Fracture strength of zirconia implants after artificial aging

Background: Zirconia (ZrO₂) might be an alternative material to titanium (Ti) for dental implant fabrication. However, no data are available on the fracture strength of one‐piece ZrO₂ oral implants. Purpose: The objective of this study was to evaluate the fracture strength of ZrO₂ implants after exposure to the artificial mouth. Materials and Methods: One hundred twenty ZrO₂ and Ti implants were used. The Ti implants were divided into two control groups (A and B). ZrO₂ implants manufactured from yttria‐stabilized tetragonal ZrO₂ polycrystal (Y‐TZP) in group C, from Y‐TZP dotted with alumina (Y‐TZP‐A) in group D, and from Y‐TZP‐A with a modified surface in groups E and F were used. In group F, the implant heads were prepared, and in group G, the implants were restored with ZrO₂ crowns. Each group included 16 samples with the exception of group D, which included 24 samples. A subgroup of each implant type (eight implants) was subjected to thermomechanical cycling in a chewing simulator prior to fracture testing. Test specimens were then loaded until a fracture occurred. Results: Seven of the 120 samples failed in the chewing simulator. ZrO₂ implant fracture occurred at 725 to 850 N when the implants were not prepared, and at 539 to 607 N when prepared. The samples in group A fractured at the level of the abutment screw. All ZrO₂ implants fractured at the level of the Technovit® resin (Heraeus Kulzer GmbH & Co., Wehrheim, Germany). No fracture of the ZrO₂ crowns in group G was observed. Conclusion: Mean fracture strength values obtained were all within the limits of clinical acceptance. However, implant preparation had a statistically significant negative influence on the implant fracture strength. Long‐term clinical data are necessary before one‐piece ZrO₂ implants can be recommended for daily practice.     

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.     

One‐piece zirconia oral implants for single‐tooth replacement: Three‐year results from a long‐term prospective cohort study

Aim

This 3‐year report of a prospective long‐term cohort investigation aimed to evaluate the clinical and radiographic outcomes of a one‐piece zirconia oral implant for single‐tooth replacement.

Materials and Methods

Sixty‐five patients received a 1‐stage implant surgery with immediate temporization. Standardized radiographs were taken at implant insertion, after 1 year, and after 3 years to monitor peri‐implant bone levels. A univariate analysis of the association of different baseline parameters on marginal bone loss from implant insertion to 36 months was performed. Soft‐tissue parameters were evaluated at prosthesis insertion, after 6 months, after 1 year, and at the 3‐year follow‐up.

Results

After 3 years, six posterior site implants were lost, giving a cumulative survival rate of 90.8%. The mean marginal bone loss was 1.45 mm; 35% of the implants lost at least 2 mm bone, and 22% more than 3 mm. The univariate analysis did not identify any parameter associated with marginal bone loss. Probing depth, clinical attachment level, and bleeding index increased over 3 years, and plaque index decreased.

Conclusions

The low survival rate of the presented ceramic implant and especially the high frequency of advanced bone loss are noticeable but remain unexplained.     

The effects of cyclic loading and preparation on the fracture strength of zirconium-dioxide implants: an in vitro investigation

Objectives: Zirconia is a potential material for the fabrication of oral implants. The aim of this study was to evaluate the effects of cyclic loading and preparation on the fracture strength of a zirconia implant system. Materials and methods: Forty‐eight one‐piece implants were divided into two groups of 24 implants: group A (without modification) and group B (1 mm chamfer preparation). Groups A and B were divided into three subgroups of eight implants each (1=no artificial load, 2=artificial load [98 N; 1.2 million loading cycles], and 3=artificial load [98 N; 5 million loading cycles]). After completion of the loading, the fracture strength of each implant was determined in a universal testing machine. A two‐way analysis of variance was used, the continuous response variable (fracture strength in Newtons) is modeled as a function of preparation, cycles, and the corresponding interaction as explanatory variables. Results: The mean fracture strength values obtained for the groups were: A1 (no preparation, no load)=1928.73 N, A2 (no preparation, 1.2 million cycles)=2044.84 N, A3 (no preparation, 5 million cycles)=1364.50 N, B1 (preparation, no load)=1221.66 N, B2 (preparation, 1.2 million cycles)=967.11 N, and B3 (preparation, 5 million cycles)=884.89 N. Fracture values were significantly different between subgroups A1 vs. A3 and B1 vs. B3. There was no significant difference between subgroups A1 vs. A2 and B1 vs. B2. Conclusions: Preparation as well as cyclic loading can decrease the fracture strength resistance of zirconia implants. Nevertheless, even the lowest values of mean fracture strength of the implants used in our study seem to withstand average occlusal forces even after an extended interval of artificial loading. To cite this article:
Kohal RJ, Wolkewitz M, Tsakona A. The effects of cyclic loading and preparation on the fracture strength of zirconium‐dioxide implants: an in vitro investigation.
Clin. Oral Impl. Res. 22 , 2011; 808–814.
doi: 10.1111/j.1600‐0501.2010.02067.x     

Effect of finish line design on stress distribution in bilayer and monolithic zirconia crowns: a three‐dimensional finite element analysis study

This study evaluated the influence of different finish line designs and abutment materials on the stress distribution of bilayer and monolithic zirconia crowns using three‐dimensional finite element analysis (FEA). Three‐dimensional models of two types of zirconia premolars – a yttria‐stabilized zirconia framework with veneering ceramic and a monolithic zirconia ceramic – were used in the analysis. Cylindrical models with the finish line design of the crown abutments were prepared with three types of margin curvature radius (CR): CR = 0 (CR0; shoulder margin), CR = 0.5 (CR0.5; rounded shoulder margin), and CR = 1.0 (CR1.0; deep chamfer margin). Two abutment materials (dentin and brass) were analyzed. In the FEA model, 1 N was loaded perpendicular to the occlusal surface at the center of the crown, and linear static analysis was performed. For all crowns, stress was localized to the occlusal loading area as well as to the axial walls of the proximal region. The lowest maximum principal stress values were observed when the dentin abutment with CR0.5 was used under a monolithic zirconia crown. These results suggest that the rounded shoulder margin and deep chamfer margin, in combination with a monolithic zirconia crown, potentially have optimal geometry to minimize occlusal stress.     

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.     

Influence of contamination on resin bond strength to nano‐structured alumina‐coated zirconia ceramic

Zhang S, Kocjan A, Lehmann F, Kosma? T, Kern M. Influence of contamination on resin bond strength to nano‐structured alumina‐coated zirconia ceramic. Eur J Oral Sci 2010; 118: 396–403. © 2010 The Authors. Journal compilation © 2010 Eur J Oral Sci The purpose of this study was to evaluate the influence of contamination and subsequent cleaning on the bond strength and durability of an adhesive resin to nano‐structured alumina‐coated zirconia ceramic. Zirconia ceramic disks were coated with nano‐structured alumina, utilizing the hydrolysis of aluminum nitride powder. After immersion in saliva or the use of a silicone disclosing agent, specimens were cleaned with phosphoric acid etching or with tap water rinsing only. Uncontaminated specimens served as controls. Plexiglas tubes filled with composite resin were bonded with a phosphate monomer [10‐methacryloxydecyl‐dihydrogenphosphate (MDP)]‐containing resin (Panavia 21). Subgroups of eight specimens each were stored in distilled water at 37°C, either for 3 d without thermal cycling (TC) or for 150 d with 37,500 thermal cycles from 5 to 55°C. The tensile bond strength (TBS) was determined using a universal testing machine at a crosshead speed of 2 mm min^?1. The topography of the debonded surface was scrutinized for fractographic features, utilizing both optical and scanning electron microscopy. The TBS to uncontaminated nano‐structured alumina‐coated zirconia ceramic was durable, while contamination significantly reduced the TBS. Phosphoric acid cleaning was effective in removal of saliva contamination from the coated bonding surface but was not effective in removal of the silicone disclosing agent. Nano‐structured alumina coating improves resin bonding to zirconia ceramic and eliminates the need for air‐abrasion before bonding.     

Survival rate and fracture strength of incisors restored with different post and core systems after exposure in the artificial mouth

The survival rate and fracture resistance of 40 decapitated endodontically treated maxillary central incisors using four different post and core systems covered with all-ceramic copings was evaluated after exposure in the artificial mouth. Ten samples of the following post and core systems were investigated: high precious metal post (Permador) and core (Olympia) (A), zirconia post (Cerapost) with a pre-fabricated bonded ceramic core (Ceracap) (B), resin-ceramic post (experimental) with a pre-fabricated bonded ceramic core (Ceracap(R)) (C) and a zirconia post (Cerapost) with a custom made ceramic core (Cosmo Ingots) (D). The all-ceramic copings (Procera) were cemented using Panavia TC. The survival rates after 1 200 000 cycles in the artificial mouth are as follows: 90% (A), 80% (B), 60% (C) and 100% (D). The results of the means and standard deviations (s.d.) of the fracture resistance during static loading are: 1270 +/- 312.5 (A), 1494.5 +/- 333.5 (B), 1146.7 +/- 182.6 (C) and 463.3 +/- 46.2 (D). There are statistically significant differences between all groups with the exception of A and B, and A and C (Wilcoxon test). None of the zirconia posts with custom made ceramic cores covered with all-ceramic copings fractured during dynamic loading in the artificial mouth. The mean fracture strength during static loading was less favourable than that of groups A, B and C but above the clinical necessary level.     

A practice‐based clinical evaluation of the survival and success of metal‐ceramic and zirconia molar crowns: 5‐year results

This practice‐based study evaluates the survival and success of conventionally luted metal‐ceramic and zirconia molar crowns fabricated by using a prolonged cooling period for the veneering porcelain. Fifty‐three patients were treated from 07/2008 to 07/2009 with either metal‐ceramic crowns (MCC) or zirconia crowns (ZC). Forty‐five patients (26 female) with 91 restorations (obser‐vational period: 64·0 ± 4·8 months) participated in a clinical follow‐up examination and were included in the study. Estimated cumulative survival (ECSv), success (ECSc) and veneering ceramic success (ECVCSc) were calculated (Kaplan–Meier) and analysed by the crown fabrication technique and the position of the restoration (Cox regression model) (P < 0·05). Five complete failures (MCC: 2, ZC: 3) were recorded (5‐year ECSv: MCC: 97·6%, (95% confidence interval (95%‐CI): [93%; 100%]/ZC: 94·0%, (95%‐CI): [87%; 100%]). Of the MCCs (n = 41), 85·0%, [95%‐CI: (77%; 96%)] remained event‐free, whereas the ECSc for the ZCs (n = 50) was 74·3% (95%‐CI): [61%; 87%]. No significant differences in ECSv (P = 0·51), ECSc (P = 0·43) and ECVCSc (P = 0·36) were detected between the two fabrication techniques. Restorations placed on terminal abutments (n = 44) demonstrated a significantly lower ECVCSc (P = 0·035), (5‐year VCF‐rate: 14·8%) than crowns placed on tooth‐neighboured abutments (n = 47), (5‐year VCF‐rate: 4·3%). In the present study, zirconia molar crowns demonstrated a 5‐year ECSv, ECSc and ECVCSc comparable to MCCs. Irrespective of the fabrication technique, crowns on terminal abutments bear a significantly increased risk for VCFs. Clinical investigations with an increased number of restorations are needed.