INDIAN DENTAL JOURNAL

Official Publication of Society of Medical Dental & Public Health

ZIRCONIA AS AN IMPLANT BIOMATERIAL

Dr. Gaurav Singh 1
1
Associate Professor, Department of Prosthodontics, ZA Dental College, AMU, Aligarh, India
Address for Correspondence: Dr. Gaurav Singh, Department of Prosthodontics, ZA Dental College, AMU,
Aligarh, India.
E-mail: [email protected]

ABSTRACT
Titanium has been the most popular material of choice for dental implantology over the past few decades.
Its properties have been found to be most suitable for the success of implant treatment. But recently,
zirconia is slowly emerging as one of the materials which might replace the gold standard of dental
implant, i.e., titanium. In the last few years, zirconia dental implant has emerged as an alternative for
titanium implant due to its potential to osseointegrate and having other beneficial properties like its
translucency and white color which mimics the natural teeth. It is radiopaque similar to titanium and can
be easily visualized on the radiograph. This review of literature aims to discuss various properties of
zirconia like osseointegration, biocompatibility, and less bacterial colonization, which make it a
biomaterial suitable to be used as dental implant, and tries to find out whether the researches done till date
authenticate its use.

KEYWORDS:

I NTRODUCTION - The loss of human

teeth and the problems associated with
their successful replacement have
plagued mankind for centuries. Every year
many people lose their teeth because of
functionally effective
appearance.2
The success of biomaterials in the body
depends on factors such as the material
and pleasing in

properties, design, and Biocompatibility of

decay, disease, accidents and old age.
the material used, as well as other factors
Following loss of a natural tooth, artificial
not under the control of the engineer,
tooth implantation was often attempted with
including the technique used by the surgeon,
a variety of materials, including carved bone
the health and condition of the patient, and
or ivory, various metals, and precious
the activities of the patient. The credit for
stones.1
the origin and evolution of
As time passed and civilization advanced todaysbioimplants are due to Harold Ridley,
with the development of biological, Paul Winchell, Per-Ingvar Branemark, Otto
chemical and physical sciences, there Wichterle, John Charnley and others. Their
occurred a slow but steady increase in both works at the laboratory were first tested on
the quantity and quality of useful materials animals which led to the birth of the ultimate
available for dental implants. The material biomaterials that could be accepted by the
should be biological compatible, readily human system. 3
available, reasonably inexpensive and easy
The various requirements of the implant
to use, to develop prosthesis that is
biomaterial are:3

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 INDIAN DENTAL JOURNAL
Official Publication of Society of Medical Dental & Public Health

1) It should be acceptable by the human Brittle materials such as porous ceramics

body i.e. should not cause any adverse and vitreous carbon have also been tried
effects like allergy, inflammation and during this period as candidates for
toxicity either immediately after surgery or implants. Ceramics are considered as an
under post-operative conditions. implant material because of its crystalline
structure which is very similar to bone but
2) It should possess sufficient mechanical
because of their brittle nature and low
strength to sustain the forces to which they
strength their use has been discontinued as
are subjected.
an implant material as they have low load
3) They must be able to form a stable bone- bearing capacity.
implant interface that is capable of carrying
In early 20th century metals were used as a
occlusal loads, and transferring or
dental implant material. Metals and metal
distributing stresses to the adjacent bone so
alloys used for implants have included
that bone vitality is maintained over long
titanium and titanium alloys, tantalum,
periods.
stainless steel, cobalt chromium alloys, gold
4) It must not interfere with the healing of alloys and zirconium alloys. These materials
host tissue are selected based on their high corrosion
5) It should remain intact for a longer period resistance, strength, rigidity, ease of shaping
and machining, and suitability for a wide
6) It should have very high corrosion and range of sterilization techniques.
wear resistance
Many of the metals and alloys (gold,
7) It should Osseo integrate stainless steel, cobalt-chromium) are now
Implants are traceable to early Egyptians obsolete within the oral implant industry.
and South Central American cultures and Titanium (Ti) and its alloys (mainly Ti-6Al-
have evolved into the present that are now 4V) have become the metals of choice for
experiencing explosive popularity. The dental implants. Metals bond with a bone via
earliest dental implants were of stone and a micromechanical interlocking and this can
ivory cited in archeological records of China be further modified by different surface
and Egypt before the Common Era.4 Gold treatments and surface coatings and
and Ivory dental implants were used in the modifications in surface designs. These
l6th and 17th centuries. Metal Implants modifications increase the surface area
devices of gold, Lead, Iridium, Tantalum, thereby improving the mechanical bonding
stainless steel and cobalt alloy were with bone.5
developed in the early 20th century. Modern Implant dentistry has been
Between these two periods a variety of revolutionized from the period of mid 1930's
polymers, including ultrahigh molecular to present .
weight polyurethane, polyamide fibers, The material of choice for oral endosseous
polymethyl methacrylate resin, implants has been and still is commercially
polytetrafluoroethylene, and polyurethane, pure titanium. Ceramics have however been
have been used as dental implant materials proposed as an alternative to titanium,
but Inferior mechanical properties, lack of because ceramic materials are white and are
adhesion to living tissues, and adverse mimicking natural teeth better than the gray
immunologic reactions have eliminated the titanium thereby improving the esthetics
application of these materials.5, 6, 7, 8

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 INDIAN DENTAL JOURNAL
Official Publication of Society of Medical Dental & Public Health

Secondly, Potential health hazards may temperatures. The metastable tetragonal

result from the release of titanium particles phase easily transforms to the monoclinic
and corrosion products provoking phase, which forms the basis for the
unwelcome host reactions. toughening mechanism of the ceramic
material .
Ceramic materials for oral implants were
already investigated and clinically used They are considered to be inert in the body
some 30- 40 years ago. At that time, the and exhibit minimal ion release compared
ceramic material utilized was aluminum with metallic implants. Yttrium-stabilized
oxide (polycrystal or single crystal). tetragonal zirconia polycrystals appear to
Currently the material of choice for ceramic offer advantages over aluminum oxide for
oral implants is Y-TZP or possibly Ce-TZP dental implants because of their higher
(ceria-stabilized TZP). Compared with fracture resilience and higher flexural
alumina, Y-TZP has a higher bending strength. They have also been used
strength (1200MPa), a lower modulus of successfully in orthopedic surgery to
elasticity (200GPa) and higher fracture manufacture ball heads for total hip
toughness (KIC: 6 - 10MPam1/2). replacements; this is still the current main
application of this biomaterial.
Preclinical investigations on the stability of
Y-TZP oral implants have shown that this Zirconia seems to be a suitable dental
material may be able to withstand oral implant material because of its tooth like
forces over an extended period of time. color, mechanical properties, and therefore
Animal experiments testing the biocompatibility. Apical bone loss and
biocompatibility and bone integration of gingival recession associated with implants
zirconia ceramics are promising.9 often uncover portions of the metal implant,
revealing a bluish discoloration of the
ZIRCONIA AS AN IMPLANT
overlying gingiva. The use of zirconia
Zirconia-based ceramics are the latest implants avoids this complication and
exceptionally high strength materials to be accedes to the request of many patients for
introduced into dentistry.10 The strength and metal-free implants. The material also
toughness of zirconia can be accounted for provides high strength, fracture toughness,
by its toughening mechanisms, such as crack and biocompatibility. The inflammatory
deflection, zone shielding, contact shielding, response and bone resorption induced by
and crack bridging. Prevention of crack ceramic particles are less than those induced
propagation is of critical importance in high- by titanium particles, suggesting the
fatigue situations, such as those encountered biocompatibility of ceramics.12
in mastication and parafunction. This
Dubruille et al 13 compared the BIC on 3
combination of favorable mechanical
types of dental implants: titanium, alumina,
properties makes zirconia a unique and
and zirconia (Sigma, Lausanne,
stable material for use in high-load
Switzerland); these were placed into the dog
situations.11
mandible. At 10 months, BIC was found to
Zirconia exists in three major phases. At be 68% for alumina, 64.6% for zirconia, and
room temperature and atmospheric pressure, 54% for titanium. Scarano et al 14
the thermodynamic phase of pure zirconia is demonstrated the bone response to zirconia
the monoclinic phase, which changes to the implants at 4 weeks. A great quantity of
intermediate tetragonal phase at higher newly formed bone was observed with

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 INDIAN DENTAL JOURNAL
Official Publication of Society of Medical Dental & Public Health

zirconia surfaces, and the percentage of BIC cases. Besides these favorable properties,
was 68.4%. These studies concluded that zirconia is proposed to accumulate dental
zirconia implants are highly biocompatible plaque to a lesser extent than titanium.
and osteoconductive. Further, in a short-term
Hoffmann et al 15 histologically assessed the clinical study, it was observed that the
degree of early bone apposition around biologic, aesthetic, and mechanical
zirconia dental implants (Z-system, properties of zirconia were favorable, and
Konstanz, Germany) at 2 and 4 weeks the material could be used in various
following insertion. The zirconia implants prosthetic indications on teeth or in
demonstrated a slightly higher degree of implants.
bone apposition (54%–55%) compared with Currently, 9 zirconia dental implant systems
the titanium implants (42%–52%) at the 2-
are commercially available. The Sigma
week time point. implant (Sandhause, Incermed, Lausanne,
ZIRCONIA AS A COATING Switzerland), which was developed in 1987,
MATERIAL was the first zirconia dental implant system.
Additional zirconia implant systems are the
Although zirconia may be used as an
CeraRoot system (Oral Iceberg, Barcelona,
implant material by itself, zirconia particles
Spain), the ReImplant system (ReImplant,
are also used as a coating material of
Hagen, Germany), the White Sky system
titanium dental implants. A sandblasting
(Bredent Medical, Senden, Germany), the
process with round zirconia particles may be
Goei system (Goei Inc, Akitsu-Hiroshima,
an alternative surface treatment to enhance
Japan), the Konus system (Konus Dental,
the osseointegration of titanium implants.
Bingen, Germany), the Z-systems (Z-
Cranin et al 16 investigated the
systems, Konstanz, Germany), and the
osseointegration of vitallium implants with
Ziterion system (Ziterion, Uffenheim,
the addition of ceramic coatings, such as
Germany).
alumina (n 5 9) or zirconia (n 5 9). All
alumina-coated vitallium implants and 5 of CONCLUSION
the zirconia coated vitallium implants failed Osseointegration of zirconia dental implants
after 32 weeks. Investigators concluded that may be comparable with that of titanium
zirconia could be considered a superior implants. They were also found to have low,
ceramic coating to alumina. well distributed, and similar stress
Sollazo et al 17 observed titanium implant distribution when compared with titanium
surfaces coated with zirconia, which can implants. Furthermore, zirconia particles
potentially have specific biologic effects. used for surface modifications of titanium
The BIC percentage was 31.8 6 3.05% for implants may have the potential to improve
uncoated titanium implants and 43.8 6 initial bone healing and resistance to
2.05% for titanium implants coated with removal of torque. The surface roughness of
zirconia at 4 weeks. It was found that zirconia was found to be comparable with
zirconia coating would enhance implant that of titanium implants. Although
osseointegration. fabrication of surface modifications for
zirconia is difficult, CO2 lasers revealed
With the development of dental CAD/CAM
distinct surface alterations to zirconia, and
systems, high-strength ceramic is becoming
additional studies about this technique may
the first choice in treating aesthetic implant

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 INDIAN DENTAL JOURNAL
Official Publication of Society of Medical Dental & Public Health

help to improve surface roughness. Coated SUMMARY

or surface-modified zirconia implants
Zirconia is an aesthetic alternative to
showed higher removal torque values than
titanium implants. As for mechanical
machined zirconia implants. To fulfill
properties, zirconia possesses sufficient
biomechanical requirements, restoring
strength and fracture strength to withstand
zirconia implants with highstrength ceramics
masticatory forces. However, more studies
or metal ceramics would be beneficial.
are needed to evaluate the modulus of
Although a few short-term clinical reports
elasticity and tensile strength of zirconia as
are available and provide satisfactory
an implant material. Despite the significant
results, controlled clinical trials with a amount of literature supporting the use of
follow-up of 5 years or longer should be zirconia as an implant material, there is need
performed to properly evaluate the clinical for long-term clinical studies on the subject.
performance of zirconia implants and to
recommend them for routine clinical use.

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Official Publication of Society of Medical Dental & Public Health

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