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Zirconia in Dentistry: ss e n c e
fo r

Part 2. Evidence-based
Clinical Breakthrough
Spiridon Oumvertos Koutayas, Dr Med Dent, DDS, CDT
Senior Lecturer, Department of Prosthodontics, School of Dentistry,
Albert-Ludwigs University, Freiburg, Germany
Private practice, Corfu, Greece

Thaleia Vagkopoulou, DDS


Postgraduate Student, Department of Prosthodontics, School of Dentistry,
Albert-Ludwigs University, Freiburg, Germany

Stavros Pelekanos, Dr med dent, DDS


Assistant Professor, Department of Prosthodontics, School of Dentistry,
National and Kapodistrian University, Athens, Greece

Petros Koidis, DDS, MSc, PhD


Professor and Chairman, Department of Fixed Prosthesis and Implant Prosthodontics,
School of Dentistry, Aristotle University, Thessaloniki, Greece

Jörg Rudolf Strub, Dr Med Dent, DDS, PhD


Professor and Chairman, Department of Prosthodontics, School of Dentistry,
Albert-Ludwigs University, Freiburg, Germany

Correspondence to: Dr Spiros Koutayas


Zafiropoulou Str. 29, 49100, Corfu, Greece; Tel: +30-26610-45747; Fax: +30-26610-82228; E-mail: koutayas@otenet.gr

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Abstract ss e n c e fo r
An ideal all-ceramic restoration that con- aided manufacturing (CAM) systems, high-
forms well and demonstrates enhanced strength zirconia frameworks can be vi-
biocompatibility, strength, fit, and esthet- able for the fabrication of full and partial
ics has always been desirable in clinical coverage crowns, fixed partial dentures,
dentistry. However, the inherent brittle- veneers, posts and/or cores, primary
ness, low flexural strength, and fracture double crowns, implant abutments, and
toughness of conventional glass and alu- implants. Data from laboratory and clini-
mina ceramics have been the main ob- cal studies are promising regarding their
stacles for extensive use. The recent intro- performance and survival. However, clin-
duction of zirconia-based ceramics as a ical data are considered insufficient and
restorative dental material has generated the identified premature complications
considerable interest in the dental com- should guide future research. In addition,
munity, which has been expressed with different zirconia-based dental auxiliary
extensive industrial, clinical, and research components (ie, cutting burs and surgical
activity. Contemporary zirconia powder drills, extra-coronal attachments and or-
technology contributes to the fabrication of thodontic brackets) can also be techno-
new biocompatible all-ceramic restora- logically feasible. This review aims to
tions with improved physical properties for present and discuss zirconia manufactur-
a wide range of promising clinical applica- ing methods and their potential for suc-
tions. Especially with the development of cessful clinical application in dentistry.
computer-aided design (CAD)/computer- (Eur J Esthet Dent 2009;4:348–380.)

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Introduction Nowadays, zirconia technology has ss e n c e
fo r
into step with computer-aided design/com-
The growing belief that metal-free dentistry puter-aided manufacturing (CAD/CAM)
will alter the traditional restorative spectrum systems that promise to transform every-
had always been stymied by the inherent day dentistry.8 The three-dimensional de-
brittle nature of dental ceramics. Therefore, sign of Y-TZP frameworks requires a com-
researchers and manufacturers have de- puter and special software (CAD) provided
veloped advanced formulas to prevent by the manufacturer. After a scanning pro-
crack propagation mainly by using yttrium- cedure of the designed work, data are
tetragonal zirconia polycrystals (Y-TZP), transferred to a computerized manufactur-
commonly known as zirconia.1-3 The advent ing unit (CAM) that performs a preset pro-
of zirconia ceramics, in conjunction with duction of the zirconia framework.9 Zirco-
computer technology, has led both dental nia-based frameworks are produced either
science and industry to experience their by milling out from a solid block (subtrac-
own “dream.” The interpretation of this spe- tive technique),10 predominantly for Y-TZP
cific “zirconia dream” could be defined as ceramics, or by using electrophoretic dep-
“the general clinical application of a highly osition (additive technique) particularly for
biocompatible zirconia ceramic material cerium-tetragonal polycrystal (Ce-TZP) ce-
that is resistant on a long-term basis to all ramics.11 Milling of zirconia blocks can be
thermal, chemical, and mechanical im- performed in the partially12 or fully sintered
pacts of the oral environment in a wide stage10 using appropriate cutting diamonds
range of dental restorations.” Over the last under water coolant if needed. The major-
decade, the dental community has been a ity of CAD/CAM systems utilize partially
witness to an industrial “big bang” regard- sintered Y-TZP ceramics, where the milling
ing zirconia processing for different appli- procedure is performed with the use of car-
4,5
cations in dentistry. The latter develop- bide burs in a dry environment. Through-
ments were characterized by a global out the designing stage, the size of a
promotion that created great expectations, prospective milled, partially sintered frame-
but on the other hand, the new technology work is analogically enlarged approximate-
seems to need a certain amount of time to ly 20% and 25% in comparison with the
be fully adapted by dentists and dental original dimensions, due to the shrinkage
technicians. The dental profession is aware occurring after the final sintering.13 More-
of the limited clinical data regarding over, milling of fully sintered or hot isostat-
strength resistance under fatigue, bonding ically pressed (HIP) zirconia blocks is time-
effectiveness, color performance, and consuming due to the increased hardness
longevity of the zirconia-based restora- of the material, but it does not exhibit any
tions.6 Nevertheless, dreaming may let us dimensional changes (ie, shrinkage). Pro-
glimpse the future, or even better accord- cessing of partially sintered Y-TZP ceram-
ing to the “expectation fulfillment theory,”7 it ics at room temperature presents limited
could realistically complete patterns of surface or in-depth damage (ie, voids,
emotional expectation that encourage re- flaws, cracks),14 in contrast with hard ma-
search and clinical trials concerning this chining of fully sintered (or HIP) that might
evolving biomaterial. induce microcracks.15 Nevertheless, sur-

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Table 1 Current CAD/CAM systems for Y-TZP zirconia processing (in alphabeti-
ss e n c e fo r
cal order).

System Company Website

®
Cad.esthetics Cad.esthetics (Skelleftea, SE) http://www.cadesthetics.com

Cynovad Neo™ Cynovad (Saint-laurent, CD) http://www.cynovad.com

CentraDent CentraDent (Haarlem, NL) http://www.centradent.nl

Ceramill Multi-x Amann Girrbach (Koblach, AU) http://www.amanngirrbach.com


®
Cercon DeguDent (Hanau, DE) http://www.degudent.de
®
ce.novation Inocermic (Hermsdorf, DE) http://www.cenovation.de
®
inLab MC XL Sirona Dental Systems (Bensheim, DE) http://www.sirona.com
®
Cyrtina Oratio (Zwaag, NL) http://www.oratio.nl

DentaCAD Hint-ELs (Griesheim, DE) http://www.hintel.de

Diadem Alkom Digital (Luxembourg, LU) http://www.alkom-digital.com


®
Digident Digident (Pforzheim, DE) http://www.digident-gmbh.com

Etkon™ Etkon (Graefelfing, DE) http://www.etkon.de

Everest KaVo (Leutkirch, DE) http://www.kavo-everest.de

GN-1 GC Corporation (Tokyo, JP) http://www.gcdental.co.jp/english/index.html

infiniDent Sirona Dental Systems (Bensheim, DE) http://www.infinident.de

Katana Noritake Dental Supply (Aichi, JP) http://www.noritake-dental.co.jp

Lava™ 3M ESPE (Seefeld, US/DE) http://cms.3m.com/cms/de/de/2-21/ufkren/view.jhtml


®
Medifacturing Bego Medical (Bremen, DE) http://www.bego-medical.de
®
MetaNova Metanova Dental (Zug, CH) http://www.metanovadental.com

Precident DCS (Allschwil, CH) -

Nanozr* Panasonic Dental (Osaka, JP) http://www.panasonic.co.jp/psec/dental


®
Procera Nobel Biocare (Göteborg, SE) http://www.nobelbiocare.com

Xawex Xawex (Fällanden, CH) http://www.xawex.com


®
Zirconzahn Zirkonzahn (Gais, JP) http://www.zirkonzahn.com
* Ceria stabilized zirconia/alumina nanocomposite.

face damage produced by CAD/CAM the fabrication of zirconia structures are list-
milling procedures in combination with dif- ed in Table 1.
ferent surface treatment methods (ie, grind- The spectrum of the contemporary clin-
ing) may decrease strength and lead to un- ical applications of zirconia includes the
expected failures.16 In addition, hard and fabrication of veneers, full and partial cov-
high-temperature milling results in near erage crowns or fixed partial dentures
surface damage and defect formation and (FPDs), posts and/or cores, primary dou-
can significantly shorten the anticipated life ble crowns, implants, and implant abut-
17
span of the restoration. All current ments. In addition, different zirconia-based
CAD/CAM systems that offer the option for auxiliary components such as cutting burs

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and surgical drills, extra-coronal attach- tion) and basic clinical not
ss e n c e
fo r
ments, and orthodontic brackets are also differ from other all-ceramic crowns (Fig 1).
available as commercial dental products. Particularly, tooth preparation clinical
The purposes of this review are to address guidelines for zirconia crowns are compa-
current knowledge regarding manufactur- rable to those for metal-ceramic restora-
ing, to highlight the indication spectrum, tions.28,29 Appropriate tooth preparation for
and to discuss clinical advantages/disad- a zirconia crown should provide favorable
vantages and survivability of zirconia ce- distribution of the functional stresses and is
ramic material in dentistry. usually performed with the use of a special-
ly designed diamond set. In general, tooth
preparation for a zirconia restoration re-
Zirconia single-tooth quires 1.5 mm to 2.0 mm incisal or occlusal
reduction and 1.2 mm to 1.5 mm axial re-
restorations
duction. The axial convergence angle of
the crown preparation should be approxi-
Bilayer veneers mately 6 degrees and all dihedral angles
Color management of discolored teeth with should be tapered. The preparation should
conventional feldspathic veneers is a rather end with a uniform 0.8 mm to 1.2 mm slight
complicated and technique-sensitive clini- subgingival (approximately 0.5 mm) deep
18
cal problem. The fabrication of bilayer ve- chamfer or marginal shoulder finishing
neers made from a veneered high-tough- with rounded internal angles. In vitro eval-
ness ceramic core is suggested in order to uation of the preparation design for zirco-
enhance both esthetics and strength.19-21 nia crowns showed significantly higher
The 0.2 mm to 0.4 mm modified core may fracture strength for a circumferential
be fabricated from various high-toughness shoulder preparation than other prepara-
ceramic materials such as zirconia. In pre- tion designs due to smaller axial stress
vious studies regarding densely-sintered concentration. However, for structurally
22,23
alumina and glass-infiltrated alumi- compromised teeth (such as endodonti-
na,24,25 bilayer veneers showed improved cally treated teeth) a slight chamfer prepa-
color performance on discolored teeth. ration was recommended.30 Regardless of
Therefore, it is assumed that, due to the in- coping thickness, the fracture load required
26,27
herent opacity of the zirconia core, the for knife-edge preparations was found to
clinical application of zirconia bilayer ve- be 38% greater than that required for
neers may offer a high-strength veneer chamfer preparations.31 Conversely, imper-
restoration with better masking ability for a fections of chamfer preparation by knife-
given discoloration. No published research edge finishing tales can put the integrity of
data could be found on this topic. the restoration at risk, since they provide a
non-uniform cement layer. Under loading,
Zirconia crowns the tensile stresses developed may exceed
Case selection criteria for zirconia crown the bond strength between the cement and
restorations (ie, limited interocclusal space, the ceramic or tooth, and this, in combina-
para-functional habits, malocclusion, short tion with production flaws or faults, intro-
clinical crowns, tooth mobility, tooth inclina- duced during the cementation process,

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may lead to fracture initiation.32 Increase of ss e n c e fo r
the axial convergence angle from 6 to 20
degrees may decrease the internal space
between the prepared abutment and the
zirconia core.33
Due to the inherent opacity of zirconia,
the abutment should be adequately pre-
pared to allow enough space for both the
substructure and the veneering material.
After milling, a 0.5 mm-thick uniform zirco-
nia core should be fabricated for single
posterior crowns. Particularly in the anteri-
or region, strength and esthetic require-
ments may allow the fabrication of 0.3 mm-
thick copings, however, reduction of the
coping thickness from 0.5 mm to 0.3 mm
can negatively influence the fracture load-
ing capacity (35% decrease) of zirconia
single crowns.31
Most systems can accommodate the
whitish shade of the raw zirconia frame-
work before sintering by a close to the final
shade staining. This shading possibility
may also be useful in cases of limited inte-
rocclusal space where veneering is limited
or omitted.
Zirconium oxide crowns may be ce-
mented using both conventional and ad-
hesive methods (compomers, resin-modi-
fied glass-ionomers and self-adhesive
composite resin cements) that provide
comparable bonding strength with the
composite resin cements.34,35 However, a
strong and durable resin bond provides
high retention, improves marginal adapta-
tion, prevents microleakage, and increases
the fracture resistance of the restored tooth
Fig 1 A total of 12 maxillary single zirconia crowns
and the restoration. Previous knowledge (teeth 16 to 26). Top: full coverage preparation of the
regarding the adhesion of luting agents abutment teeth (palatal aspect). Middle: zirconia frame-
and silica-based ceramics cannot be used works (ZENO Tec®, Wieland, Pforzheim, Germany) in
situ (palatal aspect). Bottom: final clinical situation after
for resin bonding to Y-TZP. Surface pre-
crown adhesive cementation (palatal aspect). Clinical
treatments used for glasses (ie, hydrofluo- and laboratory work performed by Dr S Pelekanos and
ric acid etching, silanization) do not im- Mr V Mavromatis (both Athens, Greece), respectively.

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prove the bonding strength of zirconium
ss e n c e
fo r
ceramics because of the high crystalline
content that cannot be modified by etch-
ing.36 In contrast to grinding, which may
lead to substantial strength degradation,
sandblasting seems to strengthen Y-TZP37
and improve bonding.37-40
It was demonstrated that the applica-
tion of the adhesive phosphate monomer
10-methacryloyloxydecyl dihydrogen phos-
phate (MDP)41 or an MDP-containing bond-
ing/silane coupling agent mixture42 after
airborne- particle abrasion (110 μm Al2O3
at 2.5 bar) and a phosphate-modified resin
cement (eg, PanaviaTM 21, Kuraray, Osaka,
Japan) may provide a long-term durable
resin bond to zirconium oxide ceramic38
with promising high tensile bond strengths
(39.2 MPa).43 Furthermore, it was shown
that the application of a tribochemical sili-
ca coating (eg, CoJetTM, 3M ESPE, Seefeld,
Germany) in combination with an MDP-
containing bonding/silane coupling agent
mixture increased the shear bond strength
between zirconium-oxide ceramic and
phosphate-modified resin cement (Pana-
via F, Kuraray).44 The tribochemical silica
coating process was also tested with zir-
conia silanization (N.B. prefabricated zir-
conia posts), which resulted in an in-
creased bond strength.45 Moreover, a
self-curing dental adhesive system con-
taining 4-META/MMA-TBB (eg, Super-
bond C&B, Sun Medical, Tokyo, Japan)
exhibited high bond strengths regardless
of the different surface treatments such as
silica coating, airborne particle abrasion,
Fig 2 Anterior six-unit zirconia fixed partial denture
restoration (teeth 13 to 23). Top: zirconia framework in
hydrofluoric acid (HF) etching and dia-
situ (palatal aspect). Middle: zirconia framework (ZENO mond grinding.46 It was illustrated that the
Tec, Wieland) after laboratory completion. Bottom: final bond strength of bis-GMA resin cement
clinical situation after adhesive cementation of the
(eg, Variolink® II, Ivoclar Vivadent, Schaan,
restoration (palatal aspect). Clinical and laboratory
work performed by Dr SO Koutayas (Corfu, Greece) Liechtenstein) to the zirconia ceramic can
and Mr E Blachopoulos (Athens, Greece), respectively. be significantly increased after pre-treat-

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ment with plasma spraying (hexamethyld- ss e n c e fo r
isiloxane) or by the use a low-fusing porce-
lain layer.47
Regardless of surface pre-treatments,
long-term in vitro water storage and ther-
mocycling can negatively influence the
durability of the resin bond strength to zir-
conia ceramic.41 Thermocycling induces a
higher impact than water storage at a con-
stant temperature.48 It is essential to avoid
contamination of the zirconia bonding sur-
faces during try-in procedures, either by
saliva contact or by a silicone disclosing
medium. It was found that air abrasion with
50 mm Al2O3 at 2.5 bar for 15 s is the most
effective cleaning method to regain an op-
timal bonding surface.49,50
The clinical application of zirconia
crowns in removable prosthodontics is a
new approach, implemented either as a
crown with guide planes and rest seats51 or
as a primary crown for double crown sys-
tems.52,53 Particularly in double crown sys-
tems, the secondary crowns are preferably
fabricated with galvano-forming technolo-
gy.53 Despite the excellent wear resistance
and biocompatibility of the primary zirconia
crown, the colored zirconia copings are a
solution to the esthetic compromise of mar-
ginal metal exposure.

Zirconia fixed partial


dentures
Based on the exceptional mechanical
properties of zirconia (eg, high flexural
Fig 3 Posterior four-unit zirconia fixed partial denture
strength and fracture resistance),54,55 Y-TZP
restoration (teeth 47 to 44). Top: zirconia framework in
is the most recent framework material for situ (occlusal aspect). Middle: zirconia framework
the fabrication of all-ceramic FPDs either in (ZENO Tec, Wieland) after laboratory completion. Bot-
56-59 tom: final clinical situation after adhesive cementation
anterior (Fig 2) or posterior sites (Fig 3).
of the restoration (occlusal aspect). Clinical and labo-
The load bearing capacity of Y-TZP FPDs ratory work performed by Dr S Pelekanos and Mr V
was found to be significantly higher than Mavromatis (both Athens, Greece).

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Clinical studies on zirconia-based fixed partial dentures (FPDs). t e s
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Table 2
se nc e
fo r
Author Year System Zirconia FPDs Units Duration Fractures (%) Chipping (%)

Anterior Posterior 3 >3 (years) (core) (veneering)


83 Direct ceramic
Sturzenegger 2000 - 21 21 1 1 0.0 0.0
machining
88
Pospiech 2003 Lava™ - 38 38 0 1.5 0.0 2.5
89 ®
Bornemann 2003 Cercon - 59 44 15 1 0.0 4.3
71
von Steyern 2005 Precident 3 17 2 18 2 0.0 15.0
86 Direct ceramic
Sailer 2006 - 57 N.R. N.R. 3 0.0 13.0
machining
87
Raigrodski 2006 Lava™ - 20 20 0 3 0.0 15.0
82 Direct ceramic
Sailer 2007 - 33 5 2.2 15.2
machining
90 ®
Edelhoff 2008 Digident 4 18 14 8 3 0.0 9.5
84
Tinschert 2008 Precident 15 50 44 21 3 0.0 6.1
85 ®
Molin and Karlsson 2008 Cad.esthetics 0 19 19 0 5 0.0 0.0*
91 ®
Roediger 2009 Cercon - 99 N.R. N.R. 4 1.0 13.1
N.R., not referred to; * 30% slightly rough or pitted occlusal surfaces.

other conventional all-ceramic systems, tors.68,69,70 Calculations, based on the fatigue


such as lithium-disilicate glass ceramics parameters, indicate that connector dimen-
and zirconia-reinforced glass-infiltrated sions should be at least 5.7 mm2, 12.6 mm2,
60
alumina, and it has been reported that and 18.8 mm2, for the fabrication of a 3-,
fracture resistance was further increased 4-, or 5-unit FPD, respectively.56 It was rec-
61
after veneering. ommended that the connector size should
Zirconia-based FPDs may exhibit a be larger than 7.3 mm2, especially for the
good long-term prognosis if connectors clinical application a 4-unit posterior Y-TZP
are properly designed and fabricated.62 Fi- FPD.60 In vitro evaluation of Y-TZP FPDs
nite element stress analysis studies on with smaller connectors (3.0 mm x 3.0 mm)
three-unit posterior FPDs showed that also revealed good fracture resistance re-
maximum tensile stresses occur on the sults.71-73 Moreover, a minimum diameter of
gingival site of the connector between the 4.0 mm for all-ceramic zirconia-based
two abutments, and the magnitude signif- FPDs with long spans or replacing molars
icantly depends on the loading conditions, has been recommended.74 Since connec-
63-65
shape, and size of the connector. Fur- tor dimensions and geometry are crucial
thermore, it has been observed that when for the appropriate stability of the restora-
zirconia FPDs are subjected to the peak of tion under functional loading, the designing
tensile stresses, the properties of the felds- features of the framework must be opti-
pathic porcelain, used for veneering of mized in order to reinforce the connector
high-toughness core materials, may con- areas and provide the adequate support to
66,67
trol the failure rate of the restoration. Re- the veneering material (note framework de-
search shows that ultimate strength can be sign in Figs 2 and 3). The marginal fit of
achieved by omitting porcelain veneering most zirconia-based FPDs fabricated with
at the gingival surface of the connec- CAD/CAM technology meets clinical re-

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quirements.61,75,76 However, regardless of the ss e n c e fo r
CAD/CAM system, the marginal adapta-
tion is influenced by framework configura-
tion.76
After fabrication, Y-TZP frameworks are
relatively opaque and white in color;77 there-
fore the compatible feldspathic porcelain
veneering material is essential to achieve
good esthetics. Literature data are rather
contradictory regarding the effect of sur-
face pre-treatment (ie, grinding, sandblast-
ing) on the strength characteristics of Y-TZP
frameworks. Moreover, during the veneer-
ing procedure the frameworks are ex-
posed to high temperatures and moisture,
which may cause a mechanical property
degradation of the restoration.78-81
Short-term clinical data showed that Y-
TZP FPDs have a promising survival time
for anterior as well as posterior regions
(Table 2).71,82-91 However, the available clini-
cal studies (see Table 2), with an observa-
tion period of up to 5 years, disclosed chip-
ping of the veneering material as a major
problem that might occur increasingly over
time (15.2%). The overall fracture rate of the
zirconia frameworks were relatively low (up
to 2.2%).82 Fractographic analyses of re-
trieved zirconia FPDs showed that primary
fractures initiated from the gingival surfaces
of the connectors to the veneering surfaces
while delamination of the ceramic struc-
tures in the veneering/ zirconia core inter-
face was controlled by secondary fracture
initiation sites and failure stresses.92 Im-
plant-supported Y-TZP FPDs have also ex-
hibited an unacceptable amount of veneer-
Fig 4 Anterior cantilevered zirconia resin-bonded
ing chipping either in vitro71 or in vivo.93
FPD (teeth 11 and 21). Top: zirconia framework (ZENO
As an alternative to complete coverage, Tec, Wieland) in situ (occlusal aspect). Middle: zirconia
partial-coverage resin-bonded zirconia RB-FPD after veneering. Bottom: final clinical situation
after adhesive cementation of the restoration (occlusal
FPDs (RB-Z-FPDs) were introduced as
aspect). Clinical and laboratory work performed by Dr
less invasive treatment options for both the SO Koutayas (Corfu, Greece) and Mr E Blachopoulos
anterior and the posterior regions. The par- (Athens, Greece), respectively.

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nTable 3 Overview of current zirconia implants.


Q ui
1995 1998 2001 2005 2005 2006
Manufacturer Gebr. Brasseler Ivoclar Vivadent Cendres+Métaux atec Dental Incermed Nordin Dental
http://www.kometde http://www.ivoclarviv http://www.nordi
Website http://www.cmsa.ch http://www.atec-dental.de http://www.incermed.ch
ntal.de adent.com n-dental.com
® ®
Name CeraPost CosmoPost CM Endofix Endoseal/WSR Biopost Biosnap Zirix
Material ZrO2 ZrO2 ZrO2 ZrO2 ZrO2 ZrO2 ZrO2 ZrO2
opaque/ opaque/ opaque/ opaque/ opaque/ opaque/ opaque/ opaque/
Color
whitish whitish whitish whitish whitish whitish whitish whitish
cylindrical cylindrical cylindrical cylindrical cylindrical cylindrical
Type conical conical
/conical /conical /tipped /conical /conical /conical
Surface smooth/ smooth/reten smooth/
smooth smooth smooth smooth smooth
CLINICAL RESEARCH

(micro/macro) screwed t. slot screwed

THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY


1.3, 1.5, 1.7, 1.1, 1.3, 1.4, 1.10, 1.25,
Diameter (mm) 0.5, 0.9, 1.1 1.4, 1.7 1.4, 1.7 1.3, 1.5 1.5, 1.6, 1.7
1.9 1.5, 1.6, 1.7 1.35, 1.50
25 to be
Length (mm) 12 20 17, 20.5 20 6 11, 14 11
measured

VOLUME 4 • NUMBER 4 • WINTER 2009


direct / indirect direct / indirect transfixation seal after direct ball attachment direct
Remarks direct restoration
restoration restoration screw-post apicoectomy restoration Ø (mm): 2.5–3.0 restoration

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tial coverage retainers of these restorations zirconium dioxide (ZrO2) prefabricated
ss e n c e
fo r
can be single (or, rarely, double) palatal ve- posts,107,108 a unique esthetic approach has
neer retainers (wings),94 partial crowns, in- been developed in combination with all-ce-
95
lays, or onlays. It has been demonstrated ramic crowns. Dentin-like shade all-ceram-
that aluminum oxide anterior cantilever ic posts and cores contribute to a deeper
resin-bonded fixed partial dentures with diffusion of light and therefore provide an
specific design features of the connectors, appropriate depth of translucency.109,110
can successfully withstand physiological Contemporary zirconia powder technol-
incisive forces for five years both in vitro96 ogy contributes to the fabrication of new
and in vivo.97,98 If the fact that the zirconia biocompatible and esthetic endodontic
connector exhibits improved strength is posts with improved flexural strength (ap-
taken into consideration, it is assumed that proximately 820 MPa) and fracture tough-
RB-Z-FPDs have the potential to produce ness (approximately 8 MPa*m1/2). As an
better clinical performance than the alu- additional indication, zirconia endodontic
minum oxide ones (Fig 4). endosseous cones seem to be acceptable
Regarding inlay-retained zirconia FPDs for sealing purposes in resected teeth af-
(IR-Z-FPDs), compressive mechanical ter apicectomy.111 Current commercially
99–101
testing showed high fracture resistance. available zirconia post systems are listed in
Considering the maximum chewing forces Table 3.
in the molar region, it was proposed that The placement of a prefabricated post
the connector size should be between (ie, zirconia post) is usually unnecessary
9 mm2 and 16 mm2.101 In order to improve for intact endodontically treated teeth (with-
strength performance of IR-Z-FPDs, clini- out proximal cavities), where only the ac-
cal trials indicated new preparation and cess opening should be sealed with hybrid
framework designs with the following composite.112 The clinical application of zir-
main features: a) 1-mm shallow occlusal conia posts in teeth with small tooth struc-
inlay, b) 0.6-mm oral retainer wing, and c) ture defects can be exercised, in conjunc-
101
non-veneered retainer. Conversely to tion with hybrid composites or special
RB-Z-FPDs, long-term clinical studies on built-up composites, according to the con-
IR-Z-FPDs are needed before their exten- cepts of contemporary adhesive den-
sive clinical application. tistry.113 If adequate sound coronal tooth
structure is present, all-ceramic posts and
cores also can be viable following two
Zirconia posts fabrication techniques: direct or indirect
application.96,114 According to the two-piece
A metal post and core system restricts light technique, a ceramic core (ie, zirconia
transmission and thus gives an undesir- core) formerly fabricated with the use of a
able dark shadow in the root and cervical copy-milling machine (ie, Celay system,
areas, especially through thin periodontal Mikrona, Spreitenbach, Switzerland) or to-
102
tissues and significantly decreases the day using CAD/CAM technology, is placed
value of the coronal part of the restora- onto the prepared tooth, and then a pre-
103
tion. With the introduction of custom- fabricated ZrO2 post (eg, CeraPost, Gebr.
made all-ceramic posts and cores104-106 or Brasseler, Lemgo, Germany) is adhesively

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Fig 5 Single crown
ss e n c e
fo r
tion of a maxillary left endodoti-
cally treated lateral incisor (tooth
12) with the use of an all-zirco-
nia post and core (Courtesy Prof
RJ Kohal, Freiburg, Germany):
a) initial situation after endo-
dontic treatment (labial aspect),
b) prefabricated zirconia post
(CeraPost, Gebr. Brasseler) with
core analogue model, c) two-
piece all-zirconia post and core
a b c after copy-milling (Celay sys-
tem, Mikrona) of a Y-TZP core
(BCE, Mannheim, Germany), d)
bonding of the post and core
restoration using an adhesive
resin (Panavia 21, Kuraray), e)
completion of the tooth prepa-
ration, f) final clinical situation
after crown placement (Em-
press, Ivoclar Vivadent). Labo-
ratory work performed by Mr F
Ferraresso (Saluzzo, Italy) and
Dr SO Koutayas (Corfu, Greece).

d e f

cemented into the root canal through the ical evaluation of zirconia posts and/or
canal of the core (Fig 5). Moreover, ac- cores were promising.121,122 A 4-year retro-
cording to the heat-pressing technique, a spective study showed that single crown
glass-ceramic core (EmpressCosmo, Ivo- restorations using prefabricated ZrO2 posts
clar Vivadent) is heat-pressed over a pre- with indirect glass-ceramic cores displayed
fabricated ZrO2 post (eg, CosmoPost, Ivo- a significantly higher failure rate than using
clar Vivadent), so that both materials are the same posts with direct composite build-
integrated to a unified and solid post-and- ups.123
core-restoration. The clinical application of zirconia posts
After placement of the zirconia posts is an almost irreversible procedure since
and cores for the pre-prosthetic manage- their removal is extremely difficult.114 Es-
ment of the remaining abutment tooth sentials for achieving clinical longevity are
structure, anterior endodontically treated tooth preservation during root canal
teeth may be successfully restored with preparation and maintenance of both the
single all-ceramic crowns and withstand appropriate ferrule effect (minimum 2 mm
functional incisive forces.115-118 Additional in height)124,125 and the periphery of the root
in vitro testing identified the incidence of canal dentin (minimum 1 mm in width).125
root fractures,119,120 however, short-term clin- Zirconia posts display a higher modulus of

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elasticity (200 MPa) than natural dentin ss e n c e fo r
(16.5 to 18.5 MPa); in the absence of the
ferrule effect, catastrophic stresses can be
transferred to the root.119,120,126 Adhesive ce-
mentation of such rigid posts might also
present interfacial defects within the built-
up composite or the dentin.127 Due to the
above-mentioned limitations, a systematic
review concerning the biomechanics of
endodontically restored teeth suggested
the use of post-and-core materials with
physical properties close to those of natu-
ral dentin.128,129

Zirconia implants
Titanium release after implant place-
ment130,131 intensified the discussion regard-
ing sensitization or allergies,132,133 which sub-
sequently stimulated holistic approaches
that embrace metal-free implant dentistry.
However, the main practical disadvantage
of titanium implants is the management of
the grayish appearance through thin peri-
implant mucosa. All of the above have ori-
ented dental research and propelled the
clinical application of implants made from
different novel ceramic biomaterials such
as single- and polycrystal alumina,134 bio-
active glasses,135 hydroxidapatite,136 and
zirconia (Fig 6).137-139 Furthermore, zirconi-
um oxide coatings (approximately 100 nm)
of Ti-6AI-4V,140 or titanium141 orthopedic im-
plants, usually after the application of
macro-texturing methods,142 may promote
bone growth and thus provide evidence of
enhanced implant osseointegration. Fig 6 Zirconia implant supported zirconia crown
Y-TZP is currently considered an attrac- (tooth 12) (Courtesy Prof RJ Kohal, Freiburg, Germany).
tive and advantageous endosseous den- Top: zirconia implant placement after tooth extraction.
Middle: 4 months later; placement of retraction cord pri-
tal implant material because it presents
or to impression. Bottom: after final cementation of zir-
enhanced biocompatibility, improved me- conia crown (Procera, Nobel Biocare). Laboratory work
chanical properties, high radiopacity, and performed by Mr W Woerner (Freiburg, Germany).

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easy handling during abutment prepara- plants.161 Furthermore, it was proposedss e n c e
fo r
143,144
tion. Zirconia ceramic is well-tolerated one-piece zirconia implants restored with
by bone and soft tissues and possesses densely sintered alumina crowns (Pro-
145
mechanical stability. Since the difference cera®, Nobel Biocare, Göteborg, Sweden)
in bone-to-implant attachment strength could possibly fulfil the biomechanical re-
between bio-inert ceramics and stainless quirements for anterior tooth replacement.
steel was not significant, it was indicated Regarding the impact of the design (one
that the affinity of bone to bio-inert ceram- or two pieces) on the biomechanical be-
ics has almost the same capacity as met- havior of Y-TZP implants using chewing
146
al alloys. simulation testing conditions, a prototype
In vitro culture tests were performed to two-piece zirconia implant revealed low
verify biocompatibility, genetic effects, and fracture resistance at the level of the im-
osteoblast interactions of potential zirconia plant head and therefore questionable
implant substrates. Recently, a series of clinical performance,162 while one-piece
well-reviewed studies147 showed no ad- zirconia implants seem to be clinically ap-
148,149 150,151
verse response, surface-specific plicable.163 Moreover, it was illustrated that
and non-surface-specific149 proliferation, preparation of the one-piece zirconia im-
attachment and spreading of osteoblasts, plant in order to accept a crown had a sta-
and no genetic effect of zirconia on bone tistically significant negative influence on
152-154
formation. the implant fracture strength.163
Animal studies that focused on zirconia To date, there are five commercially
implants without loading demonstrated available zirconia implant systems on the
comparable qualitative and quantitative market (listed in Table 4). Only one system
characteristics to that of the titanium im- (Sigma, Incermed, Lausanne, Switzerland)
plants in biocompatibility and osteoinduc- provides both one- and two-piece designs
tivity. 155-158
In vivo studies proved that micro- while all the other (CeraRoot, CeraRoot
modification of Y-TPZ implants, resulting in Dental Implants, Barcelona, Spain; Z-
a roughened surface, was beneficial for Look3, Z-Systems, Constance, Germany;
initial bone healing, bone apposition, and whiteSKY, Bredent Medical, Senden, Ger-
158,159
interfacial shear strength. Additional many, and zit-z, Ziterion, Uffenheim, Ger-
animal studies confirmed that Y-TZP and Ti many) are available in a one-piece de-
implants can be successfully osseointe- sign. Furthermore, a recent clinical trial
grated under loading conditions, however, described a type of customized zirconia
one research group noted a relatively high root-analogue implant with a micro- and
marginal bone loss160 while a second macro-retentive implant surface, however,
group reported similar soft tissue peri-im- neither the zirconia material nor the milling
plant height.138 device were specified.164
Different in vitro studies were per- Despite some promising preliminary
formed to define the feasibility of zirconia clinical results, no clinical long-term data
implant systems. A finite element assess- are available concerning zirconia implants.
ment of the loading resistance revealed Survival rates after one year were reported
non-distractive and well-distributed stress at 93% (189 one-piece implants, Z-Sys-
patterns, similar to those of titanium im- tems),165 98% (66 one-piece implants, Z-

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Systems),137 and 100% (one-piece im- mina) were first introduced as an esthetic
ss e n c e
fo r
plants, CeraRoot).166 Furthermore, a recent- alternative to titanium ones in the mid-
ly published review noted that in an ongo- 1990s.174-176 The alumina abutments pre-
ing clinical study, TZP-A (ZrO2/Y2O3/ sented pleasing optical properties,177 ade-
Al2O3) experimental implants (n = 119) with quate fracture strength for the anterior
an especially roughened surface present- regions,178 and an excellent 5-year progno-
ed a survival rate of 96.6% after a 1-year sis.179 However, implant manufacturers
147
observation period. Finally, the only sys- have turned their production to abutments
tematic review that explored the osseoin- made from zirconia (Fig 7).169 Besides
tegration and the clinical success of zirco- strength considerations, Y-TZP implant
nia dental implants confirmed that Y-TZP abutments offer enhanced biocompati-
implants can be osseointegrated to the bility,1 metal-like radiopacity for better ra-
same extent as titanium ones. Neverthe- diographic evaluation,180 and, ultimately,
less, clinical and laboratory research data reduced bacterial adhesion,181 plaque ac-
were scarce on safe recommendations for cumulation,182 and inflammation risk.183
a widespread clinical application of Y-TZP Moreover, Y-TZP abutments may promote
implants.167 soft tissue integration,184 while favorable
peri-implant soft tissues may be clinically
achieved adjacent to zirconia185 or alumi-
Zirconia implant na-zirconia abutments186 and zirconia
healing caps.187 A systematic review re-
abutments
vealed that zirconia abutments could
In modern implant dentistry, high survival maintain an equivalent bone level in com-
rates for implants and implant-supported parison to titanium, gold, and aluminum
single crowns can be expected.168 Con- oxide ones.188 In vitro examination of the
cerning the esthetic outcome, convention- cellular attachment, spreading and prolif-
al metal (titanium) abutments do shimmer, eration of human gingival fibroblasts to
especially through all-ceramic crowns with milled and polished non-veneered ceram-
increased semi-translucency and, subse- ic surfaces showed significant differences
quently, through thin peri-implant mucosa, associated with the various surface modi-
resulting in a grayish appearance of the fications, requiring further investigation and
169
entire restoration. Thin periodontal bio- documentation for clinical extrapolation.189
types cannot mask this negative effect, nor Y-TZP abutments are available in two
guarantee a long-lasting architectural sta- types: prefabricated and custom-made.
bility of the peri-implant tissue.170-172 These Prefabricated zirconia abutments are a re-
esthetic problems, or the possible expo- liable and practical solution, but CAD/
sure of the underlying metal abutment CAM technology is also beneficial in de-
which may be visually perceivable, can be signing fully individualized zirconia abut-
accommodated by the clinical application ments for ideal soft-tissue integration and
147,173
of all-ceramic abutments. esthetics. Both types of abutments give
All-ceramic implant abutments made the opportunity for further customization
from aluminum oxide ceramic material either by extra-oral or intra-oral prepara-
(glass infiltrated or densely sintered alu- tion using special water-cooled cutting di-

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amonds indicated by the manufacturer.
ss e n c e
fo r
Representative prefabricated and custom-
made Y-TZP abutments are shown in
Table 5. According to the knowledge of the
authors, additional Y-TZP implant abut-
ments are also commercially available
from the following companies: Thommen
Medical (SPI® ART abutment), Camlog
(Esthomic ceramic abutment), Zimmer
Dental (Contour ceramic abutment), Den-
taurum Tiolox Implants (Tiolox® Premium),
Wieland Dental Implants (wi.tal ceramic
abutment), Sybron Implant Solutions
(CAD/CAM-base post), Cad.esthetics
(Denzir implant post).
Concerning abutment custom prepara-
tion, cutting efficiency and finishing by dif-
ferent diamond types were explored and
the achieved effects were specified for cer-
tain kinds of abutments, indicating that
achieving the best finish lines and surfaces
may require the use of specific cutting in-
struments and protocols.144 Most manufac-
tures recommend either a pronounced
chamfer or a shoulder preparation with
rounded inner line angles. Moreover, sub-
gingival margins should not be overex-
tended beyond the point that removal of
permanent cement presents difficulties
and, generally, the emergence profile
should be rather concave and must follow
known diagnostic regimens.173 Recently, it
was shown that adhesively luted single im-
plant anterior crowns to zirconia abut-
Fig 7 Single implant all-ceramic crown restoration ments with a 0.5 mm to 0.9 mm deep cir-
(VITA®
In-Ceram SPINELL, Vident, Brea, CA, USA) with cumferential chamfer preparation have the
the use of a zirconia prefabricated abutment (Cercon® potential to successfully serve for more
for XiVE, Dentsply Friadent, Mannheim, Germany) of an
than five years of simulated fatigue.190 Mar-
upper right lateral incisor (tooth 12). Top: abutment con-
nection (labial aspect). Middle: zirconia abutment after ginal adaptation of zirconia abutments can
laboratory modification and Ti screw. Bottom: final clin- be achieved either by the abutment itself or
ical situation after crown adhesive cementation (labial
by a titanium integrated post and an oc-
aspect). Clinical and laboratory work performed by Dr
SO Koutayas (Corfu, Greece) and Dr D Charisis
clusal screw.191 In vitro fit evaluation of in-
(Athens, Greece), respectively. ternal or external hexagon CAD/CAM cus-

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Table 4 Overview of current zirconia implants.
2002 2004 2004 2007 2006

Manufacturer Incermed Z-Systems CeraRoot Bredent Ziterion


http://www.bredent- http://www.ziterio
Website http://www.incermed.ch http://www.z-systems.biz http://www.ceraroot.com
medical.com n.com
Name Sigma Z-Look3 CeraRoot whiteSKY zit-z

bivalent
polyvalent 11 21 12 14 16
millenium

Material HIP ZrO2/TZP HIP ZrO2/TZP HIP ZrO2/TZP HIP ZrO2/TZP HIP ZrO2/TZP

Color whitish whitish whitish whitish whitish

Type two-piece design one-piece design one-piece design one-piece design one-piece design one-piece design

4.8/6.0/6.5 4.1/4.8/6.0 4.1 3.5/4.8/5.8 4.8/6.5/8.0


Diameter (mm) 3.4, 3.7, 4.28 3.4 3.7 4.28 3.5, 4.0, 5.0 3.5, 4.0, 4.5

14.5, 10.0, 12.0, 10.0, 12.0, 10.0, 10.0, 12.0, 10.0, 12.0,
13.7, 14.0, 14.0 14.0 12.0, 14.0 14.0
Length (mm) 11.6, 14.4 16.7, 10.0, 11.5, 13.0 10.0, 12.0, 14.0,
16.5 16.8 14.0
18.5
abutment height 2.98– narrow neck D3.6N
transgingival
transgingival 3.28 mm reduced shoulder D4.0R
Remarks root form, scalloped shoulder height: 1.5, 2.5
height: 1.52 mm transgingival height: 0.93 ball attachment D 4.0/Ø
mm
mm 2.9

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tom abutments met clinical requirements192 ent acceptable bond strengths using ss e n c e
fo r
and hexagonal external connections cured adhesives, however, the location of
showed less than three degrees of rota- bond failure is detected at the bracket/ad-
193
tional freedom. Screw joint designs as hesive interface.202,203 Shear-strength forces
shown in previous studies194,195 or loosen- at failure were also found within clinical ac-
ing implications due to a poor fit at the ceptance and significantly higher than
implant/abutment interface should be those of metal brackets.204 Conversely, Y-
avoided through appropriate laboratory TZP orthodontic brackets, in comparison
processing.196 Generally, Y-TZP implant with the metal ones, may exhibit reduced
abutments revealed three-times higher efficiency regarding tooth movement,205,206
fracture strength than abutments made out enamel damage due to high debonding
of aluminum oxide ceramic. 197
In vitro test- rate,207 severe enamel wear to the oppos-
ing of CAD/CAM-processed, implant-sup- ing dentition,208 and an off-white, highly
ported single crowns by either prefabricat- opaque appearance.202
ed178,198,199 or customized81 Y-TZP abutments
showed that they can resist physiologic in- Precision attachments
cisive forces. Finally the results of the lab- The clinical application of prefabricated zir-
oratory studies performed in a mastication conia attachments is based on the wear
simulator178,198,199 were confirmed by clinical and strength characteristics of the materi-
studies that reported cumulative survival al. However, there is no literature available
rates of 100% after 6 years of clinical serv- regarding either clinical performance or
ice. However, due to the limited number effectiveness. Two different types of Y-TZP
and the moderate observation time of the attachments are currently on the market: a
existing clinical studies, further long-term ball attachment for overdentures as a part
evaluation is necessary.167,188 of a zirconia post (Biosnap, Incermed)
available in three diameters for three lev-
els of retention (Table 3) and an extracoro-
Zirconia dental auxiliary nal, cylindrical, or ball attachment for re-
movable partial dentures (Proxisnap,
components
Incermed).

Orthodontic brackets Cutting and surgical instruments


Currently available ceramic polycrystalline Newly developed zirconia cutting instru-
zirconia brackets offer some advantages ments (ie, drills, burs) can be used in im-
over traditional ones. Y-TZP orthodontic plantology, maxillofacial surgery, operative
brackets provide enhanced strength, su- dentistry, and soft tissue trimming (eg, Cer-
perior resistance to deformation and wear, aDrillTM CeraBurTM K1SM CeraBurTM Cer-
reduced plaque adhesion, and improved atip, respectively, all Gebr. Brasseler).
esthetics. In addition they exhibit good slid- These instruments offer optimal cutting ef-
ing properties with both stainless steel and ficiency with smooth operation and re-
nickel-titanium arch wires and the same duced vibration while their proven resist-
frictional characteristics as polycrystalline ance to chemical corrosion promises a
alumina brackets.200,201 Clinically, they pres- long-lasting performance. Finally, surgical

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Table 5 Overview of prefabricated and customized Y-TZP implant abutments.
2001 2005 2002 2001 2001 2007 2002 2005 2003

Dentsply Dentsply
Manufacturer Nobel Biocare Straumann Biomet 3i Bego Astra Tech Astra Tech
Friadent Friadent
http://www.friad http://www.friad http://www.straum http://www.b http://www.astrat http://www.atlantis
Website http://www.nobelbiocare.com http://www.biomet3i.com
ent.de ent.de ann.com ego.com echdental.com comp.com
® ®
® Procera™ Procera™ RN synOcta ® BeCe
Cercon Friadent external hex Certain
Name ® abutment abutment zirconia custom abutment ® sub-tec ZirDesign™ Atlantis™
balance Cercon ZiReal post ZiReal post
zirconia for other implants (cares) ceramic
Y-TZP Y-TZP Y-TZP
Material Y-TZP Y-TZP Y-TZP Y-TZP Y-TZP Y-TZP
Ti seating post Ti seating post Ti seating ring or post
Color whitish whitish, dentin whitish whitish whitish whitish whitish whitish whitish

internal hex internal internal cone internal cone internal hex or


internal cone internal hex external hex internal hex Ti ® external hex
Connection (synOcta 1.5) hex au- & hex & & hex & external hex &
Ti screw Ti screw Ti screw screw au-screw
Ti screw screw Ti screw Ti screw system screw
all NobelReplace™ NanoTite™ NanoTite™ Bego S internal hex
®
Implant Ankylos XiVE Brånemark NP/RP/WP Straumann Osseotite Osseotite 3.25–5.5 OsseoSpeed™ implant (**)
® ®
diameter (mm) 5.5, 7.0 3.8, 4.5 NP/RP/WP Straumann RN 4.8, RN 4.8 NT , pw, xp Certain Bego RI 3.5/4.0, 4.5/5.0 external hex
(*) camlog 3.3 to 6.0 4.1, 5.0 4.1, 5.0 3.75–5.5 implant (***)
1.5, 3.0 1.5, 3.0
Gingival height 1.0, 2.0 customized customized 4.0 customized
scalloped scalloped
straight (0º), straight (0º), straight (0º) straight (0º),
Inclination customized customized straight (0º) customized
angled (15º) angled (15º) angled (17º) angled (20º)
customized customized
Type prefabricated prefabricated customized (Procera™ 3-D CAD) prefabricated prefabricated prefabricated
(Sirona inlab) (Atlantis™ VAD)

(*) Lifecore Biomed:. Restore 3.75, Zimmer Dental: Taperlock 4.0, Sterngold: Implamed 3.75, Biomet 3i: 3.75.
(**) Astra Tech: OsseoSpeed™ 3.5/4.0, 4.5/5.0 – BioHorizons: Internal 3.5, 4.5, 5.7 - Biomet 3i: Certain™ MicroMiniplant™ 3.25/3.4, Certain™ 3.75/4.0, 5.0, 6.0, XP 4/5, XP 5/6 - No-
bel Biocare: NobelReplace™ NP (3.5), RP (4.3), WP (5.0, 6.0) – Straumann: Standard/Standard Plus Implant RN (Regular Neck) 4.8 - Zimmer Dental: Tapered Screw-Vent™ 3.5,
4.5, 5.7, Screw-Vent™ 3.5, 4.5, SwissPlus™ 4.8.
(***) BioHorizons: External 3.5, 4.0, 5.0 - Biomet 3i: MicroMiniplant™ 3.25/3.4, Miniplant™ 4.1/3.25, Standard 3.75, 4.0, Wide 5.0, 6.0, XP 3/4, 4/5, 5/6 - Sybron Implant Solutions: In-
nova Endopore 3.5, 4.1, 5.0, Innova Entegra 3.5, 4.1, 5.0 - Lifecore Biomed: Small 3.3, 3.4, Regular 3.75, 4.0, Wide 5.0, 5.5, 6.0 - Nobel Biocare: Brånemark System™ NP (3.3), RP
(3.75, 4.0), WP (5.0, 5.5), Nobel Biocare: SteriOss Replace™ 3.1, 3.5, 4.3, 5.0, 6.0, SteriOss HL™ 3.25, 3.8, 4.5, 5.0, 6.0.

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instruments such as scalpels, tweezers, included cell, thermal fatigue, colorimetric,
ss e n c e
fo r
periosteal elevators, and depth gauges marginal fit, fracture strength, and bonding
can be made out of alumina-toughened studies. In vitro results are promising, es-
zirconia (ATZ) by injection moulding (Z- pecially in all aforementioned fields, how-
Look3 Instruments, Z-Systems). ever, since clinical research focuses on
how technology affects humans and other
living organisms, extensive clinical appli-
Discussion cation of the zirconia technology should
await confirmation through cohort longitu-
Technology has many origins that include dinal clinical studies. Despite the known
a combination of inspiration, fortuitous high biocompatibility of zirconia in both
events, and basic research. After the dis- soft and hard tissues, dental zirconia
covery of the toughening transformation restorations are slowly moved from the
209
potential of zirconia in the mid-1970s, controlled experimental setting to the clin-
ample progress has been made in dental ical environment and some clinical studies
science regarding ceramic materials. To- of up to five years can be found in the lit-
day, zirconia technology has become the erature. Existing studies evaluated clinical
cynosure of the research and clinical ef- parameters (eg, fit, color performance, sur-
forts of an increasing number of dental sci- vival rates) and determined the frequency
entists. Industrial development of more of adverse effects (eg, chipping, fractures,
than 20 different CAD/CAM systems debonding), mainly regarding the clinical
(Table 1) concerning zirconia manufactur- application of zirconia FPDs and posts.213,214
ing indicates an increasing clinical interest Material-specific phase transformation,
and fosters the firm conviction that zirconia particularly from the tetragonal to the
could become the star of dental restora- monoclinic crystal phases, inhibits crack
210,211
tions. According to research of manu- propagation and results in the superior
facturers, the clinical spectrum of zirconia- mechanical performance of zirconia.
based restorations appears impressive Therefore, zirconia frameworks obtain ex-
and embraces practically every restorative cellent physical properties such as high
aspect including veneers, crowns, FPDs, strength and fracture toughness.209 Con-
posts, implant abutments, and even im- versely, during aging in an aqueous oral
plants. In 2006 more than 100 metric tons environment, spontaneous phase transfor-
of medical grade ZrO2 raw material was mations of the tetragonal zirconia to mon-
processed worldwide, while in 2008, oclinic phase, known as low temperature
250 tons were expected.212 This increased degradation (LTD), could lead to the forma-
and conspicuous consumption of zirconia tion of microcracks and subsequently to a
for dental applications signifies that zirco- decrease in strength.215,216 This problem
nia-based restorations with the support of mainly involves frameworks or parts of a
computerized systems will be of utmost framework that are not subjected to porce-
importance in the dental profession in the lain veneering and zirconia implants and
coming years. abutments that are exposed to the oral en-
Current in vitro research, performed to vironment. Non-veneered zirconia frame-
understand the nature of the technology, works should be avoided and during

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framework design it is advisable to ensure (chipping) and secondly, fractures of ss e n c e
fo r
appropriate space for coating all zirconia core and debonding of the restoration.
surfaces by a thin porcelain or glass layer. Current clinical studies revealed an in-
Recently reported degradation-free inno- creased chipping rate that ranged from
vative bioceramics such as zirconia mag- 6% to 15% between three to five years
nesia (Mg-PSZ with bioactive glass coat- (Table 2), while for the metal-ceramic
ing)213 and alumina composites (ie, 80% restorations the incidence of chipping was
TZP of 90 mol% ZrO2 + 6 mol% Y2O3 + 4 between 4% and 10% after 10 years.223
mol% Nb2O5 composition, and 20% Fracture of the zirconia frameworks is
217
Al2O3 or 70% TZP stabilized with 10 highly possible but not probable, and fail-
mol% CeO2 + 30vol% Al2O3 + 0.05 mol% ures can be attributed mainly to biological
218
TiO2) might be a future solution to LTD and technical reasons. However, after ap-
aging phenomena.219 propriate design and material selection,
Studies regarding these materials are lifetime predictions for posterior Y-TZP
limited and, particularly for the Ce- FPDs are estimated to be more than 20
TZP/Al2O3 nanocomposite of special in- years.224 According to the available data, Y-
terest for dentistry, are contradictory. Al- TZP FPDs can be comparable to the met-
though both materials exhibit similar al-ceramic FPDs and therefore successful-
activation energies (90 kJ/mol), in com- ly withstand physiologically functional
82
parison to Y-TZP, the Ce-TZP/Al2O3 nano- loading forces.
composite presents a significantly slower Chipping origin is still unknown and hy-
transformation from the tetragonal to the pothetically could be associated with the
monoclinic phase, which is controlled by bond failure between the veneering mate-
the chemical reaction of water and the Zr- rial and the zirconia framework.62 Bond
O-Zr bond.210 The instability of the tetra- strength at the specific core/veneer inter-
gonal phase possibly occurs because of face is mainly dependent on pre-stresses,
the reaction of Y2O3 with the aqueous due to differences in thermal expansion
environment (vapor) producing yttrium coefficients,225 poor core wetting and appli-
hydroxide (Y[OH]3H2O).220 Consequently, cation of liner materials;,226 porcelain firing
along with a satisfactory durability in terms shrinkage,227,228 phase transformation due
of LTD aging, Ce-TZP/Al2O3 may produce to thermal influences,229 loading stresses,
a higher biaxial flexure strength than Y-TZP, inherent flaw formation during process-
which is further increased after sandblast- ing,16 and addition of coloring pigments.230
211,221
ing. However, apart from improved bio- Thermal expansion coefficients of the
mechanical performance, bond strength veneering porcelains, especially for zirco-
of Ce-TZP/Al2O3 to veneering ceramics is nia ceramics (8.8 to 10.0 x 10-6 per C),
low, and results in a high susceptibility for have a slight but compatible mismatch to
delamination and chipping.222 those of zirconia (10.0 to 10.5 x 10-6 per
The technical complications of FPDs C).231 Since simple thermal expansion co-
identified by most clinical studies with a efficient mismatch between bulk materials
minimum three-year observation time is not likely to induce tensile stresses that
were predominantly the identification of lead to porcelain chipping, it was presup-
fractures within the veneering ceramic posed that surface property changes may

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be involved.213 Moreover, interfacial SEM systems provide sophisticated features to
ss e n c e
fo r
analysis of the elemental composition and detect preparation margins, to direct posi-
distribution failed to give an explanation of tioning of connectors and pontics and to
chemical bond since no transitional zone allow essential planning of both form and
and/or distinct ionic presentations could support. Most manufactures suggest that
be detected. 232
Further in vitro testing the minimum coping thickness should be
showed that fractures occurred adjacent to 0.4 mm, that the minimum connector size
the interface but not into the veneering ce- should be 9.0 mm2, and that the framework
ramic mass. However, a thin ceramic lay- must support the veneering porcelain,
er remained on the zirconia surface, indi- which should not include more than
cating that bond strength was higher than 2.0 mm of unsupported veneering materi-
the cohesive strength of the veneering ce- al.223,234,236
ramic. For this reason, it was assumed that Chipping or core fractures might fur-
bonding between veneering ceramics and thermore be the result of differences in the
zirconia might be based on chemical modulus of elasticity within the tooth or im-
228
bonds. To date, there is no scientific evi- plant abutment–cement framework and
dence of chemical bonding between zir- veneering material complex. Elastic prop-
conia and veneering porcelains. The two erty differences across these interfaces
materials seem to “bond” by mechanical can lead to high interfacial stresses and ul-
interlocking and through development of timate failure.66 In general, the use of
compressive stresses due to thermal tougher core materials, such as zirconia,
211
shrinkage during cooling after sintering. has been advocated to overcome this lim-
Another cause of chipping might be the itation and therefore improve clinical per-
lack of a uniform support of the veneering formance.237 Zirconia cores were found to
ceramic due to the framework design.28,233 be less susceptible to fracture than alumi-
The ceramic framework design is depend- na and critical loads for veneering fracture
ent mainly on the preparation depth, height were not significant, however, veneering
of the abutment teeth, interdental space, fractures did depend on adhesive thick-
and edentulous span length. Regarding ness.238 For this reason, a standardized
all-ceramic FPDs, the shape of the pontic- thickness of cement space should be used
connector interface seems to have an ef- throughout clinical (ie, appropriate tooth
fect on fracture characteristics, stress dis- preparation)239 and laboratory procedures
tribution, and concentration inside a (ie, computer-aided cement space deter-
framework that may induce cracking of the mination).33 Observed fractures of multi-
veneering material.234 Framework designs unit prostheses (≥ 4) mostly involve the
for posterior implant restorations that connectors or second molar abutments. In
curved in the occlusal direction may bet- addition, molar zirconia crowns were
ter withstand functional loading, however, found to be at least as good as alumina-
framework design had no significant influ- based ones.4
ence on initial fracture of veneering ceram- Finally, the cost-effectiveness of CAD/
ic.235 In order to develop a framework that CAM zirconia applications is an issue
meets all the requirements of physiology, open for discussion, because of the need
esthetics, and strength, current CAD-CAM for initial hardware investments (ie, scan-

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as high incidence of early fracturest e
n ot

n
ners, computers, machines) and because ofsei-
se nc e
fo r
of the increased final per unit cost. After zir- ther the veneering or the core materials.
conia technology enters routine clinical Longitudinal studies will help to deter-
practice, dentists and dental technicians mine the degree of clinical benefit or
should cooperatively adopt new materials severity of complications.
and methods to improve their perform- I Zirconia abutments provide a favorable
ance according to current evidence-based bio-esthetic addition to implant dentistry,
data and manufacturers´ recommenda- however, long-term clinical assessment
tions. Since zirconia technology is a rela- is needed for in-depth evaluation of im-
tively new area of dentistry, it might under- plant-supported zirconia restorations
go evolutionary changes in the near future and zirconia implants in particular.
and consequently users and technical staff I Basic research should be conducted in
should also maintain significant continuing the fields of aging, veneering, framework
education and training. design, bonding, surface modification
At the conclusion of the present review, and esthetic performance to further illu-
it is essential to underscore that zirconia minate the observed complications and
technology is the most recent of the amaz- provide solutions that will accelerate ex-
ing advances in the CAD/CAM industry. pected clinical outcomes.
Supporting technologies regarding digital-
ization, computers, and lasers will contin- References
ue to revolutionize dentistry so that “virtual
1. Piconi C, Maccauro G. Zirconia as a ceramic
labs” might even replace traditional dental biomaterial. Biomaterials 1999;20:1-25.
technology. Current clinical findings may 2. Kelly JR, Denry I. Stabilized zirconia as a struc-
tural ceramic: an overview. Dent Mater
provide a glimpse of research orientation
2008;24:289-298.
and highlight future trends. Zirconia al- 3. Vagkopoulou T, Koutayas SO, Koidis P, Strub JR.
ready has a past and an ambitious pres- Zirconia in Dentistry. Part 1: Discovering the
nature of an upcoming bioceramic. Eur J Esthet
ent however, for the fulfillment of the Dent 2009;4:130-151.
“dream,” all observed or future complica- 4. Denry I, Kelly JR. State of the art of zirconia for
dental applications. Dent Mater 2008;24:299-307.
tions must be overcome through basic re-
5. Manicone PF, Rossi Iommetti P, Raffaelli L. An
search and long-term clinical evaluation. overview of zirconia ceramics: basic properties
and clinical applications. J Dent 2007;35:819-826.
6. Chevalier J. What future for zirconia as a bioma-
terial? Biomaterials 2006;27:535-543.
Conclusions 7. Griffin J. The Origin of Dreams: How and why
we evolved to dream, vol 4. Worthing: The Ther-
apist Ltd, 1997.
I Zirconia applications seem to consoli- 8. Kohal RJ, Klaus G, Strub JR. Zirconia-implant-
date a well-established position in clin- supported all-ceramic crowns withstand long-
term load: a pilot investigation. Clin Oral
ical dentistry, due to the improvements Implants Res 2006;17:565-571.
in CAD/CAM technology and to the ma- 9. Tinschert J, Natt G, Hassenpflug S, Spiekermann
H. Status of current CAD/CAM technology in den-
terial’s exceptional physical properties.
tal medicine. Int J Comput Dent 2004;7:25-45.
I Existing clinical studies demonstrated a 10. Witkowski S. CAD-CAM in dental technology.
promising survival potential regarding Quintessence J Dent Technol 2005;28:1-16.
11. Oetzel C, Clasen R. Preparation of zirconia den-
tooth-supported restorations but also tal crowns via electrophoretic deposition. J
revealed significant complications such Mater Sci 2006;41:8130-8137.

371
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 4 • NUMBER 4 • WINTER 2009
CLINICAL RESEARCH pyrig
No Co

ht
t fo
rP

by N
ub

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tio
te ot n

n
12. Filser F, Kocher P, Weibel F, 22. Okamura M, Chen KK, Kaki- 31. Reich S, Petschelt A,
nc e
ss efin-
fo r
Luthy H, Scharer P, Gauckler gawa H, Kozono Y. Applica- Lohbauer U. The effect of
LJ. Reliability and strength of tion of alumina coping to ish line preparation and layer
all-ceramic dental restora- porcelain laminate veneered thickness on the failure load
tions fabricated by direct crown: part 1 masking ability and fractography of ZrO2
ceramic machining (DCM). for discolored teeth. Dent copings. J Prosthet Dent
Int J Comput Dent 2001;4:89- Mater J 2004;23:180-183. 2008;99:369-376.
106. 23. Zhang F, Heydecke G, Raz- 32. De Jager N, Pallav P, Feilzer
13. Raigrodski AJ. Clinical and zoog ME. Double-layer AJ. The influence of design
laboratory considerations for porcelain veneers: effect of parameters on the FEA-
the use of CAD/CAM Y-TZP- layering on resulting veneer determined stress distribution
based restorations. Pract color. J Prosthet Dent in CAD-CAM produced all-
Proced Aesthet Dent 2000;84:425-431. ceramic dental crowns. Dent
2003;15:469-476. 24. Charisis D, Koutayas SO, Mater 2005;21:242-251.
14. Tinschert J, Zwez D, Marx R, Kamposiora P, Doukoudakis 33. Iwai T, Komine F, Kobayashi
Anusavice KJ. Structural reli- A. Spectrophotometric evalu- K, Saito A, Matsumura H.
ability of alumina-, feldspar-, ation of the influence of differ- Influence of convergence
leucite-, mica- and zirconia- ent backgrounds on the color angle and cement space on
based ceramics. of glass-infiltrated ceramic adaptation of zirconium diox-
J Dent 2000;28:529-535. veneers. Eur J Esthet Dent ide ceramic copings. Acta
15. Luthardt RG, Holzhuter MS, 2006;1:142-156. Odontol Scand 2008;66:214-
Rudolph H, Herold V, Walter 25. Koutayas SO, Charisis D. 218.
MH. CAD/CAM-machining Influence of the core material 34. Ernst CP, Cohnen U, Stender
effects on Y-TZP zirconia. and the glass infiltration E, Willershausen B. In vitro
Dent Mater 2004;20:655-662. mode on the color of glass- retentive strength of zirconi-
16. Wang H, Aboushelib MN, infiltrated ceramic veneers um oxide ceramic crowns
Feilzer AJ. Strength influenc- over discolored back- using different luting agents.
ing variables on CAD/CAM grounds. A spectrophotomet- J Prosthet Dent 2005;93:551-
zirconia frameworks. Dent ric evaluation. Eur J Esthet 558.
Mater 2008;24:633-638. Dent 2008;2:160-173. 35. Palacios RP, Johnson GH,
17. Rekow D, Thompson VP. 26. Heffernan MJ, Aquilino SA, Phillips KM, Raigrodski AJ.
Near-surface damage—a per- Diaz-Arnold AM, Haselton Retention of zirconium oxide
sistent problem in crowns DR, Stanford CM, Vargas MA. ceramic crowns with three
obtained by computer-aided Relative translucency of six types of cement. J Prosthet
design and manufacturing. all-ceramic systems. Part I: Dent 2006;96:104-114.
Proc Inst Mech Eng [H] core materials. J Prosthet 36. Blatz MB. Adhesive cementa-
2005;219:233-243. Dent 2002;88:4-9. tion of high-strength ceram-
18. Gurel G. The science and art 27. Heffernan MJ, Aquilino SA, ics. J Esthet Restor Dent
of porcelain laminate Diaz-Arnold AM, Haselton 2007;19:238-239.
veneers. London: Quintes- DR, Stanford CM, Vargas MA. 37. Kosmac T, Oblak C, Jevnikar
sence Publishing Co Ltd, Relative translucency of six P, Funduk N, Marion L. The
2003. all-ceramic systems. Part II: effect of surface grinding and
19. Hager B, Oden A, Andersson core and veneer materials. J sandblasting on flexural
B, Andersson L. Procera All- Prosthet Dent 2002;88:10-15. strength and reliability of Y-
Ceram laminates: a clinical 28. Donovan TE. Factors essential TZP zirconia ceramic. Dent
report. J Prosthet Dent for successful all-ceramic Mater 1999;15:426-433.
2001;85:231-232. restorations. J Am Dent Assoc 38. Wegner SM, Kern M. Long-
20. Miyasaki M. Aesthetic rehabil- 2008;139(Suppl):14S-18S. term resin bond strength to
itation of the severely discol- 29. Sadan A, Blatz MB, Lang B. zirconia ceramic. J Adhes
ored anterior dentition: Clinical considerations for Dent 2000;2:139-147.
restorative considerations densely sintered alumina and 39. Blatz MB, Chiche G, Holst S,
using all-ceramic veneers. zirconia restorations: Part 1. Sadan A. Influence of surface
Pract Proced Aesthet Dent Int J Periodontics Restorative treatment and simulated
2004;16:277-281. Dent 2005;25:213-219. aging on bond strengths of
21. Chu FC, Andersson B, Deng 30. Beuer F, Aggstaller H, Edel- luting agents to zirconia.
FL, Chow TW. Making porce- hoff D, Gernet W. Effect of Quintessence Int
lain veneers with the Procera preparation design on the 2007;38:745-753.
AllCeram system: case stud- fracture resistance of zirconia
ies. Dent Update crown copings. Dent Mater J
2003;30:454-458,460. 2008;27:362-367.

372
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 4 • NUMBER 4 • WINTER 2009
KOUTAYAS ET ALopyrig
No C

ht
t fo
rP

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ub

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te otn

n
40. Tsukakoshi M, Shinya A, 49. Yang B, Scharnberg M, Wol- 59. Keough BE, Kay HB, Sager
Gomi H, Lassila LV, Vallittu fart S, Quaas AC, Ludwig K,
s
RD. A ten-unit all-ceramic s e n c
fo re
PK. Effects of dental adhesive Adelung R, et al. Influence of anterior fixed partial denture
cement and surface treat- contamination on bonding to using Y-TZP zirconia. Pract
ment on bond strength and zirconia ceramic. J Biomed Proced Aesthet Dent
leakage of zirconium oxide Mater Res B Appl Biomater 2006;18:37-43.
ceramics. Dent Mater J 2007;81:283-290. 60. Luthy H, Filser F, Loeffel O,
2008;27:159-171. 50. Quaas AC, Yang B, Kern M. Schumacher M, Gauckler LJ,
41. Kern M, Wegner SM. Bond- Panavia F 2.0 bonding to Hammerle CH. Strength and
ing to zirconia ceramic: contaminated zirconia reliability of four-unit all-
adhesion methods and their ceramic after different clean- ceramic posterior bridges.
durability. Dent Mater ing procedures. Dent Mater Dent Mater 2005;21:930-937.
1998;14:64-71. 2007;23:506-512. 61. Tinschert J, Natt G, Mautsch
42. Blatz MB, Sadan A, Kern M. 51. Carracho JF, Razzoog ME. W, Augthun M, Spiekermann
Resin-ceramic bonding: a Removable partial denture H. Fracture resistance of lithi-
review of the literature. J abutments restored with all- um disilicate-, alumina-, and
Prosthet Dent 2003;89:268- ceramic surveyed crowns. zirconia-based three-unit
274. Quintessence Int fixed partial dentures: a labo-
43. Wolfart M, Lehmann F, Wolfart 2006;37:283-288. ratory study. Int J Prosthodont
S, Kern M. Durability of the 52. Pellecchia R, Kang KH, 2001;14:231-238.
resin bond strength to zirco- Hirayama H. Fixed partial 62. Studart AR, Filser F, Kocher P,
nia ceramic after using differ- denture supported by all- Luthy H, Gauckler LJ.
ent surface conditioning ceramic copings: a clinical Mechanical and fracture
methods. Dent Mater report. J Prosthet Dent behavior of veneer-frame-
2007;23:45-50. 2004;92:220-223. work composites for all-
44. Atsu SS, Kilicarslan MA, 53. Rosch R, Mericske-Stern R. ceramic dental bridges. Dent
Kucukesmen HC, Aka PS. [Zirconia and removable par- Mater 2007;23:115-123.
Effect of zirconium-oxide tial dentures]. Schweiz 63. Kamposiora P, Papavasiliou
ceramic surface treatments Monatsschr Zahnmed G, Bayne SC, Felton DA.
on the bond strength to 2008;118:959-974. Stress concentration in all-
adhesive resin. J Prosthet 54. Raigrodski AJ. Contemporary ceramic posterior fixed partial
Dent 2006;95:430-436. all-ceramic fixed partial den- dentures. Quintessence Int
45. Xible AA, de Jesus Tavarez tures: a review. Dent Clin 1996;27:701-706.
RR, de Araujo Cdos R, North Am 2004;48:531-544. 64. Fischer H, Weber M, Marx R.
Bonachela WC. Effect of silica 55. White SN, Miklus VG, Lifetime prediction of all-
coating and silanization on McLaren EA, Lang LA, ceramic bridges by computa-
flexural and composite-resin Caputo AA. Flexural strength tional methods. J Dent Res
bond strengths of zirconia of a layered zirconia and 2003;82:238-242.
posts: An in vitro study. J porcelain dental all-ceramic 65. Oh WS, Anusavice KJ. Effect
Prosthet Dent 2006;95:224- system. J Prosthet Dent of connector design on the
229. 2005;94:125-131. fracture resistance of all-
46. Derand P, Derand T. Bond 56. Studart AR, Filser F, Kocher P, ceramic fixed partial den-
strength of luting cements to Gauckler LJ. Fatigue of zirco- tures. J Prosthet Dent
zirconium oxide ceramics. Int nia under cyclic loading in 2002;87:536-542.
J Prosthodont 2000;13:131- water and its implications for 66. Kelly JR, Tesk JA, Sorensen
135. the design of dental bridges. JA. Failure of all-ceramic
47. Derand T, Molin M, Kvam K. Dent Mater 2007;23:106-114. fixed partial dentures in vitro
Bond strength of composite 57. Fritzsche J. Zirconium oxide and in vivo: analysis and
luting cement to zirconia restorations with the DCS modeling. J Dent Res
ceramic surfaces. Dent Mater precident system. Int J Com- 1995;74:1253-1258.
2005;21:1158-1162. put Dent 2003;6:193-201. 67. Proos K, Steven G, Swain M,
48. Wegner SM, Gerdes W, Kern 58. Burke FJ, Ali A, Palin WM. Zir- Ironside J. Preliminary studies
M. Effect of different artificial conia-based all-ceramic on the optimum shape of
aging conditions on ceramic- crowns and bridges: three dental bridges. Comput
composite bond strength. Int case reports. Dent Update Methods Biomech Biomed
J Prosthodont 2002;15:267- 2006;33:401,402,405,406,409, Engin 2000;4:77-92.
272. 410.

373
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 4 • NUMBER 4 • WINTER 2009
CLINICAL RESEARCH pyrig
No Co

ht
t fo
rP

by N
ub

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tio
te Five- ot n

n
68. White SN, Caputo AA, Vidjak 77. Costello RV, Thompson J, 85. Molin MK, Karlsson SL. e
ss
fo r
e n c
year clinical prospective eval-
FM, Seghi RR. Moduli of rup- Sadan A, Burgess JO, Blatz
ture of layered dental ceram- MB. Light transmission of uation of zirconia-based Den-
ics. Dent Mater 1994;10:52-58. high-strength ceramics with zir 3-unit FPDs. Int J
69. Zeng K, Oden A, Rowcliffe D. four curing lights. J Dent Res Prosthodont 2008;21:223-227.
Evaluation of mechanical 2004;83(special issue 86. Sailer I, Feher A, Filser F,
properties of dental ceramic A):IADR Abstract No.1813. Luthy H, Gauckler LJ, Scharer
core materials in combination 78. Zhang Y, Lawn BR, Rekow P, et al. Prospective clinical
with porcelains. Int J Prostho- ED, Thompson VP. Effect of study of zirconia posterior
dont 1998;11:183-189. sandblasting on the long- fixed partial dentures: 3-year
70. Guazzato M, Proos K, Quach term performance of dental follow-up. Quintessence Int
L, Swain MV. Strength, reliabili- ceramics. J Biomed Mater 2006;37:685-693.
ty and mode of fracture of Res B Appl Biomater 87. Raigrodski AJ, Chiche GJ,
bilayered porcelain/zirconia 2004;71:381-386. Potiket N, Hochstedler JL,
(Y-TZP) dental ceramics. Bio- 79. Sundh A, Molin M, Sjogren Mohamed SE, Billiot S, et al.
materials 2004;25:5045-5052. G. Fracture resistance of yttri- The efficacy of posterior
71. Vult von Steyern P, Carlson P, um oxide partially-stabilized three-unit zirconium-oxide-
Nilner K. All-ceramic fixed zirconia all-ceramic bridges based ceramic fixed partial
partial dentures designed after veneering and mechani- dental prostheses: a
according to the DC-Zirkon cal fatigue testing. Dent Mater prospective clinical pilot
technique. A 2-year clinical 2005;21:476-482. study. J Prosthet Dent
study. J Oral Rehabil 80. Guazzato M, Quach L, 2006;96:237-244.
2005;32:180-187. Albakry M, Swain MV. Influ- 88. Pospiech PR, Rountree PR,
72. Att W, Grigoriadou M, Strub ence of surface and heat Nothdurft FP. Clinical evalua-
JR. ZrO2 three-unit fixed par- treatments on the flexural tion of zirconia-based allce-
tial dentures: comparison of strength of Y-TZP dental ramic posterior bridges: two-
failure load before and after ceramic. J Dent 2005;33:9-18. year results. J Dent Res
exposure to a mastication 81. Sundh A, Sjogren G. Fracture 2003; 82(Special Issue
simulator. J Oral Rehabil resistance of all-ceramic zir- B):114,IADR Abstract No.817.
2007;34:282-290. conia bridges with differing 89. Bornemann G, Rinke S,
73. Att W, Stamouli K, Gerds T, phase stabilizers and quality Huels A. Prospective clinical
Strub JR. Fracture resistance of sintering. Dent Mater trial with conventionally luted
of different zirconium dioxide 2006;22:778-784. zirconia-based fixed partial
three-unit all-ceramic fixed 82. Sailer I, Feher A, Filser F, dentures - 18-month results. J
partial dentures. Acta Odontol Gauckler LJ, Luthy H, Ham- Dent Res 2003;82(special
Scand 2007;65:14-21. merle CH. Five-year clinical issue B):117,IADR Abstract
74. Larsson C, Holm L, Lovgren results of zirconia frameworks No. 842.
N, Kokubo Y, Vult von Stey- for posterior fixed partial den- 90. Edelhoff D, Beuer F, Weber V,
ern P. Fracture strength of tures. Int J Prosthodont Johnen C. HIP zirconia fixed
four-unit Y-TZP FPD cores 2007;20:383-388. partial dentures. Clinical
designed with varying con- 83. Sturzenegger B, Feher A, results after 3 years of clinical
nector diameter. An in-vitro Luthy H, Schumacher M, service. Quintessence Int
study. J Oral Rehabil Loeffel O, Filser F, et al. [Clini- 2008;39:459-471.
2007;34:702-709. cal study of zirconium oxide 91. Roediger M, Rinke S, Huels
75. Reich S, Wichmann M, bridges in the posterior seg- A. Prospective clinical evalua-
Nkenke E, Proeschel P. Clini- ments fabricated with the tion of Cercon™ premolar
cal fit of all-ceramic three-unit DCM system]. Schweiz and molar FPDs. J Dent Res
fixed partial dentures, gener- Monatsschr Zahnmed 2000; 2009;88(special issue
ated with three different 110:131-139. B):IADR Abstract No. 2347.
CAD/CAM systems. Eur J 84. Tinschert J, Schulze KA, Natt 92. Taskonak B, Yan J, Mechol-
Oral Sci 2005;113:174-179. G, Latzke P, Heussen N, sky JJ, Jr., Sertgoz A, Kocak
76. Komine F, Gerds T, Witkowski Spiekermann H. Clinical A. Fractographic analyses of
S, Strub JR. Influence of behavior of zirconia-based zirconia-based fixed partial
framework configuration on fixed partial dentures made dentures. Dent Mater
the marginal adaptation of of DC-Zirkon: 3-year results. 2008;24:1077-1082.
zirconium dioxide ceramic Int J Prosthodont
anterior four-unit frameworks. 2008;21:217-222.
Acta Odontol Scand
2005;63:361-366.

374
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 4 • NUMBER 4 • WINTER 2009
KOUTAYAS ET ALopyrig
No C

ht
t fo
rP

by N
ub

Q ui
lica
tio
te n
ot

n
93. Larsson C, Vult von Steyern P, 101. Wolfart S, Ludwig K, Uphaus with zirconium oxide ceramic
A, Kern M. Fracture strength
ss
pins—a prospective study of e n c e
fo r
Sunzel B, Nilner K. All-ceram-
ic two- to five-unit implant- of all-ceramic posterior inlay- 112 apicoectomy teeth.
supported reconstructions. A retained fixed partial den- Fortschr Kiefer Gesichtschir
randomized, prospective clin- tures. Dent Mater 1995;40:144-147.
ical trial. Swed Dent J 2007;23:1513-1520. 112. Pontius O, Hutter JW. Survival
2006;30:45-53. 102. Takeda T, Ishigami K, Shima- rate and fracture strength of
94. Komine F, Tomic M. A single- da A, Ohki K. A study of dis- incisors restored with differ-
retainer zirconium dioxide coloration of the gingiva by ent post and core systems
ceramic resin-bonded fixed artificial crowns. Int J Prostho- and endodontically treated
partial denture for single dont 1996;9:197-202. incisors without coronoradic-
tooth replacement: a clinical 103. Frejlich S, Goodacre CJ. Elim- ular reinforcement. J Endod
report. J Oral Sci inating coronal discoloration 2002;28:710-715.
2005;47:139-142. when cementing all-ceramic 113. Heydecke G, Butz F, Strub JR.
95. Hirata R, Viotti R, Reis AF, de restorations over metal posts Fracture strength and survival
Andrade OS. All-ceramic and cores. J Prosthet Dent rate of endodontically treated
inlay-retained fixed partial 1992;67:576-577. maxillary incisors with approx-
bridge using a CAD-CAM 104. Kwiatkowski S, Geller W. A imal cavities after restoration
produced Y-TZP framework preliminary consideration of with different post and core
and fluoroapatite veneering the glass-ceramic dowel post systems: an in-vitro study. J
ceramic: a clinical report. and core. Int J Prosthodont Dent 2001;29:427-433.
Gen Dent 2007;55:657-662. 1989;2:51-55. 114. Koutayas SO, Kern M. All-
96. Koutayas SO, Kern M, Ferra- 105. Kern M, Knode H. Posts and ceramic posts and cores: the
resso F, Strub JR. Influence of cores fabricated out of In- state of the art. Quintessence
design and mode of loading Ceram—direct and indirect Int 1999;30:383-392.
on the fracture strength of all- methods. Quintessenz Zahn- 115. Butz F, Lennon AM, Hey-
ceramic resin-bonded fixed tech 1991;17:917-925. decke G, Strub JR. Survival
partial dentures: an in vitro 106. Sandhaus S, Pasche K. rate and fracture strength of
study in a dual-axis chewing Tenon radiculaire en zircone endodontically treated maxil-
simulator. J Prosthet Dent pour la réalisation d’inlays- lary incisors with moderate
2000;83:540-547. cores tout céramique. Tri- defects restored with different
97. Kern M, Strub JR. Bonding to bune Dent 1994;2:17-24. post-and-core systems: an in
alumina ceramic in restora- 107. Meyenberg KH, Luthy H, vitro study. Int J Prosthodont
tive dentistry: clinical results Scharer P. Zirconia posts: a 2001;14:58-64.
over up to 5 years. J Dent new all-ceramic concept for 116. Strub JR, Pontius O, Koutayas
1998;26:245-249. nonvital abutment teeth. J S. Survival rate and fracture
98. Kern M. Clinical long-term Esthet Dent 1995;7:73-80. strength of incisors restored
survival of two-retainer and 108. Simon M, Paffrath J. Neue with different post and core
single-retainer all-ceramic Perspektiven zur vollkeramis- systems after exposure in the
resin-bonded fixed partial chen Stabilisierung und zum artificial mouth. J Oral Reha-
dentures. Quintessence Int Aufbau devitaler Zähne. Quin- bil 2001;28:120-124.
2005;36:141-147. tessenz 1995;46:1085-1101. 117. Heydecke G, Peters MC. The
99. Kilicarslan MA, Kedici PS, 109. Ahmad I. Yttrium-partially sta- restoration of endodontically
Kucukesmen HC, Uludag BC. bilized zirconium dioxide treated, single-rooted teeth
In vitro fracture resistance of posts: an approach to restor- with cast or direct posts and
posterior metal-ceramic and ing coronally compromised cores: a systematic review. J
all-ceramic inlay-retained nonvital teeth. Int J Periodon- Prosthet Dent 2002;87:380-
resin-bonded fixed partial tics Restorative Dent 386.
dentures. J Prosthet Dent 1998;18:454-465. 118. Friedel W, Kern M. Fracture
2004;92:365-370. 110. Fradeani M, Aquilano A, Bar- strength of teeth restored with
100. Ohlmann B, Gabbert O, ducci G. Aesthetic restoration all-ceramic posts and cores.
Schmitter M, Gilde H, Ram- of endodontically treated Quintessence Int
melsberg P. Fracture resist- teeth. Pract Periodontics Aes- 2006;37:289-295.
ance of the veneering on thet Dent 1999;11:761-768. 119. Maccari PC, Conceicao EN,
inlay-retained zirconia ceram- 111. Schultze-Mosgau S, Rekers- Nunes MF. Fracture resist-
ic fixed partial dentures. Acta brink M, Neukam FW. Clinical ance of endodontically treat-
Odontol Scand 2005;63:335- and roentgenologic outcome ed teeth restored with three
342. evaluation after apicoectomy different prefabricated esthet-
ic posts. J Esthet Restor Dent
2003;15:25-30.

375
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 4 • NUMBER 4 • WINTER 2009
CLINICAL RESEARCH pyrig
No Co

ht
t fo
rP

by N
ub

Q ui
lica
tio
te ot n

n
120. Hu YH, Pang LC, Hsu CC, restoration of endodontically 137. Volz U, Blaschke C. Metal- e
ss
fo r
e n c
free reconstruction with zirco-
Lau YH. Fracture resistance treated teeth: a systematic
of endodontically treated review of the literature—Part 1. nia implants and zirconia
anterior teeth restored with Composition and micro- and crowns. Quintessence J Dent
four post-and-core systems. macrostructure alterations. Technol 2004;2:324-330.
Quintessence Int Quintessence Int 138. Kohal RJ, Klaus G. A zirconia
2003;34:349-353. 2007;38:733-743. implant-crown system: a
121. Kakehashi Y, Luthy H, Naef R, 129. Dietschi D, Duc O, Krejci I, case report. Int J Periodontics
Wohlwend A, Scharer P. A Sadan A. Biomechanical Restorative Dent
new all-ceramic post and considerations for the 2004;24:147-153.
core system: clinical, techni- restoration of endodontically 139. Polack MA. Restoration of
cal, and in vitro results. Int J treated teeth: a systematic maxillary incisors with a zir-
Periodontics Restorative Dent review of the literature, Part II conia all-ceramic system: a
1998;18:586-593. (Evaluation of fatigue behav- case report. Quintessence Int
122. Schneider U. Die Versorgung ior, interfaces, and in vivo 2006;37:375-380.
avitaler Zähne mit Wurzels- studies). Quintessence Int 140. Filiaggi MJ, Pilliar RM,
tiften aus Zirkondioxidkeramik 2008;39:117-129. Yakubovich R, Shapiro G.
- Eine Langzeitstudie beim 130. Weingart D, Steinemann S, Evaluating sol-gel ceramic
Menschen [thesis]. University Schilli W, Strub JR, Hellerich U, thin films for metal implant
of Freiburg, Germany, 1999. Assenmacher J, et al. Titanium applications. I. Processing
123. Paul SJ, Werder P. Clinical deposition in regional lymph and structure of zirconia films
success of zirconium oxide nodes after insertion of titani- on Ti-6AI-4V. J Biomed Mater
posts with resin composite or um screw implants in maxillo- Res 1996;33:225-238.
glass-ceramic cores in facial region. Int J Oral Maxillo- 141. Sollazzo V, Pezzetti F, Scara-
endodontically treated teeth: fac Surg 1994;23:450-452. no A, Piattelli A, Bignozzi CA,
a 4-year retrospective study. 131. Bianco PD, Ducheyne P, Massari L, et al. Zirconium
Int J Prosthodont Cuckler JM. Systemic titani- oxide coating improves
2004;17:524-528. um levels in rabbits with a implant osseointegration in
124. Schmitter M, Mussotter K, titanium implant in the vivo. Dent Mater
Ohlmann B, Gilde H, Ram- absence of wear. J Mater Sci 2008;24:357-361.
melsberg P. Dependence of Mater Med 1997;8:525-529. 142. Heuer D, Harrison A, Gupta
in vitro fracture strength of 132. Lalor PA, Revell PA, Gray AB, H, Hunter G. Chemically tex-
adhesive core buildup and Wright S, Railton GT, Free- tured and oxidized zirconium
crown complexes on prepa- man MA. Sensitivity to titani- surfaces for implant fixation.
ration design and cementa- um. A cause of implant fail- Key Eng Mater 2003;240-
tion technique. J Adhes Dent ure? J Bone Joint Surg Br 242:789-792.
2008;10:145-150. 1991;73:25-28. 143. Soares CJ, Mitsui FH, Neto
125. Caputo AA, Standlee JP. 133. Tschernitschek H, Borchers L, FH, Marchi GM, Martins LR.
Restoration of endodontically Geurtsen W. Nonalloyed tita- Radiodensity evaluation of
involved teeth. In: Biome- nium as a bioinert metal—a seven root post systems. Am
chanics in clinical dentistry. review. Quintessence Int J Dent 2005;18:57-60.
Chicago: Quintessence; 2005;36:523-530. 144. Park SW, Driscoll CF,
1987:185-203. 134. Kawahara H, Hirabayashi M, Romberg EE, Siegel S,
126. Akkayan B, Gulmez T. Resis- Shikita T. Single crystal alumi- Thompson G. Ceramic
tance to fracture of endodon- na for dental implants and implant abutments: Cutting
tically treated teeth restored bone screws. J Biomed efficiency and resultant sur-
with different post systems. J Mater Res 1980;14:597-605. face finish by diamond rotary
Prosthet Dent 2002;87:431- 135. Schepers E, De Clercq M, cutting instruments. J Pros-
437. Ducheyne P. Fiber-reinforced thet Dent 2006;95:444-449.
127. Dietschi D, Ardu S, Rossier- bioactive glass: a possible 145. Ichikawa Y, Akagawa Y, Nikai
Gerber A, Krejci I. Adaptation dental implant material. Bio- H, Tsuru H. Tissue compatibil-
of adhesive post and cores to med Tech (Berl) ity and stability of a new zirco-
dentin after in vitro occlusal 1987;32:309-312. nia ceramic in vivo. J Prosthet
loading: evaluation of post 136. Simunek A, Kopecka D, Dent 1992;68:322-326.
material influence. J Adhes Cierny M, Krulichova I. A six- 146. Hayashi K, Inadome T,
Dent 2006;8:409-419. year study of hydroxyapatite- Tsumura H, Mashima T, Sug-
128. Dietschi D, Duc O, Krejci I, coated root-form dental ioka Y. Bone-implant inter-
Sadan A. Biomechanical implants. West Indian Med J face mechanics of in vivo
considerations for the 2005;54:393-397. bio-inert ceramics. Biomateri-
als 1993;14:1173-1179.

376
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 4 • NUMBER 4 • WINTER 2009
KOUTAYAS ET ALopyrig
No C

ht
t fo
rP

by N
ub

Q ui
lica
tio
te G. ot n

n
147. Kohal RJ, Att W, Bachle M, 155. Dubruille JH, Viguier E, Le 162. Kohal RJ, Finke HC, Klaus e
Stability of prototype two-
ss
fo r
e n c
Butz F. Ceramic abutments Naour G, Dubruille MT, Auriol
and ceramic oral implants. M, Le Charpentier Y. Evalua- piece zirconia and titanium
An update. Periodontol 2000 tion of combinations of titani- implants after artificial aging:
2008;47:224-243. um, zirconia, and alumina an in vitro pilot study. Clin
148. Josset Y, Oum’Hamed Z, implants with 2 bone fillers in Implant Dent Relat Res
Zarrinpour A, Lorenzato M, the dog. Int J Oral Maxillofac 2008;[Epub ahead of print].
Adnet JJ, Laurent-Maquin D. Implants 1999;14:271-277. 163. Andreiotelli M, Kohal RJ.
In vitro reactions of human 156. Schultze-Mosgau S, Fracture strength of zirconia
osteoblasts in culture with zir- Schliephake H, Radespiel- implants after artificial aging.
conia and alumina ceramics. Troger M, Neukam FW. Clin Implant Dent Relat Res
J Biomed Mater Res Osseointegration of 2008;[Epub ahead of print].
1999;47:481-493. endodontic endosseous 164. Pirker W, Kocher A. Immedi-
149. Bachle M, Butz F, Hubner U, cones: zirconium oxide vs ate, non-submerged, root-
Bakalinis E, Kohal RJ. Behav- titanium. Oral Surg Oral Med analogue zirconia implant in
ior of CAL72 osteoblast-like Oral Pathol Oral Radiol single tooth replacement. Int
cells cultured on zirconia Endod 2000;89:91-98. J Oral Maxillofac Surg
ceramics with different sur- 157. Scarano A, Di Carlo F, Quar- 2008;37:293-295.
face topographies. Clin Oral anta M, Piattelli A. Bone 165. Mellinghoff J. First clinical
Implants Res 2007;18:53-59. response to zirconia ceramic results of dental screw
150. Hao L, Lawrence J, Chian KS. implants: an experimental implants made of zirconium
Effects of CO2 laser irradia- study in rabbits. J Oral oxide. Zahnärztl Impl
tion on the surface properties Implantol 2003;29:8-12. 2006;22:288-293.
of magnesia-partially sta- 158. Sennerby L, Dasmah A, Lars- 166. Oliva J, Oliva X, Oliva JD.
bilised zirconia (MgO-PSZ) son B, Iverhed M. Bone tis- One-year follow-up of first
bioceramic and the subse- sue responses to surface- consecutive 100 zirconia
quent improvements in modified zirconia implants: A dental implants in humans: a
human osteoblast cell adhe- histomorphometric and comparison of 2 different
sion. J Biomater Appl removal torque study in the rough surfaces. Int J Oral
2004;19:81-105. rabbit. Clin Implant Dent Maxillofac Implants
151. Hao L, Lawrence J, Chian KS. Relat Res 2005;7(suppl 2007;22:430-435.
Osteoblast cell adhesion on a 1):S13-S20. 167. Wenz HJ, Bartsch J, Wolfart S,
laser modified zirconia based 159. Gahlert M, Gudehus T, Eich- Kern M. Osseointegration
bioceramic. J Mater Sci horn S, Steinhauser E, Kniha and clinical success of zirco-
Mater Med 2005;16:719-726. H, Erhardt W. Biomechanical nia dental implants: a sys-
152. Carinci F, Pezzetti F, Volinia S, and histomorphometric com- tematic review. Int J Prostho-
Francioso F, Arcelli D, Farina parison between zirconia dont 2008; 21:27-36.
E, et al. Zirconium oxide: implants with varying surface 168. Jung RE, Pjetursson BE,
analysis of MG63 osteoblast- textures and a titanium Glauser R, Zembic A, Zwahlen
like cell response by means of implant in the maxilla of M, Lang NP. A systematic
a microarray technology. Bio- miniature pigs. Clin Oral review of the 5-year survival
materials 2004;25:215-228. Implants Res 2007;18:662- and complication rates of
153. Sollazzo V, Palmieri A, 668. implant-supported single
Pezzetti F, Bignozzi CA, 160. Akagawa Y, Ichikawa Y, Nikai crowns. Clin Oral Implants Res
Argazzi R, Massari L et al. H, Tsuru H. Interface histology 2008;19:119-130.
Genetic effect of zirconium of unloaded and early loaded 169. Watkin A, Kerstein RB.
oxide coating on osteoblast- partially stabilized zirconia Improving darkened anterior
like cells. J Biomed Mater endosseous implant in initial peri-implant tissue color with
Res B Appl Biomater bone healing. J Prosthet Dent zirconia custom implant abut-
2008;84:550-558. 1993;69:599-604. ments. Compend Contin
154. Palmieri A, Pezzetti F, Brunelli 161. Kohal RJ, Papavasiliou G, Educ Dent 2008;29:238-
G, Zollino I, Lo Muzio L, Mar- Kamposiora P, Tripodakis A, 240,242.
tinelli M et al. Zirconium Strub JR. Three-dimensional 170. Hurzeler MB, Quinones CR,
oxide regulates RNA interfer- computerized stress analysis Strub JR. Advanced surgical
ing of osteoblast-like cells. J of commercially pure titanium and prosthetic management
Mater Sci Mater Med and yttrium-partially stabilized of the anterior single tooth
2008;19:2471-2476. zirconia implants. Int J osseointegrated implant: a
Prosthodont 2002;15:189- case presentation. Pract Peri-
194. odontics Aesthet Dent
1994;6:13-21.

377
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 4 • NUMBER 4 • WINTER 2009
CLINICAL RESEARCH pyrig
No Co

ht
t fo
rP

by N
ub

Q ui
lica
tio
teInflu- ot n

n
171. Belser UC, Schmid B, Higgin- 181. Scarano A, Piattelli M, Caputi 188. Linkevicius T, Apse P. e
ss
fo r
e
ence of abutment material onn c
bottom F, Buser D. Outcome S, Favero GA, Piattelli A. Bac-
analysis of implant restora- terial adhesion on commer- stability of peri-implant tis-
tions located in the anterior cially pure titanium and zirco- sues: a systematic review. Int
maxilla: a review of the recent nium oxide disks: an in vivo J Oral Maxillofac Implants
literature. Int J Oral Maxillofac human study. J Periodontol 2008;23:449-456.
Implants 2004;19(suppl):30- 2004;75:292-296. 189. Mustafa K, Wennerberg A,
42. 182. Rimondini L, Cerroni L, Car- Arvidson K, Messelt EB,
172. Holst S, Blatz MB, Hegen- rassi A, Torricelli P. Bacterial Haag P, Karlsson S. Influence
barth E, Wichmann M, Eitner colonization of zirconia of modifying and veneering
S. Prosthodontic considera- ceramic surfaces: an in vitro the surface of ceramic abut-
tions for predictable single- and in vivo study. Int J Oral ments on cellular attachment
implant esthetics in the ante- Maxillofac Implants and proliferation. Clin Oral
rior maxilla. J Oral Maxillofac 2002;17:793-798. Implants Res 2008;19:1178-
Surg 2005;63:89-96. 183. Warashina H, Sakano S, Kita- 1187.
173. Yildirim M, Edelhoff D, mura S, Yamauchi KI, Yam- 190. Mitsias M, Koutayas SO, Wol-
Hanisch O, Spiekermann H. aguchi J, Ishiguro N, fart S, Lehmann F, Kern M.
Ceramic abutments—a new Hasegawa Y. Biological reac- Fracture strength of implant
era in achieving optimal tion to alumina, zirconia, tita- crowns after different zirconia
esthetics in implant dentistry. nium and polyethylene parti- abutment preparations. IADR
Int J Periodontics Restorative cles implanted onto murine 86th General Session & Exhi-
Dent 2000;20:81-91. calvaria. Biomaterials bition, Toronto, 2008; IADR
174. Prestipino V, Ingber A. Esthet- 2003;24:3655-3661. Abstact No. 1211.
ic high-strength implant abut- 184. Welander M, Abrahamsson I, 191. Brodbeck U. The ZiReal Post:
ments. Part I. J Esthet Dent Berglundh T. The mucosal A new ceramic implant abut-
1993;5:29-36. barrier at implant abutments ment. J Esthet Restor Dent
175. Prestipino V, Ingber A. Esthet- of different materials. Clin 2003;15:10-23,discussion 24.
ic high-strength implant abut- Oral Implants Res 192. Lang LA, Sierraalta M, Hof-
ments. Part II. J Esthet Dent 2008;19:635-641. fensperger M, Wang RF. Eval-
1993;5:63-68. 185. Glauser R, Sailer I, Wohlwend uation of the precision of fit
176. Andersson B. Implants for A, Studer S, Schibli M, Schar- between the Procera custom
single-tooth replacement. A er P. Experimental zirconia abutment and various
clinical and experimental abutments for implant-sup- implant systems. Int J Oral
study on the Brånemark ported single-tooth restora- Maxillofac Implants
CeraOne System. Swed Dent tions in esthetically demand- 2003;18:652-658.
J Suppl 1995;108:1-41. ing regions: 4-year results of 193. Vigolo P, Fonzi F, Majzoub Z,
177. Prestipino V, Ingber A. All- a prospective clinical study. Cordioli G. An in vitro evalua-
ceramic implant abutments: Int J Prosthodont tion of titanium, zirconia, and
esthetic indications. J Esthet 2004;17:285-290. alumina procera abutments
Dent 1996;8:255-262. 186. Bae KH, Han JS, Seol YJ, with hexagonal connection.
178. Butz F, Heydecke G, Okutan Butz F, Caton J, Rhyu IC. The Int J Oral Maxillofac Implants
M, Strub JR. Survival rate, biologic stability of alumina- 2006;21:575-580.
fracture strength and failure zirconia implant abutments 194. Tripodakis AP, Strub JR, Kap-
mode of ceramic implant after 1 year of clinical service: pert HF, Witkowski S.
abutments after chewing sim- a digital subtraction radi- Strength and mode of failure
ulation. J Oral Rehabil ographic evaluation. Int J of single implant all-ceramic
2005;32:838-843. Periodontics Restorative Dent abutment restorations under
179. Andersson B, Glauser R, 2008;28:137-143. static load. Int J Prosthodont
Maglione M, Taylor A. Ceram- 187. Degidi M, Artese L, Scarano 1995;8:265-272.
ic implant abutments for A, Perrotti V, Gehrke P, Piattelli 195. Papavasiliou G, Tripodakis
short-span FPDs: a prospec- A. Inflammatory infiltrate, AP, Kamposiora P, Strub JR,
tive 5-year multicenter study. microvessel density, nitric Bayne SC. Finite element
Int J Prosthodont oxide synthase expression, analysis of ceramic abut-
2003;16:640-646. vascular endothelial growth ment-restoration combina-
180. Manicone PF, Rossi Iommetti factor expression, and prolif- tions for osseointegrated
P, Raffaelli L, Paolantonio M, erative activity in peri-implant implants. Int J Prosthodont
Rossi G, Berardi D, Perfetti G. soft tissues around titanium 1996;9:254-260.
Biological considerations on and zirconium oxide healing
the use of zirconia for dental caps. J Periodontol
devices. Int J Immunopathol 2006;77:73-80.
Pharmacol 2007;20:9-12.

378
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 4 • NUMBER 4 • WINTER 2009
KOUTAYAS ET ALopyrig
No C

ht
t fo
rP

by N
ub

Q ui
lica
tio
te ot n

n
196. Vigolo P, Fonzi F, Majzoub Z, resulting from differences in 215. Swab J. Low temperature e
Cordioli G. An in vitro evalua-
ss
degradation of Y-TZP materi-
fo r
e n c
bracket materials]. Osaka
tion of ZiReal abutments with Daigaku Shigaku Zasshi als. J Mater Sci
hexagonal connection: in 1990;35:355-364. 1991;26:6706-6714.
original state and following 206. Saunders CR, Kusy RP. Sur- 216. Papanagiotou HP, Morgano
abutment preparation. Int J face topography and friction- SM, Giordano RA, Pober R.
Oral Maxillofac Implants al characteristics of ceramic In vitro evaluation of low-tem-
2005;20:108-114. brackets. Am J Orthod perature aging effects and
197. Yildirim M, Fischer H, Marx R, Dentofacial Orthop finishing procedures on the
Edelhoff D. In vivo fracture 1994;106:76-87. flexural strength and structur-
resistance of implant-sup- 207. Bishara SE, Trulove TS. Com- al stability of Y-TZP dental
ported all-ceramic restora- parisons of different debond- ceramics. J Prosthet Dent
tions. J Prosthet Dent ing techniques for ceramic 2006;96:154-164.
2003;90:325-331. brackets: an in vitro study. 217. Kim DJ, Lee MH, Lee DY, Han
198. Att W, Kurun S, Gerds T, Strub Part II. Findings and clinical JS. Mechanical properties,
JR. Fracture resistance of sin- implications. Am J Orthod phase stability, and biocom-
gle-tooth implant-supported Dentofacial Orthop patibility of (Y, Nb)-
all-ceramic restorations after 1990;98:263-273. TZP/Al(2)O(3) composite
exposure to the artificial 208. Douglass JB. Enamel wear abutments for dental implant.
mouth. J Oral Rehabil caused by ceramic brackets. J Biomed Mater Res
2006;33:380-386. Am J Orthod Dentofacial 2000;53:438-443.
199. Gehrke P, Dhom G, Brunner J, Orthop 1989;95:96-98. 218. Ban S. Reliability and proper-
Wolf D, Degidi M, Piattelli A. 209. Garvie RC, Hannink RH, Pas- ties of core materials for all-
Zirconium implant abutments: coe RT. Ceramic Steel? ceramic dental restorations.
fracture strength and influence Nature 1975;258:703-704. Japanese Dental Science
of cyclic loading on retaining- 210. Sato T, Shimada M. Transfor- Review 2008;44:3-21.
screw loosening. Quintes- mation of yttria-doped tetrag- 219. Heness G, Ben-Nissan B.
sence Int 2006;37:19-26. onal ZrO2 polycrystals by Innovative bioceramics. Mate-
200. Kusy RP. Orthodontic bioma- annealing in water. J Amer rials Forum 2004;27:104-114.
terials: from the past to the Ceram Soc 1985;86:356-359. 220. Lin JD Duh JG, Lo CL.
present. Angle Orthod 211. Ban S, Sato H, Suehiro Y, Mechanical properties and
2002;72:501-512. Nakanishi H, Nawa M. Biaxial resistance to hydrothermal
201. Keith O, Kusy RP, Whitley JQ. flexure strength and low tem- aging of ceria- and yttria-
Zirconia brackets: an evalua- perature degradation of Ce- doped tetragonal zirconia
tion of morphology and coef- TZP/Al2O3 nanocomposite ceramics. Mater Chem Phys
ficients of friction. Am J and Y-TZP as dental restora- 2002;87:808-818.
Orthod Dentofacial Orthop tives. J Biomed Mater Res B 221. Sato H, Yamada K, Pezzotti G,
1994;106:605-614. Appl Biomater 2008;87:492- Nawa M, Ban S. Mechanical
202. Springate SD, Winchester LJ. 498. properties of dental zirconia
An evaluation of zirconium 212. Rieger W. KS, Weber W. Pro- ceramics changed with sand-
oxide brackets: a preliminary cessing and properties of zir- blasting and heat treatment.
laboratory and clinical report. conia ceramics for dental Dent Mater J 2008;27:408-414.
Br J Orthod 1991;18:203-209. applications. Spectrum 222. Aboushelib MN, Kleverlaan
203. Winchester LJ. Bond Dialoge 2008;7:2-11. CJ, Feilzer AJ. Evaluation of a
strengths of five different 213. Rahaman MN, Li Y, Bal BS, high fracture toughness com-
ceramic brackets: an in vitro Huang W. Functionally grad- posite ceramic for dental
study. Eur J Orthod ed bioactive glass coating on applications. J Prosthodont
1991;13:293-305. magnesia partially stabilized 2008;17:538-544.
204. Kittipibul P, Godfrey K. In vitro zirconia (Mg-PSZ) for 223. Anderson RJ, Janes GR,
shearing force testing of the enhanced biocompatibility. J Sabella LR, Morris HF. Com-
Australian zirconia-based Mater Sci Mater Med parison of the performance
ceramic Begg bracket. Am J 2008;19:2325-2333. on prosthodontic criteria of
Orthod Dentofacial Orthop 214. Kim HW, Knowles JC, Li LH, several alternative alloys
1995;108:308-315. Kim HE. Mechanical perform- used for fixed crown and par-
205. Matsubara S, Tanne K, ance and osteoblast-like cell tial denture restorations:
Shibaguchi T, Sakuda M, responses of fluorine-substi- Department of Veterans
Takahashi J, Kimura H. tuted hydroxyapatite and zir- Affairs Cooperative Studies
[Changes in efficiency of conia dense composite. J project 147. J Prosthet Dent
orthodontic tooth movement Biomed Mater Res A 1993;69:1-8.
2005;72:258-268.

379
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 4 • NUMBER 4 • WINTER 2009
CLINICAL RESEARCH pyrig
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224. Studart AR, Filser F, Kocher P, 229. de Kler M, de Jager N, 235. Kokubo Y, Tsumita M,
Gauckler LJ. In vitro lifetime of Meegdes M, van der Zel JM.
ss e n c e
fo r
S, Torizuka K, Vult von Stey-
dental ceramics under cyclic Influence of thermal expan- ern P, Fukushima S. The
loading in water. Biomaterials sion mismatch and fatigue effect of core framework
2007;28:2695-2705. loading on phase changes in designs on the fracture loads
225. Aboushelib MN, Feilzer AJ, porcelain veneered Y-TZP zir- of all-ceramic fixed partial
de Jager N, Kleverlaan CJ. conia discs. J Oral Rehabil dentures on posterior
Prestresses in bilayered all- 2007;34:841-847. implants. J Oral Rehabil
ceramic restorations. J Bio- 230. Aboushelib MN, Kleverlaan 2007;34:503-507.
med Mater Res B Appl Bio- CJ, Feilzer AJ. Effect of zirco- 236. McLaren EA, Terry DA.
mater 2008;87:139-145. nia type on its bond strength CAD/CAM systems, materi-
226. Aboushelib MN, Kleverlaan with different veneer ceram- als, and clinical guidelines for
CJ, Feilzer AJ. Microtensile ics. J Prosthodont all-ceramic crowns and fixed
bond strength of different 2008;17:401-408. partial dentures. Compend
components of core 231. Ban S, Sato H, Yamashita D. Contin Educ Dent
veneered all-ceramic restora- Microstructure and mechani- 2002;23:637-641,644,646.
tions. Part II: Zirconia veneer- cal properties of recent den- 237. De Jager N, de Kler M, van
ing ceramics. Dent Mater tal porcelains. Arch Bioceram der Zel JM. The influence of
2006;22:857-863. Res 2006;6:58-61. different core material on the
227. Fischer J, Stawarczyk B, 232. Weigl P, Lauer HC. Advanced FEA-determined stress distri-
Tomic M, Strub JR, Hammer- biomaterials used for a new bution in dental crowns. Dent
le CH. Effect of thermal misfit telescopic retainer for remov- Mater 2006;22:234-242.
between different veneering able dentures. J Biomed 238. Lee JJ, Kwon JY, Bhowmick
ceramics and zirconia frame- Mater Res 2000;53:337-347. S, Lloyd IK, Rekow ED, Lawn
works on in vitro fracture load 233. Hermann I, Bhowmick S, BR. Veneer vs. core failure in
of single crowns. Dent Mater Lawn BR. Role of core sup- adhesively bonded all-
J 2007;26:766-772. port material in veneer failure ceramic crown layers. J Dent
228. Fischer J, Grohmann P, of brittle layer structures. J Res 2008;87:363-366.
Stawarczyk B. Effect of zirco- Biomed Mater Res B Appl 239. De Jager N PP, Feilzer AJ.
nia surface treatments on the Biomater 2007;82:115-121. The influence of design
shear strength of 234. Tsumita M, Kokubo Y, Vult parameters on the FEA-
zirconia/veneering ceramic von Steyern P, Fukushima S. determined stress distribution
composites. Dent Mater J Effect of framework shape on in CAD-CAM produced all-
2008;27:448-454. the fracture strength of ceramic dental crowns. Dent
implant-supported all-ceram- Mater 2005;21:242-251.
ic fixed partial dentures in the
molar region. J Prosthodont
2008;17:274-285.

380
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 4 • NUMBER 4 • WINTER 2009

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