Q U I N T E S S E N C E I N T E R N AT I O N A L
RESTORATIVE DENTISTRY
Practice-based clinical evaluation of zirconia
abutments for anterior single-tooth restorations
Sven Rinke, Priv Doz Dr med dent, MSc, MSc1/Anja Lattke, Dr med dent1/Peter Eickholz, Prof Dr med
dent2/Katharina Kramer, Dr rer nat3/Dirk Ziebolz, Priv Doz Dr med dent, MSc 4
Objective: This study aimed to determine the survival rate
and prevalence of biologic and technical complications associ-
ated with single-tooth implants with all-ceramic abutments in
the anterior region. Method and Materials: A total of 33
patients were restored with 50 anterior implants and tempo-
rarily luted all-ceramic crowns on prefabricated zirconia abut-
ments. All of the patients subsequently received annual
supportive maintenance; 27 patients (18 women, 22–74 years)
with 42 implants participated in the final maintenance visit
and were included in the study (follow-up 78.1 ± 27.0 months).
The time-dependent survival rate (Kaplan-Meier) and the fre-
quency of prosthetic complications (abutment fracture [AF],
screw loosening [SL], fracture of veneering ceramics [VF],
retention loss [RL]) and biologic complications (peri-implanti-
tis) were calculated to determine the success rates. Results:
No implant loss (implant-related survival rate 100%) but one
Key words: cement, ceramics, clinical studies, peri-implant infection, success, survival
Implant-supported single crowns (ISCs) are considered
a reliable and safe treatment modality with high sur-
vival rates in long-term clinical studies.1-3 A recently
published systematic review reported a 10-year survival
1 Dentist, Private Practice, Hanau, Germany.
2 Professor and Head, Department of Periodontology, Center for Dental, Oral, and
Maxillofacial Medicine, Johann Wolfgang Goethe-University, Frankfurt/Main,
Germany.
3 Senior Researcher, Department of Medical Statistics, Georg-August-University,
Goettingen, Germany.
4 Associate Professor, Department of Operative Dentistry, Preventive Dentistry
and Periodontology, Georg-August-University, Göttingen, Germany.
Correspondence: Priv Doz Dr Sven Rinke, Geleitstr. 68, 63456 Hanau,
Germany. Email: rinke@ihr-laecheln.com
VOLUME 46 • NUMBER 1 • JANUARY 2015
Sven Rinke
abutment fracture occurred throughout the entire observation
period; therefore, the survival rate of the superstructures (in
situ criterion) was 97.6% (95% confidence interval [CI] 0.930–
1.000) after 7 years. Eleven restorations were affected by pros-
thetic complications: RL (n = 4), VF (n = 5), and SL (n = 2).
Peri-implantitis was diagnosed for two implants (probing
depth > 5 mm, bleeding on probing [BOP]/suppuration, and
bone loss > 3 mm) (implant-related peri-implantitis rate 4.8%).
No restoration required replacement due to complications. The
success rate (event-free restoration) was 75.9% (95% CI 0.636–
0.882) after 7 years. Conclusions: Considering the calculated
survival rate, the application of all-ceramic zirconia implant
abutments in the anterior region can be recommended as a
reliable therapy in private practice. Fractures of veneering
ceramics were the most common prosthetic complication.
(Quintessence Int 2015;46:19–29; doi: 10.3290/j.qi.a32818)
rate of single-tooth implants of 96.3%, whereas the
reported survival rate of prosthetic restorations was
89.8%.1 Despite the high survival rates of implants and
crowns, clinicians must be aware that technical, bio-
logic, and esthetic complications are likely to occur.
Technical complications (mainly screw loosening) have
been documented to have an incidence of 8.8% within
the first 5 years of clinical service, and esthetic compli-
cations reached a cumulative incidence of 7.1% for the
same period.2,4-6 Published data on the prevalence of
biologic complications (peri-implantitis) still show great
variations in incidence and prevalence rates; therefore,
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more detailed information, especially derived from
prolonged observation, is required. Because implant-
supported single-tooth restorations have primarily
been examined with regard to their use in the anterior
region, the prevention of esthetic complications is
critical.2 In addition to the correct implant positioning
and proper soft tissue management, the selection of
adequate materials and designs for prosthetic restor-
ations influences the esthetic outcome significantly.6,7
For the last several decades, titanium abutments
have been the standard of care for implant-supported
restorations. Unfortunately, the blue-grayish shimmer
exhibited by these abutments, in combination with
thin overlying mucosal tissue, can negatively affect the
esthetic outcome.8,9 For this reason, yttria partially-sta-
bilized zirconia (Y-TZP) is a promising alternative ma-
terial for the fabrication of abutments and ISCs; this
material combines high strength and toughness with
excellent biocompatibility and tooth-like shading.10-12 A
limited number of clinical trials have investigated the
esthetic benefits resulting from the use of Y-TZP as an
abutment material. In two clinical studies using visual
inspection, the use of all-ceramic abutments led to less
gingival discoloration of the buccal mucosa compared
with titanium abutments.6,13 In a prospective multi-
center study using a spectrometric analysis, signifi-
cantly higher color differences in the peri-implant soft
tissues were detected for titanium abutments com-
pared with zirconia abutments.14 Another clinical study
concluded that the difference in light reflection from
the soft tissue covering titanium or Y-TZP abutments is
not perceptible if the mucosa exceeds 2 mm in thick-
ness.15 Based on these results, the use of Y-TZP abut-
ments appears to be esthetically beneficial, especially
in clinical situations involving a thin overlaying buccal
soft tissue.8,11 Regardless of the potential esthetic ben-
efits, the use of Y-TZP abutments can only be recom-
mended if their clinical performance is comparable
with that documented for titanium abutments.2,10,12
Three systematic reviews have evaluated the short-
term clinical performance of Y-TZP abutments for sin-
gle crowns. Based on an evaluation of three clinical tri-
als involving 104 abutments and a mean follow-up
20
period of 3.7 years, the clinical performance of Y-TZP
abutments was suggested to be comparable with that
of titanium abutments.10,12,16 Subsequently published
clinical trials of Y-TZP abutments for anterior ISCs
reported fracture rates of 0 to 1% for observation peri-
ods of 3 to 5 years.13,17-19
There are no published studies examining the clin-
ical performance of Y-TZP abutments used for anterior
ISCs with mean observation periods of more than 5
years and including detailed information on potential
technical and biologic problems (peri-implantitis).
The aim of this practice-based retrospective clinical
trial was to evaluate the long-term clinical performance
(a mean observation period > 5 years) of Y-TZP abut-
ments supporting anterior zirconia-based ISCs.
METHOD AND MATERIALS
Patients
This retrospective study evaluated partially edentulous
patients who were restored with single-tooth implants,
zirconia abutments, and temporarily luted all-ceramic
crowns in the anterior region in a private dental office in
Germany between 1 January 2002 and 30 October 2009.
The following inclusion criteria were applied:
• single-tooth implants of the same type in the anter-
ior region (canine to canine) of the maxilla or man-
dible (Ankylos, Dentsply Implants)
• zirconia abutments (Cercon Balance, Dentsply
Implants) and zirconia-based manually veneered
crowns (Cercon, DeguDent) luted with a provisional
cement (TempBond, Kerr Hawe)
• prophylaxis or supportive periodontal therapy
(SPT), at least annually, including a periodontal
examination (probing pocket depth [PPD] and
bleeding on probing [BOP]), at the same dental
office where the implants were inserted
• complete radiographic documentation with pan-
oramic radiographs (PT) and intraoral radiographs (IR)
• complete medical history, including smoking
• complete documentation of superstructure-related
complications or failures.
VOLUME 46 • NUMBER 1 • JANUARY 2015

Fig 1a Clinical situation of a single tooth replacement 3 weeks
after stage-two surgery.
Fig 1c Try-in of the customized zirconia abutment.
The following exclusion criteria were applied:
• aggressive periodontitis20
• no prophylaxis or periodontal therapy prior to
implant therapy
• inadequate radiographs
• other missing data.
The study was approved by the Ethics Committee of
the Medical Faculty of Georg-August University, Göt-
tingen, Germany (application no. 3/2/10). The recom-
mendations of Strengthening the Reporting of Obser-
vational Studies in Epidemiology (STROBE) were fol-
lowed.21
Treatment course
Treatment was completed in a single private practice in
Germany by two dentists with several years of experi-
ence and specific training in oral implant therapy.
Implant placement, stage-two surgery, and prosthetic
VOLUME 46 • NUMBER 1 • JANUARY 2015
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Fig 1b Prefabricated zirconia abutment (Ankylos Cercon Bal-
ance, Dentsply Implants).
Fig 1d Clinical situation after placement of the zirconia-based
crowns.
treatment were completed according to the manufac-
turers’ standard protocols. Prefabricated Y-TZP abut-
ments (Cercon Balance, Dentsply Implants) were cus-
tomized using water-cooled diamond instruments
(Figs 1a to 1c). Zirconia crown frameworks were fabri-
cated using a computer-aided design/computer-
assisted manufacture (CAD/CAM) process (Cercon,
DeguDent) and were veneered manually using a suit-
able ceramic material (Cercon ceram kiss, DeguDent)
(Fig 1d). Following the insertion of the prosthetic res-
toration with a temporary luting agent (TempBond,
Kerr Hawe), the patients were instructed in home-
based dental hygiene. They were then seen for post-
implant maintenance every 3 to 12 months. Prophylaxis
and SPT were performed in patients with and without a
history of periodontal disease, respectively. Each
patient at each appointment received treatment
encompassing the following elements: assessments of
the gingival bleeding index (GBI)22 and plaque control
21
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Rinke et al
record (PCR),23 re-instruction and re-motivation for
effective individual plaque control, professional tooth
cleaning, polishing of all teeth using rubber cups and
polishing paste, and application of a fluoride gel. Once
(in cases of prophylaxis) or twice per year (in cases of
SPT), dental status and PPD measurements were
obtained at four sites per tooth/implant. Sites exhibit-
ing a PPD of 4 mm and BOP, as well as sites with
PPD ≥ 5 mm, were scaled subgingivally using ultrasonic
and hand instruments. In cases of peri-implant mucosi-
tis, the scaling around implants was performed with a
special ultrasonic tip (KaVo SONICflex implant, KaVo
Dental), followed by manual instrumentation and the
subgingival application of a chlorhexidine gel (Corsodyl
1% Dental Gel, GlaxoSmithKline).24
Prophylaxis/SPT was administered to most patients
at 3-month intervals during the first year after implant
insertion and at 6-month intervals thereafter. Patients
exhibiting ineffective plaque control during the post-
therapeutic phase (PCR > 35%) were seen four times
per year for SPT (3-month intervals). This close recall
was maintained until a PCR < 20% was established for
three consecutive SPTs.
Data collection
The following data were retrieved from the patients’
records: age at implant placement, gender, medica-
tions, smoking, implant location (according to the FDI
scheme), implant length, number of implants, implant
loss, time of crown placement, and observation period.
All prosthesis-related technical complications, includ-
ing implant and abutment fractures, screw loosening,
retention loss, and fracture of the veneering ceramic,
were documented. Each patient’s clinical examination
was completed at annual intervals during prophylaxis
or SPT, and the following parameters were assessed:
• survival analysis of the implant and prosthetic res-
toration
• technical complications
• biologic complications (peri-implantitis).
22
PPD and BOP were assessed to the nearest mm using a
periodontal probe (PCPUNC 15, Hu-Friedy) at four sites
per implant. The deepest PPD of each implant was used
as the diagnostic criterion for peri-implant mucositis
and peri-implantitis. In cases of increased PPD (≥ 5 mm)
and BOP, an IR (rectangular technique) was obtained to
assess the radiographic bone loss to confirm the diag-
nosis of peri-implantitis. Bone loss was determined by a
metric analysis of the IR. All IRs were obtained using the
same x-ray device (Heliodent, Sirona Dental Systems)
and digital sensor (Sidexis XG, Sirona Dental Systems)
using the parallel technique. The data were analyzed
using the associated computer program (Sidexis XG,
Sirona Dental Systems) and a calibrated screen (Sync-
Master 2443SW, Samsung Electronics). The distance
between the implant shoulder and marginal bone level
(MBL) was measured at the mesial and distal aspects of
each implant. The MBL was defined as the most coronal
location at which bone covered the implant surface.
The site with the most pronounced bone loss was cho-
sen to represent the implant. The threshold level for
progressive bone loss was a bone level located at least
3.5 mm more apical, relative to the implant shoulder,
compared with the bone level on the last available
radiograph. Taking into account the anatomic magnifi-
cation and distortion in the films, the linear dimensions
of the images were calibrated. This calibration was
achieved by setting the scale in the image to the
known distance between the implant shoulder and the
most apical point of the implant.24 Baseline radiographs
(PT) after implant placement were used to ensure that
the placement of the implant shoulder at a slightly
subcrestal position (0.5 mm) conformed to the protocol
and to determine the original bone level around the
implant. All the radiographs were examined by the
same calibrated operator (DZ), and all the clinical exam-
inations were performed by a dentist (AL) who had not
placed the implants. All the patients who met the inclu-
sion criteria and underwent a final examination
between 1 August and 31 December 2012 were
included in the study.
VOLUME 46 • NUMBER 1 • JANUARY 2015

Table 1 Numbers of included and excluded subjects and the distribution of the exclusion
categories
Total number of patients
Number of included subjects
Number of excluded subjects
No regular post-therapeutic therapy
Reasons for exclusion Inadequate/missing radiographs
Other missing data (eg, medical history or periodontal status)
Case definition
The survival and success of both the implant and the
prosthetic reconstruction were the dependent vari-
ables of the study.
Survival was defined as the implant or prosthetic
reconstruction remaining in situ at the follow-up exam-
ination without exhibiting absolute failure (in situ cri-
terion).1-3 Implant success was defined as the absence of
technical or biologic complications (peri-implantitis) for
the entire follow-up period. Peri-implantitis was defined
according to previous reports25-28 as PPD ≥ 5 mm with
BOP/suppuration and radiographic bone loss with a
distance of at least 3.5 mm between the implant shoul-
der and bone level. The date of the first radiograph that
exhibited bone loss ≥ 3.5 mm was used for the time-
dependent analysis of the event “peri-implantitis”.
Prosthetic success was defined as the absence of
technical complications (ie, the restoration did not
require any intervention to maintain function during
the entire follow-up period).1-3
Statistical analysis
Data on the survival and success of the implants and
prosthetic reconstructions were used for the statistical
analysis. The implant/restoration was defined as the stat-
istical unit. The survival/success time of a restoration/
implant was defined as the period between cementation
and the last follow-up or, in cases of failure or clinical
intervention, the appointment scheduled to address the
failure/complication, as documented in the patient’s file.
The time-dependent survival rates (in situ criterion) and
the success rates of the implants (the absence of peri-
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33
27
6
4
1
1
implantitis) and prosthetic restorations (the absence of
interventions) were calculated using a Kaplan-Meier
analysis. Different observations in the same patient (sev-
eral implants per patient) were dependent. This depen-
dence was allowed by adjusting the variance estima-
tions in a marginal model.29 The statistical analysis was
performed using the “prodlim” function of the R soft-
ware program (version 2.14.1, www.r-project.org). Due
to the small sample sizes and a small number of events,
only an overall statistical analysis was carried out and no
stratification according to potential factors influencing
the biologic and technical complications was performed.
RESULTS
Patients
Between 1 January 2002 and 30 October 2009, 33 par-
tially edentulous patients with missing incisors or
canines and indications for single-tooth replacement
were treated with Ankylos implants. Twenty-seven of
these patients (18 women and 9 men), with 42
implants, fulfilled all the inclusion criteria and had com-
plete documentation available at the time of final data
acquisition (Table 1). Five of the patients were part of a
cohort examined in an earlier study.24 The reasons for
tooth loss were as follows: 15 periodontal reasons, 12
endodontic failures, 9 caries lesions, and 6 teeth with
extensive tooth fracture. The mean age of the patients
at the time of implant insertion was 55.4 ± 12.9 years. A
mean number of 1.6 ± 0.7 implants (a maximum of 3)
were placed per patient. Thirty-nine maxillary implants
were inserted to replace a maxillary incisor or canine,
23
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Table 2 Distribution (according to FDI notation) of the implants included in the study

Number of implants in the maxilla = 39

Implants 2 6 8 11 11 1
13 12 11 21 22 23
Position
43 42 41 31 32 33
Implants 1 0 0 0 0 2
Number of implants in the mandible = 3

100

Survival probability (%)

75

50

25

0
0 20 40 60 80 100 120
Time (months)

Fig 2 Abutment fracture leading to the complete loss of the Fig 3 Survival probability (in-function) of the prosthetic restor-
restoration. ations calculated using the Kaplan-Meier estimator.

and three implants replaced mandibular canines
(Table 2). Fourteen patients, accounting for 22 implants,
had a history of periodontal disease prior to implant
placement and received SPT. During the observation
period, none of these patients required additional
active periodontal therapy. Furthermore, none of the
remaining 13 patients without a history of periodontal
disease (accounting for 20 implants) required active
periodontal therapy. Five patients (18.5%), accounting
for 10 implants, were smokers. All of the patients under-
went a final clinical follow-up examination between 1
August and 31 December 2012. The mean follow-up
period for the prosthetically restored implants was
79.8 ± 25.7 months (36 months to 10.8 years).
Survival rates of implants and prosthetic
restorations
None of the 42 implants failed during the observation
period, resulting in a cumulative survival rate of 100%
after 7 years. One fractured zirconia abutment required
replacement (Fig 2), (prosthetic survival rate, 97.6%;
95% confidence interval [CI], 0.930–1.000) after 7 years
(Fig 3). None of the zirconia frameworks fractured dur-
ing the observation period.
Success rates of prosthetic restorations
A total of 11 clinical interventions were necessary to
maintain the function of the superstructures (prosthetic
success rate, 75.0%; 95% CI, 0.636–0.882 after 7 years)

24 VOLUME 46 • NUMBER 1 • JANUARY 2015

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Table 3 Reasons for complete failures and complications of the superstructure

Type of failure Number of complete failures

Abutment fracture 1
Total 1

Type of complication Number of complications

Ceramic veneer fracture 5
Retention loss 4
Abutment screw loosening 2
Total 11

100 100
Success probability (%)

Success probability (%)

75 75

50 50

25 25

0 0
0 20 40 60 80 100 120 0 20 40 60 80 100 120
Time (months) Time (months)

Fig 4 Success probability (absence of complications) of the pros- Fig 5 Success probability (absence of peri-implantitis) of the
thetic restorations calculated using the Kaplan-Meier estimator. implants calculated using the Kaplan-Meier estimator.

(Fig 4). Fractures of the veneering ceramics (n = 5) and
loss of retention (n = 4) were the most frequent techni-
cal complications (Table 3). None of the ceramic frac-
tures required replacement of the restoration, three
minor fractures were polished, and two fractures
> 2 mm2 were repaired after removal of the crown.
Crowns with a loss of retention were recemented using
a temporary luting agent. Abutment screw loosening
was detected in two zirconia abutments during the
observation period. Owing to the temporary luting of
the restorations, the abutment screws could be retight-
ened after removal of the crowns.
Success rates of implants
Peri-implant disease (implant-based)
Of the 42 implants, two developed peri-implant disease
(implant success rate, 92.9%; 95% CI, 0.840–1.000) dur-
ing the 7-year observation period (Fig 5).
The implant-based peri-implantitis rate for implants
placed in nonsmoking patients was 3.1%. Of the 10
implants placed in patients who smoked, one showed
clinical symptoms of peri-implantitis (10%). One case of
peri-implantitis was diagnosed among the 17 implants
placed in non-smoking patients with a history of peri-
odontal disease (5.9%).

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Based on the available systematic reviews,2-5 the

14 peri-implantitis most frequent technical complications associated with
no peri-implantitis
12
single-tooth implant restorations are loss of retention
1
in cemented superstructures, loosening of the abut-
Number of patients

10 ment screw, and fracture of the veneering ceramic.

8 The most frequent technical complication in the
6
4 implant-based zirconia crowns have demonstrated that
1 fractures of the veneering material represent a relevant
2
2 2 11 10
0 perio no perio perio no perio
treatment treatment treatment treatment
smokers nonsmokers
Fig 6 Distribution of patients with peri-implant disease accord-
ing to the variables “smoking” and “history of periodontal treat-
ment”.
Peri-implant disease (patient-based)
Peri-implantitis was diagnosed in two (1 woman)
patients (7.4%). One of the five smokers (20%) and one
of the 22 nonsmokers (4.5%) experienced peri-implan-
titis. No peri-implantitis was diagnosed in a subgroup
comprising the 10 nonsmoking patients without a his-
tory of periodontal disease. Among the three smokers
with a history of periodontal disease, one patient devel-
oped clinical symptoms of peri-implantitis (Fig 6).
DISCUSSION
The survival rate of the implants placed in this study
was 100%, and the survival rate of the prosthetic restor-
ations was 97.6% (95% CI, 0.930–1.000) after a mean
follow-up of 7 years. These results are in accordance
with a systematic review that analyzed the long-term
results of single-tooth implants2 and revealed a 5-year
survival rate for implant-supported single crowns of
97.2% (95% CI, 96.3–97.9%). None of the Y-TZP frame-
works fractured. This finding is in accord with the
results of other clinical studies evaluating implant-
based anterior Y-TZP restorations over functional peri-
ods of 3 to 5 years.13,17
present study was fracture of the veneering ceramic,
with an incidence of 12% after 7 years. Other studies of
clinical problem. In a retrospective study, minor chip-
ping of the veneering material of anterior implant-
based all-ceramic crowns was detected in 2% of the
restorations within the first year.17 In another prospec-
tive trial, one out of 64 anterior Y-TZP crowns required
replacement due to extensive chipping of the veneer-
ing material within the first 3 years of service.13 Based
on the findings of two systematic reviews,2,3 the preva-
lence of this technical complication ranged from 3.5%
to 5% for single crowns within 5-year observation
periods, with all-ceramic crowns demonstrating a
higher complication rate. This result is in accord with
the findings of the present study.
Several systematic reviews have found a higher
incidence of technical complications among tooth-
supported zirconia restorations compared with metal-
ceramic restorations.30-32 This finding is consistent with
the results of the present study; the 7-year data demon-
strate that chipping is the major problem associated
with zirconia-based restorations. During this study
period some recommendations for optimizing the fab-
rication process for zirconia-based FPDs were pub-
lished, eg, a modification of the firing protocol.33 This
modification can be recommended because it might
reduce the chipping rate. However, these modifications
were not applied in the present study.
In the present study, 4 of 42 crowns (9.5%) required
recementation. The prosthetic success rates for ISCs
cemented with temporary cement reported by other
studies ranged between 72% and 84% for follow-ups of
2 to 5 years.34-36 The high incidence of recementations
for the crowns luted with temporary cement in the
present study is in good accordance with other studies.

26 VOLUME 46 • NUMBER 1 • JANUARY 2015


In two systematic reviews, the incidence of screw
loosening in single crowns was reported to be as high
as 6% within 3 years5 and 8.8% within 5 years.2 In the
present study, loosening of the abutment screw
occurred in only 2 of the 42 single-crown restorations,
resulting in a complication rate of 4.8% after 7 years. A
possible explanation for this relatively low rate may be
the Morse taper connection of the implant system used
in this study. Low rates of screw loosening have also
been reported in other studies that used implant sys-
tems with a Morse taper connection.37,38
Peri-implantitis is a serious biologic complication
that, if untreated, can result in implant loss.39,40 Based
on previously published results, peri-implantitis
appears to occur in approximately 10% of all implants
and 20% of all patients during a period of 5 to 10 years
after implant placement.40
An implant-based time-to-event analysis revealed a
success rate of 92.9% after 7 years for anterior implants
with zirconia abutments and all-ceramic crowns in the
present study. The implant-based peri-implantitis rate
of 4.8% and the patient-based peri-implantitis rate of
7.4% are in the lower range of the expected disease
rates.2,40
These relatively low prevalence rates are possibly
due to the compliance of all the included patients, who
received prophylaxis or SPT at least annually. A positive
effect of compliance with professional hygiene proced-
ures (prophylaxis or SPT) on a reduced risk of peri-
implantitis has been demonstrated in other clinical tri-
als.24,41,42
Due to the relatively small sample size and the lim-
ited number of events, a statistical evaluation of poten-
tial risk factors (smoking status and history of periodon-
tal disease) was not possible.
Another important aspect of the interpretation of
this study is the definition of the endpoints. Commonly
applied success criteria (intervention-free survival) for
the survival of implants and superstructures (in situ cri-
teria)1-3 were selected for the present study. Neverthe-
less, studies published to date show great heterogene-
ity in the definition of implant-related biologic
complications (peri-implantitis).1,39,40 The threshold
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level for progressive bone loss is a particularly impor-
tant factor for the definition of peri-implantitis. In the
present study, the threshold level for progressive bone
loss was defined as a distance of at least 3.5 mm
between the implant shoulder and the bone level.
Other clinical studies using different implant systems
have applied a comparable threshold level of a distance
of > 3 mm between the implant-abutment connection
and the bone level.24-28 Nevertheless, this distance
should be noted to represent a high threshold of radio-
graphic bone loss, which indicates a pronounced pro-
gression of disease. Because the treatment of peri-
implantitis should be initiated at an early stage of the
progression of bone loss, lower threshold levels should
be used for diagnostic purposes in daily clinical prac-
tice.40,42
The present study is limited by its comparatively
small sample size and its retrospective nature. How-
ever, this limitation is partially compensated for by the
application of a strict case definition, which included
only patients with single-tooth restorations placed in
the anterior area using the same implant type and
identical superstructure materials, including a stan-
dardized cementation protocol. Moreover, this prac-
tice-based study examined both biologic and technical
complications at the implant and superstructure levels,
with a follow-up of more than 5 years. Because this
type of result is rare, this study makes a valuable contri-
bution to the evaluation of the prognosis of implant-
based restorations placed under the typical conditions
of a private practice.
CONCLUSION
Considering the limitations of the present study, the
following conclusions can be drawn.
• Zirconia abutments with all-ceramic crowns offer a
reliable treatment option under the typical condi-
tions of a private practice.
• Clinical interventions to maintain the function of
the restorations are required due to technical com-
plications. Fractures of the veneering ceramics rep-
resent the most frequent complication.
27
Q U I N T E S S E N C E I N T E R N AT I O N A L
Rinke et al
• Temporary luting of the prosthetic restorations car-
ries a risk of the loss of retention but offers the
advantage of the non-destructive removal of the
restoration in case of technical complications
(retightening of the abutment screw or repair of a
ceramic fracture).
• For patients attending a professional maintenance
program at least annually, peri-implantitis should
be expected in 4.1% of the implants and 7.4% of the
patients after a mean observation period of 7 years.
• Further clinical investigations with larger samples
and improved data (eg, randomized clinical trials)
are necessary to evaluate restoration- and patient-
related risk factors for biologic and technical com-
plications.
As the present study confirms the results of other stud-
ies on the same topics, the use of zirconia abutments
and all-ceramic crowns for single tooth replacements in
the anterior area can be recommended for general
application in esthetically demanding situations.
ACKNOWLEDGMENT
The authors thank Katrin Rinke for the critical reading and language
editing of the manuscript.
CONFLICT OF INTEREST
Sven Rinke has received lecture fees from Dentsply Implants,
Mannheim, Germany, and DeguDent, Hanau, Germany.
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