finite element models were established. Figure 2
shows that for all assemblies, the maximum principal stress at
the critical region of occlusal veneers stabilized with succes-
sive iterations of mesh refinement under a 300-N axial load.
The accuracies and efficiencies were confirmed by conver-
gence tests. These results indicated that the maximum princi-
pal stress value was numerically accurate and all modeling
assumptions were valid. The final SOV model showed
1,236,849 elements and 1,761,660 nodes, while the final
BOV model showed 1,238,734 elements and 1,767,215 nodes
(Fig. 3).
The peak values of maximum principal stress for each com-
ponent part of the restored tooth (occlusal veneers, cement
layer, enamel, and dentin) with different preparation designs
using different CAD/CAM materials are presented in Fig. 4.
Cloud atlases showing the stress distribution on the occlusal
veneer were generated by ANSYS Workbench under a 300-N
axial load and are shown in Fig. 5. Generally, SOV and BOV
models showed similar maximum principal stress values in
each layer with the same restorative material. The highest
tensile stress (positive values of the maximum principle stress)
was concentrated at the central fissure, and the highest com-
pressive stress (negative values of the maximum principle
stress) was concentrated in the region of the load application
area on the occlusal surface (Fig. 5). The BOV design showed
higher maximum principal stress than the SOV design for
Fig. 2 Convergence test for the maximum principal stress at the critical region central fissure of occlusal veneers resulting from a 300-N vertical load: a
for model simple occlusal veneer (SOV), and b for model buccal-occlusal veneer (BOV)
composite resin veneers PICN and RNC (Fig. 4a).
Maximum stress in the cement layer was slightly higher in
the model BOV than in SOV with no significant differences
(Fig. 4b).
The maximum principal stress value on veneer (Fig. 4a) for
LD glass ceramic was highest among the 3 materials. In the
model SOV, the stress for LD (135.7 MPa) was 1.5 times
higher than for PICN (89.9 MPa) and 2.6 times higher than
for RNC (52.8 MPa). In the model BOV, the stress for LD
(134.7 MPa) was 1.4 times higher than for PICN (95.6 MPa)
and 2.2 times higher than for RNC (61.7 MPa). From the
cloud atlas (Fig. 5), the area of stress concentration at the
central groove on the occlusal veneer was the largest for
RNC, and smallest for LD. The maximum principal stress
on cement (Fig. 4b) for the 3 materials, however, showed no
significant differences.
The stress of enamel under the RNC restoration was higher
than under the other two restorations (Fig. 4c). In the model
SOV (Fig. 4c), compared with the stress value for LD
(26.4 MPa), the stress value on enamel increased 1.3 times
for PICN (35.6 MPa) and 2.2 times for RNC (56.8 MPa). In
the model BOV (Fig. 4c), compared with LD (26.2 MPa),
stress values on enamel increased 1.3 times for PICN
(34.6 MPa) and 2.1 times for RNC (54.9 MPa).
Regarding stress on dentin among the 3 materials (Fig. 4d),
the stress value in group RNC was nearly 2 times higher than
in groups LD or PICN.
For the failure probability of the occlusal veneer itself,
there were significant differences among the materials. PICN
showed the highest failure probability, and RNC showed the
lowest. The model BOV showed higher probability of veneer
failure than model SOV in the RNC group. There were no
significant differences between SOV and BOV preparations
in PICN and LD groups (Fig. 6a).
However, premolars restored with RNC showed the
highest overall failure probability, while those restored with
LD showed the lowest. This indicated that LD-restored tooth
is the safest, compared with tooth restored by RNC and PICN.
The model SOV showed a slightly higher overall failure prob-
ability than model BOV in the LD group. There were no
 Clin Oral Invest

Fig. 3 Finite element (FE) models with load protocol and mesh configuration: a model simple occlusal veneer (SOV) with sagittal cross-section on the
lower left corner, b model buccal-occlusal veneer (BOV) with sagittal cross-section on the lower left corner

Fig. 4 The peak values of maximum principal stress for veneer, cement design/computer-aided manufacturing (CAD/CAM) materials: a for oc-
layer, enamel, and dentin of simple occlusal veneer (SOV) and buccal- clusal veneer, b for cement layer, c for enamel, and d for dentin
occlusal veneer (BOV) preparation designs with three computer-aided
Clin Oral Invest

Fig. 5 Image showing maximum principal stress values in megapascal infiltrated ceramic-network (PICN), d for model BOV with PICN, e for
with sagittal cross-section on the lower left corner: a for model simple model SOV with resin nano-ceramic (RNC), and f for model BOV with
occlusal veneer (SOV) with lithium disilicate (LD), b for model buccal- RNC
occlusal veneer (BOV) with LD, c for model SOV with polymer-

Fig. 6 Failure probability versus load curves of models according to Weibull risk-of-rupture analysis: for a occlusal veneer and b overall failure
probability
significant differences between SOV and BOV preparation in
RNC and PICN group (Fig. 6b).
Discussion
Our study examined 3 different materials and 2 preparation
designs for occlusal veneers for advanced erosion or abrasion
of a maxillary premolar. The first null hypothesis was rejected
because of significant differences in stress and failure risk
based on material selection in both occlusal veneer and the
tooth. The second null hypothesis was not rejected because
there were no significant differences in stress and failure risk
based on the 2 preparation designs in our study.
The modeling process in the present study can be repeated
and reproduced. We used micro-CT to obtain realistic models
of dental tissue, which include anatomical irregularities of the
real premolar tooth. Different parts of the teeth were identified
in Mimics software. The interface of the dentinoenamel junc-
tion was strictly controlled and smoothened by following an
optimization procedure in Geomagic software; therefore, no
overlaps or gaps existed between dentin and enamel. Occlusal
veneers were modeled on enamel and dentin by using curved
surface cutting tools in SolidWorks. The differences of model-
ing designs between SOV and BOV were the buccal surface
preparation. The common occlusal surface preparation
remained consistent, while the SOV model performed addi-
tional preparation of the buccal surface. We also introduced
models of PDL and alveolar bone for maximum simulation of
dental structure. Modeling the surrounding tissue is important,
particularly in terms of boundary conditions, to obtain accu-
rate results. The most external part of the surrounding bone
was constrained in all 6 degrees of freedom, which is consid-
ered to be a realistic boundary condition for providing an
optimum prediction of stress state in the tooth-cement-
restoration system [30]. PDL also plays a key role in transfer-
ring force during mastication [31]. Ignoring the PDL may
Clin Oral Invest
oversimplify the model and result in inaccurate stress distri-
bution. Moreover, we employed axial loading through an in-
denter with a simulated food layer to avoid stress concentra-
tion on the restorations [25]. The complex modeling enables
the stress distribution to be more realistic and reliable for
clinical guidance.
Small differences may remain between reality and finite
element simulation; however, FEA can calculate inaccessible
stress within the restoration complex [32]. FEA has proven to
be an appropriate method to understand restoration biome-
chanics and has been used to optimize design and material
selection in dentistry. It can simulate and compare two differ-
ent preparation designs in the same tooth with applied tissue
properties and thickness, which is difficult to achieve in vitro
[32]. The mechanical properties of materials used in finite
element and Weibull analyses were derived from various pre-
vious studies (Table 1), which could have introduced errors.
However, the mechanical properties of three CAD/CAM ma-
terials used for key comparisons were derived from the same
study, which could minimize deviations and ensure compara-
bility among different models [7, 8].
The conventional treatment for severe tooth erosion or
abrasion involves a crown; however, with the development
of adhesive dentistry and minimally invasive treatment, non-
retentive occlusal veneer serves as an alternative for more
conservative treatment. Occlusal veneer also reduces the need
for retentive geometry preparation of onlays or inlays and
preserves the maximum tooth structure in the posterior area.
Dental cements promote the required adhesive retention of
indirect restorations to the remaining tooth substrate surface
and seal tooth margins [33]. Occlusal veneer often involves
reduction of the occlusal surface alone; this was called SOV in
our study, in order to distinguish it from the BOV design. In
buccal-occlusal preparations, the use of the veneer ensures a
more esthetic restoration, in addition to providing functional
occlusion recovery. Bonding to the buccal enamel surface
undoubtedly improved bond strength, which may be more
Clin Oral Invest
important for a non-retentive occlusal veneer [18, 34]. Buccal
surface preparation should be performed completely in enam-
el to maintain an optimal bond with veneers and to decrease
stresses in the restoration [34]. However, with the longer mar-
ginal line of BOV preparation, the risk of micro-leakage may
increase.
From the numeric FEA data, we found that the preparation
design of the premolar veneer (SOV and BOV) has no distinct
influence on stress values in the veneer, cement, enamel, or
dentin. The following reasons may explain these results: (1)
FE and Weibull analyses were performed under the assump-
tion of a completely bonded interface among the tooth, ce-
ment, and restoration, such that the adhesive interfacial
debonding mechanism was not simulated. Morimoto et al.
[35] indicated that fractures were the most frequent type of
failure in partial coverage restoration. Therefore, the failure
type caused by stress concentration in our study primarily
comprises fractures or chipping of the restoration. (2)
Preparations of SOV and BOV on the occlusal surface were
simulated to be perfectly consistent with each other. The only
difference between these two models was the buccal surface
on the enamel portion. The cements were uniformly distribut-
ed with a thickness of 50 μm. Axial centric load was applied
on the occlusal veneer through a stainless steel-made indenter,
without considering lateral force components. The buccal sur-
face was approximately paralleled with the axial load direc-
tion. Therefore, buccal reduction may not have influenced the
stress state under axial centric load.
The maximum principal stress in veneer positively corre-
lated with the elastic modulus value of the restorative mate-
rials, while dentin and enamel in the corresponding model
negatively correlated with the elastic modulus value. The ma-
terial with lower elastic modulus (composite resin) generated
lower stress at the central fossa on the occlusal surface of the
veneer. The stress was more uniformly distributed on the oc-
clusal surface, since the range (maximum stress minus mini-
mum stress) of the stress value of the RNC was lowest among
the 3 materials. Our results were in accordance with the find-
ings reported by Magne et al. [24], who compared ultrathin
occlusal veneers made with 3 CAD/CAM materials with dif-
ferent elastic properties (including composite resin and ceram-
ic). Magne et al. [24] demonstrated that composite resin ve-
neer had lower stress concentration, compared to ceramic ve-
neer. The substrate tooth structures restored by composite res-
in exhibited greater stress levels under the same bite force,
compared with that restored by glass ceramic restorations,
eventually leading to a compromised long-term survival rate
of the substrate tooth. An increase in the stiffness of the ve-
neer, from 12.7 to 102.7 GPa, showed reduced maximum
principal stress within the enamel and dentin. A possible ex-
planation may be that the reasonable high elastic modulus
restorative material (102.7 GPa) could absorb some stresses;
thus, less stress might be delivered to the underlying enamel
and dentin. However, different restorative materials had no
significant effect on the cement layer, which was too flexible
and thin to act as a stress relieving factor or to present different
effects in our study.
Cyclic load fatigue test can better reflect the clinical situa-
tion of restoration failure than a single catastrophic event. The
results from static FEA are not sufficient because a monotonic
load does not represent the clinical situation in which repeti-
tive fatigue loading is characteristic [23]. Therefore, we com-
bined Weibull analyses and FEA under different vertical load
conditions to predict cumulative failure probability of clinical
longevity for restorations.
Obtaining the appropriate characteristic strength and
Weibull modulus was the main task in Weibull analyses.
Characteristic strength and Weibull modulus of the 3 CAD/
CAM materials were detected by Wendler et al. [8] using ball-
on-3-balls (B3B)-plate test. Sample size in their study was
similar to the veneer in our study, which makes the results
reasonably comparable. Brittle materials, such as tooth,
CAD/CAM materials, and cement are prone to tensile frac-
ture. Maximum principal stress was accepted as a suitable
index for judging material failure. Therefore, maximum prin-
cipal stress was noted on each element for the presented ten-
sile characteristics for elements under different load condi-
tions, in order to calculate Weibull cumulative failure proba-
bilities [23].
The three CAD/CAM materials showed significant differ-
ences in the failure probability of the overall system (including
occlusal veneer, cement, enamel, and dentin). Tooth restored
with RNC showed the highest failure risk, whereas tooth re-
stored with LD showed the lowest failure risk. Clinically, the
normal biting force is 222–445 N for the maxillary premolar
area. During clenching, the occlusal force is approximately
520–800 N [23, 28]. Considering the tooth-veneer complexes,
under normal biting force, RNC is not recommended in pos-
terior occlusal veneer restoration. Under clenching biting
force, LD-restored tooth is the only type of complex recom-
mended clinically because PICN- and RNC-restored teeth ex-
hibited a failure probability of nearly 100%. The results indi-
cate that the ceramic veneer performed better than composite
resin veneer, which is in accordance with a 3-year clinical
study by Vanoorbeek et al. [36]. For up to 3 years of function,
all-ceramic single-tooth restorations have superior success
rates compared to all-composite resin restorations.
Therefore, all-ceramic restorations remain the preferred treat-
ment for CAD/CAM-generated, metal-free, single-tooth res-
torations [36]. The Weibull curve of the LD-restored tooth was
also consistent with the study by Chun-Li et al. [23], who
reported that the overall failure probabilities were approxi-
mately 20–30% for onlay restorations in normal occlusal con-
ditions, while the probabilities were almost 100% in clenching
conditions. There were no significant differences in failure
probabilities between BOV and SOV designs. These results

imply that buccal reduction is appropriate for patients who
need better aesthetics and more enamel bonding, where reduc-
tion would not influence the risk of failure. Morimoto et al.
[35] also concluded that there was no relationship between
fractures and type of preparation for partial coverage
restorations.
Although the results from this study were obtained from an
accurate micro-CT scan of an isolated tooth, and the modeling
and analysis of the 3D finite element were complicated and
accurate, some aspects of in vivo natural physiological behav-
iors, such as oral environment and cyclic loading, were not
reproduced. Most dental tissues, such as enamel, dentin, PDL,
and cortical bone, present heterogeneous, anisotropic, and
non-linear viscoelastic behaviors; however, it is hard to intro-
duce these behaviors in FE modeling [37, 38]. Therefore,
isotropic, homogenous and linear elastic assumptions are con-
sidered in most qualitative studies in the literature, due to their
simplicity [5, 38]. Note that the linear elastic material model is
a valid assumption for brittle materials with little deformation
[26]. Despite the limitations of FEA and Weibull analyses, the
results provided an insight into 2 veneer designs and 3 CAD/
CAM materials. The results should be considered along with
experimental research and clinical data. However, no direct
clinical data are currently available on this issue; further ex-
perimental and clinical evidence is therefore needed for clin-
ical decisions.
We focused on vital teeth restored by occlusal veneers
in our study. However, to address cases involving severe-
ly worn teeth that affect or nearly affect the pulp, the use
of occlusal veneers may be extended to root canal-treated
teeth in the future. In this regard, more research is needed
to determine the effects of different CAD/CAM materials
and preparation designs on the mechanical behavior of
root canal-treated teeth that were restored by occlusal
veneers.
Conclusions
Within the limitations of the 3D FEA and Weibull analyses,
the following conclusions can be drawn:
(1) Greater stress distribution was observed at the central
fossa on the occlusal surface for each occlusal veneer.
(2) Reduction of both buccal and occlusal surfaces did not
affect the stress state or risk of failure of premolar veneer,
compared with simple occlusal veneer.
(3) CAD/CAM LD glass ceramic performed better (lower
stress on substrate teeth and lower failure probability)
for treatment of severe erosion or abrasion lesions in a
premolar than composite resin for both occlusal veneer
designs.
Clin Oral Invest
Funding This study was supported by the Sun Yat-sen University
Clinical Research 5010 Programme (grant number 2016006).
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflict of
interest.
Ethical approval All procedures performed in studies involving human
participants were in accordance with the ethical standards of the institu-
tional and/or national research committee and with the 1964 Helsinki
declaration and its later amendments or comparable ethical standards.
Informed consent Informed consent was obtained from all individual
participants included in the study.
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