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
Clinical Implications
While fully stabilized zirconia (cubic) has been
developed for use in the esthetic zone, this
polymorph does not exhibit transformation
toughening and so does not exhibit the superior
mechanical properties of partially stabilized zirconia
(tetragonal + cubic).
toughening,7 it also results in microcracking and
compromised mechanical properties. However, oxide
doping can stabilize the tetragonal phase or, at higher
doping levels, the high-temperature cubic phase upon
cooling to room temperature, thus inhibiting these phase
transformations and their potentially detrimental effects
on the mechanical properties.7
Several polycrystalline zirconia materials have been
developed for dental applications, including zirconia-
toughened alumina (ZTA), partially stabilized zirconia
(PSZ), tetragonal zirconia polycrystal (TZP), and fully
cubic stabilized zirconia (CSZ) (Table 1). CSZ is differ-
entiated from the other 3 by its isotropic character, which
can enhance light transmission.20,21 Cations of valences
lower than those of Zr4+ are used for stabilization to
room temperature.22 However, while the phase diagram
(Fig. 1)23 indicates that levels >18 mol% Y3+ are required
for full stabilization, in practice, this often is achieved at
lower levels (
6 mol%); the transformations to tetrag-
onal and then monoclinic phases are avoided by rapid
cooling. Charge balance is maintained by the generation
of oxygen vacancies.24,25
Computer-assisted design and computer assisted
manufacturing (CAD-CAM) have been used extensively
in prosthetic dentistry. Porcelain may be applied as a
veneer to partially sintered (or, more rarely, fully sin-
tered) zirconia, which has been machined to sizes 25% to
30% larger than the final size to compensate for
shrinkage during sintering.26 Cohesive failure due to re-
sidual stresses has been reported, but this is addressed
successfully by using slow heating and cooling rates.27
However, long-term clinical data are lacking to confirm
the absence of fracture. The elimination of cohesive
failure of the veneering material has driven the devel-
opment of anatomic-contour zirconia restorations.7,28-30
However, the use of such restorations has unique chal-
lenges, such as shade matching, wear resistance, and
long-term clinical stability.7,28,29
Recent improvements in the optical properties of
zirconia have led to greater use of anatomic-contour
restorations,31 with several materials being introduced
recently (Table 2). Monolithic 3 mol% yttria-doped
tetragonal zirconia polycrystal (3Y-TZP) is the most
widely used zirconia material for dental applications
(Table 3).9
Shahmiri et al
37
Electronic polarization and [valence band / con-
duction band] electron transitions are 2 mechanisms that
influence the light transmission characteristics of
nonmetallic materials.43 Such materials of different band
gaps will appear opaque, opaque and colored, or trans-
parent and colored (Table 4).43 Although nonmetallic
materials commonly have band gaps larger than w3.1 eV
and so are transparent to light, they can exhibit limited
light absorption due to electronic polarization, giving a
translucent appearance and consequent diffuse light
transmission.
The color and appearance of monolithic zirconia
dental restorations are affected by both intrinsic (mate-
rials) and extrinsic (features and surroundings) parame-
ters44 (Fig. 2). Materials and processing issues relevant to
the extrinsic characteristics, such as cement layer, thick-
ness, and low-temperature degradation, can affect the
optical properties (Table 5). While desired esthetic char-
acteristics of zirconia dental restorations can be
controlled by these parameters, color matching must also
be achieved by using consistent and appropriate light
sources.
Intrinsic microstructural features, such as grain
boundaries and pores, scatter some of the light, result-
ing in translucency or even opacity.20 The associated
interaction with light derives from differences in
refractive indices across different interfaces: grain/grain,
grain/pore, and medium 1/medium 2. Light trans-
mission also is affected by other features, such as the
interfaces between secondary phases (grain 1/grain 2)
and crystallographically anisotropic grains (orientation
1/orientation 2). Thus, the translucency and opacity of
materials depend on how and to what extent incident
light is reflected, scattered, refracted, transmitted, and
absorbed.
The light propagation through a material depends on
3 parameters: absorption coefficient (ma), scattering co-
efficient (ms), and scattering anisotropy factor (g).57 The
scattering anisotropy factor is the mean value of the
scattering angle.58 The scattering anisotropy factor in-
dicates the amount of light that is forward-scattered
(translucency) or back-scattered (opacity) in a single
scattering event.58 As the number of scattering events
increases, the light distribution becomes more uniform,
so an initially anisotropic light distribution eventually will
become isotropic. Therefore, transmitted light is attenu-
ated by both the absorption and scattering coefficients,
and the sum of these two coefficients gives the transport
coefficient (mt).58 For nonideal materials, a reduced scat-
tering coefficient (mt0 ) also is considered (Fig. 3) and is a
combined property incorporating the absorption coeffi-
cient, scattering coefficient, and scattering anisotropy
factor [mt0 =ma+(1eg)ms]. The mt0 is the fraction of scattered
light that is forward-scattered in the direction of the
refracted beam. Longer wavelengths increase the fraction
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

THE JOURNAL OF PROSTHETIC DENTISTRY Shahmiri et al

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.

Shahmiri et al THE JOURNAL OF PROSTHETIC DENTISTRY

40
Optical properties of ZrO2
Intrinsic Extrinsic
• Chemical composition
• Microstructural defects • ZrO2 surface structure
Porosity • ZrO2 thickness
• Underlying tooth structure
Secondary phases
• Light source
Exaggerated grain growth
• Phase distribution
Effect on
• Transmission
• Absorption
• Refraction
• Reflection
• Scattering
Translucence and color
Figure 2. Effect of intrinsic and extrinsic factors on optical properties
of ZrO2.
Different techniques of synthesizing nanoscale zirco-
nia have been reported, including coprecipitation,76 sol-
gel,77 hydrothermal treatment,78 combustion synthesis,79
and mechanochemical processing.80 These techniques
must be undertaken carefully to minimize agglomera-
tion.81 They also offer the potential to achieve narrow
particle size distributions, which can reduce exaggerated
grain growth and the extent of densification.82,83 Ultra-
fine nanopowders of zirconia and processing methods
have been developed to improve densification, resulting
in enhanced optical properties (Table 7). However, the
stability of the zirconia polymorphs is influenced by the
size and shape of the grains. The surface energy and
associated surface area of zirconia are critical. Below a
critical size, tetragonal zirconia grains are stable at room
temperature; if larger, they transform to the monoclinic
polymorph. Grains of irregular shape are more likely to
undergo this transformation owing to increased matrix
stresses at the asperities.12
Low-temperature sintering of TZP produces micro-
structures in which the pores are closed and intergran-
ular,84 thus enabling sinter hot isostatic pressing (sinter
HIPping). It is difficult for manufacturers to separate
hafnia (HfO2) from ZrO2 owing to the stability of their
complete solid solution,85 so commercial zirconias
contain 5 wt% HfO2.86 Also, other oxides are generally
present at levels of 1.0 wt%, where Na2O, SiO2, and
Al2O3 are the main contaminants.62
THE JOURNAL OF PROSTHETIC DENTISTRY
Volume 119 Issue 1
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
as they impart color tints to typically colorless oxides.87
Research on controlling the color of zirconia to match
natural tooth color has focused mainly on the effects of
Fe2O3 doping or co-doping of 3Y-TZP nanopowders on
the microstructure and mechanical properties.88-92
This review evaluates the characterization and
modification of the optical properties of zirconia dental
ceramics for esthetic dental restorations.
MATERIAL AND METHODS
This systematic review was developed according to the
preferred reporting items for systematic reviews and
meta-analyses (PRISMA) statement.93 The review ques-
tion was formulated using the participant, intervention,
comparison, and outcome (PICO) approach,94 where
participant = restoration of esthetic zone; intervention =
monolithic zirconia; comparison = zirconia layered or
other types of zirconia ceramics; and outcome = clinical
performance and satisfactory esthetic appearance.
The following databases were searched electronically:
Technology research via ProQuest, EMBASE, SciFinder,
MRS online proceedings library, Medline, Compendex,
and Journal of the American Ceramic Society. The
following search terms were used alone or in combina-
tion: “dental material,” “monolithic zirconia,” “sinter-
ing,” “optical properties,” “light scattering,” “light
transmission,” “zirconia,” and “zirconia nano-materials.”
In addition, a manual search of the years 2005 to 2017
was done using the following journals: Journal of Dental
Materials, Journal of the American Ceramic Society, Dental
Materials Journal, and Journal of Prosthetic Dentistry. Bib-
liographies of selected papers were subjected to more
detailed searches for potentially relevant articles. The
following inclusion criteria were used: publications in
English and publications of nonclinical studies of mate-
rials and microstructures of monolithic zirconia. Figure 5
summarizes the literature search strategy according to
the PRISMA guidelines.
RESULTS
The electronic search identified 96 titles and abstracts, of
which 63 were chosen for evaluation. Another 6 articles
were excluded, of which 2 reported thermal barrier
data,95,96 1 described the thermodynamics,97 2 were
peripherally relevant overviews,98,99 and 1 was a clinical
study of zirconia dental implants.100 Hence, 57 studies
were included in the review. Of these, 8 discussed the
interaction of light with zirconia (Table 4); 13 studies
reported the effects of extrinsic factors on the optical
properties of zirconia (Table 5); 18 considered the effects
Shahmiri et al
January 2018 41

Table 5. Extrinsic characteristics of zirconia and effects on properties

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

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

Shahmiri et al THE JOURNAL OF PROSTHETIC DENTISTRY

42 Volume 119 Issue 1

Table 6. Densification techniques suitable for enhanced processing

Technique Description
Hot pressing63,84 Concurrent uniaxial pressing
and heating in die
Hot isostatic pressing64-66 Encapsulation followed by
concurrent isostatic pressing
by gas and heating
Sinter hot isostatic Densification to closed
pressing63-66 porosity followed by
concurrent isostatic pressing
by gas and heating
Spark plasma sintering64,67 Concurrent uniaxial pressing
and heating by pulsed
direct current through
conductive die
Microwave heating68-72 Pressureless heating by
microwave absorption
Advantages Disadvantages
Rapid Simple shape capability
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
Fairly rapid Controlled atmosphere only
Low extent of grain growth Simple shape capability (metal encapsulation)
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
Fairly rapid Controlled atmosphere only
Low extent of grain growth Gas entrapment in closed pores
No encapsulation Two-stage process (sintering + HIPping)
Complex shape capability Very expensive process
Multiple sample processing Very expensive equipment
(large number) Danger from high gas pressure
Minimal microstructural anisotropy
Very rapid Controlled atmosphere only
Very low extent of grain growth Simple shape capability
Vacuum atmosphere Single sample processing
Volumetric heating Contamination and discoloration (from graphite die)
Microstructural anisotropy
Expensive process
Very expensive equipment
Very rapid Requirement of hybrid heating (non-conductors)
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
coefficient are relevant, as seen in Figure 4. The general
ranges of values of the relevant variables for dental zir-
conia are ma=0.01 to 0.10, g= −0.19 to −0.15, and ms=9 to
17. The large value of the latter causes it to dominate the
optics [mt0 =ma+(1−g)ms]. Since the band gap is high
(transparent and colorless material), this emphasizes the
fact that the microstructure is critical to the transmission.
Also, since 3Y-TZP has a very high band gap of w5.2 to
6.0 eV (w239 to 207 nm)101 and a very low distribution
density of pores,7 the grain boundaries assume the role of
primary determinant of the translucency. Finally, the
extent to which light can penetrate a solid (penetration
depth) also affects its translucency and opacity; this is the
reciprocal of coefficient of transmission.58
Monolithic zirconia is used in dental restorations to
replace enamel. Zirconia’s lack of fluorescence
diminishes its natural appearance, which is accentuated
by its propensity to change from white to gray under
low-light conditions.45 In contrast, enamel remains
essentially unchanged under these conditions. If the
fluorescence of zirconia is increased by chemical or other

THE JOURNAL OF PROSTHETIC DENTISTRY Shahmiri et al

January 2018
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
Studies included in the review: n=57
Figure 5. Published studies search strategy diagram.
means, the extent must be limited since dentin is 3 times
more fluorescent than enamel owing to dentin’s
ultraviolet-photosensitive organic component.3 Further,
in common with dentin, zirconia backscatters incident
light, also enhancing its similarity to dentin.
Features, such as interfaces between different phases
(including pores), birefringence, pores and grains of di-
ameters similar to those of the wavelengths of visible
light, and rough surface finishes, can lower the trans-
lucency of zirconia. TZP is a highly dense, single-phase,
fine-grained, polycrystalline material. Since the lattice
parameters of tetragonal zirconia are nearly identical to
those of the cubic form,15 birefringence is minimal. Since
TZP dental restorations generally are glazed or polished,
surface roughness is minimal. Hence, light scattering in
TZP (Fig. 6) is not dissimilar to that in a homogeneous
and isotropic material, so light scattering can be mini-
mized through microstructural control, thereby allowing
optimization of the translucency.
Densification of powders generally is done at high
temperatures, with and without applied pressure. While
pressureless sintering techniques require the use of a
furnace only, it is difficult to achieve relative densities
approaching the theoretical maximum. Consequently,
techniques involving concurrent pressure and heat
application have been developed (Table 6). These have
the main advantages that pore elimination is facilitated
and they are rapid, which allows the maintenance of fine
grain sizes. More details can be found in published re-
views.44,51-55
The particle sizes of TZP powders are important
because they must facilitate densification while
enhancing translucency. Since the visible light wave-
lengths are in the range w400 to 700 nm, this particle
size range must be avoided owing to the potential for
enhanced light scattering. Due to the surface energy
Shahmiri et al
43
Figure 6. Backscattered scanning electron micrograph of commercial
TZP used for dental applications (Original magnification ×6200). TZP,
tetragonal zirconia polycrystal.
requirement, equiaxed grains with critical grain size of 0.6
mm stabilize 3Y-TZP. In the presence of moisture, this
critical grain size is decreased to 0.3 mm, avoiding the
tetragonal-to-monoclinic phase transformation. In addi-
tion to the deleterious effect on the mechanical proper-
ties, optical anisotropy is introduced by the birefringence
of the monoclinic phase due to its alteration of the
refractive index at the grain boundaries.12
Most dental polycrystalline zirconia is processed by
sinter HIPping, thereby achieving grain sizes <50 nm,
nearly theoretical densities, and nearly pore-free micro-
structures.101 However, processing can be affected by the
unintentional presence of contaminants, such as HfO2,
Na2O, and/or SiO2. The last 2 contribute to glass for-
mation, which can suppress grain growth but lower
strength and toughness.2 Al2O3 is of particular impor-
tance as a contaminant because it enhances the densifi-
cation rate of zirconia but reduces the transmission of
visible light because of the segregation of Al2O3 on the
ZrO2 grain boundaries.67
More recent work has examined the effect of inten-
tional dopants on the optical properties of zirconia.
Mechanochemical processing of Pr2O3-doped 3Y-TZP
enhanced translucency and color saturation. In another
study, the addition of 0.2 mol% La2O3 and 0.1 wt%
Al2O3 to 3Y-TZP significantly improved translucency.91
The La2O3 also suppressed grain growth, thus yielding
a finer microstructure, thereby improving the mechanical
properties.
The main factors controlling the optical properties of
nanocrystalline 8Y-CSZ (8 mol% Y2O3-doped cubic
ZrO2) also have been investigated.78 The absorption co-
efficient decreased and light transmission increased
after annealing in air at 750 C, even though the true
porosity and grain size would not be expected to have
changed at this low temperature. It is probable that the
THE JOURNAL OF PROSTHETIC DENTISTRY
44
oxygen vacancies, which are intrinsic features of oxides
(ZrO2-x),59 were filled during annealing. Conversely,
reduction at the same temperature, which would have
increased the oxygen vacancy concentration, increased
the absorption coefficient and decreased the trans-
mission. Thus, the oxygen vacancy concentration also
plays an important role in the optical behavior of zirconia
ceramics. The partial or full stabilization of zirconia and,
hence, avoidance of the tetragonal-to-monoclinic phase
transformation are achieved by the formation of substi-
tutional solid solutions.7 Since zirconium ions are tetra-
valent, if the stabilizing dopants are divalent or trivalent,
they must be charge-compensated by the introduction of
positively charged defects such as oxygen vacancies (ionic
compensation) or holes (electronic compensation).25
Thus, the valence, ionic radius, and concentration of
the stabilizing dopant used as well as the processing
temperature will influence the defect concentration92 and
therefore the optical properties.
CONCLUSIONS
Based on the findings of the present systematic review,
the following conclusions were drawn:
1. Zirconia offers mechanical advantages over other
full ceramic dental restorations largely owing to the
potential for transformation toughening.
2. The zirconia-based materials that have been
considered for general dental applications are
monolithic (ZTA, PSZ, TZP, CSZ), while there also
are those specifically for esthetic (TZP, ZTLS, IPCZ)
applications.
3. Of these, ZTLS offers the best esthetic outcome but
its flexural strength is relatively low and it is suitable
only for single restorations. TZP and PSZ offer the
best mechanical outcomes but they are subject to
low temperature degradation (LTD) from the effects
of saliva and moisture as well as cyclic stress.
However, low-temperature degradation of TZP can
be avoided with the use of very small particle sizes.
4. Although CSZ does not exhibit transformation
toughening, its translucency makes it a compromise
material when esthetics are more important than
mechanical properties, as in the case of low-
intensity stress conditions.
5. While intrinsic parameters generally cannot be
manipulated, it is possible to change the interaction
of light with monolithic zirconia dental restorations
through alteration of the oxygen vacancy concen-
tration through annealing. It is possible to improve
the light transmission of CSZ by annealing in air.
6. Although extrinsic parameters can be manipulated
by the clinician in principle, the most effective
approach to improve esthetic outcomes is through
appropriate shade matching. In the clinical setting,
THE JOURNAL OF PROSTHETIC DENTISTRY
Volume 119 Issue 1
this involves shade communication using a light-
emitting diode light of 5500 K (D50) illumination.
In the dental laboratory, this involves the use of
both high- and low-light intensities during
fabrication.
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Corresponding author:
Reza Shahmiri
School of Materials Science and Engineering
University of New South Wales Sydney
Sydney NSW 2052
AUSTRALIA
Email: r.shahmiri@unsw.edu.au
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