Escolar Documentos
Profissional Documentos
Cultura Documentos
and
Cercon.
and Denzir.**
Supporters of soft-milling claim that hard-milling
may introduce microcracks in the framework during
the milling process. In contrast, hard-milling supporters
claim a superior marginal t because no shrinkage is
involved in their manufacturing process. Nevertheless,
in vitro studies support the use of both HIPed and non-
HIPed zirconia for all-ceramic FPDs, crowns and
implant abutments for the posterior of the mouth
because of their high exural strength and fracture
toughness (17).
The most utilized zirconia in dentistry, Y-TZP, has
been found to withstand cyclic fatigue testing, where
posterior all-ceramic FPDs spanning up to 5-units, had a
lifetime comparable to that achieved with metal-
ceramic restorations (2), and it has been predicted,
based on the results of this study, to have a lifetime
longer than 20 years (18). However, early clinical
ndings show that there are two main drawbacks for
zirconia restorations compared to metal-ceramics. The
rst is a high incidence of veneering porcelain fracture,
manifesting clinically as chipping fractures, and the
other is an inherent accelerated ageing problem that
has been identied to occur in zirconia in the presence
of water. This ageing phenomenon is known as
low-temperature degradation (LTD), which causes a
decrease in physical properties by spontaneous phase
transformation of the zirconia crystals from the tetrag-
onal phase to the weaker monoclinic phase putting
zirconia frameworks at risk of spontaneous catastrophic
failure (19).
The objective of this systematic review is to report
on the clinical success of HIPed and non-HIPed Y-TZP-
based restorations (single crowns, FPDs and implant
abutments), focusing on the incidence of framework
fracture and chipping of the veneering porcelain in
both groups. In addition, recent in vitro studies con-
ducted in an attempt to solve some of the reported
problems in zirconia-based restorations are also dis-
cussed.
*3M ESPE, Seefeld, Germany.
fractured
in half only 1 month after cementation on a maxillary
second molar (21), so that the success rate for this
study was 93% after 2-years. There was no signicant
difference in soft tissue health adjacent to the Cercon
crowns and the control crowns made with In-Ceram
zirconia (Vita). No chipping of the veneering porcelain
was reported after 2 years. In the mean time, no
framework fracture have been reported after 3 years
in a study with 204 single crowns fabricated with
Procera zirconia
(9).
Cementation and bonding
Because of its high exural strength, zirconia can be
conventionally cemented, just like metal-ceramic res-
torations, without the need for any pretreatment;
although bonding of zirconia is possible provided
special conditioning, treatment of the zirconia is carried
out rst because zirconia is not etchable. Indeed,
cementation of zirconia all-ceramic restorations is a
simpler process compared to other all-ceramic systems
which require added steps for bonding. This was
evident in the range of cements used by the various
authors in the published clinical trials; zinc phosphate
cement (4, 9, 20, 24, 29, 30), glassionomer cements
(GIC) (2123, 26), resin-modied GIC (12, 25) and
resin cements (913, 2730).
Loss of retention was seen in 7 of 16 studies involving
the cementation of zirconia restorations. One 3-unit
FPD cemented with Panavia F lost retention after
12 months (9), a 4-unit FPD cemented with Variolink
lost retention after 333 months in service (10), while
two 3-unit FPDs in the molar region cemented with
zinc phosphate lost retention at 17 and 32 months (29).
Ketac Cem* glassionomer cement had one posterior 3-
unit FPD decemented after 38 months (22), in addition
to two long-span FPDs at 88 and 142 months in service
(23). All debonded zirconia restorations were rece-
mented successfully for the duration of the follow-up
period in each of the studies.
In contrast, six cases of debonded inlay-retained
zirconia FPDs were seen with Panavia F (dual-cured
resin cement) and Multilink (automix self-curing resin
cement), despite the pretreatment of the zirconia with
tribochemical air abrasion (Rocatec*). Fracture of the
framework occurred in three of the six debonded
restorations (28). Similarly, in a study on single Procera
zirconia crowns, 12 of 204 crowns lost retention of
which 4 could not be recemented (30). Unfortunately,
the type of cement used for the crowns which lost
retention was not reported, as both zinc phosphate and
resin cement (Rely-X Unicem*) where used.
Despite the encouraging retentive capacity of zinc
phosphate-cemented zirconia restorations, after 5-years
follow-up of 3-unit FPDs that were cemented with
either resin cement (Panavia F) or zinc phosphate
(De Trey Zinc
also a non-HIPed
Y-TZP, demonstrated the highest incidence of fractured
frameworks in just 1-year, with a survival rate of 57%
(28). These FPDs had inlays, partial and full-crowns as
retainers with at least one retainer being an inlay.
Debonding of 20% of the retainers resulted in a 10%
framework fracture primarily when one retainer
debonded, which subsequently overloaded the connec-
tors to failure. Bonding procedures in the study used
the generally recommended bonding method for Y-TZP,
namely using tribochemical silica-coating air abrasion
(Rocatec*) pretreatment of the inner surface of the
copings, followed by silanization and cementation using
phosphate monomer resin cements, Panavia F
and
Multilink Automix
FPDs after a 5-
year follow-up, suggested to be because of using a
prototype soft-milling method which has since been
improved. Notably, no other study reported a high