Influence of Preparation Depth and Design on Stress

Distribution in Maxillary Central Incisors Restored with

Ceramic Veneers: A 3D Finite Element Analysis
Alexandros Tsouknidas,3 Eleni Karaoglani,1 Nikolaos Michailidis,4 Dimitris Kugiumtzis,5 Argiris Pissiotis,1
& Konstantinos Michalakis 1,2
1
Department of Prosthodontics, Aristotle University School of Dentistry, Thessaloniki, Greece
2
Department of Prosthodontics, Tufts University, 1 Kneeland St., Boston, MA
3
Department of Mechanical Engineering, University of Western Macedonia, Kozani, Greece
4
Mechanical Engineering, Aristotle University of Thessaloniki, Thessaloniki, Greece
5
Electrical and Computer Engineering, Aristotle University of Thessaloniki, Thessaloniki, Greece

Keywords
Veneers; ceramics; preparation; FEA; margin
design.
Correspondence
Konstantinos Michalakis, Aristotle University
of Thessaloniki – Prosthodontics University
Campus, Thessaloniki 54124, Greece; Tufts
University – Graduate Prosthodontics, 1
Kneeland St., Boston, MA 02111. E-mail:
kmichalakis@hotmail.com
The authors deny any conflicts of interest in
regards to this study.
Accepted October 8, 2019
doi: 10.1111/jopr.13121
Abstract
Purpose: To evaluate the influence of different preparation designs and depths on the
stress field developed in maxillary central incisors restored with veneers made with
different ceramic materials using finite element analysis (FEA).
Materials and Methods: A linear static three-dimensional finite element analysis
model was used with the aid of reverse engineering to develop digital models of
maxillary central incisors restored with ceramic veneers, according to two different
preparation depths (thin vs deep) and two different preparation designs (feather edge
vs butt joint). Three ceramic systems were tested: (i) feldspathic porcelain, (ii) heat
pressed glass ceramic IPS Empress 2 (Ivoclar Vivadent AG), and (iii) heat pressed
glass ceramic IPS e.max-Press (Ivoclar Vivadent AG). Each model was subjected to a
compressive force of 200N applied to the palatal surface 2 mm below the incisal edge.
The longitudinal axis of the restored tooth formed an angle of 130o with the direction
of the force. The biomechanical behavior of the different models was examined
according to the von Mises stress criterion. Statistical analysis was performed using
nonparametric confidence interval estimation using bootstrapping.
Results: The maximum observed stress values were calculated and found to be similar
between prepared and intact teeth. The cervical margin of the veneers displayed the
highest von Mises stress values. Irrespectively of the depth and preparation design,
the biggest von Mises stress values were observed at the veneer structures with
the following order: (i) IPS Empress 2, (ii) IPS e.max-Press, (iii) feldspathic (p =
0.001). Preparation depth resulted in statistically significant differences (p = 0.001)
in the stress distribution in the majority of tested structures. As the preparation depth
was increased, the stresses within the veneer structure and the tooth structures were
decreased. No statistically significant differences were detected in the stresses among
the different restored models, when the preparation design was considered.
Conclusions: This FEA study suggests that ceramic veneers could restore the biome-
chanical behavior of prepared central incisors and made it similar of that of an intact
tooth. Regardless of the preparation depth and design and the ceramic system used,
the cervical margin of ceramic veneers presents the highest von Mises stress values.
When feldspathic porcelain was compared with lithium disilicate (IPS e.max Press),
the latter displayed the lowest transfer of stresses to dental tissues. An increase in
preparation depth resulted in a statistically significant stress decrease in both the
veneer and the tooth.

Journal of Prosthodontics 29 (2020) 151–160 

C 2019 by the American College of Prosthodontists 151

Veneer Thickness and Design on Stress Distribution
Several preparation designs and depths for ceramic veneers
have been described in the literature, without considering their
impact on the biomechanical behavior of the tooth. Ideally, any
prosthesis should restore the tooth’s lost mechanical properties.
This is vitally important and is often related to the amount of
sound tooth reduction by the clinician.2 Other parameters that
have to be taken into account are ceramic fracture, microleak-
age, and restoration debonding.3-5
Two types of ceramic materials are typically used for ceramic
veneers, due to their translucency and potential to be used in
small thicknesses: (i) feldspathic porcelain, and (ii) heat pressed
glass ceramic. CAD-CAM products may also be used for that
purpose.6 The traditional feldspathic porcelain is susceptible to
fracture under mechanical stress, due to high glass contents.1
Nevertheless, feldspathic porcelains have been used for many
years as they offer natural appearance and adequate strength
after bonding to teeth.7-11 Later on, reinforced lithium disilicate
ceramics with or without ZrO2 have been employed for veneers
due to their enhanced mechanical properties.12-16
Although several types of preparation designs have been ad-
vocated in the literature, two of them are used more often, as
they present more advantages. These are: (1) the “feather edge
preparation”, which prepares minimally the labial surface up
to the incisal edge and (2) the “incisal overlap preparation”,
which involves reduction of the incisal edge. The latter can
be further divided into 2 categories, depending on the margin
configuration of the incisal area: (a) palatal chamfer, and (b)
flat incisal reduction (butt joint).17-19 The longevity of ceramic
veneers does not depend solely on the materials used. Previous
research has shown that the preparation design may influence
the final result as well.20-27
Another important factor for the clinical success of ceramic
laminate veneers (CLV) is the proper selection of prepara-
tion depth.28 These can be grouped as “minimal” (0.3 mm),
“medium” (0.6 mm), and “deep” (0.9 mm). A prerequisite in
all preparations is that enamel is present to guarantee a suc-
cessful bonding of the veneer. When the shade of the tooth
to be restored has a difference of1 shade from the proposed
definitive CLV restoration, a “minimal” preparation is required.
When there is a difference of 2 or 3 shades from the proposed
definitive CLV restoration, a "medium" preparation is required.
The “deep” preparation is required when the shade of the tooth
to be restored differs more than 3 shades from the proposed
definitive CLV restoration.29 However, regardless of patient’s
esthetic expectations, a 50% to 70% of the enamel surface
should be available for the etching procedure, as this enhances
the adhesion of the ceramic veneer.30
To date, no 3D-FEA examined the effect of different prepa-
ration designs, preparation depths and different ceramic ma-
terials on the biomechanical behavior of maxillary central
incisors.31-38 The simultaneous interaction of multiple vari-
ables affecting the mechanical behavior of a restoration can
be studied by means of simulation in a computerized model, as
3D-FEA has been proven to be one of the most powerful and
effective tools for that purpose.39,40 The aim of this study was to
assess the influence of different preparation designs and depths
on the mechanical behavior of anterior laminate veneers by
means of 3D-FEA. Three different restorative materials were
considered. Additionally, incisors restored with porcelain ve-
152 Journal of Prosthodontics 29 (2020) 151–160 
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Tsouknidas et al
neers were compared with the natural intact tooth (control).34,35
The null hypotheses were: (a) there is no difference between
feldspathic porcelain, IPS Empress 2, and IPS e.max Press heat
pressed glass ceramics in stress distribution, (b) there is no dif-
ference between “deep” and “minimal” preparation depths in
stress distribution and (c) there is no difference between butt
joint and feather-edge preparation designs in stress distribution.
Materials and methods
The solid model consisted of a maxillary central incisor, with
the periodontal ligament (PDL) and the corresponding alveolar
bone process. The 3D solid model of the incisor was generated
using data from a micro Computed Tomography (µCT) device
with a 5 µm focal spot (Werth TomoScope R
HV Compact- 225
3D CNC). An extracted human maxillary incisor was, to this
end, scanned at a 200 L magnification, resulting in a voxel size
of a 200 µm (IRB approval number: 02/26-09-2016) (Fig 1).
The intensity of the X-ray source was set to 500 µA, at a
120kV frequency, leading to an X-ray power of 60 W. The
dataset of the CT images was recorded over a 100ms exposure
time, for a 360° rotation of the incisor. A total of 1600 rotational
steps (at 4 radiographic images per step) ensured a high-quality
3D reconstruction of the incisor’s geometry. The geometric
characteristics of the incisor were then adjusted to average
values found in literature.41-43 The geometries of the sound
model, the veneer-restored models were finalized and meshed
in the computing environment of ANSA (15.2.3; BETA CAE
Systems S.A.). An average thickness of 0.2 mm of periodontal
ligament was assumed around the root surface.44 The average
anatomical dimensions of the bone were generated according
to the literature.45-48 The maxillary bone was modeled as a
cancellous core surrounded by 1.0 mm thick cortical bone.45
The buccolingual and anteroposterior dimensions of bone at the
root apex level were 7.3 mm and 13 mm, respectively.46 The
labial bone thickness at cervical, midroot, and apical locations
were 0.92 mm, 0.89 mm, and 1.57mm, respectively.47 Similarly,
the palatal bone thicknesses at cervical, midroot, and apical
locations were 1.7 mm, 3.4 mm, and 6.03 mm, respectively.48
The distance from the cementoenamel junction (CEJ) to the
crest of the bone was 1.07 mm.49
Following the intact incisor’s basic model, a second mod-
elling step was performed to obtain the veneer restored incisor
volumes. These models consisted of four main volumes: the
enamel, the dentin, the pulp and the veneer structures, accord-
ing to the different preparation designs, i.e. (i) feather-edge and,
(ii) butt joint(Fig 2).Two different preparation depths were also
considered: (i) minimal preparation: 0.3 mm in cervical and
middle 1/3rds and 0.4 mm in incisal 1/3rd, (ii) deep prepara-
tion: 0.4 mm in cervical 1/3rd and 0.9 mm in middle and incisal
1/3rds. For the models with the butt joint preparation an incisal
reduction of 1 mm was conducted. The cervical margin was
placed 1 mm coronal to the CEJ.50 Therefore, four basic finite
element enamel volumes geometrically configured were estab-
lished, according to two different preparation depths and de-
signs. The veneer restored incisor models were meshed with the
same number and size of elements of the sound incisor volume,
since the two models were equal in overall volumes summa-
tion. For every model structure convergence studies (2%) were
C 2019 by the American College of Prosthodontists

Tsouknidas et al
Figure 1 µCT principle employed in the reverse engineering process
and resultant 3D model.
Figure 2 3D structures considered during the simulations, with details
of mesh density and loading direction.
Figure 3 Characteristic stress distribution of the model at maximum
load for a restoration with minimal preparation (thin veneer) and Empress
2 material. (A) External and (B) cross-sectional view.
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Veneer Thickness and Design on Stress Distribution
conducted in order to determine the optimum size of elements
and mesh density. The element size was set at 0.2 mm, while the
number of elements for the different structures ranged between
1951 and 193,232 (Table 1). The final 3D FE model consisted of
322,865 tetrahedral elements in total, considerably higher than
previous studies reporting on similar subjects.51 As cement
layer has a thickness of 25 to 30 µm the optimal element size
for that structure was determined to be 0.007 mm, thus creating
a problematic interface with the veneer and the tooth structures
due to the big difference in element size. Use of an aspect ra-
tio allowing the simulation of the 3 structures (cement layer
with small elements and tooth and veneer structures with con-
siderably larger elements), would require skewness values that
would lead to element collapse during the subsequent analysis.
Furthermore, previous research has shown that the deformation
of the veneer did not affect the stress distribution either in the
cement layer of in the adhesive layers.46
Three ceramic systems were tested: (i) feldspathic porcelain,
(ii) heat pressed glass ceramic IPS Empress 2, and (iii) heat
pressed glass ceramic IPS emax-Press. The possible combina-
tions of the three independent variables are depicted in Table 2.
The following assumptions were adopted: (i) full bonding
between the veneer and tooth,52,53 (ii) “tied” restriction type
between the tooth structure and periodontal ligament, (iii) lin-
ear elastic behavior for all homogeneous, isotropic structures,
as characterized by Young’s modulus (E) and Poisson’s ratio
(Table 3), (iv) immobilized boundary condition of the alveolar
bone with restriction of 6 degrees of freedom, and (v) con-
straint nasal lamina of the incisor, in order to better simulate
real clinical conditions. All elements of the external surface of
the cortical bone on mesial and distal extremities of the model
were restricted from any movement.
All calculations were performed with the ANSYS (16.2;
ANSYS Inc.) software. A simulated oblique occlusal force of
200 N was applied to an ellipsoid like surface of 0.6 mm ×
1.2 mm on the palatal side, 2mm below the incisal edge.54
The longitudinal axis of both the modeled intact and restored
maxillary central incisors formed an angle of 130° with the
direction of force, simulating an Angle Class I patient.55,56 A
structural linear static analysis was performed to evaluate the
stress distribution. The complex stress states and stress redis-
tribution at the structures of the models were analyzed by the
von Mises criterion.57,60 Considering the three and two levels
of the three independent variables (material, preparation depth
and preparation design), a paired comparison analysis was per-
formed. Because of the small size of the sample, which ranged
from 4 to 6, nonparametric estimation of the confidence inter-
val (α = 0.05) for the paired differences was performed using
bootstrapping.61,62 Thus, a number of 10,000 replicates were
produced for each paired comparison and the distribution of
the difference of the maximum von Mises stress for the two
levels of each independent variable was computed. The small-
est p-value that could be obtained was p = 0.00013, if all 10001
mean differences (from the original and bootstrapped samples)
are different from zero. This had to be compared to the statis-
tical significance level of α = 0.05, or to be more rigorous, to
α = 0.01, considering the Bonferroni correction for having five
comparisons in total on the same pool of data. Statistical analy-
sis was performed using the Matlab (7.1.1.0; Math Works Inc.)
153
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Veneer Thickness and Design on Stress Distribution Tsouknidas et al

Figure 4 (A), Maximum von Mises stress values (MPa) for each structure/material with a butt joint preparation. (B), Maximum von Mises stress
values (MPa) for each structure/material with a feather edge preparation. (C), Maximum von Mises stress values (MPa) for each structure/material
with a minimal preparation. (D), Maximum von Mises stress values (MPa) for each structure/material with a deep preparation.

software. Stress distributions were investigated for all possible
combinations by changing one independent variable at a time.
Results
The recorded maximum von Mises stresses for each structure
are listed in Table 4. Stress distribution for intact and restored
incisors was similar independent of the design, depth of prepa-
ration and ceramic material. The highest von Mises stress values
concentrated in the cervical margin of the veneers.
Figure 3A exhibits a characteristic stress distribution of the
model at maximum load for a restoration with minimal prepa-
ration (thin veneer) and Empress 2 material. A tenfold de-
formation was used to emphasize the distortion of the loaded
geometry, which is superimposed on the nondeformed model.
Figure 3B demonstrates a cross-section of the same model with
a condensed fringe bar in order to highlight stress accumula-
tions within the structure. Among the tested structures, stress
concentrations exhibited approximately 15% variations in the
structure of veneer regardless of the ceramic material, the depth
and the design of preparation (Figs 4A to 4D).
The statistical analysis was concentrated on the mean dif-
ferences of pair matched types of materials to test the null
hypothesis that there is no difference in the mean von Mises
stress for each pair of material types. The results demonstrated
statistically significant differences (p < 0.01) in von Mises
stress, when different ceramic materials were considered, re-
gardless of the preparation depths and designs. When models
of feldspathic ceramic were tested the maximum von Mises
stress values were concentrated in the enamel and dentin. The

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Tsouknidas et al Veneer Thickness and Design on Stress Distribution

Table 1 Number of elements of every structure Table 2 Different material/preparation depth/preparation design combi-
nations tested
Structures-Volumes Number of elements
Material Preparation depth Preparation design Symbol
Sound enamel 12,914
Enamel prepared with feathered edge 6838 Emax Minimal Feather edge EMF
preparation design and “minimal” depth Empress 2 E2MF
Enamel prepared with feathered edge 6322 Feldspathic FMF
preparation design and “deep” depth Emax Butt joint EMB
Enamel prepared with butt joint preparation 6171 Empress 2 E2MB
design and “minimal” depth Feldspathic FMB
Enamel prepared with butt joint preparation 5668 Emax Deep Feather edge EDF
design and “deep ” depth Empress 2 E2DF
Veneer: feathered edge - “minimal” depth 4192 Feldspathic FDF
Veneer: feathered edge - “deep” depth 6592 Emax Butt joint EDB
Veneer: butt joint - “minimal” depth 4796 Empress 2 E2DB
Veneer : butt joint - “deep” depth 7266 Feldspathic FDB
Dentin 23,143
Pulp 1951
Periodontal ligament 4758
Table 3 Properties of the materials modeled
Cancellous bone 86,867
Cortical bone 193,232 Material Young’s modulus (MPa) Poisson’s ratio

Enamel19,36 84,100 0.33

maximum von Mises stress values in the veneer structures were
observed for all models of IPS Empress 2 (Tables 5–7). The
depth of preparation demonstrated statistically significant dif-
ferences (p < 0.01) in the stress levels in all studied structures,
with the exception of the enamel. Higher stresses were found
both in the dental tissue structures and in the structures of ve-
neers for all models of minimal depth preparation (Table 8).
The von Mises stresses showed that the butt joint preparation
design decreases the stress in both the veneer and tooth struc-
tures, when the maximum depth preparation was tested, regard-
less of the ceramic material. The same observation was made
when a minimal depth preparation in combination with IPS
e.max Press was used (Figs 4A to 4D). It should be mentioned
however that these differences were not statistical significant
(Table 9).
Discussion
The results of the FEA suggest that the null hypothesis on dif-
ferent ceramic materials and preparation depths should be re-
jected. However, the null hypothesis regarding preparation de-
signs should be accepted. The results of this FEA demonstrated
that porcelain veneers restored the biomechanical behavior of
a prepared tooth, and made it similar of that of an intact tooth.
The findings of the present study are in agreement with those
of a previous study of Magne and Douglas who concluded that,
the stress distribution in a tooth restored with a ceramic veneer
was similar to that of a sound tooth.38 This is probably due
to the elastic modulus of the ceramic systems tested, which
is close to that of enamel. The stresses developed below the
cervical margin of the restored teeth were the highest observed
for all tested models. Previous in silico research for porcelain
veneers has also demonstrated that the maximum stress areas
were located in the mid third of the labial cervical third.19 It
should be mentioned however that other 3D FEA studies have
shown that stress concentrates in the incisal area, as well.54,55
Dentin19,36 14,700 0.31
Pulp36 2 0.45
Periodontal ligament19,36 69 0.45
Cortical bone36,46 10,700 0.3
Cancellous bone36,46 910 0.22
IPS emax Press13 95,000 0.23
Colorite feldspathic 74,000 0.22
veneer36,46
IPS Empress 213 103,000 0.24
This could be attributed to the modeling process and the load
which was applied on the palatal surface of the incisal edge, at
135° to the longitudinal axis of the tooth.54,55 In vitro studies
with ceramic veneers revealed that the incisal margin and the
cervical area were the most likely regions to fail, with fracture
and debonding being the most frequent failure modes.24
The von Mises stress analysis of the present FEA showed
that the heat pressed glass ceramic IPS Empress 2 decreases the
stress in tooth but increases the stress in the veneer. This stress
increase within the ceramic is greatest among the three tested
materials. As the stiffness of the ceramic material increases,
so does the stress within the veneer31 and veneers made with
materials of a lower stiffness, such as feldspathic porcelain,
transfer more stress to the supporting tooth structure.31 This
finding, combined with the fact that the cervical area adjacent
to the cementoenamel junction is the region of highest stress
concentration, implies that extensive restorations could benefit
from a stiff ceramic material such as IPS Empress 2.1
The literature lacks evidence on the incidence of complica-
tions resulting from the use of different ceramic veneer mate-
rials. The majority of clinical studies have investigated various
veneer types, without taking into consideration the influence of
the material and technique used to fabricate ceramic veneers.
The results of the present study indicate that the use of heat
pressed ceramics could be beneficial for the tooth, as both the
IPS Empress 2 and IPS e.max Press transferred lower stresses

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Veneer Thickness and Design on Stress Distribution Tsouknidas et al

Table 4 Maximum von misses stresses (MPa) on different structures in the examined models

Prepared full model Periodontal Cancellous

Combination Full model Enamel Dentin Pulp Veneer without restoration ligament Cortical bone bone

Sound tooth 352.01 352.01 238.74 35.65 105.66 111.07 61.98

Prepared MBwithout 356.71 356.71 243.08 35.64 106.43 111.06 61.98
restoration∗ ,1
Prepared DBwithout 356.19 356.19 244.14 35.64 106.68 111.03 61.98
restoration∗ ,2
EMB 351.67 351.67 238.39 35.65 187.92 351.67 105.58 111.07 61.97
EDB 351.68 351.68 238.30 35.65 177.90 351.68 105.55 111.07 61.98
EMF 351.67 351.67 238.39 35.65 187.94 351.67 105.58 111.07 61.97
EDF 351.68 351.68 238.30 35.65 177.92 351.68 105.55 111.07 61.98
FDB 352.17 352.17 238.92 35.65 166.16 352.17 105.68 111.07 61.97
E2DB 351.52 351.52 238.10 35.65 186.51 351.52 105.51 111.08 61.98
FDF 352.17 352.17 238.92 35.65 166.15 352.17 105.68 111.07 61.97
E2DF 351.52 351.52 238.10 35.65 186.55 351.52 105.51 111.08 61.98
FMB 352.29 352.29 239.01 35.65 176.85 352.29 105.70 111,068 61.97
E2MB 351.47 351.47 238,196 35,647 191.67 351.47 105.55 111.07 61.97
FMF 352.29 352.29 239,005 35,6463 176.85 352.29 105.70 111.07 61.97
E2MF 351.47 351.47 238,196 35,647 191.67 351.47 105.55 111.07 61.97

Table 5 Paired – comparison analysis of IPS emax press and feldspathic ceramic materials

95% CI

Structure Mean SD Lower Upper p

Full model −0.55175 0.07362 −0.61550 −0.48800 <0.0001

Enamel −0.55175 0.07362 −0.61550 −0.48800 <0.0001
Dentin −0.61650 0.00551 −0.62100 −0.61200 <0.0001
Veneer 11.31267 0.39536 11.07875 11.60075 <0.0001
Prepared tooth without restoration −0.55175 0.07362 −0.61550 −0.48800 <0.0001
Cortical bone 0.00425 0.00150 0.00300 0.00550 <0.0001
Cancellous bone 0.00050 0.00035 0.00020 0.00080 <0.0001
Periodontal ligament −0.12400 0.00693 −0.13000 −0.11800 <0.0001
Pulp 0.00050 0.00012 0.00040 0.00060 <0.0001

to the underlying dental tissues, compared to the feldspathic
porcelain. Although IPS Empress 2 is not used anymore, it was
included in this study as it is considered to be the precursor
of IPS e.max press. The main difference between these two
ceramics is that IPS e.max Press contains up to 8% ZrO2, while
IPS Empress 2 does not contain ZrO2. 12-16
The improved biomechanical behavior of heat pressed ce-
ramics shown by the present study, along with the improved
mechanical and optical properties of IPS e.max Press demon-
strated by several studies suggest that IPS e.max Press could be
the ceramic material of choice for veneers.14,15
The present study also evaluated the generation of stresses
when maxillary central incisors are restored with porcelain
veneers of different thicknesses. Ceramic veneer thickness
demonstrated a statistically significant impact on stress dis-
tribution in the restored central incisors. As the thickness of the
veneer was increased, the stresses within the veneer structure
and the tooth structures were decreased. The “deep” prepa-
ration improved the biomechanical properties of the restored
incisors in comparison to the “minimal” preparation. Sim-
ilarly, an article by Rekow et al, showed that the ceramic
thickness has a substantial impact on stress distribution, as
it was responsible for 24.7% of the variability in the stress
levels. This analysis indicated that the factors “material” and
“thickness” are the most important determinants of strength,
accounting for 86% of the variance in magnitude of maximum
principal stress.31 A finding which is in accordance to the re-
sults of the present FEA is that the increase in stress from
stiffer materials can be offset substantially by changing the
ceramic thickness. Furthermore, in agreement to the findings
of the present study, previous in vitro studies indicated that
the crack initiation force increases when the ceramic thickness
increases.28
Based on the results of the present study, the best biomechan-
ical behavior of “deep” preparation and the fact that thicker
veneers mask better discolored teeth suggests that this prepa-
ration depth might be a better choice for the central incisors
restored with ceramic veneers. It should be emphasized though

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Tsouknidas et al Veneer Thickness and Design on Stress Distribution

Table 6 Paired – Comparison analysis of IPS emax press and IPS empress 2 ceramic materials

95% CI

Structure Mean SD Lower Upper p

Full model −0.55175 0.07362 −0.61550 −0.48800 <0.0001

Enamel −0.55175 0.07362 −0.61550 −0.48800 <0.0001
Dentin −0.61650 0.00551 −0.62100 −0.61200 <0.0001
Veneer 11.31267 0.39536 11.07875 11.60075 <0.0001
Prepared tooth without restoration −0.55175 0.07362 −0.61550 −0.61550 <0.0001
Cortical bone 0.00425 0.00150 0.00300 0.00300 <0.0001
Cancellous bone 0.00050 0.00035 0.00020 0.00020 <0.0001
Periodontal ligament −0.12400 0.00693 −0.13000 −0.13000 <0.0001
Pulp 0.00050 0.00012 0.00040 0.00040 <0.0001

Table 7 Paired – Comparison analysis of feldspathic and IPS Empress 2 ceramic materials

95% CI

Structure Mean SD Lower Upper p

Full model 0.73050 0.09642 0.64700 0.81400 <0.0001

Enamel 0.73050 0.09642 0.64700 0.81400 <0.0001
Dentin 0.81400 0.00600 0.80900 0.81900 <0.0001
Veneer −16.68733 3.21873 −19.01025 −14.82900 <0.0001
Prepared tooth without restoration 0.73050 0.09642 0.64700 0.81400 <0.0001
Cortical bone −0.00575 0.00206 −0.00750 −0.00400 <0.0001
Cancellous bone −0.00080 0.00046 −0.00120 −0.00040 <0.0001
Periodontal ligament 0.16350 0.00866 0.15600 0.17100 <0.0001
Pulp −0.00060 0.00012 −0.00070 −0.00050 <0.0001

Table 8 Paired – Comparison analysis of “minimal” and “deep” preparation depth

95% CI

Structure Mean SD Lower Upper p

Full model 0.02133 0.07807 −0.03433 0.07700 0.45247

Enamel 0.02133 0.07807 −0.03417 0.07700 0.45587
Dentin 0.09283 0.00504 0.08917 0.09633 0.00013
Veneer 8.20560 2.80889 6.04372 10.24700 0.00013
Prepared tooth without restoration 0.02133 0.07807 −0.03417 −0.07700 0.46187
Cortical bone −0.00150 0.00164 −0.00267 −0.00033 0.02533
Cancellous bone −0.00067 0.00037 −0.00093 −0.00040 0.00013
Periodontal ligament 0.02700 0.00710 0.02200 0.03200 0.00013
Pulp −0.00017 0.00010 −0.00023 −0.00010 0.00013

that in all cases an enamel layer should remain for a predictable
cementation of the ceramic veneer.7
The results of this study also showed that the preparation de-
sign was not critical for the recovery of tooth stiffness. Incisors
restored with feldspathic porcelain and glass ceramic IPS Em-
press 2 veneers with the “minimal” preparation depth presented
exactly the same maximum von Mises stress levels independent
of the preparation designs, for all tested structures. This is in
accordance with clinical studies on ceramic veneers which have
shown that different preparation designs did not influence the
survival rate.27
Nevertheless, several other authors confirmed that the incisal
overlap preparation provides adequate porcelain thickness, im-
proves the translucency of the restoration and makes the seating
of the veneer during cementation easier.21,22 It should be men-
tioned however that, the studies of Hui et al and Prasanth et
al are in contrast with the results of the present study as they
reported that the feather-edge preparation is more conservative
and presents a better tolerance in load fracture.23 The different
findings may be explained by the fact that different methodol-
ogy, i.e., in vitro study with vertical loading at the incisal edge,
was adopted by these authors.

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C 2019 by the American College of Prosthodontists 157
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Veneer Thickness and Design on Stress Distribution Tsouknidas et al

Table 9 Paired – Comparison analysis of “feather edge” and “butt joint” preparation design

95% CI

Structure Mean SD Lower Upper p

Full model 0.00029 0.00076 −0.00029 0.00071 0.17351

Enamel 0.00029 0.00076 −0.00029 0.00071 0.18111
Dentin −0.00057 0.00223 −0.00200 0.00100 0.45687
Veneer 0.00967 0.02411 −0.00600 0.02486 0.44947
Prepared tooth without restoration 0.00029 0.00076 −0.00029 0.00071 0.18631
Cortical bone −0.00014 0.00038 −0.00043 0.00000 0.67264
Cancellous bone −0.00006 0.00015 −0.00017 0.00000 0.67824
Periodontal ligament 0.00000 0.00000 0.00000 0.00000 0.00013
Pulp 0.00000 0.00000 0.00000 0.00000 0.00013

The linear static FEA used presents some limitations, one
of which is that several assumptions must be made. These as-
sumptions include the isotropy and homogeneity of all materials
tested.56 Although the nonlinear analysis would probably pre-
dict the stress and strain within involved structures in a more
realistic situation, there are numerous difficulties.57 Another
limitation of the present study is that a hypothesis of complete
veneer-enamel contact was made. The extremely thin layer of
the resin luting agent compared to the other volumes would
preclude the exact discretization of the structures.
Another limitation extends to the evaluation of the model’s
von Mises, instead of the principal, stresses as a failure cri-
terion. Both these criteria have been used in recent literature,
with the von Mises stress being of interest predominantly in
ductile materials, while the maximum and minimum principal
stress criteria are frequently used for brittle ones. The Hills
criterion—which is an extension of the von Mises criterion—
has also been used effectively in the modeling cortical bone,
while the Tsai-Wu criterion, which was originally expressed
for composite materials, has been used to predict multiaxial
failure of trabecular bone.58,59 It should be mentioned however,
that none of these criteria agrees fully with the data acquired
from in vitro studies, A problem which becomes even more
complicated when, in studies like the present one, where both
ductile and brittle structures are examined.
However, despite the limitations of the present study, the
results still provide an insight into the three ceramic systems,
two preparation depths and designs. Currently, no direct clinical
data is available on this issue, and well-designed long-term
clinical and experimental studies are needed to be considered,
along with the findings of the present study.
Conclusions
This FEA study suggests that ceramic veneers could restore
the biomechanical behavior of prepared central incisors and
made it similar of that of an intact tooth. Regardless of the
preparation depth and design and the ceramic system used,
the cervical margin of ceramic veneers presents the highest
von Mises stress values. Between lithium disilicate (IPS e.max
Press) and feldspathic porcelain, lithium disilicate displayed
the lowest transfer of stresses to dental tissues. An increase
in preparation depth resulted in a statistically significant stress
decrease in both the veneer and the tooth.
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