The Journal of Prosthetic Dentistry

Clinical efficacy of methods for bonding to zirconia: A systematic review

--Manuscript Draft--

Manuscript Number: JPD-D-19-00804R4

Article Type: Systematic Review

Keywords: resin-bonded bridge; veneer; inlay-retained fixed dental prosthesis; Zirconia; Y-TZP.

Corresponding Author: Denice Sze Shan Loo, BDSc (Hons)

University of Queensland
Herston, QLD AUSTRALIA

First Author: Niall P Quigley, BDS, MSc (Oral Surgery), MClinDent (Prosthodontics

Order of Authors: Niall P Quigley, BDS, MSc (Oral Surgery), MClinDent (Prosthodontics

Denice Sze Shan Loo, BDSc (Hons)

Clinton Choy, BDSc (Hons)

William N Ha, BDSc, PhD (Endo)

Abstract: Statement of problem. The polycrystalline nature of zirconia hinders its ability to bond
to tooth structure. Consequently, durable bonding to zirconia has been challenging. In
vitro studies have evaluated various methods of bonding to zirconia, but clinical data
are sparse.
Purpose. The purpose of this systematic review was to critically appraise clinical
studies investigating the survival rate of resin-bonded zirconia fixed partial dentures
(FPDs), inlay-retained zirconia FPDs, and zirconia veneers.
Material and methods. Searches were performed in MEDLINE, EMBASE, PubMed,
Web of Science, Scopus, Cochrane Library, and Google Scholar. Clinical studies of
over 12 months duration involving bonded zirconia restorations between 1990 and July
2018 were reviewed. All suitable studies were assessed for quality using a
‘Questionnaire for selecting articles on Dental Prostheses’ (QDP).
Results. Eight studies were ultimately included. Three studies examined posterior
inlay-retained FPDs with estimated survival rates of 12.1% at 10 years, 95.8% at 5
years, and 100% at 20 months. Five studies reviewed anterior, resin-bonded FPDs, all
of which had a 3- to 10-year survival rate of 100%. Debonds occurred in all studies, but
the prostheses could usually be rebonded.
Conclusions. With correctly designed buccal and lingual coverage retainers and
minimal if any veneering porcelain, zirconia-based, posterior, inlay-retained FPDs
appear to have a high clinical survival rate. The role of bonding efficacy in this survival
rate is unknown. Anterior, cantilevered, resin-bonded zirconia FPDs appear to have a
high clinical survival rate. While these prostheses can debond, fracture of the entire
prosthesis is unlikely, so they may be rebonded. To bond zirconia, the use of airborne-
particle abrasion with 50-µm alumina (Al2O3) at 0.1 to 0.25 MPa in combination with a
phosphate monomer-containing adhesive resin is recommended until further studies
become available. Rubber dam isolation is also recommended during zirconia bonding.

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Clinical efficacy of methods for bonding to zirconia: A systematic review

Niall P. Quigley, BDS, MSc, MClinDent,a Denice S.S. Loo, BDSc,b Clinton Choy, BDSc,c and

William N. Ha, BDSc, PhDd

a
Postgraduate tutor, School of Dentistry, King’s College London, London, United Kingdom; and

Private practice, Gold Coast, Australia.

b
Researcher, The University of Queensland School of Dentistry, Brisbane, Australia.
c
Researcher, The University of Queensland School of Dentistry, Brisbane, Australia.
d
Lecturer, The University of Queensland School of Dentistry, Brisbane, Australia; and

Postgraduate student, The University of Adelaide, Adelaide, Australia.

Corresponding author:

Dr Niall P. Quigley

Oasis Dental Studio

21/15 Victoria Avenue

Broadbeach 4218

Gold Coast, QLD

AUSTRALIA

Email: niall.1.quigley@kcl.ac.uk
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formatted.docx
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1

JPD-19-804

SYSTEMATIC REVIEW

Clinical efficacy of methods for bonding to zirconia: A systematic review

Niall P. Quigley, BDS, MSc, MClinDent,a Denice S.S. Loo, BDSc,b Clinton Choy, BDSc,c and

William N. Ha, BDSc, PhDd

a
Postgraduate tutor, School of Dentistry, King’s College London, London, United Kingdom; and

Private practice, Gold Coast, Australia.

b
Researcher, The University of Queensland School of Dentistry, Brisbane, Australia.
c
Researcher, The University of Queensland School of Dentistry, Brisbane, Australia.
d
Lecturer, The University of Queensland School of Dentistry, Brisbane, Australia; and

Postgraduate student, The University of Adelaide, Adelaide, Australia.

ABSTRACT

Statement of problem. The polycrystalline nature of zirconia hinders its ability to bond to tooth

structure. Consequently, durable bonding to zirconia has been challenging. In vitro studies have

evaluated various methods of bonding to zirconia, but clinical data are sparse.

Purpose. The purpose of this systematic review was to critically appraise clinical studies

investigating the survival rate of resin-bonded zirconia fixed partial dentures (FPDs), inlay-

retained zirconia FPDs, and zirconia veneers.

Material and methods. Searches were performed in MEDLINE, EMBASE, PubMed, Web of

Science, Scopus, Cochrane Library, and Google Scholar. Clinical studies of over 12 months
 2

duration involving bonded zirconia restorations between 1990 and July 2018 were reviewed. All

suitable studies were assessed for quality using a ‘Questionnaire for selecting articles on Dental

Prostheses’ (QDP).

Results. Eight studies were ultimately included. Three studies examined posterior inlay-retained

FPDs with estimated survival rates of 12.1% at 10 years, 95.8% at 5 years, and 100% at 20

months. Five studies reviewed anterior, resin-bonded FPDs, all of which had a 3- to 10-year

survival rate of 100%. Debonds occurred in all studies, but the prostheses could usually be

rebonded.

Conclusions. With correctly designed buccal and lingual coverage retainers and minimal if any

veneering porcelain, zirconia-based, posterior, inlay-retained FPDs appear to have a high clinical

survival rate. The role of bonding efficacy in this survival rate is unknown. Anterior,

cantilevered, resin-bonded zirconia FPDs appear to have a high clinical survival rate. While

these prostheses can debond, fracture of the entire prosthesis is unlikely, so they may be

rebonded. To bond zirconia, the use of airborne-particle abrasion with 50-µm alumina (Al2O3) at

0.1 to 0.25 MPa in combination with a phosphate monomer-containing adhesive resin is

recommended until further studies become available. Rubber dam isolation is also recommended

during zirconia bonding.

CLINICAL IMPLICATIONS

The ability of zirconia to bond to tooth structure has been a subject of debate because of its

polycrystalline nature. With emerging long-term studies, evidence now suggests that airborne-

particle abrasion with 10-methacryloyloxydecyl dihydrogen phosphate (MDP) and certain design

features can help achieve a robust bond between zirconia and tooth structure.
 3

INTRODUCTION

The use of zirconia in restorative dentistry has grown exponentially over the past decade.1,2 Early

zirconia formulations were used for frameworks because of their high flexural strength and

unesthetic opacity in porcelain-fused-to-zirconia restorations.3,4 Through processing refinements,

materials with increased translucency were introduced so that veneering with feldspathic

porcelain was not required and the material could be used in monolithic form.1

Successful ceramic-resin bonding relies on surface roughening of the ceramic substrate to

increase the surface area and allow micromechanical interlocking; surface activation also allows

the formation of chemical bonds.5,6 In conventional silica-based ceramics, this bond can be

reliably achieved by etching with hydrofluoric acid to create an etched ceramic surface7,8 and by

applying a silane for chemical coupling between the ceramic and resin monomers.6,8 However,

densely sintered, polycrystalline zirconia cannot be etched with hydrofluoric acid at

temperatures, times, and concentrations readily available to dental practitioners.9-12 Physical

methods such as surface grinding or abrading may be used to roughen the surface.13 However,

these can create surface flaws that reduce the strength of the material.13 Zirconia also lacks a

glass phase, so silica-to-silane bonds will not form.13

Kern14 and Blatz et al15 reviewed the success of bonding high-strength ceramics (alumina

and zirconia ceramics) with adhesive resin. Kern14 identified many in vitro methods of bonding,

but supporting clinical data were lacking. However, as all the clinical trials found had promising

results, further investigation of more complicated methods of bonding was not deemed

necessary. Blatz et al15 reviewed resin-bonding with all types of high-strength ceramic
 4

restorations, including complete crowns and conventional fixed partial denture (FPD) designs.15

High success and survival rates were found at over 5 years.15

As alumina restorations have been almost entirely superseded by zirconia, the purpose of

this systematic review was to examine the durability of the resin-zirconia bond in zirconia

restorations that rely primarily on adhesion for their clinical success.

MATERIAL AND METHODS

This systematic review was performed according to the Preferred Reporting Items of Systematic

Reviews and Meta-Analyses (PRISMA) statement.16 The review was undertaken in July 2018.

The electronic libraries, Medical Subject Heading (MeSH) terms, and free-text words used are

presented in Table 1.

References of relevant journals were also searched electronically and manually to

increase the yield of relevant studies. The National Institutes of Health (NIH) clinical trials

database was searched, and the authors of 3 active trials were contacted for preliminary results.

Finally, the authors of the major review articles were contacted by email for further or updated

versions of studies. Translations were sought on Google Translate (Google LLC). All titles and

abstracts were screened according to the inclusion and exclusion criteria (Table 2).

A preliminary questionnaire was applied to each of the selected articles to assess the

scientific quality of the methods used in each article. This recently developed questionnaire,

called the ‘Questionnaire for selecting articles on Dental Prostheses’ (QDP) was first published

in 2018.17 It was based on the methodical assessments associated with the following bodies:

Critical Appraisal Skills Programme (CASP), Grading Recommendations Assessment and

Development (GRADE), The University of Oxford’s Centre for Evidence-Based Medicine, and
 5

Methodological Index for Non-Randomized Studies (MINORS). The QDP requires an

affirmative answer to 2 initial questions to qualify for further assessment. All questions have

yes/no answers, with a ‘yes’ having a value of 1 and a ‘no’ having a value of 0. The values are

added together, and each paper is then assigned a score indicative of its quality: 0 to 8/15=poor,

9 to 11/15=fair, 12 to 15/15=good.

The following variables were extracted from each accepted review: sample

demographics, sample size, methodology (material, manufacturing techniques, preparation

design, and cementation protocols), treatment group, control group (if applicable), randomization

(if applicable), variables analyzed, comparison and outcome details (survival/failure rates,

follow-up times, and complications).

Success was defined as no loss of retention or the prosthesis staying in place throughout

the period of study. Failure referred to any decementation, debonding, or any fracturing of the

prosthesis that warranted its replacement. Survival was defined as the presence of the original

restoration at the time of follow-up.18 If a prosthesis debonded but could be successfully

rebonded, then the survival outcome remained positive. Complications were defined as any

undesirable or unexpected event occurring during the observation period that did not require a

replacement prosthesis. These were recorded but, for the purposes of this review, were not

accounted for in the success rates.17

RESULTS

Electronic searches retrieved 389 nonduplicate articles (Fig. 1), from which 70 were chosen after

analyzing the titles and abstracts. After examining the full texts of these articles, a further 59

were excluded. The QDP was then applied to the remaining 11 studies,19-29 and the results are
 6

presented in Supplemental Table 1. Three studies20,21,29 were excluded, the reasons being

provided in Table 3.

One of the selected studies was a randomized controlled trial,22 5 were prospective cohort

studies,19,23,25-27 and the other 2 were retrospective cohort studies.24,28 Study design, sample sizes,

material tested, clinical protocols, and follow-up times are outlined in Table 4 and Table 5.

The number of prostheses per study was generally low, except for the study by Kern et

al.28 Generally, a minimum of 12 months follow-up time was given to allow some failures to

occur. Three of the selected studies22,23,28 were from the same research team based in Kiel,

Germany; hence some comparisons across those studies are possible. Otherwise, the

heterogeneity in study design hampered any meta-analysis. Nevertheless, patterns emerged

which allowed some conclusions to be drawn.

Three of the studies19,25,27 examined posterior inlay-retained FPDs, while the others22-
24,26,28
examined anterior cantilever resin-bonded zirconia FPDs with partial-coverage retainers

(PCR).

In the posterior inlay-retained studies, the inlays all broadly followed the ideal inlay

design as recommended by Thompson et al.30 Two of the studies used a similar prosthesis

design, with short framework PCRs wrapping buccally and lingually around the abutment

teeth.19,25 This design was originally proposed by Wolfart and Kern31 as shown in Figure 2. Abou

Tara et al19 and Chaar and Kern25 described an updated design with more extensive coverage in

the PCRs (Fig. 3). These extended PCRs required a bevel preparation of 0.2 to 0.5 mm in the

enamel on the buccal and lingual surfaces. Rathmann et al27 examined a variety of prosthesis

designs, but only 13 of the 30 prostheses under investigation were of the inlay-inlay variety as

shown in Figure 4, and none of these had PCRs described as above.

 7

The 5 anterior cantilever resin-bonded zirconia FPDs with single-PCR studies were more

homogeneous in design. This is possibly because Professor Matthias Kern of Kiel University,

was involved in 3 of the 5 studies. These 3 studies22,23,28 and that of Klink and Hüthig26 all used

similar nonretentive preparations, as shown in Figure 5. Sailer and Hämmerle24 used a more

retentive type of design in their study on anterior resin-bonded prostheses. Figures 6 and 7 show

the preparation method for these.

For pretreatment of the zirconia, all included studies used a variation of airborne-particle

abrasion except for the study by Sailer and Hämmerle.24 Rathmann et al27 used the Rocatec

system (3M ESPE), which used tribochemical silica airborne-particle abrasion (TSAPA) to

embed silica particles into the zirconia framework.10 The other studies19,22,23,25,26,28 used 50-μm

Al2O3 at a pressure between 0.1 and 0.25 MPa and applied a silane (Monobond S; Ivoclar

Vivadent AG) before Panavia F (Kuraray America Inc) or Multilink Automix (Ivoclar Vivadent

AG) cementation. Alcohol cleaning was used in 5 of the 8 studies,22-25,28 and zirconia

primers/silanes were used in 3 of the 5 studies.24,26,27 The use of these primers depended on the

bonding agent used.

Six of the 8 studies reported the use of rubber dam during the bonding process.19,22-25,28

Klink and Hüthig26 did not report their isolation methods. In Rathmann et al,27 rubber dam was

used for 7 of the 30 prostheses; otherwise, cotton rolls and gingival displacement cord were used.

Panavia F or Panavia 21 (Kuraray America Inc) or Multilink Automix (Ivoclar Vivadent AG)

adhesive resin were used in all studies.19,22-28 Both Panavia F and Panavia 21 contain MDP, so

primers are not required. A list of adhesive resins used in the studies are presented in Table 6.

In reporting survival rates, Rathmann et al27 reviewed 30 prostheses over 10 years, but

only 13 of the 30 prostheses matched the inclusion criteria for this review. Only 5 participants
 8

with 7 prostheses were followed-up on because 21 participants had already lost their 22

prostheses.27 One was lost to follow-up as they had moved overseas.27 Sixteen debonds occurred

in total, but in which prostheses these debonds occurred is unknown.27 The estimated survival

rates of the inlay-retained FPDs were 44.9% in 5 years and 12.1% in 10 years.27 Abou Tara et

al19 examined 23 posterior inlay-retained prostheses. One debond occurred at 24 months, and the

prosthesis was successfully rebonded for the duration of the study.19 This gave a 95.7% bonding

success rate and a 100% survival rate at 20 months.19 Chaar and Kern25 performed a similar

study and reported a survival rate of 95.8% at 5 years because of 2 debonds. One was

successfully rebonded, but another inlay-retained prosthesis had to be replaced after 49 months

as it had debonded 8 times.25

Three papers by Sasse and Kern22,23 and Kern et al28 used similar methodologies. In Sasse

and Kern,22 2 of 30 FPDs debonded because of trauma and were successfully rebonded, giving a

100% 5-year survival. In another paper by Sasse and Kern,23 3 of the 42 FPDs were 4-unit

prostheses. One debond of a normal 2-unit FPD occurred through trauma, and 1 debond of a 4-

unit FPD occurred.23 Both were successfully rebonded, giving a 100% 6-year survival rate.23

According to Kern et al,28 7 of the 108 FPDs were of the 4-unit type described above. Six

debonds occurred in total, 3 after trauma and the other 3 from unknown cause.28 Although they

were all rebonded successfully, 1 FPD chipped, and the patient requested it be replaced with an

implant.28 A 100% survival rate at 10 years was therefore recorded.28 In Klink and Hüthig,26 1

debond occurred at 8 months and was successfully rebonded. A 100% 3-year survival rate was

subsequently recorded.26

In Sailer and Hämmerle,24 15 anterior teeth had retentive grooves placed to receive

zirconia framework FPDs. Two relatively early debonds occurred at 1.3 and 5.4 months.24 The
 9

FPDs were subsequently airborne-particle abraded with 30-μm Al2O3 at 0.2 MPa before being

retreated with silane and recemented with Panavia 21.24 No further debonds occurred during the

remainder of the follow-up period, giving an 8-year survival rate of 100%.24

DISCUSSION

Driven by higher esthetic demands and lower production costs, the use of ceramic materials in

dentistry has grown exponentially in recent years.2 This review aimed to collate and analyze the

available clinical data on the survival rates of zirconia restorations that relied primarily on

adhesive resin bonding for their success. Because of the lack of studies on posterior prostheses

and their relative heterogeneity, a meta-analysis was not conducted.

In Rathmann et al,27 there were few inlay-inlay retained prostheses, a wide variation in

prosthesis design, and the involvement of 3 different clinicians who all specialized in prosthetic

dentistry. These factors alone render the external validity of this study as low. It is difficult to

draw conclusions regarding the low survival rate in Rathmann et al27 as different factors could

have contributed to the high rate of failure, including relatively new material and framework

design protocols, prostheses made before the importance of anatomic coping designs and correct

cooling protocols was known, use of inlay-inlay design without PCRs and hence a small surface

area available for bonding, and the use of TSAPA. The Rathmann et al27 paper is significant as it

is the only paper of the included studies to use the Rocatec system. This method has been

adapted for zirconia as it has shown to be effective in bonding precious metal alloys.10 In vitro

studies have also demonstrated that TSAPA combined with an MDP-containing primer resulted

in the highest bond strengths,6 which could resist the effects of artificial aging.4 However, other

studies contradict this finding. Kern et al12 reported that TSAPA resulted in a significant increase
 10

in the initial bond strength of zirconia to the adhesive resin, but this was not stable over time.

This uncertain longevity was corroborated by Lopes et al,11 who questioned the mechanism of

the attachment and durability of the silica particles to zirconia. Indeed, in the discussion of the

Rathmann et al27 paper, the application of silane was mentioned as a possible barrier to the

formation of zirconia-MDP bonds. Care must be taken when drawing clinical conclusions based

on the results of Rathmann et al27 because of the low sample size, the heterogeneity of design,

and the zirconia framework design used.

Abou Tara et al19 and Chaar and Kern25 had similar prosthesis designs, study designs, and

results. These studies used a modified design to provide increased available surface area for

bonding, more favorable stress distribution within the restoration, and decreased torsional forces

experienced by the retainers during nonaxial loading.25 The framework designs in these studies

were inherently retentive, which could explain the high survival rate of these restorations. Both

studies19,25 had a similar bonding protocol; however, whether the success was attributable to the

meticulous bonding protocol or inherent chemical bond strengths is unknown.

No zirconia framework fractures occurred in either the Abou Tara et al or the Chaar and

Kern study.19,25 All debonds were mixed failures, meaning that the adhesive resin remained

partially on the bonding surface of the restoration and partially on the abutment teeth.19,25 This

suggests that the bond between zirconia and the adhesive resin was not the point of weakness.

Within the limitations of these 2 studies19,25 (strict inclusion criteria, low numbers of prostheses,

ideal framework design, surface activation of zirconia framework, use of Panavia 21 and Clearfil

New Bond, meticulous protocol by expert clinicians), high survival rates can be expected. The

presence of multiple variables in the posterior inlay-retained prosthesis studies make it difficult

to quantify the contribution of resin-zirconia bonding to clinical success.

 11

Except for Sailer and Hämmerle,24 where retentive grooves and no airborne-particle

abrasion were used, the 5 anterior studies22,23,26,28 were quite uniform in design, and excellent

survival rates of 100% were recorded. However, survival in this review and in the included

studies was defined as the presence of the original prosthesis at the time of follow-up,19,22-28 so

the 100% figure can be misleading. Debonds occurred in each of the included studies, but, as the

prostheses were successfully rebonded, they did not affect the survival rates.22-24,26,28 The debond

numbers were low, and repeated debonding did not occur.22-24,26,28 Generally, follow-up times

were small, but Kern et al28 reported similarly low rates of debonding over the 10-year study

period. However, this study was retrospective in contrast with the shorter randomized controlled

trial22 that was included.

No framework fractures were reported in the included studies19,22-28 because of the high

flexural strength of zirconia restorations. The increased strength of the zirconia prostheses

suggests that the point of weakness was the adhesion between the resin and zirconia substrate.

Arguably, this is a better outcome because the prostheses can be rebonded, with no apparent

decrease in survival prospects. The framework design played a key role in the survival of these

restorations, with the primary factor being the single-PCR cantilevers. A recent review by

Botelho et al18 showed that anterior cantilever metal-ceramic prostheses with single-PCR had

100% survival rates after 18 years compared with a 50% survival of similar, double-PCR

prostheses. The 2 abutment teeth have a displacement differential during function, which exerts

shear forces on 1 or both retainers.18 Only missing incisors were treated, so the results may not

be applicable to posterior teeth.18

Regarding bonding protocol, Sailer and Hämmerle24 did not use airborne-particle

abrasion. It was only used when 2 prostheses debonded within 6 months of placement. However,
 12

these prostheses had retentive features which would affect the clinical survival. Five19,22,23,25,28 of

the included studies used an airborne-particle abrasion pressure of 0.25 MPa and 226,28 used a

pressure of 0.1 MPa. In Kern et al,28 0.25 MPa was changed to 0.1 MPa during the study period.

Given that no loss in survival rate was noted with the lower pressure and that there is some

evidence that airborne-particle abrasion can induce microcrack formation, using a lower pressure

for airborne-particle abrasion may be preferable. Further studies are required to test this

hypothesis. Rubber dam isolation may also be essential to the success of zirconia bonding,32 as a

study by Audenino et al33 found that rubber dam isolation during the bonding of resin-bonded

prostheses significantly increased the survival rate.

The studies reviewed provide some evidence that zirconia can be successfully bonded to

tooth structure with a strict protocol. However, the number of variables makes it difficult to draw

a statistically significant correlation between bonding protocol and clinical survival. Factors such

as operator skill, patient compliance, and manufacturing quality could all play a role in

predicting the survival of the restorations.

CONCLUSIONS

Based on the findings of this systematic review, the following conclusions were drawn:

1. With correctly designed buccal and lingual PCRs and minimal if any veneering porcelain,

zirconia-based, posterior, inlay-retained FPDs appear to have a high clinical survival rate. The

role of bonding efficacy in this is unknown.

2. Anterior, cantilevered, resin-bonded zirconia FPDs also appear to have a high clinical survival

rate. While these prostheses can debond, fracture of the entire prosthesis is unlikely, so they may

be rebonded.
 13

3. To bond zirconia, the use of airborne-particle abrasion with 50-μm Al2O3 at 0.10 to 0.25 MPa

in combination with a phosphate monomer-containing adhesive resin is currently recommended.

Rubber dam isolation is also recommended during zirconia bonding.

 14

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25. Chaar MS, Kern M. Five-year clinical outcome of posterior zirconia ceramic inlay-retained

FDPs with a modified design. J Dent 2015;43:1411-5.

26. Klink A, Hüthig F. Zirconia-based anterior resin-bonded single-retainer cantilever fixed

dental prostheses: A 15-to 61-month follow-up. Int J Prosthodont 2016;29:284-6.

27. Rathmann F, Bömicke W, Rammelsberg P, Ohlmann B. Veneered zirconia inlay-retained

fixed dental prostheses: 10-year results from a prospective clinical study. J Dent 2017;64:68-72.

28. Kern M, Passia N, Sasse M, Yazigi C. Ten-year outcome of zirconia ceramic cantilever

resin-bonded fixed dental prostheses and the influence of the reasons for missing incisors. J

Dent. 2017;65:51-5.

29. Souza R, Barbosa F, Araújo G, Miyashita E, Bottino M, Melo R, et al. Ultrathin monolithic

zirconia veneers: reality or future? Report of a clinical case and one-year follow-up. Oper Dent

2018;43:3-11.

30. Thompson M, Thompson K, Swain M. The all‐ ceramic, inlay supported fixed partial

denture. Part 1. Ceramic inlay preparation design: a literature review. Aust Dent J 2010;55:120-

7.
 17

31. Wolfart S, Kern M. A new design for all-ceramic inlay-retained fixed partial dentures: A

report of 2 cases. Quintessence Int 2006;37:27-33.

32. Zhang Y, Lawn BR, Rekow ED, Thompson VP. Effect of sandblasting on the long-term

performance of dental ceramics. J Biomed Mater Res B Appl Biomater 2004;71:381-6.

33. Audenino G, Giannella G, Morello GM, Ceccarelli M, Carossa S, Bassi F. Resin-bonded

fixed partial dentures: Ten-year follow-up. Int J Prosthodont 2006;19:22-3.

Corresponding author:

Dr Niall P. Quigley

Oasis Dental Studio

21/15 Victoria Avenue

Broadbeach 4218

Gold Coast, QLD

AUSTRALIA

Email: niall.1.quigley@kcl.ac.uk

TABLES
Table 1. Systematic review search strategy
Electronic Databases and Libraries
MEDLINE, EMBASE, PubMed, Web of
Science, Scopus, Cochrane Library, and
Google Scholar.
18
MeSH Search Terms and Free-text
Words
Fixed dental prostheses OR Resin-bonded
bridge OR Resin-bonded fixed dental
prostheses OR Resin-bonded fixed partial
denture OR Adhesively-retained fixed
partial denture OR Adhesively-retained
fixed dental prosthesis OR Adhesively-
retained bridge OR Adhesive bridge OR
Minimally-invasive bridge OR Acid- etched
bridge OR Maryland bridge OR Single
retainer bridge OR Two-retainer bridge OR
Butterfly bridge OR Veneer* OR Inlay-
retained fixed dental prosthesis OR Inlay-
retained fixed partial denture OR Inlay-
retained FDP OR Inlay-retained FPD AND
Zirconia OR Zirconium OR Zircon* OR Y-
TZP OR TZP OR ZrO2 OR PSZ OR FSZ
OR CSZ OR Ce-TZP

Table 2. Inclusion and exclusion criteria
Inclusion criteria
Timeframe Between 1990 and July 2018
Publishing Articles published in international
details peer reviewed journals
Study design RCTs
Clinical controlled trials
Retrospective or prospective cohort
studies
Case reports/series
Type of Patients with edentulous spaces
patients (P): replaced with resin-bonded zirconia
FPDs or inlay-retained zirconia FPDs
Patients with bonded zirconia veneers
Patients with layered or monolithic
zirconia
Patients with 3Y-TZP, 4Y-TZP, 5Y-
TZP, or Ce-TZP
Type of Articles with sufficient detail
interventions regarding the retainer design,
(I): materials used, treatment of materials,
bonding protocol, and adhesive resin
used
Type of No control or comparison groups
control (C): were selected
Type of Articles with quantitative reporting of
outcomes the details of survival rates and any
(O): modes of failure such as debonding or
mechanical/biological complications
RCT, randomized controlled trial; FPD, fixed partial denture; Y-TZP, yttrium-stabilized
tetragonal zirconia polycrystal; Ce-TZP, ceria-stabilized tetragonal zirconia polycrystal.
19
Exclusion criteria
Before 1990
Articles not published in international
peer reviewed journals
Animal studies
In vitro studies
Single case studies
Patients with complete crown
conventional zirconia FPDs (either
fixed-fixed or cantilevered)
Patients with conventionally cemented
zirconia FPDs or veneers
Patients with implant-retained zirconia
Patients with zirconia hybrid materials
such as zirconia-infiltrated resins
Patients with zirconia-infiltrated
ceramics
Articles without sufficient detail on
treatment protocols
Articles with follow-up times less than
12 months, survey/phone call follow-
ups, or articles with multiple
publications on the same patient
cohort
 20

Table 3. Exclusion of studies after application of QDP

Excluded Studies Year Reasons for Exclusion
Griffin20 2011 Single case report that should have been excluded earlier.
Further investigation warranted based on novel subject
matter: resin-bonded zirconia veneers
Souza et al29 2018 Single case report that should have been excluded earlier.
Further investigation warranted based on novel subject
matter: resin-bonded zirconia veneers
Sasse et al21 2012 Participant population duplicated in other included studies
 21

Table 4. Study and patient characteristics of the included studies

Average
Mean Follow-
Number of Age of
Study Study Design up Time Dropouts
Prostheses Subjects
(months)
(years)
Abou Tara et Prospective
20.0 23 43.7 0
al, 201119 Cohort
Sasse and
RCT 64.2 30 33.3 0
Kern, 201322
Sasse and Prospective
61.8 42 32.7 0
Kern, 201423 Cohort
Sailer and
Retrospective
Hämmerle, 48.0 15 27.5 0
Cohort
201424

Chaar and Prospective

64.4 30 41.9 1
Kern, 201525 Cohort
Klink and
Prospective
Hüthig, 35.0 24 33.0 1
Cohort
201626
Rathmann et Prospective
58.8 30 42.9 1
al, 201727 Cohort
Kern et al, Retrospective
92.2 108 32.0 6
201728 Cohort

RCT, randomized controlled trial.

 22

Table 5. Methodological characteristics of included studies

Manufacturing Procedures Clinical Procedures
Author(s) Prostheses Design
Materials Surface Treatment Tooth Preparation Isolation Method Bonding System
Abou Tara et al, Posterior Zirconia framework (Vita In-Ceram YZ; Vita 50-μm Al2O3 at 0.25 MPa Retentive Rubber dam Total etch with 37% phosphoric acid and Cle
201119 Zahnfabrik) America Inc)
Fixed-fixed Box-shaped inlay cavities
Feldspathic porcelain (VITA VM 9; Vita Panavia 21 TC (Kuraray America Inc)
Inlay-retained FPD with buccal and Zahnfabrik) used on pontics only PCRs:
palatal PCRs Bevelled preparations in enamel
buccally and palatally
Sasse and Kern, Anterior IPS e.max ZirCAD, veneered with IPS e.max 50-μm Al2O3 at 0.25 MPa Non-retentive Rubber dam Etch with 37% phosphoric acid for 30 secon
201322 Ceram (Ivoclar Vivadent AG)
Cantilevered, single-retainer, resin- Then cleaned ultrasonically A mid lingual surface notch 16 with Panavia 21 TC (Kuraray America In
bonded FPD in 99% isopropyl alcohol for
3 minutes 14 with Multilink Automix (Ivoclar Vivaden
acid acrylate primer for the zirconia (Metal/Z
Vivadent AG), and a self-etching primer for
B™ of BeautyOrtho Bond™; Shofu Inc)
Sasse and Kern, Anterior Zirconia frameworks milled out of presintered 50-μm Al2O3 at 0.25 MPa Non-retentive Rubber dam Teeth were cleaned with an air polishing sys
201423 zirconia ceramic blocks, veneered with IPS e.max sodium bicarbonate cleaning powder
Cantilevered, single-retainer, resin- Ceram (Ivoclar Vivadent AG) A mid lingual surface notch
bonded FPD Enamel etched with 36% phosphoric acid for
dry
3 prostheses were 4-unit devices
Panavia 21 TC (Kuraray America Inc)
Sailer and Anterior IPS e.max ZirCAD framework (Ivoclar Vivadent Cleaned with alcohol Retentive Rubber dam Pumice on teeth. Rinse and dry
Hämmerle, 201424 AG) with zirconia veneering ceramic (GC Initial;
Cantilevered, single-retainer, resin- GC America Inc) Silane application (Clearfil Mesial and distal vertical grooves Etch with 37% phosphoric acid for 1 minute
bonded FPD Porcelain Bond Activator; and a cingulum slot
Kuraray America Inc) ED Primer (Kuraray American Inc) used as p
instructions

Panavia 21 TC (Kuraray America Inc)

Oxyguard (Kuraray America Inc) used to en

material
Chaar and Kern, Posterior Zirconia framework (Vita In-Ceram YZ; Vita 50-μm Al2O3 at 0.25 MPa Retentive Rubber dam Total etch with 37% phosphoric acid
201525 Zahnfabrik)
Fixed-fixed Ultrasonic cleaning in 96% Box-shaped inlay cavities Dentine adhesive (Clearfil New Bond; Kurar
All frameworks veneered with feldspathic isopropyl alcohol
Inlay-retained FPD with buccal and porcelain (VITA VM 9; Vita Zahnfabrik) PCRs: Panavia 21 TC (Kuraray America Inc)
palatal PCRs Bevelled preparations in enamel
buccally and palatally Oxyguard II (Kuraray America Inc) used
Klink and Hüthig, Anterior 16 Ceramill zirconia framework (Amann-Girrack 50-μm Al2O3 at 0.1 MPa Non-retentive NR No mention of etching the enamel
201626 AG) and Creation ZI-CT (Creation Willi
Cantilevered, single-retainer, resin- Geller)/e.max Ceram (Ivoclar Vivadent) veneering Monobond Plus (Ivoclar No mechanical retention, only 22 with Multilink Automix (Ivoclar Vivaden
bonded FPD Vivadent AG) ‘definite seats’ were prepared into
3 IPS e.max ZirCAD and IPS e.max Ceram the lingual surfaces of the 2 with Variolink Esthetic (Ivoclar Vivadent A
(Ivoclar Vivadent AG) abutment teeth Adhesive (Ivoclar Vivadent AG) were used a
manufacturer’s protocol
1 ICE Zirkon (Zirkonzahn) and e.max Ceram
(Ivoclar Vivadent AG)

2 KATANA Zirconia and CERABIEN ZR

(Kuraray Noritake Dental Inc)

2 Cercon ht and Cercon ceram Kiss (DeguDent)

Rathmann et al, Posterior IPS e.max ZirCAD (Ivoclar Vivadent AG) The inner surfaces of the Retentive 7 prostheses had Patients were randomized into 2 groups: Pan
201727 zirconia frameworks were rubber dam Inc) and Multilink Automix (Ivoclar Vivaden
30 inlay-retained FPDs: Veneered with pressable fluorapatite glass ceramic silica coated tribochemically Teeth had old restorations
(IPS e.max ZirPress; Ivoclar Vivadent AG) using the Rocatec system removed and an autopolymerizing Cotton roll and Both used in accordance with manufacturer’
13 had 2 dihedral inlays (3M ESPE), then silane resin was placed retraction cords
(Monobond S; Ivoclar otherwise
1 had a dihedral and a trihedral Vivadent AG) Depending on the extent of the
inlay preexisting defects, the abutments
were prepared for dihedral inlays,
6 had a partial-coverage crown and trihedral inlays, partial-coverage
a dihedral inlay crowns, and complete crowns

8 had a complete crown and a

dihedral inlay

2 had a complete crown and a

trihedral inlay
Kern et al, 201728 Anterior
Cantilevered, single-retainer, resin-
bonded FPD
7 prostheses were 4-unit devices,
bonded to the maxillary central
incisors with 2 distal cantilevers to
replace the maxillary lateral incisors
Zirconia frameworks milled out of presintered 50-μm Al2O3 Non-retentive Rubber dam Etch with 37% phosphoric acid for 30 secon
zirconia ceramic blocks, manually veneered
From 2001 to 2009 Fine incisal finishing shoulder, 94 with Panavia 21 TC (Kuraray America In
0.25 MPa was used fine cervical chamfer, small
proximal box, and cingulam ‘pin 14 with Multilink Automix (Ivoclar Vivaden
0.1 MPa was used hole’ Primer (Ivoclar Vivadent AG)
thereafter, then cleansed
ultrasonically in 99%
isopropanol

FPD, fixed partial denture; PCR, partial-coverage retainer; NR, not reported.
 23

Table 6. Description of adhesive resins used

Material Composition Manufacturer
Panavia 21 TC Catalyst: Hydrophobic aromatic Kuraray America Inc
dimethacrylate, hydrophobic aliphatic
methacrylate, MDP, fillers, BPO
Base: Hydrophobic aromatic dimethacrylate,
hydrophobic aliphatic dimethacrylate,
hydrophobic dimethacrylate, fillers, DEPT,
sodium aromatic sulfonate, hydrophilic
aliphatic dimethacrylate
Panavia F Paste A: MDP, hydrophobic and hydrophilic Kuraray America Inc
dimethacrylate, benzoyl peroxide,
camphoroquinone, colloidal silica
Paste B: sodium fluoride, hydrophobic and
hydrophilic dimethacrylate, diethanol-p-
toluidine, T-isopropylic benzenic sodium
sulfinate, barium glass, titanium dioxide,
colloidal silica
Multilink Monomer matrix: DMA, HEMA, barium Ivoclar Vivadent AG
Automix glass fillers, ytterbium trifluoride, spheroid
mixed oxide
A primer: aqueous solution of initiator
B primer: HEMA, phosphoric acid, acrylic
acid monomers
Metal/zirconia primer: phosphoric acid
acrylate and methacrylate cross-linking
agents in an organic solution
Variolink Monomer matrix: UDMA, methacrylate Ivoclar Vivadent AG
Esthetic monomers
Inorganic fillers: ytterbium trifluoride,
spheroid mixed oxide
Additional ingredients: initiators, stabilizers,
pigments

BPO, benzoylperoxide; MDP, 10-methacryloxyloxydcyl hydrogen phosphate; DMA,

dimethacrylate; HEMA, hydroxyethyl methacrylate; UDMA, urethane dimethacrylate.
 24

Supplemental Table 1. Results of QDP

Abou Sasse Sasse Chaar Klink

Sasse Kern Sailer and Rathmann Souza
Griffin, Tara et and and and and
et al, et al, Hämmerle, et al, et al,
201120 al, Kern, Kern, Kern, Hüthig,
201221 201728 201424 201727 201829
201119 201322 201423 201525 201626
Has the main purpose of the article direct
1 1 1 1 1 1 1 1 1 1 1
clinical applicability?
Is the methodology reproducible and
1 1 1 1 1 1 1 1 1 1 1
adequate for the rationale of the study?
Is the theoretical background well described
and justified with pertinent and updated 1 1 1 1 1 1 1 1 1 1 1
references?
Are the aim(s) of the study and the null
hypothesis(es) clear enough and well 1 1 1 1 1 1 1 1 1 1 1
formulated?
Are the variables of the study well defined? 0 1 1 1 1 1 1 1 0 1 0
Is the sample size (n) adequate? Are the
inclusion and exclusion criteria well
0 0 1 1 0 1 0 0 0 0 0
described? Have the patients been randomly
assigned to the groups?
For clinical trials: are both the follow-up
period and the protocol of the evaluation 1 1 1 1 1 1 1 1 1 1 1
appropriate?
Have the potential confounding variables
0 0 1 1 1 1 1 1 0 0 0
been kept under control?
Is the statistical method suitable? 0 1 1 1 1 1 1 1 1 1 0
Have the results been objectively enounced
and accompanied by appropriate figures 0 1 1 1 1 1 1 1 1 1 0
and/or tables?
Do they report on statistical significance? 0 0 1 1 1 1 1 1 1 1 0
Is there a sufficient contrast with the
0 1 1 1 1 1 1 1 1 1 0
scientific evidence?
Have the differences with other studies been
justified from the methodological point of 0 1 1 1 1 1 1 1 1 1 0
view?
Have the limitations and potential bias or
0 1 1 1 1 1 1 1 1 1 0
confounding factors been discussed?
Do they clearly answer to the null
hypothesis(es), disclosing the clinical
1 1 1 1 1 1 1 1 1 1 1
significance and stating the possible
extrapolation of the findings?
QDP score 6 12 15 15 14 15 14 14 12 13 6
 25

FIGURES

Figure 1. PRISMA flow diagram. PRISMA, Preferred Reporting Items for Systematic Reviews

and Meta-analysis.

Figure 2. Original framework design based on Wolfart and Kern.31

Figure 3. Updated design with extended PCRs. PCR, partial-coverage retainer.

Figure 4. Inlay-inlay variety.27

Figure 5. Nonretentive preparation design used in four of five anterior studies.22,23,26,28

Figure 6. A-B, Demarcation of mesial and distal vertical grooves with separating and veneer

rotary instruments. C, Centric stop prepared with round diamond rotary instrument.

Figure 7. Abutment tooth preparation design with mesial and distal vertical grooves and centric

stop.
Click here to access/download;Figure;19-804_1.tif
Click here to access/download;Figure;19-804_2.jpg
Click here to access/download;Figure;19-804_3.jpg
Click here to access/download;Figure;19-804_4.jpg
Click here to access/download;Figure;19-804_5.jpg
Click here to access/download;Figure;19-804_6A.jpg
Click here to access/download;Figure;19-804_6B.jpg
Click here to access/download;Figure;19-804_6C.jpg
Click here to access/download;Figure;19-804_7.jpg
Table 1
Table 1. Systematic review search strategy
Electronic Databases and Libraries
MEDLINE, EMBASE, PubMed, Web of
Science, Scopus, Cochrane Library, and
Google Scholar.
Click here to access/download;Table;Table 1.docx
MeSH Search Terms and Free-text
Words
Fixed dental prostheses OR Resin-bonded
bridge OR Resin-bonded fixed dental
prostheses OR Resin-bonded fixed partial
denture OR Adhesively-retained fixed
partial denture OR Adhesively-retained
fixed dental prosthesis OR Adhesively-
retained bridge OR Adhesive bridge OR
Minimally-invasive bridge OR Acid- etched
bridge OR Maryland bridge OR Single
retainer bridge OR Two-retainer bridge OR
Butterfly bridge OR Veneer* OR Inlay-
retained fixed dental prosthesis OR Inlay-
retained fixed partial denture OR Inlay-
retained FDP OR Inlay-retained FPD AND
Zirconia OR Zirconium OR Zircon* OR Y-
TZP OR TZP OR ZrO2 OR PSZ OR FSZ
OR CSZ OR Ce-TZP
Table 2 Click here to access/download;Table;Table 2.docx

Table 2. Inclusion and exclusion criteria

Inclusion criteria Exclusion criteria
Timeframe Between 1990 and July 2018 Before 1990

Publishing Articles published in international Articles not published in international

details peer reviewed journals peer reviewed journals

Study design RCTs Animal studies

Clinical controlled trials In vitro studies

Retrospective or prospective cohort Single case studies

studies

Case reports/series
Type of Patients with edentulous spaces Patients with complete crown
patients (P): replaced with resin-bonded zirconia conventional zirconia FPDs (either
FPDs or inlay-retained zirconia FPDs fixed-fixed or cantilevered)

Patients with bonded zirconia veneers Patients with conventionally cemented

zirconia FPDs or veneers
Patients with layered or monolithic
zirconia Patients with implant-retained zirconia

Patients with 3Y-TZP, 4Y-TZP, 5Y- Patients with zirconia hybrid materials
TZP, or Ce-TZP such as zirconia-infiltrated resins

Patients with zirconia-infiltrated

ceramics
Type of Articles with sufficient detail Articles without sufficient detail on
interventions regarding the retainer design, treatment protocols
(I): materials used, treatment of materials,
bonding protocol, and adhesive resin
used
Type of No control or comparison groups
control (C): were selected
Type of Articles with quantitative reporting of Articles with follow-up times less than
outcomes the details of survival rates and any 12 months, survey/phone call follow-
(O): modes of failure such as debonding or ups, or articles with multiple
mechanical/biological complications publications on the same patient
cohort
RCT, randomized controlled trial; FPD, fixed partial denture; Y-TZP, yttrium-stabilized
tetragonal zirconia polycrystal; Ce-TZP, ceria-stabilized tetragonal zirconia polycrystals.
Table 3 Click here to access/download;Table;Table 3.docx

Table 3. Exclusion of studies after application of QDP

Excluded Studies Year Reasons for Exclusion
Griffin20 2011 Single case report that should have been excluded earlier.
Further investigation warranted based on novel subject
matter: resin-bonded zirconia veneers
Souza et al29 2018 Single case report that should have been excluded earlier.
Further investigation warranted based on novel subject
matter: resin-bonded zirconia veneers
Sasse et al21 2012 Participant population duplicated in other included studies
Table 4 Click here to access/download;Table;Table 4.docx

Table 4. Study and patient characteristics of the included studies

Average
Mean Follow-
Number of Age of
Study Study Design up Time Dropouts
Prostheses Subjects
(months)
(years)
Abou Tara et Prospective
20.0 23 43.7 0
al, 201119 Cohort
Sasse and
RCT 64.2 30 33.3 0
Kern, 201322
Sasse and Prospective
61.8 42 32.7 0
Kern, 201423 Cohort
Sailer and
Retrospective
Hämmerle, 48.0 15 27.5 0
Cohort
201424

Chaar and Prospective

64.4 30 41.9 1
Kern, 201525 Cohort
Klink and
Prospective
Hüthig, 35.0 24 33.0 1
Cohort
201626
Rathmann et Prospective
58.8 30 42.9 1
al, 201727 Cohort
Kern et al, Retrospective
92.2 108 32.0 6
201728 Cohort

RCT, randomized controlled trial.

Table 5 Click here to access/download;Table;Table 5.docx

Table 5. Methodological characteristics of included studies

Potential
Manufacturing Procedures Clinical Procedures Number and Type of Complications Sources of
Author(s) Prostheses Design Bias
Materials Surface Treatment Tooth Preparation Isolation Method Bonding System Debond Others
Abou Tara et al, Posterior Zirconia framework (Vita In-Ceram YZ; Vita 50-μm Al2O3 at 0.25 MPa Retentive Rubber dam Total etch with 37% phosphoric acid and Clearfil New Bond (Kuraray 1 2 fractures of veneering Study
201119 Zahnfabrik) America Inc) porcelain financially
Fixed-fixed Box-shaped inlay cavities supported by
Feldspathic porcelain (VITA VM 9; Vita Panavia 21 TC (Kuraray America Inc) Vita
Inlay-retained FPD with buccal and Zahnfabrik) used on pontics only PCRs: Zahnfabrik
palatal PCRs Bevelled preparations in enamel
buccally and palatally
Sasse and Kern, Anterior IPS e.max ZirCAD, veneered with IPS e.max 50-μm Al2O3 at 0.25 MPa Non-retentive Rubber dam Etch with 37% phosphoric acid for 30 seconds. Rinse and dry 2 1 secondary caries detected in NR
201322 Ceram (Ivoclar Vivadent AG) Panavia 21 TC (Kuraray
Cantilevered, single-retainer, resin- Then cleaned ultrasonically A mid lingual surface notch 16 with Panavia 21 TC (Kuraray America Inc); no primer America Inc) group
bonded FPD in 99% isopropyl alcohol for
3 minutes 14 with Multilink Automix (Ivoclar Vivadent AG), using a phosphoric 1 minor rotation of abutment in
acid acrylate primer for the zirconia (Metal/Zirconia Primer; Ivoclar Panavia 21 TC (Kuraray
Vivadent AG), and a self-etching primer for the enamel (Primers A & America Inc) group
B™ of BeautyOrtho Bond™; Shofu Inc)
Sasse and Kern, Anterior Zirconia frameworks milled out of presintered 50-μm Al2O3 at 0.25 MPa Non-retentive Rubber dam Teeth were cleaned with an air polishing system using a water-soluble 2 1 secondary caries NR
201423 zirconia ceramic blocks, veneered with IPS e.max sodium bicarbonate cleaning powder
Cantilevered, single-retainer, resin- Ceram (Ivoclar Vivadent AG) A mid lingual surface notch
bonded FPD Enamel etched with 36% phosphoric acid for 30 seconds. Rinse and
dry
3 prostheses were 4-unit devices
Panavia 21 TC (Kuraray America Inc)
Sailer and Anterior IPS e.max ZirCAD framework (Ivoclar Vivadent Cleaned with alcohol Retentive Rubber dam Pumice on teeth. Rinse and dry 2 No chipping NR
Hämmerle, 201424 AG) with zirconia veneering ceramic (GC Initial;
Cantilevered, single-retainer, resin- GC America Inc) Silane application (Clearfil Mesial and distal vertical grooves Etch with 37% phosphoric acid for 1 minute
bonded FPD Porcelain Bond Activator; and a cingulum slot
Kuraray America Inc) ED Primer (Kuraray American Inc) used as per manufacturer’s
instructions

Panavia 21 TC (Kuraray America Inc)

Oxyguard (Kuraray America Inc) used to ensure complete set of the

material
Chaar and Kern, Posterior Zirconia framework (Vita In-Ceram YZ; Vita 50-μm Al2O3 at 0.25 MPa Retentive Rubber dam Total etch with 37% phosphoric acid 2 debonds. One was 2 secondary caries Study
201525 Zahnfabrik) successfully rebonded and financially
Fixed-fixed Ultrasonic cleaning in 96% Box-shaped inlay cavities Dentine adhesive (Clearfil New Bond; Kuraray America Inc) the other deemed a failure as 3 chipping of the veneering supported by
All frameworks veneered with feldspathic isopropyl alcohol it debonded 8 times porcelain Vita
Inlay-retained FPD with buccal and porcelain (VITA VM 9; Vita Zahnfabrik) PCRs: Panavia 21 TC (Kuraray America Inc) Zahnfabrik
palatal PCRs Bevelled preparations in enamel
buccally and palatally Oxyguard II (Kuraray America Inc) used
Klink and Hüthig, Anterior 16 Ceramill zirconia framework (Amann-Girrack 50-μm Al2O3 at 0.1 MPa Non-retentive NR No mention of etching the enamel 1 2 minor chips NR
201626 AG) and Creation ZI-CT (Creation Willi
Cantilevered, single-retainer, resin- Geller)/e.max Ceram (Ivoclar Vivadent) veneering Monobond Plus (Ivoclar No mechanical retention, only 22 with Multilink Automix (Ivoclar Vivadent AG) 1 abutment rotation
bonded FPD Vivadent AG) ‘definite seats’ were prepared into
3 IPS e.max ZirCAD and IPS e.max Ceram the lingual surfaces of the 2 with Variolink Esthetic (Ivoclar Vivadent AG). Syntac Primer and
(Ivoclar Vivadent AG) abutment teeth Adhesive (Ivoclar Vivadent AG) were used according to
manufacturer’s protocol
1 ICE Zirkon (Zirkonzahn) and e.max Ceram
(Ivoclar Vivadent AG)

2 KATANA Zirconia and CERABIEN ZR

(Kuraray Noritake Dental Inc)

2 Cercon ht and Cercon ceram Kiss (DeguDent)

Rathmann et al, Posterior IPS e.max ZirCAD (Ivoclar Vivadent AG) The inner surfaces of the Retentive 7 prostheses had Patients were randomized into 2 groups: Panavia F (Kuraray America 16 3 secondary caries Study
201727 zirconia frameworks were rubber dam Inc) and Multilink Automix (Ivoclar Vivadent AG) financially
30 inlay-retained FPDs: Veneered with pressable fluorapatite glass ceramic silica coated tribochemically Teeth had old restorations 1 tooth fracture supported by
(IPS e.max ZirPress; Ivoclar Vivadent AG) using the Rocatec system removed and an autopolymerizing Cotton roll and Both used in accordance with manufacturer’s recommendations Ivoclar
13 had 2 dihedral inlays (3M ESPE), then silane resin was placed retraction cords 2 irreversible pulpitis Vivadent
(Monobond S; Ivoclar otherwise
1 had a dihedral and a trihedral Vivadent AG) Depending on the extent of the 1 recurrent severe chronic
inlay preexisting defects, the abutments periodontitis
were prepared for dihedral inlays,
6 had a partial-coverage crown and trihedral inlays, partial-coverage 21 chipping
a dihedral inlay crowns, and complete crowns
10 veneer delamination
8 had a complete crown and a
dihedral inlay 6 framework fracture

2 had a complete crown and a

trihedral inlay
Kern et al, 201728 Anterior
Cantilevered, single-retainer, resin-
bonded FPD
7 prostheses were 4-unit devices,
bonded to the maxillary central
incisors with 2 distal cantilevers to
replace the maxillary lateral incisors
Zirconia frameworks milled out of presintered 50-μm Al2O3
zirconia ceramic blocks, manually veneered
From 2001 to 2009
0.25 MPa was used
0.1 MPa was used
thereafter, then cleansed
ultrasonically in 99%
isopropanol
Non-retentive
Fine incisal finishing shoulder,
fine cervical chamfer, small
proximal box, and cingulam ‘pin
hole’
Rubber dam Etch with 37% phosphoric acid for 30 seconds 6 1 prosthesis was removed at the NR
patient’s request as they wanted
94 with Panavia 21 TC (Kuraray America Inc); no primer an implant after a small chip
occurred on the pontic
14 with Multilink Automix (Ivoclar Vivadent AG) and Metal/Zirconia
Primer (Ivoclar Vivadent AG)
FPD, fixed partial denture; PCR, partial-coverage retainer; NR, not reported.
Table 6 Click here to access/download;Table;Table 6.docx

Table 6. Description of adhesive resins used

Material Composition Manufacturer
Panavia 21 TC Catalyst: Hydrophobic aromatic Kuraray America Inc
dimethacrylate, hydrophobic aliphatic
methacrylate, MDP, fillers, BPO
Base: Hydrophobic aromatic dimethacrylate,
hydrophobic aliphatic dimethacrylate,
hydrophobic dimethacrylate, fillers, DEPT,
sodium aromatic sulfonate, hydrophilic
aliphatic dimethacrylate
Panavia F Paste A: MDP, hydrophobic and hydrophilic Kuraray America Inc
dimethacrylate, benzoyl peroxide,
camphoroquinone, colloidal silica
Paste B: sodium fluoride, hydrophobic and
hydrophilic dimethacrylate, diethanol-p-
toluidine, T-isopropylic benzenic sodium
sulfinate, barium glass, titanium dioxide,
colloidal silica
Multilink Monomer matrix: DMA, HEMA, barium Ivoclar Vivadent AG
Automix glass fillers, ytterbium trifluoride, spheroid
mixed oxide
A primer: aqueous solution of initiator
B primer: HEMA, phosphoric acid, acrylic
acid monomers
Metal/zirconia primer: phosphoric acid
acrylate and methacrylate cross-linking
agents in an organic solution
Variolink Monomer matrix: UDMA, methacrylate Ivoclar Vivadent AG
Esthetic monomers
Inorganic fillers: ytterbium trifluoride,
spheroid mixed oxide
Additional ingredients: initiators, stabilizers,
pigments

BPO, benzoylperoxide; MDP, 10-methacryloxyloxydcyl hydrogen phosphate; DMA,

dimethacrylate; HEMA, hydroxyethyl methacrylate; UDMA, urethane dimethacrylate.
Supplemental Table 1 Click here to access/download;Table;Supplemental Table
1.docx

Supplemental Table 1. Results of QDP

Abou Sasse Sasse Chaar Klink

Sasse Kern Sailer and Rathmann Souza
Griffin, Tara et and and and and
et al, et al, Hämmerle, et al, et al,
201120 al, Kern, Kern, Kern, Hüthig,
201221 201728 201424 201727 201829
201119 201322 201423 201525 201626
Has the main purpose of the article direct
1 1 1 1 1 1 1 1 1 1 1
clinical applicability?
Is the methodology reproducible and
1 1 1 1 1 1 1 1 1 1 1
adequate for the rationale of the study?
Is the theoretical background well described
and justified with pertinent and updated 1 1 1 1 1 1 1 1 1 1 1
references?
Are the aim(s) of the study and the null
hypothesis(es) clear enough and well 1 1 1 1 1 1 1 1 1 1 1
formulated?
Are the variables of the study well defined? 0 1 1 1 1 1 1 1 0 1 0
Is the sample size (n) adequate? Are the
inclusion and exclusion criteria well
0 0 1 1 0 1 0 0 0 0 0
described? Have the patients been randomly
assigned to the groups?
For clinical trials: are both the follow-up
period and the protocol of the evaluation 1 1 1 1 1 1 1 1 1 1 1
appropriate?
Have the potential confounding variables
0 0 1 1 1 1 1 1 0 0 0
been kept under control?
Is the statistical method suitable? 0 1 1 1 1 1 1 1 1 1 0
Have the results been objectively enounced
and accompanied by appropriate figures 0 1 1 1 1 1 1 1 1 1 0
and/or tables?
Do they report on statistical significance? 0 0 1 1 1 1 1 1 1 1 0
Is there a sufficient contrast with the
0 1 1 1 1 1 1 1 1 1 0
scientific evidence?
Have the differences with other studies been
justified from the methodological point of 0 1 1 1 1 1 1 1 1 1 0
view?
Have the limitations and potential bias or
0 1 1 1 1 1 1 1 1 1 0
confounding factors been discussed?
Do they clearly answer to the null
hypothesis(es), disclosing the clinical
1 1 1 1 1 1 1 1 1 1 1
significance and stating the possible
extrapolation of the findings?
QDP score 6 12 15 15 14 15 14 14 12 13 6