Failure analysis of fractured dental zirconia implants

Clinical Factors on Dental Implant Fractures: A Systematic Review

Dental implant fractures pose a significant challenge to long-term treatment success. This systematic review aims to comprehensively examine the clinical factors influencing dental implant fractures (IFs). Furthermore, strategies to choose the right type of implant and prevent this complication are addressed. A systematic search was conducted across PubMed, Scopus, and Web of Science databases. Eligible studies included retrospective case-control, prospective cohort studies, and clinical trials. The initial search yielded 361 articles, of which 312 were excluded being these reviews, case reports, irrelevant, or written in languages other than English. This left 49 articles, with only 6 meeting the eligibility criteria for an in-depth review. These studies, all retrospective case-control, examine implant characteristics, patient demographics, surgical and prosthetic variables, biomechanical and functional factors, clinical and procedural variables, complications and maintenance issues. The risk of bias was assessed as low using the ROBINS-I tool. Key findings suggest a correlation between implant diameter and structural resistance, with wider implants demonstrating reduced fracture risk. Additionally, posterior regions, especially molars and premolars, exhibit higher susceptibility to IFs due to increased masticatory forces. Implant design and material may considerably influence fracture risk, with conical implants and screw-retained prostheses showing higher vulnerability. Biomechanical overload, particularly in patients with bruxism, emerges as a primary contributing factor to IFs. Prosthesis type significantly influences fracture incidence, with cantilever prostheses posing a higher risk due to increased stress. Peri-implant bone loss is strongly associated with IFs, emphasizing the need for meticulous preoperative assessments and individualized management strategies. Future research should prioritize larger and heterogeneous populations with long-term follow-up and standardized methodologies to enhance the generalizability and comparability of findings. Randomized controlled trials and biomechanical studies under controlled conditions are also essential to elucidate the complex interactions contributing to IFs and developing effective prevention strategies. Additionally, integrating patient-reported outcomes may offer a comprehensive understanding of the impact of IFs on quality of life.

Atomic Layer Deposition of Zirconia on Titanium Implants Improves Osseointegration in Rabbit Bones

Purpose

Atomic layer deposition (ALD) is a method that can deposit zirconia uniformly on an atomic basis. The effect of deposited zirconia on titanium implants using ALD was evaluated in vivo.

Methods

Machined titanium implants (MTIs) were used as the Control. MTIs treated by sandblasting with large grit and acid etching (SA) and MTIs deposited with zirconia using ALD are referred to as Groups S and Z, respectively. Twelve implants were prepared for each group. Six rabbits were used as experimental animals. To evaluate the osteogenesis and osteocyte aspects around the implants, radiological and histological analyses were performed. The bone-to-implant contact (BIC) ratio was measured and statistically analyzed to evaluate the osseointegration capabilities.

Results

In the micro-CT analysis, more radiopaque bone tissues were observed around the implants in Groups S and Z. Histological observation found that Groups S and Z had more and denser mature bone tissues around the implants in the cortical bone area. Many new and mature bone tissues were also observed in the medullary cavity area. For the BIC ratio, Groups S and Z were significantly higher than the Control in the cortical bone area (P < 0.017), but there was no significant difference between Groups S and Z.

Conclusion

MTIs deposited with zirconia using ALD (Group Z) radiologically and histologically showed more mature bone formation and activated osteocytes compared with MTIs (Control). Group Z also had a significantly higher BIC ratio than the Control. Within the limitations of this study, depositing zirconia on the surface of MTIs using ALD can improve osseointegration in vivo.

Clinical outcomes of zirconia implants: a systematic review and meta-analysis

PURPOSE

To assess the clinical outcomes of zirconia dental implants based on an updated systematic literature review.

METHODS

An electronic search was performed in three databases, last updated in June 2023, supplemented by hand searching. The eligibility criteria were clinical studies reporting patients rehabilitated with zirconia implants. The cumulative survival rate (CSR) of implants was calculated. A meta-analysis for marginal bone loss (MBL) under different follow-up times and a meta-regression assessing the relationship between mean MBL and follow-up were done.

RESULTS

Twenty-five studies were included (4017 implants, 2083 patients). Seven studies had follow-up longer than 60 months. 172 implants failed, after a mean of 12.0 ± 16.1 months (min-max 0.3-86.0), of which 47 early failures, and 26 due to implant fracture, the majority in narrow-diameter implants. The 10-year CSR was 95.1%. Implants with coronal part prepared by drills presented statistically significant lower survival than non-prepared implants (p < 0.001). Two-piece implants presented lower survival than one-piece implants (p = 0.017). Implants discontinued from the market presented lower survival than the commercially available ones (p < 0.001). The difference in survival was not significant between implants in maxilla and mandible (p = 0.637). The mean MBL fluctuated between 0.632 and 2.060 mm over long periods of observation (up until 132 months). There was an estimated MBL increase of 0.005 mm per additional month of follow-up.

CONCLUSION

Zirconia implants present high 10-year CSR and short-term low MBL. The review was registered in PROSPERO (CRD42022342055).

CLINICAL RELEVANCE

The clinical outcomes observed for zirconia dental implants are very promising, although these have not yet been extensively studied as titanium alloy implants.

Clinical and radiographic outcomes of zirconia dental implants-A systematic review and meta-analysis

OBJECTIVES

For the present review, the following focused question was addressed: In patients with root-analog dental implants, what is the effect of implants made of other materials than titanium (alloy) on implant survival, marginal bone loss (MBL), and technical and biological complications after at least 5 years.

MATERIALS AND METHODS

An electronic (Medline, Embase, Web of Science) search was performed to identify observational clinical studies published from January 2000 investigating a minimum of 20 commercially available zirconia implants with a mean follow-up of at least 60 months. Primary outcome was implant survival, secondary outcomes included peri-implant MBL, probing depths (PDs), and technical and biological complications. Meta-analyses were performed to evaluate implant survival, MBL, and PD.

RESULTS

From 5129 titles, 580 abstracts were selected, and 111 full-text articles were screened. Finally, 4 prospective and 2 retrospective observational clinical cohort studies were included for data extraction. Meta-analyses estimated after 5 years of loading mean values of 97.2% (95% CI 94.7-99.1) for survival (277 implants, 221 patients), 1.1 mm (95% CI: 0.9-1.3) for MBL (229 implants, 173 patients), and 3.0 mm (95% CI 2.5-3.4) for PDs (231 implants, 175 patients).

CONCLUSIONS

After 5 years, commercially available zirconia implants showed reliable clinical performance based on survival rates, MBL, and PD values. However, more well-designed prospective clinical studies and randomized clinical trials investigating titanium and zirconia implants are needed to confirm the presently evaluated promising outcomes.

Surface Coatings of Dental Implants: A Review

Replacement of missing teeth is possible using biocompatible devices such as endosseous implants. This study aims to analyze and recognize the best characteristics of different implant surfaces that ensure good peri-implant tissue healing and thus clinical success over time. The present review was performed on the recent literature concerning endosseous implants made of titanium, a material most frequently used because of its mechanical, physical, and chemical characteristics. Thanks to its low bioactivity, titanium exhibits slow osseointegration. Implant surfaces are treated so that cells do not reject the surface as a foreign material and accept it as fully biocompatible. Analysis of different types of implant surface coatings was performed in order to identify ideal surfaces that improve osseointegration, epithelial attachment to the implant site, and overall peri-implant health. This study shows that the implant surface, with different adhesion, proliferation, and spreading capabilities of osteoblastic and epithelial cells, influences the cells involved in anchorage. Implant surfaces must have antibacterial capabilities to prevent peri-implant disease. Research still needs to improve implant material to minimize clinical failure.

Surface modifications of zirconia with plasma pretreatment and polydopamine coating to enhance the bond strength and durability between zirconia and titanium

The aim of this study was to assess the shear bond strength and durability between plasma-pretreated and polydopamine (PDA)-coated zirconia and titanium. Four groups were prepared according to the different surface treatments (untreated ZrO₂, plasma-pretreated ZrO₂, PDA-coated ZrO₂, and plasma-pretreated and PDA-coated ZrO₂ (PP+PDA-ZrO₂). The surface topography and roughness, contact angle, and elemental analysis of the coatings of the four groups were investigated, and the bond strength and durability of the specimens were evaluated based on shear bond strength and thermocycle tests. Physical and chemical characterization results confirmed that PDA coatings can be successfully formed on zirconia substrates. The roughness and hydrophilicity were significantly higher in the PP+PDA-ZrO₂ group_, which demonstrated better shear bond strength and durability between zirconia and titanium. The plasma pretreatment of zirconia substrates can enhance the stability of the PDA coating layer, and hybrid surface modifications can provide several bonding advantages for clinical use.

Metallic Dental Implants Wear Mechanisms, Materials, and Manufacturing Processes: A Literature Review

OBJECTIVES

From the treatment of damaged teeth to replacing missing teeth, dental biomaterials cover the scientific interest of many fields. Dental biomaterials are one of the implants whose effective life depends vastly on their material and manufacturing techniques. The purpose of this review is to summarize the important aspects for metallic dental implants from biomedical, mechanical and materials science perspectives. The review article will focus on five major aspects as mentioned below. Tooth anatomy: Maximizing the implant performance depends on proper understanding of human tooth anatomy and the failure behavior of the implants. Major parts from tooth anatomy including saliva characteristics are explored in this section. Wear mechanisms: The prominent wear mechanisms having a high impact on dental wear are abrasive, adhesive, fatigue and corrosion wear. To imitate the physiological working condition of dental implants, reports on the broad range of mastication force and various composition of artificial saliva have been included in this section, which can affect the tribo-corrosion behavior of dental implants. Dental implants classifications: The review paper includes a dedicated discussion on major dental implants types and their details for better understanding their applicability and characteristics. Implant materials: As of today, the most established dental implant materials are SS316L, cobalt chrome alloy and titanium. Detailed discussion on their material properties, microstructures, phase transformations and chemical compositions have been discussed here. Manufacturing techniques: In terms of different production methods, the lost wax casting method as traditional manufacturing is considered. Selective Laser Melting (SLM) and Directed Energy Deposition (DED) as additive manufacturing techniques (AM) have been discussed. For AM, the relationships between process-property-performance details have been explored briefly. The effectiveness of different manufacturing techniques was compared based on porosity distribution, mechanical and biomechanical properties.

SUMMARY

Despite having substantial research available on dental implants, there is a lack of systematic reviews to present a holistic viewpoint combining state-of-the-art from biomedical, mechanical, materials science and manufacturing perspectives. This review article attempts to combine a wide variety of analyzing approaches from those interdisciplinary fields to deliver deeper insights to researchers both in academia and industry to develop next-generation dental implants.

Patient-specific 3D printed Poly-ether-ether-ketone (PEEK) dental implant system

Fused Filament Fabrication (FFF)-based 3D printing is an efficient technique for developing medical implants, but it is not very useful in developing small yet mechanically robust design-specific fixtures such as dental implants (<15 mm). Specifically, it is challenging to 3D print robust Polyetheretherketone (PEEK) small implants due to PEEK's high melting temperature and melt viscosity. However, in this study, we efficiently utilize high-temperature FFF to develop the first-of-its-kind patient-specific robust PEEK dental implants with high print resolution. Specifically, we explore the effects of critical FFF processing conditions on the mechanical properties of the implants and subsequently determine an optimized set of processing conditions that are essential in developing durable dental implant systems. Our results indicate that the 3D printed dental implants exhibit good fatigue properties and suffice the clinical and industrial requirements for dental implants. Furthermore, we prove that the 3D printed implants exhibit adequate mechanical durability even after simulated (accelerated) aging of 30 years.

The worldwide patent landscape of dental implant technology

In an aging society, quality of life improvement is emerging as an important issue, and as implants are accepted as the core of oral rehabilitation treatment, competition for leadership in developing related technologies is intensifying. In this trend, unlike what is evident in the literature, the patent landscape shows the status of industrial-based technology development. A database analysis of a total of 32,237 dental implant patents shows improvements in technology, diverse geographical characteristics, and new advances toward technological convergence in this field. Technologically, dental implant technology has shown a tendency to develop from conventional implant materials and surface treatment technologies to new material technologies making use of substances such as pure zirconium and tantalum or software technologies related to diagnosis and prognosis. Regionally, dental implant technology, which was developed mainly in Europe and the Unites States in the past, is growing explosively in East Asian countries accompanied by the recent growth of the Asian market. In summary, dental implant technology seems to be developing while trying to converge with various technological areas based on the local market environment. Therefore, it is necessary to develop a new dental implant material technology that is highly applicable to the development of hybrid information/communication technology and is suitable for a new manufacturing method. Our study may provide important information to help basic and translational researchers and their financial supporters set their research directions in advancing the development of dental implants.

Fracture analysis of one/two-piece clinically failed zirconia dental implants

OBJECTIVES

Analyzing factors that may have led to fracture of zirconia implants by macro/micro-fractography.

METHODS

Six one-piece and ten two-piece full-ceramic zirconia implants from two manufacturers, Z-Systems and CeraRoot, were retrieved after clinical failure. The time-to-failure ranged from 3 to 49 months. Optical and scanning electron microscopy (SEM) were used to analyze the fracture planes at the macro- and microscopic level. Treatment planning, surgical protocol, fracture-origin location and characteristic fracture features were assessed.

RESULTS

The fracture of all implants seemed to have been primarily due to overload in bending mode, while the fracture-initiation sites varied for the one- and two-piece implants. The fracture of all one-piece implants originated in the constriction region between two threads in the endosseous implant part. For two-piece implants, the abutment neck, internal abutment-implant connections and inner threads were found to be the main fracture-initiation sites. Surface defects at the root area for one-piece implants and damages at the abutment surface for two-piece implants were connected to the fracture origins. Importantly, the clinical failures of implants were often found to result from combined effects related to patient aspects, treatment planning/protocols, a high bending moment at the weakest link, implant-surface conditions and specific implant designs.

SIGNIFICANCE

This study provided information to be considered for future optimization of treatment planning and the surgical protocol for zirconia implants. Optimization of the surface conditions and the zirconia-starting powder were also suggested.

Bone Response to Conventional Titanium Implants and New Zirconia Implants Produced by Additive Manufacturing

The aim of the present study was to evaluate the in vivo bone response to an additively manufactured zirconia surface compared to osseointegration into titanium (Ti) surfaces. Scanning electron microscopy, confocal laser scanning microscopy, and electron spectroscopy for chemical analysis were performed to assess the surface characteristics of implant specimens. For the in vivo evaluation, eight Ti implants and eight 3D-printed zirconia implants were used. The surface of four Ti implants was sandblasted, large-grit, and acid-etched (Ti-SLA group), while those of the other four Ti implants were left untreated (Ti-turned group). The zirconia implants had no further surface modification. Implants were placed into the tibiae of four rabbits; two received the Ti-SLA and zirconia implants and the other two received Ti-turned and zirconia implants. The experimental animals were sacrificed after four weeks of surgery, and the undecalcified microscopic slides were prepared. The bone–implant interface was analyzed by histomorphometry to evaluate the bone response. The degree of surface roughness showed that Ti-SLA was the highest, followed by zirconia and Ti-turned surfaces. The 3D-printed zirconia surface showed similar bone-to-implant contact to the Ti-turned surface, and Ti-SLA had the most bone-to-implant contact. The additively manufactured zirconia implant surface is biocompatible with respect to osseointegration compared to the commercially pure Ti surface.

Fracture resistance and crystal phase transformation of a one- and a two-piece zirconia implant with and without simultaneous loading and aging-An in vitro study

OBJECTIVE

To evaluate the influence of artificial aging on the transformation propagation and fracture resistance of zirconia implants.

METHODS

One-piece (with integrated implant abutment, 1P; regular diameter [4.1mm]; n = 16) and two-piece (with separate implant abutment, 2P; wide diameter [5 mm]; n = 16) zirconia implants were embedded according to ISO 14801. A two-piece titanium-zirconium implant (Ti-Zr; 4.1 mm diameter) served as a control (n = 16). One subgroup (n = 8) of each system was simultaneously dynamically loaded (10⁷ cycles; 98N) and hydrothermally aged (85°C, 58 days), while the other subgroup (n = 8) remained untreated. Finally, specimens were statically loaded to fracture. Potential crystal phase transformation was examined at cross sections using scanning electron microscopy (SEM). A multivariate linear regression model was applied for statistical analyses.

RESULTS

The fracture resistance of 1P (1,117 [SD = 38] N; loaded/aged: 1,009 [60] N), 2P (850 [36] N; loaded/aged: 799 [84] N), and Ti-Zr implants (1,338 [205] N; loaded/aged: 1,319 [247] N) was not affected significantly by loading/aging (p = .171). However, when comparing the systems, they revealed significant differences independent of loading/aging (p ≤ .001). Regarding the crystal structure, a transformation zone was observed in SEM images of 1P only after aging, while 2P showed a transformation zone even before aging. After hydrothermal treatment, an increase of this monoclinic layer was observed in both systems.

CONCLUSIONS

The Ti-Zr control implant showed higher fracture resistance compared to both zirconia implants. Loading/aging had no significant impact on the fracture resistance of both zirconia implants. The wide-body 2P zirconia implant was weaker than the regular body 1P implant.

Histologic and histomorphometric evaluation of new zirconia-based ceramic dental implants: A preclinical study in dogs

OBJECTIVE

Healing of soft tissues and improvement of aesthetics have become major research objectives in implantology and renewed the interest for ceramics implants. The aim of this study was to evaluate the pre-clinical performance of screw-shaped sandblasted-etched implants processed from an innovative zirconia-based ceramic composite, in comparison to titanium.

METHODS

Twenty-four ceramic and twenty-four titanium screw-shaped sandblasted-etched dental implants were tested in a split-mouth design in six Beagle dogs. Surface topographies were investigated by confocal microscopy. Local tissue effects were evaluated at 4 and 13 weeks after implantation through histology. An ANOVA statistical analysis (5% risk; p < 0.05) was performed to compare peri-implant quantitative histomorphometric parameters on buccal and lingual sides, including Bone to Implant Contact (BIC) among test groups and time-periods.

RESULTS

Titanium and ceramic implants presented respectively moderate and minimal roughness. After 4 and 13 weeks, ceramic implants showed an inflammatory tissue response close to titanium implants. At both period of time there was no significant difference between the titanium and ceramic groups in terms of BIC values (mean ± SD) at the lingual or buccal sides or when combining buccal + lingual BIC values (respectively for titanium and ceramic, 68.4 ± 14.7 % and 75.0 ± 13.5 % at 4 weeks, and 92.0 ± 8.6 % and 86.1 ± 13.8 % at 13 weeks).

SIGNIFICANCE

Within the limits of the present study, it can be concluded that newly developed zirconia-based ceramic composite dental implants have similar biocompatibility and osseointegration to those observed in titanium implants. These pre-clinical results corroborate the potential for the use of these new zirconia-based ceramics in oral implantology.

The Influence of Surface Preparation, Chewing Simulation, and Thermal Cycling on the Phase Composition of Dental Zirconia

The effect of dental technical tools on the phase composition and roughness of 3/4/5 yttria-stabilized tetragonal zirconia polycrystalline (3y-/4y-/5y-TZP) for application in prosthetic dentistry was investigated. Additionally, the X-ray diffraction methods of Garvie-Nicholson and Rietveld were compared in a dental restoration context. Seven plates from two manufacturers, each fabricated from commercially available zirconia (3/4/5 mol%) for application as dental restorative material, were stressed by different dental technical tools used for grinding and polishing, as well as by chewing simulation and thermocycling. All specimens were examined via laser microscopy (surface roughness) and X-ray diffraction (DIN EN ISO 13356 and the Rietveld method). As a result, the monoclinic phase fraction was halved by grinding for the 3y-TZP and transformed entirely into one of the tetragonal phases by polishing/chewing for all specimens. The tetragonal phase t is preferred for an yttria content of 3 mol% and phase t″ for 5 mol%. Mechanical stress, such as polishing or grinding, does not trigger low-temperature degradation (LTD), but it fosters a phase transformation from monoclinic to tetragonal under certain conditions. This may increase the translucency and deteriorate the mechanical properties to some extent.

Two-piece zirconia implants supporting all-ceramic crowns: Six-year results of a prospective cohort study

OBJECTIVES

The aim of this prospective clinical trial was to present the 6-year outcomes of a two-piece yttria-stabilized tetragonal zirconia polycrystals (Y-TZP) implant system in partially edentulous patients.

MATERIAL AND METHODS

Forty-nine two-piece zirconia implants were placed in 32 patients systemically healthy. Zirconia abutments were connected with adhesive resin cement. Single-unit full-ceramic crowns were cemented. The cases have been followed for an average of 82.2 ± 5.86 months after loading (range 74.93-92.26 months).

RESULTS

24 participants with 39 implants were available for examination 6 years after loading. The cumulative implant survival rate was 83%. On an implant level, the cumulative mechanical complication rate was 17.5%, the cumulative technical complication rate was 13%, and the biological complication rate was 8%. After 6 years, subjects reported good satisfaction with the treatment: 3.7 ± 4.4 on a visual analog scale (VAS) from 0 to 100 mm.

CONCLUSIONS

Within the limitations of this prospective case series study, two-piece zirconia implants could offer an alternative for treatment of single edentulous spaces in the posterior region. The major complication on the long term of this pioneering system was the abutment fracture; however, due to the versatility of a two-piece implant system, replacement of the broken parts was possible.

The Effects of Syndecan on Osteoblastic Cell Adhesion Onto Nano-Zirconia Surface

Purpose

Zirconia is one of the most promising implant materials due to its favorable physical, mechanical and biological properties. However, until now, we know little about the mechanism of osseointegration on zirconia. The purpose of this study is to evaluate the effect of Syndecan (Sdc) on osteoblastic cell (MC3T3-E1) adhesion and proliferation onto zirconia materials.

Materials and Methods

The mirror-polished disks 15 mm in diameter and 1.5 mm in thick of commercial pure titanium (CpTi), 3mol% yttria-stabilized tetragonal zirconia polycrystalline (3Y-TZP) and nano-zirconia (NanoZr) are used in this study. MC3T3-E1 cells were seeded onto specimen surfaces and subjected to RNA interference (RNAi) for Syndecan-1, Syndecan-2, Syndecan-3, and Syndecan-4. At 48h post-transfection, the cell morphology, actin cytoskeleton, and focal adhesion were observed using scanning electron microscopy or laser scanning confocal fluorescence microscopy. At 24h and 48h post-transfection, cell counting kit-8 (CCK-8) assay was used to investigate cell proliferation.

Results

The cell morphology of MC3T3-E1 cells on CpTi, 3Y-TZP, and NanoZr changed into abnormal shape after gene silencing of Syndecan. Among the Syndecan family, Sdc-2 is responsible for NanoZr-specific morphology regulation, via maintenance of cytoskeletal conformation without affecting cellular attachment. According to CCK-8 assay, Sdc-2 affects the osteoblastic cell proliferation onto NanoZr.

Conclusion

Within the limitation of this study, we suggest that Syndecan affects osteoblastic cell adhesion on CpTi, 3Y-TZP, and NanoZr. Sdc-2 might be an important heparin-sensitive cell membrane regulator in osteoblastic cell adhesion, specifically on NanoZr, through the organization of actin cytoskeleton and affects osteoblastic cell proliferation.

Interactions of Osteoprogenitor Cells with a Novel Zirconia Implant Surface

Background: This study compared the in vitro response of a mouse pre-osteoblast cell line on a novel sandblasted zirconia surface with that of titanium. Material and Methods: The MC3T3-E1 subclone 4 osteoblast precursor cell line was cultured on either sandblasted titanium (SBCpTi) or sandblasted zirconia (SBY-TZP). The surface topography was analysed by three-dimensional laser microscopy and scanning electron microscope. The wettability of the discs was also assessed. The cellular response was quantified by assessing the morphology (day 1), proliferation (day 1, 3, 5, 7, 9), viability (day 1, 9), and migration (0, 6, 24 h) assays. Results: The sandblasting surface treatment in both titanium and zirconia increased the surface roughness by rendering a defined surface topography with titanium showing more apparent nano-topography. The wettability of the two surfaces showed no significant difference. The zirconia surface resulted in improved cellular spreading and a significantly increased rate of migration compared to titanium. However, the cellular proliferation and viability noted in our experiments were not significantly different on the zirconia and titanium surfaces. Conclusions: The novel, roughened zirconia surface elicited cellular responses comparable to, or exceeding that, of titanium. Therefore, this novel zirconia surface may be an acceptable substitute for titanium as a dental implant material.

Design of dental implants at materials level: An overview

Due to the excellent restoration of masticatory function, satisfaction on aesthetics and other superiorities, dental implants represent an effective method to resolve tooth losing and damaging. Current dental implant systems still have problems waiting to be addressed, and problems are centralized on the materials of implant bodies. This review aims to summarize major developments in the field of dental implant materials, starting with an overview on structures, procedures of dental implants and challenges of implant materials. Next, implant materials are examined in three categories, that is, metals, ceramics, and polymers, their mechanical properties, biocompatibility, and bioactivity are summarized. And as an important aspect, strategies of surface modification are also reviewed, along with some finite element analysis to guiding the research direction of implant materials. Finally, the conclusive remarks are outlined to provide an outlook on the future research directions and prospects of dental implants.

The osteoinduction of RGD and Mg ion functionalized bioactive zirconia coating

The objective of this study was to investigate the adhesion, proliferation and mineralization of osteoblasts on arginine-glycine-aspartic acid (RGD)- and magnesium ion (Mg⁺)-decorated zirconia coatings. The zirconia coatings were prepared via a plasma spray; RGD and Mg⁺ were immobilized via a silane-coupling agent and ion implantation, respectively. This study employed scanning electron microscopy (SEM) to observe the surface morphology of RGD- and Mg⁺-decorated zirconia coatings; surface roughness and wettability were also measured. The initial adhesion of osteoblasts was measured, and cell morphology and focal adhesion were observed. In addition, the expressions of the integrins a1, a2, a5, av, and ß1 were measured using RT-PCR. A cell count was conducted to measure proliferation. The expressions of ALP and OCN were detected based on a western blot analysis, and mineralized nodules were observed to visualize the mineralization of osteoblasts. A nanoscale surface structure could be found on the Mg⁺-decorated zirconia coating, and the RGD-decorated zirconia coating showed better wettability (p < 0.05). Cells on the RGD- and Mg⁺-decorated zirconia coating possessed better spreading properties than did cells on nondecorated surfaces, and more focal adhesion was observed. The higher expressions of the integrins a5, av and ß1 were found on the RGD-decorated zirconia coating (p < 0.05). The western blot results demonstrated that the introduction of Mg⁺ heightened the expressions of ALP and OCN. More and bigger mineralized nodules were observed on the Mg⁺- and RGD-decorated zirconia coating, which consisted of small mineralized nodules. RGD- and Mg⁺-functionalized zirconia coating facilitates the osteogenic reaction of osteoblasts. RGD improves the adhesion of osteoblasts, and Mg⁺ benefits the mineralization of osteoblasts. In addition, a synergistic effect was found between RGD and Mg⁺, allowing better performances with regard to adhesion, proliferation and mineralization when the two were used together rather than as separate decorations.

Influence of length, diameter and position of the implant in its fracture incidence: A Systematic Review

Background. Implant fractures can cause difficult problems for patients and dentists. This systematic review aimed to determine the influence of some implant parameters on the occurrence of their fracture and to determine the incidence of fractures reported in recent years.

Methods. A search was conducted in Pubmed database, from which 12 studies published in the last 12 years were selected.

Results. This review reported a 2% incidence of implant fracture. Most implants had been in function between 3 and 4 years until fracture. The studies did not provide necessary information to establish a relationship between the different parameters of implants and the incidence of fractures.

Conclusion. Thus, the indication of type, diameter and length of an implant and the bone quality in the region receiving it should be studied and accurately examined for each individual case in order to avoid future failures.

Loading capacity of CAD/CAM-fabricated anterior feldspathic ceramic crowns bonded to one-piece zirconia implants with different cements

OBJECTIVE

This study evaluated the loading capacity of CAD/CAM-fabricated anterior feldspathic ceramic crowns bonded to one-piece zirconia implants with different cements.

MATERIAL AND METHODS

Fifty one-piece zirconia implants were embedded in epoxy resin. The abutment aspect of one implant was optically scanned and a standardized upper canine was designed with CAD-software. Fifty feldspathic ceramic crowns were milled, polished, and mounted on the implants either without any cement, with a temporary cement or with three different composite resin cements after surface pretreatment as recommended by the manufacturers (n = 10). After storage in distilled water at 37°C for 24 hr, specimens were loaded until fracture on the palatal surface of the crown at an angle of 45° to the long axis of the implant and loads until fracture were detected and compared. Compressive strength of the investigated cement materials was determined. Statistical analyses were done with One-way ANOVA followed by post hoc Fisher LSD test (α = 0.05).

RESULTS

The cements revealed significantly different compressive strength values (temporary cement: 37.1 ± 7.0 MPa; composite resin cements: 185.8 ± 21.3, 277.9 ± 22.1, and 389.0 ± 13.6 MPa, respectively). Load-at-fracture values had an overall mean value of 237.1 ± 58.2 N with no significant difference among the composite resin cements (p > 0.05). Fracture load values with the temporary cement or without cement were significantly lower (p < 0.002).

CONCLUSIONS

CAD/CAM-fabricated anterior feldspathic ceramic crowns bonded to one-piece zirconia implants provide sufficient resistance to intraoral forces.

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.

Stability and aging resistance of a zirconia oral implant using a carbon fiber-reinforced screw for implant-abutment connection

OBJECTIVE

To investigate the long-term stability of a metal-free zirconia two-piece implant assembled with a carbon fiber-reinforced (CRF) screw by means of transformation propagation, potential changes in surface roughness, the gap size of the implant-abutment connection, and fracture load values.

METHODS

In a combined procedure, two-piece implants made from alumina-toughened zirconia were dynamically loaded (10⁷ cycles) and hydrothermally aged (85°, 60days). Implants made from titanium (Ti) and a titanium-zirconium (TiZr) alloy with a titanium abutment screw served as control. Transformation propagation (ATZ) and gap size of the IAC were monitored at cross-sections by scanning electron microscopy (SEM). Furthermore, changes in surface roughness of ATZ implants were measured. Finally, implants were statically loaded to fracture. Linear regression models and pairwise comparisons were used for statistical analyses.

RESULTS

Independent of the implant bulk material, dynamic loading/hydrothermal aging did not decrease fracture resistance (p=0.704). All test and control implants fractured at mean loads >1100N. Gap size of the IAC remained stable (<5μm) or decreased. None of the CFR screws fractured during static or dynamic loading. Monoclinic layer thickness of ATZ implants increased by 2-3μm at surfaces exposed to water, including internal surfaces of the IAC. No changes in surface roughness were observed.

SIGNIFICANCE

Combined hydrothermal aging and dynamic loading did not affect the above-mentioned parameters of the evaluated two-piece ATZ implant. Mean fracture loads >1100N suggest a reliable clinical application.

Effects of different surface treatments on the cyclic fatigue strength of one-piece CAD/CAM zirconia implants

OBJECTIVES

The effects of different surface treatments on cyclic fatigue strengths of computer-aided design and computer-aided manufacturing (CAD/CAM) zirconia implants and its mechanisms were evaluated.

MATERIAL AND METHODS

One-piece cylindrical screw-type zirconia (Y-TZP) implants with diameters of 4.1-mm were fabricated using CAD/CAM technique; they were divided into four groups according to the type of surface treatment: (i) sintering (control group, CTRL), (ii) sandblasting (SB), (iii) sandblasting and etching with an experimental hot etching solution (SB-ST), and (iv) sandblasting and etching with hydrofluoric acid (SB-HF). The surface morphology and roughness of the implants were evaluated. Tetragonal to monoclinic transformation was measured on the surface by micro Raman spectroscopy. Static and fatigue tests were carried out at room temperature following the ISO 14801:2014 Standard. The cyclic fatigue strength of each group was determined using the staircase method. Specimens that survived the fatigue test were statically loaded to measure the residual fracture strength.

RESULTS

Among the four groups, SB-HF exhibited the highest surface roughness. Compared with the CTRL group, the surface monoclinic content was higher after all three types of surface treatments, amongst which, SB-HF had the highest content (39.14%), significantly more than the other three groups (P < 0.01). The cyclic fatigue strengths of CTRL, SB, SB-ST, and SB-HF implants were 530 N, 662.5 N, 705 N, and 555 N, respectively. The fracture strength after fatigue loading was higher than that before fatigue loading with no significant difference (P＞0.05).

CONCLUSIONS

SB and SB-ST remarkably enhanced the fatigue resistance of zirconia implants, while SB-HF did not. One-piece 4.1-mm diameter CAD/CAM zirconia implants have sufficient durability for application in dental implants.

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

PURPOSE

Titanium based implant systems, though considered as the gold standard for rehabilitation of edentulous spaces, have been criticized for many inherent flaws. The onset of hypersensitivity reactions, biocompatibility issues, and an unaesthetic gray hue have raised demands for more aesthetic and tissue compatible material for implant fabrication. Zirconia is emerging as a promising alternative to conventional Titanium based implant systems for oral rehabilitation with superior biological, aesthetics, mechanical and optical properties. This review aims to critically analyze and review the credibility of Zirconia implants as an alternative to Titanium for prosthetic rehabilitation.

STUDY SELECTION

The literature search for articles written in the English language in PubMed and Cochrane Library database from 1990 till December 2016. The following search terms were utilized for data search: "zirconia implants" NOT "abutment", "zirconia implants" AND "titanium implants" AND "osseointegration", "zirconia implants" AND compatibility.

RESULTS

The number of potential relevant articles selected were 47. All the human in vivo clinical, in vitro, animals' studies were included and discussed under the following subheadings: Chemical composition, structure and phases; Physical and mechanical properties; Aesthetic and optical properties; Osseointegration and biocompatibility; Surface modifications; Peri-implant tissue compatibility, inflammation and soft tissue healing, and long-term prognosis.

CONCLUSIONS

Zirconia implants are a promising alternative to titanium with a superior soft-tissue response, biocompatibility, and aesthetics with comparable osseointegration. However, further long-term longitudinal and comparative clinical trials are required to validate zirconia as a viable alternative to the titanium implant.

Thirty Years of Translational Research in Zirconia Dental Implants: A Systematic Review of the Literature

Thirty years of transitional research in zirconia (Zr) ceramics has led to significant improvements in the biomedical field, especially in dental implantology. Oral implants made of yttria-tetragonal zirconia polycrystals (Y-TZP) because of their excellent mechanical properties, good biocompatibility, and esthetically acceptable color have emerged as an attractive metal-free alternative to titanium (Ti) implants. The aim of the review was to highlight the translation research in Zr dental implants that has been conducted over the past 3 decades using preclinical animal models. A computer search of electronic databases, primarily PubMed, was performed with the following key words: "zirconia ceramics AND animal trials," "ceramic implants AND animal trials," "zirconia AND animal trials," "zirconia AND in vivo animal trials," without any language restriction. However, the search was limited to animal trials discussing percentage bone-implant contact (%BIC) around zirconia implants/discs. This search resulted in 132 articles (reviews, in vivo studies, and animal studies) of potential interest. We restricted our search terms to "zirconia/ceramic," "bone-implant-contact," and "animal trials" and found 29 relevant publications, which were then selected for full-text reading. Reasons for exclusion included the article's not being an animal study, being a review article, and not discussing %BIC around Zr implants/discs. Most of the studies investigated BIC around Zr in rabbits (30%), pigs (approximately 20%), dogs, sheep, and rats. This review of the literature shows that preclinical animal models can be successfully used to investigate osseointegration around Zr ceramics. Results of the reviewed studies demonstrated excellent %BIC around Zr implants. It should be noted that most of the studies investigated %BIC/removal torque under nonloading conditions, and results would have been somewhat different in functional loading situations because of inherent limitations of Zr ceramics. Further trials are needed to evaluate the performance of Zr ceramics in clinical conditions using implants designed and manufactured via novel techniques that enhance their biomechanical properties.

ADM guidance-Ceramics: guidance to the use of fractography in failure analysis of brittle materials

OBJECTIVES

To provide background information and guidance as to how to use fractography accurately, a powerful tool for failure analysis of dental ceramic structures.

METHODS

An extended palette of qualitative and quantitative fractography is provided, both for in vivo and in vitro fracture surface analyses. As visual support, this guidance document will provide micrographs of typical critical ceramic processing flaws, differentiating between pre- versus post sintering cracks, grinding damage related failures and occlusal contact wear origins and of failures due to surface degradation.

RESULTS

The documentation emphasizes good labeling of crack features, precise indication of the direction of crack propagation (dcp), identification of the fracture origin, the use of fractographic photomontage of critical flaws or flaw labeling on strength data graphics. A compilation of recommendations for specific applications of fractography in Dentistry is also provided.

SIGNIFICANCE

This guidance document will contribute to a more accurate use of fractography and help researchers to better identify, describe and understand the causes of failure, for both clinical and laboratory-scale situations. If adequately performed at a large scale, fractography will assist in optimizing the methods of processing and designing of restorative materials and components. Clinical failures may be better understood and consequently reduced by sending out the correct message regarding the fracture origin in clinical trials.

Biomechanical and histological evaluation of the osseointegration capacity of two types of zirconia implant

The purpose of this study was to evaluate the biomechanical and histological behavior of a ceria-stabilized zirconia-alumina nanocomposite (NanoZr) in comparison with that of 3 mol% yttria-stabilized tetragonal zirconia polycrystalline (3Y-TZP) in Sprague Dawley rats. Cylindrical NanoZr and 3Y-TZP implants (diameter 1 mm, length 2 mm) were used. Implant-surface morphology and surface roughness were determined by scanning white-light interferometry and scanning electron microscopy, respectively. The cylindrical zirconia implants were placed at the distal edge of the femur of Sprague Dawley rats. At weeks 2, 4, and 8, the interfacial shear strength between implant and bone was measured by push-in test. Histological analysis was performed using hard-tissue sections. Bone-implant contact (BIC), the thickness of new bone around the implant within the bone marrow area, and osteoclast numbers were evaluated. The average surface roughness of 3Y-TZP (Sa 0.788 μm) was significantly higher than that of NanoZr (Sa 0.559 μm). The shear strengths of 3Y-TZP and NanoZr were similar at 2 weeks, but at 4 and 8 weeks the shear strength of NanoZr was higher than that of 3Y-TZP. The average BIC values within the bone marrow area for 3Y-TZP and NanoZr were 25.26% and 31.51% at 2 weeks, 46.78% and 38% at 4 weeks, and 47.88% and 56.81% at 8 weeks, respectively. The average BIC values within the cortical area were 38.86% and 58.42% at 2 weeks, 66.82% and 57.74% at 4 weeks, and 79.91% and 78.97% at 8 weeks, respectively. The mean BIC value did not differ significantly between the two zirconia materials at any time point. The NanoZr implants were biocompatible, capable of establishing close BIC, and may be preferred for metal-free dental implants.

Evaluation of stress distributions occurring on zirconia and titanium implant-supported prostheses: A three-dimensional finite element analysis

STATEMENT OF PROBLEM

Titanium implants have been successfully used to support fixed dental prostheses. Zirconia implants have been suggested as support for crowns, but information on their use to support partial fixed dental prostheses is limited.

PURPOSE

The purpose of this finite element study was to evaluate the maximum principal, minimum principal, and von Mises stresses and their distributions on zirconia and titanium implant-supported, partial fixed dental prostheses located in the anterior maxillary region.

MATERIAL AND METHODS

Zirconia and titanium implants (4 mm in diameter and 11. 5 mm in length) and prostheses made from 2 different materials (lithium disilicate and zirconia) were simulated, and 4 models were generated: Titan-IPS, Titan-Lava, Zircon-IPS, and Zircon-Lava. The maxillary bone was modeled as type 3 bone. The load was applied obliquely (534 N) and horizontally (76.5 N), and the stress values and distributions were examined.

RESULTS

Under horizontal loading, stresses generated on the cortical bone in the Zircon models were lower than those in the Titan models. Under oblique loading, stress values were similar in the same implant material and stress type. For all types of stress among the models, the stress values that occurred on the trabecular bone were found to be similar under both horizontal and oblique loading. The maximum stress values on the bones, implants, cores, and veneers did not exceed the strength of the structures.

CONCLUSIONS

Different stress values resulted from the different implant types. The prosthetic materials did not change the stress distributions in bone.

In vitro performance of two-piece zirconia implant systems for anterior application

OBJECTIVES

To investigate the influence of the implant-abutment connection on the long-term in vitro performance and fracture resistance of two-piece zirconia implant systems for anterior application.

METHODS

Six groups of two-piece zirconia implant systems (n=10/group) with screw-retained (5×) or bonded (1×) connections were restored with full-contour zirconia crowns. A two-piece screw-retained titanium system served as reference. For simulating anterior loading the specimens (n=8/group) were mounted at an angle of 135° in the chewing simulator, and subjected to thermal cycling (TC: 2×9000×5°/55°C) and mechanical loading (ML: 3.6×10(6)×100N). Failed restorations were examined (scanning electron microscopy). Fracture resistance and maximum bending stress of surviving restorations were determined. 2 specimens per group were loaded to fracture after 24h water storage without TCML. Data were statistically analyzed (ANOVA; Bonferroni; Kaplan-Meier-Log-Rank; α=0.05).

RESULTS

The bonded zirconia system and the titanium reference survived TCML without any failures. Screw-retained zirconia systems showed fractures of abutments and/or implants, partly combined with screw fracture/loosening. Failure frequency (F) varied between the groups (F=8×: 3 groups, F=3×: 1 group, F=1×: 1 group). The Log-Rank-test showed significant (p=0.000) differences. Fracture forces and maximum bending stresses (mean±standard deviation) differed significantly (

ANOVA

p=0.000) between 233.4±31.4N/317.1±42.6N/mm(2) and 404.3±15.1N/549.2±20.5N/mm(2). Fracture forces after TCML were similar to 24h fracture forces.

SIGNIFICANCE

Screw-retained two-piece zirconia implant systems showed higher failure rates and lower fracture resistance than a screw-retained titanium system, and may be appropriate for clinical anterior requirements with limitations. Failures involved the abutment/implant region around the screw, indicating that the connecting design is crucial for clinical success.

A Novel Technique for the Connection of Ceramic and Titanium Implant Components Using Glass Solder Bonding

Both titanium and ceramic materials provide specific advantages in dental implant technology. However, some problems, like hypersensitivity reactions, corrosion and mechanical failure, have been reported. Therefore, the combining of both materials to take advantage of their pros, while eliminating their respective cons, would be desirable. Hence, we introduced a new technique to bond titanium and ceramic materials by means of a silica-based glass ceramic solder. Cylindrical compound samples (Ø10 mm × 56 mm) made of alumina toughened zirconia (ATZ), as well as titanium grade 5, were bonded by glass solder on their end faces. As a control, a two-component adhesive glue was utilized. The samples were investigated without further treatment, after 30 and 90 days of storage in distilled water at room temperature, and after aging. All samples were subjected to quasi-static four-point-bending tests. We found that the glass solder bonding provided significantly higher bending strength than adhesive glue bonding. In contrast to the glued samples, the bending strength of the soldered samples remained unaltered by the storage and aging treatments. Scanning electron microscopy (SEM) and energy-dispersive X-ray (EDX) analyses confirmed the presence of a stable solder-ceramic interface. Therefore, the glass solder technique represents a promising method for optimizing dental and orthopedic implant bondings.

A Retrospective Clinical Study with Regard to Survival and Success Rates of Zirconia Implants up to and after 7 Years of Loading

PURPOSE

The study aims to retrospectively investigate the clinical performance of first-generation zirconia implants with a sandblasted surface up to and after 7 years of loading.

MATERIALS AND METHODS

Clinical records of patients treated with zirconia implants between 2004 and 2009 were screened. Consequently, adequate patients were invited to a clinical and radiographic investigation to classify each implant according to strict success criteria.

RESULTS

Seventy-one patients receiving 161 implants were available for the evaluation. Overall, 36 implants (22.4%) were lost due to early (n = 14) and late failures (n = 4) or fractures (n = 18). All surviving 125 implants fulfilled the success criteria. None of the investigated implants had a history of peri-implant infections. Mean values with regard to gingival index, plaque index, modified sulcus bleeding index, and probing depth were 0.03, 0.23, 0.59, and 2.80 mm, respectively. The radiographically evaluated mean crestal bone loss was 0.97 ± 0.07 mm. Diameter-reduced implants (3.25 mm) showed lower survival (58.5%) compared with implants with a diameter of 4.0 mm (88.9%) and 5.0 mm (78.6%). The overall longitudinal survival rate was 77.3%.

CONCLUSIONS

First-generation zirconia implants showed low overall survival and success rates. The evaluated clinical and radiographic parameters were consistent with healthy peri-implant tissues. Additionally, nonfractured failures were not associated with peri-implant infections.

A Critical Review of Dental Implant Materials with an Emphasis on Titanium versus Zirconia

The goal of the current publication is to provide a comprehensive literature review on the topic of dental implant materials. The following paper focuses on conventional titanium implants and more recently introduced and increasingly popular zirconia implants. Major subtopics include the material science and the clinical considerations involving both implant materials and the influence of their physical properties on the treatment outcome. Titanium remains the gold standard for the fabrication of oral implants, even though sensitivity does occur, though its clinical relevance is not yet clear. Zirconia implants may prove to be promising in the future; however, further in vitro and well-designed in vivo clinical studies are needed before such a recommendation can be made. Special considerations and technical experience are needed when dealing with zirconia implants to minimize the incidence of mechanical failure.

An Overview of Zirconia Dental Implants: Basic Properties and Clinical Application of Three Cases

Due to the possible aesthetic problems of titanium implants, the developments in ceramic implant materials are increasing. Natural tooth colored ceramic implants may be an alternative to overcome aesthetic problems. The purpose of this article is to give information about the basic properties of dental zirconia implants and present 3 cases treated with two-piece zirconia implants. Two-piece zirconia dental implants, 4.0 mm diameter and 11.5 mm in length, were inserted into maxillary incisor region. They were left for 6 months to osseointegrate. Panoramic and periapical radiographs were obtained and examined for bone-implant osseointegration. During the follow-up period the patients were satisfied with their prosthesis and no complication was observed.

In vitro performance of zirconia and titanium implant/abutment systems for anterior application

OBJECTIVES

To investigate the type of failure and fracture resistance behaviour of different zirconia and titanium implant/abutment systems for anterior application.

METHODS

Eight groups of implant-abutment combinations (n=8/system) were restored with identical full-contour zirconia crowns. The systems represented one-piece and multi-piece zirconia (Z) or titanium (T) implants/abutments with different types of connection (screwed=S, bonded=B). The following combinations (implant-abutment-connection) were investigated: ZZS, ZZB, ZZZB (three-piece), ZTS, TTS, TTS reference, and Z (one-piece, 2×). To simulate clinical anterior loading situations the specimens were mounted into the chewing simulator at an angle of 135° and subjected to thermal cycling (2×3000×5°/55°C) and mechanical loading (1.2×10(6)×50N; 1.6Hz). Fracture resistance and maximum bending stress were determined for all specimens that survived ageing. Data were statistically analyzed with the Kolmogorov-Smirnov-test and one-way ANOVA (α=0.05). Survival performance was calculated with the Kaplan-Meier Log-Rank test.

RESULTS

Independent of the material combinations screwed systems showed partly failures of the screws during simulation (ZZS: 3×, ZTS: 8×, TTS: 3×). Screw failures were combined with implant/abutment fractures of zirconia systems. Zirconia one-piece implants and the reference system did not show any failures, and only one specimen of the systems with a bonded connection (ZZZB) fractured. Mean (±standard deviation) fracture forces and maximum bending stresses differed significantly (p=0.000) between 187.4±42.0N/250.0±56.0N/mm(2) (ZZZB) and 524.3±43.1N/753.0±61.0N/mm(2) (Z).

CONCLUSIONS

Both material (zirconia or titanium) and the type of connection influenced failure resistance during fatigue testing, fracture force, and maximum bending stress.

CLINICAL SIGNIFICANCE

Different material combinations for implants and abutments as well as different types of connection achieved acceptable or even good failure and fracture resistance that may be satisfactory for anterior clinical application.

A single-tooth, two-piece zirconia implant located in the anterior maxilla: a clinical report

It can be difficult to achieve a natural appearance in the anterior region with implant-supported restorations because metal components may show through the soft tissue. Zirconia implants, therefore, should be considered as an alternative treatment for improved esthetics. The goal of this clinical report was to evaluate a new 2-piece zirconia implant system for the maxillary anterior region. A 2-piece zirconia dental implant was placed in the maxillary left lateral incisor position and left in place for 6 months to osseointegrate. Panoramic and periapical radiographs were examined for bone-implant osseointegration. The plaque control record (PCR), bleeding on probing (BOP), and probing depth (PD) were measured after the cementation of the definitive restoration and a 6-month follow-up period. The PCR, BOP, and PD values were compared and the marginal bone level was also evaluated by making standardized periapical radiographs. The results showed that over the 6-month follow-up period, the marginal area was healthy and presented no bleeding on probing, no plaque accumulation, and no change in periimplant marginal bone level.

An in vitro evaluation of the biological effects of carbon nanotube-coated dental zirconia

The purpose of this study is to evaluate functionalized multiwalled carbon nanotubes (fMWCNTs) as a potential coating material for dental zirconia from a biological perspective: its effect on cell proliferation, viability, morphology, and the attachment of an osteoblast-like cell. Osteoblast-like (Saos-2) cells were seeded on uncoated and fMWCNT-coated zirconia discs and in culture dishes that served as controls. The seeding density was 10⁴ cells/cm², and the cells were cultured for 6 days. Cell viability, proliferation and attachment of the Saos-2 cells were studied. The results showed that Saos-2 cells were well attached to both the uncoated and the fMWCNT-coated zirconia discs. Cell viability and proliferation on the fMWCNT-coated zirconia discs were almost the same as for the control discs. Better cell attachment was seen on the fMWCNT-coated than on the uncoated zirconia discs. In conclusion, fMWCNTs seem to be a promising coating material for zirconia-based ceramic surfaces to increase the roughness and thereby enhance the osseointegration of zirconia implants.

Clinical management of implant prostheses in patients with bruxism

There is general agreement that excessive stress to the bone-implant interface may result in implant overload and failure. Early failure of the implant due to excessive loading occurs shortly after uncovering the implant. Excess load on a final restoration after successful implant integration can result in physical failure of the implant structure. Many clinicians believe that overload of dental implants is a risk factor for vertical peri-implant bone loss and/or may be detrimental for the suprastructure in implant prostheses. It has been documented that occlusal parafunction, such as, bruxism (tooth grinding and clenching) affects the outcome of implant prostheses, but there is no evidence for a causal relation between the failures and overload of dental implants. In spite of this lack of evidence, often metal restorations are preferred instead of porcelain for patients in whom bruxism is presumed on the basis of tooth wear. The purpose of this paper is to discuss the importance of the occlusal scheme used in implant restorations for implant longevity and to suggest a clinical approach and occlusal materials for implant prostheses in order to prevent complications related to bruxism.

One-piece zirconia oral implants: one-year results from a prospective cohort study. 1. Single tooth replacement

AIM

To investigate the clinical and radiographic outcome of a one-piece zirconia oral implant for single tooth replacement after 1 year.

MATERIALS AND METHODS

A total of 65 patients received a one-stage implant surgery with immediate temporization. Standardized radiographs were taken at implant insertion and after 1 year to monitor peri-implant bone loss. A univariate analysis of the influence of different baseline parameters on marginal bone loss from implant insertion to 12 months was performed. Soft tissue parameters were evaluated at prosthesis insertion and at the 1-year follow-up.

RESULTS

After 1 year, three implants were lost, giving a cumulative survival rate of 95.4%. The marginal bone loss after 1 year was 1.31 mm. Thirty-four per cent of the implants lost at least 2 mm bone, and 14% more than 3 mm. The univariate analysis could not depict any parameter influencing marginal bone loss. Probing depth, Clinical Attachment Level, Bleeding and Plaque Index decreased over 1 year.

CONCLUSIONS

The cumulative survival rate of the presented ceramic implant was comparable to the reported survival rate of titanium implants when immediately restored. However, the frequency of increased radiographic bone loss (>2 mm) after 1 year was considerably higher as compared to conventional two-piece titanium implants. The presented zirconia implant can therefore not be recommended for clinical usage.