Rob, a dentist asks,

Ive heard that Nobel BioCares new all zirconium one piece dental implant, is supposed to come to
the U.S. market sometime in 2007. There are also other zirconium implants from other companies on
the market.

What do the dentists here think of these new all zirconium implants? Do you think they will
osseointegrate as well as titanium, and perform as well as the titanium dental implants? Do you think
they will be more prone to fracture? What might some of the benefits of an all zirconium implant be
[i can see a one-piece all zirconium implant maybe doing away with the microgap bacterial issue
seen with some titanium implants]? Thanks for your thoughts.

Zr provides lower levels of phosphates- this will compromise new bone formation relative to
oxidized Ti. It is also very difficult to prep- and in the end, you dont really know how strong the
remaining material is because there is no way to detect the presence of microfractures. I dont really
see an upside to this product, with the possible exception of very thin mucosa in the anterior. If this
product appears stark white like the other Procera products, as opposed to shaded, then even in those
instances it will be easily detected and of little or no benefit. Strength should not be a concern, other
than in the case of microfracture caused in the prepping of the material

Ceramic implants are nothing new so why

are zirconium implants offered now?
The demands of patients for highly aesthetic restorations have increased tremendously during the
past few years so that they are not willing to accept the dark shade of titanium implants in the soft
tissue (gingiva). whiteSKY meets the demands of patients and allows to fabricate aesthetically
appealing dental restorations.

These increased demands in the field of aesthetics can also be observed in the sector of conventional
prosthetic restorations in which the zirconium material is about to replace metal bridges.

Another major advantage of the zirconium material is its biocompatibility. A growing number of
patients have developed allergies to metals; zirconium implants represent an alternative for this
group of patients.

How does the whiteSKY implant differ from

the Tbingen implant?
The main difference lies in the primary stability of the implant. Owing to the lacunae, the Tbingen
implant had highly reduced primary bone contact; the result was that a very high loss rate was
observed during the healing phase. Moreover the material revealed insufficiencies which resulted in
an increased tendency to fracture after 10 years. whiteSKY features a modern implant design with a
surgical protocol matched with the respective bone quality. This protocol ensures that primary
stability is guaranteed by bone compression. Thanks to its elasticity and mechanical properties,
zirconium is less susceptible to fracture than aluminium oxide used for the Tbingen implant.

Aluminium oxide implants were highly

susceptible to fracture? What is the fracture
behaviour of zirconium?
The tendency to fracture of aluminium oxide implants was observed in the 70s especially for the
Tbingen implants. The results of this observation can be attributed to two factors; on the one hand,
aluminium oxide is a relatively brittle material and tends to break easily; on the other hand the
prosthetic concept which included cemented metal pins even led to an increase in the tendency to
fracture.
The zirconium material is much more elastic than aluminium oxide and hence less susceptible to
fracture; moreover, all measurements that were performed showed that the risk factor of fracture
could be eliminated thanks to the one-piece design of the whiteSKY implant.

Why is zirconium a suitable material for

implants?
If you consider all mechanical properties, zirconium is the perfect material for dental implants. The
flexural strength of zirconium is three times above that of titanium and two times above that of
aluminium oxide and the modulus of elasticity is between those for titanium and aluminium oxide;
i.e. it has a higher dimensional stability than titanium and is less susceptible to fracture than
aluminium oxide. Additionally, zirconium features a "defect blocking property" to avoid the
expansion of microfractures. Consequently, excellent long-term primary stability is ensured and
good results can be achieved in the field of dental implantology.

Osseointegrated zirconium?
A series of animal experiments showed that firm osseointegration can be achieved with zirconium.
In this context the surface of the implants is highly relevant. Studies with the brezirkon material that
is used for whiteSKY showed that comparable results of bone apposition were achieved for
comparable surfaces of a titanium implant and our zirconium implant. As far as surface treatment is
concerned, we continue the development of brezirkon under scientific guidance to achieve optimal
results.
Are zirconium implants going to replace
titanium implants?
Over the long term zirconium will certainly reach a high market share since there is a growing
demand for these implants for certain indications among dentists and patients as well because of the
advantages of the material (colour, biocompatibility). However, we do not believe that over the
medium term zirconium implants will entirely replace titanium implants but that both systems will
be used for specific indications.

Can zirconium implant be recommended for

all indications?
The critical phase of the single component zirconium implant is the first few weeks after implant
placement (during the healing phase). It is necessary to protect the implants against excessive stress
(loading) during this period. Therefore we recommend to use whiteSKY implants only for single
tooth replacement or small gaps in the dentition; efficient protection can be easily provided for these
indications. In cases of gaps in the dentition, each lost tooth should be replaced with one implant.
Currently, zirconium implants should not be used for free-end situations and edentulous ridges.

What type of restorations should be used for

zirconium implants during the healing
phase?
Generally, two different tendencies can be observed among our users and also in the scientific
literature. Some users attempt to protect the zirconium implants through the use of splints to avoid
any exposure to stress during the first few weeks; others try to protect the implant against excessive
stress by applying the rules of immediate loading.

What are the risks involved when using splints

for protection?
When using splints to protect implants it is important to make sure that the patient wears the splints
permanently, i.e. during day and night time since the implant needs to be protected against excessive
tongue and cheek pressure. Frequently, however, splints do not offer sufficient comfort of wearing;
as a result the patient does not wear them permanently contrary to the dentist's advice. In such cases
there is a risk that only soft-tissue integration will occur. In a very limited number of cases this could
be determined only after the insertion of the definitive restoration which caused noticeable increase
in the economic damage.
Therefore we recommend to first place a resin crown onto the implant following splint therapy
over six to eight weeks and thus continuously increase the stress (load) on the implant.

Can prosthetic restorations immediately be

placed/attached on/to the implant after the
insertion?
Basically, yes. However, it must be ensured that crowns and bridges that are immediately luted on
implants must have a considerably smaller volume than natural teeth and designed in a way to offer a
large contact area/surface with adjacent teeth so that these teeth are able to protect the implants and
the temporary restoration. Additionally, Ribbond fibres can be used to connect the restoration to the
adjacent teeth.

What is the current situation in the sector of

zirconium implants from the view of bredent
medical?
As far as zirconium implants are concerned, the market is in a similar situation as in the beginning of
the 90s when titanium implants became more and more popular. In our opinion there is still potential
for development as far as the design of the surface of zirconium implants is concerned. In the case of
titanium, manufacturers continue to develop new surface designs even after a period of thirty years.
We know that a rough surface supports osseointegration and as a market leader in the sector of
zirconium implants we are constantly increasing our research efforts. Initial scientific results such as
those obtained by the University of Cologne indicate that zirconium implants with sandblasted
surfaces result in osseointegration comparable to that of titanium implants with sandblasted surfaces.

We are going to publish corresponding scientific studies that are being conducted in cooperation
with our university partners.

Is bredent medical also going to offer two-piece

zirconium implants in the future?
Two-piece zirconium implants are being developed. The biggest challenge is the reliable, durable
connection of abutment and implant. Basically, two options of screwed and luted (adhesive)
connections are possible. Currently, however there is no method available for the zirconium material
for both approaches to ensure reliable long-term survival.
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