VOLUME 40 NUMBER 8 SEPTEMBER 2009 655

QUI NTESSENCE I NTERNATI ONAL

Long-term experience has shown that hot-
pressed glass-ceramics, which ensure good
esthetic results, as well as a good biologic
compatibility, are suitable as adhesively
bonded posterior crowns in clinical applica-
tion. Against the background of new and
faster technologies (computer-aided design/
manufacturing [CAD/CAM]), easier handling
(no adhesive cementation required), and
increased strength, new materials are being
introduced into the market. Standardized
computer-controlled ceramic processes such
as milling (Lava, 3M ESPE; Cercon,
DeguDent), ceramic buildup (ce.novation,
ce.novation), or computerized slip casting/
electrophoresis (alumina-ceramic Wolceram,
Wolceram) are discussed for the fabrication
of dental restorations.
1,2
Both high-strength
hot isostatically pressed (HIP) or partially sta-
bilized zirconia ceramics show a high frac-
ture strength with a small range of strength
Fracture performance of computer-aided
manufactured zirconia and alloy crowns
Martin Rosentritt, PhD
1
/Michael Behr, PhD
2
/Christian Thaller, DDS
3
/
Heike Rudolph, DDS
4
/Albert Feilzer, DDS, PhD
5
Objective: To compare the fracture resistance and fracture performance of CAD/CAM zir-
conia and alloy crowns. Method and Materials: One electrophoretic deposition alumina
ceramic (Wolceram, Wolceram) and 4 zirconia-based systems (ce.novation, ce.novation;
Cercon, DeguDent; Digizon, Amann Girrbach; and Lava, 3M ESPE) were investigated. A
porcelain-fused-to-metal method (Academy, Bego Medical) was used in either convention-
al casting technique or laser sintering. Sixteen crowns of each material were fabricated
and veneered with glass-ceramic as recommended by the manufacturers. Crown and root
dimensions were measured, and 8 crowns of each system were adhesively bonded or
conventionally cemented. After the crowns were artificially aged in a simulated oral envi-
ronment (1,200,000 mechanical loads with 50 N; 3,000 thermal cycles with distilled water
between 5C and 55C; 2 minutes per cycle), fracture resistance and fracture patterns
were determined and defect sizes investigated. Results: The fracture force varied
between 1,111 N and 2,038 N for conventional cementation and between 1,181 N and
2,295 N for adhesive bonding. No significant differences were found between adhesive
and conventional cementations. Fracture patterns presented mostly as a chipping of the
veneering, in single cases as a fracture of the core, and in 1 case as a fracture of the
tooth. Conclusions: Crown material and cementation do not have any significant influ-
ence on the fracture force and fracture performance of all-ceramic and metal-based
crowns. Therefore, it may be concluded that adhesive bonding is not necessary for the
application of high-strength ceramics. (Quintessence Int 2009;40:655662)
Key words: adhesive bonding, CAD/CAM, cementation, dental crown, fracture, zirconia
1
Engineer, Department of Prosthetic Dentistry, University
Medical Center Regensburg, Regensburg, Germany.
2
Professor, Department of Prosthetic Dentistry, University
Medical Center Regensburg, Regensburg, Germany.
3
Assistant, Prosthetic Dentistry, University Medical Center
Regensburg, Regensburg, Germany.
4
Assistant Professor, Prosthetic Dentistry, University Medical
Center Regensburg, Regensburg, Germany.
5
Professor and Chair, Department of Dental Materials Science,
Academic Centre for Dentistry, Universiteit van Amsterdam and
Vrije Universiteit, Amsterdam, The Netherlands.
Correspondence: Dr Martin Rosentritt, Regensburg University
Medical Center, Department of Prosthetic Dentistry, Franz-
Josef-Strauss Allee 11, Regensburg D-93042, Germany. Email:
[email protected]
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variation and a high structural reliability
compared to conventional dental glass-
ceramics.
3,4
Metal-based restorations may be
fabricated conventionally by means of cast-
ing techniques or alternatively with laser-sin-
tering (Bego Medical). Both technologies
should show only small differences in the
composition and final structure of the alloys,
regardless of the mode of melting used, ie,
laser-sintered or conventionally melted.
The computer-based fabrication process
starts with digitizing the clinical situation with
a 3-dimensional scanner, followed by CAD
designing the cores of the restorations and
their fabrication in the particular CAM
process. One system allows the alternative
scanning of waxup models (Cercon). A weak
point in view of processing and strength may
be that CAD/CAM cores have to be veneered
with comparatively low-strength conventional
glass-ceramics in press or layering technique.
Chipping of the veneering ceramic has
already been reported for porcelain-fused-to-
metal (PFM) restorations,
5
and particularly
chipping of the veneering ceramic for zirco-
nia has been widely discussed
68
since the
launch of the current zirconia systems. The
basic effects of veneering on the core-veneer-
ing interface,
9
as well as on the fracture per-
formance of 2- or 3-layer specimens, have
been reported, helping to understand failure
mechanisms.
1012
Laboratory results allow the
prediction of the combination of material lay-
ers, but failure type and pattern may vary for
clinically relevant restorations. The main rea-
son may be in the individual design and
dimension of a special restoration, in which,
for example, compliance with an optimal
veneering thickness is difficult to achieve. On
the other hand, in vivo conditions may differ
from loadings in the laboratory.
To investigate the performance of new
materials, fracture benchmark tests were
conducted. This static test on dental restora-
tions may reveal different failure patterns in
comparison to in vivo situations.
13,14
Moreover,
the influence of improper alternative tooth
abutment material (for instance, steel)
1517
may falsify results. Simulation procedures
with dynamic loading and thermal cycling
using clinically relevant chewing forces and
bath temperatures are applied for aging
specimens and are supposed to result in a
performance approximated to the clinical sit-
uation of restorations.
18,19
Failures during sim-
ulation can be compared to failures during
oral application and may help to estimate the
lifetime of new materials. If no failures occur
during simulation, a subsequent static frac-
ture test allows the locating of initiated weak
points or at least permits comparison of the
tested materials to clinically well-known sys-
tems. Basic fractographic information,
20,21
which describes ceramic failures as initiated
by flaws or damages from the marginal side
or occlusal surface,
14
contributes to the eval-
uation of results.
The null hypothesis of this investigation
was that no significant difference exists
between the fracture force and fracture per-
formance of all-ceramic and metal-based
crowns after simulation of oral service. The
influence that the dimensions of both tooth
and crown, as well as the type of cementa-
tion, have on a fracture should be consid-
ered.
METHOD AND MATERIALS
To simulate the human periodontium, the
roots of human molars (n = 96) were first
coated with a 1-mm layer of polyether materi-
al (Impregum, 3M ESPE) and then inserted
into polyethylenemethacrylate (PMMA) resin
(Palapress Vario, Heraeus Kulzer). This layer
allows the maximum tooth mobility of 0.1 mm
in axial and vertical directions at a load of
50 N. Human molars were used to ensure a
clinically relevant modulus of elasticity of the
abutments and simulate a relevant bonding
between crown and tooth. Each tooth was
prepared according to the directives for
ceramic restoration techniques using a 1-mm-
deep circular shoulder crown preparation.
Sixteen crowns of each material group listed
in Table 1 were fabricated according to
the manufacturers instructions. All frame-
works were veneered according to the man-
ufacturers instructions using glass-ceramic
materials, which were recommended by the
manufacturers of the core materials (see
Table 1).
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To compare the type of cementation, 8
crowns of each group were luted adhesively
with dual-curing composite (Variolink 2 with
Syntac Classic for bonding, Ivoclar Vivadent),
whereas the other 8 crowns were cemented
with conventional zinc oxidephosphate
cement (Harvard, Hoffman & Richter). The
dimensions of the investigated teeth and
crowns were determined for adhesive/conven-
tional cementation, respectively: mean height
standard deviation (SD) of the crown (mm): 6.8
1.1 / 6.9 1.0; length SD of the root (mm):
11.5 2.2 / 10.9 2.0; distal-mesial length
SD (mm): 9.4 1.4 / 9.0 1.6; and palatal-buc-
cal length SD (mm): 9.9 1.0 / 9.9 1.1.
Artificial aging was performed to simulate
5 years of oral service using the following
loading parameters
18
: 1,200,000 mechanical
loads with 50 N and simultaneous thermal
cycling with distilled water between 5C and
55C (3,000 times for 2 minutes per cycle). A
human molar was adjusted as an antagonist
in a dental articulator (Artex CN, Amann
Girrbach), and tooth and crown were trans-
ferred to the simulator. Antagonist-tooth rela-
tion was controlled with an occlusal foil. Aging
was interrupted every 100,000 mechanical
loading cycles, and the crowns were checked
optically for failures (fracture, chipping).
After aging, each crown was loaded until
failure by means of a testing machine (Zwick
1446, Zwick; velocity = 1 mm/min). Force
was applied using a steel ball (diameter = 12
mm), and a tin foil (1 mm) between crown
and antagonist prevented force peaks. The
crowns were examined optically before and
after fracture testing. The failure mode was
divided into the following fracture patterns:
initial crack, chipping in the veneering
ceramic, chipping down to the framework,
and fracture of the core or the tooth (Fig 1).
Location and size of failure were analyzed in
mesial, distal, buccal, and lingual directions.
Material/ Conventional
veneering (batch) Manufacturer cementation Adhesive bonding
Academy/Vita Omega Bego Medical/Vita Zahnfabrik Harvard, Syntac Classic/Variolink 2, Ivoclar Vivadent
(22920/7427) Hoffman & Richter (G22359/21260/18808/14040/
(1104C09/B11/1116B02/ 24888/L16678/22838/L9241)
2121000311)
Academy/Vita Omega Bego Medical/Vita Zahnfabrik
Laser sintering
(16020/15560)
ce.novation/Cercon ce.novation
Ceram Kiss
(50708/50739)
Cercon/Cercon DeguDent
Ceram Kiss (25264/24917)
Digizon/GC Initial Amann Girrbach/
(8276/7811) GC Europe
Lava/Lava Ceram
(KW00400133/400116) 3M ESPE
Inceram (Wolceram)/
Vita Alpha (2331/2029/ Wolceram/Vita Zahnfabrik
11050601/5303)
Tabl e 1 Materials and manufacturers
Fig 1 Type of failure.
Crack
Fracture in the veneering
Fracture between
framework and veneering
Fracture in tooth/crown
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QUI NTESSENCE I NTERNATI ONAL
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The type of crown failure was analyzed in
detail by means of scanning electron micro-
scopy (SEM; Quanta, FEI-Phillips). Overview
and detailed photographs were made (mag-
nification: 10 to 1,000; working distance:
20.4 mm; voltage: 5 kV; low vacuum).
Medians, as well as 25th and 75th per-
centiles of the fracture resistance (newtons),
were calculated. Statistical analysis was per-
formed using 1-way analysis of variance
(ANOVA) and the Kruskal-Wallis test to detect
statistically significant differences between
values by pairwise comparisons ( = .05).
Calculations were conducted using statistical
software (SPSS 11.5 for Windows, SPSS). For
power calculation, the relative effects of the
pairwise comparisons were calculated. The
power calculation for the Wilcoxon (Mann-
Whitney) rank-sum test was performed using
G*Power (Kiel University).
22
Using 8 samples
for each material and accepting a 2-sided
type I error of 5% for each comparison, a
power of 80% was achieved (0.807).
RESULTS
The mean fracture resistance of the tested
systems varied between 1,111 N and 2,038 N
for conventional cementation and 1,181 N
and 2,295 N for adhesive bonding. Fracture
force with adhesive bonding was lower for
the systems Academy laser sintering (P =
.574), Digizon (P = .279), and Lava (P = .382)
compared to conventional cementation. The
other systems revealed a higher fracture
strength with adhesive bonding, but the
results were not statistically significant
(P = .382) (Fig 2). The main failure type was
chipping of the veneering ceramic. For
Cercon (P = .779) and Wolceram (P = .382),
1 fracture of the framework could be found
for both types of cementation. For ce.novation
(P = .574), 1 core fracture could be determined
for conventional cementation and 2 core frac-
tures for adhesive bonding. In the Cercon
group, only 1 case of conventional cementa-
tion showed a fractured tooth. The detailed
fracture patterns are shown in Table 2. The
portion of the failed veneering was related to
the surface of the whole crown.
658 VOLUME 40 NUMBER 8 SEPTEMBER 2009
Variolink
Harvard
Academy Academy
laser
ce.
novation
Cercon
Kiss
Digizon Lava Wolceram
3,500
3,000
2,500
2,000
1,500
1,000
0
F
r
a
c
t
u
r
e

f
o
r
c
e

(
N
)
Variolink
Harvard
Wolceram Lava Cercon
Kiss
ce.
novation
Digizon Academy
laser
Academy
50
40
30
20
10
0
F
a
i
l
u
r
e

c
r
o
w
n

a
r
e
a

(
m
m
2
)
Fig 3 Failure crown area (mean, SD).
Fig 2 Fracture force after thermal cycling and loading (mean, SD).
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Failures varied between 5% and 32% (Fig
3). PFM restorations and Cercon Kiss (adhe-
sive) showed the lowest values, of about 10%
and less. No significant differences (P = .723)
in the propagation of defects could be deter-
mined, neither for adhesive bonding nor con-
ventional cementation. Defects occurred
more frequently on mesial and distal tooth
sides compared to labial or palatal sides (Fig
4). Figure 5 provides an example of an SEM
image of a typical crown failure.
Academy
Cercon laser
Digizon Lava ce.novation Kiss Wolceram Academy sintering
Ad Co Ad Co Ad Co Ad Co Ad Co Ad Co Ad Co
Tooth 1
Framework 2 1 1 1 1 1
Chipping 8 8 8 8 6 7 7 6 7 7 8 8 8 8
Crack 2 2
Fracture in 3 4 8 8 2 5 5 2 1 2
the veneering
Fracture between 5 2 4 1 1 4 7 8 6 8 8 8
framework and
veneering
(Ad) Adhesive; (Co) conventional.
*For defect type, see Fig 1.
Tabl e 2 No. and type of failure*
Palatinal
Mesial
Wolceram Lava Cercon
Kiss
ce.
novation
Digizon Academy
laser
Academy
1.0
0.6
0.4
0.2
0.0
0.2
F
a
i
l
u
r
e

s
i
z
e

(
%
)0.8
Palatinal
Mesial
Wolceram Lava Cercon
Kiss
ce.
novation
Digizon Academy
laser
Academy
1.0
0.6
0.4
0.2
0.0
0.2
F
a
i
l
u
r
e

s
i
z
e

(
%
)0.8
Harvard
Variolink
Distal
Mesial
Wolceram Lava Cercon
Kiss
ce.
novation
Digizon Academy
laser
Academy
1.0
0.6
0.4
0.2
0.0
0.2
F
a
i
l
u
r
e

s
i
z
e

(
%
)0.8
Distal
Mesial
Wolceram Lava Cercon
Kiss
ce.
novation
Digizon Academy
laser
Academy
1.0
0.6
0.4
0.2
0.0
0.2
F
a
i
l
u
r
e

s
i
z
e

(
%
)0.8
Harvard
Variolink
Figs 4a and 4b Failure crown area (mean, SD).
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DISCUSSION
The null hypothesis of this investigation has
to be corroborated, ie, that no significant dif-
ference exists between the fracture force and
fracture performance of all-ceramic and
metal-based crowns after the simulation of
oral service. No significant influence of the
type of cementation on the fracture could be
determined. Assuming that the strength of
the ceramic crowns tested was reduced by
cyclic loading
23,24
which was supposed to
simulate oral service of about 5 years
19
frac-
ture loading of the tested systems exceeded
the postulated requirements of 500 N
25
and
was therefore high enough to resist in vivo
chewing forces in posterior applications.
Fracture testing as a single-load test
shows no clinical relevance but may provide
helpful data for comparing tested speci-
mens. During oral simulation, flaws or other
superficial wear or aging effects contribute to
the deterioration of the material and reduce
fracture strength. Therefore, fracture testing
after simulation allows for the differentiation
of materials. In comparison to well-known
systems, these data may help to estimate the
clinical performance of new materials.
The wide distribution of fracture results
restricts their significance, indicating the high
individuality of restorations. The characteris-
tics of materials (strength, Weibull modu-
lus),
26
their fabrication (density, severity,
flaws, voids, or cracks),
27
or improper super-
ficial polishing may contribute to the high
variation of results. More relevant factors are
the differences in the core thickness of
ceramic crowns and the resulting varying lay-
ers of veneering ceramics because of labo-
ratory work. The (manual) veneering of cores
of a uniformly low thickness will result in an
increased thickness of the veneering that will
be more prone to fracture, independent of
the buccolingual or mesiodistal crown
dimensions. This could be the reason the
measured crown dimensions did not have
any significant influence on fracture results,
in contrast to the results described by other
authors for crown material and thickness.
16
The fracture pattern showed that the frac-
ture strength depends on the strength of the
weakest part of the crown, which seems to
be the veneering ceramic. In most cases, the
tested systems showed chipping of the com-
parable low-strength veneering ceramic but
seldom a fracture of the high-strength core or
the whole tooth. The fact that, in most cases,
only veneering is involved in the failure pat-
tern explains why no significant differences
exist among crowns made of differing core
materials. High-strength HIP zirconia (Digi-
zon) did not show any strength advantages
compared to zirconia systems, which were
milled in a partially sintered state or fabricat-
ed in a ceramic build-up process. Although
electrophoretically manufactured alumina
demonstrates even lower strength values, no
statistically different fracture values could be
detected between Wolceram and PFM
crowns. The fact that the fracture results
depend on the glass-ceramic veneering
would also explain why these results were
comparable to adhesively bonded glass- or
leucite-reinforced all-ceramic systems,
17,2830
since both have a comparable chemical
basis and strength (~100 to 200 GPa).
16
Furthermore, the described fracture pattern
in the veneering shows that the type of
cement did not contribute to the fracture
resistance of crowns with high-strength
cores, but significantly influences the fracture
strength of glass-ceramic crowns.
28
Fig 5 SEM image of a typical crown failure (Cercon).
Origin
Wake hackles
Arrest lines Veneering Core
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Fractographic analysis by SEM showed
that the fracture origin in the veneering was
mostly on the occlusal surface. Here, the
antagonist caused wear or superficial flaws
during thermal cycling and loading, which
was the origin of the fracture or chipping in
the following fracture test (see Fig 5). These
results are partly in agreement with investiga-
tions of in vivo failures of glass-ceramic sys-
tems, for which a failure of occlusal and mar-
ginal areas has been described.
14
These
results may explain the clinically described
chipping of PFM- and zirconia-based restora-
tions,
68
but no detailed failure analysis of zir-
conia restorations under clinical conditions
has been conducted so far.
In accordance with the literature,
9,11,12
the
present SEM pictures also demonstrated
that chipping can be divided into 2 types:
Chipping occurred interfacially between
cores and veneering ceramic or cracks ran in
the veneering itself. In the case of interfacial
fractures, a thin layer of the veneering ceram-
ic remained on the core material. These
findings underline that fracture strength is
influenced by the properties (for instance,
strength, fracture toughness) of the veneer-
ing material itself and to some smaller extent
by the veneering-core bonding. Cracks with-
in the veneering at lower fracture forces sug-
gest a lower strength value of the applied
veneering ceramic material (Lava), whereas
lower fracture forces refer to either a combi-
nation of a lower fracture toughness of the
veneering and core material or one of these
2 aspects (Wolceram). These effects could
mask one another. Further investigations are
needed with regard to the extent the surface
structure of the framework (manufacturing
process: smooth as machined, roughened
microstructure, milling patterns; see Fig 5)
contributes to the bonding of veneering
ceramics to the zirconia core.
The fact that the fracture area of PFM
crowns was smaller in contrast to failure
areas of all-ceramic crowns (see Fig 3)
requires further detailed and systematic eval-
uation. A clinical consequence may be that
although these defects are smaller, they are
more obvious because of the exposure of the
metal framework. Chipping of the ceramic
may not be visible or could be easily
removed by polishing. The small increase of
failures in the distal and mesial directions
(see Fig 4) may be attributed to the design of
the crown and may be of interest when fabri-
cating restorations for patients with high
chewing forces or bruxism.
The achieved fracture values suggest a
sufficient strength of the crown systems for
clinical application, but the fracture patterns
underline the requirement for a core design,
which supports the occlusal veneering
ceramic.
31,32
Wear of the veneering ceramic
may cause superficial defects, which may
cause chipping of an insufficiently supported
veneering in the long term.
33
The results
show that the clinical survival of all crowns
supposedly depends on the surface quality
of the veneering (strength, fracture tough-
ness, surface roughness) and, to a lesser
extent, on the bond at the veneering and
core interface, but not on the strength of the
underlying core structures.
CONCLUSIONS
This study indicated that the fracture force
and fracture performance of types of all-
ceramic and metal-based crowns depend
neither on the crown material nor the type of
cementation. Thus, it may be concluded that
adhesive bonding, which is required for other
nonzirconia ceramic systems, is not neces-
sary for crowns based on high-strength
ceramics.
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