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Fracture strength of temporary xed partial dentures: CAD/CAM versus directly fabricated restorations
Vanessa Alt b , Matthias Hannig a , Bernd Wstmann b , Markus Balkenhol a,b,
a

Clinic of Operative Dentistry, Periodontology and Preventive Dentistry, Saarland University Hospital, Building 73, D-66421 Homburg, Saar, Germany b Department of Prosthetic Dentistry, Justus-Liebig-University, D-35392 Giessen, Germany

a r t i c l e
Article history:

i n f o

a b s t r a c t
Objectives. This study aimed at investigating the inuence of fabrication method, storage condition and material on the fracture strength of temporary 3-unit xed partial dentures (FPDs). Methods. A CrCo-alloy master model with a 3-unit FPD (abutment teeth 25 and 27) was manufactured. The master model was scanned and the data set transferred to a CAD/CAM unit (Cercon Brain Expert, Degudent, Hanau, Germany). Temporary 3-unit bridges were produced either by milling from pre-fabricated blanks (Trim, Luxatemp AM Plus, Cercon Base PMMA) or by direct fabrication (Trim, Luxatemp AM Plus). 10 FPDs per experimental group were subjected either to water storage at 37 C for 24 h and 3 months, respectively, or thermocycled (TC, 5000, 555 C, 1 week). Maximum force at fracture (Fmax) was determined in a 3-point bending test at 200 mm/min. Data was analyzed using parametric statistics ( = 5%). Results. Fmax values ranged from 138.5 to 1115.5 N. FPDs, which were CAD/CAM fabricated, showed a signicant higher Fmax compared to the directly fabricated bridges (p < 0.05). TC signicantly affected Fmax for Luxatemp (p < 0.05) but not for the PMMA based materials (p > 0.05). CAD/CAM milled FPDs made of Luxatemp showed signicantly higher Fmax values compared to Trim and Cercon Base PMMA (p < 0.05). Signicance. CAD/CAM fabricated FPDs exhibit a higher mechanical strength compared to directly fabricated FPDs, when manufactured of the same material. Composite based materials seem to offer clear advantages versus PMMA based materials and should, therefore, be considered for CAD/CAM fabricated temporary restorations. 2010 Academy of Dental Materials. Published by Elsevier Ltd. All rights reserved.

Received 8 November 2010 Accepted 16 November 2010 Available online xxx Keywords: Temporary xed partial denture Interim restoration Provisional restoration Fracture strength Composites 3-Point bending test Resin Thermocycling In vitro study

1.

Introduction

Computer aided design/manufacturing (CAD/CAM) technologies have gained popularity in recent years for xed restorative and prosthodontic treatment procedures. Among others, this

process is driven by the growing demand for placing high esthetic all-ceramic restorations [1,2]. At the same time, due to improvement in physical properties of e.g. zirconia and other ceramics, these materials can be successfully used also in stress bearing areas [3]. Apart from the Cerec System, most CAD/CAM supported technologies still use labside

Corresponding author at: Clinic of Operative Dentistry, Periodontology and Preventive Dentistry, Saarland University Hospital, Building 73, D-66421 Homburg, Saar, Germany. Tel.: +49 6841 16 24 478; fax: +49 6841 16 24 954. E-mail address: markus.balkenhol@uks.eu (M. Balkenhol). 0109-5641/$ see front matter 2010 Academy of Dental Materials. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.dental.2010.11.012

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Table 1 Temporary c&b materials under investigation. Product


Luxatemp AM Plus

Manufacturer
DMG, Hamburg, Germany

MRa
10:1

Shade
A2

Batch
605703, 910935

Composition
Urethane diacrylate, aromatic diacrylate, glycol methacrylate, pigments, additives, stabilizer, silica, glass ller (44 wt.%) Highly cross-linked methyl methacrylate, pigments, benzoyl peroxide (<1 wt.%) P: ethyl methacrylate prepolymers, benzoyl peroxide, pigments, TiO2 ; L: isobutyl methacrylate, di-butyl phthlate, dimethyl-p-toluidine

Cercon Base PMMA Trim

Degudent, Hanau, Germany Bosworth, Skokie, Ilinois, USA

n.a.

B2

005366122220

1:2.3

Light

P: 0708-475 L: 0612-600

P, powder; L, liquid. All data reect information provided by the various manufacturers. Mixing ratio dimethacrylates base: catalyst [by volume]; mixing ratio mono-methacrylate liquid: powder [volume:mass].

procedures during the manufacturing process (e.g. veneering of zirconia frames/substructures) [4] and in consequence require temporary restorations to be fabricated on the prepared abutment teeth until the nal xed partial denture (FPD) is placed in situ. The temporary restorations in turn fulll a wide range of functions comprising protection of the prepared tooth structure, pulp and the surrounding periodontal tissues as well as to maintain oral functions (mastication, phonetics) and esthetics [5,6]. Most of these restorations are fabricated chairside using an over impression technique in combination with resin based temporary crown and FPD materials (t-c&bs) [7,8]. As the timeframe between preparation of a tooth and luting of the nal restoration might exceed a couple of weeks, the t-c&bs used to fabricate temporary crowns or FPDs have to meet several requirements [5,9]. Among others, the mechanical strength of a t-c&b is of particular importance as this factor might inuence the integrity of the temporary restoration during clinical service, when it is exposed to functional loads [1013]. Hence, determination of mechanical properties of t-c&bs was the subject of several studies [9,10,1419]. The chairside fabrication of temporary restorations is associated with a couple of short-comings, affecting the mechanical strength as well as its surface texture and precise t [12,20,21]. e.g. mixing procedures and lling the over impression might lead to an incorporation of voids, compromising the mechanical strength [20]. In addition, studies have indicated that exural strength is very low directly after fabricating these restorations [12]. CAD/CAM technologies used to fabricate temporary restorations may solve some of these issues. i.e. using resin based blanks cured under optimal conditions exhibit increased mechanical strength and prevent porosities within the restorations [2]. In addition, CAD/CAM fabricated temporaries reportedly reduce the chairside time and produce superior results [22]. Therefore, it was the aim of this study to compare the mechanical strength of directly fabricated temporary 3-unit FPDs versus identically CAD/CAM fabricated FPDs, milled of blanks, which were produced under optimal conditions using the same materials in a semi-clinical setup. The null-hypothesis tested was three-fold: the mechanical strength of temporary 3-unit FPDs is independent of (1) the

manufacturing process, (2) the t-c&b material used and (3) the storage condition after fabrication.

2.

Materials and methods

The mechanical properties of the different materials and manufacturing techniques were tested using a semi clinical setup on a metal master-model with a 3-unit FPD. SEM analysis of the fractured surfaces was carried out on representative samples. Table 1 gives an overview of the materials tested including their composition. All materials were used according to the manufacturers recommendations. The tests were carried out at ambient laboratory conditions (23 1 C, 50 5% rel. humidity).

2.1.

Master model

Two resin teeth (no. 25 and 27, frasaco, Tettnang, Germany) were prepared with a shoulder preparation (angle of convergence 6 ) for treatment with full crowns. Following this, the roots of the two teeth were completed with wax to simulate a natural root (root length 16 mm). The teeth were duplicated and cast using CrCo-alloy (Brealloy C + B 270, Bredent, Germany). A base corpus, representing an alveolar ridge, was manufactured (CrCo-alloy), containing two sockets for mounting the two teeth in a distance of 12 mm (gap between the socket and the root: 1 mm). The teeth were xed inside the socket with a vinyl-polysiloxane (Monopren Transfer, Kettenbach, Eschenburg, Germany) (Fig. 1A) [15,23]. This material had shown to sufciently simulate the natural tooth movement under the test conditions, as conrmed by results obtained from a Periotest device (Medizintechnik Gulden, Modautal, Germany). Finally, a jig was fabricated to record the precise position of the abutment teeth within the sockets. A 3-unit master FPD was fabricated (Fig. 1B), cast (Brealloy C + B 270, Bredent, Germany) and tted on the abutment teeth featuring an optimal marginal adaptation (Fig. 1C). The connection area between the abutment teeth and the pontic was 4.0 mm 3.25 mm (pontic height: 6.3 mm). The occlusal surface of the pontic was shaped to allow unequivocal positioning of a stainless steel spheric in the center of the FPD. The master FPD was digitized using a 3-Shape scanner (Wieland, Pforzheim, Germany) and the STL data set was saved

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Fig. 1 (A) Prepared teeth 25 and 27 made of CrCo-alloy xed in position in the sockets of the articial alveolar ridge. (B) Master bridge made of CrCo-alloy. (C) Master bridge placed in correct position on the base model prior to making the over impression. (D) Temporary resin bridges milled of the self-made base block. (E) Trimmed temporary bridge. (F) Setup with temporary bridge and spherical prior to fracture testing.

and imported in the Cercon Brain Expert system (Degudent, Hanau, Germany) to fabricate identical 3-unit FPDs.

2.2.

Direct fabrication of temporary FPDs

Direct fabrication of FPDs was performed using an over impression technique [24]. The master FPD was placed in correct position on the two abutment teeth. Correct position was conrmed by a jig. A vinyl-polysiloxane impression material (Panasil Putty/Contact Plus, Kettenbach, Eschenburg, Germany) was mixed according to the manufacturers instructions, dispensed in a metal segment tray (type C 1/2 L3, Carl Martin, Solingen, Germany) and placed in position over the master FPD (one stage putty-wash technique). The impression was removed after setting and cut into 2 pieces to remove the master FPD without altering/damaging the contour of the over impression. The impression tray was used for the correct re-assembly of the two pieces. The t-c&b materials were mixed according to the manufacturers instructions and dispensed into the over impression

from the bottom to the top to prevent incorporation of voids. The lled impression was placed in the correct position onto the master model. A slot on top of the alveolar ridge ensured correct position of the over impression. The temporary FPDs were carefully removed from the over impression after the manufacturers recommended setting time and excess material trimmed to precisely t them on the abutment teeth in the desired position.

2.3.

CAD/CAM fabrication of temporary FPDs

To obtain base blocks of Luxatemp AM Plus and Trim, which could be xed properly in the frames of the Cercon Brain Expert milling device, a siloxane mold (Duosil, Shera, Lemfrde, Germany) was fabricated (50 mm 50 mm 20 mm). Trim was mixed according to the manufacturers instructions and lled into the mold from the bottom to the top to prevent bubble formation. Luxatemp AM Plus was dispensed directly from the mixing tip inside the silicone mold as described before. For both materials, curing took place at 37 C in an

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incubator (Ehret, Emmerdingen, Germany). After curing, base blocks were stored for at least 1 week prior to milling the FPDs. The polymerized blocks as well as the Cercon Base PMMA disks (Degudent, Hanau, Germany) were xed inside the frames of the Cercon Brain Expert milling device to mill the temporary FPDs (Fig. 1D). The nal resin FPDs were carefully removed from the blocks and tted as described before (Fig. 1E).

Table 2 Results of the three-way ANOVA. Independent variable


Material Fabrication Storage Material fabrication Material storage Fabrication storage Material fabrication storage

Signicance
p < 0.001 p < 0.001 p < 0.001 p < 0.001 p < 0.01 n.s. n.s.

2.4.

Storage conditions

Dependant variable: force at fracture; n.s., not signicant.

Prior to storage, conformance of the temporary FPDs with the master FPD was checked regarding the dimensions using a digital caliper (Mitutoyo, Japan). In addition, temporary bridges were checked for bubbles, voids and other pre-damages at 40 magnication under a light microscope (M420, Leica, Wetzlar, Germany). FPDs with pre-damages and incorrect dimensions were discarded and new FPDs fabricated. Storage took place in a water bath at 37 C for 24 h or 3 months, respectively (n = 10 per material and storage condition). A third group of 10 specimens was subjected to thermocycling for 1 week (TC, 555 C, 5000 cycles, dwell time 50 s).

2.7.

Statistical analysis

2.5.

Fracture test

Mean values and standard deviations of the maximum force at fracture were calculated. The inuence of the independent variables (material, fabrication technique, storage) were analyzed for their effects by a three-way ANOVA [25,26]. Post hoc comparisons were carried out using a GamesHowell test (when variances were not homogeneous) and a Tukeys test, respectively. A t-test for independent samples was used to compare the inuence of the manufacturing process [25,26]. All statistical analyses were performed using SPSS for Windows (release 15.01, SPSS Inc., Chicago, IL, USA) on a signicance level of 5%.

The CrCo-alloy alveoar ridge master model was xed on both sides in a universal testing machine (type 1454, Zwick/Roell, Ulm, Germany) for fracture testing. A stainless steel spheric ( 12.5 mm) was centered on the occlusal surface of the pontic (Fig. 1F) and fracture test started at a crosshead speed of 200 mm/min until fracture occurred. Maximum force at fracture (Fmax) was recorded (testXpert software, release 11.1, Zwick/Roell, Ulm, Germany).

3.

Results

2.6.

SEM analysis

Representative SEM micrographs were taken from the fractured surfaces. Fracture surfaces were carefully cut from the FPD segments, stuck to specimen holders (Plano, Wetzlar, Germany) and sputtered with platinum. SEM evaluation was performed with a scanning electron microscope (type FEI XL30 ESEM FEG, FEI Company, Eindhoven, The Netherlands) at an accelerating voltage of 1020 kV and a magnication of 125 to 20,000.

Table 2 shows the results of the three-way ANOVA. As indicated by the p-values, material, fabrication and storage signicantly inuenced the fracture strengths (p < 0.001). In addition, material & fabrication as well as material & storage inuenced the fracture force in interaction (p < 0.01). The maximum forces at fracture are given in Table 3. Three months water storage and TC lead to a signicant decrease of Fmax for Luxatemp AM Plus, but not for Trim and Cercon Base PMMA. Luxatemp AM Plus and Trim showed a signicant higher Fmax, if the FPDs were CAD/CAM fabricated (t-test, p < 0.01). The directly fabricated FPDs, made of Trim, showed a signicantly lower Fmax compared to Luxatemp AM Plus (t-test, p < 0.05). In case of CAD/CAM fabrication, the composite based t-c&b showed signicantly higher Fmax values compared to the two mono-methacrylate based materials (Table 4).

Table 3 Force at fracture = Fmax in N (mean values and standard deviations). Material Fabrication 1 day
Luxatemp AM Plus CAD/CAM# Direct* CAD/CAM# Direct CAD/CAM* Direct*

Storage 37 C 1 week TC
875.8 145.5b 268.4 101.2b 325.2 86.4a n.a. 264.0 38.2a 138.5 54.4a

3 months 37 C
885.8 256.3b 367.4 148.0b 423.7 102.8a n.a. 342.6 103.2a 185.0 54.1a

1115.5 198.1a 561.9 73.1a 416.9 89.8a n.a. 379.3 172.7a 188.1 50.4a

Cercon Base PMMA

Trim

Lower case superscript letters are related to rows and denote results of the post hoc tests (inuence of storage for the respective test-groups). Same lower case letters denote groups, which do not differ signicantly (# Tukey test p > 0.05; * GamesHowell test p > 0.05).

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Fig. 2 SEM pictures of the fracture surface at different magnications of Luxatemp AM Plus fabricated directly (A and B) and CAD/CAM fabricated (C and D), respectively. No obvious differences in surface texture visible. The morphology of the fracture surfaces analyzed by SEM is shown in Figs. 25. Fig. 2 reveals the fracture surfaces of the 3-unit FPDs made of Luxatemp AM Plus fabricated directly (Fig. 2A and B) and CAD/CAM fabricated (Fig. 2C and D), respectively. No differences in morphology were obvious. At higher magnication (Fig. 3), a tight contact between ller particles and polymer are clearly visible. Fig. 4 shows the fracture surface of the Trim FPDs, when manufactured directly (Fig. 4A and B) and milled (Fig. 4C and D), respectively. No differences in morphology were obvious. Porosities, visible in Fig. 4B, are artifacts caused by the electron beam in the SEM. Pre-polymers are tightly embedded within the matrix. The fracture runs through the pre-polymer beads. Fig. 5 nally shows the fracture surface of FPDs milled of Cercon Base PMMA disks. The morphology is similar to that

Table 4 Results of the statistical comparison between the materials obtained from the CAD/CAM fabrication. Storage
Luxatemp AM Plus Trim Luxatemp AM Plus Trim Luxatemp AM Plus Trim

Cercon Base Trim PMMA


p < 0.001 n.s. p < 0.001 n.s. p < 0.01 n.s. p < 0.001 p < 0.001 p < 0.01

1 day 37 C#

1 week TC* 3 months 37 C*

Dependant variable: force at fracture = Fmax; n.s., not signicant. # Tukey test; * GamesHowell test.

Fig. 3 SEM pictures of Luxatemp AM Plus at a higher magnication. Note that ller particles are tightly embedded into the matrix. No disintegration visible.

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Fig. 4 SEM pictures of the fracture surface at different magnications of Trim fabricated directly (A and B) and CAD/CAM fabricated (C and D), respectively. No obvious differences in surface texture visible. Porosities in (B) are artifacts, caused by the electron beam in the SEM. Note that fracture line runs through the pre-polymerized particles.

of the Trim samples. However, pre-polymer beads apparently are not bonded tightly within the matrix, as they are partially exposed (Fig. 5B).

4.

Discussion

This study aimed at investigating the inuence of fabrication technique, material and storage condition on the fracture strength of temporary 3-unit FPDs. Summarizing the results requires rejection of all parts of the null-hypothesis, as the fracture strength was dependent on the material used, the fabrication technique as well as the storage condition. When fabricating temporary crowns and FPDs, the quality of the nal restoration is strongly dependent on the technique used as well as the accuracy applied during manufacturing. Therefore a semi-clinical setup with a master model was selected to simulate the clinical situation at best [15,27]. The connector between the abutment crown and pontic (4.0 mm 3.25 mm) was chosen higher than the manufacturers recommended minimum for Cercon Base PMMA (9 mm2 ). The Fmax values obtained have to be regarded primarily as relative values, as the individual dimensions of a FPD is an important factor inuencing the fracture strength [24]. Another important test parameter is the cross-head speed, which was dened as 200 mm/min to simulate a quick closure of the mouth. A temporary luting agent was omitted on purpose to exclude it as additional inuencing variable. It might be spec-

ulated that the luting agent would have increased the fracture strength; however, this issue should be addressed in further studies. As storage time and condition reportedly affect the mechanical properties of t-c&bs, 3 months storage in water as well as TC were applied to simulate articial aging as described elsewhere [15,24,28]. To be able to directly compare the fabrication techniques applied, blanks for the CAD/CAM milling process were fabricated using the same materials in addition to testing a commercially available resin base blank (Cercon Base PMMA). The maximum force at fracture was signicantly affected by the storage condition for the composite based t-c&b (p < 0.05), whereas no signicant inuence of storage was noticeable for the two mono-methacrylate based materials (p > 0.05). Nevertheless, there was a tendency for lower Fmax values, when the latter two materials had undergone TC. These results are in accordance with literature, indicating an aging effect caused by water storage and TC, respectively [2832]. This effect might be explained by the water uptake of the t-c&bs, acting as a plasticizer [15]. Furthermore, certain degradation phenomena on a molecular level between ller and matrix might have played a role in case of Luxatemp AM Plus [29,30,33,34], although not obvious in the SEM micrographs. In addition, the effect seems to be more pronounced, if the FPDs are fabricated directly. It is hypothesized that a polymerization inhibiting effect of oxygen dissolved in water [35] is the reason for this phenomenon, as the material comes

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Fig. 5 SEM pictures of the fracture surface at different magnications (A and B) of Cercon Base PMMA. Note that some of the pre-polymerized particles are exposed, i.e. the fracture line runs around the pre-polymerized particles.

in contact with water/humidity at a stage, when the process of radical polymerization is still in progress [12]. In contrast, CAD/CAM manufactured FPDs were fabricated from base blocks, cured under optimal conditions, without the interference of water. During the storage period of these base blocks at ambient conditions, post polymerization processes as well as relaxation phenomena take place [33,36]. This leads to an improvement of physical properties, as observed in the current experiment. This is in accordance with published data, reporting higher exural strength of composite based resins, when specimens are cured and stored at air [28,37]. In addition, radicals may be active over a period of 7 days, leading to a signicant post polymerization [38]. When inserting milled FPDs, the t-c&bs have reached optimal physical properties, and thus featuring a high fracture strength. Clinically, this has two positive effects: First of all CAD/CAM fabricated FPDs have a higher resistance against fracture from the moment of placing the restoration, and second, the absolute resistance against fracture is higher compared to FPDs, fabricated directly. This may be of particular importance for long span bridges and in cases, where the temporary restoration is intended as long term provisional. Hence, when used according to the manufacturers recom-

mendations, CAD/CAM fabricated Cercon Base PMMA bridges show clear advantages. The values obtained for the PMMA based materials are in a range described in literature, taking into consideration the differences in dimensions of the FPDs [10,19,23,24]. The results obtained for Luxatemp AM Plus after 24 h water storage concord with results published by Lang et al. [15]. However, in contrast to our results, Lang et al. observed an increase in fracture strength after thermo-mechanical loading. The direct fabrication of the 3-unit FPDs signicantly affected the Fmax values for both materials (Luxatemp AM Plus, Trim). As the SEM analysis of the fracture surfaces did not show any obvious signs of porosities or voids in the group of directly fabricated FPDs, it is hypothesized that the higher Fmax values are primarily related to a higher load bearing capacity of the polymer network caused by the effects described before [28,36]. Although not signicant, there was a tendency for higher Fmax values of Cercon Base PMMA FPDs in comparison to FPDs, made of Trim. This difference is most likely related to the different chemical composition of the materials used. The manufacturer of Cercon Base PMMA claims that the material is composed of highly cross-linked polymethyl methacrylate. Regular PMMA has a glass transition temperature of 125 C [39], if not cross-linked. Cross-linking even increases the glasstransition temperature and in turn the mechanical strength of the product. As denoted by the SEM micrographs, the pre-polymers seem to be not tightly embedded within the matrix. Hence it may be hypothesized that optimizing the production process of Cercon Base PMMA with tight embedded pre-polymers might even increase the mechanical strength of the product. In contrast, Trim consists of isobutyl methacrylate with embedded pre-polymers, which has a lower glass transition temperature (70 C) compared to PMMA [39]. The softener added (di-butyl phthlate) additionally decreases mechanical strength and in turn explains the lower Fmax values observed for the Trim FPDs. In contrast to Cercon Base PMMA, the prepolymers were tightly embedded within the matrix as shown by the SEM analysis. Depending on the cross-head speed, a deformation of specimens made of PMMA materials maybe observed instead of a fracture [15,40]. This can readily be explained by their chemical base structure [40]. In the current experiment, however, all FPDs broke due to the high cross-head speed applied (200 mm/min). Finally, the composite based Luxatemp AM Plus showed the highest mechanical strength when used indirectly, about twice as high as the FPDs made of Cercon Base PMMA. This result is readily explained by the difference in composition, as Luxatemp is a composite based material using well established dimethacrylate monomers as well as reinforcing ller particles. The higher mechanical strength of composite based t-c&bs in comparison to traditional mono-methacrylates is in accordance with literature [15,40]. As denoted by the SEM micrographs of the Luxatemp samples, silanization process of the ller particles seem to be very effective, as they are tightly embedded within the matrix without showing any signs of disintegration.

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According to the instruction for use, Cercon Base PMMA is recommended for FPDs with a maximum span of one pontic. If the clinical situation requires temporary FPDs with more than one pontic, t-c&bs of higher mechanical strength might be required. Therefore, manufacturers are encouraged to offer composite based blanks for CAD/CAM fabrication of FPDs. In addition, higher strength materials might feature a higher longevity without failure in clinical situations, which require long term provisional treatment. Such clinical situations may e.g. be a comprehensive re-adjustment of the entire occlusion or periodontal pre-treatment with unknown prognosis of the abutment teeth. However, the question of longevity should be addressed in further clinical studies.

5.

Conclusions

Under the limitations of this in vitro study, the following conclusions can be drawn: CAD/CAM fabricated FPDs exhibit a higher mechanical strength compared to directly fabricated FPDs, when manufactured of the same material. Composite based materials seem to offer clear advantages regarding mechanical strength versus PMMA based materials and should, therefore, be considered materials for future CAD/CAM manufactured temporary crowns and FPDs.

Acknowledgements
We are indebted to the various manufacturers for donating the materials used in the present study. We would like to thank Dr. U. Schusser and Dr. L. Vlkl from Degudent for supporting the CAD/CAM fabrication of the FPDs. The authors would further like to acknowledge the support of Mr. U. Heun (Dept. of Prosthodontics, Jutus-Liebig-University, Giessen, Germany) as well as Mr. N. Ptz (Institute of Anatomy, Saarland University, Homburg, Germany) for their support during mechanical testing and performing the SEM micrographs, respectively.

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