RESEARCH AND EDUCATION

Mechanical properties of resin-ceramic CAD/CAM

restorative materials
Abdallah Awada, DDS, MSDa and Dan Nathanson, DMD, MSDb

As chairside computer-aided ABSTRACT

design and computer-aided Statement of problem. The recent development of polymer-based computer-aided design
manufacturing (CAD/CAM) and computer-aided manufactured (CAD/CAM) milling blocks and the limited availability of
technology gains an increasing independent studies on these materials make it pertinent to evaluate their properties and
foothold in dentistry, millable identify potential strengths and limitations.
restorative materials are being Purpose. The purpose of this in vitro study was to determine and compare mechanical properties
increasingly developed and (flexural strength, flexural modulus, modulus of resilience) and compare the margin edge quality of
marketed. The variety of avail- recently introduced polymer-based CAD/CAM materials with some of their commercially available
able CAD/CAM restorative composite resin and ceramic counterparts.
materials consists mostly of Material and methods. The materials studied were Lava Ultimate Restorative (LVU; 3M ESPE),
different ceramics, composite Enamic (ENA; Vita Zahnfabrik), Cerasmart (CES; GC Dental Products), IPS Empress CAD (EMP; Ivoclar
resins, and acrylic resins.1 Some Vivadent), Vitablocs Mark II (VM2; Vita Zahnfabrik), and Paradigm MZ100 Block (MZ1; 3M ESPE).
of these materials require ad- Polished 4×1×13.5 mm bars (n=25) were prepared from standard-sized milling blocks of each
ditional processing after milling, tested material. The bars were subjected to a 3-point flexural test on a 10-mm span with a
necessitating specialized equip- crosshead speed of 0.5 mm/min. In addition, 42 conventional monolithic crowns (7 per material)
were milled. Margin edge quality was observed by means of macrophotography and optical
ment for firing and glazing, 2,3
microscopy, providing a qualitative visual assessment and a measurement of existing roughness.
while other products do not The results were analyzed by ANOVA followed by the Tukey HSD test (a=.05).
necessarily require those steps
Results. The mean flexural strength of the tested materials ranged from 105 ±9 MPa (VM2) to 219 ±20
and can generally be finished
MPa (CES). The mean flexural modulus ranged from 8 ±0.25 GPa (CES) to 32 ±1.9 GPa (EMP). The mean
with a readily available arma- modulus of resilience ranged from 0.21 ±0.02 MPa (VM2) to 3.07 ±0.45 MPa (CES). The qualitative
mentarium in the dental office.4 assessment of margin edge roughness revealed visible differences among the tested materials, with
Popular milling blocks in- mean roughness measurements ranging from 60 ±16 mm (CES) to 190 ±15 mm (EMP). The material factor
clude ceramic materials such as had a significant effect on the mean flexural strength (P<.001), flexural modulus (P<.001), modulus of
Vitablocs Mark II (VM2; Vita resilience (P<.001), and margin edge roughness (P<.001) of the tested specimens.
Zahnfabrik) and IPS Empress Conclusions. The new-generation polymer-based materials tested in this study exhibited
CAD (EMP; Ivoclar Vivadent). significantly higher flexural strength and modulus of resilience, along with lower flexural
Popular composite resin blocks modulus values compared with the tested ceramic or hybrid materials. Crowns milled from the
include Paradigm MZ100 Block new resin-based blocks seemed to exhibit visibly smoother margins compared with the ceramic
(MZ1; 3M ESPE) and Lava Ul- materials studied. (J Prosthet Dent 2015;-:---)
timate Restorative (LVU; 3M
ESPE). More recently, new block systems have been (LVU; 3M ESPE), a nanoparticle and nanocluster-filled
introduced, including Enamic (ENA; Vita Zahnfabrik), a resin, and Cerasmart (CES; GC Dental Products), a
resin infused ceramic hybrid, Lava Ultimate Restorative nanoparticle-filled resin.

Presented at the American Association of Dental Research/Canadian Association of Dental Research Annual Meeting, Charlotte, NC, March 2014.
a
Assistant Professor and Director, Implant Prosthodontics Fellowship Program, Department of Prosthodontics, Louisiana State University School of Dentistry,
New Orleans, La.
b
Professor and Chair, Department of Restorative Sciences and Biomaterials, Boston University Henry M. Goldman School of Dental Medicine, Boston, Mass.

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Clinical Implications
Determining flexural and marginal properties of 3
recently developed polymer-based computer-aided
design and computer-aided manufacturing restor-
ative materials aids in suggesting their optimal
clinical indications.
Generally, the traditional ceramic blocks can produce
esthetic restorations, and published studies report high
fracture resistance and low material wear.5,6 However,
some studies have identified a higher incidence of failure
of these materials, possibly due to the brittle nature of
ceramics, plus a potential abrasive effect on opposing
dentition.7-10 Older composite resin milling blocks may
suffer from increased material wear, loss of surface polish,
and color instability.11-13 Recent studies have also sug-
gested an increased failure rate of restorations milled from
resin-based blocks.14 Manufacturers have been developing
new formulations for chairside CAD/CAM materials that
combine the advantageous properties of ceramics, such as
durability and color stability, with those of composite
resins, such as improved flexural properties and low
abrasiveness.15,16 Two new materials of note are ENA and
CES. Enamic, a polymer-infiltrated ceramic network ma-
terial,15 contains 86% (by weight) porous feldspathic
ceramic matrix, infiltrated with a copolymer (urethane
dimethacrylate and triethylene glycol dimethacrylate).
CES is a high-density composite resin material con-
taining 71% filler particles by weight. Given the limited
availability of independent research on these materials,
their properties should be evaluated to better understand
their attributes and limitations. While no one property
can be used to predict a material’s clinical success or
failure, parameters such as flexural strength, flexural
modulus, and modulus of resilience provide insight into
the dynamic behavior of these materials under simulated
occlusal stress.17 These parameters can all be calculated
from the results of a 3-point flexural test, which subjects a
specimen to a combination of tensile, compressive, and
shear stresses. The flexural strength measurement can be
used to evaluate the resistance of a material to failure
from bending.18-20 Flexural modulus and modulus of
Table 1. List of study materials
Material Symbol Manufacturer
Vitablocs Mark II VM2 Vita Zahnfabrik
IPS Empress CAD EMP Ivoclar Vivadent
Enamic ENA Vita Zahnfabrik
Paradigm MZ100 Block MZ1 3M ESPE
Lava Ultimate Restorative LVU 3M ESPE
Cerasmart CES GC Dental Products
a
According to manufacturer’s information.
THE JOURNAL OF PROSTHETIC DENTISTRY
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resilience measurements can be used to evaluate the
stiffness of a material and the amount of energy it can
elastically store.21,22 From a biomimetic perspective,
these materials should exhibit mechanical properties that
approximate those of human enamel and dentin.23-27 It is
also pertinent to evaluate new CAD/CAM dental mate-
rials for their ability to produce well-fitting, continuous,
smooth margins in the milling process. The thin margins
of a chamfer or a knife-edge design may be challenging
to produce from a machinable material.3
The objectives of this study were to determine and
compare the flexural strength, flexural modulus, modulus
of resilience, and margin integrity of 6 dental restorative
milling blocks indicated for chairside fabrication.
MATERIAL AND METHODS
The study included 6 different CAD/CAM restorative
materials with similar clinical indications (Table 1). Me-
chanical testing was conducted in flexural mode using
3-point flexural testing to determine flexural strength,
which is defined as the maximum flexural stress at failure
(MPa), flexural modulus, defined as the slope of the elastic
portion of the stress-strain curve produced by a flexural
test (GPa), and modulus of resilience, defined as the strain
energy per unit volume required to stress a material from
an unloaded state up to the point of failure (MPa).
Twenty-five specimens of each of the 6 materials were
prepared. Each tested CAD/CAM block was sectioned
into a grid of rectangular bars with a 4 mm wide by 1 mm
thick cross section and a length of approximately 13.5
mm. The length of the bars varied because of the
dimensional constraints of the mill blocks. They were
sectioned with a diamond-wafering blade mounted on a
saw (Isomet 2000 Precision Saw; Buehler Co) under
constant water irrigation. The resulting specimens were
then sequentially polished (EcoMet 250 Grinder-
Polisher; Buehler Co) to 1 mm grit. The specimen di-
mensions were checked with a micrometer (Model no.
293-715; Mitutoyo Corp). Any specimens with out-of-
range dimensions (±50 mm) were rejected and dis-
carded. The bars were also evaluated for chipping at the
edges (especially important for ceramic materials). Any
bars with visible chipping were rejected and discarded, as
these imperfections could significantly influence the test
Compositiona
Fine-particle feldspar ceramic mill block
Leucite-reinforced glass ceramic of the SiO2-Al2O3-K2O materials system
Polymer-infiltrated-feldspathic ceramic-network material 86% ceramic by weight
Composite resin material 85% zirconia-silica ceramic by weight
Composite resin material 80% silica and zirconia nanoparticles and nanoclusters by weight
Composite resin material 71% silica and barium glass nanoparticles by weight
Awada and Nathanson
- 2015
results.28,29 All specimens were allowed to air dry for 24
hours at room temperature before testing.
A 3-point flexural test was conducted with a universal
testing device (Instron 5566A; Instron Co) and a 1 kN
load cell. Each specimen was positioned on a metal
fixture with a 10 mm support span and centered under
the loading rod. The test was run with a crosshead speed
of 0.5 mm/min, controlled with software (BlueHill 3;
Instron Co). Each specimen was loaded to failure. The
maximum load (N) and maximum extension (mm) were
recorded by the controlling software. The following
mathematical formulas were used: for flexural strength,
3×P×L
sf =
2×b×h2
for flexural modulus,
L3 ×m
Ef =
4×b×h3
and for modulus of resilience,
s2f
Ur =
2×Ef
where P is the maximum load (N), L is the support span
(mm), b is the width of the specimen at the failure site
(mm), h is the height of the specimen at the failure site
(mm), and m is the slope of the linear portion of the load-
deflection curve (N/mm).
Differences in flexural strength, flexural modulus, and
modulus of resilience were analyzed by 1-way ANOVA
with a=.05. Post hoc testing of the 3 parameters was
performed using the Tukey HSD test with a =.05 for
comparison of the means between the different mate-
rials. All statistical analyses were performed by SPSS
Statistics package for Mac, v20 (IBM Corp).
In the second part of the study, the specimens were
prepared for a qualitative visual analysis of the margin
edge integrity continuity of the crowns milled from each
of the materials. A tooth preparation for a conventional
complete-coverage crown was made for a mandibular
right first molar typodont tooth (M-PVR-1560; Columbia
Dentoform Corp) with a high-speed handpiece. A
chamfer finish line was created with a diamond rotary
instrument (6856-018; Brasseler USA) and placed 1 mm
supragingivally to facilitate scanning. Digital impressions
of the prepared tooth and the surrounding, plus
opposing quadrants were made with Cerec Bluecam and
Cerec inLab v3.8 software (Sirona Dental Systems). The
finish line was delineated, and the crown was designed,
finalized, and saved. Forty-two crowns (7 crowns per
tested material) were milled from that design file with the
Cerec inLab MC XL milling unit (Sirona Dental Systems).
For each material, a new set of rotary instruments (Step
Awada and Nathanson
3
Bur 12 and Cylinder Pointed Bur 12S) was attached to the
milling unit. Care was taken to ensure that the milling
unit was properly calibrated and that the coolant/lubri-
cant system was in good working order throughout the
milling process. After the milling procedures, the crowns
were thoroughly rinsed and allowed to air dry overnight.
Then each crown was consecutively placed on a posi-
tioning jig made from pattern resin (GC Dental Prod-
ucts). The purpose of the jig was to stabilize the crown
and allow for the subsequent crowns to be identically and
repeatably positioned. Each crown was illuminated under
uniform lighting conditions (array of halogen lamps), and
photographs of the crown margins were captured with a
macro lens (EF 100 mm f/2.8 Macro USM; Canon Inc)
mounted on a digital single-lens reflex camera (EOS
Rebel T2i; Canon Inc). The entire setup was stabilized to
generate photographs of approximately the same area of
the margin for each specimen. Using the same posi-
tioning jig, each crown was consecutively observed with a
metallurgical microscope (Axiotron; Carl Zeiss). A
charge-coupled device video capture system attached to
the microscope was used to visualize the specimens on a
computer screen. Margin roughness was then digitally
measured as the vertical distance between the highest
peak and the lowest valley in the microscope’s field of
view. To overcome the issues associated with achieving
adequate focus along a curved structure, reference im-
ages were digitally captured at multiple depths of field,
and then focus-stacked with photo-editing software
(Photoshop CS5; Adobe Inc), resulting in uniformly
sharp micrographs.
RESULTS
The results of the calculations were expressed as means
and standard deviations for each material tested.
Figures 1 to 4 illustrate a summary of the statistical
analysis for the flexural strength, flexural modulus,
modulus of resilience, and margin edge roughness data.
The results of 1-way ANOVA showed that the material
factor had a significant effect on the mean flexural
strength (P<.001; df=149; F=167), flexural modulus
(P<.001; df=149; F=1208), modulus of resilience (P<.001;
df=149; F=610), and margin edge roughness (P<.001;
df=41; F=87) of the tested specimens.
The results of the Tukey HSD post hoc test revealed
that for the flexural strength, the EMP and MZ1 means
were not significantly different (P=.665). For the modulus
of resilience, the VM2 and EMP (P=.213) and the EMP
and ENA (P=.862) means were also found not to be
significantly different. Finally, for the margin edge
roughness, the CES, LVU, MZ1, and ENA means were
found not to be significantly different (P=.408). All other
pairs of group means were significantly different
(P<.001).
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Flexural Strength (MPa)

Flexural Modulus (GPa)

32.3
219
178 26
157 151 22.1
137
105 12.6
10.8
7.9

CES LVU MZ1 EMP ENA VM2 CES LVU MZ1 ENA VM2 EMP
Figure 1. Bar graph illustrating mean flexural strength (MPa) of tested Figure 2. Bar graph illustrating mean flexural modulus (GPa) of tested
materials. Horizontal lines above bars denote groups of means that are materials.
statistically similar.

Margin Edge Roughness (µm)

Modulus of Resilience (MPa)

3.07 190
153
1.47 76
1.02 0.21 60 61 61
0.42 0.35
CES LVU MZ1 ENA EMP VM2 CES LVU MZ1 ENA VM2 EMP
Figure 3. Bar graph illustrating mean modulus of resilience (MPa) of Figure 4. Bar graph illustrating mean margin edge roughness (mm) of
tested materials. Horizontal lines above bars denote groups of means tested materials. Horizontal lines above bars denote groups of means
that are statistically similar. that are statistically similar.

Figure 5. Macrophotograph of CES restoration, buccal margin. Dashed Figure 6. Optical micrograph of CES restoration at ×50 magnification,
box represents area observed under optical microscopy. buccal margin.

Figures 5 and 6 are a representative sample of the
macrophotographs of the milled crown margins for a
resin-based material and its corresponding micrograph.
Figures 7 and 8 represent a sample of the macrophoto-
graphs of the milled crown margins for a ceramic material
and its corresponding micrograph.
A qualitative observation of the milled margins on
these photographs revealed visibly irregular edges on the
VM2 and EMP specimens. In contrast, the milled margins
from the remaining groups had visibly smoother edges.
DISCUSSION
The purpose of this in vitro study was to identify
the properties, similarities, and differences among
various dental CAD/CAM restorative blocks with different

THE JOURNAL OF PROSTHETIC DENTISTRY Awada and Nathanson

- 2015
Figure 7. Macro photograph of VM2 restoration, buccal margin. Dashed
box represents area observed under optical microscopy.
chemistries and various manufacturing sources. In general,
the polymer-based materials performed better in flexural
testing than the ceramic materials. This was evident through
the relatively high flexural strength combined with a rela-
tively low flexural modulus that these polymer-based ma-
terials exhibited during testing, with the exception of ENA.
This combination translates to an increased ability to
withstand loading by undergoing more elastic deformation
before failure. These materials tend to be less brittle and
more flexible.
In contrast, the ceramic materials exhibited relatively
high flexural strength and flexural modulus. This com-
bination translates to a decreased ability to undergo
deformation in order to absorb the stress of increased
loading. These materials are less flexible and more brittle.
This difference in elastic properties between the
polymer-based materials and the ceramic materials could
be attributed to the resin component, which helps to
reduce brittleness.
These different combinations of flexural strength and
flexural modulus can be translated into a single modulus
of resilience measurement. By definition, resilience refers
to the amount of elastic energy stored in a unit volume of
a material at its elastic limit. The modulus of resilience is
represented by the area under the elastic portion of a
material’s stress-strain curve. As such, it is directly
dependent on flexural strength and modulus. A material
with a higher modulus of resilience is capable of
absorbing more energy before permanently deforming
and/or failing.
Though the clinical advantages of a resilient restor-
ative material might seem clear, based on the above
description, situations can be envisioned where a resilient
restorative material would have undesirable effects. For
instance, repeated elastic deformation of a resilient res-
toration’s margins might lead to microleakage and sub-
sequent restorative failure at the margins coupled with
recurrent decay. Further investigation into the beneficial
limits of resilient restorative materials could yield some
useful insights.
Awada and Nathanson
5
Figure 8. Optical micrograph of VM2 restoration at ×50 magnification,
buccal margin.
Observing the margin edge roughness of milled
crowns was used as a preliminary qualitative evaluation
of the statements made by the manufacturers of ENA,
LVU, and CES that imply that smoother margins are
more likely when milling their materials compared with
the currently available CAD/CAM materials with similar
indications and fabrication methods. The results of the
macrophotography evaluation of milled margins
revealed visibly smoother milled margins milled out of
CES, LVU, ENA, and MZ1 compared with VM2 and
EMP. These results were echoed by the margin edge
roughness measurements under optical microscopy,
which suggest a higher likelihood of obtaining milling
fidelity of the polymer-based materials in areas of
possibly reduced restorative material thickness such as
crown margins. This is probably due to the reduced
brittleness of these materials compared with conven-
tional ceramics and the effect of diamond milling in-
struments. However, in preparing the typodont tooth
for this qualitative assessment, the margins were
refined within the limitations of what can be done in a
clinical setting, rather than achieving maximum
smoothness through laboratory polishing steps. More-
over, margin edge roughness was evaluated on the
same specific area of the crown for each specimen
through the use of a positioning device. This was done
in an attempt to ensure that the observations were
relatable and comparable. It must be noted that man-
ufacturers of conventional ceramic blocks generally
recommend tooth preparations with pronounced
shoulder finish lines in order to improve milling fidelity.
However, the polymer-based materials tested in this
study seem to be capable of producing acceptable
margins from more conservative preparations.
From a biomimetic perspective, LVU, CES, and
mostly ENA exhibited flexural properties that approxi-
mate those of human dentin. In that specific respect,
they would constitute an acceptable choice for
singe-unit restorations. In contrast, the low stiffness
properties of these materials could be considered
THE JOURNAL OF PROSTHETIC DENTISTRY
6 Volume
disadvantageous, as marginal seal debonding due to
flexure might occur. Further investigation of this
parameter is required to determine the desirable and
acceptable level of flexibility. The qualitative observation
of margin edge roughness for CES, LVU, ENA, and MZ1
seemed to show that more accurate margins could be
milled from these materials, with fewer irregularities
than conventional ceramic materials. As such, acceptable
clinical results can be achieved with less tooth structure
reduction and more tolerance to less than ideal prepa-
ration designs.
The margin edge roughness observations carried out
in this study are purely qualitative in nature. The purpose
was simply to explore the plausibility of obtaining
smoother margins with polymer-based materials. The
next step in research would be to implement a quantifi-
able method of assessing the edge roughness of these
different materials.
Many researchers have modified ISO 687230 in order
to accommodate the relatively small size of the mill
blocks. ISO 6872 is an international standard for the
flexural testing of ceramics. It requires specific specimen
beam dimensions for the testing conducted in this
study. These dimensions are difficult to obtain from
CAD/CAM blocks because of their small size. The
application of the biaxial flexural testing protocol out-
lined in the same standard requires the preparation of
disk-shaped specimens. This becomes a problem as the
majority of CAD/CAM materials are only available in
rectangular-shaped blocks. As a result, these blocks
would need to be machined into a cylindrical shape that
must have a diameter no less than 12 mm in order to be
tested on the standard 10 mm support span. Keeping in
mind that the average mill block’s width and/or depth is
between 12 and 14 mm, the challenges in adequate
specimen preparation for biaxial flexural testing become
evident.
Although many relevant mechanical properties of
CES, ENA, and LVU have been evaluated in this study,
not all of the important properties were studied because
of time and resource constraints. A material that per-
forms well in flexural testing may have limitations in
other aspects, such as cyclic fatigue, color stability, or
material or antagonist wear. Also, some of the materials’
properties may change depending on their geometry and
their application. Further testing of these new materials
may determine the complete range of their properties,
especially by in vivo observation.
CONCLUSIONS
Within the limitations of this in vitro study, the following
conclusions were drawn:
1. The mean flexural strength of CES and LVU is
significantly higher than that of the other ceramic
THE JOURNAL OF PROSTHETIC DENTISTRY
- Issue -
and polymer-based CAD/CAM restorative materials
tested (ENA, VM2, MZ1, and EMP).
2. The mean flexural modulus of CES and LVU is
significantly lower than that of the other ceramic
and polymer-based CAD/CAM restorative materials
tested in this study (ENA, VM2, MZ1, and EMP).
3. The mean modulus of resilience of CES and LVU is
significantly higher than that of the other ceramic
and polymer-based CAD/CAM restorative materials
tested in this study (ENA, VM2, MZ1, and EMP).
4. The polymer-based materials tested in this study
(CES, LVU, ENA, and MZ1) seem to exhibit
smother milled margins compared with the ceramic
materials tested (VM2 and EMP).
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Corresponding author:
Dr Abdallah Awada
Department of Prosthodontics
Louisiana State University School of Dentistry
1100 Florida Ave
Box 222
New Orleans, LA 70119
Email: aawada@lsuhsc.edu
Acknowledgment
The authors thank Dr Richard Pober for his expertise and support through all
phases of this research project.
Copyright © 2015 by the Editorial Council for The Journal of Prosthetic Dentistry.

Awada and Nathanson THE JOURNAL OF PROSTHETIC DENTISTRY