https://jap.or.kr J Adv Prosthodont 2019;11:48-54 https://doi.org/10.4047/jap.2019.11.1.

48

All-ceramic versus titanium-based implant

supported restorations: Preliminary 12-months
results from a randomized controlled trial
Paul Weigl1*, Georgia Trimpou2, Eleftherios Grizas2, Pablo Hess2, Georg-Hubertus Nentwig2,
Hans-Christoph Lauer1, Jonas Lorenz1
1
Department of Prosthodontics, School of Dentistry, Goethe-University Frankfurt am Main, Germany
2
Department of Oral Surgery and Implantology, School of Dentistry, Goethe-University Frankfurt am Main, Germany

PURPOSE. The aim of the present randomized controlled study was to compare prefabricated all-ceramic,
anatomically shaped healing abutments followed by all-ceramic abutments and all-ceramic crowns and pre-
fabricated standard-shaped (round-diameter) titanium healing abutments followed by final titanium abutments
restored with porcelain-fused-to-metal (PFM) implant crowns in the premolar and molar regions. MATERIALS
AND METHODS. Forty-two patients received single implants restored either by all-ceramic restorations (test
group, healing abutment, final abutment, and crown all made of zirconia) or conventional titanium-based
restorations. Immediately after prosthetic incorporation and after 12 months of loading, implant survival,
technical complications, bone loss, sulcus fluid flow rate (SFFR) as well as plaque index (PI) and implant stability
(Periotest) were analyzed clinically and radiologically. RESULTS. After 12 months of loading, an implant and
prosthetic survival rate of 100% was observed. Minor prosthetic complications such as chipping of ceramic
veneering occurred in both groups. No statistical significant differences were observed between both groups with
only a minimum of bone loss, SFFR, and PI. CONCLUSION. All-ceramic implant prostheses including a
prefabricated anatomically shaped healing abutment achieved comparable results to titanium-based restorations
in the posterior region. However, observational results indicate a benefit as shaping the peri-implant soft-tissue
with successive provisional devices and subsequent compression of the soft tissue can be avoided. [ J Adv
Prosthodont 2019;11:48-54]

KEYWORDS: Ceramic abutments; Titanium abutments; Posterior region; Soft-tissue conditioning; Ceramic sulcus former

Introduction the most popular way to shape this tissue after osseointegra-
tion of the implant is to insert prefabricated healing abut-
The development and maintenance of a healthy peri- ments. These standardized healing abutments are in most
implant soft tissue is one of the major goals to achieve in cases round-shaped, resulting in emergence profiles dissimi-
implant dentistry.1-3 The simplest, the most common, and lar to those of the tooth being replaced. Initially, healing
abutments have been designed in this shape because the
Corresponding author: cylindrical cross-section of standard (non-individual) abut-
Paul Weigl ments makes it easier to align any internal or external index-
Department of Prosthodontics, School of Dentistry, Goethe University
Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany es. For better shaping of the peri-implant soft-tissue around
Tel. +496963014288: e-mail, weigl@em.uni-frankfurt.de traditionally shaped abutments, the use of a series of pro-
Received July 24, 2018 / Last Revision December 10, 2018 / Accepted
January 21, 2019 gressively modified provisional crowns is described in the
© 2019 The Korean Academy of Prosthodontics
literature.4,5 However, this approach is time-consuming and
This is an Open Access article distributed under the terms of the Creative costly to both patient and dentist. Furthermore, the repeat-
Commons Attribution Non-Commercial License (http://creativecommons.
org/licenses/by-nc/4.0) which permits unrestricted non-commercial use,
ed removal and reinsertion of the provisional crowns may
distribution, and reproduction in any medium, provided the original cause irritation of the peri-implant soft tissue, as the fragile
work is properly cited. fibre-attachment may be disconnected and lead to soft-tis-
Implant components have been provided free of charge by Dentsply Sirona sue recessions.6
implants. Another way to optimize the soft-tissue contours is the

48
 All-ceramic versus titanium-based implant supported restorations: Preliminary 12-months results from a randomized controlled trial

use of individually customized healing abutments, which are loading. Follow up appointments were scheduled at a
fabricated with computer-aided design and computer-aided 3-month interval for the first year and a 6-month interval
manufacturing (CAD/CAM) technology in order to shape for the next 4 years. Participants of the study were informed
the peri-implant soft-tissue anatomically.7 However, to opti- about the study protocol and gave a written declaration of
mize the workflow in the dental practice, the healing abut- informed consent. The inclusion criteria were as follows:
ments are needed at the time of implant placement or sec- age of ≥ 18 years, need for a single posterior implant-sup-
ond-stage surgery. Fabricating CAD/CAM healing abut- ported crown, implant placement exclusively in healed
ments requires an impression or an intra-oral scan for the extraction sites, and natural neighboring teeth; no need for
transfer of the implant position and the anatomical situa- extensive augmentation (the simultaneous minor lateral aug-
tion to the manufacturer. This procedure might also be mentation was accepted) and no parafunctional habits or
time-consuming and costly.7 For this reason, the use of pro- general contraindications for implant surgery.
visional restorations, placed either immediately after implant Finally, participants of the study had to have the mental
placement or at the implant second surgery, has been and physical ability to enable follow-up over a 5-year period.
reported to be the most convenient way to shape the peri- Patients who had undergone an extended local bone graft
implant soft tissue. Additionally, the emergence profile can procedure in the implant region were excluded. Pregnant
be further adapted and refined by adding PMMA (polymeth- women were also excluded. Smoking was not an exclusion
ylmethacrylate) several times to the provisional crowns.8 criterion.
Independent of the types of healing abutment and pro- After inclusion in the study, randomization was per-
visional restoration, customized implant abutments seem to formed. Prior to the randomization process, each patient
be the choice for definitive prosthetic rehabilitation. 9 accepted the potential use of both types of prosthetic res-
Individualized abutments allow a better control over the toration after implant surgery: zirconia abutments (test
design and development of the gingival scalloping and facil- group, TG) and titanium abutments (control group, CG). By
itate the removal of cementum remnants.10 Compared to computer-generated random allocation, each patient was
gray titanium components, customized zirconia abutments assigned to either the test group or the control group,
also offer superior aesthetic results because of their tooth- resulting in a randomized clinical trial with 21 patients (7
like color and influence on the soft- tissue color, especially males and 14 females), with an average age of 44 years
for patients with thin gingival biotypes.11 In the past years, (range: 28 - 68 years) in the test and 21 patients (12 males
the use of ceramic abutments has been extended to the pos- and 9 females), with an average age of 53 years (range: 34 -
terior region, but concerns about the mechanical strength 72 years) in the control group.
of ceramic abutments are still present. From a scientific Each of the 42 patients received one Ankylos C implant
point of view, this apparent limitation cannot be supported (Dentsply Sirona Implants, York, PA, USA) in the premolar
by scientific data. In contrast, the favourable tissue response and molar region of the upper and lower jaw. All implants
to zirconia and patients’ preferences for white-coloured had a diameter of 3.5 mm and the implant system does not
materials support the wide indication range of zirconia possess an internal index.
abutments.12,13 Preoperative planning was performed with either pan-
The aim of the present randomized controlled trial is to oramic radiographs or cone beam computed tomography
compare prefabricated all-ceramic, anatomically shaped (CBCT) and study casts. An hour prior to the operation, a
healing abutments followed by all-ceramic abutments and rinse with chlorhexidine solution (0.2 %) and antibiotic pro-
all-ceramic crowns (Cercon, Dentsply Sirona Implants) and phylaxis of 2 g of amoxicillin (1 g tablet; or azithromycin in
pre-fabricated standard-shaped (round-diameter) titanium case of allergy) was applied.
healing abutments followed by final titanium abutments The implant placements were performed under local
restored with porcelain-fused-to-metal (PFM) implant anesthesia (Ultracain with epinephrine 1 : 200,000) by 2 oral
crowns regarding their biological and functional results surgeons specialized in implantology, who were both trained
when applied in the posterior region. with the implant system. After crestal incision, a full thick-
ness flap was raised and osteotomy preparation was con-
Materials and methods ducted according to the protocol of the manufacturer. In
each site, implants were inserted subcrestally. If required,
42 patients (19 males and 23 females), with an average age minor augmentation procedures (lateral augmentation with
of 48 years (range: 28 - 72 years), were recruited to partici- xenogenic, bovine-based bone substitute materials (BioOss
pate in this randomized controlled trial. The study was and resorbable collagen membrane BioGide, Geistlich
approved by the Ethical Committee of the J.W. Goethe Biomaterials, Wolhusen, Switzerland)) have been performed
University of Frankfurt/Main (registration number 133/05). simultaneously. Wound closure was performed to achieve
The study was performed in accordance with the fifth revi- submerged healing.
sion of the World Medical Association Declaration of 2000 After a healing period of 3 months, the second-stage
in Helsinki and the CONSORT statement of 2010. The surgery was performed and, according to the previously
study was conducted for a 5-year observation period and performed random allocation, a round-diameter titanium
preliminary results have been obtained after 12-months of abutment (control group, CG) or an anatomically shaped,

The Journal of Advanced Prosthodontics 49

 J Adv Prosthodont 2019;11:48-54

all-ceramic healing abutment were installed. ceramics) in the test and single porcelain-fused-to-metal
Table 1 gives a detailed overview of the implant localization. (PFM) implant crowns (CAD/CAM manufactured frame-
In the study group, a prefabricated anatomically shaped, work of a chromium-cobalt-molybdenum-alloy (CrKoMo),
all-ceramic healing abutment (Prototype produced in coop- veneered with glass ceramics) in the control group was per-
eration with CERCON, Dentsply Sirona Implants) with an formed.
oval shape mimicking the natural shape of a molar or pre- After sandblasting of the titanium abutment with 110
molar tooth has been placed at the second stage surgery. µm aluminium-oxide particles at 2.0 bar, PFM crowns have
The healing abutments (Fig. 1) correspond to the form and been cemented with zinc-oxide eugenol provisional cement
cross-section of a premolar/molar crown and therefore the (TempBond, Kerr dental, Biberach, Germany), while the all-
final abutments (Fig. 2). Two sizes have been applied: a ceramic crowns were secured with zinc oxide non-eugenol
smaller-diameter healing abutment for premolar sites and a cement (RelyX Temp NE, 3M Espe, St. Paul, MN, USA).
larger-diameter one for molar sites. Patients of the control To analyze the influence of healing abutment, definitive
group received a round-diameter standard shaped titanium abutment, and crown material on peri-implant soft-tissue
healing abutment (Ankylos, Dentsply Sirona Implants). health and implant success, the following parameters have
Two weeks after the second-stage surgery, an implant- been evaluated at baseline (after incorporation of final pros-
level impression was taken using Impregum (3M Espe, St. thetics) and after 12 months of loading:
Paul, MN, USA) in both groups. For each patient, a master - Implant survival
cast was fabricated. Depending on the assigned group, - Peri-implant bone stability
either a titanium Balance Posterior abutment (Control - Implant stability/mobility assessed by Periotest
group, Dentsply Sirona Implants) or the Ankylos CERCON - The sulcus fluid flow rate (SFRR)
Balance all-ceramic abutment (Test group, Dentsply Sirona - Plaque index (PI) according to Quigley and Hein14
Implants) was placed on the implant analogue. All abut- - Technical complications
ments have been thoroughly investigated by microscopy Orthopantograms recorded at baseline and after 12
before insertion to uncover potential micro-cracks. After a months of loading have been analyzed using the Sidexis
4-week provisional phase with a PMMA (polymethylmethacrylate) software program (Sidexis software program, Dentsply
crown, the final prosthetic rehabilitation consisting of single Sirona Implants, York, PA, USA) to determine the peri-
all-ceramic crowns (CAD/CAM manufactured yttrium-sta- implant bone stability. The distance between the implant
bilized zirconium dioxide framework, veneered with glass shoulder and the first radiographically observable bone-to-
implant contact (BIC) was measured at the mesial and distal
aspects of the implants to determine the annual bone-level
changes. Measurements were conducted by an experienced
Table 1. Detailed overview over allocation to study and investigator.
control group and implant localization Implant stability/mobility was assessed using the
Periotest device (Periotest, Medizintechnik Gulden e.K.). To
Control group Study group ensure reliable measurements that allow comparison of
Implants in the premolar region 11 13
obtained data, the widest circumference of the implant-
retained crown (equator) was used as a reference point for
Implants in the molar region 10 8

Fig. 1. Prototype zirconia healing abutments were Fig. 2. Final posterior zirconia abutments were also
designed and fabricated for the study. The shape produced. The form and cross-section of the healing and
mimicked the natural shape of a molar or premolar tooth final abutments corresponded perfectly.
after crown preparation.

50
 All-ceramic versus titanium-based implant supported restorations: Preliminary 12-months results from a randomized controlled trial

the Periotest device. Results

The sulcus fluid flow rate (SFFR), measured with the
Periotron system (Periotron 8000, Oraflow, Hewlett, NY, In all 42 patients, an uneventful healing after surgical treat-
USA), and the plaque index (PI) according to Quigley and ment could be observed. Two weeks after incorporation of
Hein14 were recorded to determine the plaque formation at the prefabricated all-ceramic, anatomically shaped healing
the different suprastructures and to uncover a potential abutments and the prefabricated standardshaped (round-
inflammatory response at the peri-implant soft tissue. The diameter) titanium healing abutments, a naturally dimen-
Periotron device records the SFFR as a numerical number, sioned peri-implant soft tissue without signs of infection
which indicates the health of the peri-implant mucosa. could be observed (Fig. 3). When the healing abutment was
Values from 0 to 10 indicate a healthy mucosa, and values removed two weeks after the second stage surgery, a clini-
from 10 to 40 indicate a mild peri-implant infection, while cally intact attachment of the peri-implant gingiva to the
values higher than 40 indicate a peri-implant inflammation. healing abutment of the test group was observable (Fig. 4).
Furthermore, at each follow-up appointment, any tech- At the time of the final abutment incorporation, no com-
nical complications such as loosening or fracture of abut- pression of the soft tissue in the test group could be detect-
ments, chipping of veneering porcelain, and de-cementa- ed (Fig. 5, Fig. 6). However, the incisions during the second-
tions were documented in detail. stage surgery in the TG patients had to be larger than those
Intergroup comparisons were conducted with Fisher’s made in the CG patients, in order to enable mounting of
exact test. For the quantitative variables, a normality test the larger ceramic healing abutments.
was first carried out and the data that corresponded with Before loading, one ceramic final abutment fracture
normal distribution were described with mean ± standard occurred at the lowest level of the internal cone connection
deviations (SDs) and evaluated with Student’s t-test or during the try-in procedure, possibly due to incorrect han-
repeated-measures ANOVA. Data that did not correspond dling by the clinician or technician. This was replaced by a
with normal distribution were evaluated with Wilcoxon new one before the crown fabrication. From the time of the
signed-rank test. Differences were deemed significant when restoration delivery to the 12-month follow-up appoint-
the P values were less than 0.05 (*P < .05) and highly signif- ment, no other major complications developed in either
icant when the P values were less than 0.01 (**P < .01). group.

Fig. 3. Soft tissue conditioning and clinically intact Fig. 4. Preconditioning of the emergence profile two
attachment to the zirconia healing abutment. weeks after the mounting of the anatomical shaped.

Fig. 5. Zirconia abutment corresponding to the dimension Fig. 6. Final crown in place.
of the healing abutments avoiding any compression of
the peri-implant soft tissue.

The Journal of Advanced Prosthodontics 51

 J Adv Prosthodont 2019;11:48-54

Minor chipping of the veneering porcelain was observed shaped zirconia healing abutments have been designed to
in 2 patients in the control group at the 12-month recall better shape the peri-implant soft tissue according to the
appointment and in one patient in the test group at the 6 final crown and therefore to replicate the natural tooth con-
month recall, resulting in a chipping rate of 9.5% in the tour.
control and 4.8% in the test group. The difference did not The idea of the present study, to use zirconia ceramic
show statistical significance. for healing abutments, arise from the low bacterial adher-
The mean (n = 42) sulcus fluid flow rate (mSFFRtotal-12 = ence to zirconia surface shown in different in vitro and in vivo
7.9 ± 5.4) in both groups indicated a healthy peri-implant studies.15-17 The aim of the study was to investigate if the
soft tissue condition at the 12 months follow-up. The differ- use of the healing abutment, which usually stays in place
ence between the test and the control group at the over a comparably short period of time, followed by all-
12-months recall (mSFFRZrO2-12 = 8.0 ± 6.2; mSFFRTi-12 = ceramic prosthesis has an impact on the peri-implant soft
7.9 ± 4.8) was not significant (Table 2). tissue health compared to the conventional, titanium-based
The mean (n = 42) plaque index rates (mPItotal-12 = 0.4 ± prosthesis.
0.5) for both groups at the 12-month recall were generally A clinical benefit of the present approach is that the
very low and showed no statistically significant differences anatomically shaped healing abutments are not individually
between both groups (mPITi-12 = 0.3 ± 0.5 and mPIZrO2-12 = produced and are therefore more time-saving and cost-effi-
0.4 ± 0.7) (Table 2). cient. A major risk factor in the use of zirconia in general
Implant stability evaluated with the Periotest device requires the excessive machining, which can lead to tensile
revealed no statistically significant difference between the stresses on the material surface with a direct impact on the
two groups. The mean Periotest value of all 42 implants material properties.18 Because of this, any modifications of
revealed -2.9 ± 1.9, while the mean Periotest value of the these abutments should be kept to a minimum to limit the
test group was -3.2 ± 1.5 and that of the control group was propagation of this phenomenon.
-2.5 ± 2.3. This difference was also not statistically signifi- As the ceramic final abutments have the same shape and
cant. Table 2 summarizes the findings of the clinical follow- cross-section as the ceramic healing abutments used to
up investigation (sulcus fluid flow rate, plaque index rate, develop the soft tissue, modifications to the final abutment
and Periotest) at the 12 months follow-up. by the laboratory can be reduced and, if necessary, accom-
Radiological analysis of the peri-implant bone level plished very quickly. Additionally, little to no compression
change after 12 months of loading detected no signs of a of the soft tissue occurs when the zirconia healing abut-
peri-implant infection. The mean bone loss (calculated as ment is replaced by the final abutment, which makes the
change between implant shoulder and the most coronal clinical procedure more comfortable for the patient, reduces
bone-to-implant contact) for the control group was 0.14 treatment duration, and can reduce or even abandon the
mm mesially and 0.26 mm distally. In the test group, compa- need of a prolonged provisional treatment phase.
rable values of 0.18 mm mesially and 0.16 mm distally could In both groups, the clinical follow up investigation
be found, but the result was not significant. revealed implant, abutment, and crown survival of 100%,
taking in consideration that the single observed zirconia
Discussion abutment fracture occurred before loading. The chipping of
the veneering ceramic that occurred in both groups (9.5%
In the present study, prefabricated industrially made zirconia in the control and 4.8% in the test group) is a well-known
healing abutments and subsequent all-ceramic individual complication for implant-supported restorations in general
abutments and single crowns have been investigated and and seems, at least in the present study, not to be dependent
compared to conventional titanium-based healing and final on the abutment material.19-21 However, it is important to
abutments and PFM single crowns. The anatomically state that a proper, anatomically dimensioned framework
that offers sufficient support for the veneering ceramic is
mandatory to reduce chipping.22 In the present study, manu-
facturing principles of implant-retained crowns have been
Table 2. Biological parameters (mean plaque index, addressed in both the control and the test group. A thor-
mean sulcus fluid rate, and mean Periotest values) in the ough analysis of the superstructures with chipping could
test (zirconia abutments, ZrO2) and in the control group
(titanium abutments, Ti) not identify any trigger factors.
In both groups, implant stability assessed by Periotest
mPI SFFR PTV revealed successful osseointegration of the implants, but the
difference was not significant. No signs of mobility, neither
ZrO2 abutments 0.4 ± 0.7 8.0 ± 6.2 -3.2 ± 1.5
of the implant nor of the abutment-crown complex, could
Ti abutments 0.3 ± 0.5 7.9 ± 4.8 -2.5 ± 2.3
be observed. However, the stability of the implants has to
Significance
NS NS NS be regarded detached from the abutment or crown material.
ZrO2 vs. Ti
Although several studies report a lower bacterial adhe-
Statistical significance was set at P ≤ .05. sion on zirconia, no significant difference in plaque accumu-
NS: not significant lation could be found in the present study.23-25 A systematic

52
 All-ceramic versus titanium-based implant supported restorations: Preliminary 12-months results from a randomized controlled trial

review that evaluated the impact of the abutment character- also made from zirconia, and it is therefore difficult to
istics on peri-implant tissue health revealed a significantly determine the specific influence of the healing abutment on
less increase in BOP values and plaque accumulation when the overall tissue response to the implant prosthetics.
comparing zirconia and titanium abutments. 25 From the Furthermore, the study period of 12 months allows only
present study, it has to be noted that all crown margins are insights in the short-term tissue reaction.
set subgingivally and the abutments and crown margins Within the limitations of the present study, it can be
have therefore not been exposed to the oral environment concluded that the use of a prefabricated anatomically
and therefore not accessible to plaque. shaped all-ceramic healing abutment completes the range of
Analysis of the sulcus fluid flow rate as an indicator of a all-ceramic components and can reduce treatment duration,
potential inflammatory response in the peri-implant soft-tis- discomfort, and need of shaping the peri-implant soft-tissue
sue detected only a minor, statistically insignificant differ- with successive provisional devices. Regarding the analysis
ence between the test and the control group. This result can of implant survival, implant stability, and peri-implant soft
be interpreted in contrast to the extensively proven high tissue response, no statistically significant differences
biocompatibility of zirconia, not only as material for crowns between the two groups could be found.
or abutments, but also for dental implants.25,26 The literature
reveals a high number of publications on all-ceramic abut- Conclusion
ments and all-ceramic implant-retained single crowns, but
the level of evidence, the follow-up period, and the sample The preliminary results regarding the biological stability and
size are often inadequate. technical behaviour of all-ceramic restorations compared to
In a clinical study, comparing customized zirconia and conventional, titanium-based implant prosthetics in posteri-
titanium abutments after 18 months of loading, no statisti- or regions showed no statistically significant superiority of
cally significant results regarding survival rates and techni- the all-ceramic procedure. However, the use of all-ceramic
cal, biologic, and esthetic outcomes could be found. components, including prefabricated all-ceramic healing
Interestingly, no differences in the color of the peri-implant abutments, might present an encouraging treatment option
mucosa was observed, but no additional subdivision accord- in times of rising demand for metal-free dental implant
ing to the gingiva type was performed.27 prosthetics. Larger sample-size clinical trials with a longer
In one of the few long-term follow-up studies on one- follow-up period and study designs investigating the partic-
piece internal zirconia abutments, 5-year implant survival ular benefit of all-ceramic healing abutments are necessary
and occurrence of technical complications were assessed in to further increase the tissue-compatibility of implant-
52 patients. While the implant survival was 100% after 5 retained prosthetics.
years of loading, 5 restorations (7.8%) had to be remade
due to fracture of the internal one-piece zirconia abutment. ORCID
Four of these fractures occurred in narrow-diameter
implants (diameter of 3.3 mm), which are known to be a Paul Weigl https://orcid.org/0000-0001-7434-7988
limiting factor for design and construction of one-piece zir- Jonas Lorenz https://orcid.org/0000-0002-4209-3992
conia abutments.28
In another long-term study evaluating zirconia abut- References
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