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Dent Mater. Author manuscript; available in PMC 2020 May 01.
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Published in final edited form as:

Dent Mater. 2019 May ; 35(5): 807–817. doi:10.1016/j.dental.2019.02.016.

Do thermal treatments affect the mechanical behavior of

porcelain-veneered zirconia? A systematic review and meta-
analysis.
Camila da Silva Rodrigues1, Iana Lamadrid Aurélio1, Marina da Rosa Kaizer2, Yu Zhang2,
and Liliana Gressler May3
1Post-Graduate Program in Dental Science, Federal University of Santa Maria (UFSM), 1184
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Floriano Peixoto, 7th floor, 97015-372, Santa Maria, RS, Brazil.

2Department of Biomaterials and Biomimetics, New York University, 433 First Avenue, 8th floor,
10010, New York, NY, USA.
3Department of Restorative Dentistry, Federal University of Santa Maria (UFSM), 1184 Floriano
Peixoto Street, 3rd floor, 97015-372, Santa Maria, RS, Brazil.

Abstract
Objectives.—A systematic review of in vitro studies was conducted to assess the effect of
thermal treatments on flexural strength or critical load to failure of porcelain-veneered zirconia
(PVZ).
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Sources.—Literature searches were performed up to June 2018 in PubMed/MEDLINE, Scopus

and Web of Science databases, with no publication year or language limits.

Data.—From 393 relevant studies, 21 were selected for full-text analysis, from which 7 failed to
meet the inclusion criteria. The 14 remaining papers were included for the systematic review: 8 for
meta-analysis and 6 restricted to descriptive analyses. Hand searching of reference lists resulted in
no additional papers.

Study selection.—In vitro studies using PVZ specimens testing the influence of thermal
treatments on the fracture resistance to monotonic or cyclic loading. Papers evaluating cooling rate
were divided into those applying fast cooling from above the porcelain glass transition temperature
(T g), or from below it. Meta-analyses were performed separately for flexural strength and critical
load to failure, using random effects at a 5% significance level.
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Conclusions.—Delaying furnace opening at a temperature below the porcelain T g is advised for

PVZ restorations, in order to improve their fracture resistance. Additional information is required
to confirm the apparently beneficial effect of self-glaze and repeated veneer firings on the
mechanical properties of these restorations. Finally, in order to obtain conclusive and relevant
evidence regarding thermal treatments and the fracture resistance of PVZs, future studies should
concentrate on anatomically-correct crown specimens.

Electronic address: [email protected].

 da Silva Rodrigues et al. Page 2

Keywords
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porcelain-veneered zirconia; cooling protocols; glaze firings; repeated firings; heat treatment;
mechanical properties

1. Introduction
Yttria-stabilized tetragonal zirconia polycrystal ceramic has been perceived as a superior
restorative material due to its biocompatibility and mechanical properties.1 Porcelain-
veneered zirconia restorations combine the strength of the zirconia framework with the
excellent optical properties of the veneering porcelain.2 The clinical survival rates of these
restorations range from 90% to 95% in 5 years.3–5 However, only about 70%,6–7 did not
require any intervention for continued function. Veneer fracture has been the leading cause
of the reduced success rates.6,7 These fractures may be repairable by polishing or filling with
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another restorative material (minor chipping) or not repairable (major chipping or

catastrophic fractures), which lead to restoration replacement. Several factors have been
associated to veneer failures, such as porcelain heterogeneous thickness,8,9 non-anatomical
design of the framework,10–12 coefficient of thermal expansion (CTE) mismatch,13 elastic
modulus14 and fracture toughness of porcelain,15 inadequate veneer firing,16 or residual
thermal stresses.17, 18

Deleterious thermal stress gradients have been associated to the cooling rate after the last
firing.19,20 When the bilayer restoration is fast cooled, meaning the restoration is exposed to
a thermal shock in high temperatures by immediately opening the furnace once the firing
schedule is done, the surface of the porcelain solidifies and contract earlier, while the inner
region remains at higher temperature. When the inner temperature decreases, the already
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solid surface hinders the contraction of the inner porcelain upon cooling, and residual tensile
stresses become locked into the material system.14,20 In contrary, when slow cooling is used,
the restoration stays under controlled temperature reduction, thus, the whole structure of the
restoration is expected to cool uniformly, effectively reducing residual thermal stresses.21
However, not all previous studies have shown difference in the strength of bilayer systems
after fast or slow cooling.22–24 Various other thermal treatments have been proposed to
overcome the chipping susceptibility and improve the fracture resistance of veneer ceramic,
including glaze,25 number of veneer firings,26,27 and additional firing in different
temperatures.28 Previous studies suggest that these thermal treatments may relief thermal
stresses.29,30

Considering that veneer chipping is a current clinical problem and it is strongly associated to
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the thermal treatments experienced by the porcelain veneered restoration, a systematic

compilation of the contradictory literature and pooled data analysis may provide clear
conclusions. Thus, this systematic review sought to assess the available scientific literature,
investigating the following research question: How do thermal treatments (glaze, number of
veneer firings, annealing, and cooling rate) influence the flexural strength or critical load to
failure of porcelain-veneered zirconia?

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2. Materials and methods

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This systematic review was prepared and reported according to the Preferred Reporting
Items for Systematic Reviews and Meta-Analyses (PRISMA).31 A non-registered protocol
was elaborated prior to the literature search. The PICOS question was defined as follows:
Population: porcelain-veneered zirconia (PVZ) specimens with any geometry; Intervention:
slow cooling, more than two veneer firings, over- or self-glaze, or annealing; Comparison:
fast cooling (from above or below transformation temperature (T g) of the veneer porcelain),
up to two veneer firings, no glaze, or no annealing; Outcomes: flexural strength or critical
load to failure; Study design: in vitro studies.

2.1 Search Strategy

Literature search was carried out in PubMed/MEDLINE, Scopus and Web of Science
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databases to identify relevant articles up to June 2018. The search was conducted with no
publication year or language limits. The studies were searched from PubMed/MEDLINE
using the following strategy: ((zirconi*) OR (ytzp) OR (y-tzp)) AND ((dental
porcelain*[MeSH Terms]) OR (porcelain) OR (veneer*) OR (bilayer) OR (veneered
zirconia)) AND ((glaze*) OR (firing*) OR (fast cooling) OR (slow cooling) OR (cooling
rate) OR (thermal treatment) OR (heat treatment) OR (annealing)) AND ((Compressive
strength [MeSH Terms]) OR (strength) OR (flexural) OR (resistance) OR (load) OR (failure)
OR (fatigue)). A sensitive search strategy was adapted for Scopus and Web of Sciences. The
results of all databases searches were crosschecked to eliminate duplicates.

2.2 Selection of studies and eligibility criteria

Two reviewers (CSR and ILA) independently assessed the identified publications and
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selected them by title and abstract based on the following inclusion criteria: in vitro studies
using PVZ specimens, which tested the influence of any thermal treatments on flexural
strength or critical load to failure regardless the mechanical test configuration adopted
(monotonic or cyclic loading).

The final decision about inclusion of a given study was made based on full-text evaluation of
potentially relevant papers. Those which were not in accordance with the following criteria
were excluded: 1) at least one intervention group subjected to more than two veneer firings,
glaze firing, annealing, or slow cooling; 2) at least one comparison group subjected up to
two veneer firings, no glaze, no annealing, or fast cooling, respectively; and 3) quantitative
results reported as mean values and standard deviation (or equivalent central tendency and
dispersion values) for flexural strength (MPa) or for critical load to failure (N), along with
description of the sample sizes of each group. Reference lists of the included papers were
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also screened. When fatigue data was described in terms of reliability or number of cycles,
authors were contacted and asked to provide the means and standard deviations of flexural
strength or critical load to failure. Otherwise, these papers were not considered for meta-
analyses. Any discrepancies between the reviewers were resolved through discussion and
judgment by a third reviewer (LGM). The inter-examiner agreement (Kappa coefficient) was
calculated for both phases (eligibility criteria: 0.86 and exclusion criteria: 0.95). Both

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reviewers also collected the data from the eligible studies independently, which were then
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compiled and discussed for consensus.

2.3 Risk of bias assessment

Quality of the studies was assessed by the two reviewers using the modified Consolidated
Standards of Reporting Trials (CONSORT) checklist.32 The following items were evaluated
in each paper: 1) Structured summary of trial design, methods, results and conclusions, 2a)
Scientific background and explanation of rationale, 2b) Specific objectives and/or
hypothesis, 3) The intervention of each group, including how and when it was performed,
with sufficient detail to enable replication, 4) Completely defined, pre-specified primary and
secondary measured of outcome, including how and when they were assessed, 5) How the
sample size was determined, 6) Method used to generate the random allocation sequence, 7)
Mechanism used to implement the random allocation sequence, 8) Who assigned the random
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allocation, 9) Who was blinded after assignment to the intervention, 10) Statistical methods
used to compare groups, 11) Results for each group and estimated size of effect and its
precision, 12) Trial limitations, addressing sources of potential bias, imprecision, and, if
relevant multiplicity of analysis, 13) Sources of funding and other support, 14) Where the
full trial protocol can be accessed. Each parameter was judged as reported (Yes) or not
reported (No).

2.4 Data analyses

Data analyses were carried out using Review Manager software version 5.3 (Cochrane
Collaboration). Papers evaluating cooling rate were categorized into those which used a fast
cooling (furnace opening and samples immediately removed) from above or below the T g of
the veneer porcelain. Distinct meta-analyses were performed using random effects for fast
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(aboveT g) versus slow cooling, fast (belowT g) versus slow cooling, and for flexural strength
or critical load to failure data. Forest plots were created and significance level was set at 5%
(Z test). The heterogeneity among studies was evaluated by Cochrane Q test, where P<0.1
was considered statistically significant, and the inconsistency I2 test, where values higher
than 50% were considered indicative of substantial heterogeneity. 33

Studies that could not be included in meta-analyses due to lack of data (mean and standard
deviation values and sample size) and/or due to methodological differences that did not
allow comparisons with other studies, were only descriptively analyzed.

3. Results
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3.1 Study selection

Figure 1 depicts a flowchart summarizing the selection process for studies. The search
strategy identified 393 potentially relevant records. The first screening, by title and abstract,
resulted in 21 studies that remained for full-text reading. Finally, 14 papers were included in
the systematic review: 8 for quantitative evaluation using meta-analyses and 6 restricted to
descriptive analyses. Manual searching through the reference lists of included studies
resulted in no additional papers. Table 1 describes the characteristics of included studies.

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The majority of studies evaluated cooling rate (10 studies),13,22–24,36–41 two evaluated
number of veneer firings,26,27 one evaluated self-glaze,25 and one investigated alternative
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firings.28 The included studies used 9 different commercial brands of veneer porcelains,
presenting a range of physical characteristics, such as elastic modulus (E), coefficient of
thermal expansion (CTE) and glass transition temperature (T g). These porcelains and their
characteristics are described in Table 2.

3.2 Risk of bias

Table 3 presents the estimated risk of bias of each included study. All included papers
properly presented a structured summary, specific objectives, and statistical analyses. Some
papers reported to have performed randomization,23,27,34,36,37 however, they have not
reported how this procedure was carried out. Not one study clearly reported information
about the mechanism used to implement the random allocation process, who performed it,
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and where the full trial protocol can be assessed. Background and rationale (6%),
intervention description (19%), outcome description (12%), blinding (81%), limitations
(56%), and funding resources (25%) were not always clearly reported.

3.3 Data analyses

Data analyses were performed qualitatively (descriptive summary) and quantitatively (meta-
analyses), when appropriate, for each of the following treatments topics.

3.3.1 Cooling rate—Figure 1 shows the forest plot of the meta-analysis comprising 2
studies 34,37 with high heterogeneity (65%), comparing the fast cooling from below T g
versus slow cooling effect on PVZ flexural strength. As a result, no statistical difference was
observed (P = 0.37) between cooling rates. A meta-analysis assessing the influence of fast
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cooling from above T g versus slow cooling on flexural strength was carried out including 3
studies (Figure 2).22,23,37 Heterogeneity was also considered high (61%) and no statistical
difference was detected (P = 0.08). However, when the fast cooling from above T g versus
slow cooling effect on critical load to failure of PVZ crowns was investigated, the results of
the meta-analysis involving 4 studies with low heterogeneity (33%)13,35,38,39 showed that
slow cooling yielded higher values of critical load to failure (P = 0.04) (Figure 3).

Paula et al.36 investigated the influence of cooling rates on mechanical behavior of bilayer
systems reporting only the number of cycles until failure. Thus, could not be included in
meta-analyses, being only descriptively analyzed. The authors investigated the influence of
fast cooling from above T g and slow cooling rates on the survival of crown-shaped PVZ
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specimens. Their results showed that none of the fast cooled crowns survived 106 cycles,
whereas all slow cooled crowns survived until the end of the test (106 cycles).

Another included study that was only descriptively analyzed was Meirelles et al.24, which
evaluated the effect of cooling regiments on flexural strength of different porcelains on
bilayer samples. The slow cooling protocol adopted in this study is actually identical to the
fast cooling from belowT g, in which the samples were immediately removed from the

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furnace once the firing cycle ended. The comparison group was fast cooling from aboveT g.
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The authors observed that the cooling protocols had no influence on flexural strength of the
bar-shaped PVZ specimens.

3.3.2 Number of firings—As only two methodologically distinct studies evaluated

number of veneer firings, no meta-analyses could be performed. Vichi et al (2015)27
observed that 2 and 5 veneering firings led to higher values of flexural strength [78 (13)
MPa, and 78 (12) MPa, respectively] than only one firing cycle [52 (9) MPa], when tested
with the porcelain veneer in tension. Lu et al (2011)26 tested 2, 4, 6, 8 firing cycles and did
not find any statistical difference among flexural strength means [996 (145) MPa, 999 (120)
MPa, 1019 (51) MPa, and 1008 (103) MPa, respectively], tested with the zirconia layer in
tension.
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3.3.3 Glaze and annealing—Only one included study compared groups with or
without glaze firing.25 The authors described that the load to failure of the polished and
glazed group (389 ±202 N) was significantly greater than the polished-only group (301 ±199
N).

No included study evaluated annealing treatments, however Taskonak et al.28 tested

extended firing cycles comprising a 60 min holding time stage in different temperatures
around theT g, followed by slow or fast cooling. The authors reported that the treatments at or
above the T g followed by fast cooling resulted in higher flexural strength, compared to
extended slow cooling to room temperature.

4. Discussion
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The results of this systematic review showed that thermal treatments can influence flexural
strength and critical load to failure of PVZ restorations. Most of included studies evaluated
cooling protocols, which allowed us to perform three meta-analyses. For complex geometry
samples (crowns), the cooling protocol significantly affected the critical load to failure of
PVZ. However, when simple geometry samples (bars or discs) were used, no difference in
fracture resistance was detected between different cooling regimens. Self-glaze and repeated
veneer firings appeared to increase the mechanical strength of veneered systems based on
the few studies available. However, this effect could only be descriptively analyzed, thus any
inferences should be taken with caution.

A critical aspect regarding pooling data from various or multiple cooling rate studies is that
there is no clear definition of what is considered slow cooling, since a large variety of
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protocols were used among the included studies (Table 1). Similarly, fast cooling regimens
also vary among studies. Studies were classified into those where specimens were fast
cooled from a temperature above the porcelain T g or from belowT g, considering that the
veneer porcelain behave completely different on each stage.40 Glassy materials are viscous
liquids aboveT g, and fast cooling them from above this point means that structural
contraction may lead to residual stress locked inside the material during the process.13 In

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contrast, retarding fast cooling of PVZ restorations from temperatures below the T g may
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impede the deleterious temperature gradients. Thus, avoiding the development of transient
and residual stresses, which could weaken the ceramic material.21 These observations are in
agreement with the results of our meta-analysis, indicating that flexural strength is not
affected by cooling rate when the rapid cooling stage is performed from belowT g. One
should notice, though, that this meta-analysis pooled data from studies that used simple
geometry specimens for the precise calculation of flexural strength. Finite element analysis
(FEA) studies reported that cooling down restorations from 50˚C below T g is enough to
decrease residual stresses and avoid thermal gradients;42 and that an overextended cooling
protocol (closed furnace until 25˚C at 2˚C/min), besides time consuming, added more tensile
and compressive residual stresses throughout the porcelain layer, compared to a more
reasonable slow cooling regimen (closed furnace until 450˚C). 41
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Our two meta-analyses comparing fast cooling from above T g versus slow cooling, for
flexural strength (Fig. 2) and critical load to failure (Fig. 3), presented contradictory results.
The studies evaluating flexural strength use simple geometry specimens, in which case no
differences between the two cooling rates were observed. Nonetheless, when crown-shaped
specimens were used and the critical load to failure was recorded, slow cooling yielded
superior results. In addition to the geometric differences, bar and disc specimens (in the
flexural strength analysis) had porcelain veneer thickness of 0.5 – 1.0 mm; while, the crown
specimens (in the critical load to failure analysis) had 1.5 – 2.0 mm thick porcelain veneers.
Benetti et al.21, using FEA, observed that when porcelain layer increases from 1 to 2 mm,
thermal stresses gradients increase throughout the veneer. The authors also observed that the
fast cooling (furnace opening at 800˚C – aboveT g) led to high levels of transient tensions,
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which were associated to internal microcracks and, consequently, early failures. Moreover,
previous studies have observed distinct residual stresses in curved areas of PVZ crowns,41–43
especially when fast cooling was applied.43 Thus, it is plausible that the difference in
residual stress distributions due to different geometries and thicknesses led to the
contradictory meta-analyses results regarding flexural strength and critical load to failure.

The only two included studies that evaluated number of firings in PVZ indicate that two
veneer firings may improve the flexural strength of the bilayer specimens, while no further
improvement is seen when more than two firings are applied. However, these results must be
interpreted with cautions, since one test was performed with porcelain in tension27 and the
other one with zirconia in tension.26 Such contrast resulted in extremely different flexural
strength values between the two papers, since the mechanical properties of the specimens are
determined by the material under tension.44 The study of Tang et al.46, which is not included
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in this systematic review, also did not observe differences in the flexural strength of most
monolithic veneering ceramics when fired for 2 up to 10 times. Nonetheless, other studies
evaluating monolithic porcelain specimens, observed that increasing number of firings can
improve hardness, density, and decrease porosity.45,46

Among the included studies, only one evaluated the effect of glaze firing on bilayer
specimens.25 The experimental groups included one that was just polished and another

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polished and self-glazed, which presented higher flexural strength. Self-glaze is technically
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convenient since it does not require the application of additional glazing material. This heat
treatment aims to expose a glass-based material to temperatures at or above the T g for 1 – 2
min in order to promote a superficial melting, improving gloss and healing surface deffects.
47 Previous literature is controversial, showing that self-glaze can either improve48 or
decrease49 the flexural strength of monolithic porcelains, showing a lack of evidence
regarding the effect of self- or over- glaze in mechanical properties of porcelains for bilayer
systems.

Regarding annealing, not one study evaluating this heat treatment on PVZ met the inclusion
criteria of this systematic review. Previous investigations have shown that annealing can
promote crack healing50 and improve flexural strength51 of glassy ceramics. Nevertheless,
annealing is very time consuming, firstly, the glassy material is heated and kept at a
temperature above T g for a given time, usually 10 h, to allow for atomic rearrangement;
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then, the material is slowly cooled in order to prevent new residual stresses.40 The time issue
is a practical disadvantage of annealing, which seems to discourage researchers to evaluate
its effects on bilayer systems. Nonetheless, Taskonak et al.28 studied extended firings at
different temperatures around the T g as an alternative thermal treatment. The authors tested
four different additional firing cycles at temperatures below, at, and above porcelainT g,
followed by slow or fast cooling. They observed higher flexural strength for the groups
treated at or above T g then fast cooled. This may be associated with an atomic
rearrangement, which only happens in temperatures aboveT g, when the glass viscosity
decreases.40 Nonetheless, one should note that the authors compared fast cooling with an
overextended slow cooling regimen (down to room temperature, taking around 600 min). An
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aforementioned FEA study41 showed that overextended slow cooling below T g is deleterious
even for flat specimens.

Most papers in the literature do not clearly report the details of their methodological
approaches. Similar shortcomings were also observed in the included studies (Table 3).
Similarly, previous systematic reviews of in vitro studies also found only a few papers with
low risk of bias,52,53 which demonstrates that poor methodological report is a common
problem.54 Furthermore, most of the included studies tested cooling rates, while only very
few, if any, investigated other thermal treatments. Thus, it was not possible to reach
substantial conclusions on other treatments, such as glazing, annealing, and number of
veneer firings. Another limitation relies on the heterogeneity of included studies, specially
the lack of consensus about what is a slow or a fast cooling protocol. Interestingly, some
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manufacturers already recommend, for all firing cycles, that the furnace should only be
opened below the porcelainT g, which is in agreement with the findings of our systematic
review. However, other manufacturers still disregard the deleterious effects of residual
thermal stresses and recommend fast cooling from sintering temperature or any other firings
(Table 2). In all included studies, compatible porcelains were used to veneer zirconia
substructures, as recommended by the dental ceramic manufacturers (Table 2). Nonetheless,
it is known that even small mismatches in CTE, along with the elastic properties of the

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porcelain, can affect the magnitude, location and type of residual stresses.14 Moreover, other
variables such as porcelain/zirconia thickness ratio23,35 and the indenter used for load
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application55,56 may also affect the results. Therefore, the high heterogeneity observed in
our meta-analyses, may also be explained by the pooling of data including distinct porcelain/
zirconia combinations and test configurations.

Despite all the methodological differences among the studies (Table 1), our results showed
that fast cooling PVZ from temperatures above the porcelain T g has deleterious effect on its
critical load to failure for complex geometries -- crowns. However, delaying furnace opening
to temperatures below theT g, seems to be enough to preserve the material’s mechanical
behavior. In addition, the geometry of specimens for in vitro investigations of thermal
stresses should be considered, since it seems to affect the mechanical response of veneered
zirconia systems.
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5. Conclusions
The systematic investigation of the literature has led to the recommendation to delay the
furnace opening at a temperature below the porcelain glass transition temperature for
porcelain-veneered zirconia restorations. This procedure improves the fracture resistance of
the restoration, while fast cooling from temperatures above the porcelain glass transition
temperature leads to a decrease in their critical load to failure. More studies are required to
confirm the seemingly positive effect of self-glaze and repeated firings on the mechanical
properties of these restorations. Nonetheless, future studies should concentrate on
anatomically-correct crown specimens in order to obtain conclusive and relevant evidence
regarding thermal treatments and the fracture resistance of PVZs.
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6. Acknowledgments
The authors are thankful to the Federal Agency for Support and Evaluation of Graduate Education (CAPES)
(finance code 001) by the PhD scholarship.

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Figure 1.
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Selection of studies procedures according to PRISMA

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 da Silva Rodrigues et al. Page 14
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Figure 2.
Forest plot for flexural strength analysis of fast cooling (below Tg) versus slow cooling.
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 da Silva Rodrigues et al. Page 15
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Figure 3.
Forest plot for flexural strength analysis of fast cooling (above Tg) versus slow cooling.
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 da Silva Rodrigues et al. Page 16
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Figure 4.
Forest plot for critical load to failure analysis of fast cooling (above Tg) versus slow cooling.
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Table 1.

Characteristics of included studies.

Veneer
thickness Sample
Author (year) Materials Intervention Comparison Last firing Testing set up
* size (n)
(mm)
Vita PM9 (Vita) Slow cooling (furnace 30%
Ebadian et al (2018) Fast cooling (Below Tg) Veneering Modified four-point bending 6.5 10
Vita In Ceram YZ (Vita) open until 500˚C)
da Silva Rodrigues et al.

Vita VM9 (Vita) Slow cooling (furnace closed

Passos et al (2017) Fast cooling (Below Tg) Veneering Four-point bending 0.5 20
Lava Plus (3M ESPE) until 500˚C)

IPS e.max Ceram (Ivoclar) Slow cooling (furnace closed

Tang et al (2017) Fast cooling (Above Tg) Veneering Load-to-failure (single crowns) 1.0 or 2.0 10
NaturZ (D-Max) until 500˚C)

Vita VM9 (Vita) Slow cooling (furnace closed

Meirelles et al (2016) Ceramco PZF (Dentsply) until 50˚C below Tg/ 460˚C or Fast cooling (Below Tg) Veneering Three-point-bending 1.0 30
Vita In Ceram YZ (Vita) 510 ˚C)

Vita VM9 (Vita)

Slow cooling (furnace closed
Longhini et al (2016) Vita PM9 (Vita) Fast cooling (Above Tg) Self-glaze Piston-on-three-balls 1.0 15
until room temperature)
Vita In Ceram YZ (Vita)

Initial Zr-Fs (GC Europe)

Vichi et al (2015) 3 or 5 firing cycles 1 firing cycle Veneering Three-point-bending 1.2 15
Adva Zr (GC Europe)

IPS e.max Ceram (Ivoclar) Slow cooling (furnace closed

Paula et al (2015) Fast cooling (Above Tg) Over-glaze Fatigue test (single crowns) 1.5 10
E.max ZirCAD (Ivoclar) until 50˚C)

Cercom Ceram press (DeguDent) Three-point-bending

Schmitter et al (2015) Glaze No glaze Over-glaze 4.0 8
Cercom base (DeguDent) Load-to-failure

Vita VM9 (Vita) Slow cooling (furnace closed Fast cooling (Above and
Almeida Jr. et al (2013) Veneering Three-point-bending 0.5 30
ZRHP (ProtMat) until room temperature) Below Tg)
Lava Ceram (3M ESPE) Slow cooling (6 min of cooling
Preis et al (2013) Fast cooling (Above Tg) Veneering Load-to-failure (single crowns) 2.0 6
Lava (3M ESPE) before open the furnace)

Dent Mater. Author manuscript; available in PMC 2020 May 01.

Vita VM9 (Vita)
Slow cooling (furnace closed
Lima et al (2013) Vita PM9 (Vita) Fast cooling (Above Tg) Self-glaze Four-point-bending 1.0 or 3.0 8
until 600˚C)
Vita In Ceram YZ (Vita)

Vita VM9 (Vita)

Slow cooling (furnace 10%
Belli et al (2013) Lava Ceram (3M ESPE) Fast cooling (Above Tg) Self-glaze Load-to-failure (single crowns) 1.4 16
opened until 200˚C)
YZ Cubes (Vita)

Vita VM9 (Vita)

Lu et al (2012) 4,6,or 8 firing cycles 2 firing cycles Veneering Three-point-bending 0.6 8
Kavo Zirconia (Kavo)

Vita VM9 (Vita) Slow cooling (furnace opened

Tan et al (2012) Fast (Above Tg) Self-glaze Modified four-point-bending 6.5 6
Lava (3M ESPE) 30% until 500˚C)

Cercon Ceram Kiss (DeguDent)

Slow cooling (6 min of cooling
Rues et al (2010) Cercon Ceram Love (DeguDent) Fast cooling (Above Tg) Self-glaze Load-to-failure (single crowns) 2.0 8
before open the furnace)
Cercon Base (DeguDent)
Page 17
 Author Manuscript Author Manuscript Author Manuscript Author Manuscript

Veneer
thickness Sample
Author (year) Materials Intervention Comparison Last firing Testing set up
* size (n)
(mm)
Lava Ceram (3M ESPE) Slow cooling (low cooling rate
Taskonak et al (2008) Fast cooling (Above Tg) Heat treatment Ring-on-ring 0.6 16
Lava (3M ESPE) until room temperature)

*
Occlusal thickness when specimens were crowns
da Silva Rodrigues et al.

Dent Mater. Author manuscript; available in PMC 2020 May 01.

Page 18
 Author Manuscript Author Manuscript Author Manuscript Author Manuscript

Table 2.

Characteristics of the porcelain materials used in the included studies.

Coefficient of
Glass transition
Material/ Processing Elastic thermal
Composition temperature Cooling protocol suggested by the manufacturer
Manufacturer method module expansion
(Tg)
(CTE)

a 9.0 – 9.2 10−6K−1 (25 – 500 *

Vita VM9 (Vita) Feldspathic ceramic Hand-layered 64.6 GPa 600˚C Furnace closed until 800˚C and 25% open until 600˚C
da Silva Rodrigues et al.

˚C)*

9.0 – 9.2 10−6K−1 (25 – 500 Remove the investment ring from the furnace after the
Vita PM9 (Vita) Feldspathic ceramic Heat-pressed b b end of pressing and place it on a grid to cool it down
70 GPa * 640˚C
˚C) to room temperature

9.5 10−6K−1 Glaze firing: furnace open after cooling down from
IPS e.max Ceram (Ivoclar) Fluorapatite ceramic Hand-layered a * 730˚C to 450˚C. No long-term cooling is indicated for
90 GPa * 490˚C
(100 – 400˚C) sintering firings.

6 min cooling after maximum temperature (870˚C)

Ceramco PZF (Dentsply) Feldspathic ceramic Hand-layered c d c for glaze firings.
75 GPa 9.4 10−6K−1 560˚C
No long-term cooling is indicated for sintering firings

10 10−6K−1 d
Lava Ceram (3M ESPE) Feldspathic ceramic Hand-layered 80 GPa* * 565˚C No long-term cooling is indicated
(25 – 500 ˚C)

9.2 10−6K−1 6 min cooling after maximum temperature (800˚C)

Cercon Ceram Kiss (DeguDent) Feldspathic ceramic Hand-layered a - for glaze firings.
75 GPa *
(25 – 500 ˚C) No long-term cooling is indicated for sintering firings

9.2 10−6K−1 6 min cooling after maximum temperature (800˚C)

Cercon Ceram Love (DeguDent) Feldspathic ceramic Hand-layered - * - for glaze firings.
(25 – 500 ˚C) No long-term cooling is indicated for sintering firings

10.5 10−6K−1
Cercon Ceram press (DeguDent) Feldspathic ceramic Heat-pressed - * - No long-term cooling is indicated
(25 – 500 ˚C)

Dent Mater. Author manuscript; available in PMC 2020 May 01.

Initial Zr-Fs (GC Europe) Feldspathic ceramic Hand-layered - * * No long-term cooling is indicated
9.4 10−6K−1 550˚C

*
Manufacturer,
a
Sawada et al, 2018,56
b
Choi et al, 2011,57
c
Meirelles et al, 2016,22
d
Taskonak et al, 200827
Page 19
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Table 3.

Risk of bias of included studies.

Author (year) 1 2a 2b 3 4 5 6 7 8 9 10 11 12 13 14
Ebadian et al (2018) Yes Yes Yes Yes Yes No No No No Yes Yes Yes Yes Yes No

Passos et al (2017) Yes Yes Yes Yes Yes No No No No No Yes Yes No Yes No

Tang et al (2017) Yes Yes Yes Yes Yes No No No No No Yes Yes Yes Yes No
da Silva Rodrigues et al.

Meirelles et al (2016) Yes Yes Yes Yes Yes No No No No Yes Yes Yes No Yes No

Longhini et al (2016) Yes Yes Yes Yes Yes No No No No No Yes Yes Yes No No

Vichi et al (2015) Yes Yes Yes Yes Yes No No No No No Yes Yes Yes No No

Paula et al (2015) Yes Yes Yes Yes Yes No No No No No Yes Yes No Yes No

Schmitter et al (2015) Yes Yes Yes Yes Yes No No No No No Yes Yes Yes Yes No

Almeida Jr. et al (2013) Yes Yes Yes Yes Yes No No No No No Yes Yes Yes No No

Preis et al (2013) Yes Yes Yes No Yes No No No No No Yes Yes No Yes No

Lima et al (2013) Yes Yes Yes Yes Yes No No No No No Yes Yes No Yes No

Belli et al (2013) Yes Yes Yes Yes Yes No No No No No Yes Yes No Yes No

Lu et al (2012) Yes No Yes Yes No No No No No No Yes Yes No No No

Tan et al (2012) Yes Yes Yes Yes No No No No No Yes Yes No No Yes No

Rues et al (2010) Yes Yes Yes No Yes No No No No No Yes Yes Yes Yes No

Taskonak et al (2008) Yes Yes Yes No Yes No No No No No Yes Yes No Yes No

1) Structured summary of trial design, methods, results and conclusions, 2a) Scientific background and explanation of rationale, 2b) Specific objectives and/or hypothesis, 3) The intervention of each group,
including how and when it was administered, with sufficient detail to enable replication, 4) Completely defined, pre-specified primary and secondary measured of outcome, including how and when they

Dent Mater. Author manuscript; available in PMC 2020 May 01.

were assessed, 5) How the sample size was determined, 6) Method used to generate the random allocation sequence, 7) Mechanism used to implement the random allocation sequence, 8) who generated the
random allocation, 9) Who was blinded after assignment to intervention, 10) Statistical methods used to compare groups, 11) Results for each group and estimated size of effect and its precision, 12) Trial
limitations, addressing sources of potential bias, imprecision, and, if relevant multiplicity of analysis, 13) Sources of funding and other support, 14) Where to full trial protocol can be accessed.31
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