SCIENTIFIC A R T I C L E
Australian Dental Journal 2000;45:(2):91-96
Restoring the vertical dimension of mandibular
incisors with bonded ceramic restorations
S. G. Wylie,* H-K. Tan,† K. Brooke‡
Abstract
Mandibular incisors are difficult to restore with
conventional anterior crowns due to their small
axial diameters. Crown preparation risks pulp
exposure and results in a thin core of dentine. An
experiment was designed to determine if increasing
the thickness of ceramic to restore incisal edges
affects the load at the point of restoration failure.
Forty-eight mandibular incisors were randomly
divided into four groups. The incisal edges of the
teeth in three groups were reduced so that the
coronal height was 7.5 mm (Group A), 6.5 mm
(Group B), and 5.5 mm (Group C). Group D was
designated as the experimental control. A fifth
group (Group E), independent of the random sample,
was introduced to the study for discussion purposes
and was characterized by each of the incisors
having an intact incisal edge of enamel. Groups A,
B and C were prepared in a standard fashion for
ceramic veneer restorations that were constructed
to restore the vertical height of each tooth to
8.5 mm. Prior to cementation, the preparation
surfaces were analysed and the relative surface
areas of enamel and dentine were calculated. The
ceramic restorations were cemented using a resin
luting agent. The teeth were then thermocycled
prior to loading at 135°C until failure. The mean
fracture load was 305 N (SD 134 N) for Group A,
403 N (SD 101 N) for Group B, 515 N (SD 296 N)
for Group C, 587 N (SD 187 N) for Group D and
395 N (SD 129 N) for Group E. As determined by
analysis of variance followed by a Sheffè multiple
comparison test there was a significant difference
(p£0.01) between Group A and Group D. There
were no significant correlations of load at failure
with the percentage of exposed dentine, enamel
surface area, total preparation surface area, and
the incisal surface area. The patterns of failure of
the fractured specimens were also analysed. There
were significantly (p£0.05) greater fractures of the
ceramic restorations when they were bonded with
the minimum incisal thickness of ceramic.
Key w o r d s : Ceramic veneers, vertical dimension,
mandibular incisors.
(Received for publication February 1998. Revised
February 1999. Accepted February 1999.)
*Prosthodontist, Melbourne. Clinical Instructor,The University of
Melbourne. Previously Assistant Professor, The University of
Alberta, Canada.
†Associate Professor,The University of Alberta, Canada.
‡Previously Undergraduate,The University of Alberta, Canada.
Australian Dental Journal 2000;45:2.
Introduction
While the aesthetic potential and biocompatibility
of dental ceramics are excellent, the mechanical
properties of these materials have restricted their use
in restorative dentistry. Intimate bonding of dental
ceramics to the tooth provides rigid support to the
restorative material.The bonded ceramic restoration
has attracted clinical interest due to the cosmetic
potential and the conservative nature of the
veneering procedure. Clinical applications are
emerging that broaden the scope of ultra-thin
bonded ceramic restorations.
Conventional ceramometallic crowns have an
inherent thickness that is required to establish the
ideal functional and aesthetic restoration for the tooth.
Restoring mandibular incisors with conventional
crowns risks trauma to the dental pulp (Fig. 1) and
frequently results in overcontoured crowns or
unsatisfactory aesthetic results. Consequently,
clinicians often neglect lower incisors when restoring
the anterior occlusal unit.
Evaluation of the clinical performance of ceramic
veneers is limited by the short history of the
restorative technique. Clinical trials report low
debonding rates, preserved marginal integrity,
satisfactory gingival responses and low fracture
levels.1,2 Increased complications and failures are
reported to occur when veneers are placed on existing
restorations, where the enamel bonding surface is
inadequate and with the use of inappropriate luting
agents.3
Laboratory analysis of the veneer restorative
concept has focused on upper incisors which differ
from lower incisors with respect to the availability of
enamel, and in the way the teeth are typically loaded.
The fracture resistance of porcelain veneer
restorations on plastic (Cymel 1077) mandibular
incisors that had an incremental incisal reduction of
0-2.0 mm has been investigated.4 No significant
difference in the fracture value was recorded when
varying the ceramic thickness of the incisal edge;
however, the angle of the load application influenced
91

Fig. 1. – Lower incisors prepared for conventional crowns.
the fracture behaviour. While model teeth decrease
the variability inherent in natural teeth, laboratory
analysis of the restoration of natural teeth will allow
interpretation of the sensitivity of the restorations to
the physical nature of the bonding surface.
Prior to recommending the extrapolation of
bonded ceramics as a useful tool in restoring the
vertical dimension of lower incisors, laboratory
studies are required to identify limitations of the
restorative technique. A novel leucite reinforced
pressed ceramic (IPS Empress) was used for the
analysis. The objective of this study was to observe
the fracture resistance of ceramic restorations used
to restore variable incisal heights of extracted lower
incisors. The correlation of the load at failure with
the total preparation surface area, the percentage of
the preparation having exposed dentine, the total
enamel surface area, and the incisal surface area
were also investigated.The patterns of failure of the
restored and unrestored teeth were observed for a
comparative analysis.
Materials and methods
Table 1 lists the products used in this study and
their manufacturers.
Mandibular incisor teeth were collected following
extraction and stored in thymol solution at 4°C until
use.The incisors were transilluminated and examined
under 103 magnification to ensure they were
unrestored and structurally sound. A total of 60
teeth was required for the study. Forty-eight teeth
were randomly divided into four groups. Group A,
Group B and Group C were incisors with
restorations that provided a 1 mm, 2 mm and 3 mm
increase in incisal length respectively. Group D
consisted of unrestored lower incisors from the
random sample, and Group E consisted of a
preselected sample of incisors that had intact enamel
on the incisal edge.
92
Table 1. Product Manufacturers
Product Manufacturer
IPS Empress Ivoclar,Amherst, New York, USA
LSV-1 depth gauge
bur Brasseler Canada, Montreal,Quebec, Canada
Express 3M, St Paul, Minnesota, USA.
New Fujirock G-C Dental Industrial Corporation, Tokyo,
Japan
Mop-3 digitizer Zeiss, Esslingen,Germany
Syringe Elasticon Kerr, Orange, California,USA
G-C Pattern Resin G-C America,Alsip, Illinois, USA
Syntac Vivadent, Schaan, Liechtenstein
Heliobond Vivadent, Schaan, Liechtenstein
Variolink Vivadent, Schaan, Liechtenstein
Universal mechanical
testing machine Instron,Canton, Massachusetts,USA
Microsoft Excel 97 Microsoft Corporation,Redmond,
Washington, USA
Tooth preparation
The incisal edges of the teeth were reduced so that
the coronal dimensions were 7.5 mm (Group A),
6.5 mm (Group B), and 5.5 mm (Group C).Groups
D and E were left unprepared. The dimensions of
the preparations were measured and outlined in
pencil on the individual teeth.From the labio-incisal
line angle the preparations continued apically for
4 mm. The interproximal and lingual preparations
extended 2 mm apically from the incisal edge.
Preparations were completed using a 0.5 mm depth
gauge bur (LSV-1) for initial labial enamel reduction
prior to completion of the preparation with medium
grit diamond burs. The incisal line angles were
rounded to reduce localized stress concentration.
The preparation outlines followed smooth curves
uniting margins on adjacent surfaces. All apical
extensions of the preparations were completed with
a rounded-chamfer margin with 0.5 mm reduction.
Impressions
An impression of each tooth was taken using
thimble shaped custom trays and Express polyvinyl
siloxane impression material. Dies were poured in
New Fujirock, type IV dental stone. Ceramic
restorations were constructed using the IPS Empress
system. Each restoration was waxed with axial surface
dimensions 0.7 mm thick, while the incisal dimensions
were waxed to the specifications of each experimental
group. The wax coping dimensions were verified
prior to investment. Completion of the restorations
followed the manufacturer’s recommendations. All
restorations were examined under 203 magnification
and the fit on the die was verified. Necessary
adjustments were made to the incisal edges if they
were beyond the dimensions specific for that group
(±0.1 mm). Axial wall dimensions of the ceramic
were adjusted to 0.6 mm±0.1 mm.
Surface area calculations
All teeth in groups A, B and C were wiped with
methylene blue and rinsed in water. Provisional testing
Australian Dental Journal 2000;45:2.
 Fig. 2. – Loading scheme.
identified this as a useful means of highlighting areas
of exposed dentine.Lines were drawn on the teeth at
the line angles of each surface. Magnified (123)
photographs of the five preparation surfaces of each
tooth were taken.The two dimensional views obtained
from the photographs were used to calculate the
relative total surface areas, exposed dentine surface
areas and enamel surface areas using a digitizer.
Mounting of teeth
Each tooth was mounted with the long axis
coincident to the axis of an analysing rod on a dental
surveyor. Silicone adhesive was applied to the root
surface of each tooth prior to the brush application
of a thin coat of Syringe Elasticon low viscosity
silicone impression material.The external surface of
the set silicone was coated in adhesive. The tooth
was lowered into a plastic ring mounted on a survey
table.The table was tilted 8° towards the labial sur-
face of the tooth so that the final orientation of the
lower incisor was 8° labial to the perpendicular.
Acrylic resin (G-C Pattern Resin) was applied to the
apical portion of the tooth, securing the alignment.
The plastic ring was then filled with acrylic resin to
a level 1 mm apical to the labial cemento-enamel
junction.
Cementation
The ceramic veneers were checked for accuracy of
fit on the dies and adjusted when required. The
internal surfaces were etched with 4.9 per cent
hydrofluoric acid for 60 seconds prior to saline
application. The tooth preparation surface was
etched with 37 per cent phosphoric acid.The Syntac
dentine bonding system was coated on the
preparation surface as per the manufacturer’s
instructions. Heliobond adhesive resin was applied
Australian Dental Journal 2000;45:2.
Fig.3. – Classification of failures.
to the preparation surface and to the internal surface
of the veneer prior to cementation using Variolink
bonding resin. Excess resin was removed with a
brush and the remaining resin was polymerized with
curing light application for 40 seconds on each of
the axial surfaces.
Thermocycling
All teeth were thermocycled for 1000 cycles in
water baths of 5°C and 55°C with dwell times of 10
seconds. The samples were then stored in 37°C
water until the time of testing.
Loading
Specimens were tested for resistance to fracture
using a universal mechanical testing machine with a
cross head speed of 1 mm/min.A jig provided a 135°
angle between the long axis of the teeth and the
angled face of the loading tool (Fig. 2). The peak
force at failure of each specimen was recorded.They
were analysed using an analysis of variance followed
by a Sheffè multiple comparison test. Correlations
between the load at failure and the preparation sur-
face area, the percentage of the preparation surface
area having exposed dentine, and the incisal edge
surface area were also analysed using a correlation
analysis tool (Microsoft Excel).
Pattern of failure
Each specimen was observed following the
loading procedure and the pattern of failure was
classified (Fig. 3).
Restoration failure was a cohesive ceramic and/or
partial delamination of the restoration.
Coronal fracture was a fracture through the
coronal portion of the tooth that may or may not
have been veneered in ceramic.
93
 Load (N)
900

600

300

0
Mean Load at Failure
Groups A B C D E
Fig. 4. – Mean load (N) and standard deviation at failure of restored and unrestored teeth.

Cemento-enamel junction (CEJ) fracture was a
horizontal fracture at the level of the cemento-
enamel junction.
Intraradicular fracture was a sloped or horizontal
radicular fracture occurring apical to the CEJ.
Statistical analysis using the Kruskal-Wallis test
followed by a Sheffè multiple comparison test was
used to determine if there was a significant difference
between the experimental groups with regard to the
pattern of failures.
Results
Figure 4 illustrates the mean and standard deviation
of the fracture load for incisors in the defined
groups. As determined by analysis of variance
followed by a Sheffè multiple comparison test, there
was a significant difference (p£0.01) between Group
A and Group D.
Table 2 lists the mean values for the surface areas
recorded. There was no significant correlation
between the load at failure and the percentage of the
preparation with exposed dentine, the total enamel
surface area, the total preparation surface area, or
the incisal surface area of the preparation.
Table 3 illustrates the number of teeth fracturing
at the various levels as previously defined. Statistical
analysis using the Kruskal-Wallis test followed by the
Sheffè multiple comparison test determined that
there was a significant (p£0.05) difference between
groups A and B and Groups A and C with regard to
the prevalence of restorative failures.
Discussion
The Empress ceramic system
The Empress ceramic system is a novel leucite
reinforced ceramic. It is manufactured as ingots
which are heat pressed into moulds of the desired
dimensions using the lost wax technique. Control of
the ceramic dimension at the wax pattern stage
made the use of this ceramic appropriate for this
study.
The flexural strength of the Empress ceramic has
been compared with six recently introduced ceramic
materials and was measured using a three-point-
bend test.5 The Empress system (97 MPa) was found
to have greater strength than the controls

Table 2. Preparation surface areas

Enamel Preparation Incisal
Dentine
surface area surface area surface area
(%)
(mean mm2 ) (mean mm 2) (mean mm 2)
Group A 10.1 34.5 38.7 4.35
Group B 10.8 33.1 37.1 5.7
Fig. 5. – Fractured unrestored lower incisor. Group C 15.9 30.8 36.3 5.1

94 Australian Dental Journal 2000;45:2.

Table 3. Pattern of failure of the loaded
specimens
Cemento-
Restorative Coronal enamel Radicular
junction
Group A 9 0 2 1
Group B 2 3 5 2
Group C 4 0 4 4
Group D * 8 2 2
Group E * 10 2 0
*Not applicable since teeth did not have ceramic restorations.
(conventional feldspathic 71 MPa and soda lime
glass 92 MPa). The alumina-based crystalline
reinforced materials (Inceram 446 MPa) were
stronger than the Empress ceramic.
Clinical applications of the ceramic will influence
the mat e ri a l ’s physical behaviour since the
substructure, adhesive resins and geometric
configurations of the restoration will vary.
Ultimately, laboratory tests are useful as an indicator
to suggest the use of a material in a clinical capacity.
In addition, the tests are useful for comparative
analysis with traditional and clinically proven
restorative techniques.
Load at failure
Investigations of the strength of a material indicated
for a restorative technique need to consider the
potential loads the restoration is likely to be subjected
to in the oral environment. During intercuspal
clenching, the highest occlusal forces are measured
in posterior tooth locations.6 This can be explained
biomechanically in the posterior regions by the
smaller tooth force moment arm and the more
advantageous muscle to occlusal-force ratio. The
maximum bite force generated in the incisor region
has been recorded using various techniques and is in
the range of 130-230 N.6,7 Helkimo and Ingervall
reported a mean maximum bite force in the incisal
region of 190 N.8 The smallest load that produced a
failure of a restored tooth in this study occurred at
159 N for an incisor with a 1 mm thickness of incisal
ceramic. While four restorations fractured within the
potential range of force generated in the incisal
region (£230 N), the mean load of failure for all
experimental groups was beyond the reported
maximum incisal bite force.
The mean fracture load of teeth restored with
1 mm of incisal ceramic was significantly lower than
the unrestored incisors in Group D. While the
findings were not statistically significant, the trend
was for the mean load at failure to increase with an
increase in the thickness of the incisal ceramic. This
observation requires consideration since it may
emerge that there is a minimum critical thickness
required for the ceramic restoration to have
Australian Dental Journal 2000;45:2.
adequate strength. Traditional prosthodontic
teachings have stressed the significance of keeping
the thickness of ceramic veneered to metal copings
to less than 2 mm.9 The rationale for restricting the
thickness of the ceramic is to decrease the tendency
for there to be cohesive ceramic failures when it is
bulky and unsupported.While it was obser ved that a
3 mm thickness of incisal ceramic was the strongest
of the restorative configurations tested, it is
important to note that the loading direction was pre-
dominantly axial, conducive to compressive loading
of the restoration. Previous testing has illustrated
that these restorations are sensitive to the angle of
the force application,4 and testing of this as a principal
variable will aid the process of setting design
specifications for bonded ceramic restorations.
Furthermore, this analysis may indicate which
occlusal configurations are likely to be associated
with an increased risk of ceramic fracture.
Pattern of failure
The pattern of failure of restorations in Group A
was found to be significantly different from those in
groups B and C.The observed failure of restorations
in Group A was typically sloped from the incisal por-
tion of the labial face, cervically and lingually from
the incisal edge. The ceramic then tended to
delaminate from the lingual surface of the tooth.
When a brittle material is loaded in compression,
ultimate failure tends to occur along the shear plane,
usually sloped and angled at approximately 45° to
the angle of the compressive load.10 The stresses in
the lower incisors are likely to be complex and the
135° interincisal angle is conducive to there being a
large proportion of compressive force directed to the
incisal edge. The internal resistance to the force
(stress) is distributed over an area of the restored
tooth.The greater surface area of the ceramic along
the shear plane would result in less stress per unit
force application. It is speculated that since the
surface area of the ceramic in the shear plane was
greater in Groups B and C than Group A, the
restorations withstood a greater load, increasing the
likelihood of failure at another site. Therefore, the
pattern of failure in Groups B and C illustrated less
restorative failures and an increase in CEJ and
radicular fractures.
It is interesting that the pattern of fracture of teeth
in Group E was similar to that of Group A. When
subjected to the same loading pattern, the dimensions
of the enamel resulted in shear plane fractures much
like the 1 mm ceramic restorations (Fig. 5). The
mean load at failure for the incisors with intact
enamel on the incisal edge was 90 N greater than
restorations in Group A. While ceramic does not
have the prismatic nature of enamel, it is a hard and
brittle substance like enamel. When intimately
95
bonded to the surface of the tooth, and following the
shrinkage of the adhesive cement when curing, the
ceramic may duplicate the properties of enamel on
dentine and react in similar ways to enamel when
loaded.
Groups D and E were unrestored teeth, however,
they differed in that Group E teeth had intact
enamel covering the incisal edge. Group D teeth all
had some amount of exposed dentine on the incisal
edge. The results illustrate that the intact enamel
failed in load at a mean level almost 200 N below
that of the slightly attrited teeth.
Bonding surface.
There was little variability in the relative mean
surface exposure of dentine between the experimental
groups. The mean percentage of the preparation
surface having exposed dentine ranged from
approximately 10 per cent to 16 per cent.The higher
percentage in Group C is likely to be related to the
reduction of the incisal edge prior to the ceramic
restoration placement. The predominant sites of
dentine exposure were observed along the incisal
edges and along the lingual marginal ridges. There
has been an abundance of literature looking at the
bond strength of ceramic to enamel and dentine,
however, there is a paucity of work investigating the
fracture behaviour of ceramic restorations adhered
to teeth where the percentage of exposed dentine is
the principal variable observed. Such studies are
required since the reduced bond strength and lower
modulus of elasticity of dentine alter the behaviour
of the ceramic under load. Clinical guidelines need
to determine the threshold at which the lack of
surface enamel renders a restoration liable to an
increased risk of failure.
Conclusion
The fracture behaviour of mandibular incisors
restored with variable dimensions of ceramic was
observed. Restorations with a thickness of 1 mm of
incisal ceramic were found to fracture at a
significantly lower level of force than unrestored
96
incisors from the random sample. When restored
with greater than 1 mm of incisal ceramic, teeth
fractured in the range of the unrestored incisors.The
greater bulk of ceramic also resulted in a decrease in
the tendency of the bonded ceramic to be the site of
the failure on loading.The variability of the bonding
surface did not influence the load at failure of the
restorations.
Acknowledgements
The authors acknowledge the support of Ivoclar,
North America;Aurum Ceramic Dental Laboratories,
Calgary; 3M, Canada; the Faculty of Engineering at
The University of Alberta, Canada; and Dr Michael
Grace, Statistician, the University of Alberta.
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Address for correspondence/reprints:
Dr Simon G. Wylie,
12th Floor,
Farrer House,
24 Collins Street,
Melbourne,Victoria 3000.
Australian Dental Journal 2000;45:2.