CLINICAL SCIENCE

A prospective evaluation of zirconia anterior partial xed

dental prostheses: Clinical results after seven years
Maria Fernanda Sol-Ruz, DMD, PhD, MD,a Rubn Agustin-Panadero, DMD, PhD,b
Antonio Fons-Font, DMD, PhD, MD,c and Carlos Labaig-Rueda, DMD, PhD, MDd
Since the end of the 20th
ABSTRACT
century, high-strength ceStatement of problem. Because of the high mechanical strength of zirconium dioxide, the metal in
ramics have come into use to
xed partial prostheses can now be replaced. However, the material is susceptible to aging or
replace the metal in xed reshydrothermal degradation and to chipping of the feldspathic veneer.
torations, a development that
Purpose. The purpose of this prospective study was to evaluate the survival (without failure) and
has led to high expectations.1
success (survival without any complication or failure) rate and clinical efcacy of anterior zirconia
Among the ceramics used in
partial xed dental prostheses.
these new systems, zirconium
Material and methods. Twenty-seven anterior partial xed dental prostheses of 3 to 6 units were
dioxide (zirconia) has been the
fabricated. All participants were examined after 1 month and 6 months, then annually for 7 years.
main focus of research because
Results. Three partial xed dental prostheses failed and had to be removed: 2 because of secondary
it offers a range of properties
caries, which increased failure signicantly (P=.001) and 1 because of severe chipping. Six partial
that make it suitable for use
xed dental prostheses had complications: 2 debonded, 3 had chipping, and 1 had periapical
in dentistry: biocompatibility,
pathology. All veneer porcelain fractures occurred in 6-unit xed partial prostheses (P=.002). The
high fracture resistance, low
clinical success rate was 88.8% after the 7-year follow-up.
thermal conductivity, resisConclusions. The clinical behavior of partial xed dental prostheses with a zirconium dioxide core
tance to corrosion, and a
in the anterior region provides an adequate medium-term survival rate. The main cause of failure
totally crystalline microstrucwas secondary caries. The most frequent complication was chipping, which was directly related to
ture.1,2 Yttrium-stabilized zirthe number of units of the prosthesis. (J Prosthet Dent 2015;-:---)
conium dioxide is suitable for
optical applications because of its high refraction index,
inherent problem of the material is a phenomenon
its low absorption coefcient, and its high opacity in the
known as spontaneous aging, hydrothermal degradation,
visible and infrared spectra.3 Its grain size and the disor low-temperature degradation.6,7 These factors change
tribution of different grain sizes, the pressure method
its crystalline phase from tetragonal to monoclinic, which
and conditions, and different additives all determine the
increases the volume (4% to 5%) of the crystals causing
translucency of a restoration.3 In spite of the materials
the loss of their mechanical properties and the appearhigh fracture resistance, chipping of the feldspathic porance of microcracks or macrocracks.6-9
celain veneer of zirconia xed dental prostheses during
In spite of these setbacks, the survival rates of zirconia
mastication is a frequent problem.4 This complication
feldspathic xed partial dental prostheses (FDPs) are
generates some uncertainty as to the long-term perforgreater than those of lithium disilicate-based core cemance of the material in dental restorations.5 An
ramics10 and similar to those of metal ceramic prostheses,

Adjunct lecturer, Department of Buccofacial Prosthetics, Faculty of Medicine and Dentistry, University of Valencia, Valencia, Spain.
Associate lecturer, Department of Buccofacial Prosthetics, Faculty of Medicine and Dentistry, University of Valencia, Valencia, Spain.
c
Senior lecturer, Department of Buccofacial Prosthetics, Faculty of Medicine and Dentistry, University of Valencia, Valencia, Spain.
d
Senior lecturer, Department of Buccofacial Prosthetics, Faculty of Medicine and Dentistry, University of Valencia, Valencia, Spain.
b

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Clinical Implications
Zirconia xed partial dental prostheses offer a
recommendable alternative for replacing teeth in
the esthetic zone.

which have survival rates of 97% and 99% after 5 years,

respectively.11-14
Most published research has analyzed the behavior of
zirconia restorations in the posterior zone.15,16 Chipping
or delamination has been dened as the fracture of the
veneer ceramic, and a high rate varying between 6% and
28% has been conrmed over a period of 3 to 10 years.1633
These are high values compared to the 4% fracture rate
demonstrated by conventional metal ceramic restorations
over 10 years.34
According to Heintze and Rousson,14 chipping, can
be classied by severity and by the treatment required for
repair, as follows: grade 1, small surface chipping, with
treatment being polishing the restoration surface; grade
2, moderate surface chipping, with treatment being using
a resin composite repair system (Fig. 1); and grade 3,
severe veneer ceramic chipping exposing the zirconium
dioxide core, with treatment being replacing the
damaged prosthesis. Literature reviews such as those by
Heintze and Rousson,14 Anusavice,35 and Raigrodski,36
show that the most frequent types of zirconia-based
xed dental prostheses chipping are grades 1 and 2,
which do not involve restoration failure.
Several factors have been identied that can inuence
the incidence of chipping, as follows: (1) residual tension
due to differences in the thermal expansion coefcients
of the core and the veneer materials; (2) poor wettability
of the core by the veneer ceramic37; (3) compression
resulting from ring the porcelain38,39; (4) the protocol for
heating and cooling the veneer and core37; (5) transformation of the zirconium dioxide crystal phase at the
core-porcelain veneer interface caused by thermal inuences or load forces40; (6) formation of inherent defects
during processing41; (7) veneer ceramic application
technique (stratication/injection)41-43; (8) Inadequate
thickness of veneer ceramic44; and (9) occlusal trauma.45
The aim of this study was to evaluate the success and
survival rates and biological and/or mechanical complications of zirconium dioxide FDPs in the anterior region
over a 7-year follow-up.
MATERIAL AND METHODS
Twenty-seven participants (14 women and 13 men) aged
between 30 and 65 years took part in the study, which
was carried out in the Prosthodontics and Occlusion
Department at the University of Valencia between
January 1, 2005, and January 1, 2006, with latest
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Figure 1. Chipping of veneer ceramic in maxillary central incisors of

xed dental prosthesis with zirconia core.

evaluation being on January 1, 2014. The ethical board for

clinical trials of the University of Valencia approved the
study protocol, and all participants gave their informed
consent to take part.
Inclusion criteria were the need to replace 1 or 2
anterior teeth (central or lateral incisors), indicating the
placement of FDPs of between 3 and 6 units, periodontally healthy abutment teeth, no signs of either resorption
or periapical pathology, stable occlusion, and natural
teeth in the antagonist arch.
Individuals requiring a xed partial prosthesis of more
than 2 pontics or with poor oral hygiene, a high incidence of
caries, active periodontal disease, or bruxism were excluded.
Prosthodontic procedures
Three clinicians (S.R.M.F., A.P.R., F.F.A.) with experience
in xed prosthodontics prepared the abutment teeth to
meet the following parameters: occlusal and/or incisal
reduction of 1.5 to 2 mm; axial reduction of 1 to 1.5 mm
with a 10-degree included convergence angle, and a
circular chamfer or shoulder of 1 mm. Particular attention
was paid to rounded line angles (Figs. 2, 3). The color of
each abutment tooth and adjacent teeth was identied
with a shade guide (Vita shade guide, Vita Zahnfabrik).
Interim restorations were fabricated from polymethyl
methacrylate (AcryLux C&B; Ruthinium Group, Dental
Manufacturing Spa) and cemented with eugenol-free
interim cement (Temp Bond NE; Kerr Corp).
Denitive impressions were made with polyvinyl
siloxane impression material (Exaex; GC America Inc) in
a stock perforated stainless steel tray (Zhermack; Badia
Polesine). Impressions of the opposing arch were made
with irreversible hydrocolloid impression material
(Orthoprint; Zhermack) and intermaxillary relations were
registered in wax (X-hard; Miltex).
The FDPs were fabricated with a computer-aided
design and computer-aided manufacturing (CAD/CAM)
Sol-Ruz et al

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Figure 2. Patient before treatment with existing xed dental prosthesis

and tooth wear.

Figure 3. Abutment tooth preparation.

Figure 4. A, B, Zirconia framework evaluated intraorally to ensure adequate t.

system (Lava; 3M ESPE). They had a connector surface

area of 7 mm2; a uniform coping thickness of 0.5 mm was
used for all prostheses to standardize the study protocol.
All internal frameworks were evaluated in the mouth to
ensure an adequate t (Fig. 4). The veneer ceramic used
was Lava Ceram (3M ESPE). Before bonding, the internal
surfaces of the prosthetic framework were treated by
airborne-particle abrasion with a tribochemical silica
coating with 30 mm Al2O3 particles (CoJet; 3M ESPE). A
layer of silane (Monobond; Ivoclar Vivadent) was
applied. The teeth were also treated with 35% orthophosphoric acid, followed by application of the dentin
adhesive (NT Prime Bond; 3M ESPE). All the FDPs were
bonded with a resin cement (Multilink; Ivoclar Vivadent)
(Fig. 5).

Figure 5. Fixed dental prosthesis cemented.

Clinical follow-up
The 27 participants were examined by 2 clinicians who
had not been involved in treating them, at 1 month after
restoration, after 6 months, and thereafter annually for 7
years. The clinical parameters analyzed were loss of

vitality or infection of the abutment teeth (cold test and

periapical radiographs), secondary caries, debonding,
fracture of the prosthesis core, and chipping of the veneer
ceramic. Both clinicians evaluated the prostheses independently. The parameters were such that assessment

Sol-Ruz et al

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Figure 6. A, Incisal edge chipping level 1. Maxillary right canine. B, Chipping corrected with intraoral polishing.

Table 1. Complication details in prospective evaluation after 7 years

Chipping
Core fracture
Debonding
Secondary caries
Endodontic

Complication Present

1.0

Incidence (%)

No

23

85.2

Yes

14.8

No

27

100

Yes

No

25

92.6

Yes

7.4

No

25

92.6

Yes

7.4

No

26

96.3

Yes

3.7

0.8

Survival

Complication

0.6
0.4
0.2

Survival Function
0

0.0
0.00

was objective in all prostheses, so reliability testing was

not thought to be necessary. Nevertheless, if divergences
did occur between their ndings, the lower value was
used for analysis.
Statistical analysis was performed with software
(Statistical Package for the Social Sciences; IBM SPSS
Statistics) applying initial descriptive and bivariate analyses, the Kruskal-Wallis test, the Mann-Whitney test,
and Kaplan-Meier survival analysis (a=.05).
RESULTS
The 27 participants received 27 FDPs: ten 3-unit, ten 4unit, two 5-unit, and ve 6-unit FDPs. All participants
completed the 7-year follow-up, and no appointments
were missed. After 7 years of monitoring, 3 complete
restoration failures had occurred requiring removal (one
3-unit and one 4-unit FDP failure because of secondary
caries and one 6-unit FDP failure because of irreparable
chipping). The survival rate of the zirconia core restorations was 88.8% after the 84-month follow-up (95%
condence interval [CI] 70.8 to 97.7).
The complications observed were classied as biological (secondary caries, pulp affectation) or mechanical
(fracture of the core or veneer ceramic, debonding).
Biological complications involved 2 FDPs (one 3 unit, one
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2.00

4.00

6.00

8.00

10.00

Complication time
Figure 7. Probability of survival without complications until end of
follow-up period.

4 unit) with secondary caries (7.4%) in the abutment

teeth, requiring replacement of the prosthesis at the 3year follow-up and one 4-unit FDP (3.7%) with an
endodontic problem with periapical lesions after 2.5
years; however, after periapical surgery, there was no
need to replace the prosthesis. Mechanical complications
involved 4 FDPs with chipping (14.8%), all of them 6unit FDPs: one was replaced after 3 years and the
others were corrected by polishing and intraoral repair
(Fig. 6). Two FDPs (one 4 unit and one 6 unit) debonded
after 7 and 6 months, respectively. None of the FDPs had
fracture of the internal zirconia cores (Table 1). When the
type of complication was related to the FDPs number of
units (applying the Kruskal-Wallis test), a statistically
signicant relation was identied involving chipping
(P=.002). Five 6-unit FDPs showed a higher incidence of
chipping than those with shorter spans (P<.001, MannWhitney). No identied differences were found between 3-unit and 4-unit spans (P=1.000, MW), with null
incidence of chipping. When the causes of restoration
failure were analyzed, the only statistically signicant
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1.0

Survival

0.8
0.6
0.4
Type FPD
3 units
4 units
5 to 6 units

0.2

3 units-censored
4 units-censored
5 to 6 units-censored

0.0
0.00

2.00

4.00

6.00

8.00

10.00

Complication time
Figure 8. Survival (without failure) according to FDP number of units.

factor (Mann-Whitney test) was secondary caries

(P=.001). All FDPs that presented with secondary caries
in the abutment teeth had to be removed.
The Kaplan-Meier survival test estimated an accumulated survival rate of 8 years and 5 months (95% CI
7.6 to 9.0). The critical moment for survival was around
the 3-year mark, given that a restoration that had survived 3 years maintained a constant probability of surviving the follow-up period (with a value of 0.9). The
mean survival time without any incidence of complications (success) was 6.83 years (95% CI 5.6 to 8.1). If by 3
years no complication had occurred, there was a high
probability that none would appear thereafter (Fig. 7).
When success was related to the FDP (Kaplan-Meier
test), the probability of some complication occurring
increased in relation to the number of units of the FDP
(Fig. 8). For 6-unit FDPs, complications occurred both
soon and frequently. For these restorations, the time
taken to stabilize survival probability was 2 years, but
thereafter the probability of survival was only 0.42.
DISCUSSION
Little research has been published on the clinical
behavior of anterior FDPs with zirconia cores. For this
type of restoration, the most frequent complication is
chipping of the veneer porcelain.15-34 Factors that inuence chipping are related to a series of variables, which
range from the varying thermal behavior after ring and
cooling the substrate and the overlay ceramic to insufcient wettability of the substrate in relation to the veneer
porcelain during construction, which can produce insufcient homogeneity at the veneer/core interface.3,4,37
One of the most widely studied ceramic veneer
phenomena that might be related to ceramic veneer
chipping, is aging or low-temperature degradation.
Zirconium dioxides hydrothermal transformation was
discovered by Kobayashi et al,46 who observed a
slow, progressive, spontaneous transformation of the
Sol-Ruz et al

tetragonal to monoclinic phase associated with the

degradation of the materials mechanical properties. This
phenomenon is promoted by the presence of water or
vapor and by the temperature caused by the reactions of
water and the crystalline lattice. The susceptibility of
zirconia to aging depends on factors such as grain size,
presence of residual stress, or the quantity, type, and
distribution of the stabilizing element; the larger the
grain size or the greater the residual stress or the lower
the quantity of stabilizing element, the greater the aging.46 This is also a phenomenon that is accelerated by
the presence of water vapor.47 Of particular relevance
was the news reported in various American orthopedic
journals of the fracture-after only a short time-of 400
Zircone Prozyr (3Y TZP) femoral prostheses made from
zirconia in 2001 to 2002. These had to be removed and
led to a marked reduction in the use of the material and
the closure of the supplier of the prosthesis.1 Numerous
research articles have shown how the kinetics of the
tetragonal-monoclinic transformation, which generally
appears to be linked to chemical composition, is accelerated as temperature rises.38-40 The activation energies
measured vary between 70 and 110 kcal/mol. This evidence has important technological consequences because
of zirconias low thermal conductivity (2.5 W/mK),
whereby the surface treatment of zirconium dioxide lines
by abrasion can cause notable temperature rises locally
that can initiate phase transformation.46
Crisp et al17 analyzed the behavior of 13 FDPs (3- and
4-unit prostheses), but they did not observe any complications after a 12-month follow-up, nor did Tinschert
et al18 in an analysis of 15 anterior FDPs (3- to 10-unit
prostheses) over 38 months. These results are not comparable with the present study given the small numbers
of FDPs and the shorter follow-up periods.
Schmitter et al19 monitored 30 FDPs (4- to 7-unit
prostheses) over 25 months, distributed in both the
anterior and posterior regions; among the anterior FDPs, 1
had endodontic problems and 2 debonded among the
posterior FDPs, 1 had a fracture of the internal core, and 1
had veneer chipping. Edelhoff et al20 analyzed the
behavior of 21 FDPs (3- to 6-unit prostheses) over 39
months, of which only 4 were placed in the anterior region, with 1 incidence of a loss of pulpal vitality in 1
abutment tooth.
Almost all published research of FDP behavior deals
with restorations placed in the posterior region.21-33 The
most common mechanical complication was chipping of
the veneer ceramic, although there is controversy between researchers as to its incidence. Some authors
report that chipping occurs in 3% to 6% of posterior
FDPs,17-19,22,23 whereas others state that it is 9% to
15%,8,13,20,24-29 and some report that it is as high as 19%
to 28%.21,29-31 However, several other authors have
found no mechanical complications among the FDPs
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monitored.32,33 The present study found that 14.8% of

the restorations had chipping, all of them longer, 6-unit
FDPs. None of the FDPs in the present study had fracture of the zirconia cores.
As for biological complications, the present study
found an incidence of 11.1% (2 participants [7.4%]
with secondary caries, and 1 [3.7%] endodontic problem) over the 84-month follow-up period. Again, there
is controversy between authors over the incidence of
these complications, which range between 1.5% to
5.5% 36,18-20,21,23,27,28,30 and 10.1% to 20% 26,31,29 over
clinical observation periods of between 50 and 84
months. The latter studies concur more closely with
the present one, both in the number of biological
complications and in the follow-up period.
When the causes of mechanical restoration failure are
analyzed, according to studies with 3- to 5-year followup, success rates vary between 88.8% and
100%,6,12,17,18,20,22,25,30,32,33 while for failure due to biological complications, the success rate decreases to
73.9%,11,21,23,27,29,31 ndings that agree with the present
study, in which the incidence of caries increased FDP
failure (P=.001, Mann-Whitney test).
In the studies discussed previously, most FDPs were
made with ceramic veneer over a zirconia substrate
applied in layers with a stratication technique. Christensen and Ploeger41 stated that veneer ceramics that
contain leucite and that are applied with a pressing
technique have markedly better resistance to chipping
compared to stratication. However, studies by Choi
et al42 refute this theory, and a study by Ishibe et al43
comparing the pressing technique and layered ceramic
veneers failed to identify signicant differences in zirconia or metal substrates.
Recently, monolithic zirconia restorations, which have
good optical and mechanical qualities and are not susceptible to chipping, have become popular.48 Longitudinal long-term prospective studies are needed to conrm
the performance of these restorations, although their
esthetics limits their use to the posterior region.
All the FDPs in our study were cemented with a
standard technique. To date, consensus has not been
reached as to the ideal cementation technique. Nevertheless, most authors recommend airborne-particle
abrading the internal structure with 30 mm silica oxide
particles at a pressure of 200 kPa from a distance of 2 cm
for 10 seconds and then cementing with adhesive and
composite resin.49,50 No immediate damage attributed to
airborne-particle abrasion has been observed that compromises zirconias fatigue resistance. Zhang et al51
indicated that abrasion by aluminum oxide particles of
up to 50 mm increased surface resistance, while airborneparticle abrasion with aluminum oxide particles of 120
mm signicantly weakened the structure by increasing
surface roughness.
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CONCLUSIONS
Within the limitations of this study (in particular the
small sample size), the conclusions are as follows:
1. Anterior FDPs with zirconium dioxide frameworks
showed a success rate of 88.8% within the 7-year
follow-up.
2. The most frequent cause of failure was secondary
caries (P=.001), which was related to the number of
units of the FDP.
3. The most frequent complication was chipping of the
veneer ceramic.
4. All chipping occurred in longer, 5- or 6-unit FDPs
(P=.002).
5. The critical period for the occurrence of mechanical
and biological complications was between the rst
and the third year.
6. More long-term longitudinal studies are required to
conrm the behavior of this type of restoration in
the oral environment.
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Corresponding author:
Dr Maria Fernanda Sol-Ruiz
Faculty of Medicine and Dentistry
University of Valencia
C/ Gasc Oliag, N 1
46010 Valencia
SPAIN
Email: [email protected]
Copyright 2015 by the Editorial Council for The Journal of Prosthetic Dentistry.

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