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479

Zirconia for Teeth and Implants:

A Case Series

Andrea Kollar, DDS, Dr Med Dent* In the last decade, the use of ceramic
Sandra Huber, DDS, Dr Med Dent* materials for dental reconstructions has
Ernö Mericske, DDS, Dr Med Dent** increased. Ceramics show favorable
Regina Mericske-Stern, DDS, Dr Med Dent, PhD*** properties such as durability and bio-
compatibility. A variety of different all-
This case series reports on the use of nonsilica-based high-strength full ceramics ceramic systems are currently available
for different prosthetic indications. Fifty-two consecutive patients received tooth- for use.
or implant-supported zirconia reconstructions during a 2-year period. The obser- Silica-based glass ceramics are
vation period for reexamination was 12 to 30 months. The most frequent indica- favorable with regard to optical appear-
tions were single crowns and short-span fixed partial dentures. A few implant ance and esthetic quality, but they do
superstructures were screw-retained, whereas all remaining restorations were not meet requirements regarding
cemented on natural teeth or zirconia implant abutments. Clinical examination mechanical strength and stability such
included biologic (probing depths, bleeding on probing) and esthetic (Papilla
as fracture toughness or homogeneity.
Index) parameters, as well as technical complications. No implant was lost or
This limits their range of indications.
caused any problems, but two teeth were lost after horizontal fracture. Overall,
They are preferably used for
the periodontal parameters were favorable. Fractures of frameworks or implant
abutments were not observed. Abutment-screw loosening occurred once for one
inlays/onlays, veneers, and single
premolar single crown. Furthermore, five implant crowns in the posterior region crowns,1 particularly in the esthetic
exhibited chipping of the porcelain veneering material. With regard to esthetics, zone. For zones of heavy load and for
no reconstructions were considered unacceptable, but three crowns were remade long-span fixed partial dentures (FPDs),
shortly after delivery. In this short-term study, it was observed that biologic, stronger ceramic materials are required.
esthetic, and mechanical properties of zirconia were favorable, and the material Zirconia and alumina are high-
could be used in various prosthetic indications on teeth or implants. (Int J strength ceramics that are superior to
Periodontics Restorative Dent 2008;28:479–487.) feldspathic ceramics with regard to
mechanical properties. 1,2 These
ceramics are characterized by a
*Assistant Professor, Department of Prosthodontics, University of Bern, Bern, Switzerland.
**Senior Lecturer, Prosthodontist, Department of Prosthodontics, University of Bern, Bern,
dense, monocrystalline homogeneity
Switzerland. and are free from any glass phases.
***Professor, Director and Head, Department of Prosthodontics, University of Bern, Bern, They are characterized by low thermal
Switzerland.
conductivity, low corrosion potential,
Correspondence to: Dr Regina Mericske-Stern, Department of Prosthodontics, good radiographic contrast, and good
Freiburgstrasse 7, 3010 Bern, Switzerland; e-mail: regina.mericske@zmk.unibe.ch. biologic compatibility. Zirconia has

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480
been tentatively used in orthopedic
medicine for hip joint replacement.
Its fracture toughness and flexural
strength are significantly higher com-
pared to other ceramics. Therefore,
it is suggested to use zirconia frame-
works for FPDs in the posterior region,
ie, in zones of heavy load, and for
implant abutments.1–3
Along with zirconia frameworks,
efficient computer-aided design/
computer-assisted manufacture (CAD/
CAM) systems have been developed
and analyzed.4,5 Laboratory studies
have investigated the physical charac-
teristics of zirconia and its behavior
under experimental load.6 Early clinical
studies with zirconia abutments on
implants reported good stability of
implant-supported single reconstruc-
tions.7–10 Marginal bone levels around
implants were stable and healthy soft
tissues were observed.7
Various CAD/CAM systems are on
the market for designing and process-
ing zirconia frameworks. Industrially fab-
ricated zirconia blanks are available for
the milling process. The zirconia mate-
rial for prosthetic frameworks is densely
sintered, yttrium stabilized, and hot iso-
static pressed. The size of blanks may
still limit the size of prosthetic frame-
works. Densely sintered zirconia is
extremely hard, and the milling process
is complex. Some CAD/CAM systems
use presintered, so-called green stage
zirconia that simplifies the milling
process but is subject to changes in
volume during sintering. Thus, milling
zirconia remains sensitive, slow, and
expensive. Two studies of FPDs with
tooth-supported zirconia frameworks
were recently published.11,12 Further
reports of in vitro and in vivo testing of
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Page 480
zirconia frameworks with implant
support are available.13–16
The aim of this case series was to
evaluate the application of zirconia in
different prosthetic indications on teeth
and implants. Esthetic, biologic, and
technical parameters were used for
clinical examination.
Method and materials
Patients, teeth, and implants
Over a period of 2 years, 52 patients
were consecutively treated with
zirconia superstructures supported by
implants or teeth. These patients pre-
ferred to have reconstructions made
from ceramic material, and they all
provided informed consent. Patients
were responsible for the full cost of
treatment. All patients were reexam-
ined after an observation time of 12 to
30 months. Fifty-two patients—
36 (63%) women and 16 (37%) men—
with a median age of 50.2 years
received a total of 262 zirconia FPDs
on 76 teeth and 105 implants. In 15
patients, a combination of both types
of restorations was used.
All patients receiving implants
were admitted to surgery according
to the same selection criteria. Exclusion
criteria were as follows:
• Regular medications with corti-
costeroids
• Poorly controlled diabetes
• Heart attack within the last 6
months
• Any disease that would not allow
placement of implants under local
anesthesia
• Psychiatric problems
• Unrealistic expectations
Smokers (n = 6) were informed
about the possible negative influence
on treatment outcome, and a smoking-
cessation program was recommended.
Surgical procedures
Implant surgery was performed by the
same two clinicians or under their
supervision. All patients received peri-
operative antibiotics. Replace Select
Tapered Implants (Nobel Biocare) were
placed. During surgery, minor local
bone augmentation by placement of
a membrane and filling material was
simultaneously performed for 11% of
the implants. For the augmentation
technique, the combination of graft
material (Bio-Oss, Geistlich) with a
resorbable membrane (BioGide,
Geistlich) was used.
The standard surgical protocol
defined minimum healing times of 6
weeks in the mandible and 8 to 10
weeks in the maxilla. When local aug-
mentation was performed, a minimum
of 3 months was maintained. Fifteen
implants were immediately placed in
extraction sockets, ie, during the same
surgical intervention when the teeth
were extracted. Indications for that
procedure included trauma of an ante-
rior tooth, endodontic failures, longi-
tudinal tooth fracture, and high caries
activity with favorable bone conditions
of the extraction socket. Detailed
results regarding the immediate
implant placement will be published
separately.
Mericske-Stern.qxd 9/22/08 3:36 PM Page 481
Prosthetic procedures
Procera (Nobel Biocare) technology
was applied to fabricate all prosthetic
parts from zirconia. Small units, such as
single crowns, implant abutments, and
telescopes were scanned and
designed using the Procera Piccolo or
Procera Forte Scanner, while short-
span FPDs were exclusively designed
with Procera Forte Scanner. The labo-
ratory technician fabricated a resin
pattern form scanned using the dou-
ble-scan process, or the FPD was com-
pleted virtually using the appropriate
computer software. After the scanning
process, the electronic data were sent
to the milling center in Sweden. For
the scanning and milling procedure of
two large FPDs (full arch), the waxup of
the framework had to be sent directly
to the Procera milling center. The
veneering of the zirconia frameworks
was completed with different ceramic
materials (Cerabien Noritake, e.max
Ceram, Ivoclar Vivadent; Nobel
Rondo, Nobel Biocare).
The tooth preparation followed
specific guidelines, with lateral prepa-
ration depth up to 0.8 mm and
occlusal reduction of a minimum of
1.5 mm to reach sufficient stability of
the zirconia copings.17 As determined
by the manufacturers, the wall thick-
ness of zirconia is 0.6 mm, and an
occlusal space of 1.5 to 2 mm is
required. The preset size of the
approximal connectors was 3 ⫻ 3 mm.
The neck portions of implant
crowns penetrating the soft tissue
were kept free from veneering mate-
rial since good cellular adherence of
the soft tissue to the zirconia material
was expected.18
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481
For cementation, Panavia • Biologic parameters such as caries
(Kuraray) was used for cementation of and loss of vitality of teeth, loss of
single crowns and FPDs to zirconia osseointegration, and fracture of
implant abutments. Panavia and in a teeth were recorded.
few cases Variolink (Ivoclar Vivadent) or • Technical complications included
Ketac-Cem (3M ESPE) were used for any problem or failure related to the
cementation onto teeth. All zirconia zirconia part of the reconstruction,
abutments and a minority of the the veneering material, decemen-
implant-supported reconstructions tation, or the screw connection of
were directly screw retained. the abutment to the implants.
Clinical examination Statistical analysis
After completion of the treatment, all Descriptive statistics were used for
patients were included in the regular patient demographics, implants, and
maintenance program with at least two zirconia reconstructions. Because of
visits per year in cooperation with a the short observation period and
dental hygienist. The patients were variety of prosthetic indications, other
reexamined separately by one inde- statistical methods were not applicable.
pendent investigator who had not
been involved in the treatment of the
patients. The observation time was at
12 to 30 months. The clinical parame-
ters included the following:
• Measurements of probing depth
(PD) and bleeding on probing
(BOP) were performed at four sites
on all teeth and implants.
• The Papilla Index of Jemt and
Lekholm19 was used to describe
the gingival and peri-implant soft
tissue adaptation.
• The presence of recessions was
identified for teeth and implants.
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482

Fig 1a Distribution of abutment teeth in

8 Maxilla the maxilla and mandible.

2
No. of teeth

6
Mandible
8
6 5 4 3 2 1 1 2 3 4 5 6

Tooth number (FDI)

Fig 1b Distribution of implants in the

12 Maxilla maxilla and mandible.
10

6
No. of implants

4
Mandible
6
6 5 4 3 2 1 1 2 3 4 5 6

Tooth number (FDI)

Results abutments on implants. No problems

Figure 1 shows the distribution of abut-
ment teeth and implants involved in
zirconia reconstructions. All prosthetic
treatments are shown in Table 1. The
majority were single units, such as sin-
gle crowns, telescopes, and zirconia
with implants were observed, and no
implant was lost during the observation
time. Two teeth, both single crowns,
were lost because of horizontal fracture
in one patient with bruxism habits, after
13 and 16 months. The zirconia crowns
remained intact.

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483

Table 1 Distribution of prosthetic Table 2 Papilla Index at the teeth and

treatments used in the study implants after treatment
With With Total Papilla Index Implants (%) Teeth (%)
implant tooth zirconia
0 7 3
Treatment support support units
1 52 27
Single crowns (screw retained) 13 – 13 2 13 27
Single crowns (cemented) 27 31 58 3 28 40
RPD telescopes 8 32 40 4 0 3
FPD (abutments) 47 13 60
FPD (pontics) 33 7 40
Implant abutments 51 – 51
Total zirconia units 179 83 262
RPD = removable partial denture; FPD = fixed partial denture.

Periodontal and peri-implant one supported by an implant and two

probing measurements did not
exceed 6 mm at any tooth or implant
site, and 89% of all teeth and 83% of
all implants had PD less than 4 mm.
Overall, 78% of teeth and 70% of
implants did not exhibit positive BOP
at any site. No caries developed over
the course of the present study.
Three crowns on implants in two
patients, one single crown on a tooth
in one patient, and three telescopes on
teeth in two patients showed slight
marginal recession; however, these did
not show increased PD. No implant
margin was visible in any patient or
reconstruction. Two teeth with zirconia
telescopes required endodontic treat-
ment 1 year after completion of the
treatment. Table 2 shows the results
regarding the Papilla Index for teeth
and implants. In general, scores for the
teeth were slightly better. Shape, color,
and form of the single crowns and
FPDs were mostly found to be accept-
able or good. Three single crowns,
by teeth, were considered by the clin-
ician to be unacceptable in shape and
color, even though the patients had
accepted them. These crowns were
remade shortly after delivery.
The clinical assessment of the
zirconia frameworks at the time the
prostheses were delivered revealed
proper fit of all superstructures. No
needs for remake were found during
the reexaminations. No framework
fracture occurred. The analysis of tech-
nical complications revealed chipping
of the Nobel Rondo veneering in five
posterior crowns in two patients.
Abutment screw loosening was
observed for one premolar single
crown. No differences regarding
biologic, esthetic, and technical
parameters between the types of luting
were found.
Several clinical cases will now be
presented as examples of the pros-
thetic treatment.

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484
a
Figs 2a to 2d (a) Radiograph after
implant placement. (b) Screw-retained sin-
gle crown. The subgingival border of the
zirconia crown, which is in contact with the
peri-implant soft tissue, is free of veneering
material. (c) Soft tissue and gingival border
at crown placement. (d) Contour of the gin-
gival margin and papillae 18 months later.
Case 1
A 24-year-old woman required
replacement of a lateral incisor (pri-
mary tooth) with an implant because of
root resorption (Fig 2). The maxillary
right canine was also missing. The root
was removed, and an implant was
placed 6 weeks later. A zirconia crown
was mounted after 10 weeks and
retained with a screw. Two weeks after
treatment, the papilla had not yet
regenerated. Eighteen months later,
the Papilla Index was 2, with a well-
shaped gingival contour and natural
color.
Case 2
A 68-year-old woman who had Sjögren
Syndrome for several years exhibited
high caries activity on all natural ante-
rior teeth in spite of regular care and
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b d
fluoridation (Fig 3). In the posterior
region, some teeth had been restored
with crowns, and implants had been
placed. The maxillary right premolar to
central incisor and left canine to
central incisor were extracted, and
implants were placed immediately at
the sites of the right premolar, canine,
and central incisor and the left central
incisor and canine. The patient
received a provisional FPD after a heal-
ing time of 10 weeks. This was later
replaced with two short-span FPDs
with zirconia frameworks and luted
onto individually cast zirconia abut-
ments. The Papilla Index did not
change over an observation period of
30 months.
Case 3
A 71-year-old woman with a highly
reduced dentition in the mandible
c
received a telescope-retained remov-
able partial denture in a student course
(Fig 4). The primary telescope crowns
on teeth were made from zirconia, and
the secondary telescope crowns were
processed using the galvanoforming
technique. This elegant solution is
characterized by high technical quality
and biologically favorable materials.
Case 4
In a 28-year-old man, a restoration
replacing the congenitally missing
maxillary right second premolar had to
be removed (Fig 5). The gap size cor-
responded to only one premolar. An
implant was placed and three single
crowns were fabricated to restore
these three maxillary units. All three
crowns were cemented either on the
teeth or on a zirconia abutment of the
implant.
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485

Figs 3a to 3d (a) Anterior teeth with an

irregular gingival border, low scalloped
papillae, and deep overbite, root caries,
and multiple fillings. They were extracted
and implants were immediately placed. (b)
Individual zirconia abutments mounted to
a the implants. (c) Short-span FPDs with a zir-
b
conia framework after veneering. (d)
Situation 30 months after treatment.

c d

Figs 4a and 4b (a) Intraoral view of five

zirconia telescopes. (b) Completed prosthesis
with galvanoforming secondary telescopes.

Figs 5a to 5d (a) Master cast with tooth

abutments and implant analog. (b) Wax pat-
tern forms for the double-scan technique.
(c) Intraoral view after 18 months. The
canine and molar crowns are directly
cemented to the tooth abutments, and the
implant crown is cemented to a zirconia
abutment. (d) Radiograph 18 months after
completion of the treatment; the burnout
effect on the crown border is a result of the
a all-ceramic shoulder of the crown. b

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486
Discussion
This preliminary case series demon-
strates that the CAD/CAM technology
to produce zirconia frameworks can
be used in a variety of prosthetic indi-
cations for tooth and implant support.
The CAM fabrication proved to be
reliable and satisfied the demands for
proper fit of the frameworks. To limit
the factors that could influence the
technical and clinical results, only one
CAD/CAM system was used.
During the short observation
period, only a few biologic complica-
tions were encountered, but they were
not directly attributed to the zirconia
material itself. The periodontal and
peri-implant parameters were favor-
able, and PD measurements exceed-
ing 4 mm were rare. It has been
reported that zirconia accumulates
fewer bacteria in vivo than tita-
nium.20,21 Thus, the material may pro-
mote tissue health and contribute to
the stability of the crestal bone level
around the implants.7 The need for
endodontic treatment was related to
the excessive tooth preparation of the
telescopes and may not have been
caused by the zirconia material.
The formation of the papilla is a
crucial aspect of implant-supported
restorations, particularly in the esthetic
zone. It is currently a primary goal in
implant prosthodontics to obtain a pre-
dictable papilla contour. 22,23 The
Papilla Index was used to describe one
part of the esthetic treatment out-
come. The Papilla Index is meaningful
in relation to the neighboring natural
teeth and is used mostly for single-
tooth replacement. Both single crowns
and FPDs with pontics were assessed
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Page 486
in this study. In most situations, com-
parison with corresponding contralat-
eral teeth was not possible since they
were also incorporated into recon-
structions. Often, elderly patients did
not exhibit ideal soft tissue conditions
around the remaining natural teeth.
Overall, a tendency for more favorable
results—as represented by the Papilla
Index—was found with teeth. The
majority of prostheses were single
crowns, while about 50% of prostheses
on implants were FPDs.
Various factors influence the shade
and color of ceramic crowns24–26: the
observer’s eye, the spectral character-
istics, the light source, and the fea-
tures of the adjacent teeth. The luting
agent, the nature of the ceramic mate-
rial, and the underlying tooth structure
also have an important effect on the
optical behavior, particularly with glass
ceramics.26 In contrast to metal ceram-
ics, all-ceramic reconstructions transmit
and refract light similar to natural teeth.
This advantage is lost with zirconia,
which is not translucent. However, the
grayish shine at the gingival margin
that often occurs with porcelain-fused-
to-metal prostheses and metal abut-
ments on implants does not occur with
zirconia, thus enhancing the color of
the soft tissue. In the present study, an
independent observer confirmed a
mostly positive result. In two patients,
the color of the single crowns was
judged to be too bright compared to
the neighboring natural teeth; how-
ever, the patients were satisfied with
the situation and thus no changes were
made. Three crowns were remade in
agreement between the patient and
clinicians shortly after cementation.
No abutment or framework frac-
tures occurred, and all reconstructions
were in function at the end of the
observation period. This is in accor-
dance with the limited number of stud-
ies in the literature reporting on zirco-
nia superstructures supported by teeth
and implants. The long-term use of
zirconia must be considered critically.
It seems that under occlusal load the
material characteristics may change,
reducing the strength of zirconia.27
Further, strength and toughness are
not the only important criteria for fail-
ure of ceramics.
In the present study, abutment
screw loosening occurred only once
with a premolar single crown. For all
luted reconstructions, no loss of reten-
tion was observed. Zirconia is not etch-
able, and its cementation procedure
cannot be compared to that of felds-
pathic ceramics. Therefore, other pro-
tocols must be used. So far, neither in
vitro nor in vivo studies have sufficiently
explained the best procedure for lut-
ing. Currently, based on laboratory
studies with composite resin, Panavia
is the most recommended because of
the capacity of phosphate ionomer
bonding to zirconia oxide groups.28,29
Five single crowns in the posterior
region exhibited porcelain chipping
(2.8% of all veneered units). The fracture
occurred within the veneering material
itself (Nobel Rondo) in all cases, but
not at the framework interface.
The 2-year clinical experience
from the present pilot study shows that
zirconia can be successfully applied in
different prosthetic indications.
Evidence for long-term use from clini-
cal and laboratory studies is still
needed.
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Volume 28, Number 5, 2008