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science & practice Ceramic dental implants: What beneﬁts do they offer? By Brendan Day, DTI (cid:132) Although the search for metal-free implant materials began in the late 1960s, recent improvements in ce- ramic materials have made their de- velopment process considerably eas- ier. As an alternative to tita nium- based implants, ceramic implants of- fer greater aesthetic appeal and possess tis- sue-friendly properties. This article highlights some of the companies that currently offer ceramic implants and explore why they are still much less commonly used than their tita- nium counterparts. antiallergenic and For the better part of four dec- ades, titanium and titanium-alloy on their long-term use. However, in the Clinical Implant Dentistry and Re- lated Research journal, a 2015 study of zirconia implant abutments that supported entirely ceramic crowns found that after 11 years of use, these abutments had a cumulative success rate of 96.3 per cent. In addition, a 2010 study in the journal for Clinical Oral Implants Research found that the osseointegration of zirconia im- plants is similar to that of titanium implants. Despite these positive ﬁnd- ings, the sheer lack of depth in research has deterred the majority of dental professionals from using ceramic implants. plants should continue to grow in popularity. “Ceramic implants today, in my experience and for many fellow ce- ramic implantologists, have the same success rate as titanium implants. They are now as versatile as metal im- plants thanks to the evolution in de- sign, surface enhancement protocols and biomaterial improvements”, says Dr Sammy Noumbissi, President of the International Academy of Ce- ramic Implantology (IAOCI), an asso- ciation entirely dedicated to ceramic alternatives of metal-based implants. “Various treatment modalities are ap- plicable with ceramic implants: im- aesthetically pleasing, metal-free im- plants. Given that one of the main barriers to zirconia implants is their comparatively high price, Straumann aims to make it a more widely availa- ble and affordable option. In addition, TAV Dental is one of the few companies that offer both one-piece and two-piece ceramic im- plants. Their primary focus is to cre- ate state-of-the-art zirconia dental products through an innovative ap- proach to technology, fostered by their parent company, TAV Medical. TAV Dental offers a variety of one- piece and two-piece zirconia im- plants that are entirely white, a dis- screw-in implant, allowing for a ﬂe- xible restoration with a high level of biocompatibility. Combining this with a higher resistance to corrosion results in a product that rivals tita- nium implants in performance. Z-Systems is a Switzerland- based company that, through their Zirkolith range of products, offers extensive ce- ramic implant options. Similar to TAV Dental, they offer both one-piece and two-piece implants and their osseoin- tegration rate is similar to leading ti- tanium implants. Another company, VITA Zahnfabrik, has entered the ce- ramic implant market with its own one-piece cylindroconical ceramic im- © Alex Mit/Shutterstock.com dental implants have been success- fully used as tooth replacements. However, recent research ﬁndings have raised fears regarding these im- plants’ tendency to corrode and de- cay. During the corrosion process, ti- tanium implants release particles or ions into their surrounding tissue, which could lead to implant failure and bone disintegration. A 2014 pa- per published in the Open Journal of Stomatology, titled “Corrosion aspect of dental implants—An overview and literature review”, detailed this pro- cess by explaining that the compati- bility of titanium implants is largely the result of a thin layer of oxide that forms on their surface. This layer can erode due to movements between bone tissue and the implant during loading conditions, which could lead to corrosion, leaking and an overall weakening of the implant. Given their non-metallic nature, ceramic im- plants are not susceptible to this form of decay. However, the lack of concrete ev- idence concerning the mechanical properties and osseointegration of ce- ramic implants has impeded their up- take, although this is partially due to their relative newness. The FDA only approved ceramic implants in 2007. Additionally, there have also been rel- atively few clinical studies conducted The one-piece design of ceramic implants is another element that has both positive attributes and draw- backs. A one-piece implant elimi- nates the connective point between the abutment and the ﬁxture, ideally reducing bacterial growth and im- proving overall oral health. However, a high level of attention to detail with regards to the implant’s placement is required, as it does not possess the same capability as titanium implants to correct errors in placement with an angled abutment. This inability to correct errors in placement created the demand for two-piece ceramic im- plants that allow for more ﬂexible placement options and better healing. The American Academy of Im- plant Dentistry estimates that, while three million Americans currently have at least one dental implant, this number is rising by half a million each year. Given the growing global demand for dental implants, it is more important than ever to provide patients with options that best suit their individual needs. Although they are an expensive option, ceramic im- plants are increasingly meeting the standards for stability, compatibility and osseointegration that titanium- based implants have set. Combining this with their aesthetic appeal and anti allergenic nature, ceramic im- mediate placement, immediate tem- porization, full arch and full mouth rehabilitation can be performed with excellent and predictable outcomes. I, however, believe that adopting ce- ramic implants should be accompa- nied by training or shadowing from an experienced clinician, even if one has experience with titanium im- plants.” Only a few implant manufac- turers focus on ceramics Interestingly, most of the major implant manufacturers do not have a ceramic implant on the market, let alone in development. The most nota- ble exception is Straumann. Head- quartered in Basel, Switzerland, Straumann is an international leader in implant and restorative dentistry, with its products and services avail- able in more than 100 countries. Straumann currently offers PURE, a completely zirconia-based implant that is ivory-coloured, similar to a nat- ural tooth. The company recently an- nounced that it has entered into a partnership with maxon motor, which will allow it to develop dental implant components through ce- ramic injection moulding rather than conventional cutting techniques. The move demonstrates the com pany’s recognition of the growing market for tinct aesthetic improvement from the metallic colour of a titanium im- plant that is often visible. Further- more, the inert nature of TAV Den- tal’s zirconia implants make them less likely to fracture and highly re- sistant to foreign compounds as well as the application of heat, further beneﬁtting patients. Another company manufactur- ing ceramic implants, CeraRoot, intro- duced its zirconia implant system to the European market in 2005 and the US market in 2011. Located in Barce- lona, Spain, the company utilised im- provements in ceramic materials to design a one-piece ceramic implant. Whereas implants have two separate parts—the ﬁxture and the abutment—CeraRoot’s prod- uct incorporates both elements into one implant. This ensures that there is no prosthetic connection where bacteria can grow, theoretically lead- ing to better periodontal health. titanium-based One of the primary players in ce- ramic implantology is Dentalpoint with their metal-free Zeramex sys- tem. Established in 2005, the com- pany spent four years researching and developing a two-part implant made of zirconia, presenting it to the world in 2009. Zeramex offers a revo- lutionary approach to ceramic im- plantology through their metal- free, plant. In operation since 1924, and with a focus on innovation, VITA claims their ceramic implant offers faster, safer healing than titanium- based implants. With a compatibility rate of 98 per cent for more recent models, zirconia-based ceramic im- plants are increasingly matching the standards set by titanium implants and have thereby become a more vi- able option. As Noumbissi concludes, “The fu- ture of ceramic implants is really bright for many reasons. Patients in- creasingly ask for safer, less invasive solutions, as well as metal-free alter- natives for teeth repair or replace- ment. Dental attitudes and under- standing of zirconia and bioceramics are slowly but steadily evolving, with a deﬁnite shift toward biological and inert materials. There has also been a shift in the healthcare industry to- wards wellness and well-being, and providing therapies that have little to no side effects.” Since some of the larger players in the implant industry are incorpo- rating, or have already adopted ce- ramic implants in their product lines, either by development or by corpo- rate acquisitions, implantologists could eventually look at ceramic im- plants as a viable alternative to tita- nium. (cid:26) 26th EAO Annual Scientiﬁc Meeting 11

today EAO Madrid October 06, 2017

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