Journal of Dentistry 97 (2020) 103346

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Journal of Dentistry
journal homepage: www.elsevier.com/locate/jdent

Effect of preparation design on the fracture behavior of ceramic occlusal T

veneers in maxillary premolars
Xiaoqiong Huang1, Leiyan Zou1, Run Yao, Shuyi Wu*, Yan Li*
Hospital of Stomatology, Guanghua School of Stomatology, Guangdong Provincial Key Laboratory of Stomatology, Sun Yat-sen University, Guangzhou, People's Republic of
China

A R T I C LE I N FO A B S T R A C T

Keywords: Objectives: The fracture strengths of four types of occlusal veneers and a traditional full crown ceramic re-
Finite element analysis storation and the influence of preparation design on the stress of restorations were examined.
Fracture mode Methods: Forty intact maxillary premolars randomly divided into five groups were prepared based on the de-
Fracture strength mands of type O (occlusal surface coverage), OF (occlusal and lingual surface coverage), POF (occlusal, lingual,
Maximum principal stress
and mesial surface coverage), and POFP (occlusal, lingual, mesial, and distal surface coverage) veneers and full
Occlusal veneer
Preparation design
crown, and then restored by glass ceramic. Specimens were subjected to fracture resistance tests after cyclic
loading. The fracture strengths and modes were analyzed statistically. The level of significance was set at
α = 0.05. One maxillary premolar was prepared for type O, OF, POF, POFP veneer and full crown, and then
scanned to establish finite element models. The mean fracture load was applied vertically to calculate the
maximum principal stress on the ceramic.
Results: Type O veneer showed higher fracture strength than type POF and POFP veneers (P < 0.05). Both type
O and OF veneers exhibited higher fracture strength than full crown (P < 0.05). No significant difference in
failure mode was observed. The maximum principal stress for type O, OF, POF, POFP veneers, and full crown
increased progressively and concentrated at the bonding surface directly beneath the loading area.
Conclusions: Four types of occlusal veneer showed fracture strengths that considerably exceeded normal biting
forces. They represent conservative alternatives to full crowns and present a viable treatment for severely worn
teeth.
Clinical significance: The occlusal veneers with different preparation designs, including type O, OF, POF and
POFP veneers, show higher fracture resistances than traditional full coverage crowns that considerably exceed
the normal biting forces. Therefore, these represent conservative alternatives to crown restorations and present a
viable treatment for restoring severely worn teeth.

1. Introduction popular ceramic restoration materials, as they have high translucency

When teeth wear down or severely erode, the underlying dentin can
be exposed over time [1]. The preservation of the tooth structure is
critical in dentistry [2]. With the development of adhesive bonding
techniques, minimally invasive restorations have been extensively ex-
plored [3]. One type of minimally invasive preparation design for se-
verely worn teeth are occlusal veneers, which are non-retentive adhe-
sively retained restorations that completely cover the occlusal surface
[4,5].
Ceramic restorations are widely used in the anterior and posterior
regions of the dentition, and can meet both aesthetic and functional
demands [6–9]. Lithium disilicate glass ceramics are one of the most
as well as high mechanical and bonding strengths [4,10,11]. They are
commonly used for minimally invasive restorations of lost tooth
structure [12]. The pressable version (IPS e.max Press) can be used in a
monolithic form [11]. The use of this monolithic ceramic material has
been advocated for the restoration of worn teeth [13]. It shows a good
survival rate for the posterior teeth in clinical practice [8]. The survival
rate of lithium disilicate ceramic restorations is reported to be in the
range of 95–100%, with monolithic restorations exhibiting fewer
structural problems than layered restorations [14].
The extent of damage to severely worn teeth is irregular. Tooth wear
with extensive destruction can cause defects of the occlusal surface,
functional cusps, and even proximal surfaces [15]. To restore the

⁎
Corresponding authors.
E-mail addresses: huangxq36@mail2.sysu.edu.cn (X. Huang), zouly5@mail2.sysu.edu.cn (L. Zou), shuyiwu@21cn.com (S. Wu), liy8@mail.sysu.edu.cn (Y. Li).
1
These authors contributed equally to this work.

https://doi.org/10.1016/j.jdent.2020.103346
Received 12 December 2019; Received in revised form 27 March 2020; Accepted 15 April 2020
0300-5712/ © 2020 Elsevier Ltd. All rights reserved.
X. Huang, et al.
occlusal function and morphology of such defects, the preparation de-
signs of the occlusal veneers are modified [16,17]. According to the
coverage of the tooth surfaces, occlusal veneers can be innovatively
modified and divided into four different types: type O, type OF, type
POF, and type POFP, where O represents the occlusal surface; P re-
presents the proximal surfaces, including the mesial (when P presented
before O) and distal (when P presented after O) surfaces; and F re-
presents the axial wall where the functional cusp is located (hereinafter
referred to as the functional surface), i.e., the lingual surface of max-
illary posterior teeth or buccal surface of mandibular posterior teeth.
For the maxillary premolars in this study, F represents the lingual
surface. Therefore, type O veneers are used to restore occlusal defects;
type OF veneers are used to restore defects involving the occlusal and
lingual surfaces; type POF veneers are employed to restore defects in-
volving occlusal, lingual, and one of the proximal surfaces; and type
POFP veneers are used to restore defects involving the occlusal, lingual,
mesial, and distal surfaces. We suggested that all the occlusal veneers
named using the above “FOP” nomenclature collectively be called
functional veneers. Functional veneers refer to the adhesively-luted non-
retentive restoration that cover the occlusal contact surfaces of teeth
while exerting masticatoty function. Functional veneers includes but not
limited to occlusal veneers covering only the occlusal surface.
Nondestructive techniques such as finite element analysis (FEA), in
combination with fracture resistance tests, can better elucidate the
stresses inside restorations and their failure behavior [4,18,19]. How-
ever, no prior research has been conducted to investigate modified
occlusal veneers using a combination of these methods. These analyses
can eliminate clinical inter-subject variables such as different oral en-
vironments and loading conditions [20].
In the present study, type O, type OF, type POF, and type POFP
veneers were designed. The preparation designs were compared with
each other as well as with a conventional full-coverage crown [21]. To
evaluate the effect of the preparation design on the fracture behavior
and stress state of the ceramic occlusal veneers, in vitro fracture re-
sistance tests and FEA were conducted. The purpose of this study was to
evaluate the effect of preparation design on the fracture strengths and
fracture modes of maxillary premolars restored using monolithic li-
thium disilicate glass ceramics, as well as on the values and distribution
of maximum principal stresses within the restorations. The null hy-
pothesis was that no significant difference existed in the fracture re-
sistance among the five preparation designs.
2. Methods
2.1. Specimen collection
This study was approved by the ethics review committee of our
hospital. Informed consents for research use were obtained from the
patients who underwent maxillary premolar extraction for orthodontic
purpose. Forty-one intact human maxillary premolars with similar
crown dimensions were collected. The teeth were thoroughly cleaned to
remove external debris. Thereafter, the teeth were stored at 4 °C in
0.5% chloramine-T solution (Sigma-Aldrich Corp., St. Louis, MO, USA)
for approximately three months.
2.2. In vitro mechanical tests
2.2.1. Specimen preparation
All forty-one premolars were initially prepared to obtain semi
anatomic (cuspal angulation: approximately 20°) occlusal surfaces to
simulate the occlusal surfaces of fully-restored worn premolars [22].
Forty of these teeth were randomly divided into five groups (n = 8).
Each group was prepared using a different tooth preparation design, as
follows.
Preparation of teeth for type O veneer: The occlusal surface was
reduced to a thickness of 0.7–1.0 mm (0.7 mm at fissures and 1.0 mm at
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Journal of Dentistry 97 (2020) 103346
cusps).
Preparation of teeth for type OF veneer: The occlusal surface was
reduced as for the type O veneer. The lingual surface was reduced to a
thickness of 0.5–1.0 mm (0.5 mm at the shoulder and 1.0 mm at cusps),
and a 0.5-mm-thick marginal chamfer was prepared 1 mm above the
cemento-enamel junction (CEJ) on the lingual surface. The undercuts
on the axial walls were removed with a convergence angle of 6°.
Preparation of teeth for type POF veneer: The occlusal and lingual
surfaces were prepared as for the type OF veneer. The mesial surface
was reduced to a thickness of 0.5–1.0 mm, and a 0.5-mm-thick marginal
chamfer was prepared on the mesial surface in the same manner as the
chamfer on the lingual surface.
Preparation of teeth for type POFP veneer: The occlusal, lingual,
and mesial surfaces were prepared as for the type POF veneer. The
distal surface was reduced to a thickness of 0.5–1.0 mm, and a 0.5-mm-
thick marginal chamfer was prepared on the distal surface in the same
manner as the chamfers on the lingual and mesial surfaces.
Preparation of teeth for full-coverage crown: The occlusal, lingual,
mesial, and distal surfaces were prepared as for the type POFP veneer.
The buccal surface was reduced to a thickness of 0.5–1.0 mm, and 0.5-
mm-thick marginal chamfers were prepared on the buccal surface in the
same manner as the chamfers on the lingual, mesial, and distal surfaces.
All preparation procedures were performed by the same trained
operator using a high-speed handpiece (Kavo Dental GmbH, Biberach,
Germany) with copious water irrigation cooling using high-speed
round-ended tapered diamond burs (TR-62C ISO197/018, TR-21 ISO
197/016, TR-13F ISO198/018, TR-26EF ISO199/016, EX-21EF ISO
237/019, MANI Inc., Amagasaki, Hyōgo Prefecture, Japan). All dia-
mond burs were replaced after every five restorations. Two silicone
indexes (3M ESPE, St. Paul, Minnesota, USA) were obtained at the
buccal–lingual and mesial–distal directions to check the tooth reduc-
tion. The finishing line of the occlusal surface resulted in a butt-to-butt
margin. All edges were smoothed and rounded. A diagrammatic sketch
of the five different preparation designs is shown in Fig. 1.
All prepared teeth were embedded in an autopolymerizing epoxy
resin (Guangzhou Willsun Electronic Technology Co., Ltd, Guangdong,
China) up to 2.0 mm apical to the CEJ using a plastic tube with an
internal diameter of 14 mm.
2.2.2. Restoration fabrication
Impressions of the prepared teeth were made with a single-step,
two-phase technique using silicone impression materials (3M ESPE, St.
Paul, Minnesota, USA). The impression materials were mixed according
to the manufacturer’s instructions. The master dies were fabricated with
a die stone. The restorations were fabricated from lithium disilicate
glass ceramic (IPS e.max Press, Ivoclar Vivadent, Schaan, Liechtenstein)
by a master dental laboratory technician according to the manu-
facturer’s recommendations. The restoration thicknesses for all groups
were uniform, with 0.5–1.0 mm on the axial walls and 0.7–1.0 mm on
the occlusal surface. The thicknesses were checked with a digital ca-
liper.
2.2.3. Restoration bonding
Each restoration was ultrasonically cleaned and inspected for de-
fects and assessed for proper fit. Hydrofluoric acid (5%; IPS Ceramic
Etching Gel, Ivoclar Vivadent, Schaan, Liechtenstein) was applied to the
bonding surface of the restorations for 20 s and then rinsed and dried.
The prepared tooth surfaces were etched with 37.5% phosphoric acid
(Kulzer GmbH Leipziger Straße 263450 Hanau, Germany) for 15 s,
rinsed thoroughly, and dried. Monobond N Universal Primer (Ivoclar
Vivadent, Schaan, Liechtenstein) was applied to the etched surface and
dried. Both the internal surface of the restoration and the prepared
tooth were covered with an adhesive (Single Bond Universal Adhesive,
3M EPSM, St. Paul, Minnesota, USA). Cementation was performed using
light-cured resin cement (RelyX Veneer, 3M EPSM, St. Paul, Minnesota)
according to the manufacturer’s recommendation. The cement was
X. Huang, et al.
Fig. 1. Diagrammatic sketches of different tooth preparation designs: (A) Preparation of teeth for type O veneer; (B) Preparation of teeth for type OF veneer; (C)
Preparation of teeth for type POF veneer; (D) Preparation of teeth for type POFP veneer; (E) Preparation of teeth for full-coverage crown.
applied on the bonding surface of the restoration and seated on its re-
spective prepared tooth under 6 N load for 5 min. Each surface of the
restoration was light-cured for 20 s using Elipar™ S10 Curing Light (3M
ESPE, St. Paul, Minnesota, USA). The excess marginal resin cement was
removed.
The specimens were stored in distilled water at 37 °C for 90 d before
further testing.
2.2.4. Fracture resistance tests
All 40 specimens were subjected to 20,000 cycles of compressive
load on the occlusal surface with a load of 100 N and frequency of 2 Hz
in distilled water bath at room temperature using a universal testing
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Journal of Dentistry 97 (2020) 103346
machine (Instron E3000, Instron Ltd., Norwood, Massachusetts, USA)
(Fig. 2). The load was applied parallel to the long axis of the tooth using
a stainless-steel indenter with a diameter of 4 mm. The indenter was
positioned to simultaneously contact both the buccal and lingual cusps
surrounding the central fossa of the restoration. Tin foil with a thickness
of 0.2 mm was applied between the restorations and the indenter to
minimize the stress concentration and simulate a food layer.
The specimens were then subjected to compressive load until frac-
ture using the universal testing machine with the same indenter at a
crosshead speed of 0.5 mm/min. Tin foil was used as in the cyclic
loading tests (Fig. 2). The specimens were vertically loaded until frac-
ture, and the maximum load to fracture was recorded in Newtons (N).
X. Huang, et al. Journal of Dentistry 97 (2020) 103346

Fig. 2. Experimental set-up for the in vitro mechanical test of a restored premolar.

Fig. 3. Exploded views of the five tested solid models for FEA: (A) Mod O corresponds to type O veneer-restored tooth assembly; (B) Mod OF corresponds to type OF
veneer-restored tooth assembly; (C) Mod POF corresponds to type POF veneer-restored tooth assembly; (D) Mod POFP corresponds to type POFP veneer-restored
tooth assembly; (E) Mod crown corresponds to full-coverage crown-restored tooth assembly.

Table 1
Mechanical properties of the materials used in FEA.
Material Young’s modulus (MPa) Poisson’s ratio References

Enamel 84,100 0.30 Dejak and Mlotkowski, 2015 [27]

Dentin 18,600 0.30 Dejak and Mlotkowski, 2015 [27]
Tin foil 68,971 0.33 Sciammarella et al., 2013 [28]
Indenter (structural steel) 200,000 0.30 ANSYS database
Periodontal ligament 68.9 0.45 Celebi et al., 2017 [29]
Spongious bone 1370 0.30 Celebi et al., 2017 [29]
Cortical bone 13,700 0.30 Celebi et al., 2017 [29]
Resin cement 8300 0.35 Nakamura et al., 2010 [30]
IPS e.max Press 95,000 0.23 Manufacturer’s data

4
X. Huang, et al.
Fig. 4. Schematic diagram of the finite element model with a vertical load
applied to the restored tooth through the indenter (considering the full-cov-
erage crown model as an example).
Fig. 5. Average fracture load of each group. The error bars represent one
standard deviation (SD). The asterisks (*) indicate statistical differences be-
tween the groups (P < 0.05).
The specimens were examined for the evidence of cracks, adhesive
failures, or cohesive failures [23]. The fracture surfaces were examined
under a stereomicroscope (MZ10F, Leica, Heerbrugg, Germany), and
the failure mode of each specimen was determined according to the
following classification system [24]: (I) extensive crack formation
within the ceramic; (II) cohesive fracture within the ceramic not
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Journal of Dentistry 97 (2020) 103346
involving the tooth structure; (III) fracture within the ceramic and tooth
structure above the CEJ; and (IV) catastrophic fracture of the ceramic
and tooth structure below the CEJ.
Fractographic analysis of the fracture surfaces was performed with
scanning electron microscopy (SEM, Zeiss Sigma 300, Carl Zeiss
Microscopy GmbH, Jena, Germany). Representative specimen was gold
sputtered and the fracture surface was examined under SEM magnifi-
cation to confirm the location of failure origin.
2.2.5. Statistical analysis
All data were analyzed with SPSS Statistics 22.0 (IBM Corp,
Chicago, IL, USA). The data for the fracture strengths passed the
Shapiro–Wilk normality test (P = 0.288) and equal variances test
(P = 0.128), and were evaluated using one-way analysis of variance
(ANOVA). Multiple pair-wise comparison of means was performed by
Tukey's post-hoc test. Statistical analyses on the fracture modes among
the preparation designs were evaluated using the Fisher exact prob-
ability test. The level of significance was set at α = 0.05.
2.3. Finite element analysis
The prepared premolar was selected for FEA modeling. The tooth
was scanned using micro-computed tomography (micro-CT; μCT50,
SCANCO Medical AG, Bassersdorf, Switzerland) at each stage of the
preparation process described in Section 2.2.1 (i.e., at the initial pre-
paration, type O, type OF, type POF, type POFP, and full-crown cov-
erage stages). Micro-CT was performed with a voxel dimension of
15.8 μm and an operating voltage of 70 kV. A silicone rubber base was
used to ensure that the premolar was scanned at the same position each
time.
The micro-CT images were processed using an interactive medical
image control system (Mimics 16.0, Materialise, Leuven, Belgium). The
enamel and dentin were identified and separated based on their dif-
ferent threshold ranges. The pulp was generated as empty space. Each
part was converted into stereolithography files and then further pro-
cessed with Geomagic Studio 2013 (Geomagic GmbH, Stuttgart,
Germany). The restorations were designed to occupy the space between
the external surface of the tooth after the initial preparation and the
external surface after the veneer or crown preparation, and were gen-
erated through the Boolean operation. Perfect congruence of the in-
terface was established.
The modeled objects were processed using Solidworks 2017
(SolidWorks Corp., Concord, Massachusetts, USA). Then, the resin ce-
ment layer (thickness: 0.05 mm) was built between the prepared sur-
face of the tooth and the bonding surface of the restoration. Periodontal
ligament (PDL; thickness: 0.2 mm) and tin foil (thickness: 0.2 mm) were
built around the tooth model. Finally, the surrounding bone was
modeled as a cylinder (diameter: 16 mm) based on the PDL geometry,
with 2-mm-thick cortical bone and 13-mm-thick spongious bone. The
indenter was modeled as a semisphere with a diameter of 4 mm to si-
mulate the indenter used in the fracture resistance tests.
The type O, type OF, type POF, and type POFP veneer-restored tooth
assemblies were assigned as Mod O, Mod OF, Mod POF, and Mod POFP,
and the full-coverage crown-restored tooth assembly was assigned as
Mod crown. Exploded views of these five test models are shown in
Fig. 3.
Solid models were imported into ANSYS 17.0 Workbench (ANSYS,
Canonsburg, PA, USA) for mesh generation and FEA. All models con-
sisted of tetrahedral elements. The accuracies and efficiencies of the
five models were confirmed by convergence tests [25,26].
All materials were assumed to be homogeneous, linear, elastic, and
isotropic. The Young’s modulus and Poisson’s ratio are listed in Table 1
[27–30]. The external surface of the surrounding bone was fixed in all
directions, and the indenter was restricted to movement along the z-axis
as a boundary condition. The indenter contacted both the buccal and
lingual cusps of the restored teeth through the 0.2-mm-thick piece of tin
X. Huang, et al. Journal of Dentistry 97 (2020) 103346

Fig. 6. Specimens with representative fracture modes under a stereomicroscope: (A) Mode I: Extensive crack formation within the ceramic; (B) Mode II: Cohesive
fracture within the ceramic without involving the tooth structure; (C) Mode III: Fracture within the ceramic and tooth structure above the CEJ; (D) Mode IV:
Catastrophic fracture of the ceramic and tooth structure below the CEJ.

Table 2 foil. Surface-to-surface sliding contact without separation was defined

Distribution of the fracture modes per preparation design. between the indenter and tin foil layer. Other interfaces were assumed
Preparation design Number of Percentage per failure mode (%)
to be completely bonded. The average value of the maximum load to
specimens fracture from the in vitro tests was then applied to the flat plane of the
Mode I Mode II Mode III Mode IV indenter along the center axis. (Fig. 4).
To evaluate the results of the FEA, the maximum principal stress
Type O veneer 8 0 62.5 25 12.5
Type OF veneer 8 0 62.5 0 37.5
was selected as the stress component responsible for the failure of the
Type POF veneer 8 12.5 75 0 12.5 brittle materials [31]. The maximum principal stress on the restoration
Type POFP veneer 8 0 75 0 25 was determined (MPa), and the stress distribution was presented as a
Full-coverage 8 0 100 0 0 cloud atlas.
crown
Total 40 2.5 75 5 17.5

Fig. 7. Fractographic analysis under scanning electron microscopy (SEM). (A) The SEM view at 35x shows the fracture surface of the representative specimen with
Mode II fracture. The black rectangle in (A) represents (B); (B) The SEM view at 100x and the black rectangle in (B) represents (C); (C) The SEM view at 200× shows
the approximate location of fracture origin (red arrow) and the direction of crack propagation (white arrows). (For interpretation of the references to colour in this
figure legend, the reader is referred to the web version of this article).

6
X. Huang, et al.
Fig. 8. Finite element models of the five 3D solid models with mesh configurations: (A) Mod O; (B) Mod OF; (C) Mod POF; (D) Mod POFP; (E) Mod crown.
Table 3
Numbers of nodes and elements in the FEA models.
Models with different preparation designs Nodes Elements
Mod O 1,575,340 1,110,121
Mod OF 1,580,343 1,112,607
Mod POF 1,582,550 1,114,075
Mod POFP 1,584,356 1,114,767
Mod crown 1,584,915 1,115,655
3. Results
3.1. In vitro tests
All specimens survived without fracture for the 20,000 cycles of
mechanical loading. The mean fracture load for all specimens was
1743.52 ± 425.78 N. The fracture loads of type O, type OF, type POF,
and type POFP veneers were 2153.54 ± 405.68, 1998.99 ± 432.43,
1596.57 ± 208.48, and 1540.04 ± 364.81 N, respectively, and that of
the full-coverage crown was 1428.43 ± 172.37 N.
One-way ANOVA tests showed that there were significant differ-
ences among the groups (P = 0.0003). The statistical power of one-way
ANOVA was 0.98. Post hoc Tukey tests demonstrated that type O ve-
neer had a significantly higher fracture load than type POF (P = 0.016)
and type POFP veneers (P = 0.007) as well as that of the full crown
(P = 0.001). Additionally, the type OF veneer had a considerably
higher fracture load than the crown (P = 0.013). No significant dif-
ferences were found between the other groups. The results are shown in
Fig. 5.
After the cyclic loading tests, the teeth were subjected to compres-
sive load until fracture. Four main fracture modes were observed under
a stereomicroscope, which are presented in Fig. 6. The number of
specimens that failed by each mode are given in Table 2. Seventy-five
percent of the failures across all groups were of mode II. Hence, the
specimens predominantly fail because of cohesive fracture within the
ceramic. No significant differences were observed in the fracture modes
among the five groups (P = 0.245).
The SEM view in Fig. 7 showed that the fracture origin was located
at the bonding surface of the lithium disilicate glass ceramics.
3.2. Finite element analysis
Five basic finite element models were established. Convergence
tests were performed, and the accuracies and efficiencies of the nu-
merical simulations were confirmed (Fig. 8). The number of elements
and nodes in each model are listed in Table 3.
The average value of the fracture loads of all specimens from the
fracture resistance tests (1743.52 N) was applied to the models along
the long axis of the tooth via the indenter (Fig. 4). The maximum
principal stresses in the restorations under the compressive load were
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Journal of Dentistry 97 (2020) 103346
calculated. The peak values for the type O, OF, POF, and POFP veneers
were 346.59, 379.35, 389.57, and 444.97 MPa, respectively, and that
for the full-coverage crown was 453.83 MPa. The results show that the
maximum principal stress increased with an increase in the invasive-
ness of the preparation design. The type O veneer exhibited the lowest
stress among the five preparation designs, whereas the full-coverage
crown showed the highest stress.
For all models, the maximum principal stresses were concentrated
at the bonding surface directly beneath the loading area (Figs. 9 and
10). The maximum principal stress at the lingual cusps was slightly
higher than the stress at the buccal cusps. The area of stress con-
centration corresponded to the area where the majority of the fractures
originated in the clinically failed restorations. The sagittal cross-section
views of the ceramic restorations with different preparation designs are
shown in Fig. 10. The inferred fracture origin and the direction of crack
propagation are marked using red and black arrows in Fig. 10D.
Combined with the fractographic analysis under SEM, it can be inferred
with certainty that the fractures originated at the bonding surface di-
rectly beneath the loading area.
4. Discussion
Four different non-retentive occlusal veneer preparation designs
(type O, type OF, type POF, and type POFP veneers) were successfully
fabricated and modeled alongside a full-coverage crown. The results of
fracture resistance tests and FEA for the different designs were com-
pared to support their clinical implementation. The null hypothesis that
no significant difference exists in the fracture resistances among the five
prepared designs can be rejected. Furthermore, the outcome of the
retrospective power calculation for the one-way ANOVA was satisfac-
tory. The type O veneer, which covered just the occlusal surface, ex-
hibited the highest fracture load and lowest maximum principal stress.
Then, as the number of restored axial walls increased, the fracture re-
sistance decreased, and the maximum principle stress in the restoration
increased. All of the four different types of veneers showed better
performance than the full-coverage crown during the compressive
loading tests.
These results demonstrate the initial feasibility of minimally in-
vasive treatments for restoring the occlusal and/or functional surfaces
and the proximal surfaces of severely worn teeth. Maximum preserva-
tion of the tooth structure and use of restorative materials with me-
chanical properties similar to those of the tooth structure (in this case,
lithium disilicate glass ceramic) can promote longevity of the teeth and
restorations [19]. Clinically, the normal biting force is 222–445 N for
the maxillary premolar area. During clenching, the occlusal force
reaches approximately 800 N [32,33]. Considering that the mean
fracture load for each group (1428–2154 N) was higher than the normal
human biting force and even higher than the force related to tooth
clenching, a good clinical performance by type O, OF, POF, and POFP
veneers can be expected.
X. Huang, et al. Journal of Dentistry 97 (2020) 103346

Fig. 9. Cloud atlas of the maximum principal stress (MPa) on the occlusal surface and bonding surface of type O veneer, type OF veneer, type POF veneer, type POFP
veneer and full-coverage crown.

After fracture resistance tests, the fracture surfaces were examined
under a stereomicroscope. The fracture modes of the specimens could
be classified into four modes [24,34], with the majority of specimens
(in all the tested groups) demonstrating Mode II failure, i.e., cohesive
fracture within the ceramic without involving the tooth structure. This
is because the tensile stresses mainly concentrate in the brittle ceramic
material, resulting in cohesive fracture of the ceramic [35]. These re-
sults suggest that ceramic occlusal veneers can protect restored teeth
from human masticatory forces. However, it should be noted that the in
vitro and FEA tests in this study employed simplified loading conditions.

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X. Huang, et al. Journal of Dentistry 97 (2020) 103346

Fig. 10. Cloud atlas of maximum principal stress (MPa) on the sagittal cross-section views of the ceramic restorations with different preparation designs. (A) Mod O;
(B) Mod OF; (C) Mod POF; (D) The close-up view in the black rectangle in (C) shows the fracture origin (red arrow) and the inferred direction of crack propagation
(black arrows); (E) Mod POFP; (F) Mod crown. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this
article).

Fracture resistance tests are important to analyze tooth behavior
under high intensity loading [16]. However, information regarding the
internal behavior of tooth-restoration complexes, such as the internal
stress state, cannot be obtained from these tests. Therefore, non-
destructive methodologies such as FEA should be conducted in com-
bination with destructive testing to obtain important data that can fa-
cilitate improvement of the restorative processes [19].
For the FEA, five solid models with different preparation designs
were built from the same premolar; therefore, the external structures of
the models were identical. The average fracture load obtained from
fracture resistance tests was applied to every model via a semispherical
indenter. These factors ensured comparability between the models. The
maximum principal stress increased as the number of prepared axial
walls increased. The type O veneer exhibited the lowest maximum
principal stress, whereas the full crown showed the highest maximum
principal stress. Hence, more invasive preparation of the axial walls can
lead to higher tensile stresses within the ceramic restoration. Soares
et al. [36] also confirmed that greater removal of the tooth structure
accentuated the concentration of stress.
Fractographic analyses are generally used to reveal the direction of
crack propagation and identify fracture origin in fracture resistance
tests. In the present study, the SEM images showed the details of the
fracture surface and indicated that the fracture originated at the
bonding surface of the ceramic restorations. Lithium disilicate glass
ceramics are fractographic “unfriendly” ceramics; they are difficult to
analyze precisely under SEM because the crystalline content is very
high [37]. It is possible to predict the fracture origin of brittle materials
from the distribution of maximum principal stress [31].
The stresses were concentrated on the occlusal portion and not on
the axial walls of the restorations (Fig. 9), with the peak values of
maximum principal stress located at the bonding surface directly be-
neath the loading area. High stress values at the interface can also be
attributed to the mismatch of Young’s moduli between the different
materials [38].
Based on the combined analyses of the fractographic analysis under
SEM and the stress distribution of FEA, it can be inferred that the
fracture originated at the bonding surface directly beneath the loading
area. The results were consistent with the study of Mores et al. [39]. He
found that, in anatomic crown-like restorations, compressive stresses
were concentrated at the loading area under the indenter, and tensile
stresses were concentrated at the internal surface directly beneath the
loading area; the areas of concentrated tensile stress corresponded to
the fracture origin in the failed crowns [39].
There are several limitations to this study. Sasse et al. [4]

9
X. Huang, et al.
recommended a thickness of 0.7–1.0 mm for non-retentive adhesively
retained occlusal ceramic restorations. However, it was difficult to ac-
curately control the thickness of the pressable lithium disilicate glass
ceramic. Particular attention was paid to maintain the ceramic thick-
ness using silicone impressions, wax, and digital calipers [24]. Never-
theless, Johnson et al. [16] reported that no significant differences
existed in fracture resistances of occlusal veneers with different thick-
nesses (0.3, 0.6, and 1.0 mm).
The fatigue set-up in this study was selected to accelerate the aging
process. Mechanical cycling at a load of 100 N was selected to represent
the average physiologic masticatory forces [40]. A total of 1,200,000
cycles are often used to simulate a service time of five years [40,41]. In
the present study, 20,000 dynamic loading cycles were selected to re-
duce the operation and evaluation time [42]. No fractures or cracks
were observed in any of the specimens after cyclic loading. The re-
storations were loaded vertically at the center of the occlusal surface
through a spherical load indenter, which oversimplifies the actual
loading conditions during functional and parafunctional mastication
[16]. Hence, these set-ups do not completely reproduce the clinical
situation. In the future, well-designed clinical studies are needed to
predict the long-term clinical performances of the occlusal veneers.
We focused on different types of veneers for maxillary premolars. In
the future, we should also study the failure behavior of teeth in other
positions. Thus, a more minimally invasive and personalized treatment
scheme for patients with severely worn teeth requiring occlusal re-
construction of complete dentition can be developed.
5. Conclusions
Within the limitations of this study, the following conclusions are
drawn.
1 The maximum fracture loads for the type O, OF, POF, and POFP
veneers, as well as the full-coverage crown are higher than human
masticatory forces.
2 The preparation design significantly affects the fracture strength of
the occlusal veneer. As the number of prepared axial walls in-
creased, the fracture strengths of the restorations decreased.
3 The maximum principal stresses increased as the number of pre-
pared axial walls increased, with the highest stresses observed for
the full-coverage crown, and the lowest for the type O veneer.
Therefore, minimally invasive preparation is recommended.
Clinical research on the long-term survival rates of type O, OF, POF,
and POFP veneers is needed.
CRediT authorship contribution statement
Xiaoqiong Huang: Methodology, Software, Formal analysis,
Writing - original draft, Writing - review & editing. Leiyan Zou:
Methodology, Resources, Data curation, Writing - review & editing.
Run Yao: Software, Investigation, Writing - review & editing,
Visualization. Shuyi Wu: Validation, Writing - review & editing,
Supervision, Funding acquisition. Yan Li: Conceptualization, Writing -
review & editing, Project administration, Funding acquisition.
Declaration of Competing Interest
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influ-
ence the work reported in this paper.
Acknowledgements
This work was supported by the Sun Yat-sen University Clinical
10
Journal of Dentistry 97 (2020) 103346
Research 5010 Programme (Grant number: 2016006) and Guangdong
Financial Fund for High-Caliber Hospital Construction (Grant number:
174-2018-XMZC-0001-03-0125/D-19). The authors thank Mr. Yaxiong
Yin, a master dental laboratory technician, for his help with the re-
storation fabricating process.
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