RESEARCH AND EDUCATION

Fracture load of ceramic restorations after fatigue loading

Balasudha Baladhandayutham, MS,a Nathaniel C. Lawson, DMD, PhD,b and John O. Burgess, MS, DDSc

A recent publication reported ABSTRACT

that 80.2% of all xed restora- Statement of problem. A clinician must decide what ceramic coping and veneer material to
tions produced in 2014 by a prescribe based on the amount of tooth reduction possible and the desired esthetic outcome of the
national dental laboratory restoration.
(Glidewell Dental Laboratory)
Purpose. The purpose of this in vitro study was to compare the fracture strength of monolithic and
were fabricated from ceramic bilayered lithium disilicate (IPS e.max) and zirconia (LAVA) crowns at clinically relevant thicknesses
materials compared with 23.9% after load cycling.
in 2008.1 Clinical studies using
Material and methods. Crowns (n=8) were fabricated from 6 groups: 1.2-mm monolithic lithium
these materials observed 2.1%
disilicate, 1.5-mm monolithic lithium disilicate, 1.5-mm bilayered lithium disilicate with hand-
to 6% core fractures and 3.3% layered veneer, 0.6 mm monolithic zirconia, 1.2-mm bilayered zirconia with hand-layered veneer,
to 6% veneer chipping in and 1.2-mm bilayered zirconia with milled veneer (dimension represents thickness at the
lithium disilicate xed dental occlusal pit). Crowns were cemented to identical milled resin dies with resin-modied glass
prostheses2,3 and 1% core ionomer cement. Cemented crowns were stored at 37 C for 24 hours and load cycled for
fracture and 28% veneer chip- 200 000 cycles at 25 N at a rate of 40 cycles/minute. The ultimate fracture load for each
ping in zirconia xed dental specimen was measured in a universal testing machine. Data were analyzed with a 1-way
4 ANOVA and Tukey honest signicant difference post hoc analysis (a=.05).
prostheses. In order to mini-
mize clinical failure, restora- Results. Mean SD fracture load values were 1465 330 N for monolithic lithium disilicate (1.2-mm
tions should be fabricated with thickness) and 2027 365 N (1.5-mm thickness) and 1732 315 N for bilayered hand-veneered
lithium disilicate (1.5-mm thickness). Fracture loads were 1669 311 N for monolithic zirconia
consideration of their constitu-
crowns (0.6mm thickness), 2625 300 N for zirconia milled-veneered (1.2-mm thickness), and
ent material properties. The 2655 590N for zirconia hand-veneered crowns (1.2mm thickness). One-way ANOVA showed a
exural strength of lithium statistically signicant difference among the groups (P<.01). Veneered zirconia crowns showed
disilicate is 365 MPa and that of the highest fracture strength, 1.2-mm hand veneered zirconia was similar to that of 1.5-mm
zirconia is 1039 MPa.5 Based on monolithic zirconia, and all other groups were not statistically different.
these values, manufacturers Conclusions. Crowns of 1.2-mm bilayered zirconia had higher fracture loads than 0.6-mm zirconia
recommend tooth reduction for or 1.2-mm lithium disilicate monolithic crowns. (J Prosthet Dent 2015;-:---)
posterior monolithic restora-
tions be 1.5 mm for lithium disilicate and 0.6 mm for 1.5-mm lithium disilicate crowns had signicantly lower
zirconia. strength values. Nakemura et al7 reported that 0.5-mm
Previous studies have examined the fracture proper- monolithic zirconia crowns had a higher fracture
ties of zirconia and lithium disilicate crowns at different strength than 1.5-mm monolithic lithium disilicate
occlusal thicknesses. Sun et al6 demonstrated that 1-mm crowns. Dhima et al8 measured the number of fatigue
monolithic zirconia crowns and 1.5-mm veneered zirco- cycles before ultimate failure of lithium disilicate crowns
nia crowns produced fracture strength values similar of varying occlusal thicknesses. Lithium disilicate crowns
to those of 1.5-mm metal ceramic restorations, whereas with 2-mm occlusal thickness sustained 1.7 times more

a
Postdoctoral student, Eastman Institute of Oral Health, University of Rochester, Rochester, NY.
b
Assistant Professor, Department of Biomaterials, University of Alabama at Birmingham School of Dentistry, Birmingham, Ala.
c
Professor, Division of Biomaterials, University of Alabama at Birmingham School of Dentistry, Birmingham, Ala.

THE JOURNAL OF PROSTHETIC DENTISTRY 1

2 Volume
Clinical Implications
With limited occlusal clearance, a 0.6-mm mono-
lithic zirconia crown can provide fracture strength
similar to that of 1.5-mm lithium disilicate. With 1.2
mm of reduction, a bilayered zirconia crown has
higher fracture strength than monolithic lithium
disilicate. These preparation dimensions apply to
occlusal reduction and cannot be applied to a uni-
form reduction based on the limitations of this
study.
cycles and 1.5-mm occlusal thickness, 1.5 times more
cycles than 1-mm thick crowns.
Of the previous studies examining the fracture
strength of ceramic crowns,6-17 few have taken into ac-
count the effect of mechanical fatigue. Repetitive load
cycling during mastication causes cracks to originate from
material aws in a ceramic material and propagate
through its bulk. An aqueous environment, as present in
the oral cavity, accelerates the degradation of dental ce-
ramics due to corrosion at the grain boundaries.18 A
previous study showed that ceramic materials tested after
cyclic fatigue in water demonstrated signicantly lower
strength than nonfatigued specimens.19 As zirconia ages,
its strength may decrease due to phase trans-
formation,20,21 which has also been shown to occur as a
result of mechanical fatigue.22 Therefore, ceramic resto-
rations should undergo cyclic loading in an aqueous so-
lution during in vitro evaluation.
The method of veneer fabrication also can affect the
fracture strength of bilayered crowns. Choi et al9 reported
that the fracture strength of hand-layered veneering
porcelain was signicantly less than a pressed or milled
veneering layer. Kanat-Erturk et al10 concluded, howev-
er, that a milled veneering layer was signicantly weaker
than a hand-layered or pressed veneer in one study but
stronger or equivalent in another study.11 Lawn et al12
and Altamimi et al13 have shown that an anatomically
designed core supports the overlying veneer layer, nearly
doubling its fracture load.
The purpose of this in vitro study was to measure and
compare the maximum fracture loads of zirconia (LAVA;
3M ESPE) and lithium disilicate (IPS e.max; Ivoclar
Vivadent) ceramic crowns at their manufacturers rec-
ommended thicknesses (monolithic and bilayered) after
cyclic loading in water. For LAVA and e.max cores,
feldspathic porcelain was hand-layered over the cores. In
addition, a computer-milled veneer (LAVA digital
veneering system [DVS]; 3M ESPE) was veneered over
the zirconia core. The null hypothesis was that no dif-
ferences would be found in maximum fracture load for
any of the core/veneer combinations tested. A previous
THE JOURNAL OF PROSTHETIC DENTISTRY
- Issue -
study determined the maximum occlusal masticatory
force to be approximately 1000 N,23 so this value was
used as the benchmark for crown fracture strength.
MATERIAL AND METHODS
Two core materials were used in this study, zirconia
(LAVA; 3M ESPE) and lithium disilicate (IPS e.max;
Ivoclar Vivadent). The veneering porcelains recom-
mended by the manufacturer were used for hand-layered
groups, LAVA Ceram veneering porcelain (3M ESPE)
and IPS e.max Ceram layering ceramic (Ivoclar Vivadent).
Additionally, a milled porcelain material designed to
veneer zirconia copings was evaluated (LAVA DVS; 3M
ESPE). The manufacturers recommended thicknesses for
these materials are 0.6 mm for monolithic LAVA, 1.2 mm
for LAVA DVS, no strict specications for LAVA hand-
veneered crowns, and 1.5 mm for monolithic and
hand-veneered IPS e.max. In this study, we decided to
make 1.2-mm hand-layered bilayered zirconia in order to
make a direct comparison with 1.2-mm LAVA DVS.
Additionally, a 1.2-mm monolithic lithium disilicate
group was prepared to directly compare with the ven-
eered zirconia groups. While 1.2 mm is not as thick as
Ivoclar recommends (recommended reduction is
1.5 mm), this would allow direct comparison with the
veneered zirconia groups and measure the effects of
under-reducing the preparation by 0.3 mm. A sample
size of 8 was chosen since a power analysis in a previous
study7 with similar materials and methodology calculated
a minimum sample size of 6 (assuming a=.05 and b=.02).
Preparation and fabrication of dies
A complete crown preparation was made on an ivorine left
rst mandibular molar from a typodont model (Kilgore
model 201; Kilgore Intl) as the master preparation. This
preparation was scanned with an intraoral scanner (Cerec
3; Sirona Dental Systems) and replicated (n=48) with a mill
(Cerec In Lab MC XL; Sirona Dental Systems) from a
composite resin block (Paradigm MZ100; 3M ESPE). The
digital scan of the typodont preparation was used to
fabricate the ceramic copings and crowns. Eight crowns
were fabricated for 6 groups: 0.6-mm monolithic zirconia,
1.2-mm bilayered zirconia with hand-layered veneer,
1.2-mm bilayered zirconia with milled veneer, 1.2-mm
monolithic lithium disilicate, 1.5-mm monolithic lithium
disilicate, and 1.5-mm bilayered lithium disilicate with
hand-layered veneer. The minimum dimension reported
for each group of restorations represents the thickness at
the central occlusal pit. A uniform crown thickness was not
achieved in order to produce anatomically contoured
crowns on standard tooth preparations. As the fatigue
loading and maximum fracture loads were centered in the
central occlusal pit of the crown, it was assumed that the
crack would initiate from this area.
Baladhandayutham et al
- 2015
Fabrication of zirconia crowns
Anatomically designed LAVA zirconia copings (0.8-mm
occlusal thickness) and LAVA DVS veneers (0.4-mm
occlusal thickness) were milled on a milling machine
(LAVA CNC 500; 3M ESPE). The copings were sintered in
a furnace (LAVA Furnace 200; 3M ESPE). After airborne-
particle abrasion (Rocatec Soft; 3M ESPE) the outer sur-
face of copings, porcelain (DVS Fusion; abrasion of 3M
ESPE) was applied to the surface of the copings and the
inside of the DVS veneer. DVS veneers were seated onto
the sintered LAVA zirconia copings, allowed to dry, and
fused by ring in a furnace at a temperature of 770 C for 4
minutes under vacuum. The crowns were glazed by ring
with glaze for 2 minutes at a temperature of 750 C.
For the hand-veneered group, computer-aided
design/computer-aided manufacturing (CAD/CAM)
milled and sintered copings were airborne-particle
abraded (Rocatec Soft; 3M ESPE) and veneered with
porcelain (LAVA Ceram veneering porcelain; 3M ESPE)
by an experienced dental technician. The veneering
porcelain thickness was veried to be 0.4 mm by periodic
caliper (crown gauge 68-693 mm; Miltex) measurement
at several locations around the central occlusal pit. In
total, 4 porcelain ring steps were performed under
vacuum as follows: ring for 4 minutes at 840 C after
applying modier, for 6 minutes at 810 C after applying
initial dentin porcelain, for 6 minutes at 800 C after
applying second dentin and enamel porcelain, and for 2
minutes at 750 C after applying glaze. Firing with glaze
was not carried out under vacuum.
Monolithic zirconia crowns (0.6-mm occlusal thick-
ness) were milled. The crowns were smoothed with ne-
grain abrasive paper (Wetordry abrasive sheet, 2500 grit;
3M ESPE), sintered in a furnace (LAVA Furnace 200; 3M
ESPE), and then polished to a nal high luster with a
diamond-impregnated polishing instrument (Dialite ZR
Extra-oral; Brasseler).
Fabrication of lithium disilicate crowns
IPS e.max CAD lithium disilicate anatomic copings (0.8
mm occlusal thickness) and crowns were fabricated in a
mill (CEREC In Lab MC XL; Sirona Dental Systems, Inc).
Copings were crystallized in a furnace (Programat CS
oven; Ivoclar Vivadent) and subsequently hand-veneered
with 0.4 mm of porcelain (IPS e.max Ceram layering
ceramic; Ivoclar Vivadent) by the same technician who
veneered the zirconia crowns. The veneering porcelain
thickness was veried by periodic caliper measurement at
several locations around the central occlusal pit. The
crowns were then red, glazed, and re-red according to
the manufacturers instructions.
The monolithic crowns were milled with a 1.2-mm and
1.5-mm occlusal thicknesses. The crowns were then glazed
(IPS e.max CAD Crystal Glaze Spray; Ivoclar Vivadent) and
crystallized in a Programat CS Oven under vacuum.
Baladhandayutham et al
3
Cementation of crowns on the dies
All crowns were cemented to identical composite resin
preparations with a resin modied glass ionomer cement
(RelyX Luting Plus; 3M ESPE). A weight of 2 kg was
applied to the occlusal surface of each crown during
setting to ensure complete seating. The weight was
removed after 3 minutes when excess cement was care-
fully removed. After cementation, the specimens were
stored in deionized water in an incubator (QWJ500;
Queue Systems Inc) maintained at oral temperature
(37 C) for 24 hours before cyclic loading.
Fatigue and fracture testing
The specimens were mounted into an Alabama wear
testing device.24 Articulating paper was used to position
the center of the crowns occlusal pit below a steatite ball
antagonist (diameter = 6 mm). Because of the size of the
antagonist, occlusal contact occurred on the cusp in-
clines. Specimens were tested in deionized water for
200 000 cycles with a load of 25 N at a rate of 40 cycles/
minute, which represents 1.5 years of clinical service.24
Loading was interrupted at 50 000 cycles, and each
crown was examined for chips, cracks, or bulk fracture by
surface staining with 10% methylene blue. Specimens
were examined with a digital optical microscope (VF-
Z100; Keyence) at up to 100 magnication. Cyclic
loading was then resumed to complete 200 000 total
cycles. Crowns were stained again and examined for
chips, cracks, or bulk fracture.
After fatigue testing, each crown was positioned un-
der a stainless steel ball (diameter = 6 mm) xed to the
upper crosshead of a universal testing machine (Instron
5565; Instron). Articulating paper was used to place the
crowns so that the stainless steel ball was positioned over
the central pit in the same orientation as in fatigue testing
(Fig. 1). A compressive load was applied at a crosshead
speed of 1 mm/min, and failure was recorded at a sudden
reduction to 40% of the applied load. A high-speed video
camera (CV-5000; Keyence) recorded the failures at 4000
frames/second. To determine whether there were dif-
ferences in maximum fracture load for any of the core/
veneer combinations, data were analyzed with 1-way
ANOVA followed by a Tukey HSD post hoc analysis
for multiple comparison testing (a=.05).
RESULTS
The Levene test for equality of variance revealed homo-
geneity of variance (P=.166). The 1-way ANOVA showed
statistically signicant differences among groups (P<.01).
The Tukey post hoc analysis revealed that both veneered
zirconia groups were similar (P=.99), with the highest
fracture strength. The hand-veneered zirconia group had
a bond strength similar to the 1.5-mm monolithic lithium
disilicate (P=.45), and all other groups were not
THE JOURNAL OF PROSTHETIC DENTISTRY
4 Volume - Issue -

core and veneer thickness at the central pit (Fig. 2). Most
crowns fractured at angles that were not perpendicular to
the occlusal plane (or the frame of the image); therefore,
the thickness of the fracture planes appeared longer in
the 2-dimensional images. Also, not all crowns fractured
exactly at the central pit, and the minimum occlusal
thickness displayed in the image may be larger than the
minimum thickness of the original crown.

DISCUSSION
Results of this study suggest that monolithic lithium dis-
ilicate and zirconia crowns fabricated at the manufacturers
recommended minimum thickness at the central occlusal
pit will provide equivalent fracture strength. Veneered
zirconia at 1.2-mm thickness produces a higher fracture
strength than 1.5-mm veneered lithium disilicate. All
groups showed mean fracture loads above 1400 N. A study
of maximum voluntary biting force for a molar measured
forces up to 922 N23; therefore, all crowns tested in this
study could be considered clinically feasible.
Figure 1. Positioning of crown below steel antagonist.
Previous mean values of fracture strength in similar
studies have varied. Nakemura et al7 achieved higher
Table 1. Fracture strength of ceramic crowns
values than those of the current study, such as 5558 N for
Structure, Occlusal Mean SD In Vitro Fracture
Group Material Thickness (mm) Strength (N)* monolithic zirconia (0.5 mm) and 3147 N for lithium
1 LAVA DVS Bilayered, 1.2 2625 300a disilicate (1.5 mm). Their study did not fatigue specimens
2 LAVA hand- Bilayered, 1.2 2655 590a,b and used LAVA Plus (3M ESPE) zirconia and e.max Press
veneered
(Ivoclar Vivadent) lithium disilicate bonded with a resin
3 LAVA Monolithic, 0.6 1669 311c
monolithic cement. Dhima et al14 recorded lower values (743 N for
4 IPS e. max Monolithic, 1.2 1465 330c 2-mm-thick lithium disilicate and 1106 N for 2-mm-thick
CAD LT bilayered zirconia). Their study was performed with
5 IPS e. max Monolithic, 1.5 2027 365b,c e.max ZirPress (Ivoclar Vivadent) zirconia, and fracture
CAD LT
6 IPS e. max Bilayered, 1.5 1732 315c
testing was performed under water. Sun et al6 reported
CAD values similar to those of the current study, including
CAD, computer-aided design; DVS, digital veneering system; LT, low translucency. 1912 N for monolithic lithium disilicate (1.5 mm), 2 489
a,b,c
Groups with similar superscripts represent groups that were not statistically different. N for bilayer zirconia (1.5 mm), and 1341 N for mono-
lithic zirconia (1.5 mm). Their study used LAVA Frame
statistically different. The mean failure load for each (3M ESPE) zirconia and e.max Press (Ivoclar Vivadent)
group is presented in Table 1. lithium disilicate bonded with resin cement.
After 50 000 cycles and 200 000 cycles of fatigue testing, The effects of veneer fabrication have also been re-
the crowns revealed no visible cracking, chipping, or bulk ported previously. An in vitro study by Choi et al9
fracture on the occlusal surface for any group. Wear facets concluded that fracture strength of hand-layered
from the antagonist were observed on the occlusal surface of veneering porcelain (4263 N) was lower than that of
crowns from all groups after 50 000 and 200 000 cycles. The milled veneering porcelain (6242 N) on zirconia cores.
wear facets on the monolithic zirconia crowns were One study by Kanat et al11 states that hand-layered (4323
assumed to be because the stylus penetrated the glaze and N) and milled (4408 N) veneering porcelain on zirconia
not because of the wear of zirconia. High-speed video cores produce equivalent fracture strength; whereas
recording of the fractured crowns demonstrated an initial another study by Kanat et al10 recorded a higher fracture
crack present in the surface of the veneered groups less than strength of hand-layered porcelain than a milled porce-
a second before the ultimate fracture of the crown. The lain veneer. Similar to the study by Choi et al9 and the
initial crack observed in the monolithic materials occurred at rst study by Kanat et al,11 the current study examined a
the same time as the ultimate failure of the crown, so the glass ceramic veneering material bonded to zirconia with
crack origin could not be determined. a fusing porcelain. In the second study by Kanat et al,10
Representative images from the digital microscope of however, the veneering layer was milled from porce-
fractured pieces of the crowns were used to verify the lain and cemented to zirconia. Although no differences

THE JOURNAL OF PROSTHETIC DENTISTRY Baladhandayutham et al

- 2015 5

Figure 2. A, Fractured LAVA digital veering system-veneered crown. B, Fractured LAVA hand-veneered crown. C, Fractured LAVA 0.6-mm monolithic
crown. D, Fractured IPS e.max 1.2-mm monolithic crown. E, Fractured IPS e.max 1.5-mm monolithic crown. F, Fractured IPS e.max hand-veneered crown.

between fracture strength of hand-layered and that of
milled veneering porcelain groups were found in our
study, crowns made with the LAVA DVS system pro-
duced more consistent failure loads as seen by the small
standard deviation of the fracture strength data. This
nding could be explained by a decrease in fabrication
defects within the milled veneer.
A limitation of the present study is that the ceramic
material was not uniformly thick. Part of the reason for
a nonuniform crown thickness was that anatomically
contoured crowns were fabricated on standard prepara-
tions. In order to maintain a path of placement, necessary
areas of uneven tooth reduction must be compensated by
thicker layers of ceramic. A study by Rekow et al15
modeled the stress distribution for a stylized crown
with even coping and veneer thickness and concluded
that stress distributions occurred in different locations
than with an anatomically contoured crown. Addition-
ally, the dental technician attempted to maintain an even
thickness of the veneering porcelain in the hand-layered

Baladhandayutham et al THE JOURNAL OF PROSTHETIC DENTISTRY

6 Volume
groups; however, the exact dimensions of the veneering
layer were limited by his technical abilities. Another
similar study showed that occlusal ceramic thickness
affected crown fracture strength, whereas axial thickness
did not.7
Other studies have shown that fracture initiation
begins under the indenter tip when a hard spherical
antagonist is used for fracture strength testing.15,16 High-
speed video could not conrm the fracture origin and
direction of crack propagation. Typical videos demon-
strated a crack appearing instantaneously that extended
from the cervical margin across the occlusal surface of the
crown. Surface damage could be observed under the
antagonist loading area in micrographs of fractured
specimens (Fig. 2D, E). A recent fractographic analysis of
clinically fractured restorations reported that the fracture
of 5 of 7 molar zirconia crowns originated at the inter-
proximal cervical margin.25 The authors recommend
cushioning the antagonist during in vitro testing to
distribute stress evenly, particularly at the cervical
margin.17
A further limitation of this study is the variation in
cement thickness that can be observed between the
occlusal surface of the tooth preparations and the crowns
(Fig. 2A,F). In this study, 2 different milling machines
were used to fabricate zirconia and lithium disilicate. A
previous study demonstrated that the t of a ceramic
restoration may be affected by the milling machine.26
Perhaps the variation in cement thickness can be attrib-
uted to the accuracy of the milling machines. Another
limitation in this study is that zirconia restorations did
not undergo accelerated aging. A future study should
examine the fracture strength of aged zirconia.
CONCLUSIONS
Within the limitations of the study, 0.6-mm-thick
monolithic zirconia showed fracture load comparable to
the 1.5-mm-thick monolithic lithium disilicate crowns.
Milled and hand-layered veneered zirconia crowns
(1.2-mm thickness) showed signicantly higher fracture
loads than bilayered lithium disilicate (1.5-mm thick-
ness). These preparation dimensions apply to occlusal
reduction and cannot be applied to a uniform reduction.
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Corresponding author:
Dr Nathaniel C Lawson
SDB Box 49
1720 2nd Ave S
Birmingham AL 35294-0007
Email: nlawson@uab.edu
Acknowledgments
The authors thank the manufacturers (3M ESPE and Ivoclar Vivadent) for
providing the materials used in the study; Dr Deniz Cakir and Mr Preston Beck for
their assistance with experimental testing; and Dr Mark Litaker for performing the
statistical analysis.
Copyright 2015 by the Editorial Council for The Journal of Prosthetic Dentistry.
Baladhandayutham et al