EAO POSITION

PAPERS
EAO Position Paper: Material Selection for
Implant-Supported Restorations
Bjarni Elvar Pjetursson, Prof, DDS, Dr Med Dent, MAS Perio, PhD
Department of Reconstructive Dentistry, Faculty of Odontology, University of Iceland, Reykjavik, Iceland;
Division of Fixed Prosthodontics and Biomaterials, University Clinics for Dental Medicine,
University of Geneva, Geneva, Switzerland.

Vincent Fehmer, MDT

Irena Sailer, Prof Dr Med Dent
Division of Fixed Prosthodontics and Biomaterials, University Clinics for Dental Medicine,
University of Geneva, Geneva, Switzerland.

In recent years, numerous new dental materials have been introduced as alternatives to metal-ceramics
for restorations on teeth and implants. This position paper presents the current evidence and respective
clinical recommendations of the European Association for Osseointegration (EAO), one of the scientific
partners of the International Journal of Prosthodontics, on material selection for single crowns (SCs) and
multiple-unit implant-supported fixed dental prostheses (FDPs). Metal-ceramic restorations can be utilized in
most clinical indications and are preferred to ceramic restorations in incidences such as long clinical implant
crowns; cantilever implant restorations where one implant is supporting two crowns; implant-supported FDPs
with extension units extending more than 7 to 8 mm (premolar size); implant-supported FDPs with more
than two pontics; and implant-supported FDPs with small connector diameters due to limited intraocclusal
space. Veneered or monolithic zirconia-ceramic and veneered or monolithic reinforced glass-ceramic implant-
supported SCs are indicated for most SC cases in both the anterior and posterior areas. Today, implant-
supported zirconia-ceramic FDPs that are conventionally veneered cannot be considered the material of first
priority due to the pronounced risk for fracture of the framework and catastrophic fracture of the veneering
material. Monolithic zirconia FDPs are a promising alternative to veneered implant-supported zirconia-ceramic
FDPs. The mechanical stability of the translucent and shaded zirconia differs significantly between the grades
of translucency. This must always be considered when clinical indications are recommended. As this specific
area of prosthodontics is evolving fast, numerous studies evaluating different material options in implant
prosthodontics are currently performed worldwide, and future consensus meetings will refine the present
recommendations. The EAO will therefore regularly publish updated position papers on relevant topics. Int J
Prosthodont 2022;35:XX–XX. doi: 10.11607/ijp.8013

I
n recent years, numerous new esthetic dental materials have been introduced as
alternatives to metal-ceramics for restorations on teeth and implants. Specifically,
the ceramics lithium disilicate and zirconia have gained interest. The cost efficiency
Correspondence to:
of these all-ceramic options and the diversity of their possible applications through Dr Bjarni E. Pjetursson
CAD/CAM processing technologies have shifted fixed implant-supported restora- Department of Reconstructive
tions away from metal-ceramics toward all-ceramics. Furthermore, a new abutment Dentistry
Faculty of Odontology
type, the titanium base abutment with a special antirotational configuration and a University of Iceland
parallel abutment wall for increased cement retention, has been introduced, further Vatnsmyrarvegi 16
expanding the use of ceramics for implant prosthodontics. This abutment can be 101 Reykjavik, Iceland
Email: bjarni.pjetursson@unige.ch;
used for the support of chairside or labside monolithic or veneered ceramic implant- bep@hi.is
supported restorations. These recent developments are already frequently applied in
daily clinical practice. Researchers and clinicians have been investigating the evidence Submitted September 11, 2021;
accepted November 18, 2021.
behind these new concepts in order to select the most appropriate material for the ©2021 by Quintessence
respective clinical indication. Publishing Co Inc.

Volume 35, Number 1, 2022 1

 EAO Position Papers
For clinicians, it is not only good survival rates that
are relevant for general satisfaction with restorations,
but also the complications that may occur with a spe-
cific type of restorative material. Complications can be
biologic, technical, or, in the worst case, a combination
of both.
The European Association for Osseointegration (EAO),
one of the scientific partners of the International Journal
of Prosthodontics, regularly performs Consensus Con-
ferences with the aim of elaborating the evidence on
relevant clinical topics.
In the present position paper, the current evidence and
the respective clinical recommendations of the EAO on
material selection for single crowns (SCs) and multiple-
unit implant fixed dental prostheses (FDPs) are given.
Metal-Ceramic Implant-Supported Restorations
Metal frameworks or cores veneered with feldspathic
ceramic are a long-existing, well-documented mate-
rial combination for single- and multiple-unit implant-
supported restorations (Fig 1).1,2 Metals provide high
strength as a core, so the relatively weak veneering layer
is protected against tensile stress during function. The
framework of metal-ceramic restorations can be pro-
duced from different alloys by casting, milling, or laser
melting. The main advantage of metals is their plastic
behavior under stress.
2 The International Journal of Prosthodontics
Fig 1   Three-unit implant-supported metal-
ceramic FDP.
A pair of systematic reviews1,2 analyzed the clinical
outcomes of metal-ceramic implant-supported restora-
tions. The review analyzing metal-ceramic SCs1 included
30 studies reporting on a total of 4,542 crowns, 83%
of which were cement retained and 17% of which were
screw retained. The review analyzing metal-ceramic
multiple-unit FDPs2 included 16 studies reporting on
993 FDPs supported by 2,289 implant abutments, 73%
of which were cement retained and 27% of which were
screw retained.
Hence, the majority of evidence available on implant-
supported metal-ceramic restorations is evaluating intra-
orally cemented restorations.
The meta-analyses included with these reviews esti-
mated an annual failure rate of 0.35% (95% CI: 0.19% to
0.66%), translating into a 5-year survival rate of 98.3%
for metal-ceramic implant-supported SCs,1 and an an-
nual failure rate of 0.26% (95% CI: 0.10% to 0.64%),
translating into a 5-year survival rate of 98.7% for FDPs2
(Table 1). Even though the 5-year survival rate for metal-
ceramic restorations was high, the respective complica-
tion rates were 13.3% for metal-ceramic SCs1 and 15.1%
for FDPs,2 meaning that 1 out of every 6 to 8 restorations
experienced some kind of biologic, technical, or es-
thetic complication or failure. Hence, only 86.7% of the
metal-ceramic implant-supported SCs and 84.9% of the
metal-ceramic implant-supported FDPs were free of all
complications over the entire 5-year observation period.

Table 1   Annual Failure Rates of Different Types of Implant-Supported Restorations
Type of implant-supported restoration No. of restorations evaluated
Metal-ceramic SC 4,542
Zirconia-ceramic SC 912
Reinforced glass-ceramic SC 484
Metal-ceramic FDP 993
Zirconia-ceramic FDP 175
Fig 2   Implant-supported metal-ceramic SC
showing significant ceramic chipping.
The 5-year rate of peri-implantitis or soft tissue com-
plications was estimated to be 5.1%. Furthermore, sig-
nificant bone loss, defined as marginal bone levels more
than 2 mm, below what can be expected as normal
bone remodeling, was reported for 3.3% of the im-
plants supporting metal-ceramic SCs.1 The respective
figures for metal-ceramic FDPs were 8.5% and 2.6%.2
Fracture of abutments, abutment screws, or occlusal
screws were rare complications, reported for 0.2% of
the metal-ceramic SCs1 and 1.3% of the FDPs2 during a
5-year observation period. Abutment or occlusal screw
loosening was more frequent, with a 5-year complica-
tion rate of 3.6% for metal-ceramic SCs1 and 5.3% for
metal-ceramic FDPs.2 The incidence of ceramic fractures
or chipping was over a 5-year period was 2.9% for im-
plant-supported metal-ceramic SCs,1 compared to 11.6%
for FDPs2 (Fig 2). Framework fractures, however, were
only reported for 0.2% of the metal-ceramic SCs1 and
0.5% of the FDPs.2 An overview is shown in Table 2.3
The traditional way of processing precious and base-
metal alloy frameworks and cores is casting using the
lost-wax technique. This is a costly and technique-sen-
sitive procedure. Even though the clinical outcomes of
traditionally manufactured metal-ceramic implant-sup-
ported restorations are quite good, application of tra-
ditional methods was reduced with the introduction of
computer-aided manufacturing (CAM) techniques. Com-
pared to the manual approach, CAD/CAM processes are
Pjetursson et al
Estimated annual failure rates, % (95% CI)
0.35 (0.19–0.66)
0.49 (0.21–1.18)
1.02 (0.51–2.05)
0.26 (0.10–0.64)
1.45 (1.06–1.98)
easier and faster, and the restorations are less expensive
and more predictable with respect to shape, occlusion,
and function.
To compensate for the slight distortion that often oc-
curs with traditionally manufactured metal frameworks,
screw-retained multiple-unit metal-ceramic implant-
supported restorations should preferably be made using
customized computer-aided milling from industrially fab-
ricated base-metal alloy blanks (Fig 3) or made with ad-
ditive methods via selective laser technology to achieve
passive fit of the restoration. The traditional workflow
is better suited for cemented multi-unit restorations, as
the cement gap can compensate for the distortion of
the framework. The metal framework and the implant
abutment should preferably be milled as one piece. Com-
puter-aided design (CAD) allows for the ideal thickness
of the ceramic veneer.
Single- and multiple-unit metal-ceramic restorations
have been extensively researched and have shown excel-
lent long-term outcomes. In conclusion, metal-ceramic
restorations can be utilized in most clinical indications
and are preferred to ceramic restorations in incidences
such as long clinical implant crowns (eg, as a result of a
lack of vertical bone, making the titanium base concept
less favorable); cantilever implant restorations where
one implant is supporting two crowns (Fig 4); implant-
supported FDPs with extension units extending more
than 7 to 8 mm (premolar size); implant-supported FDPs
Volume 35, Number 1, 2022 3
 EAO Position Papers

Table 2   Estimated 5-Year Failure and Complication Rates for Different Types of Implant-Supported Restorations
and Number of Implant Abutments or Restorations Analyzed
Implant-supported Implant-supported Implant-supported Implant-supported
metal-ceramic SCs zirconia-ceramic SCs metal-ceramic FDPs zirconia-ceramic FDPs
5-y 5-y 5-y 5-y
No. complication No. complication No. complication No. complication
Complication failure analyzed rate, % analyzed rate, % analyzed rate, % analyzed rate, %
Total complications, n 1,300 13.3 76 16.2 371 15.1 NA
Total technical NA NA NA NA
complications, n
Implant fracture 2,394 0.2 NA 3,207 0.5 NA
 Abutment or occlusal 3,954 3.6 694 1.0 2,804 5.3 NA
crew loosening
 Abutment or occlusal 3,998 0.2 790 0.4 2,941 1.3 169 0
screw fracture
 Fracture of core or 2,592 0.2 371 2.1 966 0.5 175 4.7
framework
Total ceramic fractures 4,090 2.9 694 2.8 781 11.6 NA
and chipping, n
 Ceramic fractures NA NA 427 4.7 102 2.5
(Repair needed)
Ceramic chipping 1,538 3.5 NA 747 7.8 NA
Loss of retention 2,211 2.0 115 0 476 1.9 NA
 Loss of the access hole 159 0 NA 545 5.4 NA
restoration
Total biologic NA NA NA NA
complications, n
 Soft tissue complications 2,118 5.1 234 5.3 871 8.5 73 10.1
 Marginal bone loss 3,254 3.3 670 4.3 1,621 2.6 NA
(> 2 mm)
 Abutment tooth NA NA NA NA
intrusion
Esthetic failures 627 1.7 224 0 94 0 73 0
 Esthetic complications 610 7.1 NA NA NA

Fig 3  Framework for a four-unit implant-

supported metal-ceramic FDP milled from in-
dustrially fabricated base-metal alloy blank.

4 The International Journal of Prosthodontics


Fig 4   Metal-ceramic cantilever restoration
with one implant supporting two units.
Fig 5   Monolithic zirconia implant-supported
SC in the position of the first molar.
with more than two pontics; and implant-supported
FDPs with small connector diameters due to limited in-
traocclusal space.
Zirconia-Ceramic Implant-Supported Restorations
The desire for materials with the appearance of natural
dental tissues led to the development and use of zirconia
ceramic as restorative material.4 Zirconia is the strongest
of all ceramics and was adapted to dental applications
in line with the development of CAD/CAM technology.5
As previously mentioned, these developments coupled
with the high demand for esthetics have opened up a
range of possibilities for ceramic restorations, allow-
ing for less costly and more time-effective production
workflows.6,7 The design and subsequent milling of high-
strength ceramics with an adequate fit and acceptable
clinical outcome are now possible.8–10 In the last decade,
zirconia has emerged as a very popular material due to
Pjetursson et al
its excellent biocompatibility and improved mechanical
properties,11 which are supported by the promising out-
comes of many studies on the properties of zirconia.12–16
Until recently, zirconia was only available as yttria-sta-
bilized tetragonal zirconia polycrystals, a rather opaque
whitish framework material that had to be veneered
with ceramic to achieve an acceptable esthetic outcome.
Lately, new variations of zirconia exhibiting tooth-like
color and more translucency have been developed, al-
lowing for a monolithic application of zirconia5 (Fig 5).
A pair of systematic reviews analyzed studies reporting
on zirconia-ceramic implant-supported SCs1 and FDPs.2
The review by Pjetursson et al1 included 8 studies report-
ing on 912 zirconia implant-supported SCs followed for
an average period of 5 years, and a review by Sailer et al2
included 3 studies reporting on a total of 175 zirconia-
ceramic FDPs followed for an average of 5.1 years. Of
the included SCs, 51% were cement retained and 49%
Volume 35, Number 1, 2022 5
 EAO Position Papers
were screw retained; for FDPs, the respective values
were 15% and 75%. The annual failure rates for implant-
supported zirconia-ceramic SCs and FDPs were estimated
to be 0.49% (95% CI: 0.21% to 1.18%)1 and 1.45%
(95% CI: 1.06% to 1.98%), respectively,2 translating into
respective 5-year survival rates of 97.6%1 and 93.0%2
(Table 1). However, the estimated 5-year complication
rate for zirconia-ceramic SCs was 16.2%, meaning that
83.8% of the SCs were free of any complication over
the entire 5-year observation period.1 The most frequent
complications reported for SCs were peri-implantitis and
soft tissue complications (5.3%), marginal bone loss
more than 2 mm (4.3%), ceramic fractures or chipping
(2.8%), fracture of the core or framework (2.1%) (Fig 6),
6 The International Journal of Prosthodontics
Fig 6   Zirconia implant-supported FDP that
fractured in the connector because of insuf-
ficient material thickness.
Fig 7   Implant-supported ceramic SC and a
customized zirconia abutment.
and abutment screw loosening (1.0%). Other complica-
tions, such as abutment or occlusal screw fracture, loss
of retention of cemented crowns, and esthetic failures,
were less frequent.1 For implant-supported zirconia-
ceramic FDPs, the most frequent complications were soft
tissue complications (10.1%) and framework fractures
(4.7%).2 An overview is shown in Table 2.3
The clinical indications for veneered or monolithic
zirconia-ceramic implant-supported SCs cover most SC
cases, both in the anterior and posterior areas. Zirconia-
ceramic is mainly used in combination with CAD/CAM
technology, and standardized or customized abutments
can be used as support (Fig 7).

Fig 8   Monolithic zirconia implant-supported
three-unit FDP.
Today, implant-supported zirconia-ceramic FDPs that
are conventionally veneered cannot be considered the
material of first priority due to the pronounced risk for
fractures of the framework and catastrophic fracture of
the veneering material, leading to loss of the restoration.
Moreover, chipping of the zirconia ceramic veneer has
been a frequently reported problem since the introduc-
tion of veneered zirconia-based restorations.17 Studies
on implant-supported zirconia FDPs have reported ce-
ramic fracture and chipping rates up to 50%.18 Further
developments of the zirconia ceramic veneers and of the
veneering procedures have helped to lower the initially
high incidences of chipping. The remaining problem is
the predominant technical complications associated with
veneered zirconia restorations. Recently, however, more
translucent and/or colored types of zirconia ceramics
were introduced, reducing the need for ceramic veneer-
ing. When using zirconia as a monolithic restoration, the
weakest link of the traditional restoration—the ceramic
veneer—is eliminated. Furthermore, the diameter of
the monolithic framework has pronounced dimensions,
reducing the risk for ceramic chipping and framework
fracture. Hence, monolithic zirconia FDPs are a promis-
ing alternative to veneered implant-supported zirconia-
ceramic FDPs (Fig 8). Unfortunately, literature on this
topic is still scarce.
A more recent systematic review19 evaluated the
3-year survival and complication rates of veneered and
monolithic zirconia-ceramic implant-supported SCs. The
survival rates of veneered and monolithic zirconia crowns
were similar, but the incidence of failure due to core
fractures or catastrophic veneer fractures was higher for
the veneered zirconia SCs. Furthermore, the incidence
of ceramic chipping was also higher for the veneered
zirconia SCs.
The mechanical stability of translucent and shaded
zirconia differs significantly between the grades of
Pjetursson et al
translucency. This must always be considered when clini-
cal indications are recommended. Five factors must be
considered when choosing between veneered or mono-
lithic zirconia restorations: (1) esthetic requirements; (2)
position in the dental arch; (3) material-specific limita-
tions; (4) possibility for surface modification; and (5)
abrasion/wear properties.
Reinforced Glass-Ceramic Implant-Supported
Restorations
To influence the strength, thermal expansion, and con-
traction behavior of glass-ceramic, crystalline fillers
such as leucite or lithium have been added.20 Today the
main filler material is lithium forming a crystalline phase
(lithium disilicate, Li2Si2O5), which makes up about 70%
of the volume of the glass-ceramic. Lithium disilicate–
reinforced glass-ceramic restorations can be produced
with heat pressing, which is performed in an investment
mold, or with computer-aided milling from prefabricated
lithium disilicate blanks. Glass-ceramic reinforced with
lithium or leucite fillers has been used for manufactur-
ing both implant-supported SCs and short-span FDPs.
A recent systematic review19 evaluated the survival
and complication rates of monolithic and veneered
reinforced glass-ceramic implant-supported SCs. Of
the included studies, 5 reported on veneered leucite
or lithium disilicate–reinforced glass-ceramic implant-
supported SCs (n = 110) and 14 on monolithic leucite
or lithium disilicate–reinforced glass-ceramic implant-
supported SCs (n = 484). The mean follow-up time for
the veneered crowns was 8.1 years, compared to 2.6
years for the monolithic crowns. The annual failure rate
was estimated at 0.80% (95% CI: 0.14% to 4.64%) for
the veneered and reinforced glass-ceramic crowns and
at 1.02% (95% CI: 0.51% to 2.05%) for the monolithic
reinforced glass-ceramic crowns, translating into respec-
tive 3-year survival rates of 97.6% and 97.0% (Table 1).
Volume 35, Number 1, 2022 7
 EAO Position Papers
The review19 also compared the overall complication
rates of different types of ceramic implant-supported SCs
and concluded that monolithic reinforced glass-ceramic
crowns had the lowest annual complication rate (1.7%),
with veneered reinforced glass-ceramic crowns the sec-
ond lowest (2.6%), compared to an annual complication
rate of 3.6% for monolithic zirconia SCs and 4.5% for
veneered zirconia-ceramic implant-supported SCs. The
respective annual complication rate for metal-ceramic
implant-supported SCs was 2.7%.1
In conclusion, the clinical indications for veneered or
monolithic reinforced glass-ceramic implant-supported
SCs are similar to those for zirconia-ceramic crowns or
most single-unit situations located in the anterior and
posterior areas (Fig 9). The main disadvantage of rein-
forced glass-ceramic implant-supported SCs is that the
prefabricated ceramic blanks have integrated titanium
base abutments, which does not allow the flexibility of a
preferred abutment choice by the clinician, and that the
heat-pressed manufacturing procedure does not allow
for the full benefits of the CAD/CAM manufacturing
procedure.
8 The International Journal of Prosthodontics
Fig 9  Monolithic reinforced glass-ceramic
SC cemented extraorally to a titanium base
abutment.
Fig 10   Comprehensive prosthetic planning
allows for the screw access holes to be posi-
tioned in the center of the occlusal surfaces.
Considering the available evidence, veneered or mono-
lithic reinforced glass-ceramic cannot be recommended
for implant-supported multiple-unit FDPs, as they suffer
from high rates of framework fracture.
Titanium-Base Abutment Concept
Traditionally, implant-supported restorations are either
screw retained directly onto the implant or through an
intermediate abutment, or they are cemented intra-
orally onto standardized or customized abutments. 21
Current evidence demonstrates that screw-retained
restorations have a lower risk of developing biologic
complications (eg, marginal bone loss or peri-implant
disease) and therefore should be preferred over intra-
orally cemented restorations. 21,22 Furthermore, the
retrievability of the restoration makes the handling
of complications easier if they do occur. To allow for
screw retention and to achieve a reasonable clinical
outcome, comprehensive prosthetic planning is man-
datory, followed by a correct 3D implant position and
axis (Fig 10).

The development of titanium base abutments allows
for full utilization of the digital workflow producing
implant-supported restorations. Different titanium base
abutment configurations are available according to each
clinical indication, and this configuration is usually in-
tegrated into the milling program. These prefabricated
titanium base abutments appear to be a promising solu-
tion, as they combine a metallic implant connection with
a ceramic outer part, thereby offering good esthetics
and mechanical stability at the same time.23–25 Follow-
ing a digital workflow, the monolithic restoration can be
designed, milled, and adhesively cemented to the tita-
nium base abutment extraorally and then directly screw
retained to the implant as a conventional one-piece,
screw-retained restoration.26–28 This type of restoration
has shown positive results in laboratory and short-term
clinical investigations.23,29,30
Different configurations of titanium base abutments
are available from different manufacturers according to
the indication, whether for single-unit or multiple-unit
restorations. Cylindrical titanium base abutments should
be preferred to conical for both SCs and FDPs, as resto-
rations supported by conical abutments have a higher
risk of debonding compared to cylindrical ones.31 This,
however, requires better 3D treatment planning and
relatively parallel placement of the supporting implants.
Notwithstanding all advantages of the titanium base
abutment concept, its success is highly dependent on
the bonding stability between the titanium base and
the ceramic components. It has been shown that there
is a significant risk of incomplete cementation, partial
decementation, or degradation of the cement, which
could lead to microleakage, increased plaque accumula-
tion, and peri-implant infections, especially when the ce-
ment gap is placed deeply under the mucosal margin.32
Hence, the position of the cementation margin and a
proper cementation protocol when using the titanium
base abutment concept are crucial. In order to achieve
a high and durable adhesive retention, several surface
pretreatments have been proposed. Considering the
outcomes of studies, airborne particle abrasion (APA) of
titanium base abutments with 50-μm aluminum oxide
is recommended. Besides pretreatment of the titanium
base abutment, selection of the resin cement also plays
a crucial role in clinical success with the titanium base
abutment concept. It has been reported that titanium
abutments can cause a change in the color appearance
of the peri-implant mucosa, especially in a clinical situ-
ation with a mucosa thickness of 2 mm or less.33–36
The abutment color can also influence the color of the
ceramic restoration, depending on the ceramic thickness.
It is reasonable to speculate that the cement bonding a
ceramic restoration to a titanium base abutment could
also contribute to the color outcome. A recent in vi-
tro study showed that the color outcomes of ceramic,
Pjetursson et al
lithium disilicate, implant-supported crowns cemented
to titanium base abutments was influenced by different
types of cement.37 More opaque cements led to less
discoloration for both APA and non-APA abutments.
Hence, the application of an opaque resin cement is rec-
ommended for good esthetic outcomes. For the titanium
base concept, appropriate pretreatment of the different
ceramics and the titanium-base abutment before the
adhesive cementation is crucial for the bond strength
values. Following manufacturer recommendations is
crucial for achieving good outcomes.
CONCLUSIONS
This position paper presents the current state of the art
regarding the selection of restorative materials and op-
tions for fixed implant restorations. As this specific area
of prosthodontics is evolving fast, numerous studies
evaluating different material options in implant prosth-
odontics are currently performed worldwide, and future
consensus meetings will refine the present recommenda-
tions. The EAO will therefore regularly publish update
position papers on relevant clinical subjects.
ACKNOWLEDGMENTS
The authors report no conflicts of interest.
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