Is zirconia a viable alternative to titanium for oral implant? A critical review

Zirconium Oxide Thin Films Obtained by Atomic Layer Deposition Technology Abolish the Anti-Osteogenic Effect Resulting from miR-21 Inhibition in the Pre-Osteoblastic MC3T3 Cell Line

Introduction

The development of the field of biomaterials engineering is rapid. Various bioactive coatings are created to improve the biocompatibility of substrates used for bone regeneration, which includes formulation of thin zirconia coatings with pro-osteogenic properties. The aim of this study was to assess the biological properties of ZrO₂ thin films grown by Atomic Layer Deposition (ALD) technology (ZrO₂^ALD).

Methodology

The cytocompatibility of the obtained layers was analysed using the mice pre-osteoblastic cell line (MC3T3) characterized by decreased expression of microRNA 21-5p (miR-21-5p) in order to evaluate the potential pro-osteogenic properties of the coatings. The in vitro experiments were designed to determine the effect of ZrO₂^ALD coatings on cell morphology (confocal microscope), proliferative activity (cell cycle analysis) and metabolism, reflected by mitochondrial membrane potential (cytometric-based measurement). Additionally, the influence of layers on the expression of genes associated with cell survival and osteogenesis was studied using RT-qPCR. The following genes were investigated: B-cell lymphoma 2 (Bcl-2), Bcl-2-associated X protein (Bax), p53 and p21, as well as osteogenic markers, i.e. collagen type 1 (Coll-1), osteopontin (Opn), osteocalcin (Ocl) and runt-related transcription factor 2 (Runx-2). The levels of microRNA (miRNA/miR) involved in the regulation of osteogenic genes were determined, including miR-7, miR-21, miR-124 and miR-223.

Results

The analysis revealed that the obtained coatings are cytocompatible and may increase the metabolism of pre-osteoblast, which was correlated with increased mitochondrial membrane potential and extensive development of the mitochondrial network. The obtained coatings affected the viability and proliferative status of cells, reducing the population of actively dividing cells. However, in cultures propagated on ZrO₂^ALD coatings, the up-regulation of genes essential for bone metabolism was noted.

Discussion

The data obtained indicate that ZrO₂ coatings created using the ALD method may have pro-osteogenic properties and may improve the metabolism of bone precursor cells. Given the above, further development of ZrO₂^ALD layers is essential in terms of their potential clinical application in bone regenerative medicine.

Two-piece zirconia versus titanium implants after 80 months: Clinical outcomes from a prospective randomized pilot trial

OBJECTIVES

To prospectively evaluate, as part of an ongoing randomized pilot trial, the clinical outcomes of two-piece zirconia implants in comparison with titanium implants 80 months after delivery of all-ceramic (lithium disilicate) single-tooth restorations.

MATERIAL AND METHODS

The original sample included 31 (16 zirconia and 15 titanium) implants in 22 healthy patients. In addition to evaluating implant survival and success, a number of clinical or radiographic parameters were statistically analyzed: plaque index (PI), bleeding on probing (BOP), pink esthetic score (PES), and marginal bone loss (MBL). Both implant groups were compared using a Mann-Whitney U test.

RESULTS

Three implants (2 zirconia and 1 titanium) had been lost, so that 28 implants (14 zirconia and 14 titanium) in 21 patients could be evaluated after a mean of 80.9 (SD: 5.5) months. All surviving implants had remained stable, in the absence of any fixture or abutment fractures and without any chipping, fracture, or debonding of crowns. The zirconia implants were associated with PI values of 11.07% (SD: 8.11) and the titanium implants with 15.20% (SD: 15.58), the respective figures for the other parameters being 16.43% (SD: 6.16) or 12.60% (SD: 7.66) for BOP; 11.11 (SD: 1.27) or 11.56 (SD: 1.01) for PES; and 1.38 mm (SD: 0.81) or 1.17 mm (SD: 0.73) for MBL.

CONCLUSIONS

No significant differences were found between the clinical outcomes of two-piece zirconia and titanium implants based on the aforementioned parameters after 80 months of clinical service. Our results should be interpreted with the limited sample size in mind.

Surrounding Tissue Response to Surface-Treated Zirconia Implants

Yttria-stabilized tetragonal zirconia polycrystals (Y-TZP), which are partially stabilized zirconia, have been used for fabricating dental implants. This study investigated the soft tissue attachment, the collagen fiber orientation to zirconia at different surface conditions, and the bone response using implantation experiments in animals. The zirconia implant surfaces were treated with ultraviolet irradiation (UV), a combination of large-grit sandblasting and hydrofluoric acid etching (blastedHF), and a combination of blastedHF and UV (blastedHF+UV). The surface treated with blastedHF and blastedHF+UV appeared rough and hydrophilic. The surface treated with blastedHF+UV appeared to be superhydrophilic. Subsequently, tapered cylindrical zirconia implants were placed in the alveolar sockets of the maxillary molars of rats. The bone-to-implant contact ratio of blastedHF and blastedHF+UV implants was significantly higher than that of the non-treated controls and UV-treated implants. The four different surface-treated zirconia implants demonstrated tight soft tissue attachments. Perpendicularly oriented collagen fibers towards zirconia implants were more prominent in blastedHF and blastedHF+UV implants compared to the controls and UV-treated implants. The area of the soft tissue attachment was the greatest with the perpendicularly oriented collagen fibers of blastedHF+UV-treated implants. In conclusion, blastedHF+UV treatment could be beneficial for ensuring greater soft-tissue attachment for zirconia implants.

Osteoblast response to zirconia modified-ORMOSILs

In this study, an in vitro evaluation of the human osteoblasts response to Organically Modified Silicate (ORMOSIL) biomaterials was conducted. These materials were synthetized by sol-gel process being modified with zirconia (ZrO₂) and/or Ca²⁺. The materials were immersed into phosphate buffer solution (PBS) in order to test precipitation of mimetic apatite-like on their surfaces. ORMOSILs were characterized by SEM, FT-IR and X-RD analysis. The response of osteoblast to ORMOSILs was analyzed as a measure of cell adhesion, proliferation and differentiation. The results showed that the addition of Ca²⁺ ions modifies the surface morphology of ORMOSILs by forming precipitates of mimetic apatite-like with cauliflower and scales morphologies. On the other hand, biological results suggest that the incorporation of zirconia to ORMOSILs increases their ability to support cell adhesion and proliferation. However, the inclusion of both zirconia and Ca²⁺ in the ORMOSILs decreases their biological compatibility by showing less cell proliferation and lower osteonectin expression, a protein related to osteoblasts. The unfavorable effect of Ca²⁺ on cell proliferation and cell viability could be due to its ability to induce the formation of mimetic apatite-like with incompatible morphology. The analysis of other proteins related to bone formation on ORMOSIL-Zr and ORMOSIL-Zr-Ca surfaces demonstrated clear expression of osteopontin and osteocalcin in cells growth. In the case of ORMOSIL-Zr, the expression of osteonectin occurred at early stages while the expression of osteopontin and osteocalcin begun at later stages, indicating a switch from an early to a mature stage being stimulated by the biomaterial. Together, these results highlight the important role of zirconia and Ca²⁺ ions in the composition of materials regulating their biocompatibility when used as scaffolds in bone regeneration.

Investigation of High Voltage Anodic Plasma (HVAP) Ag-DLC Coatings on Ti50Zr with Different Ag Amounts

The paper presents the investigation of a series of silver-incorporated diamond-like carbon (Ag-DLC) coatings with increasing Ag content on Ti50Zr and deposited using high voltage anodic plasma (HVAP). The coatings surface properties were analyzed with scanning electron microscope (SEM), atomic force microscope (AFM), and contact angle determinations. Electrochemical tests were performed in Afnor artificial saliva and evaluated by potentiodynamic polarization and electrochemical impedance spectroscopy. Based on these properties, comparisons of coatings performance were linked with the amount of deposited Ag. Increasing the Ag content led to the increase of the corrosion resistance and to the decrease of the forces exhibited on the surface. The hydrophobic character of the coating with the highest Ag amount could prevent thrombosis, thus suggesting its possible use for medical implants.

Mechanical stability of all-ceramic abutments retained with three different screw materials in two-piece zirconia implants-an in vitro study

OBJECTIVES

To measure the abutment rotation and fracture load of two-piece zirconia implants screwed with three different abutment screw materials.

MATERIAL AND METHODS

Thirty-six zirconia implants with 36 zirconia abutments were distributed into 3 test groups: group G connected with gold screws, group T with titanium screws, and group P with peek screws. In the first part of the study, the rotation angle of the abutments was measured. The second part of the study measured the maximum fracture force of adhesively bonded lithium disilicate crowns after artificial aging and fracture modes were reported.

RESULTS

In group G, the median rotation angle was 8.0°, in group T 11.6°, and in group P 9.5°. After artificial aging, no screw loosening, crown, abutment, or implant fracture occurred. The median fracture force in group G was 250 N, in group T 263 N, and in group P 196 N.

CONCLUSIONS

Rotation angles and fracture loads of two-piece zirconia implants with gold, titanium, or peek screws showed no significant differences; however, fracture loads showed inferior results for group P.

CLINICAL RELEVANCE

The indication for the material peek as an abutment screw is still questionable and should be considered carefully.

Clinical performance of zirconia implants: A meta-review

STATEMENT OF PROBLEM

The clinical effectiveness of zirconia implants as an alternative to titanium implants is still controversial.

PURPOSE

The purpose of this analysis was to identify and evaluate systematic reviews reporting on the clinical outcomes of zirconia implants for oral rehabilitation.

MATERIAL AND METHODS

An electronic search was undertaken on MEDLINE, Embase, and the Cochrane Oral Health Reviews databases up to December 24, 2018, without language restriction. Eligible reviews were screened and assessed. The eligibility criteria were systematic reviews or meta-analyses, implant survival rate, implant success, marginal bone loss, peri-implant soft tissue status, and biologic and functional complications of zirconia implants. Two review authors independently evaluated the quality assessment of the secondary studies by applying the Assessing the Methodological Quality of Systematic Reviews (AMSTAR) tool.

RESULTS

Nine reviews fulfilled the inclusion criteria and were evaluated. Seven reviews were classified as moderate and 2 as high quality. The overall AMSTAR's quality of these reports was moderate. In the primary studies contained in these reviews, zirconia implant clinical outcomes were found to be similar or inferior to those for titanium implants. The few primary clinical studies contained in these reviews were not homogeneous among each other, presented poor methodology, and only offered promising short-term outcomes due to the lack of long-term follow-ups.

CONCLUSIONS

Based on this meta-review, in spite of short-term promising results of zirconia implants, evidence with long term is lacking.

Annual review of selected scientific literature: A report of the Committee on Scientific Investigation of the American Academy of Restorative Dentistry

This comprehensive review of the 2018 dental literature is provided to inform busy dentists about progress in the profession. Developed by the Committee on Scientific Investigation of the American Academy of Restorative Dentistry, each author brings discipline-specific expertise to one of the 8 sections of the report including (1) prosthodontics; (2) periodontics, alveolar bone, and peri-implant tissues; (3) implant dentistry; (4) dental materials and therapeutics; (5) occlusion and temporomandibular disorders; (6) sleep-related breathing disorders; (7) oral medicine and oral and maxillofacial surgery; and (8) dental caries and cariology. The report targets important information that will likely influence day-to-day treatment decisions. Each review is not intended to stand alone but to update interested readers so that they may visit source materials if greater detail is desired. As the profession continues its march toward evidence-based clinical decision-making, an already voluminous library of potentially valuable dental literature continues to grow. It is the intention of this review and its authors to provide assistance in navigating the extensive dental literature published in 2018. It is our hope that readers find this work useful in the clinical management of patients moving forward.

A Novel Full-Digital Protocol (SCAN-PLAN-MAKE-DONE®) for the Design and Fabrication of Implant-Supported Monolithic Translucent Zirconia Crowns Cemented on Customized Hybrid Abutments: A Retrospective Clinical Study on 25 Patients

Purpose: To present a novel, full-digital protocol for the design and fabrication of implant-supported monolithic translucent zirconia crowns cemented on customized hybrid abutments. Methods: The present retrospective clinical study was based on data from patients who had been treated with single Morse-taper connection implants (Exacone^®, Leone Implants, Florence, Italy) and were prosthetically restored with monolithic translucent zirconia crowns, cemented on customized hybrid abutments. The full-digital protocol (SCAN-PLAN-MAKE-DONE^®) consisted of 8 phases: (1) intraoral scan of the implant position with scanbody; (2) computer-assisted design (CAD) of the individual abutment (saved as “supplementary abutment design” in external folder) and temporary crown; (3) milling of the individual zirconia abutment and of the temporary polymethyl-methacrylate (PMMA) crown, with extraoral cementation of the zirconia abutment on the relative titanium bonding base, to generate an individual hybrid abutment; (4) clinical application of the individual hybrid abutment and cementation of the temporary PMMA crown; (5) two months later, intraoral scan of the individual hybrid abutment in position; (6) CAD of the final crown with margin line design on the previously saved “supplementary abutment design”, superimposed on the second scan of the abutment in position; (7) milling of the final crown in monolithic translucent zirconia, sintering, and characterization; and (8) clinical application of the final crown. All patients were followed for a period of 1 year. The primary outcomes of this study were the marginal adaptation of the final crown (checked clinically and radiographically), the quality of occlusal and interproximal contact points at delivery, and the aesthetic integration; the secondary outcomes were the 1-year survival and success of the implant-supported restoration. An implant-supported restoration was considered successful in the absence of any biological or prosthetic complication, during the entire follow-up period. Results: In total, 25 patients (12 males, 13 females; 26–74 years of age; mean age 51.1 ± 13.3 years) who had been restored with 40 implant-supported monolithic translucent zirconia crowns were included in this study. At delivery, the marginal adaptation was perfect for all crowns. However, there were occlusal issues (2/40 crowns: 5%), interproximal issues (1/40 crowns: 2.5%), and aesthetic issues (1/40 crowns: 2.5%). The overall incidence of issues at delivery was therefore 10% (4/40 crowns). At 1 year, one implant failed; thus the survival of the restorations was 97.5% (39/40 crowns in function). Among the surviving implant-supported restorations, three experienced complications (one loss of connection between the hybrid abutment and the implant, one decementation of the zirconia abutment, and one decementation of the zirconia crown). The success of restorations amounted to 92.4%. Conclusions: The restoration of single Morse-taper connection implants with monolithic translucent zirconia crowns cemented on customized hybrid abutments via the novel SCAN-PLAN-MAKE-DONE^® full-digital protocol seems to represent a reliable treatment option. However, further studies on a larger number of patients and dealing with different prosthetic restorations (such as implant-supported fixed partial prostheses) are needed to confirm the validity of this protocol.

Translational research on clinically failed zirconia implants

OBJECTIVES

To provide fractographic analysis of clinically fractured zirconia implants recovered with their cemented crown. To calculate bending moments, corresponding stress and crack onset location on the implant's fracture surface using a mathematical model integrating spatial coordinates of the crown-implant part and occlusal loading obtained from 2D and 3D images.

METHODS

15 fractured zirconia implants parts (11 posterior and 4 anterior) with their all- ceramic crowns still cemented on it were recovered. The implants were first generations from four manufacturers (AXIS Biodental, Z-Systems, Straumann, Swiss Dental Solutions). The time-to-failure varied between 2weeks and 9years. Fractography was performed identifying the failure origin and characteristic surface crack features. From 2D and 3D digital images of the crown-implant part, spatial coordinates anchoring the crown's occlusal contacts with the implant's central axis and reference plane were integrated in a mathematical model spreadsheet. Loads of 500 N in total were selectively distributed over identified occlusal contacts from wear patterns. The resultant bending and torsion moments, corresponding shear, tensile, maximum principal stress and von Mises stress were calculated. The fracture crack onset location on the implant's fracture surface was given by an angular position with respect to an occlusal reference and compared with the location of the fracture origin identified from fractographic analysis.

RESULTS

Implants fractured from the periphery of the smaller inner diameter between two threads at the bone-entrance level except for one implant which failed half-way within the bone. The porous coating (AXIS Biodental) and the large grit alumina sandblasting (Z-System) created surface defects directly related to the fracture origin. The model spreadsheet showed how occlusal loading with respect to the implant's central axis affects bending moments and crack onset. Dominant loads distributed on contacts with important wear pattern provided a calculated crack onset location in good agreement with the fractographic findings of the fracture origin.

SIGNIFICANCE

Recovered broken zirconia implant parts with their restorative crowns can provide not only information regarding the failure origin using fractography but also knowledge regarding occlusal crown loading with respect to the implant's axis. The mathematical model was helpful in showing how occlusal loading affects the location of the fracture initiation site on clinical zirconia implant fracture cases.

Current status of zirconia implants in dentistry: preclinical tests

PURPOSE

This systematic review aimed to provide an overview of zirconia implants as well as regarding the outcome of the implant-restorative complex in preclinical studies.

STUDY SELECTION

An electronic search of the literature prior to July 2017 was performed to identify all articles related to preclinical research on zirconia implants. The search was conducted using MEDLINE (National Library of Medicine) and PubMed without restrictions concerning the date of publication. The search terminology included: zirconia implant, osseointegration, bone-to-implant contact, soft tissue, histology, histomorphometry, surface modification, surface roughness, surface characteristics, and restoration (connecting multiple keywords with AND, OR).

RESULTS

Fifty-seven studies were finally selected from an initial yield of 654 titles, and the data were extracted. The identified preclinical studies focused on several aspects related to zirconia implants, namely biocompatibility, mechanical properties, implant design, osseointegration capacity, soft tissue response, and restorative options. Due to heterogeneity of the studies, a meta-analysis was not possible. The most frequently used zirconia material for the fabrication of implants is yttria-stabilized tetragonal zirconia polycrystal. The resistance-to-fracture for zirconia implants ranged between 516-2044N. The mostly investigated parameter was osseointegration, which is compared to that of titanium. A lack of evidence was found with other parameters.

CONCLUSIONS

Due to its good biocompatibility as well as favorable physical and mechanical properties, zirconia implants are a potential alternative to titanium implants. However, knowledge regarding the implant-restorative complex and related aspects is still immature to recommend its application for daily practice.

The Use of Pulsed Electromagnetic Fields to Promote Bone Responses to Biomaterials In Vitro and In Vivo

Implantable biomaterials are extensively used to promote bone regeneration or support endosseous prosthesis in orthopedics and dentistry. Their use, however, would benefit from additional strategies to improve bone responses. Pulsed Electromagnetic Fields (PEMFs) have long been known to act on osteoblasts and bone, affecting their metabolism, in spite of our poor understanding of the underlying mechanisms. Hence, we have the hypothesis that PEMFs may also ameliorate cell responses to biomaterials, improving their growth, differentiation, and the expression of a mature phenotype and therefore increasing the tissue integration of the implanted devices and their clinical success. A broad range of settings used for PEMFs stimulation still represents a hurdle to better define treatment protocols and extensive research is needed to overcome this issue. The present review includes studies that investigated the effects of PEMFs on the response of bone cells to different classes of biomaterials and the reports that focused on in vivo investigations of biomaterials implanted in bone.

Molecular analysis of biocompatibility of anodized titanium with deposited silver nanodendrites

Titanium (>99.6% purity) and its anodically oxidized modifications, with and without deposited silver nanodendrites regarding its biocompatibility were evaluated. In human gingival fibroblasts and osteoblast cell lines grown on tested samples, the level of expression of genes encoding αV (ITGAV) and β1 (ITGB1) integrin subunits also genes encoding focal adhesion (FAK) and extracellular-signal regulated (ERK) kinases was assessed. For this purpose, the qualitative and quantitative PCR technique was used. The expression of studied genes was dependent on the origin of cell lines and the type of evaluated material. The high expression of PBGD and ITGAV genes in fibroblasts grown on the surface of anodically modified titanium with deposited silver nanodendrites indicates potentially high biocompatibility of these samples for soft tissue cells. The high expression of the ITGB1 and ERK1 genes and the enhanced expression of the FAK gene in osteoblasts cells grown on the tested material was also observed. Summarizing, the nanocrystalline Ti modified with silver deposits showed higher biocompatibility in comparison with the conventional pure Ti samples.

The Biocompatibility of Dental Graded Nano-Glass-Zirconia Material After Aging

ᅟ: A graded nano-glass/zirconia (G/Z) system has been developed via the infiltration of nano-glass into a nano-zirconia surface, which is advantageous for robust core-veneer bonds. The aging issue is a key for yttrium-stabilized tetragonal zirconia polycrystals (Y-TZPs), and therefore, it is necessary to evaluate the influence of aging degradation on the biocompatibility of G/Z systems before their possible clinical application. Herein, such biocompatibility testing was performed with human gingival fibroblasts (HGFs) seeded onto unaged/aged G/Z and Y-TZP for 2-72 h. Assessments included an oral mucous membrane irritation test in conjunction with analyses of cell viability, cell adhesion, and oxidative stress responses. Significant metabolic decreases in aged G/Z- and Y-TZP-treated cells were observed at 72 h. G/Z did not elicit any significant differences in cell viability compared with Y-TZP over 72 h both before and after aging. The oxidative stress data for the aged G/Z- and Y-TZP-treated cells showed a significant increase at 72 h. The G/Z specimens did not elicit any significant differences in ROS production compared with Y-TZP over 72 h both before and after aging. The cell adhesion rates of both G/Z and Y-TZP increased significantly after aging. The cell adhesion rates of G/Z and Y-TZP were not significantly different before and after aging. According to the oral mucous membrane irritation test, scores for macroscopic and microscopic observations for both the aged G/Z and unaged G/Z sides were 0, demonstrating no consequent irritation.

CONCLUSIONS

The excellent biocompatibility of G/Z indicates that it has potential for future clinical applications.