RESEARCH AND EDUCATION

Effect of resin cement selection on fracture resistance of

chairside CAD-CAM lithium disilicate crowns containing virgilite:
A comparative in vitro study
Carlos A. Jurado, DDS, MS,a Pranit V. Bora, BDS, MDS,b Francisco X. Azpiazu-Flores, DDS, MS, FRCD(C),c
Seok-Hwan Cho, DDS, MS,d and
Kelvin I. Afrashtehfar, DDS, MDS, MSc, Dr med dent, FCGDent, FRCD(C), FDS RCSe

ABSTRACT
Statement of problem. Studies on the fracture performance of a recently introduced computer-aided design and computer-aided
manufacturing (CAD-CAM) lithium disilicate ceramic containing virgilite with different cements are lacking.
Purpose. The purpose of this in vitro study was to evaluate the fracture resistance of crowns made of a recently introduced chairside
CAD-CAM lithium disilicate containing virgilite cemented with different types of adhesive luting cement.
Material and methods. Sixty complete coverage crowns for a maxillary right central incisor were milled out of a lithium disilicate with
virgilite (CEREC Tessera) (n=48) and a traditional lithium disilicate (e.max CAD) (n=12) using a chairside CAD-CAM system (Primescan). The
central incisor tooth preparation included a 1.5-mm incisal reduction, a 1.0-mm axial reduction, and a 1.0-mm chamfer finish line. The
restorations were bonded with different types of resin cement to 3D printed dies of the tooth preparation and were divided into 5 groups
(n=12 per group): e.max CAD with Multilink Automix (E.Mu); Tessera with Multilink Automix (T.Mu); Tessera with Calibra (T.Ca); Tessera with
Unicem (T.Un); and Tessera with Speedcem (T.Sp). The cemented restorations were stored in water for 30 days and then loaded until they
were fractured in compression. The load at fracture was analyzed with a 1-way analysis of variance (ANOVA) and the honestly significant
difference (HSD) Tukey test (α=.05).
Results. The mean fracture resistance of traditional lithium disilicate and virgilite lithium disilicate anterior crowns significantly differed
depending on the type of resin cement used (P<.05). Group E.Mu displayed the highest values (946.35 ±155 N), followed by group T.Un
(819.59 ±232 N), group T.Sp (675.52 ±153 N), and group T.Mu (656.95 ±193 N). The lowest values were displayed by group T.Ca
(567.94 ±184 N).
Conclusions. The fracture resistance of lithium disilicate containing virgilite and traditional lithium disilicate crowns cemented with the
same cement displayed statistically similar values. However, significant differences were observed when the virgilite lithium disilicate
crowns were cemented with different types of adhesive luting cement. The crowns in the T.Ca group displayed the lowest fracture
resistance. (J Prosthet Dent xxxx;xxx:xxx-xxx)

Funding: Supported by Universität Bern (Berne, Switzerland) for Open Access publication funding.
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
a
Clinical Associate Professor, Department of Prosthodontics, The University of Iowa College of Dentistry and Dental Clinics, Iowa City, Iowa.
b
Resident, Master of Sciences in Dental Materials Program, School of Dentistry, University of Alabama at Birmingham, Birmingham, Ala.
c
Assistant Professor, Department of Restorative Dentistry, Gerald Niznick College of Dentistry, University of Manitoba, Winnipeg, Manitoba, Canada; ITI Scholar,
Department of Prosthodontics, Indiana University School of Dentistry, Indianapolis, Ind.
d
Associate Professor and Department Chair, Department of Prosthodontics, The University of Iowa College of Dentistry and Dental Clinics, Iowa City, Iowa.
e
Assistant Professor and Director of Evidence-Based Practice Unit, Clinical Sciences Department, College of Dentistry, Ajman University, Ajman City, AE, United Arab
Emirates; Adjunct Research Professor, Department of Reconstructive Dentistry and Gerodontology, School of Dental Medicine, University of Bern, Bern, Switzerland;
Senior Scientific Researcher, Artificial Intelligence Research Center (AIRC), Ajman University, Dubai, United Arab Emirates; and Visiting Professor, Department of
Prosthodontics, College of Dentistry, Yonsei University, Seoul, Republic of Korea.

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for a ceramic crown with 1.5-mm incisal clearance,

Clinical Implications 1.0-mm axial reduction, and a 1.0-mm chamfer finish
Traditional lithium disilicate ceramics demonstrate margin. The typodont tooth was scanned with a chair­
higher fracture resistance than lithium disilicate side scanner (Primescan; Dentsply Sirona), and a com­
plete coverage single crown was digitally designed to
with virgilite ceramics for anterior crowns. The resin
cement type influenced fracture resistance. the dimensions of the original typodont tooth. Sixty
complete coverage restorations were milled (CEREC
Primemill; Dentsply Sirona): 48 lithium disilicate with
Recent versions of lithium disilicate ceramics, such as the virgilite (Cerec Tessera A1, Medium Translucency, C14;
one containing virgilite (Cerec Tessera; Dentsply Sirona), Dentsply Sirona) and 12 lithium disilicate (IPS e.max
CAD, A1, Medium Translucency, C14; Ivoclar AG). The
have been developed for chairside computer-aided design
and computer-aided manufacturing (CAD-CAM) systems restorations were glazed and fired (Programat S2; Ivoclar
to improve esthetic and mechanical properties.1–3 Cerec AG) according to the manufacturer's recommendations
and polished using a lithium disilicate polishing system
Tessera is composed of lithium disilicate (Li2Si2O5) and
virgilite (Li0.5AI0.5Si2.5O6) crystals, with a 0.5-μm-long (e.max Finishing/Polishing System; Brasseler). The typo­
needle-like shape embedded in a zirconia glass matrix. This dont tooth was scanned with a laboratory scanner
(Freedom HD; DOF Inc.), and 60 dies were printed from
ceramic is supplied partially crystallized, with a shortened
sintering process time. Although the manufacturer claims a resin cast using a 3D dental printer (Gray Resin V4,
better mechanical properties than those of traditional li­ FormLab 3B; Formlabs), washed (From Wash; Formlabs)
thium disilicate, limited independent data is available.3 for 15 minutes with isopropyl alcohol, and polymerized
An understanding of the cements and adhesive sys­ (Form Cure; Formlabs). The crowns were divided into 12
tems used to bond glass-ceramic restorations is important specimens per group, and their intaglio surfaces were
to clinical success.4–6 Resin cements for glass ceramics treated according to the manufacturers' recommenda­
have different properties, numbers of application steps, tions (Tables 1, 2).
Before fracture testing, the restorations were im­
viscosities, and light polymerization needs and are either mersed in water at 37 °C for 30 days to simulate the oral
self-etching or self-adhesive. Given the wide range of
environment's aging effects. The specimens were then
ceramics and cementation techniques available,7–18 resin placed in a vertical position, secured in a brass fixture,
cement selection can be challenging for inexperienced and loaded against a Ø8-mm stainless-steel ball. A
clinicians. Therefore, this study aimed to compare the
1.0-mm rubber sheet was placed between the ball and
fracture resistance of maxillary right central incisor the restorations to distribute the incisal forces. The ball
crowns made with a virgilate-containing lithium disilicate was placed on the incisal edge of the crown. The crowns
ceramic (Cerec Tessera; Dentsply Sirona) cemented with
were loaded at 1.0 mm/min with a universal testing
4 different resin cements with a traditional lithium dis­ machine (Model 44111; Instron) until fracture, recorded
ilicate (e.max CAD; Ivoclar AG) as a control. The null with a 25% reduction in load. The crowns were in­
hypotheses were that no difference would be found in the
spected to ensure that fracture had occurred, and the
fracture resistance of the crowns fabricated with the 2 fracture load was recorded as the maximum compressive
lithium disilicates or cemented with the 4 resin cements. force.19,20
The data were analyzed using a 1-way analysis of
variance (ANOVA) and the honestly significant differ­
MATERIAL AND METHODS
ence (HSD) Tukey post hoc test (α=.05). All statistical
A typodont tooth of a maxillary right central incisor analyses were performed using a statistical software
(1560 Dentoform; Columbia Dentoform) was prepared program (IBM SPSS Statistics, v25; IBM Corp).

Table 1. Description of chairside CAD-CAM ceramics tested19

Group Ceramic Type Manufacturer Date Released to Market Composition of Ceramics
E.Mu (control) e.max CAD Ivoclar AG 2006 Approximately 65 vol% of lithium disilicate
(Li2O•2SiO2) as principal crystal phase, and
30 vol% glass base.
T.Mu, T.Ca, T.Un, and T.Sp Cerec Tessera Dentsply Sirona 2022 Lithium aluminum silicate virgilite crystals.
Specific details of composition not disclosed by
manufacturer.
CAD-CAM, computer-aided design and computer-aided manufacture; E.Mu, e.max CAD with Multilink Automix; T.Ca, Tessera with Calibra; T.Sp,
Tessera with Speedcem; T.Mu, Tessera with Multilink Automix; T.Un, Tessera with Unicem.

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Month xxxx 3

BHT, butylated hydroxytoluene; DDDMA, 1,10-decanediol dimethacrylate; E.Mu, e.max CAD with Multilink Automix; MDP, methacryloyloxydecyl dihydrogenphosphate; HEMA, 2-hydroxyethyl
methacrylate; PEGDMA, polyethylene glycol dimethacrylate; T.Ca, Tessera with Calibra; TEGDMA, triethyleneglycol dimethacrylate; T.Sp, Tessera with Speedcem; T.Mu, Tessera with Multilink
RESULTS

Restoration prepared similarly to Groups E.Mu and

Restoration prepared similarly to Groups E.Mu and

Restoration prepared similarly to Groups E.Mu and

preparation surfaces with slight pressure for 15 s
Restoration etched with 5% hydrofluoric acid for

Monobond Plus applied to intaglio surface and

Cement dispensed directly into restoration and

2 coats of Prime & Bond Active coupling agent

Cement applied to restoration and seated with

Cement applied to restoration and seated with

Cement applied to restoration and seated with

Mixed Multilink Primers A/B applied to all Table 3 displays the fracture resistance results. The mean
fracture load of traditional lithium disilicate and lithium

applied to intaglio surface of restoration.

disilicate containing virgilite for anterior crowns sig­
nificantly differed depending on the resin cement used.
seated with steady vertical force.

Group e.max CAD with Multilink (E.Mu) had the

20 s and rinsed thoroughly.

highest values, whereas the lowest values were in the

allowed to react for 60 s

group Tessera with Calibra (T.Ca). Statistical differences
Application Method

steady vertical force.

steady vertical force.

steady vertical force.

between groups are presented in Table 3, and detailed
information on pairwise comparisons is available in
Supplemental Table 1 (available online).
T.Mu*

T.Mu*

T.Mu*

DISCUSSION
UDMA, di- and tri-methacrylate, phosphoric acid modified acrylate, initiators, accelerators,

Methacrylate phosphoric esters, dimethacrylate, acetate, initiators, stabilizers, glass fillers,

MultiLink Automix Cement: Dimethacrylate and HEMA, barium glass, ytterbium trifluoride,

The present comparative in vitro study aimed to de­

Multilink Primer A and B: Multilink Primer A: Aqueous solution of proprietary initiators.

UDMA, TEGDMA, PEGDMA, DDDMA, MDP, dibenzoyl peroxide, stabilizers, barium glass

termine whether the type of cement used for lithium

stabilizer, BHT, Barium boron fluoroaluminosilicate and amorphous silicon dioxide

disilicate-containing virgilite and traditional lithium

disilicate crowns affected their fracture resistance. The
null hypothesis that there would be no difference in
Multilink Primer B: HEMA, phosphonic acid and acrylic acid monomers.

fracture resistance between crowns fabricated with li­

thium disilicate and virgilite lithium disilicate with 1
control cement, was rejected. Group E.Mu lithium dis­
ilicate crowns displayed significantly different values
(P=.003) compared with lithium disilicate crowns with
virgilite cemented with the same cement (Multilink
Self-adhesive dual-polymerizing resin cement.

Self-adhesive dual-polymerizing resin cement.

Self-adhesive dual-polymerizing resin cement.

Automix). The null hypothesis that there would be no

difference in fracture strength between the lithium dis­
Composition of the Luting Cement

ilicate crowns containing virgilite cemented with 4 dif­

Dual-polymerized resin cement.

ferent resin cements was also rejected. Significant

and silica ytterbium trifluoride
silica, and calcium hydroxide

differences were found among groups, with group E.Mu

having the highest values, followed by group Tessera
spheroid mixed oxide.

with Unicem (T.Un), Tessera with Speedcem (T.Sp), and

Tessera with Multilink Automix (T.Mu), and the lowest
value being found in group T.Ca (Table 3).
Automix; T.Un, Tessera with Unicem; UDMA, urethane dimethacrylate.

A maxillary right central incisor was selected in this

study because it is in the esthetic zone, and lithium
disilicate ceramic crowns are popular for restoring
maxillary anterior teeth to improve esthetic outcomes.7–9
Dentsply Sirona
Manufacturer

A national dental practice-based study that surveyed

Ivoclar AG

Ivoclar AG

American dentists found that ceramics are the most

Table 2. Description of resin cements tested15–17

prevalent materials used for anterior crowns, with li­

3M

thium disilicate as the first option (54%), followed by

porcelain-fused-to-zirconia (17%) and leucite-re­
inforced ceramic (13%).10 A recent German survey also
Multilink Automix
Type of Cement

showed that lithium disilicate is the most common

ceramic choice for maxillary right central incisor crowns
Speedcem
Unicem

(46.7% supragingival margin), followed by porcelain-

Calibra

fused-to-zirconia (28.9% supragingival margin) and zir­

conia-reinforced lithium disilicate (13.0% supragingival
margin).11
The authors are unaware of previous studies that
and T.Mu

assessed the fracture resistance of anterior restorations

Group
E.Mu

T.Un

made of traditional and virgilate-containing lithium

T.Ca

T.Sp

disilicate ceramics. The results of the present study

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4 Volume xxx Issue xx

Table 3. Mean fracture resistance of chairside CAD-CAM lithium disilicate ceramic crowns with different resin cements
Group Ceramic Type (Manufacturer) Cement Type (Manufacturer) Mean ±Standard Deviation Force at Complete Fracture (N)
E.Mu e.max CAD Multilink Automix 946.35 ±155.85a,b,d
T.Mu Cerec Tessera Multilink Automix 656.95 ±193.31a
T.Ca Cerec Tessera Calibra 567.943 ±184.95b,c
T.Un Cerec Tessera Unicem 819.59 ±232c
T.Sp Cerec Tessera Speedcem 675.52 ±153.13d
CAD-CAM, computer-aided design and computer-aided manufacture; E.Mu, e.max CAD with Multilink Automix; SD, standard deviation; T.Ca,
Tessera with Calibra; T.Sp, Tessera with Speedcem; T.Mu, Tessera with Multilink Automix; T.Un, Tessera with Unicem.
Same lowercase letter in column indicates significant difference (P<.05).
For detailed information on pairwise comparisons, see Supplemental Table 1 (available online).

showed that, compared with Cerec Tessera, e.max CAD can withstand up to 3765 N. However, the crowns with
presented similar values for group T.Un but higher va­ RMGIC did not withstand the mastication process before
lues for groups T.Mu, T.Ca, and T.Un. These mixed re­ the fracture testing.21 A study18 evaluating the fracture
sults were consistent with those of recent studies toughness of flat lithium disilicate specimens with air­
comparing traditional and recently introduced lithium borne-particle abraded and etched treatment with dif­
disilicate ceramics on posterior teeth, including a study12 ferent types of resin cement evaluated 2 dual-
that evaluated the fracture resistance of molar crowns polymerizing resin cements (Panavia F2; Kuraray Dental,
made of lithium disilicate containing virgilite (Cerec and Variolink II; Ivoclar AG) and 1 self-adhesive resin
Tessera) versus lithium disilicate (e.max CAD) cemented cement (Multilink Sprint; Ivoclar AG), reporting sig­
with adhesive resin cement (AB), glass-ionomer (GIC), nificant differences among them: Variolink II (S: 372 J/m2;
and hybrid glass-ionomer cement (HGIC). The authors E: 470 J/m2), Panavia F2 (S: 374 J/m2; E: 805 J/m2), and
reported no significant differences in fracture force va­ Multilink Sprint (S: 33 J/m2; E: 357 J/m2).18 The authors
lues between the 2 ceramics (2101 ±752 N for AB; 2808 concluded that the fracture toughness of lithium disilicate
±1162 N for GIC; 2579 ±783 N for HGIC for Cerec glass-ceramic was affected by the surface treatment and
Tessera and 2529 ±468 N for AB; 2995 ±880 N for GIC; type of luting agent.18
2598 ±614 N for HGIC for e.max CAD). Similarly, an­ Limitations of the present study included the use of
other study13 that evaluated the fracture resistance of resin dies instead of natural dentition; although resin
lithium disilicate strengthened with aluminosilicate dies have been used in several in vitro studies,5,19,20
(n!ce; Institut Straumann AG) and traditional lithium natural teeth should yield more clinically realistic results.
disilicate (e.max CAD; Ivoclar AG) for molar crowns In addition, only 1 new type of lithium disilicate ceramic
reported no significant differences between the newer was tested. Future studies should evaluate more options
glazed ceramic (1324 ±498 N) and the traditional for dental clinicians. Lastly, this study only evaluated the
ceramic (1550 ±317 N), concluding that their survival fracture resistance of maxillary central incisor crowns.
rate was comparable. Other anterior teeth (such as canines) could also be
The fracture resistance of the lithium disilicate max­ evaluated to provide more information regarding the
illary anterior crowns containing virgilite cemented with behavior of the ceramic.
different types of resin cement displayed significant dif­
ferences. The cements used in this study are commonly
used in clinical practice.15–17 However, the authors are CONCLUSIONS
unaware of studies evaluating the fracture resistance of
Based on the findings of this in vitro study, the following
virgilate-containing lithium disilicate ceramics for anterior
conclusions were drawn:
crowns with different types of cement, although studies
have evaluated traditional lithium disilicate posterior 1. Lithium disilicate ceramics exhibited higher frac­
crowns.19–21 The present study was consistent with pre­ ture resistance compared with lithium disilicate
vious in vitro studies18–21 reporting differences in fracture ceramics containing virgilite.
resistance using different dental cements. One study21 2. The fracture resistance of maxillary central incisor
evaluated the fracture resistance of chairside milled li­ crowns made with lithium ceramics containing
thium disilicate (e.max CAD; Ivoclar AG) molar crowns virgilite was influenced by the type of cement used.
cemented with resin-modified GIC (RMGIC) (RelyX 3. The choice of cement used for anterior teeth with
Luting Plus; 3M) and resin cement (RelyX Unicem 2; 3M) glass-ceramic restorative materials should be con­
after 100 000 mastication cycles at 100 N. The results sidered to ensure optimal performance of these
suggested that the crowns cemented with resin cement restorations.

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Month xxxx 5

APPENDIX A. SUPPORTING INFORMATION 15. Chiayi S, et al. Phillips' Science of Dental Materials. 13th ed.. Elsevier; 2022.
16. Ling L, Ma Y, Chen Y, Malyala R. Physical, mechanical, and adhesive properties
Supplemental data associated with this article can be of novel self-adhesive resin cement. Int J Dent. 2022;2022:4475394.
17. Ellakany P, Madi M, Aly NM, Alshehri T, Alameer ST, Al-Harbi FA.
found in the online version at doi:10.1016/j.prosdent. Influences of different CAD/CAM ceramic compositions and thicknesses on
2023.08.019. the mechanical properties of ceramic restorations: An in vitro study.
Materials (Basel). 2023;16:646.
18. Hooshmand T, Rostami G, Behroozibakhsh M, Fatemi M, Keshvad A, van
Noort R. Interfacial fracture toughness of different resin cements bonded to
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