Clinical Oral Investigations

https://doi.org/10.1007/s00784-019-03099-1

ORIGINAL ARTICLE

Fracture force of CAD/CAM resin composite crowns

after in vitro aging
Martin Rosentritt 1 & Stefanie Krifka 1 & Thomas Strasser 1 & Verena Preis 1

Received: 3 April 2019 / Accepted: 26 September 2019

# Springer-Verlag GmbH Germany, part of Springer Nature 2019

Abstract
Objectives The aim of this in vitro study was to investigate the influence of material, preparation, and pre-treatment on the aging
and fracture force of CAD/CAM resin composite molar crowns.
Materials and methods CAD/CAM molar crowns (n = 80) were milled from four resin composites (Block HC, Shofu; Lava
Ultimate, 3 M; Grandio Blocs, Voco; and Tetric CAD, Ivoclar Vivadent, with/without sandblasting). Extracted human teeth were
prepared with optimal preparation (height 6–8 mm, angle 6–8°) or worst-case preparation (height 3.5–4 mm, angle 10–15°). Both
groups were prepared with a 1-mm deep cervical circular shoulder. Crowns were adhesively bonded after corresponding tooth
treatment required for the individual adhesive systems (Table 1). Specimens were aged for 90 days in water storage (37 °C) and
subsequently subjected to thermal cycling and mechanical loading (TCML 3000 × 5 °C/3000 × 55 °C, 2 min each cycle, H20
distilled; 1.2 × 106 cycles à 50 N, 1.6 Hz). De-bonding and fracture force was determined. Statistics: one-way-ANOVA; post hoc
Bonferroni, α = 0.05.
Results Four crowns of Lava Ultimate with worst-case preparation de-bonded during TCML. Individual crowns without
sandblasting treatment (3x Tetric CAD with optimal preparation; 1x Tetric CAD with worst-case preparation) de-bonded during
water storage. One crown of Grandio Blocs with optimal preparation showed a small chipping during TCML. All other crowns
survived TCML and water storage without failure. Fracture forces differed between 1272 ± 211 N (Lava Ultimate) and 3061 ±
521 N (Tetric CAD). All Grandio Blocs and Tetric CAD crowns revealed significantly (p ≤ 0.023) higher fracture forces than
Block HC or Lava Ultimate crowns. No significantly different (p > 0.05) fracture forces were found between optimal or worst-
case preparation/fit groups.
Conclusions De-bonding during water storage and TCML was dependent on material and crown pre-treatment. Therefore,
surface roughening seems strongly required. Fracture forces were not influenced by preparation but by the type of material.
Clinical relevance Clinical success and de-bonding of CAD/CAM resin composite crowns is strongly influenced by the type of
material and its pre-treatment.

Keywords CAD/CAM . Resin composite . Resin-based material . Preparation . Fit . CAD/CAM bloc . Dental material . TCML .
Aging . Storage

Introduction effectiveness. With increasing capabilities and acceptance of

CAD/CAM fabrication, more and more tooth-colored mate-
Restoring single teeth in a digital workflow with intraoral rials have been introduced as machinable CAD/CAM blocks:
scanning, computer-aided design, and manufacturing (CAD/ ceramics, resin-infiltrated materials, and resin composites
CAM) has a high potential with regard to time- and cost- [3–5]. Most ceramics require time-consuming fabrication
steps such as sintering, crystallization, or glazing, which have
to be performed after milling. In contrast, resin composites are
* Martin Rosentritt ready for application straight after polishing and allow there-
[email protected] fore an effective and time-saving workflow. CAD/CAM resin
composites promise interesting clinical performance, because
1
Department of Prosthetic Dentistry, UKR University Hospital they are polymerized under standardized industrial conditions,
Regensburg, 93042 Regensburg, Germany which improve physical material properties [6] and wear
 Clin Oral Invest
of recent CAD/CAM polymer materials. 4th EuroBioMAT, 2017; #Ivoclar F&E (ISO-Standard 10477:2004); +R. Böhner. Characteristics of polymer based CAD/CAM Blocks for permanent restorations.
Table 1 Materials, manufacturers, required treatment, and properties (m: data according to manufacturers' specifications; n.i.: no information available; [1] [2]; *S. Spintzyk et al.’s mechanical properties

Water uptake

resistance [7, 8] compared with conventionally layered restor-

elasticity (GPa) content (wt%) (μg/mm3)

12–13.6#

ative resin composites. Nevertheless, CAD/CAM resin com-

> 30#+
> 30+

21m#

21m#

posites may still be inferior to ceramics in their overall me-

chanical (e.g. flexural strength) and esthetic properties (e.g.
translucency) [4]. For example, thermocycling reduced the
fracture toughness of resin-based materials, whereas ceramics
Filler

61m+

(leucite, lithiumdisilicate) were stable [9]. A low modulus of

86M
80m

n. i.

n. i.

elasticity or resin composites between 8 and 18 GPa [10–12]

(Table 1) in comparison with lithiumsilicate ceramics (70–90
Modulus of

GPa) or zirconia (210 GPa) are supposed to influence the

170–210m#+ 12–15m*+

250–290m# 15–18m*#
ResiCem A+B Primer, 20 s, 170–190m# 8–10#+

lifetime of some CAD/CAM resin composites crown mate-

10m#

10m#

rials [13]. A drop-down of the flexural strength was seen with

storage or TCML, whereas modulus of elasticity was reduced
only for individual resin composites [14, 15]. Resin compos-
Flexural
strength
(MPa)

Adhese Universal, 20 s (no Variolink Esthetic DC, Adhese Universal Vivapen, 272m#

Variolink Esthetic DC, Adhese Universal Vivapen, 272m#

ites may even show different elastic modulus at different sizes

or hierarchical levels [16]. Also, a high water uptake of resin
composites between 13.6 and > 30 (μg/mm 3) [17, 18]
Futurabond U, 20s, Voco

20 s,Ivoclar Vivadent

20 s,Ivoclar Vivadent
(Table 1), which is significantly higher as for ceramic mate-
Scotchbond Universal,

rials (< 0.1 [μg/mm3]) may influence the clinical performance

of these materials. CAD-CAM resin composites even release
Treatment tooth

monomer when immersed in aqueous solutions [19] and their

20 s, 3 M

creep strain was increased after 3-month water storage [20].

Shofu

Unfortunately up to date, only few clinical data are avail-

able showing the in vivo performance of available CAD/CAM
resin composites crowns, partly reporting on de-bonding and Scotchbond Universal, 20 s RelyX Ultimate, 3 M

Ivoclar Vivadent

Ivoclar Vivadent
fracture [5, 21, 22]. Because in vivo studies are rare, in vitro
ResiCem, Shofu

Ceramic Bond, 60 s, Voco Bifix QM, Voco

attempts are required to explain the backgrounds and usability
of newer materials. In vitro tests are reported to simulate rel-
Cement
evant in vivo situations allowing to draw conclusions for the
clinical application. Standardized in vitro parameters and re-
duced patient effects may be advantageous for evaluating the

(no light curing), Ivoclar

reasons for these failures. In vitro tests were already used to

(no light curing), 3 M

Tetric CAD /NT, Ivoclar TC/NT No treatment (NT) Adhese Universal, 20 s

light curing), Ivoclar
Porcelain Primer, 10 s,
identify potential influencing factors such as resin composite
composition (resin matrix, filler content), bonding (cementa-
tion, preparation), or degradation (water uptake, hydrolytic

Vivadent

Vivadent
effects) and the combination of individual aspects [6, 10–13,

Shofu
Primer
17, 23–40].
Therefore, in vitro tests with resin-based CAD/CAM molar
crowns may be helpful to clarify the influence of preparation

Al2O3/50 μm, 0.2

Al2O3/50 μm, 0.2

Al2O3/50 μm, 0.2

Al2O3/50 μm, 0.2

Treatment crown
design and fitting parameters. Here, long-term water storage
and in vitro aging testing may enable a first prediction of the

MPa

MPa

MPa

MPa
mechanical performance of the CAD/CAM resin composite
crowns and provide information on potential failures and allow

No.0579, CED-IADR 2015; ISO 4049)

a material pre-selection. As aging effects might also appear

Code

BHC
without any visible failure, subsequent static fracture tests can

GB
LU

TC
help to identify pre-damages or initial de-bonding of the crown.

Vivadent, Liechtenstein

Vivadent, Liechtenstein
The first hypothesis of this in vitro investigation was that a

Block HC, Shofu, Japan

Grandio Blocs, Voco,

combination of insufficient preparation design and fitting pa-

Lava Ultimate, 3 M,

Tetric CAD, Ivoclar

rameters had no influence on the in vitro performance and
fracture force of resin-based CAD/CAM crowns. In a second

MN, USA

Germany
hypothesis, different CAD/CAM resin composites were inves-

Material
tigated because they are supposed to show no different in vitro
performance and fracture force. Finally, for one material the
Clin Oral Invest

influence of surface pre-treatment on the performance and NT), treated with a bonding agent, and adhesively bonded to
fracture force was investigated, assuming that there is no in- the teeth (details see Table 1). All polymerization was per-
fluence of the treatment on the performance or fracture force formed with Elipar S10 (3 M, 20 s per side).
of resin composite crowns. CAD/CAM molar crowns were stored for 90 days storage
(37 °C) in water and subsequent thermal cycling combined
with simultaneous mechanical loading (TCML 3000 × 5 °C/
Materials and methods 3000 × 55 °C, 2 min each cycle, H20 distilled; 1.2 × 106 cycles
à 50 N, 1.6 Hz) in the chewing simulator (eGo Kältesysteme,
Freshly extracted caries-free human molars (mandibular right Regensburg, Germany) was performed. TCML parameters
first molar, n = 80) were collected and stored in 0.5% chlora- were chosen to simulate long-term application and 5 years of
mine T (CAS no: 127-65-1) solution for no longer than 4 oral service. Steatite balls (diameter 12 mm, CeramTec,
weeks. The variability of human molars was respected by Plochingen, Germany) were used to standardize antagonists
preselecting teeth with comparable size and shape and by ran- in a three-point-contact situation to the crowns. During water
domly dividing the teeth to the subgroups. The roots of the storage and TCML, all crowns were controlled daily for fail-
molars were coated with a 1 mm layer of polyether impression ures or fractures. Failed or de-bonded restorations were ex-
material (Impregum, 3 M, Seefeld, Germany) to simulate the cluded from further testing. For all crowns that survived stor-
human periodontium and the resilience of the teeth. Therefore, age and TCML, fracture force was determined by mechani-
the roots of the teeth were dipped in wax, which was replaced cally loading the crowns to failure in the universal testing
by polyether in a subsequent fabrication process [41, 42] before machine 1446 (Zwick, Ulm, Germany). In analogy to
the teeth were fixed in sample holders (Palapress Vario, Kulzer, chewing simulation, the force was applied in the center of
Hanau, Germany). The preparation of the teeth was performed the restorations using a steel sphere (diameter 12 mm, cross-
simulating a (R) retentive optimal preparation and fit (height 6– head speed 1 mm/min). A 1-mm-thick tin foil was inserted
8 mm, angle 6–8°, spacer setting 100 μm) or (NR) non-reten- between the crown and sphere to prevent force peaks. The
tive, worst-case preparation and fit (height 3.5–4 mm, angle failure determination was set to a 10% loss of the maximum
10–15°, spacer setting 250 μm) (see Fig. 1). loading force or acoustic signal (crack). All crowns were op-
In every scenario, a 1-mm deep cervical circular shoulder tically examined (digital microscope VHX, Keyence, Osaka,
was prepared and all angles were rounded. The teeth were pre- Japan, magnification × 10–× 2000) after fracture testing and
pared by one person with identical preparation equipment. the failure mode was documented.
Standardized preparation was performed on the basis of an orig- Mean and standard deviations were calculated. The statis-
inal model, and preparation design was controlled with a gauge. tical analysis was performed using one-way analysis of vari-
The prepared teeth were digitalized (Cerec Omnicam, ance (ANOVA) and the Bonferroni-test for post hoc analysis
Sirona, Bensheim, Germany) and molar crowns (design: ana- (SPSS/PC+ software 23.0, SPSS, Armonk, NY, USA). The
tomic crown) with identical outer dimensions were milled level of significance was set to α = 0.05. Power calculation
(Cerec, MCXL, Sirona). The occlusal and circular wall thick- (G*Power 3.1.3, Kiel, Germany) provided an estimated power
ness of the crowns depended on simulated preparation scenario, of > 90% using eight specimens per group.
but in all cases was at least 1.0 mm circular, and the occlusal
dimensions varied between 1.5–3.5 mm (R) and 5.5–6 mm
(NR). All restorations were fabricated of resin composite Results
CAD/CAM blocks (n = 16/ material) as specified (Table 1).
For every material, both the optimal preparation/fit (R) and Three crowns of group Tetric CAD /NT (R) and one crown of
the worst-case preparation/fit (NR) (n = 8/ scenario) were sim- group Tetric CAD /NT (NR) de-bonded after 90 days water
ulated. All crowns were bonded according to the manufac- storage. Four crowns of Lava Ultimate (NR) de-bonded dur-
turers’ instructions. The inner sides of the crowns were ing TCML after 1.2 million loading cycles. The cement
sandblasted (Al2O3, 50 μm, 0.2 MPa; exception: Tetric CAD/ completely remained in the crown in most cases (Fig. 1).

Fig. 1 Left: preparation design

(R) optimal preparation and fit
(retentive: height 6–8 mm, angle
6–8°, cement gap 100 μm). Right:
(NR) worst-case preparation and
insufficient fit (non-retentive:
height 3.5–4 mm, angle 10–15°,
cement gap 250 μm (examples)
 Clin Oral Invest

Only in the case of the de-bonded Tetric CAD /NT (NR) a b

crown the cement mainly remained on the tooth (Fig. 2).
One crown of Grandio Blocs (R) showed a small chipping at
the crown margin (Fig. 3). Because the crown showed no
further failures, it was not excluded from fracture testing. All
other crowns survived storage and TCML without failure. All
crowns that were exposed to TCML showed typical occlusal
c d
wear traces.
All de-bonded crowns were excluded from statistical anal-
ysis. One-way ANOVA revealed statistically significant (p <
0.001) fracture forces between the individual groups (Table 2).
All Grandio Blocs crowns and all crowns of both Tetric CAD
groups revealed significantly (p ≤ 0.023) higher fracture
forces than Block HC or Lava Ultimate crowns. No significant Fig. 3 Exemplary pictures after loading to fracture. a Chipping of Lava
Ultimate (R) crown. b Fracture of Block HC (R) crown. c Fracture of
differences (p > 0.050) were found between Grandio Blocs
Grandio Blocs (NR) crown, combined with a fracture of the tooth. d
and both Tetric CAD groups or between Block HC and Lava Fracture of Tetric CAD (R) crown with cement remaining in the fractured
Ultimate. No significant different (p > 0.05) fracture forces crown
were found between the optimal or worst-case preparation/
fit groups. All groups but Grandio Blocs (R) showed normal materials. Only Lava Ultimate showed de-bonding of half of
distribution (p > 0.155). Two-way analysis of variance/t-test the specimens with the worst-case preparation, while all other
revealed no influence of the material (p = 0.000), but of prep- sandblasted materials provided comparable good survival and
aration design (p = 0.539) and the combination preparation/ no de-bonding. De-bonding of Lava Ultimate might be attrib-
material (p = 0.383) uted to a combination of low mechanical performance (low
After fracture testing, typical brittle fractures of the crowns flexural strength and modulus of elasticity), combined with
were found (Table 2). Failure was characterized by fracture of high water uptake. High amount of nano-type and zirconia
the crown, partly combined with a fracture of the tooth (Fig. fillers might contribute to this performance. In general, occlu-
3a–d). Individual crowns showed chipping. In most cases, the sal loading during chewing simulation combined with the
cement remained in the fractured crown (Fig. 3d). high elasticity (low modulus of elasticity) of the CAD/CAM
resin composite crowns may cause pumping and deformation
as well as spreading of the margins that might finally support
de-bonding. These negative effects are more pronounced for
Discussion resin composite materials with low modulus of elasticity and
high water uptake. Excessive water uptake during water stor-
The first hypothesis of the investigation that a combination of age may result in further decrease in the modulus of elasticity
insufficient preparation design and fitting parameters did not [4] and may cause resin composites to swell. This might be
reduce the in vitro performance and fracture force of resin- particularly relevant as the investigated resin composites show
based CAD/CAM crowns has to be confirmed for most distinct differences in water uptake. Insufficient, non-retentive
preparation designs and large cementation gaps may further
a b enhance these negative effects, as observed for Lava Ultimate.
Optical evaluation revealed that the cement mainly remained
in the crown, suggesting that the bonding to the tooth tissue
is the weakest link. A stress gradient in the bonding layer
might result from superior bonding (polymerization) be-
tween resin adhesive and resin composite compared with
a b inferior bonding (interlocking, penetration, hybridization)
between adhesive and hydroxyapatite. Better reaction and
bonding between adhesive and resin composite crown might
further influence the reactivity of the adhesive and conse-
quently reduce bonding to tooth tissues [25]. Unfavorable
bonding might rather be expected in the case of the worst-
case preparation as higher thickness of the bonding and/or
Fig. 2 Exemplary crown (a) and tooth (b) after de-bonding during
TCML with remaining cement in the crown. Above: Lave Ultimate the cement layer as well as the associated shrinking might
(NR). Below: Tetric CAD/NT (NR) negatively influence the stability.
Clin Oral Invest

Table 2 Mean fracture force [N]

after TCML (failure pattern: D: Fracture force Failure during
de-bonding, CH: chipping, C:
crown fracture) Material Mean [N] Std [N] Min/max [N] Fracture pattern 90d TCML Preparation

B HC 1670 (n = 8) 287 1069/2076 8xC +

1674 (n = 8) 321 1200/2170 8xC −
LU 1272 (n = 8) 211 937/1676 6xC, 2xCH +
1350 (n = 4) 337 1071/1805 4xC 4xD −
GB 2738 (n = 8) 454 1910/3104 7xC, 1xCH 1xCH +
2578 (n = 8) 470 2461/3757 6xC, 2xCH −
TC 2711 (n = 8) 536 1975/3278 8xC +
3061 (n = 8) 521 2137/3278 8xC −
TC/NT 2691 (n = 5) 167 1954/2258 5xC 3xD +
2755 (n = 7) 972 1623/4355 6xC, 1xCH 1xD −

Fracture results of the individual resin composites were not Optical evaluation showed that the cement of the de-bonded
significantly influenced by preparation and fitting. An impact Tetric CAD crown without treatment remained on the tooth
due to insufficient abutment support of the different prepared (Fig. 2). This indicated insufficient bonding to crowns without
teeth or the expected bending up of the crown margins was not surface treatment although adhesive and crown material was a
found. Sufficient material thickness and good bonding between resin-based system. These findings are confirmed by previous
crown and teeth might have reduced these effects. As expected, studies on CAD/CAM resin composites reporting about im-
materials with high flexural strength showed high crown frac- proved bond strength [37] and interfacial fracture toughness
ture results. Fracture force was strongly influenced by the type [36] after sandblasting of the resin composite surface.
of material, while no influence of the preparation/fit could be Increasing surface roughness by mechanical treatment was
found. Two materials (Block HC, Lava Ultimate) provided reported to have a greater impact on bond strength than chem-
mean fracture forces of about 1500 N, and the other systems ical conditioning [44]. Nevertheless, it should be considered
(Grandio Blocs, Tetric CAD) forces higher than 2500 N, which that severe sandblasting might damage the resin composite
were in a range of glass-ceramic materials or human teeth. The surface [37, 45]. To avoid loss of filler particles, cracking,
high fracture results do not indicate any failure or pre-damage and microchipping, sandblasting with small grain size and
of the crowns due to TCML. Previous studies reported about low pressure is recommended [45].
fracture forces of CAD/CAM lithium disilicate or zirconia- The present results highlight the importance of aging test-
reinforced silicate ceramic crowns ranging between about ing including long-term water storage, as de-bonding events
1800 to 2700 N, when tested on human teeth [25–27]. were initiated by water storage or became finally evident by
Considering that the found fracture forces exceeded maximum TCML. High rates of de-bonding confirm the observations
chewing forces in the posterior region, which are reported to reported in previous studies and clinical reports [21, 22, 25,
reach up to 900 N, all groups have the potential to withstand 32]. Because of the high de-bonding rate, the crown indication
physiological force peaks [43] and seem good to sufficient for a for Lava Ultimate was already removed by 3 M in 2015. Since
clinical application. Failure patterns (crown fracture, chipping) then, its application has been restricted to inlays, onlays, and
indicated contact-induced cracks in all materials. However, it veneers.
has to be kept in mind that loading to the fracture may not
reflect any clinically observable failure modes.
A significant influence of the pre-treatment for the tested Conclusion
material Tetric CAD has been found on the de-bonding but not
on fracture results. The comparison between groups Tetric Crown de-bonding during water storage and TCML was
CAD and Tetric CAD /NT revealed that the influence of shown to depend on resin composite material and surface
Al2O3 pre-treatment seemed higher than the impact of prepa- treatment. Fracture forces were not significantly influenced
ration and fitting. De-bonding took place already during 90 by preparation and fitting differences, but by type of the
days water storage at 37 °C. Comparing both groups, an ap- material.
propriate crown treatment seems essential for guaranteeing Survival and fracture force of all CAD/CAM resin com-
sufficient bonding. Without sandblasting, adhesive luting posite molar crowns except for one material seem sufficient
was not effective in avoiding de-bonding of crowns during for clinical application. Adequate surface pre-treatment
water storage, irrespective of the preparation/ fit scenario. (roughening) of the inner side of the crown is required.
 Clin Oral Invest

Acknowledgments The authors thank Ivoclar Vivadent for supporting Part 2: flexural strength testing. Dent Mater 33(1):99–109. https://
this investigation. doi.org/10.1016/j.dental.2016.10.008
12. Stawarczyk B, Liebermann A, Eichberger M, Güth JF (2015)
Evaluation of mechanical and optical behavior of current esthetic
Compliance with ethical standards dental restorative CAD/CAM composites. J Mech Behav Biomed
Mater 55:1–11. https://doi.org/10.1016/j.jmbbm.2015.10.004
Conflict of interest The authors declare that they have no conflict of 13. Rosentritt M, Preis V, Behr M, Krifka S (2019) In-vitro perfor-
interest. mance of CAD/CAM crowns with insufficient preparation design.
J Mech Behav Biomed Mater 90:269–274. https://doi.org/10.1016/
Ethical approval This article does not contain any studies with human j.jmbbm.2018.10.002
participants or animals performed by any of the authors./All applicable 14. Ikeda H, Nagamatsu Y, Shimizu H (2019) Data on changes in
international, national, and/or institutional guidelines for the care and use flexural strength and elastic modulus of dental CAD/CAM com-
of animals were followed./All procedures performed in studies involving posites after deterioration tests. Data Brief 24:103889. https://doi.
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institutional and/or national research committee and with the 1964 15. Benalcázar Jalkh EB, Machado CM, Gianinni M et al (2019) Effect
Helsinki declaration and its later amendments or comparable ethical of thermocycling on biaxial flexural strength of CAD/CAM, bulk
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