Journal of Dentistry 109 (2021) 103661

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Journal of Dentistry
journal homepage: www.elsevier.com/locate/jdent

Review article

Zirconia-reinforced lithium silicate (ZLS) mechanical and biological

properties: A literature review
Fernando Zarone a, Gennaro Ruggiero a, *, Renato Leone a, Lorenzo Breschi b, Stefania Leuci c,
Roberto Sorrentino a
a
Department of Neurosciences, Reproductive and Odontostomatological Sciences, Division of Prosthodontics and Digital Dentistry, University “Federico II” of Naples, Via
Pansini 5, 80131, Naples, Italy
b
Department of Biomedical and Neuromotor Sciences, DIBINEM, University of Bologna, Alma Mater Studiorum, Via San Vitale 59, 40125, Bologna, Italy
c
Department of Neurosciences, Reproductive and Odontostomatological Sciences, Oral Medicine Unit, School of Medicine, University “Federico II” of Naples, Via Pansini
5, 80131, Naples, Italy

A R T I C L E I N F O A B S T R A C T

Keywords: Objectives: This paper aimed to provide a literature review of the mechanical and biological properties of
ZLS zirconia-reinforced lithium silicate glass-ceramics (ZLS) in Computer-aided design / Computer-aided
Zirconia-reinforced lithium silicate manufacturing (CAD/CAM) systems.
Dental materials
Data/Sources: An extensive search of the literature for papers related to ZLS was made on the databases of
Ceramics
Zirconia
PubMed/Medline, Scopus, Embase, Google Scholar, Dynamed, and Open Grey. The papers were selected by 3
CAD-CAM independent calibrated reviewers.
Study selection: The search strategy produced 937 records. After the removal of duplicates and the exclusion of
papers that did not meet the inclusion criteria, 71 papers were included.
Conclusions: After reviewing the included records, it was found that two types of ZLS (Vita Suprinity PC; Vita
Zahnfabrik and Celtra Duo; Dentsply Sirona) are nowadays available on the market for CAD/CAM systems,
similar in their chemical composition, microstructure, and biological-mechanical properties. ZLS is reported to
be a biocompatible material, whose fracture resistance can withstand physiological chewing loads. The firing
process influences the improvements of strength and fatigue failure load, with a volumetric shrinkage.
To date, ZLS can be considered a viable alternative to other glass-ceramics for fixed single restorations.
Clinical Significance: . As to biocompatibility and mechanical properties of ZLS, data are still scarce, often
controversial and limited to short-term observational periods. These promising ceramics require further in vitro/
in vivo studies to accurately define mechanical and biological properties, mainly in the long-term performance of
restorations produced with such materials.

1. Introduction ZLS was developed by two companies, Vita (Vita Zahnfabrik, H.

Rauter GmbH & Co., Bad Säckingen, Germany) and Dentsply (Dentsply
The research and development of new restorative materials aimed at Sirona, DeguDent, GmbH, Hanau-Wolfgang, Germany), in conjunction
getting high mechanical and esthetic performances has led to the with the Fraunhofer Institute for Silicate Research (Würzburg, Ger­
introduction on the market of zirconia-reinforced lithium silicate ce­ many), separately marketed as different products: Vita Suprinity PC and
ramics (ZLS), that can be employed with Computer-aided design / Celtra Duo [1–3]. These materials exhibit similar microstructures: a
Computer-aided manufacturing (CAD/CAM) technologies. homogeneous glassy matrix contains a crystalline component made of

Abbreviations: CAD/CAM, Computer-aided design/Computer-aided manufacturing; FC, feldspathic ceramics; FEA, finite element analysis; HGFs, human gingival
fibroblasts; LS2, lithium disilicate ceramics; PICN, polymer-infiltrated ceramic networks; PMMA, polymethyl methacrylate; RNC, resin nanoceramic; SEM, Scanning
Electron Microscope; HT-Z, high translucent zirconia ceramics; ZLS, zirconia-reinforced lithium silicate ceramics.
* Corresponding author at: Department of Neurosciences, Reproductive and Odontostomatological Sciences, Division of Prosthodontics and Digital Dentistry,
University “Federico II” of Naples, Via Pansini 5, 80131, Naples, Italy.
E-mail addresses: [email protected] (F. Zarone), [email protected] (G. Ruggiero), [email protected] (R. Leone), [email protected]
(L. Breschi), [email protected] (S. Leuci), [email protected] (R. Sorrentino).

https://doi.org/10.1016/j.jdent.2021.103661
Received 26 February 2021; Received in revised form 6 April 2021; Accepted 8 April 2021
Available online 14 April 2021
0300-5712/© 2021 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
F. Zarone et al. Journal of Dentistry 109 (2021) 103661

round and submicrometric elongated grains of lithium metasilicates and 2.2. Inclusion and exclusion criteria
lithium orthophosphates; in addition to these, tetragonal zirconia fillers
are added, aimed at increasing strength values. After a crystallization Studies were considered as appropriate for the present literature
process, lithium disilicate grains are generated. Lithium metasilicate is review if they met the following inclusion criteria: 1) studies focused on
reported to be grown larger in Celtra Duo than in Suprinity (up to ~1 the biocompatibility and/or mechanical properties of ZLS for CAD/CAM
and ~0.5 μm in length, respectively) [2–6]. systems; 2) studies performed in vitro, in silico, or in vivo; 3) case reports;
This structural typology has been developed in order to combine 4) systematic reviews.
favorable optical properties with increased mechanical characteristics, The following exclusion criteria were used: 1) studies performed on
compared to other glass-ceramics, although, to date, this assumption is non-human animals; 2) studies not addressed to the dentistry field; 3)
still controversial [4,7–13]. studies referred to ZLS restorations produced by heat-pressed ceramics
ZLS blanks are available in a pre-crystallized or crystallized form. process.
The crystallization process, inside a dental furnace, allows the nucle­ No limitations were applied to the publication date or the language
ation of the crystals, with a subsequent improvement of their mechanical of the papers.
properties compared to the pre-crystallized ones [2]. Furthermore, the
fracture resistance was reported to withstand physiological occlusal 2.3. Data extraction
forces, and it increases after one firing protocol [14].
Due to its high translucency and biaxial flexural strength values, ZLS With the purpose of shedding light on the mechanical and biological
was tested for tooth- and implant-supported single partial and full res­ characteristics of ZLS, the following variables were extracted:
torations in both anterior and posterior regions [4,15,16], as well as for
occlusal veneers [7,17]. It was also tested for endocrowns [18,19], 1. Chemical composition and microstructure;
although the reported results are not satisfactory. 2. Biocompatibility;
Some findings showed that the machinability of ZLS is worse than the 3. Physico-mechanical values of ZLS;
one of LS2 [4,20], so that ZLS was defined "the most difficult to machine 4. Laboratory and post-milling manual processing;
among glass ceramics" [20]. 5. Minimal thickness;
Also, ZLS is acid sensitive [21], and it is important to clarify what the 6. Fracture patterns and plastic deformation;
ideal acid concentration and etching times are; moreover, the best ce­ 7. Fatigue failure load;
ments polymerization (dual- or light-curing) and whether it is worth 8. Marginal and internal fit.
silanizing ZLS.
ZLS is also reported to be a biocompatible material [2], but to date, According to the inclusion criteria, 3 calibrated researchers (F.Z., R.
there is no univocal evidence about in vitro data regarding cell S, and G.R.) independently selected the articles reading the titles, ab­
proliferation. stracts, and keywords. The full text of each identified article was read to
To date, the biological and mechanical performances of ZLS need a determine whether it was suitable for inclusion. In case of disagreement
more in-depth look from a scientific point of view, in order to formulate among the investigators, a majority criterion would have been used (i.e.,
a clear definition of their clinical indications and limitations. With the 2 out of 3).
purpose of shedding light on the mechanical and biological properties of The workflow of the paper screening process is reported in Fig. 1,
ZLS in CAD/CAM systems, this literature review is focused on the according to the “PRISMA 2009 Flow Diagram” [22].
chemical composition, microstructure, biocompatibility, physico-
mechanical properties, and marginal/internal fit of ZLS-based 2.4. Calibration process
restorations.
As regards the recorded titles and abstracts, the 3 reviewers per­
2. Methods formed pilot calibration exercises on a common random group of 20
references, applying the inclusion and exclusion criteria. After the ex­
2.1. Search strategy ercise, the reviewers discussed which references were included or
excluded. The reviewers aimed to reach an agreement on at least 90 % of
An extensive search of the literature for papers related to ZLS was the papers. The process would have been repeated until they had ob­
performed on the databases of PubMed/Medline, Scopus, Embase, tained the predetermined agreement level before starting the screening
Google Scholar, Dynamed, and Open Grey. of the whole set of titles and abstracts collected. Also, the calibration
The literature search was performed using combinations of the process, with the same agreement level, was used on a random sample of
keywords "zirconia-reinforced lithium silicate" or "ZLS". The following 8 papers for the full-text screening of the included articles after reading
queries were used for each electronic database: titles and abstracts.

• PubMed/Medline, Google Scholar, and Open Grey = “(zirconia- 3. Results

reinforced lithium silicate) or (zls)” was added into each query box.
• Dynamed = ZLS; zirconia-reinforced; zirconia-reinforced lithium 3.1. Data synthesis
silicate; zirconia lithium.
• Scopus = (TITLE-ABS-KEY (zirconia-reinforced AND lithium AND The literature search was completed in February 2021 and the
silicate) OR TITLE-ABS-KEY (zls)). included studies were published between 2015 and January 2021.
• Embase = ’zirconia-reinforced lithium silicate’ OR (’zirconia rein­ The search strategy produced 937 records, many of which were
forced’ AND (’lithium’/exp OR lithium) AND (’silicate’/exp OR sil­ duplicates: 188 from PubMed/Medline, 239 from Scopus, 175 from
icate)) OR zls. Embase, 294 from Google Scholar, 41 from Dynamed, and 0 from Open
Grey. All the duplicates were removed, thus all the selected databases
The references of the found records were imported as a Research produced 281 records. After the examination of titles, abstracts, and
Information Systems file into Mendeley (Mendeley Ltd., London, UK) in keywords, the reviewers excluded 180 records, because they did not
order to remove the duplicates. meet the inclusion criteria. As to the remaining 101 records, 30 more
were excluded after a full-text analysis because they did not provide
considerable information about ZLS for dental research and clinical

2
F. Zarone et al. Journal of Dentistry 109 (2021) 103661

Fig. 1. Title: Search flowchart as described in the PRISMA guidelines.

Caption: (n = number of records).

practice. The remaining 71 records were included in the present litera­ (Li3PO4) as round granules [6]. After crystallization firing, a significant
ture review (Table 1). increase was observed for both phases and a new crystal phase appears,
No systematic reviews or case reports were found. namely lithium disilicate (Li2Si2O5), crystallized from the glassy matrix;
The reviewers obtained an agreement level superior to 90 % after the such a crystallization is allowed by the presence of diphosphorus pent­
first calibration exercise on titles and abstracts screening and an oxide (P2O5) as nucleation agent [6].
agreement level of 100 % on full-text papers screening after only one Lithium metasilicate crystallites in the glassy phase show different
exercise. dimensions in Celtra Duo (about 1 μm) compared to Suprinity (about
No disagreement was pointed out among the search investigators 0.5 μm) [6,12,23], in both cases smaller than LS2 crystals, the latter
about the included records. described as elongated, needle-shaped, with length comprised between
0.5 and 4 μm [24,74]. It has been suggested that such a difference in size
between the two different brand formulations could be due to discrep­
3.2. Chemical composition and microstructure ancies in the processing parameters, like firing temperature and time,
being Suprinity treated with an additional and shorter crystallization
ZLS-based materials, to date marketed as Celtra Duo (Dentsply firing process compared to Celtra Duo [5,6].
Sirona, DeguDent, GmbH, Hanau-Wolfgang, Germany) and Suprinity X-ray diffraction analysis on Suprinity showed crystallization peaks
(Vita Zahnfabrik, H. Rauter GmbH & Co., Bad Säckingen, Germany), corresponding to lithium monosilicate, aluminum silicate, and tetrag­
showed very similar microstructures, mainly consisting of two ~70 vol. onal zirconia [24].
% crystallized phases: one is made of larger, submicrometric lithium Raman analysis in pre-crystallized ZLS confirmed the presence of
metasilicate crystallites (Li2SiO3) in slightly elongated shapes, more crystal phases made of lithium metasilicate and lithium orthophosphate;
rounded than lithium disilicate ceramics (LS2) needle-shaped ones; the post-crystallization, besides an increase in intensity related to these
other is made of smaller nanometric lithium orthophosphate crystallites

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F. Zarone et al. Journal of Dentistry 109 (2021) 103661

Table 1 The chemical composition of ZLS-based materials is specified in

An overview of the 71 included records and the variables for inclusion regarding Table 2, as reported by various sources in the literature.
each paper.
Analyzed variables Authors (Year of publication)
3.3. Biocompatibility
Chemical composition or Riquieri et al. (2018) [1], Vita Zahnfabrik (2019)
microstructure [2], Dentsply Sirona Inc. (2016) [3], Elsaka and
In the present state of knowledge, data regarding the biocompati­
Elnaghy (2016) [4], Belli et al. (2018) [5], Belli
et al. (2017) [6], Vasiliu et al. (2020) [12], Sen and bility of ZLS are scarce and controversial. Suprinity was deemed
Us (2018) [15], Wendler et al. (2017) [23], Ramos biocompatible by the "North American Science Associates Inc."
et al. (2016) [24], De Mendonca et al. (2019) [25], (NAMSA) from specific evaluations based on cytotoxicity, sensitization,
Traini et al. (2016) [26]
subchronic systemic toxicity, irritation, and genotoxicity [2].
Biocompatibility Vita Zahnfabrik (2019) [2], Rizo-Gorrita et al.
(2018) [27], Rizo-Gorrita et al. (2019) [28], Dal
Human gingival fibroblasts (HGFs) cultured onto ZLS exhibited
Piva et al. (2018) [29], De Luca et al. (2018) [30], lower cell proliferation, coverage, and spreading than onto zirconia;
Abdalla et al. (2018) [31] such a worse cellular response in ZLS could be attributed to a rougher
Physico-mechanical values of Elsaka and Elnaghy (2016) [4], Belli et al. (2018) and less homogeneous surface topography [27]. In a comparative in vitro
ZLS [5], Belli et al. (2017) [6], Al-Akhali et al. (2017)
study, ZLS and zirconia showed intermediate values of cell viability and
[7], Hamza and Sherif (2019) [8], Gomes et al.
(2017) [9], Kashkari et al. (2019) [10], collagen secretion between LS2, which exhibited the best values, and
Schwindling et al. (2017) [11], Zarone et al. polymethyl methacrylate (PMMA), which showed the lowest values
(2020) [13], Sen and Us (2018) [15], Preis et al. [28].
(2017) [16], Von Maltzahn et al. (2018) [17], Taha
Furthermore, polished ZLS surfaces have been reported to be less
et al. (2018) [18], El Ghoul et al. (2019) [19], Chen
et al. (2020) [20], Wendler et al. (2017) [23],
rough, accumulating less biofilm and displaying higher surface free
Ramos et al. (2016) [24], De Mendonca et al. energy than glazed surfaces; however, polished surfaces showed severe
(2019) [25], Nishioka et al. (2018) [32], Guilardi initial cytotoxicity for HGFs but were inert in the long term; such
et al. (2020) [33], Choi et al. (2017) [34], cytotoxicity (24 h) may be related to an initial release of remnants of the
Zimmermann et al. (2017) [35], Preis et al. (2015)
[36], Jassim and Majeed (2018) [37], Rosentritt
et al. (2017) [38], Yeğin and Atala (2020) [39], Table 2
Yilmaz et al. (2020) [40], Kermanshah et al. Analysis of ZLS chemical composition (in weight %).
(2020) [41], Dartora et al. (2020) [42], Liu et al.
Silicon dioxide
(2021) [43], Juntanvee and Uasuwan (2020) [44],
(56− 64);
Srichumpong et al. (2019) [45], Monteiro et al.
Lithium oxide (15− 21);
(2018) [46], Ottoni et al. (2018) [47], Lawson
Zirconia (8− 12);
et al. (2016) [48]
Phosphorus oxide
Laboratory or post-milling Riquieri et al. (2018) [1], Passos et al. (2019) [14], Vita Suprinity® PC. Technical and scientific
(3− 8);
manual processing Traini et al. (2016) [26], Lawson et al. (2016) [48], documentation. 2019 [2]
Potassium oxide (1− 4);
Schweitzer et al. (2020) [49], Alao and Bujang
Aluminium oxide
(2021) [50], Badawy et al. (2016) [51], Aurèlio
(1− 4);
et al. (2017) [52], Romanyk et al. (2020) [53],
Pigments (0− 6);
Passos et al. (2018) [54], Kang et al. (2020) [55],
Cerium dioxide (0− 4).
Alves et al. (2019) [56]
Silicon dioxide (58.0);
Minimal thickness Choi et al. (2017) [34], Zimmermann et al. (2017)
Lithium oxide (18.5);
[35], Monteiro et al. (2018) [46], Sieper et al.
Zirconia (10.1);
(2017) [57], Bergamo et al. (2019) [58], Shaik and Celtra® Duo. Zirconia-Reinforced Lithium Silicate (ZLS)
Phosphorus oxide (5.0);
Alfarsi (2019) [59], Tribst et al. (2018) [60], Block. Technical Monograph. 2016 [3]
Cerium dioxide (2.0);
Alammari et al. (2018) [61]
Aluminium oxide (1.9);
Fracture patterns and plastic Ramos et al. (2016) [24], De Mendonca et al.
Terbium Oxide (1.0).
deformation (2019) [25], Liu et al. (2021) [43], Monteiro et al.
Silicon (59);
(2018) [46], Sieper et al. (2017) [57], Bergamo
Lithium (20);
et al. (2019) [58], Abu-Izze et al. (2018) [62],
Zirconium (12);
Diniz et al. (2020) [63]
Phosphorus (4.2);
Fatigue failure load Von Maltzahn et al. (2018) [17], Monteiro et al. Traini et al. 2016 [26], about Suprinity fired
Potassium (2.5);
(2018) [46], Ottoni et al. (2018) [47], Alammari
Aluminium (1.5);
et al. (2018) [61], Diniz et al. (2020) [63],
Other minor
Al-Akhali et al. (2019) [64], Venturini et al. (2019)
components (0.8).
[65], Alves et al. (2020) [66], Schlenz et al. (2020)
Oxygen (51.2);
[67], Dal Piva et al. (2020) [68]
Silicon (29.6);
Marginal and internal fit Vita Zahnfabrik (2019) [2], Gomes et al. (2017)
Ramos et al. 2016 [24], about Suprinity fired Zirconia (15.5);
[9], Taha et al. (2018) [18], El Ghoul et al. (2019)
Potassium (2.3);
[19], Preis et al. (2015) [36], Alammari et al.
Aluminium (1.3).
(2018) [61], Hasanzade et al. (2020) [69],
Oxygen (52.60);
Dentsply Sirona Inc. (2017) [70], Zimmermann et
Silicious (30.95);
al (2019) [71], Falahchai et al. (2020) [72,73]
Riquieri et al. 2018 [1], about Suprinity fired Zirconium (13.00);
Potassium (2.06);
Aluminium (1.35).
components, the new crystal phase of lithium disilicate was also Oxygen (53.09);
observed [6]. Silicious (30.85);
In a microstructural comparison, LS2 is characterized by interlocking Riquieri et al. 2018 [1], about Celtra Duo fired Zirconium (12.50);
needle-shaped crystals embedded in a glassy matrix, while ZLS shows a Potassium (2.36);
Aluminium (1.17).
homogeneous fine crystalline structure with rounded and rod-like
Oxygen (52.1);
crystals. The percentage of the crystalline phase is higher in LS2 [4,24, Silicon (27.52);
25]. Actually, as found in CAD/CAM LS2, in ZLS the presence of both Zirconium (15.7);
Sen and Us. 2018 [15], about Suprinity fired
lithium metasilicate and disilicate grains has been evidenced in the final Potassium (2.34);
stage of crystallization [5,6,75–77]. Aluminium (1.28);
Carbon (1.05).

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F. Zarone et al. Journal of Dentistry 109 (2021) 103661

polishing material, reducing its cytotoxic effect after 7 days. Over time, load-to-fracture values, followed by LS2 and ZLS, the latter exhibiting
the cells strengthen their defense mechanisms and become able to pro­ significantly lower mechanical performance [10]. Also, fatigue strength,
tect themselves [29]. evaluated by biaxial flexural test on disc-shaped specimens, exhibited
Another in vitro study showed that proliferation and viability of HGFs the highest values with high translucence yttrium stabilized tetragonal
onto crystallized, not polished and polished ZLS, before and after crys­ zirconia, followed, in decreasing order by LS2, ZLS, PICN, and FC [32].
tallization, are similar to those of zirconia ceramics, with favorable Other investigations reported lower values for fracture [9] and fail­
biological properties suggesting an indication for use in implant- ure [39] loads in implant-supported ZLS monolithic crowns compared to
supported restorations with margins in contact with peri-implant tis­ LS2 ones.
sues [30]. Moreover, in a recent study, no differences were detected among
In the case of polished surfaces, ZLS demonstrated the lowest bac­ ZLS, PICN, LS2, and zirconia as to strains around the implant platform,
terial adhesion, compared to LS2 and feldspathic ceramics (FC) [31]. none of these materials offering a significant load absorption aimed at
minimizing the strains generated at the platform level. [40].
3.4. Physico-mechanical properties In ceramic inlay-retained fixed partial dentures, the fracture load of
zirconia was reported to be higher than that of ZLS [41].
3.4.1. Physico-mechanical values of ZLS In the last decade, the concept of endocrown has been gaining more
According to several reports, it can be stated that in ceramic mate­ and more popularity for the restoration of endodontically treated teeth,
rials the lower the glassy content, the higher the dental ceramic overall utilizing mechanical retention offered by the pulp chamber together
strength [23,24,32,33]. In the last decade, ZLS was introduced on the with chemical/micromechanical adhesion provided by bonding pro­
market with the purpose of offering at the same time advanced esthetic cedures. In posterior endocrowns, LS2 resistance to fracture was re­
properties, being a translucent glass-ceramic with silicate crystals ported to be higher compared to ZLS, both under axial [19] and lateral
embedded in a high content of glassy matrix, together with a favorable forces [18,19]. According to a recent in vitro and finite element analysis
mechanical behavior, thanks to the addition of tetragonal zirconia (FEA) study, the highest fracture strength resistance values were
fillers, exploiting a mechanism of crack interruption [4]. exhibited by monolithic endocrowns made of zirconia, compared to LS2,
In the last years, several studies have proved that ZLS restorations ZLS, and leucite reinforced ceramics, although monolithic zirconia and
show fracture resistance values exceeding the physiological occlusal/ ZLS showed worse failure modalities, with a higher rate of catastrophic
masticatory forces [7,9,34–36], although the concept of zirconia fillers fractures [42].
acting as an additional toughening mechanism [20,78], at the basis of The physico-mechanical values collected from different studies are
the material physico-chemical formulation, has been confuted by some shown in Table 3.
authors [24]. It has always to be considered that, due to the wide het­ It is more than evident that, in order to get a deeper insight about the
erogeneity of research designs and testing modalities, in vitro data are mechanical properties of this material, data reported by in vitro studies
not infrequently controversial, making their comparisons very difficult should be furtherly corroborated by in vivo results of clinical, long-term,
and possible correlations to in vivo biomechanical behavior not always controlled and randomized trials, that are missing, at the moment, in the
easy. scientific literature.
According to some research data, in a comparison with other
restorative materials, occlusal veneers made of LS2 and ZLS showed 3.4.2. Laboratory and post-milling manual processing
higher resistance to fracture than those fabricated with polymer- Several studies have been carried out on the modifications of the
infiltrated ceramic networks (PICN) and PMMA [7]. In another study, physico-mechanical properties of ZLS following laboratory
the load at fracture of ZLS tabletops was found to be significantly higher manufacturing, particularly sintering and crystallization. In this regard,
than that of feldspar-based ceramic ones [17]. Besides, similar results an evident increase of the following ZLS physical values was shown after
were reported by a research conducted on monolithic, crown-shaped the firing process: modulus of elasticity, flexural strength, fracture
restorations, showing higher fracture strength of LS2 and ZLS toughness, hardness, and characteristic strength [1,26,48–51], simul­
compared to PICN and a hybrid high-performance polymer composite taneously with a decrease of the Weibull modulus and a significant
resin [25]. shrinkage [1,49], as reported in Table 4. The material seemed to be
Compared to bilayered, ceramic-veneered zirconia restorations, brittler with a tendency to develop inner cracks at the partially crys­
monolithic crowns made of LS2 and ZLS were reported to exhibit higher tallized state; for this reason, particular care should be taken during the
fracture resistance [8]. manipulation process for marginal adaptation [26].
To date, several studies have been carried out in order to compare The increase of ZLS restoration strength after one firing protocol was
the mechanical properties of the two most popular silicate-based ma­ confirmed by Passos et al. [14]. Moreover, an extended glaze firing
terials, LS2 and ZLS, although the reported data are not always in protocol has been proposed, based on the same initial pre-heating time,
agreement. temperature, and temperature increase rate as the conventional
According to some in vitro investigations [4,8,11,15,37], ZLS manufacturer-recommended glaze firing, with a difference, in that the
exhibited higher mechanical performances than LS2, confirming the extended glaze firing differs by slow cooling until the temperature drops
possible efficiency of the zirconia additional phase in increasing resis­ to 200 ◦ C in a closed furnace for a dwell time of 15 min [52]. This
tance thanks to a mechanism of crack interruption. In some studies, extended glaze firing protocol, after hard machining of ZLS, repaired
compared to LS2, the material showed higher fracture [8,37] and flex­ defects by generating beneficial compressive residual stress, differently
ural strength [4,15]. In another research, carried out on monolithic from conventional glaze firings, that can create tensile stresses [52].
crowns in the anterior sites, load-to-failure values were reported to be The surface defects related to machining procedures negatively in­
slightly higher for glazed ZLS than for LS2; after submitting the resto­ fluence the mechanical performance of ZLS fabricated with CAD/CAM
rations to an extensive thermocycling test, such a fracture resistance was technologies; in this regard, the post-machining heat treatment can
still maintained by ZLS specimens [11]. partially relieve the strength-limiting damage caused by CAD/CAM
ZLS has also been tested in vitro as a material for implant-supported procedures [53].
molar crowns, reporting high fracture forces, although lower than those After the final processing of the ZLS restorations, a manual adjust­
shown by zirconia [16]. In any case, the insertion of a screw channel ment of occlusal morphology should be avoided, because it has been
might reduce the stability of ZLS restorations [38]. demonstrated that this procedure can decrease the fracture load of ZLS
On this topic, other studies report fewer positive results. In an in vitro crowns [54].
investigation, high strength zirconia crowns showed the most favorable As for the milling accuracy, ZLS showed lower mean values than LS2;

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F. Zarone et al. Journal of Dentistry 109 (2021) 103661

Table 3
Physico-mechanical values of ZLS (mean ± SD).
Authors Modulus of Flexural Fracture Vickers’ Characteristic Weibull Poisson’s Fracture Density
(Product Elasticity Strength (MPa) toughness = KIc Hardness Strength (MPa) modulus (m) ratio Resistance (N) (g/cm3)
name) (GPa) (MPa m1/2) (GPa)

Liu et al. 2020 279 2.7

[43] (Celtra
Duo)
Juntavee and 218.43 ± 38.46 234.23 6.40
Uasuwan
2020 [44]
(Suprinity)
De Mendonca 230 ± 20 6.78 ± 0.013
et al. 2019 *
[25]
(Suprinity)
Srichumpong 1.86 (Suprinity)
6.8 (Same
et al. 2019
value both
[45]
1.75 (Celtra for Suprinity
(Suprinity
Duo) and Celtra
and Celtra
Duo)
Duo)
Monteiro et al.
2018 [46] 0.30
(Celtra Duo)
Von Maltzahn
et al. 2018
1,571.1 ± 297.0
[17] (Celtra
Duo)
Ottoni et al.
2018 [47] 179 ± 56 1.93 ± 0.32 6.67 ± 0.18 197 (158; 200) 4 (3;5)
(Suprinity)
Nishioka et al.
2018 [32] 152.1 ± 7.5
(Suprinity)
Jassim et al.
2018 [37] 1404.5 ± 236.51
(Celtra Duo)
Sen and Us.
2018 [15] 510 ± 43 532 8.8
(Suprinity)
Belli et al. 1.40 ± 0.10
2018 [5] (Suprinity)
(Suprinity
1.52 ± 0.05
and Celtra
(Celtra Duo)
Duo)
Schwindling
et al. 2017
725 ± 162
[11] (Celtra
Duo)
Belli et al. 105.8 0.207 2.643
2017 [6] (Suprinity) (Suprinity) (Suprinity)
(Suprinity 0.224 2.630
108.2 (Celtra
and Celtra (Celtra (Celtra
Duo)
Duo) Duo) Duo)
611.24 5.29 0.208
Wendler et al. 104.9
(573.80;651.58) (3.96;6.45) (Suprinity)
2017 [23] (Suprinity)
(Suprinity) (Suprinity)
(Suprinity 0.222
626.84 5.19
and Celtra 107.9 (Celtra (Celtra
(587.74;669.02) (3.89;6.33)
Duo) Duo) Duo)
(Celtra Duo) (Celtra Duo)
Hamza et al.
2017 [8] 1742.9 ± 102.7
(Suprinity)
Ramos et al.
217.5 10.0 (C.I.
2016 [24] 65.6 ± 4.1 1.25 ± 0.79 0.23 ± 0.03 1.60
(151.84;238.6) 6.92− 14.41)
(Suprinity)
Lawson et al.
2016 [48] 61.0 ± 10.0 300.1 ± 16.8 4.54 ± 0.26*
(Celtra Duo)
Elsaka and
Elnaghy
70.44 ± 1.97 443.63 ± 38.90 2.31 ± 0.17 6.53 ± 0.46 460.74 13.41
2016 [4]
(Celtra Duo)
*
The numerical values of Vickers’ Hardness were different from the ones reported in the corresponding original papers. This change had the goal to report numerical
values converted to the same unit (GPa).

6
F. Zarone et al. Journal of Dentistry 109 (2021) 103661

Table 4
Physical values (mean ± SD) of unfired/fired ZLS.
Modulus of Elasticity (GPa) Flexural Strength Fracture Vickers’ Hardness (GPa)* Weibull Characteristic
(MPa) toughness = KIc (MPa Modulus (m) Strength (MPa)
m1/2)

Schweitzer et al. 2020 189.02 ± 25.5 / 8.9 / 5.81 219.3 / 314.35

[49] (Celtra Duo) 252.86 ± 53.78
1.15 ± 0.13 /
6.34 ± 0.33/ 6.5 ± 0.11*
1.39 ± 0.04
Alves et al. 2019 [56] 89.8 ± 5 / 97 ± 6.2 (Suprinity)
(Suprinity)
(Suprinity and Celtra (Suprinity) 92 ± 4.7 /
1.4 ± 0.12 /
Duo) 98.9 ± 3.8 (Celtra Duo) 6.64 ± 0.17 / 6.63 ± 0.14*
1.49 ± 0.05 (Celtra
(Celtra Duo)
Duo)
2..21 ± 0.11 / 597.533 ± 33.97 / 7.07 / 5.38 106.95 / 191.02
2.63 ± 0.14 683.267 ± 16.07 (Suprinity) (Suprinity)
Riquieri et al. 2018 [1]
(Suprinity) (Suprinity)
(Suprinity and Celtra
2.26 ± 0.80 / 682.400 ± 15.31 / 5.86 / 5.77 163.86 / 251.25
Duo)
2.51 ± 0.59 (Celtra 693.333 ± 10.85 (Celtra (Celtra Duo) (Celtra Duo)
Duo) Duo)
Lawson et al. 2016 300.1 ± 16.8 / 4.546 ± 0.26* /
61.0 ± 10.0 / 63.6 ± 3.3
[48] (Celtra Duo) 451.4 ± 58.9 5.836 ± 0.36*
Traini et al. 2016 [26]
2.8 ± 0.9 / 4.7 ± 0.8 6.8 ± 0.5 / 7.6 ± 0.7
(Suprinity)
*
The numerical values of Vickers’ Hardness were different from the ones reported in the corresponding original papers. This change had the goal to report numerical
values converted to the same unit (GPa).

nevertheless, the milling accuracy of ZLS was within 120 μm, therefore ZLS crowns and did not influence their internal and marginal fit [61].
considered clinically acceptable [55].
3.4.4. Fracture patterns and plastic deformation
3.4.3. Minimal thickness Some fractographic studies have been carried out in order to shed
Thickness is a paramount factor in all-ceramic restorations, both light on mechanical behavior and failure patterns of ZLS restorations.
from a clinical and technical point of view, in that it affects the design of Silicate-based materials like ZLS and LS2 are showed to suffer mainly
the tooth preparation and, at the same time, strongly influences fracture from unrepairable and catastrophic fracture patterns, differently from
resistance and survival rate of the prosthesis. hybrid ceramics, in which limited chipping and type II fracture patterns
In ZLS, as expected, mean fracture loads of monolithic restorations (i.e., affecting less than half the crown) are more commonly found [25].
were reported to increase significantly as thickness increased [34,35, Light microscopy showed that ZLS failures consisted primarily of
57]. bulk fractures starting from the cementation surface as radial cracks
According to an in vitro study, at a thickness of 1.5 mm Suprinity propagating to the cervical area [46,58,62,63]. It has also been evi­
exhibited a fracture resistance similar to LS2 and higher than PICN and denced that both ZLS and LS2 are susceptible to slow crack propagation,
Celtra Duo [34]; conversely, another paper reported higher mean frac­ which is one of the main causes of failure in metal-free prostheses [24].
ture loads for LS2 than for ZLS at both 1.5 mm and 1.0 mm thickness ZLS and LS2 have been reported to show similar susceptibility to
[35]. Another research showed promising durability of ZLS single subcritical crack growth, a phenomenon more limited for zirconia
crowns for the thickness of 1.0 mm [57]; at such a thickness, fracture thanks to its phase transformation known as transformation toughening
resistance values of ZLS, LS2, and PICN were shown to be similar [34]. At [43]; in another study, an effective mechanism of crack interruption was
0.5 mm thickness, a substantially reduced mechanical resistance was confirmed in ZLS by the presence of clear semicircular arrest lines at
evidenced for most metal-free, silicate-based, feldspathic, and hybrid scanning electron microscope (SEM), close to the origin of failure [57].
materials [35,58]; on the contrary, another research, aimed at
comparing fracture resistance of full-coverage minimally invasive 3.4.5. Fatigue failure load
crowns made of ZLS, PICN, and high translucent zirconia ceramics To date, it has been demonstrated that load-at-fracture resistance of
(HT-Z), showed that with minimal thickness of 0.6 mm restorations ZLS makes this material suitable for clinical purposes; cyclic loading
made of HT-Z and PICN were mechanically resistant within the range of simulating 1 year of use (i.e., 106 cycles at 4 Hz and a load of 88 N) did
biting forces, while ZLS exhibited the lowest load values [59]. not result in ZLS crowns fatigue failure [61]. As regards the effects of
FEA studies have been increasingly carried out in the last decade on thermal aging, the results reported in the literature are still controver­
the topic of metal-free materials, allowing an “in silico” reliable evalu­ sial; in an investigation, experimental aging (i.e., 106 cycles at 2.5 Hz
ation of mechanical behavior of dental restorations. In a research on and a load of 50 N with thermal aging of 10,000 cycles at 5− 55 ◦ C) did
stress distribution in occlusal veneers, a direct correlation between not compromise the mechanical stability of the material [17],
restoration thickness and concentration of tensile stresses was detected, conversely, in another study, aging (induced according to staircase
in the following decreasing order for the simulated materials: HT-Z method with 100,000 cycles at 20 Hz and thermal aging of 10,000 cycles
(highest stress concentration), LS2, FC, ZLS, and PICN [60]. Moreover, in 5− 55 ◦ C) determined a reduction in fatigue failure load [63].
the typology of restorative material differently influenced the concen­ Furthermore, it was reported that thermo-mechanical fatigue reduced
tration of stress on the cement layer, in the following decreasing order: the survival rate and fracture strength of ZLS occlusal veneers bonded to
PICN > HT-Z > ZLS > LS2 > FC. In the same study, the cement layer enamel using the self-etching technique [64].
thickness was not shown to be relevant to mechanical resistance. Several investigations evaluated the fatigue failure load of ZLS, with
In another FEA investigation, higher stress concentrations on the different experimental designs [46,47,65]. An in vitro study using the
cement interface were detected reducing ceramic thickness [46]. boundary and staircase fatigue methods showed that, after 103 cycles, a
As regards the influence of preparation design on ZLS mechanical degradation of 78 % of the initial strength occurred for both fatigue
resistance, it has been evidenced that an increase in total occlusal methods; differently, when the number of cycles increased from 103 to
convergence from 12◦ to 20◦ resulted in higher load-to-fracture values of 104, there was no further significant degradation [47].

7
F. Zarone et al. Journal of Dentistry 109 (2021) 103661

In another research, fatigue failure loads for ZLS, determined using 4. Conclusions
the staircase method (i.e., 100,000 cycles at 20 Hz) at ceramic thick­
nesses ranging from 1.0–2.5 mm, showed the following values: According to the present literature review, in the current state of
Suprinity = 716.5 ± 95.5 N (at 1.0 mm) up to 1119.6 ± 241.7 N (at knowledge, the following conclusions can be drawn for the mechanical
2.5 mm); Celtra Duo = 404.0 ± 43.3 N (at 1.0 mm) up to and biological properties of ZLS CAD-CAM:
1126.8 ± 80.2 N (at 2.5 mm). From these results, it can be asserted that
different ZLS thicknesses affect the fatigue failure load of the bonded • Despite the presence of zirconia grains in the glassy matrix, there is
system so that the thicker the ZLS, the higher the expected fatigue failure no undisputed evidence confirming a higher mechanical strength
load. Moreover, the staircase experimental procedure confirmed that the compared to LS2. The fracture resistance was reported to withstand
firing procedures (glaze firing process or crystallization firing) improved physiological occlusal forces. At 1.0 mm thickness, the durability is
the fatigue failure load [63]. promising.
Comparisons among the fatigue behavior of ZLS and other materials • ZLS crowns can exhibit clinically acceptable internal marginal gaps
have shown conflicting results among different studies, perhaps due to (≤150 μm).
the different fatigue test designs performed. • After the firing process, there is an increase of modulus of elasticity,
Comparative in vitro studies between ZLS and other materials showed flexural strength, fracture toughness, hardness, and characteristic
that CAD/CAM posterior ZLS crowns exhibited better fatigue resistance strength, in parallel with a decrease of both the Weibull modulus and
than LS2 but worse than monolithic crowns made of translucent zirconia volume (shrinkage).
[66]. In a different analysis performed with the optical coherence to­ • The firing and polishing procedures positively affect the fatigue
mography, ZLS showed the highest horizontal and vertical fatigue failure load.
damages, followed by PICN, resin composites, and 5 mol% Y2O3- • ZLS seems to show a certain degree of biocompatibility, allowing
partially stabilized zirconia [67]. proliferation, coverage, and spreading of HGFs, encouraging its use
Another in vitro investigation reported that the fatigue behavior of in contact with peri-implant soft tissues.
ZLS was similar to LS2 and leucite ceramics, better than FC and PICN but
worse than resin nanoceramic (RNC); in the same study, the fatigue Although ZLS can be considered promising hybrid ceramic materials
failure load evaluated by a step-stress approach (i.e., 400 N–2200 N; for CAD-CAM technologies, it cannot be denied that further in vitro and,
step-size of 200 N; 10,000 cycles per step; 1.4 Hz) reached 1013.33 N in particular, randomized controlled trials in vivo studies are needed to
after 40,666 cycles for ZLS [65]. accurately define mechanical properties and biocompatibility of ZLS-
These results do not clarify whether the fatigue behavior of ZLS is based restorations both tooth- and implant-supported.
better than LS2, but it should be noted that RNC [65] and resin com­
posites [67] expressed better fatigue performance than ZLS, due to the
superior flexibility and reduced brittleness, probably determined by the Declaration of Competing Interest
resinous content in their microstructure [65]. In any case, compared to
zirconia, it is clear that ZLS is less efficient even in fatigue behavior [66, The authors report no declarations of interest.
67].
Surface morphology is a factor that seems to affect fatigue behavior; References
in fact, ZLS presented higher survival probability and fatigue strength
when polished than when showing a roughened surface [68]; in support [1] H. Riquieri, J.B. Monteiro, D.C. Viegas, T.M.B. Campos, R.M. de Melo, G. de
of these results, another in vitro study reported that higher degrees of Siqueira Ferreira Anzaloni Saavedra, Impact of crystallization firing process on the
microstructure and flexural strength of zirconia-reinforced lithium silicate glass-
roughness (i.e., Ra = 1.98 μm; Rz = 12.25 μm) had a negative influence
ceramics, Dent. Mater. 34 (2018) 1483–1491, https://doi.org/10.1016/j.
on the fatigue performance of ZLS [33]. dental.2018.06.010.
[2] Vita Suprinity® PC, Technical and Scientific Documentation, Vita Zahnfabrik, Bad
Säckingen, Germany, 2019, 2021 (Accessed 20 February 2021), https://mam.vita-
3.5. Marginal and internal fit
zahnfabrik.com/portal/ecms_mdb_download.php?id=82440&sprache=en
&fallback=en&cls_session_id=&neuste_version=1.
ZLS crowns were proved to offer clinically acceptable internal and [3] Celtra® Duo, Zirconia-Reinforced Lithium Silicate (ZLS) Block. Technical
marginal gaps (≤150 μm) [9,18,19,36,69]. This is in agreement with Monograph, Dentsply Sirona Inc., DeguDent GmbH, Hanau, Wolfgang, Germany,
2016, 2021 (Accessed 20 February 2021), https://assets.dentsplysirona.co
manufacturers’ documentations reporting good edge stability at a m/dentsply/microsites/celtra/celtraduo-tech-monograph.pdf.
thickness of 160− 200 μm [2,70]. Nevertheless, higher levels of mar­ [4] S.E. Elsaka, A.M. Elnaghy, Mechanical properties of zirconia reinforced lithium
ginal misfit were reported for ZLS implant-supported crowns compared silicate glass-ceramic, Dent. Mater. 32 (2016) 908–914, https://doi.org/10.1016/j.
dental.2016.03.013.
to LS2 CAD/CAM ones in an in vitro study [9]. [5] R. Belli, M. Wendler, A. Petschelt, T. Lube, U. Lohbauer, Fracture toughness testing
As regards design preparation, it has been demonstrated that mar­ of biomedical ceramic-based materials using beams, plates and discs, J. Eur.
ginal and internal adaptation of ZLS crowns is not significantly affected Ceram. Soc. 38 (2018) 5533–5544.
[6] R. Belli, M. Wendler, D. de Ligny, M.R. Cicconi, A. Petschelt, H. Peterlik,
by the parameter of total occlusal convergence, in a range comprised U. Lohbauer, Chairside CAD/CAM materials. Part 1: measurement of elastic
from 12◦ to 20◦ [61]. With regard to ZLS overlay restorations, a prep­ constants and microstructural characterization, Dent. Mater. 33 (2017) 84–98,
aration design characterized by anatomical occlusal reduction with https://doi.org/10.1016/j.dental.2016.10.009.
[7] M. Al-Akhali, M.S. Chaar, A. Elsayed, A. Samran, M. Kern, Fracture resistance of
rounded shoulder and a central groove exhibited poorer marginal
ceramic and polymer-based occlusal veneer restorations, J. Mech. Behav. Biomed.
adaptation than one with anatomical occlusal reduction alone [71]. This Mater. 74 (2017) 245–250, https://doi.org/10.1016/j.jmbbm.2017.06.013.
latter preparation design also showed the highest fracture resistance [8] T.A. Hamza, R.M. Sherif, Fracture resistance of monolithic glass-ceramics versus
bilayered zirconia-based restorations, J. Prosthodont. 28 (2019) e259–e264,
(2737.95 ± 409.66) [72].
https://doi.org/10.1111/jopr.12684.
As regards endocrown restorations, the following, not exciting, mean [9] R.S. Gomes, C.M.C. Souza, E.T.P. Bergamo, D. Bordin, A.A. Del Bel Cury, Misfit and
values of fit were reported for ZLS: margin = 131.0 μm, fracture load of implant-supported monolithic crowns in zirconia-reinforced
axial = 160.8 μm, and occlusal = 182.3 μm [73]; internal and marginal lithium silicate, J. Appl. Oral Sci. 25 (2017) 282–289, https://doi.org/10.1590/
1678-7757-2016-0233.
adaptation of endocrowns were not demonstrated to be significantly [10] A. Kashkari, B. Yilmaz, W.A. Brantley, S.R. Schricker, W.M. Johnston, Fracture
different among ZLS, LS2, and PICN [69]. analysis of monolithic CAD-CAM crowns, J. Esthet. Restor. Dent. 31 (2019)
346–352, https://doi.org/10.1111/jerd.12462.
[11] F.S. Schwindling, S. Rues, M. Schmitter, Fracture resistance of glazed, full-contour
ZLS incisor crowns, J. Prosthodont. Res. 61 (2017) 344–349, https://doi.org/
10.1016/j.jpor.2016.12.008.

8
F. Zarone et al. Journal of Dentistry 109 (2021) 103661

[12] R.D. Vasiliu, S.D. Porojan, M.I. Bîrdeanu, L. Porojan, Effect of thermocycling, [37] Z.M. Jassim, M.A. Majeed, Comparative evaluation of the fracture strength of
surface treatments and microstructure on the optical properties and roughness of monolithic crowns fabricated from different all-ceramic CAD/CAM materials (an in
CAD-CAM and heat-pressed glass ceramics, Materials Basel (Basel) 13 (2020) 381, vitro study), Biomed. Pharmacol. J. 11 (2018) 1689–1697.
https://doi.org/10.3390/ma13020381. [38] M. Rosentritt, S. Hahnel, F. Engelhardt, M. Behr, V. Preis, In vitro performance and
[13] F. Zarone, M.I. Di Mauro, P. Ausiello, G. Ruggiero, R. Sorrentino, Current status on fracture resistance of CAD/CAM-fabricated implant supported molar crowns, Clin.
lithium disilicate and zirconia: a narrative review, BMC Oral Health 19 (2019) 134, Oral Investig. 21 (2017) 1213–1219.
https://doi.org/10.1186/s12903-019-0838-x. [39] E. Yeğin, M.H. Atala, Comparison of CAD/CAM manufactured implant-supported
[14] L. Passos, B. Linke, A. Street, Y. Torrealba, Effect of thickness, translucency, and crowns with different analyses, Int. J. Implant Dent. 6 (2020) 69.
firing protocol on the masking ability of a CAD/CAM zirconia-reinforced lithium [40] B. Yilmaz, A. Alsaery, S.H. Altintas, M. Schimmel, Comparison of strains for new
silicate for different backgrounds, Int. J. Comput. Dent. 22 (2019) 29–38. generation CAD-CAM implant-supported crowns under loading, Clin. Implant Dent.
[15] N. Sen, Y.O. Us, Mechanical and optical properties of monolithic CAD-CAM Relat. Res. 22 (2020) 397–402.
restorative materials, J. Prosthet. Dent. 119 (2018) 593–599, https://doi.org/ [41] H. Kermanshah, F. Motevasselian, S.A. Kakhaki, M. Özcan, Effect of ceramic
10.1016/j.prosdent.2017.06.012. material type on the fracture load of inlay-retained and full-coverage fixed dental
[16] V. Preis, S. Hahnel, M. Behr, L. Bein, M. Rosentritt, In-vitro fatigue and fracture prostheses, Biomater. Investig. Dent. 7 (2020) 62–70.
testing of CAD/CAM-materials in implant-supported molar crowns, Dent. Mater. 33 [42] N.R. Dartora, I.C. Maurício Moris, S.F. Poole, A. Bacchi, M.D. Sousa-Neto, Y.
(2017) 427–433. T. Silva-Sousa, E.A. Gomes, Mechanical behavior of endocrowns fabricated with
[17] N.F. von Maltzahn, O.I. El Meniawy, N. Breitenbuecher, P. Kohorst, M. Stiesch, different CAD-CAM ceramic systems, J. Prosthet. Dent. (2020) S0022–3913,
M. Eisenburger, Fracture strength of ceramic posterior occlusal veneers for https://doi.org/10.1016/j.prosdent.2019.11.008, 30739-5.
functional rehabilitation of an abrasive dentition, Int. J. Prosthodont. 31 (2018) [43] C. Liu, A. Eser, T. Albrecht, V. Stournari, M. Felder, S. Heintze, C. Broeckmann,
451–452, https://doi.org/10.11607/ijp.5817. Strength characterization and lifetime prediction of dental ceramic materials, Dent.
[18] D. Taha, S. Spintzyk, A. Sabet, M. Wahsh, T. Salah, Assessment of marginal Mater. 37 (2021) 94–105, https://doi.org/10.1016/j.dental.2020.10.015.
adaptation and fracture resistance of endocrown restorations utilizing different [44] N. Juntavee, P. Uasuwan, Flexural strength of different monolithic computer-
machinable blocks subjected to thermomechanical aging, J. Esthet. Restor. Dent. assisted design and computer-assisted manufacturing ceramic materials upon
30 (2018) 319–328. different thermal tempering processes, Eur. J. Dent. (2020), https://doi.org/
[19] W. El Ghoul, M. Özcan, M. Silwadi, Z. Salameh, Fracture resistance and failure 10.1055/s-0040-1713957.
modes of endocrowns manufactured with different CAD/CAM materials under [45] T. Srichumpong, P. Phokhinchatchanan, N. Thongpun, D. Chaysuwan,
axial and lateral loading, J. Esthet. Restor. Dent. 31 (2019) 378–387, https://doi. K. Suputtamongkol, Fracture toughness of experimental mica-based glass-ceramics
org/10.1111/jerd.12486. and four commercial glass-ceramics restorative dental materials, Dent. Mater. J. 38
[20] X.P. Chen, Z.X. Xiang, X.F. Song, L. Yin, Machinability: zirconia-reinforced lithium (2019) 378–387.
silicate glass ceram-ic versus lithium disilicate glass ceramic, J. Mech. Behav. [46] J.B. Monteiro, H. Riquieri, C. Prochnow, L.F. Guilardi, G.K.R. Pereira, A.L.
Biomed. Mater. 101 (2020) 103435, https://doi.org/10.1016/j. S. Borges, R.M. de Melo, L.F. Valandro, Fatigue failure load of two resin-bonded
jmbbm.2019.103435. zirconia-reinforced lithium silicate glass-ceramics: effect of ceramic thickness,
[21] B. Altan, S. Cinar, B. Tuncelli, Evaluation of shear bond strength of zirconia-based Dent. Mater. 34 (2018) 891–900.
monolithic CAD-CAM materials to resin cement after different surface treatments, [47] R. Ottoni, J.A. Griggs, P.H. Corazza, Á. Della Bona, M. Borba, Precision of different
Niger. J. Clin. Pract. 22 (2019) 1475–1482, https://doi.org/10.4103/njcp.njcp_ fatigue methods for predicting glass-ceramic failure, J. Mech. Behav. Biomed.
157_19. Mater. 88 (2018) 497–503.
[22] A. Liberati, D.G. Altman, J. Tetzlaff, C. Mulrow, P.C. Gøtzsche, J.P. Ioannidis, [48] N.C. Lawson, R. Bansal, J.O. Burgess, Wear, strength, modulus and hardness of
M. Clarke, P.J. Devereaux, J. Kleijnen, D. Moher, The PRISMA statement for CAD/CAM restorative materials, Dent. Mater. 32 (2016) e275–e283.
reporting systematic reviews and meta-analyses of studies that evaluate health care [49] F. Schweitzer, S. Spintzyk, J. Geis-Gerstorfer, F. Huettig, Influence of minimal
interventions: explanation and elaboration, PLoS Med. 6 (2009) e1000100, extended firing on dimensional, optical, and mechanical properties of crystalized
https://doi.org/10.1371/journal.pmed.1000100. zirconia-reinforced lithium silicate glass ceramic, J. Mech. Behav. Biomed. Mater.
[23] M. Wendler, R. Belli, A. Petschelt, D. Mevec, W. Harrer, T. Lube, R. Danzer, 104 (2020), 103644.
U. Lohbauer, Chairside CAD/CAM materials. Part 2: flexural strength testing, Dent. [50] A.R. Alao, M.H.D. Bujang, Load effect on the mechanical behaviour of zirconia-
Mater. 33 (2017) 99–109. reinforced lithium silicate glass ceramics, Ceram. Int. 47 (2021) 1353–1363.
[24] N. de C. Ramos, T.M.B. Campos, I.S. de La Paz, J.P.B. Machado, M.A. Bottino, P. [51] R. Badawy, O. El-Mowafy, L.E. Tam, Fracture toughness of chairside CAD/CAM
F. Cesar, R.M. Melo, Microstructure characterization and SCG of newly engineered materials - Alternative loading approach for compact tension test, Dent. Mater. 32
dental ceramics, Dent. Mater. 32 (2016) 870–878. (2016) 847–852, https://doi.org/10.1016/j.dental.2016.03.003.
[25] A. Furtado de Mendonca, M. Shahmoradi, C.V.D. Gouvêa, G.M. De Souza, [52] I.L. Aurélio, L.S. Dorneles, L.G. May, Extended glaze firing on ceramics for hard
A. Ellakwa, Microstructural and mechanical characterization of CAD/CAM machining: crack healing, residual stresses, optical and microstructural aspects,
materials for monolithic dental restorations, J. Prosthodont. 28 (2019) e587–e594. Dent. Mater. 33 (2017) 226–240.
[26] T. Traini, B. Sinjari, R. Pascetta, N. Serafini, G. Perfetti, P. Trisi, S. Caputi, The [53] D.L. Romanyk, Y. Guo, N. Rae, S. Veldhuis, S. Sirovica, G.J. Fleming, O. Addison,
zirconia-reinforced lithium silicate ceramic: lights and shadows of a new material, Strength-limiting damage and its mitigation in CAD-CAM zirconia-reinforced
Dent. Mater. J. 35 (2016) 748–755, https://doi.org/10.4012/dmj.2016-041. lithium-silicate ceramics machined in a fully crystallized state, Dent. Mater. 36
[27] M. Rizo-Gorrita, I. Luna-Oliva, M.Á. Serrera-Figallo, J.L. Gutiérrez-Pérez, (2020) 1557–1565.
D. Torres-Lagares, Comparison of cytomorphometry and early cell response of [54] L. Passos, Y. Torrealba, B. Linke, A. Street, S. Passos, Fracture strength of CAD/
human gingival fibroblast (HGFs) between zirconium and new zirconia-reinforced CAM posterior ceramic crowns after manual enhancement of occlusal morphology,
Lithium silicate ceramics (ZLS), Int. J. Mol. Sci. 19 (2018) 2718. Int. J. Comput. Dent. 21 (2018) 191–200.
[28] M. Rizo-Gorrita, C. Herráez-Galindo, D. Torres-Lagares, M.Á. Serrera-Figallo, J. [55] S.Y. Kang, J.M. Yu, J.S. Lee, K.S. Park, S.Y. Lee, Evaluation of the milling accuracy
L. Gutiérre-Pérez, Biocompatibility of polymer and ceramic CAD/CAM materials of zirconia-reinforced Lithium silicate crowns fabricated using the dental medical
with human gingival fibroblasts (HGFs), Polymers (Basel) 11 (2019) 1446. device system: a three-dimensional analysis, Materials Basel (Basel) 13 (2020)
[29] A.M.O. Dal Piva, L.P.C. Contreras, F.C. Ribeiro, L.C. Anami, S.E.A. Camargo, A.O. E4680, https://doi.org/10.3390/ma13204680.
C. Jorge, M.A. Bottino, Monolithic ceramics: effect of finishing techniques on [56] M.F.R.P. Alves, B.G. Simba, L.Q.B. de Campos, I. Ferreira, C. dos Santos, Influence
surface properties, bacterial adhesion and cell viability, Oper. Dent. 43 (2018) of heat-treatment protocols on mechanical behavior of lithium silicate dental
315–325. ceramics, Int. J. Appl. Ceram. Technol. 16 (2019) 1920–1931.
[30] P.G. De Luca, G.A.P. Carvalho, A.B.G. Franco, S. Kreve, G. Avila, S.C. Dias, [57] K. Sieper, S. Wille, M. Kern, Fracture strength of lithium disilicate crowns
Zirconia-reinforced Lithium silicate biocompatibility polished in different stages - compared to polymer-infiltrated ceramic-network and zirconia reinforced lithium
an in vitro study, J. Int. Dent. Med. Res. 11 (2018) 759–764. silicate crowns, J. Mech, Behav. Biomed. Mater. 74 (2017) 342–348.
[31] M.M. Abdalla, I.A.A. Ali, K. Khan, N. Mattheos, S. Murbay, J.P. Matinlinna, [58] E.T.P. Bergamo, D. Bordin, I.S. Ramalho, A.C.O. Lopes, R.S. Gomes, M. Kaizer,
P. Neelakantan, The influence of surface roughening and polishing on microbial L. Witek, E.A. Bonfante, P.G. Coelho, A.A. Del Bel Cury, Zirconia-reinforced lithium
biofilm development on different ceramic materials, J. Prosthodont. (2020) 1–7, silicate crowns: effect of thickness on survival and failure mode, Dent. Mater. 35
https://doi.org/10.1111/jopr.13260. (2019) 1007–1016, https://doi.org/10.1016/j.dental.2019.04.007.
[32] G. Nishioka, C. Prochnow, A. Firmino, M. Amaral, M.A. Bottino, L.F. Valandro, R. [59] S. Shaik, M.A. Alfarsi, Contemporary ceramic material for fabrication of minimally
M. de Melo, Fatigue strength of several dental ceramics indicated for CAD-CAM invasive full-coverage crowns: an in-vitro analysis of fracture resistance,
monolithic restorations, Braz. Oral Res. 32 (2018) e53. J. Biomater. Tiss. Eng. 9 (2019) 388–394.
[33] L.F. Guilardi, P. Soares, A. Werner, N. de Jager, G.K.R. Pereira, C.J. Kleverlaan, M. [60] J.P.M. Tribst, A.M.O. Dal Piva, M.M. Penteado, A.L.S. Borges, M.A. Bottino,
P. Rippe, L.F. Valandro, Fatigue performance of distinct CAD/CAM dental Influence of ceramic material, thickness of restoration and cement layer on stress
ceramics, J. Mech. Behav. Biomed. Mater. 103 (2020), 103540. distribution of occlusal veneers, Braz. Oral Res. 32 (2018) e118.
[34] S. Choi, H.I. Yoon, E.J. Park, Load-bearing capacity of various CAD/CAM [61] M.R. Alammari, M.H. Abdelnabi, A.A. Swelem, Effect of total occlusal convergence
monolithic molar crowns under recommended occlusal thickness and reduced on fit and fracture resistance of zirconia-reinforced lithium silicate crowns, Clin.
occlusal thickness conditions, J. Adv. Prosthodont. 9 (2017) 423–431. Cosmet. Investig. Dent. 11 (2018) 1–8.
[35] M. Zimmermann, G. Egli, M. Zaruba, A. Mehl, Influence of material thickness on [62] F.O. Abu-Izze, G.F. Ramos, A.L.S. Borges, L.C. Anami, M.A. Bottino, Fatigue
fractural strength of CAD/CAM fabricated ceramic crowns, Dent. Mater. J. 36 behavior of ultrafine tabletop ceramic restorations, Dent. Mater. 34 (2018)
(2017) 778–783. 1401–1409.
[36] V. Preis, M. Behr, S. Hahnel, M. Rosentritt, Influence of cementation on in vitro [63] V. Diniz, P.H. Condé Oliveira Prado, J.V. Meireles Rodrigues, J.B. Monteiro,
performance, marginal adaptation and fracture resistance of CAD/CAM-fabricated C. Zucuni, L.F. Valandro, R.M. Melo, Ceramic firing protocols and thermocycling:
ZLS molar crowns, Dent. Mater. 31 (2015) 1363–1369.

9
F. Zarone et al. Journal of Dentistry 109 (2021) 103661

effects on the load-bearing capacity under fatigue of a bonded zirconia lithium GmbH, Hanau, Germany, 2017, 2021 (Accessed 20 February 2021, https://www.
silicate glass-ceramic, J. Mech. Behav. Biomed. Mater. 110 (2020), 103963. celtra-dentsplysirona.com/doc/Download/Celtra_Duo/CD_Lab_BRO_EN_VFIN_
[64] M. Al-Akhali, M. Kern, A. Elsayed, A. Samran, M.S. Chaar, Influence of 22284_Screen.pdf.
thermomechanical fatigue on the fracture strength of CAD-CAM-fabricated occlusal [71] M. Zimmermann, A. Valcanaia, G. Neiva, A. Mehl, D. Fasbinder, Three-dimensional
veneers, J. Prosthet. Dent. 121 (2019) 644–650. digital evaluation of the fit of endocrowns fabricated from different CAD/CAM
[65] A.B. Venturini, C. Prochnow, G.K.R. Pereira, R.D. Segala, C.J. Kleverlaan, L. materials, J. Prosthodont. 28 (2019) e504–e509.
F. Valandro, Fatigue performance of adhesively cemented glass-, hybrid- and resin- [72] M. Falahchai, Y. Babaee Hemmati, H. Neshandar Asli, M. Neshandar Asli, Marginal
ceramic materials for CAD/CAM monolithic restorations, Dent. Mater. 35 (2019) adaptation of zirconia-reinforced lithium silicate overlays with different
534–542. preparation designs, J. Esthet. Restor. Dent. 32 (2020) 823–830.
[66] D.M. Alves, A.C. Cadore-Rodrigues, C. Prochnow, T.A.L. Burgo, A.O. Spazzin, [73] M. Falahchai, Y. Babaee Hemmati, H. Neshandar Asli, E. Rezaei, Effect of tooth
A. Bacchi, L.F. Valandro, G.K.R. Pereira, Fatigue performance of adhesively luted preparation design on fracture resistance of zirconia-reinforced Lithium silicate
glass or polycrystalline CAD-CAM monolithic crowns, J. Prosthet. Dent. (2020) overlays, J. Prosthodont. 29 (2020) 617–622.
S0022–3913, https://doi.org/10.1016/j.prosdent.2020.03.032, 30250-X. [74] W. Höland, M. Schweiger, M. Frank, V. Rheinberger, A comparison of the
[67] M. Amelie Schlenz, M. Skroch, A. Schmidt, P. Rehmann, B. Wöstmann, Monitoring microstructure and properties of the IPS Empress 2 and the IPS Empress glass-
fatigue damage in different CAD/CAM materials: a new approach with optical ceramics, J. Biomed. Mater. Res. 53 (2000) 297–303.
coherence tomography, J. Prosthodont. Res. (2020), https://doi.org/10.2186/jpr. [75] F. Zarone, M. Ferrari, F.G. Mangano, R. Leone, R. Sorrentino, “Digitally oriented
JPOR_2019_466. materials”: focus on Lithium disilicate ceramics, Int. J. Dent. 2016 (2016)
[68] A.M.O. Dal Piva, J.P.M. Tribst, A.B. Venturini, L.C. Anami, E.A. Bonfante, M. 9840594, https://doi.org/10.1155/2016/9840594.
A. Bottino, C.J. Kleverlaan, Survival probability of zirconia-reinforced lithium [76] W. Lien, H.W. Roberts, J.A. Platt, K.S. Vandewalle, T.J. Hill, T.M. Chu,
silicate ceramic: effect of surface condition and fatigue test load profile, Dent. Microstructural evolution and physical behavior of a lithium disilicate glass-
Mater. 36 (2020) 808–815. ceramic, Dent. Mater. 31 (2015) 928–940.
[69] M. Hasanzade, M. Sahebi, S. Zarrati, L. Payaminia, M. Alikhasi, Comparative [77] F. Al Mansour, N. Karpukhina, S. Grasso, R.M. Wilson, M.J. Reece, M.J. Cattell, The
evaluation of the internal and marginal adaptations of CAD/CAM endocrowns and effect of spark plasma sintering on lithium disilicate glass-ceramics, Dent. Mater.
crowns fabricated from three different materials, Int. J. Prosthodont. (2020), 31 (2015) e226–e235.
https://doi.org/10.11607/ijp.6389. [78] E. Apel, C. van’t Hoen, V. Rheinberger, W. Höland, Influence of ZrO2 on the
[70] Celtra® Duo, Zirconia - Reinforced Lithium silicate (ZLS). Developed to Make a crystallization and properties of lithium disilicate glass-ceramics derived from a
Difference. Brochure for the Dental Laboratory, Dentsply Sirona Inc., DeguDent multi-component system, J. Eur. Ceram. Soc. 27 (2007) 1571–1577.

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