Effects of the Thickness Ratio of Zirconia–Lithium Disilicate

Bilayered Ceramics on the Translucency and Flexural Strength

Jong-Hoi Kim, DDS, MSD. Graduate student

Kyung-Ho Ko, DDS, MSD, PhD. Assistant professor

Yoon-Hyuk Huh, DDS, MSD, PhD. Associate professor

Chan-Jin Park, DDS, MSD, PhD. Professor

Lee-Ra Cho, DDS, MSD, PhD. Professor

Running title: Translucency and strength of bilayered ceramics

Authors affiliations:

Department of Prosthodontics and Research Institute of Oral Science, College of

Dentistry, Gangneung-Wonju National University, Gangneung, Republic of Korea

Conflict of interest

The authors deny any conflicts of interest related to this study.

This article has been accepted for publication and undergone full peer review but has not been
through the copyediting, typesetting, pagination and proofreading process, which may lead to
differences between this version and the Version of Record. Please cite this article as doi:
10.1111/jopr.13136.

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Acknowledgments:

This work was supported by the Scientific Research (SR1803) of Gangneung-Wonju

National University Dental Hospital.

Corresponding author: Lee-Ra Cho

Department of Prosthodontics, College of Dentistry, Gangneung-Wonju National

University, Jukheongil 7, Gangneung, 25457 Korea

E-mail: lila@gwnu.ac.kr

ORICD: https://orcid.org/0000-0003-3989-2870

Accepted December 20, 2019

Purpose: To determine the effects of the total thickness and core/veneer

thickness ratio of bilayered ceramics on their three-point flexural strength and

translucency.

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Materials and Methods: Two groups of specimens were prepared with two

different total thicknesses, 1.0 mm and 0.6 mm, and these groups were divided

into five and three subgroups with ten specimens each, respectively, having

different core/veneer thickness ratios. Lithium disilicate was pressed on the

zirconia surface using the “lost-wax technique.” The translucency and three-point

flexural strength were measured, and a one-way analysis of variance test (p <

0.05) was performed to determine whether the translucency and three-point

flexural strength were affected by the total thickness and core/veneer thickness

ratio of the specimens.

Results: For the same total thickness, translucency decreased with a decrease in

the zirconia core proportion (p < 0.001). For the same core/veneer ratio, the

translucency decreased with an increase in the total thickness (p < 0.001). If the

zirconia thickness was less than half of the total thickness, the bilayered ceramic

specimens containing zirconia cores and monolithic lithium disilicate specimens

exhibited the same translucency. The three-point flexural strength increased with

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the increasing proportion of zirconia; however, it did not change significantly with

the total thickness. However, for the same total thickness, the flexural strengths of

the bilayered ceramics were higher than those of the monolithic specimens.

Conclusions: At the same total thickness, increasing the zirconia core thickness

decreased the translucency and increased the three-point flexural strength.

Bilayered ceramic specimens with low zirconia ratios exhibited translucency

similar to that of monolithic lithium disilicate ceramic but a higher flexural

strength.

Key Words:

Zirconia, lithium disilicate, translucency, three-point flexural strength, thickness,

core/veneer thickness ratio

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 Ceramic crowns are classified into two types: monolithic ceramic crowns, which

are fabricated from single materials, and bilayered ceramic crowns with

esthetically excellent veneers on high-strength cores. Zirconia (ZrO2) is most

commonly used as a monolithic material for dental restorations without

significant complications in the posterior region where large occlusal loads are

expected.1,2 ZrO2 is a high-strength polycrystalline ceramic with no glass matrix.

Therefore, it is less esthetically desirable than glass ceramics because it lacks

translucency,3,4 which is an essential factor in determining the color of natural

teeth.5-8 Meanwhile, bilayered ceramics are esthetically superior to monolithic

ZrO2. In such ceramics, using ZrO2 as the substructure instead of a metal enables

the selection of a veneer with high translucency, as the masking effect of opaque

veneering is unnecessary.9

Translucency can be determined from three parameters: the transmittance,

translucency parameter (TP), and contrast ratio (CR).10 Transmittance is the

amount of light transmitted at a particular wavelength; specifically, the ratio of

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the intensity of light before and after transmission through the medium is

expressed as a percentage. TP and CR are measured as the light reflected from

the specimen over white and black backgrounds, respectively, and are expressed

as absolute values.10 TP and CR are conventionally used in the biomedical

field,11,12 whereas in dentistry, translucency is measured mostly using TP, which

varies with several parameters. Specifically, the TP of natural central incisors

gradually increases from the cervical area to the incisal edge. Moreover, the TP of

natural teeth is usually affected by age and the thicknesses of enamel and

dentin.13 Meanwhile, the translucency of ceramics is affected by fabrication

procedures, such as the number of firings, as well as the type and thickness of

the ceramics used.6,8

To assess the feasibility of ceramics for clinical applications, their esthetic and

mechanical properties must be determined. The overall strength of a dental

material includes its flexural, tensile, and compressive strengths. However, only

the flexural strength is usually measured for ceramic materials,14 and ceramics

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with a flexural strength of approximately 300–400 MPa have been used

successfully in clinics.15,16 The flexural strength of a monolithic ceramic is affected

by the type and thickness of the material, whereas that of bilayered ceramics

depends on not only the overall thickness but also the core-to-veneer thickness

ratio.

Veneer chipping and delamination have been reported to occur more often in

bilayered ceramics than in ceramometal restorations; these phenomena are the

primary causes of bilayered ceramic failure.17,18 Veneers chipping occurs most

often in cases involving the veneering of feldspathic porcelain on a ZrO2 core.18,19

Various methods have been introduced to address these issues, including

pressing glass-ceramic veneers on ZrO2 cores,20 veneering composite resin on

ZrO2 cores,21 and the “CAD-on technique,” in which the veneer is fabricated by

computer-aided design (CAD) and computer-aided manufacturing (CAM)

techniques.20,22 However, studies on the mechanical and esthetic properties of

these materials remain lacking.

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 The TP and flexural strength of bilayered ceramics depend on the core-to-

veneer thickness ratio and tend to be inversely proportional.23 A thicker core

generally yields a lower TP and higher flexural strength, whereas a thicker veneer

yields a higher TP and lower flexural strength. However, neither the esthetic nor

physical properties of bilayered ceramics can be sacrificed, so the TP and flexural

strength must be studied together based on the core-to-veneer thickness ratio.

Most studies on the optical properties of bilayered ceramics have used ZrO2–

feldspathic porcelain. However, studies on optical properties using ZrO2–lithium

disilicate (LS2) bilayered ceramics are scarce.

In this study, a bilayered glass ceramic composed of LS2 pressed on a ZrO2

core was used to investigate the effects of both the total thickness and core-to-

veneer thickness ratio on the TP and flexural strength. The null hypothesis was

that the total thickness and thickness ratio of ZrO2–LS2 would not affect the TP

and flexural strength.

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Materials and methods

Assuming a thickness less than 1.5 mm,24 which is the minimum thickness for

metal ceramics that provides sufficient strength and esthetics for dental

applications, the total thicknesses were set to 1.0 mm and 0.6 mm to render the

materials more vulnerable to fracture than they would be in normal clinical

settings. Two groups with different total thicknesses, 1.0 mm and 0.6 mm, were

divided into five and three subgroups, respectively, wherein each subgroup (n =

10) had a different core-to-veneer thickness ratio. The number of specimens was

determined based on the results of a pilot study, and the experimental groups

are presented in Table 1.

Pre-sintered ZrO2 blocks (Zirtooth, HASS, Gangneung, Korea) were milled into

cuboid specimens after sintering at 1550 °C. The milled ZrO2 blocks were treated

with airborne particle abrasion (Basic master, Renfert, Hilzingen, Germany) by

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perpendicularly spraying them with Al2O3 powder for 10 seconds from a distance

of 10 mm under a pressure of 0.5 MPa. The specimens were then ultrasonically

cleaned (PRO-SONIC 300, Sultan Chemists Inc., Englewood, CO) for 5 minutes and

naturally dried.

The lost-wax technique was used to manufacture LS2 veneers. Wax patterns of

LS2 were fabricated on ZrO2 as equal-sized cuboids and invested (HSTM

Investment, Microstar Dental, Lawrenceville, GA, USA). Then, the LS2 ingot

(Amber® LiSi-POZ, HASS) was softened at 915°C and pressed (Austromat 654

press-i-dent, DEKEMA, Freilassing, Germany). The composition and mechanical

properties are shown in Table 2. ZrO2 and LS2 materials satisfy the ISO 6872

standard for the mechanical and chemical properties of adhesively cemented,

single-unit anterior or posterior prostheses.

CAM (ADP-1605M DMP, AM Technology, Chungnam, Korea) was performed to

obtain material specimens with the desired thickness and core-to-veneer ratio for

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each experimental subgroup. To ensure the accuracy and uniformity of the

specimens and to eliminate errors in the fabrication procedure, the specimen

surfaces were polished in the same manner using a low-speed handpiece

connected to a custom-made fixation device, as in a previous study.25 Monolithic

ZrO2 specimens (i.e., with ratios of 10/0 and 6/0) were polished with a ZrO2-

specific grinding tool (9736H; Hager & Meisinger GmbH, Neuss, Germany) for 20

s at each stage. Bilayered ceramic specimens of LS2 layered on ZrO2 cores were

polished with an LS2-specific tool (EVA Diacera; EVE Ernst Vetter GmbH, Keltern,

Germany) for 30 s at each stage. The total polishing time was 1 min for all

specimens. To standardize the surfaces, glazing was not performed. The number

and time of polishing steps were set according to standard protocol until the

surface roughness was less than 0.01 μm. All specimens were ultrasonically

cleaned and stored in distilled water at 37 °C for 24 hours. To simulate the

intraoral environment, 6000 thermocycles were performed (thermal cyclic tester,

R&B Inc., Daejeon, Korea). Specifically, the bath temperatures were set to 5 °C

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and 55 °C, each bath transfer time was 2 seconds, and the dwell time was 30

seconds.

The translucency of all specimens was measured. The ShadeEye-NCC Dental

Chroma Meter (Shofu, Kyoto, Japan) was used to measure the L*, a*, and b*

values of the polished LS2 surfaces. These values are the three coordinates (L*, a*,

b*) established by the Commission Internationale de l’Eclairage (CIE) to indicate

the difference in color between the object and the background. The values

measured with a white background (as indicated by the subscript W, i.e., *,

*, *) and black background (as indicated by the subscript B, i.e., *,

*, *) were substituted into the following equations to calculate the

translucency.

= (△L*2 + △a*2 + △b*2)½

(ΔL* = *− *, Δa* = *− *, Δb* = *− *)

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A universal testing machine (Instron3343, Instron Co., GA) was used to evaluate

the three-point flexural strength by applying compressive stress with the LS2

surface facing upward. The load cell of the Instron was a ball type with a

diameter of 15 mm. The static stress was applied at a rate of 0.5 mm/min until

the specimen fractured. The maximum fracture load (N) was recorded at the first

sign of fracture, which was verified by changes in the deflection curve. The

maximum load before the initiation of fracture was used to calculate the three-

point flexural strength (MPa) using the following equation:

δ = 3FL/2b

where δ is the bending strength, F is the maximum force, L is the distance

between the supporters, b is the width of the specimen, and h is the thickness of

the specimen.

After measuring the three-point flexural strength, the fracture surfaces of the

specimens were analyzed to determine the failure mode, which was classified into

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three types: adhesive failure, wherein LS2 delaminates from the ZrO2 surface,

cohesive failure with fracturing within the ZrO2 or LS2, and mixed failure, which is

a mixture of adhesive and cohesive failure. After the specimens fractured, three

fractured specimens were randomly selected from each subgroup, and the

fracture surfaces were observed using scanning electron microscopy (SEM,

QUANTA FEG 250, FEI, Hillsboro, OR).

The fracture surfaces of the ZrO2–LS2 ceramics were also analyzed using energy-

dispersive X-ray spectrometry (EDS, Ametek EDAX Apollo XP, Mahwah, NJ)

mapping and line scanning analysis. The distributions of zirconium and silicon,

which are the main constituent elements of ZrO2 and LS2, were used to

determine the presence of a hybrid layer and the difference in the hybrid layers

of the experimental subgroups.

According to a statistical power analysis using G*Power 3.1 (Brunsbüttel,

Germany), the appropriate number of specimens to ascertain the flexural strength

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was five per subgroup for the thickness of 0.6 mm and four per subgroup for the

thickness of 1.0 mm. However, considering other variables, the number of

specimens per subgroup was set as ten. The SPSS 23.0 program (IBM Corp.,

Armonk, NY) was used for the statistical analysis. To determine the differences in

the TP, three-point flexural strength, and fracture mode according to the total

thickness and core-to-veneer thickness ratio of the specimens, a one-way analysis

of variance (ANOVA) and Tukey’s HSD post-hoc tests were performed (confidence

interval set as 95%). A two-way ANOVA was used to analyze the effects of the

thickness ratio and total thickness on the TP and flexural strength. Because of the

different numbers of subgroups in 1.0 mm (five subgroups) and 0.6 mm (three

subgroups), the three thickness ratios of 10/0, 5/5, and 0/10 were extracted from

the 1.0-mm thickness group for the statistical analysis. Chi-squared tests were

used to determine possible correlations between the variables (thickness ratio

and total thickness) and the failure modes.

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Results

Table 3 shows the TPs of the two different groups for each thickness ratio

subgroup. At the same total thickness, the TP increased as the ZrO2 core became

thinner, and the monolithic LS2 specimens (0/10 and 0/6) without ZrO2

substructures were more translucent than the monolithic ZrO2 specimens (10/0

and 6/0) (p < 0.001, F = 167.558).

At a total thickness of 1.0 mm, the TP of the monolithic ZrO2 specimens (10/0)

was considerably lower than that of the monolithic LS2 specimens (0/10), whereas

the 1.0-mm-thick bilayered ceramics (7/3, 5/5, and 3/7 subgroups) showed no

major differences in TP (p < 0.001, F = 91.126, Table 3). Meanwhile, at a total

thickness of 0.6 mm, all subgroups (6/0, 3/3, and 0/6) showed different TPs (p <

0.001, F = 267.959), and the TP of the 0/6 subgroup was approximately twice that

of the 6/0 subgroup (Table 3).

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For the same ZrO2/LS2 ratio, the TP decreases with the increasing total thickness.

Specifically, in the 1.0-mm and 0.6-mm groups, pairs subgroups with the same

ZrO2/LS2 ratio (i.e., 10/0 and 6/0; 5/5 and 3/3; and 0/10 and 0/6 subgroups) were

compared. For all equal ZrO2/LS2 ratios, the 1.0-mm subgroups showed lower TPs

than the 0.6-mm subgroups (p < 0.001, F = 297.509). Moreover, the TP of the

monolithic ZrO2 specimen with a total thickness of 0.6 mm (6/0) was similar to

that of the 3/7 subgroup (p = 1.000), which had the highest LS2 content among

the bilayered ceramics in the 1.0-mm group.

The effects of the thickness and ZrO2/LS2 ratio on the three-point flexural

strength were also examined. Specifically, this strength decreased as the thickness

of ZrO2 decreased, whereas the monolithic ZrO2 specimens (10/0 and 6/0)

showed higher flexural strengths than both monolithic LS2 specimens without

ZrO2 substructures (0/10 and 0/6) (p < 0.001).

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At a total thickness of 1.0 mm, three of the subgroups (10/0, 7/3, and 0/10)

showed different three-point flexural strengths (p < 0.001). For both total

thicknesses, the three-point flexural strengths of the monolithic ZrO2 specimens

were approximately four times higher than that of the monolithic LS2 specimens

(Table 3). At a total thickness of 0.6 mm, all the subgroups (6/0, 3/3, and 0/6)

showed different three-point flexural strengths (p < 0.001).

Then, the subgroups with the same ZrO2/LS2 ratio in the 1.0-mm and 0.6-mm

groups (10/0 and 6/0; 5/5 and 3/3; and 0/10 and 0/6) were compared; the results

showed that the three-point flexural strengths of the 1.0-mm and 0.6-mm groups

with equal ZrO2/LS2 ratios were not different.

All the bilayered specimens (7/3, 5/5, 3/7, and 3/3) exhibited mixed failure, i.e.,

the delamination of LS2 from the ZrO2 surface (adhesive failure) together with

fracture within the LS2 veneer (cohesive failure). In the monolithic groups (10/0,

0/10, 6/0, and 0/6 subgroups), all specimens showed cohesive failure. According

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to the chi-squared test results, the failure mode was significantly different

depending on thickness ratio (p < 0.001). However, the total thickness was not

associated with the failure mode (p = 0.588).

According to the two-way ANOVA, the interactions between the thickness ratio

and total thickness were statistically significant for TP (p = 0.039, F = 3.447) and

for flexural strength (p = 0.001, F = 8.457).

The fracture surfaces were observed via SEM as well as EDS mapping and line

scan analysis, as shown for the bilayered specimens in Figs 1 and 2, respectively.

The fracture surface reveals a boundary, and dark-colored LS2 appears on the left

side, while bright-colored ZrO2 appears on the right. The LS2 region shows the

characteristics of a glass ceramic structure, while the ZrO2 region shows

polycrystallinity.

The EDS mapping reveals that in the bilayered ZrO2/LS2 ceramic specimens (7/3,

5/5, 3/7, and 3/3), these boundaries dividing the ZrO2 and LS2 layers were hybrid

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layers, as evidenced by sudden changes in component elements. The elements in

the hybrid layer show the fusion of the crystal structure between the ZrO2 and

LS2 layers. Among the four bilayered ZrO2/LS2 ceramic subgroups, the 3/7

subgroup shows a wider hybrid layer than the other subgroups.

Discussion

The present study was conducted to investigate the effects of the total thickness

and core-to-veneer thickness ratio of ZrO2/LS2 bilayered ceramics on the

translucency and flexural strength. The results showed that, at the same total

thickness, the ZrO2/LS2 bilayered ceramic specimens with a lower ZrO2 core

content and higher LS2 veneer content exhibited a higher TP and lower three-

point flexural strength. Accordingly, the null hypothesis that the total thickness

and core-to-veneer ratio of ZrO2/LS2 bilayered ceramics would not affect the TP

and three-point flexural strength was rejected.

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 Regardless of the total thickness, the monolithic LS2 ceramic specimens (0/10

and 0/6) of the 1.0-mm and 0.6-mm groups showed a TP twice that of the

monolithic ZrO2 specimens (10/0 and 6/0). In the bilayered ceramic specimens,

the TP increased as the proportion of ZrO2 decreased and the proportion of LS2

increased. This tendency is consistent with that reported in previous studies.26 The

TPs of the monolithic ceramic specimens with a total thickness of 0.6 mm (6/0

and 0/6) were approximately 1.5 times higher than those of the monolithic

ceramic specimens with a total thickness of 1.0 mm (10/0 and 0/10). In addition,

the TP of the monolithic ZrO2 ceramic specimen with a total thickness of 0.6 mm

(6/0) was similar to that of the 3/7 subgroup, which had an LS2 thickness of 0.7

mm, the highest proportion among the 1.0-mm subgroups.

Among the three parameters that are used to evaluate the translucency,

transmittance considers only the amount of absorption at a particular wavelength.

Therefore, it is disadvantageous in situations where the light source changes and

the amount of absorbed light recognized by the human eye cannot be

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evaluated.27 By contrast, TP and CR have the advantages of using the reflected

light recognized by the human eye and CIE colorimetry, which is very similar to

human color recognition. Thus, they correspond better to actual clinical

applications; thus, most previous studies have used these two parameters.11,12 The

TP and CR measurement instruments were designed to measure flat surfaces;

however, the surface of natural teeth is not flat. As a result, the teeth being

measured may not fit accurately at the edges of the measurement apparatus,

which could cause edge-loss effects that compromise the accuracy of the

measurement.27 As measuring the translucency of natural teeth can be technically

difficult,28 flat specimens were prepared in the present study for the TP

measurements.

According to a study on the TP of central incisors, the TP was measured to be 5

in the cervical area and 15 in the incisal edge, indicating that the TP value

increases from the cervical area to the incisal edge.13 Therefore, the reference

value of TP for natural teeth was assumed to be 10 in this study. The TP of the

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10/0 and 7/3 subgroups with a total thickness of 1.0 mm was lower than that of

natural teeth, whereas the TP of the 5/5, 3/7, and 0/10 subgroups was similar to

or higher than that of natural teeth. Moreover, the TP of all the subgroups with a

total thickness of 0.6 mm was similar to or higher than that of natural teeth. This

implies that a total thickness of less than 1 mm would provide sufficiently

esthetic outcomes, regardless of the material. When the total thickness of the

ZrO2/LS2 bilayered ceramic specimens exceeded 1.0 mm and the thickness ratio

of ZrO2 exceeded 50%, the TP became lower than that of natural teeth.

Brittle materials such as feldspathic porcelain or glass are more vulnerable to

tensile forces than compressive forces. Therefore, measuring the resistance to

tensile force is a suitable method for assessing the physical properties of brittle

materials.14 Flexural strength is a physical property associated with fracture that

refers to the resistance to tensile force. Moreover, as a fracture in feldspathic

porcelain or glass starts with a surface flaw, the flexural strength can be

considered a suitable parameter for determining the fracture strength.30 Thus, in

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the present study, the three-point flexural strength was measured according to

the ISO standard to measure the fracture strength of ceramics. Moreover, clinical

failures can be classified into esthetic and strength failures; the frequency of

strength failure is higher than that of esthetic failure and can cause more fatal

outcomes. Accordingly, the study was designed to determine the critical point of

three-point flexural strength without degrading the esthetic properties.

Regardless of the total thickness, the 1.0-mm and 0.6-mm monolithic ZrO2

specimens (10/0 and 6/0) showed three-point flexural strengths approximately

four times higher than those of the corresponding monolithic LS2 ceramic

specimens (0/10 and 0/6). As the ZrO2 content decreased and the LS2 content

increased in the bilayered ceramic specimens, the three-point flexural strength

decreased. This tendency is consistent with that reported in previous studies.29

Meanwhile, among the bilayered specimens in the 1.0-mm and 0.6-mm groups,

the subgroups with the same ZrO2/LS2 contents showed almost no difference in

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three-point flexural strength. Therefore, the total thickness did not affect the

three-point flexural strength. By contrast, at the same total thickness, the

ZrO2/LS2 ratio affected the three-point flexural strength. Meanwhile, for the

monolithic ZrO2 specimens (10/0 and 6/0), the flexural strengths were nearly

identical. Thus, the actual strengths of samples with different thicknesses may

differ. These results can be attributed to the design of this experiment. In the 6/0

specimens, bending may occur before fracture. Therefore, the measured strength

of the 0.6-mm-thick specimen may be higher than the actual strength.

The three-point flexural strength decreased as the ZrO2 ratio decreased.

Specifically, the decrease in the flexural strengths from the 3/7 to the 0/10

subgroups was greater than the decreases in the flexural strengths from all other

subgroups. In other words, the three-point flexural strength decreased more

rapidly between the 3/7 and 0/10 subgroups. This implies that at the same

thickness, the bilayered ceramic specimens with ZrO2 cores have much higher

flexural strengths than the monolithic LS2 ceramic specimens without ZrO2 cores.

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IPS e.max Press (Ivoclar Vivadent AG, Schaan, Liechtenstein) single crown

prostheses comprising LS2 are used successfully in all areas, including posterior

teeth, and their flexural strength is reported to be approximately 400 MPa.16

According to ISO standards, the flexural strength required for single crown

prostheses, including those for posterior teeth, is approximately 300 MPa.15 Thus,

the reference value of three-point flexural strength was set to 300–400 MPa. All

the specimens in the 1.0-mm and 0.6-mm groups, excluding the monolithic LS2

ceramic specimens (0/10 and 0/6), satisfied the flexural strength requirement. This

finding implies that not only monolithic ZrO2 specimens but also ZrO2/LS2

bilayered ceramic specimens are sufficiently strong for application in prostheses

for posterior teeth.

The observations of the fracture surfaces after the three-point flexural strength

tests revealed that the 3/7 subgroup among the ZrO2/LS2 bilayered ceramics had

a wider hybrid layer than the other subgroups. In this study, all the surface

conditions (except for the thickness ratio) and fracture test environments were

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the same. Therefore, these results are believed to be due to the selection of

observation specimens that were fractured along a slanted line rather than due to

other causes.

For sufficient strength and esthetics of metal ceramic crowns, a preparation of 1.5

mm is required.24 The present study assumed conditions that are more prone to

fracture than clinical conditions in measuring the TP and three-point flexural

strength. The total thicknesses were set to 1.0 mm and 0.6 mm, and the decrease

in total thickness decreases the three-point flexural strength, while the TP

increases. Nevertheless, the results of this study showed that even at a low total

thickness, an excellent flexural strength could be achieved with a ZrO2 core,

satisfying the ISO standard.

This study is limited by the use of cuboid specimens instead of crown-shaped

specimens. Crowns are not cuboid; rather, they have many complex curves, which

can make accurate measurements difficult owing to scattered reflection. Because

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of this three-dimensional structure, three-point flexural strength cannot be used

to determine the fracture strength. Therefore, their compressive strength is

generally measured. However, in the case of crowns, the compressive strength

values have higher errors than those for cuboids, and the results are more

difficult to interpret. Therefore, cuboid specimens were used in the present study

to increase the uniformity of the measurements and to conveniently interpret the

results. Additional studies are needed to determine the required ideal thickness

ratio for anterior versus posterior teeth. Moreover, the hypothesis of this study

must be tested in long-term clinical studies.

In this study, specimens were evaluated that are thinner than the specification

in the preparation guidelines (1.2–1.5 mm). Under this experimental condition, the

lower thickness is expected to positively affect the translucency and negatively

affect the strength. However, the translucency and flexural strength were most

affected by the existence of the ZrO2 core in this study, and this tendency is

expected to persist in bilayered ceramics thicker than 1.0 mm. The translucency of

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dental ceramics was mainly studied at the lowest thickness recommended by the

manufacturers. Moreover, the optical properties of ZrO2 are more affected by

surface polishing than by the brand and thickness of the ZrO2 block.31 Thus, the

surface conditions were strictly controlled using a standardized polishing

protocol. Therefore, the results of this study should also be applicable to the

thicknesses of bilayered ceramics used clinically.

Regarding the limitation of this study was that the bilayered ceramic was

slightly less esthetic than monolithic LS2; however, it showed advantages in terms

of strength. Therefore, using bilayered ceramics with ZrO2 cores is recommended,

even if the proportion of ZrO2 ratio is low, rather than monolithic LS2, if esthetics

are important.

Conclusions

The results of the present study indicate that the TPs of bilayered ceramic

specimens containing ZrO2 cores are not different from those of monolithic LS2

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specimens without ZrO2 cores, provided that the ZrO2 content does not exceed

half of the total thickness (5/5, 3/7, and 3/3 subgroups). On the other hand, the

three-point flexural strengths of bilayered ceramic specimens containing ZrO2

cores were much higher than those of monolithic LS2 specimens. By applying

these findings to clinical settings, bilayered ceramic crowns containing

appropriately thick ZrO2 cores can be developed with a similar TP but a much

higher strength. This would make such bilayered ceramic crowns preferable to

monolithic LS2 ceramic crowns from the perspective of esthetics and strength.

Acknowledgments:

This work was supported by the Scientific Research (SR1803) of Gangneung-Wonju

National University Dental Hospital.

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Tables

Table 1 Specimen groups prepared in this study

Group Group
1.0 mm Group 7/3 Group 5/5 Group 0/10
10/0 3/7

ZrO2 (mm) 1.0 0.7 0.5 0.3 0

LS2 (mm) 0 0.3 0.5 0.7 1.0

Group Group
0.6 mm Group 0/6
6/0 3/3

ZrO2 (mm) 0.6 - 0.3 - 0

LS2 (mm) 0 - 0.3 - 0.6

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Table 2 Materials used

Composition ISO 6872

Material Brand Chemical Amounts

physical properties
formula (wt.%)

SiO2 71–85

Li2O 10–15

Amber LiSi- P2O5 2–5

LS2 420 ±17 MPa
POZ, Hass Al2O3 1–5

B2O3 1–6

5–12

ZrO2 91.25

Y2O3 5.35
ZrO2 Zirtooth,
HfO2 3.0 1227 ±81 MPa
(3Y-TZP) Hass
Al2O3 0.21

0.19

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Table 3 Mean (± standard deviation, SD) translucency parameter (TP) and mean

(± SD) of three-point flexural strength values of specimens with different total

thicknesses

Total Mean flexural strength ±

Group
thickness Mean TP ± SD SD

(mm) (ZrO2/LS2) (MPa)

10/0 7.03 ± 1.52 f 1243.92 ± 49.21 a

7/3 9.75 ± 2.03 e 1159.32 ± 37.21 b

1.0 5/5 11.45 ± 0.96 d,e 1070.62 ± 50.51 c

3/7 12.47 ± 1.17 d 1047.19 ± 44.45 c,d

0/10 18.62 ± 0.64 b 306.75 ± 4.50 e

6/0 12.74 ± 1.25 d 1251.77 ± 53.36 a

0.6 3/3 15.55 ± 1.33 c 981.96 ± 39.72 d

0/6 24.47 ± 0.68 a 315.49 ± 19.38 e

The superscript letters indicate statistically significant differences (P < 0.05).

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Figures

Figure 1 SEM image of the fractured surface of a bilayered specimen. Fracture

plane: LS2 (L); ZrO2 (Z).

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Figure 2 EDS analysis results. (Upper row) Mapping images of bilayered ceramics:

LS2 (red spots); ZrO2 (blue spots). (Lower row) Line scan images: LS2 (pink line);

ZrO2 (orange line).

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