One vs. two piece customized implants to reconstruct mandibular continuity defects: A preliminary study in pig cadavers

ObjectivesThe reconstruction of mandibular continuity defects by bridging plates often leads to complications. Customized mandibular implants might be an alternative option. In the present study, the stability at the bone–implant-interface of customized two-piece implants was compared to one-piece implants.MethodsThirty pig mandibles were randomly divided into three groups. One group (A) was left untreated and served as reference. In groups B and C, a continuity defect was created in the left mandibular side. The defects were reconstructed by customized pure titanium implants, manufactured using the LaserCUSING^® technology. Group B received a one-piece implant; in group C a two-piece implant was inserted to reconstruct the continuity defect. The bonding strength was examined statically and dynamically under standardized conditions. Digital Image Correlation was used for distortion measurement. Different dynamic measurements were performed for orientation purposes.ResultsThe highest bonding strength was measured for the reference group. The two-piece implant showed an increased bonding strength when compared to the one-piece design. In all pig mandibles treated with individual implants a fracture occurred on the non-operated side. This indicates a high primary stability of the bone–implant-interface.ConclusionThe two-piece individual mandibular implant manufactured by LaserCUSING^® technology should be further analyzed in future studies.     

A systematic review and meta-analysis on the clinical outcome of zirconia implant–restoration complex

Purpose

This systematic review evaluates the clinical outcome of zirconia implant-associated survival and success rates, marginal bone loss, and implant–restoration complex integrity.

Persistent acute inflammation at the implant-abutment interface

The inflammatory response adjacent to implants has not been well-investigated and may influence peri-implant tissue levels. The purpose of this study was to assess, histomorphometrically, (1) the timing of abutment connection and (2) the influence of a microgap. Three implant designs were placed in the mandibles of dogs. Two-piece implants were placed at the alveolar crest and abutments connected either at initial surgery (non-submerged) or three months later (submerged). The third implant was one-piece. Adjacent interstitial tissues were analyzed. Both two-piece implants resulted in a peak of inflammatory cells approximately 0.50 mm coronal to the microgap and consisted primarily of neutrophilic polymorphonuclear leukocytes. For one-piece implants, no such peak was observed. Also, significantly greater bone loss was observed for both two-piece implants compared with one-piece implants. In summary, the absence of an implant-abutment interface (microgap) at the bone crest was associated with reduced peri-implant inflammatory cell accumulation and minimal bone loss.     

Feasibility and influence of the microgap of two implants placed in a non-submerged procedure: a five-year follow-up clinical trial

BACKGROUND: The aim of this study was to evaluate the feasibility of using a two-piece implant system in a non-submerged procedure and to study the impact of the microgap between the implant and abutment. METHODS: Sixty edentulous patients (Cawood Class V-VI) participated in this study. After randomization, 20 patients received two two-piece implants placed in a non-submerged procedure, 20 patients received two two-piece implants placed in the traditional submerged procedure, and 20 patients were treated with two one-piece dental implants placed in the traditional non-submerged procedure. The implants were placed in the mandible for overdenture treatment. A standardized clinical evaluation was performed and radiographs were taken immediately after denture insertion and yearly up to 5 years. Peri-implant samples were collected 12, 36, and 60 months after loading with sterile paper points and analyzed for the presence of putative periodontal pathogens using culture techniques. RESULTS: One two-piece implant of the non-submerged group and one two-piece implant of the submerged group were lost after 6 and 12 months, respectively. After 5 years of functioning, no significant clinical, radiological, or microbiological differences were found between the three groups. No association was found between the level of the microgap and the amount of bone loss. CONCLUSIONS: The results of this study indicate that dental implants designed for a submerged implantation procedure can also be used in a non-submerged procedure and may be as predictable as when used in a submerged procedure or as one-piece implants. The microgap at the crestal level in two-piece implants does not appear to have an adverse effect on the amount of peri-implant bone loss.     

Primary reconstruction of extensive orbital fractures using two-piece patient-specific implants: the Helsinki protocol

Purpose

We present our experience of titanium-milled two-piece patient-specific implants (PSIs) for primary reconstructions of extensive orbital floor and medial wall fractures (EOFMFs) and evaluate their postoperative functional and aesthetic outcomes in relation to commercially available implants.

Methods

We included all patients with primary reconstructions (< 22 days from injury) of EOFMFs treated in our department between January 2011 and October 2020. Extensive orbital floor and medial wall fracture was defined as involvement of orbital floor, medial wall and maxilloethmoidal junction; a fracture defect 5 mm or more; defect size more than a third of both inferior and medial walls; and Jaquiéry classification III or more. Patient characteristics, details of fracture defects and surgeries, postoperative outcomes and implant positions were retrospectively evaluated and compared between study groups.

Results

Nineteen patients were included: 5 with two-piece PSIs and 14 with commercial implants. Implant position was good in 4/5 patients with two-piece PSIs and 2/14 with commercial implants. Revision surgery, globe malposition (GMP) > 2 mm, significant diplopia and poor implant position were more frequent in patients with commercial implants than two-piece PSIs. None of the patients with a good overall implant position had any significant postoperative symptoms.

Conclusion

Extensive orbital fracture reconstructions are somewhat rare, and surgical treatment is associated with a high rate of complications and postoperative symptoms. Titanium-milled two-piece PSIs are well suited for primary reconstructions of EOFMFs, as they lead to more precise reconstructions and fewer postoperative symptoms than commercially available implants.

     

Fractographic analyses of failed one-piece zirconia implant restorations

Background

Promising results of initial clinical trials with yttria-stabilized zirconia have led to more extensive use of zirconia in dental implant superstructures. The applications have extended to abutments and complex individually designed crown-abutment one-piece structures. Little is known about their clinical success and the primary cause of failures.

Mechanical stability of angulated zirconia abutments supporting maxillary anterior single crowns on narrow-diameter implants

Objectives

To investigate the fracture strength of angulated hybrid abutments supporting anterior single crowns on narrow-diameter implants (NDIs).

Material and methods

Zirconia abutment with angulations of labial inclination 0° (TZ0Z), 15° (TZ15Z), 30° (TZ30Z) and palatal inclination 15° (TZ???15Z) was designed on 3.3-mm titanium-zirconium (Ti–Zr) NDIs. Titanium abutment connected with Ti–Zr implant (TZ0T) and 0° zirconia abutment connected with pure titanium (Ti) implant (T0Z) were control groups. Thirty-six un-restored abutments and 36 abutments restored with highly translucent zirconia (HTZ) crowns were tested. Failure loads were compared among 6 groups, and bending moments were calculated for comparison between un-restored and restored abutments.

Results

Failure loads of un-restored abutments were affected by the abutment angle. Sixty-seven percent samples in TZ30Z and 83% samples in TZ???15Z group fractured at the thinnest part of the zirconia abutment and exhibited lower failure load (p?<?.05). Failure loads of restored abutments were close to or exceeded the maximum bite force of anterior teeth, and no differences were found among six groups (p?>?.05). Except TZ15Z and TZ0T group, the bending moment increased with the crown construction, especially for TZ30Z and TZ???15Z groups (p?<?.001).

Conclusions

The fracture strength of hybrid abutments restored with HTZ crown on Ti–Zr NDIs exceeded the bite forces of anterior teeth for all the groups and were not affected by the abutment angle.

Clinical relevance

In terms of fracture strength, Ti–Zr NDIs combined with angulated hybrid abutments and HTZ crowns can be used in the anterior region.

     

In vitro performance of zirconia and titanium implant/abutment systems for anterior application

Objectives

To investigate the type of failure and fracture resistance behaviour of different zirconia and titanium implant/abutment systems for anterior application.

Methods

Eight groups of implant–abutment combinations (n = 8/system) were restored with identical full-contour zirconia crowns. The systems represented one-piece and multi-piece zirconia (Z) or titanium (T) implants/abutments with different types of connection (screwed = S, bonded = B). The following combinations (implant–abutment-connection) were investigated: ZZS, ZZB, ZZZB (three-piece), ZTS, TTS, TTS reference, and Z (one-piece, 2×). To simulate clinical anterior loading situations the specimens were mounted into the chewing simulator at an angle of 135° and subjected to thermal cycling (2 × 3000 × 5°/55 °C) and mechanical loading (1.2 × 10⁶ × 50 N; 1.6 Hz). Fracture resistance and maximum bending stress were determined for all specimens that survived ageing. Data were statistically analyzed with the Kolmogorov–Smirnov-test and one-way ANOVA (α = 0.05). Survival performance was calculated with the Kaplan–Meier Log-Rank test.

Results

Independent of the material combinations screwed systems showed partly failures of the screws during simulation (ZZS: 3×, ZTS: 8×, TTS: 3×). Screw failures were combined with implant/abutment fractures of zirconia systems. Zirconia one-piece implants and the reference system did not show any failures, and only one specimen of the systems with a bonded connection (ZZZB) fractured. Mean (±standard deviation) fracture forces and maximum bending stresses differed significantly (p = 0.000) between 187.4 ± 42.0 N/250.0 ± 56.0 N/mm² (ZZZB) and 524.3 ± 43.1 N/753.0 ± 61.0 N/mm² (Z).

Conclusions

Both material (zirconia or titanium) and the type of connection influenced failure resistance during fatigue testing, fracture force, and maximum bending stress.

Clinical significance

Different material combinations for implants and abutments as well as different types of connection achieved acceptable or even good failure and fracture resistance that may be satisfactory for anterior clinical application.     

Mechanical stability of all-ceramic abutments retained with three different screw materials in two-piece zirconia implants—an in vitro study

To measure the abutment rotation and fracture load of two-piece zirconia implants screwed with three different abutment screw materials. Thirty-six zirconi     

Biologic Width around one- and two-piece titanium implants

Gingival esthetics around natural teeth is based upon a constant vertical dimension of healthy periodontal soft tissues, the Biologic Width. When placing endosseous implants, however, several factors influence periimplant soft and crestal hard tissue reactions, which are not well understood as of today. Therefore, the purpose of this study was to histometrically examine periimplant soft tissue dimensions dependent on varying locations of a rough/smooth implant border in one-piece implants or a microgap (interface) in two-piece implants in relation to the crest of the bone, with two-piece implants being placed according to either a submerged or a nonsubmerged technique. Thus, 59 implants were placed in edentulous mandibular areas of five foxhounds in a side-by-side comparison. At the time of sacrifice, six months after implant placement, the Biologic Width dimension for one-piece implants, with the rough/smooth border located at the bone crest level, was significantly smaller (P<0.05) compared to two-piece implants with a microgap (interface) located at or below the crest of the bone. In addition, for one-piece implants, the tip of the gingival margin (GM) was located significantly more coronally (P<0.005) compared to two-piece implants. These findings, as evaluated by nondecalcified histology under unloaded conditions in the canine mandible, suggest that the gingival margin (GM) is located more coronally and Biologic Width (BW) dimensions are more similar to natural teeth around one-piece nonsubmerged implants compared to either two-piece nonsubmerged or two-piece submerged implants.     

Stability and aging resistance of a zirconia oral implant using a carbon fiber-reinforced screw for implant-abutment connection

Objective

To investigate the long-term stability of a metal-free zirconia two-piece implant assembled with a carbon fiber-reinforced (CRF) screw by means of transformation propagation, potential changes in surface roughness, the gap size of the implant-abutment connection, and fracture load values.

Evaluation of peri-implant bone loss around platform-switched implants

This clinical and radiographic prospective study evaluated bone loss around two-piece implants that were restored according to the platform-switching protocol. One hundred thirty-one implants were consecutively placed in 45 patients following a nonsubmerged surgical protocol. On 75 implants, a healing abutment 1 mm narrower than the implant platform was placed at the time of surgery. On the remaining implants, a healing abutment of the same diameter as the implant was inserted. All implants were positioned at the crestal level. Clinical and radiographic examinations were performed prior to surgery, at the end of surgery, 8 weeks after implant placement, at the time of provisional prosthesis insertion, at the time of definitive prosthesis insertion, and 12 months after loading. The data collected showed that vertical bone loss for the test cases varied between 0.6 mm and 1.2 mm (mean: 0.95 +/- 0.32 mm), while for the control cases, bone loss was between 1.3 mm and 2.1 mm (mean: 1.67 +/- 0.37 mm). These data confirm the important role of the microgap between the implant and abutment in the remodeling of the peri-implant crestal bone. Platform switching seems to reduce peri-implant crestal bone resorption and increase the long-term predictability of implant therapy.     

Scalloped implant designs enhance interproximal bone levels

Consecutively restored scalloped dental implants were evaluated radiographically and clinically. Radiographic evaluation of 16 two-piece scalloped implants and 9 one-piece scalloped implants revealed enhanced interproximal bone levels versus a nonscalloped conventional flat-top implant design. Based on the Jemt system for interproximal soft tissue level evaluation, 78% of the two-piece implants scored a 3 and 22% scored a 2, and 89% of the one-piece implants scored a 3 and 11% scored a 2. Enhanced interproximal tissue preservation from scalloped implant designs may lead to more predictable esthetic dental implant restorations in the anterior maxilla.     

Impact Fracture Resistance of Two Titanium‐Abutment Systems Versus a Single‐Piece Ceramic Implant

Background: The number of patients with oral implants has increased significantly. However, the literature addressing the effect of impact force on titanium and/or ceramic implants is inconclusive. This study sought to determine the fracture resistance to impact load of titanium and ceramic endosseous oral implants. Materials and Methods: Endosseous oral implants were vertically positioned in two different mounting media: brass and a bone‐simulation material. The implant configurations tested included an experimental one‐piece Y‐TZP implant and a commercially available titanium implant (external hex) with both titanium and zirconia abutments. The specimens were subjected to an impact load using a pendulum impact tester with tup weights varying from 0.9 to 4.5 kg delivered at a radius of 40.64 mm. Loads were delivered to the abutment at a point 4.27 mm above the implant fixture and block junction. Statistical differences (p < .05) were established using the F‐test for variances and, when different, t‐test assuming unequal variances. Results: For implants clamped in brass, the titanium implant with titanium abutment required the greatest energy to fracture the implant‐abutment system (only the abutment screw failed). The ceramic implant and ceramic abutment on titanium implant presented the lowest fracture energy (p < .01). No significant differences were observed when different systems were inserted into the foam blocks of the bone substitute (p > .25). Conclusion: This investigation showed that the fracture energy of two titanium‐abutment systems versus a single‐piece Y‐TZP implant in foam blocks simulating bone elastic modulus was not different, and that differences occurred when the embedding material elastic modulus was increased an order of magnitude.     

Stability of prototype two-piece zirconia and titanium implants after artificial aging: an in vitro pilot study

Background: Zirconia oral implants are a new topic in implant dentistry. So far, no data are available on the biomechanical behavior of two‐piece zirconia implants. Therefore, the purpose of this pilot investigation was to test in vitro the fracture strength of two‐piece cylindrical zirconia implants after aging in a chewing simulator. Materials and Methods: This laboratory in vitro investigation comprised three different treatment groups. Each group consisted of 16 specimens. In group 1, two‐piece zirconia implants were restored with zirconia crowns (zirconia copings veneered with Triceram®; Esprident, Ispringen, Germany), and in group 2 zirconia implants received Empress® 2 single crowns (Ivoclar Vivadent AG, Schaan, Liechtenstein). The implants, including the abutments, in the two zirconia groups were identical. In group 3, similar titanium implants were reconstructed with porcelain‐fused‐to‐metal crowns. Eight samples of each group were submitted to artificial aging with a long‐term load test in the artificial mouth (chewing simulator). Subsequently, all not artificially aged samples and all artificially aged samples that survived the long‐term loading of each group were submitted to a fracture strength test in a universal testing machine. For the pairwise comparisons in the different test groups with or without artificial loading and between the different groups at a given artificial loading condition, the Wilcoxon rank‐sum test for independent samples was used. The significance level was set at 5%. Results: One sample of group 1 (veneer fracture), none of group 2, and six samples of group 3 (implant abutment screw fractures) failed while exposed to the artificial mouth. The values for the fracture strength after artificial loading with 1.2 million cycles for group 1 were between 45 and 377 N (mean: 275.7 N), in group 2 between 240 and 314 N (mean: 280.7 N), and in the titanium group between 45 and 582 N (mean: 165.7 N). The fracture strength results without artificial load for group 1 amounted to between 270 and 393 N (mean: 325.1 N), for group 2 between 235 and 321 N (mean: 281.8 N), and between 474 and 765 N (mean: 595.2 N) for the titanium group. The failure mode during the fracture testing in the zirconia implant groups was a fracture of the implant head and a bending/fracture of the abutment screw in the titanium group. Conclusions: Within the limits of this pilot investigation, the biomechanical stability of all tested prototype implant groups seems to be – compared with the possibly exerted occlusal forces – borderline for clinical use. A high number of failures occurred already during the artificial loading in the titanium group at the abutment screw level. The zirconia implant groups showed irreparable implant head fractures at relatively low fracture loads. Therefore, the clinical use of the presented prototype implants has to be questioned.     

Consequences of implant design

The use of dental implants to replace missing teeth is becoming a preferred alternative for restorative dentists and their patients. There are two general surgical approaches for the placement and restoration of missing teeth using endosseous dental implants. One approach places the top of the implant at the alveolar crest and the mucosa is sutured over the implant. An alternative approach places the coronal aspect of the implant coronal to the alveolar crest and the mucosa is sutured around the transmucosal aspect of the implant. This article reviews one-piece and two-piece implants as well as biologic implications of submerged and non-submerged surgical techniques for placing implants.     

A systematic review of the clinical survival of zirconia implants

Objectives

The aim of this review was to evaluate the clinical success and survival rates of zirconia ceramic implants after at least 1 year of function and to assess if there is sufficient evidence to justify using them as alternatives to titanium implants.

Materials and methods

An electronic search in MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Clinical Trials (CENTRAL) databases was performed in April 2015 by two independent examiners to retrieve clinical studies focusing on the survival rate of zirconia implants after at least 1 year of function. Implant survival was estimated using the overall proportion reported in the studies with a Clopper-Pearson 95 % confidence interval (random effect model with a Der-Simonian Laird estimate).

Results

Fourteen articles were selected out of the 1519 titles initially screened. The overall survival rate of zirconia one- and two-piece implants was calculated at 92 % (95 % CI 87–95) after 1 year of function. The survival of implants at 1 year for the selected studies revealed considerable heterogeneity.

Conclusions

In spite of the unavailability of sufficient long-term evidence to justify using zirconia oral implants, zirconia ceramics could potentially be the alternative to titanium for a non-metallic implant solution. However, further clinical studies are required to establish long-term results, and to determine the risk of technical and biological complications. Additional randomized controlled clinical trials examining two-piece zirconia implant systems are also required to assess their survival and success rates in comparison with titanium as well as one-piece zirconia implants.

Clinical relevance

Zirconia implants provide a potential alternative to titanium ones. However, clinicians must be aware of the lack of knowledge regarding long-term outcomes and specific reasons for failure.

     

Nonlinear stress analysis of titanium implants by finite element method

With use of dental implants on the rise, there is also a tandem increase in the number of implant fracture reports. To the end of investigating the stress occurring in implants, elasticity and plasticity analyses were performed using the finite element method. The following results were obtained: (1) With one-piece type of implants of 3.3 mm diameter, elasticity analysis showed that after applying 500 N in a 45-degree direction, stress exceeding 500 MPa which is the proof stress of grade 4 pure titanium - occurred. This suggested the possibility of fatigue destruction due to abnormal occlusal force, such as during bruxism. (2) With two-piece type of implants that can tolerate vertical loading of 5,000 N, plasticity analysis suggested the possibility of screw area fracture after applying 500 N in a 45-degree direction. (3) On the combined use of an abutment and a fixture from different manufacturers, fracture destruction of even Ti-6Al-4V, which has a high degree of strength, was predicted.     

The effect of fatigue loading on the screw joint stability of zirconium abutment

PurposeThis study evaluated the effect of fatigue loading on the screw joint stability of a zirconium abutment connected to an external hexagon implant in vitro.Materials and methodsFifteen titanium and 15 zirconia abutments of 3 different heights (5, 8, and 11 mm) were connected to external titanium implants with titanium screws. A torque gauge was used to measure the reverse torque values before and after loading. An air cylindrical loading device was used to simulate mastication at a 45-degree angle to the longitudinal axis of the implant.ResultsThere were significant differences (P < 0.05) before and after the loading of titanium (5 mm) and zirconia (5, 8, and 11 mm) abutments.ConclusionZirconia abutments for external hexagon implants had durability rates similar to those of titanium abutments after repeating load on the reverse torque of the abutment screw, indicating that the zirconia abutment could be reliably used instead of the titanium abutment.     

SwissPlus Implant System,Part 1: Surgical aspects and intersystem comparisons

Implant survival in poor-quality bone continues to pose a significant clinical challenge to dentists. The SwissPlus System comprises one-piece, straight and tapered implant designs with self-tapping, apical threads, and a microtextured surface on the intraosseous portion of the implant bodies. Although both designs are indicated for all ranges of bone density, Tapered SwissPlus features double-lead threads and a soft-bone surgical protocol designed to enhance initial mechanical stability at the time of placement. This paper presents an overview of the SwissPlus System with emphasis on the surgical aspects. Presented test data also illustrate intersystem compatibility and differences between the straight SwissPlus and ITI synOcta implants.