CLINICAL SCIENCE

A prospective evaluation of zirconia anterior partial fixed

dental prostheses: Clinical results after seven years
Maria Fernanda Solá-Ruíz, DMD, PhD, MD,a Rubén Agustin-Panadero, DMD, PhD,b
Antonio Fons-Font, DMD, PhD, MD,c and Carlos Labaig-Rueda, DMD, PhD, MDd

Since the end of the 20th ABSTRACT

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

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

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

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

respectively.11-14
Most published research has analyzed the behavior of
zirconia restorations in the posterior zone.15,16 Chipping
or delamination has been defined as the fracture of the
veneer ceramic, and a high rate varying between 6% and
28% has been confirmed over a period of 3 to 10 years.16- Figure 1. Chipping of veneer ceramic in maxillary central incisors of
33
These are high values compared to the 4% fracture rate fixed dental prosthesis with zirconia core.
demonstrated by conventional metal ceramic restorations
over 10 years.34
According to Heintze and Rousson,14 chipping, can
evaluation being on January 1, 2014. The ethical board for
be classified by severity and by the treatment required for
clinical trials of the University of Valencia approved the
repair, as follows: grade 1, small surface chipping, with
study protocol, and all participants gave their informed
treatment being polishing the restoration surface; grade
consent to take part.
2, moderate surface chipping, with treatment being using
Inclusion criteria were the need to replace 1 or 2
a resin composite repair system (Fig. 1); and grade 3,
anterior teeth (central or lateral incisors), indicating the
severe veneer ceramic chipping exposing the zirconium
placement of FDPs of between 3 and 6 units, periodon-
dioxide core, with treatment being replacing the
tally healthy abutment teeth, no signs of either resorption
damaged prosthesis. Literature reviews such as those by
or periapical pathology, stable occlusion, and natural
Heintze and Rousson,14 Anusavice,35 and Raigrodski,36
teeth in the antagonist arch.
show that the most frequent types of zirconia-based
Individuals requiring a fixed partial prosthesis of more
fixed dental prostheses chipping are grades 1 and 2,
than 2 pontics or with poor oral hygiene, a high incidence of
which do not involve restoration failure.
caries, active periodontal disease, or bruxism were excluded.
Several factors have been identified that can influence
the incidence of chipping, as follows: (1) residual tension
Prosthodontic procedures
due to differences in the thermal expansion coefficients
Three clinicians (S.R.M.F., A.P.R., F.F.A.) with experience
of the core and the veneer materials; (2) poor wettability
in fixed prosthodontics prepared the abutment teeth to
of the core by the veneer ceramic37; (3) compression
meet the following parameters: occlusal and/or incisal
resulting from firing the porcelain38,39; (4) the protocol for
reduction of 1.5 to 2 mm; axial reduction of 1 to 1.5 mm
heating and cooling the veneer and core37; (5) trans-
with a 10-degree included convergence angle, and a
formation of the zirconium dioxide crystal phase at the
circular chamfer or shoulder of 1 mm. Particular attention
core-porcelain veneer interface caused by thermal in-
was paid to rounded line angles (Figs. 2, 3). The color of
fluences or load forces40; (6) formation of inherent defects
each abutment tooth and adjacent teeth was identified
during processing41; (7) veneer ceramic application
with a shade guide (Vita shade guide, Vita Zahnfabrik).
technique (stratification/injection)41-43; (8) Inadequate
Interim restorations were fabricated from polymethyl
thickness of veneer ceramic44; and (9) occlusal trauma.45
methacrylate (AcryLux C&B; Ruthinium Group, Dental
The aim of this study was to evaluate the success and
Manufacturing Spa) and cemented with eugenol-free
survival rates and biological and/or mechanical compli-
interim cement (Temp Bond NE; Kerr Corp).
cations of zirconium dioxide FDPs in the anterior region
Definitive impressions were made with polyvinyl
over a 7-year follow-up.
siloxane impression material (Exaflex; GC America Inc) in
a stock perforated stainless steel tray (Zhermack; Badia
MATERIAL AND METHODS
Polesine). Impressions of the opposing arch were made
Twenty-seven participants (14 women and 13 men) aged with irreversible hydrocolloid impression material
between 30 and 65 years took part in the study, which (Orthoprint; Zhermack) and intermaxillary relations were
was carried out in the Prosthodontics and Occlusion registered in wax (X-hard; Miltex).
Department at the University of Valencia between The FDPs were fabricated with a computer-aided
January 1, 2005, and January 1, 2006, with latest design and computer-aided manufacturing (CAD/CAM)

THE JOURNAL OF PROSTHETIC DENTISTRY Solá-Ruíz et al

- 2015 3

Figure 2. Patient before treatment with existing fixed dental prosthesis Figure 3. Abutment tooth preparation.
and tooth wear.

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

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

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

Clinical follow-up
The 27 participants were examined by 2 clinicians who
had not been involved in treating them, at 1 month after
restoration, after 6 months, and thereafter annually for 7
years. The clinical parameters analyzed were loss of
vitality or infection of the abutment teeth (cold test and
periapical radiographs), secondary caries, debonding,
fracture of the prosthesis core, and chipping of the veneer
ceramic. Both clinicians evaluated the prostheses inde-
pendently. The parameters were such that assessment

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

Table 1. Complication details in prospective evaluation after 7 years 1.0

Complication Complication Present n Incidence (%)
Chipping No 23 85.2
0.8
Yes 4 14.8
Core fracture No 27 100

Survival
0.6
Yes 0 0
Debonding No 25 92.6
0.4
Yes 2 7.4
Secondary caries No 25 92.6
Yes 2 7.4
0.2
Survival Function
Endodontic No 26 96.3 0

Yes 1 3.7 0.0

was objective in all prostheses, so reliability testing was
not thought to be necessary. Nevertheless, if divergences
did occur between their findings, the lower value was
used for analysis.
Statistical analysis was performed with software
(Statistical Package for the Social Sciences; IBM SPSS
Statistics) applying initial descriptive and bivariate ana-
lyses, the Kruskal-Wallis test, the Mann-Whitney test,
and Kaplan-Meier survival analysis (a=.05).
RESULTS
The 27 participants received 27 FDPs: ten 3-unit, ten 4-
unit, two 5-unit, and five 6-unit FDPs. All participants
completed the 7-year follow-up, and no appointments
were missed. After 7 years of monitoring, 3 complete
restoration failures had occurred requiring removal (one
3-unit and one 4-unit FDP failure because of secondary
caries and one 6-unit FDP failure because of irreparable
chipping). The survival rate of the zirconia core restora-
tions was 88.8% after the 84-month follow-up (95%
confidence interval [CI] 70.8 to 97.7).
The complications observed were classified as bio-
logical (secondary caries, pulp affectation) or mechanical
(fracture of the core or veneer ceramic, debonding).
Biological complications involved 2 FDPs (one 3 unit, one
0.00 2.00 4.00 6.00 8.00 10.00
Complication time
Figure 7. Probability of survival without complications until end of
follow-up period.
4 unit) with secondary caries (7.4%) in the abutment
teeth, requiring replacement of the prosthesis at the 3-
year follow-up and one 4-unit FDP (3.7%) with an
endodontic problem with periapical lesions after 2.5
years; however, after periapical surgery, there was no
need to replace the prosthesis. Mechanical complications
involved 4 FDPs with chipping (14.8%), all of them 6-
unit FDPs: one was replaced after 3 years and the
others were corrected by polishing and intraoral repair
(Fig. 6). Two FDPs (one 4 unit and one 6 unit) debonded
after 7 and 6 months, respectively. None of the FDPs had
fracture of the internal zirconia cores (Table 1). When the
type of complication was related to the FDP’s number of
units (applying the Kruskal-Wallis test), a statistically
significant relation was identified involving chipping
(P=.002). Five 6-unit FDPs showed a higher incidence of
chipping than those with shorter spans (P<.001, Mann-
Whitney). No identified differences were found be-
tween 3-unit and 4-unit spans (P=1.000, MW), with null
incidence of chipping. When the causes of restoration
failure were analyzed, the only statistically significant

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- 2015
1.0
0.8
Survival
0.6
0.4
Type FPD
0.2 3 units
4 units
3 units-censored
4 units-censored
5 to 6 units 5 to 6 units-censored
0.0
0.00 2.00 4.00 6.00 8.00 10.00
Complication time
Figure 8. Survival (without failure) according to FDP number of units.
factor (Mann-Whitney test) was secondary caries
(P=.001). All FDPs that presented with secondary caries
in the abutment teeth had to be removed.
The Kaplan-Meier survival test estimated an accu-
mulated survival rate of 8 years and 5 months (95% CI
7.6 to 9.0). The critical moment for survival was around
the 3-year mark, given that a restoration that had sur-
vived 3 years maintained a constant probability of sur-
viving the follow-up period (with a value of 0.9). The
mean survival time without any incidence of complica-
tions (success) was 6.83 years (95% CI 5.6 to 8.1). If by 3
years no complication had occurred, there was a high
probability that none would appear thereafter (Fig. 7).
When success was related to the FDP (Kaplan-Meier
test), the probability of some complication occurring
increased in relation to the number of units of the FDP
(Fig. 8). For 6-unit FDPs, complications occurred both
soon and frequently. For these restorations, the time
taken to stabilize survival probability was 2 years, but
thereafter the probability of survival was only 0.42.
DISCUSSION
Little research has been published on the clinical
behavior of anterior FDPs with zirconia cores. For this
type of restoration, the most frequent complication is
chipping of the veneer porcelain.15-34 Factors that influ-
ence chipping are related to a series of variables, which
range from the varying thermal behavior after firing and
cooling the substrate and the overlay ceramic to insuffi-
cient wettability of the substrate in relation to the veneer
porcelain during construction, which can produce insuf-
ficient homogeneity at the veneer/core interface.3,4,37
One of the most widely studied ceramic veneer
phenomena that might be related to ceramic veneer
chipping, is aging or low-temperature degradation.
Zirconium dioxide’s hydrothermal transformation was
discovered by Kobayashi et al,46 who observed a
slow, progressive, spontaneous transformation of the
Solá-Ruíz et al
5
tetragonal to monoclinic phase associated with the
degradation of the material’s mechanical properties. This
phenomenon is promoted by the presence of water or
vapor and by the temperature caused by the reactions of
water and the crystalline lattice. The susceptibility of
zirconia to aging depends on factors such as grain size,
presence of residual stress, or the quantity, type, and
distribution of the stabilizing element; the larger the
grain size or the greater the residual stress or the lower
the quantity of stabilizing element, the greater the ag-
ing.46 This is also a phenomenon that is accelerated by
the presence of water vapor.47 Of particular relevance
was the news reported in various American orthopedic
journals of the fracture-after only a short time-of 400
Zircone Prozyr (3Y TZP) femoral prostheses made from
zirconia in 2001 to 2002. These had to be removed and
led to a marked reduction in the use of the material and
the closure of the supplier of the prosthesis.1 Numerous
research articles have shown how the kinetics of the
tetragonal-monoclinic transformation, which generally
appears to be linked to chemical composition, is accel-
erated as temperature rises.38-40 The activation energies
measured vary between 70 and 110 kcal/mol. This evi-
dence has important technological consequences because
of zirconia’s low thermal conductivity (2.5 W/mK),
whereby the surface treatment of zirconium dioxide lines
by abrasion can cause notable temperature rises locally
that can initiate phase transformation.46
Crisp et al17 analyzed the behavior of 13 FDPs (3- and
4-unit prostheses), but they did not observe any com-
plications after a 12-month follow-up, nor did Tinschert
et al18 in an analysis of 15 anterior FDPs (3- to 10-unit
prostheses) over 38 months. These results are not com-
parable with the present study given the small numbers
of FDPs and the shorter follow-up periods.
Schmitter et al19 monitored 30 FDPs (4- to 7-unit
prostheses) over 25 months, distributed in both the
anterior and posterior regions; among the anterior FDPs, 1
had endodontic problems and 2 debonded among the
posterior FDPs, 1 had a fracture of the internal core, and 1
had veneer chipping. Edelhoff et al20 analyzed the
behavior of 21 FDPs (3- to 6-unit prostheses) over 39
months, of which only 4 were placed in the anterior re-
gion, with 1 incidence of a loss of pulpal vitality in 1
abutment tooth.
Almost all published research of FDP behavior deals
with restorations placed in the posterior region.21-33 The
most common mechanical complication was chipping of
the veneer ceramic, although there is controversy be-
tween researchers as to its incidence. Some authors
report that chipping occurs in 3% to 6% of posterior
FDPs,17-19,22,23 whereas others state that it is 9% to
15%,8,13,20,24-29 and some report that it is as high as 19%
to 28%.21,29-31 However, several other authors have
found no mechanical complications among the FDPs
THE JOURNAL OF PROSTHETIC DENTISTRY
6 Volume
monitored.32,33 The present study found that 14.8% of
the restorations had chipping, all of them longer, 6-unit
FDPs. None of the FDPs in the present study had frac-
ture of the zirconia cores.
As for biological complications, the present study
found an incidence of 11.1% (2 participants [7.4%]
with secondary caries, and 1 [3.7%] endodontic prob-
lem) over the 84-month follow-up period. Again, there
is controversy between authors over the incidence of
these complications, which range between 1.5% to
5.5% 36,18-20,21,23,27,28,30 and 10.1% to 20% 26,31,29 over
clinical observation periods of between 50 and 84
months. The latter studies concur more closely with
the present one, both in the number of biological
complications and in the follow-up period.
When the causes of mechanical restoration failure are
analyzed, according to studies with 3- to 5-year follow-
up, success rates vary between 88.8% and
100%,6,12,17,18,20,22,25,30,32,33 while for failure due to bio-
logical complications, the success rate decreases to
73.9%,11,21,23,27,29,31 findings that agree with the present
study, in which the incidence of caries increased FDP
failure (P=.001, Mann-Whitney test).
In the studies discussed previously, most FDPs were
made with ceramic veneer over a zirconia substrate
applied in layers with a stratification technique. Chris-
tensen and Ploeger41 stated that veneer ceramics that
contain leucite and that are applied with a pressing
technique have markedly better resistance to chipping
compared to stratification. However, studies by Choi
et al42 refute this theory, and a study by Ishibe et al43
comparing the pressing technique and layered ceramic
veneers failed to identify significant differences in zirco-
nia or metal substrates.
Recently, monolithic zirconia restorations, which have
good optical and mechanical qualities and are not sus-
ceptible to chipping, have become popular.48 Longitudi-
nal long-term prospective studies are needed to confirm
the performance of these restorations, although their
esthetics limits their use to the posterior region.
All the FDPs in our study were cemented with a
standard technique. To date, consensus has not been
reached as to the ideal cementation technique. Never-
theless, most authors recommend airborne-particle
abrading the internal structure with 30 mm silica oxide
particles at a pressure of 200 kPa from a distance of 2 cm
for 10 seconds and then cementing with adhesive and
composite resin.49,50 No immediate damage attributed to
airborne-particle abrasion has been observed that com-
promises zirconia’s fatigue resistance. Zhang et al51
indicated that abrasion by aluminum oxide particles of
up to 50 mm increased surface resistance, while airborne-
particle abrasion with aluminum oxide particles of 120
mm significantly weakened the structure by increasing
surface roughness.
THE JOURNAL OF PROSTHETIC DENTISTRY
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CONCLUSIONS
Within the limitations of this study (in particular the
small sample size), the conclusions are as follows:
1. Anterior FDPs with zirconium dioxide frameworks
showed a success rate of 88.8% within the 7-year
follow-up.
2. The most frequent cause of failure was secondary
caries (P=.001), which was related to the number of
units of the FDP.
3. The most frequent complication was chipping of the
veneer ceramic.
4. All chipping occurred in longer, 5- or 6-unit FDPs
(P=.002).
5. The critical period for the occurrence of mechanical
and biological complications was between the first
and the third year.
6. More long-term longitudinal studies are required to
confirm the behavior of this type of restoration in
the oral environment.
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Corresponding author:
Dr Maria Fernanda Solá-Ruiz
Faculty of Medicine and Dentistry
University of Valencia
C/ Gascó Oliag, N 1
46010 Valencia
SPAIN
Email: m.fernanda.sola@uv.es
Copyright © 2015 by the Editorial Council for The Journal of Prosthetic Dentistry.
THE JOURNAL OF PROSTHETIC DENTISTRY