Alumina‐reinforced zirconia implants: survival rate and fracture strength in a masticatory simulation trial

Background: Alumina‐toughened zirconia (ATZ) is a possible alternative material to titanium for oral implants. No data are available on the fracture strength of ATZ oral implants. Purpose: The purpose of this study was to examine one‐piece implants made of ATZ ceramic under artificial loading conditions and to compare the fracture strength of these implants with implants fabricated from tetragonal zirconium dioxide poylcrystal (TZP)‐A. Materials and methods: A total of 72 implants, 48 ATZ implants (groups A and B) and 24 TZP‐A implants (group C), were investigated. A chamfer preparation at the implant heads was performed on all implants of groups B and C. Eight implants of each group underwent 1.2 or five million thermomechanical loading cycles in the chewing simulator (load value: 98 N). Further eight implants of each group were not cyclic loaded. Finally, the fracture strength of all implants was determined using a universal testing machine. Results: No implant fractured during loading in the chewing simulator. All implants were placed in the universal testing machine to evaluate fracture strength. The mean fracture strength values±standard deviations for the implants without artificial loading were 1734±165 N (ATZ, no preparation), 1220±85 N (ATZ, with preparation), and 578±49 N (TZP‐A, with preparation); 1489±190 N (ATZ, no preparation), 1064±121 N (ATZ, with preparation), and 607±57 N (TZP‐A, with preparation) with 1.2 million loading cycles; and 1358±187 N (ATZ, no preparation), 1098±97 N (ATZ, with preparation), and 516±45 N (TZP‐A, with preparation) with five million cycles. The ATZ implants showed significantly higher mean fracture strengths compared with the TZP‐A implants. Modification of the implant head using diamond burs and increased loading time also led to a significant decrease in fracture strength. Conclusions: The ATZ implants showed an increased mechanical stability compared with the TZP‐A. Modification of the implant head resulted in a decrease in fracture strength. However, within the limits of this in vitro investigation it can be concluded that ATZ implants will withstand functional loading over an estimated period of 20 years. To cite this article:
Kohal R‐J, Wolkewitz M, Mueller C. Alumina‐reinforced zirconia implants: survival rate and fracture strength in a masticatory simulation trial.
Clin. Oral Impl. Res. 21 , 2010; 1345–1352.
doi: 10.1111/j.1600‐0501.2010.01954.x     

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.     

Retrieved implants from irradiated sites in humans: a histologic/histomorphometric investigation of oral and craniofacial implants

Purpose The aim of this report was to quantitatively and qualitatively evaluate the tissue response to bone‐anchored implants retrieved from irradiated sites in patients. Materials and Methods The material consists of 23 consecutively received Brånemark^® implants (Nobel Biocare AB, Göteborg, Sweden) placed in pre‐ or postoperatively irradiated sites. Twenty‐two of the 23 implants were suitable for histologic evaluation of undecalcified sections in the light microscope. Results The oral implants with shorter time in situ demonstrated sparse bone to implant contact with mainly dense connective tissue in the interface. However, for implants with longer time in situ, high amounts of bone‐implant contact and bone fill of threads were noted. The mean values of bone‐implant contact and bone area within the thread were calculated to 40% (16–94) and 70% (13–96), respectively. The craniofacial implants, with the exception of two implants lined with a capsular formation, demonstrated mature and newly formed bone at the bone‐implant interface. The mean value for bone‐metal contact was calculated to 45 and 53% for two specimens. The mean value for bone area within the thread ranged from 65 to 88% for three specimens. Conclusion The possibility to achieve bone anchorage of implants in irradiated tissue was supported by the findings in this study. However, due to limited material, conclusions with regard to radiation dose and bone tissue response to implants cannot be stated.     

Effect of repeated torque/mechanical loading cycles on two different abutment types in implants with internal tapered connections: an in vitro study

Objectives: Internal tapered connections were developed to improve biomechanical properties and to reduce mechanical problems found in other implant connection systems. The purpose of this study was to evaluate the effects of mechanical loading and repeated insertion/removal cycles on the torque loss of abutments with internal tapered connections.
Material and methods: Sixty-eight conical implants and 68 abutments of two types were used. They were divided into four groups: groups 1 and 3 received solid abutments, and groups 2 and 4 received two-piece abutments. In groups 1 and 2, abutments were simply installed and uninstalled; torque-in and torque-out values were measured. In groups 3 and 4, abutments were installed, mechanically loaded and uninstalled; torque-in and torque-out values were measured. Under mechanical loading, two-piece abutments were frictionally locked into the implant; thus, data of group 4 were catalogued under two subgroups (4a: torque-out value necessary to loosen the fixation screw; 4b: torque-out value necessary to remove the abutment from the implant). Ten insertion/removal cycles were performed for every implant/abutment assembly. Data were analyzed with a mixed linear model ( P ≤0.05).
Results: Torque loss was higher in groups 4a and 2 (over 30% loss), followed by group 1 (10.5% loss), group 3 (5.4% loss) and group 4b (39% torque gain). All the results were significantly different. As the number of insertion/removal cycles increased, removal torques tended to be lower. It was concluded that mechanical loading increased removal torque of loaded abutments in comparison with unloaded abutments, and removal torque values tended to decrease as the number of insertion/removal cycles increased.     

Fracture strength of four different types of anterior 3-unit bridges after thermo-mechanical fatigue in the dual-axis chewing simulator

The purpose of this study was to evaluate the fracture strength of four different types of anterior 3-unit bridges after thermo-mechanical fatigue in a dual-axis chewing simulator. Sixty-four human maxillary incisors were prepared and 32 bridges fabricated. The four groups of eight bridges each were - (GC): AGC(R) galvano-ceramic bridges (CA): Celay(R) In-Ceram(R) Alumina bridges (E2): heat-pressed lithium disilicate glass-ceramic bridges and (CM) ceramo-metal (control). Fracture loads were recorded after a dual-axis chewing simulator and in a universal testing machine. The survival rate after 5 years for the CM and the GC groups was 100%, for the E2 group 75% and for the CA group 37.5% (Kaplan-Mayer analysis). The mean fracture strengths (N) were 681.52 +/- 151.90 (CM); 397.71 +/- 59.02 (GC); 292.92 +/- 46.45 (E2) and 239.95 +/- 33.39 (CA), respectively. The log-rank test showed a significant difference between the CA and the GC or the CA and the CM groups. No significant differences between the E2 and the CA or the E2 and the GC groups were found. The study indicates that heat-pressed lithium disilicate glass-ceramic and AGC(R) galvano-ceramic bridges are alternatives to ceramo-metal 3-unit anterior bridges.     

Immediate loading of single SLA implants: drilling vs. osteotomes for the preparation of the implant site

OBJECTIVES: To evaluate whether or not preparation of the implant site with osteotomes instead of drilling may improve peri-implant bone density and/or osseointegration, and whether or not this further improves the predictability of immediate loading of SLA implants. MATERIAL AND METHODS: The second, third, and fourth premolars were extracted in both sides of the mandible in six dogs, and after at least 3 months four SLA implants were inserted into each side of the jaw. In three animals, the implant sites were prepared by means of osteotomes, while standard stepwise drilling was used in the remaining animals. In each side of the jaw, two non-adjacent implants were restored with single crowns 4 days after installation, while the remaining two implants were left without crowns to serve as non-loaded controls. After 2, 4, or 12 weeks of loading, specimens including the implants and surrounding tissues were obtained and processed for histologic analysis of undecalcified sections. RESULTS: All implants placed with osteotomes were lost (five before delivery of the crowns and the rest during the first week after loading). None of the conventionally inserted implants, however, was lost, and histomorphometrical analysis revealed similar soft- and hard peri-implant tissue characteristics at immediately loaded and non-loaded implants at all observation times. Average bone-to-implant contact was 59-72% at immediately loaded implants vs. 60-63% at non-loaded ones. CONCLUSION: Preparation of the implant site by means of osteotomes had a deleterious effect on osseointegration, while immediate loading of single, free-standing, SLA implants following a conventional surgical protocol did not jeopardize their osseointegration.     

Implant–abutment interface design affects fatigue and fracture strength of implants

Objectives: Failures of implant–abutment connections are relatively frequent clinical problems. The aim of this study was to evaluate the influence of long‐term dynamic loading on the fracture strength of different implant–abutment connections. Material and methods: Six implant systems were tested: two systems with external connections (Brånemark, Compress) and four systems with internal connections (Frialit‐2, Replace‐Select, Camlog, Screw‐Vent). Fracture strength was tested in two subgroups for each system: one subgroup with (dyn) and the other without prior dynamic loading (contr). Each subgroup consisted of eight specimens with standard implant–abutment combinations for single molar crowns. Dynamic loading was performed in a two‐axis chewing simulator with 1,200,000 load cycles at 120 N. Results: Median fracture strengths in Newton (N) and 25th and 75th percentiles [in brackets] were: Brånemark: dyn=729 [0;802]/contr=782 [771;811], Frialit‐2: dyn=0 [0;611]/contr=887 [798;941], Replace‐Select: dyn=1439 [1403;1465]/contr=1542 [1466;1623], Camlog: dyn=1482 [1394;1544]/contr=1467 [1394;1598], Screw‐Vent: dyn=0 [0;526]/contr=780 [762;847] and Compress: dyn=818[0;917]/contr=1008 [983;1028]. In some dyn subgroups, failures of the implant–abutment connection occurred already during dynamic loading: three specimens of the Brånemark and Compress groups and six specimens of the Screw‐Vent and the Frialit‐2 groups failed during dynamic loading. Statistically significant differences (P≤0.05) in fracture strength could be found between groups with different connection designs. Conclusion: Implant systems with long internal tube‐in‐tube connections and cam–slot fixation showed advantages with regard to longevity and fracture strength compared with systems with shorter internal or external connection designs.     

氧化锆对二硅酸锂玻璃陶瓷力学性能的影响

目的:测定牙科氧化锆-二硅酸锂玻璃陶瓷复合材料(ZTCLDC)的力学性能,探讨氧化锆质量分数变化对ZTCLDC力学性能的影响及机制。方法:向制备好的二硅酸锂基础玻璃粉体中分别添加不同质量分数的ZrO(21%,2%,3%,4%),静压成型晶化热处理,每组中的半数试件进行牙科热压铸处理,分别测试热压铸前后的三点弯曲强度及断裂韧性;扫描电镜观察晶体微观结构;X射线衍射分析其晶相组成。结果:热压铸前,ZTCLDC抗弯强度和断裂韧性随ZrO2含量的增加而升高;热压铸后,ZTCLDC抗弯强度随ZrO2含量的增加而降低,ZrO2加入量为4%时,压铸后的断裂韧性最高为4.3 MPa.m1/2。结论:ZrO2对实验二硅酸锂玻璃陶瓷存在增韧效果,能够提高复合材料的断裂韧性。     

Survival rate, fracture strength and failure mode of ceramic implant abutments after chewing simulation

The aim of this study was to compare titanium-reinforced ZrO(2) and pure Al(2)O(3) abutments regarding their outcome after chewing simulation and static loading. Forty-eight standard diameter implants with an external hexagon were divided into three groups of 16 implants each and restored with three different types of abutments (group A: ZrO(2) abutments with titanium inserts; group B: Al(2)O(3) abutments; group C: titanium abutments). All abutments were fixated on the implants with gold-alloy screws at 32 Ncm torque, and metal crowns were adhesively cemented onto the abutments. The specimens were exposed to 1.2 million cycles in a chewing simulator. Surviving specimens were subsequently loaded until fracture in a static testing device. Fracture loads (N) and fracture modes were recorded. A Wilcoxon Rank test to compare fracture loads among the three groups and a Fisher exact test to detect group differences in fracture modes were used for statistical evaluation (P < 0.05). All specimens but one of group B survived chewing simulation. No screw loosening occurred. The median fracture loads (+/-s.d.) were as follows: group A, 294 N (+/-53); group B, 239 N (+/-83), and group C, 324 N (+/-85). The smaller fracture loads in group B were statistically significant. The use of pure Al(2)O(3) abutments resulted in significantly more abutment fractures. It is proposed that titanium-reinforced ZrO(2) abutments perform similar to metal abutments, and can therefore be recommended as an aesthetic alternative for the restoration of single implants in the anterior region. All-ceramic abutments made of Al(2)O(3) possess less favourable properties.     

Bacterial colonization of the implant-abutment interface using an in vitro dynamic loading model

Background: Previously, we demonstrated that the geometry of the fixture–abutment interface influences the risk of bacterial invasion into the internal part of the implant, although the contribution of loading on this invasion was not evaluated. The aim of the present study is to use an in vitro dynamic‐loading model to assess the potential risk for invasion of oral microorganisms into the fixture–abutment interface microgap of dental implants with different fixture–abutment connection characteristics. Methods: Twenty‐eight implants were divided into two groups (n = 14 per group) based on their microgap dynamics. Group 1 was comprised of fixtures with internal Morse‐taper connection that connected to standard abutments. Group 2 was comprised of implants with a four‐groove conical internal connection that connected to multibase abutments. The specimens were immersed in a bacterial solution of Escherichia coli and loaded with 500,000 cycles of 15 N in a wear simulator. After disconnection of fixtures and abutments, microbial samples were taken from the threaded portion of the abutment, plated, and cultured under appropriate conditions. The difference between loosening and tightening torque value was also measured. Results: One of the 14 samples in Group 1 and 12 of the 14 of samples in Group 2 developed multiple colony forming units for E. coli. Implants in Group 1 exhibited an increase in torque value in contrast to implants in Group 2, which exhibited a decrease. Conclusion: This study indicates that differences in implant design may affect the potential risk for invasion of oral microorganisms into the fixture–abutment interface microgap under dynamic‐loading conditions.