Fatigue resistance of CAD/CAM complete

crowns with a simplified cementation

process
Adriana O. Carvalho, DDS, MS,a Greciana Bruzi, DDS, MS,b
Marcelo Giannini, DDS, MS, PhD,c and Pascal Magne, DMD, PhDd
Piracicaba School of Dentistry, Campinas State University, Piracicaba,
SP, Brazil; Federal University of Santa Catarina, Florianópolis, Santa
Catarina, Brazil; Ostrow School of Dentistry, University of Southern
California, Los Angeles, Calif
Statement of problem. Various computer-aided design and computer-aided manufacturing (CAD/CAM) materials
are available to fabricate complete crowns. The type of material may have an effect on the longevity of these
restorations.

Purpose. To evaluate the fatigue resistance, load-to-failure, failure mode, and antagonistic wear of complete molar
computer-aided design and computer-aided manufacturing (CAD/CAM) crowns made of resin nanoceramic (RNC),
feldspathic glass ceramic (FEL), or lithium disilicate (LD) placed with a simplified cementation process.

Material and methods. Forty-five molars received a standardized complete crown preparation and were restored with
CAD/CAM crowns (1.5-mm thickness, n¼15) made of RNC, FEL, and LD. After cementation, the restorations were
submitted to cyclic isometric loading: 200 (5000), 400, 600, 800, 1000, 1200, and 1400 N at a maximum of 30 000
cycles each. Surviving specimens were axially loaded until failure or to a maximum load of 4500 N. The specimens were
analyzed as to failure mode: catastrophic, possibly repairable, and repairable. The groups were compared by using the life
table survival analysis and the t test (a¼.05).

Results. All the specimens survived the fatigue process until the 800-N step. The survival rate of RNC was 80%, LD 93.3%, and
FEL 6.6%. The survival of RNC and LD crowns did not differ from each other but exceeded that of FEL. Postfatigue load-to-
failure test was 2500 N (FEL), 3122 N (RNC), and 3237 N (LD). No catastrophic failure occurred in the fatigue test, whereas
all of the specimens in the load-to-failure test exhibited catastrophic fractures. Crowns made of RNC seemed to generate the
least amount of antagonistic wear.

Conclusions. Posterior crowns made of RNC and LD were not statistically different, and both had significantly higher
fatigue resistance than FEL. All materials survived beyond the normal range of masticatory forces, and all failures were
possibly re-restorable except those in the load-to-failure test. RNC crowns seemed to cause less wear of the antagonist.
(J Prosthet Dent 2014;111:310-317)

Supported by 3M ESPE and Brazilians Federal Agencies for Support (grants CNPq 20092/2011-6, CAPES 3110/2010, and
CAPES 4979/11-7).
a
Graduate student, Department of Restorative Dentistry, Piracicaba School of Dentistry, Campinas State University.
b
Graduate student, Department of Operative Dentistry, Federal University of Santa Catarina.
c
Associate Professor, Department of Restorative Dentistry, Piracicaba School of Dentistry, Campinas State University.
d
Don and Sybil Harrington Professor of Esthetic Dentistry, Restorative Sciences, Ostrow School of Dentistry, University of Southern
California.

The Journal of Prosthetic Dentistry Carvalho et al

April 2014 311

Clinical Implications
With a simplified cementation process, resin nanoceramic and
lithium disilicate crowns demonstrated improved fracture properties
than feldspathic glass ceramic crowns. Resin nanoceramic also
demonstrated significant practical advantages, such as less mill
time, less milling bur usage, no need for firing, polishability, ease
of occlusal adjustment, repairability, and wear friendly to
antagonist teeth.

Research into metal-free, tooth-
colored restorations has been stimulated
by the increasing demand for esthetics,
combined with the health and environ-
mental concerns about some metal res-
torations. In addition, new and improved
options for indirect prosthetic treatments
have been developed. Computer-aided
design/computer-assisted manufacture
(CAD/CAM) restorations are fueling this
trend. As CAD/CAM gains in popularity,
more machinable versions of esthetic
materials have been introduced.1-3
In spite of the esthetic appearance,
color stability, biocompatibility, and
durability1,4-6 of glass ceramic restora-
tions, such materials also present some
disadvantages, including brittleness,
susceptibility to fracture, and abrasive
wear of the opposing natural teeth.7-12
Other materials used for indirect
esthetic restorations are composite
resins.13 Their main advantages include
low abrasiveness to antagonist teeth9
and a low elastic modulus, which al-
lows more absorption of functional
stresses through deformation.14 Clinical
studies have reported that the longevity
of ceramic restorations is better than
that of composite resin crowns.15-18
Some disadvantages of composite resin
remain, such as wear, deterioration of
surface finish, color instability, and
fracture. However, other investigators
have reported that the performance of
composite resins has exceeded that of
ceramics.8,11,19-25 Still other reports
have shown that the behavior of teeth
with ceramic and composite resin
crowns is similar.2,8,26,27 Overall, no
consensus exists as to the best material
for restoring posterior teeth.
Millable composite resin materials
have become popular for use as a CAD/
CAM block because of their mill-
ability.1,22,23 Recently, a new class of
millable resin nanoceramic (RNC)
blocks (LAVA Ultimate; 3M ESPE) has
been introduced for use with CAD/
CAM systems. According to the manu-
facturer, this material is not a resin or a
pure ceramic. RNC combines the ben-
efits of a highly cross-linked resin matrix
and ceramics. It consists primarily of
ceramic (60% in volume). The American
Dental Association has recently broad-
ened its definition of porcelain-ceramic
materials (effective January 1, 2013) in
its Current Dental Terminology Code
for insurance reimbursement, which
allows RNC to be classified as a por-
celain ceramic. Like composite resins,
RNC is flexible and fracture resistant.
However, limited scientific information
is available regarding its properties.
The purpose of this study was to
evaluate the fatigue resistance, load to
failure, failure mode, and antagonistic
wear of complete molar CAD/CAM
crowns made with RNC, feldspathic
glass ceramic, and lithium disilicate.
The thickness was according to the
manufacturer’s instructions for each
material. The null hypothesis was that
no significant difference would be
found with respect to fatigue resistance,
failure mode, or the wear of the
antagonist among the 3 materials used
for complete molar crowns.
MATERIAL AND METHODS
Once approval was obtained from
both the ethical committee of the
Piracicaba Dental School (Campinas
State University) and the University of
Southern California Review Board, 45
freshly extracted, sound human maxil-
lary molars were collected and stored in
a solution saturated with thymol. The
teeth were mounted in a special posi-
tioning device with acrylic resin (Pala-
press; Heraeus Kulzer), with the root
embedded up to 3.0 mm below the
cementoenamel junction (CEJ).
A standardized tooth preparation
was applied to all specimens. First, an
axial reduction of 1.5 mm was obtained
with a circular chamfer size of 1.0 mm by
following the CEJ and with a conver-
gence angle of 6 degrees between the
tooth axis and lateral wall. Second,
anatomic occlusal reduction was per-
formed, and the buccal and palatal cusp
tips were maintained at approximately
4.0 mm from the gingival margin and the
central groove at approximately 2.0 mm
from the gingival margin. Care was taken
to obtain smooth and rounded internal
line angles.
The molars were restored with the
Cerec 3 CAD/CAM system (Sirona
Dental Systems GmbH). All the speci-
mens were fitted with a crown of stan-
dardized thickness (Fig. 1) with an
average thickness of 1.5 mm at the
central groove, a maximum of 2.0 mm
at the cusp (measured with a caliper
after milling and polishing), and stan-
dardized occlusal anatomy (third
maxillary molar, Lee Culp Youth data-
base). By using the Crown Master
Mode and the Design Tools of the
Cerec software (Cerec v3.6, Sirona
Dental Systems), the occlusal surface
was moved and rotated to make the

Carvalho et al
312
1 Crown restoration and corresponding measurements and
dimensions.
cusp tips and the preparation surface
parallel and to align the central groove.
Fifteen specimens were milled with glass
ceramic blocks (Vitablocs Mark II; Vita
Zahnfabrik) (group FEL), another 15
with glass ceramic blocks (IPS e.max
CAD; Ivoclar Vivadent AG) (group LD),
and the final 15 with RNC blocks (Lava
Ultimate; 3M ESPE) (group RNC). All
restorations were milled in Endo mode,
with the sprue located at the lingual
surface, and were inspected to detect
possible milling cracks. The crowns
milled with LD blocks required crystal-
lization firing. Thus, after milling, the
LD crowns were fired in a ceramic
furnace (Austromat 624; DEKEMA
Dental-Keramiköfen GmbH) according
to the manufacturer’s instructions. For
the RNC group, the polishing proce-
dure was performed with a commercial
polishing kit (Dialite, Ultra Polisher;
Brasseler); for the FEL group, the
specimens were glazed with Akzent
glaze (Vita Zahnfabrik); and, for the LD
group with IPS e.max CAD Cristall/
Glaze (Ivoclar Vivadent AG) according
to the manufacturer’s instructions.
Before luting, each crown was seated
on its respective tooth to evaluate the
marginal fit. The glass ceramic crown
surfaces were cleaned with a steam
cleaner and etched with 5% hydrofluoric
The Journal of Prosthetic Dentistry
acid (IPS Ceramic etching gel; Ivoclar
Vivadent AG) for 60 seconds (FEL) or 20
seconds (LD), rinsed, cleaned in distilled
water in an ultrasonic bath for 1 minute
and then silanized (Rely X Ceramic
Primer; 3M ESPE) according to the
manufacturer’s instructions. The RNC
crowns were cleaned, airborne-particle
abraded with 50 mm aluminum oxide
(Danville), rinsed, and cleaned in distilled
water in an ultrasonic bath for 1 minute.
The teeth also were pretreated before
cementation. The preparations were
airborne-particle abraded with 27 mm
aluminum oxide, rinsed, and dried. Dual-
polymerizing self-adhesive resin cement
(RelyX Unicem 2 Automix; 3M ESPE) was
used for the cementation. Cement was
applied inside the restoration, and the
crown was seated on the tooth with an
approximate load of 70 N. Excess cement
was removed after brief light exposure
(approximately 2 seconds) with a light-
emitting diode unit (VALO Curing Light,
Ultradent Products Inc), and each surface
was then light polymerized for 20 sec-
onds. All the margins were covered with
an air-blocking barrier (KY Jelly; Johnson
& Johnson Inc) and additional polymeri-
zation was performed for 20 seconds per
surface. The margins were finished and
polished with a diamond ceramic polisher
(CeramiPro Dialite; Brasseler USA), a
Volume 111 Issue 4
polishing brush with diamond paste
(Diamond Twist SCL; Premier Dental),
and a buff with a muslin rag wheel.
Each specimen was stored in distilled
water at an ambient temperature for at
least 24 hours after adhesive restoration
placement. Masticatory forces were then
simulated with an artificial mouth by
using closed-loop servo hydraulics (Mini
Bionix II; MTS Systems) for the fatigue
test. Each specimen was placed into the
load chamber and situated with a posi-
tioning device. The masticatory cycle
was simulated by an isometric contrac-
tion (load control) applied through a
10-mm-diameter composite resin sphere
(Filtek Z100; 3M EPSE). Because of
the standardized occlusal anatomy, all
the specimens could be adjusted in the
same reproducible position, with the
sphere contacting the mesiobuccal, dis-
tobuccal, and palatal cusps (tripod
contact). The specimen was submerged
in distilled water in the load chamber
during testing. A cyclic load was applied
at a frequency of 10 Hz, starting with a
load of 200 N for 5000 cycles (pre-
conditioning phase to guarantee pre-
dictable positioning of the sphere with
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 fracture or
to a maximum of 185 000 cycles. The
number of endured cycles and the
mode of failure were recorded. After a
2-examiner agreement under an optical
microscope, a distinction was made be-
tween fractures above (repairable) or
below (catastrophic) the CEJ or for
cohesive fracture or fracture at the
interface.
After the fatigue test, the surviving
specimens were axially loaded until
failure or to a maximum load of 4500
N with a 10-mm composite resin
sphere. The sphere had the same 3-
point occlusal contacts as in the fa-
tigue test. The crosshead speed was 0.5
mm/min. The maximum postfatigue
load before failure was recorded in
newtons, and mean values were calcu-
lated per group. After the load tests, the
specimens were analyzed for 1 of the 3
failure modes: repairable tooth fracture
Carvalho et al
April 2014 313
(cohesive chipping within the material 100
or adhesive failure with fragment but no
loss or damage to underlying tooth 80
structure), possibly repairable (adhesive

failure with fragment and minor dam-
age, chip, or crack of underlying tooth
structure), or catastrophic tooth-root
fracture (below the CEJ) that would
require tooth extraction, or for cohesive
fracture or fracture at the interface.
The life table survival analysis was
used to compare the fatigue resistance
of the 3 groups. At each time interval
(defined by each load step), the num-
ber of specimens that started the in-
terval intact and the number of
specimens that fractured during the
interval were counted, which allowed
the calculation of survival probability
(%) at each interval. The influence of
the restorative material on the fracture
strength (load step at which failure
occurred) was analyzed by using the
log-rank test (a¼.05). Differences were
localized by using pairwise post hoc
comparisons with the same test at a
significance level of .016 (Bonferroni
correction for 3 comparisons). The
postfatigue load-to-failure resistance of
the surviving specimens was compared
with the t test (data tested normal with
the Kolmogorov-Smirnov test). For all
statistical analyses, the level of signifi-
cance was set at 95%. The data
were analyzed with statistical software
(MedCalc Software).
RESULTS
During the fatigue test, the FEL
specimens started to fail at the 1000-N
step (Fig. 2). Only one FEL specimen
survived all 185 000 load cycles, but
multiple cracks were visible at the sur-
face of the restoration. The same
specimen fractured at 2500 N in the
load-to-failure test. The LD and RNC
crowns that survived the fatigue test did
not show any evidence of fractures and/
or cracks. The LD (93.3%) and RNC
(80%) groups demonstrated a signifi-
cantly higher survival rate after the fa-
tigue test than the FEL (6.6%) group
(P<.001). The survival of the molars
restored with LD and RNC was not
Carvalho et al
Survival %
60
40
LD
RNC
20 FEL
0
200 400 600
2 Life table survival distributions by materials at each load
step (n¼15).
Table I. Failure mode during fatigue testing
Repairable
Adhesive Adhesive
Failure D Failure D
Chip or Deep Chip
Cohesive Adhesive Crack in or Crack in
Material Failure Failure Dentin Dentin
FEL 1 3
LD - -
RNC - -
FEL, feldspathic glass ceramic; LD, lithium disilicate; RNC, resin nanoceramic.
significantly different (P¼.28). Different
failure modes were observed during the
fatigue test (Table I, Fig. 3A-E), but no
catastrophic failure occurred in the fa-
tigue test. Only small subgingival
delamination fractures and cracks,
especially in the FEL group, could be
observed (10 specimens). Average
postfatigue failure loads were 3237 N
for LD (14 specimens) and 3122 N for
RNC (12 specimens). The t test was
considered to compare the postfatigue
strength of those 2 materials and
indicated no significant differences
(P¼.339). All the crowns were loaded
until catastrophic failure (Table II).
After the fatigue test, the RNC
crowns demonstrated less wear at the
antagonist sphere than the LD or FEL
crowns. The opposite can be said about
the materials themselves because well-
defined wear facets could be seen at
the contact with the RNC specimens,
whereas contact areas in the LD and
800 1000 1200 1400
Load (N)
Possibly Repairable Not Repairable
Catastrophic
Failure
1 9 -
1 - -
1 2 -
FEL groups were barely noticeable once
the specimens had been cleaned. In the
LD group, the contact areas could be
detected because of the delamination
of the glaze material.
DISCUSSION
The null hypothesis, that no signifi-
cant difference would be found with
respect to fatigue resistance, failure
mode, or the wear of the antagonist
among the 3 materials used in this
study for complete molar crowns was
partially rejected. The results revealed
an increased fatigue resistance of pos-
terior crowns made of RNC and LD
glass ceramic as opposed to FEL glass
ceramic. RNC crowns also showed less
wear to the antagonist sphere than LD
and FEL crowns. Failure modes, how-
ever, were similar across materials
(re-restorable after the fatigue test,
catastrophic after load-to-failure test).
314 Volume 111 Issue 4

3 A, Cohesive failure. B, Adhesive failure. C, Adhesive failure and chip or crack dentin. D, Adhesive failure and deep chip or
crack dentin. E, Catastrophic failure.

The use of complete crown restora- invasive nature and the development of and occlusal veneers.13 Nevertheless, the
tions has significantly decreased as the sustainable noninvasive alternatives, complete crown is still a useful option
first treatment option because of their especially bonded inlays and/or onlays when replacing an existing complete

Table II. Failure mode after load-to-failure testing

Repairable Possibly Repairable Not Repairable
Adhesive Failure D Adhesive Failure D
Cohesive Adhesive Chip or crack Deep Chip or Catastrophic
Material Failure Failure dentin Crack Dentin Failure

FEL - - - - 1
LD - - - - 14
RNC - - - - 12

FEL, feldspathic glass ceramic; LD, lithium disilicate; RNC, resin nanoceramic.

The Journal of Prosthetic Dentistry Carvalho et al

April 2014
coverage restoration. In an effort to
standardize and approximate the clinical
situation as much as possible, natural
teeth of similar dimensions were
selected. The use of natural teeth was
appropriate because their modulus of
elasticity, bonding characteristics, and
strength characteristics better match the
clinical situation. The application of a
standardized occlusal surface by the
Cerec machine and a standardized load
configuration eliminated confounding
variables from the anatomy of natural
teeth and masticatory habits. A com-
posite resin sphere was preferred, rather
than stainless steel, to simulate the
antagonist tooth. The use of a compos-
ite resin sphere was previously suggested
by Magne and Knezevic18 and Kelly.28
The lower stiffness and higher wear of
the composite resin allow more realistic
simulation of tooth contacts20 and
antagonist enamel. The resin sphere
contacted the functional and nonfunc-
tional cusps in a position close to that
found clinically. None of the spheres
failed during the test. As in previous
studies,18,20,21 the periodontal ligament
was not simulated because the elasto-
mers or silicone films usually used for
this purpose show accelerated degrada-
tion; this would allow excessive
displacement of the tooth and would
destabilize the servohydraulic control
system.
All the crowns were cemented with
self-adhesive resin cement (Rely X Uni-
cem 2 Automix; 3M ESPE). This system
was developed with the rationale of
simplifying the cementation procedure
by eliminating the pretreatment step
that involves the tooth structure.
Because these systems do not require
any pretreatment on the tooth, the
immediate dentin-sealing technique or
a dentin-bonding agent was not used.
The instructions for the use of this
cement recommend only airborne-
particle abrasion and cleaning the
resin-based restoration surface before
cementation. Therefore, no ceramic
primer was used on RNC restoration
surfaces. This simplified delivery proto-
col was chosen because it is clinically
relevant, fast, and appreciated by
Carvalho et al
clinicians and approved by the block
manufacturers.
In the present study, the mean
fracture strength of FEL crowns was
1171 N, which lies within the range
reported in earlier studies.8,12 One FEL
specimen with a crack survived to 2500
N in the postfatigue load-to-failure test,
which indicates that fatigue-generated
cracks alone do not always compro-
mise the static load performance. The
flexural strength values for FEL were
150 MPa, for RNC >204 MPa, and for
LD 360 MPa (manufacturer informa-
tion). The inferior performance of FEL
is in agreement with various in-
vestigators8,11,18,19 and correlates with
its lower flexural strength compared
with the 2 other materials. By contrast,
the performance of RNC and LD
crowns was similar in spite of their
different flexural strength. This situation
can be explained by the elastic modulus
of the material. The work of fracture,
which is the energy required to create a
new surface in a propagating flaw, is
inversely related to the elastic modulus
of the material. In other words, the
similarity of LD and RNC may be
explained by the ratio between strength
and elastic modulus (both lower for
RNC than for LD). All the results must
be viewed in the overall context of the
masticatory forces of the human
dentition.
Maximum posterior masticatory
forces lie in the 600 to 900 N range.29
Mean fracture loads for FEL (1171 N),
RNC (1333 N), and LD (1400 N)
crowns in the present study exceeded
those values, which indicates that all 3
materials tested can be used for
cemented crown restorations in vital
teeth. The present study has a shorter
follow-up time than the human life-
time, and humans vary greatly in their
masticatory forces and habits. Howev-
er, particularly with patients with a high
load, it is more likely that LD or RNC
will survive. FEL may be used in such a
situation but would then require adhe-
sive luting to supplement its lower
strength. The positive outcome of the
fatigue test is not only the relatively high
fracture loads (despite the use of a
315
simplified cementation process) but
also the fact that all failures would have
been easily repairable (especially with
RNC). No intact tooth structure was
lost, and the tooth could have been
maintained. Even with the small dentin
fracture at the subgingival margin and
chipping, it is clinically feasible to
smoothen those margins or apply the
margin elevation technique when
needed30 and to re-restore. The high
load required to induce fracture can
explain nonrestorable catastrophic fail-
ure in the load-to-failure test. At those
levels of forces, the underlying tooth
structure yielded together with the
restorative material.
From a clinical perspective, RNC
presents with significant advantages
compared with the other materials. The
milling time is reduced, the material
induces less wear of the milling burs,
and more precise margins are antici-
pated because of the resin content.22
RNC also is polishable and does not
require firing. The clinical potential is
enhanced by the ease cementation (no
HF/silane required), occlusal adjust-
ment, and intraoral reparability. Finally,
observations from the present study
revealed that it appears wear friendly
to the antagonist cusp (LD and FEL
crowns demonstrated more wear at the
antagonist sphere when compared with
RNC). The opposite can be said about
the material wear because, once speci-
mens were cleaned, well-defined wear
facets could be seen at the contact with
the RNC specimens, whereas worn
contact areas in the LD and FEL speci-
mens were barely noticeable, which
agrees with the findings of Kunzelmann
et al,9 which show that resin-based
materials will themselves wear but will
not damage the antagonist. From these
observations, the wear resistance of
RNC may be less than that of the Z100
antagonist. This may be caused by the
slightly different ceramic filler content,
85 wt% versus 80 wt% in RNC.
The limitations of the study were the
water storage time and the direction of
the load application. Twenty-four hours
is a short time for storage before initi-
ating the test. Longer aging of the
316
restoration-cement-dentin bond before
mechanical fatigue might have had
considerable impact on observed failure
modes. Furthermore, the loads were
applied only axially. Lateral forces that
may occur clinically during clenching
were not simulated. Therefore, the
clinical implication of the results in this
study should be limited to the vertical
loading situation. Another limitation is
the use of the higher frequency (10-20
Hz) in the cyclic loading test, suggested
by Kelly et al,31 which facilitated the
experiment by allowing the testing of 3
specimens per day. However, such high
frequency may generate more heat than
1 to 2 Hz and may not give time for
stress relaxation.32 Another limiting
factor was the sample size. Only one LD
specimen failed during the fatigue pro-
cess, whereas 3 RNC specimens and 14
FEL specimens failed. Larger sample
sizes may be needed to distinguish be-
tween LD and RNC performance.
Further research should explore the
bondability of the new RNC and the
potential for adding contacts or
esthetic characterizations with light-
polymerized composite resin. No cor-
rections or esthetic characterization
were applied to the crowns in this
in vitro study. Clinical applications
require additional time to add contacts
or esthetic veneering to the monolithic
base. Although those modifications are
normally performed through the addi-
tional ceramic firing of LD or FEL, only
composite resin additions can be used
with RNC. Additional research also
should be performed with the same
testing protocol and materials but in
combination with adhesive luting pro-
cedures, possibly including the imme-
diate dentin sealing technique and the
use of a silane with RNC. Advanced
bonding may yield different results
because 1.2-mm-thick polymer-based
bonded occlusal veneers performed
better than LD in a recent study by
Magne et al.21 Finally, studies on
similar restorations of nonvital teeth are
under way, as endodontically treated
molars, because of their brittleness and
loss of structural integrity present a
large set of specific challenges.
The Journal of Prosthetic Dentistry
CONCLUSION
Within the limitations of this simu-
lated fatigue study, CAD/CAM crowns
placed with a simplified cementation
process and made of RNC or LD had sig-
nificantly higher fatigue resistance than
those made of FEL. All the materials
survived beyond the normal range of
masticatory forces, and all failures during
fatigue were possibly re-restorable (except
in the load-to failure test). The new RNC
features major clinical and practical ad-
vantages compared with LD (mill time,
mill bur usage, polishability, simplicity
of insertion, and reparability).
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317
Corresponding author:
Dr Adriana Oliveira Carvalho
Rua Professor Sabino Silva
965, apt 1003, Jardim Apipema
Salvador, BA, 40.155-250
BRAZIL
E-mail: aoc1981@hotmail.com
Copyright ª 2014 by the Editorial Council for
The Journal of Prosthetic Dentistry.

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