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Evaluation of fracture resistance of inlay-retained fixed partial dentures

fabricated with different monolithic zirconia materials

Article  in  Journal of Prosthetic Dentistry · September 2017

DOI: 10.1016/j.prosdent.2017.06.008

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 RESEARCH AND EDUCATION

Evaluation of fracture resistance of inlay-retained fixed

partial dentures fabricated with different monolithic
zirconia materials
Hilal Siriner Gumus, DDS, PhD,a Nilufer Tulin Polat, DDS, PhD,b and Guler Yildirim, DDSc

Various materials have been ABSTRACT

used to restore a single missing Statement of problem. Data are lacking on the fracture resistance of monolithic zirconia inlay-
tooth, including metal-ceramic, retained fixed partial dentures as a conservative treatment for a single missing tooth.
ceramic,1 direct or indirect fiber-
Purpose. The purpose of this in vitro study was to evaluate the fracture resistance of inlay-retained
reinforced composite resin, and
fixed partial dentures produced from 3 different monolithic zirconia materials and based on 2
dental implants. Traditionally, preparation types and applications with and without thermocycling.
metal-ceramic fixed partial den-
tures have been used to treat a Material and methods. A model with missing right and left mandibular first molars was used for
different cavity preparations. A tube-shaped cavity and a box-shaped cavity were prepared.
single missing tooth.2,3 Single
Seventy-two epoxy resin casts were prepared from an additional silicone impression. Twenty-
implant-supported crowns have four inlay-retained fixed partial dentures from each monolithic zirconia material (Prettau,
also shown good long-term re- Zirkonzahn; Katana, Noritake; and Copran, Whitepeaks) were fabricated for each preparation
sults. However, patients may type and cemented to their epoxy model with dual-polymerizing adhesive resin cement; 50% of
reject implant therapy, which all specimens were thermocycled for 10 000 cycles. The specimens were subjected to a fracture
takes time, is costly, and can resistance test using a universal testing machine with a crosshead speed of 0.5 mm/min.
require bone and soft-tissue Fracture surfaces were examined with scanning electron microscopy (SEM), and a specimen
4 from each group was examined for structural changes with differential thermal analysis (DTA).
surgery. Traditional gold-inlay-
retained fixed partial dentures Results. No statistically significant differences in terms of fracture resistance were found among
are a conservative option,5 but brands with both cavity designs and with and without thermal cycles (P>.05). However, SEM and
DTA results showed some changes in monolithic zirconia structure after 1 year of aging.
the metal abutments may
be esthetically unacceptable. Conclusions. The brands and cavity preparation types for single posterior tooth loss generated
Recently, a range of esthetic similar fracture resistance. (J Prosthet Dent 2017;-:---)
materials has been introduced,
including microfilled or fiber-reinforced composite resins withstand fracture loads higher than those of layered
and high-strength ceramics used as veneered frameworks zirconia restorations.11,12 The increased translucency of
6,7
or for monolithic restorations. monolithic zirconia is accomplished by modifying the
With the development of computer-aided design and production and sintering stages.13 Replicating natural
computer-aided manufacturing (CAD-CAM) technology tooth color is achieved by using precolored zirconia
and zirconia materials, monolithic zirconia restorations blocks and coloring liquids.14 As a result of their high
8-10
have become popular. In vitro investigations have fracture resistance, monolithic zirconia crowns are resis-
shown that monolithic zirconia single crowns can tant to the forces of mastication in the molar region, even

Supported by the Scientific and Technological Research Council of Turkey (TUBITAK), project no.114S860.
a
Prosthodontist, Atasehir Oral and Dental Health Center, Istanbul, Turkey.
b
Professor, Department of Prosthodontics, Faculty of Dentistry, Inonu University, Malatya, Turkey.
c
Assistant Professor, Department of Prosthodontics, Faculty of Dentistry, Inonu University, Malatya, Turkey.

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Table 1. Compositions and manufacturers of materials

Clinical Implications Brand Name Manufacturer Composition (%)
Prettau ZirconZahn ZrO2, Y2O3 (4-6), Al2O3 (<1), SiO2 (max. 0.02),
The fracture resistance of inlay-retained fixed partial Fe2O3 (max. 0.01), Na2O (max. 0.04)
dentures made of monolithic zirconia to replace a Copran Zr White Peaks ZrO2, Y2O3 (5.15-5.55), Al2O3 (0.03-0.07),
Dental Systems Fe (0-0.01), others (0-0.02)
posterior single missing tooth suggest that it is
Katana Noritake ZrO2, Y2O3, others
suitable for clinical use.

base was 2 mm. The mesiodistal width of the cavity base

with a 0.5-mm occlusal thickness.8,11,15 These high-
was 6 mm in the molar teeth and 4 mm in the premolar
strength materials require less tooth reduction, leading
teeth (Fig. 1A). The buccolingual width of the occlusal
to less risk of pulpal damage, and may be suitable for
isthmus was 3 mm in molar teeth and 2 mm in premolar
inlay-retained fixed partial dentures.6,16 A complication
teeth (Fig. 1B).
of ceramic inlay fixed partial dentures has been chipping
The depth of the proximal box was 2 mm from the
or debonding of the veneer at the retainer-pontic junc-
occlusal surface to the base of the cavity. The mesiodistal
tion. Although ceramic materials are now widely used in
width of the cavity base was 6 mm in molar teeth and 4
dentistry, they often cannot resist mastication forces and
mm in premolar teeth. The occlusocervical height of the
are limited in their use.
cavity wall was 2 mm in both molar and premolar teeth
The fracture resistance of a dental prosthesis depends
(Fig. 2). The mesiodistal width was 1 mm in both molar
on the elastic modulus of the supporting structure, the
and premolar teeth, and the buccal-lingual width of the
properties of the bonding agent, the thickness of the
occlusal tooth was prepared as 3 mm for the molar tooth
restoration, and the design of the preparation.4 The
and 2 mm for the premolar tooth (Fig. 1B).
shape of fixed dental prostheses is not constant but varies
Impressions of the mandibular models were made
in terms of its complex structure, consisting as it does of
with addition silicone materials (Elite HD + Maxi Putty
many concave and convex contours depending on the
Soft Fast Setting and Italian Elite HD + Light Body Fast
geometry. In particular, because the connectors need to
Setting; Zhermack) to create epoxy resin casts, which
be small for biological and esthetic reasons, they expe-
were then embedded in acrylic resin blocks.
rience greater levels of stress than elsewhere in a 3-unit
The epoxy casts were scanned, and restoration de-
fixed partial denture.17
signs were made (Dental Wings Inc). Three different
This study evaluated the fracture resistance of poste-
monolithic zirconia materials for inlay-retained fixed
rior inlay-retained fixed partial dentures made from a
partial dentures were produced for each type of prepa-
recently developed translucent monolithic zirconia. The
ration (Yenamak 5 axis; Yena Machinery Industry Co Ltd)
effects of different cavity preparations and thermocycling
using the Pica Soft program (Picasoft; Dental Cam). Each
were also investigated. The null hypotheses tested were
restoration was cemented on its own epoxy cast using the
that no difference would be found in the fracture resis-
adhesive cement (Panavia F 2.0; Kuraray Noritake Dental
tance of 3 different brands of monolithic zirconia and that
Inc) in accordance with the manufacturer’s instructions.
no difference would be found between the fracture re-
All specimens were stored in deionized water at 37 C for
sistances of tube- and box-shaped cavity designs.
24 hours. Then, 72 specimens were subjected to ther-
mocycling (10 000 cycles, 5 C-55 C, 30-second intervals)
MATERIAL AND METHODS
and loaded until fracture in a universal testing machine
A total of 12 groups were formed according to 2 different (Instron Tensometer). The load was vertically applied
types of cavities and the application of thermocycling. with a 5-mmediameter stainless steel ball placed at the
Three different monolithic zirconia brands (Prettau; Zir- center of the occlusal surfaces of the pontic and a
konzahn, Katana; Noritake, and Copran; Whitepeaks) crosshead speed of 0.5 mm/min.
were used (Table 1). A power analysis showed that for A fractography analysis was performed using a stan-
a=.05 and 1eb=.8, at least 12 specimens from each group dard scanning electron microscope (SEM) on selected
(144 specimens in total) had to be prepared for an specimens, which were sputter-coated (Bal-Tec SCD 050;
average change of 150 N in fracture resistance. Bal-tec AG) with a 15-nm layer of AuePd. The images
The right and left first molar teeth were removed from were examined at 20 kV with a magnification range of
a mandibular typodont model (ANA-4; Frasaco). The between ×500 and ×10 000.
area was filled with wax, and an edentulous contour was Fractured specimens of only 1 brand (Copran), both
made. On the right side, the second premolar and the undergoing and not undergoing thermal cycles, were
second molar were prepared in a tubular design, while analyzed on the differential thermal analysis (DTA) de-
the left side was prepared in a box shape. The depth of vice (DTA-50; Shimadzu), because the groups did not
the proximal tube from the occlusal surface to the cavity differ in terms of SEM images or fracture resistance.

THE JOURNAL OF PROSTHETIC DENTISTRY Gumus et al

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Table 2. Fracture resistance values and standard deviations of

specimens (N)
2 mm 4 mm 6 mm 2 mm 95% Confidence
Interval
Brand Name/ Fracture Lower Upper
Cavity Design Thermocycle load ±SD Bound Bound
Prettau
Tube-shaped - 520 ±31.4 458.1 581.8
+ 501 ±22.1 457.2 544.7
Box-shaped - 583.1 ±31.3 521.2 645
+ 524.3 ±22.2 480.6 568.1
Copran
Tube-shaped - 571.5 ±31.3 509.7 633.4
+ 568.2 ±22.1 524.4 611.9
A Box-shaped - 567.7 ±31.3 505.8 629.6
+ 567.2 ±22.1 523.5 611
Katana
Tube-shaped - 537.4 ±31.3 475.6 599.3
+ 541.8 ±22.1 498.1 585.6
Box-shaped - 516.5 ±31.3 454.6 578.4
2 mm 3 mm + 531.2 ±22.1 487.4 574.9

F(2, 204)=.247, P=.781, P>.05.

B After the fracture test, the thin connector area was

Figure 1. Tube-shaped cavity design. A, Buccal view. B, Occlusal view. examined. The fractured area at the tube-shaped inlay-
retained fixed partial dentures was located at the
junction of the occlusal cavity and pontic connector,
and the fractured area at the box-shaped inlay-
2 mm 4 mm 6 mm 2 mm retained fixed partial dentures was located at the
2 mm 1 mm 1 mm 2 mm junction of the occlusal and proximal parts of the
cavity. However, no significant conclusion could be
drawn regarding the location of the connector (mesial
or distal). The SEM images (Fig. 3) showed that the
boundaries of the fracture surface of the 3 brands were
more pronounced and sharper with specimens that did
not undergo thermocycling and smoother with those
that did.
The application of 1 year of aging with 10 000 cycles
did not cause a significant change in the durability of the
specimens. However, a significant change in the struc-
Figure 2. Box-shaped cavity. ture, which appeared to start from the surface, was
noted. This is evident from the DTA thermograms in
Figure 4.
The experimental results were statistically analyzed
The monolithic zirconia specimens were placed in the
using software (SPSS Statistics v17.0; SPSS Inc). The 3-
DTA device with the occlusal surfaces in contact with the
way analysis of variance test was used to compare
surface of the thermocouples. For the specimen surface,
groups (a=.05).
the peak at 279 C without thermocycling (No-TC) was
not observed in the thermocycled (TC) specimens. The
RESULTS
energy change in the phase transitions at around 900 C
The minimum, maximum, mean, and standard deviation was about one-half for specimens that underwent the
of the data obtained from the fracture resistance test of thermocycling compared with those that did not undergo
the specimens are given in Table 2. The difference in the thermocycling. Furthermore, the peak in the exothermic
fracture resistance of the tube-shaped and box-shaped phase transition at 404 C without thermocycling was not
cavities between specimens that did and did not un- observed in specimens that underwent thermal cycles
dergo thermocycling was not statistically significantly (Fig. 4). Based on these findings, the surface character-
different (P>.05). istics of the specimens were changed.

Gumus et al THE JOURNAL OF PROSTHETIC DENTISTRY

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Figure 3. Representative scanning electron microscopy images of fracture surfaces (original magnification ×2500). A, Prettau without thermocycling. B,
Prettau with thermocycling. C, Copran without thermocycling. D, Copran with thermocycling. E, Katana without thermocycling. F, Katana with
thermocycling.

DISCUSSION long-term clinical success.10 Studies evaluating the frac-

ture resistance of inlay-retained fixed partial dentures
Inlay-retained fixed partial dentures, which require
have shown that these restorations require a minimum
minimal preparation, are a conservative alternative to
load of 500 N to resist the mastication forces in the molar
conventional metal-ceramic or ceramic prostheses.4
region.1,4,16,18
Recently, anatomic contour monolithic zirconia crowns
Kilicarslan et al19 found that the fracture resistance of
have been developed with fracture toughness, esthetic
zirconia fixed partial dentures (1247 N) was similar to
appearance, minimal abrasive properties of opposing
that of conventional metal-ceramic fixed partial dentures
teeth, conventional preparation, and the potential for
(1318 N) and that the inlay-retained metal-ceramic fixed

THE JOURNAL OF PROSTHETIC DENTISTRY Gumus et al

- 2017 5

388.99 C

10.00

404.57 C

Heat 2.88 J
DTA (uV)

NO-TC 37.37 J/g

0.00
382.02 C

304.99 C
TC 279.37 C Heat 1.20 J
–10.00
16.39 J/g

320.24 C

0.00 200.00 400.00 600.00 800.00 1000.00

Temp (C)
Figure 4. Differential thermal analysis (DTA) images of specimens with and without thermocycling.

partial dentures were able to withstand the mastication Further studies should evaluate slotted restorations made
forces in the posterior region (958 N). Lithium disilicate from monolithic zirconia materials. Also, the number of
specimens had significantly lower fracture resistance (303 restorations in which structural changes occur and
N). A few studies on inlay-retained fixed partial dentures resistance begins to be affected should be investigated.
have been reported. The monolithic zirconia crowns were
therefore compared in this study in terms of their fracture CONCLUSIONS
resistance. Lameira et al12 showed that the fracture
Based on the findings of this in vitro study, the following
resistance of polished zirconia (3476.2 ±791.7 N) and
conclusions were drawn:
glazed zirconia crowns (3561.5 ±991.6 N) was similar,
and these 2 groups were more durable than layered 1. Inlay-retained fixed partial dentures produced from
(0.8-mm zirconia coping + 0.7-mm porcelain veneer) Prettau, Copran, and Katana CAD-CAM monolithic
zirconia crowns (2060.4 ±810.6 N). Johansson et al13 zirconia blocks had similar fracture resistance with
reported that monolithic zirconia crowns (2795 N and and without thermocycling.
3038 N) demonstrated greater fracture resistance than 2. The fracture resistance was higher than that
other crown types, and zirconiaeceramic crowns (2229 N) required for a posterior restoration.
were more resistant than monolithic lithium disilicate 3. Thermocycling equivalent to 1 year of aging had no
crowns (1856 N) and veneered monolithic zirconia effect on the resistance of zirconia restorations.
crowns (1480 N and 1808 N). 4. The fracture resistance of restorations with tube-
Because this study aimed to retain the cavity size, the and box-shaped cavity designs did not differ.
connector size was kept smaller than usual to test the
applicability of the monolithic zirconia inlay-retained
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