CLINICAL EFFICACY OF

METHODS FOR
BONDING TO ZIRCONIA:
A SYSTEMATIC REVIEW
Qu igley NP, Loo DSS, Choy C, Ha WN. Clinical effica cy of method s fo r b onding
to zirco nia: A systema tic review. J Prosth et Dent. 20 20;S0 022 -3913 (20)30 023 -8

PRESENTED BY:
Dr. Sayali Raut
INTRODUCTION
 PURPOSE:
TO CRITICALLY APPRAISE CLINICAL STUDIES
INVESTIGATING THE SURVIVAL RATE OF RESIN-
BONDED ZIRCONIA FIXED PARTIAL DENTURES
(FPDS), INLAY RETAINED ZIRCONIA FPDS, AND
ZIRCONIA VENEERS
Criteria Inclusion Criteria
Publishing details Articles published in international peer reviewed
journals
Type of patients (P) Patients with edentulous spaces replaced with resin-
bonded zirconia FPDs or inlay-retained zirconia FPDs
Patients with bonded zirconia veneers
Patients with layered or monolithic zirconia Patients
with 3Y-TZP, 4Y-TZP, 5Y-TZP, or Ce-TZP
Type of interventions (I) Articles with sufficient detail regarding the retainer
design, materials used, treatment of materials, bonding
protocol, and adhesive resin used.
Type of control (C) No control or comparison groups were selected
Type of outcomes (O) Articles with quantitative reports of survival rates and
any modes of failure such as debonding or
mechanical/biological complications
Timeframe (T) Between 1990 and July 2018
Study design (S) RCTs ,Clinical controlled trials, Retrospective or
prospective cohort studies, Case reports/series
Exclusion Criteria
Articles not published in international peer reviewed journal
Patients with complete crown conventional zirconia FPDs (either fixed-
fixed or cantilevered)
Patients with conventionally cemented zirconia FPDs or veneers
Patients with implant-retained zirconia
Patients with zirconia hybrid materials such as zirconia infiltrated
resins
Patients with zirconia-infiltrated ceramics
Articles without sufficient detail on treatment protocol
Articles with follow-up times less than 12 months, survey/ phone call
follow-ups, or articles with multiple publications on same patient
cohort
Before 1990
Animal studies, In vitro studies, Single case studies
Electronic Databases and Libraries
MEDLINE
EMBASE
PubMed
Web of Science
Scopus
Cochrane Library
Google Scholar
 MESH TERMS USED

◦ Fixed dental prostheses OR Resin-bonded bridge OR Resin-bonded fixed dental

prostheses OR Resin-bonded fixed partial denture OR Adhesively-retained fixed
partial denture OR Adhesively-retained fixed dental prosthesis OR
Adhesivelyretained bridge OR Adhesive bridge OR Minimally-invasive bridge OR
Acidetched bridge OR Maryland bridge OR Single retainer bridge OR Two-
retainer bridge OR Butterfly bridge OR Veneer* OR Inlay-retained fixed dental
prosthesis OR Inlay-retained fixed partial denture OR Inlay-retained FDP OR
Inlay-retained FPD AND Zirconia OR Zirconium OR Zircon* OR Y-TZP OR TZP
OR ZrO2 OR PSZ OR FSZ OR CSZ OR Ce-TZP
 FLOW
CHART
FOR
SEARCH
STRATEG
Y
 OPERATIVE DEFINITIONS

No loss of retention or the prosthesis staying in place throughout the period of

SUCCESS study.

Any decementation, debonding, or any fracturing of the prosthesis that warranted

FAILURE its replacement.

SURVIVAL The presence of the original restoration at the time of follow-up.

Any undesirable or unexpected event occurring during the observation period that
COMPLICATIONS did not require a replacement prosthesis.
 STUDY AND PATIENT
CHARACTERISTICS OF
INCLUDED STUDIES
Study Design

1 Randomized 5 Prospective 2 Retrospective

Control Trial Studies Studies
 Design for
the Posterior
teeth

DESIGN 1 DESIGN 2

DESIGN 3
 Non - Retentive Design

Design for the

Anterior teeth

Retentive design
Pre treatment of zirconia
A variation of airborne-particle abrasion except for the study by Sailer and Hämmerle who used alcohol to clean the
surface followed b silane application

Rahmman et al, used the Rocatec system (3M ESPE), which used Tribochemical silica airborne-particle abrasion
(TSAPA) to embed silica particles into the zirconia framework.

Other studies used 50-μm Al 2O3 at a pressure between 0.1 and 0.25 MPa and applied a silane (Monobond S; Ivoclar
Vivadent AG) before Panavia F (Kuraray America Inc) or multilink Automix (Ivoclar Vivadent AG) cementation.

Alcohol cleaning was used in 5 of the 8 studies

Zirconia primers/silanes were used in 3 of the 5 studies

 Resin Cements
used
◦ Panavia F or Panavia 21 (Kuraray America Inc) or Multilink
Automix or Variolink Esthetic (Ivoclar Vivadent AG)
adhesive resin were used in all studies.

◦ Both Panavia F and Panavia 21 contain MDP, so primers are

not required.
Survival rates
Name of author (year) Follow up period Survival rates
Rathmann et al (2017) 5 years 44.9 %
10 years 12.1% (inlay retained FPDS)
Abou Tara et al (2011) 20 months 100 %
Chaar and Kern (2015) 5 years 95.8%
Sasse and Kern (2013) 5 years 100%
Sasse and Kern (2014) 6 years 100%
Kern et al (2017) 10 years 100%
Klink and Huthig (2016) 3 years 100%
Sailer and Hammrele (2014) 8 years 100%
DISCUSSION
DISCUSSION
 Abou Tara et al And Char and Kern

These studies used a modified design to provide:

• increased available surface area for bonding
• more favorable stress distribution within the restoration
• decreased torsional forces experienced by the retainers during nonaxial loading.

The framework designs in these studies were inherently retentive, which could explain the high survival
rate of these restorations.

No zirconia framework fractures occurred in either of the two studies.

All debonds were mixed failures, meaning that the adhesive resin remained partially on the bonding
surface of the restoration and partially on the abutment teeth.

This suggests that the bond between zirconia and the adhesive resin was not the point of weakness
Discussion
ANALYSING No framework fracture in any study – high tensile strength of Zirconia.

THE
FAILURES
So point of weakness was between the tooth and the zirconia surface – debonding is more

However it’s a better outcome since the prosthesis can be rebonded

Sailer and Hämmerle did not use airborne-particle abrasion. 2 prostheses debonded within 6 months of
BONDGING placement..
PROTOCOL
Five of the included studies used an airborne-particle abrasion pressure of 0.25 MPa and 0.1 MPa.

In Kern et al, 0.25 MPa was changed to 0.1 MPa during the study period.

No loss in survival rate noted with the lower pressure

Particle abrasion can induce microcrack formation, using a lower pressure is preferable.

01
With correctly designed buccal
and lingual PCRs and minimal
veneering porcelain, zirconia
based, posterior, inlay-retained
FPDs seem to have a high
clinical survival rate. The role
of bonding efficacy in this is
unknown.
CONCLUSION
02
Anterior, cantilevered, resin-
bonded zirconia FPDs also
seem to have a high clinical
survival rate. While these
prostheses can debond,
fracture of the entire prosthesis
is unlikely and it can be
rebonded again
03
The use of airborne-particle
abrasion with 50-mm Al 2O3
at 0.10 to 0.25 MPa in
combination with a phosphate
monomer containing adhesive
resin is currently
recommended with Rubber
dam isolation
 PICOTs criteria not
No focused question Risk of bias not checked
correctly mentioned

No complete coverage 100% survival rates can

CRITICAL restorations , only inlays
cantilevered prosthesis
be misleading – as
debonding occurred in
Follow up time was less
than 5 years for many of
APPRAISAL with partial coverage
retainers
each of the included
studies
the included studies

No comparison about the Non conclusive and Different preparation

clinical efficacy of haven’t done any thing designs could also be a
different bonding differently than the confounding factor
methods made previous SRs affecting survival rates
CROSS REFERENCES
Review of literature
 RESULTS
Surface
conditioning

PURPOSE:
• Analyze the adhesion potential of resin-based and glass-
ionomer luting cements to zirconia
• To highlight the possible dominant factors affecting the
Adhesion
bond strength results to this substrate Aging
of luting
Cement
condition type
cements
CONCLUSION:
• Increased adhesion could be expected after physicochemical
conditioning of zirconia.
• MDP-based resin cements tend to present higher results than
those of other cements types
• Adhesion studies on zirconia and reporting of data require Test method
more standardization.

Özcan M, Bernasconi M. Adhesion to zirconia used for dental restorations: a systematic review and meta-analysis. J Adhes Dent. 2015;17(1):7‐26.
PURPOSE
• To classify and analyse the existing
methods and materials suggested to
improve the adhesion of zirconia to
dental substrate

CONCLUSION
• Airborne-particle abrasion and tribo-
chemical silica coating are the pre-
treatment methods with more evidence
in the literature.
• Increased adhesion could be expected
after physico-chemical conditioning of
zirconia.
• Surface contamination has a negative
effect on adhesion.
• There is no evidence to support a
universal adhesion protocol.

Scaminaci Russo D, Cinelli F, Sarti C, Giachetti L. Adhesion to Zirconia: A Systematic Review of Current Conditioning Methods and Bonding Materials.  Dent J (Basel).
 The zirconia based ceramic is a

1.
glass-free (vitreous phase below
1%)

10 Methacryloyloxydecyl
Polycrystalline microstructure with
high fracture strength and fracture
Dihydrogen
toughness Phosphate (MDP).

But an acid-resistant or non-

etchable material.

Thus poor adhesion for resin

cements

Petre, A., & Sfeatcu, R. Adhesive cementation protocol of Zirconia restorations. Int. Poster J. Dent. Oral Med, 2013; 15(1).
 2.
TRIBOCHE
MICAL
SILICA
COATING

Petre, A., & Sfeatcu, R. (2013). Adhesive

cementation protocol of Zirconia
restorations. Int. Poster J. Dent. Oral
Med, 15(1).
 MANUFACTURER’S
INDICATIONS FOR
DHESIVE CEMENTATION

Petre, A., & Sfeatcu, R. Adhesive

cementation protocol of Zirconia
restorations. Int. Poster J. Dent. Oral
Med, 2013; 15(1).
 Blatz MB, Alvarez M, Sawyer K, Brindis M. How to Bond Zirconia: The
APC Concept. Compend Contin Educ Dent. 2016;37(9):611‐618.

Step A: Air-particle abrade the bonding surface with Aluminum oxide

Step P: Apply special zirconia Primer

Step C: Use dual-cure or self-cure composite resin Cement

A P
ir particle abrasion
with 50 μm Al2O3 at
1.5 bar pressure
C
rimer containing
ementation using dual cured resin cement
phosphate monomer
selective enamel etching and self etched dentine primer
applied
 OBSERVATIONS:
Rocatec Soft sand particles:
• Sharp al2o3 particles of irregular size, diameter:
• 10–70 μm, covered with silica particles
• With a diameter of around 50 nm

The deposited coating layer is suggested to be

chemically bonded to zirconia.

Now organosilane coupling is possible (due to silica)

Resin cement copolymerizes with the silane

monomer’s methacrylate end

Nagaoka N, Yoshihara K, Tamada Y, Yoshida Y, Meerbeek BV. Ultrastructure and bonding properties of tribochemical silica-coated zirconia. Dent Mater J. 2019;38(1):107‐113.
 Samples tested for bond strength:
TSC + Silanisation
Zirconia primer
All bond universal
Clearfil universal bond
Single bond universal
ONE-BOTTLE UNIVERSAL ADHESIVES :
Developed to bond with almost all indirect restoration materials, including resin composites, zirconia-based
and alumina based ceramics, silica-based glass ceramics, alloys, enamel and dentin.
PURPOSE:
To evaluate the bonding of resin-cement to yttria-stabilized tetragonal zirconia polycrystal (Y-TZP) via
silica coating followed by silanization, and three one-bottle universal adhesives, with or without prior
conditioning using a zirconia primer.
CONCLUSION
No statically significant differences in the universal bonding agents and their combinations with zirconia
primers
In addition, all other adhesive and/or primer combinations performed significantly worse than the use of
tribochemical sandblasting followed by silanization

Xie H, Li Q, Zhang F, et al. Comparison of resin bonding improvements to zirconia between one-bottle universal adhesives and tribochemical silica coating, which is better?.  Dent Mater. 2016;32(3):403‐411.
 Sandwich like structure consisting two
interfaces :
1. Between the resin cement and the
universal adhesive on the dentinal
surface
2. Between the resin cement and the
universal adhesive on the Y-TZP
surface

Xie H, Li Q, Zhang F, et al. Comparison of resin bonding improvements to zirconia between one-bottle universal adhesives and tribochemical silica coating, which is better?.  Dent Mater. 2016;32(3):403‐411.
 RESULT:
• Bond strength to glass-based ceramics
The review included studies that compared the bond and alloys was improved with the use
strength of universal adhesives and well-established of a specific-primer as separate step
material-specific primers to indirect before the bonding procedures
substrates: • The bond strength to zirconium
1. Lithium disilicate ceramic substrates was improved with the use
of universal adhesives
2. Yttrium-stabilized zirconium dioxide ceramic • For bond strength to composite resin
3. Leucite-reinforced ceramic, as indirect substrate, universal
4. Feldspathic porcelain adhesives performed in a manner
5. Polymer infiltrated ceramic material similar to that of the material-specific
primer
6. Resin composite
7. Metal alloys

Cuevas-Suárez CE, de Oliveira da Rosa WL, Vitti RP, da Silva AF, Piva E. Bonding Strength of Universal Adhesives to Indirect Substrates: A Meta-Analysis of in Vitro Studies. J
Prosthodont. 2020;29(4):298‐308.
Airborne-particle abrasion combined with a resin
composite containing phosphate monomers or
tribochemical silica coating plus silane (with functional
monomers) coating combined with conventional resin
cement could be considered the best surface treatment
methods CONCLUSION?
 There is no evidence to support
a universal technique of
ceramic surface treatment for
Long term comparative studies are needed adhesive cementation

Alternative Surface treatment methods (selective

infiltration etching or silica coating or plasma
treatment) have presented considerable surface
alterations and have shown promising results; however,
further studies are necessary
 REFERENCES
◦ Özcan M, Bernasconi M. Adhesion to zirconia used for dental restorations: a systematic review and meta-analysis. J Adhes Dent. 2015;17(1):7‐26.
◦ Scaminaci Russo D, Cinelli F, Sarti C, Giachetti L. Adhesion to Zirconia: A Systematic Review of Current Conditioning Methods and Bonding Materials. Dent J (Basel).
2019;7(3):74
◦ Petre, A., & Sfeatcu, R. (2013). Adhesive cementation protocol of Zirconia restorations. Int. Poster J. Dent. Oral Med, 15(1).
◦ Nagaoka N, Yoshihara K, Tamada Y, Yoshida Y, Meerbeek BV. Ultrastructure and bonding properties of tribochemical silica-coated zirconia. Dent Mater J. 2019;38(1):107‐
113.
◦ Blatz MB, Alvarez M, Sawyer K, Brindis M. How to Bond Zirconia: The APC Concept. Compend Contin Educ Dent. 2016;37(9):611‐618.
◦ Xie H, Li Q, Zhang F, et al. Comparison of resin bonding improvements to zirconia between one-bottle universal adhesives and tribochemical silica coating, which is
better?. Dent Mater. 2016;32(3):403‐411.
◦ Cuevas-Suárez CE, de Oliveira da Rosa WL, Vitti RP, da Silva AF, Piva E. Bonding Strength of Universal Adhesives to Indirect Substrates: A Meta-Analysis of in Vitro
Studies. J Prosthodont. 2020;29(4):298‐308.
◦ Quigley NP, Loo DSS, Choy C, Ha WN. Clinical efficacy of methods for bonding to zirconia: A systematic review. J Prosthet Dent. 2020;S0022-3913(20)30023-8
THANK YOU!