SYSTEMATIC REVIEW

Clinical efficacy of methods for bonding to zirconia: A

systematic review
Niall P. Quigley, BDS, MSc, MClin Dent,a Denice S. S. Loo, BDSc (hons),b Clinton Choy, BDSc (hons),c and
William N. Ha, BDSc, PhDd

The use of zirconia in restor- ABSTRACT

ative dentistry has grown
Statement of problem. The polycrystalline nature of zirconia hinders its ability to bond to tooth
exponentially over the past structure. Consequently, durable bonding to zirconia has been challenging. In vitro studies have
1,2
decade. Early zirconia for- evaluated various methods of bonding to zirconia, but clinical data are sparse.
mulations were used for
Purpose. The purpose of this systematic review was to critically appraise clinical studies
frameworks because of their
investigating the survival rate of resin-bonded zirconia fixed partial dentures (FPDs), inlay-
high flexural strength and retained zirconia FPDs, and zirconia veneers.
unesthetic opacity in
porcelain-fused-to-zirconia Material and methods. Searches were performed in MEDLINE, EMBASE, PubMed, Web of Science,
3,4 Scopus, Cochrane Library, and Google Scholar. Clinical studies of over 12 months duration involving
restorations. Through pro-
bonded zirconia restorations between 1990 and July 2018 were reviewed. All suitable studies were
cessing refinements, materials assessed for quality by using a “Questionnaire for selecting articles on Dental Prostheses”.
with increased translucency
were introduced so that 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
veneering with feldspathic months. Five studies reviewed anterior, resin-bonded FPDs, all of which had a 3- to 10-year
porcelain was not required and survival rate of 100%. Debonds occurred in all studies, but the prostheses could usually be
the material could be used in rebonded.
monolithic form.1
Conclusions. With correctly designed buccal and lingual coverage retainers and minimal if any
Successful ceramic-resin veneering porcelain, zirconia-based, posterior, inlay-retained FPDs seem to have a high clinical
bonding relies on surface survival rate. The role of bonding efficacy in this survival rate is unknown. Anterior, cantilevered,
roughening of the ceramic resin-bonded zirconia FPDs seem to have a high clinical survival rate. While these prostheses can
substrate to increase the sur- debond, fracture of the entire prosthesis is unlikely, so they may be rebonded. To bond zirconia,
face area and allow micro- the use of airborne-particle abrasion with 50-mm alumina (Al2O3) at 0.1 to 0.25 MPa in
mechanical interlocking; combination with a phosphate monomer-containing adhesive resin is recommended until
further studies become available. Rubber dam isolation is also recommended during zirconia
surface activation also allows
bonding. (J Prosthet Dent 2020;-:---)
the formation of chemical
5 ,6
bonds. In conventional
silica-based ceramics, this bond can be reliably ach- monomers.6,8 However, densely sintered, poly-
ieved by etching with hydrofluoric acid to create an crystalline zirconia cannot be etched with hydrofluoric
etched ceramic surface7,8 and by applying a silane for acid at temperatures, times, and concentrations readily
chemical coupling between the ceramic and resin available to dental practitioners.9-12 Physical methods

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.

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Table 1. Systematic review search strategy

Clinical Implications Electronic Databases
and Libraries
MeSH Search Terms and Free-Text
Words
The ability of zirconia to bond to tooth structure has MEDLINE, EMBASE, PubMed, Web of Fixed dental prostheses OR Resin-bonded
been a subject of debate because of its Science, Scopus, Cochrane Library, bridge OR Resin-bonded fixed dental
and Google Scholar. prostheses OR Resin-bonded fixed partial
polycrystalline nature. With emerging long-term denture OR Adhesively-retained fixed
studies, evidence now suggests that airborne- partial denture OR Adhesively-retained
fixed dental prosthesis OR Adhesively-
particle abrasion with 10-methacryloyloxydecyl retained bridge OR Adhesive bridge OR
dihydrogen phosphate and certain design features Minimally-invasive bridge OR Acid-
etched bridge OR Maryland bridge OR
can help achieve a robust bond between zirconia Single retainer bridge OR Two-retainer
and tooth structure. 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*
such as surface grinding or abrading may be used to OR Y-TZP OR TZP OR ZrO2 OR PSZ OR FSZ
OR CSZ OR Ce-TZP
roughen the surface.13 However, these can create sur-
face flaws that reduce the strength of the material.13
Zirconia also lacks a glass phase, so silica-to-silane
bonds will not form.13 Table 2. Inclusion and exclusion criteria
Kern14 and Blatz et al15 reviewed the success of Criteria Inclusion Criteria Exclusion Criteria
bonding high-strength ceramics (alumina and zirconia Timeframe Between 1990 and July 2018 Before 1990
ceramics) with adhesive resin. Kern14 identified many Publishing Articles published in Articles not published in
details international peer reviewed international peer reviewed
in vitro methods of bonding, but supporting clinical data journals journals
were lacking. However, as all the clinical trials found had Study design RCTs Animal studies
Clinical controlled trials In vitro studies
promising results, further investigation of more compli- Retrospective or prospective Single case studies
cated methods of bonding was not deemed necessary. cohort studies
Blatz et al15 reviewed resin-bonding with all types of Case reports/series
Type of Patients with edentulous spaces Patients with complete crown
high-strength ceramic restorations, including complete patients (P): replaced with resin-bonded conventional zirconia FPDs
crowns and conventional fixed partial denture (FPD) zirconia FPDs or inlay-retained (either fixed-fixed or
zirconia FPDs cantilevered)
designs.15 High success and survival rates were found at Patients with bonded zirconia Patients with conventionally
over 5 years15 veneers cemented zirconia FPDs or
Patients with layered or veneers
As alumina restorations have been almost entirely monolithic zirconia Patients with implant-retained
superseded by zirconia, the purpose of this systematic Patients with 3Y-TZP, 4Y-TZP, zirconia
5Y-TZP, or Ce-TZP Patients with zirconia hybrid
review was to examine the durability of the resin-zirconia materials such as zirconia-
bond in zirconia restorations that rely primarily on infiltrated resins
Patients with zirconia-infiltrated
adhesion for their clinical success. ceramics
Type of Articles with sufficient detail Articles without sufficient detail
MATERIAL AND METHODS interventions regarding the retainer design, on treatment protocols
(I): materials used, treatment of
materials, bonding protocol,
This systematic review was performed according to the and adhesive resin used
Preferred Reporting Items of Systematic Reviews and Type of No control or comparison
Meta-Analyses statement.16 The review was undertaken control (C): groups were selected
in July 2018. The electronic libraries, Medical Subject Type of Articles with quantitative Articles with follow-up times
outcomes (O): reporting of details of survival less than 12 months, survey/
Heading (MeSH) terms, and free-text words used are rates and any modes phone call follow-ups, or articles
presented in Table 1. of failure such as debonding with multiple publications on
or mechanical/biological same patient cohort
References of relevant journals were also searched complications
electronically and manually to increase the yield of rele- RCT, randomized controlled trial; FPD, fixed partial denture; Y-TZP, yttrium-stabilized
vant studies. The National Institutes of Health clinical tetragonal zirconia polycrystal; Ce-TZP, ceria-stabilized tetragonal zirconia polycrystal.
trials database was searched, and the authors of 3 active
trials were contacted for preliminary results. Finally, the A preliminary questionnaire was applied to each of
authors of the major review articles were contacted by the selected articles to assess the scientific quality of the
email for further or updated versions of studies. Trans- methods used in each article. This recently developed
lations were sought on Google Translate (Google LLC). questionnaire, called the “Questionnaire for selecting
All titles and abstracts were screened according to the articles on Dental Prostheses” (QDP) was first published
inclusion and exclusion criteria (Table 2). in 2018.17 It was based on the methodical assessments

THE JOURNAL OF PROSTHETIC DENTISTRY Quigley et al

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MEDLINE and WEB OF COCHRANE GOOGLE

PUBMED SCOPUS
EMBASE SCIENCE LIBRARY SCHOLAR
1990 - 2018 1990 - 2018
1990 - 2018 1990 - 2018 1990 - 2018 1990 - 2018
527 citation(s) 571 citation(s)
611 citation(s) 255 citation(s) 2 citation(s) 1382 citation(s)

389 non-duplicate citations screened

319 articles excluded

Inclusion/exclusion criteria applied
after title/abstract screen

70 articles retrieved 59 articles excluded

after full text screen

2 articles excluded
Inclusion/exclusion criteria applied during quality
assessment

1 duplicate article
8 articles included excluded

Figure 1. PRISMA flow diagram. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-analysis.

associated with the following bodies: Critical Appraisal
Skills Program, Grading Recommendations Assessment
and Development, The University of Oxford’s Center for
Evidence-Based Medicine, and Methodological Index for
Nonrandomized Studies. The QDP requires an affirma-
tive 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), treat-
ment group, control group (if applicable), randomization
(if applicable), variables analyzed, and 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 pros-
thesis debonded but could be successfully rebonded,
then the survival outcome remained positive. Compli-
cations were defined as any undesirable or unexpected
event occurring during the observation period that did
not require a replacement prosthesis. These were recor-
ded 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 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 out-
lined 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

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Table 3. Exclusion of studies after application of QDP Figure 4, and none of these had PCRs described as
Excluded above.
Studies Year Reasons for Exclusion
The 5 anterior cantilever resin-bonded zirconia FPDs
Griffin20 2011 Single case report that should have been excluded
earlier. Further investigation warranted based on novel with single-PCR studies were more homogeneous in
subject matter: resin-bonded zirconia veneers design. This is possibly because Professor Matthias Kern of
Souza 2018 Single case report that should have been excluded Kiel University was involved in 3 of the 5 studies. These 3
et al29 earlier. Further investigation warranted based on novel
subject matter: resin-bonded zirconia veneers studies22,23,28 and that of Klink and Hüthig26 all used
Sasse 2012 Participant population duplicated in other included similar nonretentive preparations, as shown in Figure 5.
et al21 studies
Sailer and Hämmerle24 used a more retentive type of
QDP, Questionnaire for selecting articles on Dental Prostheses 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
Table 4. Study and patient characteristics of included studies
used a variation of airborne-particle abrasion except for
Average
Mean Age of the study by Sailer and Hämmerle.24 Rathmann et al27
Follow-Up Number of Subjects used the Rocatec system (3M ESPE), which used tri-
Study Study Design Time (mo) Prostheses (y) Dropouts
bochemical silica airborne-particle abrasion (TSAPA) to
Abou Tara Prospective 20.0 23 43.7 0
et al, 201119 Cohort embed silica particles into the zirconia framework.10 The
Sasse and RCT 64.2 30 33.3 0 other studies19,22,23,25,26,28 used 50-mm Al2O3 at a pres-
Kern, 201322 sure between 0.1 and 0.25 MPa and applied a silane
Sasse and Prospective 61.8 42 32.7 0 (Monobond S; Ivoclar Vivadent AG) before Panavia F
Kern, 201423 Cohort
Sailer and Retrospective 48.0 15 27.5 0
(Kuraray America Inc) or Multilink Automix (Ivoclar
Hämmerle, Cohort Vivadent AG) cementation. Alcohol cleaning was used in
201424
5 of the 8 studies,22-25,28 and zirconia primers/silanes
Chaar and Prospective 64.4 30 41.9 1
Kern, 201525 Cohort were used in 3 of the 5 studies.24,26,27 The use of these
Klink and Prospective 35.0 24 33.0 1 primers depended on the bonding agent used.
Hüthig, Cohort Six of the 8 studies reported the use of rubber dam
201626
during the bonding process.19,22-25,28 Klink and Hüthig26
Rathmann Prospective 58.8 30 42.9 1
et al, 201727 Cohort did not report their isolation methods. In Rathmann
Kern et al, Retrospective 92.2 108 32.0 6 et al,27 rubber dam was used for 7 of the 30 prostheses;
201728 Cohort otherwise, cotton rolls and gingival displacement cord
RCT, randomized controlled trial. 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
study design hampered any meta-analysis. Nevertheless, Panavia 21 contain MDP, so primers are not required. A
patterns emerged which allowed some conclusions to be list of adhesive resins used in the studies are presented in
drawn. Table 6.
Three of the studies19,25,27 examined posterior inlay- In reporting survival rates, Rathmann et al27
retained FPDs, while the others22-24,26,28 examined reviewed 30 prostheses over 10 years, but only 13 of
anterior cantilever resin-bonded zirconia FPDs with the 30 prostheses matched the inclusion criteria for this
partial-coverage retainers (PCR). review. Only 5 participants with 7 prostheses were
In the posterior inlay-retained studies, the inlays all followed-up on because 21 participants had already lost
broadly followed the ideal inlay design as recommended their 22 prostheses.27 One was lost to follow-up as they
by Thompson et al.30 Two of the studies used a similar had moved overseas.27 Sixteen debonds occurred in
prosthesis design, with short framework PCRs wrapping total, but in which prostheses these debonds occurred is
buccally and lingually around the abutment teeth.19,25 unknown.27 The estimated survival rates of the inlay-
This design was originally proposed by Wolfart and retained FPDs were 44.9% in 5 years and 12.1% in 10
Kern31 as shown in Figure 2. Abou Tara et al19 and years27 Abou Tara et al19 examined 23 posterior inlay-
Chaar and Kern25 described an updated design with retained prostheses. One debond occurred at 24
more extensive coverage in the PCRs (Fig. 3). These months, and the prosthesis was successfully rebonded
extended PCRs required a bevel preparation of 0.2 to for the duration of the study.19 This gave a 95.7%
0.5 mm in the enamel on the buccal and lingual sur- bonding success rate and a 100% survival rate at 20
faces. Rathmann et al27 examined a variety of prosthesis months19 Chaar and Kern25 performed a similar study
designs, but only 13 of the 30 prostheses under inves- and reported a survival rate of 95.8% at 5 years because
tigation were of the inlay-inlay variety as shown in of 2 debonds. One was successfully rebonded, but

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Table 5. Methodological characteristics of included studies

Number and Type of
Manufacturing Procedures Clinical Procedures Complications
Potential
Prostheses Surface Tooth Isolation Bonding Sources of
Author(s) Design Materials Treatment Preparation Method System Debond Others Bias
Abou Tara Posterior Zirconia framework 50-mm Al2O3 at Retentive Rubber dam Total etch with 37% 1 2 fractures of Study
et al, Fixed-fixed (Vita In-Ceram YZ; 0.25 MPa Box-shaped inlay phosphoric acid and veneering financially
201119 Inlay-retained Vita Zahnfabrik) cavities Clearfil New Bond porcelain supported
FPD with buccal Feldspathic PCRs: (Kuraray America Inc) by Vita
and palatal PCRs porcelain (VITA VM Bevelled Panavia 21 TC Zahnfabrik
9; Vita Zahnfabrik) preparations in (Kuraray America Inc)
used on pontics enamel buccally
only and palatally
Sasse and Anterior IPS e.max ZirCAD, 50-mm Al2O3 at Nonretentive Rubber dam Etch with 37% 2 1 secondary NR
Kern, Cantilevered, veneered with IPS 0.25 MPa Mid lingual phosphoric acid for caries
201322 single-retainer, e.max Ceram Then cleaned surface notch 30 seconds. Rinse and detected in
resin-bonded (Ivoclar Vivadent ultrasonically in dry Panavia 21
FPD AG) 99% isopropyl 16 with Panavia 21 TC TC (Kuraray
alcohol for 3 (Kuraray America Inc); America Inc)
minutes no primer group
14 with Multilink 1 minor
Automix (Ivoclar rotation of
Vivadent AG), by abutment in
using phosphoric acid Panavia 21
acrylate primer for TC (Kuraray
zirconia (Metal/ America Inc)
Zirconia Primer; group
Ivoclar Vivadent AG),
and self-etching
primer for enamel
(Primers A & B of
BeautyOrtho Bond;
Shofu Inc)
Sasse and Anterior Zirconia 50-mm Al2O3 at Nonretentive Rubber dam Teeth cleaned with 2 1 secondary NR
Kern, Cantilevered, frameworks milled 0.25 MPa Mid lingual air polishing system caries
201423 single-retainer, from presintered surface notch by using water-
resin-bonded zirconia ceramic soluble sodium
FPD blocks, veneered bicarbonate cleaning
3 prostheses with IPS e.max powder
were 4-unit Ceram (Ivoclar Enamel etched with
devices Vivadent AG) 36% phosphoric acid
for 30 seconds. Rinse
and dry
Panavia 21 TC
(Kuraray America Inc)
Sailer and Anterior IPS e.max ZirCAD Cleaned with Retentive Rubber dam Pumice on teeth. 2 No chipping NR
Hämmerle, Cantilevered, framework (Ivoclar alcohol Mesial and distal Rinse and dry
201424 single-retainer, Vivadent AG) with Silane application vertical grooves Etch with 37%
resin-bonded zirconia veneering (Clearfil Porcelain and cingulum slot phosphoric acid for 1
FPD ceramic (GC Initial; Bond Activator; minute
GC America Inc) Kuraray ED Primer (Kuraray
America Inc) American Inc) used as
per manufacturer’s
instructions
Panavia 21 TC
(Kuraray America Inc)
Oxyguard (Kuraray
America Inc) used to
ensure complete
polymerization of
material
Chaar and Posterior Zirconia framework 50-mm Al2O3 at Retentive Rubber dam Total etch with 37% 2 debonds. 2 secondary Study
Kern, Fixed-fixed (Vita In-Ceram YZ; 0.25 MPa Box-shaped inlay phosphoric acid One caries financially
201525 Inlay-retained Vita Zahnfabrik) Ultrasonic cavities Dentin adhesive successfully 3 chipping of supported
FPD with buccal All frameworks cleaning in 96% PCRs: (Clearfil New Bond; rebonded veneering by Vita
and palatal PCRs veneered with isopropyl alcohol Bevelled Kuraray America Inc) and other porcelain Zahnfabrik
feldspathic preparations in Panavia 21 TC deemed
porcelain (VITA VM enamel buccally (Kuraray America Inc) failure as it
9; Vita Zahnfabrik) and palatally Oxyguard II debonded 8
(Kuraray America times
Inc) used
(continued on next page)

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Table 5. (Continued) Methodological characteristics of included studies

Number and Type of
Manufacturing Procedures Clinical Procedures Complications
Potential
Prostheses Surface Tooth Isolation Bonding Sources of
Author(s) Design Materials Treatment Preparation Method System Debond Others Bias
Klink and Anterior 16 Ceramill zirconia 50-mm Al2O3 at Nonretentive NR No mention of 1 2 minor NR
Hüthig, Cantilevered, framework 0.1 MPa No mechanical etching enamel chips
201626 single-retainer, (Amann-Girrack Monobond Plus retention, only 22 with Multilink 1 abutment
resin-bonded AG) and Creation (Ivoclar Vivadent “definite seats” Automix (Ivoclar rotation
FPD ZI-CT (Creation Willi AG) were prepared into Vivadent AG)
Geller)/e.max lingual surfaces of 2 with Variolink
Ceram (Ivoclar abutment teeth Esthetic (Ivoclar
Vivadent) Vivadent AG). Syntac
veneering Primer and Adhesive
3 IPS e.max ZirCAD (Ivoclar Vivadent AG)
and IPS e.max were used according
Ceram (Ivoclar to manufacturer’s
Vivadent AG) 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 Posterior IPS e.max ZirCAD Intaglio surfaces Retentive 7 prostheses Patients randomized 16 3 secondary Study
et al, 30 inlay-retained (Ivoclar Vivadent of zirconia Teeth had existing had rubber into 2 groups: Panavia caries financially
201727 FPDs: AG) frameworks silica restorations dam F (Kuraray America 1 tooth supported
13 had 2 Veneered with coated removed and Cotton roll Inc) and Multilink fracture by Ivoclar
dihedral inlays pressable tribochemically by autopolymerizing and Automix (Ivoclar 2 irreversible Vivadent
1 had dihedral fluorapatite glass using Rocatec resin placed displacement Vivadent AG) pulpitis
and trihedral ceramic (IPS system (3M ESPE), Depending on cords Both used in 1 recurrent
inlay e.max ZirPress; then silane extent of otherwise accordance with severe
6 had partial- Ivoclar Vivadent (Monobond S; preexisting defects, manufacturer’s chronic
coverage crown AG) Ivoclar Vivadent abutments recommendations periodontitis
and dihedral AG) prepared for 21 chipping
inlay dihedral inlays, 10 veneer
8 had complete trihedral inlays, delamination
crown and partial-coverage 6 framework
dihedral inlay crowns, and fracture
2 had complete complete crowns
crown and
trihedral inlay
Kern et al, Anterior Zirconia 50-mm Al2O3 Nonretentive Rubber dam Etch with 37% 6 1 prosthesis NR
201728 Cantilevered, frameworks milled From 2001 to 2009 Fine incisal phosphoric acid for removed at
single-retainer, out of presintered 0.25 MPa used finishing shoulder, 30 seconds patient’s
resin-bonded zirconia ceramic 0.1 MPa used fine cervical 94 with Panavia 21 TC request as
FPD blocks, manually thereafter, then chamfer, small (Kuraray America Inc); implant
7 prostheses veneered cleaned proximal box, and no primer wanted after
were 4-unit ultrasonically in cingulum “pin 14 with Multilink small chip
devices, bonded 99% isopropanol hole” Automix (Ivoclar occurred on
to maxillary Vivadent AG) and pontic
central incisors Metal/Zirconia Primer
with 2 distal (Ivoclar Vivadent AG)
cantilevers to
replace maxillary
lateral incisors

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

another inlay-retained prosthesis had to be replaced
after 49 months as it had debonded 8 times.25
Three articles 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

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Figure 2. Original framework design based on Wolfart and Kern.31
27
Figure 4. Inlay-inlay variety.
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 months24
The FPDs were subsequently airborne-particle abraded
with 30-mm 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 hetero-
geneity, a meta-analysis was not conducted.
Quigley et al
7
Figure 3. Updated design with extended PCRs. PCR, partial-coverage
retainer.
Figure 5. Nonretentive preparation design used in 4 of 5 anterior
studies.22,23,26,28
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 article 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 found 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 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
THE JOURNAL OF PROSTHETIC DENTISTRY
8 Volume
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.
mechanism of the attachment and durability of the silica
particles to zirconia. Indeed, in the discussion of the
Rathmann et al27 article, 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
THE JOURNAL OF PROSTHETIC DENTISTRY
- Issue -
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 adhe-
sive 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.
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 suc-
cessfully 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 res-
torations, with the primary factor being the single-PCR
cantilevers. A recent review by Botelho et al18 reported
that anterior cantilever metal-ceramic prostheses with
Quigley et al
- 2020
Figure 7. Abutment tooth preparation design with mesial and distal
vertical grooves and centric stop.
Table 6. Description of adhesive resins used
Material Composition Manufacturer
Panavia 21 Catalyst: Hydrophobic aromatic dimethacrylate, Kuraray
TC hydrophobic aliphatic methacrylate, MDP, fillers, America Inc
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
dimethacrylate, benzoyl peroxide, America Inc
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 glass fillers, Ivoclar
Automix ytterbium trifluoride, spheroid mixed oxide Vivadent AG
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 organic solution
Variolink Monomer matrix: UDMA, methacrylate monomers Ivoclar
Esthetic Inorganic fillers: ytterbium trifluoride, spheroid mixed Vivadent AG
oxide
Additional ingredients: initiators, stabilizers, pigments
BPO, benzoylperoxide; MDP, 10-methacryloxyloxydcyl hydrogen phosphate; DMA,
dimethacrylate; HEMA, hydroxyethyl methacrylate; UDMA, urethane dimethacrylate.
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 displace-
ment 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, 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
Quigley et al
9
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 evi-
dence that airborne-particle abrasion can induce
microcrack formation, by 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 corre-
lation 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 seem to have
a high clinical survival rate. The role of bonding
efficacy in this is unknown.
2. Anterior, cantilevered, resin-bonded zirconia FPDs
also seem to have a high clinical survival rate. While
these prostheses can debond, fracture of the entire
prosthesis is unlikely, so they may be rebonded.
3. To bond zirconia, the use of airborne-particle
abrasion with 50-mm Al2O3 at 0.10 to 0.25 MPa in
combination with a phosphate monomer-
containing adhesive resin is currently recom-
mended. Rubber dam isolation is also recom-
mended during zirconia bonding.
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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
Copyright © 2020 by the Editorial Council for The Journal of Prosthetic Dentistry.
https://doi.org/10.1016/j.prosdent.2019.12.017
Quigley et al