CASE REPORT

Mechanical, biological and clinical

aspects of zirconia implants
Eric Van Dooren, DDS
Private Practice, Antwerp, Belgium

Marcelo Calamita, DDS, MSc, PhD

Private Practice, Sao Paulo, Brazil

Murilo Calgaro, DMT

Sao Paulo, Brazil

Christian Coachman, DDS, DMT

Private Practice, Sao Paulo, Brazil

Jonathan L. Ferencz, DDS

Private Practice, New York, USA

Nelson RFA Silva, DDS, MSc, PhD

Department of Prosthodontics, New York University College of Dentistry,
New York, USA

Correspondence to: Eric Van Dooren DDS

Tavernierkaai, 2, 2000 Antwerpen, Belgium; Tel: +32-3-2380835; E-mail: vandoorendent@skynet.be

2
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
70-6.&

t
/6.#&3

t
8*/5&3


VAN DOOREN ET AL

Abstract

scenarios where zirconia implant proto-

The objective of this narrative overview

possible scientific and clinical concerns

is to discuss several in vitro and in vivo

that may affect the functional, biological

studies regarding the performance of

and esthetic long term outcomes.

types were utilized with emphasis on the

one-piece zirconia implants in combination with the description of two clinical

(Eur J Esthet Dent 2012;7:xxxxxx)

3
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
70-6.&

t
/6.#&3

t
8*/5&3


CASE REPORT

Introduction

piece zirconia implant might be an option to fulfill the esthetic and functional

Despite the recognized biocompatibil-

requirements in dental implant therapy,

ity of titanium alloy surface protective

particularly when thin biotype tissue is

oxide layers, metallic ion release has

present.

raised concerns over the last decade.

It is important to note that although

Increased concentration of titanium has

several zirconia implant systems are

been observed in tissues close to the

available on the market (examples of

implant

surfaces2

and also in regional

DFSBNJD
JNQMBOUT
BSF
8IJUF
4LZ
JNQMBOU

lymph nodes.3 Although the clinical rel-

TZTUFN
#SFEFOU
.FEJDBM

$P


$FSB-

evance of these observations is uncer-

root one-piece zirconia implant system

tain, demand for metal-free treatments is

(Ceraroot

4JHNB
JNQMBOUT
*ODFSNFE

increasing in dental practice.

4"

[JU[
JNQMBOUT
;JUFSJPO

;-PPL

Due to its high flexural strength (900-

(Z-systems

SJHPSPVT
QSPTQFDUJWF

 

.1B

GBWPSBCMF
GSBDUVSF
UPVHI-

and retrospective clinical trials have not

OFTT
,*$

UP


.1BN

BOE
TBUJT-

been reported. Moreover, several arti-



(1B


cles available in the literature present

Zirconia (yttria-stabilized tetragonal zir-

zirconia implant prototypes (not avail-

DPOJB
QPMZDSZTUBM
:5;1

IBT
CFFO
QSP-

BCMF
JO
UIF
NBSLFU

XIJDI
NBLF
JUT
DMJO-

posed as an alternative to metallic alloys.

ical application controversial.

GBDUPSZ
:PVOHT
NPEVMVT

Biologically, zirconia has been shown in

This article discusses in vitro and in

both in vitro and in vivo experiments to

vivo studies using zirconia implants and

exhibit desirable osseointegration, cell

presents two clinical scenarios in which

metabolism, and soft tissue response.5,6

zirconia prototype implants were utilized

In addition, zirconia implant human his-

as the treatment of choice, illustrating

tology has demonstrated morphology

their potential to enhance the final long-

suggestive of lamina dura and, thereby,

term clinical esthetic outcome.

the potential for increased quality of osseointegration.6

In orthopedics, zirconia has been extensively utilized as a material for femoral ball-heads in total hip replacements

Mechanical behavior:
in vitro investigations

TJODF
JUT
JOUSPEVDUJPO
JO
UIF
T7 In

Unlike orthopedic devices, zirconia im-

dentistry, zirconia has been used for

plants frequently need to be modified

cores and frameworks in all-ceramic

after surgical placement to achieve op-

restorations, as well as for ceramic abut-

timal crown contours. This preparation

prostheses.8

is performed using course and fine

ments in dental implant

Although ceramic abutments associ-

HSBJO
EJBNPOE
CVST
'JH




"CSBTJWF

ated with all-ceramic crowns have been

surface damage has been implicated in

shown to be an excellent treatment in

decreasing the clinical life expectancy

critical esthetic situations, the presence

of dental ceramics as a result of slow

of an abutment fixture junction has raised

crack growth. The assumptions were

concerns.9

obtained from mechanical tests per-

Thus, the utilization of a one-

4
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
70-6.&

t
/6.#&3

t
8*/5&3


VAN DOOREN ET AL

GPSNFE
PO

UP


NN
UIJDL
HMBTT
PS

ceramic-layered structures. Therefore,
abrasive

surface

damage

becomes

relevant for cores and veneers on partial or full crown restorations and fixed
dental prostheses. This deleterious effect on ceramics worsens when water is
present during loading, a phenomenon
known as hydraulic pumping, where
flaws on the ceramic surfaces created
by grinding or wear entraps water (or
TBMJWB

6OEFS
GBUJHVF
PS
NBTUJDBUJPO

GPSDFT

UFOTJPO
TJUFT
BU
UIF
DSBDL
UJQT

are generated because of the presence
of fluid forced into these flaws, resulting
in faster crack growth. Considering the
fact that the final crown is always cemented on prepared zirconia implants,
it is reasonable to expect that the water
pumping phenomenon will not have any

Fig 1

*NBHF
iBw
TIPXT
EJHJUBM
QJDUVSF
BOE
TDBO-

effect on the long term survival of zirco-

OJOH
FMFDUSPO
NJDSPTDPQJD
4&.

QJDUVSF
PG
UIF
IFBE

nia implants although damage might be

PG
B
POFQJFDF
[JSDPOJB
JNQMBOU
/PCFM
#JPDBSF

BGUFS

incurred on the cemented restoration.

In vitro investigations evaluating the
mechanical

of

sents the SEM area. Note the white arrows pointing

UP
UIF
TDSBUDIFT
QSPEVDFE
CZ
DPVSTF
CVS
iCw
5IF

zirconia

overall preparation shows prominent marks pro-

oral implants are available in the litera-

duced even after utilization of fine grain diamond

tureo.

performance

full crown preparation. The black dotted box repre-

These studies also address the

CVS
iDw

surface damage created during crown

preparation. Three of the investigations
evaluated fatigue response of similar zirconia implantso
and one study investigated the impact fracture resistance of
zirconia implants in comparison to two

the implant undamaged.
Also, the dif-

systems.

ferences in fracture mechanism suggest

This study found no difference in fracture

that a patient receiving a traumatic injury

energy between two titanium-abutment

that would result in fracture of a natural

TZTUFNT
UJUBOJVN
BOE
[JSDPOJB
BCVUNFOU

tooth, might not fracture an osseointe-

and one-piece zirconia implants placed

grated titanium or zirconia implant. The

in foam blocks. In all instances the foam

same research team evaluated fatigue

block fractured, suggesting that when

reliability of as-received compared to zir-

titanium or ceramic fixtures are osseoin-

conia implants with coronal portions pre-

tegrated, facial trauma is likely to lead to

pared by diamond burs. All specimens

alveolar fracture, consequently leaving

were step-stress fatigued until failure

titanium-implant-abutment

5
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
70-6.&

t
/6.#&3

t
8*/5&3


CASE REPORT

or survival. The authors concluded that

limited under in vivo conditions until

crown preparation does not influence

Chevalier 
reported early failures of

the reliability of the one-piece zirconia


GFNPSBM
IFBET
JO

5IF
GBJMVSFT

ceramic implant, and that fatigue has

were associated with a change in the

little influence on the survival of these

processing technique and accelerated

implants at loads under 600 N. Another

ageing of two batches of Prozyr femoral

research

group

evaluated the fracture

heads.

strength of one-piece zirconia implants

The mechanism of the ageing pro-

using a universal testing machine after

cess and its deleterious effect on the

artificial loading in the chewing simula-

performance of zirconia involves an in-

UPS
'JGUFFO
EJGGFSFOU
HSPVQT

UJUBOJVN

crease of surface roughness and sub-

JNQMBOU
HSPVQT
BOE

[JSDPOJB
JNQMBOU

sequent microcracking.  These two

HSPVQT
XJUI
EJGGFSFOU
QSFUSFBUNFOUT

phenomena combined might lead to

were investigated. Seven of the 72 arti-

pullout of the zirconia grains. Therefore,

ficially loaded implant samples failed in

the biological interaction of these small

the chewing simulator. Zirconia implant

particles with immune system cells be-

fracture occurred at 725 to 850 N when

comes critical. These observations

the implants were not prepared, and at

from Chevaliers group were based on

539 to 607 N when prepared. In contrast

the fact that the zirconia head is in direct

to Silva et al, this study concluded that

contact with an antagonist part of the

implant preparation had a negative in-

prosthesis, therefore an increase in wear

fluence on the zirconia implant fracture

rate can be exacerbated by the conse-

strength. It is important to recognize that

quences of ageing.

the zirconia implants in both studies 

Reports in the dental literature are

received full crown preparations follow-

limited and inconclusive regarding the

ing guidelines for preparation of anterior

possible implications of the accelerated

teeth and the failure loads were signifi-

ageing phenomenon of zirconia on the

cantly higher than the maximum biting

mechanical properties and biological



/
.

response for crowns, fixed partial den-

It was concluded that the zirconia im-

tures, abutments, and implants. From

plants should withstand intraoral loading

a clinical perspective, the crown prep-

conditions in the esthetic zone.

aration performed on zirconia implants

GPSDF
JO
UIF
BOUFSJPS
SFHJPO

may lead to an accelerated ageing

phenomenon as a result of the damage

Low temperature
degradation of zirconia

caused by the burs. However, one can-

It is known that zirconia undergoes

crowns are cemented on the prepara-

low-temperature degradation via sur-

tions. Conversely, depending on the

face transformation from the tetragonal

type of surface treatment performed on

to monoclinic phase in the presence

the zirconia to promote better osseoin-

of water or water vapor. This ageing

tegration, the accelerated ageing phe-

phenomenon was considered to be very

nomenon might become an important

6
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
70-6.&

t
/6.#&3

t
8*/5&3


not expect wear directly on the zirconia

implants after crown preparation, since

VAN DOOREN ET AL

factor affecting the biological response.

zirconia implants in the tibiae of rabbits

The clinical relevance of the acceler-

and reported 68% BIC. Akagawa et al

ated aging phenomenon on one-piece

evaluated the degree of BIC of loaded

zirconia implants is not yet clear and

and nonloaded zirconia implants placed

no failures of these implants associated

in the maxillae using the dog model.

with accelerated aging phenomenon

There was a slightly higher BIC found

have been reported. All these assump-

GPS
UIF
OPOMPBEFE
JNQMBOUT


DPN-

tions related to the accelerated ageing

QBSFE
UP
UIF
MPBEFE
POFT


5IFSF

process of zirconia point to the need for

was also loss of crestal bone evident

further investigations in the fields of or-

around the loaded implants. Another

thopedics and dentistry.

study performed by the same group25

revealed direct bone apposition (> 50%
#*$

BGUFS
UXP
ZFBST
JO
UIF
EJGGFSFOU
JN-

Radioactivity concerns

plant investigation groups.

Zirconia is well known for promoting

parison between different zirconia im-

positive

Sennerby et al26 performed a com-

However,

plant surfaces. One particular modified

concerns regarding the presence of

zirconia implant surface showed resist-

radioactive components during its fab-

ance to torque forces similar to oxidized

SJDBUJPO
[JSDPOJB
QPXEFS

IBWF
CFFO

titanium implants. Considering implant

discussed.
The

tissue

responses.

radioactive exposure

placement location using a rabbit model

is caused by impurities in the zirconia

for the study26, two tested modified zir-

manufacturing process. Although, in

conia implant surfaces showed a BIC

vitro carcinogenicity and mutagenicity

in the femur of 60 to 70% compared to

tests on zirconia have shown negative

~ 78% for titanium oxide implants and

results,  ceramic manufacturers are

of approximately 20 to 30% in the tibia

encouraged to control the purification

compared to ~ 25% for titanium oxide

process of zirconia22 to avoid any pos-

implants. Hofmann et al27 compared

sible radioactive impurity in one-piece

CPOF
BQQPTJUJPO
BSPVOE

[JSDPOJB
JN-

ceramic implants. Radiation protection

QMBOUT
BOE

TVSGBDFNPEJmFE
UJUBOJVN

while handling zircon sands is frequently

implants. The degree of BIC (zirco-

utilized for the safety of professionals in

nia 2 weeks: ~ 55%, titanium 2 weeks:

this field.

_


[JSDPOJB


XFFLT
_


UJUBOJVN


XFFLT
_



XBT
TJNJMBS
PO
BMM

implants during an early healing phase.

In vivo investigations

Depprich et al28 did not find statistically

significant differences between acid-

This section presents some of the stud-

etched zirconia and titanium implants

ies on zirconia implants utilized in animal

after implants were inserted in tibias of

models, mainly investigating the effects

mini pigs. Lee et al29 evaluated nano-

of surface modifications on bone-to-im-

technology-modified zirconia implants

QMBOU
DPOUBDU
#*$

SFTQPOTF
4DBSBOP

placed in rabbits. Three different zirco-

et

al23

investigated the bone response of

nia implant groups (two with a nanotech-

7
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
70-6.&

t
/6.#&3

t
8*/5&3


CASE REPORT

nology surface modification using calDJVN
QIPTQIBUF

XFSF
DPNQBSFE
XJUI

Clinical evaluations

titanium oxide implants. The titanium im-

8IJMF
NPSF
EFmOJUJWF
BOTXFST
BSF
OPU

plants demonstrated a BIC of 77% after

yet available regarding the mechanical

3 weeks of healing, being significantly

and biological performance of zirconia

different to the nanomodified zirconia

implants, including the effect of accel-

surfaces. The unmodified zirconia sur-

erated aging phenomena, some clinical

GBDF
IBE
B
#*$
PG

BGUFS


XFFLT

studies heave already been performed

Kohal et

al30

presented the biomechani-

using these implants. For instance, in

cal and histological behavior of zirconia

two of these studies, Oliva et al pre-

implants with no statistically significant

sented one- and five-year follow-ups of

different BIC values for rough titanium

ceramic implants placed in patients with

BOE
[JSDPOJB
TVSGBDFT
"GUFS

EBZT
PG

BHFT
SBOHJOH
GSPN

UP
32,33 The au-

healing, rough titanium showed a BIC of

thors also compared implants with differ-


BOE

'PS
SPVHI
[JSDPOJB
BGUFS

ent surface roughnesses and designs.


EBZT
UIF
#*$
BNPVOUFE
UP

GPS
UJ-

The implants were placed in anterior

tanium and 59% for zirconia. Rocchietta

and posterior regions following standard

et al investigated a topographically

surgical procedures. Olivas group pre-

modified zirconia using oxidized tita-

sented an overall success rate of 98%

nium implants as a control group. The

BOE

BGUFS

BOE

ZFBST
SFTQFDU-

removal torque values for the different

ively.32,33 The success rate of the acid-

zirconia implants were not statistically

FUDIFE
JNQMBOU
HSPVQ


XBT
TJH-

significant different ranging from 29 N/

OJmDBOUMZ
IJHIFS
UIBO
DPBUFE


cm2 (not HA coated

UP


/DN2 (sput-

BOE
VODPBUFE
JNQMBOUT



UFS
DPBUFE

5IF
IJTUPMPHJDBM
BOBMZTJT
SF-

Lambrich et al conducted a study

vealed values for the BIC from 28% (not

JO
XIJDI

JNQMBOUT

[JSDPOJB

)"
DPBUFE

UP

PYJEJ[FE
UJUBOJVN

BOE

UJUBOJVN

JO

QBUJFOUT
XFSF

with no significant differences (95% con-

placed and followed for an observation

mEFODF
JOUFSWBMT


QFSJPE
PG

NPOUIT
5IF
TVSWJWBM
SBUF

It can be concluded that the above-

of the titanium implants were 98% in the

mentioned studies comparing zirconia

maxilla and 97% in the mandible, while

to titanium implants showed that the

the zirconia implants showed a survival

bone-to-implant contact was similar for

SBUF
PG

JO
UIF
NBYJMMB
BOE

JO
UIF

both materials, demonstrating that zirco-

NBOEJCMF
5IF
GBJMVSFT

JNQMBOUT
JO
UIF

nia can potentially be utilized as a ma-

NBYJMMB
BOE
POF
JNQMBOU
JO
UIF
NBOEJCMF

terial for dental implants.

occurred during the healing period up

to the first 6 months. No implant fracture
was reported.
There is clearly a need for well-designed, long-term, prospective studies
concerning one-piece zirconia dental
implants that include peri-implant bone
remodeling/loss data.

8
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
70-6.&

t
/6.#&3

t
8*/5&3


VAN DOOREN ET AL

Success of zirconia
implants based on design
and clinical guidelines

particularly for highly crucial esthetic

The success of zirconia implants is de-

with Nobel Biocare in the beginning of

pendent on proper understanding of

2006. The main idea behind this project

implant design and surface character-

was to create an implant design with a

istics, patient selection and adherence

concave transmucosal region and evalu-

UP
QSPQFS
TVSHJDBM
HVJEFMJOFT
8IFO

ate the long-term soft tissue stability af-

working in the esthetic zone, clinicians

ter implant placement. Until now, scien-

must preserve the natural components

tific and histological evidence showing

of the smile. Tooth morphology, soft tis-

fibrous attachment on implant or abut-

sue architecture, lip support and smile

ment surfaces is limited. The long-term

design need to be optimal for the final

soft tissue stability in the transmucosal

esthetic outcome. New advancements

zone relies on the thickness of the con-

in dental technology have created treat-

nective tissue fibers, referred to as the

ments never possible in the past, espe-

i0SJOH
FGGFDUw35,36

situations.
New prototypes of one-piece zirconia
implants were designed in collaboration

cially for dental implant therapy. Howev-

Therefore, the soft tissue thickness

er, caution is advised to avoid creating

could potentially be improved utilizing a

unrealistic expectations based on case

concave transmucosal design between

reports in the literature and presenta-

the head and first thread of the zirco-

tions at dental meetings. Inadequate

nia implant. Another option could be the

diagnosis and treatment planning could

combination of a concave transmucosal

lead to dissatisfying and unacceptable

form

esthetic results, disappointing both clin-

abutment. However this screw-retained

ician and patient.

system presents a potential design limi-

with

screw-retained

zirconia

The success of implant dentistry in

tation as the thickness of the zirconia

critical esthetic zones depends on the

abutment is reduced significantly at the

combination of prosthetic and surgical

implant/screw/abutment interface, po-

soft tissue managements. Minor surgi-

tentially leading to mechanical failures.

cal errors could create major soft tissue

Therefore, the one-piece ceramic im-

discrepancies. Moreover, inadequate

plant seems to be the optimal design.

utilization of prosthetic components and

restorative materials might lead to disappointing results in the esthetic zone,
and subsequent failure of the final esthetic result.
The creation of ideal and stable soft
and hard tissue contours around implant-supported restorations is still a
challenge. Zirconia implants were introduced to the market to potentially enhance the oral implant armamentarium,

9
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
70-6.&

t
/6.#&3

t
8*/5&3


CASE REPORT

reported long-term success (Van Dooren E, Rompen E and Touati B, unpublished data

BOE
XJMM
CF
QSFTFOUFE
JO
UIF

clinical cases descriptions.

Surgical and prosthetic

considerations
This section addresses clinical aspects
related to zirconia implant design and
Fig 2

One piece ceramic implant prototypes. (a)

clinical concerns that may influence the

shows a prototype with a circular transmucosal re-

clinical success of zirconia implant ther-

HJPO
CMBDL
BSSPX


(b) represents front and side

apy. Two clinical scenarios were select-

views of a zirconia central incisor implant. (c) shows

front and side view of a lateral zirconia implant. Note

ed and presented in this article in order

in (b) and (c) the scalloped transmucosal regions

to explain the concept and surgical pro-

compared to (b). (b) and (c)
BMTP
TIPX
UIF

EF-

tocol associated with the prosthetic re-

gree inclination of the axial walls of the head of the

habilitation when zirconia implants were

implants to facilitate prosthetic procedures.

Zirconia implant
prototypes

the treatment therapy of choice.

Surgical considerations
DBTF
SFQPSU


A 30-year-old female patient presented

The first implant prototypes presented a

XJUI
B
GSBDUVSFE
MFGU
MBUFSBM
JODJTPS
'JH

B


straighter configuration with symmetri-

Microscopic evaluation revealed a crack

DBM
GPSN
'JH

B

5IF
TFDPOE
QSPUPUZQF

in the labial aspect of the root. The frac-

'JHVSF

C
BOE
D

XBT
EFWFMPQFE
BG-

tured coronal part was bonded provi-

UFS


ZFBS
XJUI
BO
BTTZNFUSJDBM
EFTJHO

sionally to the root with a metal post. Ra-

The circumferential concave transmu-

diographically, the supracrestal fracture

cosal groove of the first prototype was

MJOF
XBT
WJTJCMF
'JH

B


/P
CMFFEJOH

modified into a scalloped transmucosal

was present during probing and the la-

groove, simulating the silhouette of the

bial bone was intact. The patient exhib-

natural tooth surrounding bone. The

ited a very thin gingival biotype35,36 and

prosthetic coronal part of the implant

a moderate to high smile line,37 with full

IFBE

QSFTFOUFE
B

EFHSFF
BOHVMB-

exposure of the dento-gingival complex

tion with a specific prosthetic diameter,

and surrounding soft tissues.

where a narrower prosthetic platform

The patient was willing to undergo

was used for lateral incisors and wider

comprehensive treatment in order to

prosthetic platform for central incisors

achieve her esthetic goals, however she

BOE
DBOJOFT
'JH

C
BOE
D

5IF
TDBM-

was reluctant to proceed unless mini-

loped prototype implants were placed

mally invasive surgery was performed. A

and evaluated in several patients with

treatment plan was proposed, involving

10
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
70-6.&

t
/6.#&3

t
8*/5&3


VAN DOOREN ET AL

Fig 3

11
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
70-6.&

t
/6.#&3

t
8*/5&3


CASE REPORT

extraction of the lateral incisor followed

A nontraumatic extraction38 was per-

by the immediate zirconia implant place-

formed using periotomes to preserve

ment and temporization for subsequent

the facial bone contour. Care was taken

prosthetic replacement.

to completely debride the socket with

12
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
70-6.&

t
/6.#&3

t
8*/5&3


VAN DOOREN ET AL

a curette and remove the periodontal

into the facial pouch. The connective tis-

ligament before implant placement. A

sue graft allowed for partial compensa-

one-piece zirconia implant (Nobel Bio-

tion of the crestal bone resorption that

DBSF

XJUI
B
iOBSSPX
QSPTUIFUJD
EJBN-

commonly occurs after extraction.


FUFSw
'JH

D

XBT
QMBDFE
JO
UIF
FYUSBD-

8JUI
UIJT
HSBGU
BQQSPBDI
UIJDL
DPO-

tion socket. The implant was secured by

nective tissue could be formed around

engaging the palatal bone of the extrac-

the transmucosal zone where the zirco-

tion socket to obtain primary stabiliza-

nia implant prototype presents the con-

tion and avoid contact of the facial bone

cave design. The prosthetic component

plate, allowing a 2 mm gap for the graft-

of the implant with the facial-lingual an-

JOH
QSPDFEVSF
#JP0TT
(FJTUMJDI

39

HVMBUJPO
PG

EFHSFFT
BMMPXFE
JNNFEJ-

Subsequently, a connective tissue graft

BUF
QSPWJTJPOBMJ[BUJPO
'JH

F


was harvested from the tuberosity region

5IF
QPTUPQ
SBEJPHSBQI
'JH

G

TIPXT

and secured into a split thickness facial

the position of the most coronal scal-

QPVDI
XJUI
B
TVMDVMBS
BQQSPBDI
'JH
Co

MPQFE
JOUFSEFOUBM
UISFBE
8JUI
DPOWFO-

E

4VUVSFT
'JH

F

XFSF
QMBDFE
BOE

tional implant systems, fixtures are fre-

care was taken to have a passive, ten-

quently placed excessively deep with

sion-free fit of the connective tissue graft

the potential to induce bone resorption.

13
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
70-6.&

t
/6.#&3

t
8*/5&3


CASE REPORT

8JUI
UIF
VUJMJ[BUJPO
PG
UIF
QSPUPUZQF
EF-

Prosthetic considerations

scribed in this article, less interdental

DBTF
SFQPSU


bone resorption might be observed due

to the more coronal position of the inter-

A 28-year-old male patient presented

dental threads.

with a severe esthetic problem associ-

After 3 months of healing, the mar-

ated with trauma of the anterior denti-

ginal soft tissue form was excellent. This

UJPO
'JH

B

5IF
MFGU
DFOUSBM
JODJTPS
XBT

might be a result of the combination of

endodontically treated and restored with

connective tissue grafting and the im-

a fiber post, followed by a composite

plant

profile,

build-up. The right central incisor exhib-

allowing for soft tissue thickness and

ited a vertical fracture line, necessitating

stability in the critical zone. Compared

extraction. Neither bleeding nor facial

UP
CBTFMJOF
'JH

B

QBQJMMB
IFJHIU
BOE

bone loss was detectable by probing.

volume decreased very slightly initially,

A two-unit provisional bridge was fab-

due to surgical trauma. At this stage, ini-

ricated prior to extraction and implant

tial healing was complete and osseoin-

placement.

transmucosal

concave

tegration achieved.

"
POFQJFDF
[JSDPOJB
JNQMBOU
'JH

C

The provisional crown was removed,

was placed with the same surgical pro-

and preparation was perfomed by es-

tocol as described in the prior clinical

tablishing adequate marginal soft tissue

example. For this clinical scenario, the

contours and a zenith position and re-

implant design with a wider prosthetic

traction cord were
JOTFSUFE
'JHVSF

Ho

EJBNFUFS
XBT
VTFE
'JH

C

5IJT
JNQMBOU

K

GPS
mOBM
JNQSFTTJPOJOH
"
1SPDFSB

configuration allowed for better anatom-

BMVNJOB
DPQJOH
/PCFM
#JPDBSF

XBT

ical form of the final crown to match the

GBCSJDBUFE
EPVCMF
TDBOOJOH
UFDIOJRVF

dimensions of a central incisor.

'JH

L

BOE
UIF
QPSDFMBJO
WFOFFS
BQ-

However, even with these advanced

QMJFE
'JHVSF

M

/PCFM
3POEP
/PCFM

asymmetrical designs, utilization of one-

#JPDBSF

$BSF
XBT
UBLFO
UP
QSPWJEF
UIF

piece implant systems requires a more

optimal prosthetic gingival support al-

specific understanding of the prosthetic

lowing for optimal long-term soft tissue

rehabilitation. In general, two-piece im-

stability. At the 3-year recall, the soft tis-

plant systems allow individualized trans-

TVF
MFWFMT
SFNBJOFE
TUBCMF
'JH

N

5IF

mucosal designs, whereas one-piece

3- year post-op radiograph shows only

implant systems have limitations. It is

minor changes of interdental bone lev-

important that both prosthodontist and

FMT
'JH

O


lab technician understand the impact

The impact of the proper design of the

of soft tissue contouring and prosthetic

transmucosal component in the soft tis-

support on the biology for the stability of

sue health and stability was evident in

the soft tissue.

the clinical scenario described above.

Although provisionalization and re-

The combination of concave zirconia im-

lining could promote soft tissue archi-

plant design and connective tissue graft

tecture during the temporization step,

seems to play a significant role in the long

it becomes imperative that the techni-

term esthetic and functional outcome.

cian optimizes the soft tissue contour

14
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
70-6.&

t
/6.#&3

t
8*/5&3


VAN DOOREN ET AL

b
Fig 4

15
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
70-6.&

t
/6.#&3

t
8*/5&3


CASE REPORT

Fig 5
c

on the master cast. For this procedure,

tooth, with the abutment margin being

two master casts are needed: a first die

positioned slightly within the gingival

cast with silicone soft tissue mask and

TVMDVT
8JUI
B
POFQJFDF
JNQMBOU
TZT-

a solid cast to check the contact points.

tem the crown emerges in the last 25 to

The master cast represents a perfect

30% of the transmucosal space to allow

replica of the existing clinical situation.

for proper prosthetic soft tissue support.

For the case presented in this section,

Although the provisional bridge was re-

there is a clear discrepancy between the

lined in this clinical case, the technician

diameter of the implant when compared

needed to optimize the peri-implant soft

to the contralateral natural tooth (Fig-

tissue contour on the master cast.

VSF
BoD

UIBU
NBZ
SFTVMU
JO
B
EFFQFS

Figure 6a to 6f illustrates the removal

cement margin when compared to a

of the dies and the reshaping of the soft

two-piece implant system with custom

tissue mask with a diamond bur mimick-

transmucosal abutment designs. From

ing the gingival emergence angle, con-

this point, the objective is to mimic the

tour and zenith position of the contralat-

preparation configuration of a natural

eral tooth. Two Procera Alumina copings

16
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
70-6.&

t
/6.#&3

t
8*/5&3


VAN DOOREN ET AL

Fig 6

17
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
70-6.&

t
/6.#&3

t
8*/5&3


CASE REPORT

Fig 7

/PCFM
#JPDBSF

XFSF
GBCSJDBUFE
5IF

The

subgingival

contour

and

the

dental technician applied an additional

emergence angle of the implant crown

volume of marginal ceramic (Nobel Ron-

is completely different from the natural

EP
/PCFM
#JPDBSF

PO
UIF
GBDJBM
BTQFDU

tooth. Care must be taken to avoid exces-

PG
UIF
DPQJOH
'JHVSF

F
BOE
G

JO
PSEFS

sive pressure on the transmucosal mask

to mimic the contour and shade of the

tissue. A slightly concave subgingival

natural tooth.

contour or negative submergence pro-

The marginal ceramic is believed to

file is essential to minimize pressure and

be stable after processing due to its high

to leave the space for connective tissue

firing temperature and seems to have

JO
UIF
DSJUJDBM
[POF
'JH
BoE

4JODF
JU
JT

minimal shrinkage during multiple firings

virtually impossible to exactly duplicate

throughout the layering process.

the profile and soft tissue contour on the

18
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
70-6.&

t
/6.#&3

t
8*/5&3


VAN DOOREN ET AL

Fig 8

Fig 9

19
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
70-6.&

t
/6.#&3

t
8*/5&3


CASE REPORT

Fig 10

zirconia implant restoration compared to

"U
NPOUIT
QPTUPQ
'JHVSF

B

UIF

the contralateral natural tooth, and since

soft tissue appearance was satisfacto-

there is a lack of papilla thickness and

ry, although a lack of papilla height and

height on the distal aspect of most of im-

especially of papilla volume at the dis-

plant restorations, clinicians need to rely

tal site of the implant-supported restor-

on the dental technicians skills to obtain

ation was observed. The lack of volume

the optimal esthetics desired.

resulted in a slight shadow at the mesial

The greatest challenge in creating

and distal angle of the crown. Howev-

implant-supported restorations in the

er, the clinical outcome improved sub-

esthetic zone involves creating the ideal

TUBOUJBMMZ
BU
ZFBS
QPTUPQ
TIPXJOH
B

position and shape of a natural tooth.

clear gain in papilla height and volume

Any excessive gingival pressure of the

EJTUBM
QBQJMMB

PG
UIF
JNQMBOUTVQQPSU-

prosthetic components might lead to

ed crown, resulting in a better match of

apical tissue migration or recession.

UIF
SFTUPSFE
OBUVSBM
UPPUI
'JHVSF

C



Therefore, for anterior implant restora-

5IF
ZFBS
QPTUPQFSBUJWF
SBEJPHSBQI

tions, the dental technician is advised to

'JHVSF

B

FYIJCJUFE
TUBCMF
CPOF
MFW-

work with optical illusion to achieve the

els. The authors speculate that the soft

CFTU
FTUIFUJD
SFTVMU
'JH

BoE

XJUIPVU

tissue thickness associated with the O-

compromising the soft tissue stability.

ring effect of the connective tissue fib-

After finalizing the crowns, the right

ers might have resulted in the long-term

MBUFSBM
JODJTPS
'JHVSF

BoE

XBT
SF-

bone level stability observed in Figure

stored

restoration

9a and 9b. The radiograph in Figure

to match the esthetics of the anterior

with

composite

a reveals a minor change in bone

crowns (courtesy of Dr Claudio Pinho,

levels into the interdental concavity.

#SB[JMJB
%'
#SB[JM


5IF
DPNQPTJUF
XBT

The authors speculate that soft tissue

fabricated according to a wax-up and

maturation may occur over a period of

silicone index fabricated in the labora-

time of 2 years and that phenomenon

tory with the final crowns in situ.

is the key for long-term esthetic out-

20
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
70-6.&

t
/6.#&3

t
8*/5&3


VAN DOOREN ET AL

come of zirconia implant restorations

zirconia implants. The clinical cases pre-

'JH

C

.PSF
TVCKFDUT
GPS
MPOHUFSN

sented in this article demonstrate long-

observations are needed to confirm

term soft tissue stability combined with

these observations.

very high esthetic results. Increasing or

improving the soft tissue thickness and
quality and the combination of connec-

Conclusion

tive tissue graft and precise prosthetic

One-piece zirconia implants have shown

tional and esthetic results when one-

to be very robust after mechanical test-

piece zirconia implants are used.

design seems to promote optimal func-

ing evaluations. The issues related to

phase transformation of zirconia are still
not clear and more investigations are
needed. In vivo studies have showed
very positive bone tissue and soft tissue
response to the zirconia surface. More
in vitro and in vivo research is needed to
increase clinicians confidence in using

References

4NJUI
%$
-VHPXTLJ
4

McHugh A, Deporter D,
8BUTPO
1"
$IJQNBO
.

Systemic metal ion levels in
dental implant patients. Int
J Oral Maxillofac Implants
o
2. Bianco PD, Ducheyne P,
Cuckler JM. Local accumulation of titanium released
from a titanium implant in the
absence of wear. J Biomed
.BUFS
3FT
o

8FJOHBSU
%
4UFJOFNBOO
4

4DIJMMJ
8
4USVC
+3
)FMMFSich U, Assenmacher J, et
al. Titanium deposition in
regional lymph nodes after
insertion of titanium screw
implants in maxillofacial
region. Int J Oral Maxillofac
4VSH
 
1U

o


1JDPOJ
$
.BDDBVSP
(
;JSDPnia as a ceramic biomaterial.
#JPNBUFSJBMT
o

,PIBM
3+
,MBVT
(
4USVC
+3

Zirconia-implant-supported
all-ceramic crowns withstand
long-term load: a pilot inves-

Acknowledgments
The authors thank the Department of Prosthodontics
and Department of Biomaterials and Biomimetics at
New York University for the outstanding research in
ceramics under the leadership and guidance from
Drs Van P. Thompson and Elizabeth Dianne Rekow.

tigation. Clin Oral Implants

3FT
o
6. Blaschke C, Volz U. Soft
and hard tissue response
to zirconium dioxide dental
JNQMBOUT
o
B
DMJOJDBM
TUVEZ
JO

man. Neuro Endocrinol Lett
 TVQQM

o

1JDPOJ
$
#VSHFS
8
3JDIUFS

)(
$JUUBEJOJ
"
.BDDBVSP

(
$PWBDDJ
7
FU
BM
:5;1

ceramics for artificial joint
replacements. Biomaterials
o

3BJHSPETLJ
"+
$IJDIF
(+

Potiket N, Hochstedler JL,
Mohamed SE, Billiot S, et
al. The efficacy of posterior
three-unit zirconium-oxidebased ceramic fixed partial
dental prostheses: a prospective clinical pilot study. J ProsUIFU
%FOU
o
9. Canullo L, Morgia P, Marinotti
F. Preliminary laboratory
evaluation of bicomponent
customized zirconia abutments. Int J Prosthodont
 
o

3FLPX
%
5IPNQTPO
7
&Ogineering long-term clinical
success of advanced cer-

amic protheses. J Mater Sci:

.BUFS
.FE
o

4JMWB
/3
$PFMIP
1(
'FSnandes CA, Navarro JM,
Dias RA, Thompson VP.
Reliability of one-piece ceramic implant. J of Biomed
Mater Res B Appl Biomater
o

4JMWB
/3
/PVSJBO
1
$PFMIP

1(
3FLPX
&%
5IPNQTPO
71

Impact Fracture Resistance of
Two Titanium-Abutment Systems Versus a Single-Piece
Ceramic Implant. Clin Implant
Dent Relat Res 2009;Epub
ahead of print.

"OESFJPUFMMJ
.
,PIBM
3+

Fracture strength of zirconia
implants after artificial aging.
Clin Implant Dent Relat Res
o

,PIBM
3+
,MBVT
(
4USVC
+3

Zirconia-implant-supported
all-ceramic crowns withstand
long-term load: a pilot investigation. Clin Oral Implants
3FT
o

)BSBMETPO
5$(
*OHFSWBMM

B. Functional state, bite
force and postural muscle
activity in patients with

21
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
70-6.&

t
/6.#&3

t
8*/5&3


CASE REPORT

osseointegrated oral implant

bridges. Acta Odontol Scand
o

8FO[
)+
#BSUTDI
+
8PMGBSU

S, Kern M. Osseointegration and clinical success of
zirconia dental implants: a
systematic review. Int J ProsUIPEPOU
o

$IFWBMJFS
+
8IBU
GVUVSF
GPS

zirconia as a biomaterial?
#JPNBUFSJBMT
 
o


$IFWBMJFS
+
(SFNJMMBSE
-

Deville S. Low-temperature
degradation of zirconia and
implications for biomedical
implants. Annu Rev Mater
3FT
o

'JTDIFS#SBOEJFT
&
1SBU[FM

)
8FOEU
5
;VS
SBEJPBLUJWFO

belastung durch implantate
aus Zirkonoxid. Dtsch Zahnar[UM
;
o
20. Covacci V, Bruzzese N, MacDBVSP
(
"OESFBTTJ
$
3JDDJ

("
1JDPOJ
$
FU
BM
*O
WJUSP

evaluation of the mutagenic
and carcinogenic power of
high purity zirconia ceramic.
#JPNBUFSJBMT
o
376.

5BLBNVSB
,
)BZBTIJ
,

Ishinishi N, Yamada T, Sugioka Y. Evaluation of carcinogenicity and chronic toxicity
associated with orthopedic
implants in mice. J Biomed
.BUFS
3FT
o

#VSHFS
8
3JDIUFS
)(
1JDPOJ

C, Vatteroni R, Cittadini A,
Boccalari M. New Y-TZP
powders for medical grade
zirconia. J Mater Sci Mater
.FE
o
23. Scarano A, Di Carlo F,
Quaranta M, Piattelli A. Bone
response to zirconia ceramic implants: an experimental study in rabbits.
Journal of Oral Implantology
o

"LBHBXB
:
*DIJLBXB
:
/JLBJ

H, Tsuru H. Interface histology of unloaded and early
loaded partially stabilized
zirconia endosseous implant
in initial bone healing. J ProsUIFU
%FOU
o
25. Akagawa Y, Hosokawa R,
Sato Y, Kamayama K. Com-

parison between freestanding and tooth-connected

partially stabilized zirconia
implants after two years
function in monkeys: a clinical and histologic study.
Journal of Prosthetic DentisUSZ
o
26. Sennerby L, Dasmah A,
Larsson B, Iverhed M. Bone
tissue responses to surfacemodified zirconia implants:
A histomorphometric and
removal torque study in the
rabbit. Clin Implant Dent
Relat Res 2005;(suppl
4
o
27. Hoffmann O, Angelov N,
(BMMF[
'
+VOH
3&
8FCFS
'&

The zirconia implant-bone
interface: a preliminary histologic evaluation in rabbits.
Int J Oral Maxillofac Implants
o
28. Depprich R, Zipprich H,
Ommerborn M, Naujoks C,
8JFTNBOO
)1
,JBUUBWPSOcharoen S, et al. Osseointegration of zirconia implants
compared with titanium: an
in vivo study. Head Face
.FE

29. Lee J, Sieweke JH, Rodriguez NA, Schpbach P,
Lindstrm H, Susin C, et
al. Evaluation of nanotechnology-modified zirconia
oral implants: a study in
rabbits. J Clin Periodontol
o

,PIBM
3+
8PMLFXJU[
.

Hinze M, Han JS, Bchle M,
Butz F. Biomechanical and
histological behavior of zirconia implants: an experiment
in the rat. Clin Oral Implants
3FT
o

3PDDIJFUUB
*
'POUBOB
'

Addis A, Schupbach P, Simion M. Surface-modified zirconia implants: tissue response
in rabbits. Clin Oral Implants
3FT
o
32. Oliva J, Oliva X, Oliva JD.
One-year follow-up of first
DPOTFDVUJWF

[JSDPOJB

dental implants in humans:
A comparison of 2 different rough surfaces. Int J
Oral Maxillofac Implants
o

22
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
70-6.&

t
/6.#&3

t
8*/5&3


33. Oliva J, Oliva X, Oliva JD.

Five-year success rate of

DPOTFDVUJWFMZ
QMBDFE

zirconia dental implants in
humans: a comparison of
three different rough surfaces. Int J Oral Maxillofac
*NQMBOUT
o

-BNCSJDI
.
*HMIBVU
(

Vergleich der berlebensrate von Zirkondioxid- und
Titanimplantaten. Zeitschrift
fr Zahnrztliche ImplantoloHJF
o
35. Rompen E, Raepsaet N,
Domken O, Touati B, Van
Dooren E. Soft tissue stability
at the facial aspect of gingivally converging abutments
in the esthetic zone: a pilot
clinical study. J Prosthet Dent
 
TVQQM
To
36. Rompen E, Touati B, Van
Dooren E. Factors influencing marginal tissue
remodeling around implants.
Pract Proced Aesthet Dent
o



5KBO
")
.JMMFS
(%
5IF

+(
4PNF
FTUIFUJD
GBDUPST

in a smile. J Prosthet Dent
o

(BSCFS
%"
4BMBNB
."

Salama H. Immediate total
tooth replacement. Compend Contin Educ Dent
o

39. Berglundh T, Lindhe J. Healing around implants placed in
bone defects treated with BioOss. An experimental study
in the dog. Clin Oral Implants
3FT
o

(SVOEFS
6
$SFTUBM
SJEHF

width changes when placing
implants at the time of tooth
extraction with and without
soft tissue augmentation
after a healing period of 6
NPOUIT
SFQPSU
PG

DPOsecutive cases. Int J Periodontics Restorative Dent
o

4DIOFJEFS
%
(SVOEFS
6

Ender A, Hammerle CH,
Jung RE. Volume gain and
stability of peri-implant tissue following bone and soft
UJTTVF
BVHNFOUBUJPO
ZFBS

results from a prospective cohort study. Clin Oral
*NQMBOUT
3FT
o

Queries
1.
The same research team11 evaluated fatigue reliability
of as-received compared to zirconia implants with coronal
portions prepared by diamond burs what do you mean by
as-received?
2.
not HA coated what does this mean?
3.
Van Dooren E, Rompen E and Touati B, unpublished
data what year was this?
4.
Figure legends 3 to 10 are missing, please provide text.