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Received: Aug.

2013

Review Article

Accepted: Sep. 2013

Zirconia: An Up-to-date Literature Review


Khamverdi, Z.* Moshiri, Z.**
*Associate Professor, Dept. of Operative Dentistry, Dental Research Center, Dental Faculty, Hamadan
University of Medical Sciences, Hamadan, Iran.
** Assistant Professor; Dept. of Prosthodontics, Dental Faculty, Zanjan University of Medical Sciences,
Zanjan, Iran.

ABSTRACT
The interest of dental research in metal-free restorations has been rising in the last 20 years
following the introduction of innovative all-ceramic materials in the daily practice. In particular,
high-strength ceramics and related CAD/CAM techniques have widely increased the clinical
indications of metal-free restorations, showing more favorable mechanical characteristics
compared to the early ceramic materials. Zirconia has been recently introduced in prosthetic
dentistry for the fabrication of crowns and fixed partial dentures, in combination with CAD/CAM
techniques. The aim of the present paper was to provide a brief review on some aspects of zirconia
dental restorations with focus on recent scientific researches.

Keywords: Zirconium oxide, CAD/CAM, Drug Evaluation, Preclinical, Complications.


INTRODUCTION

accumulation.(13)

An ideal all-ceramic dental material should

oxide) was introduced by Martin Heinrich

exhibit excellent esthetic characteristics,

Klaproth in 1789.(4) This material is a non-

like translucency, natural tooth color,

cytotoxic metal oxide, is insoluble in water

outstanding light transmission and, at the

and has no potential of bacterial adhesion.

same time, optimal mechanical properties,

In addition, it has radio-opacity properties

like flexural strength, fracture toughness

and exhibits low corrosion.(5,6)

and limited crack propagation at the

STRUCTURE

functional

load

Three crystalline shapes of this material

conditions, in order to ensure long-term

at different temperatures are as follows:

service.

cubic (c) (from 2680C to 2370C);

and

To

date,

parafunctional

zirconia

has

been

considered a suitable choice for dental


restorations due to its good mechanical
properties,
appearance

tooth-colored
and

and
low

natural
plaque

Corresponding Author: Z. Moshiri, Address:

Zirconia

(zirconium

tetragonal (t) (from 2370C to 1170C);


monoclinic (m) (from 1170C to room
temperature).(7) Monoclinic (m) phase is
a more stable phase. Incorporation of

Department of Prosthodontics, Faculty of Dentistry,

cubic oxides like MgO, CaO, Y2O3 and

Zanjan University of Medical Sciences, Zanjan, Iran.

CeO2 to zirconia can delay creation of

Tel09125421693 E.mailshaneldent@gmail.com

DJH 2012; Vol.4, No.1

the transformation phase. Subsequently,

Khamverdi et al.

Zirconia: An Up-to-date Literature Review

the zirconia crystals in their tetragonal

The

or cubic shape at room temperature

mechanical behavior of zirconia. It

remain stable. These materials are

means that higher temperatures and

referred to as stabilizers.(5)

longer sintering times produce larger

One of the most important properties is

grain sizes. The critical crystal size is

fracture

approximately 1 m and zirconia with

toughness of the material by hindering,

larger crystals are more prone to

but not preventing, the propagation of a

spontaneous PTT due to lower stability,

crack;

concentration

whereas a smaller grain size generates

converts the transformation from (t)

favorable properties. It is reported that

phase to the (m) phase.(8)

with grain sizes below 0.2 m, PTT

remarkable

increase

tensile

Increasing

stress

the

in

crystal

volume,

grain

size

influences

the

does not increase and fracture toughness

constrained by the surrounding ones,

decreases.

leads to a favorable compressive stress.

conditions are important because they

cracks.(7)

affect the crystal size, the mechanical

This

limits

growth

of

However,

the

sintering

Transformation toughening or phase

properties

transformation toughening (PTT) is the

zirconia.(11)

reported mechanism for exceptional

CLASSIFICATION OF ZIRCONIA-

flexural strength and fracture toughness

BASED CERAMICS

of

other

Although, many types of zirconia-based

ceramics.(9) Heating the material at a

ceramics are available, three zirconia-

low temperature (9001000C) for a

containing systems have been used in

short time changes the phase from

dentistry. Two of them are bi-phasic

monoclinic back to tetragonal form and

materials:

generates

the

toughened alumina (ZTA) and the

advantageous compressive stress at the

magnesium partially-stabilized zirconia

surface, resulting in a decrease in the

(Mg-PSZ); the third type is the yttria

material toughness.(10) Thus, the high

partially-stabilized tetragonal zirconia

temperature

polycrystal (3Y-TZP), a mono-phasic

zirconia

among

all

the

relaxation

thermal

of

process

of

and

the

stability

glass-infiltrated

of

zirconia-

veneering zirconia with feldspathic

material which is used commonly.(12)

ceramic should be considered a possible

In-Ceram zirconia is a glass-infiltrated

risk

zirconia-toughened alumina (ZTA), in

for

such

transformation.(1)

detrimental

reverse

which, for the first time, zirconium

DJH 2012; Vol.4, No.1

Khamverdi et al.

Zirconia: An Up-to-date Literature Review

oxide was used as a dental ceramic. Due

temperature degradation (LTD) than Y-

to its metastable nature, zirconia is a

TZP.(14,15)

high-performance

According

ceramic

material.

to

the

manufacturers

High-strength cores are composed of 67

indications, ZTA is suitable for 3-unit

wt% of aluminum oxide and 33% of 12

FPD frameworks with one pontic in the

mol%

stabilized

posterior site (reported 94.5% survival

zirconium oxide; therefore, zirconia

rate during a 3-year period, while, it

crystals (grain size <1 m) are embedded

exhibits

in an alumina matrix (larger grains <26

translucency;

m, high elastic modulus) in such a

efficient masking power in the presence

composition that yields the highest

of dark colors or discolored teeth, ZTA

tenacity and flexure strength inside this

is not suggested for situations with a

class of ceramics (400800 MPa):

high esthetic result.(16)

microcracks may trigger the so-called

The

transformation

of

partially-stabilized zirconia (Mg-PSZ)

zirconia, so that a crack tip is more

consists of clusters of tetragonal crystals

often seen to propagate through the

within

alumina

matrix. The added stabilizer is MgO (8

cerium-partially

toughening

matrix

surrounding

the

intense

opacity

despite

microstructure

cubic

10%

manufactured according to two different

applications,

processes:

(Denzir-MDentronic

machining

or

slip

low

providing

of

an

magnesium

stabilized zirconia

transformed crystals.(1,4) ZTA can be

soft

mol).

and

As

regards

with

dental

some exceptions
AB),

such

casting.

material has not been extensively used,

The latter presents the advantage of a

neither

more limited shrinkage but, at the same

popularity

time,

higher

it

due

encountered
to

its

large

remarkable

and

poorer

porosity, large grain size (3060 m),

than

yttrium

low stability, tendency to framework

partially-stabilized tetragonal zirconia

wear,14 and overall poor mechanical

mechanical

porosity

has

properties

polycrystal (3Y-TZP),

(13)

the strongest

properties, especially when compared to

and most commonly used zirconia-

3Y-TZP.(17)

based ceramic. Moreover, stabilization

The third common zirconia is yttrium

by cerium oxide provides better thermal

partially-stabilized tetragonal zirconia

stability

polycrystal (3Y-TZP). This type of

and

resistance

to

low

zirconia is made of transformable, t-

DJH 2012; Vol.4, No.1

Khamverdi et al.

Zirconia: An Up-to-date Literature Review

shaped grains stabilized by the addition

study reported that zirconia FPD failure

of 3 mol% yttrium-oxides (Y2O3). It is

occurs under 379501 MPa loads.

placed in category 4-polycrystalline

Therefore, these restorations can be

solids (alumina and zirconia) and has no

used for long periods.(20)

glassy components. All the atoms are

Zirconia ceramics yield superior wear

packed into a regular pattern making it

behavior and lower antagonistic wear

dense and stronger. Procera system is a

compared to porcelains. A trend to

computer-aided

higher ceramic and antagonistic wear

designing

and

computer-aided manufacturing system

was

(CAD-CAM). This ceramic is the

treatments.(21,22) Degradation of zirconia

frequently

happens

used

commercially

form

of

available

for

zirconia
dental

shown

in

after

low

grinding

temperatures

and

without mechanical load application.

use.(18)

This condition, so-called "aging", is a

MECHANICAL PROPERTIES OF

transformation of the tetragonal phase

ZIRCONIA

to monoclinic phase which is a stable

Mechanical properties of zirconia have

form. Aging decreases the physical

been reported to be higher than other

properties of the material and increases

ceramics

applications.

risk of failure in zirconia restorations.(23)

Fracture resistance of 610 MPa/m1/2,

Presence of mechanical stresses and

a flexural strength of 9001200 MPa

moisture accelerates zirconia aging.

and a compression resistance of 2000

Grain size, temperature, vapor, the

MPa have been reported for it.(19)

presence of surface defects, type,

Zirconia restorations bear an average

percentage

and

load of 755 N. Fracture loads of

stabilizing

oxides

7064100 N have been reported; all the

techniques influence this process.(7)

studies have demonstrated that in dental

Meanwhile, there is evidence in relation

restorations

higher

to the long-term evaluation of effects of

fracture loads than alumina or lithium

aging of zirconia on dental restorations.

disilicate.(20)

Aging leads to changes in the behavior

Numerous studies have evaluated the

of the material, weakening it, and

mechanical performance of zirconia in

subsequently, to material degradation,

both single crowns and in 3- and 4-unit

with microcracks decreasing strength

FPD, reporting varying results. A recent

properties.(23)

for

dental

zirconia

yields

distribution
and

of

processing

DJH 2012; Vol.4, No.1

Khamverdi et al.

Zirconia: An Up-to-date Literature Review

PREFABRICATION

compensate

PROCEDURES

procedure, the framework is machined

Two

commonly

techniques

used

are

different

available

for

shrinkage.

In

CAM

according to the designed form. After


this step, the sinterization is performed.

prefabrication of zirconia frameworks:

Since linear

soft machining of pre-sintered blocks

restoration is about 25%, the zirconia

or hard machining of fully sintered

framework

(24)

volume

shrinkage

reverses

of

previous

blocks.

dimensions. Performance of these steps

The soft machining process is the most

provides cores with high stability.(1)

common manufacturing system for 3Y-

However, a certain amount of cubic

TZP, based on milling of pre-sintered

zirconia may be present due to an

blocks that are fully sintered at a final

uneven distribution of yttrium oxide.

stage. The process of production of

The cubic phase has stable oxides than

these blocks consists of compacting

the tetragonal crystals which may

zirconia powder in the presence of a

provide

binder through a cold, isostatic pressing

Addition of metal oxides to zirconia

process; this leads to homogeneous

powder or immersing cores in metal salt

distribution of the components inside

solutions might yield colored cores.

the block.(14) Processing at a proper

This

pre-sintering temperature of zirconia is

mechanical

an

this

cores.(24) Many manufacturers prefer

hardness,

this technique i.e. Procera Zirconia

important

parameter

factor

because

influences

an

material.(11)

unstable

coloration

does

properties

of

zirconia

(Nobel

blocks. Hardness and machinability

Sweden), Lava (3MESPE, Seefeld,

properties act as reverse factors; this

Germany)

means if hardness of block is adequate,

Degudent, Hanau, Germany).

manipulation of blocks is performed

In the hard machining technique, the so-

safely, but, high hardness is unsuitable

called "hot isostatic pressing", the 3Y-

for

an

TZP blocks are sintered and condensed

increase in pre-sintering temperatures

at high temperatures (14001500C)

Moreover,
(1)

generates rougher surfaces.


Usually,

CAD

software

Cercon

Goteborg,

(Dentsply

and under high pressure in inert gas


programs

design the enlarged framework to

DJH 2012; Vol.4, No.1

and

AB,

affect

machinability and roughness of the

machinability.

Biocare

not

medium. These blocks are very hard,


dense and homogeneous.(25)

Khamverdi et al.

Zirconia: An Up-to-date Literature Review

Selection of each one of these two

It appears that residual stress due to

techniques as suitable technique is a

processing the restoration, especially

matter of controversy. Meanwhile, the

coefficient of thermal expansion (CTE)

most

soft-

difference between the fired zirconia

machining is the difference in the

and the veneering material, plays a

sintering shrinkage of the framework

more

and the enlargement values.(4) The

treatments in aging potential.(28)

major

Recently,

important

problem

disadvantage

of

in

the

hard

important

role

cerium

than

oxide

surface

has

been

machining technique is more time-

introduced as a stabilizer for dental

consuming and requires very tough and

applications.

wear-resistant cutting devices. Provision

zirconia

of these pieces of equipment renders the

suitable thermal stability and LTD

production procedure more costly.(8)

resistance

Milling zirconia blocks at thin sections

demonstrates

provides various

strength in dental ceramics. Presence of

types

of surface

The

ceria-stabilized

(Ce-TZP)

than
the

exhibits

more

Y-TZP.

Ce-TZP

highest

bending

microcrack and defects. It seems that

yellow-brownish

factors such as the grain size of the

discoloration

diamond burs or the rotation speed are

zirconia restorations to dark gray is a

effective.(26)

limitation for dental applications.(8,28)

Surface

treatments

provide

more

Other

color
of

factors

such

and

future

ceria-containing

as

framework

roughness but decrease toughness and

thickness, connector shape and size,

the strength resulting in the exposure of

coefficient

the processing defects to moisture. It

difference between the coping and

has been reported that it induces aging

veneer affect mechanical properties of

potential and decreases serviceability of

zirconia

the restoration.(27,28)

framework thickness

The hard machining procedure leads to

necessary

the production of monoclinic zirconia

veneering material and avoid core

that is a weak phase in terms of aging

deformation. CTE of coping must be

and

microcracking.(11)

There

is

of

thermal

frameworks.

for

Minimum

(0.5

copings

to

mm) is
support

close to veneering ceramic to reduce

controversy about the results of studies

stress in restorations.(16,29)

on the surface treatments of zirconia.(1)

FITNESS

expansion

DJH 2012; Vol.4, No.1

Khamverdi et al.

Zirconia: An Up-to-date Literature Review

Various studies have reported different

Many studies have been performed on

values for precision of fit of zirconia

survival rates of zirconia restorations.

restorations, which is attributed to

Available studies are few for single

differences in experimental designs and

crowns. Cehreli(34) reported a success

evaluation procedures. In these studies,

rate of 93% for Cercon crowns after a 2-

the marginal gaps ranged between 9.0

year period. Another study showed a

and 148.8 m, with an average value of

survival rate of 93% for Procera crowns

(15,30)

73.8 m.

Higher discrepancies

for a 3-year period and complications

have been detected at the internal gap

were recorded as loss of retention,

(i.e. the internal distance measured

extraction of abutment teeth, pain and

between the coping and the abutment),

porcelain chipping.(35)

ranging between 68.8 and 215 m in the

The bulk of data available for zirconia

occlusal direction and between 52.3 and

posterior FPDs indicate the best clinical

(19)

192 m in the axial direction.


Single

crowns

with

all-ceramic

systems. Complications of zirconia

zirconia copings have exhibited better

FPDs have been reported as cracking or

fit (074 m).(30) Comlekoglu et al(31)

chipping of veneering ceramic, whereas

reported values of marginal gap for

other

feather-edge, mini-chamfer, shoulder

exhibited some framework fractures. A

and

8710,

study reported successful service of 34

11411, 11416 and 14414 m,

bridges at a three-year review. All Y-

respectively.

is

TZP frameworks were intact and no

dependent on the extension and shape of

bridge retainers had deboned. Only two

zirconia frameworks. Long-span and

veneering ceramics were chipped.(36)

curved

Sasse(37) evaluated the clinical outcome

finish

Marginal

zirconia

with

(93.3%)

dense

chamfer

milled

results

lines:

opening

frameworks

have

all-ceramic

restorations

have

exhibited less marginal fit.(32,33) Hard-

of

machining

has

for

resin-bonded fixed dental prostheses

complex

restorations

some

(RBFDPs) with a cantilevered single-

been

advised
by

studies.(19)

30

CAD/CAM zirconia-ceramic

retainer design at a time of 64.2 months.


AND

One deboning occurred in each group.

COMPLICATIONS OF ZIRCONIA-

In this study, effect of the bonding

BASED RESTORATIONS

system was considerable.

SURVIVAL

RATES

DJH 2012; Vol.4, No.1

Khamverdi et al.

Zirconia: An Up-to-date Literature Review

A study retrospectively reported that the

ceramic, firing shrinkage of porcelain,

success rate of 26 CAD/CAM cross-

areas of porosities, flaws on veneering,

arch zirconia implant bridges was

poor wetting by veneering material on

98.6% at the unit level after 5 years of

core, improper framework support,

service.

overloading and fatigue.(15,16,43) Because

Successful

soft

tissue

parameters were found around all the

of

implants.(38)

composition

After 4 years of service, the reported

(composed

failure rates were 46%.(39) However, a

zirconia, glass-ceramics and feldspathic

reliable

ceramics),

comparison

of

studies

is

differences

in

of
of

the

material

ceramic

systems

metal,

different

alumina

treatments

or

are

difficult due to evaluation period and

required for the exposed material

parameters,

surfaces

research

methodology,

after

chipping.

Use

of

sample size and the systems used.

hydrofluoric acid etching, air abrasion,

Routine mechanical complications of

tribochemical coating, silanization and

such restorations have been reported as

metal primers or zirconia primers seem

framework

of

to be the most successful conditioning

veneering ceramic and loss of retention

methods for durable bonding and

or deboning. Bulk fracture is a rare

repair.(44)

occurrence and usually such fractures

BONDING TO ZIRCONIA

fractures,

chipping

(40)

occur in long-span FPDs.

Range of

One problem of zirconia application is

the incidence of chipping reported in

its adhesion to different substrates.

zirconia-based

Routine

restorations

was

methods

for

bonding

of

different. In non-load-bearing areas,

restorations to hard tooth structures and

these unsuitable factors can result in

restorative materials do not provide

failures

such

as

(40,41)

chipping.

desired

bond

strength

for

ZrO2

However, areas under loading such as

components.(45) Surface treatment of

connectors are susceptible to chipping

zirconia produces an activated surface

with a higher incidence rate.(42) It is

in different applications.(46)

clear that ceramic veneer cracking is a

Conventional

multifactorial phenomenon and that

techniques

only some of its possible causes have

(typically

been distinctly highlighted: differences

diamond (or other) rotary instruments,

in

(3) air abrasion with alumina (or other)

CTEs

between

framework

and

surface
are

(1)

HF),

(2)

treatment
acid

etching

abrasion

with

DJH 2012; Vol.4, No.1

Khamverdi et al.

Zirconia: An Up-to-date Literature Review

particles, (4), application of different

to allow infiltration of boundaries with

laser types and (5) a combination of

molten glass. The glass is then etched

these techniques that actually roughen

out using HF, creating a network of

surfaces.

inter-granular porosity that allows nano-

Since zirconia is resistant to aggressive

mechanical

chemical treatment, very aggressive

cement. The advantage of SIE is that it

mechanical abrasion methods must be

only involves grains that are exposed to

used to provide sufficient surface

molten glass, allowing control of the

roughness.(47)

area to be etched. The use of SIE

Zandparsa et al

(48)

interlocking

of

resin

compared the effect

improved nano-mechanical retention of

of airborne particle abrasion, acid-

zirconia by increasing the surface area

etching

available

(Piranha

solution),

and

for

bonding.

This

was

application of an alloy primer on shear

confirmed by AFM work carried out by

bond strength of zirconia to enamel and

Casucci et al, showing that the surface

concluded

roughness of ZrO2 is significantly

abrasion

that
in

application

airborne

combination
of

particle
with

zirconia

the

greater after SIE, when compared to

primer

particle air-abrasion or HF etching.(51,52)

provides a durable bond strength.

Recently, it was reported that the

Surface grinding is a commonly used

experimental hot etching solution could

alternative for roughening the surface of

be considered an alternative treatment

ZrO2 to improve mechanical bonding.

modality to sandblasting for zirconia

There are several methods used for

cores to avoid phase transition at the

surface roughening: roughening with

surface from tetragonal to monoclinic

abrasive paper or wheels (SiC or

that

Al2O3), particle air-abrasion

using

longevity of the zirconia-veneering

Al2O3 or other abrasive particles

ceramic restoration.(53) AFM has shown

ranging in size from 50 to 250 m and

that the application of hot chemical

grinding with a diamond bur.(4850) A

etching solution produces a surface

novel surface roughening technique that

roughness that is significantly greater

has been explored for ZrO2 is selective

than SIE. It is possible that this

infiltration etching (SIE). SIE uses a

technique

heat-induced maturation process to pre-

mechanical retention of ZrO2.(51) Use of

stress surface grain boundaries in ZrO2

traditional

DJH 2012; Vol.4, No.1

may be

detrimental

might

for

enhance

organosilanes

the

the

for

Khamverdi et al.

Zirconia: An Up-to-date Literature Review

improvement of adhesion to zirconia as

Ural(59)

a chemical bonding agent is not

different power outputs of a carbon

considerable. Zirconia has a non-polar

dioxide (CO2) laser on shear bond

and

strength of resin cement to zirconium

stable

surface

and

is

not

hydrolyzed.
An in

assessed

the

influence

of

dioxide-based ceramic. It was found

vitro study indicated

that

that the shear bond strength values were

application of silane alone decreases

affected by power outputs of laser.

bond strength values.


Some

studies

(54)

However, output power of the laser and

have

tribochemical

shown

coating,

that

the energy level is a critical factor on

before

micromechanical retention. A study

silanization, increases bond strength and

indicated

other studies have shown a decrease in

roughness and bond strength values

bond strength. It appears that high

were achieved with short pulse duration

hardness of and cleaning of ZrO2

of

surface

of

Foxton(61) showed that Er:YAG laser

tribochemical may be reasons for a

treatment of the zirconia surface did not

strength.(55,56)

result in a durable resin cement/ceramic

Recently, use of lasers is a method for

bond; however, a durable bond between

roughening of surface of zirconia

a conventional dual-cured resin cement

restorations.

laser-based

and Procera All Ceram and Procera All

studies are controversial. Akyl et al

Zirkon was formed using a ceramic

reported that roughening of the surface

primer

of Y-TZP ceramic by Er:YAG laser

monomer, MDP, without any additional

increased the shear bond strengths of

surface treatment. It has been shown

ceramic

reduced

that the Nd:YAG laser created more

microleakage scores.(57) A recent study

roughness on zirconia when compared

evaluated

the

to

morphology

of

after

decrease

in

to

application

bond

Results

dentin

of

and

roughness
after

Nd:YAG

the

the

laser

containing

CO2

laser

highest

surface

irradiation.(60)

the

phosphate

and

abrasion

air

treatments. Silica-coating increased the

abrasion and Er:YAG laser application

SBS of lased and non-lased zirconia.

of different intensities. The results

Significant microcracks were found on

demonstrated that the air abrasion group

specimens treated with CO2.(62)

had significantly higher roughness than

Resin cement is a standard material for

the other groups.(58)

luting a ceramic prosthetic to tooth

10

zirconia

and

that

DJH 2012; Vol.4, No.1

Khamverdi et al.
structures.
cements

Zirconia: An Up-to-date Literature Review

Resin-based
have

composite

compositions

and

adhesion

of

zirconia

to

different

substrates and to avoid chipping of

characteristics similar to conventional

veneer to zirconia cores.

restorative composite resins and consist

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TEGDMA, UDMA).(63) The use of

follow-up study of In-Ceram Alumina FPDs. Int

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(e.g.

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