Fracture Strength of Monolithic All-Ceramic Crowns on

Titanium Implant Abutments

Michael Weyhrauch, DMDVChristopher Igiel, DMD*2/H erbert Scheller, DMD, PhD3/
Gernot Weibrich, MD, DMD, PhD4/Karl Martin Lehmann, DMD, PhD5

Purpose: The fracture strengths of alt-ceramic crowns cemented on titanium implant abutments may vary
depending on crown materials and luting agents. The purpose of this study was to examine differences in
fracture strength among crowns cemented on implant abutments using crowns made of seven different
monolithic ceramic materials and five different luting agents. Materials and Methods: In total, 525 crowns
(75 each of Vita Mark II, feldspathic ceramic [FSC]; Ivoclar Empress CAD, ieucite-reinforced glass ceramic
[LrGC]; Ivoclar e.max CAD, lithium disilicate [LiDS]; Vita Suprinity, presintered zirconia-reinforced lithium
silicate ceramic [PSZirLS]; Vita Enamic, polymer-reinforced fine-structure feldspathic ceramic [PolyFSP],
Lava Ultimate; resin nanoceramic [ResNC], Celtra Duo; fully crystallized zirconia-reinforced lithium silicate
[FcZirLS]) were milled using a CAD/CAM system. The inner surfaces of the crowns were etched and silanized.
Titanium implant abutments were fixed on implant analogs, and airborne-particle abrasion was used on
their exterior specific adhesion surfaces (Al20 3, 50 pm). Then, the abutments were degreased and silanized.
The crowns were cemented on the implant abutments using five luting agents (Multilink Implant, Variolink II,
RelyX Unicem, GC FujiCEM, Panavia 2.0). After thermocycling for 5,000 cycles (5 to 55°C, 30 seconds dwell
time), the crowns were subjected to fracture strength testing under static load using a universal testing
machine. Statistical analyses were performed using analysis of variance (a = .0002) and the Bonferroni
correction. Results: No significant difference among the luting agents was found using the different all
ceramic materials. Ceramic materials LiDS, PSZirLS, PolyFSP, and ResNC showed significantly higher fracture
strength values compared with FSC, FcZirLS, and LrGC. The PSZirLS especially showed significantly better
results. Conclusion: Within the limitations of this study, fracture strength was not differentially affected
by the various luting agents. However, the fracture strength was significantly higher for PSZirLS, PolyFSP,
ResNC, and LiDS ceramics than for the FSP, LrGC, and the FcZirLS ceramic with all luting agents tested.
In t J O r a l M a x il l o f ac Imp l a n t s 2016;31:304-309. doi: 10.11607/jomi.4601

Keywords: CAD/CAM, cement, ceramic, fracture strength, implant, luting agents

P
atient demand for metal-free fixed partial dentures
is increasing, and all-ceramic materials and hybrid
dental ceramics represent an option that offers excellent
^■Resident, Department of Prosthetic Dentistry,
University Medical Centre Mainz, Germany.
Assistant Medical Director, Department of Prosthetic
Dentistry, University Medical Centre Mainz, Germany.
3Medical Director, Department of Prosthetic Dentistry,
University Medical Centre Mainz, Germany.
Associate Professor, Department of Prosthetic Dentistry,
University Medical Centre Mainz, Germany.
Assistant Professor, Department of Prosthetic Dentistry,
University Medical Center Mainz, Germany.
Correspondence to: Dr Michael Weyhrauch,
Department of Prosthetic Dentistry, University
Medical Centre Mainz, Augustusplatz 2, 55131
Mainz, Germany. Fax: +49-613117 5517.
Email: michael.weyhrauch@unimedizin-mainz.de
©2016 by Quintessence Publishing Co Inc.
biocompatibility, optimal esthetics, and low thermal
conductivity .1-3 Several ceramic systems using various
materials and techniques for CAD/CAM crown fabrication
have been developed and introduced .4-5 In particular,
monolithic all-ceramic materials are increasingly used to
manufacture crowns for the restoration of natural teeth .6
These materials have addressed concerns regarding es
thetics ,6 marginal fit ,7*and fracture strength8-13and may
improve fracture strength over restorations based on a
core material layered with a veneering ceramic.14 Such
crowns may also be suitable for prosthetic restorations
placed on implant abutments10*and may bean alternative
to core-based and zirconia-based crowns with ceramic
veneers. Hybrid ceramics were designed to further en
hance these advantages of the monolithic all-ceramics.
CAD/CAM technology may allow efficient replacement
of a missing tooth on an implant abutment. This proce
dure can save time and materials, and when combined
with the immediate loading of a dental implant, can
fulfill the patient's demand for permanent replacement

3 0 4 Volume 31, Number 2, 2016

 Weyhrauch et al

f TTTTTTf 1 T
m ? rm H
TT
11 ft <1

?10 Gft 0 0 0 0 f
I
. I I I
- • T
111
f r
*
r i
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i i-
i

Fig 1 (a) Fixed implant-abutment-crown complexes in the socket before

static loading using the universal testing machine, (b and c) Fractured
ceramic crowns with titanium implant abutment after static loading.

#— m
SB SM
1 Table 1 Ceramic Materials and Luting Agents Tested in This Study (j
Ceramic material Manufacturer Specification
Vita Mark II (FSC) VITA Zahnfabrik H. Rauter Finely structured feldspathic ceramic
Empress CAD (LrGC) ivoclar Vivadent Leucite-reinforced glass ceramic
e.max CAD (LiDS) ivoclar Vivadent Lithium disilicate glass ceramic
Vita Suprinity (PSZirLS) VITA Zahnfabrik H. Rauter Zirconia-reinforced lithium silicate; presintered; 10% zirconia;
90% lithium silicate
Vita Enamic (PolyFSP) VITA Zahnfabrik H. Rauter Hybrid dental ceramic with polymer network; 86% ceramic
network; 14% polymer network
Lava Ultimate (ResNC) 3M Deutschland Resin nanoceramic; 80% nanoceramic; embedded in highly
cross-linked polymetric matrix
Celtra Duo (FcZirLS) Dentsply Detrey Zirconia-reinforced lithium silicate; fully crystallized;
10% zirconia; 90% lithium silicate
Multilink Implant Ivoclar Vivadent Self-polymerizing luting composite with light-curing option
Variolink II Ivoclar Vivadent Dual-/light- polymerizing, resin-based dental luting material
RelyX Unicem 3M ESPE Dual-polymerizing, self-adhesive resin cement
GC FujiCEM GC Self-polymerizing, resin-reinforced glass-ionomer luting cement
Panavia 2.0 Kuraray Europe GmbH Dual-polymerizing, self-adhesive resin cement

The International Journal of Oral & Maxillofacial Implants 305

Weyhrauch et al

Fig 2 Box plots of the ceramic material fracture strengths with the different luting agents, determined with the universal testing
machine.

Table 2 Conditioning of the Ceramic Material all-ceramic materials cem ented on tita n iu m im p lan t
abutments was used.
Material Conditioning Bonding
The null hypothesis was form ulated ^7^ that all luting
FSC 60 s, hydrofluoric acid 60 s, Monobond S
agents would show equal fracture strength, independent
LrGC 60 s, hydrofluoric acid 60 s, Monobond S o f the type o f ceramic material, and (2) that all ceramic
LiDS 20 s, hydrofluoric acid 60 s, Monobond S materials tested w ould behave independently o f the
PSZirLS 60 s, hydrofluoric acid 60 s, Monobond S type o f luting agent.
PolyFSP 60 s, hydrofluoric acid 60 s, Monobond S
ResNC sandblasted (Al20 3, 2 bar) 60 s, Monobond S
FcZirLS 30 s, hydrofluoric acid 60 s, Monobond S
MATERIALS AND METHODS

In to ta l, 525 im p la n t a b u tm e n ts (No. 57120, Bego

o f a missing to oth in a single visit. Thus, it is im portant
to test the strength o f m o n o lith ic CAD/CAM crowns
under conditions th a t approxim ate this clinical situa
tion. Load transfer should avoid surface damage and
produce tension stress at the cementation interface.15,16
Luting agents play an im portant role in these factors,
influencing the strength and resistance o f ceramics to
fracture.16-19 In the present study, an in vitro model to
examine the fracture strength o f five clinically available
luting systems in com bination w ith seven m onolithic
Im pla nt Systems; Fig 1) were screwed o n to im p la n t
laboratory analogs (No. 56696, Bego Im plant Systems)
using a driver (No. 55799, Bego Im plant Systems) w ith
30 Ncm o f torque. A total o f 75 m andibular right first
prem olar crowns were made from each ceramic ma
terial (Vita Mark II, feldspathic ceramic [FSC]; Ivoclar
Empress CAD, leucite-reinforced glass ceramic [LrGC];
Ivoclar e.max CAD, lith iu m disilicate [LiDS]; Vita Su-
prinity, presintered zirconia-reinforced lithium silicate
ceram ic [PSZirLS]; Vita Enamic, p olym e r-re in fo rce d

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 Weyhrauch et al

Table 3 Fracture Strength Table 4 P Values Comparing Mean Fracture

Ceramic material Mean ± SD (N) Range(N ) Strengths of Ceramic Materials and
FSC
Luting Agents Tested
851 ± 2 2 1 310-1,032
LrGC 822 ± 138 18 8-1 ,1 98 Ceramic material (1) Ceramic material (J) P

LiDS 2,377 ± 572 0a-3,017 FSC LrGC > .999

PolyFSP 2,128 ± 504 435-2,793 LiDS < .001*

PSZirLS 3,056 ± 642 2 3 5-4 ,9 31 PolyFSP < .001*

ResNC 2,309 ± 284 43 -2 ,8 5 6 PSZirLS < .001*

FcZirLS 1,430 ± 566 0a-3 ,2 3 6 ResNC < .001*

aSome crowns were fractured below 1 N, as the Zwick Universal Test FcZirLS .056
Unit reported. These crowns would be previously damaged by the LrGC FSC > .999
thermocycling process, but no visible defects were detected before.
LiDS < .001*
PolyFSP < .001*
fine-stru ctu re feldspathic ceramic [PolyFSP]; Lava PSZirLS < .001*
U ltim ate; resin nanoceram ic [ResNC]; Celtra Duo, ResNC < .001*
fu lly crystallized zirconia-reinforced lithium silicate FcZirLS .012*
[FcZirLS]; Table 1) using a CAD/CAM system (Cerec LiDS FSC < .001*
inLab ver. 4.1, Sirona; 14-mm block size, settings:
LrGC < .001*
30-mm cement space, 0-mm spacer). The exterior sur
PolyFSP .002*
faces of the implant abutments were airborne-particle
abraded (50 pm, approximately 10 mm distance, 1 bar, PSZirLS < .001*
approximately 60-second airborne-particle abrasion ResNC > .999
tim e per abutm ent), degreased, and silanized w ith FcZirLS < .001*
Monobond S for 60 seconds (Ivoclar Vivadent Clinical). PolyFSP FSC < .001*
The ceramic materials LiDS and PSZirLS were sintered, LrGC < .001*
and the FcZirLS received a glaze firing. The inner sur
LiDS .002*
faces of the crowns were etched with hydrofluoric acid
PSZirLS < .001*
or sandblasted (Ivoclar Vivadent Clinical; Table 2) and
ResNC .094
silanized with Monobond S. The adhesion surface of
the abutment and inner crown surfaces were also con FcZirLS < .001*

ditioned with Monobond S. PsZirLS FSC < .001*

These procedures resulted in 15 different test series. LrGC < .001*
The seven ceramic materials and five luting agents LiDS < .001*
(Table 1) were used in accordance with the manufac PolyFSP < .001*
turers'instructions. In the case of dual-curing systems, ResNC < .001*
the crowns were exposed to a polymerization light
FcZirLS < .001*
(Bluephase, Ivoclar Vivadent Clinical) according to the
ResNC FSC < .001*
manufacturers' instructions. All excess cement was
removed immediately, and each luting system's pro LrGC < .001*

prietary glycerin gel was subsequently applied at the LiDS > .999
crown margin. PolyFSP .094
To simulate the oral environm ent, the im p la n t- PSZirLS < .001*
abutm ent-crow n complexes were placed in a moist FcZirLS < .001*
container at 37°C for 30 minutes. Any remaining ce FcZirLS FSC .056
ment residue was then removed completely, and the
LrGC .012*
specimens were placed in water at 37°C for 1 week.
LiDS < .001*
Then, 5,000 cycles of thermocycling were performed
(5 to 55°C, 30-second dw ell tim e; Therm o Haake PolyFSP < .001*

EK30 DC10; Willytec, SD Mechatronik). PSZirLS < .001*

Each crow n-abutm ent complex was subjected to ResNC < .001*
adjacent fracture strength testing. Masticatory forces *Significant difference, P < .05, using ANOVA and Bonferroni’s
were sim ulated using a universal testing machine Adjustment.

(Model BZ1-MM11210.1 NO 1; Zwick Roell; software:

The International Journal of Oral & Maxillofacial Implants 307

Weyhrauch et al
testX pert II), w hich tran sm itted force th ro ug h a flat-
topped cylindrical steel stamp to a metal sphere w ith a
5-mm diameter that was placed on the occlusal crown
surface (Fig 1a). The standardized occlusal anatom y
allowed each specimen to be m ounted in the testing
machine in the same reproducible position, w ith the
load sphere contacting the mesiobuccal, distobuccal,
and lingual cusps equally ("trip o d " contact). A three-
p o in t loading was thus provided under static load to
reduce uncontrollable stress w ithin the ceramic m ate
rial. The specimens were taken from the w ater bath
before the fracture strength test and m ounted in the
test machine. The test machine was adjusted so th a t
the tw o tensile heads moved tow ard each other at a
crosshead speed o f 1 m m /m inu te until spontaneous
rupture (Fig 1b), which was perceived as a reduction in
force, as indicated by the testing machine.
Before th e te s t results o f th e 35 g ro u p s w ere
co m p ared using analysis o f variance (ANOVA), th e
n o rm a lity o f data d is trib u tio n was v e rifie d using a
Jarque-Bera-test. Bonferroni's adjustm ent was used to
control for m ultiple testing (a = .0002 for comparisons
o f luting agents for each ceramic material).
RESULTS
The median fracture strength values as well as maxi
mum and m inim um data fo rth e ceramic materials and
luting agents tested are shown in Fig 2 andTable 3.The
P values o f the tests are given in Table 4. In this study,
ceramic materials LiDS, PSZirLS, PolyFSP, and ResNC
showed significantly higher values in terms o f fracture
strength compared w ith FSP, FcZirLS, and LrGC. The
PSZirLS ceramic especially showed significantly bet
ter results. Analysis o f the luting agents revealed no
significant difference using the different all-ceramic
materials.
DISCUSSION
The experimental design o f this study closely simulated
the clinical situation where crowns made o f all-ceramic
and hybrid-ceramic materials are fixed on im plant abut
ments, thus allowing a reasonably comparable assess
m ent o f the ceramic materials' fracture strength. To
date, only a few reports have addressed the stability of
m onolithic all-ceramic crowns cemented on im plant
abutments.8-10Thus, the present in vitro study was per
form ed to investigate the influence o f the luting agent
and the ceramic material on the fracture strength of
m onolithic all-ceramic crowns cemented on im plant
abutments. Special attention was paid to the dwell tim e
o f the cemented crowns in 100% hum idity before they
3 0 8 Volume 31, Number 2, 2016
were placed in water. No long-term water storage was
performed. Although Ernst et al17 showed that even
long-term water storage had no significant effect on
retentive strength, in that study, water storage was per
formed to simulate the clinical situation. Also, a stainless-
steel sphere was used, rather than a resin sphere, as in
other studies,9-18 because prelim inary testing showed
that the relatively high single-loading forces (until frac
ture) employed in this study sometimes fractured the
resin sphere.
The first w orking hypothesis, that each ceramic ma
terial w ould behave independently o f the type o f ce
ramic material in fracture strength tests, was partially
confirmed for FSC vs LrGC/FcZirLS; LrGC vs FcZirLS;
LiDS vs ResNC; and PolyFSP vs ResNC. All luting agents
showed similar mean fracture strengths for identical
ceramic materials; no significant difference was found.
Thus, the bonding between the ceramic materials and
the titanium abutments did not seem to influence the
fracture strength o f the different com binations o f ce
ramic material and luting agents.These results showed
that the luting agents tested had no significant influence
on fracture strength. Thus, all o f the luting agents tested
could be used clinically.
The second working hypothesis, namely, that the lut
ing agents tested would result in equal fracture strength
values independently o f the type o f ceramic material,
was rejected. Significantly greater fracture strength was
found in crowns made o f LiDS, PSZirLS, PolyFSP, and
ResNC ceramics.These findings are consistent with other
studies11,14demonstrating the high fracture strength o f
zirconia-reinforced lithium silicate materials. The fin d
ings support other evidence that zirconia and zirconia-
reinforced materials have higher fracture strengths than
other ceramic materials.
The high fracture strength o f the materials w ith a
polym er component, eg, ResNC and PolyFSP, could be
explained by the attributes o f the material, as the resin
in the structure o f both materials exhibits a cushion
ing effect, as shown by the high modulus o f elasticity.19
Flere, no difference was seen between these materials,
which differ in the chemical com position.The material
o f the ResNC consists o f almost 80% nanoceramic com
ponents, which are bonded zirconia and silica nanoparti
cles embedded in a highly cross-linked polymeric matrix
(20%). In contrast, the PolyFSP hybrid dental ceramic has
a dom inant ceramic netw ork (86%), strengthened by a
polymer netw ork (14%).
Also, the high fracture strength of LiDS has been found
in other studies; the LiDS has a higher fracture strength
and higher flexural strength than other glass and feld-
spathic ceramics (eg, FSC and LrGC).20 In the present
study, the PSZirLS showed significantly higher values in
fracture strength than the FcZirLS. The latter FcZirLS is
m illed in a fully crystallized condition, as m entioned in

the manufacturer's processing instructions, whereas the
form er PSZirLS ceramic is milled in a presintered condi
tion and has to be sintered in a separate step. Conceiv
ably, the process o f m illing could have influenced the
stability o f the fu lly crystallized crowns. These findings
need to be confirm ed in further investigations.
The mean loads applied by the universal testing ma
chine were approximately 3 to 17 times higher than the
forces normally exerted in the premolar region, 291 N.21
Ferrario et al showed th a t bite forces in the front teeth
are about half those o f the premolar and molar region.
Thus, the materials tested would be suitable for the front
to oth area, using a cutback technique, for example, and
these ceramic materials would also qualify for the lateral
teeth area because o f their high stability.
The fracture patterns were similar to each ceramic
material (Figs 1band 1c).Thus, it is obvious that the frac
ture strength o f all-ceramics is significantly influenced
by the design o f the abutm ent in the occlusal part. The
edges and rims especially are a failure indication o f all
ceramic crowns regarding occlusal force. This is in con
cordance w ith Zhang et al, w ho showed th a t ceramic
materials are often broken over sharp edges.22
Flowever, in this study, no cyclic loading, which would
better simulate the clinical situation but may cause
cracking, was performed. Thus, given the lim itations
o f the in vitro approach described, the direct transfer
o f these results to in vivo conditions is lim ited. Indeed,
fu rthe r clinical research is necessary to confirm these
in vitro findings.
CONCLUSIONS
W ithin the lim itations o f this in vitro study, the fo llo w
ing conclusions can be drawn.
Com parison o f th e lu tin g agents showed no sig
nificant difference in fracture strength am ong luting
agents w ith the ceramic materials tested.
Comparison o f the ceramic materials showed th a t
th e PSZirLS ceram ic m aterial e xhibite d sign ifican tly
higher fracture strength on im p lan t abutm ents com
pared w ith th e o th e r m aterials w ith all five lu tin g
agents. The m illing process under different crystalliza
tion conditions may influence the fracture strength of
ceramic materials on im plant abutments.
ACKNOWLEDGMENTS
The authors thank BEGO Implant Systems for providing the im
plant laboratory analogs and the corresponding implant abut
ments and Ivoclar Vivadent, VITA Zahnfabrik, and Dentsply
Detray for providing the ceramic materials. The authors reported
no conflicts of interest related to this study.
Weyhrauch et al
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