Ralf-Joachim Kohal

Fracture Strength of Zirconia Implants after Artificial Aging

BACKGROUND Zirconia (ZrO(2)) might be an alternative material to titanium (Ti) for dental implant fabrication. However, no data are available on the fracture strength of one-piece ZrO(2) oral implants. PURPOSE The objective of this study was to evaluate the fracture strength of ZrO(2) implants after exposure to the artificial mouth. MATERIALS AND METHODS One hundred twenty ZrO(2) and Ti implants were used. The Ti implants were divided into two control groups (A and B). ZrO(2) implants manufactured from yttria-stabilized tetragonal ZrO(2) polycrystal (Y-TZP) in group C, from Y-TZP dotted with alumina (Y-TZP-A) in group D, and from Y-TZP-A with a modified surface in groups E and F were used. In group F, the implant heads were prepared, and in group G, the implants were restored with ZrO(2) crowns. Each group included 16 samples with the exception of group D, which included 24 samples. A subgroup of each implant type (eight implants) was subjected to thermomechanical cycling in a chewing simulator prior to fracture testing. Test specimens were then loaded until a fracture occurred. RESULTS Seven of the 120 samples failed in the chewing simulator. ZrO(2) implant fracture occurred at 725 to 850 N when the implants were not prepared, and at 539 to 607 N when prepared. The samples in group A fractured at the level of the abutment screw. All ZrO(2) implants fractured at the level of the Technovit resin (Heraeus Kulzer GmbH & Co., Wehrheim, Germany). No fracture of the ZrO(2) crowns in group G was observed. CONCLUSION Mean fracture strength values obtained were all within the limits of clinical acceptance. However, implant preparation had a statistically significant negative influence on the implant fracture strength. Long-term clinical data are necessary before one-piece ZrO(2) implants can be recommended for daily practice.

One‐piece zirconia oral implants: one‐year results from a prospective cohort study. 1. Single tooth replacement

AIM To investigate the clinical and radiographic outcome of a one-piece zirconia oral implant for single tooth replacement after 1 year. MATERIALS AND METHODS A total of 65 patients received a one-stage implant surgery with immediate temporization. Standardized radiographs were taken at implant insertion and after 1 year to monitor peri-implant bone loss. A univariate analysis of the influence of different baseline parameters on marginal bone loss from implant insertion to 12 months was performed. Soft tissue parameters were evaluated at prosthesis insertion and at the 1-year follow-up. RESULTS After 1 year, three implants were lost, giving a cumulative survival rate of 95.4%. The marginal bone loss after 1 year was 1.31 mm. Thirty-four per cent of the implants lost at least 2 mm bone, and 14% more than 3 mm. The univariate analysis could not depict any parameter influencing marginal bone loss. Probing depth, Clinical Attachment Level, Bleeding and Plaque Index decreased over 1 year. CONCLUSIONS The cumulative survival rate of the presented ceramic implant was comparable to the reported survival rate of titanium implants when immediately restored. However, the frequency of increased radiographic bone loss (>2 mm) after 1 year was considerably higher as compared to conventional two-piece titanium implants. The presented zirconia implant can therefore not be recommended for clinical usage.

Biofilm formation and composition on different implant materials in vivo

Biofilm formation was evaluated on the following titanium and zirconia implants in vivo: machined titanium (Ti-m), modified titanium (TiUnite), modified zirconia (ZiUnite), machined alumina-toughened zirconia (ATZ-m), sandblasted alumina-toughened zirconia (ATZ-s), and machined zirconia (TZP-A-m). Bovine enamel slabs were used as controls. Surface morphologies were examined by atomic force (AFM) and scanning electron microscopy (SEM). The surface wettability was also determined. Twelve healthy volunteers wore a splint system with the tested materials. After 3 and 5 days the materials were examined by fluorescence in situ hybridization (FISH) and confocal laser scanning microscopy (CLSM). The levels of Streptococcus spp., Veillonella spp., Fusobacteriaum nucleatum, and Actinomyces naeslundii were quantitatively determined. The biofilm thickness was found to be between 19.78 and 36.73 μm after 3 days and between 26.11 and 32.43 μm after 5 days. With the exception of Ti-m the biofilm thickness after 3 days was correlated with surface roughness. In addition to Streptococcus spp. as the main component of the biofilm (11.23-25.30%), F. nucleatum, A. naeslundii, and Veillonella spp. were also detected. No significant differences in biofilm composition on the implant surfaces could be observed. In total, the influence of roughness and material on biofilm formation was compensated by biofilm maturation.

Stability of Prototype Two‐Piece Zirconia and Titanium Implants after Artificial Aging: An In Vitro Pilot Study

BACKGROUND Zirconia oral implants are a new topic in implant dentistry. So far, no data are available on the biomechanical behavior of two-piece zirconia implants. Therefore, the purpose of this pilot investigation was to test in vitro the fracture strength of two-piece cylindrical zirconia implants after aging in a chewing simulator. MATERIALS AND METHODS This laboratory in vitro investigation comprised three different treatment groups. Each group consisted of 16 specimens. In group 1, two-piece zirconia implants were restored with zirconia crowns (zirconia copings veneered with Triceram; Esprident, Ispringen, Germany), and in group 2 zirconia implants received Empress 2 single crowns (Ivoclar Vivadent AG, Schaan, Liechtenstein). The implants, including the abutments, in the two zirconia groups were identical. In group 3, similar titanium implants were reconstructed with porcelain-fused-to-metal crowns. Eight samples of each group were submitted to artificial aging with a long-term load test in the artificial mouth (chewing simulator). Subsequently, all not artificially aged samples and all artificially aged samples that survived the long-term loading of each group were submitted to a fracture strength test in a universal testing machine. For the pairwise comparisons in the different test groups with or without artificial loading and between the different groups at a given artificial loading condition, the Wilcoxon rank-sum test for independent samples was used. The significance level was set at 5%. RESULTS One sample of group 1 (veneer fracture), none of group 2, and six samples of group 3 (implant abutment screw fractures) failed while exposed to the artificial mouth. The values for the fracture strength after artificial loading with 1.2 million cycles for group 1 were between 45 and 377 N (mean: 275.7 N), in group 2 between 240 and 314 N (mean: 280.7 N), and in the titanium group between 45 and 582 N (mean: 165.7 N). The fracture strength results without artificial load for group 1 amounted to between 270 and 393 N (mean: 325.1 N), for group 2 between 235 and 321 N (mean: 281.8 N), and between 474 and 765 N (mean: 595.2 N) for the titanium group. The failure mode during the fracture testing in the zirconia implant groups was a fracture of the implant head and a bending/fracture of the abutment screw in the titanium group. CONCLUSIONS Within the limits of this pilot investigation, the biomechanical stability of all tested prototype implant groups seems to be - compared with the possibly exerted occlusal forces - borderline for clinical use. A high number of failures occurred already during the artificial loading in the titanium group at the abutment screw level. The zirconia implant groups showed irreparable implant head fractures at relatively low fracture loads. Therefore, the clinical use of the presented prototype implants has to be questioned.

Clinical Outcomes of Zirconia Dental Implants: A Systematic Review

To determine the survival rate and marginal bone loss (MBL) of zirconia dental implants restored with single crowns or fixed dental prostheses. An electronic search was conducted up to November 2015 (without any restriction regarding the publication time) through the databases MEDLINE (PubMed), Cochrane Library, and EMBASE to identify randomized controlled clinical trials and prospective clinical trials including >15 patients. Primary outcomes were survival rate and MBL. Furthermore, the influence of several covariates on MBL was evaluated. Qualitative assessment and statistical analyses were performed. This review was conducted according to preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines for systematic reviews. With the applied search strategy, 4,196 titles could be identified. After a screening procedure, 2 randomized controlled clinical trials and 7 prospective clinical trials remained for analyses. In these trials, a total of 326 patients received 398 implants. The follow-up ranged from 12 to 60 mo. Implant loss was mostly reported within the first year, especially within the healing period. Thereafter, nearly constant survival curves could be observed. Therefore, separate meta-analyses were performed for the first and subsequent years, resulting in an implant survival rate of 95.6% (95% confidence interval: 93.3% to 97.9%) after 12 mo and, thereafter, an expected decrease of 0.05% per year (0.25% after 5 y). Additionally, a meta-analysis was conducted for the mean MBL after 12 mo, resulting in 0.79 mm (95% confidence interval: 0.73 to 0.86 mm). Implant bulk material and design, restoration type, and the application of minor augmentation procedures during surgery, as well as the modes of temporization and loading, had no statistically significant influence on MBL. The short-term cumulative survival rates and the MBL of zirconia implants in the presented systematic review are promising. However, additional data are still needed to confirm the long-term predictability of these implants.

Promotion of osteoblast differentiation in 3D biomaterial micro-chip arrays comprising fibronectin-coated poly(methyl methacrylate) polycarbonate.

Due to the architecture of solid body tissues including bone, three-dimensional (3D) in vitro microenvironments appear favorable, since herein cell growth proceeds under more physiological conditions compared to conventional 2D systems. In the present study we show that a 3D microenvironment comprising a fibronectin-coated PMMA/PC-based micro-chip promotes differentiation of primary human osteoblasts as reflected by the densely-packed 3D bone cell aggregates and expression of biomarkers indicating osteoblast differentiation. Morphogenesis and fluorescence dye-based live/dead staining revealed homogenous cell coverage of the microcavities of the chip array, whereat cells showed high viability up to 14 days. Moreover, Azur II staining proved formation of uniform sized multilayered aggregates, exhibiting progressive intracellular deposition of extracellular bone matrix constituents comprising fibronectin, osteocalcin and osteonectin from day 7 on. Compared to 2D monolayers, osteoblasts grown in the 3D chip environment displayed differential mostly higher gene expression for osteocalcin, osteonectin, and alkaline phosphatase, while collagen type I remained fairly constant in both culture environments. Our results indicate that the 3D microenvironment, based on the PMMA biomaterial chip array promotes osteoblast differentiation, and hereby renders a promising tool for tissue-specific in vitro preconditioning of osteoblasts designated for clinically-oriented bone augmentation or regeneration.

Evaluation of Zirconia‐Based All‐Ceramic Single Crowns and Fixed Dental Prosthesis on Zirconia Implants: 5‐Year Results of a Prospective Cohort Study

Objective The objective of this 5-year cohort investigation was to determine the survival and success rate of all-ceramic reconstructions on zirconia oral implants. Material and Methods Ninety-three patients received 122 one-piece zirconia implants. One hundred seventeen implants were restored with 63 single crowns (SCs) and 27 three-unit bridges (fixed dental prostheses, FDPs) fabricated using zirconia frameworks (Procera® Zirconia, Nobel Biocare®, Goteborg, Sweden) hand-layered with a silicate ceramic (NobelRondo™ Zirconia, Nobel Biocare®). With any occurrence of chipping regarded as an event, Kaplan-Meier success curves were plotted. Covariates (gender, location, manufacturing date) were estimated by the use of log-rank tests. Results Eighty-nine patients received prosthetic reconstructions. Sixty-three of them were seen at the 5-year follow-up, with a mean observation time of 58.2 months (47 patients with SCs, 16 patients with FDPs). Reasons for the decreasing number of patients at the follow-up sessions included dropouts due to implant loss (n = 21), moving (n = 3), missed appointments (n = 1), and severe illness (n = 1). Over half of the SCs (57.2%) and 38% of the FDPs were successful after an observation time of 5 years (overall success rate of 51.7%). The performed log-rank tests revealed no statistically significant differences for the success curves regarding the above-mentioned covariates. Among the 63 restorations that completed the study, 11 of 47 SCs and one of 16 FDPs had to be replaced due to the severity of the observed chipping. This results in survival rates of 76.6% for the SCs and 93.8% for the FDPs. No framework fractures or decementations were observed in any group. Conclusion Hand-layering of zirconia-based SCs and FDPs with NobelRondo™ Zirconia restoring one-piece zirconia implants did not show acceptable survival and success rates. Meanwhile, the material has been recalled from the market. It is advised that new materials should undergo adequate preclinical evaluation before coming to the market.OBJECTIVE The objective of this 5-year cohort investigation was to determine the survival and success rate of all-ceramic reconstructions on zirconia oral implants. MATERIAL AND METHODS Ninety-three patients received 122 one-piece zirconia implants. One hundred seventeen implants were restored with 63 single crowns (SCs) and 27 three-unit bridges (fixed dental prostheses, FDPs) fabricated using zirconia frameworks (Procera(®) Zirconia, Nobel Biocare(®), Göteborg, Sweden) hand-layered with a silicate ceramic (NobelRondo(™) Zirconia, Nobel Biocare(®)). With any occurrence of chipping regarded as an event, Kaplan-Meier success curves were plotted. Covariates (gender, location, manufacturing date) were estimated by the use of log-rank tests. RESULTS Eighty-nine patients received prosthetic reconstructions. Sixty-three of them were seen at the 5-year follow-up, with a mean observation time of 58.2 months (47 patients with SCs, 16 patients with FDPs). Reasons for the decreasing number of patients at the follow-up sessions included dropouts due to implant loss (n = 21), moving (n = 3), missed appointments (n = 1), and severe illness (n = 1). Over half of the SCs (57.2%) and 38% of the FDPs were successful after an observation time of 5 years (overall success rate of 51.7%). The performed log-rank tests revealed no statistically significant differences for the success curves regarding the above-mentioned covariates. Among the 63 restorations that completed the study, 11 of 47 SCs and one of 16 FDPs had to be replaced due to the severity of the observed chipping. This results in survival rates of 76.6% for the SCs and 93.8% for the FDPs. No framework fractures or decementations were observed in any group. CONCLUSION Hand-layering of zirconia-based SCs and FDPs with NobelRondo(™) Zirconia restoring one-piece zirconia implants did not show acceptable survival and success rates. Meanwhile, the material has been recalled from the market. It is advised that new materials should undergo adequate preclinical evaluation before coming to the market.

Alumina reinforced zirconia implants: Effects of cyclic loading and abutment modification on fracture resistance

OBJECTIVE The aim of the study was to evaluate the thermomechanical behavior of alumina-toughened zirconia (ATZ) oral implants in the artificial mouth and the fracture resistance (fracture load and bending moment) in a subsequent static fracture load test. The effects of abutment modification and different cyclic loadings were evaluated. METHODS A total of 48 implants were used. 24 implants were left as machined (Group A), and 24 implants were shape modified at the abutment (Group B). Groups were divided into three subgroups composed of 8 samples each (A1/B1: no cyclic loading; A2/B2: 1.2 million cycles; A3/B3: 5 million cycles). Subsequently, all implants were statically loaded to the point of fracture. RESULTS The implants showed the following survival rates after the artificial mouth: A2 and B2 100%; A3 and B3 87.5%. The following average fracture resistance values were found (fracture load [N]/bending moment [Nmm]): A1 (583/2907), B1 (516/2825), A2 (618/2737), B2 (550/3150), A3 (802/3784) and B3 (722/3809). After 5 million loading cycles a significant increase in fracture load and bending moment was found. Modification of the abutment significantly decreased the fracture load of implants without foregoing dynamic loading. However, the shape modification altered the lever arm. For that reason, a smaller load resulted in the same bending moment. Therefore, abutment modification had no significant influence on the fracture resistance of ATZ. SIGNIFICANCE Neither thermomechanical cycling in an aqueous environment nor modification of the abutment had a negative effect on the fracture resistance of ATZ.

Alumina reinforced zirconia implants: 1-year results from a prospective cohort investigation

OBJECTIVE The objective of this investigation was to determine the clinical and radiographic outcome of a one-piece alumina-toughened zirconia (ATZ) oral implant for single tooth replacement after 1 year. MATERIALS AND METHODS A total of 27 patients received one ATZ implant each in a one-stage implant surgery with immediate temporization. Standardized radiographs were taken at implant insertion and after 1 year to monitor peri-implant bone loss. Several soft tissue parameters were evaluated at prosthesis insertion and at the 1-year follow-up. RESULTS Three patients did not receive a prosthetic reconstruction due to implant loss during the healing period. As a result, 24 patients were seen at the 1-year follow-up, giving a cumulative survival rate of 88.9%. The average marginal bone loss after 1 year was 0.77 mm. Only two implants (8.3%) lost at least 2 mm bone, whereas none of the implants lost more than 3 mm. Probing depth and clinical attachment level increased over 1 year at the implant sites, whereas gingival recession remained stable. Mombellis bleeding and plaque indices showed no statistically significant change within the first year. CONCLUSION Owing to a total of 27 inserted implants, three failures within the first 4 months after implant placement carry weight. Therefore, the cumulative survival rate of the presented ceramic implant was slightly below reported survival rates of titanium implants when immediately restored. The recorded radiographic bone loss and peri-implant soft tissue parameters showed promising short-term results. The presented ATZ implant seems to be a candidate for clinical usage.

Clinical and Patient-reported Outcomes of a Zirconia Oral Implant: Three-year Results of a Prospective Cohort Investigation

The objective of this study was to determine the clinical, radiographic, and patient-reported outcomes of a 1-piece alumina-toughened zirconia implant restored with single crowns (SCs) or 3-unit fixed dental prostheses (FDPs) after 3 y of observation. Forty patients received 53 implants, placed in a 1-stage operation with immediate temporization. Finally, 50 implants were restored with 24 SCs and 13 FDPs. To evaluate peri-implant bone loss, standardized radiographs were taken at implant insertion, at final restoration delivery, and after 1 and 3 y. Additionally, several soft tissue parameters and patient-reported outcome measures were evaluated. Linear mixed models with random intercept for each patient and patients as clusters were used to compare subgroups. Three patients did not receive a SC due to early implant loss, and 1 patient died. As a result, 36 patients with 49 implants were followed-up for 3 y, giving a cumulative survival rate of 94.2%. The average marginal bone loss amounted to 0.79 mm (SCs, 0.47 mm; FDPs, 1.07 mm; P < 0.001). After the delivery of the final prosthetic restoration, further bone loss was not statistically significant (0.09 mm; P = 0.700). Probing depth, clinical attachment level, and modified bleeding index increased significantly at the implant sites, whereas gingival recession decreased significantly. Compared with the pretreatment questionnaires, the patient-reported outcome measures showed a permanently improved perception of function, aesthetics, sense, speech and self-esteem. The survival rate of the investigated ceramic implant system seems to be comparable to reported survival rates of titanium implants when immediately restored. The recorded parameters suggest its potential for clinical utilization.