CLINICAL RESEARCH

Prospective cohort clinical study assessing the 5-year survival

and success of anterior maxillary zirconia-based crowns with
customized zirconia copings
Sami Dogan, DDS,a Ariel J. Raigrodski, DMD, MS,b Hai Zhang, DMD, MS,c and Lloyd A. Mancl, PhDd

Metal ceramic restorations are ABSTRACT

considered to be the gold Statement of problem. Studies evaluating anterior zirconia-based crowns are limited.
standard for measuring the
performance of tooth-colored Purpose. The purpose of this prospective cohort clinical study was to assess the efficacy of zirconia-
based anterior maxillary crowns with 0.3-mm customized copings at the cervical third and
fixed restorations.1,2 The long-
anatomical design elsewhere for up to 5 years of service.
term survival rate of metal
ceramic crowns was estimated Material and methods. Eighteen participants who required an anterior maxillary crown (n=20) and
to be approximately 92% after who had signed a consent form approved by the University of Washington Health Sciences Center
Human Subjects Division were enrolled. All preparations were standardized and prepared with an
10 years3 and 75% after 15
occlusal reduction of 1.5 to 2 mm and an axial reduction of 1 to 1.5 mm with 10 degrees of
years.4 Metal ceramic crowns convergence angle. All finish lines were located on the sound tooth structure. Zirconia copings
showed only 3% of repair and (Lava; 3M ESPE) were custom designed and milled to a 0.3-mm thickness at the cervical third and
failure rates in 5 to 10 years of with selective thickness elsewhere to support the veneering porcelain. All restorations were luted
clinical service in a private with self-etching self-adhesive composite resin cement. Recall appointments were at 2 weeks, 6
practice environment.5 In a months, and 12 months, and annually thereafter for 5 years. Modified Ryge criteria were used to
recent systematic review, the assess the clinical fracture measurements, esthetics, marginal discoloration, marginal adaptation,
radiographic proximal recurrent caries, and periapical pathoses. Descriptive statistics and 95%
estimated survival rate of metal
confidence intervals were used to describe the number and rate of complications and self-
ceramic crowns after 5 years of reported satisfaction with the crowns.
service was reported as 95.7%
Results. Twenty crowns with a mean follow-up of 58.7 months were evaluated. All crowns were
compared with ceramic crowns,
rated as Alfa for fracture measurements (smooth surface, no fracture/chipping). Twelve crowns
which ranged between 90.7% were rated esthetically as Romeo (no mismatch in color and shade) and 8 as Sierra (mismatch in
and 96.6%, depending on the color and shade within normal range). Twelve crowns were rated as Alfa (no visible evidence of
ceramic core material used.6 crevice) and 8 as Bravo (visible evidence of crevice, no penetration of explorer) for marginal
To meet the increasing de- integrity. Nineteen were rated as Alfa (no discoloration) and 1 as Bravo (superficial discoloration)
mand for esthetics, many types for marginal discoloration. No proximal caries or periapical pathoses were detected in 5 years.
of ceramics, including glass Participants were highly satisfied with their crowns after 5 years (mean ±SD: 9.8 ±0.4 on 0 to 10
scale).
infiltrated magnesium alumina,
leucite reinforced glass ce- Conclusions. Zirconia-based anterior maxillary crowns with customized copings with 0.3-mm
ramics, lithium disilicate, and thickness at the cervical third and zirconia margins performed well after 5 years of
yttrium-stabilized zirconia have service. (J Prosthet Dent 2017;117:226-232)

Supported by a research grant from 3M ESPE. Presented at the International Association for Dental Research, Seattle, Wash, March 2013.
a
Assistant Professor, Department of Restorative Dentistry, School of Dentistry, University of Washington, Seattle, Wash.
b
Professor, Department of Restorative Dentistry, School of Dentistry, University of Washington, Seattle, Wash.
c
Associate Professor, Department of Restorative Dentistry, School of Dentistry, University of Washington, Seattle, Wash.
d
Research Associate Professor, Department of Dental Public Health Sciences, University of Washington, Seattle, Wash.

226 THE JOURNAL OF PROSTHETIC DENTISTRY

February 2017 227

systems are able to replace human dentin in terms of

Clinical Implications esthetics because the color and translucency parameters
This study suggests that zirconia-based anterior of zirconia are similar to those of human dentin.33
A 1-mm facial vertical cutback of the metal coping
crowns layered with the corresponding veneering
was indicated for anterior metal ceramic crowns with
porcelain with 0.3-mm cervical third customized
porcelain margins to promote light transmission at the
anatomic coping may serve as an esthetic and
cervical aspect without decreasing the fracture strength of
functional restorative alternative for restoring
the crowns.34 Vertical cutback and shoulder porcelain
anterior teeth.
prompted the use of adhesive cementation procedures
for such metal ceramic crowns but may not be necessary
with zirconia-based restorations. The level of light
been used to fabricate metal-free restorations for single or
transmission was shown to increase with the reduction of
multiple unit restorations.7-10 Among them, zirconia has
thickness of the zirconia core material.35 A standard
been used increasingly for copings and frameworks of
minimum core thickness of 0.5 mm for metal ceramic
fixed restorations because of its excellent mechanical
crowns has been adapted for zirconia-based crown
properties.11-13 Zirconia is biocompatible14 and shows low
frameworks in the posterior region.36,37 In in vitro testing
bacterial adhesion compared with titanium.15,16
in the anterior segment, a 0.3-mm thickness for the zir-
Clinically, crowns may present with technical or bio-
conia coping in the cervical region was shown to be
logical complications. Common technical problems are
adequate to achieve esthetic results compared with the
framework fracture, ceramic chipping, marginal discol-
traditional porcelain margin design.38 In addition, the
oration, loss of retention, and poor esthetics. Loss of
results of a clinical study assessing anterior teeth restored
abutment tooth vitality, abutment tooth fracture, and
with 0.3-mm-thick zirconia copings showed a survival
secondary caries are common biological complications.
rate of 100% for restoring severely compromised anterior
Of all the technical problems, fracture or chipping of
teeth after 3 years of service.39
the veneering material remains one of the major prob-
Although zirconia-based ceramic posterior 3-unit
lems.17-20 Studies have found that veneer ceramic frac-
restorations may be a viable prosthetic option to metal
tures occur across all veneer ceramics and significantly
ceramic restorations,40 there are limited long-term clin-
more often with the ceramics used on zirconia than with
ical reports on the survival of anterior zirconia-based
those used on metal.21 However, ceramic crowns used
crowns with a thinner coping at the cervical aspect in
for anterior teeth showed 5-year survival rates compa-
terms of function and esthetics. The primary purpose of
rable with those of metal ceramic crowns.22 The mean
this clinical study was to evaluate the zirconia-based
estimated annual failure percentage for zirconia-based
anterior ceramic restorations with a 0.3-mm cervical
crowns was reported as 0% on anterior teeth and 1.5%
coping design and with an anatomic design elsewhere for
on posterior teeth in a recent systematic review.23 No
their clinical fracture, and the secondary purposes were to
statistically significant difference in the survival rates of
evaluate the esthetics, marginal adaptation, and discol-
anterior and posterior crowns was shown for metal
oration during 5 years of service.
ceramic and zirconia-based crowns.6
Initially, because of software limitations, fixed dental
MATERIAL AND METHODS
prosthesis (FDP) frameworks or crown copings were
milled with a uniform thickness with limited consider- Eighteen participants who presented with either a
ation for adequate support of the veneering porcelain, structurally compromised anterior maxillary tooth
which might have contributed to the high number of requiring a crown, and who complied with the following
ceramic chippings.24-27 The reduced number of chippings inclusion criteria were enrolled in the study: healthy
for zirconia-based restorations might be partly attributed participants over the age of 18 with an anterior maxillary
to optimized crown copings, and FDP frameworks with tooth requiring an anterior maxillary crown, in an Angle
selective thickness to provide adequate support for Class I dental relationship with minimum of 20 teeth in
veneering porcelain made possible with improved soft- both arches, with good oral health, and with no active
ware.23,28-31 caries or periodontal disease (Fig. 1). Participants with no
Matching shades in the esthetic zone has been a opposing natural dentition, with severe wear facets, and/
clinical challenge. Zirconia has esthetic advantages over or reporting parafunctional activities, reduced inter-
metal alloys as a core material for complete coverage occlusal distance, supraerupted opposing dentition,
restorations,23,32 although zirconia-based restorations wearing removable complete or partial dentures, or with
have been questioned as viable esthetic alternatives unfavorable crown to root ratio were excluded. The study
because of their semi-opaque nature. Studies have was approved by the University of Washington Health
shown that both noncolored and colored zirconia Sciences Center Human Subjects Division.

Dogan et al THE JOURNAL OF PROSTHETIC DENTISTRY

228 Volume 117 Issue 2

Figure 1. Preoperative labial view of failing maxillary left central incisor

metal ceramic crown. A, With shade tab. Note visible metal margins and
inadequate shade match. B, Palatal view. Note interim restoration placed
after endodontic therapy.

All preparations were made by 1 operator (A.J.R.) in a for the evaluators took place before assigning the par-
standardized manner.41 Twenty abutment teeth in 18 ticipants to the study. Each evaluator collected data
participants were prepared with an occlusal reduction of using the postoperative data collection form until they
1.5 to 2 mm and an axial reduction of 1 to 1.5 mm with a obtained an agreement with a high kappa (>.75).
10-degree convergence angle. All finish-lines were Enforced consensus was used in case of disagreement.
located on the sound tooth structure. Rounded shoulder All restorations were evaluated intraorally before
finish lines were prepared 0.5-mm subgingivally on the cementation. Articulating film (ARTI-FOL; Bausch) was
facial and supragingivally on the lingual surface. All line used to evaluate proximal contacts, which were then
angles were rounded (Fig. 2). Definitive impressions were adjusted with a diamond disk (Miniflex; Brasseler USA)
made with polyvinyl siloxane (PVS) impression material as needed and polished with a porcelain polishing kit
(Imprint3; 3M ESPE) in stock impression trays (Rim Lock; (CeramiPro Dialite; Brasseler USA). Marginal integrity
Dentsply Intl). Definitive and opposing casts were and the fit of the intaglio surfaces were assessed by using
mounted in a semiadjustable articulator (Model 2240Q; a silicone disclosing paste (Fit Checker; GC America).
Whip Mix Corp) after working dies were fabricated. Once adequate proximal contacts and fit had been
Immediately after definitive impressions, polymethyl confirmed, occlusal contacts were assessed with an
methacrylate interim restorations (Jet Tooth Shade Pro- articulating film (ARTI-FOL; Bausch), and adjustments
visional Material; Lang Dental) were delivered and were made with the porcelain polishing kit (Dialite;
cemented with interim cement (RelyX Temp NE; 3M Brasseler USA). After achieving occlusal contacts in
ESPE). maximum intercuspation with no interferences in lateral
Computer-aided design and computer-aided excursions, the restorations were cemented with a self-
manufacturing (CAD-CAM) technology was used to etching resin cement (RelyX Unicem; 3M ESPE) accord-
design and customize yttria-stabilized zirconia polycrystal ing to the manufacturer’s instructions with no surface
(Y-TZP) copings with software (Lava Wax Knife v2.0; 3M treatment to the intaglio surface of the restoration.
ESPE). Zirconia copings were milled to adequately support The same evaluators (S.D. and Z.H.) evaluated the
the veneering porcelain with 0.3-mm thickness at the participants during the recall appointments with a mirror
cervical third and with selective thickness at the mid-and and a sharp explorer at 2 weeks, 6 months, 12 months,
incisal-thirds (Fig. 3). All restorations were fabricated and annually for 5 years. Periapical radiographs were
with zirconia margins and layered with veneering porce- made annually. Postoperative data were collected and
lain (Lava Ceram; 3M ESPE) by 3 dental technicians. used as a documentation tool with the clinical
Two independent evaluators (S.D. and Z.H.), photographs.
members of the Department of Restorative Dentistry, Clinical fracture measurements, esthetics, marginal
measured the thickness of the copings, and the resto- discoloration, marginal adaptation, radiographic proximal
rations were layered with porcelain. A training session recurrent caries, and periapical pathoses were assessed

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February 2017 229

Figure 2. Finished preparation of maxillary left central with fiber post Figure 3. Facial view of zirconia coping with 0.36-mm thickness at facial
and composite resin core. aspect. Note excellent marginal fit.

with modified Ryge criteria.42 The traditional 4-point scales number and types of complications after 5 years of follow-
of the California Dental Association or the US Public up. Confidence intervals for the rate of complications were
Health Service that generally list 2 categories (Alfa and computed using exact binomial distribution methods.44,45
Bravo or Romeo and Sierra) for acceptable performance Outcomes for 1 participant who was lost to follow-up af-
and 2 categories for unacceptable performance (Charlie ter 3 years were carried forward to summarize the number
and Delta or Tango and Victor) were used.43 Categorical and types of complications. After delivering the crowns,
variables as defined in Table 1 were used to determine the the participants were asked to rate the level of the satis-
faction with their restorations by using a 1 to 10 numeric
rating scale (1=poor, 5=acceptable, 10=excellent) at 2
weeks, 6 months, 12 months, and annually for 5 years
Table 1. Clinical evaluation of restorations by using modified
(Table 2). Mean, standard deviation and 95% confidence
Ryge criteria
interval for the mean were used to summarized patient
Variable Definition
satisfaction. Confidence intervals should be interpreted as
Fracture measurements
Alfa A. Smooth surface (shiny after air-drying)
exploratory because of the small sample size and do not
Bravo B. Dull surface and/or chipping of porcelain that do not
account for potential intraparticipant correlation due to 2
impair function participants receiving 2 crowns.
Charlie C. Chipping of the veneering porcelain impairing esthetics
and function and/or exposing core material
RESULTS
Delta D. Fracture through the core material
Esthetics Twenty zirconia-based anterior maxillary crowns in 18
Romeo R. No mismatch in color shade and/or translucency between participants (9 men and 9 women with a mean ±SD age
the restoration and adjacent tooth structure
of 44.5 ±12.4 between the ages of 27 and 69 were eval-
Sierra S. Mismatch between restoration and tooth structure within
the normal range of tooth color, shade, and/or translucency uated at 2 weeks, 6 months, 12 months, and annually
Tango T. Mismatch between restoration and tooth structure outside thereafter for 5 years. Nineteen restorations were eval-
the normal range of tooth color, shade, and/or translucency uated at 5 years, and 1 participant left the study after 3
Victor V. Esthetically displeasing color, shade, and/or translucency years (relocated) (mean follow-up time of 58.7 months).
Marginal adaptation
Fourteen of the teeth were maxillary central and 6 were
Alfa A. No visible evidence of crevice along the margins; no catch
or penetration of the explorer maxillary lateral incisors. Thirteen teeth were nonvital
Bravo B. Visible evidence of crevice and/or catch of the explorer; and 7 were vital. After 5 years, all crowns (100%) were
no penetration of the explorer rated Alfa (no fracture) for clinical fracture measurements
Charlie C. Visible evidence of crevice and penetration of the explorer (95% CI; 83% to 100%). Twelve restorations were rated
Delta D. Restoration is mobile, fractured, or missing as Romeo and 8 (40%) as Sierra for esthetic evaluation
Marginal discoloration
(95% CI; 19% to 64%). Cervical coping thickness was
Alfa A. No discoloration at the margins
measured with a mean ±SD thickness of 0.38 ±0.08 mm,
Bravo B. Superficial discoloration not penetrating in pulpal direction
and the average thickness of the mid-buccal coping
Charlie C. Discoloration penetrating in a pulpal direction
was 0.43 ±0.13 mm with an average total thickness of
Alfa, Bravo: restoration acceptable; Charlie, Delta: restoration not acceptable and must be
replaced; Romeo, Sierra: restoration acceptable; Tango, Victor: restoration not acceptable
1.46 ±0.40 mm for the completed restoration (core and
and must be replaced. veneering porcelain) at the mid-buccal location. The

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230 Volume 117 Issue 2

Table 2. Patient satisfaction self-evaluation using visual analog scale ranging from 0 (extremely unsatisfied) to 10 (extremely satisfied)
Preoperative 2 wk 6 mo 12 mo 24 mo 36 mo 48 mo 60 mo
Mean (±SD) 4.4 (3.1) 9.2 (0.7) 9.5 (0.5) 9.5 (0.5) 9.6 (0.5) 9.5 (0.5) 9.7 (0.5) 9.8 (0.4)
95% CI 2.8, 5.9 8.8, 9.6 9.1, 9.7 9.2, 9.8 9.2, 9.8 9.2, 9.8 9.4, 9.9 9.5, 10
Min-max 0-10 8-10 9-10 9-10 9-10 9-10 9-10 9-10

Figure 5. Labial view of zirconia-based crown rated Alfa in terms of

fracture measurements and Romeo in terms of esthetics on left maxillary
central incisor immediately after placement.

Figure 4. Radiographic evaluation of maxillary left central after 5 years of

service demonstrating no pathologic findings.

veneering porcelain thickness measured at the mid-

buccal location was 1.03 ±0.35 mm.
After 5 years, 12 restorations were rated as Alfa and 8
(40%) as Bravo for marginal integrity (95% CI; 19 to
64%). Nineteen restorations were rated as Alfa and 1
(5%) as Bravo for marginal discoloration (95% CI;
0-25%). Radiographic evaluation showed no evidence of
proximal recurrent caries or periapical pathoses (Fig. 4).
No fracture of a coping or loss of retention was noted
throughout the study period. The survival rate without
major or minor chipping after 5 years of in situ service Figure 6. Labial view of crown rated Alfa in terms of fracture
measurements and Romeo in terms of esthetics 5 years after placement.
was 100% (95% CI; 83-100%) (Figs. 5, 6). Tooth fracture
at the gingival level was observed after 2 years for 1
nonvital right lateral incisor. A retrofitted post and core
are encouraging since the restorations were fabricated
was placed, and the original crown was recemented. The
with zirconia margins and luted with resin cement with
crown has been in service since with no further adverse
no surface treatment of the intaglio surface of the
events.
restorations.
Participants rated their satisfaction as very high, from
A minimum of 5 years of service of metal ceramic
9.2 ±0.7 at 2 weeks to 9.8 ±0.4 at 5 years (Table 2).
restorations is accepted as gold standard in the dental
Sensitivity was only evaluated for 6 months. None of the
literature to compare the survival of ceramic restora-
patients reported any sensitivity before or thereafter.
tions.1,2 Although zirconia is a biocompatible material in
the oral environment,14-16 common clinical problems of
DISCUSSION
zirconia-based restorations are fracture or chipping of the
The results in this study showed the survival of the veneering porcelain. The results of the present study
anterior zirconia-based restorations in terms of fracture/ showed that zirconia-based restorations layered with
chipping, esthetics, and marginal adaptation. The results veneering porcelain is an alternative to metal ceramic in

THE JOURNAL OF PROSTHETIC DENTISTRY Dogan et al

February 2017 231

terms of chipping/fracture and esthetics for the anterior bruxism must be considered as risk factors for the survival
and posterior dentition3-12,41 although the studies have of zirconia-based as for other ceramic restorations. Such
reported fracture/chipping as one of the main technical patients may be more susceptible to porcelain fracture.
problems for the zirconia-based restorations.13,17-21 The According to the study results, careful selection of patients
nonanatomic design of the zirconia core material was for zirconia-based restorations is advised to minimize the
reported as one of the major reasons for fracture/ clinical failure of the zirconia-based restorations.
chipping of the veneering porcelain. In the present study, Aging and stress fatigue in the oral environment, as
all 20 crowns, with copings which were designed and well as function and parafunction, all affect the longevity
manufactured with an anatomic core to support the of ceramic restorations.40 Therefore, continued follow-up
veneering porcelain showed no fracture or chipping after of longer than 5 years is needed to provide information
5 years of service. Adequate support of the veneering regarding the survival of zirconia-based restorations. The
ceramics might facilitate the longevity of such restora- present study is limited by its small sample size. Future
tions. Recent improvements of CAD-CAM software and studies with a larger sample size and control groups are
milling techniques allowed the fabrication of frameworks needed to evaluate the survival of anterior zirconia-based
with anatomic form. The results of this study confirmed restorations with veneered porcelain as an alternative to
that anatomically designed frameworks might give better the metal ceramic gold standard restorations and as a
support to the veneering porcelain and might reduce viable functional and esthetic alternative in the anterior
veneering porcelain chipping as suggested in other segment.
studies.23-31
Esthetic zirconia-based crowns layered with the CONCLUSIONS
corresponding veneering porcelain were provided. The
coping design had a 0.3-thickness at the facial cervical Within the limitations of this clinical study, the following
aspect and a disappearing margins design. The results conclusions were drawn:
of the present study confirmed that porcelain margin Anterior maxillary zirconia-based crowns with
design was not necessary for zirconia-based restora- customized copings with 0.3-mm coping thickness at the
tions to increase the light transmission of the resto- cervical aspect and with zirconia margins performed well
rations as proposed for metal ceramic restorations.34 after 5 years of service in terms of function and esthetics.
Because of the semi-opaque nature of zirconia,
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