Fracture Resistance of Zirconia Oral Implants In Vitro: A Systematic Review and Meta-Analysis

Various protocols are available to preclinically assess the fracture resistance of zirconia oral implants. The objective of the present review was to determine the impact of different treatments (dynamic loading, hydrothermal aging) and implant features (e.g., material, design or manufacturing) on the fracture resistance of zirconia implants. An electronic screening of two databases (MEDLINE/Pubmed, Embase) was performed. Investigations including > 5 screw-shaped implants providing information to calculate the bending moment at the time point of static loading to fracture were considered. Data was extracted and meta-analyses were conducted using multilevel mixed-effects generalized linear models (GLMs). The Šidák method was used to correct for multiple testing. The initial search resulted in 1864 articles, and finally 19 investigations loading 731 zirconia implants to fracture were analyzed. In general, fracture resistance was affected by the implant design (1-piece > 2-piece, p = 0.004), material (alumina-toughened zirconia/ATZ > yttria-stabilized tetragonal zirconia polycrystal/Y-TZP, p = 0.002) and abutment preparation (untouched > modified/grinded, p < 0.001). In case of 2-piece implants, the amount of dynamic loading cycles prior to static loading (p < 0.001) or anatomical crown supply (p < 0.001) negatively affected the outcome. No impact was found for hydrothermal aging. Heterogeneous findings of the present review highlight the importance of thoroughly and individually evaluating the fracture resistance of every zirconia implant system prior to market release

Identification of Zirconia Particle Uptake in Human Osteoblasts by ToF-SIMS Analysis and Particle-Size Effects on Cell Metabolism

As the use of zirconia-based nano-ceramics is rising in dentistry, the examination of possible biological effects caused by released nanoparticles on oral target tissues, such as bone, is gaining importance. The aim of this investigation was to identify a possible internalization of differently sized zirconia nanoparticles (ZrNP) into human osteoblasts applying Time-of-Flight Secondary Ion Mass Spectrometry (ToF-SIMS), and to examine whether ZrNP exposure affected the metabolic activity of the cells. Since ToF-SIMS has a low probing depth (about 5 nm), visualizing the ZrNP required the controlled erosion of the sample by oxygen bombardment. This procedure removed organic matter, uncovering the internalized ZrNP and leaving the hard particles practically unaffected. It was demonstrated that osteoblasts internalized ZrNP within 24 h in a size-dependent manner. Regarding the cellular metabolic activity, metabolization of alamarBlue by osteoblasts revealed a size- and time-dependent unfavorable effect of ZrNP, with the smallest ZrNP exerting the most pronounced effect. These findings point to different uptake efficiencies of the differently sized ZrNP by human osteoblasts. Furthermore, it was proven that ToF-SIMS is a powerful technique for the detection of zirconia-based nano/microparticles that can be applied for the cell-based validation of clinically relevant materials at the nano/micro scale

Non-Precious Metal Alloy Double Crown-Retained Removable Partial Dentures: A Cross-Sectional In Vivo Investigation.

(1) Background: An alternative material to precious metal alloys are non-precious metal alloys. The material properties of these are different and, therefore, their clinical, biological and mechanical behaviors may also differ. Hence, the purpose of this in vivo investigation was to analyze the clinical and patient-reported outcomes of patients restored with non-precious metal alloy double crown-retained removable partial dentures (NP-D-RPDs). (2) Methods: Partially edentulous patients were restored with non-precious metal alloy partially veneered NP-D-RPDs. Survival rates, success rates, failures and patient-reported outcomes were investigated and statistically evaluated. (3) Results: A total of 61 patients (65.6 ± 10.8 years) were included and clinically and radiographically examined. The mean follow-up time was 25.2 ± 16.5 months. In total, 82 NP-D-RPDs and 268 abutment teeth were examined. The overall survival rate of the NP-D-RPDs was 100% after a mean follow-up time of 2.1 years. The overall success rate was 68.3%. The overall satisfaction with the NP-D-RPDs was 94.3%. (4) Conclusions: Non-precious metal alloy partially veneered NP-D-RPDs seem to be an efficient alternative to precious metal alloy RPDs with excellent patient-reported outcomes

Long-term stability of an injection-molded zirconia bone-level implant: A testing protocol considering aging kinetics and dynamic fatigue

Abstract Objective Separately addressing the fatigue resistance (ISO 14801, evaluation of final product) and aging behavior (ISO 13356, standardized sample) of oral implants made from yttria-stabilized zirconia proved to be insufficient in verifying their long-term stability, since (1) implant processing is known to significantly influence transformation kinetics and (2) aging, up from a certain level, is liable to decrease fatigue resistance. Therefore, the aim of this investigation was to apply a new testing protocol considering environmental conditions adequately inducing aging during dynamic fatigue. Methods Zirconia implants were dynamically loaded (107 cycles), hydrothermally aged (85\ub0, 60 days) or subjected to both treatments simultaneously. Subsequent, monoclinic intensity ratios (Xm) were obtained by locally resolved X-ray microdiffraction (\u3bc-XRD2). Transformation propagation was monitored at cross-sections by \u3bc-Raman spectroscopy and scanning electron microscopy (SEM). Finally, implants were statically loaded to fracture. Linear regression models (fracture load) and mixed models (Xm) were used for statistical analyses. Results All treatments resulted in increased fracture load (p 64 0.005), indicating the formation of transformation induced compressive stresses around surface defects during all treatment modalities. However, only hydrothermal and combinational treatment were found to increase Xm (p < 0.001). No change in Xm was observed for solely dynamically loaded samples (p 65 0.524). Depending on the variable observed, a monoclinic layer thickness of 1\u20132 \u3bcm (SEM) or 6\u20138 \u3bcm (Raman spectroscopy) was measured at surfaces exposed to water during treatments. Significance Hydrothermal aging was successfully induced during dynamic fatigue. Therefore, the presented setup might serve as reference protocol for ensuring pre-clinically long-term reliability of zirconia oral implants

One-Piece Zirconia Oral Implants for the Support of Three-Unit Fixed Dental Prostheses: Three-Year Results from a Prospective Case Series

The objective was to investigate the clinical and radiological outcome of one-piece zirconia oral implants to support three-unit fixed dental prostheses (FDP) after three years in function. Twenty-seven patients were treated with a total of 54 implants in a one-stage surgery and immediate provisionalization. Standardized radiographs were taken at implant placement, after one year and after three years, to evaluate peri-implant bone loss. Soft-tissue parameters were also assessed. Linear mixed regression models as well as Wilcoxon Signed Rank tests were used for analyzing differences between groups and time points (p &lt; 0.05). At the three-year evaluation, one implant was lost, resulting in a cumulative survival rate of 98.1%. The mean marginal bone loss amounted to 2.16 mm. An implant success grade I of 52% (bone loss of &le;2 mm) and success grade II of 61% (bone loss of &le;3 mm) were achieved. None of the evaluated baseline parameters affected bone loss. The survival rate of the zirconia implants was comparable to market-available titanium implants. However, an increased marginal bone loss was observed with a high peri-implantitis incidence and a resulting low implant success rate

The Mechanical Behavior of a Screwless Morse Taper Implant&ndash;Abutment Connection: An In Vitro Study

The use of screwless Morse taper implant&ndash;abutment connections (IAC) might facilitate the clinician&rsquo;s work by eliminating the mechanical complications associated with the retention screw. The aim of this study is to evaluate the effect of artificial chewing on the long-term stability of screwless Morse taper IACs. Thirty-two implant abutments restored with an upper central incisor zirconia crown were used and divided into four groups according to the implant&ndash;abutment assembling manner (C1,H: screw retained (20 Ncm); C2: tapped; or C3: torqued (20 Ncm; the screws were removed before the dynamic loading)). All specimens were subjected to a cyclic loading (98 N) for 10 million chewing cycles. The survived samples were exposed to a pull-off force until failure/disassembling of the connection. All the samples revealed a 100% survival. Regarding the pull-off test, the screw-retained internal hexagonal IAC revealed significantly higher resistance to failure/disassembling (769.6 N) than screwless conical IACs (171.6 N&ndash;246 N) (p &lt; 0.0001). The retention forces in the Morse taper groups were not significantly different (p &gt; 0.05). The screw-retained hexagonal IAC showed the highest retention stability. The screw preload/retention in the conical IAC was lost over time in the group where the screws were kept in place during loading. Nevertheless, the screwless Morse taper IACs were stable for an extended service time and might represent a valid form of treatment for single-tooth replacement

All-ceramic single crowns supported by zirconia implants: 5-year results of a prospective multicenter study

OBJECTIVES To assess survival/success rates and patient-reported outcome of zirconia-based posterior single crowns (SCs) supported by zirconia implants in a prospective two-center study after five years of observation. MATERIAL AND METHODS Forty-five patients were restored with 45 zirconia implant-supported posterior SCs composed of zirconia frameworks hand-layered with a leucite-reinforced feldspathic ceramic. Survival rates of SCs were assessed and technical success was evaluated according to modified United States Public Health Care (USPHS) criteria. Furthermore, patient-reported outcome measures (PROMs) were assessed by applying visual analog scales (VAS). Wilcoxon matched-pairs signed-rank test, mixed-effects ordered logistic regression, and linear mixed models were used to evaluate time effects on response variables. RESULTS Forty patients were available after a mean observation period of 61.0 ± 1.4 months. One SC had to be replaced, resulting in a Kaplan-Meier (KM) survival estimate for the SCs of 97.5 ± 2.47%. Since nine reconstructions showed at least in one category a major deviation from the ideal (five major chippings, four with increased occlusal roughness, one significant crevice, and one pronounced over-contouring), the KM success estimate was 79.3 ± 5.8%. Incidence of chipping (n = 19) and occlusal roughness (n = 35) was frequent (p < 0.001). All PROMs at prosthetic delivery except for speech (p = 0.139) showed significantly improved VAS scores (81%-94%; p < 0.001) compared to pre-treatment evaluations. Thereafter, no decrease in satisfaction could be observed until the 5-year follow-up (93%-97%). CONCLUSION Veneered zirconia-based SCs supported by zirconia implants showed high survival rates and highly satisfied patients' needs. However, significant incidence of technical complications is compromising the clinical long-term outcome for this indication

Platelet-Derived Growth Factor-Modulated Guided Tissue Regeneration with a Bioresorbable Membrane in Class III Furcation Defects: A Histometric Study in the Monkey

It was the aim of this study to histometrically evaluate guided tissue regeneration (bioresorbable membrane plus bone mineral) (GTR) with or without platelet-derived growth factor (PDGF) in two different types of class III furcation defects (small keyhole defects and horizonal defects) in monkeys. In six cynomolgus monkeys, two types of class III furcation defects were created and allowed to chronify for 5 months in mandibular first and second molars. After a hygiene program the molars were assigned to GTR group (collagen membrane plus bovine bone mineral), PDGF group (collagen membrane plus bovine bone mineral plus PDGF), or negative control group (flap reposition only). Histologic sections were made after 7 months of healing and descriptive statistics were provided from the histometric parameters. Postoperative healing was uneventful despite marginal membrane exposures in the GTR and PDGF group. Bone regeneration of 23–35% of the original defect area was found in the two treatment groups. In none of the evaluated key parameters (formation of bone, root cementum, connective tissue, or epithelium) differences were detected between GTR and PDGF groups. However, the negative control teeth exhibited better bone regeneration than the treatment groups. The type of class III defect did not influence the regenerative outcome. Within the limits of this study PDGF was not able to enhance the histologic regeneration of class III furcation areas in monkeys compared to bone mineral enhanced GTR treatment regardless of the defect configuration. Membrane exposure during early healing might have influenced these outcomes

EAO Position Paper: Current Level of Evidence Regarding Zirconia Implants in Clinical Trials

Titanium oral implants are still considered "state of the art" in implant dentistry, with well-documented survival rates. However, their grayish color and high prevalence of peri-implant infections have resulted in controversial discussion as to whether tooth-like-colored, metal-free zirconia ceramic implants provide sufficient potential to be considered equal regarding treatment outcomes. The present position paper has been composed upon invitation by the European Association of Osseointegration in order to provide an update on the current level of evidence regarding zirconia implants in clinical trials. To date, most available and scientifically documented zirconia implant systems are one-piece implants that require an experienced surgeon and prosthodontist due to the restricted flexibility in cases of compromised angulation or vertical positioning. Taking this limitation into account, there is evidence of a comparable outcome for one-piece zirconia implants compared to titanium implants for the fixed replacement of one to three missing teeth. In contrast, currently available clinical data evaluating two-piece zirconia implants with an adhesively bonded implant-abutment interface suggest an inferior outcome. Data evaluating the clinical applicability of screw-retained solutions, even if revealing sufficient fracture resistance in laboratory investigations, are still missing. High survival rates were reported for all-ceramic reconstructions supported by zirconia implants, but with increased technical complications; ie, fractures of the ceramic veneer in the case of bilayered restorations. Sufficient clinical evidence for recommending monolithic approaches is limited to single crowns