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Ozlem
Malkondua, Neslihan Tinastepea, Ender Akan
lub
and Ender Kazazog
a
Faculty of Dentistry, Department of Prosthodontics, Yeditepe University, Istanbul, Turkey; bFaculty of Dentistry, Department of Prosthodontics,
_Izmir Katip Celebi
ABSTRACT
ARTICLE HISTORY
Zirconia restorations have been used successfully for years in dentistry owing to their
biocompatibility and good mechanical properties. Because of their lack of translucency, zirconia
cores are generally veneered with porcelain, which makes restorations weaker due to failure of the
adhesion between the two materials. In recent years, all-ceramic zirconia restorations have been
introduced in the dental sector with the intent to solve this problem. Besides the elimination of
chipping, the reduced occlusal space requirement seems to be a clear advantage of monolithic
zirconia restorations. However, scientic evidence is needed to recommend this relatively new
application for clinical use. This mini-review discusses the current scientic literature on monolithic
zirconia restorations. The results of in vitro studies suggested that monolithic zirconia may be the
best choice for posterior xed partial dentures in the presence of high occlusal loads and minimal
occlusal restoration space. The results should be supported with much more in vitro and
particularly in vivo studies to obtain a nal conclusion.
Introduction
Metal ceramic restorations are a type of ceramic system
for xed prosthetic rehabilitation that has been widely
used since the early 1960s.[1] They have superior physical properties, and their marginal and internal adaptation and aesthetics are clinically acceptable.[1 4]
However, light reecting from the opaque porcelain
used to mask the metal, particularly at the cervical third
of the restoration causes a light grey appearance of the
adjacent gingival tissue. This phenomenon led researchers to search for more aesthetic solutions to produce
xed prostheses. Although the rst feldspathic porcelain
crown was introduced to the eld of dentistry by Land
[5] in 1903, the development of metal-free ceramics only
gained speed after the rst attempt to strengthen feldspathic porcelain by adding Al2O3 by McLean [6] in 1965.
Since then, several types of full ceramic systems have
been developed to meet the demands of both patients
and dentists for highly aesthetic and natural-appearing
restorations. However, some of the mechanical properties of these materials, such as brittleness, crack propagation, fracture toughness, low tensile strength, wear
resistance, marginal accuracy and difculty of repair,
have limited their clinical use.[7] Zirconia was introduced
in dentistry in the early 1990s and has been used as a
core material to support more aesthetic ceramic
CONTACT Ender Akan
KEYWORDS
ender.akan@ikc.edu.tr
In vitro studies
The performance of monolithic zirconia has been extensively studied in vitro, since such studies are fast, repeatable, relatively inexpensive and simple and also allow
precise control of the environment. Over the last ve
years, most in vitro studies have focused mainly on the
effect of surface treatment on the wear of the material
itself and/or antagonists,[24 35] surface roughness,
[24,25,27,34,36 38] fracture resistance,[35,39 45] exural strength,[23,44,46] chipping resistance,[23] compressive strength,[44] elastic modulus,[44] hardness,[33]
laser transmission,[47] LTD [48] and CTE-generated stress
elds in monolithic zirconia,[49] translucency and colour
(Table 1).[35,46,50 56] Although the results from in vitro
studies may not fully reect the clinical performance of
the materials due to the complexity of the clinical
Table 1. Recent in vitro and in vivo studies on the performance
of monolithic zirconia in dentistrya.
Type of
study
In vitro
In vivo
a
Investigated
parameters
Wear
Surface roughness
Fracture resistance
Flexural strength
Chipping resistance
Compressive strength
Elastic modulus
Hardness
Laser transmission
Low-temperature degradation
CTE-generated stress elds
Translucency and colour
Contour, marginal adaptation, occlusion
and shade, gingival response
Reference(s)
[24 35]
[24,25,27,34,36 38]
[35,39 45]
[23,44,46]
[23]
[44]
[44]
[33]
[47]
[48]
[49]
[35,46,50 56]
[57 59]
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environment, they have still contributed to the accumulation of a growing body of useful information on the
performance of monolithic zirconia.
Wear
The effect of different surface treatments of monolithic
zirconia on antagonists has been extensively studied in
recent years because the use of zirconia without porcelain overlay became popular.[24 35] For example, in a
study by Sabrah et al., [24] polished zirconia was shown
to cause the least wear on synthetic hydroxyapatite in a
two-body rotating pin-on-disk wear test as compared to
glazed and as-machined zirconia (1.3, 2.7 and 2.7 mm3,
respectively). Janyavula et al. [25] evaluated the wear of
polished or glazed zirconia, polished then reglazed zirconia, enamel and veneering porcelain on enamel, using
an Alabama wear-testing device. The authors reported
that the volume loss of enamel was least in the polished
zirconia group (0.11 0.04 mm3 at 200,000 cycles and
0.21 0.05 mm3 after 400,000 cycles). Glazed and polished then reglazed zirconia showed signicant opposing enamel wear (0.59 0.1 mm3 and 0.87 0.21 mm3
at 200,000 cycles and 0.4 0.88 0.12 mm3 and 1.18 0.2
mm3 after 400,000 cycles). The most pronounced enamel
wear was observed for veneering porcelain (1.46 0.5
mm3 and 2.15 0.5 mm3 at 200,000 and 400,000 cycles,
respectively). Thus, the authors concluded that polished
zirconia is wear-friendly for the opposing teeth. Kontos
et al. [26] tested the wear capacity of zirconia after various surface treatments using an Alabama wear-testing
device. Polished zirconia had a low wear effect (66 23
mm) on the antagonist steatite ball, whereas, glazed zirconia had the highest wear effect (85 33 mm). Kim
et al. [27] investigated the volume loss of enamel and
feldspathic porcelain after simulated mastication against
three types of monolithic zirconia, heat-pressed ceramic
and feldspathic porcelain. The zirconia specimen caused
the least wear volume of the enamel (Prettau, Lava and
Rainbow: 0.04 0.02, 0.04 0.02 and 0.04 0.02 mm,
respectively), but the difference in wear compared to
the other specimens (e.max Press, 0.06 0.03 and VitaOmega 900, 0.11 0.03) tested was not signicant. In
the study by Sripetchdanond and Leevailoj,[28] the
enamel wear mean depth caused by monolithic zirconia
(1.83 0.75 mm) was signicantly lower than that
caused by glass ceramic (7.32 2.06 mm) and enamel
(10.72 6.31 and 8.81 5.16 mm). Another study by
Jung et al. [29] reported that polished zirconia caused
less wear (0.031 0.033 mm3) on enamel when tested
with a chewing simulator than glazed zirconia
(0.078 0.063 mm3). The polished zirconia full-coverage
crown without glazing was, therefore, more effective in
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Surface roughness
Surface roughness could affect the amount of wear on
natural enamel antagonists. Different surface treatment
methods of a restoration result in different roughness
values. With regard to this issue, Sabrah et al. [24] found
that the glazed surfaces (Ra: 0.42 mm and Rq: 0.63 mm)
were the smoothest among the red ones (Ra: 0.84 mm
and Rq: 1.13 mm), the surfaces nished using diamond
burs (Ra: 0.89 mm and Rq: 1.20 mm) and those polished
after nishing with diamond burs (Ra: 0.49 mm and Rq:
0.76 mm). Janyavula et al. [25] reported that glazed zirconia (Ra: 0.76 0.12 mm) and polished and then glazed
zirconia (Ra: 0.69 0.1 mm) had smoother surfaces than
enamel (2.6 1.1 mm) and veneered zirconia (1.6 0.16
mm) but were rougher than polished zirconia (Ra: 0.17
Fracture resistance
The fracture resistance of monolithic zirconia has been
explored by different authors, since it has been recommended to use full-contour zirconia especially in loadbearing areas. Preis et al. [39] evaluated the failure
and fracture resistance of three-unit zirconia-based
FPDs under the inuence of different surface treatments (veneering and glazing) and adjustment (polishing and grinding) procedures. All the groups were
subjected to thermal cycling (TC) and mechanical
loading (ML). Except for one group, all the groups
were anatomically designed. Sintering, sandblasting
and glazing procedures were performed on the specimens of the control group without TC and ML. The
authors [39] observed no failure of FDPs during TC
and ML conducted in a chewing simulator, but wear
occurred at contact points. The median fracture force
ranged between 1173.5 and 1316.0 N without signicant differences either between the groups, or in
647
Hardness
rmann et al. [33] reported that the mean hardness
Mo
(Martens Hardness, MH) value of monolithic zirconia is
7996 (MH). Among the nine aesthetic CAD/CAM materials, a resin-based nanocomposite, human enamel and a
zirconium dioxide ceramic had the greatest hardness.
One can expect that the hardest materials would have
the greatest wear potential to antagonist teeth. However, the wear potential of a material does not only
depend on the hardness but also on other properties
such as surface roughness. This has been conrmed by
several studies which showed that the surface condition
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MALKONDU ET AL.
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Sari et al. [47] tested the erbium-doped yttrium aluminium garnet (Er:YAG) laser transmission ratio through different dental ceramics with a thickness of 0.5 and 1 mm.
The transmission values decreased with increasing thickness of the ceramic sample. For both the 0.5 and 1 mm
thicknesses, monolithic zirconia showed higher transmission ratios (0.78 0.01 for 0.5 mm and 0.69 0.00 for
1 mm) than feldspathic ceramics (0.68 0.01 for 0.5 mm
and 0.44 0.00 for 1 mm) and yttrium stabilized zirconia
core ceramic (0.62 0.01 for 0.5 mm and 0.47 0.01 for
1 mm). Lithium disilicate reinforced glass ceramics had
the highest transmission values (0.88 0.01 for 0.5 mm
and 0.70 0.01 for 1 mm) regardless of the thickness.
Thus, this study demonstrated that the parameters of
laser irradiation should be adjusted according to the restoration material and the thickness during laser debonding of ceramic restorations.
Translucency
Low-temperature degradation
In vivo studies
Although in vitro studies are fast, simple and inexpensive
and generally avoid the ethical and legal issues, they
may not replicate the oral environment exactly and misleading results may be obtained. That is why, to obtain
more reliable results, in vivo studies are needed. In their
in vivo study, Stober et al. [57] evaluated the enamel
wear caused by MZCs under clinical conditions (20 MZCs
placed in 20 patients requiring full molar restoration).
The patients had natural opposing teeth, and two natural contralateral antagonistic teeth were included. Subjects with clinical signs or/and symptoms of bruxism
were excluded from the study. Tooth wear was evaluated based on plaster models made at baseline and after
six months with three-dimensional (3D) laser-scanning
methods. Mean vertical loss (maximum vertical loss in
parentheses) was found to be 10 (43) mm for the zirconia
crowns, 33 (112) mm for the opposing enamel, 10 (58)
mm for the contralateral teeth and 10 (46) mm for the
contralateral antagonists. The authors concluded that
MZCs caused more wear on the opposing enamel than
natural teeth. However, they noted that the amount of
wear caused by zirconia even after six months is less
than that of other ceramics based on previous studies.
In another study, Batson et al. [58] assessed the quality of CAD/CAM fabricated single tooth restorations in
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Clinical reports
Implant-supported xed-dental prosthesis with monolithic zirconia have been reported to serve successfully
up to four years with pleasing aesthetics.[60 67] In an
18-month follow-up study, Chang et al.[68] stated that
zirconia cylinders may be exposed to excessive stress
when screw retained zirconia restorations were fabricated. Inlay retained xed-dental prosthesis using monolithic zirconia has been recommended as a clinical
alternative to traditional full-coverage xed-dental prosthesis and implant-supported crowns.[69] The clinical
reports indicate that monolithic zirconia has a very high
expectancy of surviving for a long time when treatment
planning and case selection are done properly.
Conclusions
Taken together, the reviewed reports suggest that
monolithic zirconia may present some clinical advantages over veneered zirconia restorations. While selecting a restorative material, the wear of natural dentition is
an important factor, particularly in the presence of parafunctional habits. In vitro and in vivo studies showed that
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Disclosure statement
The authors declare that there is no conict of interests
regarding the publication of this paper.
ORCID
Ender Akan
http://orcid.org/0000-0002-4596-2612
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