Biomechanical behavior of molars restored with direct and indirect restorations in combination with deep margin elevation.

Rijkje Bresser*, Marco Aurelio de Carvalho, Lucas Zago Naves, H. Melma, Marco Cune, Marco Gresnigt

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review

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Statement of problem
The existing knowledge is insufficient for comprehending the fatigue survival and fracture resistance of molars that have deep approximal direct and indirect restorations, whether with or without deep margin elevation (DME).

The aim of this laboratory and in silico study is to investigate the fatigue survival, fracture strength, failure pattern and tooth deformation of molars restored with DME in combination with a direct or indirect restoration.

Material and methods
This study utilized 45 extracted sound human molars, divided into three groups (n = 15). Standardized 100% inter-cuspal inlay preparations were performed, extending 2 mm below the CEJ and immediate dentin sealing (IDS) was applied. Group 1 (Co_1) was restored with direct composite; Group 2 (Hyb_2) with a 2 mm DME of direct composite and a glass-ceramic lithium disilicate restoration; Group 3 (Cer_3) a glass-ceramic lithium disilicate restoration. All specimens were exposed to a fatigue process involving thermal-cyclic loading (50N for 1.2 × 106 cycles at 1.7 Hz, between 5 and 55 °C), if teeth survived, they were fractured using a load-to-failure test and failure types were analyzed. Finite element analysis (FEA) was conducted to assess tooth deformation and tensile stress in the restorations. Statistical evaluation of fracture strength was conducted using the Kruskal-Wallis test. Fisher's exact test was utilized to analyze the fracture types and repairability. A statistical significance level of α < 0.05 was set for all analyses.

All specimens successfully withstood the fatigue testing procedure, and no statistically significant differences in fracture strength were observed among the three groups (P > 0.05). The Fisher's exact test indicated a significant association between the restorative material and fracture type (F2 = 18.315, df = 2, P = 0.004), but also for repairability (F2 = 13.725, df = 2, P = 0.001). Crown-root fractures were significantly more common in the Cer_3 group compared to the Co_1 group (P = 0.001) and the Co_1 group had significantly more repairable fractures (F2 = 13.197, df = 2, P = 0.001). FEA revealed comparable outcomes of deformation among models and higher maximum tensile stress on models with higher frequency of catastrophic failures.

All tested restoration materials exhibited comparable fatigue survival and fracture strength in this laboratory and in silico study. However, it is important to recognize the potential for more severe and irreparable fractures when opting for deeply luted glass-ceramic inlay restorations in clinical practice. In such cases, it would be prudent to consider the alternative option being a direct composite approach, because of its more forgiving fracture types and repairability.

Clinical implications
Molars with deep approximal direct and indirect restorations, whether with or without DME, are comparable in their fatigue survival and fracture resistance to withstand intra-oral forces. Deep direct restorations exhibit more repairable fractures compared to deeply luted glass-ceramics.
Original languageEnglish
Article number106459
Number of pages13
JournalJournal of the Mechanical Behavior of Biomedical Materials
Publication statusPublished - Apr-2024


  • Humans
  • Molar
  • Finite Element Analysis
  • Flexural Strength
  • Fractures, Bone
  • Laboratories
  • Tooth Fractures


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