Velho 2023
Velho 2023
Velho 2023
How does the occlusal contact region influence the mechanical fatigue
performance and fracture region of monolithic lithium disilicate
ceramic crowns?
Helder Callegaro Velho a, Lucas Saldanha da Rosa a, Kiara Serafini Dapieve a, Alexandre Luiz
Souto Borges b, Gabriel Kalil Rocha Pereira a, Andressa Borin Venturini a, Luiz Felipe Valandro a, *
a
MSciD and Ph.D. Post-Graduate Program in Oral Sciences, Faculty of Dentistry, Federal University of Santa Maria (UFSM), Santa Maria, Rio Grande do Sul State,
Brazil
b
Department of Dental Materials and Prosthodontics, São Paulo State University, São José dos Campos, São Paulo, Brazil
A R T I C L E I N F O A B S T R A C T
Keywords: Objective: To characterize the effect of the occlusal contact region on the mechanical fatigue performance and on
Dental ceramics the fracture region of monolithic lithium disilicate ceramic crowns.
Fatigue Materials and methods: Monolithic lithium disilicate ceramic crowns were machined in a CAD/CAM system and
Fracture
adhesively luted onto glass-fiber reinforced epoxy resin preparations with resin cement. The crowns were divided
Loading pattern
into three groups (n = 16) according to load application region (cusp tip: restricted to cusp tips; cusp plane:
restricted to cuspal inclined plane; or mixed: associating tip cusp and cuspal inclined plane). The specimens were
submitted to a cyclic fatigue test (initial load: 200 N; step-size: 100 N; cycles/step: 20,000; loading frequency: 20
Hz; load applicator: 6 mm or 40 mm diameter stainless steel) until observing cracks (1st outcome) and fracture
(2nd outcome). The data were analyzed by the Kaplan-Meier + Mantel-Cox post-hoc tests for both outcomes
(cracks and fracture). Finite element analysis (FEA), occlusal contact region, contact radii measurements, and
fractographic analyzes were performed.
Results: The mixed group presented worse fatigue mechanical behavior (550 N / 85.000 cycles) compared to the
cuspal inclined plane group (656 N / 111,250 cycles) (p < 0.05) for the first crack outcome, while the cusp tip
group was similar to both groups (588 N / 97,500 cycles) (p > 0.05). The mixed group had the worst fatigue
behavior (1413 N / 253,029 cycles) in relation to the other groups (Cusp tip: 1644 N / 293,312 cycles; Cuspal
inclined plane: 1631 N / 295,174 cycles) considering the crown fracture outcome (p < 0.05). FEA showed higher
tensile stress concentration areas just below the load application region. In addition, loading on the cuspal in
clined plane induced a higher tensile stress concentration in the groove region. The most prevalent type of crown
fracture was the wall fracture. Groove fracture was observed in 50% of the loading specimens exclusively on the
cuspal inclined plane.
Conclusion: Load application on distinct occlusal contact regions affects the stress distribution pattern and
consequently the mechanical fatigue performance and fracture region of the monolithic lithium disilicate
ceramic crowns. A combination of loading at distinct regions is recommended to promote better evaluation of the
fatigue behavior of a restored set.
* Corresponding author. Federal University of Santa Maria, Faculty of Odontology, MSciD-PhD Graduate Programs in Oral Sciences, Prosthodontics Unit, 1000
Roraima Av, T Street, Building 26F, Room 2360, UFSM Campus, 97105-900, Santa Maria, Brazil.
E-mail addresses: heldercvelho@hotmail.com (H.C. Velho), lucas.saldanha.da.rosa@gmail.com (L.S. da Rosa), kiara_s_d@hotmail.com (K.S. Dapieve),
alexanborges@gmail.com (A.L.S. Borges), gabrielkrpereira@hotmail.com (G.K.R. Pereira), andressa.venturini@hotmail.com (A.B. Venturini), valandrolf@gmail.
com (L.F. Valandro).
https://doi.org/10.1016/j.jmbbm.2023.105746
Received 23 January 2023; Received in revised form 23 February 2023; Accepted 26 February 2023
Available online 1 March 2023
1751-6161/© 2023 Elsevier Ltd. All rights reserved.
H.C. Velho et al. Journal of the Mechanical Behavior of Biomedical Materials 140 (2023) 105746
pores and flaws within the material, which results in greater reliability Table 1
and lower risk of clinical failure compared to traditional Description of materials, commercial name, manufacturer, composition, and
porcelain-veneered crowns (Belli et al., 2017; Zhang and Kelly, 2017). batch number.
However, they still have limitations such as brittleness and are prone to Material Commercial Compositiona Batch
mechanical failures that can lead to catastrophic fractures and chipping name/ number
(Della Bona and Kelly, 2008; Mazza et al., 2022; Zahran et al., 2008). manufacturer
An important factor to decrease the risk of failure in ceramic resto Lithium IPS e.max CAD, SiO2 57–80 %wt, Li2O X27104
rations is adequate occlusion between natural teeth, restorations and/or disilicate glass Ivoclar, Schaan, 11–19 %wt, K2O 0–13 %wt,
ceramic Liechtenstein P2O5 0–11 %wt, ZrO2 0–8 %
fixed prostheses, as inadequate occlusal contacts can generate stress
wt, ZnO 0–8 %wt, Al2O3 0–5
concentration areas which consequently tend to lead to failures (Amin %wt, MgO 0–5 %wt,
et al., 2019). Therefore, it is important to consider that the loading colouring oxides 0–8 %wt.
pattern (distribution of occlusal contacts) and the direction of applied Silane- Monobond N, Alcohol solution of silane Y29207
forces may influence the performance of ceramic restorations (Corazza containing Ivoclar methacrylate, phosphoric
universal acid methacrylate and
et al., 2015; Zhang et al., 2013). The way in which restorations are primer sulphide methacrylate.
loaded will particularly depend on the design of the occlusal surface and 5% hydrofluoric Condac Porcelana, <5% hydrofluoric acid. 020819
consequently on the amount and location of occlusal contacts (Dittmer acid FGM, Joinville,
et al., 2011). Brazil
10% Condac Porcelana, <10% hydrofluoric acid. 220920
The first contact after the preparatory and crushing phases during
hydrofluoric FGM
the masticatory cycle occur in an eccentric position (cusp tip), followed acid
by sliding until centric occlusion (central fossa) (DeLong and Douglas, Dual cure resin Multilink N, Base: Dimethacrylates and Y26001
1983). Occlusal contact in the central fossa region is more stable and cement Ivoclar HEMA 33.1 %wt, Barium
better distributes stress; on the other hand, contact in the cusp tip glass filler 37.4 %wt,
ytterbium trifluoride, 23 %
generates high stress at the contact area, where it contributes to the
wt, highly dispersed silica
origin of failures (Corazza et al., 2015; Dittmer et al., 2011). However, 5.4 %wt, catalysts and
most laboratory studies use a single load at the center of the occlusal stabilizer 1 %wt, pigments
surface (Velho et al., 2022b). Thus, axial loading on the cusp tips and <0.03 %wt
Catalyst: Dimethacrylates
central fossa also needs to be considered when aiming to approximate to
and HEMA 32.4 %wt,
the clinical scenario. Barium glass filler 37.4 %wt,
In view of the above, evaluating distinct in vitro occlusal contact ytterbium trifluoride, 23 %
modes which can reproduce or approximate clinically observed failure wt, highly dispersed silica
modes in ceramic monolithic crowns becomes a relevant topic. There 5.4 %wt, catalysts and
stabilizer 1.8 %wt
fore, this study aimed to characterize the effect of the occlusal contact
Primer Multilink Primer Primer A: water 85.7 %wt, Z000M9
region on the mechanical fatigue performance and on the fracture region (A and B), Ivoclar initiators 14.3 %wt.
of monolithic ceramic crowns considering 3 load application regions Primer B: phosphonic acid Z003PX
(restricted to cusp tips; restricted to cuspal inclined plane; associating tip acrylate 48.1 %wt,
(hydroxyethyl
cusp and cuspal inclined plane). The hypothesis tested was that the
methacrylate, methacrylate
occlusal loading region influences the mechanical fatigue performance mod. Polyacrylic acid) 51.9
and the fracture region of monolithic lithium disilicate ceramic crowns. %wt, stabilizer <0.02 %wt.
Glass-fiber Perfil Pultrudado Continuous filament woven –
2. Material and methods reinforced F, Protec, São fiberglass bonded with
epoxy resin Paulo, Brazil epoxy resin.
2
H.C. Velho et al. Journal of the Mechanical Behavior of Biomedical Materials 140 (2023) 105746
Fig. 2. Illustrations of glass-fiber reinforced epoxy resin preparations and ceramic crown planning. A - Scanning of glass-fiber reinforced epoxy resin preparations. B
– Digital design of ceramic crowns with a thickness of 1 mm onto the preparation. C – Machined ceramic crowns. D - Verification of fit between glass fiber-reinforced
epoxy resin preparations/ceramic crowns.
3
H.C. Velho et al. Journal of the Mechanical Behavior of Biomedical Materials 140 (2023) 105746
Fig. 3. Representations of the region of load application of each experimental group. Load application on the cusp tips was performed with a 40 mm diameter
stainless steel load applicator. The load application in the cuspal inclined plane was obtained with a 6 mm diameter stainless steel load applicator, while the mixed
group used both load regions and pistons.
Models of ceramic crowns, resin cement, glass-fiber reinforced epoxy 2.8. Data analysis
resin preparations and load applicators were performed. Three-
dimensional models were created using a software program (Rhinoc The FFL and CFF data for both outcomes (first crack and crown
eros version 5.0 SR8, McNeel North America, Seattle, USA), and fracture) were statistically analyzed through a survival analysis using
analyzed using the ANSYS CAE software program (ANSYS 19.3, ANSYS Kaplan Meier and Mantel-Cox (log-rank) post-hoc tests (α = 0.05) in the
Inc., Houston, USA). A static structural analysis was applied according to IBM SPSS software program (IBM, Armonk, USA). The FEA, contact
the fatigue test assembly of the cusp tip and cusp plane groups (Fig. 3). point measurements and fractographic data were qualitatively analyzed.
All materials were considered isotropic, linear, and homogeneous.
Young’s moduli (GPa) and Poisson’s ratios for lithium disilicate ceramic 3. Results
(E = 95; Gpa; ν = 0.25), glass-fiber reinforced epoxy resin (E = 14.9;
GPa; ν = 0.31), resin cement (E = 7.5; GPa, ν = 0.3) and stainless steel (E The mixed loading group presented lower fatigue behavior consid
= 190; GPa; ν = 0.27) were obtained from previous studies (Kelly et al., ering the first crack outcome in relation to the cuspal inclined plane
2010; Machry et al., 2021; Ramos et al., 2016). The cusp tip group model group, while the cusp tip group was similar to both groups (Table 3,
was composed of 158,312 tetrahedron solid elements with 233,766 Fig. 4). In addition, the mixed group showed the worst fatigue behavior
nodes and the cusp plane group was composed of 156,189 tetrahedron regarding the crown fracture outcome compared to the other groups
solid elements with 230,228 nodes. The connections among the base, (Table 3, Fig. 4).
restoration and resin cement were considered perfectly bonded and FEA data showed higher tensile stress concentrations areas just
frictional (0.12) to the load applicator and restoration. The models were below the load application region. In addition, loading on the cuspal
loaded (100 N) at the top of the load applicator and constrained at the inclined plane induced a higher tensile stress concentration in the cen
bottom surface of the base. After the coherence and mesh convergence tral groove region compared to cusp tip loading (Fig. 5). The occlusal
test, the maximum principal stress was used as the failure criteria to contact point regions as well as the mean values of the contact radii are
compare the groups. shown in Fig. 6.
The most prevalent type of crown fracture was the wall fracture
2.6. Contact point region and contact radii measurements (Table 3). The fractographic analysis (Fig. 7) showed the failure starting
from the bonding surface as a radial crack and then the failure also starts
In aiming to determine the contact point region for the two loading to propagate with increasing load from the occlusal surface (hertzian-
patterns adopted before the fatigue test, all specimens had their contact cone crack) towards the bonding surface until reaching the radial crack
point between the load applicator and the ceramic crown highlighted (the fracture moment). On the other hand, the groove fracture occurred
using a carbon paper (Contacto paper, 100 μm, Angelus, Londrina, in 50% of the loading specimens exclusively on the cuspal inclined
Brazil) and a compressive load application of 10 N was applied in the plane. These failures involved the displacement of ceramic and sup
testing machine. Then, the contact radii were measured in a stereomi porting substrate in the groove region. It is not possible to identify an
croscope (Discovery V20, Carl Zeiss, Gottingen, Germany), and the apparent failure origin in the ceramic – the failure possibly occurred
mean values were calculated. from the shear rupture of the supporting substrate (Fig. 7).
Two failures modes were considered: first crack (initial crack, iden Overall, this study showed that load application at distinct occlusal
tified by transillumination) and crown fracture (final failure, involving contact regions affected the stress distribution pattern owing to different
crown breaking into one or more fragments). In addition, the crown tip sizes, and consequently the mechanical fatigue performance and
fractures were classified as wall fracture (when displacement of a frag fracture region, since the group with combined loading induced the
ment of the crown wall occurred) or groove fracture (when the failure worst behavior. Thus, the assumed hypothesis was accepted.
involved fracture in the central groove region of the crown and cohesive In addition, worse mechanical fatigue performance was observed
failure of the substrate). Next, one representative specimen of each type considering the loading associating the cusp tip and cuspal inclined
of failure was selected and submitted to Scanning Electron Microscopy plane contacts (mixed group) (Table 3, Fig. 4). This can be associated
(SEM, JSM-6360, JEOL, Tokyo, Japan) at 30 × and 100 × magnifica with the loading pattern adopted, which consequently generated tensile
tions to access and illustrate the failure origin and characterize the stress concentration in two regions (cusp tip and cuspal inclined plane –
4
H.C. Velho et al. Journal of the Mechanical Behavior of Biomedical Materials 140 (2023) 105746
Table 3
Mean fatigue failure loads (FFL) in Newtons, number of cycles for failure (CFF) with their respective 95% confidence interval (CI) of each evaluated outcome and
region of fracture.
Groups First crack Crown fracture
Different letters indicate statistical differences on each column for each considered outcome.
* Kaplan-Meier and Mantel-Cox (log-rank) tests for FFL and CFF.
Fig. 4. Survival curves according to the fatigue failure loads (FFL) and number of cycles for failure (CFF) steps in which each luted crown failed (according to first
crack and crown fracture), obtained by the Kaplan–Meier and Log-rank tests.
Fig. 5), contributing to a faster fatigue mechanical degradation in rela (Deng et al., 2002; Lawn et al., 2004; Zhang et al., 2009). A radial crack
tion to the other groups. Furthermore, the predominant failure mode initially forms and progresses towards the occlusal surface (Zhang et al.,
was wall fracture (Table 3), which is similar to the total fractures of 2009). As the applied load and number of cycles increase, contact
clinical crowns reported by Skjold et al. (2022). From the fractographic damage to the occlusal surface tends to occur (Zhang et al., 2005), which
analysis (Fig. 7), it is possible to observe that the failure happened from contributes to the formation of hertzian-cone cracks.
radial and hertzian-cone cracks, which are competing failure modes On the other hand, the groups with exclusive loading in one region
5
H.C. Velho et al. Journal of the Mechanical Behavior of Biomedical Materials 140 (2023) 105746
Fig. 5. Finite elements analysis (FEA) demonstrates the tensile stress in the inner surface of the ceramic crowns (Maximum Principal Stress – MPS). The higher tensile
stress concentration areas are located just below the load application region. In addition, loading on the inclined cuspal plane induced a higher tensile stress
concentration in the central groove region compared to cusp tip loading.
6
H.C. Velho et al. Journal of the Mechanical Behavior of Biomedical Materials 140 (2023) 105746
Fig. 7. SEM micrographs (30 × and 100 × magnification) illustrating the fractographic pattern accessed at one representative specimen of each crown fracture
region (Wall and Groove fracture). The yellow arrows indicate the origin of failure, while the dashed black arrows indicate the direction of the crack propagation
(DCP); and the filled arrows indicate the Wallner lines. Wall fracture: The failure starting from the bonding surface as a radial crack and with increasing loading the
failure also starts to propagate from the occlusal surface (hertzian-cone crack) towards the bonding surface until reaching the radial crack - moment of fracture.
Groove fracture: Involved the displacement of ceramic and supporting substrate in the region of groove. It is not possible to identify an apparent failure origin in the
ceramic, the failure possibly occurred from the shear rupture of the supporting substrate.
similar in both scenarios (Table 3). However, these contacts do not sliding movements. Therefore, the data must be interpreted with
happen in an isolated way during the masticatory cycle (Corazza et al., caution. New studies proposing changes in the model of restorations in
2015). The first contact after the preparatory and the crushing phases which the load is taken towards the crown margin are suggested, so that
occur in an eccentric position (cusp tip), followed by sliding until centric the model can better approximate what happens clinically. Lastly,
occlusion (central fossa) (DeLong and Douglas, 1983). Thus, the present sliding movements approaching the occlusal surface are encouraged.
study used loading associating tip cusp and cuspal inclined plane in
aiming to approach this masticatory cycle. In this sense, considering that 5. Conclusion
the mechanical fatigue behavior of this group was worse (Table 3), the
loading being restricted to only one region may overestimate the me Load application at the distinct occlusal contact regions influenced
chanical behavior of the restoration. However, the mixed scenario the stress distribution pattern, and consequently the mechanical fatigue
explored herein should not be considered as a perfect simulation to what performance and the fracture region of monolithic lithium disilicate
is seen in clinical function, since sliding movements are not reproduced. crowns. Although there are limitations in relation to simulating the
The specimen model used in this study was designed to increase the clinical loading pattern, the association of in vitro loading regions is
complexity of the model in relation to simplified non-anatomic crowns recommended to promote better evaluation of the fatigue behavior of a
(occlusal plane) (Velho et al., 2022b). Therefore, restoration design restored set.
parameters – such as the thickness, preparation height, margin geome
try, cusp inclination, presence of surface irregularities and sharp fea CRediT authorship contribution statement
tures of the occlusal anatomy – can influence the restoration’s
mechanical behavior (Shahmoradi et al., 2020; Sornsuwan and Swain, Helder Callegaro Velho: Writing – original draft, Methodology,
2011). While the model still enables isolating factors such as ceramic Investigation, Formal analysis, Data curation, Conceptualization. Lucas
thickness, the loading pattern and the stress distribution in the resto Saldanha da Rosa: Writing – review & editing, Methodology, Investi
ration, it tends to be more complex in relation to simplified gation, Formal analysis, Data curation. Kiara Serafini Dapieve: Writing
non-anatomic crowns. However, there are still limitations such as the – review & editing, Methodology, Investigation, Formal analysis, Data
origin of failure restricted to the occlusal surface and the absence of curation. Alexandre Luiz Souto Borges: Writing – review & editing,
7
H.C. Velho et al. Journal of the Mechanical Behavior of Biomedical Materials 140 (2023) 105746
Validation, Supervision, Formal analysis. Gabriel Kalil Rocha Pereira: Dittmer, M.P., Kohorst, P., Borchers, L., Schwestka-Polly, M., Stiesch, M., 2011. Stress
analysis of an all-ceramic FDP loaded according to different occlusal concepts.
Writing – review & editing, Visualization, Validation, Supervision,
J. Oral Rehabil. 38, 278–285. https://doi.org/10.1111/j.1365-2842.2010.02147.x.
Project administration, Funding acquisition, Formal analysis, Concep Kelly, J.R., Rungruanganunt, P., Hunter, B., Vailati, F., 2010. Development of a clinically
tualization. Andressa Borin Venturini: Writing – review & editing, validated bulk failure test for ceramic crowns. J. Prosthet. Dent 104, 228–238.
Visualization, Validation, Supervision, Project administration, Funding https://doi.org/10.1016/S0022-3913(10)60129-1.
Lawn, B.R., Pajares, A., Zhang, Y., Deng, Y., Polack, M.A., Lloyd, I.K., Rekow, E.D.,
acquisition, Formal analysis, Conceptualization. Luiz Felipe Valandro: Thompson, V.P., 2004. Materials design in the performance of all-ceramic crowns.
Writing – review & editing, Visualization, Validation, Supervision, Biomaterials 25, 2885–2892. https://doi.org/10.1016/j.biomaterials.2003.09.050.
Project administration, Funding acquisition, Formal analysis, Machry, R.V., Borges, A.L.S., Pereira, G.K.R., Kleverlaan, C.J., Venturini, A.B.,
Valandro, L.F., 2021. Influence of the foundation substrate on the fatigue behavior of
Conceptualization. bonded glass, zirconia polycrystals, and polymer infiltrated ceramic simplified CAD-
CAM restorations. J. Mech. Behav. Biomed. Mater. 117, 104391 https://doi.org/
10.1016/j.jmbbm.2021.104391.
Mazza, L.C., Lemos, C.A.A., Pesqueira, A.A., Pellizzer, E.P., 2022. Survival and
Declaration of competing interest complications of monolithic ceramic for tooth-supported fixed dental prostheses: a
systematic review and meta-analysis. J. Prosthet. Dent 128, 566–574. https://doi.
The authors declare that they have no known competing financial org/10.1016/j.prosdent.2021.01.020.
Øilo, M., Hardang, A.D., Ulsund, A.H., Gjerdet, N.R., 2014. Fractographic features of
interests or personal relationships that could have appeared to influence glass-ceramic and zirconia-based dental restorations fractured during clinical
the work reported in this paper. function. Eur. J. Oral Sci. 122, 238–244. https://doi.org/10.1111/eos.12127.
Ramos, N. de C., Campos, T.M.B., Paz, I.S. de La, Machado, J.P.B., Bottino, M.A.,
Cesar, P.F., Melo, R.M. de, 2016. Microstructure characterization and SCG of newly
Data availability
engineered dental ceramics. Dent. Mater. 32, 870–878. https://doi.org/10.1016/j.
dental.2016.03.018.
No data was used for the research described in the article. Shahmoradi, M., Wan, B., Zhang, Z., Wilson, T., Swain, M., Li, Q., 2020. Monolithic
crowns fracture analysis: the effect of material properties, cusp angle and crown
thickness. Dent. Mater. 36, 1038–1051. https://doi.org/10.1016/j.
Acknowledgements dental.2020.04.022.
Skjold, A., Schriwer, C., Gjerdet, N.R., Øilo, M., 2022. Fractographic analysis of 35
clinically fractured bi-layered and monolithic zirconia crowns. J. Dent. 125, 104271
This study was partly supported by the Brazilian Federal Agency for https://doi.org/10.1016/j.jdent.2022.104271.
Coordination of Improvement of Higher Education Personnel – CAPES, Sornsuwan, T., Swain, M.V., 2011. Influence of occlusal geometry on ceramic crown
Brazil (Finance code 001, Doctorate Scholarship of H.C.V., L.S.R and K. fracture; role of cusp angle and fissure radius. J. Mech. Behav. Biomed. Mater. 4,
1057–1066. https://doi.org/10.1016/j.jmbbm.2011.03.014.
S.D), and by the Foundation to Research Support of the Rio Grande do Velho, H.C., Dapieve, K.S., Borges, A.L.S., Pereira, G.K.R., Venturini, A.B., Valandro, L.F.,
Sul State (FAPERGS; #18/2551-0000520-7; #19/2551-0001221-7). 2022a. Effects of material and piston diameter on the fatigue behavior, failure mode,
This study is part of the Doctorate Thesis by (H.C.V.). The authors and stress distribution of feldspathic ceramic simplified restorations. J. Mech. Behav.
Biomed. Mater. 134, 105398 https://doi.org/10.1016/j.jmbbm.2022.105398.
declare no conflicts of interest. Velho, H.C., Dapieve, K.S., Rocha Pereira, G.K., Fraga, S., Valandro, L.F., Venturini, A.B.,
2020. Accelerated loading frequency does not influence the fatigue behavior of
polymer infiltrated ceramic network or lithium disilicate glass-ceramic restorations.
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