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References

1- Chappuis V, Cavusoglu Y, Gruber R, Kuchler U, Buser D, Bosshardt DD. Osseointegration of Zirconia in the Presence of Multinucleated Giant Cells. 2016 Aug;18(4):686-98. doi: 10.1111/cid.12375. Epub 2015 Sep 17.


Current strategies to reduce medical device-associated infections propose zirconia as a potential implant material which may limit bacterial adhesion. Link

2- Derks J, Håkansson J, Wennström JL, Tomasi C, Larsson M, Berglundh T. Effectiveness of implant therapy analyzed in a Swedish population: early and late implant loss. 2015 Mar;94(3 Suppl):44S-51S. doi: 10.1177/0022034514563077. Epub 2014 Dec 11.


Treatment outcomes in implant dentistry have been mainly assessed as implant survival rates in small, selected patient groups of specialist or university clinical settings. This study reports on loss of dental implants assessed in a large and randomly selected patient sample. Link

3- Derks J, Schaller D, Håkansson J, Wennström JL, Tomasi C, Berglundh T. Effectiveness of Implant Therapy Analyzed in a Swedish Population: Prevalence of Peri-implantitis. 2016 Jan;95(1):43-9. doi: 10.1177/0022034515608832.


Peri-implantitis is an inflammatory disease affecting soft and hard tissues surrounding dental implants. As the global number of individuals that undergo restorative therapy through dental implants increases, peri-implantitis is considered as a major and growing problem in dentistry. Link

4- 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.


About 10 years ago, one-piece zirconia implants were introduced to dentistry. The aim of the study was to evaluate the clinical success of two-piece zirconia implants regarding osseointegration using the manufacturers' warranty data. Link

5- Cosgarea R, Gasparik C, Dudea D, Culic B, Dannewitz B, Sculean A. Peri-implant soft tissue colour around titanium and zirconia abutments: a prospective randomized controlled clinical study. 2015 May;26(5):537-44. doi: 10.1111/clr.12440. Epub 2014 Jun 24.


To objectively determine the difference in colour between the peri-implant soft tissue at titanium and zirconia abutments. Link

6- Kajiwara N, Masaki C, Mukaibo T, Kondo Y, Nakamoto T, Hosokawa R. Soft tissue biological response to zirconia and metal implant abutments compared with natural tooth: microcirculation monitoring as a novel bioindicator. 2015 Feb;24(1):37-41. doi: 10.1097/ID.0000000000000167.


Zirconia is often used for implant abutments for esthetics. The aim of this clinical study was to compare the effects of zirconia and metal abutments on periimplant soft tissue. Link

7- Wachi T, Shuto T, Shinohara Y, Matono Y, Makihira S. Release of titanium ions from an implant surface and their effect on cytokine production related to alveolar bone resorption. 2015 Jan 2;327:1-9. doi: 10.1016/j.tox.2014.10.016. Epub 2014 Nov 3.


Although interest in peri-implant mucositis and peri-implantitis has recently been increasing, the mechanisms driving these diseases remain unknown. Link

8- Addison O, Davenport AJ, Newport RJ, Kalra S, Monir M, Mosselmans JF, Proops D, Martin RA. Do 'passive' medical titanium surfaces deteriorate in service in the absence of wear? 2012 Nov 7;9(76):3161-4. Epub 2012 Jul 25.


Globally, more than 1000 tonnes of titanium (Ti) is implanted into patients in the form of biomedical devices on an annual basis. Link

9- Oliva J, Oliva X, Oliva JD. Five-year success rate of 831 consecutively placed Zirconia dental implants in humans: a comparison of three different rough surfaces. 2010 Mar-Apr;25(2):336-44.


The aim of this study was to evaluate the 5-year success rate of zirconia (ZrO2) implants with three different kinds of surfaces. Link   

10- Manzano G, Herrero LR, Montero J. Comparison of clinical performance of zirconia implants and titanium implants in animal models: a systematic review. 2014 Mar-Apr;29(2):311-20. doi: 10.11607/jomi.2817.


This study aimed to compare the values of removal torque (RT) and bone-implant contact (BIC) reported in different animal studies for zirconia and titanium implants. Link

11- Cionca N, Müller N, Mombelli A. Two-piece zirconia implants supporting all-ceramic crowns: a prospective clinical study. 2015 Apr;26(4):413-8. doi: 10.1111/clr.12370. Epub 2014 Mar 26.


The aim of this prospective clinical study is to evaluate the safety and efficacy of a new all-ceramic implant system to replace missing teeth in partially edentulous patients. Link

12- Scarano A, Piattelli M, Caputi S, Favero GA, Piattelli A. Bacterial adhesion on commercially pure titanium and zirconium oxide disks: an in vivo human study. 2004 Feb;75(2):292-6.


Little is known about the mechanisms of bacterial interaction with implant materials in the oral cavity. A correlation between plaque accumulation and progressive bone loss around implants has been reported. Link

13- Sridhar S, Wilson TG Jr, Palmer KL, Valderrama P, Mathew MT, Prasad S, Jacobs M, Gindri IM, Rodrigues DC. In Vitro Investigation of the Effect of Oral Bacteria in the Surface Oxidation of Dental Implants. 2015 Oct;17 Suppl 2:e562-75. doi: 10.1111/cid.12285. Epub 2015 Jan 27.


Bacteria are major contributors to the rising number of dental implant failures. Inflammation secondary to bacterial colonization and bacterial biofilm is a major etiological factor associated with early and late implant failure (peri-implantitis). Link

14- Monzavi M, Noumbissi S, Nowzari H. The Impact of In Vitro Accelerated Aging, Approximating 30 and 60 Years In Vivo, on Commercially Available Zirconia Dental Implants. 2017 Apr;19(2):245-252. doi: 10.1111/cid.12462. Epub 2016 Nov 9.


Despite increased popularity of Zirconia dental implants, concerns have been raised regarding low temperature degradation (LTD) and its effect on micro-structural integrity. Link

15- Canullo L, Tallarico M, Radovanovic S, Delibasic B, Covani U, Rakic M. Distinguishing predictive profiles for patient-based risk assessment and diagnostics of plaque induced, surgically and prosthetically triggered peri-implantitis. 2016 Oct;27(10):1243-1250. doi: 10.1111/clr.12738. Epub 2015 Nov 20.


To investigate whether specific predictive profiles for patient-based risk assessment/diagnostics can be applied in different subtypes of peri-implantitis. Link

16- Kohal R, Klaus G, Strub JR. Zirconia‐implant‐supported all‐ceramic crowns withstand long‐term load: a pilot investigation. Clin Oral Implants Res. 2006;17(5):565-571.


TZP, study shows that implants fulfil biomechanical requirements for anterior teeth (tested with 1.2 million cycles). Link

17- Kohal R, Finke HC, Klaus G. Stability of Prototype Two‐Piece Zirconia and Titanium Implants after Artificial Aging: An In Vitro Pilot Study. Clin Implant Dent Relat Res. 2009;11(4):323-329.


Study with prototype abutments showing that the biomechanical stability for this prototype is borderline for possible occlusal forces.   Link

18- Andreiotelli M, Kohal R. Fracture strength of zirconia implants after artificial aging. Clin Implant Dent Relat Res. 2009;11(2):158-166.


TZP, study shows that fracture strength values are within clinical acceptance level, ageing in the artificial mouth with 1.2 million cycles.   Link

19- Kohal R, Wolkewitz M, Mueller C. Alumina‐reinforced zirconia implants: survival rate and fracture strength in a masticatory simulation trial. Clin Oral Implants Res. 2010;21(12):1345-1352.


Comparison ATZ / TZP, showing that ATZ can withstand functional loading over an estimated period of 20 years (5 million simulated loading cycles.   Link

20- Kohal RJ, Wolkewitz M, Tsakona A. The effects of cyclic loading and preparation on the fracture strength of zirconium‐dioxide implants: an in vitro investigation. Clin Oral Implants Res. 2011;22(8):808-814.


TZP, showing that the implants are able to withstand occlusal forces even after an extended interval of artificial loading (5 million cycles / roughly 20 years).   Link

21- Akagawa Y, Hosokawa R, Sato Y, Kamayama K. Comparison between freestanding and tooth-connected partially stabilized zirconia implants after two years’ function in monkeys: a clinical and histologic study. J Prosthet Dent. 1998;80(5):551-558.


In vivo animal study, primate model, partially stabilized zirconia implants placed with a 1-stage procedure achieve long-term stability of osseointegration.   Link

22- Scarano A, Di Carlo F, Quaranta M, Piattelli A. Bone response to zirconia ceramic implants: an experimental study in rabbits. J Oral Implantol. 2003;29(1):8-12.


In vivo animal study, zirconia implants, This study concluded that these implants are highly biocompatible and osteoconductive.   Link

23- Kohal RJ, Weng D, Bächle M, Strub JR.  Loaded custom-made zirconia and titanium implants show similar osseointegration: an animal experiment. J Periodontol. 2004;75(9):1262-1268.


In vivo animal study, custom-made zirconia implants osseointegrated to the same extent as custom-made titanium control implants.   Link

24- Sennerby L, Dasmah A, Larsson B, Iverhed M. Bone Tissue Responses to Surface‐Modified Zirconia Implants: A Histomorphometric and Removal Torque Study in the Rabbit. Clin Implant Dent Relat Res. 2005;7(s1):s13-s20. In vivo animal study,


The findings suggest that surface-modified zirconia implants can reach firm stability in bone.   Link

25- Gahlert M, Gudehus T, Eichhorn S, Steinhauser E, Kniha H, Erhardt W. Biomechanical and histomorphometric comparison between zirconia implants with varying surface textures and a titanium implant in the maxilla of miniature pigs. Clin Oral Implants Res. 2007;18(5):662-668.


In vivo animal study, ZrO2r implants can achieve a higher stability in bone than ZrO2m implants. Roughening enhances bone apposition.   Link

26- Depprich R, Zipprich H, Ommerborn M, et al. Osseointegration of zirconia implants compared with titanium: an in vivo study. Head Face Med. 2008;4(1):30.


In vivo animal study, zirconia implants with modified surfaces result in an osseointegration which is comparable with that of titanium implants.   Link

27- Tetè S, Mastrangelo F, Bianchi A, Zizzari V, Scarano A. Collagen fiber orientation around machined titanium and zirconia dental implant necks: an animal study. Int J Oral Maxillofac Implants. 2008;24(1):52- 58.


Zirconia showed connective tissue adhesion that was similar to that seen on the machined titanium surface, but demonstrated limited plaque formation.  Link

28- Langhoff JD, Voelter K, Scharnweber D, et al. Comparison of chemically and pharmaceutically modified titanium and zirconia implant surfaces in dentistry: a study in sheep. Int J Oral Maxillofac Surg. 2008;37(12):1125-1132.


In vivo animal study, comparison between titanium and zirconia, There were no significant differences in Bone Implant Contact at 2 - 8 weeks.   Link

29- Rocchietta I, Fontana F, Addis A, Schupbach P, Simion M. Surface‐modified zirconia implants: tissue response in rabbits. Clin Oral Implants Res. 2009;20(8):844-850.


In vivo animal study, additional specific chemical modifications of the topographically modified zirconia implants do not seem to enhance the Bone Implant Contact.   Link

30- Yamashita D, Machigashira M, Miyamoto M, et al. Effect of surface roughness on initial responses of osteoblast-like cells on two types of zirconia. Dent Mater J. 2009;28(4):461.


In vitro, the overall results demonstrated that NANOZR and 3Y-TZP with rough surface could provide good initial cell responses, adequate for future implant usage.   Link

31- Kohal RJ, Wolkewitz M, Hinze M, Han J, Bächle M, Butz F. Biomechanical and histological behavior of zirconia implants: an experiment in the rat. Clin Oral Implants Res. 2009;20(4):333-339.


In vivo animal study, all tested zirconia and titanium implant surfaces were biocompatible and osseoconductive.   Link

32- Koch FP, Weng D, Krämer S, Biesterfeld S, Jahn‐Eimermacher A, Wagner W. Osseointegration of one‐piece zirconia implants compared with a titanium implant of identical design: a histomorphometric study in the dog. Clin Oral Implants Res. 2010;21(3):350-356.


In vivo animal study, zirconia implants are capable of establishing close BIC rates similar to what is known from the osseointegration behaviour of titanium implants.   Link

33- Schliephake H, Hefti T, Schlottig F, Gédet P, Staedt H. Mechanical anchorage and peri‐implant bone formation of surface‐modified zirconia in minipigs. J Clin Periodontol. 2010;37(9):818-828.


In vivo animal study, all implants achieved osseointegration with similar degrees of BIC and BVD; however, titanium implants showed a higher resistance to removal torque, probably due to higher surface roughness.   Link

34- Stadlinger B, Hennig M, Eckelt U, Kuhlisch E, Mai R. Comparison of zirconia and titanium implants after a short healing period. A pilot study in minipigs. Int J Oral Maxillofac Surg. 2010;39(6):585-592.


In vivo animal study, The results suggest that unloaded zirconia and titanium implants osseointegrate comparably, within the healing period studied.   Link

35- Hoffmann O, Angelov N, Zafiropoulos G-G, Andreana S. Osseointegration of zirconia implants with different surface characteristics: an evaluation in rabbits. Int J Oral Maxillofac Implants. 2011;27(2):352-358.


In vivo animal study, comparable rates of bone apposition in the zirconia and titanium implant surfaces at 6 and 12 weeks.   Link

36- Bormann K-H, Gellrich N-C, Kniha H, Dard M, Wieland M, Gahlert M. Biomechanical evaluation of a microstructured zirconia implant by a removal torque comparison with a standard Ti-SLA implant. Clin Oral Implants Res. 2012;23(10):1210-1216. doi:10.1111/j.1600- 0501.2011.02291.x.


In vivo study, 4 - 12 weeks, biomechanical bone- tissue response of the investigated zirconia implants is non-inferior to that of the well- documented, roughened titanium surface.   Link

37- Möller B, Terheyden H, Açil Y, et al. A comparison of biocompatibility and osseointegration of ceramic and titanium implants: an in vivo and in vitro study. Int J Oral Maxillofac Surg. 2012;41(5):638-645.


In vivo comparison of titanium and zirconia, the results indicated similar biocompatibility and osseointegration for zirconium compared to titanium implants. Link

38- Gahlert M, Roehling S, Sprecher CM, Kniha H, Milz S, Bormann K. In vivo performance of zirconia and titanium implants: a histomorphometric study in mini pig maxillae. Clin Oral Implants Res. 2012;23(3):281-286. In vivo animal study,


The results indicate that there was no difference in osseointegration between ZrO2 implants and Ti-SLA controls regarding peri- implant bone density and BIC ratio.   Link

39- Mai R, Kunert-Keil C, Grafe A, et al. Histological behaviour of zirconia implants: An experiment in rats. Ann Anat - Anat Anzeiger. 2012;194(6):561-566. doi:http://dx.doi.org/10.1016/j.aanat.2012.09.00.


In vivo animal study, osseointegration of zirconia implants after 28 and 56 days, conclusion that surface osseointegrates and is osseoconductive.   Link

40- Aboushelib MN, Salem NA, Taleb ALA, El Moniem NMA. Influence of surface nano-roughness on osseointegration of zirconia implants in rabbit femur heads using selective infiltration etching technique. J Oral Implantol. 2013;39(5):583-590.


In vivo animal study, osseous healing of selective infiltration-etched (SIE) zirconia implants compared to as-sintered zirconia and titanium implants, anhanced osseointegration.   Link

41- Saulacic N, Erdösi R, Bosshardt DD, Gruber R, Buser D. Acid and alkaline etching of sandblasted zirconia implants: a histomorphometric study in miniature pigs. Clin Implant Dent Relat Res. 2014;16(3):313-322.


In vivo animal study, Zeramex T implants with the proprietary surface treatment, osseointegration is confirmed with high BIC.   Link

42- Glauser R1, Sailer I, Wohlwend A, Studer S, Schibli M, Schärer P. Prosthodontics R. Experimental zirconia abutments for implant- supported single-tooth restorations in esthetically demanding regions: 4-year results of a prospective clinical study. Int J Prosthodont. 2004 May-Jun;17(3):285-90.


Zirconia abutments offered sufficient stability to support implant-supported single-tooth reconstructions in anterior and premolar regions. The soft and hard tissue reaction toward zirconia was favorable.   Link

43- Sailer I, Philipp A, Zembic A, Pjetursson BE, Hämmerle CHF, Zwahlen M. A systematic review of the performance of ceramic and metal implant abutments supporting fixed implant reconstructions. Clin Oral Implants Res. 2009;20(s4):4-31.


The 5-year survival rates estimated from annual failure rates appeared to be similar for ceramic and metal abutments. No provision of evidence for differences of the technical and biological outcomes of ceramic and metal abutments.   Link

44- Ekfeldt A, Fürst B, Carlsson GE. Zirconia abutments for single-tooth implant restorations: a retrospective and clinical follow-up study. Clin Oral Implants Res. 2011;22(11):1308-1314. doi:10.1111/j.1600- 0501.2010.02114.x.


Zirconia abutments for single-implant crowns seem to demonstrate good short-term technical and biological results (> 3 years).   Link

45- Vanlıoglu BA, Özkan Y, Evren B, Özkan YK. Experimental custom‐made zirconia abutments for narrow implants in esthetically demanding regions: a 5-year follow-up. Int J Oral Maxillofac Implants. 2011;27(5):1239-1242.


Custom-made zirconia abutments offered sufficient stability to support all-ceramic restorations over narrow implants in anterior regions over a 5-year period. The soft and hard tissue reactions to zirconia were favorable. Link

46- Kim S-S, Yeo I-S, Lee S-J, et al. Clinical use of alumina-toughened zirconia abutments for implant-supported restoration: prospective cohort study of survival analysis. Clin Oral Implants Res. 2013;24(5):517-522. doi:10.1111/j.1600-0501.2011.02413.x.


Alumina-toughened zirconia abutments are likely to exhibit excellent long-term survival in clinical use for fixed restorations. Single tooth replacement at the molar region may require special care.   Link

47- Hosseini M, Worsaae N, Schiødt M, Gotfredsen K. A 3-year prospective study of implant-supported, single-tooth restorations of all-ceramic and metal-ceramic materials in patients with tooth agenesis. Clin Oral Implants Res. 2013;24(10):1078-1087. doi:10.1111/j.1600-0501.2012.02514.x.


The biological outcomes at the zirconia and metal abutments were comparable. All-ceramic crowns demonstrated better colour match, but higher frequency of marginal discrepancy compared to metal-ceramic crowns.   Link

48- Zembic A, Bösch A, Jung RE, Hämmerle CHF, Sailer I. Five-year results of a randomized controlled clinical trial comparing zirconia and titanium abutments supporting single-implant crowns in canine and posterior regions. Clin Oral Implants Res. 2013;24(4):384-390. doi:10.1111/clr.12044.


No statistically or clinically relevant differences between the 5-year survival rates, and the technical and biological complication rates of zirconia and titanium abutments in posterior regions.   Link

49- Zembic A, Philipp AOH, Hämmerle CHF, Wohlwend A, Sailer I. Eleven- Year Follow-Up of a Prospective Study of Zirconia Implant Abutments Supporting Single All-Ceramic Crowns in Anterior and Premolar Regions. Clin Implant Dent Relat Res. 2014:n/a - n/a. doi:10.1111/cid.12263.


Customized zirconia single implant abutments exhibited excellent long-term outcomes in anterior and premolar regions. (> 11 y).   Link


50- Roehling S, Astasov-Frauenhoffer M, Hauser-Gerspach I, Braissant O, Woelfler H, Waltimo T, Kniha H, Gahlert M. In Vitro Biofilm Formation on Titanium and Zirconia Implant Surfaces. J Periodontol. 2017 Mar;88(3):298-307. doi: 10.1902/jop.2016.160245. Epub 2016 Oct 7.   Link


Zirconia implant surfaces showed a statistically significant reduction in human plaque biofilm formation after 72 hours of incubation in an experimental anaerobic flow chamber model compared with titanium implant surfaces.

80- Ermüdungstests nach ISO14801; Report Nr. 16010106-D-CS vom 31.3.2016 und Report Nr. 14070102-D-CS vom 21.4.2015; Spineserv GmbH & Co. KG, Söflinger Strasse 100, DE-89077 Ulm.  Link
81 Locator® is a registered trademark of Zest IP Holdings LLC, USA.     Link
82- Information PEEK-OPTIMA® Ultra-Reinforced  Invibio T-PB-PUR-E-0031-A (3/2013).    Link

83- Boyer R et al., Materials Properties Handbook: Titanium Alloys, ASM International, 1994. Link