By Dr. Jacques Imbeau D.M.D., NZDREX, FACNEM, SMART Certified
The author is Head of Professional Affairs at Zeramex Australasia. Dr. Imbeau has practiced dental medicine for over 35 years, both in Canada and New Zealand, including over 10 years of clinical experience in ceramic implantology. In this article he explores the development of ceramic implants and the important role played by Dentalpoint AG in the research and manufacturing of two-piece ceramic implants, including the ZERAMEX® XT that is at the leading edge of ceramic implantology.
A singular focus with a vision
From day one Zeramex has been fully focused on two-part ceramic implants so this technological expertise has been nurtured in a creative and supportive environment while many other manufacturers ignored the issues related to metallic implants. Now almost 14 years after the introduction of the first two-part ceramic implant, the Zeramex T, the current situation has fully validated the choice made in 2005 as there is growing awareness of the issues related to titanium implants and many implant manufacturers and suppliers are now including at least one ceramic implant in their portfolio as they see the increasing awareness and demand for ceramic implants.
Of course, this has not been easy and such an achievement cannot be understated. As the leading manufacturer of Zeramex two-piece ceramic implants, Dentalpoint AG is the owner of the intellectual property that underpins such a technological breakthrough.
The long road to Zeramex Ceramic Implants
Zirconia has been in used in dental applications for decades with mixed results and early zirconia implants introduced before 2000 , such as the Tübingen implants, were associated with problems such as fracturing either during surgery or after loading as well as lack of osteointegration.  These issues were related to microscopic defects due to material inconsistencies caused by sub-optimal manufacturing processes, choice of material, unsuitable surface modification as well as design flaws.
The fact is that zirconia is not a metal, it is a ceramic and any manufacturing and design processes that does not respect the unique properties of zirconia are likely to fail. Many have learned that it is not possible to simply use 40 years of knowledge and experience with titanium implant manufacturing and apply it to zirconia.
The serious challenges presented by zirconia as an implant material, such as brittleness, have initially led to the development of one-piece implants by other manufacturers, to make it stronger. Such one-piece designs have some advantages but lack the flexibility and versatility offered by titanium implants and desired by dental implantologists as, unfortunately, they adversely affect placement, restorability and intra-oral adjustment.
Development of two-piece zirconia implants was therefore necessary, but a novel approach was required, one that showed a clear understanding of zirconia powders and particles in combination with the ideal compaction and processing method, amongst many variables. The wrong choice can easily lead to degradation and flaws either in the short or long term, ending in failure.
It is with this deep knowledge that Zeramex scientists have designed and developed exacting manufacturing and surface modification processes to preclude any manufacturing flaws, even minute imperfections. Such measures must be taken with the materials to ensure clinical predictably and favourable long-term results. 
Evidence based quality manufacturing – driven by science
As a dentist, when you are placing an implant into the bone, you want strength, stability, and long-term durability to withstand occlusal forces. In short you want reliability, but you also want biological stability and safety. You want excellent aesthetics and tissue friendly materials  to avoid any adverse impact on the health of your patients. Success it not simply determined by dental results but also by the lack of adverse systemic response to the implant.[21,22,23,24,25]
Research has shown that certain alumina-toughened zirconia (ATZ) compounds, properly prepared, are suitable for this application. ATZ provides the kind of toughness and bending strength needed to facilitate the long-term performance of the implant, especially at the joint interface, where the peak stress forces are concentrated. The choice of the type of zirconia compound is only one aspect. How the material is processed is also critical.
Some manufacturers may be tempted to pursue low-cost injection moulding which can result in a relatively high degree of material flaws as a result. 
Unlike other manufacturers, Zeramex implants only use sintered and BIO-HIP alumina-toughened zirconia in a precise manufacturing processes of hot isostatic pressing, followed by machining, post compaction and additional grinding, entirely developed and completed in-house. These processes have been developed and refined over many years. Thus, it is possible to guarantee the maximum strength and precision required. Additional quality controls such as post-manufacturing scanning of every component is also part of this exacting process to ensure clinical predictability and favourable long-term results.
Yes, it is a complex process, but one dictated by the nature of the material, so for the sake of long-term reliability and performance, all Zeramex ceramic implants are manufactured in house out of fully sintered ATZ ceramic via hard machining.
We also understand that any abutment-implant connection design could not be a copy from existing titanium-based systems. So more than 5 years ago the robust metal-free, Vicarbo carbon fibre connecting screw was introduced and more recently our unique “Bolt-In-Tube” internal connection was launched. These developments and our many years of experience are what set us apart from other ceramic implant systems and manufacturers. And while some of our products have been made available on a commercial basis to one major titanium implant manufacturer, the manufacturing process and technical expertise remain under the full control of Zeramex manufacturer.
This world class expertise is a key element in the superior quality and reliability of all Zeramex implant systems, backed by our Zeramex guarantee.
All these steps provide significant benefits. Zirconia is already proven to osseointegrate as well, if not better, than titanium 7,8 and all Zeramex implants have the Zerafil™ surface to insure excellent hard and soft tissue integration around our implants.  Research also show a clear benefit with regards to inflammatory responses compared to titanium implants. [5-10]
The Zerafil™ surface is a micro-structured implant surface that enables decisive osseointegration of the dental implants.
The success rate of Zeramex implants with a Zerafil™ surface is approx. 98.0 percent, depending on the system, and bears witness to the decisive osseointegration thanks to the optimum surface structure. The hydrophilic implant surface Zerafil™ is sandblasted and etched so that osteoblasts grow directly up to the implant and firm adhesion to the implant surface is achieved. 
Currently Zeramex is the only one offering a choice of multiple 100% metal-free two-piece ceramic implant system. The Zeramex P6 and the Zeramex XT. Both with our unique Vicarbo technology: 100% metal-free, corrosion-free, cement-free and fully reversible screwed connections. Customized prosthetic flexibility with peace of mind. With Zeramex, you can confidently provide a truly metal-free solution.
When patients ask for a metal-free solution and you offer them a two-piece zirconia product, can you in good conscience connect the two pieces with a titanium screw? We at Zeramex Australasia don’t think so.
The Vicarbo screw connection
All our Zeramex implants are two-piece designed with a fully reversible screwable abutment to eliminate the risks associated with excess cement. Again, it was not desirable to simply copy titanium implants and use a titanium screw.
Why? Titanium is a metal with totally different property than ATZ ceramic. A such it would adversely impact on the ceramic surface with long term detrimental effects on fatigue under loading. On the other hand, a zirconia screw is too rigid and will bind in the implant, impacting retrievability. This is exactly why an entirely new screw was developed based on technology used in the aerospace industry – Our Vicarbo screw made of carbon-fibre-reinforced PEEK (polyetheretherketone) - unique to Zeramex implants.
The Vicarbo screw, when tightened, conforms to the contour of the internal thread of the implant and does not display the stress concentration typical of metal in contact with zirconia. This allows more surface contact between the Vicarbo screw and the ATZ ceramic compared to titanium in a similar situation. It provides high tensile strength, a stable concretion joint between the implant and the abutment while being fully reversible.
Can Zeramex implants replace titanium implants?
While many titanium implant manufacturers, who are heavily invested in titanium technology, are finally acknowledging that ceramic implants are becoming an alternative worthy of consideration due to the inherent aesthetic characteristics of zirconia as well as its tissue friendly biological properties, they still have what could be called a short term view of the situation. The fact is recent research raises valid concerns about the biological properties of titanium [15,16,17,18,19,20], especially with regards to peri-implantitis. Individuals with specific polymorphisms (SNPs) are even at greater risk both from a dental and systemic point of view. At the same time research on zirconia is quite positive and progressing by leaps and bounds.
In discussions with Adrian Hunn, Head of Marketing and Sales at Dentalpoint, it is clear that we are seeing right now a massive increase in demand from patients for metal-free implants. More and more patients want natural and biocompatible products and are asking their dentists about alternatives to titanium implants. Of course, this puts pressure on dentists to offer both titanium and ceramic implants. So, if they do not want to lose patients, they will be forced to offer ceramic implants as well. According to market studies, the market share of ceramic implants is currently about 3 to 5 percent. The share is predicted to rise to 24 per cent by 2022. For us, this means that above-average growth with ceramic implants is possible in such a quickly growing market.
Any conventional treatment for single tooth or bridges can be implemented with Zeramex ceramic implants. Along with the usual contra-indications for the patient, there are also certain limitations in relation to reduced diameters or special abutments. But all options are possible. We will soon be launching the new VICARBO® screw-retained Docklocs® as well, and this will also make metal-free hybrid treatment possible in edentulous jaws.
So, in most cases, Zeramex ceramic implants can be used instead of titanium implants. As more research becomes available about long term results and biological benefits of ceramic implants, we believe they will become the preferred choice of many dental implantologists.
What about digital workflow with Zeramex implants?
DentalPoint AG is all about innovations. On the digital side, we will be introducing the full integration of the digital workflow. The workflow for digital impression taking with an intraoral scanner from the more recent Zeramex XT system has already been available since March in Europe. The CAD libraries for Exocad and 3Shape are now available for use. Fully individualised abutments or monolithic zirconia crowns will also be available later in the year. Dentalpoint AG has established the new digital solutions department, which will be rolled out over the next few months for dentists, dental technicians and laboratories for optimal support with digital treatment. It will provide dental technicians with a comprehensive service package which they can use to send in data and in return receive a complete treatment plan, with little processing time required. In addition, our service centre is on hand to offer advice to dentists by hotline and email. As for other innovations, there is the new metal-free Docklocs®. Also, a reduced diameter is going to be introduced for the Zeramex XT system in autumn. There are more innovations and surprises in the pipeline, but we are keeping them under wraps for now.
What about the public?
As for member of the public, in a recent survey in Europe of over 250 people, when offered the option of titanium implants or ceramic implants, most patients choose ceramic implants. As more people become aware of what the research is showing this trend will continue to accelerate. The same evolution that took place regarding amalgam vs composites is now happening in dental implantology.  So, most of your patients are already quite receptive to the idea of ceramic implants. By offering them ZERAMEX ceramic implants you have a winning scenario.
Zeramex Ceramic Implants tick all the boxes:
With Vicarbo®, Zerafil™, Docklocs®, Exocad, 3Shape. Zeramex ceramic implants are clinically proven, 100% metal-free, naturally white, highly aesthetic, durable, versatile, reliable, effective, fully reversible screwable abutments for customised prosthetic flexibility with the full benefits of submerged healing and digital workflow.
At Zeramex Australasia we believe that once Australian and New Zealand dentists fully understand the science and benefit of Zeramex ceramic implants, they will see the many advantages of offering this solution to their patients who, in turn will further appreciate the expertise and care of their dentist.
Zeramex Australasia is your partner in the exciting field of ceramic oral implantology so you and your patients can now benefit from the advantages of Zeramex Ceramic Implants.
1. Cionca N, Hashim D, Mombelli A. Zirconia dental implants: where are we now, and where are we heading? Periodontol 2000 2017;73(1):241-58.
2. Osman R, Swain M. A Critical Review of Dental Implant Materials with an Emphasis on Titanium versus Zirconia. Materials 2015;8(3):932.
3. Osman R, Swain M. A Critical Review of Dental Implant Materials with an Emphasis on Titanium versus Zirconia. Materials 2015;8(3):932.
4. Kohal RJ, Spies BC, Bauer A, Butz F. One-piece zirconia oral implants for single-tooth replacement: Three-year results from a long-term prospective cohort study. J Clin Periodontol 2018;45(1):114-24.
5. Cionca N, Hashim D, Cancela J, Giannopoulou C, Mombelli A. Pro-inflammatory cytokines at zirconia implants and teeth. A cross-sectional assessment. Clin Oral Investig 2016;20(8):2285-91.
6. Spies BC, Sauter C, Wolkewitz M, Kohal RJ. Alumina reinforced zirconia implants: effects of cyclic loading and abutment modification on fracture resistance. Dental Materials 2015;31(3):262-72.
7. Pieralli S, Kohal RJ, Jung RE, Vach K, Spies BC. Clinical Outcomes of Zirconia Dental Implants. J Dent Res 2017;96(1):38-46.
8. Pieralli S, Kohal RJ, Lopez Hernandez E, Doerken S, Spies BC. Osseointegration of zirconia dental implants in animal investigations: A systematic review and meta-analysis. Dental Materials 2018;34(2):171-82.
9. Chappuis V, Cavusoglu Y, Gruber R, et al. Osseointegration of Zirconia in the Presence of Multinucleated Giant Cells. Clin Implant Dent Relat Res 2016;18(4):686-98.
10. Cionca N, Hashim D, Cancela J, Giannopoulou C, Mombelli A. Pro-inflammatory cytokines at zirconia implants and teeth. A cross-sectional assessment. Clin Oral Investig 2016;20(8):2285-91.
11. Jank S, Hochgatterer G. Success Rate of Two-Piece Zirconia Implants: A Retrospective Statistical Analysis. 2016 Apr;25(2):193-8. doi: 10.1097/ID.0000000000000365.
12. Bollen CM (2017) Zirconia: The Material of Choice in Implant Dentistry? An Update. J Dent Health Oral Disord Ther 6(6): 00219. DOI: 10.15406/jdhodt.2017.06.00219
13. Curd ML Bollen. “White or Grey?Ceramic or Metal?”. EC Dental Science ECO.01 (2016): 28-29.
14. Jacobi-Gresser E, Huesker K, Schütt S. Int J Oral Maxillofac Surg. 2013 Apr;42(4):537-43. doi: 10.1016/j.ijom.2012.07.018. Epub 2012 Aug 24.
15. Noumbissi S, Scarano A, Gupta S. Materials (Basel). 2019 Jan 24;12(3). pii: E368. doi: 10.3390/ma12030368. https://www.mdpi.com/1996-1944/12/3/368
16. Alrabeah GO, Brett P, Knowles JC, Petridis H.J Dent. 2017 Nov;66:91-101. doi: 10.1016/j.jdent.2017.08.002. Epub 2017 Aug 4.
17. Safioti LM, Kotsakis GA, Pozhitkov AE, Chung WO, Daubert DM. J Periodontol. 2017 May;88(5):436-442. doi: 10.1902/jop.2016.160524. Epub 2016 Nov 18.
18. Pettersson M, Pettersson J, Johansson A, Molin Thorén M.A. J Oral Rehabil. 2019 Feb;46(2):179-188. doi: 10.1111/joor.12735. Epub 2018 Nov 16.
19. Noronha Oliveira M, Schunemann WVH, Mathew MT, Henriques B4, Magini RS, Teughels W, Souza JCM. J Periodontal Res. 2018 Feb;53(1):1-11. doi: 10.1111/jre.12479. Epub 2017 Aug 2.
20. Delgado-Ruiz R, Romanos G. Int J Mol Sci. 2018 Nov 13;19(11). pii: E3585. doi: 10.3390/ijms19113585.
21. Johann Lechner & Sammy Noumbissi & Volker von Baehr. EPMA Journal (2018) 9:331–343. https://doi.org/10.1007/s13167-018-0138-6
22. Siddiqi A, Payne AG, De Silva RK, Duncan WJ. Clin Oral Implants Res. 2011 Jul;22(7):673-80. doi: 10.1111/j.1600-0501.2010.02081.x. Epub 2011 Jan 20.
23. MakiHosoki, KeisukeNishigawa, YoujiMiyamoto, GoOhe, YoshizoMatsuka, Journal of Prosthodontic Research Volume 60, Issue 3, July 2016, Pages 213-219
24. Kim KT1, Eo MY2, Nguyen TTH2, Kim SM3,4,5.
25. Int J Implant Dent. 2019 Mar 11;5(1):10. doi: 10.1186/s40729-019-0162-x.