Fracture Resistance of Lithium Disilicate, Alumina-, and ZirconiaBased Three-Unit Fixed Partial Dentures: A Laboratory Study

Joachim Tinschert, Dr Med Denta Gerd Natt, MDTb Walter Mautsch, Dr Med Dent, MScc Michael Augthun, Dr Med Dent, PhDc Hubertus Spiekermann, Dr Med, Dr Med Dent, PhDd

Purpose: The purpose of this study was to determine the fracture resistance of three-unit fixed partial dentures (FPD) made of new core ceramics. Materials and Methods: A base metal three-unit master FPD model with a maxillary premolar and molar abutment was made. Tooth preparation showed 0.8-mm circumferential and 1.5-mm occlusal reduction and a chamfer margin design. FPDs were constructed with a uniform 0.8-mm-thick core ceramic and a porcelain veneer layer. In-Ceram Alumina, In-Ceram Zirconia, and DCZirkon core ceramics were machined by a computer-aided design/manufacturing system, whereas IPS Empress 2 core ceramic was indirectly built up using the fabrication technology of waxing and heat pressing. FPDs of IPS Empress were heat pressed as complete restorations without core material. To ensure standardized dimensions, the FPDs were controlled at different points. All FPDs were cemented with ZnPO4 on the master model and loaded on a universal testing machine until failure. The failure load and mode of failure were recorded. Results: The highest failure loads, exceeding 2,000 N, were associated with FPDs of DC-Zirkon. FPDs of IPS Empress and In-Ceram Alumina showed the lowest failure loads, below 1,000 N, whereas intermediate values were observed for FPDs of IPS Empress 2 and In-Ceram Zirconia. Differences in mean values were statistically significant. Conclusion: The high fracture resistance evaluated for FPDs made of DC-Zirkon underscores the remarkable mechanical properties of highperformance ceramic, which could be useful for highly loaded all-ceramic restorations, especially in the molar region. Int J Prosthodont 2001;14:231238.

ental ceramic materials exhibit many desirable material properties, including biocompatibility, esthetics, diminished plaque accumulation, low thermal conductivity, abrasion resistance, and color stability.13 However, brittleness and low tensile strength are weak points of ceramic materials. Therefore, the clinical success of all-ceramic fixed partial dentures (FPD) has been disappointing, especially for posterior FPDs when compared with metal-ceramic restora-

aAssistant Professor, Department of Prosthodontics, University of Aachen, Germany. bDental Technician, Dental Laboratory Gerd Natt, Kln, Germany. cAssociate Professor, Department of Prosthodontics, University of Aachen, Germany. d Professor and Chairman, Department of Prosthodontics, University of Aachen, Germany.

Reprint requests: Dr J. Tinschert, Department of Prosthodontics, University of Aachen, Pauwelsstrasse 30, D-52074 Aachen, Germany. Fax: + 49 2418888410. e-mail: jtinschert@online.de COPYRIGHT 2001 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS
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tions.47 Although metal frameworks have inherent disadvantages, metal-ceramic restorations are currently the most widely and successfully used for FPDs. Because metal-ceramic FPDs are the standard of care in practice, their clinical survival rate should be used as the criterion for new all-ceramic systems. 5,7 Unfortunately, only a few reliable studies are concerned with the survival rate and average service times of metal-ceramic FPDs in clinical practice.813 Available data suggest that conventional FPDs show a survival rate of approximately 90% at 10 years.14 Until recently, only small FPDs made of glass-infiltrated alumina porcelain were recommended for the anterior area. Available data from clinical studies on all-ceramic anterior FPDs indicate a success rate of 93% to 100% after 3 years.7,1517 However, the small number of restorations investigated in these studies as well as the short observation period limit any further conclusion from the results. To achieve all-ceramic FPDs with appropriate fracture strength,

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Table 1
Product

Ceramic Materials Used for the Fabrication of the Three-Unit FPDs

Code IE IE2 ICA ICZ DZ Core ceramic Leucite-reinforced porcelain Lithium disilicate glass ceramic Glass-infiltrated alumina porcelain Zirconia-reinforced glass-infiltrated alumina porcelain Partially stabilized zirconia ceramic Veneering porcelain Fluorapatite glass ceramic Feldspathic porcelain Feldspathic porcelain Feldspathic porcelain Manufacturer Ivoclar-Vivadent Ivoclar-Vivadent Vita Vita DCS Dental/Vita

IPS Empress IPS Empress 2 In-Ceram Alumina In-Ceram Zirconia DC-Zirkon

new ceramic core materials were recently introduced into the dental market. Apart from lithium disilicate glass ceramic,18,19 new zirconia- and alumina-based ceramic materials are now available.2022 The mechanical properties of high-performance alumina and zirconia ceramics make them interesting as potential candidates for all-ceramic restorations in high stressbearing areas.2327 These ceramics are manufactured under optimized industrial conditions, and they are designed to be processed by computer-aided design/manufacturing (CAD/CAM) technologies.28,29 The purpose of the present in vitro study was to test the fracture resistance of three-unit FPDs made of new core ceramics.

Materials and Methods

The maxilla of a phantom model (OK-16, Kavo) was used to create the clinical situation of a three-unit FPD replacing the first molar. The second premolar and the second molar were prepared with chamfer margins for complete crowns. Tooth preparations were standardized with (1) a total convergence angle of 10 to 12 degrees, (2) chamfer margins of 30 degrees circumferentially, and (3) occlusal reduction of 1.5 mm. All line angles were rounded. The prepared teeth were placed in their correct positions in the maxillary arch, and a half-arch impression was made of the prepared teeth with a silicone impression material (President Coltne, Coltne). The impression was poured in a resin material (Palavit 55, Heraeus-Kulzer) to create a preparation model that was invested, burned out, and cast in a nickel chromium alloy (Wiron 99, Bego). In this way, a nickel chromium model of a three-unit FPD with fixed dies was fabricated. The surfaces of the dies were smoothed with rubber polishers, first with coarser, then with finer rubber cusps and points (Shofu Dental). The metal master model was used as a working cast to fabricate the FPDs and to evaluate their fracture strength in an axial load test. Various three-unit FPDs with substructures made of lithium disilicate, alumina-, and zirconia-based core ceramics were tested in this study. In addition, three-

unit FPDs constructed of leucite-reinforced porcelain without core ceramic were also investigated. All ceramic materials used for the fabrication of the FPDs are listed in Table 1. FPDs that consisted of a substructure and a veneering porcelain layer were constructed with a uniform 0.8-mm-thick core ceramic. The connector areas of the substructures between the abutment retainers and the pontics were modeled with an occlusogingival height of 4.0 mm. Before and after veneering, all FPDs were controlled at different measurement points using a digital micrometer to ensure standardized dimensions as shown in Fig 1. The core ceramics ICA, ICZ, and DZ were machined by the Precident DCS system (Digitizing Computer System, Production). Therefore, the tooth preparation and the position of the dies were measured and digitized by a mechanical scanning instrument (Digitizer). The data were transmitted to a computer to design and calculate the substructures of the FPDs. Afterward, the resulting control and milling data of the substructures were forwarded to a milling machine (Precimill). The substructures were ground from various ceramic blanks manufactured under optimized industrial conditions. After grinding, the substructures of group ICZ ceramic were additionally infiltrated with a low-viscosity infiltration glass (InCeram Zirconia glass powder) according to the recommendations of the manufacturer. Finally, the substructures were veneered with their respective veneering porcelains. Restorations of groups IE and IE2 ceramic were indirectly fabricated using the fabrication technology of waxing and heat pressing. FPDs of group IE ceramic were obtained directly from the wax pattern using the surface-coloration technique, whereas FPDs of group IE2 ceramic were produced with the layering technique. After wax elimination, the appropriate ceramic ingots were pressed into the preheated muffles. A temperature of 1,075C was required for pressing the complete form, and a temperature of 920C was used for the layering technique. Both techniques required 5 kPa of pressure for 30 to 40 minutes. When the layering technique was used, the substructures were ultimately covered with veneering porcelain followed
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2.3 (0.18)

2.5 (0.20)

1.6 (0.11)

2.2 (0.22)

1.5 (0.13) 1.0 (0.09)

5.4 (0.22)

5.4 (0.26)

1.5 (0.12) 1.0 (0.09)

Fig 1

Measurement points and dimensions of the veneered three-unit FPDs. Measurements

by a glazing cycle. During the manufacturing process, various jigs were used to standardize the dimensions of the substructures and the final veneering porcelain layer as mentioned before. A total of five veneered FPDs as well as five substructures without a veneering porcelain layer were stored and tested dry in an axial load test for each group of restoration. Additionally, five FPDs of group IE ceramic were included as all-ceramic restorations without core material. Before testing, the restorations were cemented on their respective metal master models with zinc phosphate cement. Each FPD was loaded occlusally in the midpontic region at a cross-head speed of 0.5 mm/min by using a universal testing machine (Zwick). For each FPD, a diagram of the load at initial fracture (Fig 2) and the mode of failure were recorded (Fig 3). Afterward, the mean failure loads were calculated. Two-way analysis of variance (ANOVA) was applied to determine statistically significant differences. The significance level was established at a P value < .05. Differences between groups were identified with the Scheff F multiple comparison test.

5000

3750

Load (N)

2500

1250

0 0.0 0.1 0.2 0.3 0.4 Cross-head path length (mm) 0.5

Fig 2 Typical load-strain diagram of a veneered FPD made of group DZ ceramic.

Results
Two-way ANOVA revealed that there were significant differences between the mean failure loads of the investigated FPDs (P < .001). The highest failure load, exceeding 2,000 N, was found for FPDs of group DZ veneered ceramic (Fig 4). Generally, FPDs of group DZ ceramic revealed fracture values that were greater than those of all other FPDs. FPDs of group IE and ICA ceramics exhibited the lowest mean failure loads, below 1,000 N, whereas intermediate values were observed for FPDs of group ICZ and IE2 ceramics. Except for FPDs of group IE and ICA ceramics, Scheff F multiple comparison analysis indicated that the
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differences in the mean failure loads were statistically significant (P < .05). Veneered FPDs were always associated with higher failure loads than those evaluated for the pure substructures without veneering porcelain. The statistical analysis yielded significantly different mean values (P < .05). In comparison with the mean failure loads of the pure substructures and veneered FPDs of group IE2, ICA, ICZ, and DZ ceramics, FPDs of group IE ceramic showed also statistically significant differences (P < .05). During the load test, initial crack formation occurred adjacent to the load points. The initial fracture originated from the locally induced stresses of the load application, and further crack propagation was

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Figs 3a and 3b Examples of a fractured substructure and veneered FPD made of group DZ ceramic. The propagation of the critical cracks is indicated by arrows.

2500 FPD without substructure 2000 Substructure Veneered FPD Failure load (N) 1500

1000

500

IPS Empress

IPS Empress 2

In-Ceram Alumina

In-Ceram Zirconia

DC-Zirkon

Fig 4

Mean failure loads and standard deviation bars of the tested restorations.

observed along the plane of maximum tensile stress from the load point to the mucosal side of the connectors (Fig 3). Sometimes fractures of the abutment crowns were also localized at the gingival margin adjacent to the connector areas.

Discussion
New core ceramics may offer a unique alternative to conventional restorations, but are they strong enough for the use of all-ceramic FPDs? Maximal bite forces have to be considered first. Numerous investigators have been interested in the maximal bite forces used during mastication. 3032 Apart from individual anatomic and physiologic characteristics, it has been shown that bite force varies with the region in the oral cavity. The greatest bite force was found in the first

molar region, whereas at the incisors it decreased to only about one third to one fourth that in the molar region. In these previous studies, mean values for the maximal force level have varied from 216 to 847 N.3338 For the incisal region, smaller values ranging from 108 to 299 N have been reported.33,35,36,38 Men often achieve significantly greater bite forces than women.37,38 From the results of several studies, Krber and Ludwig39 surmised that posterior FPDs should be strong enough to withstand a mean load of 500 N. Additionally, cyclic fatigue loading and stress corrosion fatigue caused by the oral environment must be considered. In contrast to crowns or FPDs of castmetal alloys, these are important factors that can considerably weaken the fracture resistance of all-ceramic restorations.40,41 Under the conditions of the oral environment, the inherent flaws of ceramic materials act
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as the origin of crack propagation and can grow to critical size.4245 Catastrophic failures ultimately result from a final loading cycle that exceeds the mechanical capacity of the remaining sound portion of the ceramic material. This is different from metal-ceramic restorations that have an inherent stress-absorbing mechanism in the metal substructure that limits crack propagation.4,40 As a rule of thumb, the endurance limit for fatigue cycling that can be applied to dental ceramics is approximately 50% of the maximal fracture strength.4648 Therefore, it is reasonable to assume that an initial fracture resistance within a safety range of 1,000 N should be required for a favorable clinical prognosis of all-ceramic FPDs. Nevertheless, further in vivo studies must ensure that this claim is transferable to clinical situations. FPDs of group IE ceramic exhibited the lowest failure loads of all restorations tested. The mean values imply that a possible clinical failure may occur even at very small loads. The low mechanical properties of group IE ceramic are obviously not adequate for threeunit FPDs, particularly not for the posterior tooth area. This may be why this kind of restoration has not been recommended by the manufacturer. However, the low strength of this material does not negate its indication for dental ceramic crowns. In several clinical studies, it was found that single-crown restorations of group IE ceramic have favorable clinical long-term stability, especially in the anterior dentition, when the procedures outlined are carefully followed.49,50 Compared with restorations of group IE ceramic, higher failure loads were found for FPDs of group ICA ceramic. But the mean values of the investigated FPDs did not reach the initial fracture strength of 1,000 N. These findings challenge the use of glass-infiltrated alumina porcelain for posterior FPDs and agree with clinical results reported by Sorensen et al.7 In a study on 61 three-unit FPDs, there was no failure of anterior restorations, but a 35% failure rate of posterior FPDs was recorded at the 3-year recall. In reviewing the seven failed FPDs, crack propagation was always observed through the connector.51 The majority of failures had already occurred within the first year after cementation. Therefore, it was concluded that glass-infiltrated alumina porcelain cannot be reliably used for posterior FPDs as advised by the manufacturer. In contrast to the fracture results of group IE and ICA ceramics, three-unit FPDs of group IE2 ceramic revealed mean failure loads of 1,000 N. However, it must be considered that this value was not observed for all FPDs tested in this investigation, particularly not for substructures without a veneering porcelain layer. For this reason, FPDs of group IE2 ceramic should be used only in the premolar region, as recommended by the manufacturer, not in high stressbearing areas
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like the molar region. In a clinical study on 60 threeunit FPDs fabricated with lithium disilicate glass ceramic, Sorensen et al52 determined a failure rate of 7%. Within a period of 6 to 12 months, four FPDs suffered a catastrophic failure, defined as a fracture through the core material. Three failures occurred in the premolar region, whereas only one failure was observed in the anterior region. Thus, those authors also suggest caution in the use of group IE2 ceramic for premolar FPDs unless an occlusogingival connector height of 5.0 mm can be achieved. The second highest failure loads in this investigation were found for zirconia-reinforced FPDs of group ICZ ceramic. The mean values of these FPDs were almost twice as high as those made of conventional glass-infiltrated alumina porcelain of group ICA ceramic. This demonstrates that the fracture strength of glass-infiltrated alumina porcelain can be significantly increased by the addition of partially stabilized zirconia.20,26 It is likely that the so-called transformationtoughening mechanism contributes to the improved fracture strength of group ICZ ceramic.24,25 Under unrestrained conditions, zirconia undergoes a highto-low-temperature phase transformation from the tetragonal state into the monoclinic phase, which involves a 3% to 5% volume increase.23 In the case of group ICZ ceramic, the tetragonal phase of the zirconia grains is constrained at room temperature by the addition of a stabilizing oxide (33% ZrO2 stabilized by 16% CeO2). A propagating crack, however, can release the stresses on the zirconia grains, which then transform again from the metastable state into the monoclinic phase. The transformed phase occupies a greater volume in the bulk material, resulting in compressive stresses that tend to counteract or shield any advancing crack propagation. Thus, in contrast to FPDs of group IE2 ceramic, the higher failure loads of zirconia-reinforced restorations may allow the clinical use of all-ceramic FPDs also in the molar region. FPDs of group DZ ceramic revealed the highest failure loads of all restorations tested in this study. Particularly, the veneered FPDs achieved fracture values comparable to metal-ceramic restorations. Mean values in the range of 2,000 to 2,500 N were reported for metal-ceramic three-unit FPDs with dimensions similar to the all-ceramic FPDs used in this study.5355 However, it must be considered that the metal-ceramic FPDs showed cracks only in the ceramic layer, whereas the all-ceramic FPDs of the present study underwent global fracture. Nevertheless, the high mean failure loads of FPDs of group DZ ceramic underscore the potential of CAD/CAM-manufactured high-performance ceramic restorations, which makes them of great interest for restorative dentistry. In contrast to the zirconia/alumina-containing material ICZ, group DZ

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ceramic consists of pure partially stabilized zirconia particles (95% ZrO2 stabilized by 5% Y2O3) with a mean grain size of 0.4 m. These particles are densely sintered under industrial conditions, resulting in a final microstructure in which voids, flaws, and cracks are reduced to a minimum.23 For this reason, and because of the transformation-toughening mechanism, FPDs of group DZ ceramic offered remarkable mechanical properties that are useful for highly loaded all-ceramic restorations in the posterior dentition. In comparison with FPDs fabricated with new core ceramics of groups IE2 and ICZ, the fracture strengths of zirconia FPDs were significantly higher and almost three times as high as those made of the conventional ceramic materials of group IE and ICA ceramics. After veneering, the failure loads of all FPDs increased even further. The mean failure load values of the veneered FPDs were significantly different from the failure loads of the pure substructures. This suggests that there was a stable bond between the veneering porcelain layers and the core ceramics. However, the mean failure loads of the restorations tested in this study demonstrate that FPDs made of core ceramics gain their high strength from the core material. From a clinical point of view, these types of FPDs do not require adhesive cementation techniques to strengthen the restoration,7,52,56,57 whereas acid etching and cementation with adhesive resins are recommended for other all-ceramic crown systems like group IE ceramic.49,50,58 Several studies showed that an apparent increase of the fracture resistance can be expected when glass-ceramic or leucite-reinforced porcelain crowns are bonded to the underlying dentin of the crown preparation.5961 Although FPDs of group IE2, ICA, ICZ, and DZ ceramics can also be used with adhesive resins,62,63 all FPDs tested in this study were cemented with zinc phosphate cement because this cementation technique is less time consuming and technique sensitive under clinical conditions. However, caution must be exercised when extrapolating laboratory data to clinical situations because many in vivo variables are excluded from a controlled laboratory study. Although the model used resembled clinical conditions, it did not simulate the movement of the abutment teeth within the periodontal ligament.4 Considering this fact, the clinician who is confronted with the indication of an allceramic FPD should also take the mobility of the dental abutments into account. When loaded with an occlusal force, teeth undergo deflection because of the compression of the Sharpeys fibers. The magnitude of this effect cannot be estimated, but the rigid metal model used in this study probably increased the load resistance of the tested FPDs.51,64 Moreover, in the oral environment, the forces applied on

dental restorations are more likely to be of a cyclic nature.65 Therefore, cycling loading would simulate more accurately the mastication forces under clinical conditions than the static strength used in this investigation. The fracture mode observed in this investigation, however, was consistent with clinical data of previous in vivo studies.7,52 After analyzing the clinically failed restorations, it was detected that most of the allceramic FPDs failures occurred in the occlusoproximal line angles of the abutments adjacent to the pontic. 51 Consequently, crack propagation to the connector areas was also expected in this in vitro study, because these regions commonly receive maximum stress concentrations.6668 Therefore, the occlusogingival connector dimension or vertical connector height of all-ceramic FPDs should be maximized as far as possible. Unfortunately, the connector areas of FPDs are generally limited in posterior regions. Under clinical conditions, the occlusal contact and the gingival tissue define the limits of the connector dimensions, and the vertical connector height of 5.4 mm used for the FPDs in this study cannot be achieved in every situation. Additionally, a gingival embrasure must be maintained for oral hygiene access and avoidance of iatrogenic periodontal disease. If the minimum vertical dimension is not available, the clinician may consider performing electrosurgery to remove the soft tissue to gain space for the connector height, although the extent of tissue removal is limited and biologic width must be respected.52 Because the core ceramic is significantly stronger than the veneering porcelain, it is sometimes recommended that little or no veneering porcelain be applied at the tissue side of the connectors.52,57 This will also maximize the strength conferred by the core material.

Conclusions
A laboratory investigation of the fracture strength of three-unit all-ceramic FPDs was performed. The following conclusions can be drawn: 1. The mean failure loads of the investigated FPDs were significantly different. All-ceramic FPDs made of partially stabilized zirconia ceramic revealed the highest failure loads of all FPDs tested in this investigation. In comparison with FPDs consisting of conventional dental ceramic materials, the mean failure loads were almost three times as high. 2. After veneering, the fracture resistance of the FPDs increased even further. The mean failure loads of pure substructures were significantly lower than those evaluated for the veneered FPDs. However, the fracture results demonstrate that
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FPDs made of core ceramics gain their high strength from the core material. 3. Caution must be exercised when extrapolating the laboratory data to clinical situations because many in vivo variables, such as cyclic loading or stress corrosion, were excluded from the present study. Therefore, further clinical studies must be performed to ensure that the in vitro results are transferable to clinical situations.

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Fracture Resistance of FPDs Made with Different Core Ceramics

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Evaluation of speech in patients rehabilitated with various oral implantsupported prostheses.

Speech function was assessed in 138 subjects: 113 patients with various implant-supported prostheses and 25 subjects with natural dentitions constituting a control group. There were four subgroups of the patients wearing implant-supported prostheses: (1) complete maxillary denture + complete-arch mandibular fixed prosthesis on implants (n = 22); (2) maxillary complete-arch fixed prosthesis on implants + natural dentition in the mandible (n = 27); (3) maxillary complete denture + mandibular overdenture on two implants (n = 49); and (4) complete-arch fixed prostheses on implants in both jaws (n = 15). A standard clinical evaluation of the speech was carried out by a speech pathologist. One or more pronunciation difficulties were noted for 84% of the patients with implant-supported prostheses, compared to 52% in the control group (P < 0.05). The pronunciation of s-z sounds and/or t-d sounds was significantly different in the experimental groups compared to the control group (P < 0.001). The difference was more pronounced for the subjects having a fixed implant-supported prosthesis in the maxilla. Subjects with fixed implant-supported prostheses in the maxilla seemed to experience more problems with s-z sounds, and those with fixed prostheses in the mandible had more problems with t-d sounds. However, no clear relationships could be established between different oral prosthetic factors and speech performance.
Jacobs R, Manders E, Van Looy C, Lambrechts D, Naert I, van Steenberghe D. Clin Oral Implants Res 2001;12:167175. References: 38. Reprints: Dr Reinhilde Jacobs, Departmant of Periodontology, Catholic University of Leuven, Kapucijnenvoer 7, B-3000 Leuven, Belgium. e-mail: reinhilde.jacobs@kuleuven.ac.beSP

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