CLINICAL APPLICATION

fo r

Zirconia Implants
and All-Ceramic Restorations
for the Esthetic Replacement
of the Maxillary Central Incisors
Josep Oliva, MSc
Private Practice
Granollers, Barcelona, Spain

Xavi Oliva, MSc

Private Practice
Granollers, Barcelona, Spain

Josep D. Oliva, DMD

Private Practice
Granollers, Barcelona, Spain

Correspondence to: Dr Josep Oliva

126 Josep Umbert, 08400 Granollers, Barcelona, Spain;
fax: +34 938792373; e-mail: [email protected].

174
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 3 NUMBER 2 SUMMER 2008

ot

Q ui

by N
ht

pyrig
No Co
t fo
rP
ub
lica
tio
n
te
ss e n c e

OLIVA ET AL

ot

Q ui

by N
ht

pyrig
No Co
t fo
rP
ub
lica
tio
n
te
ss e n c e

fo r

Abstract
Ceramics have been used in dentistry and

zirconia implants in an esthetically de-

medicine for many years. Today, one of the

manding case. The 28-year-old male pa-

most popular ceramics is zirconia because

tient required replacement of the maxillary

of its outstanding mechanical properties,

central incisors. Two rough-surface zirconia

which make it suitable for many indications

implants (CeraRoot) were used to immedi-

formerly reserved for metals. Zirconia-

ately replace the extracted teeth. Immediate

based ceramics have been used for many

provisional restorations were placed for a

years as the core for single crowns and

period of 3 months until the final all-ceram-

long-span fixed prostheses. Zirconia-based

ic restorations were cemented. Zirconia im-

ceramics have also been used as implants

plants may be a good alternative for tooth

for hip replacements and finger, toe, and

replacement, especially in esthetically de-

wrist joints. Recently, some articles in the

manding cases. More studies are needed

dental literature suggest the possible use of

to evaluate the long-term results of zirconia

zirconia implants for tooth replacement. The

dental implants with different surfaces.

present case report illustrates the results

that can be achieved using rough-surface

(Eur J Esthet Dent 2008;3:174185.)

175
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 3 NUMBER 2 SUMMER 2008

CLINICAL APPLICATION

ot

Q ui

by N
ht

pyrig
No Co
t fo
rP
ub
lica
tio
n
te
ss e n c e

fo r

The material of choice for dental implants

integration process,23 but the turning of zir-

is commercially pure titanium due to its

conia rods results in a relatively smooth

and

surface. Sennerby et al20 demonstrated

suitability for tooling. This material has been

better implant retrieval torque resistance of

used for about 30 years as implant sub-

porous zirconia surfaces in rabbits. In a

strate with good success rates.2 One pos-

recent publication, Oliva et al24 studied the

sible alternative to titanium is tooth-colored

1-year survival rate of 100 rough-surface

materials such as ceramics.3,4 Ceramic

zirconia implants in humans, and reported

materials are highly biocompatible and

a success rate comparable to titanium

can be used as dental devices.5 One

implants. The one-piece zirconia implants

ceramic material that was used in the past

used in this study (CeraRoot) had a rough

for dental implants was aluminum oxide.68

surface, and no mechanical preparation of

This material showed good osseointegra-

the abutment was needed for the final

tion, but did not have sufficient mechanical

restoration.

well-documented

biocompatibility

properties for long-term loading and was

withdrawn from the market.
Recently, another ceramic material with

Case presentation

potential as a dental implant material was

introduced.

good

The patient was a 28-year-old man who

flexural

was a nonsmoker in good general health.

strength (900 to 1,200 MPa), hardness

The patient presented for an initial exami-

(1,200 Vickers), and Weibull modulus (10 to

nation with pain at the maxillary left central

physical

911

12).

Zirconia

properties,

12

possesses
such

as

stressed the importance

incisor, and loosening of the crowns on

of the threshold stress intensity factor of zir-

both maxillary central incisors (Figs 1 to 4).

Marx et al

conia (K10 = 3.1 0.2 MPam) for deter-

He was also concerned about the esthet-

mining long-term stability. Furthermore, its

ics of his smile. The dental history revealed

biocompatibility has been demonstrated

that he had broken the central incisors

in several animal investigations.1320 In vitro

while playing basketball at age 18. Root

experiments showed that the material is

canal treatment had been performed and

capable of withstanding simulated long-

two metal-ceramic crowns were placed.

term load; however, the mechanical prop-

The patient reported that the crowns were

erties of zirconia seem to be influenced by

very loose and that he had been back to

the mechanical preparation of the materi-

his dentist many times for recementation.

al.17,21 Moreover, the exposure of zirconia

The patient was concerned about metal

implants to the artificial mouth has no sta-

materials and requested a metal-free tooth

tistically significant influence on the mean

replacement and metal-free restoration.

21

fracture strength values of the implants.

Kohal et al22 published a case report of a

Initial examination

machined zirconia implant and zirconia

After an initial examination and periapical

crown in one patient, achieving an excel-

radiographs, the authors confirmed a root

lent esthetic result. Modern implant re-

fracture on the left central incisor. There

search shows that a rough surface topog-

was also high mobility with palatal inflam-

raphy is desirable to enhance the bone

mation and periapical chronic lesions (Figs

176
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 3 NUMBER 2 SUMMER 2008

OLIVA ET AL

fo r

Fig 1

The patient had a high smile line, with dark col-

ot

Q ui

by N
ht

pyrig
No Co
t fo
rP
ub
lica
tio
n
te
ss e n c e

Fig 2

Intraoral view of the preoperative situation.

Fig 4

Radiograph showing the periapical lesion at

oration visible through the gums.

Fig 3

Occlusal view showing palatal inflammation.

the left central incisor.

3 and 4). The papilla between the central

extrusion of the mandibular incisors and

incisors was inflamed (Figs 1 and 2).

maxillary central incisors. The occlusion

Esthetically, the metal from the restoration

was Class I on the right side and Class II

was visible in the margin of the restoration

on the left side. There were interproximal

and the dark color of the root was visible

open embrasures in the mandibular ante-

through the gingiva, even though the pa-

rior region. The mandibular right first molar

tient showed a thick soft tissue biotype. The

had

smile line was very high, with more than

showed a chronic periapical lesion, which

5 mm of gums visible above the central in-

the patient decided to have treated at a

cisors. A deep bite was present due to the

later time.

been

endodontically

treated

and

177
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 3 NUMBER 2 SUMMER 2008

CLINICAL APPLICATION

ot

Q ui

by N
ht

pyrig
No Co
t fo
rP
ub
lica
tio
n
te
ss e n c e

fo r

Treatment plan
Systemic antibiotics were administered for
4 days before surgery and 7 days after surgery. The maxillary central incisors were
considered hopeless teeth and planned for
extraction. The patient asked for a metalfree restoration. The patient was informed
about the possibility of zirconia implants
and all-ceramic restorations, and he requested this treatment. One-piece root
form

zirconia

implants

were

selected

(CeraRoot). As seen in Fig 5, the implant

has a transgingival part with a scalloped

Fig 5

Frontal (left) and interproximal (right) views of

the CeraRoot zirconia implant.

design to support the interproximal tissues.

Additionally, the design of the abutment is
such that there is no need to prepare it for

to give the drills the appropriate inclination

the provisional or final restoration.

to follow the incisal edge of the two missing teeth (Figs 10 and 11). A profile drill

Surgical treatment

was used to finalize the shape of the im-

The surgical treatment started with atrau-

plant site. The implants were inserted at

matic teeth and root extractions using

the contra-angle using a special key. The

scalpels and forceps (Figs 6 to 9). The ex-

implant buccal shoulder was left 1.5 mm

traction sockets were debrided and the

apically to the lateral incisors to compen-

chronic periapical cyst was extracted fol-

sate for the extrusion of the old central in-

lowed by irrigation with saline solution. The

cisors (Figs 12 and 13). An optimal primer

drilling sequence used two pilot drills fol-

stability (> 35 N) of both implants was

lowed by twist drills. Special care was taken

achieved at surgery.

Figs 6 and 7

Radiograph and intraoral view following extraction of the left central incisor.

178
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 3 NUMBER 2 SUMMER 2008

OLIVA ET AL

fo r

Fig 8

Extraction of the right central incisor.

Fig 9

ot

Q ui

by N
ht

pyrig
No Co
t fo
rP
ub
lica
tio
n
te
ss e n c e

Frontal view following extraction of the central

incisors.

Fig 10

Implant site preparation with optimal inclina-

tion.

Fig 12

Fig 11

Drilling must be performed in the direction of

the final crown.

Placement of zirconia implants in the optimal

occlusal direction.

Fig 13

Zirconia implants in place. Note the integrity

of the papilla due to the atraumatic surgery.

179
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 3 NUMBER 2 SUMMER 2008

CLINICAL APPLICATION

ot

Q ui

by N
ht

pyrig
No Co
t fo
rP
ub
lica
tio
n
te
ss e n c e

fo r

Immediate provisional restoration

taken to leave the provisionals out of oc-

The provisionals were fabricated before

clusion, and the patient was informed that

surgery with standard resin. To adjust the

he should not use this provisional restora-

provisionals to the implants, prefabricated

tion for at least 1 month. For temporary ce-

resin caps with the implant shoulder were

mentation, light-curing cement was used

used (Fig 14). Photopolymerizing compos-

(Provilink TM, Ivoclar-Vivadent) (Figs 15

ite (Protemp, 3M ESPE) was used to as-

and 16). Immediately following cementa-

semble

provisional

tion, panoramic radiographs were taken to

restorations and resin caps. The excess

confirm the adequate fit of the provisional

composite was then removed and the pro-

restoration and the correct position of the

visionals were polished. Special care was

zirconia implants (Fig 17).

Fig 14

Fig 15

the

prefabricated

Prefabricated provisional restoration is adapt-

ed to the zirconia implants using prefabricated resin

Immediate provisional in place. Cementation

is carried out with temporary cement.

caps and composite.

Fig 16

The esthetic appearance is acceptable im-

mediately after surgery.

180
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 3 NUMBER 2 SUMMER 2008

Fig 17

Panoramic radiograph following cementation

of the provisional restoration.

OLIVA ET AL

ot

Q ui

by N
ht

pyrig
No Co
t fo
rP
ub
lica
tio
n
te
ss e n c e

fo r

Healing period
Fifteen days postsurgery, the appearance
of the soft tissues was very good and little
inflammation was visible (Figs 18 to 20).
The patient reported high satisfaction at
this point because he did not feel much
pain and had no bleeding. The patient was
seen every 2 weeks for clinical, photographic, and radiographic assessment.
No problems were reported during the
3-month healing period.
Fig 18

Figs 19 and 20

Periapical radiograph 15 days postsurgery.

Optimal soft tissue adaptation was evident 15 days postsurgery.

181
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 3 NUMBER 2 SUMMER 2008

CLINICAL APPLICATION

fo r

Figs 21 and 22

ot

Q ui

by N
ht

pyrig
No Co
t fo
rP
ub
lica
tio
n
te
ss e n c e

The provisionals were removed 3 months postsurgery for final impression taking. Note that

the soft tissue volume is greatly preserved.

Figs 23 and 24

Frontal and lateral views in occlusion. Note the adequate positioning of the implants for the

final restoration.

Final restoration

electrosurgery unit (Martin) was used to re-

Three months after surgery, the soft tissues

move any excess soft tissue around the im-

had healed perfectly around the zirconia

plant shoulder. Impressions for the final

implants and provisional restoration (Figs

restorations were taken with polyether (Im-

21 to 24). No inflammation or bleeding was

pregum, 3M ESPE) without using retraction

present around the implants. The papilla

cords. The final restoration was fabricated

between the implants was intact, and the

with an all-ceramic system (Empress II,

color of the gums was identical to those

Ivoclar-Vivadent), and the final cementation

around the neighboring teeth, giving the

(Figs 25 to 27) was carried out 4 months af-

impression of a natural look. At this time, an

ter surgery with resin modified glass-

182
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 3 NUMBER 2 SUMMER 2008

OLIVA ET AL
Q ui

by N
ht

pyrig
No Co
t fo
rP
ub
lica
tio
n
te
ss e n c e

ot

fo r

Figs 25 and 26

Periapical and panoramic radiographs to confirm the fit of the final all-ceramic restoration

and optimum position of the zirconia implants.

Fig 27

Cementation of the final restorations. The

Fig 28

One-year follow-up. Note the perfect integra-

gums still need to adapt to the new restoration.

tion of soft tissues with the all-ceramic restoration.

ionomer cement (GC FujiCEM, GC Amer-

Follow-up

ica). Special attention was given to the oc-

The 1-year follow-up showed high stabili-

clusion to avoid excess contact in centric

ty of the implants and gums (Fig 28), and

and protrusive displacements. A slight

the patient reported no adverse symptoms

infraocclusion was left to compensate for

or complaints. The esthetic appearance

the periodontal ligament of the neighboring

was greatly improved and the patient was

teeth. Periapical and panoramic radio-

very satisfied with the final result (Figs 29

graphs were taken to confirm the adequate

and 30).

fit of the restoration (Figs 25 and 26).

183
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 3 NUMBER 2 SUMMER 2008

CLINICAL APPLICATION

fo r

Figs 29 and 30

ot

Q ui

by N
ht

pyrig
No Co
t fo
rP
ub
lica
tio
n
te
ss e n c e

Before and after photographs. After treatment there is no difference in the soft tissue color

around natural teeth and zirconia implants. The all-ceramic restoration has a natural look.

Discussion
When using zirconia implants to restore

mans and reported a success rate compa-

teeth, the latest implant research should be

rable to titanium implants. The one-piece

taken into consideration. The biocompati-

zirconia implants used in this study had a

bility of zirconia has been demonstrated in

rough surface, and no mechanical prepa-

1320

several animal investigations.

Also, in

vitro experiments showed that the materi-

ration of the abutment was needed for the

final restoration.

al is capable of withstanding simulated

It is important to exercise careful case

long-term load; however, the mechanical

selection when using zirconia implants.

properties of zirconia seem to be influ-

Since only cemented restorations can be

enced by the mechanical preparation of

used, the implant must be placed in the

17,21

The same authors reported

perfect position and inclination. A surgical

that the exposure of zirconia implants to

guide is useful in this regard. It is also im-

the artificial mouth has no statistically sig-

portant to have good and stable occlusion

nificant influence on the mean fracture

to avoid placing too much stress on the

strength values of the implants. Moreover,

implants.

the material.

modern implant research shows that a

rough surface topography is desirable to
enhance the bone integration process,23

Conclusions

but the turning of zirconia rods results in a

relatively smooth surface. Sennerby et al20

Zirconia implants may be a good alterna-

demonstrated

retrieval

tive for tooth replacement, especially in

torque resistance of porous zirconia sur-

esthetically demanding cases. More stud-

faces in rabbits. In a recent publication, Oli-

ies are needed to evaluate the long-term

va et al24 studied the 1-year survival rate of

results of zirconia implants with different

100 rough-surface zirconia implants in hu-

surfaces.

better

implant

184
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 3 NUMBER 2 SUMMER 2008

OLIVA ET AL
Q ui

by N
ht

pyrig
No Co
t fo
rP
ub
lica
tio
n
te
ss e n c e

ot

fo r

References
1.

2.

3.

4.

5.

6.

7.

8.

9.

Kasemo B, Lausmaa J. Biomaterial and implant surfaces:

A surface science approach.
Int J Oral Maxillofac Implants
1988;3:247259.
Kasemo B, Lausmaa J. Biomaterials and interfaces. In: Naert
I, van Steenberghe D, Worthington P (eds). Osseointegration in Oral Rehabilitation.
London: Quintessence, 1993:
6375.
Heydecke G, Kohal R, Glaser
R. Optimal esthetics in singletooth replacement with the ReImplant system: A case report.
Int J Prosthodont 1999;12:
184189.
Wohlwend A, Studer S, Schrer P. The zirconium oxide abutmentA new all-ceramic concept for esthetically improving
suprastructures in implantology [in German]. Quintessenz
Zahntech 1996;22:364381.
Silva VV, Lameiras FS, Lobato
ZI. Biological reactivity of zirconia-hydroxyapatite composites.
J Biomed Mater Res 2002;63:
583590.
Schulte W. The intra-osseous
Al2O3 (Frialit) Tuebingen
Implant. Developmental status
after eight years (IIII). Quintessence Int 1984;15:139.
Schulte W, dHoedt B. Thirteen
years of the Tbingen implant
system made by Frialitadditional results [in German].
Z Zahnrztl Implantol 1988;3:
167172.
De Wijs FLJA, Van Dongen RC,
De Lange GL. Front tooth
replacement with Tbingen
(Frialit) implants. J Oral Rehabil
1994;21:1126.
Marx R. Modern ceramic
materials for esthetic restorationsStrengthening and fracture toughness [in German].
Dtsch Zahnrztl Z 1993;48:
229236.

10. Piconi C, Burger W, Richter

HG, et al. Y-TZP ceramics for
artificial joint replacements.
Biomaterials 1998;19:
14891494.
11. Stevens R. Zirconia and Zirconia Ceramics. An Introduction
to Zirconia, ed 2. Twickenham,
UK: Litho, 2000:151.
12. Marx R, Jungwirth F, Walter P.
Threshold intensity factors as
lower boundaries for crack
propagation in ceramics.
BioMedical Engineering Online
2004;3:41.
13. Albrektsson T, Hansson HA,
Ivarsson B. Interface analysis
of titanium and zirconium
bone implants. Biomaterials
1985;6:97101.
14. Akagawa Y, Ichikawa Y, Nikai
H, Tsuru H. Interface histology
of unloaded and early loaded
partially stabilized zirconia
endosseous implant in initial
bone healing. J Prosthet Dent
1993;69:599604.
15. Akagawa Y, Hosokawa R, Sato
Y, Kamayama K. Comparison
between freestanding and
tooth-connected partially stabilized zirconia implants after
two years function in monkeys: A clinical and histological study. J Prosthet Dent
1998;80:551558.
16. Ichikawa Y, Akagawa Y, Nikai
H, et al. Tissue compatibility
and stability of a new zirconia
ceramic in vivo. J Prosthet
Dent 1992;68:322326.
17. Kohal R J, Papavasiliou G,
Kamposiora P, Tripodakis A,
Strub J. Three-dimensional
computerized stress analysis
of commercially pure titanium
and yttrium-partially stabilized
zirconia implants. Int J Prosthodont 2002;15:189194.

18. Kohal R J, Weng D, Bchle M,

Strub J. Loaded custom-made
zirconia and titanium implants
show similar osseointegration.
J Periodontol 2004;75:
12621268.
19. Kohal RJ, Hrzeler MB, Mota
LF, et al. Custom-made root
analogue titanium implants
placed into extraction sockets.
An experimental study in monkeys. Clin Oral Implants Res
1997;8:386392.
20. Sennerby L, Dasmah A, Larsson B, Iverhed M. Bone tissue
responses to surface-modified
zirconia implants: A histomorphometric and removal torque
study in the rabbit. Clin Implant
Dent Relat Res 2005;7 Suppl
1:s13s20.
21. Andreiotelli M. Survival Rate
And Fracture Resistance of Zirconium Dioxide Implants After
Exposure to the Artificial
Mouth: An In-Vitro Study
[thesis]. Freiburg, Germany:
University of Freiburg, 2006.
22. Kohal R J, Klaus G. A zirconia
implant/zirconia crown system.
A case report. Int J Periodontics Restorative Dent 2004;24:
147153.
23. Wennerberg A. On surface
roughness and implant incorporation [thesis]. Gteborg:
University of Gteborg, 1996.
24. Oliva J, Oliva X, Oliva DJ.
One-year follow-up of first consecutive 100 zirconia dental
implants in humans. A comparison of two different rough
surfaces. Int J Oral Maxillofac
Implants 2007;22:430435.

185
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 3 NUMBER 2 SUMMER 2008