Journal of Dentistry 111 (2021) 103709

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Journal of Dentistry
journal homepage: www.elsevier.com/locate/jdent

Effect of different CAD/CAM cutting depths on the post-fatigue

load-bearing capacity of novel multilayer zirconia restorations
Xuejing Li a, Qiang Wang a, Xiaohai Qiu b, Baohong Zhao a, *
a
School and Hospital of Stomatology, China Medical University, Liaoning Provincial Key Laboratory of Oral Diseases, Shenyang, China
b
Tianjin Stomatological Hospital, Nankai University, Tianjin, China

A R T I C L E I N F O A B S T R A C T

Keywords: Objectives: To investigate the post-fatigue load-bearing capacity of restorations milled at various cutting depths in
Multilayer zirconia a novel strength- and color-gradient multilayer zirconia CAD/CAM disk.
Strength- and color- gradient Methods: Identical crowns were divided into 4 groups (n = 25 per group): crowns milled at 3 CAD/CAM cutting
CAD/CAM cutting depth
depths in multilayer zirconia disks as 3 experiment groups and homogeneous zirconia crowns as a control group.
post-fatigue load-bearing capacity
The color differences between various cutting depths were measured. In each group, crowns were tilted at 15◦
and subjected to fatigue loading for various numbers of cycles (0, 106, 2 × 106, 3 × 106 or 4 × 106, n = 5 per
subgroup). All surviving crowns were subsequently submitted to a static fracture test to determine load-bearing
capacity. The data were analyzed by ANOVA and Weibull distribution analysis. Failure modes were observed
with SEM.
Results: For a novel multilayer zirconia, a deeper CAD/CAM cutting depth corresponded to a higher load-bearing
capacity but a darker color. After 106 cycles of fatigue loading, there was not a significant reduction in fracture
load. However, after 4 × 106 cycles, the load-bearing capacity of all crowns decreased significantly by
approximately 50%. For multilayer and homogeneous zirconia materials, similar failure mode and Weibull
modulus were identified.
Conclusions: Restorations can be milled at various CAD/CAM cutting depths in a novel multilayer zirconia disk
depending on the durability and esthetic requirements. The load-bearing capacity of multilayer restorations
degraded significantly after 4 × 106 cycles of fatigue loading, but not after 106 cycles.
Clinical Significance: For a novel multilayer zirconia disk, a posterior restoration can be milled from the middle or
bottom of the disk to improve its load-bearing capacity. For an anterior restoration, to meet the esthetic re­
quirements, milling the entire thickness of a multilayer disk is recommended.

1. Introduction
With the increasing use of CAD/CAM (computer-aided design/
computer-aided manufacturing) technology for the manufacture of
dental restorations, monolithic zirconia crowns were the first candidate
especially due to its excellent mechanical properties [1,2]. However, the
application of monolithic zirconia used as dental restorations has been
limited by their whitish shade and opacity [3]. Over the past 20 years,
monolithic zirconia crowns have evolved from whitish shade to mono­
chromatic appearance, from opacity to transparency [4,5], while pre­
serving their adequate mechanical properties [6,7]. More recently, a
novel monolithic zirconia named “multilayer zirconia” have been
introduced into the dental market [8]. They have polychromatic layers,
appearing gradually deepening colors from the surface to material
interior, which mimics the shade-gradient of natural teeth. This multi­
layer zirconia is achieved by dry-pressing technology, in which zirconia
layers with various compositions of metal oxides are superimposed on
each other [5,8,9,10]. Some metal oxides, such as MgO, Al2O3 and Y2O3,
are regarded as stabilizer. Zirconia occurs as different formulations
depending on the chemical composition and amount of the stabilizer.
The most widely used is 3%mol (5.18 wt.%) yttrium cation-doped
tetragonal zirconia polycrystal (3Y-TZP) [4,11]. To address its opaque
disadvantage [3], translucent zirconia was introduced by increasing the
yttria dopant content. 4% and 5%mol (equal to 8 wt.% and 9.32 wt.%

* Corresponding author at: Center of Implant Dentistry, School and Hospital of Stomatology, China Medical University, No. 117 North Avenue Nanjing, Heping
District, Shenyang, Liaoning, China.
E-mail addresses: mfqwang@cmu.edu.cn (Q. Wang), bhzhao@cmu.edu.cn (B. Zhao).

https://doi.org/10.1016/j.jdent.2021.103709
Received 8 February 2021; Received in revised form 22 April 2021; Accepted 25 May 2021
Available online 29 May 2021
0300-5712/© 2021 Elsevier Ltd. All rights reserved.
X. Li et al. Journal of Dentistry 111 (2021) 103709

respectively) yttria partially stabilized cubic zirconia (4Y-PSZ, 5Y-PSZ) 2. Materials and methods
were developed. Increasing the amount of cubic phase with its larger
grain size made the zirconia more translucent [12]. Doping various Novel multilayer zirconia CAD/CAM disks (Upcera Meiying Multi­
yttria composition into zirconia layers in increments can provide the layer Zirconia, Upcera, Shenzhen, China) with a diameter of 98 mm and
multilayer zirconia a translucency-gradient. However, the greater the a thickness of 20 mm were used as experiment groups in this study. Each
amount of cubic phase, the lower the flexural strength [5]. Therefore, polychromatic zirconia disk had five color-gradient layers with deep­
the multilayer zirconia not only has color- and translucency-gradient, ening shades from the external surface to the interior: the enamel layer
but also has a gradient change in flexural strength. The literature on (4.6 mm thick or 23% of the total thickness) and dentin layer (4.6 mm
its mechanical and esthetic performance is scarce; thus, further evalu­ thick or 23% of the total thickness) at the top and bottom surface
ation is required. respectively, sandwiching 3 transition layers (3.3 mm thick or 18% of
Static flexural tests can provide a first prediction of the load-bearing the total thickness). The dimensions and configurations of the multilayer
capacity of brittle materials [13]. Several in-vitro experiments have zirconia disk were showed in Fig. 1. A monochromatic zirconia CAD/
investigated the flexural strength of beam-shaped multilayer zirconia, CAM disk (VITA YZ HT, Vita Zahnfabrik, Bad Sackingen, Germany) was
obtaining a wide range of values from 356 to 1152 Mpa [11,14,15]. used as a control group. The YZ disk has a diameter of 98.4 mm and a
However, clinical failures of zirconia restorations typically occur at thickness of 14 mm. The composition and flexural strength of the ma­
lower loads than predicted by static flexural tests owing to the cyclic terials used in this study are listed in Table. 1.
stresses induced by mastication in the oral cavity [16]. Progressive and
localized brittle cracking occurs under repeated cyclic stresses, thus
weakening the load-bearing capacity and reducing the lifespan of res­ 2.1. Design of the specimen
torations [17]. In materials science, this is referred to as fatigue [17].
Consequently, applying monotonic loading of disk/beam-shaped An analog served as the implant and implant abutment (Fig. 2A). The
simplified models made from a novel multilayer zirconia to failure ap­
pears inadequate to predict their clinical performance. Fatigue loading Table 1
tests simulating chewing characteristics and force configuration on Composition (wt.%) and flexural strengths (MPa) of the materials used in this
anatomically designed specimens should be undertaken to provide study (provided by the manufactures).
clinical guidelines for the application of novel multilayer zirconia [18, Materials Configuration Composition (wt.%) Flexural
19]. (100%) strength (MPa)
When a restoration is milled from a novel multilayer zirconia CAD/ Multilayer Enamel layer 5Y-PSZa 10–15% ≥800
CAM disk, which consists of various layers with a color-gradient com­ Zirconia coloring agentb
bined with a flexural strength-gradient, it is difficult to identify the layer 0.5–1.1%
or layers that constitute restorations of each patient. In other words, Transition layer 1 4Y-PSZa 5–10% ≥850
5Y-PSZ 5–10%
once the axial cutting depth along thickness direction of a multilayer coloring agent 1–2%
zirconia disk changes, restorations may be made of layers with different Transition layer 2 4Y-PSZ 15–20% ≥900
flexural strength and composition. To the authors’ knowledge, it is still coloring agent 2–4%
unclear whether changes in the cutting depth in a multilayer zirconia Transition layer 3 3Y-TZPc 5–10% ≥1000
4Y-PSZ 5–10%
cause variation in the mechanical performance andestheticexpectations
coloring agent 2–4%
of restorations of each patient. The aim of this paper was therefore to Dentin layer 3Y-TZP 25–30% ≥1100
evaluate the difference in the post-fatigue load-bearing capacity and coloring agent
color of restorations milled at different axial cutting depths in multilayer 9–12%
zirconia CAD/CAM disks. The null hypothesis was that there was no VITA YZ HT Homogeneous 3Y-TZP ≥85% ≥1150
structure coloring agent
variation in the (1) post-fatigue load-bearing capacity and (2) color of
≤6–15%
restorations milled at different cutting depths. In the meanwhile, the Pigments 0–1%
effect of fatigue loading tests with various numbers of cycles on the load- a
4Y-PSZ, 5Y-PSZ: 4% and 5% mol yttria partially stabilized cubic zirconia;.
bearing capacity of restorations and mechanical reliability of the novel b
coloring agent: some metal oxides, such as Er2O3, Fe2O3 and CeO2;.
multilayer structure were also assessed. c
3Y-TZP: 3% mol yttrium cation-doped tetragonal zirconia.

Fig. 1. The dimensions and configurations of the multilayer zirconia disk. The layers of the disk were divided into enamel layer (23%), 3 transition layers (18%) and
dentin layer (23%).

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X. Li et al. Journal of Dentistry 111 (2021) 103709

Fig. 2. Flowchart of specimen fabrication of the experiment groups. (A) Left of the arrow: Front view of the analog and its dimensions; Right of the arrow: Scanning
the analog for the base of specimen design. (B) Design of the zirconia restorations: Buccal, Mesial, Occlusal and Bottom view. (C) CAM programming: Designing three
axial cutting depths in the multilayer zirconia disks. The cusp tip of the top group and the lowest point of the bottom group were approximately 1 mm from the top
and bottom surface of the multilayer zirconia disks, respectively. The cusp tip of the middle crown was at the midpoint of the vertical distance between the cusp tips
of the top and bottom group. (D) Crowns of 3 experiment groups after cutting and sintering.

length of the lower part simulating an implant was 10 mm. The height of
the upper part simulating an implant abutment was 5 mm. The analog
used for the base of specimen design was scanned (3D Scanner
AutoScan-DS-EX, Shining 3D, Hangzhou, China) for CAD use in a CAD
software (exoCAD dental, exoCAD GmbH, Darmstadt, Germany). Then
the modified mandibular posterior tooth used as the specimen model
was designed to adapt to each analog (Fig. 2B). To reduce error due to
complex geometry, most fissures were removed, with the mandibular
first molar as a prototype. The length, width and thickness of occlusal
surface were 8, 6 and 1.5 mm, respectively. The thickness of the center
of buccal surface was 2.0 mm measured by a digital caliper. The analog
and the specimen designs were saved to get identical original data for
each test group.
2.2. Specimen fabrication
Before milling, in the CAM programming software (SUM3D Dental,
Germany), three cutting depths in multilayer zirconia disks along their
thickness direction, i.e., the top, middle and bottom (The top, middle
and bottom group), were chosen to investigate the difference in the load-
bearing capacity among different layers (Fig. 2C). Then the designed
data were output to the CAM milling machine (Dental Cutting Machine-
AM-X5, Aidite, Qinhuangdao, China) to fabricate 75 multilayer zirconia
crowns of 3 groups (25 specimens per group). Similarly, twenty-five YZ
crowns were milled from YZ zirconia disks as a control group (The YZ
group). All procedures were performed by an instructed dental techni­
cian (H.T., Shenyang Qing Aomei Dental Technology, Shenyang, China).
The specimens were then sintered and glaze fired (Fig. 2D). Finally, the
crowns were ultrasonically bathed in deionized water bath for 5 min and
stored dry at room temperature. After being sandblasted with 100 µm
Al2O3 particles at 0.2 MPa, each analog was then cemented to each
crown with resin cement (RelyX™ Unicerm Aplicap, 3 M ESPE, AG,
Seefeld, Germany) under a load of 10 N, ensuring that the crowns were
fully attached to the analogs.
cutting depths in multilayer zirconia disks (the top, middle and bottom
group) was measured 3 times at the identical position (the center of
buccal surface) with a portable spectrophotometer (VITA Easyshade V,
VITA Zahnfabrik, Bad Sackingen, Germany), according to the CIE
L*a*b* color scale, using a standard illuminant D65, a standard observer
and a white background (CIE L* = 90.0, a* = − 0.3, b* = − 7.3). The
CIELAB parameters (L*, a* and b*) of restorations were recorded. The
average values for L*, a* and b* were considered as the color of each
group. Color differences (ΔE) between different groups were calculated
using the following formula [20]:
( )1/2
ΔE = ΔL∗2 + Δa∗2 + Δb∗2
Where ΔL∗ , Δa∗ and Δb∗ denotes the variation of brightness (L*), red-
green (a*) and yellow-blue (b*), respectively. ΔE was evaluated by in
terms of perceptibility threshold (PT) and acceptability threshold (AT).
PT means the smallest color difference that can be detected by 50% of
the testers, while AT stands for the smallest color difference that can be
accepted by 50% of the testers [21]. Paravina et al. [22] concluded that
50% PT was 0.8 units and 50% AT was 1.8 units.
2.4. Fatigue loading test
To determine the effect of fatigue loading on the load-bearing ca­
pacity, the 25 specimens in each group were further divided into five
subgroups (n = 5) according to the number of fatigue loading cycles (0,
106, 2 × 106, 3 × 106, 4 × 106). Table. 2 presents the distribution of the
specimens.
The specimens were embedded in polymethyl methacrylate (PMMA)
Table 2
Distribution of specimens in groups and subgroups.
Groups (N = 100/n = 25) Subgroups (N = 25/n = 5)
0 106 2 × 106 3 × 106 4 × 106

Top 5 5 5 5 5
2.3. Color measurements Middle 5 5 5 5 5
Bottom 5 5 5 5 5
YZ 5 5 5 5 5
After cementation, the color of each restoration milled at 3 axis

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X. Li et al.
resin (Nissin, Kunshan, China) and then mounted in an electro-magnetic
force fatigue testing machine (M-12,000, CARE Measurement & Control,
Tianjin, China) through a special holder. A hemispherical indenter
which is made of the hot-working die steel (diameter=2 mm) was used,
ensuring that the loading force was applied to the center of the incline of
buccal cusp. To simulate the shear forces that occur during lateral ex­
cursions of the mandible, the special holder was set at 15◦ (as shown in
the schematic in Fig. 3). Each specimen was subjected to sinusoidal
compressive-compressive loading from 50 to 500 N at 15 Hz for various
numbers of cycles. The fatigue loading test was scheduled to stop when
the specimen fractured or when the number of cycles reached, which
ever occurred first.
2.5. Post-fatigue fracture test
All surviving specimens from the fatigue loading test were subse­
quently subjected to a static fracture test with a load-to-fracture pro­
gram at a rate of 0.5 mm/min. The test stopped when each specimen
failed and the post-fatigue fracture load (N) was registered. Scanning
electron microscopy (SEM) (JSM-6390A, Tokyo, Japan) was used to
examine the fracture surfaces of all specimens to analyze the initial
cracks and characterize the failure modes.
2.6. Data analysis
A pre-experiment was used to predetermine effect size=0.42.
Assuming the significance level was 0.05, the effect size was 0.42 and
the statistical power was 90%; therefore, a total of 100 subjects (25 in
each group) were estimated to be required to complete the study
(G*Power A-priori analysis, Kiel, Germany). Data analysis was per­
formed with IBM SPSS Statistics software (v23.0, IBM Corp., Chicago,
USA). The Kolmogorov Smirnov test (P = 0.200) and Levene test (P =
0.866) were used to analyze the normality of the data distribution and
homogeneity of variance, respectively. Post-fatigue fracture load values
were analyzed by 2-way ANOVA. Bonferroni’s multi-comparison post-
hoc test was performed for multiple comparisons between groups. A P
value of <0.05 between groups was considered statistically significant.
A Weibull distribution function analysis was conducted on the post-
fatigue fracture load data to determine the Weibull modulus. The Wei­
bull distribution function was calculated using the following formula:
Pf = 1 − exp[ − (σ /σ0 )m ]
Where Pf stands for the probability of failure, σ denotes the post-fatigue
Fig. 3. Schematic of fatigue loading test. Fatigue loading was applied at the
incline of the cusp with a hemispherical-shaped indenter. The specimen holder
was set at 15◦ to simulate the lateral force from the antagonist. Each specimen
was subjected to a sinusoidal load varying between a lower (–50 N) and an
upper (–500 N) bound at 15 Hz for various number of cycles. PMMA: poly­
methyl methacrylate.
4
Journal of Dentistry 111 (2021) 103709
fracture load of specimens tested, σ0 is the characteristic strength for
measured fracture load associated with 63.2% probability of failure and
( )
m is the Weibull modulus. A plot with lnln [1− 1P(σ)] on the ordinate and a
corresponding lnσ on the abscissa was constructed. The slope of the
fitted line equals m value [23].
3. Resuits
3.1. Color differences
ΔE values between groups, with reference to the PT and AT are
presented in Fig. 4. Color changes resulted from different CAD/CAM
cutting depths (Top-Middle: 5.64; Middle-Bottom: 5.96; Top-Bottom:
10.59) were all above PT and AT.
3.2. The effect of fatigue loading on the load-bearing capacity
The analyzed data of the post-fatigue fracture load (N) of the 4
groups are summarized in Fig. 5. The reduction in the fracture load from
the unfatigued (%) for the fatigued specimen is presented in Table. 3. An
increasing number of fatigue loading cycles had a significant effect on
the load-bearing capacity of each group (P<0.001). Fatigue loading with
106 cycles led to a reduction in the load-bearing capacity of approxi­
mately 10% in multilayer zirconia and 5% in YZ zirconia, but there was
no statistical difference (P>0.05). The load-bearing capacity of resto­
rations degraded gradually with the increasing number of fatigue
loading cycles. After a long-term service period of 4 × 106 cycles, the
load-bearing capacity decreased significantly by approximately 50%
regardless of materials.
3.3. The effect of CAD/CAM cutting depth on the load-bearing capacity
Means and standard deviations (SDs) of the post-fatigue fracture load
of each subgroup are displayed in Fig. 6. Within each subgroup, the YZ
group presented the highest load-bearing capacity followed by the
bottom, middle, and top groups of the multilayer zirconia disk. There
was statistical significance among the 4 groups (P<0.001); however, no
significant difference was observed between the YZ group and the bot­
tom group (P>0.05). For the multilayer zirconia specimens, the load-
bearing capacity enhanced with the increasing CAD/CAM cutting
depth. No significant difference was observed between the middle and
the bottom groups (P>0.05). Fig. 7 and Table. 4 depict the Weibull
distribution for the fracture load. Although the YZ group tended to in­
crease the Weibull modulus (m), the difference between the multilayer
and YZ group was not significant, due to the overlapping 95% confi­
dence intervals (CI).
3.4. Fracture modes
Fracture mode distribution and the number of fragments in each
group is presented in Table. 5. Chipping and catastrophic fracture were
observed. Chipping, which refers to a partial fracture and the major
structure of a restoration remaining on the abutment, was identified for
4 specimens in the top group and 1 specimen in the middle group,
occurring in the fracture test after fatigue loading with 4 × 106 cycles
(Fig. 8A). Delamination is the separation of layers caused by the lateral
extension of crack after approaching the interface between layers. For
the multilayer zirconia in the present study, no delamination was
observed. Catastrophic fracture, which means complete failure with no
structure present on the abutment, was the predominant fracture mode
for both 2 zirconia materials (Fig. 8B). Cumulative fatigue damage
resulted in a cone crack produced by the cone-shaped indenter (Fig. 9).
The cone crack with radial propagation spread throughout the entire
crown thickness, as the loading force increased during the static fracture
test, leading to catastrophic failure. The catastrophic failure presented
X. Li et al. Journal of Dentistry 111 (2021) 103709

Fig. 4. Color differences (ΔE) calculated for restorations milled at 3 CAD/CAM cutting depths. ΔE for every two groups were all above PT and AT. AT: acceptability
threshold. PT: perceptibility threshold.

Fig. 5. Boxplots of fracture load values after fatigue loading for various cycles. (A) The top group. (B) The middle group. (C) The bottom group. (D) The YZ group.
Superscript letters (a, b, c, d) indicate statistically significant differences in the fracture load values.

the number of fractures in two or three fragments, whereas the number

Table 3
of chipping fragments is two, as showed in Table. 5.
Reduction in the post-fatigue fracture load from the unfatigued fracture load
(%).
4. Discussion
Groups Subgroups
6 6 6 6
10 2 × 10 3 × 10 4 × 10
The influence of the fatigue loading on the load-bearing capacity of
Top 10.03% 22.08% 45.88% 53.65% dental zirconia has already extensively been studied [17,24,25].
Middle 11.95% 25.77% 34.81% 47.30%
Numerous studies have reported the fatigue loading led to a reduction in
Bottom 9.60% 24.58% 33.76% 48.78%
YZ 5.35% 15.94% 33.73% 49.00% the load-bearing capacity [17,25]. On the contrary, in the study of Curtis

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X. Li et al. Journal of Dentistry 111 (2021) 103709

Fig. 6. The post-fatigue fracture load of the 4 groups within each subgroup (0, 106, 2 × 106, 3 × 106, 4 × 106). Superscript letters (a, b, c, d) indicate statistically
significant differences in the fracture load values.

Fig. 7. Weibull distribution function analysis for the subgroups. (A) 0 subgroup. (B) 106 subgroup. (C) 2 × 106 subgroup. (D) 3 × 106 subgroup. (E) 4 ×
106 subgroup.

et al. [26], the load-bearing capacity of zirconia specimens was not decrease in the load-bearing capacity of zirconia bridges after fatigue
degraded by the fatigue loading, either in air or moist conditions. loading was not observed by Sundh et al. [27]. However, the maximum
Increasing the loading force failed to show any additional effect on the force of 50 N was applied, far less than the maximum chewing force
load-bearing capacity, whereas only 2000 cycles were applied. Any encountered in the mouth. Anatomically, the occlusal force varies

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X. Li et al. Journal of Dentistry 111 (2021) 103709

Table 4
The Weibull distribution modulus (m) for the fracture load of each group.
Subgroups Groups
Top Middle Bottom YZ
m 95% CI m 95% CI m 95% CI m 95% CI

0 9.23 6.39–12.07 8.90 8.44–9.36 8.90 7.63–10.17 9.93 5.62–14.24

106 7.49 1.71–13.27 8.58 2.91–14.25 10.32 3.65–17.00 11.42 4.91–17.92
2 × 106 7.85 4.81–10.89 8.09 3.72–12.46 7.56 2.30–12.82 12.21 4.46–19.96
3 × 106 7.09 2.68–11.50 8.12 6.36–9.87 6.13 3.56–8.71 10.00 1.32–18.67
4 × 106 5.41 4.17–6.66 8.07 3.46–12.67 7.83 2.32–13.35 10.12 7.32–12.08

m: Weibull modulus. CI: 95% confidence intervals.

Table 5
Fracture mode distribution of specimens in each group and number of
fragments.
Groups (N = Failure mode
100/n = 25) Chipping Delamination Catastrophic

Top 4(two 0 21(two fragments:16;

fragments:4) three fragments:5)

Middle 2(two 0 23(two fragments:17;

fragments:2) three fragments:6)
Bottom 0 0 25(two fragments:22;
three fragments:3)
YZ 0 0 25(two fragments:23;
three fragments:2)

Fig. 9. Representative SEM images (Original magnification, × 50) from the

fracture surface of specimens. (A) The YZ group. (B) The Multilayer group. A
partial cone crack was observed after fatigue loading on the contact surface
with indenter (white box). The cone crack propagated radially to the entire
crown thickness (black arrows).

relatively long-term service period of fatigue loading with 106, 2 × 106,

Fig. 8. Visual view of fractured multilayer zirconia restorations. (A) chipping.
(B) catastrophic fracture.
widely according to the tooth site and physiological factor of in­
dividuals, depending on the texture of food bolus. Generally, the
occlusal force can vary from 42 to 412 N with an implant-supported
posterior restoration [28]. A previous study indicated that the
maximal occlusal force was 545.7 N in men and 383.6 N in women in the
molar region [29]. To imitate clinical reality as faithfully as possible, the
cyclic loading force applied in the present study were set at 50–550 N,
which matched the physiological masticatory force encountered in the
oral cavity. In this sense, it seems reasonable to evaluate the effect of
fatigue loading on an implant-supported restoration. Furthermore, a
3 × 106 and 4 × 106 cycles was applied to the restorations. It is more
convincing to predict the effect of fatigue loading on the novel zirconia
material. In the present study, attenuation in the load-bearing capacity
of restorations for fatigue loading with 106 cycles may be not detected.
With the number of fatigue loading cycles increasing, the load-bearing
capacity of all restorations degraded gradually (Fig. 5 and Table. 3).
After fatigue loading with 4 × 106 cycles, the load-bearing capacity of
restorations degraded considerably. However, there were limitations to
this in-vitro study. A moist environment and oral temperature were not
considered. Numerous studies have revealed that exposure to water
molecules with a changing temperature accelerates aging and slow crack
growth in zirconia materials [30,31]. Consequently, it would be more
accurate to apply additional thermal cycling to mechanical loading
(TCML) in an artificial oral environment to predict the mechanical
performance of the novel zirconia restorations [32,33].
When a restoration is milled from a novel color- and flexural
strength-gradient multilayer zirconia CAD/CAM disk, there is no study
on whether layers with different composition constitute a restoration
will influenceesthetic or mechanical performance. Some metal oxides,
such as Er2O3, Fe2O3 and CeO2, are regarded as coloring agent. By

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X. Li et al.
doping different quantities of coloring agent into zirconia layers in in­
crements, multilayer with a color-gradient can be achieved. In the pre­
sent study, due to the high content of coloring agent, color of the bottom
group is the deepest (Table 1 and Fig. 4). Color difference between each
group was above the perceptibility threshold (PT) and acceptability
threshold (AT). Also, consistent with the least yttria additives and thus
the smallest cubic fraction, the bottom group showed the least trans­
lucency. 3Y-TZP is known as the strongest and toughest zirconia mate­
rial. It consists of 90% or more tetragonal phase (t) zirconia. Induced by
stress, temperature change or surface treatments, the t phase can be
transformed into the monoclinic phase (m) [34]. The t→m phase
transformation results in a volume extension, suppressing crack propa­
gation. This mechanism is called transformation toughening, leading to
higher fracture toughness and flexural strength [34]. As yttria content
increases, the t phase is transformed into the cubic phase (c). 4Y-PSZ and
5Y-PSZ consists of 50% c phase content and 50% t phase. As t phase
decreases and c phase increases, due to a reduction in the extent of
transformation toughening, flexural strength and fracture toughness
decrease compared to 3Y-TZP. In the present study, with the most t
phase and thus the highest flexural strength of 3Y-TZP, the bottom group
showed the highest post-fatigue load-bearing capacity, whereas the top
group, which was made of (4.5–6) Y-PSZ, had the least t phase, was the
weakest (Table 1 and Fig. 6). These explain why post-fatigue load-­
bearing capacity gradually improves and color gradually deepens as the
cutting depth deepens in multilayer zirconia. Hence, the null hypothesis
of this study was rejected. It is noted that, even after 4 × 106 cycles, the
load-bearing capacity of all restorations were still higher than 1000 N, a
value that exceeds the reported maximum occlusal force (900 N) with
bruxism included [35].
Based on these data, crowns can be milled at different cutting depths
in novel multilayer zirconia disks depending on the requirements, such
as age, gender, tooth site and so on. When a multilayer zirconia is
required for restorations in a patients’ posterior area with great masti­
catory effort and low esthetic demands, technicians and clinicians can
choose layers with better mechanical performance for the occlusal sur­
face of a crown by appropriately increasing the CAD/CAM cutting depth
in a multilayer zirconia disk. Particularly under more severe conditions,
such as bruxism, the mechanical properties of the crowns milled from
the bottom or middle of the disk will offer better performance than the
crowns milled from the top. However, as the cutting depth increases, the
color becomes darker, suggesting that color changes are hard to control
as a result of changes in the CAD/CAM cutting depth in a multilayer
zirconia. The variations may affect the esthetic expectation in terms of
color matching with the adjacent teeth or restorations. When an anterior
restoration with low load-bearing capacity requirements, is milled from
the multilayer zirconia CAD/CAM disk, for esthetic consideration,
technicians and clinicians can select the corresponding thickness of the
disk according to the height of a restoration, so that the restoration
contains all layers of the disk. The enamel and dentin layer constitute the
incisal edge and cervix of the restoration, respectively. In this way, the
anterior restoration has gradually deepening colors from the incisal edge
to cervix, which mimics the shade-gradient of natural teeth. Therefore,
technicians and clinicians must counterbalance durability and esthetic
requirements depending on each individual patient.
A recent study compared the flexural strength of multilayer beam-
shaped specimens with individual layers through biaxial flexural tests
and finite element analysis (FEA) [8]. The results indicated that, relative
to the homogeneous enamel and dentin layer beams, the multilayer
beam exhibited a 30% smaller flexural strength due to weak interfaces.
The interface between the various layers fabricated by the dry-pressing
technique may be more susceptible to fracture or delamination similarly
to the bilayered structure. The Weibull distribution analysis enabled an
assessment of the mechanical reliability of the novel material [36]. The
Weibull modulus, m, is a measure of the flaw distribution. A greater
value of m corresponds to a narrower distribution of flaws [37]. The m
values of the novel multilayer zirconia and the monochromatic zirconia
8
Journal of Dentistry 111 (2021) 103709
with a homogeneous structure were both within the acceptable range of
5 to 15 for dental ceramics (Fig. 7) [38]. Although the homogeneous
structure tended to increase the m values of the YZ group, the difference
between groups was not significant (Table. 4). Furthermore, the multi­
layer structures in the present study still showed mostly catastrophic
fracture, rather than chipping or delamination, similar to homogeneous
structures (Table. 5 and Fig. 8). Catastrophic failures were associated to
cone cracks originating on the contact surface with the indenter. As the
number of cycles in the fatigue loading test or the loading force in static
fracture test increased, cone cracks propagated radially through the
entire crown thickness (Fig. 9). Finally, the catastrophic fracture
occurred. Although the structural integrity may be compromised by the
weak interfaces between layers in the multilayer structure, the novel
multilayer zirconia appears to be a very promising material both in
terms of load-bearing capacity and fracture behavior, which are similar
to homogeneous structures. Further experimental studies with a larger
specimen size should be made to confirm the outcomes of the present
study and further scientific evidence is recommended to evaluate the
novel multilayer zirconia under complex clinical conditions that will
eventually optimize the clinical application of these novel zirconia
materials.
5. Conclusion
Within the limitations of this in-vitro study, following conclusions
can be drawn:
1 Restorations can be milled at various CAD/CAM cutting depths in a
novel multilayer zirconia disk depending on the durability and
esthetic requirements. It is recommended that a posterior restoration
can be milled from the middle or bottom of the disk to improve the
load-bearing capacity. For an anterior restoration, to meet the
esthetic requirements, a corresponding thickness according to the
height of a restoration should be selected and then milling the entire
thickness of a multilayer disk is recommended.
2 Attenuation, due to fatigue, in the load-bearing capacity of zirconia
restorations subjected to 106 cycles may be not detected. However,
after a long-term service of 2 × 106, 3 × 106, or 4 × 106 cycles, fa­
tigue degraded the load-bearing capacity of restorations
considerably.
Authors contributions
Xuejing Li: Execution of experimental part, qualitative analyzes,
statistical analysis, interpretation of data and drafting the article;
Qiang Wang: Acquisition and helped with the execution of the
experimental part and revising the article;
Xiaohai Qiu: Acquisition and execution of complementary analysis;
Baohong Zhao: Idea, conception, design, revising the article critically
for important intellectual content and final approval of the version to be
published, coordinator of the group
Funding
This work was supported by the National Natural Science Foundation
of China [grant number 82071151] and the Natural Science Foundation
of Liaoning Province, China [grant numbers 20170541059,
2018225059, 2020-MS-150 and 2020-MS-168].
Declaration of Competing Interest
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influence
the work reported in this paper.
X. Li et al.
Acknowledgement
The authors thank Ning Lv, Dental Technology Research Center,
School of Stomatology, China Medical University for the technical
support during the experimental work.
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