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An overview of monolithic zirconia in dentistry

zlem Malkondu, Neslihan Tinastepe, Ender Akan & Ender Kazazolu
To cite this article: zlem Malkondu, Neslihan Tinastepe, Ender Akan & Ender Kazazolu
(2016) An overview of monolithic zirconia in dentistry, Biotechnology & Biotechnological
Equipment, 30:4, 644-652, DOI: 10.1080/13102818.2016.1177470
To link to this article: http://dx.doi.org/10.1080/13102818.2016.1177470

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Date: 14 August 2016, At: 19:12

BIOTECHNOLOGY & BIOTECHNOLOGICAL EQUIPMENT, 2016

VOL. 30, NO. 4, 644 652
http://dx.doi.org/10.1080/13102818.2016.1177470

REVIEW; MEDICAL BIOTECHNOLOGY

An overview of monolithic zirconia in dentistry

Ozlem
Malkondua, Neslihan Tinastepea, Ender Akan

lub
and Ender Kazazog

a
Faculty of Dentistry, Department of Prosthodontics, Yeditepe University, Istanbul, Turkey; bFaculty of Dentistry, Department of Prosthodontics,
_Izmir Katip Celebi

University, Izmir, Turkey

ABSTRACT

ARTICLE HISTORY

Zirconia restorations have been used successfully for years in dentistry owing to their
biocompatibility and good mechanical properties. Because of their lack of translucency, zirconia
cores are generally veneered with porcelain, which makes restorations weaker due to failure of the
adhesion between the two materials. In recent years, all-ceramic zirconia restorations have been
introduced in the dental sector with the intent to solve this problem. Besides the elimination of
chipping, the reduced occlusal space requirement seems to be a clear advantage of monolithic
zirconia restorations. However, scientic evidence is needed to recommend this relatively new
application for clinical use. This mini-review discusses the current scientic literature on monolithic
zirconia restorations. The results of in vitro studies suggested that monolithic zirconia may be the
best choice for posterior xed partial dentures in the presence of high occlusal loads and minimal
occlusal restoration space. The results should be supported with much more in vitro and
particularly in vivo studies to obtain a nal conclusion.

Received 3 November 2015

Accepted 8 April 2016

Introduction
Metal ceramic restorations are a type of ceramic system
for xed prosthetic rehabilitation that has been widely
used since the early 1960s.[1] They have superior physical properties, and their marginal and internal adaptation and aesthetics are clinically acceptable.[1 4]
However, light reecting from the opaque porcelain
used to mask the metal, particularly at the cervical third
of the restoration causes a light grey appearance of the
adjacent gingival tissue. This phenomenon led researchers to search for more aesthetic solutions to produce
xed prostheses. Although the rst feldspathic porcelain
crown was introduced to the eld of dentistry by Land
[5] in 1903, the development of metal-free ceramics only
gained speed after the rst attempt to strengthen feldspathic porcelain by adding Al2O3 by McLean [6] in 1965.
Since then, several types of full ceramic systems have
been developed to meet the demands of both patients
and dentists for highly aesthetic and natural-appearing
restorations. However, some of the mechanical properties of these materials, such as brittleness, crack propagation, fracture toughness, low tensile strength, wear
resistance, marginal accuracy and difculty of repair,
have limited their clinical use.[7] Zirconia was introduced
in dentistry in the early 1990s and has been used as a
core material to support more aesthetic ceramic
CONTACT Ender Akan

KEYWORDS

Monolithic zirconia; fullcontour restorations; allceramic zirconia

materials. Zirconia shows similar mechanical properties

to stainless steel [8] and the highest ones among
ceramics used in dentistry. As the strongest and toughest of all dental ceramics,[9] zirconia has 900 1200 MPa
exural strength, and 9 10 MPam1/2 fracture toughness.[10] These characteristics enable the manufacturing
of posterior xed partial dentures (FPDs) with diminished
core thickness. Clinical failure of zirconia-supported
restorations, regardless of the applied zirconia veneer
system, is mostly due to chipping of the veneering
ceramic (cohesive fractures within the veneering ceramic).[10] The rates of chipping of zirconia
veneering ceramics have been reported to be 2% 9%
for single crowns after 2 3 years and 3% 36% for FDPs
after 1 5 years.[11,12] Differences in the coefcient of
thermal expansion (CTE) between the zirconia substructure and the veneering ceramic,[13] improper framework
design, rapid cooling rates and low fracture toughness
and exural strength of veneering ceramic compared to
the zirconia core have been considered as the cause of
this cohesive failure.[14 17] In addition, the amount of
the occlusal load, the size and location of occlusal contacts [18] and the thickness of the porcelain [19] are
thought to play a role in this failure. Various techniques
have been used to prevent veneering failure. Some of
these are sintering high-strength computer-aided

ender.akan@ikc.edu.tr

2016 The Author(s). Published by Taylor & Francis.

This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (http://creativecommons.org/licenses/by-nc-nd/4.0/),
which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way.

BIOTECHNOLOGY & BIOTECHNOLOGICAL EQUIPMENT

design/computer-aided manufacturing (CAD/CAM)-fabricated veneering porcelain cap onto zirconia coping,[20]

applying veneering ceramic via pressing it over to zirconia copings (press-on technique),[21] and in addition to
press-on veneering ceramic, layering veneer ceramics on
zirconia copings (double veneering technique).[22]
Recently, there has emerged a trend of fabrication of
full-contour zirconia restoration to avoid veneering failure as an alternative to the aforementioned methods. To
increase the translucency and aesthetics of full-contour
zirconia, some modications, such as the sintering temperature, fabrication processes and addition of colouring
liquids, have been applied. These modications may
affect the mechanical and autocatalytic surface-transformation (low-temperature degradation (LTD)) properties
of zirconia.[23] This mini-review examines the current
scientic literature on the performance of monolithic
zirconia (full-contour zirconia).

In vitro studies
The performance of monolithic zirconia has been extensively studied in vitro, since such studies are fast, repeatable, relatively inexpensive and simple and also allow
precise control of the environment. Over the last ve
years, most in vitro studies have focused mainly on the
effect of surface treatment on the wear of the material
itself and/or antagonists,[24 35] surface roughness,
[24,25,27,34,36 38] fracture resistance,[35,39 45] exural strength,[23,44,46] chipping resistance,[23] compressive strength,[44] elastic modulus,[44] hardness,[33]
laser transmission,[47] LTD [48] and CTE-generated stress
elds in monolithic zirconia,[49] translucency and colour
(Table 1).[35,46,50 56] Although the results from in vitro
studies may not fully reect the clinical performance of
the materials due to the complexity of the clinical
Table 1. Recent in vitro and in vivo studies on the performance
of monolithic zirconia in dentistrya.
Type of
study
In vitro

In vivo
a

Investigated
parameters
Wear
Surface roughness
Fracture resistance
Flexural strength
Chipping resistance
Compressive strength
Elastic modulus
Hardness
Laser transmission
Low-temperature degradation
CTE-generated stress elds
Translucency and colour
Contour, marginal adaptation, occlusion
and shade, gingival response

Reference(s)
[24 35]
[24,25,27,34,36 38]
[35,39 45]
[23,44,46]
[23]
[44]
[44]
[33]
[47]
[48]
[49]
[35,46,50 56]
[57 59]

Based on a PubMed search (http://www.ncbi.nlm.nih.gov/pubmed) for

articles published over the last ve years, using monolithic zirconia,
full-contour zirconia and high translucent zirconia as key words.

645

environment, they have still contributed to the accumulation of a growing body of useful information on the
performance of monolithic zirconia.

Wear
The effect of different surface treatments of monolithic
zirconia on antagonists has been extensively studied in
recent years because the use of zirconia without porcelain overlay became popular.[24 35] For example, in a
study by Sabrah et al., [24] polished zirconia was shown
to cause the least wear on synthetic hydroxyapatite in a
two-body rotating pin-on-disk wear test as compared to
glazed and as-machined zirconia (1.3, 2.7 and 2.7 mm3,
respectively). Janyavula et al. [25] evaluated the wear of
polished or glazed zirconia, polished then reglazed zirconia, enamel and veneering porcelain on enamel, using
an Alabama wear-testing device. The authors reported
that the volume loss of enamel was least in the polished
zirconia group (0.11 0.04 mm3 at 200,000 cycles and
0.21 0.05 mm3 after 400,000 cycles). Glazed and polished then reglazed zirconia showed signicant opposing enamel wear (0.59 0.1 mm3 and 0.87 0.21 mm3
at 200,000 cycles and 0.4 0.88 0.12 mm3 and 1.18 0.2
mm3 after 400,000 cycles). The most pronounced enamel
wear was observed for veneering porcelain (1.46 0.5
mm3 and 2.15 0.5 mm3 at 200,000 and 400,000 cycles,
respectively). Thus, the authors concluded that polished
zirconia is wear-friendly for the opposing teeth. Kontos
et al. [26] tested the wear capacity of zirconia after various surface treatments using an Alabama wear-testing
device. Polished zirconia had a low wear effect (66 23
mm) on the antagonist steatite ball, whereas, glazed zirconia had the highest wear effect (85 33 mm). Kim
et al. [27] investigated the volume loss of enamel and
feldspathic porcelain after simulated mastication against
three types of monolithic zirconia, heat-pressed ceramic
and feldspathic porcelain. The zirconia specimen caused
the least wear volume of the enamel (Prettau, Lava and
Rainbow: 0.04 0.02, 0.04 0.02 and 0.04 0.02 mm,
respectively), but the difference in wear compared to
the other specimens (e.max Press, 0.06 0.03 and VitaOmega 900, 0.11 0.03) tested was not signicant. In
the study by Sripetchdanond and Leevailoj,[28] the
enamel wear mean depth caused by monolithic zirconia
(1.83 0.75 mm) was signicantly lower than that
caused by glass ceramic (7.32 2.06 mm) and enamel
(10.72 6.31 and 8.81 5.16 mm). Another study by
Jung et al. [29] reported that polished zirconia caused
less wear (0.031 0.033 mm3) on enamel when tested
with a chewing simulator than glazed zirconia
(0.078 0.063 mm3). The polished zirconia full-coverage
crown without glazing was, therefore, more effective in

646

MALKONDU ET AL.
O.

reducing antagonistic teeth wear. In accordance with

previous results, Amer et al. [30] found that polished
crystal zirconia (4.2 1.27 mm2) resulted in less wear of
the antagonist enamel than the glazed surface
(5.58 0.66 mm2) after the three-body wear test. The
two-body wear test of monolithic zirconia showed similar results. A lower wear rate on enamel antagonists was
found in the polished monolithic zirconia group (manually polished zirconia; 27.3 15.2 mm and mechanically
polished zirconia; 28 11.1 mm) compared to the
glazed (glazed with a glaze ceramic; 118 30.9 mm).
However, it caused higher rates of enamel cracks.[31]
Polished zirconia showed similar results against steatite
antagonist in a two-body wear test in a study by Preis
et al. [32] In another two-body wear test, monolithic zirconia showed no material wear and low wear of the
enamel antagonist. In addition, monolithic zirconia
behaved similarly or better in terms of tooth brushing
wear than natural enamel.[33]
Glazed zirconia caused greater wear (mean height of
84.9 mm, volume loss of 9.9 mm3) on the antagonist
Empress than as-machined zirconia (mean height of
68.4 mm, volume loss of 7.6 mm3), whereas, they showed
similar wear effect on e.max.[34] In contrast, Beuer et al.
[35] reported that polished zirconia showed more contact wear at stainless steel antagonist than glazed and
veneered zirconia, using a special wear method in the
chewing simulator (120,000 mechanical cycles, 5 kg
load, 0.7 mm sliding movement, 320 thermocycles).
Taken together, these reports illustrate that the type
of restoration materials and the surface conditions obviously have an impact on the wear potential of the restorative materials. Based on the results from in vitro studies,
it could be concluded that polished zirconia seems to be
used safely as an antagonist to enamel or feldspathic
porcelain.

Surface roughness
Surface roughness could affect the amount of wear on
natural enamel antagonists. Different surface treatment
methods of a restoration result in different roughness
values. With regard to this issue, Sabrah et al. [24] found
that the glazed surfaces (Ra: 0.42 mm and Rq: 0.63 mm)
were the smoothest among the red ones (Ra: 0.84 mm
and Rq: 1.13 mm), the surfaces nished using diamond
burs (Ra: 0.89 mm and Rq: 1.20 mm) and those polished
after nishing with diamond burs (Ra: 0.49 mm and Rq:
0.76 mm). Janyavula et al. [25] reported that glazed zirconia (Ra: 0.76 0.12 mm) and polished and then glazed
zirconia (Ra: 0.69 0.1 mm) had smoother surfaces than
enamel (2.6 1.1 mm) and veneered zirconia (1.6 0.16
mm) but were rougher than polished zirconia (Ra: 0.17

0.07 mm). The surface roughnesses of three different

brands of polished zirconia (Prettau, Lava and Rainbow;
Ra: 0.284 0.052, 0.459 0.075 and 0.411 0.034 mm,
respectively) were found to be greater than that of emax press (0.249 0.015 mm) but less than that of feldspathic porcelain (Ra: 0.704 0.094 mm) in a study by
Kim et al. [27] As-machined monolithic zirconia showed
signicantly higher mean roughness values (Ra D
0.83 mm, Rq D 1.09 mm) than glazed zirconia (Ra D
0.53 mm, Rq D 0.78 mm) in the study by Luangruangrong
et al. [34] Hmaidouch et al. [36] found that the maximum
roughness depth (Rmax: the perpendicular distance
between the highest peak and lowest valley of the
roughness prole within the measurement line) of
glazed zirconia (4.311 0.93 mm) was higher than that
of ne-polished zirconia surfaces (2.41 0.51 mm) but
not statistically signicant.
Preis et al. [37] investigated the surface properties
(roughness, composition and phase transformation) of
monolithic zirconia after dental adjustment procedures
(grinding and polishing) and wear simulation. The ndings of the study revealed that grinding signicantly
increased the roughness of sintered zirconia, whereas,
polishing signicantly reduced Ra. Wear had little effect
on roughness and no inuence on phase transformation.
Amer et al. [38] reported that surface roughness of
monolithic zirconia did not change after being subjected
to three-body wear-opposing human enamel as conventional feldspathic porcelain.
Overall, these results indicate that zirconia restorations are required to be polished intra-orally after the
nal occlusal adjustments.

Fracture resistance
The fracture resistance of monolithic zirconia has been
explored by different authors, since it has been recommended to use full-contour zirconia especially in loadbearing areas. Preis et al. [39] evaluated the failure
and fracture resistance of three-unit zirconia-based
FPDs under the inuence of different surface treatments (veneering and glazing) and adjustment (polishing and grinding) procedures. All the groups were
subjected to thermal cycling (TC) and mechanical
loading (ML). Except for one group, all the groups
were anatomically designed. Sintering, sandblasting
and glazing procedures were performed on the specimens of the control group without TC and ML. The
authors [39] observed no failure of FDPs during TC
and ML conducted in a chewing simulator, but wear
occurred at contact points. The median fracture force
ranged between 1173.5 and 1316.0 N without signicant differences either between the groups, or in

BIOTECHNOLOGY & BIOTECHNOLOGICAL EQUIPMENT

comparison to the control. Full-contour polished or

glazed zirconia FDPs might be an alternative to veneered restorations because of their high resistance to
failure and fracture. Zesewitz et al. [40] used single
monolithic zirconia crown (MZC), monolithic lithium
disilicate and monolithic feldspar ceramic in their
study. Monolithic zirconia showed the highest fracture
resistance of all the samples studied under axial loading. The highest mean fracture force was reported as
5.620 N for zirconia crowns. Beuer et al. [35] tested the
load-bearing capacity of full-contour zirconia with different surface treatments. Polished, sintered and
glazed zirconia showed a signicantly higher loadbearing capacity than conventional veneering. The
authors found no signicant difference in the fracture
load between polished and glazed zirconia, while sintered zirconia had a signicantly lower load-bearing
capacity than polished zirconia and glazed zirconia.
The mean fracture load for both polished and glazed
zirconia was above 10,000 N, which is higher than
most values reported in the literature. The authors
ascribed this result to the abutment material, which
was metal, and the diameter of the loading piston
(tungsten ball with a 10.0 mm diameter).
Sun et al. [41] performed a load-to-fracture test to
evaluate the load-bearing capacity of monolithic zirconia
with different thicknesses. The fracture load for MZCs
(1.5 mm), calculated as 4109.93 610.18 N, was found to
be signicantly higher than that of monolithic lithium
disilicate (1863.16 116.81 N), metal ceramic
(2284.77 355.60
N)
and
layered
zirconia
(2308.0 510.94 N). The value of the fracture load of
monolithic zirconia decreased with reduced material
thickness (3068.31 233.88 N for MZC (1.2 mm),
2429.88 315.03 N for MZC (1.0 mm), 1814.60 68.21 N
for MZC (0.8 mm) and 1308.38 111.38 N for MZC (0.6
mm)). The fracture mode was catastrophic failure for
MZCs, which indicates better resistance to fracture load
than veneered crowns.
In a study by Nakamura et al., [42] the effect of the
axial and occlusal thickness of MZCs on the fracture load
was tested. The fracture resistance of MZCs with reduced
thickness was compared with that of monolithic lithium
disilicate crowns with regular thickness. The load-to-failure test revealed that the fracture load of the zirconia
crowns with occlusal thickness of 0.5 mm (5558 522 N)
was signicantly higher than that of lithium disilicate
crowns with occlusal thickness of 1.5 mm (3147 409
N). The axial wall thickness did not affect the fracture
resistance of MZCs.
High translucent zirconia crowns (two different
brands) were found to have higher fracture resistance
(2795 and 3038 N) than heat-pressed monolithic lithium

647

disilicate crowns (1856 N), porcelain-veneered zirconia

crowns (2229 N) and porcelain-veneered high translucent zirconia (1480 and 1808 N) in a study by Johansson
et al. [43]. Kok et al. [44] reported that implant-supported
anatomic contour zirconia crowns (LAVA Plus) showed a
higher initial load to failure (6065 N) than veneered lithium disilicate (2788 N).
The inuence of LTD (autoclaved at 134  C for 0 200
h) and cyclic loading (300 N for 240,000 cycles) on fracture resistance of monolithic zirconia was studied by
Nakamura et al. [45] The fracture load of the crowns signicantly decreased from 5683 to 3975 N after LTD
induced by autoclaving. The effect of cyclic loading on
fracture load was not statistically signicant.
Generally, the results from in vitro studies show that
MZCs exhibit high fracture resistance even at minimum
thicknesses. Therefore, they could be used in load-bearing areas without the chipping problem as frequently
observed in their veneered counterpart.

Chipping resistance, exural strength, compressive

strength and elastic modulus
In a study by Zhang et al., [23] monolithic zirconia
ceramics were found to have superior chipping and exural fracture resistance compared to glass-inltrated zirconia, lithium disilicate and veneering porcelain. In
another study conducted by Kok et al., [44] the exural
strength (1235 MPa), compressive strength and elastic
modulus (113.1 GPa) of anatomic contour zirconia were
found to be signicantly higher than those of lithium disilicate and composite resins. Ebeid et al. [46] investigated
the effect of sintering temperature on exural strength
of monolithic zirconia and found that increased sintering
temperature did not change the exural strength of
monolithic zirconia. With these superior mechanical
properties, monolithic zirconia suggests promising
future for both durable and aesthetic restorations.

Hardness
rmann et al. [33] reported that the mean hardness
Mo
(Martens Hardness, MH) value of monolithic zirconia is
7996 (MH). Among the nine aesthetic CAD/CAM materials, a resin-based nanocomposite, human enamel and a
zirconium dioxide ceramic had the greatest hardness.
One can expect that the hardest materials would have
the greatest wear potential to antagonist teeth. However, the wear potential of a material does not only
depend on the hardness but also on other properties
such as surface roughness. This has been conrmed by
several studies which showed that the surface condition

648

MALKONDU ET AL.
O.

of monolithic zirconia affected the wear of antagonist

enamel and restoration.

materials when these areas overlap with functional

occlusal stress elds.

Transmission of ER-YAG laser

Effects of surface treatments on colour of monolithic

zirconia

Sari et al. [47] tested the erbium-doped yttrium aluminium garnet (Er:YAG) laser transmission ratio through different dental ceramics with a thickness of 0.5 and 1 mm.
The transmission values decreased with increasing thickness of the ceramic sample. For both the 0.5 and 1 mm
thicknesses, monolithic zirconia showed higher transmission ratios (0.78 0.01 for 0.5 mm and 0.69 0.00 for
1 mm) than feldspathic ceramics (0.68 0.01 for 0.5 mm
and 0.44 0.00 for 1 mm) and yttrium stabilized zirconia
core ceramic (0.62 0.01 for 0.5 mm and 0.47 0.01 for
1 mm). Lithium disilicate reinforced glass ceramics had
the highest transmission values (0.88 0.01 for 0.5 mm
and 0.70 0.01 for 1 mm) regardless of the thickness.
Thus, this study demonstrated that the parameters of
laser irradiation should be adjusted according to the restoration material and the thickness during laser debonding of ceramic restorations.

Alghazzawi et al. [48] showed that low-temperature

exposure during the fabrication procedures for monolithic zirconia restorations signicantly increased the surface roughness (from 12 to 22 nm (Ra) and monoclinic
phase fractions but signicantly decreased the hardness
(17 to 15 GPa) and Youngs modulus (276 to 257 GPa).
No signicant effect on the yttria content and exural
strength was observed. The authors concluded that the
LTD induced a tetragonal-to-monoclinic phase transformation during the fabrication of zirconia restorations.
Consequently, this study suggests that food debris could
be a concern due to increased surface roughness resulting from the fabrication procedures of monolithic zirconia. Therefore, surface-conditioning methods should be
used to achieve a smoother surface.

Colour was studied by Kim et al. [50,51] in two different

studies. In one, they investigated the effect of the number
of colouring liquid applications on the colour, translucency and opalescence of monolithic zirconia restorations.[50] A double-beam spectrophotometer was used to
measure the colour and spectral distribution of the zirconia specimens. Although the colour coordinate CIE L and
the opalescence parameter values decreased, CIE b
increased with increasing the colouring liquid applications. However, the translucency parameter (TP) values
were not signicantly altered. The highest colour difference was observed between the no treatment group and
the ve applications of coloured liquid group (DEab of
15.7). The authors concluded that repeated application of
coloured liquid causes the zirconia to become darker and
more yellowish. In addition, the opalescence of monolithic zirconia is reduced with coloured liquid application.
The authors also concluded that translucency cannot be
controlled by the colouring procedure.
The other study by Kim et al. [51] investigated the
effect of polishing and glazing on the colour and spectral
distribution of monolithic zirconia, using reection spectrophotometry. Signicant differences were found in the
colour coordinates CIE L, a and b values and spectral
reectance between different surface treatments. The
authors concluded that polishing procedures decrease
the lightness of monolithic zirconia and created a perceptible colour difference. Glazing also decreased the
lightness, and after this surface treatment, monolithic zirconia restorations became yellow. Thus, since the surface
treatment methods and coloured liquid application may
cause deviations in the nal colour of a restoration, clinicians should take this into consideration when selecting
the shade of restoration.

Residual thermal stress level

Translucency

Bonfante et al. [49] evaluated the CTE-generated stress

elds in monolithic zirconia when cooled from high-temperature processing using nite element analysis. They
reported that the Y-ZTP crown showed less compressive
stresses in the volume of the cusp compared to the allceramic crown but more than the alumina crown cusp.
The least compressive stress in the volume of the material occurred in the all-metal crown. The results of this in
vitro study suggest that high residual stresses in some
elds of a restoration may cause fracture or cracking of

Beuer et al. [35] reported that the light transmission of

the polished zirconia full-crown, determined by direct
transmission in an industrial spectrophotometer, was
signicantly higher than that of glazed and veneered
zirconia. In another study, Ilie et al. [52] compared the
amount of light transmission through translucent zirconia and conventional zirconia and glass ceramic with
respect to material thickness and different polymerizing
modes. The study revealed that zirconia was less translucent (the light passing through specimens ranged from

Low-temperature degradation

BIOTECHNOLOGY & BIOTECHNOLOGICAL EQUIPMENT

48.4 to 102.6 mW/cm2) than glass ceramic (190.3 536.7

mW/cm2) and the translucency decreased with increased
material thickness. The irradiance transmission was
affected by the polymerizing mode of the light-emitting
diode polymerizing unit. The results were consistent
with another study by the same authors.[53] Another
study by Sulaiman et al. [54] reported that zirconia thickness affects the degree of conversion of luting cement
and more polymerizing time may be needed for some
brands of zirconia. Harianawala et al. [55] observed that
the transmittance value of translucent zirconia was signicantly lower than that of lithium disilicate. Ebeid et al.
[46] investigated the effect of sintering temperature on
the translucency of monolithic zirconia restorations. The
results indicated that increased sintering time and temperature lead to increased translucency (the contrast
ratio decreased from 0.75 to 0.68). Wang et al. [56]
reported that the TP values of the zirconia ceramics
ranged from 5.5 to 15.1 for thicknesses ranging from 1.0
to 0.4 mm.
Although the translucency of zirconia has increased in
recent years with improved technology, it is not comparable to glass ceramics. The results from the studies indicate that care should be taken in selecting the shade
and polymerizing modes.

In vivo studies
Although in vitro studies are fast, simple and inexpensive
and generally avoid the ethical and legal issues, they
may not replicate the oral environment exactly and misleading results may be obtained. That is why, to obtain
more reliable results, in vivo studies are needed. In their
in vivo study, Stober et al. [57] evaluated the enamel
wear caused by MZCs under clinical conditions (20 MZCs
placed in 20 patients requiring full molar restoration).
The patients had natural opposing teeth, and two natural contralateral antagonistic teeth were included. Subjects with clinical signs or/and symptoms of bruxism
were excluded from the study. Tooth wear was evaluated based on plaster models made at baseline and after
six months with three-dimensional (3D) laser-scanning
methods. Mean vertical loss (maximum vertical loss in
parentheses) was found to be 10 (43) mm for the zirconia
crowns, 33 (112) mm for the opposing enamel, 10 (58)
mm for the contralateral teeth and 10 (46) mm for the
contralateral antagonists. The authors concluded that
MZCs caused more wear on the opposing enamel than
natural teeth. However, they noted that the amount of
wear caused by zirconia even after six months is less
than that of other ceramics based on previous studies.
In another study, Batson et al. [58] assessed the quality of CAD/CAM fabricated single tooth restorations in

649

terms of contour, marginal adaptation, occlusion and

shade, as well as the gingival response to selected CAD/
CAM materials. Ten zirconia restorations were compared
to 12 metal ceramic and 10 lithium disilicate counterparts. Impressions and clinical measurements were used
to compare the parameters among groups. The association among crown types and their marginal adaptation,
shade or contour was not statistically signicant. The
gingival response did not differ among crown systems.
Zirconia crowns showed the least amount of marginal
discrepancy. Eighty per cent of zirconia crowns needed
no occlusal adjustment.
Mundhe et al. [59] compared the wear of enamel
opposing natural enamel, polished zirconia and glazed
metal ceramic crowns one year after the cementation. A
total of 36 crowns were placed in 10 participants and
evaluated from casts by 3D analysis software. The occlusal wear of the antagonistic enamel one year after the
cementation of metal ceramic crowns ranged from
69.20 4.10 to 179.70 8.09 mm, whereas, for zirconia
crowns, it was from 42.10 4.30 to 127.00 5.03 mm.
The occlusal wear of natural enamel opposing natural
enamel ranged from 17.30 1.88 to 35.10 2.60 mm.
The results from these in vivo studies suggest that zirconia restorations could be used as an antagonist to
enamel with good marginal adaptation, contour and
minimum gingival response. However, the number of in
vivo studies is still limited and further studies are needed.

Clinical reports
Implant-supported xed-dental prosthesis with monolithic zirconia have been reported to serve successfully
up to four years with pleasing aesthetics.[60 67] In an
18-month follow-up study, Chang et al.[68] stated that
zirconia cylinders may be exposed to excessive stress
when screw retained zirconia restorations were fabricated. Inlay retained xed-dental prosthesis using monolithic zirconia has been recommended as a clinical
alternative to traditional full-coverage xed-dental prosthesis and implant-supported crowns.[69] The clinical
reports indicate that monolithic zirconia has a very high
expectancy of surviving for a long time when treatment
planning and case selection are done properly.

Conclusions
Taken together, the reviewed reports suggest that
monolithic zirconia may present some clinical advantages over veneered zirconia restorations. While selecting a restorative material, the wear of natural dentition is
an important factor, particularly in the presence of parafunctional habits. In vitro and in vivo studies showed that

650

MALKONDU ET AL.
O.

polished zirconia causes less wear on enamel than

glazed zirconia and glazed-veneering porcelain. Considering its high mechanical strength, polished monolithic
zirconia is the best candidate for posterior FPDs in the
presence of grinding or clenching. However, it should be
noted that although the mechanical properties are still
clinically acceptable, zirconia shows increased LTD in the
presence of wetness and the long-term results are not
well known. Dental adjustment procedures after cementation may also increase the wear of antagonist enamel
by increasing the surface roughness. To prevent this situation, zirconia should be polished afterwards.
Limited occlusal crown space may be another case in
which monolithic zirconia should be used due to its
higher fracture resistance compared to veneered counterparts and other monolithic ceramics even at minimum thicknesses. As an anterior restoration, although it
has improved translucency, the effect of surface treatment and coloured liquid application procedures on the
colour of monolithic zirconia restorations should be kept
in mind while selecting the shade of the restoration.
These procedures can cause perceptible colour difference. Based on the data considered in this review, further studies should be conducted both in vitro and
particularly in vivo with larger sample sizes and over longer periods of time. Moreover, ways to improve the aesthetic properties of MZCs other than translucency, such
as texture and opalescence, need to be investigated.

Disclosure statement
The authors declare that there is no conict of interests
regarding the publication of this paper.

ORCID
Ender Akan

http://orcid.org/0000-0002-4596-2612

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