d e n t a l m a t e r i a l s 2 7 ( 2 0 1 1 ) 83–96

available at www.sciencedirect.com

journal homepage: www.intl.elsevierhealth.com/journals/dema

From porcelain-fused-to-metal to zirconia: Clinical and

experimental considerations

Fernando Zarone ∗ , Simona Russo, Roberto Sorrentino

Dept. of Fixed Prosthodontics, University “Federico II” of Naples, Italy

a r t i c l e i n f o a b s t r a c t

Article history: Objective. The interest of dental research in metal-free restorations has been rising in
Received 7 October 2010 the last 20 years following the introduction of innovative all-ceramic materials in the
Accepted 22 October 2010 daily practice. In particular, high strength ceramics and related CAD/CAM techniques have
widely increased the clinical indications of metal-free prostheses, showing more favourable
mechanical characteristics compared to the early ceramic materials.
Keywords: The purpose of the present paper is providing a brief review on the all-ceramic dental
Dental ceramics materials, evaluating pros and cons in the light of the most recent scientific results and of
Esthetics the authors’ clinical experience.
Zirconia Materials. A structured review of the literature was given on the basis of medical and engi-
Alumina neering papers published in the last decades on the use of dental ceramics and zirconia
CAD/CAM in particular. The experimental and clinical findings of the most relevant researches were
Fixed prosthesis reported.
Results. Zirconia is one of the most promising restorative materials, because it yields very
favourable mechanical properties and reasonable esthetic. Several in vitro and in vivo inves-
tigations reported suitable strength and mechanical performances of zirconia, compatible
with clinical serviceability as a framework material for both single crowns and short-span
fixed partial dentures. However, clinical results are not comparable, at the moment, with
conventional metal–ceramic restorations, neither is there sufficient long-term data for val-
idating the clinical potential of zirconia in the long run.
Significance. The use of zirconia frameworks for long-span fixed partial dentures or for
implant-supported restorations is currently under evaluation and further in vivo, long-term
clinical studies will be needed to provide scientific evidence for drawing solid guidelines.
© 2010 Academy of Dental Materials. Published by Elsevier Ltd. All rights reserved.

along with a clinically acceptable quality of their marginal

1. Introduction to the review
In the last decades, since the development of porcelain-fused-
to-metal (PFM) procedures in the early sixties, metal–ceramic
restorations have represented the “gold standard” for years
in prosthetic dentistry, thanks to their good mechanical
properties and to somewhat satisfactory esthetic results,
and internal adaptation [1–7]. The predictability and con-
sistency of positive clinical results, validated by long-term
scientific evidence, the ease and accuracy of the conven-
tional casting procedures, as well as the findings of rare
adverse reactions to precious alloys have made PFM crowns
and bridges more and more popular and widespread over
time.

∗
Corresponding author.
E-mail address: zarone@tin.it (F. Zarone).
0109-5641/$ – see front matter © 2010 Academy of Dental Materials. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.dental.2010.10.024
84 d e n t a l m a t e r i a l s 2 7 ( 2 0 1 1 ) 83–96
Nevertheless, the technical procedures of investing wax
patterns and casting precious metal alloys involve many tech-
nical variables and a considerable number of operative steps
and firing cycles, making the final quality of the restorations
highly technique-sensitive. Moreover, the metal framework
and the layer of opaque porcelain needed for masking the
underlaying metal grayish shade are likely to introduce a sig-
nificant limitation for the esthetic result due to the absence of
translucency, especially when a clear tooth color is to be repro-
duced: in fact, metal–ceramic restorations can only absorb
or reflect light, while dental tissues show a high degree of
translucency [8]. Furthermore, from an economic standpoint,
the cost of precious metals has markedly risen over the years
[9].
Since the early introduction of the porcelain jacket single
crowns into the dental practice, at the end of the XIX cen-
tury, dental ceramics have been considered among the most
promising restorative materials, because of noticeable pros-
thetic advantages: esthetic appearance, chromatic stability,
biocompatibility, low plaque retention and fluids absorption,
high hardness, wear resistance, low thermal conductivity,
chemical inertness. However, early dental ceramics encoun-
tered a undeniable degree of resistance in the clinicians’
perspective of an extensive, routine use due to limiting
factors for an acceptable restoration longevity, mainly asso-
ciated to mechanical shortcomings: brittleness, low tensile
strength and fracture toughness, ease of crack propagation,
poor marginal fit, difficulty of repair.
In the last 30 years, the growing patients’ demand for highly
esthetic and natural-appearing restorations has led to the
development of new all-ceramic materials, whose mechani-
cal characteristics have been dramatically improved, in order
to provide suitable longevity and limitation of the technical
problems. In a few cases, however, the increasing industrial
pressure on the one hand and growing enthusiasm for attrac-
tive esthetic outcomes on the other have led to an early intro-
duction on the market of unreliable, not sufficiently tested
products, resulting in commercial and clinical disasters.
To date, a large number of studies and scientific data
have been produced in order to investigate the mechanical
properties of dental ceramics, mainly aimed at getting an
evidence-based validation of the metal-free materials and of
the related manufacturing systems.
The purpose of the present paper is providing a brief review
on the all-ceramic dental materials and their related produc-
tion techniques, evaluating pros and cons in the light of the
most recent scientific results and of the personal prosthodon-
tic experience of the authors.
2. Literature
2.1. Glass- and alumina-based dental ceramics
An ideal all-ceramic dental material should exhibit excellent
esthetic characteristics, like translucency, natural tooth color,
outstanding light transmission and, at the same time, opti-
mal mechanical properties, like flexural strength (), fracture
toughness and limited crack propagation at the functional and
parafunctional load conditions, in order to ensure lifetime ser-
viceability. Unfortunately, today, none of the available dental
ceramics fulfills all of these requirements at the same time,
neither is any of them suitable for every different clinical situ-
ation both in anterior and posterior regions. A comprehensive
review on this topic was provided in 2007 by Conrad et al. [10].
First of all, it has to be pointed out that not all of the dental
ceramics show equally favorable esthetic features: to date, an
inverse proportion between strength (i.e., the mechanical per-
formance) and optical properties (i.e., the esthetic appearance)
still seems to be a rule.
Feldspathic ceramics usually provide excellent esthetic,
together with very good biocompatibility and mechanical
resistance to compressive forces, but, unfortunately, they eas-
ily fracture under shear loads, owing to low tensile strength.
A first, successful attempt at strenghtening feldspathic porce-
lain was made by McLean and Hughes [11] in the mid-sixties,
who dramatically reinforced dental porcelain with the addi-
tion of up to 50% aluminum oxide powder.
Today, the best esthetic characteristics are still displayed
by the class of the glass–ceramics: optimal light transmission,
high translucency and natural, tooth-like colors also in the
presence of very light shades. Early glass–ceramics, like Dicor
(Dentsply, USA), no longer on the market, attained only limited
success because of the modest survival rates [12]; on the con-
trary, leucite-reinforced glass–ceramic (IPS Empress—Ivoclar
Vivadent, Lichtenstein) have been highly appreciated for more
than 20 years thanks to their outstanding esthetic perfor-
mances [13–16]. Inside the Empress ceramic ingots, leucite
crystals, that measure only a few microns, are embedded in
a glass matrix; the wax pattern of the restoration is invested
and burned out, then, at high temperature the glass–ceramic
is pressed into the mold (“hot-pressed”). Due to their low val-
ues of flexural strength (∼100–120 MPa) [17], leucite-reinforced
ceramics are only indicated in the anterior region, where
esthetic is paramount, both for single crowns (SCs) and lam-
inate veneers. In a long-term study (11 years), a remarkable
survival rate of 98.9% was evidenced with IPS Empress anterior
SCs, however such a value dropped to 84.4% in the posterior
region [18]. With respect to the veneers, IPS Empress yielded
a success rate of 98.8% after 6 years [19], equivalent to the
positive results reported for the veneers made of feldspathic
ceramics (91–94% at 12 years) [20,21].
A significant improvement in clinical performance was
introduced by lithium disilicate glass–ceramics, veneered
with fluoroapatite-based ceramics, like IPS Empress 2 (Ivoclar
Vivadent, Lichtenstein), showing higher flexural strength
(∼350 MPa) than the precedent ones and, at the same time,
very appealing translucency, much more suitable than in
zirconia-based ceramics [8,22]. For such promising charac-
teristics, lithium disilicate glass–ceramics have been advised
for clinical use in SCs (molar region excluded) and 3-units
fixed partial dentures (FPDs) in the anterior region; in the last
years, moreover, both their mechanical and optical proper-
ties have been enhanced, with the development of IPS e.max
Press (Ivoclar Vivadent, Lichtenstein), thanks to some tech-
nical improvements in the production process [23]. Favorable
survival rates for SCs have been reported, from 95% [24] to
100% [25] at 5 years; less encouraging was the survival data
related to the IPS Empress 2 FPDs, with very different results
at 2 years (50% survival rate according to Taskonaz and Sert-
 d e n t a l m a t e r i a l s 2 7 ( 2 0 1 1 ) 83–96
guz [26] compared to 93% reported by Esquivel-Upshaw et al.
[27]) but quite poor results at 5 years (70%) [25].
Another noticeable improvement in the mechanical prop-
erties of all-ceramic restorations was offered by the so-called
“glass-infiltrated high-strength ceramic core systems”, devel-
oped for the first time in the late eighties with In-Ceram
Alumina, followed, after some years, by In-Ceram Spinell and
In-Ceram Zirconia (VITA Zahnfabrik, Germany). All of these
oxide-ceramics allow the realization of highly stable frame-
works for SCs or three-unit bridges with one pontic, based on
the so-called “slip-casting technique”: a semi-liquid mixture
containing up to 80 wt% of metal-oxides, like Al2 O3 (In-Ceram
Alumina), MgAl2 O4 (In-Ceram Spinell) or Al2 O3 + ZrO2 (In-
Ceram Zirconia), is sintered to a refractory die, so creating
a porous, oxide-ceramic core that undergoes a further fir-
ing cycle for lanthanum glass infiltration. Thanks to such a
process, the framework flexural strength and load-bearing
capacity are remarkably enhanced: the infiltrated glass fills
the minute spaces and voids that might initiate cracks and
induce excessive stress concentrations in the core struc-
ture [28]. Eventually, the esthetic veneering material (i.e. a
feldspathic ceramic) is layered on the core surface. In-Ceram
Alumina (described flexural strength between 350 and 500 MPa
[17,22,29–32]) has been on the market for more than 20 years,
well accepted by clinicians not only for its fairly good mechan-
ical properties but also for a natural esthetic appearance.
Survival rates shown by many studies on In-Ceram Alumina,
with observational periods comprised between 3 and 7 years,
ranged from 94% to 99.1% for SCs, with a higher amount
of complications in the posterior sites (crown fractures or
chippings) [29,33–36]. A similar trend was evidenced for the
In-Ceram Alumina posterior bridges when compared to the
anterior 3-unit FPDs: a survival rate of 83% in the posterior
sites, mainly influenced by connector fractures, was evidenced
by Sorensen et al. in a three years study, raising to 100% in
the anterior regions [37]. Other studies with longer obser-
vational periods (between 5 and 10 years) showed, for such
3-unit FPDs, survival rates ranging from 73.9% at 5 years [38]
to 88% at 10 years [39]. In-Ceram Spinell is characterized by
a lower mechanical strength ( = 350–400 MPa) than the other
glass-infiltrated ceramics, but shows better optical properties,
like high translucency and optimal light diffusion. Its use has
been limited to the anterior crowns, with fairly good survival
rates (from 97.5% at 5 years [40]). In-Ceram Zirconia is a glass-
infiltrated zirconia-toughened alumina (ZTA), in which, for the
first time, zirconium oxide was used as in a dental ceramic;
as reported below, thanks to its metastable nature, zirconia
is a high performance ceramic material [41]. High strength
cores are composed of 67 wt% of aluminum oxide + 33% of
12 mol% cerium-partially stabilized zirconium oxide [16], so
that zirconia crystals (grain size < 1 ␮m) are embedded in an
alumina matrix (larger grains <2–6 ␮m, high elastic modulus)
in such a composition that yields the highest tenacity and
flexure strength inside this class of ceramics ( = 400–800 MPa):
microcracks may trigger the so-called “transformation toughen-
ing” of zirconia (see below), so that a crack tip is more often
seen to propagate through the alumina matrix surrounding
the transformed crystals [42,43]. ZTA can be manufactured
according to two different processes: soft machining or slip-
casting. The latter presents the advantage of a more limited
85
shrinkage but, at the same time, higher porosity and poorer
mechanical properties than yttrium partially stabilized tetrago-
nal zirconia polycrystal (3Y-TZP) [43–46], the strongest and most
commonly used zirconia-based ceramic. Moreover, stabiliza-
tion by cerium oxide provides better thermal stability and
resistance to Low Temperature Degradation (LTD) than Y-TZP
[47–50]. According to the manufacturer’s indications, ZTA is
suitable for 3-unit FPD frameworks with one pontic in the
posterior sites (reported survival rate at 3 years = 94.5% [51]),
while, on the other hand, it exhibits intense opacity and low
translucency [22]; although providing an efficient masking
power in presence of dark colors or discolored teeth, ZTA is
not appropriate for situations in which a high esthetic result
is paramount.
Besides slip-casting for the glass-infiltration technique,
another widespread and successful production system for
alumina-based restorations is CAD/CAM industrial manu-
facturing of densely sintered, high-purity alumina (Procera
AllCeram, Nobel Biocare AB, Goteborg Sweden) introduced in
the early nineties and extensively utilized for both single-
unit restorations and 3-unit anterior FPDs so far. The Procera
AllCeram core is realized by compacting, with an industrial
process performed at a centralized manufacturing plant in
Sweden, high purity aluminum oxide against an enlarged,
refractory die of the prepared tooth obtained through a scan-
sion by the dental technician; eventually, the coping is milled
in the outer aspect and then sintered to full density. In
the end, the resulting, leucite-free porcelain framework, con-
taining about 99.9% alumina in a polycrystalline state, is
veneered with low-fusing feldspathic ceramic. AllCeram cores
are characterized by a higher flexural strength than glass-
infiltrated pre-sintered alumina [52] that, in addition to the
pure and homogeneous structure of aluminum oxide and to
the accuracy of the sinterization process, can explain the
very good mechanical performance and resistance to frac-
ture, still maintaining a fair translucency and opalescence
[14,53–55]. As to the marginal fit, gaps ranging between 60
and 80 ␮m were detected, demonstrating a suitable prosthetic
precision of fit [56,57] and also from the clinical standpoint
marginal integrity was reported to be excellent or acceptable
[54,55,58].
In a recent study, the use of luting resin cement with
Procera AllCeram alumina SCs significantly showed a lower
amount of mechanical complications in a sample of 209 tooth-
and implant-supported SCs, with cumulative survival and
success rates of 95.2% and 90.9%, respectively, after 6 years
of function [55]. Other authors observed lower microleakage
when aluminum oxide blasting plus silane treatment was per-
formed before the luting phase [57,59,60].
Various studies in the last years reported a quite good clin-
ical serviceability of polycrystalline, densely sintered alumina
SCs. Cumulative survival rates of 97.7% and 93.5% and cumu-
lative success rates of 97.7% and 92.2% after 5 and 10 years,
respectively were recorded [58]. A recent retrospective clinical
study on 86 alumina SCs reported success rates, in anterior
esthetic sites, of 100% (supported by natural tooth) and 98.3%
(implant-supported) over 4 years of function; the total crown
success rate was 98.8% [54]. In another clinical investigation,
the cumulative survival rate was 100% in the anterior region
and 98.8% in the posterior region after 5 and 7 years of service;
86 d e n t a l m a t e r i a l s 2 7 ( 2 0 1 1 ) 83–96
clinical success was achieved irrespective of the tooth position
[61].
From such data, it can be inferred that Procera AllCeram
alumina crowns can provide reliable, high strength clinical
solutions for anterior sites restorations, both supported by
natural teeth and by osseointegrated implants, with a pref-
erential indication when high load conditions are foreseen
and the more translucent and esthetic glass–ceramics would
be likely to fail. On the contrary, some criticism arose about
the clinical use of laminate veneers made of high density
polycrystalline alumina (Procera AllCeram, Nobel Biocare AB,
Goteborg Sweden). A 3D finite element analysis (FEA) study
based on a very careful and up-to-date modeling technique
was conducted to evaluate the biomechanical behavior of
feldspathic versus alumina porcelain veneers [62]; its results
demonstrated different performances in terms of elastic
deformations and stress distributions, feldspathic ceramics
better simulating the biomechanics of sound enamel. On
the contrary, alumina significantly withstanded deformations
inside the veneer structure but, at the same time, high stress
concentrations at the adhesive interfaces were generated;
these might negatively influence the clinical performances of
both the side of bonding agent and of resin cement, with high
risk of bonding failure [62]. Another drawback for an exten-
sive use of such veneers is that densely sintered alumina is
a non-etchable material and the adhesion between this poly-
crystalline ceramic and dental tissues remains controversial,
to date; compared with the high predictability of the adhesion
between feldspathic ceramics and resin cements, this aspect
represents a further noticeable limitation that, along with a
poorer esthetic outcome and a scarceness of scientific sup-
port, does not justify to replace materials like glass/pressed
ceramics for laminate veneers [63].
2.2. Zirconia
Since it was introduced in Dentistry, the polycrystalline
zirconium dioxide (zirconia) resulted particularly attractive
in prosthodontics, due to its excellent mechanical proper-
ties and improved natural-looking appearance compared to
metal–ceramics [43].
Due to the increasing interest in dental applications of such
an innovative material, a brief review of the main related top-
ics is presented here, with no reference to cementation and to
the optical/chromatic properties, in that these issues will be
treated in different articles.
Zirconia is chemically an oxide and technologically a
ceramic material [64], not soluble in water, that was proved
not to be cytotoxic [65–67] and not to enhance the bacterial
adhesion, that is lower than on titanium, as demonstrated by
both in vitro and in vivo studies [68–70]; moreover, it exhibits
a favorable radio-opacity and a low corrosion potential [43].
Pure, unalloyed zirconia is polymorphic and allotropic at
ambient pressure, presenting three crystallographic shapes
at different temperatures: cubic (c) (from 2680 ◦ C, the melt-
ing point, to 2370 ◦ C); tetragonal (t) (from 2370 ◦ C to 1170 ◦ C);
monoclinic (m) (from 1170 ◦ C to room temperature) [64]. When,
upon cooling, the spontaneous transformation from the (t)
phase to the more stable (m) phase occurs, a simultane-
ous, noticeable volume increase of the crystals (4–5%) ensues
[42,71], creating high compressive stresses in the material: as
a matter of fact, until the twenties, in spite of the worldwide
abundance of zirconia in very large quantities, such a material
could not be utilized as a refractory for brick manufacturing
due to the onset of severe cracks, as reported by Lughi and
Sergo [64] in their elegant and updated review on the mechan-
ical properties of zirconia. In the thirties, such a drawback
was clarified and interpreted as a potential, outstanding prop-
erty of the zirconia [41,72]: when alloyed with other “cubic”
oxides like MgO, CaO, Y2 O3 and CeO2 (so-called “stabilizers”),
the phase transformation could be prevented, so retaining the
zirconia crystals in their tetragonal or cubic shape at room
temperature, in a thermodynamically metastable state. This
property is the main reason why the biomedical research over
the last years has been increasingly focusing on such a mate-
rial, in that it can induce a remarkable increase in fracture
toughness of the material by hindering (but not preventing
[10,16,73]) the propagation of a crack; in fact, at a possible crack
tip, tensile stress concentration generates the transformation
from metastable (t) ZrO2 to the (m) crystalline phase. The con-
sequent volume increase of the crystals, constrained by the
surrounding ones, results in a favorable compressive stress,
that acts as a crack-limiter [64]. Such a mechanism has been
defined “transformation toughening” or “phase transforma-
tion toughening” (PTT) [71,74] and, along with the grain size of
such a material, can explain why zirconia presents the highest
flexural strength and fracture toughness among all the other
ceramics.
At room temperature, the transformation from tetragonal
to monoclinic is a one-way process. This means that, once
it takes place, the crack-hindering effect cannot be exploited
for limiting further fractures, “like a used match cannot be
lit again” [64]. Heating the material at a temperature between
900 ◦ C and 1000 ◦ C for a short time, the process can be reversed
[75,76]; in this case, the phase transition from monoclinic back
to tetragonal form, rather than making crystals available again
for further transformation and crack repair, generates a relax-
ation of the advantageous compressive stress at the surface,
reducing the material toughness. From this point of view, the
high temperature thermal process of veneering zirconia with
feldspathic ceramic should be taken into account as a possible
risk of such a detrimental reverse transformation [43].
The grain size dramatically influence the mechanical
behavior of zirconia, in that higher temperatures and longer
sintering times produce larger grain sizes [77]. The critical
crystal size is approximately 1 ␮m: above such dimension, zir-
conia is more prone to spontaneous PTT due to lower stability,
whereas a smaller grain size makes zirconia less susceptible
to this phenomenon [78], although below 0.2 ␮m PTT does not
happen and zirconia fracture toughness decreases [79]. Con-
sequently, the sintering conditions are paramount since they
influence the crystal size, strongly affecting the mechanical
properties and the stability of zirconia [80] and have to be
strictly controlled in the whole production process.
Although being many types of zirconia-based ceramics
available, to date three zirconia-containing systems have been
more or less extensively used for dental applications. Two
of them are by-phasic materials: the previously mentioned
“glass-infiltrated zirconia-toughened alumina” (ZTA) and the
“magnesium partially stabilized zirconia” (Mg-PSZ); the third,
 d e n t a l m a t e r i a l s 2 7 ( 2 0 1 1 ) 83–96
most used, is the “yttria partially stabilized tetragonal zirconia
polycrystal” (3Y-TZP), a mono-phasic material [43,74].
2.3. Magnesium partially stabilized zirconia (Mg-PSZ)
The microstructure of Mg-PSZ consists of clusters of tetrag-
onal crystals within a cubic stabilized zirconia matrix. The
added stabilizer is MgO (8–10 mol%). As regards dental applica-
tions, with some exceptions (Denzir-M—Dentronic AB), such a
material has not been extensively used, neither has it encoun-
tered large popolarity due to its remarkable porosity, large
grain size (30–60 ␮m), low stability, tendency to framework
wear [73], and overall poor mechanical properties, especially
when compared to 3Y-TZP [43,48].
2.4. Yttrium partially stabilized tetragonal zirconia
polycrystal (3Y-TZP)
This type of zirconia is made of transformable, t-shaped grains
stabilized by the addition of 3 mol% yttrium-oxide (Y2 O3 ). Such
a polycrystalline material exhibits low porosity and high den-
sity [81]; at the moment it is the most popular and frequently
used form of zirconia commercially available for dental appli-
cations.
2.5. Mechanical properties of zirconia
The mechanical performances of zirconia were extensively
investigated on both SCs and 3- and 4-unit FPDs, with variable
reported data, due to a noticeable difference of experimental
conditions and measurements. Mechanical properties of zir-
conia were proved to be higher than those of all other ceramics
for dental use, with a fracture toughness of 6–10 MPa/m1/2 ,
a flexural strength of 900–1200 MPa and a compression resis-
tance of 2000 MPa [43,73,82]. An average load-bearing capacity
of 755 N was reported for zirconia restorations [83]. Fracture
loads ranging between 706 N [83], 2000 N [84] and 4100 N [76]
were reported; all of the studies demonstrated that in dental
restorations zirconia yields higher fracture loads than alumina
or lithium disilicate. A recent in vitro investigation on zirco-
nia FPDs evidenced failure loads ranging between 379 and
501 MPa, thus higher than average human biting force, con-
firming a satisfactory serviceability of such frameworks [85].
2.6. “Aging” of zirconia
The low temperature degradation (LTD), or “aging”, of zirconia
is a well known process, strictly related to the PTT, of which
represents the other side of a same coin: it consists in a sponta-
neous, slow transformation of the crystals from the tetragonal
phase to the stabler monoclinic phase in absence of any
mechanical stress. This phenomenon decreases the physical
properties of the material and exposes zirconia frameworks
at the risk of spontaneous catastrophic failure [86]. Mechani-
cal stresses and wetness accelerate zirconia LTD; other factors
affecting such a process are: grain size, temperature, vapor,
surface defects of the material, type, percentage and distribu-
tion of stabilizing oxides and processing techniques [64,87].
Although LTD is to be considered as a risk factor for
mechanical prosthetic failures, to date such a direct relation-
87
ship has not been demonstrated by scientific evidence in the
clinical service [43,88]. Even though the long-term effects of
LTD on zirconia in dental restorations have not been com-
pletely investigated yet, aging is regarded as likely to induce
detrimental changes in the mechanical behavior of the mate-
rial, like microcracking, strength decrease, enhanced wear
rates with release of zirconia grains in the surrounding envi-
ronment [89,90], as well as surface roughening, with further
degradation of mechanical and esthetic properties [43,86,91].
An in vitro research was aimed at comparing failure loads of
standardized zirconia 3-unit FPDs before and after exposure to
an artificial aging process by means of a mastication simulator,
corresponding to a 5-years of clinical function (about 1,200,000
cycles of thermomechanical fatigue in liquid environment).
Such a treatment reduced the failure loads of all test samples,
with significant differences due to different fabrication tech-
niques for each system, but such a reduction ranged within
clinically acceptable values; in fact, all test specimens showed
minimum failure loads higher than 1000 N, both before and
after fatigue loading, thus widely exceeding average masti-
catory loads [92]. In the same paper, a cautionary warning
was addressed to clinicians about the risks of intentionally
leaving a Y-TZP framework without ceramic veneering at the
level of the gingival side of the FPDs, as suggested by other
researchers, in order to enhance the core strength [46]; this
would expose the framework zirconia to the intraoral sali-
vary environment, increasing, at the same time, the potential
for plaque retention and reducing resistance to low temper-
ature degradation and service life [92]. Such an issue is still
debated and controversial; in any case, further investigations
will be necessary to elucidate the relationship between aging
of zirconia and long-term survival of the products [88].
2.7. Manufacturing procedures
CAD/CAM zirconia dental frameworks can be produced
according to two different techniques: “soft machining” of pre-
sintered blanks or “hard machining” of fully sintered blanks
[43,93,94].
The soft machining process is the most diffused manu-
facturing system for 3Y-TZP, based on milling of pre-sintered
blanks that are fully sintered at a final stage. Such zirconia
blanks, at the so-called “green state”, are produced by com-
pacting zirconia powders (in presence of a binder that will be
eliminated in the following pre-sinterization step) through a
cold, isostatic pressing process; this results in a very narrow
pore size (20–30 nm) and quite homogeneous distribution of
the components inside the blank [43,80]. Processing at a proper
pre-sintering temperature of zirconia is a crucial factor since
this parameter affects hardness, machinability and roughness
of the blanks. From the manufacturers’ point of view about the
choice of the most convenient production technique, hardness
and machinability act as opposite factors: an adequate hard-
ness is necessary to manipulate the 3Y-TZP blanks safely, but,
if excessive, it is detrimental to a proper machinability. More-
over, higher pre-sintering temperatures create rougher blank
surfaces [43,80].
After scanning a stone die of the supporting abutment(s) (or
directly the wax pattern of the crown/FPD), a virtual, enlarged
framework is designed by sofisticated CAD softwares. Then,
88 d e n t a l m a t e r i a l s 2 7 ( 2 0 1 1 ) 83–96
through a CAM milling procedure, a framework with enlarged,
accurately controlled dimension is machined out of the blank.
At the end, the sinterization is completed at high temperature:
the zirconia framework acquires its final mechanical proper-
ties in that it undergoes a linear volume shrinkage of about
25%, so regaining its proper dimensions. Such processing is
known to produce very stable cores containing a significant
amount of tetragonal zirconia with surfaces virtually free from
monoclinic phase [43]. Nevertheless, a certain amount of cubic
zirconia may be present due to an uneven distribution of
yttrium oxide. The cubic phase is richer in stabilizing oxides
than the surrounding tetragonal crystals and this may nega-
tively influence the stability of the material [77].
Frameworks can be colored either adding minimum
amounts of metal oxides to the zirconia powder or, after
machining, by soaking the core in solutions of metal salts
(like cerium, bismuth or iron); the framework coloration seems
neither to induce PTT nor to decrease the mechanical perfor-
mance of the restorations [43,95].
Soft-machining is the preferred process by the majority of
the manufacturers, like Procera Zirconia (Nobel Biocare AB,
Goteborg, Sweden), Lava (3 M ESPE, Seefeld, Germany) and Cer-
con (Dentsply Degudent, Hanau, Germany).
In the hard machining technique, on the other hand, the
3Y-TZP blocks are previously densely sintered through a pro-
cess called “hot isostatic pressing”: at high temperatures
(1400–1500 ◦ C) and high pressure in inert gas environment,
very hard, dense and homogeneous blocks of fully sintered
zirconia are produced [96], out of which the frameworks
are shaped to the proper, desired form and to the right,
final dimension by using powerful and resistant milling
machines with diamond abrasives. Hard-machining of Hi-
pressed (“HiPed”) Zirconia is utilized by Denzir (Decim AB,
Skelleftea, Sweden) and DC-Zirkon (DCS Dental AG, Allschwill,
Germany).
The issue of which technique is suitable to get the bet-
ter outcomes still remains a controversial topic. The major
drawback of soft-machining is the problem of matching the
sintering shrinkage of the framework to the enlargement
amount programmed by the software as precisely as possible
[16]. In any case, some in vitro investigations have confirmed
high fracture toughness and flexural strength with differ-
ent production techniques, using both hot and cold isostatic
pressed zirconia blanks [45,46].
It is clear that, compared to the soft-machining, the hard-
milling procedure is more time consuming and requires
cutting devices that have to be very tough and resistant to
wear; the fully sintered 3Y-TZP blocks are much harder and
less machinable of both fully sintered zirconia and densely
sintered alumina blocks, making milling time much longer
and the production procedure more expensive [64]. From an
operative point of view, moreover, milling zirconia blanks at
thin sections is very difficult and can lead to unpredictable
results [97]. Finally, it has been demonstrated that grinding
such blocks introduces various kinds of surface microcrack
and defects [98], both of the “brittle” and the “ductile” type,
depending on various factors, such as the grain size of the
diamond burs or the rotation speed: fine burs determine a
more “ductile” damage compared to the “brittle” fractures
due to the coarse ones, while high speed grinding proce-
dure allows to reduce the applied force to the block and
minimize the dimension and depth of the surface defects
[98]. In any case, there is high level of evidence that all sur-
face treatments creating stress, like grinding, sandblasting or
indentations on the zirconia surface determine some degree of
(t) > (m) transformation before clinical use [64,99] being detri-
mental to the long-term serviceability of zirconia restorations
[100–102]. Surface grinding can determine deep defects that
reduce toughness [99,103], decrease the strength [104,105],
and the consequent exposure of the processing flaws to wet-
ness may have further detrimental effects [87]; the resultant
alteration of phase integrity is reported to increase the suscep-
tibility of the material to aging [106]. Frameworks produced
by hard machining exhibit a considerable amount of mon-
oclinic zirconia, associated with higher susceptibility to LTD
and surface microcracking, resulting in a less stable material
[77]. In any case, since there is no standardization of the treat-
ments utilized, it is very difficult to compare the results of
the studies focused on the surface treatments of zirconia [43].
Soft machining procedures provide predictable stability of the
framework, as long as its surface is not damaged after sinter-
ing (e.g. by an occlusal adjustment). To date, the surface state
after processing is still a controversial issue, particularly after
hard machining, although there is wide agreement on the fact
that microcracking due to processing flaws or occlusal adjust-
ments is among the main causes of fatigue damage and failure
[43].
Residual stress, like that arising when zirconia is fired at
high temperature and then rapidly cooled down or when a
ceramic material with different coefficient of thermal expan-
sion (CTE) is used for veneering, was found to be a more critical
factor than final surface roughness in inducing LTD [106]. Fur-
thermore, the presence of large cubic phases is detrimental to
the resistance of zirconia to LTD and aging [77].
Scientific interest has been rising over the last years toward
a possible use of cerium oxide as a stabilizer for dental appli-
cations at higher concentration than yttria (8 mol%) [107].
Under similar conditions and thermo-cycling, ceria partially
stabilized zirconia (Ce-TZP) showed better thermal stability
and resistance to LTD than Y-TZP and, furthermore, before
the fracture point, it exhibited the highest bending capac-
ity among the ceramic materials [47]. The major drawback
that has mainly limited a use of such a material in the den-
tal practice is its basic yellow-brownish color, along with a
marked mutability over time, with the tendency to a dark gray
shade after exposition to reducing substances (like glucose or
lactose) [64]. Further investigation is needed to identify possi-
ble future utilization of mixtures between alumina, ceria and
yttria to get better and better outcomes [64].
As regards the framework thickness, almost all manufac-
turers agree in considering 0.5 mm the minimum thickness
for copings, in order to prevent core deformation [43,108]. It is
a well accepted concept that framework thickness and shape
should be optimized and individualized to achieve an even
thickness of veneering ceramic [48] as well as a suitable sup-
port for it.
CTE compatibility between the zirconia-based framework
and the veneering ceramic is a very critical factor from the
mechanical point of view. This topic will be treated at a later
point.
 d e n t a l m a t e r i a l s 2 7 ( 2 0 1 1 ) 83–96
Another important aspect determining the mechanical
properties of zirconia-based FPDs is connector shape and
size. In some clinical trials, fractures of zirconia FPDs have
been shown to be associated with insufficient connector
height [109–112], since such prosthetic component, con-
necting retainers and pontic(s), represents a locus minoris
resistentiae under load [113]. Flexural strength has to be high
enough to withstand occlusal loads, since connectors are
under applied tensile stress, so the dimensions of connectors
are paramount factors for the long-term success of zirconia
FPDs; however, they are limited in height by the presence of the
periodontal soft tissues [109,113]. Notwithstanding the lack of
strong scientific evidence about the ideal connector size, some
in vitro analyzes recommended minimum diameters of about
3.0–6.0 mm for 3-unit, 4.0–6.0 mm for 4-unit and 5.0–6.0 mm for
5-unit zirconia FPDs [114] and these are the recommended fig-
ures by most manufacturers. Moreover, another in vitro study
suggested that the radius of curvature at the gingival embra-
sure of the connector strongly affects the fracture resistance
of all-ceramic FPDs; therefore, the gingival embrasure should
have a radius as wide as possible [113].
2.8. Precision of fit
The precision of the zirconia-based restorations is dependent
on various factors, like differences in manufacturing systems,
individual characteristics of the prosthesis (e.g. span length,
framework configuration), effect of veneering and influence
of aging [82]. As to soft-machined 3Y-TZP restorations, the
precise numerical compensation required by such a system
for the enlargement ratio of the model is a paramount factor,
strictly dependent also on the composition and homogeneity
of pre-sintered zirconia blanks that should be consistent and
precise [82].
For SCs, milled dense zirconia copings showed high accu-
racy of fit, ranging between 0 and 74 ␮m [45,46,97,103,115,116].
As regards zirconia FPDs, in recent literature various in vitro
and in vivo studies investigated the precision of fit of such
restorations, although different experimental designs and
evaluation procedures made the data comparison very hard to
do: for example, some studies did not cement the specimens
while others used different luting agents; furthermore, some
procedures involved impression taking whereas other inves-
tigations employed scanning techniques. In these studies, the
absolute marginal gaps ranged between 9.0 and 148.8 ␮m,
with an average value of 73.8 ␮m. Higher discrepancies were
detected at the internal gap (i.e. the internal distance mea-
sured between the coping and the abutment), ranging between
68.8 and 215 ␮m in the occlusal direction and between 52.3 and
192 ␮m in the axial direction [82].
An in vitro investigation [117] reported lower values of
absolute marginal opening when a feather-edge was realized
during the tooth preparation (87 ± 10 ␮m), while the detected
values were higher for mini-chamfer (114 ± 11 ␮m), shoulder
(114 ± 16 ␮m) and chamfer finish line (144 ± 14 ␮m); however,
due to the limits of the in vitro experimental design and to
the mechanical limitations of feather edge preparations, such
a finish line design was not recommended for clinical appli-
cations of zirconia SCs by the same authors.
89
A relationship between the extension of zirconia FPD and
the marginal fit has been demonstrated, in that the larger
the FPD span, the higher the detected marginal discrepancies
[97,118]. Moreover, also the shape of the framework exhibits
a relationship to marginal fit: a straight framework design,
i.e. with pontics positioned in the straight line with retain-
ers, resulted in more accurate margins than curved framework
configurations [119]. Some authors advise that, in case of com-
plex prosthetic geometry, post-sintered, hard machining is the
most predictable manufacturing system [82].
As to veneering process, its final effect on the overall fit still
remains controversial.
About manufacturing techniques, two studies demon-
strated less marginal discrepancies with post-sintered
machining [120,121], while another investigation did not
record any difference between hard- and soft-milling [122].
Moreover, two studies proved that CAD/CAM systems resulted
in lower marginal discrepancies [111,120], whereas other two
investigations did not highlight any significant difference
between CAD/CAM, in which the design step is performed by
software, and CAM only, where such a procedure is realized
by scanning both the internal and the external aspects of a
wax-modeled physical framework [119,121].
Interestingly, a fatigue load simulation demonstrated that
thermal and masticatory stimulation did not influence the
marginal fit of zirconia FPDs. At the same time, aging seemed
not to affect the long-term stability of zirconia fit and marginal
integrity [122].
It can be concluded that most of the currently available
zirconia-manufacturing systems provide clinically acceptable
marginal and internal gaps; however, remarkable variations
were evidenced using different systems and materials. For an
extended, detailed analysis of the research data on zirconia-
based restorations fit, refer to the review by Abduo et al. [82].
2.9. Clinical and experimental studies on zirconia
As pointed out, in the last decade an increasing interest
in the zirconia as a dental material for SCs and FPDs has
led to the realization of several clinical trials focused on
defining success/survival rates of such restorations. Most
of these studies investigated the clinical results with pos-
terior FPDs [111,112,123–139], while only a few were about
SCs [140,141] and implant abutments [124,142,143]; only one
regarded implant-supported FPDs [132].
The choice of zirconia as a core material for SCs, both in
the anterior and in the posterior sites, has been increasing
over time with clinical results that seem quite comparable to
metal–ceramic single restorations, although clinical trials are
very few, to date. Zirconia SCs showed a success rate of 93%
after a 2 years observation period, with a favorable soft tis-
sue response, in a limited sample size of 15 Cercon crowns
(Dentsply Degudent, Hanau, Germany) [140]. Another investi-
gation with a longer observational period (3 years), performed
on 204 Procera zirconia SCs delivered in a private practice,
showed a survival rate of 93%; in this study, 16% of compli-
cation were recorded (6% loss of retention, 2.5% extraction of
abutment teeth, 5% persistent pain, 2% porcelain chipping)
[141].
90 d e n t a l m a t e r i a l s 2 7 ( 2 0 1 1 ) 83–96
On the contrary, a larger amount of data regarding zir-
conia posterior FPDs is emerging from various studies that
showed quite favorable clinical results; not differently from
metal–ceramic bridges, failures have been reported, both
related to biologic complications, like secondary caries, and
to technical problems, such as fracture of the bridge or chip-
ping of the veneering ceramic [6,124,144]. Comprehensive
systematic reviews of the literature on the survival rates of
all-ceramic SCs and FPDs in comparison with metal–ceramic
restorations have been published [5,6], reporting, after 5
years of observation, favorable survival rates (95.6%) for
metal–ceramic prostheses, to be compared to a figure of
93.3% for all-ceramic restorations, among which zirconia-
based prostheses showed the best clinical performances and
resulted as the most reliable all-ceramic systems. Zirconia was
affected only by cracking or chipping of veneering ceramic,
whereas other all-ceramic restorations showed some frame-
work fractures. It has been pointed out that it is very difficult,
and in some cases impossible, to make a scientifically valid
comparison between the results of different clinical stud-
ies conducted on the various zirconia-based FPDs, for the
diversity in the research methods, evaluation parameters, pro-
duction techniques and observation periods. After 2 years of
function, a recent clinical short-term research reported 100%
survival rate [126]. After 3 years of clinical service, almost
all of the studies reported very good clinical outcomes for
zirconia-based FPDs, with failure rates between 0% and 4.8%
[111,124], showing a promising reliability of such restorations
[123,130,145]. In a clinical study on 18 teeth, one failure was
reported, due to a radicular fracture [145]. At 4 years of use,
the reported failure rates were comprised within 4% and 6%
[138,139]. To date, in such studies the longest observational
period was 5 years [6,128]; 3–5-unit posterior zirconia FPDs on
natural teeth were evaluated, with the only exception of a 3-
unit FPD in the anterior site, replacing a lateral incisor [128].
After 5 years of clinical service, the overall survival rate ranged
between 74% [6] and 100% [125,128].
In conclusion, positive success rates have been recorded in
most investigations and a suitable serviceability of zirconia-
based FPDs seems to be expected in the medium-term.
The reported mechanical complications related to such
restorations are framework fractures, chipping of veneering
ceramic and loss of retention.
Zirconia framework fractures were reported in only 5 stud-
ies, 3 on FPDs [6,111,112], 1 on SCs [140] and 3 on inlay-retained
FPDs [134]. The incidence of core fractures ranged between 3%
[112] and 10% [134] and such data seem to indicate a strong
relationship to the design of the prostheses, in that the high-
est incidence was recorded with inlay-retained FPDs. It can be
inferred that bulk fractures should be considered very unfre-
quent events; when they occur, connectors of multi-unit FPDs
or second molar abutments are mainly interested.
Conversely, crazing or chipping (superficial cohesive frac-
tures) of the veneering porcelain were reported by the majority
of the studies as the most frequent complications affecting
zirconia-based prostheses, mainly at level of posterior teeth
and indipendently from the type of restoration. According to
Sailer et al. [129], after 5 years of clinical service, 3–5-unit
posterior zirconia FPDs supported by natural teeth exhibited
secondary caries as the most common cause of (biologic) fail-
ure, affecting 21.7% of the restorations, whereas porcelain
chipping occurred in 15.2% of the prostheses. In a study con-
ducted on implant-supported FPDs, a much higher incidence
of porcelain chipping (54% after 1 year of clinical service) was
reported [132]. So far, the incidence of chipping reported in the
studies in zirconia-based restorations ranges from 0% to 54%
after 1 or 2 years of observation [123,127,132,146], in any case
less favorable than the figures referred to PFM restorations
(gold-based alloys) in the scientific literature: 98% of intact
porcelain over 5 years [147] and 4–6% of ceramic-related fail-
ures recorded over 10 years [148]. The estimated risk per year
of ceramic chipping for all-ceramic restorations is 2.92% [6].
Nonetheless, it is quite arduous to come to conclusions based
on the comparison of such data, due to evident differences
in machining systems, failure evaluation criteria, follow-up
period and clinical experience of the operators. It has also to
be highlighted that, in the majority of the cases, chippings
did not hinder function, being repairable [123,127,132,137];
sometimes the problem was easily solved by intraorally pol-
ishing the restoration surface [112,137], while, in another
study, repair was carried out with composite resin [131]. Only
in very few cases of major chipping or when serious esthetic
problems arose, the restorations needed a total replacement
[6,141].
Although minor cohesive fracture of veneering ceramic
being the most frequent typology of failure reported in the
majority of the cited clinical studies, exposure of the under-
lying zirconia core was rarely observed and, in any case, it
is very hard to detect by the naked eye. Chipping of veneer-
ing porcelain occurred also in non-load bearing areas [6,112],
even though second molars and connectors of mandibular
posterior FPDs were the preferential sites for such mechan-
ical complications, probably due to the more intense biting
forces [123,133,141].
The causes of porcelain chipping may be material-related
to some extent; on the other hand, factors may be also
dependent on the prosthetic design, such as core-porcelain
thickness ratio and framework architecture. An incorrect
shaping of the framework does not provide adequate, uniform
support to the veneering ceramic and this could play a critical
role in porcelain chipping. As well as in metal–ceramics, the
zirconia-based FPD frameworks should be shaped in order to
ensure an optimal support to veneering porcelain, that should
be mainly subjected to compressive loads, limiting detrimen-
tal tensile stresses. In metal–ceramics, this is conventionally
achieved by wax-modeling the complete anatomic contour
of the restoration and, later, creating the correct spacing for
veneering ceramics by means of the controlled, so-called “cut-
back” technique; in this way, the proper ceramic thickness for
both an optimal esthetic and mechanical performance can be
achieved, avoiding excessive porcelain thickness (>2 mm) [9].
The shape of zirconia frameworks should be customized by
dental technicians according to such requisites, rather than
modeled according to the concept of uniform thickness of zir-
conia.
As previously seen, surface damages can represent a start-
ing point for the onset of fractures. Recent fractographic
examinations [111,112,124] demonstrated that chipping of the
veneering ceramic may origin from occlusal roughness, that
can be the consequence of possible incorporation of air bub-
 d e n t a l m a t e r i a l s 2 7 ( 2 0 1 1 ) 83–96
bles during the powder buildup for veneering porcelain or
the result of damages originating from occlusal adjustments,
likely exposing the underlying zirconia core. Spontaneous
delamination, i.e. interfacial adhesive failure separating the
zirconia core from the veneering ceramic, also has been con-
sidered as a possible modality of failure, but it can only be
evidenced by a microscopic examination [134] and, in any case,
most authors are quite skeptical about a likely occurrence
of delamination, since the bond strength between zirconia
and dedicated veneering ceramics is higher than the cohesive
force of the porcelain itself [49,50,149–152].
It is clear that ceramic veneer cracking is a multifactorial
phenomenon and that only some of its possible causes have
been distinctly highlighted: among the others, differences in
CTEs between framework and ceramic, firing shrinkage of
porcelain, areas of porosities, flaws on veneering, poor wetting
by veneering material on core, improper framework sup-
port, overloading and fatigue [49,50,153–155]. Even though the
nature of the bonding between zirconia cores and veneering
porcelain has not been completely clarified and the compat-
ibility parameters have not been definitely characterized yet
[151], CTE seems to play a crucial role in such a phenomenon.
Dedicated ceramics have been developed for zirconia in order
to reduce mechanical problems, but further investigations on
the bond between zirconia core and veneering ceramic are
needed. Nowadays, almost all of zirconia-based systems offer
veneering ceramics specifically developed to exhibit CTEs
compatible with zirconia frameworks. In agreement with a
principle that has been widely applied by dental technicians
in manufacturing metal–ceramic restorations, a little, con-
trolled mismatch of such parameters seems to be advisable,
in terms of a lower veneering ceramic CTE than the zirco-
nia CTE, in order to place porcelain under compression and
reduce the risk of crack development by increasing the bond-
ing strength to the framework [82,156]. At the same time,
tempering residual stresses are to be controlled, to prevent
the onset of detrimental tensile forces and to limit porcelain
chipping risks; this is obtained by lowering the cooling rate
after the final firing or glazing of porcelain [155]. Presumably,
other interacting factors can be involved in the compatibil-
ity issue between zirconia and veneering ceramics, but not
all of them have been sufficiently studied yet: tensile stresses
concentrated at the zirconia–ceramic interface [64]; chemical
processes, like the harmful dissolution of refractory materi-
als (like zirconia) induced by silicate glasses contained in the
veneering ceramics [157]; surface phase changes, as those due
to a depletion of stabilizing oxides determined by functional
wear or ceramic adjustments, leading to destabilization of the
(t)—zirconia [158,159]. All of these and other possible factors
will need further investigation to understand the nature, clin-
ical impact and possibility of prevention of porcelain chipping
in zirconia-based crowns and bridges.
Loss of retention has been reported to be another possible
technical complication with all kinds of luting agents, partic-
ularly in FPDs; anyway, in the zirconia clinical trials, all of the
debonded restorations were eventually recemented success-
fully [96]. The estimated risk per year of loss of retention for
all-ceramic prostheses has been reported to be around 0.47%
[6]. Differently, catastrophic, not repairable fractures probably
caused by debonding of the restorations were observed with
91
some inlay-retained FPDs cemented with resin luting agents
[134].
None of the cited clinical trials took bruxism into account,
more often such a parafunction figuring among the exclu-
sion criteria: consequently, since they were not considered in
any clinical investigation, parafunctional activities should be
regarded as a potential limitation for zirconia-based restora-
tions [96].
Although it has been demonstrated that, among the
metal-free restorative materials, zirconia exhibits the high-
est mechanical properties, from a clinical standpoint, zirconia
bridges maximum span remains controversial: 5-unit is the
maximum serviceable extension for zirconia FPDs supported
by a piece of scientific evidence [132]. As regards more
extended prostheses, further investigations with longer obser-
vational times are needed to draw solid guidelines, even
though some manufacturers suggest and support the tech-
nology for fabricating full-arch restorations.
It has to be noticed that in a few of the analyzed clinical tri-
als, some restorations presented cantilevers; notwithstanding
none of them was affected by framework failure, the authors
themselves did not recommend the cantilevered design for
zirconia FPDs, particularly in distal segments [134].
According to in vitro cyclic fatigue tests, Y-TZP was
reported to have a lifetime prevision comparable to that
of metal–ceramic prostheses, with a predicted serviceability
longer than 20 years [114]. Nevertheless, two main drawbacks
were noticed to be more frequent for zirconia in comparison
to metal–ceramic restorations: chipping of veneering ceramic
and accelerated aging, so further clinical studies with longer
observational period will be necessary to thoroughly investi-
gate the clinical behavior and reliability of zirconia in the long
term.
As a last note, it has to be taken into account that, in the last
years, a conspicuous interest in the clinical utilization of zirco-
nia in implant-borne restoration has been growing. Most of the
implant manufacturer’s brands provide customized zirconia
abutments for their platforms, either produced by CAD/CAM
techniques or milled from fully sintered blocks. The few pub-
lished studies show promising results and favorable hard and
soft tissues responses after 4 years of service; no abutment
fracture was reported but two screw loosenings were observed
[142]. Another study recorded 100% survival rate of zirconia
single implant abutments after 3 years of follow-up [143]. How-
ever, as stated in a recent consensus report [160], the mean
follow-up time of ceramic abutments in the available clinical
reports is 3.7 years, while for metal abutments is 4.8 years; so
far, data are not sufficient to define the indications and per-
formance limits for such abutments. Similarly, as regards the
application of CAD/CAM technologies for fabricating implant-
supported all-ceramic restorations, especially FPDs or large
fixed, full-arch prostheses, available data are not sufficient to
compare at a convenient level of evidence such production
systems with the conventional ones.
3. Summary
The trend toward an increasingly extended use of all-ceramic
SCs and FPDs is an undeniable reality in Fixed Prosthodon-
92 d e n t a l m a t e r i a l s 2 7 ( 2 0 1 1 ) 83–96
tics. After the development era, dental ceramics introduced
in the last 20 years exhibit different, favorable and promis-
ing esthetic and mechanical properties. At the moment, there
is no one ceramic material that equally excels in all of these
characteristics. The choice of one specific typology of ceramic,
rather than on the latest fashion, should be based on a care-
ful evaluation of the very advantages and disadvantages of
the material related to the specific dental application, always
referring to clinical data with a proper level of scientific evi-
dence and paying attention to the real esthetic needs of the
patient.
Further investigations regarding bonding to veneering
ceramic, cementation procedures, aging and wear and, above
all, long-term clinical performance of zirconia will be needed
to define potential and limitations of such an innovative,
promising and intriguing restorative material.
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