Received: 1 September 2023 Revised: 1 October 2023 Accepted: 3 October 2023

DOI: 10.1111/jerd.13151

REVIEW ARTICLE

Zirconia restoration types, properties, tooth preparation

design, and bonding. A narrative review

Taiseer A. Sulaiman DDS, PhD 1 | Abdulhaq A. Suliman BDS, MS, MS, PhD 2 |
3 4
Aous A. Abdulmajeed DDS, PhD | Yu Zhang PhD, FADM

1
Division of Comprehensive Oral Health,
University of North Carolina, Adams School of Abstract
Dentistry, Chapel Hill, North Carolina, USA
Objective: The purpose of this review was to provide dental professionals with
2
Department of Clinical Sciences, College of
Dentistry, Ajman University, Ajman, UAE
information regarding the various types of zirconia restorations, their mechanical and
3
Department of General Practice, School of optical properties, tooth preparation design, and bonding protocol in an effort to
Dentistry, Virginia Commonwealth University, enhance the longevity and durability of zirconia restorations.
Richmond, Virginia, USA
4
Department of Preventive and Restorative
Overview: The yttria content of zirconia ceramics determines their classification.
Sciences, School of Dental Medicine, The mechanical and optical properties of each type are discussed, with an empha-
University of Pennsylvania, Philadelphia,
sis on the effect of yttria concentration on the properties of zirconia. The proces-
Pennsylvania, USA
sing and sintering methods are also discussed as they have a direct impact on the
Correspondence
properties of zirconia. The design of tooth preparation, specifically occlusal
Taiseer A. Sulaiman, Division of
Comprehensive Oral Health, University of reduction, varies depending on the type of zirconia used in each case. Finally, a
North Carolina, Adams School of Dentistry,
4604 Koury Oral Health Science Building,
protocol for zirconia restoration bonding is described to ensure optimal bonding
CB 7450, Chapel Hill, NC 27599, USA. to the tooth structure.
Email: sulaiman@unc.edu
Conclusion: Not all zirconia restorations are the same. The selection of zirconia type
based on yttria concentration, processing and sintering methods, tooth preparation
design, and adherence to the bonding protocol are all critical to the success and lon-
gevity of zirconia restorations.
Clinical Significance: Zirconia restorations are the most commonly used indirect
restorative material. The selection of the most appropriate zirconia type based on its
yttria content, which determines its strength and translucency, is critical to the success
and the longevity of the restoration. Tooth preparation design also influences the
strength and translucency of the zirconia. Air-borne particle abrasion, followed by a
ceramic primer and resin cement, can ensure a durable bond to the tooth structure.

KEYWORDS
ceramics, operative dentistry, properties, prosthodontics, restorative dentistry, zirconia

1 | I N T RO DU CT I O N zirconia materials depending on their yttria concentration and struc-

When a clinician writes a laboratory prescription to his or her dental
technologist requesting a “monolithic zirconia restoration,” the state-
ment is incomplete unless the type of zirconia necessary for a particu-
lar case is specified. This review will describe the many types of
ture design. In addition, the mechanical and optical properties of each
zirconia type, as well as how to optimize the bonding of the zirconia
restoration to the tooth structure, will be discussed, along with clinical
recommendations for selecting the most appropriate type of zirconia
restoration based on tooth locations.

J Esthet Restor Dent. 2023;1–7. wileyonlinelibrary.com/journal/jerd © 2023 Wiley Periodicals LLC. 1

2 SULAIMAN ET AL.
2 | Z I R C O N I A C E R A M I C S A N D YT T R I A
C O N CE N TR A T I O N
Yttria-stabilized tetragonal zirconia polycrystal (Y-TZP) is the most
robust, biocompatible, and corrosion resistant of all restorative
ceramics. It exists in three phases: monoclinic (at room temperature),
 
tetragonal (above 1170 C), and cubic (above 2370 C) with tetrag-
onal being the strongest and most durable. Yttria is added to the zir-
conia powder to stabilize tetragonal zirconia at room temperature.1
There are traces of other oxides in zirconia ceramics and with no glass,
therefore, zirconia cannot be etched with conventional hydrofluoric
acid used for etching glass ceramics. The zirconia ceramics' strength is
a major factor in its widespread use in dentistry.
The first generation of zirconia ceramics contained 3 mol% of
yttria and 0.25 wt% alumina and is referred to as 3Y-zirconia. This
generation was characterized by its high strength and very low trans-
lucency. However, due to its affordable cost, improvements had to be
made to the restoration's translucency for it to be accepted. To
achieve that, the alumina content was reduced from 0.25 to 0.05 wt
%. This effectively reduced the concentration of alumina particles at
the boundaries of the tetragonal grains, allowing more light to trans-
mit through than the first generation.2–4 This second generation con-
tains >70% tetragonal and <30% cubic, depending on the sintering
temperature, and is also referred to as 3Y-zirconia.5 It possesses high
strength due to a phenomenon called transformation toughening. This
indicates that when a crack starts to propagate it triggers the sur-
rounding tetragonal particles to partially transform to the monoclinic
phase. The monolithic crystals are larger in size and volume than the
tetragonal crystals, creating a compressive stress around the crack
that prevents its propagation.6,7 As the use of monolithic zirconia as a
full contour restoration increased, manufacturers investigated the
possibility of further increasing zirconia's translucency so that it can
be used in the anterior dentition for more esthetically demanding
cases. By increasing the concentration of yttria from 3 to 5 even
6 mol%, researchers were able to improve the translucency of
zirconia, and this “third (5Y)” generation zirconia restoration was
advertised as cubic (containing) or translucent zirconia. The push for
5Y-zirconia as a translucent and long-lasting and esthetic indirect
restorative material aimed to compete with glass ceramics. What was
overlooked about 5Y-zirconia was that the increase in its translucency
came with the sacrifice of its strength, yet it was nonetheless classi-
fied as monolithic zirconia. The explanation of this to the clinician and
technician was not made clear. When the concentration of yttria
increases from 3 to 5 mol%, the proportion of cubic content to tetrag-
onal content increases to an estimated ratio ranging from 50:50 to
70:30.5 It is not possible for cubic zirconia to undergo phase transfor-
mation. Therefore, the zirconia's resistance to crack propagation
reduces, and its fracture strength decreases significantly. As a rule, as
the percentage of yttria increases, the translucency increases and the
strength decreases (Table 1).
Unfortunately, there are no specific clinical studies that support
the use of 5Y-zirconia. Long-term follow up of any clinical trial involv-
ing monolithic zirconia restorations is minimal to conclude any clinical
effectiveness. Communications between clinicians, technicians, and
researchers have risen due to the increased observation in monolithic
zirconia fractures, and there was much confusion as to why such a
robust ceramic material might fracture. It is now acknowledged that
increasing the yttria concentration weakens the material and is the
primary cause of zirconia restorations failing prematurely. This issue
was recognized by manufacturers and a 4Y-zirconia was introduced to
increase the strength while keeping an acceptable level of translu-
cency in comparison to 3Y zirconia. With 60%–75% tetragonal or
25%–40% cubic contents, 4Y-zirconia is promoted as a zirconia type
that can combines strength and translucency.5 Chairside-zirconia mill-
ing has been a favor for this type of zirconia such as Chairside Zirconia
(3M, USA) and Katana STML (Kuraray Noritake, Japan).
Recently, a multi-yttria type of zirconia (5 and 3Y) and (5 and 4Y)
has been introduced. This type of zirconia is intended for the lower
yttria concentration to be designed in the cervical-middle third of the
crown (for strength) and higher yttria concentration in the middle-
occlusal third (for translucency). With the weakest part of zirconia
located on the functional portion of the crown, there is a risk that
under load, cracks that originate in the occlusal third may progress,
resulting in chip fracture or, in the best-case scenario, ceasing in the
middle-cervical third.8 A recent chewing simulation study9 compared
the fracture resistance and survival rate of multi-yttria layered zirconia
(5/3Y, ZirCAD Prime and 5/4Y ZirCAD MT Multi; Ivoclar Vivadent:
Schaan, Liechtenstein) to 4 and 3Y-zirconia (ZirCAD LT and MT;
Ivoclar Vivadent: Schaan, Liechtenstein). The yttria content signifi-
cantly affected the fracture resistance of the crowns. The mean
fracture resistance, from highest to lowest was 3Y-PSZ, 4Y-PSZ,
followed by the 5/3Y and 5/4Y zirconia. The fracture resistance of
multilayer zirconia crowns is dictated by the amount of the weaker
zirconia phase in the occlusal portion of the restoration, and not
by the stronger zirconia in the cervical portion.
Certificates issued by the Division of Identalloy Council describ-
ing the manufacturer of the zirconia crown and the composition
should now be mandatory to present with every case returned by the
laboratory. Importantly, the percentage of yttria has always been pre-
sented to clinicians by unit mol%. It is presented on the certificate by
unit wt%. This means 5–6 wt% equals 3 mol%, 7–8 wt% equals 4 mol
%, and 8–9 wt% equals 5 mol%.
A clinician is strongly encouraged to collaborate with a dental
technician who is not only talented but also knowledgeable. It is
equally important for the technician to understand the differences
between the various types of zirconia and to follow the request made
by the clinician on the lab form. The clinician could request that the
laboratory to check the IFU for the zirconia to determine the pub-
lished Y wt%. Alternatively, if the technician believes that the clini-
cian's request is not appropriate for the case, he or she can provide
their opinion regarding the most appropriate option. In a recent study,
zirconia specimens were ordered from 9 dental laboratories for poste-
rior (high strength) and anterior (high translucency) clinical indications.
The specimens were then tested and evaluated for their mechanical,
physical, and optical properties.10 The outcome was quite interesting
and confirming that there is a large discrepancy in strength and
SULAIMAN ET AL.
TABLE 1 Mechanical properties of different zirconia types based on yttria concentration.
Yttria concentration
Zirconia type (mol%, wt%)
3Y-zirconia 3 mol%, 5–6 wt%
4Y-zirconia 4 mol%, 7–8 wt%
5Y- zirconia 5 mol%, 8–9 wt%
5Y/3Y-zirconia 3–5 mol%, 5–9 wt%
5Y/4Y-zirconia 4–5 mol%, 7–9 wt%
translucency based on yttria content. Moreover, dental laboratories
DID NOT always adhere to the details requested in a prescription for
zirconia.
3 | ZIRCONIA PROCESSING AND
SINTERING
Regardless of the type of zirconia, pre-sintered zirconia pucks are
milled and then sintered. Zirconia's mechanical, physical, and optical
properties are significantly influenced by the sintering process.11 The
traditional sintering process can take up to 12 h. As the processing
and sintering processes are carried out in the laboratory and require
attention to detail, it is essential to work with a technician who pos-
sesses the necessary expertise. Clinician only sees the end result and
has no idea how the zirconia was processed and sintered, as most zir-
conia restorations appear identical; however, their properties can be
severely compromised.
Focus has been placed on reducing sintering time to allow zirco-
nia to be processed in 1 day. Currently, furnaces are equipped with
sintering programs that allow zirconia to be sintered in as little as
10 min. Due to the function of sintering, the primary concern with
changing the sintering program was the potential impact on the zirco-
nia's properties. In vitro studies have confirmed that speed sintering
has no effect on zirconia's properties,12,13 which is great news for
same-day dentistry as zirconia restorations can be delivered on the
same day. It is essential to note, however, that not all zirconias can be
speed sintered. When speed sintered, certain zirconia types may
result in the formation of voids between particles14; certain restora-
tion geometrical parameters, notably thickness, may cause nonuni-
form densification and even introduce cracks.15,16 It is crucial to
calibrate the type of zirconia that can be speed sintered by contacting
the manufacturer.
4 | Z I R C O N I A R E S T O RA T I O N P R O P E R T I E S
Zirconia can be manufactured as a core material that is then veneered
with porcelain, or as a monolithic restoration. Monolithic zirconia
strength can range from 400 to 1300 MPa depending on yttria con-
tent. It also has a fracture toughness that can range from 2.4 to
6 MPa m1/2. Due to the relatively high mechanical properties, the
3
Strength Fracture toughness Elastic
(MPa) (MPa m1/2) modulus (GPa)
900–1300 3.5–4.5 200–210
600–800 2.5–3.5 200–210
300–600 2.2–2.7 200–210
300–1200 2.2–4.5 200–210
300–600 2.2–3.5 200–210
hardness (around 14 GPa) and elastic modulus (around 210 GPa) of
zirconia are high as well (Table 1).17 These properties are significantly
higher as compared to those of a natural tooth. Concerns regarding
such a strong, hard, and stiff material should not be disregarded. What
long-term effect will this material have on the periodontal ligament or
an osteointegrated implant? Only long-term clinical follow-up will
accurately answer this question.
Optical characteristics of zirconia has been a focus of researchers
and manufacturers alike. Translucency parameter values at 1 mm
thickness can range from 12 (3Y-zirconia) to 25 (5Y-zirconia), the
smaller the value the lower the translucency.3–5 In addition, contrast
ratio value of 1 is a complete opaque state. It is reported that
contrast ratio value at 1 mm for 3Y-zirconia has been reported to be
around 0.90, and for 5Y-zirconia around 0.70.3–5 Understanding how
the eyes perceive translucency is crucial from a clinical standpoint.
These reported values exceed the translucency threshold, indicating
that you can perceive the difference in translucency between 3Y- and
5Y-zirconia, with the latter being more translucent (Table 2). Clinically,
it is important to understand these properties when deciding which
type of zirconia to use to mask a dark underlying structure, as the
more translucent 5Y-zirconia will have difficulty masking it effectively.
Alternately, and because of its low translucency, 3Y-zirconia should
be considered when there is a dark underlying structure, such as an
amalgam or cast core, or a titanium abutment. Cast post and core
were planned to be restored with a zirconia fixed dental prosthesis, as
shown in Figure 1A. For the purpose of clinically demonstrating the
significance of selecting the proper type of zirconia when masking
dark underlying structure, a 5Y zirconia restoration (Figure 1B) was
utilized to demonstrate how a more translucent zirconia has a difficult
time masking the cast post and core. The more appropriate selection
in this case would be a 3Y zirconia restoration (Figure 1C), with a
thickness more than 1 mm, combined with using a white opaque-
shade luting resin-based cement, ultimately has enough opacity to
mask the cast post and core. For enhanced characterization, layering
the facial with porcelain would be ideal to result in the most esthetic
outcome. Another study18 has also confirmed that layered zirconia
and the white-opaque resin-based luting agent presented a significant
effect on the substrate masking ability.
Most anterior monolithic zirconia restorations are externally
stained and glazed to try and emulate the appearance of natural teeth.
This is concerning because the stability of stains and glazes is ques-
tionable. A 5-year toothbrush simulation study evaluated the color
4 SULAIMAN ET AL.

T A B L E 2 Optical properties of
Yttria
concentration Translucency Contrast
different zirconia types based on yttria
Zirconia type (mol%, wt%) parameter ratio concentration.

3Y-zirconia 3 mol%, 5–6 wt% 12–14 0.90–0.93

4Y-zirconia 4 mol%, 7–8 wt% 15–18 0.80–0.85
5Y-zirconia 5 mol%, 8–9 wt% 18–25 0.72–0.78
5Y/3Y-zirconia 3–5 mol%, 5–9 wt% 12–25 0.72–0.93
5Y/4Y-zirconia 4–5 mol%, 7–9 wt% 15–25 0.72–0.85

F I G U R E 1 (A) Cast post and core (teeth #s 5–7, and 10–12) that was restored for demonstration purposes with a 5Y zirconia fixed dental
prosthesis (10–12) (B) to show lack of ability to mask dark underlying structure. (C) 3Y zirconia fixed dental prosthesis (10–12) was used as final
restoration, which shows its capability of masking dark underlying structures.

stability of ceramics externally stained and glazed according to
19
manufacturer instructions. Glass ceramics retained color better
than 3- and 5Y zirconias, while all ceramics loss 40%–50% of its
gloss. Interestingly, a more abrasive (charcoal) toothpaste resulted
in less color stability and greater loss of gloss than a regular and
less abrasive toothpaste. Clinically, when selecting monolithic zir-
conia for esthetic cases, the facial aspect should be cut back and
layered with porcelain to achieve the best esthetic outcome
instead of relying on stains/glazes.
5 | T O O T H P R E P A R A T I O N DE S I G N
Understanding the tooth preparation requirements for any type of
indirect restoration is fundamental for its longevity and outcome
of the restoration. For gold and porcelain-fused-to-metal restora-
tions, classic prosthodontic preparation principles have been eluci-
dated. Many classical principles were recommended for
contemporary ceramics, such as zirconia, but this is not necessarily
the optimal design to maximize the longevity of this restoration.
Based on many manufacturers' recommendation for a layered zir-
conia restoration is to reduce the tooth structure sufficiently to
make room for the bilayered restoration comparable to porcelain
fused to metal. A 1 mm reduction of axial wall is minimal with a
1.5–2 mm reduction of incisal and occlusal surfaces. A skilled tech-
nician will design the core to conform to the tooth's anatomy while
also providing adequate support for the veneering porcelain. A flat
core design will create occlusal anatomy with unsupported porce-
lain, which has been one of the primary causes of porcelain chip-
ping. There are no defined tooth reduction design principles for
monolithic zirconia preparation design. Some manufacturers have
recommended that a 0.5 mm reduction is sufficient, while a 1 mm
reduction is optimal. Others recommended reducing the tooth
structure like a gold restoration. Important to consider when pre-
paring for a monolithic zirconia restoration: Are tooth preparation
guidelines the same for all types of zirconia?
A fatigue study evaluated the fracture and fatigue resistance
of 3-, 4-, and 5Y zirconias with 0.7- and 1.2-mm thicknesses, simu-
lating a 5-year clinical outcome.20 Fatiguing had minimal effect on
the fracture strength of zirconia. However, the most clinically rele-
vant outcome is survivability. 3Y zirconia specimens had zero fail-
ure post-fatiguing for both thicknesses. This can be explained
simply by the transformation toughening phenomenon, as previ-
ously explained, because 3Y zirconia is predominantly tetragonal
and can transform to monoclinic and resist crack propagation. The
4Y zirconia at 0.7 mm thickness had 50% fracturing before com-
pleting the 5-year clinical simulation. When the thickness was
increased to 1.2 mm thickness, no fracture occurred. For the 5Y
zirconia specimens, 75% fractured at 0.7 mm thickness, while 35%
fractured at 1.2 mm thickness. The lack of fracture resistance in 5Y
zirconia can also be explained by the transformation toughening
phenomenon, in which a lower proportion of tetragonal particles
and a higher proportion of cubic particles reduces the ability to
resist crack propagation.
The contention that ceramics are strengthened when a resin
cement is used to bond the restoration to the structure is controver-
sial. A recent review asked the question: Does adhesive luting rein-
force the mechanical properties of dental ceramics used as restorative
materials? Twenty studies were included in the meta-analysis, and the
conclusion was that adhesive luting strengthens the mechanical prop-
erties of glass–ceramic restorations but not zirconia restorations.21
Regardless if you agree or not with this conclusion, when strength is
of the essence, it is important to select a zirconia type with optimal
strength that can resist fracture in heavy-load-bearing areas, if
SULAIMAN ET AL.
adhesive luting enhances the strength in any way, that would be a
“cherry on top.”
In response to the question: are tooth preparation guidelines the
same for all zirconia types? The obvious response is NO. Based on
the outcome of the fatigue study,20 the occlusal reduction guideline
for zirconia restorations should be 1 mm when a 3Y zirconia is
selected, 1.2 mm minimal reduction for a 4Y zirconia, and 1.5 minimal
reduction if a 5Y zirconia ceramic is used. Axial wall reduction must be
a minimum of 1 mm with a light chamfer margin design. Some clini-
cians have advocated a feather edge design for simplicity and tooth
conservation; however, when communicating with technicians, this
will present difficulties in finishing the margin and preventing chip-
ping. Once the crown with a feather-edge margin has been bonded to
the tooth, the concern is alleviated. Finally, respect and follow an ana-
tomical preparation, particularly occlusally in the central groove area,
where a flat-cut preparation will challenge the technician to design
occlusal anatomy, resulting in reduced thickness in the area where
clinical fractures are most likely initiate.
6 | C E M E N T A T I O N / B O N DI NG OF
ZIRCONIA RESTORATIONS
When proper resistance and retention form are present in the abut-
ment, any conventional cement may be utilized. However, when there
is insufficient retention form, the zirconia restoration must be bonded
using a resin cement. If a diligent bonding protocol is followed, a zirco-
nia restoration can be bonded to the tooth structure.22 The bonding
protocol is a combination mechanical and chemical pre-treatment.
The mechanical pre-treatment involves air-borne particle abrasion
with 50 μm Al2O3 particles, 2.5 bar pressure for 10 s at a 10 mm
standoff distance. While the chemical pre-treatment involves using a
ceramic primer that contains silane and a 10-MDP monomer. An
adhesive or self-adhesive resin cement is used to bond the zirconia to
23
the tooth structure. These steps were simplified by Blatz et al. using
the acronym APC, which stands for Air-borne particle abrasion,
Primer, and Resin Cement.
Debonding of zirconia has been an issue in recent years, causing
many clinicians to lose confidence in bonding zirconia restorations.
Due to zirconia's high affinity for salivary, blood lipids, and proteins,
contamination during the try-in phase was a leading cause of debond-
ing. Decontamination cannot be achieved with conventional methods
used for glass ceramics for example phosphoric acid, steaming, ultra-
sonic bathing, and so forth. There have been numerous cleaning solu-
tions that have been introduced to address this issue. A study
examined cleaning methods and solutions of contaminated zirconia
24
material. Rinsing the contaminated surface with water, applying
phosphoric acid, and applying a ceramic primer prior to contamination
were all ineffective at decontaminating the zirconia surface and signif-
icantly decreased the bond strength. Designated zirconia cleaning
solutions (Katana Cleaner; Kuraray, Ivoclean; Ivoclar, ZirClean; Bisco)
performed similarly and as expected by chemically decontaminating
the zirconia surface. Airborne-particle abrasion was the most effective
5
method for removing salivary contamination from zirconia, as it
mechanically decontaminates the surface.
After cleaning the zirconia surface, a ceramic primer is applied. It
is recommended to scrub the primer with agitation and allow it to
soak into the dense particle surface of zirconia rather than quickly
blasting the primed surface with air.23,24 After applying the primer for
2–3 min, a gentle stream of air is used to evaporate any excess sol-
vents. An adhesive or self-adhesive resin cement is used to bond the
zirconia to the tooth structure.
It is recommended that the clinician takes responsibility of air-
borne particle abrasion themselves after try in, due to the critical
parameters that must be meticulously followed. Moreover, it has been
researched that air-borne particle abrasion instantly after try in, fol-
lowed by primer application within this brief period, creates a posi-
tively charged surface whose surface energy allows a better priming
capability.25 On the other hand, if a technician were to abrade the zir-
conia 2–3 days before sending the restoration to the clinician, the sur-
face energy is lost and priming capabilities are not as efficient
resulting in significantly lower bond strength. The recommended
sequence for optimally bonding zirconia is as follows: ask the techni-
cian not to abrade the surface, try in the restoration, followed by air-
particle abrasion according to the previously defined parameters,
steam clean, or air-blast the surface, then primer application followed
by the resin cement.
Proper polymerization of the resin requires sufficient light curing.
This is frequently overlooked by clinicians and can be a significant
cause of zirconia debonding. Zirconia attenuates light due to its opac-
ity, preventing sufficient light energy from penetrating to the resin.
Thickness of the restoration is also a confounding factor.3 To over-
come and prevent under-curing the resin cement, sufficient energy
can be delivery by increasing the curing time.3 To achieve this, it is
recommended to cure each surface for at least 40 s. Be cautious of
curing lights with high irradiance that claim to shorten curing times;
they do not provide sufficient energy to the resin cement.
7 | A FT E R Z I R C O N I A C E M E NT A T I O N
Occlusal adjustment is a common clinical practice to ensure proper
occlusion. When zirconia is the restoration required to adjust, it is
important to understand that this ceramic restoration behaves differ-
ently than other indirect restorations. Generally, chairside ceramic
adjustment introduces microcracks, weakens the ceramic, and can
result in ceramic fracture. Due to the ceramic nature of zirconia, its
adjustment is significantly more challenging. Any adjustment of the
zirconia could result in phase transformation. For 3Y and, to a lesser
extent, 4Y zirconias, phase transformation can initially increase
strength; however, as more adjustments are made, more cracks are
introduced, and phase transformation can no longer prevent crack
propagation, resulting in premature fracture.6,26,27 This is more chal-
lenging with 5Y zirconia because it does not undergo phase transfor-
mation to the same extent as 3- and 4Y zirconia due to its lower
tetragonal content. It has been proved that chairside adjustment
6 SULAIMAN ET AL.
reduces zirconia strength regardless of yttria content.28,29 If zirconia
must be adjusted, it is advised to use a fine-grit diamond rotary instru-
ment rather than a coarse-grit instrument, followed by a meticulous
polishing method.30 When polishing is inadequate, a rough zirconia
surface can cause the opposing tooth to wear. However, a highly
polished unglazed zirconia is the friendliest to an opposing natural
tooth compared to other ceramics and even enamel to enamel. 31
Communicate with your technician when completing the zirconia res-
toration to first polish the surface of the zirconia and then, if desired,
apply the glaze. After the glaze has worn away, a highly polished zirco-
nia surface will be revealed.
Clinical survivability of layered zirconia restorations has
acceptable level of evidence. A small number of studies concluded
a 5-year cumulative survival rate of 96% for tooth-supported lay-
ered zirconia restorations and 97% survival rate for implant-
supported restorations.32 Well-designed controlled clinical trials
are extremely lacking, especially for monolithic zirconia. A retro-
spective multicentric study in private practices aimed to evaluate
the outcomes of 619 3- and 4Y monolithic zirconia crowns fol-
lowed up between 18 and 84 months.33 The survival rate was 99%
with 1 crown fracturing and 9 debonded. Laboratory survey stud-
ies have been helpful in providing an early sense of indication of a
newly introduced ceramic system, especially given the paucity of
clinical evidence for the majority of these systems.34 Laboratories
surveyed provide a 5-year warranty for ceramics they fabricated,
which can enforce the numbers, allowing them to evaluate a large
number of ceramic restorations in relatively short period of time.
Zirconia restorations were classified into four categories: single
crowns, fixed dental prosthesis, monolithic and layered restora-
tions. Over 77,000 monolithic single unit 3Y zirconia restorations
were reviewed for remake reasons due to fracture only, resulting
in a fracture rate of approximately 0.5%, and 33,036 layered zirco-
nia restorations had a fracture rate of approximately 2.8%. For
fixed dental prosthesis, approximately 16,500 monolithic 3Y zirco-
nia were reviewed, resulting in a fracture rate of 1.30%. While
approximately 13,000 layered 3Y fixed dental prosthesis resulted
in a fracture rate of 1.50%.34 Studies of this nature are not a
replacement for clinical trials, but they can provide early insight
and information regarding a recently introduced ceramic material
that is being provided to patients with little to no clinical evidence.
8 | CONCLUDING REMARKS
• Yttria concentration in zirconia composition is integral to the opti-
cal and mechanical properties of zirconias. In general, as the con-
centration of yttria increases, the translucency increases while the
strength decreases.
• The most recent type of zirconia is composed of multi-layering of
yttria (5- and 3Y) or (5- and 4Y) intended to mimic the translucency
of the tooth structure from cervical to incisal or occlusal. Due to
the fact that the weakest zirconia is on the functional surfaces of
the crown, where the majority of cracks originate, caution is
required when selecting this type of zirconia.
• Fast sintering of zirconia enables the delivery of zirconia crowns in
a single visit. More research is required to understand and confirm
any possible effect such sintering process may have on the proper-
ties of zirconia.
• The bonding of zirconia restorations to tooth structure can be
long-lasting if a strict and meticulous protocol is followed; air-
particle abrasion, ceramic primer containing the MDP monomer,
and a resin cement. Light cure efficiently (40 s/surface) to ensure
proper light energy passing through zirconia for optimal resin
cement curing.
• Regardless of yttria content, chairside zirconia adjustment weakens
the zirconia. It is best to prevent zirconia adjustments whenever
possible. If a zirconia adjustment is necessary, it is advised to use a
fine diamond bur rather than a coarse bur.
• Monolithic tooth- and implant-supported zirconia restorations are
arguably the most prescribed indirect ceramic material, despite the
severe lack of clinical evidence to support their use. This ceramic
material possesses high hardness, is resistant to wear, and does
not wear when polished. These characteristics are not similar to
the behavior of the tooth structure, which makes the long-term
success of these restorations questionable, especially concerning
biological aspects of the tooth.
CONFLIC T OF INTER E ST STATEMENT
The authors declare that they do not have any financial interest in the
companies whose materials are included in this article.
DATA AVAILABILITY STAT EMEN T
The data that support the findings of this study are available from the
corresponding author upon reasonable request.
OR CID
Taiseer A. Sulaiman https://orcid.org/0000-0002-3826-316X
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How to cite this article: Sulaiman TA, Suliman AA,
Abdulmajeed AA, Zhang Y. Zirconia restoration types,
properties, tooth preparation design, and bonding. A narrative
review. J Esthet Restor Dent. 2023;1‐7. doi:10.1111/jerd.
13151