SYSTEMATIC REVIEW

Crestal bone loss and periimplant inflammatory parameters

around zirconia implants: A systematic review
Fahim Vohra, MRD RCS, MClinDent, MFDS, BDS,a Abdul Aziz Al-Kheraif, PhD,b
Siti Mariam Ab Ghani, MClinDent,c Mohamed Ibrahim Abu Hassan, PhD,d Talal Alnassar, MDS,e and
Fawad Javed, PhDf

With recent advances in ABSTRACT

implant dentistry, yttrium- Statement of problem. Zirconia implants have been used for oral rehabilitation; however, evi-
stabilized zirconia, a chemically dence of their ability to maintain crestal bone and periimplant soft tissue health is not clear.
inert and biocompatible mate-
Purpose. The purpose of this systematic review was to evaluate crestal bone loss (CBL) around
rial, implants have been used
zirconia dental implants and clinical periimplant inflammatory parameters.
to rehabilitate partially and
completely edentulous in- Material and methods. The focus question addressed was, “Do zirconia implants maintain crestal
dividuals.1,2
In a recent pro- bone levels and periimplant soft tissue health?” Databases were searched for articles from 1977
through September 2014 with different combinations of the following MeSH terms: “dental im-
spective clinical trial, Borgonovo
plants,” “zirconium,” “alveolar bone loss,” “periodontal attachment loss,” “periodontal pocket,”
et al3 reported comparable “periodontal index.” Letters to the editor, case reports, commentaries, review articles, and articles
crestal bone loss (CBL) around published in languages other than English were excluded.
zirconia (ZrO2) implants from
Results. Thirteen clinical studies were included. In 8 of the studies, the CBL around zirconia implants
baseline up to 4 years of follow- was comparable between baseline and follow-up. In the other 5 studies, the CBL around zirconia
up, with implant survival rates implants was significantly higher at follow-up. Among the studies that used titanium implants as
of up to 100%. Similarly, Brull controls, 2 studies showed significantly higher CBL around zirconia implants, and in 1 study, the
et al4 showed a mean CBL of CBL around zirconia and titanium implants was comparable. The reported implant survival rates
0.1 mm around ZrO2 implants for zirconia implants ranged between 67.6% and 100%. Eleven studies selectively reported the
at 3 years of follow-up with a periimplant inflammatory parameters.
mean implant survival rate Conclusions. Because of the variations in study design and methodology, it was difficult to reach a
(ISR) of 96.5%. consensus regarding the efficacy of zirconia implants in maintaining crestal bone levels and peri-
Although titanium (Ti) im- implant soft tissue health. (J Prosthet Dent 2015;-:---)
plants are commonly used to
replace missing teeth and have shown promising out- shown low bacterial adherence and low potential for
comes (implant survival rates up to 99.7%),5-7 the periimplant infection.10 Studies have also suggested that
occurrence of complications (infection) such as periim- immune reactions as a result of sensitivities and allergies
plant mucositis and periimplantitis around Ti implants to Ti implants could lead to biologic complications.11-13
8,9
cannot be ignored. In comparison, ZrO2 implants have Moreover, the bluish-gray appearance of Ti implant

Supported, partially, by the Research Centre, College of Applied Medical Sciences and the Deanship of Scientific Research at King Saud University,
Riyadh, Saudi Arabia.
a
Assistant Professor, Department of Prosthetic Dental Sciences, College of Dentistry, King Saud University, Riyadh, Saudi Arabia.
b
Associate Professor and Chair, Dental Materials Research, College of Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia.
c
Senior Lecturer and Head, Centre for Restorative Dentistry Studies, Faculty of Dentistry, University of Technology (MARA), Shah Alam, Malaysia.
d
Dean, Faculty of Dentistry, Department of Restorative Dentistry, University of Technology (MARA), Shah Alam, Malaysia.
e
Assistant Professor, Department of Prosthetic Dental Sciences, College of Dentistry, King Saud University, Riyadh, Saudi Arabia.
f
Research Associate, Eastman Institute for Oral Health, Division of General Dentistry, University of Rochester, Rochester, NY.

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Records identified Additional records

Clinical Implications through database
searching
identified through
other sources

Identification
Although zirconia dental implants can osseointe- (n = 50) (n = 5)
grate and remain functionally stable, they cannot be
considered as an alternate to traditional Ti implants Records after duplicates
because well-designed randomized controlled trials removed
(n = 55)
are unavailable.

Screening
Records screened Records excluded
(n = 55) (n = 38)
collars in areas of thin mucosa or mucosal recession
compromises the esthetics of the definitive implant. Full-text articles Full-text articles
These biologic and esthetic complications have led to the assessed for eligibility excluded, with reasons

Eligibility
(n = 17) (n = 4)
search for an alternative implant material to Ti.
In a recent systematic review, Depprich et al14 showed
that the implant survival rates of ZrO2 implants ranged Studies included in
qualitative and
between 74% and 98% for up to 56 months of follow-up. quantitative synthesis
However, a possible risk of bias in the studies assessed by (n = 13)

Depprich et al14 cannot be disregarded. It is well known
that the maintenance of crestal bone levels plays an
important role in the long-term survival and success of
dental implants,15-17 as does an inflammation-free peri-
implant soft tissue environment.18,19 However, certain
parameters such as plaque index (PLI), bleeding index
(BI) bleeding on probing (BOP), periimplant pocket
depth (PPD), and clinical attachment loss (CAL) were not
addressed in the study.14
With this background, the purpose of the present
study was to systematically review the crestal bone levels
and clinical periimplant inflammatory parameters around
ZrO2 dental implants.
MATERIAL AND METHODS
The focused question addressed was, “Do zirconia dental
implants maintain crestal bone levels and periimplant
soft tissue health?”
The following inclusion criteria were imposed: original
studies, clinical studies with 12 months of follow-up,
intervention recording crestal bone loss and periimplant
inflammatory parameters around ZrO2 dental implants,
and articles published only in English. Letters to the
editor, historic reviews, commentaries, experimental
(animal) studies, case-reports, and unpublished articles
were excluded.
In order to identify studies relevant to the focused
question, the MEDLINE database, the EMBASE data-
base, the Cochrane Central Register of Controlled Trials
(CENTRAL), Scopus, and the Web of Knowledge and
Google-Scholar databases were electronically searched.
Databases were searched for articles from 1977 through
September 2014 with the following Medical Subject
Headings (MeSH) terms: (1) dental implantation, (2)
dental implants, (3) zirconium, (4) alveolar bone loss, (5)
periodontal attachment loss, (6) periodontal pocket, (7)
periodontal index, (8) dental plaque index, and the
Included
Studies included in
quantitative synthesis
(n = 13)
Figure 1. Literature search strategy using PRISMA flow diagram.
combinations 1 or 2 and 3; 1 or 2 and 3 and 4; 1 or 2
and 3 and 5; 1 or 2 and 3 and 5 or 6 or 7 or 8 ; and 1 or 2
and 3 and 4 and 5 or 6 or 7 or 8. Other relevant non-
MeSH keywords were used in the search process to
identify articles discussing periodontal inflammatory pa-
rameters around ZrO2 implants. These included “yttria-
stabilized zirconia implants,” “zirconia,” “inflammation,”
“bleeding index” and “bleeding on probing,” and “peri-
implant pocket” and “clinical attachment loss.” The titles
and abstracts of studies identified with the described
protocol were screened by 3 authors (F.V., A.A.K., F.J.)
and checked for agreement. The full texts of those studies
judged by title and abstract to be relevant were read by
authors (F.V., M.I.A., T.S.) and independently evaluated
in accordance with the eligibility criteria. An additional
hand search was performed in the reference lists of all full
texts of all studies identified during the initial search. The
tables of contents of Journal of Prosthetic Dentistry, Implant
Dentistry, Clinical Oral Implant Research, Clinical Implant
Dentistry and Related Research, Journal of Clinical Peri-
odontology, and the European Journal of Oral Implantology
were independently hand searched by 2 authors (F.V.,
T.S.) for relevant studies published up to September
2014. This was done to identify any studies missed in the
previous step. The identified studies were then checked
for disagreement after discussion among the authors.
Kappa scores (Cohen kappa coefficient) were used to
determine the level of agreement between the 2 re-
viewers.20,21 Articles available online in electronic form
ahead of print were considered eligible for inclusion.
Figure 1 summarizes the literature search strategy

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Table 1. Characteristics of studies that fulfilled eligibility criteria

No. of Mean Age Female, Follow-up
Author Study Design Patients (y), range % (n) Study Groups (mo) Outcome
Brull et al4 Retrospective 74 51 (18-72) NA Group 1: 55 1-piece Up to 36 CBL around ZrO2 implants at baseline
ZrO2 implantsb and follow-up was comparable
Group 2: 66 2-piece (0.1 ±0.6 mm)
ZrO2 implants
Cionca et al27 Prospective 32 51.9 (24-75) 56.2 (18) 49 ZrO2 implants Up to 24 CBL around implants at baseline
and follow-up was comparable
Payer et al32 Prospective 22 46 (24-77) 40.9 (9) Group 1: 16 ZrO2 implants Up to 24 Both ZrO2 and Ti implant showed
Group 2: 15 Ti implants significant CBL at follow-up, Ti:
1.43 ±0.67 vs. ZrO2 1.48 ±1.05
ZrO2 implant showed significantly
higher CBL than Ti implants in
mandible
Osman et al30,a Prospective 19 62 (46-80) 21.0 (4) Group 1: 73 ZrO2 implantsb Up to 12 CBL around ZrO2 implants at baseline
Group 2: 56 Ti implantsb and follow-up was comparable
(0.42 mm ±0.40)
Siddiqi et al1,a Prospective 22 62 (50-79) 18.1 (4) Group 1: 68 Alveolar Up to 12 CBL around ZrO2 and Ti implants at
ZrO2 implantsb baseline and follow-up was comparable
Group 3: 60 alveolar
Ti implantsb
Borgonovo et al3 Prospective 13 60 (38-75) 7.6 (1) 35 ZrO2implantsb Up to 48 CBL was comparable between baseline
and follow-up
Kohal et al29 Prospective 28 55.7 (39-75) 39.2 (11) 56 ZrO2 implantsb Up to 12 CBL was significantly higher than baseline.
In 40% of subjects CBL was greater
than 2 mm
Payer et al31 Prospective 20 44.4 (27-71) 45.0 (9) 20 ZrO2 implantsb Up to 24 CBL was significantly higher at follow-up
compared with baseline
Borgonova et al25 Prospective 6 NA NA 14 ZrO2 implantsb Up to 48 CBL was comparable between loading
and follow-up
Borgonova et al24 Prospective 5 56.2 (50-65) NA 29 ZrO2 implantsb Up to 48 CBL (<1.6 mm) was comparable between
loading and follow-up
Kohal et al28 Prospective 65 NA 38.4 (25) 66 ZrO2 implantsb Up to 12 In 34% of subjects CBL was  2 mm
23
Borgonova et al Prospective 16 54 (36-72) 6.2 (1) 42 ZrO2 implantsb Up to 24 CBL was comparable between baseline
and follow-up. CBL was >1.5 mm around
one implant
Cannizzaro et al26 Prospective 40 38.5 (18-55) 57.5 (23) Group 1: 20 non- occlusal Up to 12 CBL was significantly higher at follow-up
ZrO2 implantsb as compared to baseline in both
Group 2: 20 occlusal ZrO2 test groups
implantsb

CBL, crest bone loss; NA, not available; ZrO2, zirconia; Ti, titanium.
a
Implants supporting complete overdentures.
b
1-piece implants.

according to the PRISMA guidelines. The research
methodology of the present systematic review was
adopted from previous published work, and the review
pattern focused on summarizing the relevant data.22
The search yielded 55 studies. Overall, 42 studies were
excluded (Appendix A, available online). In total, 13 studies
were included and data analysis was performed (Fig. 1).
RESULTS
All the studies1,3,4,23-32 were performed either at uni-
versities or health care centers. The number of partici-
pants in the studies ranged between 5 and 74. Eleven
studies1,3,4,23,24,26,27,29-32 reported the mean age of par-
ticipants, which was between 38.5 years and 62 years
(age range 18 to 80). Ten studies1,3,23,26-32 reported the
percentage of female participants, which ranged between
6% and 57.5% (Table 1). In 3 studies,1,30,32 Ti implants
were compared with ZrO2 implants. In 2 studies,4,26
smokers were included. In 5 studies,3,23,24,27,30
individuals smoking more than 10 cigarettes daily were
excluded. In all studies,1,3,4,22-31 CBL was measured using
conventional 2- dimensional radiographs. The follow-up
period ranged from 12 months to 48 months.
The number of implants placed ranged between 14
and 150, with diameters between 3.5 mm and 6 mm and
lengths between 6 mm and 16 mm. All implants had
rough surfaces. In 11 studies,1,3,4,23-26,28-31 1-piece im-
plants were used. In 3 studies,1,30,32 CBL and implant
survival rates around ZrO2 implants were compared with
Ti implants. In 3 studies,26,28,29 implants were placed
using flapped and flapless surgical procedures. In 4
studies,4,26,28,29 implants were placed in fresh extraction
sockets as well as in healed sites. In 6 studies,3,23-25,28,29
adjunct guided bone regeneration procedures were per-
formed at the time of implant placement. In 2
studies,26,31 implants were loaded immediately after
placement (Table 2).
In summary, there was a lack of homogeneity in the
assessment of periimplant inflammatory parameters

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Table 2. Implant-related characteristics of included studies

Implant
No. of Dimensions Loading Follow-up
Author Implants (mm), W/L Implant Placed Protocol (mo) Mean CBL (mm), SD Implant Survival (%)
Brull et al4 121 3.5->5/8-15 Healed sites and Conventional Up to 36 ZrO2 implants: 0.1 (0.6) ZrO2: 96.5
extraction sockets
Cionca et al27 49 3.5-5.5/8-12 Healed sites Conventional Up to 24 ZrO2 implants: <2 ZrO2: 87.3
Payer et al32 31 4/10-13 Healed sites Conventional Up to 24 ZrO2 implants ZrO2: 93.3
At placement: 0.1 (0.19) Ti: 100
At follow-up: 1.48 (1.05)
Ti implants
At placement: 0.16 (0.24)
At follow-up: 1.43 (0.67)
Osman et al30,a 129 3.8-5/6-11.5 Healed sites Conventional Up to 12 ZrO2 implants: 0.42 (0.40) ZrO2: 71.2
Ti Implants: 0.18 (0.47) Ti: 82.1
Siddiqi et al1,a 150 3.8-5/6-11.5 Healed sites Conventional Up to 12 ZrO2 implantsb ZrO2 alveolar: 67.6
At loading: 7.52 (1.34) Ti alveolar: 66.7
At follow-up: 7.82 (1.54)
Ti Implantsb
At loading: 7.36 (0.61)
At follow-up: 7.45 (0.62)
Borgonova et al3 28 4/10-14 Healed sites Delayed Up to 48 ZrO2 Implants ZrO2: 100
At placement: 0.0
At loading: 1.38 (0.02)
At follow-up: 1.631
Kohal et al29 56 4.3-5/10-16 Healed sites and Early and Up to 12 ZrO2 implants: ZrO2: 98.2
extraction sockets conventional At placement: 0.1
At loading: 1.65 (1.27)
At follow-up: 1.95 (1.71)
Payer et al31 20 3.5-4.5/11-14 Healed sites Immediate Up to 24 ZrO2 implants: ZrO2: 95
At loading: 1.46 (0.4)
At follow-up: 2.75 (0.14)
Borgonova et al25 14 3.5-4.5/10-14 Healed sites Delayed Up to 48 ZrO2 implants: ZrO2: 100
At follow-up: 0.665
Borgonova et al24 20 3.5-4.5/10-14 Healed sites Delayed Up to 48 ZrO2 implants: ZrO2: 100
At 6 months: 1.37 (0.38)
At follow-up: 1.208 (0.41)
Kohal et al28 66 4.3-5/10-16 Healed sites and Early and Up to 12 ZrO2 implants: ZrO2: 95.4
extraction sockets conventional At loading: 1.13 (1.47)
At follow-up: 1.31 (1.49)
Borgonova et al23 42 3.5-4.5/10-14 Healed sites Delayed Up to 24 ZrO2 implants: ZrO2: 92.3
At follow-up: only one site
(2.3%) showed CBL (>1.5 mm)
Cannizzaro et al26 40 3.5-6/10-15.5 Healed sites and Immediate Up to 12 Non occlusal ZrO2 implants Survival rates were
extraction sockets and delayed At placement 0.08 (0.18) comparable among
At follow-up: 0.97 (0.47) the groups
Occlusal ZrO2 implants
At placement 0.11 (0.28)
At follow-up: 0.83 (0.52)

Conventional, loading at 3 months; immediate, loading same day as implant placement; early, loading within 6 weeks; delayed, loading at 6 months or later; NA, not available; mm, millimeters;
ZrO2, zirconia; Ti: titanium; CBL, crestal bone loss; SD, standard deviation.
a
Implants were placed in edentulous maxilla and mandible.
b
CBL was distance from top of implant (head of ball) to first crestal bone contact at mesial and distal aspect of implant was measured.

(plaque index [PLI], bleeding index [BI], bleeding
on probing [BOP], periimplant pocket depth [PPD],
and clinical attachment loss [CAL]) among the studies
that fulfilled our eligibility criteria.1,3,4,23-32 In 5
studies,23,24,27,31,32 plaque scores in participants with
ZrO2 implants were expressed as a percentage of full-
mouth sites, which ranged from 19% to 92%. However,
in another 5 studies,1,3,25,28,29 PLI ranged between 0 and
0.29 (Loe and Silness plaque index score) around ZrO2
implants at follow-up. In 4 studies,1,25,28,29 BI was re-
ported, which was 0.15 to 0.57 at follow-up. Five
studies4,23,24,31,32 reported BOP, which ranged from
0.15% to 92%. The PPD around ZrO2 implants was re-
ported in 9 studies1,3,4,23-25,27-29 and ranged from 1.8 to
3.2 mm. CAL was reported in 2 studies28,29 and ranged
from 2.84 mm to 3.24 mm at follow-up (12 months).
Only 1 study1 reported the amount of keratinized mu-
cosa around implants at baseline and follow-up, which
was comparable. In 2 studies,26,30 not all periimplant
inflammatory parameters were reported. These results
are summarized in Table 3.
In 8 studies,1,3,4,23-25,27,30 the CBL around ZrO2 im-
plants was comparable between baseline (0.0 mm) and
follow-up (0.66 to 7.82 mm) (up to 48 months). In 4
studies,26,28,29,31,32 the CBL around ZrO2 implants was
significantly higher at follow-up (0.83 to 2.75mm) (up to
24 months) compared with baseline (0.08 to 0.16 mm).
Among the studies1,30,32 that used Ti implants as controls,

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Table 3. Clinical periimplant parameters in included studies

Author PLI BI BOP (%) PPD (mm) CAL (mm)
Brull et al4 NA NA Implant: 4.1 Implant: 1.8 NA
Teeth: 7.2 Teeth: 2.1
Cionca et al27 At loading: 7% At loading: 6% NA At loading: 3.1 ±0.6 NA
At 12 mo: 21% At 12 mo: 27% At 12 mo: 3.2 +-0.7
Payer et al32 ZrO2 implants NA ZrO2 implants NA NA
At placement: 15.75% (2.72) At placement: 10.9 (5.63)
24 months: 19.38% (0.88) 24 months: 9.1(4.34)
Ti implants Ti implants
At placement: 11.25% (3.67) At placement: 9.0 (6.32)
24 mo: 16.05% (8.29) 24 mo: 7.4 (3.39)
Osman et al30 NA NA NA NA NA
Siddiqi et al1 ZrO2 implants At loading: 0.35 (0.44) NA At loading: 1.59 (0.61) NA
At loading: 0.37 (0.45) 12 mo: 0.22 (0.32) 12 mo: 2.23 (0.69)
12 mo: 0.25 (0.33)
Ti implants
At loading: 0.58 (0.50)
1 mo: 0.71 (0.58)
Borgonova et al3 At loading: 1 NA At loading: 1 At loading: 3.0 NA
At 48 mo: 0 At 48 mo: 0.15 At 48 mo: 3.19
Kohal et al29 At loading: 0.51 (0.49) At loading: 0.46 (0.55) NA At loading: 2.85 (0.73) At loading: 3.14
At 12 mo: 0.09 (0.16) At 12 mo: 0.15 (0.18) At 12 mo: 2.65 (0.62) At 12 mo: 3.24
Payer et al31 At loading: 27% (5.3) NA At loading: 25 (5.6) NA NA
At 24 mo: 22% (6.4) At 24 mo: 15 (5.5)
Borgonova et al25 At 48 mo:0.29 (0.47) At 48 mo: 0.57 (0.51) NA At 48 mo: 3.13 (0.87) NA
Borgonova et al24 At 6 mo: 50% NA At 6 mo: 50 At 6 mo: 2.85 (1.85-2.1) NA
Kohal et al28 At loading: 0.26 (0.35) At loading 0.36 (0.50) NA At loading: 2.75 (0.75) At At loading: 2.84 (1.19)
At 12 mo: 0.11 (0.23) At 12 mo: 0.23 (0.32) 12 mo: 2.34 (0.66) 12 mo: 2.71 (0.75)
Borgonova et al23 At 12 mo: 92.3% NA At 12 mo: 92.3 At 12 mo: < 5mm NA
Cannizzaro et al26 NA NA NA NA NA

PLI, plaque index; BI, bleeding index; BOP, bleeding on probing; PPD, periimplant probing depth; CAL, clinical attachment loss; NA, not available; Gp, group; mm, millimeters; ZrO2, zirconia; Ti,
titanium.

2 studies1,30 showed significantly higher CBL around
ZrO2 implants, and in 1 study,32 the CBL around ZrO2
and Ti implants was comparable. In the study by Kohal
et al,28 the CBL was greater or equal to 2 mm in 34% of
study participants. In the study by Borgonovo et al,23
more than 1.5 mm of CBL was found around 1 implant.
In the study by Siddiqi et al,1 bone level was
measured from the top of the implant (head of ball) to
the first crestal bone contact at the mesial and distal
aspect of the implant. In the studies by Payer et al31 and
Borgonova et al,24 bone level was measured from the
implant shoulder to the crest. The use of these modified
bone level assessment techniques resulted in a baseline
bone level in excess of zero.
The survival rates for ZrO2 implants ranged between
67.6% and 100%. In 3 studies1,30,32 in which Ti implants
were compared with ZrO2 implants, the survival rates
were comparable. In the study by Siddiqi et al,1 the
survival rate of ZrO2 implants was 67.6% and that of Ti
implants was 66.7%. The follow-up period in the studies
included ranged from 12 to 48 months.1,3,4,23-32
DISCUSSION
One of the most frequently reported criteria for the
success of conventional osseointegrated Ti implants is
CBL of greater than 1.5 mm/year (with no radiographic
signs of pathology) during the first year of implant
loading.33 Among the studies included in the present
review,1,3,4,23-32 11 studies3,4,23-30,32 reported CBL of
greater than 1.5 mm up to 4 years of follow- up. It is
therefore speculated that crestal bone levels with ZrO2
and conventionally used Ti implants are comparable.
However, in 93,4,23-29 of the 11 studies3,4,23-30,32 that re-
ported CBL greater than 1.5 mm around ZrO2 implants,
ZrO2 implants were not compared with Ti implants. In an
attempt to clarify whether ZrO2 implants minimize CBL,
these implants must be compared with Ti implants. From
the studies included in the present systematic review, 3
studies1,30,32 compared CBL with ZrO2 and Ti implants.
The results of the studies by Osman et al30 and Siddiqi
et al1 reported increased CBL around ZrO2 implants
compared with Ti implants, whereas, in the study by
Payer et al,32 CBL was comparable around ZrO2 and Ti
implants. This may be explained by the markedly varied
methodologies of these studies. For example, in the
studies by Osman et al30 and Siddiqi et al,1 ZrO2 and Ti
implants were placed in edentulous jaws and were fol-
lowed up for 12 months, whereas, in the study by Payer
et al,32 implants were placed in partially dentate in-
dividuals and were followed up for 24 months. Moreover,
the implant locations also varied among the studies. For
instance, in the study by Payer et al,32 more than 75% of
implants were placed in the mandible compared with

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50% in the studies by both Osman et al30 and Siddiqi
et al.1 Furthermore, in 2 studies,1,30 1-piece implants
were used to support implant overdentures, but 2-piece
implants were used to retain crowns and partially fixed
dental prostheses in the study by Payer et al.32 One-piece
implants may minimize bone loss by avoiding the
implant abutment microgap and micromovements.
Therefore, implant design, implant location, and coronal
implant-supported restorations could have influenced
the crestal bone levels around the implants reported in
the studies comparing ZrO2 and Ti implants.1,30,32
Further long-term studies should focus on crestal bone
levels around ZrO2 and Ti implants using standardized
protocols.
In the present review, 38% of studies26,28,29,31,32
showed significant CBL around ZrO2 implants at
follow-up; however, in nearly 62% of the studies,1,3,4,23-
25,27,30
CBL around ZrO2 implants at baseline and
follow-up was comparable. Multiple factors can explain
the variability in these results. Alveolar bone remodeling
is known to vary in immediate and conventionally placed
implants.34-36 From the literature reviewed, in 326,28,30 of
the 5 studies that showed significant bone loss around
ZrO2 implants, the implants were placed in healed sites
as well as fresh extraction sockets, making it difficult to
estimate the precise amount of CBL that occurred around
ZrO2 implants. Further studies focusing on ZrO2 im-
plants placed in either healed sites or fresh extraction
sockets are warranted to determine the extent of CBL
around ZrO2 implants. Other factors that could have
biased the outcomes of the reported studies include
smoking and the use of guided bone regeneration. In the
studies in which smokers were included,3,4,23,24,26,27,30
the duration of the habit was not reported. Smoking
jeopardizes the outcome of the oral surgical procedure
and increases CBL.37 In more than 45% of studies,3,23-
25,28,30
bone augmentation procedures were performed
to enhance new bone formation around ZrO2 implants.
This is a potential source of bias, in that new bone for-
mation as a result of guided bone regenerative protocols
would most likely mask the contribution of dental im-
plants (regardless of their type, ZrO2 or Ti) in main-
taining crestal bone heights.38,39 Assessing whether ZrO2
implants are able to maintain crestal bone levels in a
manner similar to traditional Ti implants would have
been possible if ZrO2 and Ti implants had been assessed
exclusively in nonsmokers without the adjunct use of
guided bone regeneration.
The biologic response of periimplant soft tissue is
favorable for ZrO2 implants because of the low bacterial
adherence of ZrO2.10 With regard to clinical periimplant
inflammatory parameters, periimplant inflammatory
parameters remained uninvestigated in 2 studies.26,30
However, in the remaining studies,1,3,4,23-25,27-29,31,32 only
selective clinical periimplant inflammatory parameters were
THE JOURNAL OF PROSTHETIC DENTISTRY
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investigated. For example, in the study by Brull et al,4 BOP
and PPD were assessed around ZrO2 implants, whereas
PPD and BI remained uninvestigated in the study by Payer
et al.32 Likewise, CAL (a critical factor in the assessment of
periodontal/ periimplant disease) was assessed in only 2
studies.28,29,40 In order to assess the influence of ZrO2 on
periimplant inflammatory parameters, studies with stan-
dardized protocols are required.
CONCLUSIONS
The variations in study design and methodology make a
consensus difficult regarding the efficacy of ZrO2 implants
in maintaining crestal bone levels and periimplant soft
tissue health. Further long-term, randomized controlled
trials with a standard methodology are needed.
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Corresponding author:
Dr Fahim Vohra
King Saud University
PO Box 60169
Riyadh 11545
SAUDI ARABIA
Email: fahimvohra@yahoo.com
Copyright © 2015 by the Editorial Council for The Journal of Prosthetic Dentistry.
THE JOURNAL OF PROSTHETIC DENTISTRY