Michael Payer All-ceramic restoration of zirconia

Alexander Heschl
Martin Koller
two-piece implants – a randomized
Gerwin Arnetzl controlled clinical trial
Martin Lorenzoni
Norbert Jakse

Authors’ affiliations:
Michael Payer, Norbert Jakse, Department of Oral
Surgery and Radiology, School of Dentistry,
Medical University of Graz, Graz, Austria
Alexander Heschl, Martin Koller, Gerwin Arnetzl,
Martin Lorenzoni, Department of Prosthodontics,
School of Dentistry, Medical University of Graz,
Graz, Austria
Corresponding authors:
Dr. Alexander Heschl, Dr. Martin Koller
Department of Prosthodontics
School of Dentistry, Medical University Graz
Auenbruggerplatz 12, A-8036 Graz, Austria
Tel.: +43-316-385-12976
Fax: +43-316-385-13376
e-mail: alexander.heschl@medunigraz.at,
martin.koller@medunigraz.at
Key words: all-ceramic crowns, titanium implants, yttria-stabilized zirconia implants
Abstract
Objectives: Aim of this controlled prospective randomized study was to evaluate the outcome of
two-piece zirconia implants compared to titanium implants over a period of up to 24 months.
Material and methods: A total of 31 implants (16 zirconia/Ziterion vario Zâ + 15 titanium/Ziterion
vario Tâ) were inserted primary stable (>30 Ncm) in the maxilla (7) and mandible (24) of 22
patients (13 male, nine female) requiring neither bone nor soft tissue augmentation. After a
healing period of 6 months in the maxilla and 4 months in the mandible, ceramic abutments were
luted adhesively to the zirconia implants and definitive all-ceramic restoration was performed with
high-density ceramics. Radiographic bone levels, condition of the peri-implant mucosa, aesthetic
outcome, implant survival and success were recorded for up to 24 months.
Results: Measurements of mean marginal bone levels 24 months after surgery showed a
significant bone loss (P < 0.001) in both groups (Ti: 1.43 (SD  0.67) vs. Zir 1.48 (SD  1.05). One
zirconia implant was lost 8 months after restoration. No further complications were recorded,
giving an overall survival and success rate of 93.3% for zirconia and 100% for titanium implants
after a period of up to 24 months.
Conclusions: After 24 months, success rates of the two-piece ceramic implants showed no
significant difference compared to control two-piece titanium implants. The bonded zirconia
implant abutment connection appears to be capable with clinical application over the observed
period. However, further control measurements need to confirm the presented data.

The current commercial dental implant application of alternatives to titanium, the

material of choice is pure titanium. Its prop-
erties have been well documented in numer-
ous experimental and clinical applications
over the past decades. A major driver, how-
ever, for alternatives to titanium in implant
dentistry is an ongoing discussion on sensi-
tivities and allergies associated with failure
of dental titanium implants (Sicilia et al.
2008; Pigatto et al. 2009). To date, there
seems to be no evidence for clinical relevance
of this hypothesis (Wenz et al. 2008). Further
potential aesthetic advantages of ceramics
over titanium as implant material in the
anterior zone and in patients with compro-
mised soft tissue have been used as argu-
Date: ments to justify the search for alternative
Accepted 6 January 2014
materials. But here, too, little reliable data
To cite this article: are available on the aesthetic outcome of zir-
Payer M, Heschl A, Koller M, Arnetzl G, Lorenzoni M, Jakse
N. All-ceramic restoration of zirconia two-piece implants – a conia implants compared to titanium
randomized controlled clinical trial.
implants. Even though it is at present hard
Clin. Oral Impl. Res. 26, 2015, 371–376
doi: 10.1111/clr.12342 to find evidence-based arguments for the
current demand for metal-free materials in
dentistry is keeping the search for alterna-
tives to titanium in implantology alive (Wo-
hlwend et al. 1996; Heydecke et al. 1999;
Zembic et al. 2009).
As a potential alternative to titanium, zir-
conium dioxide (ZrO2, zirconia) – an inert,
nonresorbable and biocompatible metal
oxide – exhibits promising chemical and
physical properties (Stevens 1986; Marx 1993;
Geis-Gerstorfer & F€assler 1999; Piconi &
Maccauro 1999). Zirconia, usually available
as 3–5 M% yttrium-stabilized tetragonal
polycrystal (Y-TZP; Kelly & Denry 2008),
was first used in orthopaedic surgery for ball
heads in total hip replacement. Compared to
earlier alumina ceramic implants, which had
to be withdrawn from the market due to high
fracture rates in clinical use, zirconia seems
to have a higher potential for use in implant
dentistry (Schulte et al. 1992; Sandhaus &

© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd 371
Payer et al
Restoration of zirconia two-piece implants
Pasche 1997; Kohal et al. 2004; Andreiotelli
et al. 2009; Hobkirk & Wiskott 2009). In
experimental models, Y-TZP has been shown
to be biocompatible and to be susceptible to
mechanisms of osseointegration (Albrektsson
et al. 1985; Akagawa et al. 1993; Akagawa
et al. 1998; Schultze-Mosgau et al. 2000;
Scarano et al. 2003) and de novo bone forma-
tion on roughened surface textures (Sennerby
et al. 2005). Improvements in material stabil-
ity of Y-TZP have allowed successful clinical
application of zirconia-fixed partial dentures,
crowns and implant abutments in humans
(Yildirim et al. 2000; Andersson et al. 2003;
Glauser et al. 2004).
Since so far no applicable and stable con-
nection between zirconia abutments and
implants could technically be realized,
Y-TZP has predominantly been used for the
fabrication of single-piece implants (Payer
et al. 2013). Over the last decade, numerous
types of zirconia single-piece implants had
been introduced in the market, but interest-
ingly reliable clinical data are still very lim-
ited (Gahlert et al. 2013; Kohal et al. 2013).
A major drawback of single-piece implants
in general, but especially in the aesthetic
zone, is a reduced prosthetic versatility due
to a lack of options for abutment angulation,
potentially leading to compromised implant
positioning. This is especially relevant for
zirconia single-piece implants, for which
insufficient data on the effects of intra-oral
grinding as well as patients requiring bone
augmentations are available (Wenz et al.
2008).
Another fact to be considered when using
single-piece implants of either material is
that loading forces onto the supramucosal
part of the implant (abutment) will occur
through masticatory activity and tongue
movements immediately after placement
(Finne et al. 2007; Ostman et al. 2007; Senn-
erby et al. 2008). Even if a patient is provided
with a removable protection splint of perfect
fit, as usually recommended by manufactur-
ers, it remains unclear and compliance
dependent whether a single-piece implant
will be allowed to heal in a stress-free envi-
ronment. Nonremovable provisional bridging
devices between adjacent teeth lacking con-
tact to a single-piece implant could guarantee
load-free healing, even though limitations
with regard to free-end situations and the
accomplishment of accurate oral hygiene
around the implant will then have to be con-
sidered.
Additionally for single-piece implants,
which are usually constructed with a submu-
cosally submerged prosthetic platform, a
372 | Clin. Oral Impl. Res. 26, 2015 / 371–376
provisional or a soft tissue-forming device
should be applied after insertion, otherwise
the mucosa will have to be detached trau-
matically prior to the impression for fabrica-
tion of the provisional or permanent crown.
An immediate provisionalization and condi-
tioning of peri-implant soft tissue therefore
seems recommendable in single-piece
implants, even though, again, data on imme-
diate provisional restoration and/or loading
are limited for zirconia (Hobkirk & Wiskott
2009; Payer et al. 2013).
To avoid the complicated precautions evi-
dently necessary for single-piece implants
when using zirconia in future, the present
controlled pilot trial aimed to evaluate – to
our knowledge for the first time – the out-
come of a clinical application of zirconia
two-piece implants in carefully selected
patients over a period of up to 24 months.
Material and methods
Study population
The current study was conducted between
2009 and 2010 as a prospective, randomized
and controlled clinical single-centre pilot
trial at the Dental School, Medical Univer-
sity of Graz, Austria. All patients agreed to
participate in the trial before treatment and
gave their informed consent. Randomization
and group allocation was performed prior to
surgery for each patient using a web-based
software (Randomizer for clinical trialsâ).The
study protocol was approved by the local eth-
ics committee EKNr: 20-337 ex 08/09 (Medi-
cal University of Graz, Austria).
Only patients matching the following crite-
ria were consecutively included in the inves-
tigation: (i) Patients of 18 years or older who
had given their informed, written consent;
(ii) providing tooth gaps up to three missing
units with a sufficient amount of horizontal
and vertical bone and soft tissue volume for
the placement of implants with a minimum
length of 10 mm and a width of 4 mm; (iii)
acceptance of the scheduled protocol of clini-
cal and radiographic analysis and mainte-
nance.
Patients to whom any of the following
exclusion criteria applied were not admitted
to the trial: (i) smokers; (ii) signs of occlusal
parafunctions (e.g. bruxers); (iii) present acute
periodontal disease; (iv) lack of compliance or
failure to give consent; (v) general contra-
indications against implant treatment or
medication potentially compromising osseo-
integration (e.g. immunodeficiency, advanced
systemic diseases, corticosteroid or bisphos-
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
phonate medication); (vi) pregnancy, assessed
with a pregnancy test (HCG Schnelltestâ,
DiaChrom bj-giagnostik, Giessen, Germany);
(vii) previous irradiation in the neck/head
area; ( viii) need for bone augmentation and
soft tissue augmentation procedures.
Clinical assessments
Within the present pilot study, 16 two-piece
yttria-stabilized zirconia implants (Ziterionâ
vario z, Ziterion GmbH, Uffenheim, Ger-
many) and 15 standard two-piece titanium
implants (Ziterionâ vario t) of identical shape
were inserted by two surgeons (M.P & R. K)
randomly allocated (Randomizer for clinical
trialsâ) between 2009 and 2010 in 22 patients
(13 males, 9 females) aged from 24 to
77 years with a mean age of 46 years. The
inserted zirconia implants measured 4 mm in
diameter and 10 mm, 11.5 mm or 13 mm in
length. Titanium control implants measured
4 mm in diameter and 11.5 mm in length
(Fig. 1 & Table 1).
Seven implants were placed in maxillary
and 24 in mandibular sites. Of these, two
(one zirconia and one titanium implant) were
inserted to replace premolars, five implants
for the replacement of incisors (three zirconia
and two titanium implants) and 24 as molar
implants (12 zirconia implants, 12 titanium
implants; Table 2). In all patients, implants
were placed no earlier than 6 months after
tooth extraction (late implant insertion) with-
out any simultaneous regenerative procedures.
Prior to surgery, panoramic radiographs (Sidex-
is Intraoral, Orthophos plus DS, Sirona Dental
Systems, Bensheim, Germany) were evaluated
for adequate amount of bone height. Addition-
ally, a preoperative bone-mapping technique
on plaster casts was performed to estimate the
approximate width of the alveolar ridge at the
implant site (Traxler et al. 1992). Patients
identified as providing insufficient amount of
bone at the implant site and thus requiring
augmentation procedures were excluded from
the study.
After flap elevation following a mid-crestal
incision, drilling sequences were performed
according to the instructions of the manufac-
turer using all drill diameters available to
achieve accurate prosthetic implant position-
ing (Payer et al. 2008). Insertion torque was
measured with a torque control device
(W&Hâ Implantmed, W&H Dentalwerk
B€urmoos GmbH, B€ urmoos, Austria). The
implants were placed supracrestally, and
cover pins (for zirconia) and screws were
inserted. Patients received oral antibiotics
(Dalacin Câ 300 mg; 4 9 1/day, Pfizer,
Vienna, Austria) for 4 days, starting 1 day
 Payer et al
Restoration of zirconia two-piece implants

Table 1. Distribution and number of inserted After a healing period of 4 months for man- Clinical photographs of the implant crowns
implants
dibular and 6 months for maxillary implants, and soft tissue, including at least one natural
Dimensions Material No. of implants as recommended by the manufacturer, sec- adjacent tooth on each side, were obtained
4.0/10.0 mm Zirconia 4 ond-stage surgery was carried out. Straight or with a digital camera (D80, Nikonâ, Tokyo,
4.0/10.0 mm Titanium 0 angulated prefabricated standard ceramic Japan) at baseline and at the follow-up assess-
4.0/11.5 mm Zirconia 7
4.0/11.5 mm Titanium 15 abutments (Ziterionâ ZrO2 Abutment) were ments.
4.0/13.0 mm Zirconia 5 luted adhesively (Multilink-Automixâ, Ivo- Implant success was defined as proposed
4.0/13.0 mm Titanium 0 clar-Vivadent, Schaan, Liechtenstein) into the by Naert et al. and Snauwaert, et al. (Naert
31
zirconia implants after rubber dam applica- et al. 1992; Snauwaert et al. 2000): implant
tion (G.A.). in position; periotest value < +8; no peri-
Conventional impressions with polyether implant translucency, no implant-induced
(Impregum NFâ, 3M ESPE, Seefeld, Germany) pain, infection or paraesthesia, no implant
were carried out for fabrication of all-ceramic fracture, implant must support a prosthetic
lithium disilicate crowns (e.maxâ CAD- suprastructure.
Blocks, Ivoclar-Vivadent, Schaan, Liechten-
stein), whereas titanium abutments Radiographic assessments
(Ziterionâ-Titanium abutment) were used for At delivery of the prosthetic superstructure
the control implants. In both groups, ceramic (baseline) and at follow-up examinations (6,
colour selection for the final restoration was 12, 18 and 24 months postrestoration), intra-
performed with the help of a clinical spectro- oral digital radiographs (Sidexisâ Intraoral,
photometer (Easyshadeâ Vita Zahnfabrik, Bad Orthophos plus DS, Sirona Dental Systems,
S€ackingen, Germany) prior to fabrication of Bensheim, Germany) with rectangular colli-
the restorations. The restorations were luted mation were obtained to measure the mesial
adhesively (Multilink-Automixâ Ivoclar-Viva- and distal bone loss around each implant.
dent, Schaan, Liechtenstein) for the idea of a Using implant diameter as references, the
microgap-less concept between crown, abut- indicator scale was calibrated and the dis-
ment and implant. All restorations were fab- tance of marginal bone loss was measured
ricated as single-tooth crowns. At the time of from the implant shoulder to the crestal
integration and at follow-ups, special care bone margin on mesial and distal aspects. If
was taken to prevent eccentric occlusal con- there were overlapping buccal and lingual
tacts on the implant-supported restoration. bone contours, a mean value was utilized.
Follow-up examinations focusing on occlu- All radiographs were investigated for evalu-
sion and oral hygiene were performed at ability by an experienced investigator (A.H.)
4-week intervals within the first year after not involved in the clinical procedure, at 92
restoration. magnification and statistically analysed. In
The clinical examinations at baseline and case of questionable measurements, two
at follow-ups 6, 12, 18 and 24 months pos- additional independent investigators evalu-
trestoration included further assessment of ated the sites and values were based on a
plaque index (PI), bleeding on probing (BOP; consensus.
Fig. 1. Zirconia two-piece implant (Ziterionâ vario z, Lange et al. 1977) and implant stability
Ziterion GmbH, Uffenheim, Germany) used in the
(Periotestâ; PV; Medizintechnik Gulden e. Statistical analysis
study.
K., Modautal, Germany). The aesthetic result A strict protocol and timetable for the
of crown and peri-implant tissues was mea- assessment of clinical and radiological
Table 2. Diameter and length of inserted sured with the pink aesthetic score (PES; parameters (PI, BOP, PES, PV, MBL) was
implants F€urhauser et al. 2005), an instrument for maintained for each patient. A time span of
Region Material No. of implants reproducible evaluation of aesthetics and a maximum of 1 week within the foreseen
Max inc Zirconia 3 peri-implant tissues around single-tooth schedule was tolerated for recalls 6, 12, 18
Max inc Titanium 2 implant crowns. The pink aesthetic score is and 24 months postrestoration. The statisti-
Max molar Zirconia 0
based on seven variables: mesial papilla, dis- cal evaluation of data at several points in
Max molar Titanium 2
Mand premolar Zirconia 1 tal papilla, soft tissue level, soft tissue con- time between 0 and 24 months after provi-
Mand premolar Titanium 1 tour, alveolar process deficiency, soft tissue sional implant restoration was performed
Mand molar Zirconia 12 with the nonparametric Brunner–Langer test
colour and texture. Each variable is assessed
Mand molar Titanium 10
31 with a 2–1–0 score, with 2 being the best and for longitudinal data (Brunner & Langer
0 being the poorest score. All variables are 1999). Primary outcome variables were
assessed by comparison with a reference implant success and survival, and secondary
tooth. outcome variables were marginal bone level
preoperatively, as well as nonsteroidal analge- All clinical assessments were performed by (MBL), BOP, PI, PV and PES. Data distribu-
sics (Seractil forteâ 400 mg; 3 9 1/day, Gebro one independent investigator 1 h after deliv- tion was evaluated with the Kolmogorov–
Pharma GmbH, Fieberbrunn, Austria) for ery of the final restoration (baseline) 12 and Smirnov test. Due to the limited sample
3 days postoperatively. 24 months postimplant insertion. (M.K.). size and dependent data (some patients

© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd 373 | Clin. Oral Impl. Res. 26, 2015 / 371–376
Payer et al
Restoration of zirconia two-piece implants
received more than one implant), results are
presented as means and medians (ME) using
the nonparametric F1_LD_F1 model of Brun-
ner–Langer for data analysis. The unit of
analysis was at implant level. P-values
below 0.05 were considered to be significant.
The data were analysed using SPSSâ soft-
ware version 17 (SPSS, Chicago, IL, USA)
and SASâ software version 9.2 (SAS Insti-
tute, Cary, NC, USA). Manuscript structure
has been performed according to the
CONSORT statement (Appendix S1).
Results
A total of 16 two-piece yttria-stabilized zirco-
nia implants and 15 titanium implants were
placed in 22 patients. All inserted implants
showed a final torque of more than 35 Ncm.
Wound healing was uneventful in all
patients. One zirconia implant of 4.0 mm
width and 10 mm length replacing a second
lower molar was lost 8 months after restora-
tion.
No other complications or serious device-
related adverse events were recorded during
the healing and further observation period of
up to 2 years, resulting in an overall survival
and success rate of 93.3% for zirconia
implants and 100% for titanium implants.
Life table analysis revealed a mean survival
of 16.2 months (6.5; 14.4 median/ME) with
a confidence interval (CI) between 12.8 and
19.7 for zirconia and 17.0 (6.8; 12.9 ME)
months with a CI between 13.3 and 20.8 for
titanium implants.
Clinical assessments
At follow-ups, all cases exhibited inconspicu-
ous wound healing and maintenance of oral
hygiene. Assessment of plaque index for zir-
conia implants at baseline and at follow-ups
6, 12, 18 and 24 months postimplant inser-
tion revealed 15.75% (2.72; ME 15.8),
14.17% (6.04; ME 15.0), 15.88% (6.67; ME
12.0), 11.9 (4.77; ME 18.0) and 19.38 (0.88;
ME 24.0), respectively, and 11.25% (3.67;
ME 11.3), 12.88% (4.54; ME 12.0), 11.19%
(5.69; ME 9.8), 14.13 (4.77; ME 14.2) and
16.05 (8.29; ME 16.8), respectively, for tita-
nium implants.
Evaluation of bleeding on probing revealed
for zirconia implants 10.9% (5.63; ME 11.3)
at baseline, 4.8% (0.95; ME 5.3) after 6,
11.9% (9.44; ME 9.5) after 12, 7.6% (6.15;
ME 9.1) after 18 and 9.1% (4.34; ME 9.2)
after 24 months and 9.0% (6.32; ME 9.0) at
baseline, 11.4% (0.88; ME 11.4) after 6,
7.9% (4.98; ME 7.9) after 12, 14.3% (3.89;
374 | Clin. Oral Impl. Res. 26, 2015 / 371–376
ME 14.3) after 18 and 7.4% (3.39; ME 7.0)
after 24 months for titanium implants
(Table 3). No significant overall difference
between zirconia and titanium implants
could be observed.
All implants appeared to be clinically stable
according to manual examination and Perio-
testâ values of 2.8 (1.2), 1.3 (1.0), 1.9
(0.4), 2.9 (0.5) and 2.1 (0.9) for zirco-
nia implants and 2.0 (0.8), 3.0 (1.2),
2.4 (1.3), 1.9 (1.1) and 2.5 (1.8) for
titanium implants at baseline, after 6, 12, 18
and 24 months, respectively (Table 3).
The mean PESs for zirconia implants were
6.88 (2.1; ME [median] 6.0) at baseline 1 h
after placement of the permanent restora-
tion, 8.0 (3.66; ME 8.5) after 6, 10.33
(2.06; ME 9) after 12, 11.0 (2.0; ME 11.0)
after 18 and 11.22 (1.56; ME 11.0) after
24 months.
For titanium implants, the clinical evalua-
tions revealed 2.43 (1.27; ME 2.0) at base-
line 6.5 (4.3; ME 4.5) after 6 months, 9.0
(3.54; ME 10) after 12, 8.14 (3.58; ME 8.0)
after 18 and 10.75 (0.71; ME 11) after
24 months showing a significant difference
(P = 0.004) between zirconia and titanium
implants according to the nonparametric
Brunner–Langer test (Brunner & Langer 1999;
Table 3).
Radiographic assessments
The radiographic baseline evaluation revealed
supracrestal placement of the zirconia
implants with a mean marginal bone level of
0.10 mm (SD  0.19; ME 0.0). Further mean
MBL measurements after 6, 12, 18 and
24 months postrestoration yielded 0.67 mm
(SD  0.95 ME 0.29), 1.16 mm (SD  1.01;
ME 0.8), 1.2 mm (SD  0.76; ME 1.11) and
1.48 mm (SD  1.05; ME 1.1), respectively,
showing a significant bone loss (P < 0.001)
and time effect within 24 months according
to the statistical model of Brunner and Lan-
ger. The mean marginal bone level for tita-
nium implants was 0.16 mm (SD  0.24; ME
0.0), 0.4 mm (SD  0.38; ME 0.34), 0.88 mm
(SD  0.56; ME 0.88), 1.15 mm (SD  0.73;
ME 1.12) and 1.43 mm (SD  0.67; ME 1.1),
respectively, at baseline and after 6, 12, 18
and 24 months postrestoration with a statis-
tical significant time effect within
24 months according to the statistical model
of Brunner and Langer. The comparison of
mean marginal bone levels of zirconia and
titanium implants of identical shape of the
same manufacturer revealed no statistical dif-
ference over time according to the nonpara-
metric Brunner–Langer test (Brunner &
Langer 1999; Table 3).
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Discussion
Our controlled clinical pilot study included
22 patients prospectively treated with 16
two-piece zirconia and 15 titanium implants
of identical shape. The preliminary data
24 months after all-ceramic restoration
revealed no significant difference in the clini-
cal outcome between zirconia and titanium
implants.
To our knowledge, the present study is
the first in which zirconia two-piece
implants were investigated within a con-
trolled clinical trial. All included implants
were allowed to heal in a submerged, stress-
free environment without the presence of
any loading forces. So far, most data avail-
able on zirconia implants deal with single-
piece implants that have either been
allowed to heal with different protection
devices aiming to prevent any functionaliza-
tion (Wenz et al. 2008) or with zirconia sin-
gle-piece implants that were immediately
treated with a prosthetic restoration (Payer
et al. 2013). According to earlier animal
experiments, zirconia seems capable of
osseointegration to a similar degree as com-
mercially pure titanium. Even though the
exact microbiological and microstructural
mechanisms remain unclear so far, an
increasing body of experimental (Hoffmann
et al. 2012; Lee et al. 2013; Park et al. 2013)
and clinical data indicates stable osseointe-
gration of zirconia implants.
Also in the present trial after a healing per-
iod of 4 months in mandibular and 6 months
in maxillary site, all implants were both clin-
ically and radiologically stable and osseointe-
grated.
However, the presented data should be
interpreted critically and with caution before
drawing final conclusions about zirconia as
implant material, as our study included only
cases providing hard and soft tissue that
allowed implant placement without simulta-
neous regenerative procedures.
Within this specific indication of uncom-
plicated implant insertion, the outcome of
the included zirconia implants performed
comparable as the included control group.
However, especially when evaluating the
applied prosthetic protocol for the two-piece
zirconia implants for daily clinical applica-
bility, major concerns have to be stated.
First of all, no data regarding long-term per-
formance of adhesive abutment fixation on
sub-gingival levels of the crestal bone is yet
available. Further, a rubber dam application
at crestal levels seems a challenge, but is a
 Payer et al
Restoration of zirconia two-piece implants

Table 3. Clinical and radiographic parameters evaluated at follow-ups presented as means and medians (ME)
Mean marginal bone
Mo Material No PI BOP PV PES level/Bone loss
0 Zirconia 16 15.75% (2.72; ME 15.8) 10.9% (5.63; ME 11.3) 2.8 (1.2) 6.88 (2.1; ME 6.0) 0.10 (0.19; ME 0.0)
Titanium 15 11.25% (3.67; ME 11.3) 9.0% (6.32; ME 9.0) 2.0 (0.8) 2.43 (1.27; ME 2.0 0.16 (0.24; ME 0.0)
6 Zirconia 16 14.17% (6.04; ME 15.0) 4.8% (0.95; ME 5.3) 1.3 (1.0) 8.0 (3.66; ME 8.5) 0.67 (0.95; ME 0.29)
Titanium 15 12.88% (4.54; ME 12.0) 11.4% (0.88; ME 11.4) 3.0 (1.2) 6.5 (4.3; ME 4.5) 0.4 (0.38; ME 0.34),
12 Zirconia 15 15.88% (6.67; ME 12.0) 11.9% (9.44; ME 9.5) 1.9 (0.4) 10.33 (2.06; ME 9) 1.16 (1.01; ME 0.8)
Titanium 15 11.19% (5.69; ME 9.8) 7.9% (4.98; ME 7.9) 2.4 (1.3) 9.0 (3.54; ME 10) 0.88 (0.56; ME 0.88)
18 Zirconia 13 11.9 (4.77; ME 18.0) 7.6% (6.15; ME 9.1) 2.9 (0.5) 11.0 (2.0; ME 10) 1.2 (0.76; ME 1.11)
Titanium 12 14.13 (4.77; ME 14.2) 14.3% (3.89; ME 14.3) 1.9 (1.1) 8.14 (3.58; ME 8.0) 1.15 (0.73; ME 1.12)
24 Zirconia 7 19.38 (0.88; ME 24.0) 9.1% (4.34; ME 9.2) 2.1 (0.9) 11.22 (1.56; ME 11.0) 1.48 (1.05; ME 1.1)
Titanium 8 16.05 (8.29; ME 16.8) 7.4% (3.39; ME 7.0) 2.5 (1.8) 10.75 (0.71; ME 11) 1.43 (0.67; ME 1.1)

BOP, bleeding on probing; PES, pink aesthetic score; PI, plaque index; PV, periotest value.

prerequisite for a proper adhesive fixation of
the zirconia abutment to the zirconia
implant.
As no healing abutments were yet avail-
able for the zirconia implant system used in
the present study, the ceramic abutment
needed to be attached to the zirconia implant
simultaneously with second-stage surgery,
meaning that proper bleeding control and
suction need to be applied to guarantee a dry
environment for the subsequent steps of
adhesive abutment fixation. As for prosthetic
superstructures, a thorough removal and
cleaning of excess adhesive material is must,
of course be performed after abutment instal-
lation. Although under full visibility due to
the opened flap during second-stage surgery,
this step proved manageable but complex at
crestal levels.
A potential disadvantage of this maximally
invasive and time-consuming type of second-
stage surgery, compared to the titanium con-
trol group, could be a minor performance in
the aesthetic outcome due to a higher degree
of tissue remodelling. However, in this trial,
the evaluation of data of the aesthetic out-
come revealed no difference between the two
treatment groups. It still seems surprising
that in the search for rational arguments for
zirconia as an implant material, one is con-
fronted with considerations of potential
minor aesthetics caused by the invasiveness
necessary for its application.
The pure adhesive abutment fixation of the
zirconia two-piece implant system used in the
present study is an attempt to overcome
the fact that screw connections so far cannot
be used in ceramic implants. However, from a
microbiological point of view, this conve-
niently eliminates the so-called micro-gap –
one of the major disadvantages of conventional
screw-type implant abutment connections.
Although this micro-gap-less adhesive concept
currently still appears to have rather an experi-
mental character and presents very complex in
its application, it performed well and proved
capable of withstanding loading forces in the
present trial. No single abutment loosening or
fracture of abutment or implant was evident in
this short observation period of the 16 included
two-piece zirconia implants.
One zirconia implant in position of a sec-
ond lower molar was lost after 8 months in
function. The number of included zirconia
implants (16) in the present study is, of
course, too small for a serious search for fail-
ure reasons of this single implant. However,
all other 15 included zirconia implants were
in function and presented inconspicuous
upon follow-up examination. Within the lim-
its of the very small study population and
the short period of observation, it appears
that an adhesive implant abutment connec-
tion is capable of withstanding clinical load-
ing forces, irrespective of the implant
location in the patient’s mouth. However,
the prosthetic protocol currently still appears
very complex and will have to be simplified
if a wider application in daily practice is to
be a target. Further, only data on the long-
term outcome will allow final interpretation
and conclusions for zirconia as an implant
material and the applied protocol for zirconia
two-piece implants.
Acknowledgements: Dr. Philipp
Kober, D.I. Irene Mischak, Univ. Prof. Dr.
Andrea Berghold, Lara Holly, Dominik
Kreuzer.
Funding
The study was supported by Ziterion GmbH,
Uffenheim, Germany.

References
Akagawa, Y., Hosokawa, R., Sato, Y. & Kamayama,
K. (1998) Comparison between freestanding and
tooth-connected partially stabilized zirconia
implants after two years’ function in monkeys: a
clinical and histologic study. The Journal of Pros-
thetic Dentistry 80: 551–558.
Akagawa, Y., Ichikawa, Y., Nikai, H. & Tsuru, H.
(1993) Interface histology of unloaded and early
loaded partially stabilized zirconia endosseous
implant in initial bone healing. The Journal of
Prosthetic Dentistry 69: 599–604.
Albrektsson, T., Hansson, H.A. & Ivarsson, B.
(1985) Interface analysis of titanium and zirco-
nium bone implants. Biomaterials 6: 97–101.
Andersson, B., Glauser, R., Maglione, M. & Taylor, A.
(2003) Ceramic implant abutments for shortspan
FPDs: a prospective 5-year multicenter study. The
International Journal of Prosthodontics 16: 640–646.
Andreiotelli, M., Wenz, H.J. & Kohal, R.J. (2009)
Are ceramic implants a viable alternative to tita-
nium implants? A systematic literature review.
Clinical Oral Implants Research 20(Suppl. 4): 32–
47.
Brunner, E. & Langer, F. (1999) Nichparametrische
Analyse longitudinaler Daten, 1st edition, 54–91.
M€ unchen/Wien: R. Oldenbourg Verlag.
Finne, K., Rompen, E. & Toljanic, J. (2007) Prospec-
tive multicenter study of marginal bone level and
soft tissue health of a one-piece implant after two
years. The Journal of Prosthetic Dentistry 97:
79–85. Erratum in: The Journal of Prosthetic Den-
tistry (2008) 99(3): 167.
F€
urhauser, R., Florescu, D. & Benesch, T. (2005)
Evaluation of soft tissue around single-tooth
implant crowns: the pink esthetic score. Clinical
Oral Implants Research 16: 634–639.
Gahlert, M., Burtscher, D., Pfundstein, G., Grunert,
I., Kniha, H. & Roehling, S. (2013) Dental zirco-
nia implants up to three years in function: a
retrospective clinical study and evaluation of
prosthetic restorations and failures. The Interna-
tional Journal of Oral & Maxillofacial Implants
28: 896–904.
Geis-Gerstorfer, J. & F€assler, F. (1999) Untersuch-
ungen zum Erm€ udungsverhalten der Dentalke-
ramiken Zirkonoxid TZP und In-Ceram.
Deutsche Zahn€ arztliche Zeitschrift 54: 692–
694.

© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd 375 | Clin. Oral Impl. Res. 26, 2015 / 371–376
Payer et al
Restoration of zirconia two-piece implants
Glauser, R., Sailer, I., Wohlwend, A., Studer, S.,
Schibli, M. & Sch€ arer, P. (2004) Experimental zir-
conia abutments for implant-supported single
tooth restorations in esthetically demanding
regions: 4-year results of a prospective clinical
study. The International Journal of Prosthodon-
tics 17: 285–290.
Heydecke, G., Kohal, R. & Gl€aser, R. (1999) Opti-
mal esthetics in single-tooth replacement with
the Re-Implant system: a case report. The Inter-
national Journal of Prosthodontics 12: 184–189.
Hobkirk, J.A., Wiskott, H.W. & Working Group 1.
(2009) Ceramics in implant dentistry (Working
Group 1). Clinical Oral Implants Research 20
(Suppl 4): 55–57.
Hoffmann, O., Angelov, N., Zafiropoulos, G.G. &
Andreana, S. (2012) Osseointegration of zirconia
implants with different surface characteristics: an
evaluation in rabbits. International Journal of
Oral Maxillofacial Implants 27: 352–358.
Kelly, J.R. & Denry, I. (2008) Stabilized zirconia as
a structural ceramic: an overview. Dental Materi-
als 24: 289–298.
Kohal, R.J., Patzelt., S.B., Butz F. & Sahlin, H.
(2013) One-piece zirconia oral implants: one-year
results from a prospective case series. 2. Three-
unit fixed dental prosthesis (FDP) reconstruction.
The Journal of Clinical Periodontology 40: 553–
562.
Kohal, R.J., Weng, D., B€ achle, M. & Strub, J.R.
(2004) Loaded custom-made zirconia and tita-
nium implants show similar osseointegration: an
animal experiment. Journal of Periodontology 75:
1262–1268.
Lange, D.E., Plagmann, H.C., Ecenboom, A. &
Promesberger, A. (1977) Klinische Bewertungsver-
fahren zur Objektivierung der Mundhygiene.
Deutsche Zahn€ arztliche Zeitschrift 32: 44–47.
Lee, B.C., Yeo, I.S., Kim, D.J., Lee, J.B., Kim, S.H. &
Han, J.S. (2013) Bone formation around zirconia
implants combined with rhBMP-2 gel in the
canine mandible. Clinical Oral Implants
Research 24: 1332–1338.
Marx, R. (1993) Moderne keramische Werkstoffe f€ ur
€asthetische Restaurationen – Verst€arkung und
Bruchz€ ahigkeit. Deutsche Zahn€ arztliche Zeitsch-
rift 48: 229–236.
Naert, I., Quirynen, M., van Steenberghe, D. &
Darius, P. (1992) A six-year prosthodontic study
of 509 consecutively inserted implants for the
treatment of partial edentulism. The Journal of
Prosthetic Dentistry 67: 236–245.
376 | Clin. Oral Impl. Res. 26, 2015 / 371–376
Ostman, P.O., Hellman, M., Albrektsson, T. &
Sennerby, L. (2007) Direct loading of nobel direct
and nobel perfect one-piece implants: a 1-year
prospective clinical and radiographic study. Clini-
cal Oral Implants Research 18: 409–418.
Park, Y.S., Cung, S.H. & Shon, W.J. (2013)
Peri-implant bone formation and surface charac-
teristics of rough surface zirconia implants manu-
factured by powder injection molding technique
in rabbit tibiae. Clinical Oral Implants Research
24: 586–591.
Payer, M., Arnetzl, V., Kirmeier, R., Koller, M.,
Arnetzl, G. & Jakse, N. (2013) Immediate provi-
sional restoration of single-piece zirconia
implants: a prospective case series – results after
24 months of clinical function. Clinical Oral
Implants Research 24: 569–575.
Payer, M., Kirmeier, R., Jakse, N., Pertl, C.,
Wegscheider, W. & Lorenzoni, M. (2008) Surgical
factors influencing mesiodistal implant angula-
tion. Clinical Oral Implants Research 19: 265–270.
Piconi, C. & Maccauro, G. (1999) Zirconia as a
ceramic biomaterial. Biomaterials 20: 1–25.
Pigatto, P.D., Guzzi, G., Brambilla, L. & Sforza, C.
(2009) Titanium allergy associated with dental
implant failure. Clinical Oral Implants Research
20: 857.
Sandhaus, S. & Pasche, K. (1997) L’implantologie
en un temps chirugical. Introduite en 1962, rec-
onnue en 1997. Actualites Odonto-Stomatologi-
ques 9: 539–558.
Scarano, A., Di Carlo, F., Quaranta, M. & Piatelli,
A. (2003) Bone response to zirconia ceramic
implants; an experimental study in rabbits. Jour-
nal of Oral Implantology 29: 8–12.
Schulte, W., d’Hoedt, B., Axmann, D. & Gomez-
Roman, G. (1992) 15 Jahre T€ ubinger Implantat
und seine Weiterentwicklung zum Frialit-2 Sys-
tem. Zeitschrift f€ur Zahn€ arztliche Implantologie
8: 77–96.
Schultze-Mosgau, S., Schliephake, H., Radespiel-
Troger, M. & Neukam, F.W. (2000) Osseointegra-
tion of endodontic endosseous cones: zirconium
oxide vs titanium. Oral Surgery Oral Medicine
Oral Pathology Oral Radiology and Endodontics
89: 91–98.
Sennerby, L., Dasmah, A., Larsson, B. & Iverhed,
M. (2005) Bone tissue responses to surface-modi-
fied zirconia implants: a histomorphometric and
removal torque study in the rabbit. Clinical
Implant Dentistry and Related Research 7:
13–20.
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Sennerby, L., Rocci, A., Becker, W., Jonsson, L.,
Johansson, L.A. & Albrektsson, T. (2008) Short-
term clinical results of Nobel Direct implants: a
retrospective multicentre analysis. Clinical Oral
Implants Research 19: 219–226.
Sicilia, A., Cuesta, S., Coma, G., Arregui, I., Guisa-
sola, C., Ruiz, E. & Maestro, A. (2008) Titanium
allergy in dental implant patients: a clinical study
on 1500 consecutive patients. Clinical Oral
Implants Research 19: 823–835.
Snauwaert, K., Duyck, J., van Steenberghe, D., Qui-
rynen, M. & Naert, I. (2000) Time dependent fail-
ure rate and marginal bone loss of implant
supported prostheses: a 15-year follow-up study.
Clinical Oral Investigations 4: 13–20.
Stevens, R.. (1986) Zirconia and zirconia ceramics.
In: An Introduction to Zirconia, 2nd edition,
Twickenham: Litho 2000.
Traxler, M., Ulm, C., Solar, P. & Lill, W. (1992)
Sonographic measurement versus mapping for
determination of residual ridge width. Journal of
Prosthetic Dentistry 67: 358–361.
Wenz, H.J., Bartsch, J., Wolfart, S. & Kern, M. (2008)
Osseointegration and clinical success of zirconia
dental implants: a systematic review. The Interna-
tional Journal of Prosthodontics 21: 27–36.
Wohlwend, A., Studer, S. & Sch€arer, P. (1996) Das
Zirkonoxid-Abutment ein neues vollkeramisches
Konzept zur €asthetischen Verbesserung der Supra-
struktur in der Implantologie. Quintessenz der
Zahntechnik 22: 364–381.
Yildirim, M., Edelhoff, D., Hanisch, O. & Spieker-
mann, H. (2000) Ceramic abutments – a new era
in achieving optimal esthetics in implant den-
tistry. International Journal of Periodontics &
Restorative Dentistry 20: 81–91.
Zembic, A., Sailer, I., Jung, R.E. & H€ammerle, C.H.
(2009) Randomized-controlled clinical trial of cus-
tomized zirconia and titanium implant abut-
ments for single-tooth implants in canine and
posterior regions: 3-year results. Clinical Oral
Implants Research 20: 802–808.
Supporting Information
Additional Supporting Information may be
found in the online version of this article:
Appendix S1. CONSORT statement 2001
checklist.