Fracture Resistance of Additively Manufactured Zirconia

Crowns when Cemented to Implant Supported Zirconia

Abutments: An in vitro Study
Amirali Zandinejad, DDS, MSc ,1 Mohammad Mujtaba Methani, BDS, MS ,2
Emet D. Schneiderman, PhD,2 Marta Revilla-León, DDS, MSD ,1 & Dean Morton BDS, MS3
1
Department of Comprehensive Dentistry, College of Dentistry,Texas A&M University, Dallas, TX
2
Department of Biomedical Sciences, College of Dentistry, Texas A&M University, Dallas, TX
3
Department of Prosthodontics, Indiana University School of Dentistry, Indianapolis, IN

Keywords
Additive manufacturing; 3D printing; zirconia
crowns; digital dentistry; dental implant;
fracture resistance.
Correspondence
Amirali Zandinejad, College of Dentistry,
Texas A&M University, AEGD Program,
Room 611, 3302 Gaston Avenue, Dallas, TX.
E-mail: zandinejad@tamhsc.edu
The authors declare that they have no
potential conflict of interest.
Accepted August 5, 2019
doi: 10.1111/jopr.13103
Abstract
Purpose: To compare the fracture resistance of implant-supported milled zirconia,
milled lithium disilicate, and additively manufactured zirconia crowns.
Materials and Methods: Maxillary cast with a dental implant replacing right sec-
ond bicuspid was obtained. Custom abutments and full-contour crowns for milled
zirconia, milled lithium disilicate, and additively manufactured zirconia crowns
(n = 10/group) were digitally designed and fabricated. The crowns were cemented to
implant-supported zirconia abutments and mounted onto polyurethane blocks. Frac-
ture resistance was determined by vertical force application using a universal testing
machine at a crosshead speed of 2 mm/minute. Kruskal-Wallis test was used to analyze
data and failure mode was determined for all the groups.
Results: Milled zirconia crowns demonstrated the highest median fracture resistance
(1292 ± 189 N), followed by milled lithium disilicate (1289 ± 142 N) and additively
manufactured zirconia (1243.5 ± 265.5 N) crowns. Statistical analysis showed no sig-
nificant differences in fracture resistance between the groups (p = 0.4). All specimens
fractured at the implant-abutment interface.
Conclusion: Additively manufactured zirconia crowns demonstrated similar fracture
resistance to milled ceramic crowns, when cemented to implant supported zirconia
abutments. The results of this in vitro study signify the promising potential of additive
manufacturing for the fabrication of all ceramic zirconia crowns.

Increasing demands for esthetic restorations have led to the
growing popularity of ceramics in implant dentistry. Re-
placing missing teeth in the esthetic zone is a challenging,
but predictable procedure.1-7 Ceramic abutments were devel-
oped in an attempt to deliver esthetically optimal clinical re-
sults. With respect to the final color of the restoration and
soft tissue surrounding the crown, all ceramic crowns sup-
ported by ceramic abutments yield esthetically superior restora-
tions in contrast to full metal or porcelain fused to metal
crowns.8-10
The incorporation of digital workflow in dentistry has led
to the further development of all-ceramic crowns. CAD/CAM
milling or subtractive manufacturing is currently regarded as
state-of-the-art technology to manufacture all-ceramic restora-
tions including zirconia.11 However, some limitations of this
technology include material wastage, introduction of microc-
racks, and limited reproduction of surface details depending
upon the size of milling tool.12,13
Additive manufacturing (AM) technologies are an alternative
to milling and have been successfully used in manufacturing
resin and metal prosthesis,14-16 with only limited progress in
fabrication of zirconia and ceramic restorations.17,18 AM has
been defined by the American Society of Testing and Materials
(ASTM) as “the process of joining materials to make objects
from 3-dimensional (3D) model data, usually layer-upon-layer,
as opposed to subtractive manufacturing methodologies.” The
ASTM has classified seven different technologies for AM:
stereolithography (SLA), material jetting, material extrusion,
binder jetting, powder base fusion, sheet lamination, and
direct energy deposition. Besides many other advantages,
AM technologies can also be selected to create dental
restorations with complex macrogeometries and controlled
gradients, which cannot be fabricated using conventional
machining technique.19,20 AM has the potential to overcome
the limitations associated with milling of dental ceramics.
AM technologies have many advantages including mass

Journal of Prosthodontics 28 (2019) 893–897 

C 2019 by the American College of Prosthodontists 893
Additively Manufactured Zirconia Crowns Zandinejad et al

Table 1 Physical and mechanical properties of additive manufactured

zirconia

Physical/mechanical property 3D Mix ZrO2 3D Ceram

Grade 700
Particle size (m) 0.1-0.8
Density (g/cm3 ) 5.97
Vickers Hardness (GPa) 12.6
Young´s modulus (GPa) 209.4
Shear modulus (GPa) 79.8
Flexural strength (MPa) 1088
Compressive strength (MPa) 2070
Coefficient thermal expansion (K−1 ) 12.4

Information provided by the manufacturer.

Figure 1 A, Maxillary master model with implant replacing right max-
illary first premolar. B, Milled zirconia abutment for cemented crown
restoration.

Figure 2 STL2 file. A, Proximal view. B, Occlusal view.

production, reduction in manufacturing time, and less raw
material wastage.21
The objective of this study was to compare the fracture resis-
tance of milled zirconia (MZr), milled lithium disilicate (MLD),
and AM zirconia (AMZr) crowns when cemented to MZr im-
plant abutment.
Material and methods
A maxillary cast with a dental implant replacing right second
bicuspid was obtained (Fig 1A, B). Dental laboratory scan-
ner (DWOS 7 Series scanner; Straumann, Basel, Switzerland)
was used to digitize the master casts. A dental CAD software
(CARES Software; Straumann) was used to design a custom
abutment and the Standard Tessellation Language (STL)1 file
was obtained, which was used to manufacture zirconia implant
abutments (CARES zirconium-dioxide abutment; Straumann,
Arlington, TX) with a chamfer finish line. Abutments were de-
signed to have a buccal and lingual wall height of 6 mm, and a
proximal wall height of 4 mm. The preparation of the abutment
had a total convergence angle of 10° to 12° and a circumferen-
tial chamfer margin of 1 mm (Fig 1 A, B). A total of 30 zirconia
abutments were milled.
The same dental laboratory scanner and CAD software were
used to digitize the zirconia custom abutment and design a full-
contour crown to obtain the STL2 file (Fig 2A, B). Thickness
of the restorative material ranged from 1 to 2 mm. STL2 file
Figure 3 Crowns cemented to zirconia abutments before mechanical
testing. AM full-contour zirconia.
was used to mill 10 lithium disilicate (IPS e.max CAD crown
HT A1; Ivoclar Vivadent, Amherst, NY) and 10 zirconia (Lava
Plus Zirconia W1, 3M Co., St. Paul, MN) implant-supported
crowns.
The same STL2 file was used for AM (CeraMaker 900;
3DCeram Co.) of 10 full-contour zirconia (3DMix ZrO2 paste;
3DCeram Co.) crowns. All the AM samples were produced
by the manufacturer (3DCeram Co., Table 1). The STL2 file
was exported to the manufacturer and crowns were printed in
a layerwise fashion based on the principles of laser SLA. A
suspension of Zirconia particles and liquid photosensitive resin
was used in a reservoir as a raw material to manufacture green
crowns. The working platform descended sequentially and was
loaded with a layer of zirconia slurry tantamount to the thick-
ness of each layer as defined by the printing parameters. The
green crowns were subsequently debinded to eliminate the resin
component, followed by sintering.
All the zirconia abutments were positioned and torqued to
35 N/cm on an implant analog (Straumann RC; Straumann)22
and divided into three groups: MZr crowns; MLD crowns, and
additively manufactured full-contour zirconia crowns (AMZr,
Table 2).
The screw access of the abutment was sealed with Teflon
tape and all the abutments were cleaned (Ivoclean; Ivoclar

894 Journal of Prosthodontics 28 (2019) 893–897 

C 2019 by the American College of Prosthodontists
Zandinejad et al
Table 2 Characteristics of milled and stereolithography (SLA), additive manufactured (AM) zirconia specimens
Group Materials
MZr Cares Zirconia (Straumann)
MLD Lithium disilicate
AMZr 3D Mix ZrO2 (3D Ceram)
*
NP: Not provided.
Vivadent, Schaan, Liechtenstein) following the manufacturer’s
instructions. The intaglio surfaces of the crowns in MZr and
AMZr groups were cleaned similarly (Ivoclean; Ivoclar Vi-
vadent), while the MLD crowns were treated with hydroflu-
oric acid (IPS ceramic etching gel; Ivoclar Vivadent), fol-
lowed by the application of silane coupling agent (Monobond
plus; Ivoclar Vivadent). Subsequently, the intaglio surfaces
of the crowns were filled with a self-adhesive resin cement
(Speedcem plus; Ivoclar Vivadent) followed by the placement
of crowns on the abutments. The crowns were seated us-
ing thumb pressure and excess cement was wiped off using
a 2 × 2 gauze, followed by the application of LED curing
light (3M ESPE Elipar S10; 3M ESPE, 3M Co., St. Paul,
MN) for 20 seconds on all the four external surfaces of the
crown (buccal, lingual, mesial, and distal) to ensure adequate
polymerization.
The implant analog, abutment and crown assemblies (Fig 3)
were subsequently mounted into solid rigid polyurethane foam
blocks (SKU: 1522-05, Saw Bones, Vashon WA). A 12-mm
deep hole was drilled into the center of cuboid polyurethane
blocks for mounting the implant analogs harboring the abut-
ment and cemented crown. Polymethyl methacrylate resin ce-
ment (methyl methacrylate Resin; Monomer-Polymer & Dajac
Laboratories INC., Trevose, PA) was used for cementing the
analogs within the polyurethane blocks. The cement was al-
lowed to set for 24 hours before subjecting the samples to
mechanical loading.
Figure 4 Fracture resistance of control (MZr & MLD) and experimental group AMZr. A, Bar graph. B, Box plot.
Journal of Prosthodontics 28 (2019) 893–897 
C 2019 by the American College of Prosthodontists
Additively Manufactured Zirconia Crowns
Fabrication technique Composition
∗
Milling 5-axis NP
Milling 5-axis NP∗
Laser stereolithography (SLA) Zirconia stabilized with 3% yttria
Mandibular right second bicuspid was prepared on a
mandibular Kavo study model (Kavo Dental model; Kavo, NC)
to receive a cast Co-Cr stainless steel crown (DPM NobleBond;
Argen, San Diego, CA). The Co-Cr crown was used as an antag-
onist to load the experimental crowns. It was cemented using
resin cement (methyl methacrylate resin) on a titanium rod.
Together this assembly contributed to the loading arm, which
was mounted onto the loading frame of the universal testing
machine (MTS Bionix 370; MTS Systems Corp., Eden Prairie,
MN).
Polyurethane blocks harboring the cemented crown on zir-
conia abutment were mechanically affixed between two metal
arms on the horizontal platform of the universal testing ma-
chine (MTS Bionix 370; MTS Systems Corp. Eden Prairie,
MN). Prior to mechanical loading, the experimental and the an-
tagonist metal crowns were locked into maximum intercuspa-
tion. Thereafter, each specimen was subjected to static vertical
loading using the universal testing machine (MTS Bionix 370;
MTS Systems Corp.) at a crosshead speed of 2 mm/minute and
25 kN load cell failure.23 The machine was stopped when a sud-
den reduction in force was observed on the force displacement
curve, which marked the mechanical failure of the system. Fol-
lowing mechanical loading, all the specimens were analyzed to
determine the mode of failure using 4.6× magnification.
Statistical software (SPPS v22; IBM Corp., Armonk, NY)
was used to calculate the means and standard deviations of the
fracture resistance in all groups. Data analysis, histograms,
895
Additively Manufactured Zirconia Crowns Zandinejad et al

Discussion
Zirconia abutments were used in this study as they offer an
esthetic alternative to metal abutments, particularly for patients
presenting with a high smile line and thin gingival margins.
In combination with all ceramic crowns, zirconia abutments
deliver esthetically optimal results.8-10 However, Van Thomp-
son and coworkers demonstrated that titanium abutments with-
stood significantly higher loads than zirconia abutments before
fracturing.24 Other studies have reported similar concerns re-
garding zirconia implant abutments.9 Clinically, however, zir-
conia abutments are capable of withstanding occlusal loads in
the anterior region of the mouth.25-27
In a similar study by Martinez et al, the mean fracture re-
sistance values of MLD (392.9 N) and MZr (340.3 N) crowns
cemented to zirconia abutments were less than the mean frac-
Figure 5 The fracture of zirconia abutment, which was recorded for all ture resistance values for MLD (1257 N) and MZr (1330 N) in
samples in all groups. this study. This can be attributed to the difference in loading
angulation and tooth type.28
Although subtractive computer numerically controlled
and box plots revealed that fracture resistances were not
milling is an approbated technology for the fabrication of all ce-
normally distributed. Therefore, the Kruskal-Wallis test was
ramic restorations in dentistry,29 there are some inherent draw-
used to determine the existence of a significant difference, if
backs associated with this technology. While machining of fully
any, in fracture resistance between the three groups.
sintered ceramic blocks provides precision and accuracy to the
restoration, it subjects the milling tools to heavy abrasion and
Results introduces microscopic cracks on the ceramic surface, which is
detrimental to the longevity of the restoration.13,30 Today, most
MZr demonstrated the highest median fracture resistance
of the commercial systems utilize presintered ceramic blocks
(1292 ± 189 N), followed by MLD (1289 ± 142 N) and AMZr
for milling dental restorations.31 However, the restoration is
(1243.5 ± 265.5 N) crowns (Fig 4A, B). The Kruskal-Wallis
subjected to dimensional changes after further sintering that
test indicated that there was no significant difference in fracture
can compromise the integrity of the restoration.32 Also, a ma-
resistance (p = 0.4) between any of the three groups. Owing to
jor proportion of the prefabricated ceramic blocks is discarded
some technical complications in the universal testing machine,
during the milling process.12,13
fracture resistance values were not recorded for one specimen
Although AM offers many advantages, it has not been ap-
in the MZr and MLD groups (Table 3).
proved as a fabrication technique for ceramic restorations yet.
Samples in all the three groups fractured at the abutment. The
There have been very limited studies on 3D printing of den-
fracture line was located near the interface of zirconia abutment
tal ceramics. To date, there have been no published studies
and implant analog. No significant differences were found in
that have investigated the fracture resistance of printed ceramic
the mode of failure between any of the three groups (p = 0.4)
crowns supported by implants. Therefore, the authors were not
(Fig 5). The crowns were intact in all the groups at the end of
able to find any study to compare and validate the experimental
experimental procedure.
findings related to AM zirconia crowns.
Zirconia abutment turned out to be a common mode of failure
Table 3 Fracture resistance (N), median, and interquartile range for each for all the samples consequent to mechanical loading. The result
group is similar to a previous study by Martinez et al.28 However, in
that study, a combination of crown and abutment fracture was
Sample MZr MLD AMZr reported with lithium disilicate crowns whereas in our study,
1 1250 1093 1355 abutment fracture was the primary mode of failure for lithium
2 1439 1387 1331 disilicate crowns. Using titanium abutments or a combination
3 1400 1331 1038 of titanium base and zirconia could have potentially changed
4 Not Recorded 1520 1205 the outcome of our study by switching the weakest point, which
5 1473 1256 1308 was the zirconia abutment in this study.
6 1292 937 1512 Based on the results of this study, AM zirconia crowns had a
7 1158 1189 624 comparable fracture resistance to MZr crowns when cemented
8 1261 1289 1054 to zirconia abutments. However, this is a pilot study and AM
9 1444 1308 1077 ceramic crowns need to be subjected to further research incor-
10 1249 Not Recorded 1282 porating intraoral simulative parameters to validate AM as a
Median 1292 1289 1243.5 viable technology for the fabrication of ceramic restorations in
Interquartile Range 189 142 265.5 clinical dentistry.

896 Journal of Prosthodontics 28 (2019) 893–897 

C 2019 by the American College of Prosthodontists
Zandinejad et al
Conclusion
AM all ceramic crowns cemented on zirconia abutments had a
comparable fracture resistance to milled restorations in this in
vitro study. AM appears to be a promising technology for the
fabrication of all ceramic restorations with great potential for
improvement in the near future.
Acknowledgment
This work was supported by the International Team for Implan-
tology (ITI) Grant no. 929 2013.
The authors gratefully acknowledge Dr. Danieli Rodriguez
and the Department of Biomedical Engineering at the Uni-
versity of Texas at Dallas for their support of facilities, test
equipment, and other assistance throughout the project.
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