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

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

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

experimental considerations

Fernando Zarone ∗ , Simona Russo, Roberto Sorrentino

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

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

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

along with a clinically acceptable quality of their marginal

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

∗
Corresponding author.
E-mail address: [email protected] (F. Zarone).
0109-5641/$ – see front matter © 2010 Academy of Dental Materials. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.dental.2010.10.024
84 d e n t a l m a t e r i a l s 2 7 ( 2 0 1 1 ) 83–96

Nevertheless, the technical procedures of investing wax viceability. Unfortunately, today, none of the available dental
patterns and casting precious metal alloys involve many tech- ceramics fulfills all of these requirements at the same time,
nical variables and a considerable number of operative steps neither is any of them suitable for every different clinical situ-
and firing cycles, making the final quality of the restorations ation both in anterior and posterior regions. A comprehensive
highly technique-sensitive. Moreover, the metal framework review on this topic was provided in 2007 by Conrad et al. [10].
and the layer of opaque porcelain needed for masking the First of all, it has to be pointed out that not all of the dental
underlaying metal grayish shade are likely to introduce a sig- ceramics show equally favorable esthetic features: to date, an
nificant limitation for the esthetic result due to the absence of inverse proportion between strength (i.e., the mechanical per-
translucency, especially when a clear tooth color is to be repro- formance) and optical properties (i.e., the esthetic appearance)
duced: in fact, metal–ceramic restorations can only absorb still seems to be a rule.
or reflect light, while dental tissues show a high degree of Feldspathic ceramics usually provide excellent esthetic,
translucency [8]. Furthermore, from an economic standpoint, together with very good biocompatibility and mechanical
the cost of precious metals has markedly risen over the years resistance to compressive forces, but, unfortunately, they eas-
[9]. ily fracture under shear loads, owing to low tensile strength.
Since the early introduction of the porcelain jacket single A first, successful attempt at strenghtening feldspathic porce-
crowns into the dental practice, at the end of the XIX cen- lain was made by McLean and Hughes [11] in the mid-sixties,
tury, dental ceramics have been considered among the most who dramatically reinforced dental porcelain with the addi-
promising restorative materials, because of noticeable pros- tion of up to 50% aluminum oxide powder.
thetic advantages: esthetic appearance, chromatic stability, Today, the best esthetic characteristics are still displayed
biocompatibility, low plaque retention and fluids absorption, by the class of the glass–ceramics: optimal light transmission,
high hardness, wear resistance, low thermal conductivity, high translucency and natural, tooth-like colors also in the
chemical inertness. However, early dental ceramics encoun- presence of very light shades. Early glass–ceramics, like Dicor
tered a undeniable degree of resistance in the clinicians’ (Dentsply, USA), no longer on the market, attained only limited
perspective of an extensive, routine use due to limiting success because of the modest survival rates [12]; on the con-
factors for an acceptable restoration longevity, mainly asso- trary, leucite-reinforced glass–ceramic (IPS Empress—Ivoclar
ciated to mechanical shortcomings: brittleness, low tensile Vivadent, Lichtenstein) have been highly appreciated for more
strength and fracture toughness, ease of crack propagation, than 20 years thanks to their outstanding esthetic perfor-
poor marginal fit, difficulty of repair. mances [13–16]. Inside the Empress ceramic ingots, leucite
In the last 30 years, the growing patients’ demand for highly crystals, that measure only a few microns, are embedded in
esthetic and natural-appearing restorations has led to the a glass matrix; the wax pattern of the restoration is invested
development of new all-ceramic materials, whose mechani- and burned out, then, at high temperature the glass–ceramic
cal characteristics have been dramatically improved, in order is pressed into the mold (“hot-pressed”). Due to their low val-
to provide suitable longevity and limitation of the technical ues of flexural strength (∼100–120 MPa) [17], leucite-reinforced
problems. In a few cases, however, the increasing industrial ceramics are only indicated in the anterior region, where
pressure on the one hand and growing enthusiasm for attrac- esthetic is paramount, both for single crowns (SCs) and lam-
tive esthetic outcomes on the other have led to an early intro- inate veneers. In a long-term study (11 years), a remarkable
duction on the market of unreliable, not sufficiently tested survival rate of 98.9% was evidenced with IPS Empress anterior
products, resulting in commercial and clinical disasters. SCs, however such a value dropped to 84.4% in the posterior
To date, a large number of studies and scientific data region [18]. With respect to the veneers, IPS Empress yielded
have been produced in order to investigate the mechanical a success rate of 98.8% after 6 years [19], equivalent to the
properties of dental ceramics, mainly aimed at getting an positive results reported for the veneers made of feldspathic
evidence-based validation of the metal-free materials and of ceramics (91–94% at 12 years) [20,21].
the related manufacturing systems. A significant improvement in clinical performance was
The purpose of the present paper is providing a brief review introduced by lithium disilicate glass–ceramics, veneered
on the all-ceramic dental materials and their related produc- with fluoroapatite-based ceramics, like IPS Empress 2 (Ivoclar
tion techniques, evaluating pros and cons in the light of the Vivadent, Lichtenstein), showing higher flexural strength
most recent scientific results and of the personal prosthodon- (∼350 MPa) than the precedent ones and, at the same time,
tic experience of the authors. very appealing translucency, much more suitable than in
zirconia-based ceramics [8,22]. For such promising charac-
teristics, lithium disilicate glass–ceramics have been advised
2. Literature for clinical use in SCs (molar region excluded) and 3-units
fixed partial dentures (FPDs) in the anterior region; in the last
2.1. Glass- and alumina-based dental ceramics years, moreover, both their mechanical and optical proper-
ties have been enhanced, with the development of IPS e.max
An ideal all-ceramic dental material should exhibit excellent Press (Ivoclar Vivadent, Lichtenstein), thanks to some tech-
esthetic characteristics, like translucency, natural tooth color, nical improvements in the production process [23]. Favorable
outstanding light transmission and, at the same time, opti- survival rates for SCs have been reported, from 95% [24] to
mal mechanical properties, like flexural strength (), fracture 100% [25] at 5 years; less encouraging was the survival data
toughness and limited crack propagation at the functional and related to the IPS Empress 2 FPDs, with very different results
parafunctional load conditions, in order to ensure lifetime ser- at 2 years (50% survival rate according to Taskonaz and Sert-
 d e n t a l m a t e r i a l s 2 7 ( 2 0 1 1 ) 83–96 85

guz [26] compared to 93% reported by Esquivel-Upshaw et al. shrinkage but, at the same time, higher porosity and poorer
[27]) but quite poor results at 5 years (70%) [25]. mechanical properties than yttrium partially stabilized tetrago-
Another noticeable improvement in the mechanical prop- nal zirconia polycrystal (3Y-TZP) [43–46], the strongest and most
erties of all-ceramic restorations was offered by the so-called commonly used zirconia-based ceramic. Moreover, stabiliza-
“glass-infiltrated high-strength ceramic core systems”, devel- tion by cerium oxide provides better thermal stability and
oped for the first time in the late eighties with In-Ceram resistance to Low Temperature Degradation (LTD) than Y-TZP
Alumina, followed, after some years, by In-Ceram Spinell and [47–50]. According to the manufacturer’s indications, ZTA is
In-Ceram Zirconia (VITA Zahnfabrik, Germany). All of these suitable for 3-unit FPD frameworks with one pontic in the
oxide-ceramics allow the realization of highly stable frame- posterior sites (reported survival rate at 3 years = 94.5% [51]),
works for SCs or three-unit bridges with one pontic, based on while, on the other hand, it exhibits intense opacity and low
the so-called “slip-casting technique”: a semi-liquid mixture translucency [22]; although providing an efficient masking
containing up to 80 wt% of metal-oxides, like Al2 O3 (In-Ceram power in presence of dark colors or discolored teeth, ZTA is
Alumina), MgAl2 O4 (In-Ceram Spinell) or Al2 O3 + ZrO2 (In- not appropriate for situations in which a high esthetic result
Ceram Zirconia), is sintered to a refractory die, so creating is paramount.
a porous, oxide-ceramic core that undergoes a further fir- Besides slip-casting for the glass-infiltration technique,
ing cycle for lanthanum glass infiltration. Thanks to such a another widespread and successful production system for
process, the framework flexural strength and load-bearing alumina-based restorations is CAD/CAM industrial manu-
capacity are remarkably enhanced: the infiltrated glass fills facturing of densely sintered, high-purity alumina (Procera
the minute spaces and voids that might initiate cracks and AllCeram, Nobel Biocare AB, Goteborg Sweden) introduced in
induce excessive stress concentrations in the core struc- the early nineties and extensively utilized for both single-
ture [28]. Eventually, the esthetic veneering material (i.e. a unit restorations and 3-unit anterior FPDs so far. The Procera
feldspathic ceramic) is layered on the core surface. In-Ceram AllCeram core is realized by compacting, with an industrial
Alumina (described flexural strength between 350 and 500 MPa process performed at a centralized manufacturing plant in
[17,22,29–32]) has been on the market for more than 20 years, Sweden, high purity aluminum oxide against an enlarged,
well accepted by clinicians not only for its fairly good mechan- refractory die of the prepared tooth obtained through a scan-
ical properties but also for a natural esthetic appearance. sion by the dental technician; eventually, the coping is milled
Survival rates shown by many studies on In-Ceram Alumina, in the outer aspect and then sintered to full density. In
with observational periods comprised between 3 and 7 years, the end, the resulting, leucite-free porcelain framework, con-
ranged from 94% to 99.1% for SCs, with a higher amount taining about 99.9% alumina in a polycrystalline state, is
of complications in the posterior sites (crown fractures or veneered with low-fusing feldspathic ceramic. AllCeram cores
chippings) [29,33–36]. A similar trend was evidenced for the are characterized by a higher flexural strength than glass-
In-Ceram Alumina posterior bridges when compared to the infiltrated pre-sintered alumina [52] that, in addition to the
anterior 3-unit FPDs: a survival rate of 83% in the posterior pure and homogeneous structure of aluminum oxide and to
sites, mainly influenced by connector fractures, was evidenced the accuracy of the sinterization process, can explain the
by Sorensen et al. in a three years study, raising to 100% in very good mechanical performance and resistance to frac-
the anterior regions [37]. Other studies with longer obser- ture, still maintaining a fair translucency and opalescence
vational periods (between 5 and 10 years) showed, for such [14,53–55]. As to the marginal fit, gaps ranging between 60
3-unit FPDs, survival rates ranging from 73.9% at 5 years [38] and 80 ␮m were detected, demonstrating a suitable prosthetic
to 88% at 10 years [39]. In-Ceram Spinell is characterized by precision of fit [56,57] and also from the clinical standpoint
a lower mechanical strength ( = 350–400 MPa) than the other marginal integrity was reported to be excellent or acceptable
glass-infiltrated ceramics, but shows better optical properties, [54,55,58].
like high translucency and optimal light diffusion. Its use has In a recent study, the use of luting resin cement with
been limited to the anterior crowns, with fairly good survival Procera AllCeram alumina SCs significantly showed a lower
rates (from 97.5% at 5 years [40]). In-Ceram Zirconia is a glass- amount of mechanical complications in a sample of 209 tooth-
infiltrated zirconia-toughened alumina (ZTA), in which, for the and implant-supported SCs, with cumulative survival and
first time, zirconium oxide was used as in a dental ceramic; success rates of 95.2% and 90.9%, respectively, after 6 years
as reported below, thanks to its metastable nature, zirconia of function [55]. Other authors observed lower microleakage
is a high performance ceramic material [41]. High strength when aluminum oxide blasting plus silane treatment was per-
cores are composed of 67 wt% of aluminum oxide + 33% of formed before the luting phase [57,59,60].
12 mol% cerium-partially stabilized zirconium oxide [16], so Various studies in the last years reported a quite good clin-
that zirconia crystals (grain size < 1 ␮m) are embedded in an ical serviceability of polycrystalline, densely sintered alumina
alumina matrix (larger grains <2–6 ␮m, high elastic modulus) SCs. Cumulative survival rates of 97.7% and 93.5% and cumu-
in such a composition that yields the highest tenacity and lative success rates of 97.7% and 92.2% after 5 and 10 years,
flexure strength inside this class of ceramics ( = 400–800 MPa): respectively were recorded [58]. A recent retrospective clinical
microcracks may trigger the so-called “transformation toughen- study on 86 alumina SCs reported success rates, in anterior
ing” of zirconia (see below), so that a crack tip is more often esthetic sites, of 100% (supported by natural tooth) and 98.3%
seen to propagate through the alumina matrix surrounding (implant-supported) over 4 years of function; the total crown
the transformed crystals [42,43]. ZTA can be manufactured success rate was 98.8% [54]. In another clinical investigation,
according to two different processes: soft machining or slip- the cumulative survival rate was 100% in the anterior region
casting. The latter presents the advantage of a more limited and 98.8% in the posterior region after 5 and 7 years of service;
86 d e n t a l m a t e r i a l s 2 7 ( 2 0 1 1 ) 83–96

clinical success was achieved irrespective of the tooth position [42,71], creating high compressive stresses in the material: as
[61]. a matter of fact, until the twenties, in spite of the worldwide
From such data, it can be inferred that Procera AllCeram abundance of zirconia in very large quantities, such a material
alumina crowns can provide reliable, high strength clinical could not be utilized as a refractory for brick manufacturing
solutions for anterior sites restorations, both supported by due to the onset of severe cracks, as reported by Lughi and
natural teeth and by osseointegrated implants, with a pref- Sergo [64] in their elegant and updated review on the mechan-
erential indication when high load conditions are foreseen ical properties of zirconia. In the thirties, such a drawback
and the more translucent and esthetic glass–ceramics would was clarified and interpreted as a potential, outstanding prop-
be likely to fail. On the contrary, some criticism arose about erty of the zirconia [41,72]: when alloyed with other “cubic”
the clinical use of laminate veneers made of high density oxides like MgO, CaO, Y2 O3 and CeO2 (so-called “stabilizers”),
polycrystalline alumina (Procera AllCeram, Nobel Biocare AB, the phase transformation could be prevented, so retaining the
Goteborg Sweden). A 3D finite element analysis (FEA) study zirconia crystals in their tetragonal or cubic shape at room
based on a very careful and up-to-date modeling technique temperature, in a thermodynamically metastable state. This
was conducted to evaluate the biomechanical behavior of property is the main reason why the biomedical research over
feldspathic versus alumina porcelain veneers [62]; its results the last years has been increasingly focusing on such a mate-
demonstrated different performances in terms of elastic rial, in that it can induce a remarkable increase in fracture
deformations and stress distributions, feldspathic ceramics toughness of the material by hindering (but not preventing
better simulating the biomechanics of sound enamel. On [10,16,73]) the propagation of a crack; in fact, at a possible crack
the contrary, alumina significantly withstanded deformations tip, tensile stress concentration generates the transformation
inside the veneer structure but, at the same time, high stress from metastable (t) ZrO2 to the (m) crystalline phase. The con-
concentrations at the adhesive interfaces were generated; sequent volume increase of the crystals, constrained by the
these might negatively influence the clinical performances of surrounding ones, results in a favorable compressive stress,
both the side of bonding agent and of resin cement, with high that acts as a crack-limiter [64]. Such a mechanism has been
risk of bonding failure [62]. Another drawback for an exten- defined “transformation toughening” or “phase transforma-
sive use of such veneers is that densely sintered alumina is tion toughening” (PTT) [71,74] and, along with the grain size of
a non-etchable material and the adhesion between this poly- such a material, can explain why zirconia presents the highest
crystalline ceramic and dental tissues remains controversial, flexural strength and fracture toughness among all the other
to date; compared with the high predictability of the adhesion ceramics.
between feldspathic ceramics and resin cements, this aspect At room temperature, the transformation from tetragonal
represents a further noticeable limitation that, along with a to monoclinic is a one-way process. This means that, once
poorer esthetic outcome and a scarceness of scientific sup- it takes place, the crack-hindering effect cannot be exploited
port, does not justify to replace materials like glass/pressed for limiting further fractures, “like a used match cannot be
ceramics for laminate veneers [63]. lit again” [64]. Heating the material at a temperature between
900 ◦ C and 1000 ◦ C for a short time, the process can be reversed
2.2. Zirconia [75,76]; in this case, the phase transition from monoclinic back
to tetragonal form, rather than making crystals available again
Since it was introduced in Dentistry, the polycrystalline for further transformation and crack repair, generates a relax-
zirconium dioxide (zirconia) resulted particularly attractive ation of the advantageous compressive stress at the surface,
in prosthodontics, due to its excellent mechanical proper- reducing the material toughness. From this point of view, the
ties and improved natural-looking appearance compared to high temperature thermal process of veneering zirconia with
metal–ceramics [43]. feldspathic ceramic should be taken into account as a possible
Due to the increasing interest in dental applications of such risk of such a detrimental reverse transformation [43].
an innovative material, a brief review of the main related top- The grain size dramatically influence the mechanical
ics is presented here, with no reference to cementation and to behavior of zirconia, in that higher temperatures and longer
the optical/chromatic properties, in that these issues will be sintering times produce larger grain sizes [77]. The critical
treated in different articles. crystal size is approximately 1 ␮m: above such dimension, zir-
Zirconia is chemically an oxide and technologically a conia is more prone to spontaneous PTT due to lower stability,
ceramic material [64], not soluble in water, that was proved whereas a smaller grain size makes zirconia less susceptible
not to be cytotoxic [65–67] and not to enhance the bacterial to this phenomenon [78], although below 0.2 ␮m PTT does not
adhesion, that is lower than on titanium, as demonstrated by happen and zirconia fracture toughness decreases [79]. Con-
both in vitro and in vivo studies [68–70]; moreover, it exhibits sequently, the sintering conditions are paramount since they
a favorable radio-opacity and a low corrosion potential [43]. influence the crystal size, strongly affecting the mechanical
Pure, unalloyed zirconia is polymorphic and allotropic at properties and the stability of zirconia [80] and have to be
ambient pressure, presenting three crystallographic shapes strictly controlled in the whole production process.
at different temperatures: cubic (c) (from 2680 ◦ C, the melt- Although being many types of zirconia-based ceramics
ing point, to 2370 ◦ C); tetragonal (t) (from 2370 ◦ C to 1170 ◦ C); available, to date three zirconia-containing systems have been
monoclinic (m) (from 1170 ◦ C to room temperature) [64]. When, more or less extensively used for dental applications. Two
upon cooling, the spontaneous transformation from the (t) of them are by-phasic materials: the previously mentioned
phase to the more stable (m) phase occurs, a simultane- “glass-infiltrated zirconia-toughened alumina” (ZTA) and the
ous, noticeable volume increase of the crystals (4–5%) ensues “magnesium partially stabilized zirconia” (Mg-PSZ); the third,
 d e n t a l m a t e r i a l s 2 7 ( 2 0 1 1 ) 83–96 87

most used, is the “yttria partially stabilized tetragonal zirconia ship has not been demonstrated by scientific evidence in the
polycrystal” (3Y-TZP), a mono-phasic material [43,74]. clinical service [43,88]. Even though the long-term effects of
LTD on zirconia in dental restorations have not been com-
2.3. Magnesium partially stabilized zirconia (Mg-PSZ) pletely investigated yet, aging is regarded as likely to induce
detrimental changes in the mechanical behavior of the mate-
The microstructure of Mg-PSZ consists of clusters of tetrag- rial, like microcracking, strength decrease, enhanced wear
onal crystals within a cubic stabilized zirconia matrix. The rates with release of zirconia grains in the surrounding envi-
added stabilizer is MgO (8–10 mol%). As regards dental applica- ronment [89,90], as well as surface roughening, with further
tions, with some exceptions (Denzir-M—Dentronic AB), such a degradation of mechanical and esthetic properties [43,86,91].
material has not been extensively used, neither has it encoun- An in vitro research was aimed at comparing failure loads of
tered large popolarity due to its remarkable porosity, large standardized zirconia 3-unit FPDs before and after exposure to
grain size (30–60 ␮m), low stability, tendency to framework an artificial aging process by means of a mastication simulator,
wear [73], and overall poor mechanical properties, especially corresponding to a 5-years of clinical function (about 1,200,000
when compared to 3Y-TZP [43,48]. cycles of thermomechanical fatigue in liquid environment).
Such a treatment reduced the failure loads of all test samples,
2.4. Yttrium partially stabilized tetragonal zirconia with significant differences due to different fabrication tech-
polycrystal (3Y-TZP) niques for each system, but such a reduction ranged within
clinically acceptable values; in fact, all test specimens showed
This type of zirconia is made of transformable, t-shaped grains minimum failure loads higher than 1000 N, both before and
stabilized by the addition of 3 mol% yttrium-oxide (Y2 O3 ). Such after fatigue loading, thus widely exceeding average masti-
a polycrystalline material exhibits low porosity and high den- catory loads [92]. In the same paper, a cautionary warning
sity [81]; at the moment it is the most popular and frequently was addressed to clinicians about the risks of intentionally
used form of zirconia commercially available for dental appli- leaving a Y-TZP framework without ceramic veneering at the
cations. level of the gingival side of the FPDs, as suggested by other
researchers, in order to enhance the core strength [46]; this
2.5. Mechanical properties of zirconia would expose the framework zirconia to the intraoral sali-
vary environment, increasing, at the same time, the potential
The mechanical performances of zirconia were extensively for plaque retention and reducing resistance to low temper-
investigated on both SCs and 3- and 4-unit FPDs, with variable ature degradation and service life [92]. Such an issue is still
reported data, due to a noticeable difference of experimental debated and controversial; in any case, further investigations
conditions and measurements. Mechanical properties of zir- will be necessary to elucidate the relationship between aging
conia were proved to be higher than those of all other ceramics of zirconia and long-term survival of the products [88].
for dental use, with a fracture toughness of 6–10 MPa/m1/2 ,
a flexural strength of 900–1200 MPa and a compression resis- 2.7. Manufacturing procedures
tance of 2000 MPa [43,73,82]. An average load-bearing capacity
of 755 N was reported for zirconia restorations [83]. Fracture CAD/CAM zirconia dental frameworks can be produced
loads ranging between 706 N [83], 2000 N [84] and 4100 N [76] according to two different techniques: “soft machining” of pre-
were reported; all of the studies demonstrated that in dental sintered blanks or “hard machining” of fully sintered blanks
restorations zirconia yields higher fracture loads than alumina [43,93,94].
or lithium disilicate. A recent in vitro investigation on zirco- The soft machining process is the most diffused manu-
nia FPDs evidenced failure loads ranging between 379 and facturing system for 3Y-TZP, based on milling of pre-sintered
501 MPa, thus higher than average human biting force, con- blanks that are fully sintered at a final stage. Such zirconia
firming a satisfactory serviceability of such frameworks [85]. blanks, at the so-called “green state”, are produced by com-
pacting zirconia powders (in presence of a binder that will be
2.6. “Aging” of zirconia eliminated in the following pre-sinterization step) through a
cold, isostatic pressing process; this results in a very narrow
The low temperature degradation (LTD), or “aging”, of zirconia pore size (20–30 nm) and quite homogeneous distribution of
is a well known process, strictly related to the PTT, of which the components inside the blank [43,80]. Processing at a proper
represents the other side of a same coin: it consists in a sponta- pre-sintering temperature of zirconia is a crucial factor since
neous, slow transformation of the crystals from the tetragonal this parameter affects hardness, machinability and roughness
phase to the stabler monoclinic phase in absence of any of the blanks. From the manufacturers’ point of view about the
mechanical stress. This phenomenon decreases the physical choice of the most convenient production technique, hardness
properties of the material and exposes zirconia frameworks and machinability act as opposite factors: an adequate hard-
at the risk of spontaneous catastrophic failure [86]. Mechani- ness is necessary to manipulate the 3Y-TZP blanks safely, but,
cal stresses and wetness accelerate zirconia LTD; other factors if excessive, it is detrimental to a proper machinability. More-
affecting such a process are: grain size, temperature, vapor, over, higher pre-sintering temperatures create rougher blank
surface defects of the material, type, percentage and distribu- surfaces [43,80].
tion of stabilizing oxides and processing techniques [64,87]. After scanning a stone die of the supporting abutment(s) (or
Although LTD is to be considered as a risk factor for directly the wax pattern of the crown/FPD), a virtual, enlarged
mechanical prosthetic failures, to date such a direct relation- framework is designed by sofisticated CAD softwares. Then,
88 d e n t a l m a t e r i a l s 2 7 ( 2 0 1 1 ) 83–96

through a CAM milling procedure, a framework with enlarged, dure allows to reduce the applied force to the block and
accurately controlled dimension is machined out of the blank. minimize the dimension and depth of the surface defects
At the end, the sinterization is completed at high temperature: [98]. In any case, there is high level of evidence that all sur-
the zirconia framework acquires its final mechanical proper- face treatments creating stress, like grinding, sandblasting or
ties in that it undergoes a linear volume shrinkage of about indentations on the zirconia surface determine some degree of
25%, so regaining its proper dimensions. Such processing is (t) > (m) transformation before clinical use [64,99] being detri-
known to produce very stable cores containing a significant mental to the long-term serviceability of zirconia restorations
amount of tetragonal zirconia with surfaces virtually free from [100–102]. Surface grinding can determine deep defects that
monoclinic phase [43]. Nevertheless, a certain amount of cubic reduce toughness [99,103], decrease the strength [104,105],
zirconia may be present due to an uneven distribution of and the consequent exposure of the processing flaws to wet-
yttrium oxide. The cubic phase is richer in stabilizing oxides ness may have further detrimental effects [87]; the resultant
than the surrounding tetragonal crystals and this may nega- alteration of phase integrity is reported to increase the suscep-
tively influence the stability of the material [77]. tibility of the material to aging [106]. Frameworks produced
Frameworks can be colored either adding minimum by hard machining exhibit a considerable amount of mon-
amounts of metal oxides to the zirconia powder or, after oclinic zirconia, associated with higher susceptibility to LTD
machining, by soaking the core in solutions of metal salts and surface microcracking, resulting in a less stable material
(like cerium, bismuth or iron); the framework coloration seems [77]. In any case, since there is no standardization of the treat-
neither to induce PTT nor to decrease the mechanical perfor- ments utilized, it is very difficult to compare the results of
mance of the restorations [43,95]. the studies focused on the surface treatments of zirconia [43].
Soft-machining is the preferred process by the majority of Soft machining procedures provide predictable stability of the
the manufacturers, like Procera Zirconia (Nobel Biocare AB, framework, as long as its surface is not damaged after sinter-
Goteborg, Sweden), Lava (3 M ESPE, Seefeld, Germany) and Cer- ing (e.g. by an occlusal adjustment). To date, the surface state
con (Dentsply Degudent, Hanau, Germany). after processing is still a controversial issue, particularly after
In the hard machining technique, on the other hand, the hard machining, although there is wide agreement on the fact
3Y-TZP blocks are previously densely sintered through a pro- that microcracking due to processing flaws or occlusal adjust-
cess called “hot isostatic pressing”: at high temperatures ments is among the main causes of fatigue damage and failure
(1400–1500 ◦ C) and high pressure in inert gas environment, [43].
very hard, dense and homogeneous blocks of fully sintered Residual stress, like that arising when zirconia is fired at
zirconia are produced [96], out of which the frameworks high temperature and then rapidly cooled down or when a
are shaped to the proper, desired form and to the right, ceramic material with different coefficient of thermal expan-
final dimension by using powerful and resistant milling sion (CTE) is used for veneering, was found to be a more critical
machines with diamond abrasives. Hard-machining of Hi- factor than final surface roughness in inducing LTD [106]. Fur-
pressed (“HiPed”) Zirconia is utilized by Denzir (Decim AB, thermore, the presence of large cubic phases is detrimental to
Skelleftea, Sweden) and DC-Zirkon (DCS Dental AG, Allschwill, the resistance of zirconia to LTD and aging [77].
Germany). Scientific interest has been rising over the last years toward
The issue of which technique is suitable to get the bet- a possible use of cerium oxide as a stabilizer for dental appli-
ter outcomes still remains a controversial topic. The major cations at higher concentration than yttria (8 mol%) [107].
drawback of soft-machining is the problem of matching the Under similar conditions and thermo-cycling, ceria partially
sintering shrinkage of the framework to the enlargement stabilized zirconia (Ce-TZP) showed better thermal stability
amount programmed by the software as precisely as possible and resistance to LTD than Y-TZP and, furthermore, before
[16]. In any case, some in vitro investigations have confirmed the fracture point, it exhibited the highest bending capac-
high fracture toughness and flexural strength with differ- ity among the ceramic materials [47]. The major drawback
ent production techniques, using both hot and cold isostatic that has mainly limited a use of such a material in the den-
pressed zirconia blanks [45,46]. tal practice is its basic yellow-brownish color, along with a
It is clear that, compared to the soft-machining, the hard- marked mutability over time, with the tendency to a dark gray
milling procedure is more time consuming and requires shade after exposition to reducing substances (like glucose or
cutting devices that have to be very tough and resistant to lactose) [64]. Further investigation is needed to identify possi-
wear; the fully sintered 3Y-TZP blocks are much harder and ble future utilization of mixtures between alumina, ceria and
less machinable of both fully sintered zirconia and densely yttria to get better and better outcomes [64].
sintered alumina blocks, making milling time much longer As regards the framework thickness, almost all manufac-
and the production procedure more expensive [64]. From an turers agree in considering 0.5 mm the minimum thickness
operative point of view, moreover, milling zirconia blanks at for copings, in order to prevent core deformation [43,108]. It is
thin sections is very difficult and can lead to unpredictable a well accepted concept that framework thickness and shape
results [97]. Finally, it has been demonstrated that grinding should be optimized and individualized to achieve an even
such blocks introduces various kinds of surface microcrack thickness of veneering ceramic [48] as well as a suitable sup-
and defects [98], both of the “brittle” and the “ductile” type, port for it.
depending on various factors, such as the grain size of the CTE compatibility between the zirconia-based framework
diamond burs or the rotation speed: fine burs determine a and the veneering ceramic is a very critical factor from the
more “ductile” damage compared to the “brittle” fractures mechanical point of view. This topic will be treated at a later
due to the coarse ones, while high speed grinding proce- point.
 d e n t a l m a t e r i a l s 2 7 ( 2 0 1 1 ) 83–96 89

Another important aspect determining the mechanical A relationship between the extension of zirconia FPD and
properties of zirconia-based FPDs is connector shape and the marginal fit has been demonstrated, in that the larger
size. In some clinical trials, fractures of zirconia FPDs have the FPD span, the higher the detected marginal discrepancies
been shown to be associated with insufficient connector [97,118]. Moreover, also the shape of the framework exhibits
height [109–112], since such prosthetic component, con- a relationship to marginal fit: a straight framework design,
necting retainers and pontic(s), represents a locus minoris i.e. with pontics positioned in the straight line with retain-
resistentiae under load [113]. Flexural strength has to be high ers, resulted in more accurate margins than curved framework
enough to withstand occlusal loads, since connectors are configurations [119]. Some authors advise that, in case of com-
under applied tensile stress, so the dimensions of connectors plex prosthetic geometry, post-sintered, hard machining is the
are paramount factors for the long-term success of zirconia most predictable manufacturing system [82].
FPDs; however, they are limited in height by the presence of the As to veneering process, its final effect on the overall fit still
periodontal soft tissues [109,113]. Notwithstanding the lack of remains controversial.
strong scientific evidence about the ideal connector size, some About manufacturing techniques, two studies demon-
in vitro analyzes recommended minimum diameters of about strated less marginal discrepancies with post-sintered
3.0–6.0 mm for 3-unit, 4.0–6.0 mm for 4-unit and 5.0–6.0 mm for machining [120,121], while another investigation did not
5-unit zirconia FPDs [114] and these are the recommended fig- record any difference between hard- and soft-milling [122].
ures by most manufacturers. Moreover, another in vitro study Moreover, two studies proved that CAD/CAM systems resulted
suggested that the radius of curvature at the gingival embra- in lower marginal discrepancies [111,120], whereas other two
sure of the connector strongly affects the fracture resistance investigations did not highlight any significant difference
of all-ceramic FPDs; therefore, the gingival embrasure should between CAD/CAM, in which the design step is performed by
have a radius as wide as possible [113]. software, and CAM only, where such a procedure is realized
by scanning both the internal and the external aspects of a
wax-modeled physical framework [119,121].
2.8. Precision of fit Interestingly, a fatigue load simulation demonstrated that
thermal and masticatory stimulation did not influence the
The precision of the zirconia-based restorations is dependent marginal fit of zirconia FPDs. At the same time, aging seemed
on various factors, like differences in manufacturing systems, not to affect the long-term stability of zirconia fit and marginal
individual characteristics of the prosthesis (e.g. span length, integrity [122].
framework configuration), effect of veneering and influence It can be concluded that most of the currently available
of aging [82]. As to soft-machined 3Y-TZP restorations, the zirconia-manufacturing systems provide clinically acceptable
precise numerical compensation required by such a system marginal and internal gaps; however, remarkable variations
for the enlargement ratio of the model is a paramount factor, were evidenced using different systems and materials. For an
strictly dependent also on the composition and homogeneity extended, detailed analysis of the research data on zirconia-
of pre-sintered zirconia blanks that should be consistent and based restorations fit, refer to the review by Abduo et al. [82].
precise [82].
For SCs, milled dense zirconia copings showed high accu-
racy of fit, ranging between 0 and 74 ␮m [45,46,97,103,115,116]. 2.9. Clinical and experimental studies on zirconia
As regards zirconia FPDs, in recent literature various in vitro
and in vivo studies investigated the precision of fit of such As pointed out, in the last decade an increasing interest
restorations, although different experimental designs and in the zirconia as a dental material for SCs and FPDs has
evaluation procedures made the data comparison very hard to led to the realization of several clinical trials focused on
do: for example, some studies did not cement the specimens defining success/survival rates of such restorations. Most
while others used different luting agents; furthermore, some of these studies investigated the clinical results with pos-
procedures involved impression taking whereas other inves- terior FPDs [111,112,123–139], while only a few were about
tigations employed scanning techniques. In these studies, the SCs [140,141] and implant abutments [124,142,143]; only one
absolute marginal gaps ranged between 9.0 and 148.8 ␮m, regarded implant-supported FPDs [132].
with an average value of 73.8 ␮m. Higher discrepancies were The choice of zirconia as a core material for SCs, both in
detected at the internal gap (i.e. the internal distance mea- the anterior and in the posterior sites, has been increasing
sured between the coping and the abutment), ranging between over time with clinical results that seem quite comparable to
68.8 and 215 ␮m in the occlusal direction and between 52.3 and metal–ceramic single restorations, although clinical trials are
192 ␮m in the axial direction [82]. very few, to date. Zirconia SCs showed a success rate of 93%
An in vitro investigation [117] reported lower values of after a 2 years observation period, with a favorable soft tis-
absolute marginal opening when a feather-edge was realized sue response, in a limited sample size of 15 Cercon crowns
during the tooth preparation (87 ± 10 ␮m), while the detected (Dentsply Degudent, Hanau, Germany) [140]. Another investi-
values were higher for mini-chamfer (114 ± 11 ␮m), shoulder gation with a longer observational period (3 years), performed
(114 ± 16 ␮m) and chamfer finish line (144 ± 14 ␮m); however, on 204 Procera zirconia SCs delivered in a private practice,
due to the limits of the in vitro experimental design and to showed a survival rate of 93%; in this study, 16% of compli-
the mechanical limitations of feather edge preparations, such cation were recorded (6% loss of retention, 2.5% extraction of
a finish line design was not recommended for clinical appli- abutment teeth, 5% persistent pain, 2% porcelain chipping)
cations of zirconia SCs by the same authors. [141].
90 d e n t a l m a t e r i a l s 2 7 ( 2 0 1 1 ) 83–96

On the contrary, a larger amount of data regarding zir- ure, affecting 21.7% of the restorations, whereas porcelain
conia posterior FPDs is emerging from various studies that chipping occurred in 15.2% of the prostheses. In a study con-
showed quite favorable clinical results; not differently from ducted on implant-supported FPDs, a much higher incidence
metal–ceramic bridges, failures have been reported, both of porcelain chipping (54% after 1 year of clinical service) was
related to biologic complications, like secondary caries, and reported [132]. So far, the incidence of chipping reported in the
to technical problems, such as fracture of the bridge or chip- studies in zirconia-based restorations ranges from 0% to 54%
ping of the veneering ceramic [6,124,144]. Comprehensive after 1 or 2 years of observation [123,127,132,146], in any case
systematic reviews of the literature on the survival rates of less favorable than the figures referred to PFM restorations
all-ceramic SCs and FPDs in comparison with metal–ceramic (gold-based alloys) in the scientific literature: 98% of intact
restorations have been published [5,6], reporting, after 5 porcelain over 5 years [147] and 4–6% of ceramic-related fail-
years of observation, favorable survival rates (95.6%) for ures recorded over 10 years [148]. The estimated risk per year
metal–ceramic prostheses, to be compared to a figure of of ceramic chipping for all-ceramic restorations is 2.92% [6].
93.3% for all-ceramic restorations, among which zirconia- Nonetheless, it is quite arduous to come to conclusions based
based prostheses showed the best clinical performances and on the comparison of such data, due to evident differences
resulted as the most reliable all-ceramic systems. Zirconia was in machining systems, failure evaluation criteria, follow-up
affected only by cracking or chipping of veneering ceramic, period and clinical experience of the operators. It has also to
whereas other all-ceramic restorations showed some frame- be highlighted that, in the majority of the cases, chippings
work fractures. It has been pointed out that it is very difficult, did not hinder function, being repairable [123,127,132,137];
and in some cases impossible, to make a scientifically valid sometimes the problem was easily solved by intraorally pol-
comparison between the results of different clinical stud- ishing the restoration surface [112,137], while, in another
ies conducted on the various zirconia-based FPDs, for the study, repair was carried out with composite resin [131]. Only
diversity in the research methods, evaluation parameters, pro- in very few cases of major chipping or when serious esthetic
duction techniques and observation periods. After 2 years of problems arose, the restorations needed a total replacement
function, a recent clinical short-term research reported 100% [6,141].
survival rate [126]. After 3 years of clinical service, almost Although minor cohesive fracture of veneering ceramic
all of the studies reported very good clinical outcomes for being the most frequent typology of failure reported in the
zirconia-based FPDs, with failure rates between 0% and 4.8% majority of the cited clinical studies, exposure of the under-
[111,124], showing a promising reliability of such restorations lying zirconia core was rarely observed and, in any case, it
[123,130,145]. In a clinical study on 18 teeth, one failure was is very hard to detect by the naked eye. Chipping of veneer-
reported, due to a radicular fracture [145]. At 4 years of use, ing porcelain occurred also in non-load bearing areas [6,112],
the reported failure rates were comprised within 4% and 6% even though second molars and connectors of mandibular
[138,139]. To date, in such studies the longest observational posterior FPDs were the preferential sites for such mechan-
period was 5 years [6,128]; 3–5-unit posterior zirconia FPDs on ical complications, probably due to the more intense biting
natural teeth were evaluated, with the only exception of a 3- forces [123,133,141].
unit FPD in the anterior site, replacing a lateral incisor [128]. The causes of porcelain chipping may be material-related
After 5 years of clinical service, the overall survival rate ranged to some extent; on the other hand, factors may be also
between 74% [6] and 100% [125,128]. dependent on the prosthetic design, such as core-porcelain
In conclusion, positive success rates have been recorded in thickness ratio and framework architecture. An incorrect
most investigations and a suitable serviceability of zirconia- shaping of the framework does not provide adequate, uniform
based FPDs seems to be expected in the medium-term. support to the veneering ceramic and this could play a critical
The reported mechanical complications related to such role in porcelain chipping. As well as in metal–ceramics, the
restorations are framework fractures, chipping of veneering zirconia-based FPD frameworks should be shaped in order to
ceramic and loss of retention. ensure an optimal support to veneering porcelain, that should
Zirconia framework fractures were reported in only 5 stud- be mainly subjected to compressive loads, limiting detrimen-
ies, 3 on FPDs [6,111,112], 1 on SCs [140] and 3 on inlay-retained tal tensile stresses. In metal–ceramics, this is conventionally
FPDs [134]. The incidence of core fractures ranged between 3% achieved by wax-modeling the complete anatomic contour
[112] and 10% [134] and such data seem to indicate a strong of the restoration and, later, creating the correct spacing for
relationship to the design of the prostheses, in that the high- veneering ceramics by means of the controlled, so-called “cut-
est incidence was recorded with inlay-retained FPDs. It can be back” technique; in this way, the proper ceramic thickness for
inferred that bulk fractures should be considered very unfre- both an optimal esthetic and mechanical performance can be
quent events; when they occur, connectors of multi-unit FPDs achieved, avoiding excessive porcelain thickness (>2 mm) [9].
or second molar abutments are mainly interested. The shape of zirconia frameworks should be customized by
Conversely, crazing or chipping (superficial cohesive frac- dental technicians according to such requisites, rather than
tures) of the veneering porcelain were reported by the majority modeled according to the concept of uniform thickness of zir-
of the studies as the most frequent complications affecting conia.
zirconia-based prostheses, mainly at level of posterior teeth As previously seen, surface damages can represent a start-
and indipendently from the type of restoration. According to ing point for the onset of fractures. Recent fractographic
Sailer et al. [129], after 5 years of clinical service, 3–5-unit examinations [111,112,124] demonstrated that chipping of the
posterior zirconia FPDs supported by natural teeth exhibited veneering ceramic may origin from occlusal roughness, that
secondary caries as the most common cause of (biologic) fail- can be the consequence of possible incorporation of air bub-
 d e n t a l m a t e r i a l s 2 7 ( 2 0 1 1 ) 83–96 91

bles during the powder buildup for veneering porcelain or some inlay-retained FPDs cemented with resin luting agents
the result of damages originating from occlusal adjustments, [134].
likely exposing the underlying zirconia core. Spontaneous None of the cited clinical trials took bruxism into account,
delamination, i.e. interfacial adhesive failure separating the more often such a parafunction figuring among the exclu-
zirconia core from the veneering ceramic, also has been con- sion criteria: consequently, since they were not considered in
sidered as a possible modality of failure, but it can only be any clinical investigation, parafunctional activities should be
evidenced by a microscopic examination [134] and, in any case, regarded as a potential limitation for zirconia-based restora-
most authors are quite skeptical about a likely occurrence tions [96].
of delamination, since the bond strength between zirconia Although it has been demonstrated that, among the
and dedicated veneering ceramics is higher than the cohesive metal-free restorative materials, zirconia exhibits the high-
force of the porcelain itself [49,50,149–152]. est mechanical properties, from a clinical standpoint, zirconia
It is clear that ceramic veneer cracking is a multifactorial bridges maximum span remains controversial: 5-unit is the
phenomenon and that only some of its possible causes have maximum serviceable extension for zirconia FPDs supported
been distinctly highlighted: among the others, differences in by a piece of scientific evidence [132]. As regards more
CTEs between framework and ceramic, firing shrinkage of extended prostheses, further investigations with longer obser-
porcelain, areas of porosities, flaws on veneering, poor wetting vational times are needed to draw solid guidelines, even
by veneering material on core, improper framework sup- though some manufacturers suggest and support the tech-
port, overloading and fatigue [49,50,153–155]. Even though the nology for fabricating full-arch restorations.
nature of the bonding between zirconia cores and veneering It has to be noticed that in a few of the analyzed clinical tri-
porcelain has not been completely clarified and the compat- als, some restorations presented cantilevers; notwithstanding
ibility parameters have not been definitely characterized yet none of them was affected by framework failure, the authors
[151], CTE seems to play a crucial role in such a phenomenon. themselves did not recommend the cantilevered design for
Dedicated ceramics have been developed for zirconia in order zirconia FPDs, particularly in distal segments [134].
to reduce mechanical problems, but further investigations on According to in vitro cyclic fatigue tests, Y-TZP was
the bond between zirconia core and veneering ceramic are reported to have a lifetime prevision comparable to that
needed. Nowadays, almost all of zirconia-based systems offer of metal–ceramic prostheses, with a predicted serviceability
veneering ceramics specifically developed to exhibit CTEs longer than 20 years [114]. Nevertheless, two main drawbacks
compatible with zirconia frameworks. In agreement with a were noticed to be more frequent for zirconia in comparison
principle that has been widely applied by dental technicians to metal–ceramic restorations: chipping of veneering ceramic
in manufacturing metal–ceramic restorations, a little, con- and accelerated aging, so further clinical studies with longer
trolled mismatch of such parameters seems to be advisable, observational period will be necessary to thoroughly investi-
in terms of a lower veneering ceramic CTE than the zirco- gate the clinical behavior and reliability of zirconia in the long
nia CTE, in order to place porcelain under compression and term.
reduce the risk of crack development by increasing the bond- As a last note, it has to be taken into account that, in the last
ing strength to the framework [82,156]. At the same time, years, a conspicuous interest in the clinical utilization of zirco-
tempering residual stresses are to be controlled, to prevent nia in implant-borne restoration has been growing. Most of the
the onset of detrimental tensile forces and to limit porcelain implant manufacturer’s brands provide customized zirconia
chipping risks; this is obtained by lowering the cooling rate abutments for their platforms, either produced by CAD/CAM
after the final firing or glazing of porcelain [155]. Presumably, techniques or milled from fully sintered blocks. The few pub-
other interacting factors can be involved in the compatibil- lished studies show promising results and favorable hard and
ity issue between zirconia and veneering ceramics, but not soft tissues responses after 4 years of service; no abutment
all of them have been sufficiently studied yet: tensile stresses fracture was reported but two screw loosenings were observed
concentrated at the zirconia–ceramic interface [64]; chemical [142]. Another study recorded 100% survival rate of zirconia
processes, like the harmful dissolution of refractory materi- single implant abutments after 3 years of follow-up [143]. How-
als (like zirconia) induced by silicate glasses contained in the ever, as stated in a recent consensus report [160], the mean
veneering ceramics [157]; surface phase changes, as those due follow-up time of ceramic abutments in the available clinical
to a depletion of stabilizing oxides determined by functional reports is 3.7 years, while for metal abutments is 4.8 years; so
wear or ceramic adjustments, leading to destabilization of the far, data are not sufficient to define the indications and per-
(t)—zirconia [158,159]. All of these and other possible factors formance limits for such abutments. Similarly, as regards the
will need further investigation to understand the nature, clin- application of CAD/CAM technologies for fabricating implant-
ical impact and possibility of prevention of porcelain chipping supported all-ceramic restorations, especially FPDs or large
in zirconia-based crowns and bridges. fixed, full-arch prostheses, available data are not sufficient to
Loss of retention has been reported to be another possible compare at a convenient level of evidence such production
technical complication with all kinds of luting agents, partic- systems with the conventional ones.
ularly in FPDs; anyway, in the zirconia clinical trials, all of the
debonded restorations were eventually recemented success-
fully [96]. The estimated risk per year of loss of retention for 3. Summary
all-ceramic prostheses has been reported to be around 0.47%
[6]. Differently, catastrophic, not repairable fractures probably The trend toward an increasingly extended use of all-ceramic
caused by debonding of the restorations were observed with SCs and FPDs is an undeniable reality in Fixed Prosthodon-
92 d e n t a l m a t e r i a l s 2 7 ( 2 0 1 1 ) 83–96

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