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Article history: Objective. Dental all-ceramic restorations of zirconia, with and without an aesthetic veneer-
Received 10 March 2017 ing layer, have become a viable alternative to conventional metal-ceramic restorations. The
Received in revised form aim of this study was to evaluate whether factors of the production methods or the mate-
18 May 2017 rial compositions affect load at fracture, fracture modes, internal fit or crown margins of
Accepted 13 June 2017 monolithic zirconia crowns.
Available online xxx Methods. Sixty crowns made from six different commercially available dental zirconias were
produced to a model tooth with a shallow circumferential chamfer preparation. Internal
Keywords: fit was assessed by the replica method. The crown margin quality was assessed by light
Dental crowns microscopy on an ordinal scale. The cemented crowns were loaded centrally in the occlusal
Anatomic contour fossa with a horizontal steel cylinder with a diameter of 13 mm at 0.5 mm/min until fracture.
Zirconia Fractographic analysis was performed on the fractured crowns.
CAD/CAM Results. There were statistically significant differences among the groups regarding crown
Fractographic analysis margins, internal fit and load at fracture (p < 0.05, Kruskall Wallis). Fracture analyses revealed
Fracture strength that all fractures started cervically and propagated to the occlusal surface similar to clinically
Ceramics observed fractures. There was statistically significant correlation between margin quality
and load at fracture (Spearmans rank correlation, p < 0,05).
Significance. Production method and material composition of monolithic zirconia crowns
affect internal fit, crown margin quality and the load at fracture. The hard-machined Y-TZP
zirconia crowns had the best margin quality and the highest load at fracture. Reduction
of margin flaws will improve fracture strength of monolithic zirconia crowns and thereby
increase clinical success.
2017 The Academy of Dental Materials. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Schriwer C, et al. Monolithic zirconia dental crowns. Internal fit, margin quality, fracture mode and load at
fracture. Dent Mater (2017), http://dx.doi.org/10.1016/j.dental.2017.06.009
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Table 1 The materials used with brand name, production method, material composition and grain size. Data from the
manufacturers. N/A = not available.
Code Brand name, manufacturer Production method Material composition Grain size
BX Prismatik BruxZir Milling Soft-machined ZrO2 , Yttria, N/A N/A
Blank
Glidewell laboratories Temp: 1530 C
Please cite this article in press as: Schriwer C, et al. Monolithic zirconia dental crowns. Internal fit, margin quality, fracture mode and load at
fracture. Dent Mater (2017), http://dx.doi.org/10.1016/j.dental.2017.06.009
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Fig. 1 Grading scale for crown margin quality assessment with images representing each grade. The horizontal white bar
indicates 0.5 mm. Arrows pointing out a defect.
Please cite this article in press as: Schriwer C, et al. Monolithic zirconia dental crowns. Internal fit, margin quality, fracture mode and load at
fracture. Dent Mater (2017), http://dx.doi.org/10.1016/j.dental.2017.06.009
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Please cite this article in press as: Schriwer C, et al. Monolithic zirconia dental crowns. Internal fit, margin quality, fracture mode and load at
fracture. Dent Mater (2017), http://dx.doi.org/10.1016/j.dental.2017.06.009
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Fig. 5 A fractographic map of a broken crown NobelProcera (PZ) where the fracture origin can be traced back to machining
flaws on the outside of the crown margins. Red triangle indicates the origin of fracture. Dotted large arrows indicate
direction of crack propagation through the specimen. Small full arrows indicate direction of fracture features such as hackle.
The two images at the bottom show the location of the fracture origin at the two fracture surfaces remounted. Seen from the
inside (left) and from the outside of the crown margin (right). (For interpretation of the references to color in this figure
legend, the reader is referred to the web version of this article.)
range. The grain size of 3Y-TZP can be manipulated with the may reflect the more complex production processes where
sintering temperature. With higher temperature of the sinter- sintering shrinkage must be counterweighed during the pro-
ing process, larger grain size is the result [22]. Lower sintering cess involved in soft-machining. The mean cement gap in this
temperature, results in smaller grain size and thus less t m study ranged from 49,5 m to 141,6 m, indicating that the dig-
transformation. Too low sintering temperature also causes itally calculated shrinkage incorporated in the 3D models, may
insufficient material density [23]. The sintering temperature not compensate for the actual shrinkage occurring during sin-
of the 3Y-TZP is normally between 13501550 C. The products tering after machining. The mean variation is in accordance
tested have sintering temperatures between 14501600 C and with other studies [24,25]. However, there is no consensus on
thus in the normal area. the limit for clinical acceptable values for internal fit.
The hard-machined groups, DM and DY, had less varia- Variation in cement thickness can give different mechan-
tion in the internal fit than the soft-machined groups. This ical and clinical complications. Previous studies have shown
Please cite this article in press as: Schriwer C, et al. Monolithic zirconia dental crowns. Internal fit, margin quality, fracture mode and load at
fracture. Dent Mater (2017), http://dx.doi.org/10.1016/j.dental.2017.06.009
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Fig. 6 The fracture origin is on the inside of the crown margin of this soft-machined zirconia Dental Direkt (DD). This is
probably due to a small machining crack form the processing, although it was not detected before the fracture loading.
Explanations of the symbols see Fig. 6.
that cement thickness can influence failure loads by to high The limitation of the present study is that it has been
cement thickness can reduce failure loads on feldspathic performed with static loading on pristine specimens. Future
ceramics [26]. Too narrow axial cement gap prevent cement research should include aging, fatigue and dynamic loading to
escape at the crown margin, and thus result in poor seat- failure to further increase the clinical relevancy of the results.
ing and a thick occlusal cement layer. The present results do It can be expected that aging of the zirconia would result in
not, however, indicate a correlation between occlusal cement lower loads due to low temperature degradation (LTD) [30].
thickness and fracture load. The specimens in this experiment Every crown in clinical use is subjected to complex forces,
were, however, not exposed to any aging or fatigue regimens thermal and chemical exposure, which would lead to LTD.
which may have an impact on the results for this parameter. Moreover, adjustments performed by the dentist or the den-
It is likely that the observed margin flaws are a result of the tal technician will further weaken the crowns. The absence
machining procedure, since the restorations were not handled of these factors can explain the high loads at fracture in this
further by hand after the milling before the margin inspections experiment.
were performed [27]. There are obvious differences in the two The method used for fracturing crowns in this study has
processes for soft-machining and hard machining. It has been previously demonstrated to create clinically relevant fracture
expected that the hard machining procedure results in more modes [31]. Fracture analysis showed that all the 41 fractured
machining damage [28], but our results suggest that this is not in this study started cervically similar to the mode observed
the case. in clinically failed zirconia crowns [32,33]. Fracture initiation
The finding that the magnesia-stabilized hard-machined at a defect is expected as predicted by fractography theory
zirconia crowns had more flaws at the margins than the [34,35]. Other fracture modes have been observed in clinical
yttria-stabilized ones, may be a result of a larger grain size all-ceramic crown failures as well, such as inner radial cracks
of the magnesia-stabilized zirconia, between 30 and 40 m, starting from the intaglio surface [36,37] and surface chipping
compared to the conventional Y-TZP with a grain size of [38,39]. The present study addressed the margin initiated fail-
approximately 0,20,5 m [29]. ure modes as observed in multiple zirconia-based crowns [31].
Please cite this article in press as: Schriwer C, et al. Monolithic zirconia dental crowns. Internal fit, margin quality, fracture mode and load at
fracture. Dent Mater (2017), http://dx.doi.org/10.1016/j.dental.2017.06.009
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Fig. 7 The fracture origin of this hard machined magnesia stabilized crown Denzir Mg-PSZ(DM) was in the proximal
region, but no obvious flaws could be detected. The grinding marks form the processing are, however, very distinct and
have probably functioned as stress concentrators. The very tortuous fracture surface is due to the large grain structure.
Explanations of the symbols see Fig. 6.
4.1. Clinical significance at higher loads than considered clinical relevant, suggests
that monolithic zirconia crowns can withstand even excessive
Both technical and biological complications can make it nec- mastication forces. The finding that 19 crowns did not fracture
essary to replace a dental crown [15]. Strong and well-fitting further supports this.
restoration are needed to reduce failures and subsequent Based on the current findings more emphasis should be
replacement. Each replacement increases the risk of adverse made on developing manufacturing techniques for dental zir-
effects, pulpal complications, and eventually tooth loss. conia that limit processing damages in the crown margins.
Increased longevity of dental restorations will reduce cost, The correlation between the severity of the margin defects
time and risk for both patients and health care providers and the load at fracture indicates that efforts should be made
and patient satisfaction. The finding that all crowns fractured
Please cite this article in press as: Schriwer C, et al. Monolithic zirconia dental crowns. Internal fit, margin quality, fracture mode and load at
fracture. Dent Mater (2017), http://dx.doi.org/10.1016/j.dental.2017.06.009
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Fig. 8 Microstructure of the fractured surfaces imaged by SEM showing the different materials; (A) BruxZir, (B) Dental
Direkt, (C) ZirkonZahn, (D) NobelProcera, (E) Denzir Y-TZP, and (F) Denzir Mg-PSZ.
to minimize both number and size of margin defects in order [4] Heffernan MJ, Aquilino SA, Diaz-Arnold AM, Haselton DR,
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fracture. Dent Mater (2017), http://dx.doi.org/10.1016/j.dental.2017.06.009
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Please cite this article in press as: Schriwer C, et al. Monolithic zirconia dental crowns. Internal fit, margin quality, fracture mode and load at
fracture. Dent Mater (2017), http://dx.doi.org/10.1016/j.dental.2017.06.009