The aim of this work was to evaluate the influence of specimen preparation and test method on the flexural strength results of monolithic zirconia. Different monolithic zirconia materials (Ceramill Zolid (Amann Girrbach, Koblach, Austria), Zenostar ZrTranslucent (Wieland Dental, Pforzheim, Germany), and DD Bio zx2 (Dental Direkt, Spenge, Germany)) were tested with three different methods: 3-point, 4-point, and biaxial flexural strength. Additionally, different specimen preparation methods were applied: either dry polishing before sintering or wet polishing after sintering. Each subgroup included 40 specimens. The surface roughness was assessed using scanning electron microscopy (SEM) and a profilometer whereas monoclinic phase transformation was investigated with X-ray diffraction. The data were analyzed using a three-way Analysis of Variance (ANOVA) with respect to the three factors: zirconia, specimen preparation, and test method. One-way ANOVA was conducted for the test method and zirconia factors within the combination of two other factors. A 2-parameter Weibull distribution assumption was applied to analyze the reliability under different testing conditions. In general, values measured using the 4-point test method presented the lowest flexural strength values. The flexural strength findings can be grouped in the following order: 4-point < 3-point < biaxial. Specimens prepared after sintering showed significantly higher flexural strength values than prepared before sintering. The Weibull moduli ranged from 5.1 to 16.5. Specimens polished before sintering showed higher surface roughness values than specimens polished after sintering. In contrast, no strong impact of the polishing procedures on the monoclinic surface layer was observed. No impact of zirconia material on flexural strength was found. The test method and the preparation method significantly influenced the flexural strength values.

Zirconia as a restoration dental material are gaining attention because of their high mechanical properties and good biocompatibility. Therefore, investigation of the flexural strength of zirconia is of great interest. For this purpose, Weibull statistics for description of the material reliability are frequently used. The aim of this work was to present a blinded data set to two independent statisticians for two parallel statistical analyses in order to find an optimal statistical approach for analysis of in-vitro measured flexural strength data of zirconia materials. A prospectively planned independent blinded statistical analysis implementing three quality control actions "blinded data set", "independent statistical analyses" and "parallel manuscript writing" was designed. Statistical analysis paths taken by both biostatisticians differed. They arrived at complementary results. The major difference was caused by two alternative distributional assumptions (Weibull/Normal) and alternative fitting methods (LS/ML). The parallel statistical analysis and manuscript writing approach on a blinded data set greatly supported our choice of statistical methods for analysis of flexural strength results of zirconia materials.

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