Comparison of Load-Fatigue

Performance of Posterior Ceramic

Onlay Restorations under Different
Preparation Designs
Dean E. Kois, DMD, MSD; Yada Chaiyabutr, DDS, MSD, DSc; and
John C. Kois, DMD, MSD

AbstractOBJECTIVE: The objective of this study was to evaluate the load-fatigue performance of posterior ceramic
onlay restorations relative to two variables: preparation design (with or without buccal veneers); and the existing amount of
tooth structure (non-worn tooth, worn tooth). METHODS: Sixty extracted third molars were divided into five groups. One group
received a mesial-occlusal-distal (MOD) gold onlay restoration (control). The other four experimental groups were prepared for
ceramic onlay restorations. Two of the groups additionally received 2-mm occlusal reduction to simulate occlusal wear. All restored
teeth were subjected to thermocycling prior to fatigue testing. A fatigue load of 150 N was applied on the occlusal surface at a
frequency of 1.2 hz, at an angle of 135 degrees to the long axis of the tooth. Specimen failure was defined as the occurrence of crack
propagation in the luting cement layer. This was monitored by the strain gauge on the specimen. RESULTS: All specimens restored
on worn tooth had significantly lower fatigue failure cycle counts than those of non-worn tooth. The fracture mode analysis
revealed that ceramic fracture tended to be demonstrated only in the group of worn tooth groups. CONCLUSIONS: The addition
of a buccal veneer component had no significant effect on the load-fatigue performance of posterior ceramic onlay restorations,
but the existing amount of tooth structure did have a significant effect on the load-fatigue performance of posterior ceramic onlay
restorations. Catastrophic failures (ceramic fracture) occurred only in the group of worn tooth.

Keywords: ceramic onlay restoration, cusp-covering restoration, load fatigue, tooth preparation

D
entistry has benefited from tremendous
advances in technology, techniques, and
materials. While metal restorations have
been an outstanding treatment option for
posterior teethas demonstrated by their
long-term success1-3their use, compared to that of metal-
ceramic and all-ceramic restorations, has decreased over the
past decade due to patients interest in tooth-colored restora-
tions. Posterior ceramic onlay restoration is considered to be
a conservative treatment modality that provides an esthetic
treatment option, as it requires minimal tooth preparation
(Figure 1 through Figure 5). Several studies have reported
the clinical success rate with posterior ceramic restorations
to be between 92% and 97%, with observation periods of up
to 5 years,4-8 and 94%9 to 98%10 at the 7-year and 8-year in-
tervals, respectively. Despite their high clinical success rate,
various factorssuch as the adhesive potential of the remain-
ing tooth structure, tooth morphology, ceramic thickness,
aberrant function, and geometry of preparationcan affect
the long-term prognosis of restorations. In general, the tooth
preparation design of ceramic onlay has been adapted from
cast metal preparation designs, with the main alteration being
additional occlusal reduction.11 The physical characteristics
of ceramic make it very strong in compression but low in re-
sistance to tension.12 Ceramic onlay is inherently breakable
and must rely on adequate bonding to the remaining tooth
structure. It is well known that predictable enamel bond-
ing favorably influences the predictability of ceramic onlays.
When ceramic restorations were bonded partially to enamel
but mostly to dentin, there was an increased risk of restora-
tion failures.13,14
In clinical situations, there may not always be an ideal
amount of existing tooth structure. For example, patients
exhibiting occlusal attrition and/or erosion present with a
loss of occlusal tooth structure. The preparation design on
worn teeth does not provide the same anatomic occlusal con-
figuration of enamel and dentin to endorse optimal adhesive
bonding. Because the amount of remaining enamel in poste-
rior teeth is proportional to the amount of occlusal reduction
required for the tooth preparation, the progressive thinning of

VOLUME 33 SPECIAL ISSUE 2 www.dentalaegis.com/cced Research Supplement 3

D. Kois :: Chaiyabutr :: J. Kois
FIG. 1
FIG. 3
FIG. 5
enamel may cause more dentin structure to be exposed. In ad-
dition, previous studies revealed that tooth preparation design
appeared to be the major cause for posterior tooth fracture15;
as the width and the depth of the tooth preparation increased,
the strength of the remaining tooth structure diminished.16,17
Fatigue failure is a major type of load failure that den-
tal restorations experience in the oral environment.18 The
purpose of this study was to evaluate load-fatigue perfor-
mance of posterior onlay restorations in relation to two
variables: 1) preparation designswith and without a buccal
veneer component; and 2) the existing amount of tooth struc-
ture (no-worn tooth and worn tooth). The first null hypothesis
held that there would be no difference between the prepara-
tion designs with or without a buccal veneer component on
the load-fatigue performance of the posterior ceramic onlay
restorations. The second null hypothesis was that the existing
amount of tooth structure had no effect on the load-fatigue
performance of posterior ceramic onlay restorations.
4 Compendium www.dentalaegis.com/cced
FIG. 2
FIG. 4
Figure 1 through Figure 5 Representative photographs of: tooth
preparation for posterior ceramic onlay restorations without buccal veneer
(Fig 1) and with buccal veneer (Fig 2); occlusal view of posterior teeth
restored with ceramic onlay restorations without buccal veneer (Fig 3) and
with buccal veneer (Fig 4); and a lateral view of posterior teeth restored with
ceramic onlay restorations (Fig 5).
Materials and Methods
Sixty extracted human third molars were selected on the basis
of their relatively large surface areas, as they would resist
fracture when stressed and had diverging roots, which resist
removal from the embedding acrylic resin during testing. Im-
mediately following the extraction, the teeth were cleaned of
surface debris, disinfected in 0.5% sodium hypochlorite, and
kept in this liquid until the study was performed. Teeth were
then selected from the liquid based on the following criteria:
they were intact and lacked cracks or fractures in the crown;
they contained no evidence of caries; and they had no prior
restorations. The bucco-lingual, mesio-distal, and occluso-
cervical dimensions of the teeth were measured using a digi-
matic caliper accurate to within 0.01 mm (Mitutoyo series 551;
Mitutoyo USA, www.mitutoyo.com). Three measurements
were made at the greatest bucco-lingual, mesio-distal, and
occluso-cervical widths of the specimens, and the averages
were determined. Overall, tooth sizes were within a 10%
deviation. The roots of the selected teeth were notched for
retention with a high-speed handpiece and diamond rotary
JUNE 2012
Research Supplement
cutting instrument (KS-1, Brasseler USA, www.brasselerusa.
com). The teeth were then attached to a dental surveyor (J.M.
Ney Co., www.jmney.com) rod using a sticky wax (Kerr sticky
wax, Kerr Dental, www.kerrdental.eu) on a vertically prepared
surface so that the long axis of the teeth would be parallel to
the surveyor rod. The teeth were lowered into the copper
cylinder and positioned in the center of the cylinder with
the buccal cementoenamel junction 3 mm above the top of
the copper-mounting cylinder. Premixed autopolymerizing
resin (Pattern Resin, GC America Inc., www.gcamerica.
com) was injected into the cylinder until it was completely
full. After acrylic resin polymerization, the dental surveyor
rod was detached and the specimens of teeth were stored in
distilled water at room temperature.
The mounted teeth were allocated into five total groups
(n = 12); three of the groups were treated as a non-worn
occlusal surface and the other two groups were additionally
reduced 2 mm at the occlusal surface to simulate occlusal
wear. The control group (C) was a mesial-occlusal-distal
(MOD) gold onlay. The four experimental groups were:
NTnon-worn tooth without a buccal veneer; NT-V2-mm
occlusal reduction on a non-worn occlusal surface, non-worn
tooth with a buccal veneer; WT2-mm occlusal reduction
on a non-worn occlusal surface, worn tooth without a buccal
veneer; and WT-V2-mm occlusal reduction on a simulated
worn occlusal surface, worn tooth with a buccal veneer (Fig-
ure 6). Specimens in group C were prepared with the following
principles for cast metal par-
FIG. 6
tial coverage restorations19: a
1.5-mm functional cusp and
1-mm non-functional cusp
reduction (330MWV, KS7;
Brasseler USA); and a 0.5-
mm occlusal shoulder on a
functional cusp (KS0, KS0F; Group C Group NT
Brasseler USA). A 2.5-mm
isthmus was prepared, and non-worn tooth
the pulpal floor was prepared
to a depth of 2.5 mm from the Figure 6 Schematic representative of the preparation designs evaluated: group Ca MOD gold onlay restoration;
occlusal cavosurface margin. groups NT and WTa 2-mm occlusal reduction maintaining cusp steepness of 45 degrees relative to the occlusal
The bucco-lingual widths on surface; groups NT-V and WT-Va 2-mm occlusal reduction maintaining cusp steepness of 45 degrees relative to the
the mesial and distal boxes occlusal surface with a buccal veneer that extended from the mesio-buccal line angle to the disto-buccal line angle.
were similar to the occlusal
isthmus width. Each box had a
gingival floor width of 1.5 mm mesio-distally and an axial wall
height of 2 mm. Finish lines were prepared with 90-degree
cavosurface angles. Final beveling and finishing was done with
rotary (170L, 169L; Brasseler USA) and hand instrumenta-
tion (enamel hatchet, CP , Hu-Friedy, www.hu-friedy.com).
The remaining groups were all prepared for posterior ce-
ramic onlay restorations with the following criteria: group NT
and group WT received a 2-mm occlusal reduction, maintain-
ing cusp steepness of 45 degrees relative to the occlusal surface
VOLUME 33 SPECIAL ISSUE 2
(330MWV, KS7, KS0, KS0F; Brasseler USA). Group NT-V and
group WT-V received a 2-mm occlusal reduction, maintaining
cusp steepness of 45 degrees relative to the occlusal surface
with an addition of a buccal veneer that extended from the
mesio-buccal line angle to the disto-buccal line angle. Depth-
cutting diamond burs were used to standardize the depth of the
veneer preparations so as to achieve a 0.3-mm deep reduction
cervically and a 0.5-mm reduction mid-buccally and occlusally.
A bevel was added at the junction of the veneer and occlusal
reduction (330MWV, KS7, KSO, KSOF, 8280.3 mm and
0.5 mm; Brasseler USA). All specimens were prepared using
a high-speed electric handpiece (KaVo Dental Corp., www.
kavo.com) and diamond rotary cutting instrument and carbide
burs under cool water irrigation. Following tooth preparation,
the thickness of circumferential remaining enamel on the oc-
clusal surface was measured under an optical microscope x10
magnification (Wolfe Contour Cordless Binocular Micro-
scope, Carolina Biological Supply, www.carolina.com). The
four measurements using a digital caliper accurate to within
0.025 mm (Mitutoyo series 551, Mitutoyo USA) on the mid-
width of facial, lingual, mesial, and distal were measured, and
the average of the remaining enamel thickness were calculated
and recorded (Figure 7 through Figure 9).
An impression of each prepared tooth was made with light-
and heavy-body polyvinyl siloxane (PVS) impression material
(Impressiv, Cosmodent, www.cosmedent.com) using a dual-
phase single-stage technique according to the manufacturers
Group NT-V Group WT Group WT-V
worn tooth
instructions. After 24 hours the impressions were poured
with a vacuum-mixed die stone (ETI Empire Direct, www.
etiempiredirect.com) and allowed to set for 24 hours. The
stone cast was recovered and inspected for any defects under
x10 magnification. For the gold onlay, one coat of die hardener
(Stone Die and Plaster Hardener Resin, George Taub Prod-
ucts and Fusion Co., Inc., www.taubdental.com) was applied
to each stone die, and three coats of die spacer were applied to
the cavity surfaces, each 8 microns thick (Tru-fit Die Spacer,
www.dentalaegis.com/cced Research Supplement 5
D. Kois :: Chaiyabutr :: J. Kois
George Taub Products and Fusion Co., Inc.). Care was taken
to ensure that the finish line was not covered. The gold was
cast (AuriumX, Aurium Research, www.aurium-alloys.com )
using a broken arm-casting machine (Pro-Craft Centrifugal,
Grobet, www.deltaonelapidary.com). For the ceramic onlays,
two coats of die spacer (Rem-e-die, Ivoclar Vivadent, www.
ivoclarvivadent.us) were utilized. A custom pattern was used
to provide a standardized notch location on the waxed on-
lay where the fatigue load was applied. This standardized
notch was created on the wax pattern using the specimens
cementoenamel junction as a standardized reference point
and then waxed to 10 mm in total occluso-cervical height. The
fatigue load was applied at this notch. The notch simulated a
contact point similar to the junction of the central fossa and
the most inferior point of the buccal triangular ridge. After
waxing, each pattern was transferred back to its working die
and the pattern margins refined under x10 magnification.
Sprue formers were attached to the patterns with four pat-
terns placed into each investment ring. All of the wax patterns
were invested in a phosphate bound investment material for
the gold specimens (Ceramigold, Whip Mix, www.whipmix.
com) and IPS PressVest Investment Material (Ivoclar Viva-
dent). Ceramic veneers (IPS Empress, Ivoclar Vivadent)
were pressed according to the manufacturers protocol. The
burnout furnace cycle (Grobet USA, www.grobetusa.com)
used a two-stage burnout at 255C for 30 minutes and up to
848C with a hold time of 60 minutes. The ceramic invest-
ments were transferred to the P 300 ceramic furnace (Ivoclar
Vivadent). A pressable ceramic (IPS Empress) was utilized
to cast the restorations with VP1989/4 ingot material using
a temperature of 915C and a holding time of 20 minutes.
Divestment was performed using 50-micrometer aluminum
oxide airborne particle abrasion at 50 psi. The ceramic onlay
fit was verified using green aerosol (Occlude, Pascal Interna-
tional, www.pascalinternational.net) sprayed over the stone
die. All restorations were adjusted and refitted to the master
dies by removing interferences on the internal aspects of the
restorations. High spots on the ceramic onlays were removed
using a medium-grit diamond rotary cutting instrument.
Specimen cementation included mechanical debridement
using aluminous oxide abrasion (PrepStart, Danville Mate-
rials, www.danvillematerials.com) with a particle size of 27
m at 40 psi at a distance of 2 mm from the tooth surfaces.20
The control group was cemented with zinc phosphate cement
(Flecks Zinc Cement, www.pattersondental.com). For the
ceramic restorations, the prepared teeth were etched for 15
seconds with 37% phosphoric acid, (Scotchbond Etchant, 3M
ESPE, www.3MESPE.com) rinsed for 10 seconds, and dried
sparingly. The bonding agent (ONE-STEP, Bisco, Inc., www.
bisco.com) was applied to specimens in two coats for 15 sec-
onds and gently air-dried. The intaglio surfaces of the ceramic
onlays were treated with 9.5% hydrofluoric acid (Porcelain
Etching Gel, Ultradent Products, Inc., www.ultradent. com)
6 Compendium www.dentalaegis.com/cced
FIG. 7 FIG. 8
Figure 7 Representative photograph of
a
occlusal view of non-worn tooth (group NT)
after occlusal reduction.
d Figure 8 Representative photograph
b
of occlusal view of worn tooth (group WT)
after occlusal reduction.
c Figure 9 Schematic representative of
FIG. 9 an average thickness of circumferential
remaining enamel, calculated by measur-
ing the greatest width of each side ([buccal
(a) + mesial (b) + lingual (c) + distal (d)]/4).
for 90 seconds, then silanated with ceramic primer (Scotch-
bond Primer, 3M ESPE). The ceramic onlays were luted with
dual-polymerizing composite resin cement (RelyX ARC, 3M
ESPE). The restorations were held in place for the duration of
the manufacturers recommended setting time under finger
pressure and simultaneously photopolymerized with a light
intensity of 480 nm and a power of 1,100 mW/cm2 (10%)(
Optilux, Kerr Corp.) for a 5-second burst; then the excess was
removed to mimic intraoral conditions. Specimens were then
fully polymerized for 40 seconds on all surfaces. The remaining
excess was removed with a #12 Bard-Parker blade (BD Medi-
cal, www.bd.com) and all restoration margins were polished
with fine polishing discs (Sof-Lex, 3M ESPE). The bonded
specimens were stored in water at room temperature for 24
hours before thermal cycling. Restored specimens were then
thermocycled (RM20, Lauda, Artisan Scientific Corporation,
www.artisan-scientific.com) between water temperatures of
5C and 55C for 5,000 cycles with a 1-minute dwell time at
each temperature to simulate intraoral conditions prior to
fatigue testing.
Specimen failure was defined as the point at which prelim-
inary failure or propagation of a crack in or around the luting
cement layer occurs. This was monitored by the strain gauge
on the specimen. Strain gauge technology has been used to
measure changes in tooth deformation or micro-movement
of indirect restorations.21-23 The gauge connects as one arm of
a Wheatstone Bridge circuit. Voltage output from this circuit
is proportional to the movement of the restoration margin in
relation to the tooth, as measured by the gauge.22 Amplitude
of the strain gauge is small and regular initially, indicating
that movement of the ceramic restoration and tooth during
loading is elastic. However, as failure in the cement layer or
JUNE 2012
Research Supplement
bonding interface is enlarged, the movement increases, and
the magnitude goes beyond the detection range of the strain
gauge. This point was used as an indication of preliminary
failure. A strain gauge (model EA-06-062AP-120 LE, Vishay
Precision Group, Inc., www.vishaypg.com) was placed on the
palatal surface of the restoration-tooth interface. Luting of
the strain gauge was achieved with a strain-gauge adhesive
(3M Scotch-Weld Epoxy Adhesive DP460, 3M ESPE).
This process ensured that the strain-gauge grid would be
centered over the restoration-tooth interface. The strain-
gauge adhesive was allowed to set for a minimum of 24 hours
before fatigue testing. Following the set of the adhesive, tray
adhesive (Caulk Tray Adhesive, DENTSPLY Caulk, www.
caulk.com) was painted over the strain gauge to ensure water
exclusion during the fatigue test. Specimens were tested
under fatigue load with a specialized loading machine (Coil
Cycler, Proto-Tech, www.proto-tech.com). To closely ap-
proximate in vivo loading conditions, each specimen was
subjected to a fatigue load of 150 N at a frequency of 72
cycles per minute. The mean of the physiological mastica-
tory force has been reported to be in the range of 100 N to
400 N for the posterior dentition, and the frequency of the
loading device, which conforms to the masticatory rate, has
been reported to be in the range of 60 to 120 strokes per
minute.24 Therefore, the force applied falls with the limits
of normal human bite forces and chewing cycles.25 The load
was applied at a 135-degree angle to the long axis of the tooth
to simulate an appropriate bending motion of the restora-
tions. All specimens were immersed in a room temperature
water bath during the fatigue loading. Evidence of prelimi-
nary failure was recorded with computer software (Data
Acquisition System Laboratory, Microstar Laboratories,
www.mstarlabs.com). After a cycle of preliminary fatigue
failure was recorded, the specimens were examined under
an optical microscope (Wolfe Contour Cordless Binocular
TABLE 1
Mean (SD) of the Number of Cycles to Preliminary and Catastrophic Failures by Group
Group Cycles to
Preliminary Failure
C 62,900 (22,000)
NT 75,400 (9,000)
NT-V 74,700 (10,700)a
WT 4,300 (1,900) b
WT-V 4,700 (1,100)b
Note that the catastrophic failure was classified in accordance with one of the following mode criteria: an adhesive failure along the ceramic surface
(Type I); a mixture of adhesive failure in ceramic and tooth fracture (Type II); a cohesive failure of ceramic fracture at loading area (Type III); intact
restoration (Type IV).
VOLUME 33 SPECIAL ISSUE 2
Microscope) to examine for failure in the ceramic resto-
rations. Thereafter, the specimens were loaded until cata-
strophic failure in ceramic restoration was reached. The
number of cycles to complete fatigue failure was recorded,
and all restorations were inspected under x10 magnification
to obtain the failure type. The catastrophic failure was classi-
fied in accordance with one of the following mode criteria: an
adhesive failure along the ceramic surface (Type I); a mixture
of adhesive failure in ceramic and tooth fracture (Type II);
a cohesive failure of ceramic fracture at loading area (Type
III); and intact restoration (Type IV).
The normality of data distribution of preliminary failure
cycle counts was verified using r-program statistical soft-
ware (www.r-project.org). Then, the numbers of cycles to
preliminary failure in all groups were analyzed using the non-
parametric Kruskal-Wallis test with Bonferroni correction
( = .05) to evaluate differences among the testing groups.
In addition, the relationship between the numbers of cycles
to preliminary failure and the amount of circumferential re-
maining enamel thickness on occlusal surface was analyzed.
Results
The mean values and standard deviation of the number of cy-
cles to preliminary fatigue failure and complete fatigue failure
cycles are shown in Table 1. The data distribution of fatigue
failure cycle counts revealed non-normality distribution.
Therefore, the power of the Kruskal-Wallis tests was com-
puted using the extended average X and Y power estimates.26
It was revealed that the computed power of the present study
was 0.85. A significant difference was found among all testing
groups with respect to the number of cycles to preliminary
failure (P < 0.001). Group C, group NT, and group NT-V had
significantly higher preliminary fatigue failure cycle counts
than the worn groups, WT and WT-V (P < 0.001). No signifi-
cant difference was found between groups C, NT, and NT-V.
Cycles to Type and Frequency of
Catastrophic Failure Catastrophic Failure Modes
I II III IV
a
> 100,000 A
0 0 0 12
a
98,900 (3,700) A
0 0 0 12
> 100,000A 0 0 0 12
5,900 (1,900) B
8 3 1 0
6,000 (1,700)B 0 5 7 0
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D. Kois :: Chaiyabutr :: J. Kois
FIG. 10 FIG. 11
Figure 10 Representative photograph of specimen catastrophic failures
in the wear groups observed after fatigue load and an adhesive failure along
the ceramic surface.
Figure 11 Representative photograph of specimen catastrophic failures
in the wear groups observed after fatigue load and a mixture of adhesive
failure in ceramic and tooth fracture.
In addition, no significant difference was detected between
groups WT and WT-V.
The mean (SD) of the width of circumferential remaining
enamel thickness on the occlusal surface were as follows:
group NT (1.69 [0.44]), group NT-V (1.53 [0.10]), group WT
(0.97 [0.17]), and group WT-V (0.96 [0.11]). An ordinary least
squares linear regression model was performed on each group,
comparing the amount of circumferential remaining enamel
thickness on the occlusal surfaces. Two distinct data clouds
resulted when plotted together comparing the group of non-
worn tooth and the group of worn tooth. There was a signifi-
cant linear correlation between the preparation designs and
the amount of circumferential remaining enamel thickness
on occlusal surfaces (P < 0.05). The fracture mode analysis
revealed that ceramic fractures tended to demonstrate in
group WT (Figure 10) and group WT-V (Figure 11).
Discussion
Two different existing tooth structures of posterior teeth,
a non-worn tooth and a worn tooth, were evaluated. The
second null hypothesis was rejected, as the fatigue failure
cycle counts of the group of worn tooth were significantly
lower than that of the non-worn tooth. The deterioration of
load-fatigue performance of ceramic onlay restorations on
worn teeth may derive from a lesser amount of enamel bond-
ing surface. The worn groups demonstrated the thickness of
the circumferential remaining enamel at approximately 32%
to 49% lower than that of non-worn groups. Enamel is an
intrinsically dry substrate, which contains 92% inorganic hy-
droxyapatite by volume; therefore, an insignificant amount
of water is present in the body of the enamel substrate. This
prevents water contamination within the monomers when
the adhesive materials are photopolymerized.27 Previous
studies indicated that decreasing the peripheral enamel
seal and the enamel bonding surface caused the deleteri-
8 Compendium www.dentalaegis.com/cced
ous effects of the bonding interface between the restoration
and the tooth over time.28,29 If the bonding interfaces have
deteriorated, the bonds ability to transfer stresses from
the restoration to the tooth will be less effective. Thus,
the fatigue resistance of restorations may be diminished.
Enamel structure is a tightly packed mass of hydroxyapatite
crystals known as enamel rods. These rods are larger when
oriented in their most occlusal position and orientation.
As the preparation moves apically through the tooth the
rods begin to change orientation and become smaller, and
tensile stresses increase. This may have a direct impact on
bond predictability.30 The present finding was consistent
with previous reports. Another factor that could affect the
fatigue performance of the worn tooth was the involvement
of compromised dentin structure. The bonding mechanism
to dentin is more complicated than it is to enamel due to
the complex histological structures and variable composi-
tion of dentin itself. Dentinal tubules are arranged in or-
ganic matrixes that consist primarily of collagen, which is
intimately connected with the pulp tissue, and numerous
fluid-filled tubules transverse through dentin from the pulp
to the dentinoenamel junction.31 Previous studies showed
that the bond strength of the restoration to the deep dentin
substrate (peritubular) was statistically decreased compared
to the superficial dentin (intertubular).32,33 As the occlusal
reduction approaches the pulp, the bond strength of dentin
might be decreased.
It has been debated whether slow-crack propagation in the
ceramic was the primary cause for the failure of the all-ceramic
restorations. The strength of ceramic to resist occlusal shear
load resulted from a reinforcement bond from the underlying
tooth structure. If the reinforcement bond failed, the ceramic
would break because of its relatively low flexural strength.21
The present study found that ceramic onlays were intact after
preliminary failure occurred, and no cracks in ceramic were
found. These ceramic onlays might have failed secondary to
adhesive failure of the luting cement. It was also interesting to
note that the load fatigue performance of gold onlay restora-
tions with mechanical retentive features performed similarly
to the ceramic-bonded onlay restorations on non-worn teeth.
The loading machine was stopped at 100,000 cycles, as the
significant differences among the testing groups were found
within these numbers of cycles. The specimens of gold onlay
restorations and a group of non-worn tooth with a buccal ve-
neer were also stopped at this number of cycles. Perhaps, a
higher number of cycles may have yielded different results
between those two groups. Including a buccal veneer com-
ponent is a viable alternative clinically to control esthetics,
primarily color, and contour. The present study indicated that
an addition of a buccal veneer component did not significantly
affect the number of cycles to fatigue failure. A buccal veneer
component did not enhance adhesion nor reduce the potential
for adhesive failure.
JUNE 2012
Research Supplement
There are several limitations to this study. The results of this
study are applicable to only the veneering ceramic and luting
system that was evaluated. It has been recommended that
occlusal thickness of all-ceramic restorations be 1.5 mm to 2
mm to provide adequate bulk for strength. In the present study,
the ceramic thickness of all specimens was in the range of
the recommendation; however, unequal ceramic thicknesses
among testing groups developed as a result of different oc-
clusal reductions. All specimens were non-axial load at 135
degrees, which was intended to disadvantage the adhesive
bonding interface, thus stressing the adhesive interface and al-
lowing for an increase in the bending moment. The embedding
method did not simulate clinical tooth mobility and, therefore,
might represent a different biomechanic situation compared
to that in the oral cavity. The use of finger pressure to seat the
restoration was not standardized; however, this technique is
clinically applicable. These influences on parameters need to
be considered in future research.
Conclusion
Within the limitations of this in vitro study, the addition of
a buccal veneer component had no significant effect on the
load-fatigue performance of posterior ceramic onlay restora-
tions, while the existing amount of tooth structure did have a
significant effect on the load-fatigue performance of posterior
ceramic onlay restorations. Catastrophic failures (ceramic
fracture) occurred only in the group of worn tooth.
Clinical Implications
When vertical tooth preparation depth minimizes the amount
of circumferential enamel thickness on the occlusal surface
and involves compromised dentin structure, ceramic bonded
onlay restorations may be contraindicated.
ACKNOWLEDGMENT
The authors would like express their gratitude to Dr. Keith Phillips for
his contribution and 3M ESPE and Ivoclar Vivadent for the donation
of their materials in this study. The Empress onlays were fabricated at
Rory Dental and Technical Art, Seattle, Washington. We are grateful
to Mr. Claudio Bucceri and his team for their valuable technical skills.
The photographs and drawings were prepared with assistance from
Scott Rogerson and Brent Rosenburgh.
ABOUT THE AUTHORS
Dean E. Kois, DMD, MSD
Private Practice
Seattle, Washington
Yada Chaiyabutr, DDS, MSD, DSc
Affiliate Instructor, Department of Restorative Dentistry,
School of Dentistry, University of Washington
Seattle, Washington
VOLUME 33 SPECIAL ISSUE 2
Private Practice
Seattle, Washington
John C. Kois, DMD, MSD
Affiliate Instructor, Department of Restorative Dentistry,
School of Dentistry, University of Washington
Seattle, Washington
Private Practice
Seattle, Washington
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D. Kois :: Chaiyabutr :: J. Kois

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