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Review Article

Clinical trials in zirconia: a systematic review
B. AL-AMLEH, K. LYONS & M. SWAI N Department of Oral Rehabilitation, Faculty of Dentistry, University of
Otago, Dunedin, New Zealand
SUMMARY Zirconia is unique in its polymorphic crys-
talline makeup, reported to be sensitive to manu-
facturing and handling processes, and there is debate
about which processing method is least harmful to
the final product. Currently, zirconia restorations are
manufactured by either soft or hard-milling
processes, with the manufacturer of each claiming
advantages over the other. Chipping of the veneering
porcelain is reported as a common problem and has
been labelled as its main clinical setback. The objec-
tive of this systematic review is to report on the
clinical success of zirconia-based restorations fabri-
cated by both milling processes, in regard to frame-
work fractures and veneering porcelain chipping. A
comprehensive review of the literature was com-
pleted for in vivo trials on zirconia restorations in
MEDLINE and PubMed between 1950 and 2009. A
manual hand search of relevant dental journals was
also completed. Seventeen clinical trials involving
zirconia-based restorations were found, 13 were
conducted on fixed partial dentures, two on single
crowns and two on zirconia implant abutments, of
which 11 were based on soft-milled zirconia and six
on hard-milled zirconia. Chipping of the veneering
porcelain was a common occurrence, and framework
fracture was only observed in soft-milled zirconia.
Based on the limited number of short-term in vivo
studies, zirconia appears to be suitable for the
fabrication of single crowns, and fixed partial den-
tures and implant abutments providing strict proto-
cols during the manufacturing and delivery process
are adhered to. Further long-term prospective stud-
ies are necessary to establish the best manufacturing
process for zirconia-based restorations.
KEYWORDS: zirconia, fracture, porcelain chipping,
crowns, fixed partial dentures, implant abutments
Accepted for publication 13 March 2010
Introduction
In dentistry, gold and metal-alloys have passed the test
of time and are recognized as predictable and well-
established clinical materials for the restoration of
various fixed prostheses (1). Indeed, metal-ceramic
systems require relatively little special knowledge for
their routine use which has led to their worldwide
acceptance and use since their inception. Nevertheless,
the increasing aesthetic demand in dentistry has driven
the development of a number of ceramics for their
aesthetic capability, biocompatibility, colour stability,
wear resistance and low thermal conductivity (2). As
far back as 1885, porcelain jacket crowns were first used
for single crowns for the anterior teeth because of
their aesthetic and natural appearance (3). However,
ceramics cannot withstand deformation strain of more
than 0Æ1%–0Æ3% without fracturing and are susceptible
to fatigue fracture. It is this brittleness, because of the
ionic-covalent atomic bonding, which has limited their
use in dentistry for decades (4).
The most recent introduction to the dental ceramics
family is zirconia, which in its pure form is a polymor-
phic material that occurs in three temperature-depen-
dant forms that are: monoclinic (room temperature to
1170 °C), tetragonal (1170 °C–2370 °C) and cubic
(2370 °C – up to melting point) (5). However, when
stabilizing oxides such as magnesia, ceria, yttria and
calcium are added to zirconia, the tetragonal phase is
retained in a metastable condition at room tempera-
ture, enabling a phenomenon called transformation
toughening to occur. The partially stabilized crystalline
ª 2010 Blackwell Publishing Ltd doi: 10.1111/j.1365-2842.2010.02094.x
Journal of Oral Rehabilitation 2010 37; 641–652
J o u r n a l o f
Oral Rehabilitation
tetragonal zirconia, in response to mechanical stimuli,
such as tensile stress at crack tips, transforms to the
more stable monoclinic phase with a local increase in
volume of approximately 4%. This increase in volume
closes the crack tips, effectively blunting crack propa-
gation. It is this transformation-toughening process
which gives zirconia its strength and toughness,
exceeding all currently available sintered ceramics.
Compared to alumina, zirconia has twice the flexural
strength, partly because of its grain size and the
transformation-toughening mechanism. (6).
To date, there are three types of zirconia-containing
ceramics which are used in dentistry. Glass-infiltrated
zirconia-toughened alumina ceramics, magnesium-
doped partially stabilized zirconia and 3 mol% yttria
containing tetragonal zirconia polycrystalline (Y-TZP),
with the latter being the most utilised form in dentistry
because of its higher flexural strength reported to range
from 900 to 1200 MPa (7). Y-TZP has been used in root
canal posts (8), frameworks for all-ceramic posterior
crowns and fixed partial dentures (FPDs) (9–12),
implant abutments (13, 14) and dental implants (15).
Advances in CAD ⁄ CAM technology has made it
possible to more readily use zirconia in dentistry. This
technology enables complex shapes to be milled out of
pre-made zirconia blanks (or blocks), where the
prepared abutment is first scanned, then using com-
puter software, the desired framework is designed prior
to milling (16).
There are two types of zirconia milling processes
available: (i) soft-milling and (ii) hard-milling. Soft-
milling involves machining enlarged frameworks out of
pre-sintered blanks of zirconia, also called the ‘‘green’’
state. These are then sintered to their full strength,
which is accompanied by shrinkage of the milled
framework by approximately 25% to the desired
dimensions. Hard-milling involves machining the
framework directly to the desired dimension out of
densely sintered (higher strength and more homoge-
nous) zirconia blanks, typically these have been hot
isostatic pressed (HIPed). However, because of the
extreme hardness of sintered zirconia, a robust milling
system is required that needs an extended milling
period compared to the soft-milling process as well as
placing heavy demands on the rigidity of the cutting
instruments. The relative ease and speed of soft-milling
may be why more manufacturers chose this method to
fabricate their dental zirconia products, while only a
smaller number have used HIPed zirconia. Among the
common representative systems utilizing soft-milling
are Lava,* Procera zirconia,

IPS e.max ZirCAD

and
Cercon.
§
Systems that utilize hard-milling of HIPed
zirconia include DC-Zirkon

and Denzir.**
Supporters of soft-milling claim that hard-milling
may introduce microcracks in the framework during
the milling process. In contrast, hard-milling supporters
claim a superior marginal fit because no shrinkage is
involved in their manufacturing process. Nevertheless,
in vitro studies support the use of both HIPed and non-
HIPed zirconia for all-ceramic FPDs, crowns and
implant abutments for the posterior of the mouth
because of their high flexural strength and fracture
toughness (17).
The most utilized zirconia in dentistry, Y-TZP, has
been found to withstand cyclic fatigue testing, where
posterior all-ceramic FPDs spanning up to 5-units, had a
lifetime comparable to that achieved with metal-
ceramic restorations (2), and it has been predicted,
based on the results of this study, to have a lifetime
longer than 20 years (18). However, early clinical
findings show that there are two main drawbacks for
zirconia restorations compared to metal-ceramics. The
first is a high incidence of veneering porcelain fracture,
manifesting clinically as chipping fractures, and the
other is an inherent accelerated ageing problem that
has been identified to occur in zirconia in the presence
of water. This ageing phenomenon is known as
low-temperature degradation (LTD), which causes a
decrease in physical properties by spontaneous phase
transformation of the zirconia crystals from the tetrag-
onal phase to the weaker monoclinic phase putting
zirconia frameworks at risk of spontaneous catastrophic
failure (19).
The objective of this systematic review is to report
on the clinical success of HIPed and non-HIPed Y-TZP-
based restorations (single crowns, FPDs and implant
abutments), focusing on the incidence of framework
fracture and chipping of the veneering porcelain in
both groups. In addition, recent in vitro studies con-
ducted in an attempt to solve some of the reported
problems in zirconia-based restorations are also dis-
cussed.
*3M ESPE, Seefeld, Germany.

Nobel Biocare AB, Carolinsk, Sweden.

Vivadent-Ivoclar, Ellwangen, Germany.
§
Dentsply-Degudent, Hanau, Germany.

DCS Dental AG, Allschwil, Germany.
**Decim AB, Skelleftea˚ , Sweden.
B. AL - AML E H et al. 642
ª 2010 Blackwell Publishing Ltd
Materials and methods
A search was performed in MEDLINE and PubMed
for in vivo trials on zirconia restorations published
between 1950 and June 2009. The main keywords
used for the search and the number of articles
produced were:
1 ‘‘zirconia AND clinical’’- 329 articles
2 ‘‘zirconia AND fixed partial dentures’’- 130 articles
3 ‘‘zirconia AND FPD’’- 23 articles
4 ‘‘zirconia AND implant abutments’’- 61 articles
5 ‘‘zirconia AND single crowns’’- 73 articles
In addition, a manual hand search was conducted
through the literature to identify any possible clinical
trials on Y-TZP which may have not been listed on
MEDLINE and PubMed. The articles found were read to
identify ones which satisfied the following inclusion
and exclusion criteria:
Inclusion Criteria:
1 Human in vivo only
2 Conducted on Y-TZP
3 Fixed prosthetics (single
crowns, FPDs or implant abutments)
4 Study has a set inclusion and exclusion criteria
5 Study has a materials and methods
6 In the English language
Exclusion Criteria:
1 Case reports
2 In vitro trials
3 Animal studies
4 Trials <12 months
The search yielded 19 articles and abstracts involving
Y-TZP restorations in clinical trials which satisfied the
inclusion criteria. Following this, one final search was
done by inspecting the bibliographies of the 19
reviewed articles for any additional studies, however,
none were found.
Results
In total, only 17 clinical trials involving Y-TZP-based
restorations were found in the literature, of which only
three are randomized control trials (14, 20, 21). The
majority of studies investigated all-ceramic FPDs in the
posterior mouth (4, 9–12, 20, 22–29), while a small
number investigated single crowns (21, 30), implant
abutments (13, 14, 31), and only one study was
available on implant-supported zirconia FPDs (20).
Eight different brands of Y-TZP were identified among
the 17 studies with Cercon zirconia being the most
investigated brand (Table 1).
Thelongest follow-upperiodfoundwas 5 years, where
two papers reported results on patients restored with
zirconia all-ceramic FPDs (9, 10). Bothstudies involved 3
to5-unit FPDs onnatural teethinthepremolar andmolar
regions, except for one 3-unit FPD that replaced a lateral
incisor (9). The survival rate of Y-TZP FPDs over 5 years
was 100% (9) and 74% (10), and in the latter study, a
5-unit FPD framework fracture occurred, reportedly
because of accidental biting of a stone in a piece of bread.
While the incidence of chipping of the veneering ceramic
was 15Æ2%, in this study, secondary caries was found to
be the most common cause of failure (21Æ7%). This was
attributed to the poor marginal fit produced by a
prototype milling technique usedtofabricatethe zirconia
restorations in this particular study.
Four studies reported data on 1-year follow-up
periods for four different treatment modalities. These
were zirconia FPDs on natural teeth (27), FPDs restored
on titanium implant abutments (20), inlay-retained
FPDs (28) and zirconia implant abutments(31), two of
which are randomized control trials (20, 31). The
highest incidence of framework fracture and chipping
veneering porcelain was both reported in 1-year follow-
up studies (10%(28) and 54%(20), respectively) when
compared to longer follow-up periods.
Zirconia implant abutments
Zirconia implant abutments demonstrated encouraging
early results in the only two studies conducted on
single-tooth implant abutments using both HIPed and
non-HIPed zirconia. Glauser et al. reported no fractures
of the 38 HIPed-based zirconia abutments in the
anterior and premolar regions in 18 patients evaluated
after 4 years (13), and favourable hard and soft tissue
responses were also reported. All abutments were
restored with Empress I (Leucite reinforced) crowns
and cemented with Panavia TC
††
resin cement. How-
ever, screw loosening of two zirconia abutments at 8
and 27 months was reported, nevertheless no frame-
work fracture occurred during the follow-up period.
In a randomized controlled trial, 20 customized non-
HIPed-based zirconia single-tooth implant abutments
(Procera

) and 20 customized titanium single-tooth
implant abutments (Procera

) were followed for
††
Kuraray, Okayama, Japan.
C L I NI C AL T R I AL S I N Z I R C ONI A 643
ª 2010 Blackwell Publishing Ltd
3 years, with no fractures or loosening of abutments in
either group, and a 100% survival rate reported (14). In
this study, the abutments were restored in the canine to
molar regions. There was no difference in the soft tissue
health around both abutment groups, nevertheless
using spectrophotometric analysis, both zirconia and
titanium abutments induced similar amount of discol-
ouration of the mucosa when compared to the gingiva
of natural teeth.
Both trials on zirconia implant abutments were
conducted on regular platform, externally hexed
implants (Bra˚ nemark system- RP

)were used for sin-
gle-tooth replacement. The Bra˚ nemark implant system
was the first titanium dental implant introduced in the
mid 1970s, nevertheless recently introduced internal
type connections have been shown to improve the
fracture resistance and stability of the implant-
abutment system (32). However, so far there are no
published clinical trials using internal type zirconia
implant abutments, so no comparison could be made of
the long-term stability of both systems using zirconia
abutments.
Zirconia single crowns
Single crowns have a small representation in pub-
lished clinical trials on Y-TZP. In a 2-year randomized
control trial, 1 of 15 Cercon zirconia crowns
§
fractured
in half only 1 month after cementation on a maxillary
second molar (21), so that the success rate for this
study was 93% after 2-years. There was no significant
difference in soft tissue health adjacent to the Cercon
crowns and the control crowns made with In-Ceram
zirconia (Vita). No chipping of the veneering porcelain
was reported after 2 years. In the mean time, no
framework fracture have been reported after 3 years
in a study with 204 single crowns fabricated with
Procera zirconia

in a private practice setting (30).
However, 16% of the crowns had some type of
complication, and 6% were recorded as a failure. Loss
Table 1. List of in vivo trials conducted in yttria-stabilized tetragonal zirconia polycrystalline
Type of
zirconia Brand Study
Follow-up
periods
Type of
restorations
Sample
size
Framework
fracture, %
Veneering
porcelain
fracture,
%
Non-HIPed Cercon zirconia
(Dentsply)
Sailer et al. 2007 (10) 5 years 3–5 units FPD 33 8 15
Beuer et al. 2009 (22) 3 years 3 units FPD 21 5 0
Cehreli et al. 2009 (21) 2 years Single crowns 15 7 0
Schimitter et al. 2009 (23) 2 years 4–7 units FPD 30 3 3
Bornemann et al. 2003 (24) 1Æ5 years 3–4 units FPD 59 0 3
Lava (3M ESPE) Raigrodski et al. 2006 (25) 2Æ5 years 3 units FPD 20 0 25
Pospeich et al. 2003 (26) 2 years 3 units FPD 38 0 3
Crisp et al. 2008 (27) 1 year 3–4 units FPD 38 0 3
Procera zirconia
(Nobel Biocare)
Zembic et al. 2009 (14) 3 years Implant
abutments
18 0 –
Ortrop et al. 2009 (30) 3 years Single crowns 204 0 2
IPS e.max Zir ⁄ CAD
(Vivadent-Ivoclar)
Ohlmann et al. 2008 (28) 1 year IRFPD 30 10 13
HIPed Denzir (Cadesthetics
AB)
Molin & Karlsson 2008 (9) 5 years 3 units FPD 19 0 36
Larsson et al. 2006 (20) 1 year 2–5 units
FPD ⁄ Ti abut
13 0 54
DC- Zirkon
(DCS Dental AG)
Tinschert et al. 2008 (29) 3 years 3–10 units
+cantilever
65 0 6
Vult von Steyern et al.
2005 (4)
2 years 3–5 units FPD 23 0 15
Digizon Edelhoff et al. 2008 (12) 3 years 3–6 units FPD 21 0 9Æ5
Wohlwend Glauser et al. 2004 (13) 4 years Implant
abutments
54 0 –
HIPed, hot isostatic pressed zirconia; FPD, fixed partial denture; IRFPD, inlay-retained fixed partial denture; Ti abut, titanium implant
abutment.
B. AL - AML E H et al. 644
ª 2010 Blackwell Publishing Ltd
of retention (12 ⁄ 204 = 6%), extraction of abutment
tooth (5 ⁄ 204 = 2Æ5%), persistent pain (10 ⁄ 204 = 5%)
and chipping of veneering porcelain (4 ⁄ 204 = 2%)
were some of the complications reported in this study
which had a cumulative survival rate of 93% at
3 years.
Although zirconia single crowns appear to demon-
strate good short-term success rates of 93% after
2 years and a survival rate of 93% after 3 years, these
must be viewed with caution as they reflect data from a
study with a small sample size of 15, and the other
study reported data from a private practice setting that
was mainly based on patients records rather than
clinical evaluation.
Zirconia-fixed partial dentures
The most investigated treatment modality are the
zirconia-fixed partial dentures, with 13 different clinical
trials reporting data on FPD spans ranging from 3 to
10-units. Except for one study, all FPDs used natural
teeth as abutments; the exception used titanium
implant abutments. Zirconia PFDs demonstrated
favourable results, exhibiting a high success rate in
most studies. A relatively small number of framework
fractures have been reported in the clinical trials and do
not appear to have occurred spontaneously, but rather
an initiating factor was determined to have contributed
to the fractured framework. The longest FPD spanned
10-units (5 pontics on 5 abutments) with the frame-
work made with DC-Zirkon

and the veneering porce-
lain was Vita D (29). This study also included two
cantilever posterior FPDs. No framework fractures were
reported after 3 years of follow-up; however, chipping
of the veneering porcelain was reported in 4 posterior
FPDs of the 65 FPDs placed in the anterior and posterior
regions.
Zirconia framework fracture
Fracture of Y-TZP substructures mostly occurred in
FPDs, nevertheless this was found to be rare, and was
only reported in five studies on two zirconia brands
(Table 2). The incidence of framework fracture was
directly related to the design of the FPD, where inlay-
retained FPDs (IRFPD) showed the highest failure rate
of 10% after only 12 months. These IRFPDs were made
with IPS e.max ZirCAD

, where debonding of the inlay
pontic has been concluded to be the cause of the
framework fractures. In the review, Cercon zirconia
suffered the majority of frameworks fractures compared
to the other investigated zirconia brands; however, it
must be kept in mind that it is also the most investi-
gated brand (5 of 18 trials), followed by Lava* (3 of 18
trials). Both IPS e.max ZirCAD and Cercon zirconia are
a non-HIPed zirconia manufactured by the soft-milling
process.
Veneering porcelain fracture
The most common complication observed in zirconia-
based restorations was fracture of the veneering porce-
lain, manifesting clinically as chipping fractures of the
veneering ceramic with or without exposing the
underlying Y-TZP framework. All eight of the investi-
gated zirconia brands exhibited chipping fractures, even
when using specifically manufactured veneering
porcelains with modified coefficients of thermal
expansions compatible with zirconia (>11 · 10
)6
K
)1
)
(10, 25). These chipping fractures were found to occur
in non-load-bearing areas, such as the mesio-lingual
cusps on a mandibular second molars (23), and the
lingual aspect of FPD pontics (10). Possible trends in the
location of the chipping have been identified by some
authors and included the premolar and molar regions
Table 2. In vivo studies which reported Y-TZP framework fracture and the time until fracture
Study Brand of Zirconia
Type of
restoration
Follow-up
periods
Time until
fracture
Number of units
fractured
Incidence,
%
Sailer et al. 2007 (10) Cercon zirconia 3–5 unit FPD 5 years 38 months 1 out of 13 8
Beuer et al. 2009 (22) Cercon zirconia 3 unit FPD 3 years 30 months 1 out of 21 5
Schimitter et al. 2009 (23) Cercon zirconia 4–7 unit FPD 2 years 1 month 1 out of 30 3
Cehreli et al. 2009 (21) Cercon zirconia Single crowns 2 years 1 month 1 out of 15 7
Ohlmann et al. 2008 (28) IPS e.max ZirCAD IR FPD 1 year Not specified
(<12months)
3 out of 30 10
C L I NI C AL T R I AL S I N Z I R C ONI A 645
ª 2010 Blackwell Publishing Ltd
(30), particularly the second molars on FPDs (25) and
the connector area in mandibular posterior FPDs (29).
Denzir zirconia
‡‡
frameworks veneered with Espri-
dent Triceram,
§§
demonstrated the highest incidence of
veneering porcelain fracture at 1 year of 54% when
FPDs were using titanium implant abutments (20). In
addition, there was a 36% incidence of roughness ⁄ pit-
ting on occlusal surfaces of 3-unit FPDs on natural teeth
after 5 years with Denzir zirconia frameworks veneered
with either a feldspathic porcelain Vita Veneering
Ceramic D (Vita) or leucite reinforced pressed ceramic
IPS Empress

(9).
Cementation and bonding
Because of its high flexural strength, zirconia can be
conventionally cemented, just like metal-ceramic res-
torations, without the need for any pretreatment;
although bonding of zirconia is possible provided
special conditioning, treatment of the zirconia is carried
out first because zirconia is not etchable. Indeed,
cementation of zirconia all-ceramic restorations is a
simpler process compared to other all-ceramic systems
which require added steps for bonding. This was
evident in the range of cements used by the various
authors in the published clinical trials; zinc phosphate
cement (4, 9, 20, 24, 29, 30), glass–ionomer cements
(GIC) (21–23, 26), resin-modified GIC (12, 25) and
resin cements (9–13, 27–30).
Loss of retention was seen in 7 of 16 studies involving
the cementation of zirconia restorations. One 3-unit
FPD cemented with Panavia F lost retention after
12 months (9), a 4-unit FPD cemented with Variolink
lost retention after 33Æ3 months in service (10), while
two 3-unit FPDs in the molar region cemented with
zinc phosphate lost retention at 17 and 32 months (29).
Ketac Cem* glass–ionomer cement had one posterior 3-
unit FPD decemented after 38 months (22), in addition
to two long-span FPDs at 8Æ8 and 14Æ2 months in service
(23). All debonded zirconia restorations were rece-
mented successfully for the duration of the follow-up
period in each of the studies.
In contrast, six cases of debonded inlay-retained
zirconia FPDs were seen with Panavia F (dual-cured
resin cement) and Multilink (automix self-curing resin
cement), despite the pretreatment of the zirconia with
tribochemical air abrasion (Rocatec*). Fracture of the
framework occurred in three of the six debonded
restorations (28). Similarly, in a study on single Procera
zirconia crowns, 12 of 204 crowns lost retention of
which 4 could not be recemented (30). Unfortunately,
the type of cement used for the crowns which lost
retention was not reported, as both zinc phosphate and
resin cement (Rely-X Unicem*) where used.
Despite the encouraging retentive capacity of zinc
phosphate-cemented zirconia restorations, after 5-years
follow-up of 3-unit FPDs that were cemented with
either resin cement (Panavia F) or zinc phosphate
(De Trey Zinc
§
), visible evidence of ditching along the
margins was only seen in the zinc phosphate-cemented
group. Ditching was reported in 5% of mesial abut-
ments and 26% in distal abutments in this study,
however, this problem was not reported in the other
trials using zinc phosphate cement.
Discussion
With the limited number of published clinical trials, one
can conclude that Y-TZP has the potential for being
accepted as a suitable material for fixed prosthodontic
dental treatment; however, larger sample sizes and
longer in vivo studies are needed. The majority of
published studies are prospective clinical trials, with the
longest follow-up period being 5 years. In addition,
only three randomized control trials exist, with 1 to
3-year follow-up periods. Long-span multi-unit FPDs
have also been included in a number of studies
demonstrating confidence in the structural potential
of zirconia frameworks (4, 10, 12, 20, 23, 29).
Certainly, the published clinical trials demonstrate a
careful and meticulous approach in their treatments,
with steps taken to insure that the zirconia frameworks
are delivered at their best possible condition before final
cementation. Furthermore, it was interesting to note
that all 17 studies included bruxism in their exclusion
criteria, and therefore this should alert a potential
limitation of this all-ceramic system that is not being
investigated clinically.
Zirconia framework fracture
The probability of fracture of zirconia FPDs has been
estimated to be almost 0% after a simulated 10-year
clinical service study (33), however, framework fracture
has been reported in several in vivo trials of less than
‡‡
Cadesthetics AB, Skelleftae, Sweden.
§§
Dentaurum, Ispringen, Germany.
B. AL - AML E H et al. 646
ª 2010 Blackwell Publishing Ltd
5-years (10, 21–23, 28). Four of 5 studies involving
Cercon zirconia reported framework fractures both in
single crowns and FPDs. Inanin vitro trial, it was reported
that a force of 379 to 501 MPa was needed to load Cercon
zirconia 4-unit FPDs to failure which is higher than the
average human bite, confirming its suitability as a
substructure framework for FPDs (34). Cercon zirconia
is a non-HIPed Y-TZP, and it is too early to say whether it
is a weaker brand of zirconia compared to others because
of the limited number of trials published so far, and
keeping in mind that Cercon zirconia has been the most
clinically investigated brand of Y-TZP so far.
A 5-unit Cercon zirconia maxillary FPD fractured at
theconnector betweentwopontics at the first andsecond
premolars after 38 months in service (10). The dimen-
sion of the fractured connector was 19Æ28 mm
2
, well
above the recommended connector area of 9–16 mm
2
by
Raigrodski (2004) (35). Accidental biting on a stone was
reported to be the primary reason for failure. Scanning
electron microscopy (SEM) analysis revealed the pri-
mary crack initiation site on a Cercon zirconia FPD that
failed 29 days after insertion to be from the gingival
aspect of the connector that was around 10Æ5 mm
2
in
surface area (23). It was claimed by the authors to be
because of inappropriate alteration performed by a
dental technician during the veneering of the FPD. This
confirms reports that the most susceptible part of fracture
inall-ceramic FPDs is the connector area (36, 37). In fact,
fractographic analyses of five failed 4-unit Cercon zirco-
nia FPDs confirmed all the connector failures were
initiated fromthe gingival surface; where tensile stresses
were the greatest (34). In contrast, lithium disilicate-
based FPDs were found to fracture from the occlusal
surface of the failing connector (38).
As for single crowns, one Cercon zirconia crown
restoring a non-vital maxillary second molar fractured
in half after 1 month in service (21). This tooth did not
have a post, and although bruxism was part of their
exclusion criteria, the patient reportedly had nocturnal
bruxism, for which he had been undertaking muscle-
relaxation splint therapy.
Despite the promising results reported in vitro (39),
IRFPDs made with IPS e.max ZirCAD

also a non-HIPed
Y-TZP, demonstrated the highest incidence of fractured
frameworks in just 1-year, with a survival rate of 57%
(28). These FPDs had inlays, partial and full-crowns as
retainers with at least one retainer being an inlay.
Debonding of 20% of the retainers resulted in a 10%
framework fracture primarily when one retainer
debonded, which subsequently overloaded the connec-
tors to failure. Bonding procedures in the study used
the generally recommended bonding method for Y-TZP,
namely using tribochemical silica-coating air abrasion
(Rocatec*) pretreatment of the inner surface of the
copings, followed by silanization and cementation using
phosphate monomer resin cements, Panavia F
††
and
Multilink Automix

. Debonding was explained by the
reduced area of adhesion, either because of the small
surface area of the inlay retainers or because of voids in
the resin cement. No other in vivo study investigated the
longevity of inlay-retained FPDs, and furthermore, it is
the only in vivo study conducted on IPS e.max ZirCAD.
The physical properties of IPS e.max ZirCAD are no
lower than the average Y-TZP (40), hence the high
failure rate seen could only be explained by the design
of the inlay-retained framework. Wolfart & Kern
reported two case studies on IRFPDs. These IRFPDs
had modified wrap-around wing retainers resembling
metal winged resin-bonded retainers to increase the
bonding surface area that also had full thickness
zirconia that omitted any veneering ceramic for max-
imum strength (41). Nevertheless, in contrast to other
treatment modalities, Y-TZP IRFPDs cannot yet be
recommended and should not be clinically prescribed
until improvements in bonding of zirconia is achieved
and further long-term clinical trials are published.
An in vitro study of five framework-designed canti-
lever zirconia FPDs made of Lava* showed poor fracture
resistance, where most fractures occurred at the distal
wall of the terminal abutment (42). As a consequence,
cantilever FPDs made of zirconia were not recom-
mended by the authors; nevertheless, a 3-unit and a
4-unit cantilever Y-TZP FPDs survived 3 years in
function in the posterior region of the mouth (29).
These cantilever FPDs were made from DC-Zirkon

HIPed densely sintered blanks and cemented with zinc
phosphate cement. Further larger sample sizes and
longer follow-up periods are necessary before zirconia
cantilever FPDs can be recommended.
Chipping of veneering porcelain
Zirconia has a white opaque colour, which needs
masking by veneering it with a more translucent, and
aesthetic porcelain to achieve an acceptable aesthetic
result, as with porcelain-fused-to-metal restorations
(PFM). The most striking finding which has been
reported in the literature is the high incidence of
C L I NI C AL T R I AL S I N Z I R C ONI A 647
ª 2010 Blackwell Publishing Ltd
cohesive failure of the veneering porcelain, manifesting
clinically as chipping of the veneering ceramic with or
without exposing the underlying Y-TZP framework.
The incidence of chipping fractures ranged from 0% in
two studies, both on Cercon zirconia at 2 years (21) and
3 years(22), to as high as 54% in just 1 year (20). No
brand of Y-TZP has escaped this problem, and it has
been reported in all seven brands of zirconia investi-
gated for crowns and bridges as follows: Cercon [15% in
5 years (10), 3% in 2 years (23), 3% in 1Æ5 years (24)];
Lava [25% in 2Æ5 years (25), 3% in 1 year (27) and 3%
in 2 years (26)]; IPS e.max ZirCAD [13% in 1 year
(28)]; Procera [2% in 3 years (30)]; DC-Zirkon [6% in
3 years(29), 15% in 2 years (4)]; Denzir [36% in
5 years (9), 54% in 1 year (20)] and Digizon [9Æ5% in
3 years (12)]. In some occasions, they occur at non-
load-bearing areas, and no set pattern has been iden-
tified so far, although the second molars have been
reported to have a higher incidence than the rest of the
dentition because of higher forces found at the posterior
of the mouth (25, 29).
It is important to appreciate that a large number of
chip fractures reported were undetected by the patients
and were an incidental finding during review appoint-
ments (4, 20, 27), and some patients were satisfied with
simply polishing the rough margins (23, 27), or repair-
ing the fracture with composite resin (12), while in
some cases, the patients chose not to have them
polished at all (25). Nevertheless, some restorations
did require total replacement because of major chipping
fractures which could not be polished or because they
posed aesthetic concerns (10, 30).
Chipping fractures can be a disappointment to both
the clinician and patient, and it has been noted in the
literature as a serious problem (43), instigating a large
number of studies investigating this phenomenon in
an attempt to solve it. Numerous reasons have been
suggested, such as mismatch of the CTE between the
veneering porcelain and the zirconia substructure
(44), mechanically defective micro-structural regions
in the porcelain, areas of porosities (28), surface
defects or improper support by the framework (43),
overloading and fatigue (45), low fracture toughness
of the veneering porcelain (46) and finally the low
thermal conductivity of zirconia (47). Delamination,
as opposed to chip fractures, has also been proposed as
a cause of failure. Delamination is the adhesive failure
between the veneering ceramic and zirconia, mani-
festing clinically as the complete loss of porcelain
partially exposing the substructure, although Ohl-
mann et al. (2008) argued that delamination can only
be confirmed after microscopic examination, which is
impossible if the restoration remains in situ, and
therefore it is quite possible that many fractures that
have been classified as delamination may in fact be
chipping fractures. This speculation is supported by
the evidence that the bond strength between zirconia
and a large number of veneering porcelains with
varying CTEs was higher than the cohesive strength of
the porcelain itself (44, 48, 49). Consequently, it has
been concluded that the veneering porcelain is the
weakest link, and improving its strength could reduce
the incidence of veneering porcelain chipping (44,
50). This was attempted by using high-strength heat-
pressed ceramics which have shown to have better
bond strengths to zirconia frameworks compared to
traditional layering ceramics and have been receiving
support in the literature (51). Aboushelib et al.(52)
described a ‘‘double veneering’’ technique which
combines the high bond strength of heat-pressed
ceramics with the superior aesthetics of layered
porcelain in an effort to improve the overall strength
and aesthetics of the veneering porcelain. Unfortu-
nately, chipping fractures have also been reported in
pressed porcelain in clinical trials on zirconia FPDs
and do not appear to have solved this chipping
problem (9, 28).
Swain (2009) (47) proposed that tempering residual
stress was the basis for the preponderance of chipping of
porcelain bonded to zirconia. He concluded that there
are three factors which contribute these residual
stresses and the unstable chipping fractures in zirconia:
mismatch of the higher thermal expansion coefficient
of porcelains bonded to zirconia; thickness of the
veneering porcelain and cooling rate. The cooling rate
after the removal of the sintered restoration from the
furnace, while the restoration is still at elevated
temperatures, generates significant thermal gradients
within the porcelain and is directly related to the low
thermal conductivity of zirconia, which is much lower
than that of metal-alloys and even alumina ceramic,
which has not experienced similar incidences of chip-
ping fractures. He suggests that by more slowly cooling
the restoration above the glass transition temperature
of the porcelain, it is possible to prevent the develop-
ment of high tensile subsurface residual stresses in the
porcelain which may result in unstable cracking or
chipping. This approach of a reduced cooling rate after
B. AL - AML E H et al. 648
ª 2010 Blackwell Publishing Ltd
the final firing or glazing procedure is now recom-
mended by most dental material producers.
Improper design of the zirconia framework has also
been suggested to be a contributing factor in chipping
fractures, because of the inadequate support provided
by the thin zirconia copings commonly milled. Re-
cently, an improved customised zirconia-coping design
has been recommended by bulking out the substructure
to provide adequate support to the veneering porcelain.
This was demonstrated in a case report by Marchack
and colleagues (43), where the design of their zirconia
crowns was taken from the conventional PFM tech-
nique of a full contour wax-up which was then cut back
to allow for the veneering porcelain. An aesthetic
drawback would be the visible opaque white zirconia
along the palatal or lingual surfaces; however, the
authors argue that patient acceptance is high as soon as
they are given the choice between the appearance of a
metal margin or a white ceramic. Tinschert et al. (29)
adopted this modified framework design in their FPDs,
however, chipping fractures still occurred in 4 of 65
FPDs in their clinical trial spanning 3 years. Alteration
of the zirconia crystalline structures during sandblasting
prior to the veneering process was suggested by the
authors to be a possible reason why they had chipping
fractures, however, if that was the case, then complete
delamination of the porcelain would be expected rather
than chipping fracture of the superficial porcelain.
A novel approach in veneering zirconia copings has
been described by Beuer and colleagues (46) by
sintering a CAD ⁄ CAM-milled lithium disilicate veneer
cap onto the zirconia coping significantly increasing the
mechanical strength of the restoration. Other than
improved strength, they claimed this method to be a
cost-effective way of fabricating all-ceramic restora-
tions. To date, there are no clinical trials that have
adopted this method, and further in vitro studies are
needed before they can be clinically trialed.
Low-temperature degradation
Catastrophic failure of zirconia restorations has been a
major concern because of the inherent spontaneous
ageing problem of zirconia in the presence of water.
Low-temperature degradation (LTD) was first described
by Kobayashi in 1981 (53), where in a humid envi-
ronment, spontaneous slow transformation from the
tetragonal phase to the more stable monoclinic phase
occurred in zirconia grains at relatively low tempera-
tures of 150–400
°
C. This ageing process initiates at
surface grains and then later progresses towards the
bulk material causing a reduction in flexural strength of
the material, putting it at risk of spontaneous cata-
strophic failure. How great a problem this ageing
process is going to be for zirconia restorations is
currently unknown. The vulnerability of zirconia to
ageing is exacerbated by the fact that its severity has
been shown to differ between different zirconias from
different manufacturers, and even in zirconia from the
same manufacturer but which have been processed
differently (54). This may be reflected clinically, for
example, in the fractured zirconia frameworks reported
with Cercon zirconia, suggesting a possible weakness of
this brand compared to others, however, before this can
be confirmed, further studies with larger sample sizes
and following a longer review period must be com-
pleted; especially that each case of framework fracture
was caused by an initiating factor, such as accidentally
biting a stone, improper laboratory technique, insuffi-
cient thickness of the zirconia coping and poor design,
which if avoided, a longer restoration life-time may
have been expected.
HIPed vs. non-Hiped zirconia
The type of blanks with which the zirconia restorations
are milled from have been suggested to have a direct
affect on the final outcome of the restoration. Support-
ers of soft-milling using the non-HIPed zirconia claim
that hard-milling of HIPed zirconia could introduce
microcracks to the framework during the milling pro-
cess, reducing its overall physical strength and longevity
of the prosthesis (16). This was not evident in the
published clinical trials; in contrast, zirconia cata-
strophic fractures have only been reported in non-
HIPed zirconia and not in HIPed zirconia. On the other
hand, HIPed zirconia supporters claimsuperior marginal
fit because no shrinkage is involved in the manufactur-
ing process, and precise margins are not possible with
non-HIPed zirconia, giving rise to recurrent caries,
periodontal conditions and unaesthetic margins. Sailer
et al. (2007) reported the highest incidence of secondary
caries (22%) in a non-HIPed zirconia
¶¶
FPDs after a 5-
year follow-up, suggested to be because of using a
prototype soft-milling method which has since been
improved. Notably, no other study reported a high
¶¶
Cercon zirconia, Dentsply Degudent, Hanau, Germany.
C L I NI C AL T R I AL S I N Z I R C ONI A 649
ª 2010 Blackwell Publishing Ltd
incidence of caries, even when using non-HIPed zirco-
nia. Reich and colleagues (55) examined the clinical fit
of 4-unit posterior FPDs made by non-HIPed zirconia
and found a median marginal gap of 77 lm in 24 FPDs,
well within the clinically acceptable marginal gap limit
of 100–120 lm (56). Further, in vivo studies with larger
sample sizes and longer follow-up periods are needed to
establish any significant differences between HIPed and
non-HIPed zirconia restorations; and although more
dental zirconia manufacturers supply non-HIPed Y-
TZP, so far clinical results are in favour of HIPed
zirconia because of the absence of any framework failures
in the short-term.
The future of zirconia
Case reports of large multi-unit tooth and implant FPDs
suggest that the dental community may have some
confidence in zirconia as a restorative material, with
some authors restoring full mouth rehabilitations using
zirconia abutments and frameworks despite limited
scientific evidence (57–59).
The issue of porcelain chipping appears to be germane
to zirconia frameworks despite their intrinsic superior
mechanical properties and that porcelain mechanical
properties are almost framework independent. Despite
this apparent anomaly methods of strengthening the
veneering porcelain are being developed to control the
unstable chipping fractures. These include novel con-
cepts that are being reported in the literature, such as
the high-strength CAD ⁄ CAM-fabrication of the veneer-
ing porcelain (46) and the ‘‘double veneering’’ tech-
nique (52). Other approaches include bulking out the
zirconia framework and omitting veneering porcelain at
non-aesthetic areas such as the lingual and palatal
aspects of the restoration.
At this time, investigations appear to have been
directed towards zirconia materials with stabilisers
other than yttria which are less prone to LTD, such as
magnesia partially stabilized zirconia (Mg-PSZ) (60) and
ceria-stabilized zirconia ⁄ alumina nanocomposites
(Ce-TZP ⁄ A) (61). These non-yttria-stabilized zirconia
materials may be less susceptible to LTD and spontane-
ous phase transformation, however, their fracture
toughness and flexural strengths are not as high as Y-
TZP and so they may not be suitable for medium to
long-span FPDs. Therefore, long-term in vivo studies
must be carefully evaluated before non-yttria-stabilized
zirconia materials could be recommended.
Conclusion
1 Based on the limited short-term studies available,
zirconia can be said to be suitable for the fabrication
of all-ceramic posterior single crowns, long-span
FPDs and implant abutments.
2 Inlay-retained FPDs cannot be recommended in light
of published in vivo trials.
3 Chipping of the veneering porcelain is confirmed to
be an ongoing problem with zirconia all-ceramic-
based restorations.
4 Zirconia framework fractures have only been reported
in soft-milled non-HIPed zirconia, with a possible
advantage being seen in hard-milling HIPed zirconia.
5 Zirconia-based all-ceramic restorations can be
cemented with conventional luting cements, how-
ever, bonding to tooth structure is also possible but
with limited success.
Conflicts of interest
The authors declare no conflicts of interests.
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Correspondence: Basil Al-Amleh, Department of Oral Rehabilitation,
Faculty of Dentistry, University of Otago, PO Box 647, Dunedin 9054,
New Zealand. E-mail: alamleh@gmail.com
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ª 2010 Blackwell Publishing Ltd