Zirconia Implants in the Esthetic Zone
Immediate placement and provisional restoration
Paul S. Petrungaro, DDS, MS
The use of dental implants for tooth replacement procedures has become commonplace in the treatment planning process for dentists and dental specialists.1,2 During the last 20 years, variations in the conventional, multistep process of implant reconstruction have begun to demonstrate the benefits of immediate restoration, especially in the esthetic zone.3-8 These benefits include minimally invasive protocols, shortened treatment times, preservation of soft-tissue contours and emergence profiles, and delivery of a stable, esthetic, provisional restoration (instead of a removable temporary) that can begin the process of tissue sculpting and forming the final emergence profile.9-11
Ensuring the appropriate volume and quality of the peri-implant soft tissues, especially in the esthetic zone, is paramount not only for the peri-implant environment and long-term maintenance of bone levels but also for the long-term esthetic results achieved.9-11
In areas where there is a deficiency in the quality and quantity of attached keratinized tissue around a final implant restoration, peri-implant mucositis and peri-implantitis have a higher incidence of occurrence, not to mention the compromised esthetics that can result when dark colors from a titanium implant or abutment complex become visible through the soft tissues.12,13 In these situations, premature tissue loss, bone loss, and eventual implant failure may ensue.14,15 Numerous factors have been identified that can lead to the development of the previously mentioned peri-implant diseases.
The peri-implantitis disease state is generally caused by plaque and biofilm, which can accumulate on an implant surface in the same manner as on teeth.16,17 Other factors that can contribute to peri-implant disease include a lack of oral hygiene that causes inflammation and bone loss around implants,18,19 a lack of attached keratinized tissues,20 and the effects of tobacco use21-all of which have been shown to negatively affect implant success rates. Genetic factors can also play a role in the development of peri-implantitis,22,23and corrosionof the base material of an implant can cause the destruction of osseous tissue, resulting in peri-implantitis.24-27
To address some of these issues associated with titanium dental implants, implants made from alternative materials have been introduced by the dental implant industry. In recent years, high strength zirconia has been shown to be a successful alternative to titanium for dental implant designs.28-32 The use of zirconia dental implants prevents the discoloration of the peri-implant soft tissues that is oftentimes associated with titanium dental implants.33-36 Zirconia also offers a high level of biocompatibility and fracture toughness.37-39 In addition, the dental literature has shown that, when compared with titanium, bone resorption and the inflammatory response are reduced around zirconia dental implants and the development of biofilm and associated plaque levels is reduced around zirconia implants as well.40-43 Blaschke and colleagues44 demonstrated that the soft-tissue response of zirconia implants is superior to that of titanium, and both Gahlert and colleagues45 and Hashim and colleagues46 reported that the potential for zirconia implants with diameters of less than 3.25 mm to fracture as a result of lateral forces was approximately 10%. With one-piece zirconia implant designs, care must be taken to thoroughly debride any excess cement from the provisional and final prosthesis to prevent the early stages of peri-implant inflammation. Just as with titanium, this is still a potential issue for zirconia implants.
This article presents two cases that demonstrate the use of a one-piece, all-zirconia dental implant design with an immediate restoration protocol to replace the natural tooth system in the esthetic zone.
Case Report 1
A 34-year-old, nonsmoking female patient presented for replacement of both maxillary central incisors (Figure 1). The patient had experienced a past traumatic incident to the central incisors, which required root canal therapy for teeth Nos. 8 and 9 as well as post and core buildups and two different sets of final restorations. Figure 2 and Figure 3 show the serial computed tomography (CT) scan views of teeth Nos. 8 and 9, respectively. A lack of buccal bone plate was evident on both CT scan serial views. Esthetically, the patient was unhappy with the dark color of the facial height of contour of the thin, biotype gingival tissues, which included the emergence profile areas of both maxillary central incisors (Figure 1).
Due to the patient's chief concern of discoloration of the gingival tissues and high level of esthetic expectations (she was also considering enhancement of the adjacent natural dentition), the decision was made to utilize a one-piece zirconia implant for her restorations. One day before the procedure, the patient was given a preoperative antibiotic (Augmentin® 875 mg).
On the day of the procedure, an appropriate local anesthetic (Septocaine® and epinephrine 1:200,000, Septodont) was administered and teeth Nos. 8 and 9 were removed atraumatically, taking care to protect the natural soft-tissue architecture and emergence profiles present (Figure 4). Following an aggressive debridement of the peri-root areas to ensure that all remnants of the periodontal ligament, periapical granulomatous tissue, or infected tissue were removed, site preparation began. Using a surgical guide system (TempStent™ II)47 allows for ideal placement of the zirconia implant fixtures and ease of conversion to an immediate, esthetic provisional restoration. Prior to implant insertion, an autologous blood draw was performed and the centrifugation process initiated for the fabrication of advanced platelet-rich fibrin (A-PRF). Once this process was complete, the A-PRF clot was mixed with a bioactive bone grafting material (Osseolive®DENTAL, Curasan Inc.) (Figure 5). This graft material has been shown to stimulate osteogenesis and facilitate total replacement with autogenous bone in the grafted area.
Two 4.0 x 12 mm zirconia one-piece tapered screw implants (Ceramic Implant System, Z-Systems) were placed with an initial stability of 45 Ncm (Figure 6 and Figure 7). Figure 7 demonstrates the depth of the margin and the implant platform placement, which was at the depth of the facial height of contour of the remaining/planned buccal plate of bone. Figure 7 also demonstrates the facial defect that was present after placement of the one-piece implants. The graft complex was inserted into this "pouch"46 area to assist in the regeneration of the facial plate of bone (ie, buccal to the zirconia implants placed) (Figure 8). Next, conversion of the TempStent II surgical guide system allowed for the fabrication and immediate placement of an esthetic, nonfunctional provisional restoration.
The patient was recalled for a follow-up evaluation 7 days postoperatively (Figure 9). At the 14-day postoperative follow-up appointment, the natural soft tissue emergence profiles obtained during this early time period after the surgical placement procedure can be seen (Figure 10). The patient was allowed to follow a healing and maturation period of 3 months, which was uneventful, and then abutment level impressions were initiated.
At the restoration seating visit, the final zirconia implant restorations were placed (Figure 11 and Figure 12). Three months after cementation, excellent tissue emergence profiles were achieved in the final all-zirconia implant complex (Figure 13). Postoperative CT scans of the implants at the sites of teeth Nos. 8 and 9, demonstrate the restoration of the facial-osseous structures buccal to the zirconia implant fixtures (Figure 14 and Figure 15).
Case Report 2
A 72-year-old, nonsmoking, female patient presented for treatment of a loose bridge complex that was occupying the right side of her maxillary anterior sextant (Figure 16 and Figure 17). Teeth Nos. 6, 8, and 9 had all been previously treated with root canal therapy, and several fixed bridges had been constructed throughout a period of more than 20 years. Recurrent decay on teeth Nos. 8 and 9 and compromised remaining bone support for teeth Nos. 5 and 6 necessitated their extraction. The patient stated that she did not want a removable prosthesis for the definitive restoration or at any stage of the treatment process. In addition, the patient was particularly susceptible to plaque and tartar accumulation-a concern that influenced implant design and material selection, considering the long-term potential for the development of peri-implantitis. The patient also had significant esthetic concerns and noted that she had been unhappy with the appearance of her smile for many years.
The decision was made to proceed with dental implant reconstruction at the sites of teeth Nos. 5, 6, 8, and 9. Impressions, a bite registration, and midline records were acquired, and a diagnostic wax-up was completed. After the TempStent II surgical guide system was fabricated, the patient was scheduled for the surgical procedure and administration of preoperative antibiotics (Augmentin 875 mg).
On the day of the procedure, an appropriate local anesthetic (Septocaine and epinephrine 1: 200,000, Septodont) was administered and the failing bridge was removed (Figure 18). It was evident that the remaining supragingival tooth structures were compromised. After atraumatic tooth removal and debridement of the extraction sockets, insertion of the TempStent II surgical guide was followed by initial and final site preparation. Four zirconia one-piece tapered screw implants (Ceramic Implant System, Z Systems) were placed, including one 4.0 x 10 mm implant at the site of tooth No. 5 and three 4.0 x 12 mm implants at the sites of teeth Nos. 6, 8, and 9. All four implants achieved an initial stability of 45 Ncm (Figure 19). The buccal plate deficiencies and facial defects (ie, buccal to the implants) were managed by minimally invasive techniques using the patient's platelets (ie, A-PRF) and bone grafting material (Osseolive DENTAL, Curasan Inc.).
Following grafting of the implant sites, the nonfunctional provisional restoration was immediately placed (Figure 20) and a postoperative CT scan serial view was obtained (Figure 21). After 10 days, the patient was recalled for a follow-up evaluation, at which time there was a noticeable level of soft-tissue maturity present (Figure 22).
Replacing the failing, natural tooth system with dental implants for sites involving single or multiple missing teeth has been well-documented in the dental literature. The provisionalization of titanium dental implants at the time of the fixture placement procedure is a predictable way to aid in the formation and maintenance of natural soft-tissue emergence profiles and has become the treatment protocol of choice for tooth replacement in the esthetic zone.11
As a result of complications observed in some clinical situations involving the use of titanium dental implants and the rising incidence of peri-implant mucositis and peri-implantitis affecting both the short- and long-term survival rates of titanium dental implants, the use of an alternative material, zirconia, has been shown to have similar integration success when compared with titanium,40-43 offer a soft-tissue response that is superior to that of titanium,44 and have less of an affinity to collect plaque or biofilm when compared with titanium surfaces.40-43 It is important to note that when using any one-piece implant system, cement removal at the gingival margins of both temporary and final restorations is of paramount importance to prevent the initial development of peri-implant inflammation, which if present, can lead to the development of peri-implant bone loss around both titanium and zirconia implants.
In the esthetic zone, where soft-tissue complications have a higher incidence of occurrence, one-piece zirconia implants may offer an additional level of security and flexibility for the dental implant surgeon and restorative/esthetic clinician. Additional studies are necessary to continue to evaluate the effectiveness and success rates of zirconia implants both short- and long-term.
About the Author
Paul S. Petrungaro, DDS, MS
1. Adell R, Lekholm U, Rockler B, et al. A 15-year study of osseointegrated implants in the treatment of the edentulous jaw. Int J Oral Surg. 1981;10(6):387-416.
2. Adell R, Eriksson B, Lekholm U, et al. Long-term follow up study of osseointegrated implants in the treatment of totally edentulous jaws. Int J Oral Maxillofac Implants. 1990;5(4):347-359.
3. Petrungaro PS. Implant placement and provisionalization in extraction, edentulous, and sinus grafted sites: a clinical report on 1,500 sites. Compend Contin Educ Dent. 2005;26(12):879-890.
4. Kan JY, Rungcharassaeng K, Lozada JL. Bilaminar subepithelial connective tissue grafts for immediate implant placement and provisionalization in the esthetic zone. J Calif Dent Assoc. 2005;33(11):865-871.
5. Kan JY, Rungcharassaeng K, Morimoto T, et al. Facial gingival tissue stability after connective tissue graft with single immediate tooth replacement in the esthetic zone: consecutive case report. J Oral Maxillofac Surg. 2009;67(11 Suppl):40-48.
6. Petrungaro PS. Immediate restoration of dental implants in the aesthetic zone. Dent Implantol Update. 2001;12(12):89-95.
7. Wöhrle PS. Single-tooth replacement in the aesthetic zone with immediate provisionalization: fourteen consecutive case reports. Pract Periodontics Aesthet Dent. 1998;10(9):1107-1114; quiz 1116.
8. Petrungaro PS. An update on implant placement and provisionalization in extraction, edentulous, and sinus-grafted sites: a clinical report on 3200 sites over 8 years. Compend Contin Educ Dent. 2008;29(5):288-294,296, 298-300.
9. Kan JY, Rungcharassaeng K, Lozada J. Immediate placement and provisionalization of maxillary anterior single implants: 1-year prospective study. Int J Oral Maxillofac Implants. 2003;18(1):31-39.
10. Kan JY, Morimoto T, Rungcharassaeng K, et al. Gingival biotype assessment in the esthetic zone: visual versus direct measurement. Int J Periodontics Resotrative Dent. 2010;30(3):237-243.
11. Petrungaro PS. Options for the esthetic zone using the immediate restoration procedure: observational data of 15 Years and 5000 Implants. Compend Contin Educ Dent. 2017;38(5):318-325.
12. Chen S, Darby I. Dental implants: maintenance, care and treatment of peri-implant infection. Aust Dent J. 2003;48(4)212-220; quiz 263.
13. Wilson TG Jr. The positive relationship between excess cement and peri-implant disease: a prospective clinical endoscopic study. J Periodontol. 2009;80(9):1388-1392.
14. Froum SJ, Froum SH, Rosen PS. Successful management of peri-implantitis with a regenerative approach: a consecutive series of 51 treated implants with 3- to 7.5-year follow-up. Int J Periodontics Restorative Dent. 2012;32(1):11-20.
15. Klinge B, Gustafsson A, Berglundh T. A systematic review of the effect of anti-infective therapy in the treatment of peri-implantitis. J Clinical Periodontol. 2002;29 Suppl 3:213-25; discussion 232-3.
16. Cortes AR, Ferraz P, Tosta M. Influence of etiologic factors in peri-implantitis: literature review and case report. J Oral Implantol. 2012;38(5):633-637.
17. Heuer W, Elter C, Demling A, et al. Analysis of early biofilm formation on oral implants in man. J Oral Rehabil. 2007;34(5):377-382.
18. George K, Zafiropoulos GG, Murat Y, et al. Clinical and microbiological status of osseointegrated implants. J Periodontol. 1994;65(8):766-770.
19. Montes CC, Pereira FA, Thomé G, et al. Failing factors associated with osseointegrated dental implant loss. Implant Dent. 2007;16(4):404-412.
20. Apse P, Ellen RP, Overall CM, et al. Microbiota and crevicular fluid collagenase activity in the osseointegrated dental implant sulcus: a comparison of sites in edentulous and partially edentulous patients. J Periodontal Res. 1989;24(2):96-105.
21. Baig MR, Rajan M. Effects of smoking on the outcome of implant treatment: a literature review. Indian J Dent Res. 2007;18(4):190-195.
22. Bormann KH, Stühmer C, Z'Graggen M, et al. IL-1 polymorphism and periimplantitis. A literature review. Schweiz Monatsschr Zahnmed. 2010;120(6):510-520.
23. Plagnat D, Giannopoulou C, Carrel A, et al. Elastase, alpha2-macroglobulin and alkaline phosphatase in crevicular fluid from implants with or without periimplantitis. Clin Oral Implants Res. 2002;13(3):227-233.
24. Tengvall P, Elwing H, Sjöqvist L, et al. Interaction between hydrogen peroxide and titanium: a possible role in biocompatibility of titanium. Biomaterials. 1989;10(2):118-120.
25. Depprich R, Zipprich H, Ommerborn M, et al. Osseointegration of zirconia implants compared with titanium: an in vivo study. Head Face Med. 2008;4:30.
26. Stejskal J, Stejskal VD. The role of metals in autoimmunity and the link to neuroendocrinology. Neuro Endocrinol Lett. 1999;20(6):351-364.
27. Yamauchi R, Morita A, Tsuji T. Pacemaker dermatitis from titanium. Contact Dermatitis. 2000;42(1):52-53.
28. Andreiotelli M, Kohal RJ. Fracture strength of zirconia implants after artificial aging. Clin Implant Dent Relat Res. 2009;11(2):158-166.
29. Sennerby L, Dasmah A, Larsson B, et al. 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):S13-20.
30. Piconi C, Maccauro G. Zirconia as a ceramic biomaterial. Biomaterials. 1999;20(1):1-25.
31. Warashina H, Sakano S, Kitamura S, et al. Biological reaction to alumina, zirconia, titanium and polyethylene particles implanted onto murine calvaria. Biomaterials. 2003;24(21):3655-3661.
32. Bacchelli B, Giavaresi G, Franchi M, et al. Influence of a zirconia sandblasting treated surface on peri-implant bone healing: an experimental study in sheep. Acta Biomater. 2009;5(6):2246-2257.
33. Wenz HJ, Bartsch J, Wolfart S, et al. Osseointegration and clinical success of zirconia dental implants: a systematic review. Int J Prosthodont. 2008;21(1):27-36.
34. Lacefield WR. Materials characteristics of uncoated/ceramic-coated implant materials. Adv Dent Rec. 1999;13:21-26.
35. Kohal RJ, Klaus G. A zirconia implant-crown system: a case report. Int J Periodontics Restorative Dent. 2004;24(2):147-153.
36. Pirker W, Kocher A. Immediate, non-submerged, root-analogue zirconia implant in single tooth replacement. Int J Oral Maxillofac Surg. 2008;37(3):293-295.
37. Silva NR, Coelho PG, Fernandes CA, et al. Reliability of one-piece ceramic implant. J Biomed Mater Res B Appl Biomater. 2009;88(2):419-426.
38. Sennerby L, Dashmah A, Larsson B, et al. 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):S13-20.
39. Sykaras N, Iacopino AM, Marker VA, et al. Implant materials, designs, and surface topographies: their effect on osseointegration. A literature review. Int J Oral Maxillofac Implants. 2000;15(5):675-690.
40. Scarano A, Piatelli M, Caputi S, et al. Bacterial adhesion on commercially pure titanium and zirconium oxide disks: an in vivo human study. J Periodontol. 2004;75(2):292-296.
41. Hall-Stoodley L, Costerton JW, Stoodley P. Bacterial biofilms: from the natural environment to infectious diseases. Nat Rev Microbiol. 2004;2(2);95-108.
42. Nascimento CD, Pita MS, Fernandes FHNC, et al. Bacterial adhesion on the titanium and zirconia abutment surfaces. Clin Oral Implant Res. 2014;25(3):337-343.
43. Han Y, Chen D, Sun J, et al. UV-enhanced bioactivity and cell response of micro-arc oxidized titania coatings. Acta Biomater. 2008;4(5):1518-1529.
44. Blaschke C, Volz U. Soft and hard tissue response to zirconium dioxide dental implants--a clinical study in man. Neuro Endocrinol Lett. 2006;27(Suppl 1):69-72.
45. Gahlert M, Burtscher D, Grunert I, et al. Failure analysis of fractured dental zirconia implants. Clin Oral Impl Res. 2012;23(3):287-293.
46. Hashim D, Cionca N, Courvoisier DS, et al. A systematic review of the clinical survival of zirconia implants. Clin Oral Investig. 2016;20(7):1403-1417.
47. Petrungaro PS. The Tempstent™ surgical guide provisionalization method for immediate restoration for dental implants. Contemp Esthet Rest Pract. 2002;6(5):84-90.