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Available online at www.sciencedirect.com

ScienceDirect

journal homepage: www.intl.elsevierhealth.com/journals/dema

Has zirconia made a material difference in implant

prosthodontics? A review

Steven J. Sadowsky
University of the Pacific, Arthur A. Dugoni School of Dentistry, San Francisco, CA, United States

a r t i c l e i n f o a b s t r a c t

Article history: Objective. The main goal of this review is to provide an in-depth description of published work
Available online xxx on the application of zirconia for dental implansts and restorations on titanium implants,
with an emphasis on clinical studies from the past dozen years with at least 1-year follow-up.
Keywords: Methods. Online databases (Pubmed, Science Direct, Web of Science) were consulted on this
Zirconia topic. Published work from 2007 to 2019 was collected, analyzed and pertinent articles were
Implants selected for inclusion on this review.
Abutments Results. No clear superiority has been documented in biocompatibility, osteoconductiv-
Crowns ity, physical properties or allergenicity with zirconia implants compared to titanium,
Complete arch fixed implant notwithstanding an esthetic benefit. While short-term studies have been promising, larger
supported prosthesis multicentered, longitudinal and randomized clinical trials with success data are required
to validate zirconia as a viable alternative to the titanium implant and its design. Zirconia
abutments with a titanium base have revealed a high survival rate and show no differ-
ence to metal. Bi-layered zirconia ceramic restorations are a valid treatment alternative to
metal ceramic implant restorations for single crowns with similar biological complications
and enhanced esthetics. Monolithic zirconia restorations hold promise to address the chip-
ping incidence of the bi-layered ceramic restoration, but longer-term studies are necessary,
and work needs to be done to improve their esthetics. The gingival feldspathic porcelain
veneered monolithic zirconia complete arch prosthesis versus a resin metal prosthesis, in
medium-term studies, offers a high survival rate and low mechanical complication rate,
reduced laboratory costs, superior durability and wear characteristics, enhanced fit due to
digital fabrication, availability of a digital file for duplication in the future, acrylic try-for
adjustment and approval, and reduced plaque and biofilm accumulation.
Significance. Zirconia is a versatile material for implant prosthodontic application. Longer-
term multi-centered studies are needed to assess success criteria and patient-related
outcomes measurements. Monolithic zirconia offers enhanced mechanical properties for
implant restorations, but development is needed to optimize esthetics.
© 2019 Published by Elsevier Inc. on behalf of The Academy of Dental Materials.

E-mail address: ssadowsky@pacific.edu

https://doi.org/10.1016/j.dental.2019.08.100
0109-5641/© 2019 Published by Elsevier Inc. on behalf of The Academy of Dental Materials.

Please cite this article in press as: S.J. Sadowsky. Has zirconia made a material difference in implant prosthodontics? A review. Dent Mater (2019),
https://doi.org/10.1016/j.dental.2019.08.100
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1. Introduction
The confluence between the digital revolution and mate-
rial science development has offered a potential solution
to biological, esthetic and mechanical limitations reported
with conventional titanium implant supported restorations.
In the last generation, a heightened demand for metal-free
restorations has amplified the search for a new implant
and restorative material [1]. Data regarding lack of titanium
implant biocompatibility [2] contributing to peri-implant dis-
ease and even toxicity [3–5] have been documented in the
literature. Furthermore, titanium implants and abutments
have esthetic drawbacks. Several investigators have revealed
that technical complications are higher with implant metal
ceramic single crowns and fixed dental prostheses [6–8] than
their tooth-borne counterparts, due to 8.7 times lower tac-
tile sensitivity [9–12]. Fractures and accelerated wear have
also plagued complete arch resin-metal implant supported
restorations. These issues have prompted the development
of a new implant and restorative material that is more bio-
compatible, durable and esthetic. Milled zirconia holds such
a promise but an evidence-based review of its present clinical
application is in order as a pro-innovation bias is not uncom-
mon [13,14].
This paper presents an overview of published studies
(last 12 years) concerning the use of zirconia in implant
prosthodontics. This includes its use as a replacement mate-
rial for titanium implants, titanium abutments, implant
supported metal-ceramic restorations and complete arch
resin-metal prostheses. The purpose of the review is to cull the
best available data on the biological, mechanical and esthetic
properties of zirconia while summarizing its merits and dis-
advantages when compared to traditional materials.
2. Methods
An extensive literature search was completed using the
electronic databases of PubMed, Science Direct and Web of Sci-
ence. The used keywords strings were: Zirconia AND implants.
The following filters were applied: (1) time interval from 2007
to 2019, (2) Additional refined search within the results: com-
plete arch restorations, language: English
Abstracts were analyzed and excluded if they were clinical
studies of less than 1 year of follow-up or if they did not include
survival and success data. In vitro studies on physical and bio-
logical properties of zirconia were selected to complement this
review.
3. Zirconia implants
Titanium dental implants have been documented with high
restorative survival rates of 97.2% after 5 years for single
crowns, 93.1% after 5 years for implant fixed dental prosthe-
ses (FDP) [11] and 96.8% after 10 years for implants supporting
FDPs in edentulous jaws [15]. However, a sobering statistic
regarding subject-based peri-implant disease of 66.66% in a
recent meta-analysis [16] has prompted investigations for a
metal-free alternative that may be more biocompatible and
Please cite this article in press as: S.J. Sadowsky. Has zirconia made a material difference in implant prosthodontics? A review. Dent Mater (2019),
https://doi.org/10.1016/j.dental.2019.08.100
osteoconductive, while having similar physical properties,
lower allergenicity and offer a clear esthetic benefit [17].
Regarding biocompatibility concerns, titanium plasma
sprayed implants have shown accumulation of titanium par-
ticles in regional lymph nodes as well as lungs and bones
after implant placement using animal histologic sections and
energy-dispersive x-ray analysis [18,19]. In addition, when
titanium is placed in contact with fluoride or low pH in the
saliva, a tribocorrosion process is initiated, releasing parti-
cles [20]. The original micro-gap between the titanium parts
can also lead to micromotion and wear and the initiation of
corrosion by the penetration of oral fluids and bacteria into
the connection [21]. It must be added that wear, corrosion,
environmental factors, titanium particle release, inflamma-
tion and microorganisms take part in a complex host response
to foreign bodies, which is not unidirectional [5]. Titanium
alloy particles and ions due to corrosion may lead to bone
loss due to inflammatory reactions, and subsequent osseoin-
tegration failure [3]. Nonetheless, researchers have detected a
concentration of implant particles in peri-implantitis groups
versus none in the controls [22].
In contrast, zirconia implants and titanium blasted with
a zirconia surface have shown a reduction of the adhe-
sion of bacteria especially after coating with saliva pellicle,
when compared to titanium [23]. It has been postulated that
biofilm accumulates less on zirconia than on titanium because
of lower surface energy and surface wettability [23]. Also,
the inflammatory response and bone resorption induced by
ceramic particles are less than those seen with titanium par-
ticles, which suggests superior biocompatibility, but it must
be stated that the clinical relevance of these observations vis-
à-vis titanium implants remains unclear [21,24,25].
When evaluating the osteoconductive capacity of zirco-
nia vs. titanium, again the data do not demonstrate a clear
advantage for zirconia. Various in vitro and in vivo studies
have revealed the osteoconductive nature of zirconia with no
cytotoxic, or mutogenic effects on bone and fibroblasts after
implantation [26–28]. However, even when airborne particle
abrasion and acid etching was used to increase the surface
roughness of zirconia implants with enhanced cell prolifera-
tion, no statistical difference in bone to implant contact (e.g.
72.9% for titanium implants and 67.4% for zirconia implants
after 9-month healing [29]) was reported in multiple studies
between titanium and zirconia [30–34].
The physical properties of zirconia implants made of yit-
tria doped zirconia tetragonal polycrystals (3Y-TZP) have been
shown to possess good mechanical strength and wear in
comparison to titanium alloy [35,36]. Zirconia has excellent
resistance to corrosion and a Vickers hardness is 1200, Weibull
modulus is 10–12 with a high radiopacity with a low ther-
mal conductivity [37]. Both clinical and in vitro investigations
have reported similar flexural strength, fracture toughness
and static fracture strength of 3Y-TZP to be 900–1200 MPa,
8–10 MPa and 725–850 N respectively [38,39]. However, cyclic
loading and preparation can decrease fracture strength resis-
tance of zirconia implants and fractures can occur in smaller
diameters (3.25 mm) [40].
Questions regarding sensitivity to titanium have been aris-
ing in recent years [41–44]. However, the prevalence has been
estimated at only 0.6%, using the most reliable test which is
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the memory lymphocytic immunostimulation assay (MELISA)
[45].
An advantage of zirconia implants is its white color, with
the possibility of staining zirconia with tooth or gingival col-
ors. The Pink Esthetic Score and White Esthetic Score have
been demonstrated to be superior to titanium implants [46,47].
This difference is pronounced in esthetic areas with a thin
gingival biotype as the greyish shade of titanium has been
reported to through the peri-implant tissues [48]. This may
even be a late presentation for titanium implants, as contin-
ual cranial facial growth may predicate a thinning or loss of
facial bone over time [49,50]. Of note is the finding that when a
buccal dehiscence develops, zirconia implants with a modified
surface significantly perform better than titanium implants in
preserving the peri-implant mucosal height [51].
3.1. One-piece zirconia implants
A majority of zirconia implants have been produced as one-
piece implants [52–54]. However, this design has several
limitations. The surgical placement is more rigorous to satisfy
both the bony housing demands and prosthetic requirements,
as angled abutments are unavailable to correct misalign-
ment, and secondary corrections of shape by grinding must be
avoided because of reduction of fracture strength [26]. In addi-
tion, single-piece implants are immediately exposed to forces
from tongue or mastication [55]. Implants are often inserted
more deeply in the esthetic zone to hide the crown margin,
but in this case, without the ability to adjust the abutment
margin, the likelihood of retained excess cement and peri-
implant disease is high [56]. Until recently, only one 3-year
multicentered prospective study [57] has been completed to
investigate one-piece zirconia implants. Now in 2019, Spies
et al have assessed immediately restored zirconia implants
with provisional restorations and later zirconia-based single
units or fixed dental prostheses were cemented on 40 patients
after 5 years [58]. The mean survival rate was more than 98%
for the 3- and 5-year studies with low marginal bone loss.
3.2. Two-piece zirconia implants
Clinical data on two-piece zirconia implants, using different
connecting geometries and screws, are more limited in length
of follow-up [59,60]. Two-piece systems are preferable to the
one-piece implant when initial stability is not optimized at
implant placement. Bone augmentation procedures can also
be used with two-piece system [61]. However, this design
showed higher failure rates and lower fracture resistance than
comparable titanium two-piece implant system, due to failure
around the weakest link the connecting screw, which could
be the new challenge for zirconia implants [17]. Carbon-fiber-
reinforced polymer screws for zirconia abutment-implant
assembly have been tested for anterior application under
thermal cycling and mechanical loading, but could not be
recommended [62]. In a recent systematic review and meta-
analysis, with a majority reporting only a 1-year. follow-up,
the failure rate of two-piece zirconia implants (183) was docu-
mented at 13.7% [63]. The investigators concluded that results
from two-piece implants do not provide sufficient data to sup-
Please cite this article in press as: S.J. Sadowsky. Has zirconia made a material difference in implant prosthodontics? A review. Dent Mater (2019),
https://doi.org/10.1016/j.dental.2019.08.100
3
port their clinical use and no abutment or cementing materials
could be recommended.
3.3. Zirconia root analogue implants
A novel concept using zirconia root analogue implants in
an immediate placement, non-submerged scenario has been
reported by Pirker et al [64–67]. In this minimally invasive and
time/cost saving protocol, an extracted tooth is atraumatically
removed intact and the socket is cleaned with curettage and
an iodoform gauze is placed. Macro-retentions are prepared
to the entire interdental radicular surface while reducing the
diameter next to the thin cortical bone to avoid fracture and
pressure induced bone loss. A crown preparation is com-
pleted and then the tooth is laser scanned and a replica is
milled (CAD/CAM technology) from a medical grade zirco-
nia block, followed by sandblasting and then sintered for 8 h.
The root analogue is cleaned in an ultrasonic bath contain-
ing 96% ethanol for 10 min and steam sterilized. On day 4,
the gauze is removed, alveolar socket curetted and flushed
with sterile saline and the implant is tapped in with a mal-
let. Primary stability is evaluated by percussion and palpation.
Patient compliance is essential not to chew over this site until
12–16 weeks when a definitive crown is fabricated. This use of
a roughened zirconia modified root analogue has been docu-
mented with excellent osseointegration, soft and hard tissue
response, and esthetics, but with only case reports of up to 30
months follow-up [67].
Regarding the aforementioned data on zirconia implants,
compared to titanium implants, the following statements
can be supported at this time: No clear superiority has been
documented in biocompatibility, osteoconductivity, physical
properties or allergenicity. Zirconia offers a plausible esthetic
benefit, especially in thin biotype patients. While short-term
studies have been promising, larger multicentered, longitu-
dinal and randomized clinical trials with success data are
required to validate zirconia as a viable alternative to the tita-
nium implant and its design [38,68].
4. Zirconia abutments supported by
titanium implants
Replacing a missing tooth in the anterior zone with an
implant-supported restoration is demanding because of bio-
logical, mechanical and especially esthetic considerations
[69]. The latter concerns have prompted the use of a replace-
ment for titanium abutments to address the greyish coloration
of the peri-implant mucosa. Zirconia has been the favored
material because of better mechanical properties than other
ceramics such as alumina [70]. Current design options include
prefabricated abutments, CAD/CAM custom abutments and
abutments with titanium inserts (Ti base). A systematic review
concluded that CAD/CAM abutments provide better soft tissue
stability, but there is no difference between custom and pre-
fabricated abutments in mechanical outcomes up to 12 years
[71]. While stock abutments provide a maximum angulation of
20 degrees, CAD/CAM abutments may be designed to an angu-
lation of 30 degrees and should not exceed that parameter
[71,72].
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It has been reported that zirconia abutments with a tita-
nium base are stronger than all-zirconia abutments [73].
Internally connected zirconia abutments using a secondary
titanium component exhibited resistance to the highest bend-
ing moments whereas internally connected one-piece zirconia
abutments were the weakest of those investigated [74]. In
addition, one-piece zirconia abutments restoring single crown
restorations on narrow diameter implants have a higher rate
of fracture than those mated with regular diameter implants
[75]. Moreover, premature loss of an implant has been reported
from 1-piece zirconia abutments due to significant wear dam-
age to the titanium internal connection [76]. However, the
interface between the titanium base and zirconia sleeve has
become under scrutiny because of reports of fracture or
debonding. The back-taper design of the zirconia coping on
the titanium base versus a shoulder or especially a chamfer
has been found to be significantly more stable in resisting frac-
ture between the zirconia and titanium base [77]. Selection of
an adhesive with predictable bonding is important. The high-
est retention was found with Panavia SA Cement Automix and
RelyX Unicem 2 Automix with a luting space of 60 ␮m when
bonding zirconia copings to titanium [78].
In summation, zirconia abutments with a titanium base
have revealed a high survival rate and show no difference to
metal after a mean observation period of 5–7 years [79,80].
Statistically significant differences between non-veneered zir-
conia and titanium abutments have not been established in
probing depths, soft tissue recession, bleeding on probing,
marginal bone level, mechanical complications and patient-
reported outcomes [81–85]. However, zirconia abutments have
demonstrated a deltaE mean value that was significantly lower
than titanium in patients that have a facial soft-tissue thick-
ness of <2 mm [86]. This esthetic advantage has been a driving
force for zirconia’s application. As a cautionary note, when
treating hypermasticatory patients that can exhibit bruxing
forces [87], zirconia abutment fracture resistance threshold
(737.6 N +/− 245) [88] could be exceeded. The use titanium
nitride (gold hue) abutments has been shown to have dou-
ble the load to failure of zirconia [89] and have similar esthetic
value or deltaE (11.43 vs. 11.37) as zirconia abutments [90].
5. Zirconia restorations supported by
titanium implants
Can implant supported zirconia restorations improve on metal
ceramic restorations as far as esthetics and mechanical com-
plications? Does it matter if the zirconia is monolithic or
layered? Is the digital fabrication as accurate as the analogue
one?
In a recent systematic review, implant supported bi-layered
zirconia single crowns demonstrated superior esthetics to
metal ceramic crowns [91]. The 5-year survival rate was 97.6%
for zirconia-based restorations with no significant differences
in survival with metal ceramic crowns. The incidence of
chipping of the veneering ceramic was similar between the
material groups (2.9% metal ceramic, 2.8% zirconia-ceramic)
but significantly more zirconia crowns failed due to fracture.
Sailer et al. [92] evaluated implant-supported fixed dental
prostheses with conventionally veneered zirconia and found
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https://doi.org/10.1016/j.dental.2019.08.100
a significant risk for framework fractures and chipping of
the zirconia veneering ceramic. This ongoing finding has
led to investigation of monolithic zirconia restorations to
reduce the risk that veneering procedures introduce [93], but
clinical medium to long-term investigations are not avail-
able presently. An in vitro study has demonstrated superior
chipping resistance of monolithic zirconia crowns versus bi-
layered zirconia restorations [94]. In addition, a short-term
(1–3 years.) case series reports of monolithic zirconia recon-
structions on implants (63 implants supporting single and
multiple restorations) and teeth revealed no differences in
biological or technical complications [95]. For the implant-
supported restorations, no fractures or cracks were recorded
and no instance of debonding of the titanium base. Further-
more, two-body wear tests have shown that polished zirconia
produces less contact wear of the opposing enamel than
feldspathic ceramics [96,97]. This is most likely due to the
homogeneous surface as when coloring and glazing liquids
are used, a similar wear to feldspathic porcelains are seen [98].
Regarding color matching, missing translucency leading to
higher opacity was noted with the monolithic zirconia, favor-
ing posterior restorations [95]. One recommendation would be
a cutback on the buccal aspect, not on the occlusal, to improve
the esthetics [99].
Attention has also been given to the accuracy of fit and
marginal adaptation of CAD/CAM reconstructions, in com-
parison with conventional waxing, casting, and ceraming of
porcelain fused to metal designs. Euan et al [100] evaluated
marginal fit of zirconium dioxide copings and reported the
mean values for the chamfer group were 18.45 ␮m which were
consistent with range of clinical acceptability.
In review, bi-layered zirconia ceramic restorations are a
valid treatment alternative to metal ceramic implant restora-
tions for single crowns with similar biological complications
and less esthetic problems. The incidence of veneer chip-
ping was similar to metal ceramic crowns, but more zirconia
crowns failed because of material fracture. Veneer and frame-
work fracture were more pronounced with zirconia implant
fixed dental prostheses. Monolithic zirconia holds promise
to address the chipping incidence of the bi-layered ceramic
restoration, but longer-term studies are necessary and there
is an esthetic challenge to apply this design to the anterior
region without a facial cutback with a veneering porcelain. It
has been encouraging when a randomized trial evaluated dig-
ital fabrication of a monolithic zirconia crown and analogue
workflow of a metal ceramic crown for premolars and molars,
after 1 year of follow-up, there were no differences in clini-
cal or radiographic outcomes, and patients preferred reduced
active treatment time and costs of the digital fabrication [101].
6. Zirconia complete-arch fixed implant
prostheses supported by titanium implants
Complete arch fixed implant supported prostheses on the
maxillary or mandibular arch have been widely used as a treat-
ment modality for edentulism, with an implant survival rate
well over 90% with up to 10 years follow-up [15,102]. Tradition-
ally, fixed prostheses restoring the edentulous arch have been
designed with a metal-acrylic prosthesis. However, a high per-
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centage of prosthesis-related technical complications (acrylic
veneer fracture, fracture and wear of the denture teeth, and
fracture of the prosthetic framework) have been reported in
the short-term as well as in longitudinal studies [103–105].
In addition, the fixed metal-acrylic prothesis has been shown
to have poor gingival esthetics [106] and attract a potentially
deleterious biofilm [107,108]. Metal-ceramic prostheses have
also been used to restore edentulous patients, but although
high implant survival rates have been recorded in a 10-year
follow-up, only approximately 10% were free of technical or
biological complications after 10 years Th [109]. The advent
of computer-aided design and computer aided manufactur-
ing (CAD/CAM) complete arch zirconia restoration has shown
promise in clinical investigations with a 1–5 year follow-up
[106,110,111]. In a systematic review of 12 clinical studies in
the short-term, zirconia framework fractures were reported
at a low rate of 1.4%, but chipping of the veneered porcelain
was 14.7% [110]. These data appear to be time-dependent as
a 2-year follow-up does not show significant chipping with
this design but a 5-year study is confirmatory [112,113]. This
has prompted the use of a monolithic zirconia design with
a veneered feldspathic gingival region. Using this protocol,
a cumulative survival rate of 99.3% was documented in a 5-
year period [114]. Most impressive was a complication rate
of veneered porcelain of 0%. A number of recommendations
[114,115] have been advanced to achieve this favorable out-
come: (a) use high quality zirconia, (b) adhere to laboratory
procedure of slow heating and cooling the zirconia, (c) assure
at least 12 mm of interocclusal space for the zirconia, (d)
restrict the mandibular cantilever to less than 14 mm and the
maxillary cantilever to 8 mm, (e) provide at least 3 mm of zir-
conia circumferential to screw access holes, (f) use implant
manufacturer’s titanium cylinders bonded to zirconia, (g) use
a milled acrylic prototype to verify fit, occlusion, esthetics and
to provide adjustment before fabricating zirconia prosthesis.
The gingival feldspathic porcelain veneered monolithic zir-
conia complete arch prosthesis versus a resin metal prosthesis
offers reduced laboratory costs, superior durability and wear
characteristics, enhanced fit due to digital fabrication, avail-
ability of a digital file for duplication in the future, acrylic
try-for adjustment and approval, and less plaque and biofilm
accumulation [116]. However, it has been documented that
repair is not possible and adjusting and polishing are difficult
[112].
7. Final considerations
Digital workflows using all zirconia ceramic materials, have
offered implant patients a metal-free restorative alternative,
with potential for enhanced esthetics and time/cost effi-
ciencies, while achieving comparative biocompatibility and
mechanical properties. For zirconia implants, further design
developments and documentation are needed to assure the
clinician of long-term success of two-piece implants. While
the one-piece system has enjoyed up to a 5-year high sur-
vival and success rate, limitations in surgical positioning and
loading restrict its use to select patients.
Zirconia implant abutments with a titanium base have
achieved similar 5–7-year biologic and mechanical outcomes
Please cite this article in press as: S.J. Sadowsky. Has zirconia made a material difference in implant prosthodontics? A review. Dent Mater (2019),
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5
to titanium abutments, with enhanced esthetics especially
in thin biotype patients. A limitation of this use remains in
patients with high applied forces.
Bi-layered zirconia ceramic implant restorations have been
investigated with a 5-year follow-up and have compared well
to metal-ceramic implant restorations for single crowns with
similar biological complications and less esthetic problems.
However, the incidence of chipping has been worrisome. While
monolithic zirconia holds a promise to address the needs of
both single crowns and fixed dental prostheses, long-term
studies are lacking.
Monolithic zirconia complete arch implant prostheses with
a feldspathic porcelain veneer in the gingival region have
been documented with a very low implant failure rate and
prosthetic complication rate with a 5-year observation period.
This design modality, however, is technique sensitive and
requires meticulous planning and appropriate patient selec-
tion to achieve an enduring high success rate.
In conclusion, continual improvements in the design of zir-
conia implants as well as the strength of zirconia implant
abutments, and the esthetics of monolithic zirconia, cou-
pled with more longitudinal randomized controlled studies
will advance a broader application of zirconia in implant
prosthodontics.
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