J Prosthodont Res.

2024; 68(2): 326–335

Original
Journal of Prosthodontic Research article

Marginal adaptation and fracture resistance of milled and

3D-printed CAD/CAM hybrid dental crown materials with various
occlusal thicknesses
Pisit Suksuphan a, Nantawan Krajangta a, Pavinee Padipatvuthikul Didron b,
Thanakorn Wasanapiarnpong c, Thanasak Rakmanee a,*
aDepartment of Restorative and Esthetic Dentistry, Faculty of Dentistry, Thammasat University, Pathumtani, Thailand, b Department of General Dentistry,
Faculty of Dentistry, Srinakharinwirot University, Bangkok, Thailand, c Department of Materials of Science, Faculty of Science, Chulalongkorn University,
Bangkok, Thailand

Abstract
Purpose: To evaluate the marginal adaptation and fracture resistance of three computer-aided design/computer-assisted
manufacturing hybrid dental materials with different occlusal thicknesses.
Methods: Ninety single-molar crowns were digitally fabricated using a milled hybrid nanoceramic (Cerasmart, CE),
polymer-infiltrated ceramic network (PICN, Vita Enamic, VE), and 3D-printed materials (Varseosmile, VS) with occlusal
thicknesses of 0.8, 1, and 1.5 mm (10 specimens/group). Anatomical 3D-printed resin dies (Rigid 10K) were used as sup-
porting materials. A CEREC MCX milling unit and a DLP-based 3D printer, Freeform Pro 2, were utilized to produce the
crown samples. Before cementation, the marginal adaptation, absolute marginal discrepancy (AMD), and marginal gap
(MG) were assessed using micro-CT scanning. After cementation with self-adhesive resin cement, fracture resistance was
evaluated using a universal testing machine. The number of fractured crowns and the maximum fracture values (N) were
recorded. Data were statistically analyzed using both one- and two-way ANOVA, followed by Tukey’s honestly significant
difference (HSD) test.
Results: For all occlusal thicknesses, the VS crowns demonstrated the lowest AMD and MG distances, significantly different
from those of the other two milling groups (P < 0.05), whereas CE and VE did not differ significantly (P > 0.05). All VS crowns
were fractured using the lowest loading forces (1480.3±226.1 to 1747.2±108.7 N). No CE and 1 and 1.5 mm VE crowns
fractured under a 2000 N maximum load.
Conclusions: All hybrid-material crowns demonstrated favorable marginal adaptation within a clinically acceptable range,
with 3D printing yielding superior results to milling. All materials could withstand normal occlusal force even with a 0.8
mm occlusal thickness.
Keywords: Hybrid ceramic, Composite resin nanoceramic, 3D-printing, Marginal adaptation, Fracture resistance

Received 24 March 2023, Accepted 26 June 2023, Available online 12 July 2023

1. Introduction age[1]. The current CAD/CAM techniques encompass both subtrac-

tive milling and additive manufacturing, commonly referred to as
Digital technologies have become pervasive across various three-dimensional (3D) printing[2]. Compared to subtractive milling,
stages of the dental workflow[1] owing to improvements in com- additive manufacturing offers several benefits such as reduced ma-
puter-aided design/computer-assisted manufacturing (CAD/CAM). terial waste and the capability to produce complex shapes including
Currently, CAD/CAM technology is used to manufacture several undercuts or inaccessible areas that cannot be milled[3]. Recently,
restorations with excellent esthetic properties. The advantages of new hybrid materials have been developed for CAD/CAM systems
the CAD/CAM generation technique include access to industrially that combine the advantages of ceramics in terms of esthetic char-
prefabricated and almost-defect-free dental restorations, improve- acteristics, durability, and color stability with the advantages of
ment in precision and planning, higher reproducibility, automatic resin composites, such as high flexural strength, low abrasiveness,
and high-speed data processing, and simpler and efficient data stor- and intraoral reparability. Currently, most hybrid ceramics used
as restorative materials can be milled using subtractive milling[4].
Two examples of the hybrid materials are Cerasmart® (CE) and Vita
DOI: https://doi.org/10.2186/jpr.JPR_D_23_00089 Enamic® (VE). Cerasmart® is a high-density resin composite material
*Corresponding author: Thanasak Rakmanee, Department of Restorative Dentistry,
Faculty of Dentistry, Thammasat University, 99, Moo18, Paholyothin Road, Klong Luang,
containing 71% filler particles (by weight), referred to as a “flexible
Pathumthani, 12121 Thailand. nanoceramic”[5]. VE or polymer-infiltrated ceramic network (PICN)
E-mail address: [email protected] materials consist of an 86% (by weight) porous feldspathic ceramic
Copyright: © 2023 Japan Prosthodontic Society. All rights reserved. matrix infiltrated with a copolymer (urethane dimethacrylate and
 P. Suksuphan, et al. / J Prosthodont Res. 2024; 68(2): 326–335 327

Table 1. Lists and details of the materials

Group Products Manufacturer Composition Lot No.
GC Corporation; Silica (20 nm) and barium glass (300 nm) nanoparticles 71 wt.%,
Cerasmart® 1807201
Tokyo, Japan Bis-MEPP, UDMA, and DMA Polymers 29 wt.%
Milling
Vita Zahnfabrik;
Vita Enamic® Feldspar ceramic 86 wt.%, Methacrylate polymer 14 wt.% 90001
Bad Säckingen, Germany
Total content of inorganic fillers (particle size 0.7 μm) 30–50 wt.%,
Bego; Bremen, 4.4’-isopropylidiphenol, ethoxylated and 2- methylprop-2enoic acid,
3D-Printing Varseosmile® 600512
Germany silanized dental glass, methyl benzoylformate, diphenyl
(2,4,6- trimethylbenzoyl) phosphine oxide
Powder: glass fillers, silica, calcium hydroxide, self-curing initiators,
Resin luting pigments, light-curing initiators, substituted pyrimidine, peroxy
RelyX Unicem® 3M ESPE; USA 8713388
cement compound Liquid: methacrylated phosphoric esters, dimethacrylates,
acetate, stabilizers, self- curing initiators, light- curing initiators
Silane Coupling RelyX Ceramic
3M ESPE; USA Ethyl alcohol, water, 3-methacryloxypropyltrimethoxysilane NF21800
Agent Primer®
Highly glass-filled resins-based methacrylate
Resin die Rigid 10K Resin Formlabs Inc.; USA 4c-0000001f3f36
(9 GPa of E-Modulus after UV-post-cured)[18]

triethylene glycol dimethacrylate). Both the materials are manufac- fracture force of three types of particle-filled composites (LU, CE,
tured using a milling process. Only a few 3D-printed hybrid materials Brillilliant Crios; BC) produced with different occlusal thicknesses
are available for fixed, permanent, or single restorations. Recently, (0.5, 1.0, and 1.5 mm) and compared with VE and e.max CAD®. The
Varseosmile Crown plus® (VS), a novel 3D-printable hybrid material, study found that all particle-filled composite crowns with 0.5 mm
additively fabricated by digital light processing (DLP) technology, thickness survived fatigue testing and e.max CAD® and VE showed
has been launched[6]. The manufacturer claims that this material lower strength than CE[5]. However, the minimum thicknesses of 1.0
has high dimensional stability, flexural strength, and modulus, with and 1.5 mm for VE and CE, respectively, were recommended by the
excellent esthetics[7]. manufacturers[14]. Thus far, only a few studies have investigated the
marginal fit and fractural strength of hybrid materials.
The three basic requirements for assessing the favorable out-
comes of dental restorations are esthetic perception, margin adap- The CAD/CAM hybrid dental materials are mostly categorized
tation, and fracture resistance[7]. Although the key considerations as weak materials, which may be due to inappropriate evaluation
for esthetic success are subjective, judgement is not universal and methods[15]. Most of the available in vitro studies have investigated
depends on various factors. Inadequate marginal adaptation may hybrid materials fabricated by milling techniques[16,17], and no
induce plaque accumulation, causing microleakage, potentially studies have investigated the marginal fit and fracture load of 3D-
increasing the risk of caries, and causing gingival inflammation[8]. printed hybrid materials made with different occlusal thicknesses.
Moreover, it could contribute to cement dissolution, compromising Therefore, the aim of the present study was to evaluate the marginal
the esthetics[8]. In 2014, Yildirim et al., evaluated the marginal and adaptation and fracture resistance of three CAD/CAM hybrid materi-
internal adaptations of three different materials (VE, Lava Ultimate®, als, that is, milled CE (hybrid nanoceramic), VE (PICN), and 3D-printed
LU and Vita Suprinity®, and VSU) compared with those of lithium dis- VS (hybrid composite) with three different occlusal thicknesses. The
ilicate (e.max CAD®, IPS) using microcomputed tomography (micro- null hypothesis was that there would be no statistically significant
CT) scanning; they observed that the hybrid materials demonstrated differences in the marginal adaptation and fracture resistance of
significantly lower adaption than the lithium disilicate[8] but within the three hybrid crown materials fabricated with different occlusal
a clinical acceptable range[9]. On the contrary, in 2017, Azarbal et al. thicknesses.
reported that VE crowns fabricated using the CEREC system showed
superior marginal adaptation to that of e.max CAD® crowns[10]. 2. Materials and Methods
Preserving the tooth structure is an important principle of Details of the materials used in this study are described in Table
tooth preparation and is related to the fracture resistance of the 1. A mandibular 1st molar typodont tooth (Nissin; Kyoto, Japan) was
restoration. Thin-layer restorations offer an alternative treatment to scanned using an optical scanner (E3; 3shape, Denmark) and then
avoid pulp exposure in patients with limited occlusal space and in virtually prepared to create a resin die using CAD software (Autodesk
juveniles. Previous studies have shown that hybrid ceramic crowns fusion 360; CA, USA) (Fig. 1) based on the preparation guidelines for
with minimal thickness can withstand fracture loads, making them full ceramic crowns (1.0 mm occlusal reduction, 1.2 mm proximal,
suitable for single posterior restorations[11,12]. In 2020, Rabeae et axial reduction with 6 degrees of convergence profile, 0.8 mm deep
al.[13] studied the fracture load on VE and lithium disilicate restora- chamfer crown margin, and round line angles). The CAD file of the
tions with occlusal thicknesses of 0.3, 0.6, and 1.0 mm and showed no prepared tooth was imported to a 3D printing machine (Form 3B;
significant difference between the two materials. The failure load of MA, USA), and a highly glass-filled resin-based methacrylate (Rigid
VE with a thickness of 0.3 mm was 547–846 N, which was still higher 10K; Formlabs Inc., USA) was utilized to fabricate the resin dies (Fig.
than the normal occlusal load (50–300 N), but less than the clenching 2A) and post-cured with a UV post-curing unit (Form Cure; MA, USA)
force (1200 N)[13]. However, the study concluded that the 0.3 mm for 60 min at 70°C according to the specifications of the manufac-
restoration may not survive in the oral environment and instead turer[18], then stored under the same conditions in a dark storage
recommended the use of either a 0.6 or 1.0 mm thickness in clinical compartment[19].
situations[13]. However, in 2019, Zimmermann et al.[5] studied the
328 P. Suksuphan, et al. / J Prosthodont Res. 2024; 68(2): 326–335

Fig. 1. Virtual CAD design of resin dies and crowns with different occlusal thicknesses using Autodesk fusion 360 pro-
gram. A virtual die preparation of all ceramic crown designed for mandibular 1st molar (A), setting of 50 μm cement
spacer parameter (B), a CAD design of single-molar crown (C), and virtual seating of the designed crown over the die (D).

Fig. 2. CAM fabrications of specimens; Rigid 10K resin dies (A), Cerasmart® milled crowns (B), Vita Enamic® milled crowns
(C), and Varseosmile® 3D-printed crowns (D)

Single-molar crowns with occlusal thicknesses of 0.8, 1, and 1.5

mm (Fig. 3) were designed using CAD software (3Shape Dental System
version 2020), and the cement spacer was set to 50 μm, whereas the
other parameters were set to 0 μm (Fig. 1B). Milling fabrication (Figs.
2B and C) was performed using a CEREC MCX (Dentsply Sirona; New
York, USA) equipped with a cylindrical pointed bur 12 S and step
bur 12. To prevent damage to the samples, the milling burs were
replaced after finishing 30 crowns and prior to commencing work
on a new material[20]. The 3D-printed group was fabricated using
a DLP-based 3D printer, Freeform Pro 2 (ASIGA; Anaheim Hills, USA) Fig. 3. Resin dies designed in a CAD software. The surface of bucco-lingual
view shows different occlusal crown thicknesses of 0.8 mm (A), 1.0 mm (B),
(Fig. 2D), with the imported STL data file, and post-cured according and 1.5 mm (C).
 P. Suksuphan, et al. / J Prosthodont Res. 2024; 68(2): 326–335 329

Fig. 4. Micro-CT scan images. Cross-sectional slice (A) with five equidistant bucco-lingual sections (red) and five equidistant
mesio-distal sections (yellow), a coronal section (B) represents the bucco-lingual measurements, and a sagittal section (C) rep-
resents the mesio-distal measurements.

to the manufacturer’s recommendations.

Marginal adaptation was investigated using micro-CT scans

(Skyscan 1172; Bruker) before the cementation of the crowns. All
crowns were cleaned with ultrasonic baths, air-dried, and passively
seated onto 3D-printed dies directed by four indentation points
(mesial, lingual, buccal, and distal) and a temporary adhesive with
spots of clear glue fixation (DUO glue clear adhesive; American Inter-
national Industries, USA). The marginal adaptation of all specimens
was measured by placing each specimen perpendicular to the X-ray
beam scanning tube[8] with an operating voltage of 67 kV and cur- Fig. 5. Measurement of marginal adaptation (perpendicular distance be-
rent of 41 μA using an Al filter (1 mm) and an image pixel size of 10 tween crown and master die margin measured). AMD: absolute marginal dis-
μm by averaging three frames and performing 360° scanning with a crepancy, MG: marginal gap.
rotation step of 0.2°; subsequently, the acquired projection images
were reconstructed into cross-sectional slices (Fig. 4A) using a soft-
ware (NRecon v1.6.9; Bruker Micro-CT). Depending on the number of stand[13], residual resin cement was removed, and then a 20 s light
slices, five coronal sections (Fig. 4B) were obtained at 100 equidis- curing was performed on each crown surface using a curing lamp
tant slice intervals from the bucco-lingual direction and five sagittal of 470 nm wavelength and 1000 mW/cm2 intensity (SmartLite Focus,
sections (Fig. 4C) were obtained at 100 equidistant slice intervals Dentsply Sirona; USA). Subsequently, the specimens were stored in
along the mesio-distal direction. There were four measurement distilled water at 37°C in a heating cabinet for 24 h.
points for each slide, including two absolute marginal discrepancies
(AMD) and two marginal gaps (MG) (Fig. 5). Forty measurements For single load-to-fracture testing, the specimens were mounted
of each crown (a total of 3600 points at the buccal, lingual, mesial, onto a universal testing machine (Shimadzu; Kyoto, Japan), and the
and distal aspects) were performed using the DataViewer program long axis of the ball steel was perpendicular to the horizontal plane
(v.1.5.1.2; Bruker Micro-CT). All two-dimensional (2D) measurements with a crosshead speed of 1 mm/min using a 5 mm diameter ball tip
were performed by a single examiner (P.S.)[13]. stainless steel antagonist with a 2000 N load cell. Load was applied
to the central fossa until the crown broke. The number of fractured
For cementation, a 5% hydrofluoric acid gel (VITA ADIVA CERA- crowns (n) and maximum forces of fracture (N) were recorded.
ETCH, VITA Zahnfabrik, Germany) was applied for 60 s in the inner
surface of all the crowns, followed by 60 s water rinsing, 20 s air Statistical analyses were performed using SPSS software (v26.0;
drying, and silanation (RelyX® Ceramic Primer, 3M/ESPE, USA)[6]. A IBM Corp). The Kolmogorov-Smirnov test was used to verify normal-
resin cement (RelyX unicem, 3M/ESPE, USA) was used for cementa- ity. Levene’s test of the equality of error variance was performed.
tion according to the manufacturer’s instructions, and the crowns An interaction between material type and thickness (P < 0.05) was
were seated with a constant load of 20 N by a force gauge with a test observed when the marginal adaptation was analyzed. Marginal
330 P. Suksuphan, et al. / J Prosthodont Res. 2024; 68(2): 326–335

Table 2. Mean ±SD (µm) values of absolute marginal discrepancy (AMD) for the test group
Mean ± SD
Types Thickness (mm.)
Buccal Lingual Mesial Distal
0.8 85.4 ± 8.3B 69.0 ± 15.8BCD 45.6 ± 23.6B 60.0 ± 14.9CDEF
Cerasmart 1.0 58.6 ± 21.8B 78.0 ± 10.9BCD 49.6 ± 15.0B 69.0 ± 8.2DEFG
1.5 32.8 ± 8.0A 75.7 ± 8.8BCD 39.6 ± 9.9B 61.8 ± 9.2CDEFG
0.8 74.6 ± 22.7B 52.2 ± 18.8BC 43.0 ± 6.9B 51.2 ± 11.0BCDE
VitaEnamic 1.0 70.0 ± 24.6B 65.4 ± 30.0BCD 62.8 ± 21.3B 70.2 ± 16.3DEFG
1.5 65.0 ± 24.3B 91.4 ± 20.5CD 54.4 ± 15.8B 77.8 ± 11.7EFG
0.8 19.8 ± 4.8A 23.4 ± 8.7A 18.4 ± 5.2A 28.0 ± 13.8AB
Varseosmile 1.0 21.6 ± 7.2A 31.4 ± 9.7AB 18.0 ± 7.8A 36.6 ± 10.8ABC
1.5 18.0 ± 8.7A 21.4 ± 6.2A 15.6 ± 7.6A 27.2 ± 11.7AB
AMD values with the same capital letters within the same column are not statistically different (P > 0.05). Statistical analysis was performed using two-way
ANOVA and post-hoc Tukey's test (significance level α = 0.05).

Table 3. Mean ±SD (µm) values of marginal gap (MG) for the test group
Mean ± SD
Types Thickness (mm.)
Buccal Lingual Mesial Distal
0.8 97.2 ± 10.8DEF 78.6 ± 13.3EFG 89.0 ± 13.1DEFG 84.8 ± 12.6H
Cerasmart 1.0 82.0 ± 10.3BCDEF 60.8 ± 8.9BCD 68.0 ± 16.8BCDE 63.2 ± 11.0DEFG
1.5 72.8 ± 8.7BCD 64.8 ± 5.5CDEF 69.3 ± 7.4BCDEF 58.6 ± 4.7BCDEFG
0.8 78.2 ± 10.1BCDE 80.2 ± 7.5FG 78.0 ± 15.3BCDEFG 65.2 ± 9.8DEFG
VitaEnamic 1.0 88.8 ± 17.4CDEF 74.4 ± 8.6DEFG 80.6 ± 14.0BCDEFG 60.0 ± 10.8CDEFG
1.5 88.8 ± 8.3CDEF 72.4 ± 9.2DEFG 87.4 ± 9.1CDEFG 58.0 ± 4.6 ABCDEFG
0.8 51.0 ± 6.1A 50.0 ± 3.0ABC 44.8 ± 5.2A 47.4 ± 4.0ABCDE
Varseosmile 1.0 50.0 ± 4.4A 49.4 ± 4.0AB 46.6 ± 4.0A 46.4 ± 3.1ABCD
1.5 53.8 ± 6.1A 53.4 ± 4.8ABC 48.2 ± 3.6A 50.8 ± 7.1ABCDEF
MG values with the same capital letters within the same column are not statistically different (P > 0.05). Statistical analysis was performed using two-way
ANOVA and post-hoc Tukey's test (significance level α = 0.05).

adaptation values (AMD and MG) were analyzed using two-way 4). No fractures were observed in the supporting dies. The fracture
ANOVA. resistance forces for each group are listed in Table 5. Notably, where
the loading force values were within the linearity limit, as observed
3. Results from the stress-strain plots for each tested crown under the loading
forces, both the CE and VE (except 0.8 mm) specimens that did not
All 3600 investigating points from the three materials (VE, CE, break demonstrated the plasticity of the material. For VS crowns,
and VS) with different occlusal thicknesses (0.8, 1.0, and 1.5 mm) those with an occlusal thickness of 0.8 mm fractured at the lowest
were measured for the AMD and MG. Descriptive analyses of AMD loading force (1480.3 ± 226.1 N). Fracture resistance increased with
are shown in Table 2. There were no significant differences (P > 0.05) the occlusal thickness of the crowns (Table 5).
in almost all the AMD values in the milled groups (CE and VE). AMD
values were significantly different from those of the other milled 4. Discussion
groups only at the buccal aspect of 1.5 mm CE (P < 0.05). Most of
the 3D-printed VS group (8 of 12 points) had significantly lower AMD The null hypothesis was rejected as statistically significant differ-
values than the milled groups (P < 0.05), except at the lingual of 1.0 ences were observed in the obtained results. Owing to the novelty of
mm VS. The distal of all VS were not significantly different (P > 0.05). this 3D-printed hybrid crown material, no study has investigated the
The MG test results are presented in Table 3. and a pattern similar to marginal fit and fracture load of this material made from different
that of the AMD results was observed. Almost all MG values at the occlusal thicknesses or compared them with milled hybrid materials.
lingual and distal aspects of all thicknesses of the VS groups were Marginal adaptation is a major predictor of the clinical success of
not significantly different from those of the milled groups (P > 0.05), fixed prosthetic restorations[20,21], and many methods have been
except at the distal of the 0.8 mm CE, which was significantly higher examined. The most widely used method is the direct microscopic
than that of the milled groups (P > 0.05). evaluation of gaps along the crown margins. However, this method
has major disadvantages because the reference points may be diffi-
The fracture resistance was evaluated after crown cementation. cult to prove, leading to projection errors[22]. The micro-CT scan was
Fractured crowns were observed in four out of nine groups (0.8 mm used in the present study, and by this innovative and nondestructive
VE and all thicknesses of VS) (Fig. 6). Five of the six milled crowns did technique, the marginal and internal adaptation of the restoration
not fracture, even with a maximum force of 2000 N (Table 4). All the can be simultaneously evaluated. Moreover, micro-CT scans provide
3D-printed crowns fractured at a certain compressive force (Table both 2D and 3D imaging of the space between the restoration and
 P. Suksuphan, et al. / J Prosthodont Res. 2024; 68(2): 326–335 331

Fig. 6. Exemplary pictures after loading to fracture; occlusal thicknesses of 0.8, 1, and 1.5
mm for Cerasmart (1, 2, 3), occlusal thicknesses of 0.8, 1, and 1.5 mm for Vita Enamic (4, 5,
6), occlusal thicknesses of 0.8, 1, and 1.5 mm for Varseosmile (7, 8, 9).

Table 4. Overview of the maximum loading force in Newton (N); n is the number of specimens and n* is the number of fractured specimens
95% CI
Types Thickness (mm.) n n* Mean SD Min Max
lower upper
0.8 10 0 >2000 - - - - -
Cerasmart 1.0 10 0 >2000 - - - - -
1.5 10 0 >2000 - - - - -
0.8 10 10 1812.3 161.4 1404.9 1991.1 1696.9 1927.8
VitaEnamic 1.0 10 0 >2000 - - - - -
1.5 10 0 >2000 - - - - -
0.8 10 10 1480.3 226.1 1191.1 1815.7 1318.6 1642.0
Varseosmile 1.0 10 10 1629.4 118.5 1479.8 1834.8 1544.6 1714.2
1.5 10 10 1747.2 108.7 1584.3 1954.9 1669.4 1824.9

Table 5. Mean ±SD values of fracture resistance force in Newton (N) die, providing very closed sections of the marginal area, which al-
lows a large number of measurement sites[8,23]. In 2000, Groten
Thicknesses Types
(mm) et al.[22] investigated the gaps along crown margin in a scanning
CE VE VS electron microscope on the master steel die without cementing and
0.8 > 2000* 1812.3 ±161.4 1480.3 ±226.1A on replica dies after conventional cementing. They showed that fifty
1.0 > 2000* >2000* 1629.4 ±118.5A measurements of the marginal fit caused less than ±5 μm variability
1.5 > 2000* >2000* 1747.2 ±108.7B for arithmetic means[22]. However, in 2004, Gassino et al.[24] argued
* In the table, the values >2000 represent specimens that are not fractured that only eighteen points were necessary and ninety observation
when a loading force of 2000 N is applied; therefore, the statistical analy- points will produce a sample mean value within ±5 μm of the true
ses for the Cerasmart (CE) and VitaEnamic (VE) groups are not performed. mean, with ≤4 μm of standard error[24]. In the present study, forty
For Varseosmile (VS) group only, one-way ANOVA and post-hoc Tukey's test
(significance level α = 0.05) are used; the values are presented as mean ±SD; measurements of each crown (3600 points in total) were performed.
within the same column, the values with the same capital letters are not In 2014, Yildirim et al.[8] evaluated the AMD and MG values of hybrid
statistically different (P > 0.05).
332 P. Suksuphan, et al. / J Prosthodont Res. 2024; 68(2): 326–335

materials (VE and LU) and compared them with those of lithium dis- 2022[33], which showed that implant-supported 3D-printed de-
ilicate (e.max CAD®) using micro-CT scanning and demonstrated that finitive composite crowns (Saremco Print, Crowntec) had better mar-
the hybrid materials showed considerably better marginal adapta- ginal adaptation than those fabricated using the milling technique
tion than lithium disilicate[8] with a clinically acceptable range of less (CE,VE, and BC)[33]. In addition, Kakinuma et al., in 2022[34], also
than 120 μm as suggested by McLean and Von Fraunhofer in 1917[9]. found that 3D-printed resin-composite crowns (TNG-GPM101, GC)
Conversely, a study by Azarbal et al.[10], in 2017, reported that VE demonstrated higher accuracy with fewer marginal gaps than milled
crowns fabricated using the CEREC milling system showed marginal crowns (CE) after twenty-eight assessments of only bucco-lingually
adaptation superior to that of lithium disilicate crowns[10]. In this sectioned cemented crowns with a laser microscope to represent the
study, all the hybrid material crowns produced MG values within the marginal gaps[34]. By contrast, this study used micro-CT to obtain
clinically acceptable range[9] similar to previous studies[25,26]. forty assessments (3600 points in total) from both the bucco-lingual
and mesio-distal sites of each crown, which truly represented the
The marginal adaptation of the milled dental crowns is affected marginal adaptation. Furthermore, to disregard the influence of
by various factors, including machinability-related aspects, such the luting cement characteristics, this study was performed before
as the sharpness and diameter of the milling burs, hardness of the cementing. The results of this study indicate the advantage of addi-
milled materials, abutment preparation design, cement space tive manufacturing in producing complex shapes with undercuts or
setting, and measuring period (before or after cementing)[27]. To locations that cannot be produced or are limited by the milling pro-
ensure the sharpness of the milling burs, this study used a cylindrical cess. Nonetheless, various printing parameters affect the accuracy of
pointed bur 12S and a step bur 12 equipped with the CEREC MCX prostheses, such as build orientation, layer thickness, x-y resolution,
milling unit, and the burs were replaced according to the research light exposure time, post-processing, and printing materials[35].
protocol. From our observations, after milling the CE and VE crowns, Only a few studies have varied these factors and comparatively in-
the average wear percentages of the milling burs reduced from vestigated the marginal adaptation of 3D-printed crowns. Therefore,
100% to 25%, which may imply that the hybrid materials may cause further studies on the factors associated with 3D printing techniques
less wear to the milling burs[26–28]. It was suggested that marginal are required.
adaptation of CAD/CAM restorations is material dependent[26,28]
and the specificity of chemical and microstructural properties of When evaluating new materials, it is important to test their me-
each material impacts the accuracy and precision of the CAD/CAM chanical properties using the basic tests specified by the ISO. Com-
production[27]. The MG results of this study are similar to those of mon mechanical evaluations for dental materials include flexural
the previous study[27], where the MG range was 68.5±23.8 μm for strength and modulus tests[16]. In three-point bending tests (ISO
the milled resin ceramics (CE, VE, and BC) and were not significantly norm DIS 6872), various flexural strength values have been reported,
different between the groups[27]. indicating that CE is the strongest: CE, ranging from 181.15 ±13.56[36]
to 216.5 ±28 MPa[37]; VE, ranging from 148.16 ±10.04[38] to 155.26
For the preparation design from in vitro studies, teeth should be ±16.13 MPa[39]; and VS, ranging from 119.85 ±17.95 to 143.39 ±12.88
prepared in accordance with clinical conditions[7]. Thus, the use of MPa[40]. The flexural modulus was found to be 25 GPa for CE[37],
metallic models with overly simplified shapes or flat occlusal surfaces 23.3±6.4 GPa for VE[37], and 4.37 ±0.8 to 4.69 ±0.15 GPa for VS[40].
is not directly related to the actual clinical circumstances. According In addition, flexural strengths reported by the manufacturers of CE,
to Habib et al., in 2014[29], the accuracy of the marginal and inter- VE, and VS are 238[14], 150–160[41], and 116–150 MPa[6], respectively.
nal adaptation of zirconia copings of the anatomical preparation Goujat et al., in 2018, also found that CE (216.5 ±28 MPa) had a sig-
showed better marginal and internal adaptation[29]. In the present nificantly higher flexural strength than VE (148.7±9.5 MPa)[37]. How-
study, an anatomical occlusal design was used; therefore, all three ever, there were no statistically significant differences in the flexural
hybrid material crowns demonstrated good marginal adaptation. strength between the VE and VS groups (P > 0.001)[40]. The strengths
For cement space setting, the setting in CAD design usually followed of these materials are consistent with the results of this study; the CE
an international standards for polymer-based filling restorative and and VE groups demonstrated higher fractural strength than the VS
luting materials mixing ratio of base and catalyst (International Or- group. As a result, CE, of all occlusal thicknesses, and VE, when >1.0
ganization for Standardization (ISO) 4049:2019), where 50 μm is set mm, could endure loading forces >2000 N without any visible cracks.
as the critical thickness of the cement. Therefore, it was simply set This suggests that these hybrid materials exhibit high capacities to
to 50 μm by the CAD process. Dauti et al., in 2019[30], evaluated the disperse energy by elastic and plastic deformation. In contrast, all VS
influence of 50 and 80 μm cement space settings on the marginal crowns in this study were broken and sustained the lowest maximum
and internal adaptation of VE crowns and suggested that both vir- loading force. This may be due to the low flexural modulus of VS,
tual spacer settings could be used for manufacturing without any which reflects the differences in its structural compositions (relatively
significant differences[30]. Although the cement thickness acted as low filler contents) and manufacturing method. Despite the low filler
a cushion between the crown and abutment, a larger luting material content, this may add an advantage in liquefying the hybrid material
thickness caused higher tensile stress in the core of the crown, lead- during the 3D-printing process[40]. Notably, VS-group specimens
ing to a higher degree of crown flexure and failure[31]. As a result, with occlusal thickness >1.0 mm exhibit a significant increase in
a cement layer as thin as possible was selected. Maneenakarith et toughness of the restorations against the loading force (P < 0.05).
al.[32], in 2022, also found that thinner resin cement showed a higher
shear bond strength of cement-zirconia than thicker cement[32]. The However, the aforementioned conventional flexural strength
present study also revealed that increasing occlusal thickness did not test may not be suitable for the evaluation of dental restorative
affect marginal adaptation. materials because of the differences in the loading forces applied in
laboratory settings and the actual forces in intraoral conditions[5].
The 3D-printed hybrid material crowns (VS) demonstrated lower Instead, many studies investigating fracture strength using crown-
AMD and MG values than the milled crowns. The results of the CE shaped specimens with minimum crown thickness have been re-
and VE groups were similar to those reported by Donmez et al., in ported[4,42,43]. Usually, the fracture resistance testing method uses
 P. Suksuphan, et al. / J Prosthodont Res. 2024; 68(2): 326–335 333

a universal testing machine with a ball steel indenter on the crown nique had the lowest flexural strength compared to the other hybrid
shape specimens[44]. In a literature review, it was found that the ma- materials in this study, it provided the best marginal adaptation
terial and thickness of the crown are the main factors for evaluating values, as mentioned earlier. Notably, the manufacturing method
fracture behavior[45]. In addition, the fracture resistance was mainly influenced the marginal adaptation of the restoration. The flexural
determined by the E-Modulus of the supporting structures[46]. Frac- strength and modulus values indicated by the structural composition
ture forces of the all-ceramic crowns increased with augmentation of of the material may be key factors for fracture resistance. Although
the E-modulus of the supporting material[47]. Ideally, using natural the 3D-printing technique provided superior restorations in terms of
teeth makes standardization difficult because of large variations in marginal fit, the total production time was longer than that of the
tooth anatomy, patient age, and storage time after extraction[48]. milling technique and required post-curing processes.
Therefore, many studies have used metals, epoxy resins, and acrylic
resins as supporting dies[49]. From a previous study, an acrylic resin 5. Limitations
die material (inCoris SLS) was used with the characteristics of 2.5
GPa E-Modulus, 110–130 MPa fracture resistance, and 80–84 Shore This is a controlled in-vitro experimental study with some limita-
D of shore hardness[5]. It concluded that a supporting material tions. The virtually and ideally designed dies (tooth abutment) and
with an E-modulus comparable to that of natural dentin (between crown preparations with predefined CAD/CAM procedures can pose
7 and 13 GPa)[50] was suggested for use in fracture tests. Therefore, challenges in real-world non-ideal clinical scenarios. For instance, a
a Rigid 10K (Formlabs) highly glass-filled resin (9 GPa of E-modulus 50 μm cement space setting may impact crown fitting, resulting in
and fracture resistance of 126 MPa)[18] was selected in this study, and an increased marginal gap. Cementation was strictly controlled by
the results may be comparatively close to the natural dentin condi- surface treatment procedures, and only one type of adhesive was
tions[5]. In this study, all hybrid material groups could sustain normal used; therefore, different surface treatment protocols and types of
occlusal load (50–300 N) and clenching load (1200 N)[13], even with adhesives may yield different outcomes. Moreover, natural tooth
an occlusal thickness of 0.8 mm. According to the manufacturer, dentin has a wide range of elastic moduli[53]. However, the present
a minimum occlusal thickness of 1.0 mm is recommended for VE study uses a Rigid 10K resin die, which represents only a constant
crown; thus, 0.8 mm VE crowns were expectedly cracked at a certain elastic modulus of the supporting structure, which may not be gen-
loading force. Notably, a minimum of 1.5 mm CE occlusal thickness eralizable in a variety of clinical situations. In addition, fracture resis-
was recommended by the manufacturer, but the results from this tance is only a static loading test, and the clinical function of dental
study demonstrated that even a 0.8 mm CE sustained the loading crowns is more complex with multidirectional forces. Variations in
force without any visible cracked defects, as shown in Figure 6. As a the above-mentioned factors are suggested for further investiga-
result, CE may require minimal occlusal reduction to achieve a good tions, including a higher force of the loading cell, clenching or brux-
clinical outcome when there is limited occlusal space and a non-ideal ism conditions, cyclic fatigue tests, and even finite element analysis.
preparation design and thickness[5]. Similar to the report by Sorren- Nonetheless, hybrid materials may also have other limitations, such
tino et al., in 2018[51], CE showed sufficient fracture resistance for use as color stability and wear resistance. Further evaluation of their
in molar regions with the occlusal thickness >0.5 mm[51]. physical properties, especially in the in-vivo conditions, should also
be conducted.
It can be speculated that these hybrid materials can be used
with a minimum of 0.8 mm thickness to sustain the loading forces. 6. Clinical significance
Only a few studies have investigated factors affecting the mechani-
cal properties of 3D-printed restorations[40,52]. Grzebieluch et al., 1. CAD/CAM hybrid materials can be an alternative, minimally
in 2021[40], found that vertically printed VS samples to the platform invasive treatment that provide good marginal adaptation and
exhibited the best mechanical properties owing to printed objects acceptable fracture resistance. This is favorable for a clinical
positioning in such a way that tensile force generated during masti- situation with limited occlusal space, such as severe tooth at-
cation was applied along and not across the layer. This led to a more trition usually present with a short clinical crown. Furthermore,
random distribution of inorganic particles in the textures[40]. In this resin-bonded with a thin occlusal veneer restoration of hybrid
study, the printing orientation was designed parallel to the loading dental materials is suggested in the case of unnecessary tooth
force direction. removal.
2. The 3D-printing technique provides superior marginal adapta-
Previous studies showed that after milling, materials with high tion over the milling ones.
flexural strength provide better internal and marginal adaptations 3. Although the advantages of 3D printing are its low cost and
because of their machinability[26–28,37,52]. However, although a the generation of less waste in the fabrication process, the
difference in the flexural strength was observed, there was no statis- mechanical properties of the 3D-printing material still need
tically significant difference in the adaptation of the hybrid materials improvement to be comparable with those of other hybrid
(VE and LU)[8]. Similar to our results, marginal adaptation was not materials.
significantly different (P > 0.05) between the milling groups (CE and
VE), although it has been reported that CE has significantly higher 7. Conclusions
flexural strength than VE[37]. CE and VE crowns were efficiently
fabricated by the milling machine, despite the differences in surface Within the limitations of the present study, the following can be
hardness and material compositions according to the brittleness concluded. 1) The type of hybrid crown material used is directly as-
index of both CE and VE (<4.3 μm-1/2), which is the cut-off point for sociated with marginal adaptation and fracture resistance. 2) The 3D
machinability[52] and milling burs were replaced in every group as printing technique of the hybrid materials provides superior margin-
mentioned above. This suggests that machinability may be a major al adaptation compared to the milling techniques. 3) The CAD/CAM
factor in the favorable restoration of hybrid materials with a good hybrid material crown demonstrates favorable marginal adaptation
marginal fit. Although the VS manufactured by the 3D-printing tech- and fracture resistance even with only 0.8 mm of occlusal thickness.
334 P. Suksuphan, et al. / J Prosthodont Res. 2024; 68(2): 326–335

4) Occlusal thickness affects the fracture resistance. [15] Venturini AB, Prochnow C, Pereira GKR, Segala RD, Kleverlaan CJ, Valandro
LF. Fatigue performance of adhesively cemented glass-, hybrid- and
resin-ceramic materials for CAD/CAM monolithic restorations. Dent
Acknowledgements Mater. 2019;35:534–42. https://doi.org/10.1016/j.dental.2019.01.013,
PMID:30686711
Special thanks to Associate Professor Kamon Budsaba, Ph.D. [16] Okada R, Asakura M, Ando A, Kumano H, Ban S, Kawai T, et al. Fracture
Mathematics and Statistics for providing necessary guidance re- strength testing of crowns made of CAD/CAM composite resins. J Prostho-
garding statistics. This research was supported by the Thammasat dont Res. 2018;62:287–92. https://doi.org/10.1016/j.jpor.2017.10.003,
PMID:29605190
University Research Unit in Restorative and Esthetic Dentistry, Tham-
[17] Abd El Shakour AS, Mohsen CA, Ramzy MI. Fracture strength of two types
masat University, Pathumtani, Thailand, and the Faculty of Dentistry, of posterior occlusal veneers made of hybrid ceramics with different thick-
Srinakharinwirot University, Bangkok, Thailand (Grant contract num- nesses. Indian J Public Health Res Dev. 2020;11:913–9.
ber 545/2564). [18] Material properties data of Rigid 10K resin. Formlabs Inc.; 2020.
[19] Lin LH, Granatelli J, Alifui-Segbaya F, Drake L, Smith D, Ahmed KE. A proposed
Conflict of interest statement in vitro methodology for assessing the accuracy of three-dimensionally
printed dental models and the impact of storage on dimensional stability.
Appl Sci (Basel). 2021;11:5994. https://doi.org/10.3390/app11135994
The authors explicitly state that there are no conflicts of interest [20] Mously HA, Finkelman M, Zandparsa R, Hirayama H. Marginal and internal
related to this article. adaptation of ceramic crown restorations fabricated with CAD/CAM tech-
nology and the heat-press technique. J Prosthet Dent. 2014;112:249–56.
References https://doi.org/10.1016/j.prosdent.2014.03.017, PMID:24795263
[21] Şeker E, Ozcelik TB, Rathi N, Yilmaz B. Evaluation of marginal fit of CAD/CAM
restorations fabricated through cone beam computerized tomography
[1] Baba K. Database-driven prosthodontics-future of digital dentistry. J and laboratory scanner data. J Prosthet Dent. 2016;115:47–51. https://doi.
Prosthodont Res. 2021;65: vi–vii. https://doi.org/10.2186/jpr.JPR_65_4_ed, org/10.1016/j.prosdent.2015.08.006, PMID:26518986
PMID:34657929
[22] Groten M, Axmann D, Pröbster L, Weber H. Determination of the minimum
[2] Sidhom M, Zaghloul H, Mosleh IES, Eldwakhly E. Effect of different CAD/ number of marginal gap measurements required for practical in vitro
CAM milling and 3D printing digital fabrication techniques on the accuracy testing. J Prosthet Dent. 2000;83:40–9. https://doi.org/10.1016/S0022-
of PMMA working models and vertical marginal fit of PMMA provisional 3913(00)70087-4, PMID:10633021
dental prosthesis: an in vitro study. Polymers (Basel). 2022;14:1285. https://
[23] Pelekanos S, Koumanou M, Koutayas SO, Zinelis S, Eliades G. Micro-CT
doi.org/10.3390/polym14071285, PMID:35406159
evaluation of the marginal fit of different In-Ceram alumina copings. Eur J
[3] Ahlholm P, Lappalainen R, Lappalainen J, Tarvonen PL, Sipilä K. Challenges Esthet Dent. 2009;4:278–92. PMID:19704928
of the direct filling technique, adoption of CAD/CAM techniques, and at-
[24] Gassino G, Barone Monfrin S, Scanu M, Spina G, Preti G. Marginal adaptation
titudes toward 3D printing for restorative treatments among Finnish den-
of fixed prosthodontics: a new in vitro 360-degree external examination
tists. Int J Prosthodont. 2019;32:402–10. https://doi.org/10.11607/ijp.6343,
procedure. Int J Prosthodont. 2004;17:218–23. PMID:15119875
PMID:31486810
[25] Özcan M, Naffah N, Bassal H, Bassal H, Salameh Z. Evaluation of the adapta-
[4] Zimmermann M, Ender A, Egli G, Özcan M, Mehl A. Fracture load of CAD/
tion and fracture resistance of three CAD-CAM resin ceramics: an in vitro
CAM-fabricated and 3D-printed composite crowns as a function of mate-
study. J Contemp Dent Pract. 2019;20:571–6. https://doi.org/10.5005/jp-
rial thickness. Clin Oral Investig. 2019;23:2777–84. https://doi.org/10.1007/
journals-10024-2560, PMID:31316020
s00784-018-2717-2, PMID:30368664
[26] Oguz EI, Kılıçarslan MA, Özgür ME, Orhan K, Shujaat S. Comparison of
[5] Awada A, Nathanson D. Mechanical properties of resin-ceramic CAD/
marginal adaptation of different resin-ceramic CAD/CAM crowns: an in
CAM restorative materials. J Prosthet Dent. 2015;114:587–93. https://doi.
vitro study. Journal of Advanced Oral Research. 2021;12:112–8. https://doi.
org/10.1016/j.prosdent.2015.04.016, PMID:26141648
org/10.1177/2320206820975971
[6] Instruction for use on Varseosmile crown plus. Bremen, Germany: The
[27] Hasanzade M, Moharrami M, Alikhasi M. How adjustment could affect
BEGO company group; 2022.
internal and marginal adaptation of CAD/CAM crowns made with different
[7] Contrepois M, Soenen A, Bartala M, Laviole O. Marginal adaptation of ce- materials. J Adv Prosthodont. 2020;12:344–50. https://doi.org/10.4047/
ramic crowns: A systematic review. J Prosthet Dent. 2013;110:447–454.e10. jap.2020.12.6.344, PMID:33489018
https://doi.org/10.1016/j.prosdent.2013.08.003, PMID:24120071
[28] El Ghoul WA, Özcan M, Ounsi H, Tohme H, Salameh Z. Effect of different
[8] Yildirim G, Uzun IH, Keles A. Evaluation of marginal and internal adaptation CAD-CAM materials on the marginal and internal adaptation of endocrown
of hybrid and nanoceramic systems with microcomputed tomography: restorations: an in vitro study. J Prosthet Dent. 2020;123:128–34. https://doi.
an in vitro study. J Prosthet Dent. 2017;118:200–7. https://doi.org/10.1016/j. org/10.1016/j.prosdent.2018.10.024, PMID:31027958
prosdent.2016.11.005, PMID:28089331
[29] Habib SR, Asiri W, Hefne MJ. Effect of anatomic, semi-anatomic and non-
[9] McLean JW, von F. The estimation of cement film thickness by an in anatomic occlusal surface tooth preparations on the adaptation of zirconia
vivo technique. Br Dent J. 1971;131:107–11. https://doi.org/10.1038/ copings. J Adv Prosthodont. 2014;6:444–50. https://doi.org/10.4047/
sj.bdj.4802708, PMID:5283545 jap.2014.6.6.444, PMID:25551003
[10] Azarbal A, Azarbal M, Engelmeier RL, Kunkel TC. Marginal fit comparison [30] Dauti R, Lilaj B, Heimel P, Moritz A, Schedle A, Cvikl B. Influence of two dif-
of CAD/CAM crowns milled from two different materials. J Prosthodont. ferent cement space settings and three different cement types on the fit of
2018;27:421–8. https://doi.org/10.1111/jopr.12683, PMID:29143397 polymer-infiltrated ceramic network material crowns manufactured using
[11] Magne P, Schlichting LH, Maia HP, Baratieri LN. In vitro fatigue resistance of a complete digital workflow. Clin Oral Investig. 2020;24:1929–38. https://doi.
CAD/CAM composite resin and ceramic posterior occlusal veneers. J Pros- org/10.1007/s00784-019-03053-1, PMID:31515700
thet Dent. 2010;104:149–57. https://doi.org/10.1016/S0022-3913(10)60111-4, [31] Liu B, Lu C, Wu Y, Zhang X, Arola D, Zhang D. The effects of adhesive type
PMID:20813228 and thickness on stress distribution in molars restored with all-ceramic
[12] Björn AL, Björn H, Grkovic B. Marginal fit of restorations and its relation crowns. J Prosthodont. 2011;20:35–44. https://doi.org/10.1111/j.1532-
to peridontal bone level. I. Metal fillings. Odontol Revy. 1969;20:311–21. 849X.2010.00650.x, PMID:21073593
PMID:5262284 [32] Maneenacarith A, Rakmanee T, Klaisiri A. The influence of resin cement
[13] Rabeae HS, Mohsen CA, Amgad SW. Assessment of fracture force of CAD- thicknesses on shear bond strength of the cement-zirconia. Czas Stomatol.
CAM-fabricated occlusal veneer restorations with different thicknesses. 2022;75:7–12. https://doi.org/10.5114/jos.2022.114349
Indian J Public Health Res Dev. 2020;11:1125–30. [33] Donmez MB, Okutan Y. Marginal gap and fracture resistance of implant-
[14] Instruction for use on Cerasmart. GC America Inc.; 2014. supported 3D-printed definitive composite crowns: an in vitro study.
J Dent. 2022;124:104216. https://doi.org/10.1016/j.jdent.2022.104216,
PMID:35803388
 P. Suksuphan, et al. / J Prosthodont Res. 2024; 68(2): 326–335 335

[34] Kakinuma H, Izumita K, Yoda N, Egusa H, Sasaki K. Comparison of the ac- [44] Celebi AA, Lee SH, Kau CH. Size discrepancies in molars and first key to
curacy of resin-composite crowns fabricated by three-dimensional printing optimal occlusion. Eur J Dent. 2017;11:250–2. https://doi.org/10.4103/ejd.
and milling methods. Dent Mater J. 2022;41:808–15. https://doi.org/10.4012/ ejd_339_16, PMID:28729802
dmj.2022-074, PMID:35793943 [45] Rekow E, Harsono M, Janal M, Thompson V, Zhang G. Factorial analysis of
[35] Alharbi N, Wismeijer D, Osman R. Additive manufacturing techniques in variables influencing stress in all-ceramic crowns. Dent Mater. 2006;22:125–
Prosthodontics: where do we currently stand? A critical review. Int J Prosth- 32. https://doi.org/10.1016/j.dental.2005.04.010, PMID:16000218
odont. 2017;30:474–84. https://doi.org/10.11607/ijp.5079, PMID:28750105 [46] Thompson VP, Rekow DE. Dental ceramics and the molar crown testing
[36] Shafter M. Effect of thermocycling on flexural strength of different CAD/ ground. J Appl Oral Sci. 2004;12:26–36. https://doi.org/10.1590/S1678-
CAM material. J Dent Oral Disord. 2017;3. 77572004000500004, PMID:20959944
[37] Goujat A, Abouelleil H, Colon P, Jeannin C, Pradelle N, Seux D, et al. Mechani- [47] Scherrer SS, de Rijk WG. The fracture resistance of all-ceramic crowns on
cal properties and internal fit of 4 CAD-CAM block materials. J Prosthet supporting structures with different elastic moduli. Int J Prosthodont.
Dent. 2018;119:384–9. https://doi.org/10.1016/j.prosdent.2017.03.001, 1993;6:462–7. PMID:8297457
PMID:28552287 [48] Potiket N, Chiche G, Finger IM. In vitro fracture strength of teeth restored
[38] Lucsanszky IJR, Ruse ND. Fracture toughness, flexural strength, and flex- with different all-ceramic crown systems. J Prosthet Dent. 2004;92:491–5.
ural modulus of new CAD/CAM resin composite blocks. J Prosthodont. https://doi.org/10.1016/j.prosdent.2004.09.001, PMID:15523339
2020;29:34–41. https://doi.org/10.1111/jopr.13123 , [49] Sagsoz NP, Yanikoƒlu N, Sagsoz O. Effect of die materials on the fracture
[39] Shakibafard M, Ezoji F, Esmaeili B, Bijani A. Evaluation of the effects of differ- resistance of CAD/CAM monolithic crown restorations. Oral Health Dent
ent concentrations of bleaching agents on flexural strength and microhard- Manag. 2016;2016:165–8.
ness of Vita Enamic. Dent Res J. 2022;19:32.https://doi.org/10.4103/1735- [50] Kinney JH, Marshall SJ, Marshall GW. The mechanical properties of human
3327.344155. dentin: a critical review and re-evaluation of the dental literature. Crit Rev
[40] Grzebieluch W, Kowalewski P, Grygier D, Rutkowska-Gorczyca M, Koza- Oral Biol Med. 2003;14:13–29. https://doi.org/10.1177/154411130301400103,
kiewicz M, Jurczyszyn K. Printable and machinable dental restorative PMID:12764017
composites for CAD/CAM application—comparison of mechanical proper- [51] Sorrentino R, Nagasawa Y, Infelise M, Bonadeo G, Ferrari M. In vitro analysis
ties, fractographic, texture and fractal dimension analysis. Materials (Basel). of the fracture resistance of CAD-CAM monolithic lithium disilicate molar
2021;14:4919. https://doi.org/10.3390/ma14174919, PMID:34501009 crowns with different occlusal thickness. J Osseointegration. 2018;10:50–6.
[41] Instruction for use on Vita Enamic. Vita Zahnfabrik H, Germany. 2020. https://doi.org/10.23805/jo.2018.10.02.04
[42] Jang GW, Kim HS, Choe HC, Son MK. Fracture strength and mechanism of [52] Chaysuwan D, Sirinukunwattana K, Kanchanatawewat K, Heness G,
dental ceramic crown with zirconia thickness. Procedia Eng. 2011;10:1556– Yamashita K. Machinable glass-ceramics forming as a restorative dental
60. https://doi.org/10.1016/j.proeng.2011.04.260 material. Dent Mater J. 2011;30:358–67. https://doi.org/10.4012/dmj.2010-
[43] Chen SE, Park AC, Wang J, Knoernschild KL, Campbell S, Yang B. Fracture 154, PMID:21597218
resistance of various thickness e.max CAD lithium disilicate crowns ce- [53] Zhang YR, Du W, Zhou XD, Yu HY. Review of research on the mechanical
mented on different supporting substrates: an in vitro study. J Prosthodont. properties of the human tooth. Int J Oral Sci. 2014;6:61–9. https://doi.
2019;28:997–1004. https://doi.org/10.1111/jopr.13108, PMID:31469479 org/10.1038/ijos.2014.21, PMID:24743065

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