OONTINUINC EDUOATION 1

DENTAL CERAMICS

Dental Ceramics: A Current Review

Nathaniel C. Lawson, DMD, PhD; and John O. Burgess, DDS, MS

LEARNING OBJECTIVES

Abstract: Ceramics are used for many dental applications and are characterized " categorize all-ceramic
restorative materiais
in various ways, including by their hardness, brittleness, thermal and electrical according to glass/crystai
insulation, and biocompatibility. The ceramics most commonly used in dentistiy content
• prescribe type, design, •
are oxides, particularly silicon dioxide (SiOi), or silica; aluminum oxide (AI2O3), or
and fabrication method
alumina; and zirconium dioxide (ZrO2), or zirconia. This article reviews the micro- of ail-ceramic restorative
materiais
structure of current dental ceramic materials and how it relates to their mechanical
• ciioose surface finisii for
properties, clinical techniques, and optical properties. Typical ceramics currently in aii-ceramic restoration
use are described, and their clinically relevant properties such as strength, fracture, and determine metiiod
of cementing
polishability, and wear are compared. Cementation methods are also discussed.

M
etals, polymers, ceramics, and composites are Overview
used in dentistry to restore teeth. Ceramics are Dental ceramics can be divided into primarily glass-containing
usedformany dental applications ranging from (ie, feldspathic porcelain), reinforced glass (ie, leucite and lithium
the glass in clinicians' loupes to the filler in re- disilicate), and crystalline (ie, zirconia and alumina). The most
storative resins. Ceramics are characterized by frequent clinical failure of bilayered all-ceramic restorations is
their hardness, brittleness, thermal and electrical insulation, and chipping of veneering porcelain caused by core-veneer coeffi-
biocompatibility. The ceramics most commonly used in dentistry cient of thermal expansion (CTE) mismatch, surface grinding,
are oxides, particularly silicon dioxide (SiO,), aluminum oxide inadequate core design, or overloading. Monolithic crystalline
(AljOg), and zirconium dioxide (ZrO^). The nomenclaturefornam- ceramic crowns have a smaller incidence of fracture, because these
ing oxide ceramics is achieved by removing the suffix of the metallic ceramic materials are stronger than reinforced glass ceramics.
atom and replacing it with ~a; for example, silicon dioxide becomes Crystalline (zirconia and alumina) and reinforced glass ceram-
silica. This article reviews the microstructure of current ceramic ics (lithium disilicate) produce less opposing enamel wear than
materials and how it relates to their mechanical properties, clinical veneered porcelain. Polishing ceramic restorations after occlusal
techniques, and optical properties. Typical ceramics currently in adj ustments typically produces less opposing wear than staining
use are described and their clinically relevant properties compared. or glazing the restoration.
Ceramic crowns can either be traditionally cemented or ad-
hesively bonded depending upon several factors, including: the
strength of the ceramic used; the retentiveness of the preparation;
whether the preparation is in dentin or enamel; and the ability to
isolate. Porcelain and reinforced glass ceramics should be etched
with hydrofluoric acid (HF) and silanated prior to bonding. Zirconia
and alumina crowns should be tribochemically coated, 10-methac-
Figi. ryloyloxydecyldihydrogen phosphate (MDP)-primed, or both prior
to adhesive bonding. Bonding with resin cements produces a higher
bond of dentin to porcelain and glass ceramics than traditional
Fig 1. Microstructure of a giass (A), crystai (B), and partiaily crystalline
(C) ceramic. Spiieres represent metaiiic and non-metaiiic eiements; cementing with resin-modified glass ionomer. Cementing untreat-
rods represent chemicai bonds. ed zirconia to dentin with resin-modified glass ionomer or many

www.compendiumlive.com March 2014 COMPENDIUM 161

CONTINUING EDUCATION 1 | DENTAL CERAMICS

resin cements produces a sim- CTE than glasses. Additionally,

ilar bond strength. Adhesive ceramics are stronger in com-
resin bonding strengthens pression than in tension or
feldspathic porcelain but not shear. Therefore, veneering
necessarily glass ceramics or ceramics need to have a lower
polycrystalline ceramics. CTE than the core material
they are covering in order to
Ceramic place the veneering ceramic
Microstructure in compression. When fabri-
Ceramics are composed of a cating a bilayered crown, the
metal and non-metal element. core and veneer material fase
In a liquid state, these ele- at the melting temperature of
ments are freely moving. Upon the veneer. As the two materi-
solidification, these elements Fig 2. Chipping of veneering iayer of aii-ceramic restoration. als cool, the veneering ceramic
can either arrange themselves (with a lower CTE) will shrink
in an ordered structured crystal or into an amorphous unstructured less than the core material, causing the core material to squeeze the
glass. Generally, cooling a ceramic material slowly will allow it time veneer with compressive force. The greater shrinkage of the core
to solidify into a ciystal, whereas cooling it rapidly forces the atoms material places the veneer under compression, thus strengthening it.
into random orientations as seen in a glass (Figure 1, elements A Although it is helpful to generalize ceramics as either crystals or
and B). The process of heating a crystalline or partially crystalline glasses to explain their physical properties, in reality most ceramics
ceramic and then rapidly cooling it, thereby creating a glassy coat- have both crystal and glass phases (Figure 1, element C). Various
ing, is termed vitrification. A crown can be intentionally vitrified in types of ceramics are used in current dental prostheses.
order to self-glaze its surface or unintentionally de-vitrified during
the fabrication process, increasing its opacity. Types of Ceramics
The microstructure of the ceramic determines its mechanical Current dental ceramics can be classified in three categories: porce-
and optical properties. Crystalline ceramics have atoms arranged lain, which contains mostly glass phase; glass ceramics, which have
into closely packed crystals with a high atomic density; glasses have a high concentration of reinforcing crystal content; and polycrystal-
a lower atomic density. Therefore, a crack propagating through a line ceramics, which are composed of mostly crystals. Strength and
crystalline ceramic will have to break more atomic bonds per unit toughness values of each category are presented in Table 1.
area than a crack travelling through the same unit area of a glass Porcelain—Dental porcelain is the most translucent type of ce-
ceramic. Thus, crystalline ceramics are generally stronger than ramic and is typically used for esthetic applications such as ve-
glass ceramics. The lower atomic density of glass also allows light to neers or veneering core materials. Dental porcelain, also called
pass through it, which causes it to be translucent. Crystal ceramics, feldspathic porcelain, is a specific type of ceramic composed of
conversely, are typically opaque. There are some exceptions (such feldspar, kaolinite, and quartz. The feldspar contributes the glassy
as cubic zirconia or quartz), where the crystalline microstructure of matrix of the porcelain, and the kaolinite and quartz contribute
the ceramic corresponds to the wavelength of light and the crystal is reinforcing crystals of alimiina and silica. Since porcelain is also
translucent. In summary, assuming proper processing techniques the weakest ceramic, it is either used as a veneer of a stronger core
are used, higher crystal content of a ceramic generally contributes material or chemically bonded to the underlying tooth to increase
to higher strength and decreased translucency. its strength. When used to veneer a core material, the crystal con-
The crystal content of a ceramic also affects its CTE, and, re- tent and CTE of the porcelain is adjusted to match the CTE of the
sultantly, crystal content is used to match the CTE of a veneer- material it is covering (ie, higher crystal content and lower CTE
ing ceramic to its supporting core material. Crystals have a lower when veneering zirconia than metal).

TABLE 1

Dental Ceramic Materials' Strength and Toughness Values

CERAMIC MATERIAL FLEXURAL STRENGTH (MPa) FRACTURE TOUGHNESS (MPam'^^)

Feldspathic porcelain 80 1.1
Leucite-reinforced porcelain 100 to 120 1.2
Lithium disilicate 360 to 400 2.5
Glass-infused alumina 400 4.5
Glass-infused zirconia 550 5.5
Zirconia 9 to 1,100 7 toll

162 COMPENDIUM March 2014 Volume 35, Number 3

 Glass ceramics—Ceramics in this category contain a high con- crowns loaded to fracture discovered that the failure mode was 75%
centration of reinforcing crystals. Crystals embedded within a glass core veneer interfacial, 20% within the veneering material, and 5%
matrix help to deflect cracks and therefore strengthen the ceramic' core fractures."" Fractographic analysis of 19 failed veneered zirconia
Leucite (KAlSi^Oj^ crystals are used to strengthen feldspathic por- crowns found 10 fractures originating from the surface of the ve-
celain while maintaining its translucency and decreasing its CTE. neer and six originating from the core-veneer interface.' Interfacial
Lithium disilicate (LiS^O^^ is a needle-shaped crystal composed fractures of bilayered all-ceramic restorations have been attributed
of 30% amorphous silica and 70% crystalline lithium-disilicate to tensile preloads in the veneer created by mismatched CTEs of
crystals with increased flexural strength but decreased translu- the core and veneer ceramics. Adjusting the CTE of the veneering
cency compared to feldspathic porcelain. These materials provide ceramic can help improve the bond between the veneer and the
a balance between strength and translucency that allows them to core.^ ^' Another source of interfacial failure is the bond between
be used as monolithic (single-layered) prostheses for restoration the veneer and core material. Unfortunately, this bond is poorly
of anterior teeth. understood and may develop from mechanical or chemical bond-
Polycrystalline ceramics—The last category of dental ceramics ing.'" Surface treatments (particle-abrasion and liners) have been
is polycrystals. The two common polycrystals (also called metal developed to improve the bond, however studies" '^ have reported
ceramics) are alumina and zirconia. In these materials, zirconium that these techniques provide limited improvement. Cohesive failure
or aluminum and oxygen atoms arrange in specific crystal patterns. within the veneering material results from inadequate core sup-
Auniform arrangement of atoms in a given crystal pattern forms a port of the veneer, overloading of the crown, and surface defects
crystalline grain, and a bulk piece of zirconia or alumina contains from adjustments.' Cores that are designed to support an even layer
many crystalline grains. A unique property of zirconia is that it of veneering ceramic (particularly at cusps and marginal ridges)
undergoes transformation toughening. In this process, grains of perform better than cores of uniform thickness.'*''^ Anatomic cores
the more compact tetragonal crystal structure of zirconia expand increase the fracture strength of the restoration by 30%."^ Based
into the monoclinic phase, induced by a propagating crack. The ex- on this information, clinical recommendations to prevent fracture
pansion causes compression and halting of the crack.^ Polycrystals include proper occlusal adjustment and polishing with a heatless
are the most opaque and strongest class of ceramics and have been stone and rubber polisher, as well as ensuring that the laboratory
typically used as core materials veneered with porcelain or for has adequately designed an anatomical core framework and chosen
monolithic posterior crowns. Current research to produce more a veneering porcelain that matches the core CTE.
translucent forms of these materials by manipulating grain size
and varying doping agents to produce more esthetic monolithic
restorations is underway.^ COMPRESSION
Resin ceramics represent a new category of ceramics. These
materials contain a high content of ceramic particles (more than
80% wt) in a resin matrix and are essentially very highly filled
resin composites that offer a high surface polish, high elasticity,
and shorter milling times.

Clinically Relevant Properties of Dental Ceramics

In this section, clinically relevant properties of dental ceramics are
addressed, and a comparison of these properties between classes
of materials is provided.

Strength and Fracture Properties

Ceramics are brittle, meaning that they tend to fracture without
significant deformation (ie, high strength but relatively low tough-
Fig 3.
ness). Failures are more frequent in the veneering material (Figure
2), as reported in a recent systematic review of 3-year clinical trials
of zirconiafixedpartial dentures (FPDs), which found a 27% chip- _ COMPRESSION
ping occurrence in the veneering porcelain and only a 1% incidence
of fracture of the framework.* The severity of the veneer fracture
will determine whether the defect can be polished, repaired with
composite, or if the restoration requires replacement. Reasons
for replacing the restoration include fractures that extend to a
functional area (ie, occlusal contact or supporting a connector) or
produce unacceptable anatomic contours or esthetics." Fig 4.

Veneerft-acturetypically originates either in the veneering ceramic Fig 3. Compressive and tensile zones of a crown. Fig 4. Compressive
or at the core-veneer interface. An in-vitro study of lithium-disilicate and tensile zones of a fixed partial denture.

www.coiTipendiumlive.com March 2014 COMPENDIUM 163

CONTINUING EDUCATION 1 I DENTAL CERAMICS

Recently, monolithic or full-contour restorations have become volumetric enamel wear from 400,000 chewing cycles measured
popular because they avoid porcelain veneer chipping. The choice 0.33 mm^ against zirconia, 0.36 mm^ against lithium disilicate,
of material for a monolithic restoration is partially based on the 2.15 mm'' against veneering porcelain, and 0.45 mm^ against
strength of the ceramic and the amount of tooth reduction that enamel.^'' When veneering porcelains are worn against enamel,
is possible. Lin reported that the biaxial flexural strength of ce- the porcelain surface becomes rough from microfractures of
ramics increases with increased crystal content: 163.95 MPa for the material. The rough surface of the porcelain is abrasive to
leucite, 365.06 MPa for lithium disilicate, and 1,039.71 MPa for the enamel and results in opposing enamel wear (Figure 5 and
zirconia." Based on these differences, manufacturers have recom- Figure 6).^' High-strength ceramics do not fracture when worn
mended axial tooth reduction for posterior monolithic crowns of against enamel; therefore, their surface remains smooth and
1.5 mm for lithium disilicate and 0.6 mm for zirconia. An in-vitro wear-friendly to opposing enamel. Additionally, high-strength
test reported an ultimate crown fracture strength of 1,668 MPa ceramics experience very little wear on their own surface. The
for 0.6 mm uniform monolithic zirconia, 2,026 MPa for 1.5 mm recent trend in full-contonr monolithic lithium-disilicate and
uniform monolithic lithium disilicate, and 1,465 MPa for 1.2 mm zirconia crowns is partially justified by the wear-compatibility
uniform monolithic lithium disilicate after thermocycling and between these ceramics and opposing enamel.
load cycling.'" When preparing full-contour crowns, it is there- To maintain the smooth surface of ceramics after occlusal adjust-
fore important to ensure proper tooth reduction for the selected ments, it is important to polish the surface of the zirconia or lithium
restorative material. disilicate. There is significantly less opposing enamel wear when
Fractures that initiate in the core material arise from radial cracks ceramics are polished following grinding than with grinding alone.^"
on the internal surface of the crown.''^ Ceramics are subjected to ten- Studies have also compared opposing enamel wear after polishing
sile forces at the internal surfaces of crowns, making them more sus- and glazing zirconia. Glazing zirconia produces a 30-^m-to 50-[im-
ceptible to fracture in this area (Figure 3). Grinding the ceramic core thick, relatively soft layer of glassy glaze.^° During function, this layer
with a rough diamond has shown to decrease theflexuralstrength of glaze quickly wears away and the roughened glaze layer causes
of the material,^" so clinicians should adjust the tooth preparation wear of opposing enamel.^' Clinically, it is recommended to polish
instead of the intaglio surface of the ceramic crown whenfittingan ceramic restorations with a heatless alumina stone followed by a
all-ceramic crown. Another source of core fracture is at the FPD silica, silicon carbide, or diamond impregnated rubber polisher.^'
connectors with inadequate connector area. Recommendations for
connector dimensions are 16 mm^ for lithium disilieate and 9 mm^ Cementation Methods
for zirconia. Connector fractures originate from veneering porcelainCeramic prostheses can be cemented to a tooth preparation either
in sharply contoured gingival embrasures where tensile stresses through traditional cementing or adhesive bonding. Traditional
concentrate (Figure 4).^' cementing relies on micromechanical retention, whereas adhesive
bonding utilizes chemical and micromechanical retention (Figure
Polishing and Wear Properties 7). Traditional cementation can be accomplished with glass-iono-
Ceramic hardness ranges from 481 Hv to 647 Hv for veneering nier cement (GIC), resin-modified glass-ionomer cement (RMGIC),
porcelain to 1,354 Hv to 1,378 Hv for zirconia.-^•^•'' Since enamel or zinc-phosphate cement. Adhesive bonding implies that an adhe-
has a hardness of300Hvto500 Hv,^* concerns have been raised sive bonding agent is applied to the tooth surface, a coupling agent
that ceramic restorations will cause destructive wear to oppos- (eg, silane) is applied to the ceramic, and the prosthesis is bonded
ing teeth. Studies measuring the wear of enamel opposing zir- with a resin cement. The decision to cement or bond a restoration
conia and lithium disilicate, however, have proven that these is based on several clinical factors such as: the type of restoring
high-strength ceramics produce less opposing enamel wear than ceramic, the substrate (enamel or dentin), the retentiveness of the
veneering ceramics or enamel itself.^""^^ For example, in-vitro preparation, and the ability to isolate the tooth.

Fig 5 and Fig 6. All-ceramic restorations (Fig 5) and opposing dentition wear (Fig 6) produced by ail-ceramic feldspathic restorations.

164 COMPENDIUM March 2014 Volume 35, Number 3

 When choosing to bond an all-ceramic restoration, the protocol
differs for the type of ceramic material. To chemically bond to CERAMIC
feldspathic porcelain and reinforced glass ceramics, hydrofluoric
acid (Figure 8) and a silane coupling agent (Figure 9) are used.
Etchant concentration and etch time vary depending on the ce-
ramic substrate.^"- Silane is a coupling molecule that bonds on one
end to silica in glass and bonds to the organic matrix of the resin
cement on the other end (Figure 10, element B). Silane is applied
to the etched intaglio surface of the ceramic crown and bonds
the porcelain or glass ceramic to the resin cement. Porcelain and
glass ceramics are not alumina air-abraded as this will decrease Fig 7.
the strength of the ceramic.^^ (The cited abstract is a project com-
pleted in the authors' laboratory, which showed a decrease in
ñexural strength of lithium disilicate after air abrasion.) Bonding
to zirconia or alumina cannot be accomplished with silane alone
because there is not enough silica in these materials. Effective
strategies for chemically bonding to polycrystalline ceramics
include tribochemical silica coating and 10-methacryloyloxydec-
yl dihydrogen phosphate (MDP) monomer coating.-" The first
strategy is to air-abrade the ceramic surface with silica-covered
alumina particles, which both roughens the ceramic surface and
deposits silica on its surface. The deposited silica can then bond
to silane or MDP coupling agents.^'^ The second strategy is the
use of MDP, a bifunctional molecule that bonds to metal oxides
(including zirconia) at one end and the organic matrix of resin on
the other (Figure 10, element A).^'*'^'
One factor to consider when luting ceramic crowns is the bond
strength of the cement. A study by Peutzfeldt compared the shear
Fig 10.
bond strength of dentin to porcelain (etched and silanated), leu-
cite glass ceramic (etched and silanated), and zirconia (untreated). Fig 7. Luting a ceramic restoration can be done via adhesive bonding
Cementing porcelain and leucite ceramic with zinc phosphate, glass through a chemicai bond (A) or with traditionai cementing through
micromechanicai retention (B). Fig 8 and Fig 9. Etching a iithium-
ionomer, and resin-modified glass ionomer produced lower bond disiiicate crown with 5% HF for 20 seconds (Fig 8), and applying siiane
strengths than adhesively bonding them with most resin cements. (Fig 9) to the iithium-disiiicate crown. Fig 10. MDP molecuie (A) and
Conversely, zirconia showed similar bond strength when cemented siiane molecuie (B) with bonding groups for organic resin (biue), siiica
(green), and metal oxides (tan).
with RMGIC as with many of the resin cements.^^ As mentioned
previously, adhesively bonding zirconia with an MDP primer or
tribochemical coating will increase its bond strength.^'*''' The type Conclusion
of resin cement, such as total-etch (separate etch and primer step), The choice of ceramic selected for a clinical application is de-
self-etch (separate primer step), or self-adhesive (no etch or prim- pendent on the required strength and esthetics of the restoration.
er), can affect the bond strength. Total-etch cements show a higher Broadly, polycrystalline ceramics are stronger and more opaque
bond strength than self-etch or self-adhesive resin cements.'''^ For than glass ceramics and porcelain. The type of ceramic selected
tooth preparations with less than 3 mm of occlusal height or more will dictate the design of the restoration and the options for lut-
than 5 degrees of taper, adhesively bonding zirconia and lithium- ing the restoration. All-ceramic materials should be polished
disilicate crowns is recommended to achieve sufiicient retention.'*" following delivery.
Another consideration when selecting a cement is its ability to
strengthen the ceramic material. Adhesively bonding feldspathic
ABOUT THE AUTHORS
porcelain to tooth structure increases the fracture strength of
the porcelain.*' Heintze demonstrated that leucite and lithium- Nathaniel C. Lawson, DMD, PhD
disilicate crowns adhesively bonded with resin cement had higher Assisianl Professor, University of Alabama at Birmingham School of Dentistry,
Birmingham. Alabama
fracture strength than those cemented with GIC.*^ Another study
by Al-Wahadni showed no difference in fracture strength of lithi- John O. Burgess, DDS, MS
um-disilicate and alumina crowns cemented with GIC or bonded Professor and Assistant Dean for Clinical Research, University of Alabama at
Birmingham School of Dentistry, Birmingham, Alabama
with resin cement.**^ Clinical studies have shown no difference
in the 8-year success rate of lithium-disilicate crowns cemented Queries to the author regarding this course may be submitted to
with RMGIC or bonded with resin cement""*^ [email protected].

www.compendi umlive.com March 2014 COMPENDIUM 165

CONTINUING EDUCATION 1 | DENTAL CERAMICS

REFERENCES 2009;88(2):366-377
23. Shijo Y, Shinya A, Gomi H, et al. Studies on mechanicai strength,
1. Apei E, Deubener J, Bernard A, et ai. Phenomena and mechanisms thermai expansion of layering porceiains to alumina and zirconia ce-
of craci< propagation in glass-ceramics. J Mech Behav Biomed Mater. ramic core materiais. Dent Mater J. 2009;28(3):352-361.
2008;l(4):313-325. 24. Park S, Quinn JB, Romberg E, Aroia D. On the brittieness of enamei
2. Garvie RC, Hannink RH, Pascoe RT. Ceramic steel? Nature. and seiected dental materials. Dent Mater. 2008:24(11):1477-1485.
1975;258:7O3-7O4. doi:10.1038/258703a0 25. Rosentritt M, Preis V, Behr M, et al. Two-body wear of dental porcelain
3. Kim MJ, Ahn JS, Kim JH, et al. Effects of the sintering conditions and substructure oxide ceramics. Clin Orai Investig. 2012;16(3):935-943.
of dentai zirconia ceramics on the grain size and translucency. J Adv 26. Syklawer SB, Janyavuia S, Beck P, et al. Wear of ceramics
Prosthodont. 2013;5(2):161-166. and enamel in artificial chewing simulator [abstract]. J Dent Res.
4. Heintze SD, Rousson V. Survival of zirconia- and metai-supported 2O13:92(spec iss A):19O2.
fixed dentai prostheses: a systematic review. Int J Prosthodont. 27. Janyavuia S, Lawson N, Cakir D, et al. The wear of polished and
2010;23(6):493-502. glazed zirconia against enamei. J Prosthet Dent. 2013;1090):22-29.
5. Anusavice KJ. Standardizing failure, success, and survivai decisions 28. Kim MJ, Oh SH, Kim JH, et al. Wear evaluation of the human
in ciinicai studies of ceramic and metai-ceramic fixed dental prosthe- enamel opposing different Y-TZP dental ceramics and other porceiains.
ses. Dent Mater. 2012;28(l):102-111. JDent. 2012;40(11):979-988.
6. Zhao K, Pan Y, Guess PC, et al. Influence of veneer application on 29. Oh WS, Delong R, Anusavice KJ. Factors affecting enamei and
fracture behavior of lithium-disiiicate-based ceramic crowns. Dent ceramic wear: a iiterature review. J Prosthet Dent. 2002:87(4):451-459.
Mater. 2012;28(6):553-660. 30. Heintze SD, Cavaiieri A, Forjanic M, et ai. Wear of ceramic and
7. Aboushelib MN, Feilzer AJ, Kleverlaan CJ. Bridging the gap between antagonist—a systematic evaiuation of infiuencing factors in vitro.
clinical failure and laboratory fracture strength tests using a fracto- Dent Mater. 2008;24(4):433-449.
graphic approach. Dent Mater. 2OO9;25(3):383-391. 31. ai-Wahadni A, Martin DM. Glazing and finishing dentai porceiain: a
8. Fischer J, Stawarzcyk B, Trottmann A, Hämmerie CIH. impact of iiterature review. J Can DentAssoc. 1998;64(8):580-583.
thermai misfit on shear strength of veneering ceramic/zirconia com- 32. Soares CJ, Soares PV, Pereira JC, Fonseca RB. Surface treatment
posites. Dent Mater. 2009;25(4):419-423. protocols in the cementation process of ceramic and iaboratory-
9. Biatz MB, Bergier M, Ozer F, et al. Bond strength of different veneer- processed composite restorations: a iiterature review. J Esthet Restor
ing ceramics to zirconia and their susceptibiiity to thermocyciing. Am Dent. 2005;17(4):224-235.
J Dent. 2010;23(4):213-216. 33. Meenes T, Burgess JO, Cakir D, et al. Abrasion and etching ef-
10. Choi EC, Waddeil JN, Torr B, Swain MV. Pressed ceramics onto zir- fects on lithium disilicate fiexurai strength [abstract]. J Dent Res.
conia. Part 1: Comparison of crystalline phases present, adhesion to a 2014;93(spec iss A):184572.
zirconia system and flexural strength. Dent Mater. 2Oll;27(12):12O4-1212. 34. Mair L, Padipatvuthikui P. Variables related to materiais and pre-
11. Kim IHJ, Lim HP, Park YJ, Vang MS. Effect of zirconia surface treat- paring for bond strength testing irrespective of the test protocoi. Dent
ments on the shear bond strength of veneering ceramic. J Prosthet Mater. 2OlO;26(2):el7-e23.
Dent. 2O11;105(5):315-322. 35. Atsu SS, Kiiicarsian MA, Kucukesmen HC, Aka PS. Effect of
12. Kirmaii O, Akin H, Özdemir AK. Shear bond strength of veneering zirconium-oxide ceramic surface treatments on the bond strength to
ceramic to zirconia core after different surface treatments. Photomed adhesive res'm. J Prosthet Dent. 2006:95(6):430-436.
Laser Surg. 2013;31(6):261-268. 36. Attia A, Kern M. Long-term resin bonding to zirconia ceramic with
13. Musharraf R, Rismanchian M, Savabi O, Ashtiani AH. Infiuence of a new universai pnmer. J Prosthet Dent. 2011;106(5):319-327
surface modification techniques on shear bond strength between 37. Blatz MB, Sadan A, Martin J, Lang B. in vitro evaiuation of shear
different zirconia cores and veneering ceramics. J Adv Prosthodont. bond strengths of resin to densely-sintered high-purity zirconium-
2011;3(4):221-228. oxide ceramic after iong-term storage and thermai cyciing. J Prosthet
14. Guess PC, Bonfante EA, Silva NR, et al. Effect of core design and Dent. 2OO4:91(4):356-362.
veneering technique on damage and reliabiiity of Y-TZP-supported 38. Peutzfeidt A, Sahafi A, Flury S. Bonding of restorative materials to
crowns. Dent Mater. 2O13;29(3):3O7-316. dentin with various luting agents. Oper Dent. 2011:36(3):266-273.
15. Rosentritt M, Steiger D, Behr M, et al. Influence of substructure de- 39. Viotti RG, Kasaz A, Pena CE, et ai. Microtensiie bond strength of
sign and spacer settings on the in vitro performance of moiar zirconia new seif-adhesive iuting agents and conventionai multistep systems. J
crowns. J Dent. 2009;37(12):978-983. Prosthet Dent. 2009;102(5):306-312.
16. Fischer J. Strength of zirconia singie crowns related to coping de- 40. Powers JM, Farah JW, O'Keefe KL, et al. Guide to ail-ceramic bond-
sign [abstract]. J Dent Res. 2005;84(spec iss A). Abstract 0546. ing. The Dentai Advisor. 2OO9;2:l-12.
17. Lin W, Ercoli C, Feng C, Morton D. The effect of core materiai, 41. Jensen ME, Sheth JJ, Toiliver D. Etched-porcelain resin-bonded
veneering porceiain, and fabrication technique on the biaxial fiexurai fuli-veneer crowns: in vitro fracture resistance. Compendium.
strength and weibuil analysis of seiected dentai ceramics. J Prostho- 1989:10(6):336-347.
dont. 2012;2K5):353-362. 42. Heintze SD, Cavaiieri A, Zeiiweger G, et ai. Fracture frequency
18. Baladhandayutham B, Beck P, Litaker MS, et al. Fracture strength of all-ceramic crowns during dynamic ioading in a chewing simu-
of ail-ceramic restorations after fatigue ioading [abstract]. J Dent Res. iator using different loading and iuting protocols. Dent Mater.
2012;91(spec iss A):24. 2OO8:24(1O):1352-I361.
19. Rekow ED, Suva NR, Coelho PG, et al. Performance of dental ce- 43. Ai-Wahadni AM, Hussey DL, Grey N, Hatamieh MM. Fracture
ramics: chaiienges for improvements. J Dent Res. 20n;90(8):937-952. resistance of aluminium oxide and iithium disilicate-based crowns us-
20. Curtis AR, Wright AJ, Fieming GJ. The infiuence of surface modi- ing different iuting cements: an in vitro study. J Contemp Dent Pract.
fication techniques on the performance of a Y-TZP dentai ceramic. J 2009;10(2):51-58.
Dent. 2OO6;34(3);195-206. 44. Gehrt M, Wolfart S, Rafai N, et al. Ciinicai resuits of lithium-
21. Taskonak B, Yan J, Mecholsky JJ Jr, et ai. Fractographic anaiyses of disiiicate crowns after up to 9 years of service, din Orai investig.
zirconia-based fixed partial dentures. Dent Mater. 2008;24(8):1077-1082. 2013;17(l):275-284.
22. Pittayachawan P, McDonaid A, Young A, Knowles JC. Flexural 45. Wolfart S, Eschbach S, Scherrer S, Kern M. Ciinicai outcome of
strength, fatigue iife, and stress-induced phase transformation study three-unit lithium-disiiicate giass-ceramic fixed dentai prostheses: up
of Y-TZP dentai ceramic. J Biomed Mater Res B AppI Biomater. to 8 years resuits. Dent Mater. 2009:25(9):e63-e71.

166 COMPENDIUM March 2014 Volume 35, Number 3

Copyright of Compendium of Continuing Education in Dentistry (15488578) is the property
of AEGIS Communications, LLC and its content may not be copied or emailed to multiple
sites or posted to a listserv without the copyright holder's express written permission.
However, users may print, download, or email articles for individual use.