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SYSTEMATIC REVIEW

Optical properties of zirconia ceramics for esthetic dental


restorations: A systematic review
Reza Shahmiri, MEngStMedTech,a Owen Christopher Standard, PhD,b Judy N. Hart, PhD,c and
Charles Christopher Sorrell, PhDd

Natural looking dental restora- ABSTRACT


tions require appropriate mate- Statement of problem. Yttria-stabilized tetragonal zirconia polycrystal has been used as a dental
rials selection, form, surface biomaterial for several decades because the fracture toughness and bend strength are increased
texture, translucency, and color.1 by a stress-induced transformation-toughening mechanism. However, its esthetics are
Natural dentin and enamel compromised by its poor translucency and grayish-white appearance.
backscatter and forward-scatter Purpose. The purpose of the present systematic review was to assess information on the me-
light, resulting in selective trans- chanical, chemical, and optical requirements of monolithic zirconia dental restorations.
mission of specific wavelengths.2,3
Material and methods. The following databases (2010 to 2015) were electronically searched:
Dentin’s orange color is coun-
ProQuest, EMBASE, SciFinder, MRS Online Proceedings Library, Medline, Compendex, and Journal
teracted partly by its fluorescent, of the American Ceramic Society. The search was limited to English-language publications, in vitro
ultraviolet-photosensitive, organic studies, experimental reports, and modeling studies.
component.3 Enamel’s bluish-
Results. The data from 57 studies were considered in order to review the intrinsic and extrinsic
white color derives from the characteristics of zirconia and their effects on the optical properties.
small, polycrystalline, aligned,
hydroxyapatite platelets that Conclusions. The materials and microstructural issues relevant to the esthetics and long-term
stability of zirconia have been considered in terms of monolithic restorations, while there also
selectively scatter shorter wave-
are restorations specifically for esthetic applications. Although zirconia-toughened lithium silicate
lengths. No single dental ceramic offers the best esthetic outcomes, transformation-toughened zirconia offers the best mechanical
can replicate the complex properties and long-term stability; cubic stabilized zirconia offers a potential compromise. The
behavior of light and display the properties of these materials can be altered to some extent through the appropriate application
optical characteristics of natural of intrinsic (such as, annealing) and extrinsic (such as, shade-matching) parameters. (J Prosthet
dental tissue. 4 Dent 2018;119:36-46)
Existing nonzirconia dental
ceramics, including feldspathic porcelain and glass- Zirconia dental ceramics exhibit sufficient mechanical
ceramics, generally provide good esthetic results when strength and toughness to allow their use in low-load
bonded to nondiscolored tooth structure because of areas of the mouth for longer restoration lifetimes.6,7
their light transmission.5 They are color-stable and Zirconia exhibits a tetragonal-to-monoclinic phase
more wear resistant than composite resin restorations.6 transformation on cooling, which is accompanied by a
However, ceramics are brittle and susceptible to fatigue 3% to 5% volume increase. While this imposes residual
fracture after cyclic loading.6 compressive stresses and consequent transformation

Presented at the 17th International Conference on Biomechanics and Biomedical Engineering, Dubai, United Arab Emirates, December 2015.
a
Doctoral student, University of New South Wales Sydney, Sydney, New South Wales, Australia.
b
Deputy Head and Senior Lecturer, School of Materials Science and Engineering, University of New South Wales Sydney, Sydney, New South Wales, Australia.
c
Lecturer, School of Materials Science & Engineering, University of New South Wales Sydney, Sydney, New South Wales, Australia.
d
Professor, School of Materials Science & Engineering, University of New South Wales Sydney, Sydney, New South Wales, Australia.

36 THE JOURNAL OF PROSTHETIC DENTISTRY


January 2018 37

Electronic polarization and [valence band / con-


Clinical Implications duction band] electron transitions are 2 mechanisms that
While fully stabilized zirconia (cubic) has been influence the light transmission characteristics of
nonmetallic materials.43 Such materials of different band
developed for use in the esthetic zone, this
gaps will appear opaque, opaque and colored, or trans-
polymorph does not exhibit transformation
parent and colored (Table 4).43 Although nonmetallic
toughening and so does not exhibit the superior
materials commonly have band gaps larger than w3.1 eV
mechanical properties of partially stabilized zirconia
and so are transparent to light, they can exhibit limited
(tetragonal + cubic).
light absorption due to electronic polarization, giving a
translucent appearance and consequent diffuse light
toughening,7 it also results in microcracking and transmission.
compromised mechanical properties. However, oxide The color and appearance of monolithic zirconia
doping can stabilize the tetragonal phase or, at higher dental restorations are affected by both intrinsic (mate-
doping levels, the high-temperature cubic phase upon rials) and extrinsic (features and surroundings) parame-
cooling to room temperature, thus inhibiting these phase ters44 (Fig. 2). Materials and processing issues relevant to
transformations and their potentially detrimental effects the extrinsic characteristics, such as cement layer, thick-
on the mechanical properties.7 ness, and low-temperature degradation, can affect the
Several polycrystalline zirconia materials have been optical properties (Table 5). While desired esthetic char-
developed for dental applications, including zirconia- acteristics of zirconia dental restorations can be
toughened alumina (ZTA), partially stabilized zirconia controlled by these parameters, color matching must also
(PSZ), tetragonal zirconia polycrystal (TZP), and fully be achieved by using consistent and appropriate light
cubic stabilized zirconia (CSZ) (Table 1). CSZ is differ- sources.
entiated from the other 3 by its isotropic character, which Intrinsic microstructural features, such as grain
can enhance light transmission.20,21 Cations of valences boundaries and pores, scatter some of the light, result-
lower than those of Zr4+ are used for stabilization to ing in translucency or even opacity.20 The associated
room temperature.22 However, while the phase diagram interaction with light derives from differences in
(Fig. 1)23 indicates that levels >18 mol% Y3+ are required refractive indices across different interfaces: grain/grain,
for full stabilization, in practice, this often is achieved at grain/pore, and medium 1/medium 2. Light trans-
lower levels (6 mol%); the transformations to tetrag- mission also is affected by other features, such as the
onal and then monoclinic phases are avoided by rapid interfaces between secondary phases (grain 1/grain 2)
cooling. Charge balance is maintained by the generation and crystallographically anisotropic grains (orientation
of oxygen vacancies.24,25 1/orientation 2). Thus, the translucency and opacity of
Computer-assisted design and computer assisted materials depend on how and to what extent incident
manufacturing (CAD-CAM) have been used extensively light is reflected, scattered, refracted, transmitted, and
in prosthetic dentistry. Porcelain may be applied as a absorbed.
veneer to partially sintered (or, more rarely, fully sin- The light propagation through a material depends on
tered) zirconia, which has been machined to sizes 25% to 3 parameters: absorption coefficient (ma), scattering co-
30% larger than the final size to compensate for efficient (ms), and scattering anisotropy factor (g).57 The
shrinkage during sintering.26 Cohesive failure due to re- scattering anisotropy factor is the mean value of the
sidual stresses has been reported, but this is addressed scattering angle.58 The scattering anisotropy factor in-
successfully by using slow heating and cooling rates.27 dicates the amount of light that is forward-scattered
However, long-term clinical data are lacking to confirm (translucency) or back-scattered (opacity) in a single
the absence of fracture. The elimination of cohesive scattering event.58 As the number of scattering events
failure of the veneering material has driven the devel- increases, the light distribution becomes more uniform,
opment of anatomic-contour zirconia restorations.7,28-30 so an initially anisotropic light distribution eventually will
However, the use of such restorations has unique chal- become isotropic. Therefore, transmitted light is attenu-
lenges, such as shade matching, wear resistance, and ated by both the absorption and scattering coefficients,
long-term clinical stability.7,28,29 and the sum of these two coefficients gives the transport
Recent improvements in the optical properties of coefficient (mt).58 For nonideal materials, a reduced scat-
zirconia have led to greater use of anatomic-contour tering coefficient (mt0 ) also is considered (Fig. 3) and is a
restorations,31 with several materials being introduced combined property incorporating the absorption coeffi-
recently (Table 2). Monolithic 3 mol% yttria-doped cient, scattering coefficient, and scattering anisotropy
tetragonal zirconia polycrystal (3Y-TZP) is the most factor [mt0 =ma+(1eg)ms]. The mt0 is the fraction of scattered
widely used zirconia material for dental applications light that is forward-scattered in the direction of the
(Table 3).9 refracted beam. Longer wavelengths increase the fraction

Shahmiri et al THE JOURNAL OF PROSTHETIC DENTISTRY


38 Volume 119 Issue 1

Table 1. Zirconia materials developed for dental applications


Material Code Microstructure Composition Mechanism Optical Characteristics
Zirconia ZTA Tetragonal zirconia Vita method: Mixture of alumina Transformation tougheningb For 3.0-4.5 mol% Y-PSZ, refractive indices
toughened (t-ZrO2) dispersed as with 33 mol% zirconia (zirconia are 2.192-2.470 and birefringence values
alumina minor phase in Al2O3 stabilized with 12 mol% CeO2);a are 0.020-0.033, depending on
matrix InCeram was first ZTA developed composition.11,12 Corresponding values
for dental applications8,9; for Al2O3 are 1.768 and 0.008.13 Hence,
however, large pore content addition of latter to former will lower
(8-11%)10 both values closer to those of enamel.c
Partially PSZ Tetragonal ZrO2 8-10 mol% MgO or 3 mol% Y2O3 Transformation toughening,b For 3.0-4.5 mol%Y-PSZ, since refractive
stabilized dispersed or is used to partially stabilize however, with slightly lower energy indices are 2.192-2.470 and birefringence
zirconia precipitated in cubic zirconia8,14 for tetragonal to monoclinic values are 0.020-0.033, depending on
ZrO2 transformation15 composition,11,12 higher reflectivity can
result in enhanced whiteness and
opacity.
Tetragonal TZP Single phase 2-4 mol% Y2O3 as dopant yields Below critical grain size, tetragonal For 3 mol% Y-TZP, refractive index is
zirconia tetragonal ZrO2 >98% tetragonal zirconia of fine zirconia stable; larger grain sizes, 2.214 and birefringence is 0.038.12 While
polycrystal grain size (w0.2-0.5 mm)8,16 stress, heat, and/or moisture can refractive index is in lower range of those
cause transformation to monoclinic of PSZ, birefringence is higher, resultant
zirconia, resulting in toughening or greater scattering can alter color and
compromise of mechanical increase opacity.
properties16
Cubic CSZ Single phase cubic 6 mol% Y2O3 as dopant used No transformation-toughening Refractive indices for 9-17 mol% Y-CSZ
stabilized ZrO2 to fully stabilize zirconia mechanism are 2.177-2.088.17 Although lower
zirconia refractive indices relative to PSZ and TZP
and absence of birefringence are
advantageous optically, greater
thicknesses are required to compensate
for inferior mechanical properties,
resulting in reduced translucency.
a
VITA In-Ceram YZ; VITA Zahnfabrik H. Rauter GmbH & Co. http://vitanorthamerica.com/wp-content/uploads/2011/11/VITA-In-Ceram-YZ-Working-Instructions_1649E-.pdf, 2011. bTransformation
toughening refers to beneficial tetragonal-to-monoclinic phase transformation, which results in volumetric expansion in dense matrix, thereby imposing compressive stress that closes crack tip
and impedes further crack growth. Unusually, this phase transformation is both thermally- and stress-induced.9 cRefractive index of dentin is 1.540 and that of enamel is 1.63118; both have a
birefringence of 0.007.19

of forward-scattered light in the direction of the refracted 3000


Liquid (L)
beam in zirconia in the visible light range (Fig. 4). L+C
Pores are the main cause of light scattering,59 espe- 2500
cially when they are of a size similar to that of the
Cubic (C)
Temperature (˚C)

wavelengths of visible light (w400 to 700 nm). In dental 2000


ceramics, submicrometer pores must be eliminated to
Tetragonal (T)

decrease opacity. Pores can be either intragranular or 1500


intergranular, and the optical characteristics of these T+C

types of pores are different. Intragranular pores repre-


1000
sent discrete interfaces between 2 effectively isotropic
Monoclinic (M)

phases, whereas intergranular pores locate a pore be-


500
tween typically 2 or 3 crystalline grains of different ori- M+C
entations on grain boundaries (which can be considered T
M C
amorphous regions of defects in the form of atomic 0
0 5 10 15 20
vacancies). Mol. % YO1.5
The partial or complete elimination of pores occurs
during densification, which is a high-temperature ionic Figure 1. Partial phase diagram of system ZrO2-Y2O3.13
diffusion-driven process.60 It is essential that pores
remain at the grain boundaries and, hence, intergranular intragranular pores and large intergranular pores;
for them to be removed.54 If pores are encompassed by another possible outcome is that the intragranular pores
growing grains during densification, then the pores are eliminated, thereby forming large grains that are
become intragranular and effectively impossible to subject to exaggerated grain growth. The large pores and
remove. However, an important consideration is the grains can have deleterious effects on both the me-
presence of agglomerates in powders, which are discrete chanical and optical properties. The small pores also can
volumes that are bonded together, separate from the play a deleterious role but to a lesser extent than the
remainder of the individual grains.61 When agglomerates larger microstructural features.
are heated, they densify and shrink independently of the Ceramic powders are usually compacted to 40% to
matrix. These can result in the formation of small 50% apparent porosity prior to densification.62 Fine

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January 2018 39

Table 2. Zirconia materials developed for fabrication of monolithic restorations in esthetic zone
Material Code Microstructure Advantages Disadvantages
Tetragonal TZP 3 mol% Y2O3 doped ZrO2 (Y-TZP)9 Desirable characteristics, well Shade matching, elastic modulus mismatch
zirconia characterized, and hence most widely (enhanced wear of teeth), long-term clinical
polycrystal used for dental applications6 stability (phase transformation)7,28,29
Zirconia- ZTLS ZrO2 toughened (20 wt% Y-TZP) glassy Excellent mechanical and optical High ZrO2 contents can result in
toughened Li2O$SiO27,32,33 properties for dental applications;34 agglomeration, which may affect
lithium silicate increases refractive index32,35 deleteriously matrix grain growth and
transformation-toughening36
ZrO2 toughened (Y-TZP) crystalline Li2O$2SiO2 Improves translucency due to increasing High ZrO2 contents can result in
glass-ceramic4,23 refractive index and reduced light agglomeration, which may affect
scattering due to decreasing grain size35 deleteriously matrix grain growth and
transformation-toughening36
Interpenetrating- IPCZ Vita In-Ceram: Glass (20-25 vol%) infiltrated into Fully dense net-shape ceramic7 Lengthy process, complex technique, labor-
phase composite porous ZTA (69 vol% Al2O3 + 21 vol% intensive
zirconia Ce-TZP)7,8
3M Paradigm MZ100*: Porous mixture of 85 wt% CEREC: Acquisition of CAD-CAM facility Optical properties insufficiently
nanocrystalline zirconia-silica (sol-gel allows fabrication in clinical setting7 characterized7
processed) + solid bisGMA (bisphenol A
diglycidyl ether dimethacrylate), infiltrated with
liquid TEGDMA (tri[ethylene glycol]
dimethacrylate) monomer37
Lava Ultimate: 80 wt% zirconia-silica CEREC, E4D and Straumann CARES: Significantly lower flexural modulus and
(combination of discrete zirconia and silica plus Acquisition of CAD-CAM facility allows flexural strength than zirconia restoration;
zirconia-silica nano-cluster) + nanomer filler38 fabrication in clinical setting and use of mechanical properties influenced negatively
Lava Milling center by storage in water38
*3M. 3M Paradigm MZ100 Block Technical product profile.http://multimedia.3m.com/mws/media/471861O/lavatm-zirconia-scientific-facts.pdf, 2007.

Table 3. Manufacturers’ compositional details of monolithic zirconia for dental applications


Trade Name Manufacturer Composition*
DD Bio ZM Dental Direkt GmbH32 ZrO2 + HfO2 + Y2O3, 99.0 wt%
Zeno Star Wieland and Ivoclar Vivadent AG32 ZrO2 + HfO2 + Y2O3, >99.0 wt%
Prettan Anterior ZirkonZhan32 ZrO2 + Y2O3, >99.0 wt%
GC ZR Disc CIP GC Europe32 ZrO2 + Y2O3, >99.0 wt%
Ceramill Zolid Amann Girrbach32 ZrO2 + HfO2 + Y2O3, >99.0 wt%
Incoris TZI Dentsply Sirona32,39 ZrO2 + HfO2 + Y2O3, 99.0 wt%
BruxZir Glidewell Lab (www.accessdata.fda.gov) Not specified
Katana Kurary Noritake Inc40 ZrO2 + HfO2 + Y2O3, >99.0 wt%
NANOZR Matsushita Electric41 Ce-TZP/Al2O3 (67.9 wt% ZrO2, 10.6 wt% CeO2, 21.5 wt% Al2O3,
0.06 wt% MgO, 0.03 wt% TiO2)
TZ-3YB-E Tosoh (www.tosoh.com) ZrO2 + Y2O3, >99.0 wt%
InCeram Vita (http://vitanorthamerica.com) Porous Al2O3-CeO2-ZrO2 (33 wt%) + Lanthanide glass
Lava 3M ESPE39 ZrO2 + HfO2 + Y2O3, >99.0 wt%
Kavo Everest Z (http://kavousa.com) ZrO2 + Y2O3, >99.0 wt%
Kavo Everest HPC (http://kavousa.com) ZrSiO4 + Si-glass phase, (ZrSi2, ZrO2, Al2O3, MgO,
Plooxyethylene sorbitan monostearate, Alkyl silicane resin)
Procera NobelBiocare (www.nobelbiocare.com) ZrO2 + HfO2 + Y2O3, 99.0 wt%
IPS e.max ZirCAD Ivoclar Vivadent AG (http://www.roedentallab) ZrO2 + HfO2 + Y2O3, >99.0 wt%
Denzir Cadesthetics AB (http://www.denzir.com) ZrO2 + HfO2 + Y2O3, >99.0 wt%
DC-Zirkon DCS Dental AG (http://www.lastruttura.it) Y-TZP
Digizon Amann Girrbach42 ZrO2 + HfO2 + Y2O3, 99.0 wt%
*Based on manufacturer information.

powders (1 mm) are used because the main driving


Table 4. Effect of band gap on light interaction with nonmetallic
force for diffusion is the high surface energies associated
materialsa
with such powders. Although high temperatures are
Absorption Transmission
required for the densification of ceramic materials, their Band of Visible of Visible Optical
low diffusion coefficients and the common presence of Gap (eV) Spectrumb Spectrum Appearance
agglomerates make the achievement of full density in <1.8 (690 nm) Complete None White and opaque

most ceramics difficult. Thus, processing methods for the 1.8-3.1 Partial Partial Colored and opaque
(690-400 nm)
fabrication of ultrafine nanopowders and densification >3.1 eV (400 nm) None Complete Colorless and transparent
methods other than pressureless sintering have been a
Adapted from Callister.43 bLight absorption involves excitation of electrons from valence band
developed (Table 6). to conduction band.

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40 Volume 119 Issue 1

Optical properties of ZrO2 The optical properties can be modified through pro-
cessing by intentionally adding dopants (as distinct from
the stabilizers). Transition and rare earth metals are used
Intrinsic Extrinsic as they impart color tints to typically colorless oxides.87
Research on controlling the color of zirconia to match
• Chemical composition
• Microstructural defects • ZrO2 surface structure natural tooth color has focused mainly on the effects of
Porosity • ZrO2 thickness Fe2O3 doping or co-doping of 3Y-TZP nanopowders on
• Underlying tooth structure
Secondary phases
• Light source
the microstructure and mechanical properties.88-92
Exaggerated grain growth
• Phase distribution
This review evaluates the characterization and
modification of the optical properties of zirconia dental
ceramics for esthetic dental restorations.
Effect on
MATERIAL AND METHODS
This systematic review was developed according to the
• Transmission preferred reporting items for systematic reviews and
• Absorption
• Refraction meta-analyses (PRISMA) statement.93 The review ques-
• Reflection tion was formulated using the participant, intervention,
• Scattering comparison, and outcome (PICO) approach,94 where
participant = restoration of esthetic zone; intervention =
monolithic zirconia; comparison = zirconia layered or
Translucence and color other types of zirconia ceramics; and outcome = clinical
performance and satisfactory esthetic appearance.
Figure 2. Effect of intrinsic and extrinsic factors on optical properties The following databases were searched electronically:
of ZrO2. Technology research via ProQuest, EMBASE, SciFinder,
MRS online proceedings library, Medline, Compendex,
and Journal of the American Ceramic Society. The
Different techniques of synthesizing nanoscale zirco-
following search terms were used alone or in combina-
nia have been reported, including coprecipitation,76 sol-
tion: “dental material,” “monolithic zirconia,” “sinter-
gel,77 hydrothermal treatment,78 combustion synthesis,79
ing,” “optical properties,” “light scattering,” “light
and mechanochemical processing.80 These techniques
transmission,” “zirconia,” and “zirconia nano-materials.”
must be undertaken carefully to minimize agglomera-
In addition, a manual search of the years 2005 to 2017
tion.81 They also offer the potential to achieve narrow
was done using the following journals: Journal of Dental
particle size distributions, which can reduce exaggerated
Materials, Journal of the American Ceramic Society, Dental
grain growth and the extent of densification.82,83 Ultra-
Materials Journal, and Journal of Prosthetic Dentistry. Bib-
fine nanopowders of zirconia and processing methods
liographies of selected papers were subjected to more
have been developed to improve densification, resulting
detailed searches for potentially relevant articles. The
in enhanced optical properties (Table 7). However, the
following inclusion criteria were used: publications in
stability of the zirconia polymorphs is influenced by the
English and publications of nonclinical studies of mate-
size and shape of the grains. The surface energy and
rials and microstructures of monolithic zirconia. Figure 5
associated surface area of zirconia are critical. Below a
summarizes the literature search strategy according to
critical size, tetragonal zirconia grains are stable at room
the PRISMA guidelines.
temperature; if larger, they transform to the monoclinic
polymorph. Grains of irregular shape are more likely to
RESULTS
undergo this transformation owing to increased matrix
stresses at the asperities.12 The electronic search identified 96 titles and abstracts, of
Low-temperature sintering of TZP produces micro- which 63 were chosen for evaluation. Another 6 articles
structures in which the pores are closed and intergran- were excluded, of which 2 reported thermal barrier
ular,84 thus enabling sinter hot isostatic pressing (sinter data,95,96 1 described the thermodynamics,97 2 were
HIPping). It is difficult for manufacturers to separate peripherally relevant overviews,98,99 and 1 was a clinical
hafnia (HfO2) from ZrO2 owing to the stability of their study of zirconia dental implants.100 Hence, 57 studies
complete solid solution,85 so commercial zirconias were included in the review. Of these, 8 discussed the
contain 5 wt% HfO2.86 Also, other oxides are generally interaction of light with zirconia (Table 4); 13 studies
present at levels of 1.0 wt%, where Na2O, SiO2, and reported the effects of extrinsic factors on the optical
Al2O3 are the main contaminants.62 properties of zirconia (Table 5); 18 considered the effects

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January 2018 41

Table 5. Extrinsic characteristics of zirconia and effects on properties


Extrinsic Factor Comments Advantages Disadvantages
Cementing Autopolymerized Adequate bonding strength45 Preclusion of roughening by etching in absence of
resin-bonded Marginal integrity8 etchable glass on or in ZrO246
Higher compressive strength than zinc Introduction of unknown optical effects by etched
phosphate45 glass surface and/or material47
In absence of etchable glass, inadequate
micro-chemical adhesion to zirconia46
Dual polymerized More effective chemical bond than self- Necessity of light-polymerization protocol (time,
resin-bonded polymerization (due to dual chemical and light distance, orientation)40
activation)45 Requirement of adequate light source (wavelength,
Adequate retention and marginal integrity48,49 intensity)40
Significantly increased degree of monomer Impairment of adequate light-cured cement
conversion from presence of Al2O3 in ZTA50 polymerization due to opacity of ZrO251
Influence of resin cements on final color52
Zinc phosphate cemented Non-requirement of etching of fitting surface Lack of chemical bonding to ZrO253
(improved compliance from direct cement-ZrO2 Limited marginal integrity53
apposition) Lower compressive strength than polymerized
resin-bonded cements53
Thickness Lambert-Beer law: light Reduction in amount of tooth to be removed Exponential decrease in light transmission by ZrO2
transmittance decreases during preparation due to thin wall thickness due to increasing thickness when additional
with increasing thickness of ZrO2 (1.0 mm)28 structural support in high-load areas is required
and absorption coefficient54
Low-temperature Exposure of ZrO2 to saliva/ Not applicable Destabilization of t-ZrO2 from interaction of OHe ions
degradation moisture and cyclic loading (from water) and point defects (oxygen vacancies) in
induce microcracking47 ZrO2,55 thus altering light transmission, absorption,
reflection, and scattering and hence color and
appearance of surface finish
Light sources Different light sources Provision of superior simulation of daylight by Complications in shade matching from lighting
(daylight, LED, fluorescent, LED56 differences between clinical, laboratory, and
incandescent) exhibit Suitability of spectra generated by other types of environmental settings1
different spectra and light sources Complications in shade matching from
associated absorption and Standard of shade comparability deriving from environmental differences due to daylight variations
reflection use of 5500 K (D50) illumination in a clinical from geographical location, time of day, and
setting1 atmospheric conditions1
Complications in shade matching from differences in
spectral response between 5500 K (D50) illumination
and other conditions1

LTD, low-temperature degradation; ZTA, zirconia toughened alumina.

Least scattered Most scattered


22
Scattering Coefficient (mm–1)

20 Scattering Reduced scattering

18

16

14

12

10

8
450 500 550 600 650
Wavelength (nm)
Figure 4. Spectral values for scattering coefficient of zirconia (450 to
650 nm).57
Figure 3. Interaction of light with materials and their microstructures.

DISCUSSION
of pores and/or agglomerates as well as the densification
method on the optical properties (Table 6); 2 reported Minimal scattering of light at the wavelength w520 nm
grain size effects on the optical properties (Table 7); 7 by zirconia has been reported (Fig. 4).57 Since lower
covered the synthesis of zirconia; and 10 reported the scattering corresponds to greater translucency (the ratio
effects of impurities on the optical properties. between the intensity of light passing through a material

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42 Volume 119 Issue 1

Table 6. Densification techniques suitable for enhanced processing


Technique Description Advantages Disadvantages
Hot pressing63,84 Concurrent uniaxial pressing Rapid Simple shape capability
and heating in die Low extent of grain growth Single-sample processing
Vacuum, controlled, and ambient Contamination and discoloration (if graphite die)
atmospheres Microstructural anisotropy
Fairly expensive process
Expensive equipment
Hot isostatic pressing64-66 Encapsulation followed by Fairly rapid Controlled atmosphere only
concurrent isostatic pressing Low extent of grain growth Simple shape capability (metal encapsulation)
by gas and heating Vacuum atmosphere Expensive process
(within encapsulated) Very expensive equipment
Complex shape capability Danger from high gas pressure
(glass encapsulation)
Multiple-sample processing
(large number)
Minimal microstructural anisotropy
Sinter hot isostatic Densification to closed Fairly rapid Controlled atmosphere only
pressing63-66 porosity followed by Low extent of grain growth Gas entrapment in closed pores
concurrent isostatic pressing No encapsulation Two-stage process (sintering + HIPping)
by gas and heating Complex shape capability Very expensive process
Multiple sample processing Very expensive equipment
(large number) Danger from high gas pressure
Minimal microstructural anisotropy
Spark plasma sintering64,67 Concurrent uniaxial pressing Very rapid Controlled atmosphere only
and heating by pulsed Very low extent of grain growth Simple shape capability
direct current through Vacuum atmosphere Single sample processing
conductive die Volumetric heating Contamination and discoloration (from graphite die)
Microstructural anisotropy
Expensive process
Very expensive equipment
Microwave heating68-72 Pressureless heating by Very rapid Requirement of hybrid heating (non-conductors)
microwave absorption Very low extent of grain growth Potential porosity retention (absence of pressure)
Vacuum, controlled, and ambient Surface heat loss (non-hybrid heating)
atmospheres Limited lifetime of magnetron
Volumetric heating Very expensive equipment (high kW magnetron)
Complex shape capability73,74
Multiple sample processing
(small number)
Minimal microstructural anisotropy
Very inexpensive process
Very inexpensive equipment
(low-kW magnetron)75

HIPping, hot isostatic pressing.

Table 7. Effects of particle size range of TZP


Particle Size (nm) Effects
<100 Particles of this size have higher thermodynamic (meta) stability such that, during crack propagation, they tend to remain tetragonal and not
transform to monoclinic phase.82 This prevents transformation-toughening mechanism (Table 1).
<400 Particles of this size readily densify, which results in optimal translucency.82 However, this also enhances
scattering at grain boundaries due to their high total volume.
>500 Particles of this size subject to spontaneous phase transformation to monoclinic phase12. As grain size (as well as aging and/or stress application)
increases, transformation enhanced.16 Presence of 2 phases of different refractive indices enhances light scattering.
>700 Particles of this size and into micrometer range difficult to densify without pressure.82 Also, use of such coarse powders results in higher level of
residual porosity, which has been shown to have greater effect on light scattering than grain boundaries.12

TZP, tetragonal zirconia polycrystal.

and that of the incident light), data for the scattering primary determinant of the translucency. Finally, the
coefficient are relevant, as seen in Figure 4. The general extent to which light can penetrate a solid (penetration
ranges of values of the relevant variables for dental zir- depth) also affects its translucency and opacity; this is the
conia are ma=0.01 to 0.10, g= −0.19 to −0.15, and ms=9 to reciprocal of coefficient of transmission.58
17. The large value of the latter causes it to dominate the Monolithic zirconia is used in dental restorations to
optics [mt0 =ma+(1−g)ms]. Since the band gap is high replace enamel. Zirconia’s lack of fluorescence
(transparent and colorless material), this emphasizes the diminishes its natural appearance, which is accentuated
fact that the microstructure is critical to the transmission. by its propensity to change from white to gray under
Also, since 3Y-TZP has a very high band gap of w5.2 to low-light conditions.45 In contrast, enamel remains
6.0 eV (w239 to 207 nm)101 and a very low distribution essentially unchanged under these conditions. If the
density of pores,7 the grain boundaries assume the role of fluorescence of zirconia is increased by chemical or other

THE JOURNAL OF PROSTHETIC DENTISTRY Shahmiri et al


January 2018 43

Total studies identified: n=96

Studies excluded on basis of


titles and/or abstracts: n=33

Potentially relevant studies identified


for full text review: n=63

Articles excluded for following


reasons, n=6:
Thermal barrier
Thermodynamic calculation
Overview
Zirconia dental Implant

Figure 6. Backscattered scanning electron micrograph of commercial


Studies included in the review: n=57
TZP used for dental applications (Original magnification ×6200). TZP,
Figure 5. Published studies search strategy diagram. tetragonal zirconia polycrystal.

means, the extent must be limited since dentin is 3 times requirement, equiaxed grains with critical grain size of 0.6
more fluorescent than enamel owing to dentin’s mm stabilize 3Y-TZP. In the presence of moisture, this
ultraviolet-photosensitive organic component.3 Further, critical grain size is decreased to 0.3 mm, avoiding the
in common with dentin, zirconia backscatters incident tetragonal-to-monoclinic phase transformation. In addi-
light, also enhancing its similarity to dentin. tion to the deleterious effect on the mechanical proper-
Features, such as interfaces between different phases ties, optical anisotropy is introduced by the birefringence
(including pores), birefringence, pores and grains of di- of the monoclinic phase due to its alteration of the
ameters similar to those of the wavelengths of visible refractive index at the grain boundaries.12
light, and rough surface finishes, can lower the trans- Most dental polycrystalline zirconia is processed by
lucency of zirconia. TZP is a highly dense, single-phase, sinter HIPping, thereby achieving grain sizes <50 nm,
fine-grained, polycrystalline material. Since the lattice nearly theoretical densities, and nearly pore-free micro-
parameters of tetragonal zirconia are nearly identical to structures.101 However, processing can be affected by the
those of the cubic form,15 birefringence is minimal. Since unintentional presence of contaminants, such as HfO2,
TZP dental restorations generally are glazed or polished, Na2O, and/or SiO2. The last 2 contribute to glass for-
surface roughness is minimal. Hence, light scattering in mation, which can suppress grain growth but lower
TZP (Fig. 6) is not dissimilar to that in a homogeneous strength and toughness.2 Al2O3 is of particular impor-
and isotropic material, so light scattering can be mini- tance as a contaminant because it enhances the densifi-
mized through microstructural control, thereby allowing cation rate of zirconia but reduces the transmission of
optimization of the translucency. visible light because of the segregation of Al2O3 on the
Densification of powders generally is done at high ZrO2 grain boundaries.67
temperatures, with and without applied pressure. While More recent work has examined the effect of inten-
pressureless sintering techniques require the use of a tional dopants on the optical properties of zirconia.
furnace only, it is difficult to achieve relative densities Mechanochemical processing of Pr2O3-doped 3Y-TZP
approaching the theoretical maximum. Consequently, enhanced translucency and color saturation. In another
techniques involving concurrent pressure and heat study, the addition of 0.2 mol% La2O3 and 0.1 wt%
application have been developed (Table 6). These have Al2O3 to 3Y-TZP significantly improved translucency.91
the main advantages that pore elimination is facilitated The La2O3 also suppressed grain growth, thus yielding
and they are rapid, which allows the maintenance of fine a finer microstructure, thereby improving the mechanical
grain sizes. More details can be found in published re- properties.
views.44,51-55 The main factors controlling the optical properties of
The particle sizes of TZP powders are important nanocrystalline 8Y-CSZ (8 mol% Y2O3-doped cubic
because they must facilitate densification while ZrO2) also have been investigated.78 The absorption co-
enhancing translucency. Since the visible light wave- efficient decreased and light transmission increased
lengths are in the range w400 to 700 nm, this particle after annealing in air at 750 C, even though the true
size range must be avoided owing to the potential for porosity and grain size would not be expected to have
enhanced light scattering. Due to the surface energy changed at this low temperature. It is probable that the

Shahmiri et al THE JOURNAL OF PROSTHETIC DENTISTRY


44 Volume 119 Issue 1

oxygen vacancies, which are intrinsic features of oxides this involves shade communication using a light-
(ZrO2-x),59 were filled during annealing. Conversely, emitting diode light of 5500 K (D50) illumination.
reduction at the same temperature, which would have In the dental laboratory, this involves the use of
increased the oxygen vacancy concentration, increased both high- and low-light intensities during
the absorption coefficient and decreased the trans- fabrication.
mission. Thus, the oxygen vacancy concentration also
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2ZrO2.Y2O3 thermal barrier coatings resistant to degradation by molten Email: r.shahmiri@unsw.edu.au
CMAS: part I, optical basicity considerations and processing. J Am Ceram
Soc 2014;97:3943-9. Copyright © 2017 by the Editorial Council for The Journal of Prosthetic Dentistry.

Noteworthy Abstracts of the Current Literature

Efficacy of local and systemic statin delivery on the osseointegration of implants:


A systematic review

Kellesarian SV, Al Amri MD, Al-Kheraif AA, Ghanem A, Malmstrom H, Javed F


Int J Oral Maxillofac Implants 2017;32:497-506
Purpose. In indexed literature, a systematic review of the efficacy of statins in enhancing osseointegration is lacking.
The aim of this systematic review was to assess the efficacy of local and systemic statin delivery on the osseointegration
of implants.
Material and Methods. To address the focused question, "Does local and systemic statin delivery affect osseointe-
gration around implants?", indexed databases were searched from 1965 through November 2015 using various key-
words. Letters to the Editor, case reports/case series, historic reviews, and commentaries were excluded. The pattern of
this systematic review was customized to primarily summarize the pertinent data.
Results. Nineteen studies were included. All studies were experimental and were performed in animal models. In
seven studies, statins were delivered systemically via oral, intraperitoneal, intraosseous, subcutaneous, and percuta-
neous routes. Among the 12 studies, where statins were delivered locally, statin-coated implants were used in seven
studies, whereas in the remaining studies, statins were delivered via topical application on the bone cavities. The
follow-up duration ranged between 1 and 12 weeks. Results from 18 studies showed that statin administration
enhanced new bone formation (NBF) around implants and/or bone-to-implant contact. One study showed that statin-
coated implant surfaces impaired osseointegration. Seven studies reported that statin administration enhanced NBF
around implants in osteoporotic rats.
Conclusions. On experimental grounds, local and systemic statin delivery seems to enhance osseointegration; how-
ever, from a clinical perspective, further studies are needed to assess the role of statins in promoting osseointegration
around dental implants.
Reprinted with permission of Quintessence Publishing.

THE JOURNAL OF PROSTHETIC DENTISTRY Shahmiri et al