d e n t a l m a t e r i a l s 2 6 ( 2 0 1 0 ) 67–75

available at www.sciencedirect.com

journal homepage: www.intl.elsevierhealth.com/journals/dema

Fracture strength of prefabricated all-ceramic posterior

inlay-retained fixed dental prostheses

Christian Mehl ∗ , Klaus Ludwig, Martin Steiner, Matthias Kern

Department of Prosthodontics, Propaedeutics and Dental Materials, Dental School, Christian-Albrechts University Kiel,
Arnold-Heller-Straße 16, 24105 Kiel, Germany

a r t i c l e i n f o a b s t r a c t

Article history: Objectives. The purpose of this in vitro study was to compare the centric and eccentric
Received 19 December 2008 quasi-static and fatigue fracture strength of industrially prefabricated resin-bonded three-
Received in revised form unit inlay-retained fixed dental prostheses (IPIRFDPs). The IPIRFDPs consisted of industrial
23 July 2009 manufactured yttria-stabilized tetragonal zirconia (Y-TZP) frameworks with an industrially
Accepted 29 July 2009 added microhybrid composite veneering.
Methods. Identical IPIRFDP-models consisted of a second premolar, a missing first molar
and a second molar (CoCrMo alloy) integrated in a low melting alloy base. Roots were
Keywords: covered with a soft silicone layer to simulate an artificial parodontium. Premolars had an
Prefabricated restorations occlusal–distal inlay-preparation and molars a mesial–occlusal inlay-preparation. Forty-two
FDP IPIRFDPs with a connector size of 9 mm2 and a framework connector size of 4.7 mm2 were
Fracture load cemented adhesively to the IPIRFDP-models. Quasi-static fracture strength was tested with
Zirconia ceramic centric (n = 12) and eccentric (n = 6) loading in a universal testing machine at a cross-head
Y-TZP speed of 1 mm/min. Fatigue fracture strength was tested at 1200 N with centric loading
Inlay-retained (n = 12) and at 600/500 N with eccentric loading (n = 6) at a frequency of 0.5 Hz. Statistical
Composite comparison of groups was performed with the Mann–Whitney U test.
Results. Quasi-static fracture strength differed significantly between centric (1749 N) and
eccentric loading (880 N, p < 0.001). Mean loading cycles until fracture were 4432 for centric
loading at 1200 N compared to only 3 and 410 loading cycles for eccentric loading at 600 and
500 N, respectively.
Significance. Considering the maximum chewing forces in the molar region, it seems clini-
cally possible to use prefabricated IPIRFDPs with Y-TZP as a core material with a framework
connector size of 4.7 mm2 .
© 2009 Academy of Dental Materials. Published by Elsevier Ltd. All rights reserved.

missing molar might be an important consideration to prevent

1. Introduction
Among the permanent dentition, the first molar has the high-
est incidence of tooth loss due to caries, endodontic reasons,
tooth fractures and periodontal diseases [1,2]. However the
first molar has a significant role in maintaining the intercus-
pal and condylar position [3,4]. Therefore the replacement of a
further functional problems [2,4].
The traditional way of molar replacement is either a fixed
dental prosthesis (FDP) or an implant retained crown [5]. Irre-
spective of the type of FDP (porcelain fused to metal vs.
all-ceramic crown) the clinician uses, a crown preparation is
always a risk to pulp vitality and may lead to pulpal reactions
in the long term [6]. Approximately 63–73% of the coronal tooth

∗
Corresponding author at: Private Practice, 10 Brook Street, W1S 1BG London, United Kingdom. Tel.: +44 845 0944004; fax: +44 845 0943003.
E-mail address: cmehl@proth.uni-kiel.de (C. Mehl).
0109-5641/$ – see front matter © 2009 Academy of Dental Materials. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.dental.2009.07.013
68 d e n t a l m a t e r i a l s 2 6 ( 2 0 1 0 ) 67–75
Table 1 – Materials used in this study.
Product Material type
Gapless hydrofluoric etchant Hydrofluoric etchant
Calibra Silane Coupling Agent Silane
XP-Bond Bonding agent
SCA Self-curing activator
Calibra esthetic resin cement Self-curing resin based
dental luting cement
Base/Catalyst
Airblock Oxygen blocking gel
Gapless FPD Prefabricated all-ceramic
inlay-retained three-unit
FPDs
structure is removed when teeth are prepared for crowns [7].
Regarding these facts it seems desirable to adapt the type of
abutment preparation to the extent of sound tooth structure
after caries removal not only for a single tooth restoration, but
also for abutment preparations for FDPs. Therefore, if a patient
rejects an implant treatment and enough sound tooth struc-
ture is available it would be desirable to restore a missing tooth
with an inlay-retained FDP instead of a crown-retained FDP.
Clinical evaluations of inlay-retained three-unit FDPs
showed a failure rate of 10% [8] after 9 months (Empress II)
and 13% [9] after 37 months (IPS e.max Press, Ivoclar-Vivadent,
Schaan, Liechtenstein). In both studies the failure was evoked
by debonding or a combination of both debonding and frac-
ture. Despite these failure rates the inlay-retained FDP could
be a favorable treatment option with respect to biological [6,7]
and economic reasons [5].
Recently, yttria-stabilized tetragonal zirconia (Y-TZP)
has been made available to dentistry through CAD/CAM-
techniques [10] and provides excellent mechanical perfor-
mance, superior strength and fracture resistance compared
to other ceramics [11]. Therefore Y-TZP ceramic might be an
alternative material for the fabrication of inlay-retained FDPs
to minimize the risk of fracture.
In the present study the quasi-static and fatigue fracture
strengths of industrially prefabricated inlay-retained FDPs,
consisting of Y-TZP frameworks with a microhybrid compos-
ite veneering, were determined. The null hypothesis tested
was that centric and eccentric loading does not influence their
fracture strength. In addition, it should be evaluated whether
these FPDs provide fracture strengths, which make them a
viable treatment option to replace a missing first molar during
a single patient appointment.
2. Materials and methods
All materials used and batch numbers are summarized in
Table 1.
2.1. Prefabricated all-ceramic three-unit inlay-retained
fixed dental prostheses
In this study industrially prefabricated three-unit inlay-
retained fixed dental prostheses (IPIRFDPs) were used
(Gapless, Umkirch, Germany, Fig. 1). They are designed to
restore upper or lower first molars chairside in one session.
Manufacturer Batch no.
Gapless GmbH, Umkirch, Germany LOT 07161
Dentsply DeTrey, Konstanz, Germany LOT 070511
Dentsply DeTrey, Konstanz, Germany LOT 0702001786
Dentsply DeTrey, Konstanz, Germany LOT 070119
Dentsply DeTrey, Konstanz, Germany LOT 070525 (base)
LOT 0705291 (cat.)
Dentsply DeTrey, Konstanz, Germany LOT 072161
Gapless GmbH, Umkirch, Germany LOT 10084-1-2+3/88,
LOT 10084-1-2+3/89
Three sizes (9, 10, and 11 mm pontic size) and three different
colors (A, B, C, Gapless colors) are available.
The IPIRFDPs consist of an industrially manufactured
yttria-stabilized tetragonal zirconia (Y-TZP) framework, a
thin layer of feldspathic ceramic and microhybrid composite
veneering [12]. The Y-TZP framework has a connector height
of 2.5 mm (4.7 mm2 ) and provides a high fracture strength of
IPIRFDPs, which was in previous tests 1200 N [13]. A thin layer
of feldspathic ceramic is fired to the framework in order to
increase the bond strength between the Y-TZP framework and
the veneering microhybrid composite and to enable the den-
tist to etch the surface of the connector area with hydrofluoric
acid in preparation for the adhesive cement.
The microhybrid composite veneering is added industri-
ally to the framework. The composite has a connector height
of 2.3 mm above the Y-TZP framework, which leads to an over-
all connector height of 4.8 mm (9 mm2 ). The height of the
composite veneering in the pontic region of 2.9 mm above
and 2.3 mm below the framework allows the dentist to adjust
the base and the occlusal area of the pontic. The veneer-
ing microhybrid composite contains 24% (weight) organic
matrix (Bis-GMA and Diurethandimethacylat) and 75% silane
Fig. 1 – The industrial prefabricated three-unit
inlay-retained FDP with a framework made of
yttria-stabilized tetragonal zirconia and microhybrid
composite veneering. The height of the veneering
microhybrid composite is 2.9 mm above and 2.3 mm below
the framework, which leads to an overall connector size of
9 and 4.7 mm2 framework connector size.
 d e n t a l m a t e r i a l s 2 6 ( 2 0 1 0 ) 67–75 69

coated, inorganic siliciumdioxid filler particles, with a size of

0.04–3 ␮m and an average filler particle size of 0.7 ␮m. Accord-
ing to the manufacturer, the microhybrid composite resin
has a fracture strength of 145 MPa and an elastic modulus of
9700 MPa (three-point flexural strength (DIN 13922/EN 24049)).
The shear bond strength of the veneering microhybrid com-
posite to the feldspathic layer on the Y-TZP framework was
900 N [14]. The IPIRFDPs have been used as delivered without
any modification.

2.2. Master models

Artificial teeth (No. 15 and 17, KaVo, Biberach, Germany) were

integrated in an otherwise toothless KaVo model. A box-
shaped inlay-preparation (3◦ divergence, 4.8 mm height, 1 mm
minimal depth) was performed with a special diamond bur
(100 ␮m grained) according to the manufacturer’s instructions
(Gapless preparation set, Gapless). The teeth were duplicated
(Speedy-duplication-technique [15]) and afterwards cast in a
CoCrMo alloy (Wironit, Bego, Bremen, Germany). To create
the master models one IPIRFDP was cemented provisionally
(Freegenol, GC, Tokyo, Japan) to the prepared artificial teeth in
the KaVo model and teeth and IPIRFDP afterwards duplicated
together (Transpaduplisil, Wichnalek, Augsburg, Germany).
The roots of the manufactured metal teeth were covered with
a 200 ␮m thick soft silicone layer (Erkoskin, Erkodent, Pfalz-
grafenweiler, Germany) to provide an artificial periodontal
membrane, which allowed a periodontal movement of 50 ␮m
[16]. Tooth mobility was controlled with an electronic dis-
placement transducer under a horizontal load of 20 N (W1T3,
HBM, Darmstadt, Germany). Next, the prepared teeth were
inserted into the duplicated form of the master models and the
duplicated form filled with a low melting alloy (MCP 70, HEK,
Fig. 2 – Schematic diagram of a test specimen. Abutments
were made from a cobalt-chromium alloy. Roots were
covered with a 200 ␮m thick soft silicone layer. The basis
around the teeth was made from a low melting alloy (MCP
70). The dimensions (mm) of the prefabricated
inlays-retained FDP are shown.
Lübeck, Germany). Fig. 2 exemplarily shows the schematic dia-
gram of one specimen (IPIRFDP-model) and Fig. 3 explains the
workflow from master model to specimen.
According to this procedure, 42 identical specimens with
resilient supported teeth were fabricated and divided into the
following four groups: centric (group CQSFS) and eccentric

Fig. 3 – Workflow from master model to specimen: (A) Preparation of the inlay cavities with the preparation guide (Gapless).
(B) Both teeth were duplicated in cobalt-chromium alloy using a wax duplication technique. (C) After the roots of the metal
dies were covered with an artificial periodontal membrane, they were inserted in a duplication form and the form was filled
with a low melting alloy. (D) Specimen removed from the duplication form and after cleaning procedure ready for adhesive
cementation.
70 d e n t a l m a t e r i a l s 2 6 ( 2 0 1 0 ) 67–75
(group EQSFS) quasi-static fracture strength testing and cen-
tric (group CFFS) and eccentric (group EFFS) fatigue fracture
strength testing.
2.3. Adhesive cementation
For all groups the surfaces of the IPIRFDPs were conditioned
by etching with 5% hydrofluoric acid (Gapless) for 30 s and an
application of silane coating (Calibra Silane, Dentsply DeTrey,
Constance, Germany) for 1 min. The inlay cavities of the metal
abutments were air-abraded with 110 ␮m alumina particles
for 10 s at 0.3 MPa pressure. To ensure that the air-abraded
surface was free of loose alumina particles, the metal abut-
ments were ultrasonically cleaned for 3 min in isopropanol
(96%) [17]. In previous studies [18–20] this procedure showed
no negative effect on the bond strength of the luting resin.
Finally, XP-BOND and SCA (Dentsply DeTrey) were mixed (1:1),
applied to the IPIRFDPs and the inlay cavities for 3 min, but not
light cured. After these conditioning procedures IPIRFDPs of
all groups were cemented to the metal abutments with com-
posite resin cement (Calibra, Dentsply DeTrey) according to
the manufacturer’s recommendations. After removing excess
luting resin, an air-blocking gel (Airblock, Dentsply DeTrey)
was applied to the bonding margins and the luting resin was
then light cured for 40 s at each of three different sites. The
cemented IPIRFDPs were stored in distilled water for 3 days at
37 ◦ C.
2.4. Testing procedures
A summary of all testing procedures and parameters is given
in Fig. 4. The centric quasi-static fracture strength (group
Fig. 4 – Flow chart describing all the test procedures and their parameters.
CQSFS, n = 16) was tested in a universal testing machine (Zwick
BZD10/TNZA, Ulm, Germany). The load was applied perpen-
dicular to and at the centre of the IPIRFDPs using a stainless
steel ball (diameter 5 mm) at a cross-head speed of 1 mm/min
until fracture occurred. To avoid primary cracks at the point
of loading a 0.5 mm foil of Makrolon (Macrolon, Bayer, Lev-
erkusen, Germany) was inserted for all groups.
The eccentric quasi-static fracture strength (group EQSFS,
n = 8) was also tested in the universal testing machine (Zwick
BZD10/TNZA), but this time the load was applied 3 mm eccen-
tric to the mesio-distal direction at the fissure between the
mesiobuccal and distobuccal cusp of the IPIRFDPs. A stainless
steel stamp (diameter 1.5 mm) was used at a cross-head speed
of 1 mm/min until fracture occurred.
The centric fatigue fracture strength (group CFFS, n = 12)
was tested in a universal testing machine (Zwick 1435, Ulm,
Germany) and the specimen subjected to a dynamic load
between 10 and 1200 N with a frequency of 0.5 Hz until the
first fracture event occurred. As before, the load was applied
perpendicular to and at the centre of the IPIRFDP pontic using
a stainless steel ball (diameter 5 mm) and a 0.5 mm foil of
macrolon. The steel ball was not lifted from the IPIRFDPs dur-
ing loading. With these settings and the application of a basic
loading of 10 N an impact pulse could be avoided.
The eccentric fatigue fracture strength (group EFFS, n = 6)
was also tested in a universal testing machine (Zwick 1435,
Ulm, Germany). The specimens were subjected to a dynamic
load between 10 and 600 N with a frequency of 0.5 Hz until
the first fracture event occurred. As in group EQSFS the load
was applied 3 mm eccentric to the mesio-distal direction at
the fissure between the mesiobuccal and distobuccal cusp of
the IPIRFDPs using a stainless steel stamp (diameter 1.5 mm).
 d e n t a l m a t e r i a l s 2 6 ( 2 0 1 0 ) 67–75 71

Table 2 – Medians of centric and eccentric quasi-static fracture strengths of groups CQSFS (n = 16) and EQSFS (n = 8) in N.
Group CQSFS Group EQSFS

Batch no. LOT 10084-1-2+3/88 LOT 10084-1-2+3/89 Pooled LOT 10084-1-2+3/89

Median 1504 1789 1749 880
25th percentile 1433 1674 1477 804
75th percentile 1910 1869 1891 918
Group CQSFS, centric quasi-static fracture strength; group EQSFS, eccentric quasi fracture strength. No difference could be found between the
specimen of the two batch numbers of group EQSFS and therefore the results where pooled (Mann–Whitney test, p = 0.49).

At the top load of 600 N the fractures occurred for the first two
specimens after a few trials and therefore the top load was
reduced to 500 N (n = 4) for group EFFS.
2.5. Statistical analyses
could be found and therefore the results for group CQSFS for
both batch numbers have been pooled. The median quasi-
static fracture strength for group CQSFS was 1749 N and for
group EQSFS (n = 8) 880 N. Examples for typical fractures are
shown in Fig. 5A and C.

Due to the small group sizes and abnormally distributed data

in some groups non-parametric testing was calculated by
comparison of medians with the Mann–Whitney U test. All
hypothesis testing was conducted at a 95% level of confidence.
3. Results
3.1. Quasi-static fracture strength
The medians of the quasi-static fracture strengths of all
groups are shown in Table 2. The fracture strength was tested
until the specimen fractured completely, previous fractures of
the veneering ceramic have not been considered.
For group CQSFS no statistical differences for the medians
(p = 0.49) between the two batch numbers (batch no. 1 = LOT
10084-1-2+3/88, n = 8; batch no. 2 = LOT 10084-1-2+3/89, n = 8)
3.2. Fatigue tests
The medians and single values of loading cycles performed
until the first fracture occurred are shown for all groups in
Table 3. For group CFFS no statistical differences for the medi-
ans (p = 0.69) between the two batch numbers (batch no. 1, n = 6;
batch no. 2, n = 6) could be found and therefore the results for
group CFFS have been pooled.
Two fracture events of the veneering composite occurred
in group CFFS (specimens 2 and 5 of batch no. 2) before the
framework fractured. Statistical testing revealed no significant
difference between framework and veneering composite frac-
ture (p ≥ 0.05) and therefore all 12 single values of group CFFS
have been analyzed. The mean number of loading cycles for
group CFFS was 4432.

Fig. 5 – Selected samples of fractured IPIRFDPs. The typical fracture lines are shown by black lines: (A) Specimen tested with
centric quasi-static load and (B) fatigued with a centric load. The veneering composite fractured first, especially the buccal
lamella, directly followed by a central fracture of the framework. (C) Specimen tested with eccentric quasi-static load and (D)
fatigued with an eccentric load. When an eccentric load was applied, the connectors fractured first.
72 d e n t a l m a t e r i a l s 2 6 ( 2 0 1 0 ) 67–75
Table 3 – Medians and single values of loading cycles for the first fracture event for groups CFFS (n = 12) and EFFS (n = 2 for
600 N, n = 4 for 500 N) in N.
Dynamic load Group CFFS
Batch no. LOT 10084-1-2+3/88 LOT 10084-1-2+3/89
1200 N (n = 12), median 1371
No. 1 91
No. 2 14,487
No. 3 205
No. 4 9230
No. 5 2008
No. 6 735
Mean 4432b
Group CFFS, centric fatigue fracture strength; group EFFS, eccentric fatigue fracture strength.
a
Fracture of the veneering composite, no framework fracture.
b
Mean at a tested load of 1200 N is shown. Mean calculated for specimens of both batch numbers as no difference between the specimens of
the batch numbers was found (Mann–Whitney test, p = 0.69).
c
Mean at a tested load of 600 N is shown.
d
Mean at a tested load of 500 N is shown.
For group EFFS the number of loading cycles for 600 N (n = 2)
loading force was one and five loading cycles for specimens 1
and 2 and therefore the applied loading force was reduced to
500 N. Since the number of specimens tested was too small to
calculate the median, the mean of 410 loading cycles was cal-
culated for group EFFS at 500 N. Examples for typical fractures
are shown in Fig. 5B and D.
4. Discussion
In this study industrially prefabricated three-unit inlay-
retained fixed dental prostheses (IPIRFDPs, Gapless) were
used. They are designed to restore upper or lower first
molars chairside in one session. Identical shape of all sam-
ples assured identical stress conditions for all samples, since
different geometry of inlay-retained FDPs can cause differ-
ent fracture patterns [16]. Additionally, to minimize variable
factors and in an effort to get homogenous results in the
present in vitro study, standardized “master teeth” were pre-
pared with a preparation positioning guide (Gapless) and
then duplicated. Therefore the IPIRFDPs could be bonded to
nearly identical metal casts using the protocol described in
Section 2.
The Y-TZP frameworks of the IPIRFDPs were industrially
manufactured. Y-TZP ceramic has proved its superior material
characteristics in various studies [11,16]. It consists of partially
stabilized zirconia particles (95% ZrO2 partially stabilized by
5% Y2 O3 ) with a mean grain size of 0.4 ␮m. These particles are
densely sintered, resulting in a final microstructure in which
voids, flaws and cracks are reduced to a minimum [21]. For this
reason and because of the transformation-toughening mech-
anism Y-TZP frameworks offer remarkable fracture strengths
[16,21].
The veneering of the framework was conducted industri-
ally by adding a microhybrid composite. The wear resistance
of this composite has shown to be comparable to other micro-
hybrid composites [22]. Because of a reported high incidence
for chipping of veneering ceramics [23] this material might
Group EFFS (no. 1 + 2 at 600 N, no. 2–6 at 500 N)
LOT 10084-1-2+3/89
2660 –
4976 1
30a 5
345 101
12,069 32
27a 703
8983 805
3c
410d
offer an approach to reduce chipping. However, any repair or
adjustment can easily be performed by adding or removing
composite [24,25].
New dental materials in combination with new preparation
designs have to be tested before they can be recommended
for clinical use [16]. It is not known what fracture resistance is
needed to achieve a good long-term outcome of IPIRFDPs in the
molar region. Numerous authors have investigated the maxi-
mum bite forces during mastication and mean values for the
maximum bite force level varied from 216 to 847 N [26–28]. The
highest bite force was found in the first molar region. Review-
ing the literature, Körber and Ludwig [29] summarized that
posterior FDPs should be strong enough to withstand a load
of 500 N.
Additionally, cyclic fatigue loading caused by mastication
can considerably weaken the fracture resistance of all-ceramic
restorations [30]. Under the conditions of the oral environ-
ment, the inherent flaws of ceramic materials act as the origin
of crack propagation and can grow to critical sizes [21]. The
endurance limit for fatigue cycling that can be applied to den-
tal ceramics is approximately 50% of the maximal fracture
strength [31]. Therefore it seems reasonable to assume that
an initial fracture resistance of 1000 N should be required for
a favorable clinical prognosis of posterior inlay-retained FDPs
with all-ceramic frameworks. With 1749 N the median of group
CQSFS exceeded this threshold value by far. Other studies
[16,21,32] with centric Y-TZP framework testing showed frac-
ture strength values of 1000–3000 N. In a comparable study
[16] Y-TZP inlay-retained FDPs with a connector size of 9 mm2
showed values for centric quasi-static fracture strength test-
ing of 3100 N.
However, the way of testing Y-TZP frameworks centrically
favors the characteristics of this material [16,21] and it does
not correspond to the reality of the oral cavity, where forces are
not always applied perpendicular to the axis of a restoration.
Therefore in group EQSFS specimens were tested eccentri-
cally to the mesio-distal axis of the IPIRFDPs and showed a
significantly reduced median fracture strength of only 880 N.
Therefore, the hypothesis that centric and eccentric loading
 d e n t a l m a t e r i a l s 2 6 ( 2 0 1 0 ) 67–75
does not influence the fracture strength has to be rejected. So
IPIRFDPs with a framework connector size of 4.7 mm2 seem to
be sufficiently strong regarding the threshold value for centric
loading, but must be reviewed critically when eccentric forces
occur.
Additional to quasi-static fracture strength testing, the
IPIRFDPs were fatigued under centric and eccentric loading.
Since the testing in a chewing simulator needs too many
cycles to fatigue Y-TZP FDPs and an impact pulse should be
avoided [16], specimens were tested in a universal testing
machine until the first fracture occurred. The specimens in
groups CFFS/EFFS were tested at a maximum load of 70% of
the median centric/eccentric quasi-static values. Specimens
of group CFFS were fatigued at a maximum load of 1200 N
after 4432 cycles. For eccentric fatigue tests (group EFFS) a
maximum load of 600 N was chosen initially, but the first two
specimens fractured after one and five cycles, respectively.
Therefore the maximum load was reduced to 500 N and due
to the small number of specimens the mean was calculated
at 410 cycles. However, the small number of specimens (n = 2
for 600 N, n = 4 for 500 N) in group EFFS is a limitation of this
study.
Additionally, it was detected by visual inspection, that with
the exception of two specimens all IPIRFDPs fractured com-
pletely, which speaks for good adhesion of the veneering
composite to the framework (examples for typical fractures
see Fig. 5). Besides this fact, it could also be detected that the
buccal lamella of the veneering material not only fractured
when it was stressed eccentrically, but also when stressed
centrically. Dynamic loading, e.g. a leading function during
mastication or parafunctions, should be monitored during
clinical placement of the restoration.
Although in vitro studies are important for preclinical test-
ing, the transferability of the results of an in vitro study to
the clinical situation is limited. It was shown that the modu-
lus of elasticity of the luting resin and the abutment material
influenced the fracture resistance of all-ceramic crowns [33].
In accordance with this outcome another study [34] showed,
that fracture force was found to be significantly greater for
all-ceramic single crowns fixed on CoCrMo alloy materials
(1838 N) than for crowns on human teeth (888 N). However,
these studies are transferable only in part to the present study,
because the support of the abutment material by a full crown
and an inlay retainer differs substantially. However, also in
the present study, the stiffness of the metal abutment might
have influenced the result, because of the different modulus
of elasticity of CoCr alloy (180–240 GPa), dentin (15–20 GPa) and
enamel (50–85 GPa). Further, it has been demonstrated that
abutment mobility is a decisive factor in the evaluation of frac-
ture strength, and when a small amount of abutment rotation
is allowed, failure is more likely [35]. In this context Kappert
et al. reported a mean fracture strength of 703 N for three-unit
In-Ceram posterior FDPs with physiological abutment mobil-
ity in comparison to 2225 N for the group without abutment
mobility [36]. Therefore, according to other studies [37,38] in
the present study a 200 ␮m thick soft silicone layer was used to
generate a tooth mobility of 50 ␮m to simulate a physiological
tooth mobility of grade 0 [39].
To the knowledge of the authors, clinical studies deter-
mining the success rate of inlay-retained FDPs with Y-TZP
73
frameworks are not available. However, a prospective clinical
evaluation was published recently to show the long-term clin-
ical behavior of resin-bonded fixed dental prostheses (RBFDPs)
with a retentive, minimally invasive preparation design [40].
Since 1985, 232 RBFDPs with a retentive preparation design
were placed and 84 RBFDPs could be re-evaluated in 2005/2006.
The total of 12 failures was observed and resulted in a survival
rate of 77% after 10 years. However, only four catastrophic fail-
ures occurred. After re-bonding or reparation the survival rate
increased to 88%. Interestingly, RBFDPs made of a titanium
alloy exhibited a statistically significantly higher survival rate
than RBFDPs made of a non-precious CoCr alloy in terms of
all failures. As mentioned before CoCr alloys have a modu-
lus of elasticity of 180–240 GPa, which is comparable to Y-TZP
ceramic (210 GPa). In contrast to that titanium based alloys
have an elastic modulus of 75 GPa. A possible explanation for
the significantly lower failure rate might be that inlay-retained
FDPs made of titanium based alloys are balancing the tooth
mobility to a certain extent in comparison to rigid materials
like Y-TZP or CoCr alloys.
On the other hand, a prospective clinical cohort study [41]
determined the success rate of three to five-unit posterior
FDPs with Y-TZP frameworks after 3 years of function. In this
study 36 patients with 46 FDPs were available for examina-
tion after 36 months. No fractures occurred, rendering a 100%
success rate of the Y-TZP frameworks. Seven FDPs had to be
replaced because of biological and technical problems. Thus,
the survival rate was 84.8%. Secondary caries was found in
10.9% of the FDPs, and chipping of the veneering ceramic was
found in 13.0%. A similar study [42] showed comparable results
(mean observation time 31 months) for 20 three-unit poste-
rior FDPs with a survival rate of 100% and minor chipping of
the veneering ceramic of 25%. Even though the design of the
FDPs was different in these in vivo studies, compared to the
present in vitro study, all studies showed that Y-TZP frame-
works demonstrated sufficient stability for replacement of
posterior teeth. Since the veneering of the restorations seems
to be a limiting factor, an easily reparable composite veneer-
ing with wear characteristics similar to human enamel might
be considered as an option for veneering inlay-retained FDPs.
However, the prospective clinical testing of the industrially
prefabricated inlay-retained FDPs has to be performed before
they can be recommended for general clinical use.
5. Conclusions
Under the limitations of the study the following conclusions
can be drawn:
- Considering the maximum bite forces in the molar region,
it seems possible to use yttria-stabilized tetragonal zirconia
ceramic with a connector size of 4.7 mm2 as a framework
material.
- The prefabricated all-ceramic inlay-retained FDPs seem
suitable for restoring missing upper and lower first molars.
- It seems advisable to remove any contact points in eccentric
static or dynamic occlusion.
74 d e n t a l m a t e r i a l s 2 6 ( 2 0 1 0 ) 67–75
Acknowledgement
The authors are grateful to Mr. Ulrich Wennemann (Gap-
less, Umkirch, Germany) for providing the prefabricated
all-ceramic inlay-retained FDPs used in this study.
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