Accelerated Fatigue Resistance of Thick CAD/CA M

Composite Resin Overlays Bonded with Light- and

Dual-polymerizing Luting Resins
Jack Goldberg3*/ Jan-Frederik Guthb / Pascal Magnec

Purpose: To evaluate the accelerated fatigue resistance of thick CAD/CAM composite resin overlays luted with
three different bonding methods.

Materials and Methods: Forty-five sound human second mandibular molars were organized and distributed into
three experimental groups. All teeth were restored with a 5-mm-thick CAD/CAM composite resin overlay. Group A:
immediate dentin sealing (IDS) with Optibond FL and luted with light-polymerizing composite (Herculite XRV). Group
B: IDS with Optibond FL and luted with dual-polymerizing composite (Nexus 3). Group C: direct luting with Optibond
FL and dual-polymerizing composite (Nexus 3). Masticatory forces at a frequency of 5 Hz were simulated using
closed-loop servo-hydraulics and forces starting with a load of 200 N for 5000 cycles, followed by steps of 400,
600, 800, 1000, 1200 and 1400 N for a maximum of 30,000 cycles. Each step was applied through a flat steel
cylinder at a 45-degree angle under submerged conditions.

Results: The fatigue test generated one failure in group A, three failures in group B, and no failures in group C. The
survival table analysis for the fatigue te st did not demonstrate any significant difference between the groups
(p = 0.154). The specimens that survived the fatigue test were set up for the load-to-failure test with a limit of
4600 N. The survival table analysis for the load-to-failure test demonstrates an average failure load of 3495.20 N
with survival of four specimens in group A, an average failure load of 4103.60 N with survival of six specimens in
group B, and an average failure load of 4 075.33 N with survival of nine specimens in group C. Pairwise compari­
sons revealed no significant differences (p < 0.016 after Bonferroni correction).

Conclusion: Within the limitations of this in vitro study, it can be concluded that although the dual-polymerizing lut­
ing material seems to provide better results under extreme conditions, light-polymerizing luting composites in com­
bination with IDS are not contraindicated with thick restorations.

Keywords: CAD/CAM, composite resin, dual-polymerizin g, fatigue resistance, immediate dentin sealing, light-poly­
merizing, overlays.

J Adhes Dent 2016; 18: 341-348. Submitted for publication: 23.08.15; accepted for publication: 01.06.16
doi: 10.3290/j.jad.a3651 5

rom a biomimetic perspective, the conservation of tooth
F structure is paramount in maintaining the subtle equilib­
rium between biological, mechanical, functional, and esthetic
3 Private Practice, Mexico City, Mexico. Idea, conducted the experiments, wrote
the manuscript.
b Associate Professor, Department of Prosthetic Dentistry, Ludwig Maximilian
University, Munich, Germany. Statistical evaluation, contributed substantially
to conducting the experiments, proofread the manuscript.
c Associate Professor, Division of Restorative Sciences, and Don and Sybil Har­
rington Foundation Professor of Esthetic Dentistry, Herman Ostrow School of
Dentistry of University of Southern California, Los Angeles, CA, USA. Experimen­
tal design, contributed substantially to the discussion, proofread the manuscript.
Correspondence: Dr. Jack Goldberg, Grupo Dental Bosques/Oral Health &
Smile Design, Paseo de los Laurales 458-302 B, Bosques de las Lomas,
C iudad de M exico D.F. 0 5 1 2 0 , M exico. Tel: + 5 2 -5 5 -1 3 2 7 -0 0 5 0 ;
e-mail: jackgoidbergdds@gm ail.com
parameters.25 It is clearly beneficial to keep the pulp alive by
preventing endodontic treatm ent and avoiding the use of
posts and cores, because these more invasive approaches
violate the biomechanical balance and compromise the per­
formance of restored teeth over tim e.45 As quantified by
Edelhoff et al,10*preparations with deep shoulders and cham­
fers, as required for complete coverage crowns utilizing con­
ventional retention and resistance forms, have been strongly
associated with decreased remaining tooth structure and
subsequent pulpal complications.14’43
Even though posts are frequently used to retain coronal
buildup materials, they do not reinforce roots and may even
weaken them through loss of radicular dentin necessitated
by post space preparation.3 The loss of tooth structure dur­
ing preparation affects tooth stiffness, reduces its resis­
tance to fracture, and consequently lim its its prognosis.

Vol 18, No 4, 2016 341

Goldberg et al
Other studies12-16’23'27 have confirmed that endodontically
treated teeth restored without posts have similar fracture
resistances and failure modes compared with those with
posts, which suggest th a t posts are not necessarily re­
quired.
Partial coverage preparations with reduced macroreten-
tive geometry, such as onlays and partial coverage ceramic
crowns, could be a good alternative in such cases and have
been reported to remove half the amount of tooth structure
compared to a complete coverage metal ceramic crown.10
With survival rates of 88.7% after 17 years35 and 84% after
12 years,13 porcelain adhesive inlays and onlays have dem­
onstrated long-term reliability.
The performance of composite resins has also improved
significantly during the last decade22-24’44 through a super­
ior bond between the different phases34 and various post­
polymerization treatm ents.39 Key properties of composite
resin restorations include their low abrasiveness to antago­
nistic teeth21 and low elastic modulus, allowing more ab­
sorption of functional stresses through deformation 30 The
fatigue resistance of CAD/CAM composite resin overlays
has proved to exceed that of CAD/CAM porcelain ones.29
Given the development of stronger materials in combination
with CAD/ CAM techniques and innovative adhesive technol­
ogy such as immediate dentin sealing (IDS),8'26'32'37 which
implies sealing the freshly cut dentin with a dentin bonding
agent directly following tooth preparation, more conservative
approaches should consequently be considered.
Several kinds of resin cements are available for use as
luting agents for indirect restorations.40 It is essential to
achieve adequate polymerization of the luting resin under
the restoration, because the degree of monomer conversion
of the resin is intimately related to its final mechanical and
biological properties.4-38 Therefore, the extent of the poly­
merization of the resin cement indirectly plays an important
role in the ultimate success of the restoration. The pres­
ence of a composite resin or ceramic restoration between
the light tip and the resin cement impairs the transmission
of the polymerizing light, thus reducing the energy density
available for the photoinitiated polymerization.1-24
The question still remains whether to use a dual-polymer­
izing or light-polymerizing luting agent to bond the restor­
ation to the conservatively prepared tooth. As early as
1995, Besek et al5 found that dual-polymerizing resin had
no advantages over light-polymerizing resin with respect to
polymerization rate when seating Cerec CAD/CAM inlays.
Park et al36 found that the restorative composites polymer­
ized more efficiently than did the dual-polymerizing resin
cements, and Kramer et al19 concluded that the substance
loss within the luting gap of restorative composites was
more resistant to mechanical wear than dual-polymerizing
resins.
Kramer et al18 and Schulte et al42 found that solely light-
polymerized luting composite can be used successfully in
routine clinical therapy, demonstrated a certain advantage
in handling, and found less excess at the margins due to
the ability of the clinician to remove the excess prior to
polymerization. Recently, Kameyama et al17 concluded that
342
high power light curing of a direct composite may be a via­
ble alternative to luting lithium disilicate glass-ceramic
CAD/CAM restorations.
Gregor et al15 concluded that the Vicker’s microhardness
values of the dual-polymerized resin cement and the light-
polymerized restorative composite resin through 7.5-mm-
thick endocrowns reached at least 80% of the control Vick-
e r’s m icrohardness values, which m eans th a t both
materials can be adequately polymerized when they are
used for luting thick indirect restorations.
The purpose of this study was to assess and compare
the accelerated fatigue resistance and fracture load of
5-mm-thick non-retentive CAD/CAM composite resin over­
lays luted with three different luting methods for the reha­
bilitation of heavily compromised molars. The null hypothe­
sis considered was that no significant difference would be
found with respect to fatigue resistance among the three
luting methods used in this study for composite overlays.
MATERIALS AND METHODS
Once approval was obtained from the Ethics Committee of
the University o f Southern C alifornia Review Board,
45 freshly extracted sound human second mandibular mo­
lars were stored in 0.1% thymol solution (Tymol Crystal,
Merck; Darmstadt, Germany).
Using the stratified random sampling process, all teeth
(N = 45) were organized into groups of three by approxi­
mately similar sizes (medium-sized buccolingual and mesio-
distal dimensions, height); afterwards, these teeth were
randomly distributed into the te s t groups A, B, and C
(n = 15). A single operator with 12 years of experience per­
formed all the procedures. Teeth were mounted in a special
positioning jig with acrylic resin (Palapress vario light pink,
Heraeus Kulzer; Hanau, Germany), embedding the root up
to 2.0 mm below the cementoenamel junction (CEJ).
Tooth Preparation
A standardized, flat, nonretentive tooth preparation was cre­
ated by removing the clinical crown down to 2 mm above
the CEJ using a round-ended tapered diamond rotary cutting
instrument (850-023, Brasseler USA; Savannah, GA, USA)
without opening the pulp chamber (Fig 1). Once the prepar­
ation was completed, the specimens from groups A and B
received immediate dentin sealing, whereas delayed dentin
bonding was carried out for specimens in group C. As sug­
gested by several authors,28-29'31 a three-step etch-and-
rinse dentin bonding agent (OptiBond FL, Kerr; Orange, CA,
USA) was used following the manufacturer’s instructions;
15-s dentin etching with 37.5% phosphoric acid (Ultra-Etch,
Ultradent; South Jordan, UT, USA), copious rinsing, careful
air drying for 3 to 5 s without desiccation, application of the
primer with a light brushing motion for 15 s, air drying for 3
to 5 s, and application of adhesive resin only on dentin by
gentle brushing for 20 s (no air thinning). The adhesive was
then light polymerized for 20 s at 1000 mW /cm2 (Valo; Ul­
tradent) with an additional 10 s under an air barrier (K-Y
The Journal of Adhesive Dentistry

Fig 1 Standardized flat nonretentive preparation with anti-rota­
tional features.
Fig 3 Restoration design using Cerec 3 CAD/CAM system.
Jelly; Johnson & Johnson; New Brunswick, NJ, USA) to re­
duce the oxygen-inhibition layer (Fig 2). Excess adhesive
resin was then removed from the surrounding enamel with
a round diamond rotary cutting instrument (801-023, Bras-
seler USA; Savannah, GA, USA) and 2-mm-deep indenta­
tions were prepared with a round diamond rotary cutting in­
strument (801-014, Brasseler USA; Savannah, GA, USA) in
the mesial and distal areas for anti-rotation purposes at
1500 rpm. Each tooth was then stored in distilled water for
24 h before the designing, machining and adhesive place­
ment of the CAD/CAM restorations.
Design and Fabrication of the Restorations
All specimens were restored using the Cerec 3 CAD/CAM
system (Fig 3) (Cerec software v3.03; Sirona Dental Sys­
tems; Bensheim, Germany) and were fitted with a standard­
ized 5-mm-thick cylindrical overlay milled out of a CAD/CAM
block of composite resin (Lava Ultimate, 3M/ESPE; St Paul,
MN, USA). All restorations were inspected to detect even­
tual cracks generated by milling, polished and finished
using brushes (Jiffy Composite Polishing Brushes, Ultra­
dent).
Luting Procedure
Surface conditioning of the restorations for all groups was
initiated by airborne-particle abrasion with 27-pm aluminum
oxide at 0.5 bar (Rondoflex plus 360, KaVo Dental; Char­
Vol 18, No 4, 2016
Goldberg et al
Fig 2 Immediate dentin sealing, step-by-step procedure (groups A
and B).
Fig 4 Excess of light-polymerized restorative composite (Herculite
XRV, group A).
lotte, NC, USA), following thorough rinsing for 20 s with oil-
free water. Cleaning included the application of 37.5%
phosphoric acid (Ultra-Etch; Ultradent), as recommended in
previous studies,940,21,39 followed by rinsing for 20 s and
immersion in distilled water in an ultrasonic bath for 3 min.
After air drying, the intaglio surfaces were silanated (Silane,
Ultradent) and heat dried at 100°C for 1 min (DI500 oven,
Coltene; Altstatten, Switzerland).
Group A
To reactivate the IDS-surface, all teeth in group A were air­
borne-particle abraded with 27-pm aluminum oxide at
0.5 bar (Rondoflex plus 360, KaVo Dental), and etched for
30 s with 37.5% phosphoric acid (Ultra-Etch, Ultradent),
rinsed and dried. The adhesive resin (Optibond FL, bottle 2;
Kerr; Orange, CA, USA) was applied to both fitting surfaces
of the restoration and the tooth and left unpolymerized. The
specimens received light polymerizing restorative composite
resin as a luting material (Herculite XRV, Enamel A2; Kerr),
preheated at 68°C in Calset (Fig 4) (Calset, AdDent; Dan­
bury, CT, USA).
Group B
To reactivate the IDS-surface, all teeth in group B were air­
borne-particle abraded with 27-pm aluminum oxide at
0.5 bar (Rondoflex plus 360, KaVo Dental), and etched for
30 s with 37.5% phosphoric acid (Ultra-Etch, Ultradent),
343
Goldberg et al
Fig 5 Excess of dual-polymerized luting agent (Nexus 3, groups B
and C).
rinsed and dried. The adhesive resin (Optibond FL, bottle 2;
Kerr) was applied to both fitting surfaces of the restoration
and the tooth and left unpolymerized. The specimens were
luted utilizing a dual-polymerizing luting agent (Nexus 3,
Kerr) (Fig 5).
Group C
Specimens in group C received a delayed bonding protocol
which consisted of a 3-step etch-and-rinse dentin bonding
agent (OptiBond FL, Kerr) following the manufacturer’s in­
structions: 15-s dentin etching with 37.5% phosphoric acid
(Ultra-Etch, Ultradent), copious rinsing, careful air drying for
3 to 5 s without desiccation, application of the primer with
a light brushing motion for 15 s, air drying for 3 to 5 s, and
application of adhesive resin by gentle brushing for 20 s,
air thinning for 3 s, but no light curing. The adhesive resin
(Optibond FL, bottle 2; Kerr) was applied to the fitting sur­
face of the restoration and the specimens were luted utiliz­
ing a dual-polymerizing luting agent (Nexus 3, Kerr).
The restorations for all groups were carefully seated and
then subjected to a standardized load of 6N (by applying
weights through a custom device) during removal of excess
luting material (CompoSculp DD1/DD2, Suter; Chico, CA,
USA) and initial light polymerization. Occlusal, vestibular,
and lingual surfaces were exposed to 1000 mW/cm2 (Valo,
Ultradent) for 60 s (20 s per surface, repeated 3 times).
The margins were then covered with an air barrier (K-Y Jelly,
Johnson & Johnson; New Brunswick, NJ, USA) and light po­
lymerized for an additional 20 s. Restorations and margins
were then polished mechanically using a composite resin
polishing system (Kit 4 47 7, Q-Polishing System, Komet;
Rock FHills, SC, USA) and a silicon bristle brush (Oc-
clubrush, Kerr). Each specimen was then stored individually
in a labeled container in distilled water at ambient tempera­
ture for at least 24 h before testing.
Fatigue Testing
Masticatory forces were applied using closed-loop servo-
hydraulics (MiniBionix II MTS Systems; Eden Prairie, MN,
USA) with a flat-surface steel cylinder. Each specimen was
placed in the load chamber at a 45-degree angle and situ­
344
Fig 6 Specimen in the load chamber at 45-degree angle.
ated with a positioning device (sliding table) in a reproduc­
ible position, in order to achieve simultaneous contact of
the loading surface with a flattened edge of the restoration
(Fig 6). Ultrafine 600-grit wet sandpaper (Norton Abrasives;
Worcester, MA, USA) was used until sim ultaneous and
equal contact was accomplished. The load chamber was
filled with distilled water until complete immersion of the
specimen, and isometric mastication (under load control)
was simulated at a frequency of 5 Hz, starting with a load
of 200 N for 5000 cycles (preconditioning phase to guaran­
tee predictable positioning of the specimen) followed by
stages of 400, 600, 800, 1000, 1200 and 1400 N at a
maximum of 30,000 cycles each. Specimens were loaded
until catastrophic failure (lost restoration fragments) or to a
maximum of 1 8 5 ,0 0 0 cycles (loading protocol modified
from Fennis et al11-20). The fracture load was determined
as the load step at which the machine stopped (triggered by
the displacement-based, failure-detection module of the
testing software). The number of endured cycles and failure
mode were recorded.
The specimens that survived the fatigue test were stati­
cally loaded until failure or to a maximum of 4600 N with
the same loading configuration explained above, with the
antagonist loading surface at a crosshead speed of
0.5 m m/min. The maximum post-fatigue load before failure
was recorded in Newtons.
Following a two-examiner agreement under optical mi­
croscopy at 32X magnification (Leica MZ 125, Leica Micro­
systems; Wetzlar, Germany), a distinction was made be­
tween cohesive fracture (within the restoration) or adhesive
fractures at the bonding interface, and photographed under
standardized conditions at 1.5X m agnification (Nikon
D7000 and Nikkor 105 mm lens, Nikon; Tokyo, Japan).
The endurance of all groups was compared using life-ta­
ble survival analysis. During the fatigue test, for each time
interval (defined by each load step), the difference between
the specimens starting the interval intact and the speci­
mens failing during that interval was counted, providing the
survival probability (%) at each load step. Differences were
analyzed using the Log Rank (Mantel Cox) test at a signifi­
cance level of 5%.
The Journal of Adhesive Dentistry

Fig 7 Survival table analysis for the fatigue
test.
0.0
Fig 8 Survival table analysis for the load-to-
failure test.
The specimens that survived the fatigue test (group A:
n = 14; group B: n = 12; group C: n = 15) were subse­
quently loaded to failure. The data were then analyzed
using the Kaplan-Meier survival analysis (step scale of
575 N). The influence of the luting material on the survival
rate was observed by comparing the survival curves using
the Log Rank (Mantel Cox) test at a significance level of
0.05. Differences were localized using pairwise post-hoc
comparisons with the chi-squared test at a significance
level of 0.016 (after Bonferroni correction for 3 compari­
sons).
RESULTS
The fatigue test generated one failure in group A, three fail­
ures in group B, and no failures in group C (Table 1), all of
which were mixed, adhesive in part between the restoration
Vol 18, No 4, 2016
Goldberg et al
Factor
— Group A
— Group B
— Group C
1000.00 2000.00 3000.00 4000.00 5000.00
load [N]
and the tooth, and cohesive within the tooth with fracture of
the root. The survival table analysis for the fatigue test
(Fig 7) did not demonstrate any significant difference be­
tween the groups (p = 0.154).
The specimens that survived the fatigue test were set up
for the load-to-failure test with a limit of 4600 N due to the
holding jig ’s capabilities and considering clinical signifi­
cance, because it is virtually impossible to exceed these
limits in an oral environment. The survival table analysis for
the load-to-failure test (Fig 8) demonstrates an average fail­
ure load of 3495.20 N with survival of four specimens in
group A, an average failure load of 4103.60 N with survival
of six specimens in group B, and an average failure load of
4075.33 N with survival nine specimens in group C
(Table 1). Pairwise comparisons revealed no significant dif­
ferences at a significance level of 0.016 after Bonferroni
correction: 1) group A vs B: p = 0.109; 2) group B vs C:
p = 0.543; 3) group A vs C: p = 0.026. Disregarding the
345
Goldberg et al

Table 1 Comparison of fatigue test and load-to-failure

test results

Specimen Fatigue test Load-to-failure test

Maximum load Cycles Maximum load

Al Survived 185,000 3493 N
B1 Survived 185,000 4185 N
Cl Survived 185,000 4139 N Group A Group B Group C
A2 1007 N 101,005 Failed fatigue test
B2 807 N 66,514 Failed fatigue test
C2 Survived 185,000 Survived
Fig 9 Example of failure modes per group.
A3 Survived 185,000 2473 N
B3 Survived 185,000 4022 N
C3 Survived 185,000 3834 N Bonferroni correction leads to significant differences be­
A4 Survived 185,000 3349 N tween group A and C.
B4 Survived 185,000 3467 N Failure modes for all three groups (Fig 9) exhibited a ten­
C4 Survived 185,000 Survived dency similar to that during the fatigue test, ie, mixed fail­
A5 Survived 185,000 3783 N ures, adhesive in part between the restoration and the
B5 1208 N 130,104 Failed fatigue test
tooth, and cohesive within the tooth with fracture of the
root. In all cases, a portion of the remaining crown or root
C5 Survived 185,000 Survived
demonstrated a fracture. Load-to-failure testing of the fa­
A6 Survived 185,000 4147 N
tigued specimens started to demonstrate differences above
B6 Survived 185,000 3907 N 3200 N; 40% of the tested specimens failed below 3200 N
C6 Survived 185,000 4237 N for group A, while 100% of the tested specimens for groups
A7 Survived 185,000 4585 N B and C survived the load of 3200 N.
B7 Survived 185,000 4574 N
C7 Survived 185,000 3817 N
DISCUSSION
A8 Survived 185,000 Survived
B8 Survived 185,000 Survived
The null hypothesis, namely, that no significant difference
C8 Survived 185,000 Survived
would be found with respect to resistance among the three
A9 Survived 185,000 3113 N luting methods used in this study for posterior composite
B9 Survived 185,000 Survived overlays was accepted, owing to the fact that no significant
C9 Survived 185,000 Survived differences were found within the test groups.
A10 Survived 185,000 Survived Flowever, during load-to-failure testing, when disregarding
BIO Survived 185,000 4467 N the statistical Bonferroni correction, the dual-polymerizing
luting agent showed an increased fatigue resistance com­
CIO Survived 185,000 Survived
pared to the light-polymerizing luting agent, even though
A ll Survived 185,000 3817 N
these differences only started to appear beyond 3200 N,
B ll Survived 185,000 Survived
which far exceeds normal human physiological masticatory
C ll Survived 185,000 4211 N forces.
A12 Survived 185,000 3011 N In the present study, a closed-loop servo-hydraulic con­
B12 Survived 185,000 Survived trol system in combination with a stepped load protocol
C12 Survived 185,000 Survived was applied to create a testing method which allows a
A13 Survived 185,000 3181 N physiological representation of mastication.6 Based on orig­
inal studies by Fennis et al,11 this test strategy seems to
B13 Survived 185,000 Survived
provide a better simulation of the clinical conditions than do
C13 Survived 185,000 4214 N
static load tests. The presented protocol appears to be the
A14 Survived 185,000 Survived best compromise between available in vitro fatigue testing
B14 Survived 185,000 Survived methods and clinical reality. It is critical to elucidate that
C14 Survived 185,000 Survived during the pilot tests for the present study, the specimens
A15 Survived 185,000 Survived did not fail when the load was applied at 30 degrees; there­
B15 1411 161,505 Failed fatigue test fore, the authors decided to modify the angle of force to 45
C15 Survived 185,000 Survived
degrees in order to create a more extreme simulation and
increase the stress concentration in the bonded area. Al­
though this testing protocol surpasses the physiological

346 The Journal of Adhesive Dentistry


forces found in humans, it was deemed necessary to create
a study design that would test the restoration as a whole
unit comprised of the tooth, bonding area, and restoration.
Healthy humans exhibit maximal isometric bite forces in
the molar region ranging between 597 N (women) and 847
N (men), but they can also reach up to 900 N.46 Even
higher forces can occur by an accidental bite on a hard for­
eign body found in a food bolus. Although it is difficult to
draw direct correlations between the load ranges applied in
this study and their significance in vivo, a study by Sakagu-
chi et al,41 using a similar machine, correlated 250,000 cy­
cles at only 13.6 N with one year of clinical service. Due to
the application of far higher forces in this study, it can be
expected that an accelerated life cycle of the restored tooth
may have been simulated. Restorative materials are often
tested by subjecting standardized beams to a 3- or 4-point
flexural cyclic load. Only two modes of fatigue can be simu­
lated by this process: contact and flexure.2 In the present
study, a fully functional restored natural tooth was simu­
lated, which constitutes the uniqueness of this protocol.
Although in vitro studies only partially mimic the clinical
reality, their main advantage over clinical studies is the
possibility to minimize confounding variables and further
enable the testing of samples with a well-defined biomech­
anical status.7 Because of the high standardization level
that can be attained at all preparation and restorative
steps, the remaining confounding variable is limited to the
age, size, and shape of extracted teeth. Therefore, only
mandibular second molars were used and distributed
evenly into each experimental group. Further, after stan­
dardized preparation of the specimens, standardized cylin­
drical onlays were designed using CAD/CAM technology; all
of the above facilitated the loading of the specimen in an
identical configuration.
The luting procedure utilized during this study consti­
tuted another strong element of the protocol. It included
“immediate dentin sealing” associated with application of a
preheated light-polymerizing composite resin restorative ma­
terial as a luting agent. Even though IDS did not present a
significant advantage in terms of fracture strength during
this test, it still possesses other notable clinical advan­
tages, eg, including protecting against bacterial leakage
and sensitivity during the provisional phase. A distinction
between this in vitro study and clinical reality should be
mentioned: in a clinical setting after preparing the tooth for
an indirect restoration, a provisional restoration is needed.
Therefore, it is important to utilize provisional cement that
will not interfere with the bonding procedure that takes
place during final delivery of the restoration.
It is fascinating to observe that despite the extremely
high loads used in the present study during the fatigue test,
most of the specimens survived; it took massive amounts
of static force to reach the breaking point of these speci­
mens. In most cases, the weak point was the tooth struc­
ture, and fracture of the remaining crown or root portion
resulted. This suggests that by utilizing the appropriate ma­
terials under strict protocols, a very stable and resistant
bonded restoration can be achieved.
Vol 18, No 4, 2016
Goldberg et al
In this study, it was decided to use 5-mm-thick onlays,
which are not encountered frequently in the clinical setting
(most of the time a thinner restoration will be fabricated).
Nevertheless, it was the objective of this study to create a
very extreme restoration and loading protocol to test the
system under exceptional circumstances. It is essential to
mention that in most cases, depending on each specimen’s
natural anatomy, a 1- to 2-mm rim of enamel was left cir­
cumferentially on the flat preparation, which contributed
greatly to achieving a stable bond between the restoration
and the tooth.
Regarding the results observed, the use of light-polymer­
izing composite resin as a luting agent with thick CAD/CAM
restorations might be an alternative to traditional luting
agents, such as dual- or chemically polymerizing resin ce­
ment. This would provide the clinician with the advantages
of using a light-polymerizing luting agent, such as longer
and determinable working time, improved biomechanical
properties and wear resistance, as well as ease of removal.
From a clinical standpoint, given the extraordinarily high
loads required to break the specimens in this study, the
three luting protocols tested provided enough in vitro fa­
tigue resistance to be considered as viable options for lut­
ing CAD/CAM composite resin restorations, even though
this in vitro research does not fully simulate the oral envi­
ronment. Thus, it is difficult to draw direct correlations to
the clinical performance of these restorations. The present
study is therefore limited, and further research should in­
clude clinical trials.
CONCLUSION
Within the limitations of this in vitro study, it can be con­
cluded that although dual-polymerizing luting material
seems to provide better results under extreme conditions,
light-polymerizing luting composites in combination with IDS
are not contraindicated with thick restorations. Extraordi­
narily high loads (2300 to 4600 N) were required to break
the specimens, which also speaks for the performance of
the adhesive systems used in this study.
ACKNOWLEDGMENTS
The authors would like to thank Kerr and 3M ESPE for providing the
materials needed for this study.
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Clinical relevance: The use of both dual-polymerizing
and light-polymerizing luting materials provided suffi­
cient in vitro fatigue resistance to be considered viable
options for luting CAD/CAM restorations.
The Journal of Adhesive Dentistry