Complete and partial contour zirconia designs for crowns and fixed dental prostheses: A clinical report

Baldwin W. Marchack, DDS, MBA,a Shoko Sato, DDS,b Christopher B. Marchack, DDS,c and Shane N. White, BDentSc, MS, MA, PhDd The Herman Ostrow School of Dentistry of USC, Los Angeles, Calif; Showa University School of Dentistry, Tokyo, Japan; UCLA School of Dentistry, Los Angeles, Calif
Since the introduction of milled zirconia copings for ceramic crowns, a variety of techniques have been introduced to reduce the incidence of chipping or fracturing of the porcelain veneer. These include methods of improving the interface between the coping and the veneer, reducing thermal incompatibility between the two, and optimizing the coping design to minimize tensile loading on the porcelain. Another method of reducing porcelain chipping and fracture is to limit or eliminate the porcelain coverage of zirconia copings and frameworks. Even though patients often demand tooth colored or nonmetallic restorations, they tend to be less concerned with the optimal esthetics of their posterior teeth. This article describes 4 representative clinical situations where efforts were made to minimize or eliminate porcelain coverage on posterior zirconia crowns and a fixed dental prosthesis, while still achieving acceptable, but not optimal, esthetics. (J Prosthet Dent 2011;106:145-152) Zirconia is stronger and tougher than most other ceramics used in dentistry.1-4 Zirconia frameworks have become widely used for crowns and partial fixed dental prostheses (FDPs) since being introduced to dentistry more than a decade ago.5 Today, various zirconia types and processing techniques are available.3-5 However, the chipping and fracturing of veneering porcelains applied to zirconia substructures remains problematic.3-20 Porcelain fracture and chipping has been reported at annual rates ranging from 0 to 54%, with annual rates between 1 and 8% being the most commonly reported.3-20 These complications appear to be substantially higher than for metal ceramic and alumina-based FDPs and crowns.14,17,21,22 Several factors have been reported to affect the rate of veneer fractures. These factors include strength of the porcelain to zirconia bond, framework surface treatments, porcelain and zirconia types, fabrication methods, thermal incompatibility between the porcelain and zirconia; the relatively low thermal conductivity of zirconia, and the relatively low elastic modulus of zirconia.10,23-27 Inappropriate preparation designs, including insufficient axial reduction, inadequate chamfer depth, or sharp internal and external line angles are also problematic. The design of the zirconia coping may influence the performance of veneering porcelain. The thickness of generically milled ceramic copings, typically a uniform 0.4 mm to 0.7 mm, has been based on empirical guidelines5,10 rather than upon clinical research. Moreover, in contrast to metal copings made with the lost wax process intended to support and protect porcelain from tensile forces, many milled ceramic copings are not contoured with respect to porcelain thickness. Coping and framework designs that minimize the tensile loading of veneering porcelain may reduce mechanical failure. A method of customizing zirconia copings with an anatomic-contour waxing and cut back in conjunction with a dual-scan technique was developed to customize and optimize the design of milled zirconia crown copings.10 This technique facilitated the achievement of even and controlled porcelain thickness. However, as for many other zirconia prostheses and crowns, approximately 12 of the 200 such crowns placed by the authors in the last 4 years have exhibited some porcelain

Presented at the annual meeting of the Pacific Coast Society for Prosthodontics in Napa Valley, California, June 2010. Councilor, The Herman Ostrow School of Dentistry of USC, Board of Councilors; private practice, Pasadena, California. Research Fellow, Showa University School of Dentistry; private practice, Saitama, Japan. c Associate Clinical Professor, The Herman Ostrow School of Dentistry of USC; private practice, Pasadena, California. d Professor, UCLA School of Dentistry.
a b

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chipping or gross fracture not involving the coping. Therefore, in an effort to further reduce porcelain chipping and fracture, the authors also now place highly polished or glazed zirconia crowns on second molars. For sites with greater visibility, zirconia crowns or FDPs are designed to incorporate limited porcelain veneering on the buccal aspects. To the authors knowledge, complete and partial contour zirconia restorations have not yet been described in the dental literature. This article describes an approach to minimizing or eliminating the use of veneering porcelain while achieving acceptable, but less than optimal, esthetics for zirconia-based prostheses.

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CLINICAL REPORT
Complete-contour polished zirconia crown A 36-year-old male presented to a private practice with gross caries in the mandibular left second molar. Caries removal resulted in a pulpal exposure and referral to an endodontist for endodontic therapy. Subsequently, a composite resin core (Build-It; Pentron Clinical, Wallingford, Conn) was placed. A cast gold crown was recommended because of the second molar location. Not only did the patient reject the use of a gold restoration, or any metal crowns, but he also explained that he was dissatisfied with the appearance of his previous metal ceramic crowns. Because of data suggesting that ceramic crowns have higher fracture rates in posterior teeth, a complete-contour zirconia crown was suggested, to which the patient consented.17,22,28-30 Polyether impressions (Impregum Penta; 3M ESPE, St Paul, Minn) were made and Class V stone casts (Die-Keen; Heraeus Kulzer, South Bend, Ind) were prepoured. A dual scan technique was used to create and merge datasets from the stone die and from an anatomic-contour waxing in the dental office. A contact scanner (NobelProcera Forte; Nobel Biocare USA, Yorba Linda, Calif ) used submarginal data points to orientate the separate data sets, so they could be merged.10 The merged file was transmitted to a

1 Anatomic-contour zirconia crown on articulated casts for evaluation, adjustment, and final polishing.

2 Anatomic-contour zirconia crown after polishing; all milling marks were removed, including those from occlusal grooves.

3 Anatomic-contour zirconia crown after cementation. Despite form color and opacity, it was as esthetically acceptable as adjacent metal ceramic crowns.

4 Anatomic-contour zirconia crown showing occlusal anatomy and surface polish.

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milling facility (NobelProcera Milling Center, Marwah, NJ) and the crown was milled from yttrium-stabilized zirconia (NobelProcera Zirconia; Nobel Biocare USA) in the light shade, 1 of 4 available shades. After milling, the crown was sintered by the manufacturer and sent to the dental office. After evaluation and adjustment on the stone cast (Fig. 1), it was polished with diamond-impregnated polishing points and wheels (Dialite Ceramic Polishing System; Brasseler, Savannah, Ga) (Fig. 2). Polished zirconia is more wear resistant to and less abrasive to the opposing dentition than feldspathic porcelain.31,32 It was inserted with minimal adjustment and cemented with an encapsulated glassionomer cement (Ketac Cem Aplicap, 3M ESPE, St Paul, Minn) (Figs. 3,4). The esthetics of this crown was similar to the adjacent crown on the mandibular left first molar. Complete-contour characterized and glazed zirconia crown A 51-year-old woman presented with pain upon occluding on her right mandibular second molar, which had an existing Class I amalgam restoration. This tooths pulpal and apical diagnoses were determined to be reversible pulpitis and normal, respectively. The restoration was removed, caries was removed, and an underlying mesial to distal crack was identified. The tooth was restored with a dentin bonding agent (Adper Single Bond Plus; 3M ESPE) and an opaque composite resin (Build-It; Pentron Clinical). The patient was advised that although endodontic therapy or extraction might be required, it was possible that placement of a gold crown could prevent further growth of the existing crack. She chose to have the tooth prepared (Fig. 5) and a provisional crown placed to assess the effect of this course of action. After a 2-week trial period with the provisional crown, she reported the tooth to be asymptomatic. Although the provision of a gold or metal ceramic crown was recommended, she rejected these options. Because of the history of enamel and dentin cracking in her second molar and data suggesting that ceramic crowns have higher

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5 Mandibular molar after placement of a composite resin foundation restoration showing staining in and around vertical cracks.

6 Mandibular molar complete contour zirconia crown as received from milling center. Internal and external line angles were rounded to reduce stress concentrations.

7 Mandibular molar complete contour zirconia crown glazed after evaluating and adjusting occlusion.

8 Mandibular molar complete contour zirconia crown after cementation; characterization is visible in primary and secondary occlusal grooves.

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9 Maxillary molar wax pattern for zirconia crown with buccal facing. Wax cutback was limited to ensure that porcelain to zirconia junction would be protected from direct occlusal function.

10 Maxillary molar zirconia coping after occlusal adjustment but before polishing and porcelain application.

11 Maxillary molar zirconia crown after polishing, porce- 12 Maxillary molar zirconia crown with porcelain facing lain application, staining, and cementation. after cementation. Milling marks visible in Figure 10 were removed by careful polishing. fracture rates in posterior teeth, a complete-contour zirconia crown was suggested, to which she consented.17,22,28-30 The tooth was impressed and stone casts were fabricated as previously described; then the casts were digitized with a laser scanner (3Shape, Copenhagen, Denmark). An appropriately shaped crown was selected from a digital library of teeth, the occlusal design and axial contours were finalized with associated software (Dental System 2009; 3Shape), and the file was transmitted to a milling facility (Diadem Digital Solutions, Troy, Mich). The crown was milled with a milling machine (Roeders of America, Inc, Nanuet, NY) from yttrium- stabilized zirconia (Zircad; Ivoclar Vivadent, Schaan, Liechtenstein) in 1 of 3 available shades, MO 1 (Fig. 6). After milling, the crown was sintered and returned to the dental office, evaluated and adjusted on the stone casts (Fig. 7), characterized (ArtiStains LFS, Pentron Ceramics, Inc, Somerset, NJ), and glazed (New Universal Porcelain Glaze; Pentron Ceramics). It was inserted without further adjustment and cemented with a resin-modified glass-ionomer cement (Fuji Plus; GC America, Alsip, Ill) (Fig. 8). The esthetics of this crown was similar to those of the adjacent crown on the mandibular right first molar, which had a zirconia coping completely veneered with feldspathic porcelain (Fig. 8). Zirconia crown with a buccal porcelain facing A 59-year-old woman with a wide smile and a high lip line presented with recurrent caries in the maxillary right first molar, which had previously been restored with a gold onlay. The extent of the caries necessitated a complete crown. She was advised of the available metal ceramic and ceramic options but indicated a preference for a durable nonmetal restoration. She chose a zirconia-based crown with porcelain applied to the buccal surface only. The tooth was prepared and impressions and casts were made as previously described. An anatomic-

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contour waxing was made, and the buccal surface was then cut back to obtain a uniform 1 mm space for veneering porcelain (Fig. 9). The wax cutback was designed so that porcelain would overlap the buccal cusp, and the mandibular molar buccal cusps would contact a zirconia occlusal surface at least 1 mm thick (Fig. 9). To maximize strength, the rest of the crown was maintained in zirconia. All of the porcelain-zirconia junctions were formed as butt joints; all internal and external line angles were rounded. The wax was also cut back to create a uniform porcelain labial margin. The dual scan technique was performed as previously described, but with a laser scanner instead of a contact scanner (NobelProcera Scanner; Nobel Biocare USA). A zirconia (NobelProcera Zirconia; Nobel Biocare USA) medium shade coping was milled, sintered, returned to the dental office, and mounted on a stone cast (Fig. 10). Although the wax had been cut back to create space for a buccal porcelain labial margin, the software default settings in the milling system produce a narrow zirconia margin. Therefore, the zirconia in the porcelain labial margin area was carefully cut back by hand. Similarly, software default settings ensured that the coping was at least 0.6 mm thick, regardless of the thickness indicated by the waxing. The zirconia coping was carefully polished (Dialite Ceramic Polishing System; Brasseler), and porcelain (ZiroX; Wieland Dental, Pforzheim, Germany) was applied and glazed. Occlusal grooves were characterized (ZiroX; Wieland Dental). The crown was cemented with an encapsulated glass-ionomer cement (Ketac Cem Aplicap; 3M ESPE). The esthetics of this crown was similar to those of the opposing mandibular first molar which had a metal ceramic crown (Figs. 11,12). Zirconia fixed dental prosthesis with a partial porcelain facing A 74-year-old woman presented with recurrent caries on the abutment teeth of an FDP. The FDP extended from the left mandibular second premolar to the left second molar (Fig. 13). The FDP had complete coverage abutments and was entirely metal except for a resinous facing on the buccal surface of the first molar pontic.

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13 Partial FDP made of metal, with resinous facing, which failed because of recurrent decay.

14 FDP anatomic contour wax pattern on articulated casts.

15 Dyed zirconia FDP framework showing cutback for partial porcelain facing, and connector design features described in detail within text.

16 Dyed zirconia FDP framework showing that entire functional occlusal surface was maintained in zirconia so that porcelain to zirconia junction was at least 1 mm beyond any potential occlusal contact.

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The patient wanted a more esthetic solution and indicated a preference for a ceramic restoration. She accepted a zirconia FDP with porcelain applied only to the buccal surfaces of the premolar and first molar. The patient was forewarned that opaque tooth-colored zirconia would be visible on all of the occlusal surfaces and on the occlusal aspect of the facial surfaces of the second premolar and first molar, as well as on the entire second molar. The patient believed that this would be far preferable to her previous silver-colored FDP. An anatomic-contour wax pattern of the new FDP was fabricated on a working cast (Fig. 14). The buccal surfaces of the 2 anterior teeth were cut back to allow space for veneering porcelain. The porcelain-zirconia junctions were created as butt joints, and internal and external line angles were rounded. To protect the porcelain from occlusal forces, the cutback began several mm from the maximum intercuspal contacts and at least 1 mm from the excursive occlusal contacts (Figs. 15,16). A narrow marginal collar was maintained on the buccal aspect of the anterior abutment. Approximately 1 mm of space was provided for the partial porcelain veneer. The pontic connectors were at least 5 mm in height; their tissue-facing and occlusal surfaces were not cut back; and they were maintained in zirconia.1,5,33,34 The manufacturer (Aadva Zirconia Coping; GC Advanced Technologies, Costa Mesa, Calif ) recommended a cross-sectional connector area of at least 9 mm2. Limited in vitro data indicate that thicker connectors increase strength and decrease stress.1,33,34 This design maximized the height of the connector and preserved the tissue facing, or tensile surface, of the FDP in zirconia.1,5 The design also provided considerable bulk of zirconia in the area where the connector met the proximal wall of the abutment crown, an area often involved in ceramic FDP fractures. The radii of the curvature of the embrasures were maximized to reduce stress concen-

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17 Zirconia FDP after porcelain application, staining, and cementation.

18 Zirconia FDP with a partial porcelain facing. Despite extensive zirconia surfaces, and less than optimal shade matching, result was pleasing. trations on the tensile surfaces of the connectors.5,17,34 The design concepts were largely based on the extrapolation of in vitro data because clinical outcome data remain insufficient. The cast and wax pattern were sent to a scanning and milling facility (GC Advanced Technologies). The wax pattern was sprayed with a nonreflecting powder (Quickcheck Indicating Spray; Vacalon, Pickerington, Ohio) to reduce reflections during laser scanning. A dual scanning technique was used, the datasets obtained were merged, and the coping was milled in a partly sintered zirconia block (Aadva Zirconia; GC Advanced Technologies). After milling, the framework was dipped in a dye for a specific period of time to achieve Aadva shade 13, one of 10 available shades, broadly equivalent to Vita shade A4. The zirconia framework was then fully sintered (Figs. 15,16). The FDP framework was returned on the working cast. Although the wax pattern had a marginal collar, this area of the framework was refined by hand so as to create a definite porcelain-zirconia butt joint. Porcelain (ZiroX; Wieland Dental) was then applied to the buccal surfaces of the second premolar abutment and the first molar pontic. Next, a colored glaze (ZiroX; Wieland Dental) was applied to the smooth surfaces of the second molar, and all the fissures stained (ZiroX; Wieland Dental). Once the occlusion was confirmed on the articulated cast, the FPD was cemented (Fuji Plus; GC America) (Figs. 17,18). Even though the occlusal surfaces were opaque, the esthetic result was considered acceptable to the patient. For all patients presented in this re-

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port, the prostheses have been in place for over 2 years, and no complications have occurred to date. Current design software tends to facilitate the achievement of uniform coping thickness, not uniform porcelain thickness. Advances are anticipated. The use of zirconia on external surfaces requires careful polishing of machined surfaces (Figs. 10,12). Poorly polished zirconia surfaces could be abrasive. Glazes may improve hue and chroma, but they are no substitute for internally characterized translucent porcelains. Glazes are less wear resistant, weaker, and more abrasive to opposing enamel than polished porcelains37,38 and they do not permit the achievement of a wide range of subtle surface textures. Although different shades of zirconia are currently available from various manufacturers, a wide range of shades and translucencies is currently unavailable. Despite these limitations, acceptable esthetics was achieved in the posterior restorations reported.

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REFERENCES
1. White SN, Miklus VG, McLaren EA, Lang LA, Caputo AA. Flexural strength of a layered zirconia and porcelain dental all-ceramic system. J Prosthet Dent 2005;94:125-31. 2. Kelly JR, Denry I. Stabilized zirconia as a structural ceramic: an overview. Dent Mater 2008;24:289-98. 3. Denry I, Kelly JR. State of the art of zirconia for dental applications. Dent Mater 2008;24:299-307. 4. Silva NRFA, Sailer I, Zhang Y, Coelho PG, Guess PC, Zembic A, et al. Performance of zirconia for dental healthcare. Materials 2010;3:863-896. 5. McLaren EA, White SN. Glass-infiltrated zirconia/alumina-based ceramic for crowns and fixed partial dentures. Pract Periodontics Aesthet Dent 1999;11:985-94. 6. Larsson C, Vult von Steyern P, Sunzel B, Nilner K. All-ceramic two- to five-unit implant-supported reconstructions. A randomized, prospective clinical trial. Swed Dental J 2006;30:45-53. 7. Raigrodski AJ, Chiche GJ, Potiket N, Hochstedler JL, Mohamed SE, Billiot S, et al. The efficacy of posterior three-unit zirconium-oxide-based ceramic fixed partial dental prostheses: a prospective clinical pilot study. J Prosthet Dent 2006;96:237-44. 8. Sailer I, Fehr A, Filser F, Lthy H, Gauckler LJ, Schrer P, et al. Prospective clinical study of zirconia posterior fixed partial dentures: 3-year follow-up. Quintessence Int 2006;37:685-93. 9. Sailer I, Fehr A, Filser F, Gauckler LJ, Lthy, Hmmerle CH. Five-year clinical results of zirconia frameworks for posterior fixed partial dentures. Int J Prosthodont 2007;20:383-8. 10.Marchack BW, Futatsuki Y, Marchack CB, White SN. Customization of milled zirconia copings for all-ceramic crowns: a clinical report. J Prosthet Dent 2008;99:169-73. 11.Tinschert J, Schulze KA, Natt G, Latzke P, Heussen N, Spiekermann H. Clinical behavior of zirconia-based fixed partial dentures made of DC-Zirkon: 3-year results. Int J Prosthodont 2008;21:217-22. 12.Edelhoff D, Florian B, Florian W, Johnen C. HIP zirconia fixed partial dentures - clinical results after 3 years of clinical service. Quintessence Int 2008;39:459-71. 13.Kollar A, Huber S, Mericske E, MericskeStern R. Zirconia for teeth and implants: a case series. Int J Periodontics Restorative Dent 2008;28:479-87. 14.Sailer I, Gottnerb J, Kanelb S, Hammerle CH. Randomized controlled clinical trial of zirconia-ceramic and metal-ceramic posterior fixed dental prostheses: a 3-year follow-up. Int J Prosthodont 2009;22:553-60. 15.Schmitter M, Mussotter K, Rammelsberg P, Stober T, Ohlmann B, Gabbert O. Clinical performance of extended zirconia frameworks for fixed dental prostheses: two-year results. J Oral Rehabil 2009;36:610-5.

DISCUSSION
The designs for crowns and partial FDPs described in this article are intended to maximize the thickness and bulk of zirconia in posterior restorations and to minimize or eliminate weaker veneering porcelain. The authors focused on minimizing or eliminating the extent of veneering porcelain coverage on molar restorations because posterior ceramic restorations tend to have higher incidences of fracture than anterior ceramic restorations.17,22,28-30 Even though patients frequently request tooth-colored or nonmetal restorations, they tend to be less concerned about optimal esthetics for the posterior teeth. Zirconia is the toughest ceramic core material currently available.1-4 Although other stronger and tougher industrial ceramics are available, their poor esthetics and difficulty of processing for individual customized prostheses currently preclude their use as prosthodontic cores or frameworks. Although the importance of toughness, or fracture resistance, is obvious, other factors such as elastic modulus, or stiffness, as well as strength are also important. Clinical failure mechanisms remain poorly understood.35,36 Clearly, research is needed to fully understand the failure mechanisms of ceramic crowns and fixed dental prostheses fabricated in the manner described. Until tooth-preparation parameters, coping and framework design, and materialsperformance parameters have received additional study, precise recommendations or predictions cannot be made with confidence. The fabrication techniques described in this article for achieving minimal and even thickness of porcelain veneering require the use of anatomic contour waxings and dual scan techniques. Both steps are laborious. Current design software is not ideal for making customized digital cutbacks.

SUMMARY
Because porcelain chipping and fracturing remain problematic for zirconia-based restorations, the use of complete and partial contour zirconia restorations was described. Four representative clinical treatments were described demonstrating the efforts made to minimize or eliminate porcelain coverage on posterior zirconia crowns and a fixed dental prosthesis, while still achieving acceptable esthetics. Technical procedures included a dual scan technique to customize coping designs for controlled porcelain application, the use of preshaded zirconia blocks, the use of a dye to shade a partly sintered zirconia block, the external characterizing and glazing, and the surface polishing of zirconia. A variety of zirconia products and fabrication methods were included. Acceptable, but not optimal, esthetics was achieved on posterior teeth for patients who requested durable tooth-colored nonmetal restorations.

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16.Schley J, Heussen N, Reich S, Fischer Jan, Haselhuhn K, Wolfart S. Survival probability of zirconia-based fixed dental prostheses up to 5 yr: a systematic review of the literature. Eur J Oral Sci 2010;118:443-50. 17.Heintze SD, Rousson V. Survival of zirconia- and metal-supported fixed dental prostheses: a systematic review. Int J Prosthodont 2010;23:493-502. 18.Komine F, Blatz MB, Marsumura H. Current status of zirconia-based fixed restorations. J Oral Sci 2010;52:531-9. 19.Al-Amleh B, Lyons K, Swain M. Clinical trials in zirconia: a systematic review. J Oral Rehabil 2010;37:641-52. 20.Christensen RP, Ploeger BJ. A clinical comparison of zirconia, metal and alumina fixed-prosthesis frameworks veneered with layered or pressed ceramic: a three-year report. J Am Dent Assoc 2010;141:1317-29. 21.Goodacre CJ, Bernal G, Rungcharassaeng K, Kan JY. Clinical complications in fixed prosthodontics. J Prosthet Dent 2003;90:31-41. 22.McLaren EA, White SN. Survival of InCeram crowns in a private practice: a prospective clinical trial. J Prosthet Dent 2000;83:216-22. 23.Aboushelib MN, Kleverlaan CJ, Feilzer AJ. Effect of zirconia type on its bond strength with different veneer ceramics. J Prosthod 2008;17:401-8. 24.Fischer J, Stawarzcyk B, Trottmann A, Hmmerle CH. Impact of thermal misfit on shear strength of veneering ceramic/zirconia composites. Dent Mater 2009;25:419-23. 25.Swain MV. Unstable cracking (chipping) of veneering porcelain on all-ceramic dental crowns and fixed partial dentures. Acta Biomater 2009;5:1668-77. 26.Anunmana C, Anusavice KJ, Mecholsky JJ Jr. Interfacial toughness of bilayer dental ceramics based on a short-bar, chevron-notch test. Dent Mater 2010;26:111-7. 27.Fischer J, Stawarczyk B, Sailer I, Hmmerle CH. Shear bond strength between veneering ceramics and ceria-stabilized zirconia/ alumina. J Prosthet Dent 2010;103:267-74. 28.Malament KA, Socransky SS. Survival of Dicor glass-ceramic dental restorations over 14 years: Part I. Survival of Dicor complete coverage restorations and effect of internal surface acid etching, tooth position, gender, and age. J Prosthet Dent 1999;81:23-32. 29.Land MF, Hopp CD. Survival rates of allceramic systems differ by clinical indication and fabrication method. J Evid Based Dent Pract 2010;10:37-8. 30.Malament KA, Socransky S. Survival of Dicor glass-ceramic dental restorations over 20 years: Part IV. The effects of combinations of variables. Int J Prosthodont 2010;23:134-40. 31.Jung YS, Lee JW, Choi YJ, Ahn JS, Shin SW, Huh JB. A study on the in-vitro wear of the natural tooth structure by opposing zirconia or dental porcelain. J Adv Prosthodont 2010;2:111-5. 32.Preis V, Behr M, Kolbeck C, Hahnel S, Handel G, Rosentritt M. Wear performance of substructure ceramics and veneering porcelains. Dental Mater 2011;27:796-804. 33.Larsson C, Holm L, Lvgren N, Kokubo Y, Vult von Steyern P. Fracture strength of four-unit Y-TZP FPD cores designed with varying connector diameter. An in-vitro study. J Oral Rehabil 2007;34:702-9.

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34.Quinn GD, Studart AR, Hebert C, VerHoef JR, Arola D. Fatigue of zirconia and dental bridge geometry: Design implications. Dent Mater 2010;26:1133-6. 35.Kelly JR. Clinically relevant approach to failure testing of all-ceramic restorations. J Prosthet Dent 1999;81:652-61. 36.Lawn BR, Pajares A, Zhang Y, Deng Y, Polack MA, Lloyd IK, et al. Materials design in the performance of all-ceramic crowns. Biomaterials 2004;25:2885-92. 37.Jagger DC, Harrison A. An in vitro investigation into the wear effects of unglazed, glazed, and polished porcelain on human enamel. J Prosthet Dent 1994;72:320-3. 38.Rosenstiel SF, Baiker MA, Johnston WM. Comparison of glazed and polished dental porcelain. Int J Prosthodont 1989;2:524-9. Corresponding author: Dr Baldwin Marchack 301 South Fair Oaks Avenue Suite 408 Pasadena, CA 91105 Fax: 626-793-8777 E-mail: bmarchack@aol.com Acknowledgment The authors are most grateful to their colleagues Tomikazu Tada, RDT, Emaline Stapleton, CDT, and Shaun Urata, RDT for their invaluable technical skills and generous advice in fabricating the restorations described in this paper. Copyright 2011 by the Editorial Council for The Journal of Prosthetic Dentistry.

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