Consensus Report

J. A. Hobkirk H. W. A. Wiskott
Members of Working Group: Jens Fischer Theodoros Kapos Mathias Kern Ralph Kohal Ailsa Nicol zcan Mutulu O Richard Palmer Michael Payer Irena Sailer V an Thompson

Ceramics in implant dentistry (Working Group 1)

Authors afliations: J. A. Hobkirk, UCL Eastman Dental Institute, University College London, London, UK H. W. A. Wiskott, School of Dental Medicine, University of Geneva, Geneva, Switzerland Correspondence to: J. A. Hobkirk UCL Eastman Dental Institute University College London London UK Tel.: 44 1223 207698 Fax: 44 1223 207698 e-mail: j.hobkirk@eastman.ucl.ac.uk
Conicts of interest and source of funding statement: The authors declare no conicts of interest. Group 1 participants declared that they had no conict of interests. Moreover, the 2nd Consensus Conference of the European Association of Osseointegration (EAO) was nancially supported by an unrestricted educational grant from the EAO without other resources.

Key words: biomaterials, bone implant interactions, clinical research, clinical trials, prosthodontics Abstract Introduction: The remit of this working group was to update the existing knowledge base in ceramics in implant dentistry. The reviews from working group 1 formed the basis for this update. Moreover, clinical applications as well as suggestions for further research have been formulated. Materials and methods: The papers in the working group critically reviewed the literature on the topic. Manuscripts were produced on: 1. The performance of ceramic and metal implant abutments supporting xed implant reconstructions. 2. The viability of ceramic implants as alternatives to titanium implants. 3. The survival and complications of CADCAM reconstructions as compared with FDPs which have been fabricated using conventional techniques. Results: The results and conclusions of the review process are presented in the following papers, together with the group consensus statements, clinical implications and directions for future research: mmerle C. H. F., Zwahlen M. A systematic Sailer I., Philipp A., Zembic A., Pjetursson B. E., Ha review of the performance of ceramic and metal implant abutments supporting xed implant reconstructions. Andreiotelli M., Wenz H. J., Kohal R.-J. Are ceramic implants a viable alternative to titanium implants? A systematic literature review. Harder S., Kern M. Survival and complications of CAD-CAM vs. conventionally fabricated reconstructions: a systematic review.

To cite this article: Hobkirk JA, Wiskott HWA. Ceramics in implant dentistry (Working Group 1). Clin. Oral Impl. Res. 20 (Suppl. 4), 2009; 5557. doi: 10.1111/j.1600-0501.2009.01779.x

The remit of this working group was to update the existing knowledge base in ceramics in implant dentistry. The following three papers searched and critically reviewed the literature: Sailer I., Philipp A., Zembic A., Pjetursson B. E., Ha mmerle C. H. F., Zwahlen M. A systematic review of the performance of

ceramic and metal implant abutments supporting xed implant reconstructions. Andreiotelli M., Wenz H. J., Kohal R.-J. Are ceramic implants a viable alternative to titanium implants? A systematic literature review. Harder S., Kern M. Survival and complications of CADCAM vs. conventionally

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fabricated reconstructions: a systematic review. The method used by the working group was an iterative process based upon a structured review of the relevant literature by the three rapporteurs. The review papers were circulated to the members of the group before the conference and formed the basis for subsequent discussions. Each paper was subject to detailed collective analysis and subsequently modied on the basis of the panels discussions and referenced to additional relevant literature where appropriate. The group assessed the levels of evidence for the statements made in the supporting documentation and recognized that it was necessary to adopt a compromise between acceptance of the lowest level, resulting in the largest body of material, and the highest level which in some cases produced little evidence. While this approach does not represent endorsement of lower evidence levels per se it was designed to provide conclusions of clinical utility within the existing knowledge base. The consensus statements were prepared after a detailed consideration of the papers submitted to the workshop by the working group. The papers were scrutinized, amended and approved by the group. The basis of each paper is described in the section on search strategy and denes the parameters within which the consensus statements were prepared.

The review was based on the analysis of 29 clinical and 22 laboratory studies and included only ve clinical investigations of ceramic abutments of which three dealt with alumina and two referred to zirconia abutments. These (and subsets thereof) formed the basis for the groups consensus. Many clinical studies reported on the survival of abutments which was dened as their remaining in situ for the observation period with or without modications (Lang et al. 2004); this term is used in the following consensus statements. Also, a wide range of non-standardized terminology was found in the literature, thus making comparisons between studies a challenging process. The mean follow-up time of ceramic abutments was 3.7 years, and the mean follow-up time of metal abutments 4.8 years.
Major conclusions

ments. There were no statistically signicant differences in materials regarding bone loss, gingival recession or other soft tissue complications.
Laboratory studies

Available physical characterization studies lack standardization.

Clinical implications

Three- to 5-year data support the use of ceramic abutments in the anterior and premolar regions. There were very limited data available for the use of ceramic abutments in the molar region. Clinicians should limit their choice of abutments to systems that have been scientically evaluated.
Implications for research

Is the performance of ceramic abutments similar to that of metal abutments?

Sailer, I., Philipp, A., Zembic, A., Pjetursson, B. E., Ha mmerle, C. H. F., Zwahlen, M.

After a mean estimated observation period of 5 years, high survival rates for ceramic (99.1%) and metal (97.4%) abutments can be expected. All-ceramic crowns supported by ceramic abutments exhibited the same survival rates as metalceramic crowns supported by metal abutments. No difference in the technical and biological performance of ceramic and metal abutments could be demonstrated in this review. Because the risk of fracture of a ceramic abutment increases over time, more studies with increased follow-up time of ceramic abutments are needed to verify the conclusion that ceramic and metal abutments have similar failure rates. Finally, a standardization of laboratory tests to evaluate the strength of abutments is needed.
Groups consensus

There is a need for the following: Well-designed RCTs investigating the outcomes of ceramic vs. metal abutments. Outcomes should include: technical and biological complications and patient-reported outcomes. An improved ISO standard (14801) for future physical characterization studies. Further standardized laboratory investigations into the effects of design and loading conditions on clinical abutment performance.

Are ceramic implants a viable alternative to titanium implants?

Andreiotelli, M., Wenz, H.J., Kohal, R.J.
Aim

Aims

Clinical studies

(1) To obtain robust estimates of the 5year survival of ceramic abutments and to describe the incidence of biological and technical complications. (2) To compare the survival rates and complication rates of ceramic abutments with those of metal abutments (gold-standard). (3) To review factors inuencing the mechanical strength of the two types of abutments.

At 3 years there is no difference in the survival rates of metal and ceramic abutments. Technical complication rates were not different between ceramic and metal abutments. Abutment screw loosening was the most frequent technical complication; no difference between the screw loosening rates of ceramic and metal abutments was found. Biological complication rates were not different between ceramic and metal abut-

To systematically screen the dental literature in order to locate scientic animal and clinical data on boneimplant contact and clinical survival/success that would help to answer the question Are ceramic implants a viable alternative to titanium implants? The review was based on the analysis of 13 clinical and 12 animal studies. These (and subsets thereof) formed the basis for the groups consensus. The strength of the supporting data was low as only cohort studies with a moderate to high risk of bias were available. This particularly applied to the three zirconia implant studies. In general, surface roughness was not
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reported. Regarding bone-to-implant contact comparisons between metal and ceramics, roughness measurements were only available in two studies.
Major conclusions

Clinical implications

Until supportive data become available for ceramic implants, titanium is still the material of choice for oral implants.
Implications for research

CADCAM restorations were evaluated (i.e. full arch and single unit restorations). It should be recognized that the collective term CADCAM encompasses a wide range of techniques using many different materials.

This systematic review could identify histological animal studies showing similar bone-to-implant contact between alumina, zirconia and titanium. However, only cohort investigations were found making it impossible to answer the posed hypothesis with certainty. Currently, the scientic clinical data for ceramic implants in general and for zirconia implants in particular are not sufcient to recommend ceramic implants for routine clinical use.
Groups consensus Animal studies

In animal studies, the bone-to-implant contact as assessed at a light-microscope level was similar for zirconia, alumina and titanium implants. However, conicting results of the two studies where surface roughness was reported do not allow conclusive statements regarding the effect of surface roughness on bone-to-implant contact in ceramic implants.
Clinical studies

There is a need for the following: In vitro studies comparing mechanical properties of ceramic and titanium implants under a range of loading and environmental conditions with established successful titanium implants as a benchmark. Studies investigating the impact of implant materials, designs and surface modications on mechanical and biological performance. RCTs investigating the outcomes of ceramic vs. titanium implants. Outcomes should include: biological and mechanical complications and patient-reported outcomes.

Major conclusions

Only a small number of clinical studies reporting on implant-supported CAD CAM fabricated restorations are available which makes a scientically valid comparison with conventionally fabricated restorations impossible.

Groups statements

The lack of data makes it impossible to scientically compare CADCAM and conventionally fabricated implant-borne restorations.

Clinical implications

Survival and complications of CADCAM vs. conventionally fabricated implant-supported reconstructions: a systematic review
Harder, S., Kern, M. The review was based on the analysis of one RCT, and two prospective and one retrospective cohort studies. These formed the basis for the groups consensus. The duration of the studies ranged from 2 to 5 years. There were no controls in the cohort studies. Two studies were designed to investigate issues other than the performance of CADCAM reconstructions (i.e. immediate loading). The level of evidence was dependent on the study design (i.e. RCT vs. cohort studies). Only two types of

CADCAM technologies are rapidly evolving and in wide usage; however, the clinical pros and cons for implant-borne restorations have not been determined.

Implications for research

Clinical investigations up to 10 years showed a wide range of survival rates (23 98%) for alumina implants. No clinical follow-up studies on alumina implants were published after 2000. No alumina implants are currently marketed. The quality of currently available data is not sufcient to recommend the use of zirconia implants.

Investigations should be designed to quantify possible advantages/disadvantages of CADCAM generated implant-borne restorations, in particular concerning the effectiveness and efciency of CAD CAM technologies. The use of CADCAM generated restorations in implant-supported applications would benet from large-scale practice-based trials. The relative effects of materials and those of processing techniques should be clearly distinguished.

References
Andreiotelli, M., Wenz, H.J. & Kohal, R.J. (2009) Are ceramic implants a viable alternative to titanium implants? A systematic literature review. Clinical Oral Implants Research 20 (Suppl. 4): 3247. Harder, S. & Kern, M. (2009) Survival and complications of CADCAM vs. conventionally fabricated implant-supported reconstructions: a systematic review. Clinical Oral Implants Research 20 (Suppl. 4): 4854. Lang, N.P., Berglundh, T., Heitz-Mayeld, L.G., Pjetursson, B.E., Salvi, G.E. & Sanz, M. (2004) Consensus statements and recommended clinical procedures regarding implant survival and complications. International Journal of Oral Maxillofacial Implants 19: 150154. Sailer, I., Philipp, A., Zembic, A., Pjetursson, B.E., Ha mmerle, C.H.F. & Zwahlen, M. (2009) A systematic review of the performance of ceramic and metal implant abutments supporting xed implant reconstructions. Clinical Oral Implants Research 20 (Suppl. 4): 431.

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