Group 3 ITI Consensus Report: Materials and antiresorptive drug-associated outcomes in implant dentistry.

OBJECTIVES: The aim of Working Group 3 was to address the influence of both material- and anti-resorptive drug- related factors on clinical and biological outcomes and complications in implant dentistry. Focused questions were addressed on (a) implant materials other than titanium (alloy)s, (b) transmucosal abutment materials and (c) medications affecting bone metabolism were addressed. MATERIALS AND METHODS: Three systematic reviews formed the basis for discussion in Group 3. Consensus statements and clinical recommendations were formulated by group consensus based on the findings of the systematic reviews. Patient perspectives and recommendations for future research were also conveyed. These were then presented and accepted following further discussion and modifications as required by the plenary. RESULTS: Zirconia is a valid alternative to titanium as material for implant and transmucosal components, allowing soft and hard tissue integration with clinical outcomes-identified by implant survival, marginal bone loss and peri-implant probing depths-up to 5-years comparable to titatnium. However, most of the evidence for zirconia implants is based on 1-piece implants limiting the indication range. Furthermore, based on expert opinion, zirconia transmucosal components might be preferred in the esthetic zone. In patients receiving low-dose bisphosphonate therapy, the rate of early implant failure is not increased, while the long-term effects remain poorly studied. Although it has not been sufficiently addressed, similar outcomes can be expected with low-dose denosumab. A drug holiday is not recommended when considering implant placement in patients treated with low-dose ARD. However, the specific therapeutic window, the cumulative dose and the administration time should be considered. Access to peri-implant supportive care is mandatory to prevent peri-implantitis-related medication-related osteonecrosis of the jaw (MRONJ) or implant-related sequestra (IRS). In patients receiving low-dose anti-resorptive drugs (ARD) therapy, the risk of complications related to implant placement is high, and implant procedures in this specific population should be strictly treated in a comprehensive multidisciplinary center. Finally, healthy dental implants should not be removed before low or high-dose ARD. CONCLUSIONS: Zirconia implants can be an alternative to titanium implants in selected indications. However, the current state of evidence remains limited, especially for 2-piece implant designs. Administration of low-dose ARD did not show any negative impact on early implant outcomes, but careful follow-up and supportive care is recommended in order to prevent peri-implant MRONJ and IRS. Implant placement in high-dose patients must be strictly considered in a comprehensive multidisciplinary center.

Crestal bone response to loaded zirconia and titanium implants: a radiographic and histometric analysis in canines.

OBJECTIVES: To evaluate the crestal bone response to a two-piece zirconia implant compared with a control titanium implant using periapical radiographs (PAs) and histometry. MATERIALS AND METHODS: Thirty zirconia and 30 titanium implants were placed in healed posterior mandibles of five canines. Full-ceramic single-tooth restorations were cemented after 6 weeks of healing. Three observers measured the distance between the implant shoulder and the crestal bone (DIB) at placement, loading, and harvesting after 4 or 16 weeks in function. The influence of implant material and loading time on DIB as well as the inter-observer agreement were analyzed. Additionally, histometric distance between implant shoulder and most coronal bone-to-implant contact (IS-cBIC) was compared with DIB. RESULTS: Mean DIB values increased between 4 and 16 weeks of loading for both zirconia (from 1.66 to 2.25 mm; P < 0.0001) and titanium (from 1.81 to 1.95 mm; P = 0.06). Zirconia yielded mean IS-cBIC values of 2.18 mm and 2.48 mm (P < 0.001) and titanium 2.23 mm and 2.34 mm (P = 0.27) after 4 and 16 weeks, respectively. The raters reached an excellent intraclass correlation coefficient. PAs underestimated the bone loss on average by 0.39 mm. CONCLUSIONS: Zirconia implants showed a greater increase of DIB during early healing and function than titanium. CLINICAL RELEVANCE: Crestal peri-implant tissue dimensions may show more pronounced changes around two-piece zirconia implants during early healing. PAs may underestimate peri-implant bone loss.

Zirconia compared to titanium dental implants in preclinical studies-A systematic review and meta-analysis.

OBJECTIVES: To evaluate whether zirconia implants demonstrate differences in hard and soft tissue integration compared to titanium implants in preclinical studies. MATERIAL AND METHODS: In March 2017, electronic (MEDLINE, EMBASE) and hand search was performed to identify preclinical studies comparing zirconia and titanium implants. Primary outcomes were bone-to-implant contact (BIC) and removal torque out (RTQ), respectively, push-in (PI) measurements. Secondary outcomes included biologic width (BW) dimensions. RESULTS: A total of 37 studies were included for data extraction after screening of 91 from 1,231 selected titles. Thirty-seven experimental studies using six different species were identified. The follow-up periods ranged between 0.4 and 56 weeks. For titanium, mean values of 59.1% (95% CI: 53.3 - 64.8), 102.6 Ncm (95% CI: 81.5 - 123.6), and 25.1 N (95% CI: 20.2 - 30.0) for BIC, RTQ, and PI were estimated, respectively. The mean values for zirconia were 55.9% (95% CI: 51.6 - 60.1), 71.5 Ncm (95% CI: 51.1 - 91.9), and 22.0 N (95% CI: 13.2 - 30.7) for corresponding parameters. Confounding factors such as animal species, implant material, loading protocol, and study or loading duration significantly influenced the outcomes. Similar qualitative soft tissue integration was reported for zirconia and titanium implants. However, faster maturation processes of epithelial and connective tissues around zirconia implants were assumed. Quantitatively, similar BW dimensions were evaluated for titanium (3.5 mm; 95% CI: 2.9 - 4.2) and zirconia (3.2 mm; 95% CI: 2.7 - 3.7), whereas the loading protocol significantly influenced the outcomes. CONCLUSIONS: Zirconia and titanium implants demonstrate a similar soft and hard tissue integration capacity. However, titanium tended to show a faster initial osseointegration process compared to zirconia. Importantly, not only material characteristics but predominantly animal species and study protocols can significantly influence the outcomes.

Ligature-Induced Peri-implant Bone Loss Around Loaded Zirconia and Titanium Implants.

PURPOSE: To radiographically investigate ligature-induced peri-implant bone loss around loaded titanium (Ti-SLA) and zirconia (ZrO2-ZLA) implants using a canine model. MATERIALS AND METHODS: Forty sandblasted and acid-etched titanium and zirconia implants were alternately placed in the mandibles of five canines (20 Ti-SLA, 20 ZrO2-ZLA). Implants were restored after 6 weeks of unloaded healing. After 4 weeks of functional loading, oral hygiene procedures were stopped and experimental peri-implant bone loss was initiated by placing cotton ligatures. After 8 weeks of active progression, ligatures were removed and plaque was allowed to accumulate for another 16 weeks of spontaneous progression (without ligatures). Standardized radiographs were taken at implant placement, at functional loading, and every 2 weeks during active and spontaneous progression of bone loss. RESULTS: Before ligature placement, all implants were successfully osseointegrated and no clinical or radiographic signs of peri-implant infections were detectable. Two weeks after ligature removal, one titanium implant was lost; however, no zirconia implant failures were observed during the study. Radiographically, zirconia implants revealed statistically significantly less crestal peri-implant bone loss compared to titanium implants at the end of the active progression period (Ti-SLA: 3.92 mm; ZrO2-ZLA: 2.65 mm; P < .01); however, no significant differences occurred after the spontaneous progression period (P = .6). Combining the active and spontaneous progression periods together, zirconia implants demonstrated significantly reduced peri-implant bone loss compared to titanium implants (Ti-SLA: 3.76 mm; ZrO2-ZLA: 2.42 mm; P < .01). CONCLUSION: These results demonstrate a significantly reduced ligature-induced inflammation and bone loss for ZrO2-ZLA implants compared to Ti-SLA implants in the canine model.

Group 2 ITI Consensus Report: Prosthodontics and implant dentistry.

OBJECTIVES: Working Group 2 was convened to address topics relevant to prosthodontics and dental implants. Systematic reviews were developed according to focused questions addressing (a) the number of implants required to support fixed full-arch restorations, (b) the influence of intentionally tilted implants compared to axial positioned implants when supporting fixed dental prostheses (FDPs), (c) implant placement and loading protocols, (d) zirconia dental implants, (e) zirconia and metal ceramic implant supported single crowns and (f) zirconia and metal ceramic implant supported FDPs. MATERIALS AND METHODS: Group 2 considered and discussed information gathered in six systematic reviews. Group participants discussed statements developed by the authors and developed consensus. The group developed and found consensus for clinical recommendations based on both the statements and the experience of the group. The consensus statements and clinical recommendations were presented to the plenary (gathering of all conference attendees) and discussed. Final versions were developed after consensus was reached. RESULTS: A total of 27 consensus statements were developed from the systematic reviews. Additionally, the group developed 24 clinical recommendations based on the combined expertise of the participants and the developed consensus statements. CONCLUSIONS: The literature supports the use of various implant numbers to support full-arch fixed prostheses. The use of intentionally tilted dental implants is indicated when appropriate conditions exist. Implant placement and loading protocols should be considered together when planning and treating patients. One-piece zirconia dental implants can be recommended when appropriate clinical conditions exist although two-piece zirconia implants should be used with caution as a result of insufficient data. Clinical performance of zirconia and metal ceramic single implant supported crowns is similar and each demonstrates significant, though different, complications. Zirconia ceramic FDPs are less reliable than metal ceramic. Implant supported monolithic zirconia prostheses may be a future option with more supporting evidence.

Performance and outcome of zirconia dental implants in clinical studies: A meta-analysis.

OBJECTIVES: To evaluate implant survival, peri-implant marginal bone loss, technical, and biological complications as well as aesthetic outcomes of zirconia implants in clinical studies. MATERIAL AND METHODS: Electronic (Medline, Embase) and hand searches were performed to identify clinical studies published between January 2004 and March 2017 investigating zirconia dental implants with a mean follow-up of at least 12 months. Primary outcomes were implant survival and peri-implant marginal bone loss. Secondary outcomes included technical and biological complications as well as aesthetic outcomes. Meta-analyses were performed to estimate implant survival and marginal bone loss. RESULTS: From 943 titles, 264 abstracts were selected. Subsequently, 80 full-text articles were screened, and 18 studies were included for data extraction. One- (14 studies) and 2-piece zirconia implants (4 studies) were investigated. Commercially available (CA) (510 implants, 398 patients) and not commercially available (NCA) zirconia implants (618 implants, 343 patients) were identified. For CA implants (follow-up: 12-61.20 months), technical complications (1.6%), implant fractures (0.2%) and biological complications (4.2%) were reported. Meta-analyses estimated 1- and 2-year survival rates of 98.3% (95% CI: 97.0%-99.6%) and 97.2% (95% CI: 94.7%-99.7%), respectively, and a mean 1-year marginal bone loss of 0.7 mm (95% CI: 0.4-1.0 mm). CONCLUSIONS: Since 2004, the survival rates of CA implants significantly improved compared with NCA implants. CA 1-piece zirconia implants showed similar 1- and 2-year mean survival rates and marginal bone loss after 1 year compared with published data for titanium implants. However, more clinical long-term data are needed to confirm the presently evaluated promising short-term outcomes.

Bone response to functionally loaded, two-piece zirconia implants: A preclinical histometric study.

OBJECTIVE: To evaluate the bone response to a two-piece zirconia implant in comparison with a control titanium implant in the canine mandible 4 and 16 weeks after restoration. MATERIAL AND METHODS: Zirconia and titanium implants were alternately placed bilaterally in healed mandibular molar and premolar sites of five canines. Full-ceramic single-tooth restorations were cemented after 6 weeks of transmucosal healing, allowing for full functional loading of the implants. Histologic and histometric analyses were performed on orofacial and mesiodistal undecalcified sections of the specimens obtained upon sacrifice after 4 and 16 weeks of functional loading. Bone-to-implant contact (BIC), multinucleated giant cells-to-implant contact (MIC), crestal bone level, and peri-implant bone density were histometrically assessed. RESULTS: All 60 implants and 60 restorations were still in function after 4 and 16 weeks of loading in both test and control groups. No implant loss, no implant or abutment fracture, and no chipping of the restorations could be detected. Histometric analysis showed no statistically significant differences between zirconia and titanium implants in BIC, crestal bone level, and peri-implant bone density at both time points. Between 4 and 16 weeks, the crestal bone level around zirconia implants showed a small but statistically significant increase in its distance from the implant shoulder. MIC was very low on both implant types and both time points and decreased statistically significantly overtime. CONCLUSION: The present two-piece zirconia implant showed a similar bone integration compared to the titanium implant with similar surface morphology after 4 and 16 weeks of loading.

In Vitro Biofilm Formation on Titanium and Zirconia Implant Surfaces.

BACKGROUND: It has been hypothesized that zirconia might have a reduced bacterial adhesion compared with titanium; however, results from experimental studies are rather controversial. The aim of the present study is to compare biofilm formation on zirconia and titanium implant surfaces using an in vitro three-species biofilm and human plaque samples. METHODS: Experimental disks made of titanium (Ti) or zirconia (ZrO2) with a machined (M) or a sandblasted (SLA) and acid-etched (ZLA) surface topography were produced. An in vitro three-species biofilm or human plaque samples were applied for bacterial adhesion to each type of disk, which after 72 hours of incubation was assessed using an anaerobic flow chamber model. RESULTS: Zirconia showed a statistically significant reduction in three-species biofilm thickness compared with titanium (ZrO2-M: 8.41 µm; ZrO2-ZLA: 17.47 µm; Ti-M: 13.12 µm; Ti-SLA: 21.97 µm); however, no differences were found regarding three-species-biofilm mass and metabolism. Human plaque analysis showed optical density values of 0.06 and 0.08 for ZrO2-M and ZrO2-ZLA, and values of 0.1 and 0.13 for Ti-M and Ti-SLA, respectively; indicating a statistically significant reduction in human biofilm mass on zirconia compared with titanium. Additionally, zirconia revealed a statistically significant reduction in human plaque thickness (ZrO2-M: 9.04 µm; ZrO2-ZLA: 13.83 µm; Ti-M: 13.42 µm; Ti-SLA: 21.3 µm) but a similar human plaque metabolism compared with titanium. CONCLUSION: Zirconia implant surfaces showed a statistically significant reduction in human plaque biofilm formation after 72 hours of incubation in an experimental anaerobic flow chamber model compared with titanium implant surfaces.

A Retrospective Clinical Study with Regard to Survival and Success Rates of Zirconia Implants up to and after 7 Years of Loading.

PURPOSE: The study aims to retrospectively investigate the clinical performance of first-generation zirconia implants with a sandblasted surface up to and after 7 years of loading. MATERIALS AND METHODS: Clinical records of patients treated with zirconia implants between 2004 and 2009 were screened. Consequently, adequate patients were invited to a clinical and radiographic investigation to classify each implant according to strict success criteria. RESULTS: Seventy-one patients receiving 161 implants were available for the evaluation. Overall, 36 implants (22.4%) were lost due to early (n = 14) and late failures (n = 4) or fractures (n = 18). All surviving 125 implants fulfilled the success criteria. None of the investigated implants had a history of peri-implant infections. Mean values with regard to gingival index, plaque index, modified sulcus bleeding index, and probing depth were 0.03, 0.23, 0.59, and 2.80 mm, respectively. The radiographically evaluated mean crestal bone loss was 0.97 ± 0.07 mm. Diameter-reduced implants (3.25 mm) showed lower survival (58.5%) compared with implants with a diameter of 4.0 mm (88.9%) and 5.0 mm (78.6%). The overall longitudinal survival rate was 77.3%. CONCLUSIONS: First-generation zirconia implants showed low overall survival and success rates. The evaluated clinical and radiographic parameters were consistent with healthy peri-implant tissues. Additionally, nonfractured failures were not associated with peri-implant infections.

Implant Supported Fixed Dental Prostheses Using a New Monotype Zirconia Implant-A Case Report.

Currently, titanium or specific titanium alloys are the most often used materials for the fabrication of dental implants. Many studies have confirmed the osseointegrative capacity and clinical long-term performance of moderately rough titanium implants. However, disadvantages have also been reported with regard to peri-implant infections and the titanium metal properties. Tooth colored ceramic implants have attracted the interest of clinicians since the end of the 1960s. Initially, alumina was used for the fabrication of ceramic implants; however, due to the poor biomechanical properties, alumina implants are not commercially available any more. Since end of the 1990s, zirconia has been established in dentistry due to its superior biomechanical properties compared to other oxide ceramics such as alumina. Currently, zirconia is the material of choice for the fabrication of ceramic implants. Zirconia implants show superior biocompatibility compared to titanium and other metals. Additionally, it has been reported that zirconia implants with a micro-rough surface topography show at least a comparable osseointegrative capacity and similar clinical survival rates to moderately rough titanium implants. The present case reports a fixed implant-supported reconstruction of a large edentulous space with compromised local bone conditions using new monotype zirconia dental implants with a micro-rough surface topography.

Dental zirconia implants up to three years in function: a retrospective clinical study and evaluation of prosthetic restorations and failures.

PURPOSE: The clinical evaluation of one-piece zirconia dental implants with different diameters to determine survival rate and type of implant failure. MATERIALS AND METHODS: Information concerning implant surgery (number, diameter, length, and position of inserted implants; patient age, sex, risk factors, and bone quality) was extracted from the clinical records. All treated patients were then recalled for a follow-up examination to check the current clinical parameters concerning soft tissue, implants, and prosthetic reconstructions. RESULTS: A total of 79 patients received 170 implants (diameter-reduced 3.25 mm: n = 59; diameter 4.0 mm: n = 82; diameter 5.0 mm: n = 29). The clinical examination showed no signs of gingival inflammation. Prosthetic information was available for 119 implants restored with single crowns (87 implants), fixed partial dentures (25 implants), and removable hybrid dentures (7 implants). Overall, 30 implants were lost due to lack of osseointegration (n = 17) or fracture (n = 13). The diameter-reduced implants showed the lowest survival rate (59.5%) compared to the implants with a diameter of 4.0 mm (90.6%) and 5.0 mm (73.9%). The survival rate for diameters of 3.25 mm was significantly lower than that for diameters of 4.0 mm. The estimated cumulative survival rate up to 3 years demonstrated a survival probability of 82.4% for all types of implant diameters and failure. CONCLUSIONS: Based on these results, diameter-reduced zirconia dental implants cannot be recommended for clinical use. The overall survival rate of 82.4% is not acceptable in comparison to the well-established survival rate of titanium implants.