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An Overview of Zirconia Ceramics: Basic


Properties and Clinical Applications
ARTICLE in JOURNAL OF DENTISTRY DECEMBER 2007
Impact Factor: 2.75 DOI: 10.1016/j.jdent.2007.07.008 Source: PubMed

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3 AUTHORS, INCLUDING:
Pierfrancesco Rossi Iommetti
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Retrieved on: 29 December 2015

journal of dentistry 35 (2007) 819826

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Review

An overview of zirconia ceramics: Basic properties


and clinical applications
Paolo Francesco Manicone, Pierfrancesco Rossi Iommetti *, Luca Raffaelli
Catholic University of Sacred Heart, Institute of Clinical Dentistry, Largo F.Vito 1, 00168 Rome, Italy

article info

abstract

Article history:

Zirconia (ZrO2) is a ceramic material with adequate mechanical properties for manufactur-

Received 21 February 2007

ing of medical devices. Zirconia stabilized with Y2O3 has the best properties for these

Received in revised form

applications. When a stress occurs on a ZrO2 surface, a crystalline modification opposes the

17 July 2007

propagation of cracks. Compression resistance of ZrO2 is about 2000 MPa. Orthopedic

Accepted 19 July 2007

research led to this material being proposed for the manufacture of hip head prostheses.
Prior to this, zirconia biocompatibility had been studied in vivo; no adverse responses were
reported following the insertion of ZrO2 samples into bone or muscle. In vitro experimenta-

Keywords:

tion showed absence of mutations and good viability of cells cultured on this material.

Zirconia

Zirconia cores for fixed partial dentures (FPD) on anterior and posterior teeth and on

Biocompatibility

implants are now available. Clinical evaluation of abutments and periodontal tissue must

Fixed partial dentures

be performed prior to their use. Zirconia opacity is very useful in adverse clinical situations,

Implant abutment

for example, for masking of dischromic abutment teeth. Radiopacity can aid evaluation
during radiographic controls. Zirconia frameworks are realized by using computer-aided
design/manufacturing (CAD/CAM) technology. Cementation of Zr-ceramic restorations can
be performed with adhesive luting. Mechanical properties of zirconium oxide FPDs have
proved superior to those of other metal-free restorations. Clinical evaluations, which have
been ongoing for 3 years, indicate a good success rate for zirconia FPDs. Zirconia implant
abutments can also be used to improve the aesthetic outcome of implant-supported
rehabilitations. Newly proposed zirconia implants seem to have good biological and
mechanical properties; further studies are needed to validate their application.
# 2007 Elsevier Ltd. All rights reserved.

1.

Introduction

Zirconia is a crystalline dioxide of zirconium. Its mechanical


properties are very similar to those of metals and its color is
similar to tooth color.1 In 1975, Garvie proposed a model to
rationalize the good mechanical properties of zirconia, by
virtue of which it has been called ceramic steel.2 Zirconia
crystals can be organized in three different patterns: monoclinic (M), cubic (C), and tetragonal (T). By mixing ZrO2 with

other metallic oxides, such as MgO, CaO, or Y2O3, great


molecular stability can be obtained.1 Yttrium-stabilized
zirconia, also known as tetragonal zirconia polycrystal
(TZP), is presently the most studied combination.3 The
aforementioned three phases are present in a common ZrO2
crystal. Every transition between the different crystalline
reticulations is due to a force on the zirconia surface, and this
produces a volumetric change in the crystal where the stress is
applied. When a stress occurs on a zirconia surface, cracking

* Corresponding author. Fax: +39 06 30154079.


E-mail address: pierfrancesco.rossi1@tin.it (P. Rossi Iommetti).
0300-5712/$ see front matter # 2007 Elsevier Ltd. All rights reserved.
doi:10.1016/j.jdent.2007.07.008

820

journal of dentistry 35 (2007) 819826

energy creates a T M transition. This crystalline modification


is followed by an expansion that seals the crack.4 ZrO2
stabilized with Y2O3 has better mechanical properties than
other combinations; although its sintering is much more
difficult, this is the principal kind of zirconia considered for
current medical use.
The first proposal of the use of zirconium oxide for medical
purposes was made in 1969 and concerned orthopedic
application. ZrO2 was proposed as a new material for hip
head replacement instead of titanium or alumina prostheses.5
They evaluated the reaction upon placing ZrO2 in a monkey
femur and reported that no adverse responses arose.
Orthopedic research focused on the mechanical behavior of
zirconia, on its wear, and on its integration with bone and
muscle. Moreover, these first studies were largely carried out
in vivo because in vitro technology was not yet sufficiently
advanced. Prior to 1990, many other studies were performed,
in which zirconia was tested on bone and muscle without any
unfavorable results.611 Since 1990, in vitro studies have also
been performed in order to obtain information about cellular
behavior towards zirconia.12 In vitro evaluation confirmed
that ZrO2 is not cytotoxic1315 (Fig. 1). Uncertain results were
reported in relation to zirconia powders that generated an
adverse response.16,17 This was probably due to zirconium
hydroxide, which is no longer present after sintering so that
solid samples can always be regarded as safe. Mutagenicity
was evaluated by Silva and by Covacci, and both reported that
zirconia is not able to generate mutations of the cellular
genome18,19; in particular, mutant fibroblasts found on ZrO2
were fewer than those obtained with the lowest possible
oncogenic dose compatible with survival of the cells.19
Moreover, zirconium oxide creates less flogistic reaction in
tissue than other restorative materials such as titanium.20
This result was also confirmed by a study about peri-implant
soft tissue around zirconia healing caps in comparison with
that around titanium ones.21 Inflammatory infiltrate, microvessel density, and vascular endothelial growth factor
expression were found to be higher around the titanium caps

Fig. 1 Scanning electron microscopy (SEM) observation of


fibroblasts cultured on zirconia: cells grow on the whole
zirconia surface, covering it with a cellular layer. A cellular
body covered by cytoplasm is discernible (magnification
7400T).

than around the ZrO2 ones. Also, the level of bacterial


products, measured with nitric oxide synthase, was higher
on titanium than on zirconium oxide. Zirconia can up- or
down-regulate expressions of some genes, so that zirconia can
be regarded as a self-regulatory material that can modify
turnover of the extracellular matrix.22
Zirconia has mechanical properties similar to those of
stainless steel. Its resistance to traction can be as high as
900 1200 MPa and its compression resistance is about
2000 MPa.1 Cyclical stresses are also tolerated well by this
material. Applying an intermittent force of 28 kN to zirconia
substrates, Cales found that some 50 billion cycles were
necessary to break the samples, but with a force in excess of
90 kN structural failure of the samples occurred after just 15
cycles.23 Surface treatments can modify the physical properties of zirconia. Exposure to wetness for an extended period of
time can have a detrimental effect on its properties.24 This
phenomenon is known as zirconia ageing. Moreover, also
surface grinding can reduce toughness.25 Kosmac confirmed
this observation and reported a lower mean strength and
reliability of zirconium oxide after grinding.26

2.

Clinical aspects

In the search for the ultimate aesthetic restorative material,


many all-ceramic systems have been proposed. Dental
research is nowadays directed towards metal-free prosthetic
restorations in order to improve aesthetical outcome of FPD
restorations. Natural look of soft tissue in contact with fixed
partial dentures is influenced by two factors: mucosal
thickness and typology of restorative material. Metal-free
restorations allow to preserve soft tissue color more similar to
the natural one than porcelain fused to metal restorations.27
Many ceramics, such as spinel, alumina, and ceramic
reinforced with lithium disilicate, have been proposed for
the construction of metal-free restorations.28 These materials
have precise indications for fixed partial dentures (FPD); Luthy
measured average load-bearing capacities of 518 N for
alumina restorations, 282 N for lithium disilicate restorations,
and 755 N for zirconia restorations.29 Raigrodski analyzed
different all-ceramic systems and concluded that reinforced
ceramics can only be used to replace anterior teeth with single
crown restorations or maximum with three units FPDs. On the
other hand, ZrO2 restorations have a wider application field.
Other ceramic technologies only allow the construction of
structures that are resistant to chewing stresses on anterior
teeth. On the contrary, Zr-ceramic FPDs can also be used on
molars.28 Tinschert compared lifetime of different metal-free
core for FPD and reported that Zr-ceramic with alumina oxide
had the highest initial and most favorable long-term
strength.30 Connecting surface area of the FPD must be at
least 6.25 mm2.31 For this reason, ceramic FPDs should only be
used when the distance between the interproximal papilla and
the marginal ridge is close to 4 mm. In a comparison between
3-, 4- and 5-unit zirconia fixed partial dentures and minimal
connecting surface resulted, respectively, 2.7 mm2, 4.0 mm2
and 4.9 mm2.32 Height of abutment is fundamental to obtain
ZrO2 frameworks with correct shape and dimension in order to
ensure mechanical resistance of restoration. This aspect must

journal of dentistry 35 (2007) 819826

821

Fig. 2 Intraoral view of prepared discolored non-vital


teeth (#2.5 and #2.6) and of the soft tissue morphology.

Fig. 4 Radiographic evaluation of the two zirconia-ceramic


restorations on #2.5 and #2.6 after resin-bonded luting:
note the complete marginal adaptation.

be carefully considered when realizing a metal-free FPD.


Zirconia restorations have found their indications for FPDs
supported by teeth or implants. Single tooth restorations and
fixed partial dentures with a single pontic element are possible
on both anterior and posterior elements because of the
mechanical reliability of this material.3335 It is possible to use
juxtagingival marginal preparations and various finishing
lines to obtain a good aesthetic.36 FPD extension is nowadays a
limitation in using Zr-ceramic restorations. Although some
manufacturer allows obtaining also full arch restorations, 5
units-FPDs are reported to be as maximal possible.37 As a
matter of facts, reliability of greater extensions must be
investigated. Some physical properties of zirconia must be
considered in order to obtain a good aesthetic outcome. As a
matter of fact, zirconia has not only a color similar to teeth but
is also opaque38; this can be an advantage for the technician:
when a dischromic tooth or a metal post must be covered, a
zirconia core allows concealment of this unfavorable aspect
(Figs. 2 and 3). On the contrary, if translucency is absolutely
needed, it can be attained with other ceramic materials such
as alumina or lithium disilicate. Moreover, some manufac-

turers make provision for zirconia colored cores in order to


enhance aesthetic outcomes. Preventive evaluation of natural
teeth color and transparency is necessary to select an
appropriate all-ceramic system. Moreover, when Zr-ceramic
restoration is preferred, a preoperative choice between
different colored cores is suggested. Also, the radiopacity of
zirconia is very useful for monitoring marginal adaptation
through radiographic evaluation, especially when intrasulcular preparation is used (Fig. 4).1
In order to produce a ZrO2 core for a prosthetic restoration, it
is necessary to use a computer-aided design/manufacturing
(CAD/CAM) system that can deal with zirconia and create a
fitting framework. The realization of the ZR-ceramic restorations must be conducted in a precise sequence of steps that
involves both the clinician and the laboratory technician. Tooth
preparation can be realized with various finishing lines,
although chamfer and rounded shoulder are recommended.
Preparation must follow the scallop of the free gingival margin;
anterior teeth reduction must be at least 1.5 mm incisal and of
1.0 mm axial on margin with a 4868 taper; axial reduction in
aesthetical areas can be extended up to 1.5 mm. Posterior teeth
should be prepared with 1.5 mm of occlusal reduction and with
1.0 mm of axial reduction on marginal region with a 4868
taper.39,40 After conventional impression procedures are performed, a master die is created and a CAD/CAM procedure is
followed. Scanning procedure can be influenced by many
factors that clinician and technician must control to optimize
marginal fit of restoration. External line angle of preparation
must be linear to allow an adequate scanning. Moreover,
accurate impression and master die preparation must be
performed to prevent mismatch between framework and
abutments.41 After die scanning, it is possible to realize a
zirconia core by means of a CAD/CAM system in two different
ways42,43: milling a fully sintered piece of zirconia, or milling a
partially sintered zirconia block and then completing the
sintering thereafter. As a matter of fact, fully sintered zirconia
is very hard, which makes milling very difficult; moreover,
milling operations can be detrimental to the mechanical
properties. On the other hand, if zirconia is cut before fully
sintering, a 20% shrinkage must be allowed for in order to obtain
a fitting core. Although this second system can create superior

Fig. 3 Intraoral view of try in of zirconia frameworks on


#2.5 and #2.6: the opacity of the zirconia framework masks
the dischromic abutment on the left second premolar
(#2.5).

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journal of dentistry 35 (2007) 819826

structures, organization and management of the production is


more demanding. Zirconia sintered after milling has better
mechanical properties than densely sintered zirconia; moreover ceramic veneering can improve ZrO2 fracture strength.44
Comparing different core designs a higher fracture strength was
found when Zr core thickness is optimized in order to obtain a
uniform thickness of veneer ceramic.45 After clinical control of
the core adaptation, technician can realize ceramic veneering.
Zirconium oxideceramic relationship is not yet well
known. Coreveneer interface is one of the weakest aspect
of these restorations so that ceramic chipping or cracking are
possible.46 Different factors may influence veneer cracking as
differences in thermal expansion coefficients between core
and ceramic, firing shrinkage of ceramic, flaws on veneering
and poor wetting by veneering on core. Special ceramics are
nowadays developed for zirconia in order to minimize this
unfavorable aspect, but more evaluation of zirconia core
veneer bond must be performed.47 After veneering control and
finishing, luting of restoration can be performed (Fig. 5).
Resin-bonded luting has proved to be the best choice for Zrceramic restorations, although the use of conventional
cementation may also be permissible.40 Bindl et al. reported
that conventional luting did not reduce fracture resistance of
Zirconia-ceramic restoration.48 Derand and Derand reported a
shear bond strength of 8.9 MPa for a zirconium restoration
with resin-bonded luting.49 Palacios et al. measured shear
bond strengths of resin cementation of between 5.1 and
6.0 MPa depending on the luting agent.50 Blatz et al. reported a
shear bond strength of 16.85 MPa for self-etching bonding
adhesive cementation after 180 days of thermal cycling51; Atsu
et al. compared shear bond strength of zirconia-ceramic
restoration without surfacial treatment (15.7 MPa), with
silanization (16.5 MPa) and with trebochemical treatment
(22.9 MPa).52 Kern and Wegner underlined that airborne or
silane utilization did not improve resin bond adhesion on
zirconia.53 Nowadays there is no accordance in results
between different studies about luting procedures for Zrceramic restoration. The need of internal surface treatment
requires further experimental evaluation. Airborning and
silanization result not influencing adhesion; trebochemical
treatment seems to improve bonding.52

Fig. 5 Intraoral view of cemented zirconia-ceramic


restorations on left second premolar and first molar (#2.5
and #2.6).

Surface treatment seems to be unnecessary to obtain good


adhesion. At the present time Zr-ceramic restorations should
be luted with resin cement without surface treatment or, at
least, with trebochemical treatment.52 In our opinion, from a
clinical standpoint, resin cementation appears one of the most
favorable choices in order to obtain adequate values of
adhesion and good mechanical features of ZrO2 restorations.
The mechanical resistance of zirconia FPDs has been
studied on single tooth restorations and on three or four-unit
FPDs. The numerical results are not consistent if the different
studies are compared; Tinschert et al. reported a fracture load
for ZrO2 of over 2000 N,54 Sundh et al. measured fracture loads
in the range 27004100 N,55 whereas Luthy et al. asserted that a
zirconia core could fracture under a load of 706 N.29 However,
these results are not directly comparable because the methods
of measurement were not standardized between the studies.
On the other hand, in each of these tests it was demonstrated
that zirconia restorations yield superior results in terms of
fracture resistance as compared with alumina or lithium
disilicate ceramic restorations.
Ageing of Zirconia can have detrimental effects on its
mechanical properties. Mechanical stresses and wetness
exposure are critical to accelerate this process.24 Nowadays
effects of ageing on zirconium oxide used for oral rehabilitation are not yet well known. By an in vitro simulation resulted
that, although ageing reduce mechanical features of Zirconia,
resistance values decrease into clinical acceptable values.56
Further evaluations are needed because zirconia behavior in
long time period is not yet investigated.57 Moreover relationship between ageing of ZrO2 frameworks and long term
loading must be evaluated.
By using CAD/CAM technology, it is now possible to obtain
zirconia implant abutments. Replacing missing teeth with an
implant-supported FPD requires functional and aesthetic
evaluation by the clinician. In order to achieve a good outcome
for an implant-supported FPD, many aspects need to be
considered. A natural-looking emergence must be obtained in
order to harmonize restoration and natural teeth. Intrasulcular abutment design is critical to reduce the risk of metallic
blue shimmer through thin soft tissue. The use of ceramic
abutments reduces this risk, allowing for optimal adaptation
between the margins of the restoration and the soft tissue58
(Figs. 6 and 7).
Precision at the implant interface between the abutment
and the fixture was assessed by comparing the rotational
freedom of titanium, alumina, and zirconia abutments with
hexagonal external connections. Titanium and zirconia each
showed a significantly lower mean rotational freedom
compared to the alumina abutment. The rotational freedom
between the abutment and the fixture amounted to less than
38 for all of the abutments studied.59 In another study, it was
reported that a zirconia abutment with a machined titanium
base had a rotational freedom of less than 38.60 Moreover,
abutments milled by means of CAD/CAM systems can also be
modified by the clinician to obtain a better marginal adaptation.61 In a study about 54 zirconia implant abutments, after 4
years neither of them showed structural failure with good
peri-implant tissue health. Though these studies indicate that
ZrO2 abutment could be suitable for clinical use for single
tooth implant replacement, some aspects must be evalu-

journal of dentistry 35 (2007) 819826

Fig. 6 Labial view of customized zirconia implant


abutment on right maxillary central incisor (#1.1): note the
submarginal emergence profile of the abutment and the
support of the peri-implant soft tissue.

ated.62 In particular, a possible wear behavior under loading at


implant/abutment interface between titanium external connection and zirconia abutment must be investigated. As a
matter of facts wear can reduce both mechanical properties of
zirconia both fit between implant and abutment. Moreover
also zirconia resistance on screwing abutment must be
evaluated; minimal thickness of abutment walls must be
established in order to perform adequate screwing torque of
abutment without compromising zirconia abutment resistance.
Butz et al. evaluated the survival rate, fracture strength,
and failure mode of this kind of abutment and concluded that
after chewing simulation and fracture loading, ZrO2 abutments were comparable to titanium ones (281 N as opposed to
305 N). Also, the fracture rate of zirconia abutments was
similar to that of their titanium counterparts.63

Fig. 7 Scanning electron microscopy (SEM) observation of


the implant interface between a zirconia CAD-CAM
abutment and a fixture with a hexagonal external
connection: the zirconia abutment is perfectly fitted and
screwed onto the implant hexagonal connection
(magnification 30.2T).

823

Bacterial adhesion, which is an important aspect in order to


maintain zirconia restorations without marginal infiltrations
or periodontal alterations, proved to be satisfactorily slight;
Scarano et al. reported a degree of coverage by bacteria of
12.1% on zirconia as compared to 19.3% on titanium.64
Rimondini et al. confirmed these results with an in vivo
study, in which Y-TZP accumulated fewer bacteria than Ti in
terms of the total number of bacteria and presence of potential
putative pathogens such as rods.65 Surfacial roughness in this
context appears very important; Kou et al. compared different
polishing systems for zirconia and concluded that polishing
creates surfaces similar to the just sintered ones and smoother
than only grinding surfaces.66 These studies indicate that
zirconium oxide can be suitable for implant abutment but
more clinical and mechanical trials are necessary for a
complete understanding of behavior of zirconia abutment
throughout a long time period. Edelhoff has proposed inlays
and onlays with a zirconium oxide core. In order to realize
these restorations, an occlusal reduction of almost 2 mm is
necessary, and the axial reduction must be of 1.5 mm with a
cavosurfacial angle of 1001208.67,68
Zirconia implants are a recent proposal. In a clinical case,
Khoal reported an all-ceramic custom-made zirconia implantcrown system for the replacement of a single tooth.69 In an
experimental study in rabbits, mean bone implant surface was
reported about 68.4%.70 Sennerby compared the osseointegration and removal torque of zirconia implants, titanium oxide
implants, and zirconia with a modified surface when these
were inserted in the tibia and femur of rabbits. He concluded
that although osseointegration appeared similar between the
different samples, the removal torque of the pure zirconia
implant was lower than those of the other two implants,
suggesting that surface modification can improve zirconia
implant stability.71 Titanium implants with a coronal base in
zirconia are also available, the aim of which is to combine the
safety of titanium with the aesthetic features of zirconia.72
Moreover, an in vitro experimental study, pointed out that
zirconia implants are able to sustain chewing stresses.
Cyclical mechanical resistance of zirconia implants with
ceramic restorations in comparison with that of traditional
implant-prosthodontic restorations was studied. The mean
fracture load after cyclical stress in titanium-porcelain fused
to metal restorations amounted to 668.6 N, whereas for
zirconia implants with all-ceramic restorations fracture
occurred at a mean load of 555.5 N. It was concluded that
ZrO2 implants are able to bear fatigue and stresses sufficiently
well for anterior teeth implant replacement.73
Suarez studied the outcome 3 years after the placement of
ZrO2-ceramic restorations on 18 teeth. Only one tooth had
failed after the experimental period because of radicular
fracture. According to this study, it is possible to consider
zirconium oxide restorations as reliable for clinical use.74
Raigrodski et al. studied the durability of three-unit zirconia
FPDs and asserted that these also showed a good outcome
after 3 years.75 This result is in agreement with a study by
Sailer et al., in which a similar outcome was found for
restorations of this kind.76 A systematic review of the
literature evaluated all-ceramic restorations survival rate in
comparison with porcelain fused to metal and, inside all
ceramic group, with zirconia ceramic restorations.77,78 5-years

824

journal of dentistry 35 (2007) 819826

survival rate of all-ceramic restorations resulted 93.3%,


whereas metal-ceramic restorations have a 5-years survival
rate of 95.6%. In particular, all ceramic restorations on
posterior teeth resulted to have the worst 5-year survival
percentage (84.4%). These results did not considered zirconia
restorations. On the other hand, when comparing Zr-ceramic
restorations with other all-ceramic systems, zirconia frameworks resulted as the most reliable. The weakest point of these
restorations resulted veneering chipping or cracking whereas
other all-ceramic restorations showed a percentage of framework fracture. These results are in accordance with clinical
indication for all ceramic restorations that indicates that all
ceramic systems can be used preferably on anterior teeth; only
zirconia showed adequate mechanical resistance for both
anterior both posterior restorations.28 More clinical long term
evaluation must be performed to understand behavior and
reliability of zirconia compared with porcelain fused to metal
restorations that are, nowadays, the most reliable system for
FPD restorations.

3.

Conclusion

Although clinical long-term evaluations are a critical requirement to conclude that zirconia has good reliability for dental
use, biological, mechanical, and clinical studies published to
date seem to indicate that ZrO2 restorations are both well
tolerated and sufficiently resistant. Ceramic bonding, luting
procedures, ageing and wear of zirconia abutment should be
evaluated in order to guide adequate use of zirconia as
prosthetic restorative material. Patient selection, coupled with
adequate clinical and technical protocols, are imperative in
order to obtain good performance of these restorations.

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