materials

Article
Mechanical Behavior of Different Restorative Materials and
Onlay Preparation Designs in Endodontically Treated Molars
Ana Beatriz Gomes de Carvalho 1 , Guilherme Schmitt de Andrade 1 , João Paulo Mendes Tribst 2 ,
Elisa Donária Aboucauch Grassi 1 , Pietro Ausiello 3, *, Guilherme de Siqueira Ferreira Anzaloni Saavedra 1 ,
Adriano Bressane 4 , Renata Marques de Melo 1 and Alexandre Luiz Souto Borges 1

1 Department of Dental Materials and Prosthodontics, Institute of Science and Technology,

São Paulo State University (Unesp), São José dos Campos 12245-000, Brazil;
[email protected] (A.B.G.d.C.); [email protected] (G.S.d.A.);
[email protected] (E.D.A.G.); [email protected] (G.d.S.F.A.S.);
[email protected] (R.M.d.M.); [email protected] (A.L.S.B.)
2 Graduate Program in Dentistry, Department Dentistry, University of Taubate (UNITAU),
Taubate 12020-270, Brazil; [email protected]
3 Department of Neurosciences, Reproductive and Odontostomatological Sciences, School of Dentistry,
University of Naples Federico II, 80138 Naples, Italy
4 Graduate Oral Health Applied Science, Institute of Science and Technology,
São Paulo State University (Unesp), São José dos Campos 12245-000, Brazil; [email protected]
* Correspondence: [email protected]






Abstract: This study evaluated the effect of the combination of three different onlay preparation
Citation: Gomes de Carvalho, A.B.; designs and two restorative materials on the stress distribution, using 3D-finite element analysis.
de Andrade, G.S.; Mendes Tribst, J.P.;
Six models of first lower molars were created according to three preparation designs: non-retentive
Grassi, E.D.A.; Ausiello, P.; Saavedra,
(nRET), traditional with occlusal isthmus reduction (IST), and traditional without occlusal isthmus
G.d.S.F.A.; Bressane, A.; Marques de
reduction (wIST); and according to two restorative materials: lithium-disilicate (LD) and nanoceramic
Melo, R.; Borges, A.L.S. Mechanical
resin (NR). A 600 N axial load was applied at the central fossa. All solids were considered isotropic,
Behavior of Different Restorative
Materials and Onlay Preparation
homogeneous, and linearly elastic. A static linear analysis was performed, and the Maximum
Designs in Endodontically Treated Principal Stress (MPS) criteria were used to evaluate the results and compare the stress in MPa on
Molars. Materials 2021, 14, 1923. the restoration, cement layer, and tooth structure (enamel and dentin). A novel statistical approach
https://doi.org/10.3390/ was used for quantitative analysis of the finite element analysis results. On restoration and cement
ma14081923 layer, nRET showed a more homogeneous stress distribution, while the highest stress peaks were
calculated for LD onlays (restoration: 69–110; cement layer: 10.2–13.3). On the tooth structure, the
Academic Editor: Claudio Poggio material had more influence, with better results for LD (27–38). It can be concluded that nRET design
showed the best mechanical behavior compared to IST and wIST, with LD being more advantageous
Received: 18 March 2021
for tooth structure and NR for the restoration and cement layer.
Accepted: 7 April 2021
Published: 12 April 2021
Keywords: mechanical stress; finite element analysis; dental onlays; dental prosthesis; dental materials

Publisher’s Note: MDPI stays neutral

with regard to jurisdictional claims in
published maps and institutional affil-
1. Introduction
iations.
Onlay is defined as “partial-coverage restoration that restores one or more cusps and
adjoining occlusal surfaces or the entire occlusal surface and is retained by mechanical or
adhesive means” [1]. Despite the excellent performance of onlays and metal crowns [2,3],
Copyright: © 2021 by the authors.
the demand for materials that increasingly meets the aesthetic demand presses for the
Licensee MDPI, Basel, Switzerland.
development of new materials. The advent of enamel etching in the mid-twentieth cen-
This article is an open access article
tury [4], dentin adhesion in the 1970s [5], and the development of hydrofluoric acid etching
distributed under the terms and of dental porcelains [6] made it possible to perform indirect adhesive partial restorations,
conditions of the Creative Commons such as laminate veneers, inlays, and onlays.
Attribution (CC BY) license (https:// Partial-coverage adhesive restorations are a good alternative to full crowns on the
creativecommons.org/licenses/by/ treatment posterior teeth with great loss of dental structure [7–9]. Since onlay preparation
4.0/). limits are cavity-dependent [10], the preparation is less aggressive, removing less sound

Materials 2021, 14, 1923. https://doi.org/10.3390/ma14081923 https://www.mdpi.com/journal/materials

Materials 2021, 14, 1923 2 of 13

dental structure than a full crown [10–12]. The onlays are indicated when the tooth
presents a great loss of coronary structure with less than 1.5 mm of thickness in the cusps;
it is recommended to re-perform its covering, which can be total or partial, according
to the coronary involvement [13,14]. Unlike onlays, restorations known as “tabletop”
are indicated when there is structural loss due to erosion or wear in the occlusion, with
indication for minimal or no preparation [15].
Dental materials technology evolved since the advent of partial adhesive restorations
with the development of high-performance dental ceramics, indirect composite resin [16,17],
CAD-CAM (Computer Aided Design-Computer Aided Manufacturing) systems [18], and
reliable adhesive systems [19,20]. Thus, dental ceramics have become very popular; in addi-
tion, the evolution of these materials allows for the optimization of optical and mechanical
properties of restorations, popularizing their use among clinicians and researchers [21–23].
Regarding restorative materials, ceramics and composites are the most used today for
onlay manufacturing, as they present relatively compatible survival rates [24,25]. Com-
posite resin seems to be indicated especially in patients with high masticatory forces and
suspected parafunctional habits such as bruxism [26]. On the other hand, because they are
more rigid, ceramic onlays have the ability to mimic tooth enamel, creating a restoration
with mechanical behavior similar to the intact teeth [27].
In contrast, the concept of dental preparation has barely evolved [28,29]. The major
differences between traditional ceramic and alloy preparations are that: the walls of the
dental preparation must be more expulsive; box shapes may be present; grooves and sharp
angles must be avoided; and bevels are not indicated [30]. However, with new materials
and with the reliability of adhesive procedures, retention and resistance forms of cavity
preparations can be questioned [27–29,31], since these forms are acquired at the expense of
wear of sound dental structure.
The adhesive cementation process makes the restoration, adhesive layer, and tooth
become a strong biomechanical unit, improving stress distribution [29]. Thus, some authors
recently proposed new preparation designs for partial-coverage restorations, associating
minimally invasive dentistry with a better force distribution in the remaining tooth struc-
ture [28,29,31–33]. Basically, for onlay restorations, it is possible to perform three different
types of preparation: (1) Traditional onlay preparation, which is characterized by 6–10 de-
grees axial walls, rounded internal angles, at least 2 mm occlusal isthmus, proximal boxes,
and chamfer cusp coverage [34]; (2) The Morphology Drive Preparation Technique [28],
which is a preparation technique in which the occlusal reduction is guided by tooth mor-
phology without isthmus preparation, and the preparation also contain butt-joint margins
in the proximal box; (3) and Simplified Non-retentive Tooth Preparation, which consists of
2 mm occlusal reduction, a U-shaped proximal box with smooth transition, and an oblique
bevel in the cavosurface angles [29].
For studies like this, Finite element analysis (FEA) recently demonstrated great rel-
evance in dentistry, since it makes it possible to predict the mechanical and structural
behavior of materials through a non-destructive and mathematical approach [26,35–37].
To date, few studies have evaluated the effect of the design of different full-coverage
onlay preparations. Regarding the polymerization shrinkage stress, a study compared three
types of preparations and concluded that less retentive preparations tend to reduce the
polymerization shrinkage stress [38]. This same result was obtained in relation to fracture
resistance. When comparing different preparation geometries, the teeth that presented both
the least invasive and retentive preparations proved to be more resistant to fracture [39]; in
addition, both lithium-disilicate and leucite-reinforced glass ceramic restorations appear
to be promising for clinical application in preparations without retention forms [40]. For
marginal adaptation, teeth with the most complex preparation design showed inferior
marginal adaptation when compared to those with more simplified and less retentive ge-
ometries [41]. Clinically, the studies that evaluated the execution of restorative treatments
with preparations without emphasis on the retention method were promising, recommend-
ing more and more the importance of the conservation of the remaining healthy dental
 Materials 2021, 14, x FOR PEER REVIEW 3 of 13

Materials 2021, 14, 1923 3 of 13

of restorative treatments with preparations without emphasis on the retention method

were promising, recommending more and more the importance of the conservation of
the remaining
structure healthy
[28], both dental
for resin andstructure
ceramic [28], both for[10,11].
restorations resin and ceramic restorations
The guidelines for these
[10,11]. The guidelines for these preparations are introduced in
preparations are introduced in critical literature reviews [29,31,34]; even so, critical literature reviews
it is advisable
[29,31,34]; even so, it is advisable to carry
to carry out a long-term control of these restorations.out a long-term control of these restorations.
Basedon
Based onthis,
this,the
theaimaimofof this
this study
study waswas to evaluate
to evaluate the effect
the effect of preparation
of preparation designdesign
and
and restorative
restorative materialmaterial combination
combination ondistribution
on stress stress distribution at the restoration,
at the restoration, tooth
tooth structure,
structure,
and andinterface,
adhesive adhesiveusing interface, using
the finite the finite
element element
analysis analysis
(FEA). (FEA).
The first nullThe first null
hypothesis
hypothesis is that the preparation design will not affect the stress distribution
is that the preparation design will not affect the stress distribution on restoration, cement on resto-
ration, cement layer, and tooth structure; the second null hypothesis is
layer, and tooth structure; the second null hypothesis is that the restorative material willthat the restora-
tiveaffect
not material will not affect
the analyzed the analyzed structures.
structures.

2.2.Materials
Materialsand
andMethods
Methods
The study
The study followed a 33 ××2 2factorial
factorialdesign,
design, considering
considering thethe factors’
factors’ preparation
preparation de-
design: non-retentive
sign: non-retentive adhesive
adhesive preparation
preparation (nRET)
(nRET) [29],[29], traditional
traditional all-ceramic
all-ceramic onlayonlay
prep-
preparation
aration withwith occlusal
occlusal isthmus
isthmus reduction(IST)
reduction (IST)[42],
[42],and
and traditional all-ceramic
all-ceramic onlay
onlay
preparation
preparationwithout
withoutocclusal
occlusalisthmus
isthmusreduction
reduction(wIST)
(wIST)[28,42];
[28,42];and
andthe
theonlay
onlayrestorative
restorative
material:
material:lithium-disilicate
lithium-disilicate(LD)
(LD)and andCAD-CAM
CAD-CAMnanoceramic
nanoceramicresinresin(NR)
(NR)(Figure
(Figure1).
1).

Figure1.1.Study
Figure Studygroups.
groups.Factor
Factorpreparation
preparationdesign:
design:nRET—Non
nRET—Non retentive
retentive adhesive
adhesive preparation;
preparation; IST—
IST—traditional all-ceramic onlay preparation design with occlusal isthmus reduction;
traditional all-ceramic onlay preparation design with occlusal isthmus reduction; wIST—traditional
wIST—traditional all-ceramic onlay preparation without occlusal isthmus reduction. Factor onlay
all-ceramic onlay preparation without occlusal isthmus reduction. Factor onlay restorative material:
restorative material: lithium-disilicate (LD); nanoceramic resin (NR).
lithium-disilicate (LD); nanoceramic resin (NR).

Toobtain
To obtainthethemodels
models forfor finite
finite element
element analysis
analysis (FEA),
(FEA), all preparations
all preparations were were exe-
executed
cuted on a lower right first molar typodont (MOM, Marília, São Paulo,
on a lower right first molar typodont (MOM, Marília, São Paulo, Brazil), according to Brazil), according
to following
the the following
recommendations:recommendations: simplified preparation
simplified non-retentive non-retentive preparation
(nRET)—occlusal
(nRET)—occlusal reduction following the natural tooth morphology
reduction following the natural tooth morphology (2 mm on functional cups, 1.5 (2 mm on functional
mm on
cups, 1.5 mm cusp),
non-functional on non-functional cusp), no all
no isthmus preparation, isthmus
angles preparation, all angles
and walls smoothed andand walls
rounded,
smoothed proximal
U-shaped and rounded, U-shaped
box with smoothproximal
transition,boxand
with smooth
oblique transition,
bevel and oblique
in the cavosurface
bevel [29,38];
angles in the cavosurface angles with
traditional overlay [29,38]; traditional
isthmus overlay
preparation with isthmus
(IST)—occlusal preparation
reduction fol-
(IST)—occlusal
lowing the natural reduction following (2
tooth morphology themmnatural tooth morphology
on functional cups, 1.5 mm (2 on
mmnon-functional
on functional
cups, 1.5
cusp), mm on
isthmus non-functional
preparation of 2 ×cusp),
2 mm, isthmus
proximalpreparation of 2 ×of2 1mm,
box thickness mm,proximal
chamferbox
of
1thickness
mm in the of axial
1 mm,walls,
chamfer
andof an1 overall
mm in preparation
the axial walls, andofan6–10
angle ◦
overall preparation
toward angle
the occlusal
of 6–10°
aspect toward
[38,43]; andthe occlusal onlay
traditional aspectwithout
[38,43];isthmus
and traditional onlay
preparation without isthmusprepa-
(wIST)—butt-joint prep-
ration in the proximal box with 1 mm of thickness, interior walls diverging 6–10◦ , occlusal
anatomy reduction following fissure directions and the resulting proportion of the cusps
Materials 2021, 14, x FOR PEER REVIEW 4 of 13
Materials 2021, 14, x FOR PEER REVIEW 4 of 13

Materials 2021, 14, 1923

aration (wIST)—butt-joint preparation in the proximal box with 1 mm of thickness,4 of 13
inte-
aration (wIST)—butt-joint preparation in the proximal box with 1 mm of thickness, inte-
rior walls diverging 6–10°, occlusal anatomy reduction following fissure directions and
rior walls diverging 6–10°, occlusal anatomy reduction following fissure directions and
the resulting proportion of the cusps (2 mm on functional cups, 1.5 mm on non-functional
the resulting proportion of the cusps (2 mm on functional cups, 1.5 mm on non-functional
cusp),
(2 mm on and chamfer preparation of 1 mm on the axial walls [28,38,42]. For the standardi-
cusp), andfunctional cups, 1.5 mm
chamfer preparation of on
1 mmnon-functional
on the axial cusp), and chamfer
walls [28,38,42]. Forpreparation
the standardi-of
zation
1zation of
mm onofthethe preparation’s
axial walls extension,
[28,38,42]. For a
the silicone matrix
standardization was
of made
the and used extension,
preparation’s to mark the a
the preparation’s extension, a silicone matrix was made and used to mark the
limits ofmatrix
silicone extracoronary
was made preparations
and used to with
mark athe
brush pen.
limits of extracoronary preparations with a
limits of extracoronary preparations with a brush pen.
An
brushAn unprepared typodont and the prepared ones were digitally impressed with an
pen.
unprepared typodont and the prepared ones were digitally impressed with an
intraoral scanner (CS 3600, Carestream, Nova York, NY, USA). The 3D “.stl” (file exten-
intraoral scanner (CStypodont
An unprepared and the prepared
3600, Carestream, Nova York,onesNY,were digitally
USA). The 3Dimpressed with
“.stl” (file an
exten-
sion) mesh
intraoral was
scanner exported to Non-Uniform Rational Basis Spline (NURBS) modeling
sion) mesh was (CS 3600, Carestream,
exported to Non-Uniform Nova York, NY, USA).
Rational Basis The 3D “.stl”
Spline (NURBS)(file extension)
modeling
software
mesh was(Rhinoceros
exported to6.0SR8, McNell Rational
Non-Uniform North America, Seattle,
Basis Spline WA, USA).
(NURBS) Then, following
modeling software
software (Rhinoceros 6.0SR8, McNell North America, Seattle, WA, USA). Then, following
the BioCAD6.0SR8,
(Rhinoceros technique [44],North
McNell an intact toothSeattle,
America, was designed.
WA, USA). TheThen,
root,following
pulp, andthe dentin
Bio-
the BioCAD technique [44], an intact tooth was designed. The root, pulp, and dentin
morphology
CAD technique were
[44],estimated basedwas
an intact tooth on designed.
common The toothroot,
anatomy
pulp, and[45,46].
dentinAnmorphology
endodontic
morphology were estimated based on common tooth anatomy [45,46]. An endodontic
treatment
were (crown-down
estimated technique
based on common with
tooth 4% conicity,
anatomy [45,46].25%
An tapering),
endodontica treatment
large class(crown-
II me-
treatment (crown-down technique with 4% conicity, 25% tapering), a large class II me-
sio-occluso-distal)
down technique with (MOD) cavity with
4% conicity, 25% 2tapering),
± 0.5 mma thickness
large classofIIremaining wall, and a
mesio-occluso-distal)
sio-occluso-distal) (MOD) cavity with 2 ± 0.5 mm thickness of remaining wall, and a
composite
(MOD) cavityresin
with 2 ± 0.5 mm
build-up werethickness
generated ofin order to wall,
remaining simulate
and aa clinical
compositecondition of tooth
resin build-up
composite resin build-up were generated in order to simulate a clinical condition of tooth
structure
were loss. in order to simulate a clinical condition of tooth structure loss.
generated
structure loss.
The
The3D 3D“.stl”
“.stl”mesh
meshobtained
obtainedfromfromthethedigital
digitalimpression
impressionof ofthe
thepreparations
preparationsmade madein in
The 3D “.stl” mesh obtained from the digital impression of the preparations made in
the
thetypodont
typodontwas wasused
usedforformodelling
modellingthe thepreparation
preparationdesigns
designs(Figure
(Figure2).
2).Then,
Then,aaBoolean
Boolean
the typodont was used for modelling the preparation designs (Figure 2). Then, a Boolean
subtraction
subtractionwas wasperformed
performedonon thethe
MOD MOD restored tooth
restored obtained
tooth obtainedby the
byBioCAD
the BioCAD technique
tech-
subtraction was performed on the MOD restored tooth obtained by the BioCAD tech-
(Figure 3). The 3).
nique (Figure external layer oflayer
The external the onlay
of thepreparation was duplicated
onlay preparation and used
was duplicated andasused
a base as
nique
for (Figure a3).100-micron
modelling The external layer of the
cementing layeronlay preparation
thickness. This was
step duplicated
was repeated andfor
used
eachas
a base for modelling a 100-micron cementing layer thickness. This step was repeated for
a base for modelling
preparation design. a 100-micron cementing layer thickness. This step was repeated for
each preparation design.
each preparation design.

Figure2.2. (a)
Figure (a) Typodont digital impression
impression of
of the
theintact
intacttooth;
tooth;(b)
(b)digital
digitalmodelling
modellinginin NURBS
NURBSof of
thethe
intact tooth
intact with
tooth an-
with
Figure 2. (a) Typodont digital impression of the intact tooth; (b) digital modelling in NURBS of the intact tooth with an-
atomic
anatomicdental structures;
dentalstructures; (c) MOD
structures;(c)(c)MOD cavity
MODcavity simulation;
cavitysimulation; (d)
simulation;(d) Structures
(d)Structures of the
Structuresofofthe final
thefinal model.
finalmodel.
model.
atomic dental

Figure 3. Steps for obtaining FEA preparations models: (a) onlay dental preparation on typodont;
Figure 3.
3. Steps for obtaining FEA preparations models: (a)
(a)onlay dental
dentalpreparation on
ontypodont;
(b) virtualSteps
Figure modelforobtained
obtaining
byFEA preparations
digital impression;models: onlay
(c) designing preparation
of preparations typodont;
using BioCAD
(b) virtual model obtained by digital impression; (c) designing of preparations using BioCAD
(b) virtual model obtained by digital impression; (c) designing of preparations using BioCAD technique.
technique.
technique.
The
Thegeometries
geometrieswere
wereimported
importedinto
intoaaComputer
ComputerAided
AidedEngineering
Engineering(CAE)
(CAE)software
software
The19.2,
(ANSYS geometries
ANSYS were
Inc., importedTX,
Houston, intoUSA)
a Computer
in Aided
“.step” Engineering
format, and (CAE)elements
tetrahedral software
(ANSYS 19.2, ANSYS Inc., Houston, TX, USA) in “.step” format, and tetrahedral elements
(ANSYS
were used19.2, ANSYSthe
to generate Inc., Houston,
mesh. TX, USA)
The number in “.step”and
of elements format,
nodesand
aretetrahedral
described inelements
Table 1,
and they were defined after the mesh convergence test with 10% of relevance. The cervical
region of the root (2 mm below the cement-enamel junction) was selected for system
 system fixation condition, ensuring that the only movement constraint was on the Z-axis.
The interfaces were considered perfectly bonded, and the geometries were considered
isotropic, homogeneous, and linearly elastic. A vertical occlusal load of 600 N [47] was
applied at the central fossa region, in the internal surface of the mesio and disto-lingual
Materials 2021, 14, 1923 cusps, and in the internal surface of the buccal median cusp (tripod contact) (Figure 5 of 13
4)
[48–50]. The solid volumes described in the final models are displayed in Table 1. The
mechanical properties, such as elastic modulus (E) in GPa and Poisson’s ratio (V), were
achieved through the literature or manufacturer data. The solid structures present in the
fixation condition, ensuring that the only movement constraint was on the Z-axis. The
final models consisted of: onlay made of lithium-disilicate (E = 95; V = 0.3) [51] or nanoc-
interfaces were considered perfectly bonded, and the geometries were considered isotropic,
eramic resin (E = 12.8; V = 0.3) [52], enamel (E = 84; V = 0.3) [53], dentin (E = 18; V = 0.23)
homogeneous, and linearly elastic. A vertical occlusal load of 600 N [47] was applied at
[54,55],
the cement
central fossa layer
region,(Ein= the
7; Vinternal
= 0.3) [56], and of
surface bulkfill composite
the mesio resin build-up
and disto-lingual (E =and
cusps, 8; Vin=
0.25) [57]. The results in the restoration, cement layer, and tooth structure
the internal surface of the buccal median cusp (tripod contact) (Figure 4) [48–50]. The solid were obtained
using Maximum
volumes describedPrincipal Stress
in the final (MPS),
models are which indicates
displayed the1.tensile
in Table stress results
The mechanical in MPa.
properties,
such asA elastic
limitation of the(E)FEin model
modulus GPa and may be the ratio
Poisson’s load (V),
application, since through
were achieved this analysis
the
sim-ulates a static and not a dynamic load. In this study, only the
literature or manufacturer data. The solid structures present in the final models application ofconsisted
axial load
was
of: considered
onlay made oftolithium-disilicate
control the included (E =variables in the
95; V = 0.3) [51]present study. Byresin
or nanoceramic applying
(E = loads
12.8;
on cusp inclination, the angle of the inclination could influence the
V = 0.3) [52], enamel (E = 84; V = 0.3) [53], dentin (E = 18; V = 0.23) [54,55], cementresults [54]. Another
layer
limitation
(E = 7; V = is the[56],
0.3) fact and
that bulkfill
Residualcomposite
shrinkageresinstressbuild-up
was not (Esimulated,
= 8; V =since
0.25)it[57].
can influ-
The
ence the
results in biomechanical
the restoration, behavior of the
cement layer, restoration
and and interfaces
tooth structure [58]. Inusing
were obtained addition, as it is
Maximum
an in silico
Principal analysis,
Stress (MPS),itwhich
does not matchthe
indicates all tensile
real clinical
stressconditions, which is also a limita-
results in MPa.
tion of the technique.
Table 1. Number of nodes, elements, and volume of tooth structure reduction (sum of the restoration
Table
and 1. Number
cement of nodes,according
layer volume), elements,to
and
thevolume of each
model of toothpreparation
structure reduction
design. (sum of the restora-
tion and cement layer volume), according to the model of each preparation design.
Preparation Design Nodes Elements Volume (mm3 ) 3*
Preparation Design Nodes Elements Volume (mm ) *
nRET 196,316 160,426 159
nRET 196,316 160,426 159
IST 199,025 160,944 179
IST
wIST 199,025
200,391 160,944
161,748 179
159
wIST 200,391 161,748
* Sum of the dentin volume and enamel of each preparation design. 159
* Sum of the dentin volume and enamel of each preparation design.

Figure4.4.FEA
Figure FEA processing
processing steps:
steps: (a)
(a) mesh
mesh generation;
generation; (b)
(b)fixation
fixationof
ofthe
thesystem;
system;and
and(c)
(c)axial
axialload
load
application (600 N).
application (600 N).

AAlimitation
novel statistical
of the approach
FE modelwas mayused for load
be the quantitative analysis
application, sinceofthis
the analysis
finite element
sim-
analysis results. For this, after the finite element analysis was performed,
ulates a static and not a dynamic load. In this study, only the application of axial the tensile
load
stress
was peaks on to
considered restoration;
control thecementing layer andin
included variables tooth structure
the present wereBy
study. exported
applying from
loadsthe
CAE
on cuspsoftware (ANSYS
inclination, 19.2, ANSYS
the angle Inc., Houston,
of the inclination couldTX, USA), the
influence according
results to theAnother
[54]. element
number corresponding
limitation to the numerical
is the fact that Residual shrinkage calculation.
stress was notA simulated,
correlationsince
wasitmade between
can influence
realbiomechanical
the and theoretical probabilities,
behavior of the in order to define
restoration the distribution
and interfaces curve thatasbest
[58]. In addition, it isfits
an the
in
data. analysis,
silico The stress distribution
it does not matchwasallrecorded as colorimetric
real clinical maps (MPa)
conditions, which is also with adjustable
a limitation of
the technique.
A novel statistical approach was used for quantitative analysis of the finite element
analysis results. For this, after the finite element analysis was performed, the tensile stress
peaks on restoration; cementing layer and tooth structure were exported from the CAE
software (ANSYS 19.2, ANSYS Inc., Houston, TX, USA), according to the element number
corresponding to the numerical calculation. A correlation was made between real and
theoretical probabilities, in order to define the distribution curve that best fits the data. The
stress distribution was recorded as colorimetric maps (MPa) with adjustable color scale
corresponding to the stress magnitude comparison between the preparation designs for
each analyzed structure.
Materials 2021, 14, 1923 6 of 13

3. Results
The FEA results are represented in colorimetric graphs in Figure 5, and the values
of the Maximum Principal Stress (MPa) in the form of distribution graphs are plotted in
Figure 6. The shape parameters of the distribution graphs are summarized in Table 2. To
obtain the stress distribution, the automatic labelling maximum value in the CAE software
was used to detect the region of higher stress magnitude; in sequence, the stress data
were exported in “.txt” file instead of colorimetric maps. The stress data were organized
according to their distribution and shape. The stress on the tooth structure (enamel, dentine,
and build-up) was measured using the Maximum probe detected by the Mechanical APDL
(ANSYS 19.2, ANSYS Inc., Houston, TX, USA). After that, the peaks were plotted in bar
graphs (Figure 6).

Table 2. Distribution and shape parameter of each of the stress peak data of each group.

Structure Group Distribution Correlation Coefficient Shape/* Local Scale

nRET LD Weibull 0.917 1.51 16.13
nRET NR GEV 0.841 −2.46 * 1.63
IST LD Weibull 0.948 1.89 20.64
Restoration
IST NR GEV 0.848 2.96 * 1.49
wIST LD Weibull 0.918 1.48 19.75
wIST NR Weibull 0.962 2.80 7.40
nRET LD Weibull 0.968 2.01 11.06
nRET NR Weibull 0.913 2.16 11.05
IST LD Weibull 0.976 1.71 9.14
Cement Layer
IST NR Weibull 0.973 1.49 8.36
wIST LD Weibull 0.949 2.26 11.45
wIST NR Weibull 0.967 1.54 10.79
nRET LD Logistic 0.973 1.03 * 1.36
nRET NR Logistic 0.996 1.09 * 0.85
IST LD Logistic 0.969 1.79 * 1.36
Tooth Structure
IST NR Logistic 0.992 1.53 * 0.72
wIST LD Logistic 0.966 1.76 * 1.84
wIST NR Logistic 0.994 1.51 * 0.91
* GEV: generalized extreme value.

Observing the stress distribution on the restoration’s intaglio surface, LD onlays

(69–110 MPa) showed higher tensile stress concentration than NR (10–24 MPa). For NR
models, the wIST preparation stress peaks were twice that of nRET (12 MPa), with IST
being slightly higher (17 MPa) than nRET. It can be seen in the FEA distribution graph
(Figure 6) that stress peak values below 10 MPa were more frequent in the nRET LD and
wIST LD groups. Stress values between 30 and 50 MPa were more frequent in the IST
LD group, with a similar distribution for the nRET LD and wIST LD groups. For groups
restored with NR, higher stress peaks were more frequent in the wIST group, followed
by the IST and nRET groups. For LD onlays, the stress distribution on the restoration’s
intaglio showed that the preparation design influenced the stress distribution; nRET had
a homogeneous distribution and lower peaks (68 MPa), followed by IST (77 MPa), and
higher for wIST (110 MPa) (Figures 5 and 6).
Materials 2021,
Materials 14, x1923
2021, 14, FOR PEER REVIEW 77 of
of 13
13

Figure5.
Figure FEAMaximum
5.FEA MaximumPrincipal
PrincipalStress
Stress results:
results: (a)
(a)restoration’s
restoration’s intaglio
intaglio surface;
surface; (b)
(b) cement
cement layer;
layer; (c)
(c) tooth
tooth structure.
structure.
Materials 2021, 14, 1923 8 of 13
Materials 2021, 14, x FOR PEER REVIEW 8 of 13

Figure
Figure 6.
6. Quantitative
Quantitative FEA
FEA analysis:
analysis: (a)
(a)distribution
distribution graph
graph of
of the
the stress
stress data
data on
on the
the restoration
restoration exported
exported from
from the
the analysis
analysis
software;
software; (b)
(b) stress
stress peaks
peaks on
on each
each group.
group.

4. Discussion
4. Discussion
Results of this study indicated that the first null hypothesis was rejected, because the
Results of this study indicated that the first null hypothesis was rejected, because the
preparation design affected the stress concentration in the restoration, cement layer, and
preparation design affected the stress concentration in the restoration, cement layer, and
tooth
tooth structure.
structure.
The
The basic
basic form
form ofof dental
dental preparations
preparations did did not
not significantly
significantly change
change over
over the
the years,
years,
even
even with the advent of new restorative materials [59]. However the mechanical behavior
with the advent of new restorative materials [59]. However the mechanical behavior
of
of restoration,
restoration, cement
cement layer
layer surface,
surface, and
and tooth
tooth structure
structure were
were affected
affected according
according toto the
the
preparation design. The results of the present study confirm that non-retentive
preparation design. The results of the present study confirm that non-retentive preparations prepara-
tions
have have mechanical
mechanical advantages
advantages in all in all analyzed
analyzed structures.
structures.
The IST preparation was firstly designed on
The IST preparation was firstly designed on the non-adhesivethe non-adhesive restorations,
restorations, pre-
presenting
senting the concepts of mechanical retention and the material’s resistance
the concepts of mechanical retention and the material’s resistance [34]. However, with [34]. However,
with the development
the development of the of the adhesive
adhesive dentistry,
dentistry, theseshapes
these dental dental are
shapes are not anymore.
not required required
anymore.
Moreover,Moreover,
the presence theofpresence
shoulders ofand
shoulders
isthmusand isthmus provided
preparation preparation provided
a complex a
geo-
complex
metrical geometrical
shape to theshape to the preparation,
preparation, which high
which promoted promoted
stresshigh stress concentration
concentration on all the
on all the simulated
simulated clinical situations
clinical situations observed observed in this
in this study. In study. In fact, retentive
fact, retentive preparationsprepara-
with
tions with complex geometry have more internal angles, and these geometric changes
Materials 2021, 14, 1923 9 of 13

complex geometry have more internal angles, and these geometric changes result in greater
stress in these areas, and these regions are potentially considered as breaking points for the
restorations [21,40].
The lithium-disilicate wIST and IST groups concentrated more tensile stress on the
restoration intaglio surface than nRET. Non-retentive preparations with simplified geome-
try can transform the negative tensile stresses for ceramic restorations into non-damaging
compression stresses [27,29]. This aspect was also detected by Falahchai et al. [39] who
found that simplified designs without retention forms reduced the incidence of restora-
tion fracture.
Since the most frequent clinical failure pattern in teeth restored with onlay is fracture
of the restoration [25,60,61], non-retentive preparation could increase the longevity of this
type of restoration. Besides, the presence of pronounced shoulders was proven to require
an extensive removal of tooth structure [62].
Another common clinical failure mode in onlays restorations is debonding [25]. Al-
though it can be considered that more retentive preparations would have less risk of
detachment or debonding, our study indicated that the nRET model preparation concen-
trated less tensile stress in the cement layer compared to the retentive one. In addition,
the area with more stress concentration was located on enamel, a more reliable adhesive
substrate [63]. In this sense, the occurrences of reported clinical failures could be associated
with operative errors with the adhesive technique.
During the preparation design, IST preparation required more tooth reduction on
tooth structure, resulting in loss of structural tissue, while wIST could reduce the loss
of dental tissues [28]. Thus, the execution of isthmus preparation could weaken the
dental structure [64], especially because the intracoronal extension can create a wedge
effect [39]. In this sense, the nRET and wIST preparations were more advantageous for
dental structure integrity.
The nRET preparation does not require resistance and retention forms; the geometry
follows a smooth and fluid curve with open angles. These characteristics render this opera-
tive technique easier to perform, and it also provides a minimally invasive intervention
once there is no need to remove sound tooth structure to achieve the ideal geometric
forms. It was specified that dental procedures, especially inlays and onlays, performed
by unexperienced professionals tend to present higher failure rates when comparing to
experienced dentists [65].
On the other hand, the retentive features of IST and wIST will provide a defined path
of insertion of the onlay, which will facilitate seating during cementation and reduce the
exposure of the cement at the margin [25]. Besides that, the longevity of the restorative
treatment in non-retentive preparation relies on the adhesion to dental tissues and restora-
tive material. Thus, techniques such as immediate dentin sealing [66], air abrasion [67],
oblique cut of the enamel [68], and the use of reliable adhesive materials supported by the
literature are indicated [69].
The second null hypothesis of the study, that the restorative material would have no
effect on mechanical behavior, was also rejected. That is, the results showed that LD onlays
concentrate more tensile stress on the restoration and in the cement layer, while NR onlays
concentrate stress mainly in the tooth structure.
When a more elastic material was used, the design of the preparation did not signif-
icantly affect the mechanical behavior of the restoration. Composite resin onlays can be
advantageous, especially in patients with high masticatory forces and suspected parafunc-
tional habits such as bruxism, since there is a lower risk of the restoration fracture [26,49,50].
Additionally, when comparing the mechanical behavior of resin-based materials, especially
for the nRET preparation, this material presented a mechanical behavior that resembles
a natural tooth, as analyzed by Costa et al., 2017 [70], which evaluated the influence of
different occlusal contacts and used premolars as models.
Resin-based materials (NR) homogeneously distributed stress n almost all of the
cement surface, with a higher frequency of lower values, while lithium-disilicate (LD)
Materials 2021, 14, 1923 10 of 13

concentrated higher peaks in more localized points (at the preparation margins and at
the axial-occlusal edge) (Figure 5). Since the bond strength of lithium-disilicate is higher
than that of nanoceramic resin, the highest stress values for LD are not critical for the
occurrence of debonding. The same premise is valid for NR. Since the peaks in FEA were
between 8 and 9.6 MPa, they do not reach 50% of the microtensile bond strength value of
the composite resin [71]. Given this assumption, composite resin-based onlays could be
cemented over non-retentive preparations [49,50].
On the other hand, NR onlays promoted a higher stress concentration and higher
peaks in the dental structure. Therefore, in situations with extremely fragile teeth, with thin
remaining walls or with the presence of cracks, the restorative material with the greatest
biomechanical advantage seems to be dental ceramics [27,72]. Based on what was exposed,
it is assumed that despite the better mechanical performance of NR, which acts as a stress
absorber due to the different Young’s modulus than LD (NR: E = 12.8; LD: E = 95), both
materials have their own clinical indication, and clinical success can be achieved using
both materials, depending on the correct indication.
A possible limitation of the study is that the simulated mesio-occluso-distal cavity
was designed arbitrarily with the CAD software, and not made from a real clinical condi-
tion such as those simulated in patient-specific FEA studies. Probably, a patient-specific
assessment could bring new information about the effect of the preparation design [26,73].
In addition, the simulated occlusal contact generates loads in the axial direction [74]; hori-
zontal loads could simulate more critical effects on tooth, cement layer, and restoration.
Further studies should evaluate the clinical variables, such as the effect of fatigue behavior,
accuracy, and precision of digital and traditional impression, and clinical trials should be
encouraged to better understand the effect of the preparation design.

5. Conclusions
Within the limitations of this study, it is possible to appreciate that:
1. The finite element analysis carried out on non-retentive onlay dental preparation
showed the best mechanical behavior compared to other preparation designs;
2. The finite element analysis also showed that resin-based materials presented a better
mechanical behavior than lithium-disilicate ceramic;
3. Lithium-disilicate ceramic materials could represent an interesting alternative of
restorative material in specific clinical situations, such as extremely fragile teeth or in
the presence of cracks.

Author Contributions: A.B.G.d.C.; Conceptualization, investigation, writing—original draft prepara-

tion, visualization, funding acquisition; G.S.d.A.; Conceptualization, methodology, software, formal
analysis, project administration, investigation, writing—original draft preparation, writing—review
and editing, visualization.; J.P.M.T.; Conceptualization, methodology, software, validation, formal
analysis, investigation, resources, writing—review and editing, visualization, supervision, funding
acquisition; E.D.A.G.; Conceptualization, investigation, formal analysis, writing—original draft
preparation; P.A.; investigation, formal analysis, writing—review and editing, funding acquisition;
G.d.S.F.A.S.; Conceptualization, investigation, formal analysis, writing—review and editing, funding
acquisition; A.B.; investigation, methodology, software, validation, formal analysis, writing—review
and editing; R.M.d.M.; investigation, formal analysis, writing—review and editing; A.L.S.B.; Concep-
tualization, methodology, software, validation, formal analysis, project administration, investigation,
resources, writing—review and editing, visualization, supervision, funding acquisition. All authors
have read and agreed to the published version of the manuscript.
Funding: This research was supported by the Fundação de Amparo à Pesquisa do Estado de São
Paulo (FAPESP) under Carvalho ABG PhD Scholarship Grant (2020/07693-5).
Institutional Review Board Statement: Not applicable
Informed Consent Statement: Not applicable
Data Availability Statement: Data sharing is not applicable for this article.
Materials 2021, 14, 1923 11 of 13

Conflicts of Interest: The authors declare no conflict of interest.

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