The Survival Rate of Zirconia Versus Titanium Dental Implants: A Systematic Review

Abreu, Francisca; Correia, Francisco; Caetano, Tiago; Faria-Almeida, Ricardo

doi:10.3390/surgeries6010020

Open AccessSystematic Review

The Survival Rate of Zirconia Versus Titanium Dental Implants: A Systematic Review

¹

Specialisation in Periodontology and Implants, Faculty of Dental Medicine, University of Porto, 4200-393 Porto, Portugal

²

Associated Laboratory for Green Chemistry (LAQV) of the Network of Chemistry and Technology (REQUIMTE), 4050-342 Porto, Portugal

^*

Author to whom correspondence should be addressed.

Surgeries 2025, 6(1), 20; https://doi.org/10.3390/surgeries6010020

Submission received: 26 December 2024 / Revised: 11 February 2025 / Accepted: 20 February 2025 / Published: 7 March 2025

(This article belongs to the Special Issue Dental Surgery and Care)

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Abstract

:

Objective: The aim of this systematic review is to compare the survival rates of zirconia and titanium dental implants, by evaluating the most recent scientific evidence, in order to comprehend the behaviour of zirconia implants as an alternative to titanium, due to the latter’s biological properties. Methods: An electronic search was performed on the Pubmed/MEDLINE and Scopus databases in November 2023 to identify clinical trials that investigated zirconia and titanium implants’ behaviour with a follow-up of at least 5 years. The primary outcome was the implant survival rate—defined as the maintenance of the implant in situ during the period of study. The secondary outcome was the implant success rate, which is associated with the values of the peri-implant variables—the probing depth, marginal bone loss, gingival recession, bleeding on probing, plaque index, and aesthetics scores. Results: A total of 17 articles were selected from the search, resulting in a sample of 364 studies. A total of 15 articles fulfilled the selection criteria. Zirconia implants showed satisfactory results. Due to the lack of data available with follow-up times of more than five years, it is not possible to conclusively describe the benefits of zirconia in comparison with titanium implants. Conclusions: While zirconia implants show promise as a future alternative to metal implants, more research is needed to understand their long-term benefits and peri-implant behaviour.

Keywords:

dental implants; zirconia implants; titanium implants; dental prosthesis; osseointegration; dental materials; ceramics; systematic review

1. Introduction

Peri-implantitis is a chronic inflammatory disease caused by bacterial activity that leads to the destruction of supporting implant tissue—compromising the peri-implant assessment parameters. Although bacterial activity is the primary cause, it is important to note that the condition is often aggravated by excessive immune responses against bacterial invasion [1].

1.1. Titanium Implants

Titanium is currently the most commonly used material in the implant industry due to its favourable characteristics—biocompatibility and mechanical and corrosion resistance [1,2]. However, Nakagawa M et al. [3] found that this corrosion resistance decreases in low oxygen conditions, such as in an intra-gingival environment. Titanium implants’ osseointegration is also slow and could be accompanied by aseptic loosening or insufficient osseointegration [4]. Several studies have shown that titanium particles can be released during osseointegration, which may cause allergic reactions and damage to the tissues around the implant. This happens because the particles trigger inflammation, increase cytokine levels, and affect the bone around the implant, making osseointegration more difficult. Contrary to this, Wachi T et al. [2] found a reduced level of ion release from titanium materials owing to the formation of a non-stoichiometric titanium dioxide (TiO₂) film; on the other hand, these materials are not safe from failure because of a fibrous layer that forms at the bone–tissue interface. Additionally, nano-engineered titanium implants, such as those enhanced by electrochemical anodization (EA), promote the formation of a thickened TiO₂ film with distinctive nano-microgeometries, which could potentially benefit soft-tissue integration at the gingival–abutment interface, improving the overall performance and reducing the likelihood of failure [5]. Despite the current knowledge, no hard evidence exists of a causal relation between the release of titanium particles and implant failure [6,7,8,9,10,11,12,13,14].

1.2. Zirconia Implants

Zirconia implant research has been undertaken for more than fifty years because of their aesthetic outcomes and since titanium implants are not always the preferred choice to rehabilitate anterior regions [7,8,15]. These aesthetic concerns, combined with the possible biological complications induced by titanium particles, have led to zirconia becoming an increasingly studied material in recent years as an opportunity to implement metal-free implant procedures [16]. Despite the fact that zirconia implants have shown optimal responses during the early healing phase and osseointegration, because of the low rate of bone loss and peri-implant infections, these responses were not always statistically significant [6,7,16].

Compared to titanium, Y-TZP has a lower elasticity modulus (around 100 GPa vs. 200 GPa) combined with a high level of fracture resistance due to its distinctive characteristic, stress-induced transformation [7,15,17,18]. Y-TZP synthesis includes the addition of yttria to stabilise the tetragonal phase of pure zirconia, and this addition makes it more stable to the influence of thermal fluctuations [19].

Kohal RJ et al. [20] reported that a one-piece zirconia implant was twice as resistant to fracture than a two-piece. In spite of the evolution of zirconia resistance to fracture through the years, Gahlert M et al. [21] showed that the foremost cause of implant failure was a reduced implant diameter of 3.25 mm.

Osman RB et al. [22] emphasised the difficulty of placing zirconia implants in dense bone tissue and the necessity of improving surgical protocols to reduce the failure rate, such as to minimise the risk of implant fracture.

1.3. Objective

The aim of this systematic review is to compare the survival rate of zirconia and titanium dental implants by evaluating the most recent scientific evidence in order to comprehend the behaviour of zirconia implants, as an alternative to titanium, due to the latter’s biological properties.

2. Materials and Methods

This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement [23].

2.1. Research Conduct

The search process was carried out during November 2023 and included two databases: PubMed/MEDLINE and Scopus, with a time restriction for paper publish after 2009. The search strategy combined the following keywords: “Implants”, “Zirconia”, “Titanium”, “Ceramic”, “Survival”, and “Survival rate”. In PubMed, filters were applied to include only clinical trials and randomised controlled trials (N = 263), whereas in Scopus, the search was limited to research articles, case reports, and studies within the fields of medicine and dentistry (N = 77). A manual search was also performed.

2.2. Study Selection

The sample selection strategy followed the Population, Intervention, Comparison, Outcome and Study Design (PICOS) method:

P—patients undergoing implant surgery;

I—zirconia dental implants;

C—titanium dental implants;

O—survival rate (SR), success rate (ScR), periodontal variables (peri-implant probing depth (PPD), marginal bone loss (MBL), gingival recession (GR), bleeding on probing (BoP), plaque index (PI), and aesthetics scores (PINK));

S—clinical trials and randomised controlled trials.

2.3. Inclusion Criteria

The following inclusion criteria were applied:

(a): Studies involving adult human participants;
(b): Reporting the survival rate of zirconia or titanium implants;
(c): Clinical trials and randomised controlled trials published from 2010 onward;
(d): A minimum follow-up period of five years.

2.4. Exclusion Criteria

Studies in which implants and bone grafts were placed simultaneously were excluded to minimise the risk of regeneration-related failure. Additionally, studies evaluating implants composed of both titanium and zirconia were not considered. Studies comparing only abutment materials were also excluded. The detailed exclusion criteria are provided in Appendix A.

2.5. Screening Method

The screening was performed by two reviewers (F.A. and T.C.) in accordance with the inclusion and exclusion criteria explained above. In cases of uncertainty, a third reviewer (R.F.-A.) assessed the study.

The screening began with the removal of duplicated articles. Titles and abstracts were then reviewed for relevance, followed by a full-text assessment to determine whether the studies addressed the research question. The PRISMA 2020 flow diagram is presented in Figure 1.

2.6. Data Extraction and Outcomes

The primary outcome is implant SR, defined as the maintenance of the implant in situ during the study period.

The secondary outcome is the implant ScR, which is associated with peri-implant variables values—PPD, MBL, GR, BoP, and PINK scores.

Data extraction was performed by one reviewer (F.A.) using data extraction tables; only intelligible information was selected. The data extracted were organised in four sections:

(1): Study characteristics—author, year, type of design (randomised clinical trial [RCT]/clinical trial [CT], follow-up (years), intervention (titanium/zirconia/comparing both), patient sample (sample size and mean age [years]), implant sample (sample size, restoration type [partial/full edentulous; fixed dental prosthesis (FDP)/single crown (SC)], and location (maxilla/mandible/both).
(2): Implant design—material, characteristics (type of implant [one/two-piece], diameter [mm], and length [mm]), brand.
(3): Evaluation criteria—SR, ScR, BoP, PPD, GR, PI, MBL, PI, and PINK Score.
(4): Outcomes divided into three subsections—(i) comparative studies, (ii) titanium studies, (iii) zirconia studies—periodontal parameters (BoP, PPD, GR, PI, and MBL), PINK Score, SR, and ScR.

For periodontal and aesthetic parameters, only results expressed as mean/median and standard deviation were considered.

For SR and ScR, results were accepted if expressed as a percentage (%).

2.7. Quality Assessment and Risk of Bias

Bias assessment was conducted by two researchers (F.A. and T.C.) by submitting the sample to the criteria of RoB 2 (randomised clinical trials) [24] and ROBINS-I (non-randomised clinical trials) [25] tools, which follow the Cochrane Handbook for Systematic Reviews recommendations. Non-randomised clinical trials, labelled as non-randomised studies of interventions (NRSI) by Cochrane, include cohort studies, case–control studies, controlled before-and-after studies, and interrupted-time-series studies.

3. Results

The search resulted in 364 articles—340 articles from the primary database search, and 24 from the secondary manual research. After the removal of duplicate articles, 237 studies were screened, and only 15 articles fulfilled the selection criteria, which were included in the qualitative synthesis. The agreement level between the reviewers was strong (k = 0.85).

3.1. Studies Characteristics

Of the fifteen articles included, four were randomised clinical trials (RCT), and 11 were non-randomised clinical trials (nRCT), whose characteristics included in Table 1. The studies were published between 2011 and 2023; only one article directly compared titanium and zirconia implants (published in 2020) [Koller 2020] [6], six articles studied titanium implants’ behaviour (published between 2011 and 2018) [S. Ma DClinDent 2018 [26]; Cochran, D.L. 2011 [27]; Ravald, N 2013 [28]; Müller, F 2015 [29]; van Velzen, FJ 2015 [30]; Buser, D 2012 [9]]; and eight studies analysed zirconia implants (published between 2015 and 2023) [Balmer, M 2020 [31]; Brunello, G 2022 [32]; Grassi, FR 2015 [33]; Cionca, N 2021 [34]; Spies, BC 2015 [35]; Lorenz, J 2019 [36]; Kiechle S 2023 [37]; Kohal RJ 2023 [38]]. The follow-up ranged between 5 and 15 years.

The sample size was heterogeneous among studies, ranging from 16 to 303 patients; the minimum mean age was 46, and the maximum was 76 years old.

This systematic review included the evaluation of 2496 implants—1986 titanium implants and 464 zirconia implants. These implants were part of partial and full edentulous restorations, located on the maxilla and/or mandibula; partial edentulous restorations include single crowns (SCs) and fixed dental prostheses (FDPs), and full edentulous restorations were restored with FDPs.

3.2. Implant Characteristics

This review included seven titanium articles [6,9,26,27,28,29,30] and nine zirconia articles [6,31,32,33,34,35,36,37,38]; the zirconia ones were composed of Y-TZP or ZrO₂. The titanium implants were all two-pieces, with diameters ranging from 3.3 to 4.8 mm and lengths between 8.0 and 14.0 mm, from the brands Ziteron^®, Southern Implants^®, Astra Tech^®, Brånemark^®, and Straumann^®. The zirconia ones were made of Y-TZP or ZrO₂. Regarding zirconia implants, only one was a one-piece ZrO₂ implant with a 4.1 mm diameter and available in 8.0, 10.0, and 12.0 mm lengths, manufactured by Straumann^®. The remaining zirconia implants were composed of Y-TZP and included both one- and two-piece designs, with diameters ranging from 3.25 to 5.5 mm and lengths between 8.0 and 16.0 mm, from Nobel Biocare^®, Straumann^®, Oensingen^®, Bredent Medical^®, Zircon Medical^®, and VITA Zahnfabrik^®.

3.3. Output Measurement Methods and Results (Table 2 and Table 3)

3.3.1. Survival Rate Criteria (SR)

The survival rate was calculated in 13 studies [Koller et al. [6], Cochran D.L. 2011 [27], Ravald, N et al. [28], F. Müller 2015 [29], van Velzen, FJ 2015 [30], Buser, D et al. [9], Balmer, M et al. [31], Brunello, G et al. [32], Grassi, FR et al. [33], N. Cionca 2021 [34], Lorenz, J et al. [36], Kiechle S 2023 [37], Kohal RJ 2023 [38]] and was defined as the implant remaining in situ.

The implant survival rate ranged from 71.9% to 99.7% for titanium implants and 55% to 100% for zirconia implants.

The lowest survival for both materials was reported by Koller et al. [6] for maxillary implants, although the patient sample size was small (N = 15).

Cochran D.L et al. [27] described one of the lowest SRs, 87%, after 5.0 years, for 626 titanium implants. In contrast, Buser, D et al. [9] reported a survival rate of 98.8% in 511 titanium implants after 10.0 years.

Koller et al. [6] compared titanium and zirconia implants, and the SR difference was not statistically significant between the groups (p > 0.05).

S. Ma DClinDent et al. [26] and Lorenz, J et al. [36] did not report survival rate data.

3.3.2. Success Rate Criteria (ScR)

Success rate data were reported in eight articles [S. Ma DClinDent 2018 [26], Cochran D.L. 2011 [27], F. Müller 2015 [29], Buser D 2012 [9], Grassi FR 2015 [33], N. Cionca 2021 [34], BC Spies 2015 [35], Kiechle S 2023 [37]]. Among them, only Kiechle S. et al. [37] did not specify the criteria used. The criteria for defining success varied among authors. S. Ma DClinDent et al. [26] classified cases as successful despite marginal bone loss exceeding 1.8 mm over a 5-year follow-up. Cochran, DL et al. [27] and BC Spies et al. [35] used Kaplan–Meier survival analysis [39], while the remaining studies adopted the Albrektsson et al. [40] criteria, which define success as follows: the absence of implant mobility, suitability for prosthetic restoration, no evidence of persistent complaints, no continuous radiolucency, and vertical bone loss of less than 0.2 mm per year [Müller, F 2015 [29], Buser, D 2012 [9], Grassi, FR 2015 [33], N. Cionca 2021 [34]].

The success rate ranged from 92.5% to 97% for titanium implants and 51.7% to 96.9% for zirconia implants. These values are consistent with the peri-implant variables reported in Table 2 and Table 3.

3.3.3. Bleeding on Probing (BoP)

The BoP parameter was assessed in studies by Koller et al. [6], Ravald, N et al. [28], Buser, D et al. [9], Balmer, M et al. [31], Brunello, G et al. [32], Grassi, FR et al. [33], and Lorenz, J et al. [36]. With the exception of Ravald, N et al. [28], Balmer, M et al. [31], and Brunello, G et al. [32], who recorded bleeding scores after probing at six sites around the implant, and Lorenz, J et al. [36], who used sulcus bleeding index (SBI), which recorded four sites per implant, Koller et al. [6], Buser D et al. [9], and Grassi, FR et al. [33] classified BoP according to the modified Sulcus Bleeding Index (mSBI) and measured bleeding at six sites around the implant—0, no bleeding when a periodontal probe is passed along the gingival margin; 1, isolated bleeding spots visible; 2, blood forms a confluent red line on margin; 3, heavy or profuse bleeding.

Due to the discrepancies in the measurement methods, we found it difficult to compare the BoP through the studies. Nonetheless, the zirconia group exhibited the lowest values, with 12.9 ± 15.8% reported by Brunello G. et al. [32] and 0.47 ± 0.51 using the mSBI by Lorenz J. et al. [36]. However, Koller et al. [6] found lower BoP values in titanium implants compared to zirconia, although the difference was not statistically significant (p = 0.130).

3.3.4. Peri-Implant Probing Depth (PPD)

Seven articles reported data on PPD using a periodontal probe [van Velzen, FJ 2015 [30], Buser D 2012 [9], Balmer, M 2020 [31], Brunello, G 2022 [32], Grassi, FR 2015 [33], Cionca, N 2021 [34], Lorenz, J 2019 [36]]. With the exception of Lorenz J. et al. [36], who measured PPD at four sites per implant, all other studies assessed recorded PPD values at six sites around the implant.

The lowest PPD value was observed in the zirconia group—2.2 ± 0.53 mm, with 96.9% ScR [Grassi FR, 2022 [33]]. The highest PPD for zirconia was 3.5 ± 1.0 mm, as reported by Cionca N. et al. [34] ], with a success rate of only 63%. In contrast, in the titanium group, although PPD values were approximately 4.0 mm, the success rate was higher than that of zirconia—97% [Buser D, 2012 [9]], in a study with a larger sample size.

3.3.5. Gingival Recession (GR)

Among the seven articles that evaluated the GR parameter [Koller 2020 [6], S. Ma DClinDent 2018 [26], Buser, D 2012 [9], Balmer, M 2020 [31], Brunello, G 2022 [32], Grassi, FR 2015 [33], Lorenz, J 2019 [36]], GR was generally measured as the distance from the implant shoulder to the mucosal margin (DIM). S. Ma DClinDent [26] used the cervical margins of adjacent natural teeth as a reference, while Grassi, FR et al. [33] also considered the epimucosal position of the crown margin. Given the absence of a cementoenamel junction in implants, Grassi F.R. et al. [33] assessed GR by measuring the distance from the incisal edge to the most apical point of the vestibular margin. Koller et al. [6] did not provide a clear explanation.

GR values were comparable between groups; however, the titanium group exhibited the lowest GR value (0.08 ± 0.20 mm) [S. Ma DClinDent 2018 [26]], whereas the zirconia group presented the highest value (1.27 ± 0.81 mm) [Koller 2020 [6]].

3.3.6. Plaque Index (PI)

The plaque index was assessed using different methodologies across the seven studies that reported results. The measurement method was not specified by Koller et al. [6]. Ravald, N et al. [28], Balmer, M et al. [31], and Lorenz, J et al. [36] recorded PI based on individual implant surfaces (mesial, distal, buccal, and lingual). Buser, D. et al. [9] and Grassi, FR et al. [33], applied a modified plaque index (mPLI), where a score of 0 indicated no detection of plaque, a score of 1 indicated that plaque were only recognised by running a probe across the smooth marginal surface of the implant, a score of 2 indicated plaque could be seen by the naked eye, and a score of 3 indicated an abundance of soft matter. Brunello, G et al. [32] assessed PI as a dichotomous variable—0 indicating an absence of plaque, and 1 indicating presence of plaque.

Overall, zirconia implants exhibited a higher PI, with a mean value of 26.2 ± 27.5% [Balmer, M 2020 [31]].

3.3.7. Marginal Bone Loss (MBL)

MBL was assessed in ten studies [Koller 2020 [6], S. Ma DClinDent 2018 [26], N. Ravald 2013 [28], F. Müller 2015 [29], van Velzen FJ 2015 [30], Buser D 2012 [9], Balmer, M 2020 [31], Grassi, FR 2015 [33], Cionca, N 2021 [34], Lorenz, J 2019 [36]]. The majority defined it as the distance through the implant shoulder and the first bone-to-implant contact (DIB).

Buser, D et al. [9] and Cionca, N et al. [34] converted DIB values into a qualitative classification—<2.5 mm, no bone loss or even bone gain; [2.51–3.50 mm], no or minimal bone loss; [3.51–4.5 mm], moderate bone loss; and >4.51 mm, progressive bone loss, including the implants with peri-implant infections.

Titanium demonstrated superior performance in minimizing bone loss, which aligns with the PI results.

3.3.8. Aesthetic Score (PINK)

Koller et al. [6]’s study was the only study to provide results of the PINK aesthetic score. This score was assessed based on the evaluation of mesial and distal papilla; the integrity of alveolar process; and the contour, colour, and texture of peri-implant mucosa.

The PINK score did not show a significant difference between zirconia and titanium implants (p = 0.428). However, it is important to note that, after 30 months, zirconia implants exhibited higher scores, although the difference was not statistically significant. Conversely, after 80 months, titanium implants attained the highest scores.

3.4. Risk of Bias Assessment

The risk of bias (Table 4) was assessed using the ROB2 tool for four RCTs, all of which were classified as having “Some concern” [Koller 2020 [6], N. Ravald 2013 [28], F. Müller 2015 [29], Lorenz J 2019 [36]]. Upon reassessing the studies, we found that the outcomes remained clear and did not substantiate any significant issues. However, the identified concerns were related to three specific domains, classified as “Some concern” due to factors such as a lack of blinding or unclear randomisation procedures.

For the eleven nRCTs assessed with the ROBINS-I tool, three studies were flagged as having a high risk of bias due to issues related to the selection of reported results, including missing or incomplete outcome data [Balmer, M 2020 [31], BC Spies 2015 [35], Kohal RJ 2023 [41]]. Buser D et al. [9] exhibited low risk, supporting the robustness of the review.

4. Discussion

The purpose of this systematic review was to compare the survival rates of zirconia and titanium dental implants and evaluate the performance of zirconia implants as an alternative to titanium, given the latter’s biological properties. In contrast with the systematic reviews that have been published to date [42,43,44,45,46], we restricted the follow-up period to a minimum of five years after the implant surgery to properly evaluate the osseointegration and the wear rate of the implants. There was only one study [6] that compared titanium and zirconia directly, in accordance with our inclusion criteria. Therefore, this systematic review also included articles about titanium and zirconia implants individually to support Koller et al.’s findings and motivate the publication of new articles that compare both implants in the same investigation [6].

The analysis of this outcome requires a cautious interpretation due to the discrepancy in sample size of titanium and zirconia implants–1986 vs. 464, respectively. Given the small number of studies, the sample is heterogeneous in a range of aspects, such as the implant system (one-piece and two-pieces), rehabilitation type (SC and FDPs) and position (anterior and posterior; maxilla and mandible), implant brand, and implant characteristics. Regarding the rehabilitation type, zirconia implants were generally placed in SCs, while titanium implants were part of FDPs. The follow-up differences between titanium and zirconia studies—5.0 to 15.0 years vs. 5.0 to 9.0 years—should be considered. The study that compared both implants simultaneously had a follow-up of 6.7 years. These differences made it challenging to combine the results in a statistically meaningful way, as variations in study designs, patient populations, and outcome measures created a high degree of heterogeneity [6].

The recent introduction of zirconia in the marketplace justifies the lack of studies with longer follow-up periods. In addition, according to Roehling S et al. [16], a significant portion of the investigated zirconia implants, including the ones from recent studies, has been discontinued, which complicates the interpretation of zirconia implant behaviour. However, the decline in zirconia implant failure rates over the years and the improvement in its mechanical properties should be noted [16].

Studies with a 5-year follow-up, such as those conducted by Müller et al. [29] and Balmer et al. [31], which had the highest survival rates in each group, demonstrated similar results regardless of the implant material (titanium 97.8% and zirconia 98.4%). Both materials showed functional stability in partial edentulous scenarios. Zirconia implants, particularly one-piece designs like those used by Grassi et al. [33] and Balmer et al. [31], presented high success rates. However, studies indicated that one-piece zirconia implants might exhibit slightly higher peri-implant bone loss due to design limitations [47].

For intermediate follow-ups (8 to 10 years), a study by Kiechle et al. [37] on zirconia revealed a 100% survival rate. There are no studies on titanium implants with intermediate follow-ups. Zirconia implants, specifically two-pieces models seen by Brunello et al. [32], reported a success rate of approximately 96.7% at 9 years. However, zirconia’s susceptibility to micro-cracking and potential for earlier mechanical failure in one-piece designs was noted as a concern.

Studies extending beyond a decade, such as those by Ravald et al. [28], indicated that titanium implants retained high survival rates exceeding 94% in fully edentulous cases. In contrast, long-term data on zirconia implants are still limited, with no studies reporting follow-ups beyond the 10-year mark. The available data suggest that zirconia’s biocompatibility supports soft tissue integration well but may be compromised by material brittleness over extensive periods. This reflects an ongoing debate about the reliability of zirconia implants in sustaining similar durability as titanium counterparts, particularly in stress-bearing areas [47].

The design, whether one-piece or two-pieces, significantly influences outcomes. One-piece implants, common in zirconia models (e.g., Balmer et al. [31]), show ease of placement but limited reparability. Two-piece titanium implants, with a modular approach, enable better prosthetic flexibility and adaptation over long-term follow-ups, as seen in studies like Buser et al. [9] and van Velzen et al. [30]. Zirconia’s two-piece systems (Brunello et al. [32]) are emerging with improved success, yet concerns about material fractures persist. In two-piece implants, the load can be more effectively distributed across the entire implant system rather than being concentrated directly on the implant body, as is the case with one-piece implants. This feature of two-pieces implants provides greater biomechanical flexibility, allowing the abutment to absorb a significant portion of the force [48,49]. Another drawback of one-piece implants, which may impact the aesthetic advantages of zirconia implants, is the cementation process. When one-piece implants are cemented to the crown, excess cement can accumulate in the surrounding mucosa, potentially causing infections and increasing the risk of peri-implantitis [50,51,52,53].

The PINK score result leads us to conclude that the appearance of the implant is not the most important factor for the final aesthetics of the restoration but rather the properties of the implant itself, which facilitate proper osseointegration and soft tissue adaptation [6]. This conclusion contradicts the findings of previously published systematic reviews and complements those with shorter follow-up periods and highlights that zirconia, although chosen for its aesthetic potential, does not confer the long-term aesthetic benefits previously expected [44,46,54,55].

Although zirconia implants have demonstrated promising results, caution must be exercised in their use due to the limited evidence available, particularly with follow-up data beyond five years, making it difficult to confidently assess their benefits compared to titanium implants [56].

5. Conclusions

Despite the satisfactory results attained by zirconia implants, there is insufficient long-term data beyond five years to confidently conclude the benefits of this material when compared to titanium implants. However, while zirconia implants show great potential as an alternative to titanium implants, further research is essential to better understand its advantages and properties, refine surgical guidelines, and directly analyse peri-implant behaviour.

Author Contributions

The contributions of the authors are as follows: conceptualization, R.F.-A. and F.A.; methodology, F.A. and F.C.; software, F.A.; validation, F.A., T.C., F.C. and R.F.-A.; formal analysis, F.C. and R.F.-A.; investigation, F.A. and T.C.; resources, R.F.-A.; data curation, F.A.; writing—original draft preparation, F.A.; writing—review and editing, F.C. and R.F.-A.; visualization, F.A.; supervision, R.F.-A.; project administration, R.F.-A. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Conflicts of Interest

The authors declare no conflicts of interest.

Appendix A

Table A1. Exclusion criteria per article—(1) follow-up <5 years; (2) reviews and clinical cases; (3) in vitro and animals; (4) abutments or/and crown material; (5) titanium–zirconia implants; (6) bone regeneration; (7) other science or thematic.

Author	Year	Title	Criteria
A. V. Lombardi, Jr.; K. R. Berend; B. E. Seng; I. C. Clarke; J. B. Adams	2010	Delta ceramic-on-alumina ceramic articulation in primary THA: prospective, randomized FDA-IDE study and retrieval analysis	7
M. M. Bornstein; J. G. Wittneben; U. Brägger; D. Buser	2010	Early loading at 21 days of non-submerged titanium implants with a chemically modified sandblasted and acid-etched surface: 3-year results of a prospective study in the posterior mandible	1
M. Todisco	2010	Early loading of implants in vertically augmented bone with non-resorbable membranes and deproteinised anorganic bovine bone. An uncontrolled prospective cohort study	1
C. Larsson; P. Vult von Steyern	2010	Five-year follow-up of implant-supported Y-TZP and ZTA fixed dental prostheses. A randomized, prospective clinical trial comparing two different material systems	4
P. O. Ostman; A. Wennerberg; T. Albrektsson	2010	Immediate occlusal loading of NanoTite PREVAIL implants: a prospective 1-year clinical and radiographic study	4
R. Crespi; P. Capparè; E. Gherlone	2010	Osteotome sinus floor elevation and simultaneous implant placement in grafted biomaterial sockets: 3 years of follow-up	1 + 6
Moschovitis A, Simon R, Seidenstücker A, Klauss V, Baylacher M, Lüscher TF, Moccetti T, Windecker S, Meier B, Hess OM	2010	Randomised comparison of titanium-nitride-oxide coated stents with bare metal stents: five year follow-up of the TiNOX trial	7
F. A. Quereshy; H. S. Dhaliwal; S. A. El; M. P. Horan; S. S. Dhaliwal	2010	Resorbable screw fixation for cortical onlay bone grafting: a pilot study with preliminary results	7
M. Veltri; M. Ferrari; P. Balleri	2010	Stability values of titanium dioxide-blasted dental implants in edentulous maxillas: A 3-year pilot study	1
J. Jofré; Y. Conrady; C. Carrasco	2010	Survival of splinted mini-implants after contamination with stainless steel	7
G. Liddelow; P. Henry	2010	The immediately loaded single implant-retained mandibular overdenture: a 36-month prospective study	1
M. Merli; F. Lombardini; M. Esposito	2010	Vertical ridge augmentation with autogenous bone grafts 3 years after loading: resorbable barriers versus titanium-reinforced barriers. A randomized controlled clinical trial	6
M. Esposito; G. Cannizarro; E. Soardi; G. Pellegrino; R. Pistilli; P. Felice	2011	A 3-year post-loading report of a randomised controlled trial on the rehabilitation of posterior atrophic mandibles: short implants or longer implants in vertically augmented bone?	1
B. Zerahn; L. Borgwardt; S. Ribel-Madsen; A. Borgwardt	2011	A prospective randomised study of periprosthetic femoral bone remodeling using four different bearings in hybrid total hip arthroplasty	7
U. Salihoglu; D. Boynuegri; D. Engin; A. N. Duman; P. Gokalp; K. Balos	2011	Bacterial adhesion and colonization differences between zirconium oxide and titanium alloys: an in vivo human study	4
I. J. De Kok; K. H. Chang; T. S. Lu; L. F. Cooper	2011	Comparison of three-implant-supported fixed dentures and two-implant-retained overdentures in the edentulous mandible: a pilot study of treatment efficacy and patient satisfaction	1
R. van Brakel; M. S. Cune; A. J. van Winkelhoff; C. de Putter; J. W. Verhoeven; W. van der Reijden	2011	Early bacterial colonization and soft tissue health around zirconia and titanium abutments: an in vivo study in man	4
S. M. Dogus; K. S. Kurtz; I. Watanabe; J. A. Griggs	2011	Effect of Engaging Abutment Position in Implant-Borne, Screw-Retained Three-Unit Fixed Cantilevered Prostheses	4
P. Magne; E. Oderich; L. L. Boff; A. C. Cardoso; U. C. Belser	2011	Fatigue resistance and failure mode of CAD/CAM composite resin implant abutments restored with type III composite resin and porcelain veneers	4
L. Hjalmarsson; J. I. Smedberg; M. Pettersson; T. Jemt	2011	Implant-level prostheses in the edentulous maxilla: A comparison with conventional abutment-level prostheses after 5 years of use	4
E. Bressan; G. Paniz; D. Lops; B. Corazza; E. Romeo; G. Favero	2011	Influence of abutment material on the gingival color of implant-supported all-ceramic restorations: a prospective multicenter study	4
T. Sornsuwan; A. Ellakwa; M. V. Swain	2011	Occlusal geometrical considerations in all-ceramic pre-molar crown failure testing	4
M. Suzuki; E. Bonfante; N. R. Silva; P. G. Coelho	2011	Reliability testing of indirect composites as single implant restorations	4
E. Nkenke; E. Vairaktaris; M. Spitzer; M. Kramer; M. Stamminger; L. Holbach; C. Knipfer; F. Stelzle	2011	Secondary reconstruction of posttraumatic enophthalmos: prefabricated implants vs. titanium mesh	7
M. Weissinger; A. Grübl; G. Pöll	2011	Serum-cobalt levels with metal-on-metal bearings in the cement-free total hip arthroplasty results covering two years; prospective study	7
L. den Hartog; H. J. Meijer; B. Stegenga; N. Tymstra; A. Vissink; G. M. Raghoebar	2011	Single implants with different neck designs in the aesthetic zone: a randomized clinical trial	1
M. Weinländer; V. Lekovic; S. Spadijer-Gostovic; B. Milicic; W. A. Wegscheider; E. Piehslinger	2011	Soft tissue development around abutments with a circular macro-groove in healed sites of partially edentulous posterior maxillae and mandibles: A clinical pilot study	4
M. Stilling; F. Madsen; A. Odgaard; L. Rømer; N. T. Andersen; O. Rahbek; K. Søballe	2011	Superior fixation of pegged trabecular metal over screw-fixed pegged porous titanium fiber mesh: a randomized clinical RSA study on cementless tibial components	7
D. Pakvis; J. Luites; G. van Hellemondt; M. Spruit	2012	A cementless, elastic press-fit socket with and without screws	4
B. Möller; H. Terheyden; Y. Açil; N. M. Purcz; K. Hertrampf; A. Tabakov; E. Behrens; J. Wiltfang	2012	A comparison of biocompatibility and osseointegration of ceramic and titanium implants: an in vivo and in vitro study	1
B. Al-Nawas; U. Brägger; H. J. Meijer; I. Naert; R. Persson; A. Perucchi; M. Quirynen; G. M. Raghoebar; T. E. Reichert; E. Romeo; H. J. Santing; M. Schimmel; S. Storelli; C. ten Bruggenkate; B. Vandekerckhove; W. Wagner; D. Wismeijer; F. Müller	2012	A double-blind randomized controlled trial (RCT) of Titanium-13Zirconium versus Titanium Grade IV small-diameter bone level implants in edentulous mandibles--results from a 1-year observation period	1
S. Vandeweghe; A. Ackermann; J. Bronner; A. Hattingh; A. Tschakaloff; H. De Bruyn	2012	A Retrospective, Multicenter Study on a Novo Wide-Body Implant for Posterior Regions	7
A. Acocella; C. Ercoli; A. Geminiani; C. Feng; M. Billi; G. Acocella; D. Giannini; R. Sacco	2012	Clinical evaluation of immediate loading of electroeroded screw-retained titanium fixed prostheses supported by tilted implant: a multicenter retrospective study	4
A. Örtorp; T. Jemt	2012	CNC-milled titanium frameworks supported by implants in the edentulous jaw: a 10-year comparative clinical study	7
H. J. Nickenig; K. A. Schlegel; M. Wichmann; S. Eitner	2012	Expression of interleukin 6 and tumor necrosis factor alpha in soft tissue over ceramic and metal implant materials before uncovering: a clinical pilot study	1
L. M. Martins; E. A. Bonfante; R. A. Zavanelli; A. C. Freitas Jr; N. R. F. A. Silva; L. Marotta; P. G. Coelho	2012	Fatigue reliability of 3 single-unit implant-abutment designs	4
C. Mangano; F. G. Mangano; J. A. Shibli; M. Ricci; V. Perrotti; S. d’Avila; A. Piattelli	2012	Immediate loading of mandibular overdentures supported by unsplinted direct laser metal-forming implants: results from a 1-year prospective study	4
R. A. Levine; P. Sendi; M. M. Bornstein	2012	Immediate restoration of nonsubmerged titanium implants with a sandblasted and acid-etched surface: five-year results of a prospective case series study using clinical and radiographic data	7
A. Pozzi; G. Sannino; A. Barlattani	2012	Minimally invasive treatment of the atrophic posterior maxilla: a proof-of-concept prospective study with a follow-up of between 36 and 54 months	7
A. E. Borgonovo; A. Fabbri; V. Vavassori; R. Censi; C. Maiorana	2012	Multiple teeth replacement with endosseous one-piece yttrium-stabilized zirconia dental implants	1
T. Kaneko; I. Masuda; N. Horie; T. Shimoyama	2012	New bone formation in nongrafted sinus lifting with space-maintaining management: a novel technique using a titanium bone fixation device	7
R. J. Kohal; M. Knauf; B. Larsson; H. Sahlin; F. Butz	2012	One-piece zirconia oral implants: one-year results from a prospective cohort study. 1. Single tooth replacement	1
L. Barbier; J. Abeloos; C. de Clercq; R. Jacobs	2012	Peri-implant bone changes following tooth extraction, immediate placement and loading of implants in the edentulous maxilla	7
P. Felice; R. Pistilli; M. Piattelli; E. Soardi; V. Corvino; M. Esposito	2012	Posterior atrophic jaws rehabilitated with prostheses supported by 5 × 5 mm implants with a novel nanostructured calcium-incorporated titanium surface or by longer implants in augmented bone. Preliminary results from a randomised controlled trial	7
M. Sasse; S. Eschbach; M. Kern	2012	Randomized clinical trial on single retainer all-ceramic resin-bonded fixed partial dentures: Influence of the bonding system after up to 55 months	4
R. Oliveira; M. El Hage; J. P. Carrel; T. Lombardi; J. P. Bernard	2012	Rehabilitation of the edentulous posterior maxilla after sinus floor elevation using deproteinized bovine bone: a 9-year clinical study	6
R. van Brakel; G. J. Meijer; J. W. Verhoeven; J. Jansen; C. de Putter; M. S. Cune	2012	Soft tissue response to zirconia and titanium implant abutments: an in vivo within-subject comparison	4
T. Grandi; G. Garuti; P. Guazzi; L. Tarabini; A. Forabosco	2012	Survival and success rates of immediately and early loaded implants: 12-month results from a multicentric randomized clinical study	1
A. E. Büttel; H. Lüthy; P. Sendi; C. P. Marinello	2012	Wear of ceramic and titanium ball attachments in subjects with an implant-retained overdenture: a controlled clinical trial	4
M. Hosseini; N. Worsaae; M. Schiødt; K. Gotfredsen	2013	A 3-year prospective study of implant-supported, single-tooth restorations of all-ceramic and metal-ceramic materials in patients with tooth agenesis	1 + 4
K. Akca; Y. Cavusoglu; S. Uysal; M. C. Cehreli	2013	A prospective, open-ended, single-cohort clinical trial on early loaded Titanium-zirconia alloy implants in partially edentulous patients: up-to-24-month results	5
M. Naumann; C. Hohmann; A. Happe; F. Beuer; R. Frankenberger; R. Seemann; M. Rosentritt	2013	Are implants more reliable than severely compromised endodontically treated teeth as abutments for zirconia-based FPDs?: In vitro results of long-term preclinical load simulation	3 + 4
A. E. Borgonovo; V. Vavassori; R. Censi; J. L. Calvo; D. Re	2013	Behavior of endosseous one-piece yttrium stabilized zirconia dental implants placed in posterior areas	1
H. T. Faber; C. A. J. Dun; R. C. Nelissen; E. A. M. Mylanus; C. W. R. J. Cremers; M. K. S. Hol	2013	Bone-anchored hearing implant loading at 3 weeks: Stability and tolerability after 6 months	1
M. Sasse; M. Kern	2013	CAD/CAM single retainer zirconia-ceramic resin-bonded fixed dental prostheses: clinical outcome after 5 years	4 + 5
A. Pozzi; M. Tallarico; F. Mangani; A. Barlattani	2013	Different implant impression techniques for edentulous patients treated with CAD/CAM complete-arch prostheses: a randomised controlled trial reporting data at 3 year post-loading	7
A. Zembic; A. Bösch; R. E. Jung; C. H. Hämmerle; I. Sailer	2013	Five-year results of a randomized controlled clinical trial comparing zirconia and titanium abutments supporting single-implant crowns in canine and posterior regions	4
J. K. Foong; R. B. Judge; J. E. Palamara; M. V. Swain	2013	Fracture resistance of titanium and zirconia abutments: an in vitro study	3 + 4
R. M. de Freitas; C. Susin; R. Spin-Neto; C. Marcantonio; U. M. Wikesjö; L. A. Pereira; E. Marcantonio, Jr.	2013	Horizontal ridge augmentation of the atrophic anterior maxilla using rhBMP-2/ACS or autogenous bone grafts: a proof-of-concept randomized clinical trial	7
K. S. Choi; H. C. Yoon; Y. S. Cho	2013	Immediate provisionalization of mini-implants with friction-engaging abutments in the mandibular anterior region: A 1-year retrospective study	4
F. Mangano; S. Pozzi-Taubert; P. A. Zecca; G. Luongo; R. L. Sammons; C. Mangano	2013	Immediate restoration of fixed partial prostheses supported by one-piece narrow-diameter selective laser sintering implants: a 2-year prospective study in the posterior jaws of 16 patients	7
C. do Nascimento; M. S. Pita; V. Pedrazzi; R. F. de Albuquerque Junior; R. F. Ribeiro	2013	In vivo evaluation of Candida spp. adhesion on titanium or zirconia abutment surfaces	4
G. W. Omlor; J. P. Kretzer; J. Reinders; M. R. Streit; T. Bruckner; T. Gotterbarm; P. R. Aldinger; C. Merle	2013	In vivo serum titanium ion levels following modular neck total hip arthroplasty--10 year results in 67 patients	7
C. do Nascimento; C. da Rocha Aguiar; M. S. Pita; V. Pedrazzi; R. F. de Albuquerque, Jr.; R. F. Ribeiro	2013	Oral biofilm formation on the titanium and zirconia substrates	1
R. Pistilli; P. Felice; M. Piattelli; M. Gessaroli; E. Soardi; C. Barausse; J. Buti; V. Corvino	2013	Posterior atrophic jaws rehabilitated with prostheses supported by 5 × 5 mm implants with a novel nanostructured calcium-incorporated titanium surface or by longer implants in augmented bone. One-year results from a randomised controlled trial	7
K. Fischer; T. Stenberg	2013	Prospective 10-year cohort study based on a randomized, controlled trial (RCT) on implant-supported full-arch maxillary prostheses. Part II: Prosthetic outcomes and maintenance	4
K. Patel; N. Mardas; N. Donos	2013	Radiographic and clinical outcomes of implants placed in ridge preserved sites: a 12-month post-loading follow-up	1
M. Esposito; I. Dojcinovic; L. Germon; N. Lévy; R. Curno; S. Buchini; P. Péchy; B. O. Aronsson	2013	Safety and efficacy of a biomimetic monolayer of permanently bound multi-phosphonic acid molecules on dental implants: 1 year post-loading results from a pilot quadruple-blinded randomised controlled trial	7
L. den Hartog; G. M. Raghoebar; J. J. Slater; K. Stellingsma; A. Vissink; H. J. Meijer	2013	Single-tooth implants with different neck designs: a randomized clinical trial evaluating the aesthetic outcome	1
A. Happe; V. Schulte-Mattler; S. Fickl; M. Naumann; J. E. Zöller; D. Rothamel	2013	Spectrophotometric assessment of peri-implant mucosa after restoration with zirconia abutments veneered with fluorescent ceramic: a controlled, retrospective clinical study	4
T. Koutouzis; G. Koutouzis; H. Gadalla; R. Neiva	2013	The effect of healing abutment reconnection and disconnection on soft and hard peri-implant tissues: A short-term randomized controlled clinical trial	4
G. I. Benic; G. O. Gallucci; M. Mokti; C. H. Hämmerle; H. P. Weber; R. E. Jung	2013	Titanium-zirconium narrow-diameter versus titanium regular-diameter implants for anterior and premolar single crowns: 1-year results of a randomized controlled clinical study	5
D. Lops; E. Bressan; M. Chiapasco; A. Rossi; E. Romeo	2013	Zirconia and titanium implant abutments for single-tooth implant prostheses after 5 years of function in posterior regions	4
A. Carrillo de Albornoz; F. Vignoletti; L. Ferrantino; E. Cárdenas; M. De Sanctis; M. Sanz	2014	A randomized trial on the aesthetic outcomes of implant-supported restorations with zirconia or titanium abutments	4
R. B. Osman; M. V. Swain; M. Atieh; S. Ma; W. Duncan	2014	Ceramic implants (Y-TZP): are they a viable alternative to titanium implants for the support of overdentures? A randomized clinical trial	1
N. A. Smith; I. Turkyilmaz	2014	Evaluation of the sealing capability of implants to titanium and zirconia abutments against Porphyromonas gingivalis, Prevotella intermedia, and Fusobacterium nucleatum under different screw torque values	4
M. Rosentritt; A. Hagemann; S. Hahnel; M. Behr; V. Preis	2014	In vitro performance of zirconia and titanium implant/abutment systems for anterior application	3
M. Karl; T. D. Taylor	2014	Parameters determining micromotion at the implant-abutment interface	4
R. B. Osman; S. Ma	2014	Prosthodontic maintenance of overdentures on zirconia implants: 1-year results of a randomized controlled trial	1
J. F. Esquivel-Upshaw; A. E. Clark; J. J. Shuster; K. J. Anusavice	2014	Randomized clinical trial of implant-supported ceramic-ceramic and metal-ceramic fixed dental prostheses: preliminary results	4
R. van Brakel; G. J. Meijer; C. de Putter; J. W. Verhoeven; J. Jansen; M. S. Cune	2014	The association of clinical and microbiologic parameters with histologic observations in relatively healthy peri-implant conditions- a preliminary short-term in vivo study	1 + 4
T. Borges; T. Lima; A. Carvalho; C. Dourado; V. Carvalho	2014	The influence of customized abutments and custom metal abutments on the presence of the interproximal papilla at implants inserted in single-unit gaps: A 1-year prospective clinical study	4
W. C. Jennings; S. W. Galt; S. Shenoy; S. Wang; E. D. Ladenheim; M. H. Glickman; P. Kathuria; B. J. Browne	2014	The Venous Window Needle Guide, a hemodialysis cannulation device for salvage of uncannulatable arteriovenous fistulas	7
M. Borg; P. Vult von Steyern; C. Larsson	2014	Titanium- and zirconia-based implant-supported fixed dental prostheses. A randomized, prospective clinical pilot study	1
K. Bechara; A. M. Dottore; P. Y. Kawakami; S. A. Gehrke; P. G. Coelho; A. Piattelli; G. Iezzi; J. A. Shibli	2015	A histological study of non-ceramic hydroxyapatite as a bone graft substitute material in the vertical bone augmentation of the posterior mandible using an interpositional inlay technique: A split mouth evaluation	7
M. Payer; A. Heschl; M. Koller; G. Arnetzl; M. Lorenzoni; N. Jakse	2015	All-ceramic restoration of zirconia two-piece implants--a randomized controlled clinical trial	1
C. A. Barwacz; K. A. Brogden; C. M. Stanford; D. V. Dawson; E. N. Recker; D. Blanchette	2015	Comparison of pro-inflammatory cytokines and bone metabolism mediators around titanium and zirconia dental implant abutments following a minimum of 6 months of clinical function	4
M. Ferrari; M. C. Cagidiaco; F. Garcia-Godoy; C. Goracci; F. Cairo	2015	Effect of different prosthetic abutments on peri-implant soft tissue. A randomized controlled clinical trial	4
A. Lons; A. Arnould; T. Pommepuy; E. Drumez; J. Girard	2015	Excellent short-term results of hip resurfacing in a selected population of young patients	7
K. Kuhn; H. Rudolph; M. Graf; M. Moldan; S. Zhou; M. Udart; A. Böhmler; R. G. Luthardt	2015	Interaction of titanium, zirconia and lithium disilicate with peri-implant soft tissue: study protocol for a randomized controlled trial	4
B. Bloch; S. Brown; D. Angadi; E. Crawfurd	2015	Long-term follow-up of a cemented titanium stem	7
R. Cosgarea; C. Gasparik; D. Dudea; B. Culic; B. Dannewitz; A. Sculean	2015	Peri-implant soft tissue colour around titanium and zirconia abutments: a prospective randomized controlled clinical study	4
M. Quirynen; B. Al-Nawas; H. J. Meijer; A. Razavi; T. E. Reichert; M. Schimmel; S. Storelli; E. Romeo	2015	Small-diameter titanium Grade IV and titanium-zirconium implants in edentulous mandibles: three-year results from a double-blind, randomized controlled trial	1
T. Joda; U. Brägger	2015	Time-Efficiency Analysis Comparing Digital and Conventional Workflows for Implant Crowns: A Prospective Clinical Crossover Trial	4
S. P. Lyngstadaas; A. Verket; E. M. Pinholt; C. Mertens; H. R. Haanaes; G. Wall; M. Wallström; L. Rasmusson	2015	Titanium Granules for Augmentation of the Maxillary Sinus—A Multicenter Study	7
M. Ollivier; S. Parratte; A. Galland; A. Lunebourg; X. Flecher; J. N. Argenson	2015	Titanium-titanium modular neck for primary THA. Result of a prospective series of 170 cemented THA with a minimum follow-up of 5 years	4
A. Ioannidis; G. O. Gallucci; R. E. Jung; S. Borzangy; C. H. Hämmerle; G. I. Benic	2015	Titanium-zirconium narrow-diameter versus titanium regular-diameter implants for anterior and premolar single crowns: 3-year results of a randomized controlled clinical study	5
D. Spinelli; G. De Vico; R. Condò; L. Ottria; C. Arcuri	2015	Transcrestal guided sinus lift without grafting materials: A 36 months clinical prospective study	7
M. Ferrari; M. G. Tricarico; M. C. Cagidiaco; A. Vichi; E. F. Gherlone; F. Zarone; R. Sorrentino	2016	3-Year Randomized Controlled Prospective Clinical Trial on Different CAD-CAM Implant Abutments	4
R. Zita Gomes; A. Paraud Freixas; C. H. Han; S. Bechara; I. Tawil	2016	Alveolar Ridge Reconstruction with Titanium Meshes and Simultaneous Implant Placement: A Retrospective, Multicenter Clinical Study	1 + 6
P. King; C. Maiorana; R. G. Luthardt; K. Sondell; J. Øland; P. Galindo-Moreno; P. Nilsson	2016	Clinical and Radiographic Evaluation of a Small-Diameter Dental Implant Used for the Restoration of Patients with Permanent Tooth Agenesis (Hypodontia) in the Maxillary Lateral Incisor and Mandibular Incisor Regions: A 36-Month Follow-Up	1
G. Fabbri; M. Fradeani; G. Dellificorelli; M. De Lorenzi; F. Zarone; R. Sorrentino	2016	Clinical evaluation of the influence of connection type and restoration height on the reliability of zirconia abutments: A retrospective study on 965 abutments with a mean 6-year follow-up	4
S. Mistry; R. Roy; B. Kundu; S. Datta; M. Kumar; A. Chanda; D. Kundu	2016	Clinical Outcome of Hydroxyapatite Coated, Bioactive Glass Coated, and Machined Ti6Al4V Threaded Dental Implant in Human Jaws: A Short-Term Comparative Study	4
F. Nejatidanesh; H. Moradpoor; O. Savabi	2016	Clinical outcomes of zirconia-based implant- and tooth-supported single crowns	4
J. H. Lee; C. B. Kong; J. J. Yang; H. J. Shim; K. H. Koo; J. Kim; C. K. Lee; B. S. Chang	2016	Comparison of fusion rate and clinical results between CaO-SiO(2)-P(2)O(5)-B(2)O(3) bioactive glass ceramics spacer with titanium cages in posterior lumbar interbody fusion	7
L. F. Cooper; D. Tarnow; S. Froum; J. Moriarty; I. J. De Kok	2016	Comparison of Marginal Bone Changes with Internal Conus and External Hexagon Design Implant Systems: A Prospective, Randomized Study	7
C. A. Barwacz; C. M. Stanford; U. A. Diehl; F. Qian; L. F. Cooper; J. Feine; M. McGuire	2016	Electronic assessment of peri-implant mucosal esthetics around three implant-abutment configurations: a randomized clinical trial	4
N. Baldini; C. D’Elia; M. Clementini; A. Carrillo de Albornoz; M. Sanz; M. De Sanctis	2016	Esthetic Outcomes of Single-Tooth Implant-Supported Restorations Using Metal-Ceramic Restorations with Zirconia or Titanium Abutments: A Randomized Controlled Clinical Study	4
R. E. Jung; P. Grohmann; I. Sailer; Y. N. Steinhart; A. Fehér; C. Hämmerle; J. R. Strub; R. Kohal	2016	Evaluation of a one-piece ceramic implant used for single-tooth replacement and three-unit fixed partial dentures: a prospective cohort clinical trial	1
A. Pozzi; M. Tallarico; P. K. Moy	2016	Four-implant overdenture fully supported by a CAD-CAM titanium bar: A single-cohort prospective 1-year preliminary study	7
P. E. de Lacerda; A. A. Pelegrine; M. L. Teixeira; V. A. Montalli; H. Rodrigues; M. H. Napimoga	2016	Homologous transplantation with fresh frozen bone for dental implant placement can induce HLA sensitization: a preliminary study	7
A. Kammermeier; M. Rosentritt; M. Behr; S. Schneider-Feyrer; V. Preis	2016	In vitro performance of one- and two-piece zirconia implant systems for anterior application	3
P. P. Karjalainen; W. Nammas; A. Ylitalo; B. de Bruyne; J. Lalmand; A. de Belder; F. Rivero-Crespo; K. Kervinen; J. K. E. Airaksinen	2016	Long-term clinical outcome of titanium-nitride-oxide-coated stents versus everolimus-eluting stents in acute coronary syndrome: Final report of the BASE ACS trial	7
L. Tolentino; F. Sukekava; J. Garcez-Filho; M. Tormena; L. A. Lima; M. G. Araújo	2016	One-year follow-up of titanium/zirconium alloy X commercially pure titanium narrow-diameter implants placed in the molar region of the mandible: a randomized controlled trial	1
D. S. Thoma; F. Brandenberg; V. Fehmer; D. L. E. Büchi; C. H. F. Hämmerle; I. Sailer	2016	Randomized Controlled Clinical Trial of All-Ceramic Single Tooth Implant Reconstructions Using Modified Zirconia Abutments: Radiographic and Prosthetic Results at 1 Year of Loading	1
R. C. Nelissen; C. A. den Besten; E. A. Mylanus; M. K. Hol	2016	Stability, survival, and tolerability of a 4.5-mm-wide bone-anchored hearing implant: 6-month data from a randomized controlled clinical trial	1
T. Joda; U. Brägger	2016	Time-efficiency analysis of the treatment with monolithic implant crowns in a digital workflow: a randomized controlled trial	4
E. Chong; R. J. Mobbs; M. H. Pelletier; W. R. Walsh	2016	Titanium/Polyetheretherketone Cages for Cervical Arthrodesis with Degenerative and Traumatic Pathologies: Early Clinical Outcomes and Fusion Rates	7
F. Martínez-Rus; M. Prieto; M. P. Salido; C. Madrigal; M. Özcan; G. Pradíes	2017	A Clinical Study Assessing the Influence of Anodized Titanium and Zirconium Dioxide Abutments and Peri-implant Soft Tissue Thickness on the Optical Outcome of Implant-Supported Lithium Disilicate Single Crowns	4
M. S. Gil; S. Ishikawa-Nagai; H. W. Elani; J. D. Da Silva; D. M. Kim; D. Tarnow; U. Schulze-Späte; N. Bittner	2017	A prospective clinical trial to assess the optical efficacy of pink neck implants and pink abutments on soft tissue esthetics	4
C. Cacaci; F. Cantner; T. Mücke; P. Randelzhofer; J. Hajtó; F. Beuer	2017	Clinical performance of screw-retained and cemented implant-supported zirconia single crowns: 36-month results	1 + 4
M. Esposito; E. Bressan; M. G. Grusovin; F. D’Avenia; K. Neumann; L. Sbricoli; G. Luongo	2017	Do repeated changes of abutments have any influence on the stability of peri-implant tissues? One-year post-loading results from a multicentre randomised controlled trial	4
S. Acham; P. Rugani; A. Truschnegg; A. Wildburger; W. A. Wegscheider; N. Jakse	2017	Immediate loading of four interforaminal implants supporting a locator-retained mandibular overdenture in the elderly. Results of a 3-year randomized, controlled, prospective clinical study	4
P. P. Karjalainen; W. Nammas; K. Kervinen; A. de Belder; F. Rivero-Crespo; A. Ylitalo; J. K. Airaksinen	2017	Impact of Calcified Target Lesions on the Outcome of Percutaneous Coronary Intervention for Acute Coronary Syndrome: Insights From the BASE ACS Trial	7
D. Lops; E. Stellini; L. Sbricoli; N. Cea; E. Romeo; E. Bressan	2017	Influence of abutment material on peri-implant soft tissues in anterior areas with thin gingival biotype: a multicentric prospective study	4
Y. Kumar; V. Jain; S. S. Chauhan; V. Bharate; D. Koli; M. Kumar	2017	Influence of different forms and materials (zirconia or titanium) of abutments in peri-implant soft-tissue healing using matrix metalloproteinase-8: A randomized pilot study	4
T. H. Lanman; J. K. Burkus; R. G. Dryer; M. F. Gornet; J. McConnell; S. D. Hodges	2017	Long-term clinical and radiographic outcomes of the Prestige LP artificial cervical disc replacement at 2 levels: results from a prospective randomized controlled clinical trial	7
W. Nammas; A. de Belder; M. Niemelä; J. Sia; H. Romppanen; M. Laine; P. P. Karjalainen	2017	Long-term clinical outcome of elderly patients with acute coronary syndrome treated with early percutaneous coronary intervention: Insights from the BASE ACS randomized controlled trial: Bioactive versus everolimus-eluting stents in elderly patients	7
T. Joda; M. Ferrari; U. Brägger	2017	Monolithic implant-supported lithium disilicate (LS2) crowns in a complete digital workflow: A prospective clinical trial with a 2-year follow-up	1
A. Marković; A. Đinić; J. L. Calvo Guirado; A. Tahmaseb; M. Šćepanović; B. Janjić	2017	Randomized clinical study of the peri-implant healing to hydrophilic and hydrophobic implant surfaces in patients receiving anticoagulants	7
F. D. Brandenberg; I. Sailer; V. Fehmer; D. L. Büchi; C. H. Hämmerle; D. S. Thoma	2017	Randomized controlled clinical pilot study of all-ceramic single-tooth implant reconstructions: clinical and microbiological outcomes at one year of loading	1
G. O. Alrabeah; P. Brett; J. C. Knowles; H. Petridis	2017	The effect of metal ions released from different dental implant-abutment couples on osteoblast function and secretion of bone resorbing mediators	4
E. Bressan; M. G. Grusovin; F. D’Avenia; K. Neumann; L. Sbricoli; G. Luongo; M. Esposito	2017	The influence of repeated abutment changes on peri-implant tissue stability: 3-year post-loading results from a multicentre randomised controlled trial	4
A. Trbakovic; P. Hedenqvist; T. Mellgren; C. Ley; J. Hilborn; D. Ossipov; S. Ekman; C. B. Johansson; M. Jensen-Waern; A. Thor	2018	A new synthetic granular calcium phosphate compound induces new bone in a sinus lift rabbit model	3 + 7
C. Y. Lee; C. A. Johnson, Jr.; J. A. Siordia; J. M. Lehoux; P. A. Knight	2018	Comparison of Automated Titanium Fasteners to Hand-Tied Knots in Open Aortic Valve Replacement	7
D. Bordin; L. Witek; V. P. Fardin; E. A. Bonfante; P. G. Coelho	2018	Fatigue Failure of Narrow Implants with Different Implant-Abutment Connection Designs	4
M. Øilo; D. Arola	2018	Fractographic analyses of failed one-piece zirconia implant restorations	1
T. Sampatanukul; P. Serichetaphongse; A. Pimkhaokham	2018	Histological evaluations and inflammatory responses of different dental implant abutment materials: A human histology pilot study	4
M. Erhan Çömlekoğlu; N. Nizam; M. D. Çömlekoğlu	2018	Immediate definitive individualized abutments reduce peri-implant bone loss: a randomized controlled split-mouth study on 16 patients	4
R. Davó; P. Felice; R. Pistilli; C. Barausse; C. Marti-Pages; A. Ferrer-Fuertes; D. R. Ippolito; M. Esposito	2018	Immediately loaded zygomatic implants vs. conventional dental implants in augmented atrophic maxillae: 1-year post-loading results from a multicentre randomised controlled trial	7
M. Esposito; R. Davó; C. Marti-Pages; A. Ferrer-Fuertes; C. Barausse; R. Pistilli; D. R. Ippolito; P. Felice	2018	Immediately loaded zygomatic implants vs. conventional dental implants in augmented atrophic maxillae: 4 months post-loading results from a multicentre randomised controlled trial	7
T. Linkevicius; R. Linkevicius; J. Alkimavicius; L. Linkeviciene; P. Andrijauskas; A. Puisys	2018	Influence of titanium base, lithium disilicate restoration and vertical soft tissue thickness on bone stability around triangular-shaped implants: A prospective clinical trial	4
U. T. Kalyoncuoglu; B. Yilmaz; S. G. Koc; Z. Evis; P. U. Arpaci; G. Kansu	2018	Investigation of surface structure and biocompatibility of chitosan-coated zirconia and alumina dental abutments	4
G. Gastaldi; P. Felice; V. Pistilli; C. Barausse; D. R. Ippolito; M. Esposito	2018	Posterior atrophic jaws rehabilitated with prostheses supported by 5 × 5 mm implants with a nanostructured calcium-incorporated titanium surface or by longer implants in augmented bone. 3-year results from a randomised controlled trial	7
P. Felice; C. Barausse; R. Pistilli; D. R. Ippolito; M. Esposito	2018	Short implants versus longer implants in vertically augmented posterior mandibles: result at 8 years after loading from a randomised controlled trial	7
A. Bösch; R. E. Jung; I. Sailer; B. Goran; C. H. Hämmerle; D. S. Thoma	2018	Single-Tooth Replacement Using Dental Implants Supporting All-Ceramic and Metal-Based Reconstructions: Results at 18 Months of Loading	1
C. L. Sikora; M. F. Alfaro; J. C. C. Yuan; V. A. Barao; C. Sukotjo; M. T. Mathew	2018	Wear and Corrosion Interactions at the Titanium/Zirconia Interface: Dental Implant Application	4
S. S. Ghazal; G. Huynh-Ba; T. Aghaloo; S. Dibart; S. Froum; R. O’Neal; D. Cochran	2019	A Randomized, Controlled, Multicenter Clinical Study Evaluating The Crestal Bone Level Change Of SLActive Bone Level Ø 3.3 mm Implants Compared To SLActive Bone Level Ø 4.1 mm Implants For Single-Tooth Replacement	5
P. Korovessis; V. Syrimpeis; V. Tsekouras; A. Baikousis; K. Vardakastanis; P. Fennema	2019	A unilateral less invasive posterolateral approach for disc debridement and titanium cage insertion supplemented by contralateral transfascial screw fixation for high-morbidity patients suffering from septic thoracolumbosacral spondylodiscitis	7
T. Wang; L. Wang; Q. Lu; Z. Fan	2019	Changes in the esthetic, physical, and biological properties of a titanium alloy abutment treated by anodic oxidation	4
T. N. Pansani; F. G. Basso; I. D. R. Souza; J. Hebling; C. A. de Souza Costa	2019	Characterization of titanium surface coated with epidermal growth factor and its effect on human gingival fibroblasts	4
M. S. Gil; S. Ishikawa-Nagai; H. W. Elani; J. D. Da Silva; D. M. Kim; D. Tarnow; U. Schulze-Späte; C. Silva; N. Bittner	2019	Comparison of the Color Appearance of Peri-implant Soft Tissue with Natural Gingiva Using Anodized Pink-Neck Implants and Pink Abutments: A Prospective Clinical Trial	4
S. Roffel; G. Wu; I. Nedeljkovic; M. Meyer; T. Razafiarison; S. Gibbs	2019	Evaluation of a novel oral mucosa in vitro implantation model for analysis of molecular interactions with dental abutment surfaces	3 + 4
R. Reis; P. Nicolau; N. Calha; A. Messias; F. Guerra	2019	Immediate versus early loading protocols of titanium-zirconium narrow-diameter implants for mandibular overdentures in edentulous patients: 1-year results from a randomized controlled trial	1
D. Edelhoff; J. Schweiger; O. Prandtner; M. Stimmelmayr; J. F. Güth	2019	Metal-free implant-supported single-tooth restorations. Part I: Abutments and cemented crowns	4
M. Esposito; C. Barausse; R. Pistilli; M. Piattelli; S. Di Simone; D. R. Ippolito; P. Felice	2019	Posterior atrophic jaws rehabilitated with prostheses supported by 5 × 5 mm implants with a nanostructured calcium-incorporated titanium surface or by longer implants in augmented bone. Five-year results from a randomised controlled trial	7
B. K. AlZarea	2019	Randomized controlled clinical investigation on the association between personality profiles and the impacts of two types of maxillary anterior implant-supported crown restorations on daily living and dental satisfaction	4
C. W. Cheng; C. H. Chien; C. J. Chen; P. Papaspyridakos	2019	Randomized Controlled Clinical Trial to Compare Posterior Implant-Supported Modified Monolithic Zirconia and Metal-Ceramic Single Crowns: One-Year Results	1 + 4
F. L. Guljé; G. M. Raghoebar; A. Vissink; H. J. A. Meijer	2019	Single crowns in the resorbed posterior maxilla supported by either 11-mm implants combined with sinus floor elevation or 6-mm implants:A 5-year randomised controlled trial	6
T. S. de Oliveira Silva; A. R. de Freitas; R. F. de Albuquerque; V. Pedrazzi; R. F. Ribeiro; C. do Nascimento	2020	A 3-year longitudinal prospective study assessing microbial profile and clinical outcomes of single-unit cement-retained implant restorations: Zirconia versus titanium abutments	1 + 4
J. H. Lee; S. K. Kim; S. S. Kang; S. J. Han; C. K. Lee; B. S. Chang	2020	A Long-Term Follow-up, Multicenter, Comparative Study of the Radiologic, and Clinical Results Between a CaO-SiO2-P2O5-B2O3 Bioactive Glass Ceramics (BGS-7) Intervertebral Spacer and Titanium Cage in 1-Level Posterior Lumbar Interbody Fusion	7
J. G. Wittneben; J. Gavric; I. Sailer; D. Buser; D. Wismeijer	2020	Clinical and esthetic outcomes of two different prosthetic workflows for implant-supported all-ceramic single crowns-3 year results of a randomized multicenter clinical trail	1 + 4
G. E. Salvi; R. Moëne; B. Wallkamm; S. P. Hicklin; M. Bischof; R. Nedir; A. Mombelli; A. Sculean	2020	Clinical and radiographic changes at tissue level implants with either a machined or a modified transmucosal neck surface: A 3-year multicentre randomized controlled proof-of-concept study	1 + 4
N. Bittner; U. Schulze-Späte; C. Silva; J. D. Da Silva; D. M. Kim; D. Tarnow; S. Ishikawa-Nagai; M. S. Gil	2020	Comparison of Peri-implant Soft Tissue Color with the Use of Pink-Neck vs. Gray Implants and Abutments Based on Soft Tissue Thickness: A 6-Month Follow-up Study	4
Esquivel-Upshaw JF, Mecholsky JJ Jr, Clark AE, Jenkins R, Hsu SM, Neal D, Ren F	2020	Factors influencing the survival of implant-supported ceramic-ceramic prostheses: A randomized, controlled clinical trial	4
A. Azizi; F. Zamparini; A. Spinelli; C. Pirani; M. G. Gandolfi; C. Prati	2020	Maryland-bridge application as a suitable technique to preserve marginal bone level of not-submerged supracrestal implants	7
S. A. Barbosa-Júnior; G. K. R. Pereira; K. S. Dapieve; P. S. Machado; L. F. Valandro; C. Schuh; R. L. X. Consani; A. Bacchi	2020	Mechanical Fatigue Analysis of PEEK as Alternative to Zirconia for Definitive Hybrid Abutments Supporting All-Ceramic Crowns	4
M. Arts; B. Torensma; J. Wolfs	2020	Porous titanium cervical interbody fusion device in the treatment of degenerative cervical radiculopathy; 1-year results of a prospective controlled trial	7
S. Mühlemann; T. Lakha; R. E. Jung; C. H. F. Hämmerle; G. I. Benic	2020	Prosthetic outcomes and clinical performance of CAD-CAM monolithic zirconia versus porcelain-fused-to-metal implant crowns in the molar region: 1-year results of a RCT	7
Cigerim L, Kaplan V.	2020	The Effect of Age of Titanium Dental Implants on Implant Survival and Marginal Bone Resorption: A 5-Year Retrospective Follow-Up Study	1
Jacobs R, Gu Y, Quirynen M, De Mars G, Dekeyser C, van Steenberghe D, Vrombaut D, Shujaat S, Naert I	2021	A 20-year split-mouth comparative study of two screw-shaped titanium implant systems	7
S. Wolfart; A. Rittich; K. Groß; O. Hartkamp; A. von der Stück; S. Raith; S. Reich	2021	Cemented versus screw-retained posterior implant-supported single crowns: A 24-month randomized controlled clinical trial	1 + 4
S. P. Bienz; M. Hilbe; J. Hüsler; D. S. Thoma; C. H. F. Hämmerle; R. E. Jung	2021	Clinical and histological comparison of the soft tissue morphology between zirconia and titanium dental implants under healthy and experimental mucositis conditions-A randomized controlled clinical trial	1
L. Wang; T. Wang; Y. Lu; Z. Fan	2021	Comparing the Clinical Outcome of Peri-implant Hard and Soft Tissue Treated with Immediate Individualized CAD/CAM Healing Abutments and Conventional Healing Abutments for Single-Tooth Implants in Esthetic Areas Over 12 Months: A Randomized Clinical Trial	4
B. Yilmaz; B. Batak; R. Seghi; W. M. Johnston; L. A. Lang	2021	Effect of Crown Height on the Screw Stability of Titanium Screw-Retained Crowns	4
M. Toia; M. Stocchero; E. Corrà; J. P. Becktor; A. Wennerberg; D. Cecchinato	2021	Fixed full-arch maxillary prostheses supported by four versus six implants with a titanium CAD/CAM milled framework: 3-year multicentre RCT	1
F. Rathe; R. Junker; S. Gröger; J. Meyle; M. Schlee	2021	Inflammatory effects of individualized abutments bonded onto titanium base on peri-implant tissue health: A randomized controlled clinical trial	4
J. Pitta; J. Hjerppe; F. Burkhardt; V. Fehmer; P. Mojon; I. Sailer	2021	Mechanical stability and technical outcomes of monolithic CAD/CAM fabricated abutment-crowns supported by titanium bases: An in vitro study	4
T. Guo; K. Gulati; H. Arora; P. Han; B. Fournier; S. Ivanovski	2021	Race to invade: Understanding soft tissue integration at the transmucosal region of titanium dental implants	2
P. A. Ruiz Henao; L. Caneiro Queija; S. Mareque; A. Tasende Pereira; A. Liñares González; J. Blanco Carrión	2021	Titanium vs. ceramic single dental implants in the anterior maxilla: A 12-month randomized clinical trial	1
A. Cucchi; E. Vignudelli; D. Franceschi; E. Randellini; G. Lizio; A. Fiorino; G. Corinaldesi	2021	Vertical and horizontal ridge augmentation using customized CAD/CAM titanium mesh with versus without resorbable membranes. A randomized clinical trial	6
L. Stucki; A. G. Asgeirsson; R. E. Jung; I. Sailer; C. H. F. Hämmerle; D. S. Thoma	2021	Zirconia Restorations Cemented onto Nonoriginal Titanium Bases May Result in Increased Bleeding on Probing, Probing Depth Values, and Varying Mean Marginal Bone Levels	4
M. Hosseini; N. Worsaae; K. Gotfredsen	2022	A 5-year randomized controlled trial comparing zirconia-based versus metal-based implant-supported single-tooth restorations in the premolar region	4
K. Vazouras; H. Gholami; M. Margvelashvili-Malament; Y. J. Kim; M. Finkelman; H. P. Weber	2022	An Esthetic Evaluation of Different Abutment Materials in the Anterior Maxilla: A Randomized Controlled Clinical Trial Using a Crossover Design	4
S. T. Lamperti; K. Wolleb; C. H. F. Hämmerle; R. E. Jung; J. Hüsler; D. S. Thoma	2022	Cemented versus screw-retained zirconia-based single-implant restorations: 5-year results of a randomized controlled clinical trial	4
M. T. Salem; M. El-Layeh; S. A. A. El-Farag; A. S. Salem; A. Attia	2022	Clinical assessment of different implant-supported esthetic crown systems fabricated with semi-digital workflow: Two-year prospective study	1 + 4
A. Happe; G. S. von Glasser; J. Neugebauer; K. Strick; R. Smeets; R. Rutkowski	2022	Clinical performance of zirconia implant abutments luted to a titanium base–a retrospective cross-sectional study	5
K. W. Hsu; C. H. Liang; Y. C. Peng; C. C. Hsiao	2022	Comparison of the residual cement on custom computer-aided design and computer-aided manufacturing titanium and zirconia abutments: A preliminary cohort study	4
T. Linkevicius; J. Alkimavicius; R. Linkevicius; E. Gineviciute; L. Linkeviciene	2022	Effect of Ti-Base Abutment Gingival Height on Maintenance of Crestal Bone in Thick Biotype Patients: A Randomized Clinical Trial with 1-Year Follow-up	4
M. B. Knudsen; J. K. Thillemann; P. B. Jørgensen; S. S. Jakobsen; H. Daugaard; K. Søballe; M. Stilling	2022	Electrochemically applied hydroxyapatite on the cementless porous surface of Bi-Metric stems reduces early migration and has a lasting effect: an efficacy trial of a randomized five-year follow-up radiostereometric study	7
F. A. Spitznagel; E. A. Bonfante; F. Vollmer; P. C. Gierthmuehlen	2022	Failure Load of Monolithic Lithium Disilicate Implant-Supported Single Crowns Bonded to Ti-base Abutments versus to Customized Ceramic Abutments after Fatigue	4
P. Atalay; D. D. Öztaş	2022	Fatigue resistance and fracture strength of narrow-diameter one-piece zirconia implants with angled abutments	3
R. D. Kraus; C. Espuelas; C. H. F. Hämmerle; R. E. Jung; I. Sailer; D. S. Thoma	2022	Five-year randomized controlled clinical study comparing cemented and screw-retained zirconia-based implant-supported single crowns	4
C. R. Leles; M. S. de Paula; T. F. F. Curado; J. R. Silva; J. L. R. Leles; G. McKenna; M. Schimmel	2022	Flapped versus flapless surgery and delayed versus immediate loading for a four mini implant mandibular overdenture: A RCT on post-surgical symptoms and short-term clinical outcomes	7
I. Milinkovic; A. D. Krasavcevic; S. Jankovic; J. Sopta; Z. Aleksic	2022	Immunohistochemical analysis of soft tissue response to polyetheretherketone (PEEK) and titanium healing abutments on dental implants: a randomized pilot clinical study	4
R. Lang; K. A. Hiller; L. Kienböck; K. Friedl; K. H. Friedl	2022	Influence of autoclave sterilization on bond strength between zirconia frameworks and Ti-base abutments using different resin cements	4
M. Â. Gouveia; S. I. V. Sousa; P. Fonseca; P. T. B. S. Branco; J. M. S. Quintanilla	2022	Marginal Bone Loss and Pink Esthetic Evaluation of Narrow-Diameter Dental Implants for Single Crowns: 1-Year Prospective Clinical Study	1
Gahlert M, Kniha H, Laval S, Gellrich NC, Bormann KH.	2022	Prospective Clinical Multicenter Study Evaluating the 5-Year Performance of Zirconia Implants in Single-Tooth Gaps	6
P. Ayyadanveettil; V. Thavakkara; N. Latha; M. Pavanan; A. Saraswathy; M. S. Kuruniyan	2022	Randomized clinical trial of zirconia and polyetheretherketone implant abutments for single-tooth implant restorations: A 5-year evaluation	4
N. Enkling; M. Marder; S. Bayer; W. Götz; M. Stoilov; D. Kraus	2022	Soft tissue response to different abutment materials: A controlled and randomized human study using an experimental model	4
S. Mühlemann; S. T. Lamperti; L. Stucki; C. H. F. Hämmerle; D. S. Thoma	2022	Time efficiency and efficacy of a centralized computer-aided-design/computer-aided-manufacturing workflow for implant crown fabrication: A prospective controlled clinical study	4
F. Zamparini; A. Spinelli; A. Buonavoglia; M. G. Gandolfi; C. Prati	2023	10-year Historical Prospective Cohort Study of Calcium Phosphate–Blasted Acid-Etched Titanium Implants Placed in Different Ridges	4
V. L. Humm; I. Sailer; D. S. Thoma; C. H. F. Hämmerle; R. E. Jung; A. Zembic	2023	13-year follow-up of a randomized controlled study on zirconia and titanium abutments	4
M. Strasding; S. P. Hicklin; A. Todorovic; V. Fehmer; P. Mojon; I. Sailer	2023	A multicenter randomized controlled clinical pilot study of buccally micro-veneered lithium-disilicate and zirconia crowns supported by titanium base abutments: 1-year outcomes	4
V. Thakare; S. Chaware; V. Kakatkar; A. Darekar	2023	An insight performance of zirconia implant abutment: A systematic review and meta-analysis of randomized controlled clinical trial	4
M. R. Norton	2023	Biologic and Mechanical Stability of Screw-Retained Layered Zirconia Crowns Bonded to CAD/CAM Titanium Abutments Using Angulated Screw Access: A Prospective Closed Cohort Study	4
S. R. Sherigar; J. S. Feine; L. F. Cooper; C. M. Stanford; C. A. Barwacz; M. McGuire; S. Abi Nader; R. F. de Souza	2023	Can patients detect peri-implant mucosal inflammation? Results from a multicentre randomized trial	4
V. Valantijiene; A. Mazeikiene; J. Alkimavicius; L. Linkeviciene; E. Alkimaviciene; T. Linkevicius	2023	Clinical and immunological evaluation of peri-implant tissues around ultra-polished and conventionally-polished zirconia abutments. A 1-year follow-up randomized clinical trial	1 + 4
Y. Zhang; D. Wei; J. Tian; Y. Zhao; Y. Lin; P. Di	2023	Clinical evaluation and quantitative occlusal change analysis of posterior implant-supported all-ceramic crowns: A 3-year randomized controlled clinical trial	1 + 4
A. Di Fiore; S. Granata; C. Monaco; E. Stellini; B. Yilmaz	2023	Clinical performance of posterior monolithic zirconia implant-supported fixed dental prostheses with angulated screw channels: A 3-year prospective cohort study	1
T. C. Bittencourt; N. M. Souza Picorelli Assis; C. G. Ribeiro; C. F. Ferreira; B. S. Sotto-Maior	2023	Evaluation of the peri-implant tissues in the esthetic zone with prefabricated titanium or zirconia abutments: A randomized controlled clinical trial with a minimum follow-up of 7 years	4
L. Ferrantino; A. Carrillo de Albornoz; M. Sanz	2023	Five-year outcomes of a randomized controlled clinical trial comparing single-tooth implant-supported restoration with either zirconia or titanium abutments	4
R. Takano; J. Honda; T. Kobayashi; K. Kubochi; H. Takata; F. Komine	2023	Fracture strength of implant-supported hybrid abutment crowns in premolar region fabricated using different restorative CAD/CAM materials	4
M. Pisano; D. Melodia; M. Tallarico; A. M. I. Lumbau; E. Baldoni; G. Spano; A. Demartis; B. Fornaca; S. M. Meloni	2023	FULLY DIGITAL WORKFLOW FOR IMMEDIATE LOADING OF SCREW-RETAINED TITANIUM-RESIN PROSTHESES ON MORSE CONE TISSUE-LEVEL CONNECTORS: 1-YEAR POST-LOADING RESULTS OF A CASE SERIES	3 + 4
W. Derksen; T. Joda; J. Chantler; V. Fehmer; G. O. Gallucci; P. C. Gierthmuehlen; A. Ioannidis; D. Karasan; A. Lanis; K. Pala; B. E. Pjetursson; M. Roccuzzo; I. Sailer; F. J. Strauss; T. C. Sun; S. Wolfart; N. U. Zitzmann	2023	Group 2 ITI Consensus Report: Technological developments in implant prosthetics	2
B. Al-Nawas; F. Lambert; S. W. M. Andersen; M. M. Bornstein; M. Gahlert; A. Jokstad; J. Jung; Y. D. Kwon; I. Laleman; G. Oteri; S. Roehling; E. Schiegnitz; Y. Takeda; H. Terheyden	2023	Group 3 ITI Consensus Report: Materials and antiresorptive drug-associated outcomes in implant dentistry	2
G. B. Menchini-Fabris; S. Cosola; P. Toti; M. Hwan Hwang; R. Crespi; U. Covani	2023	Immediate Implant and Customized Healing Abutment for a Periodontally Compromised Socket: 1-Year Follow-Up Retrospective Evaluation	4
T. F. F. Curado; J. R. Silva; L. N. Nascimento; J. L. R. Leles; G. McKenna; M. Schimmel; C. R. Leles	2023	Implant survival/success and peri-implant outcomes of titanium-zirconium mini implants for mandibular overdentures: Results from a 1-year randomized clinical trial	1 + 3
A. Pozzi; L. Arcuri; G. Fabbri; G. Singer; J. Londono	2023	Long-term survival and success of zirconia screw-retained implant-supported prostheses for up to 12 years: A retrospective multicenter study	4
J. Ravi; S. Duraisamy; K. Rajaram; R. Kannan; E. Arumugam	2023	Survival rate and stability of surface-treated and non-surface-treated orthodontic mini-implants: a randomized clinical trial	7
W. Derksen; D. Wismeijer	2023	Three-Year Follow-up of a Randomized Clinical Trial on Screw-Retained Monolithic Zirconia Restorations on Ti-Base Abutments Based on Digital or Conventional Impression Techniques	4

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Figure 1. PRISMA 2020 flow diagram.

Table 1. Study characteristics.

Study				Patients		Implants (T/Z)			Material	Implant Type	Characteristics
Study	Design	Follow-up (y)	Outcome	N (M/F)	Age (y/mean)	IMPs	Restoration Type	Zone (P/A/Both)	Material	Implant Type	Characteristics	Brand
Koller 2020	RCT	6.7	Comparing	22 (13/9)	46	29 (15/14)	Partial edentulous (SCs)	Both (maxilla and mandible)	Titanium	Two-piece implant	Diameter: 4.0 mm Length: 10 to 13 mm	Ziterion^®
									Y-TZP	Two-piece implant	Diameter: 4.0 mm Length: 10 to 13 mm	Ziterion^®
S. Ma DClinDent 2018	nRCT	5.0	Titanium	16 (4/12)	47.1	17	Partial edentulous (SCs)	Anterior (maxilla)	Titanium	Two-piece implant	Diameter: 4.0 mm Length: –	Southern Implants^®
Cochran, D.L. 2011	nRCT	5.0	Titanium	200 (100/100)	50	626	Partial edentulous (FDPs)	Anterior (maxilla and mandible)	Titanium Hollow Cylinder (maxilla) Solid Screw (mandible)	Two-piece implant Tissue Level	Diameter: 3.5 mm Length: 8.0 to 12.0 mm
									Titanium Hollow Cylinder (maxilla) Solid Screw (mandible)	Tissue Level	Diameter: 3.3 and 4.1 mm Length: 8 to 16 mm
N. Ravald 2013	RCT	12.0–15.0	Titanium	46 (19/27)		371	Full edentulous (FDPs)	Both (maxilla and mandible)	Titanium	Two-piece implant
Astra Tech				25 (12/13)	73.1	184				Bone Level	Diameter: 3.5 and 4.0 mm Length: 9.0 to 19.0 mm
Branemark				21 (7/14)	75.7	187				Bone Level	Diameter: 3.75 and 4.0 mm Length: 10.0 to 18.0 mm
F. Müller 2015	RCT	5.0	Titanium	47 (24/23)	72	72	Full edentulous (FDPs)	Anterior (mandible)	Titanium	Two-piece implant	Diameter: 3.3 mm Length: 8, 10, 12, and 14 mm	Straumann^®
van Velzen FJ 2015	nRCT	10.0	Titanium	177 (-/-)	50	374	Partial and full edentulous (FDPs)	Both (maxilla and mandible)	Titanium	Two-piece implant	Diameter: 3.3, 4.1, and 4.8 mm Length: 8, 10, and 12 mm	Straumann^®
Buser D 2012	nRCT	10.0	Titanium	303 (143/170)	48	511	Partial edentulous (SCs (N = 170); FDPs (N = 341))	Both (maxilla and mandible)	Titanium	Two-piece implant	Diameter: 3.3, 4.1, and 4.8 mm Length: 6, 10, 12, and 14 mm	Straumann^®
Balmer, M 2020	nRCT	5.0	Zirconia	53 (-/-)	–	63	Partial edentulous (SCs (N = 43); FDPs (N = 22))	Both (maxilla and mandible)	Y-TZP	One-piece implant	Diameter: 4.0, 4.5, and 5.5 mm Length: 8, 10, 12, and 14 mm	VITA Zahnfabrik^®
Brunello, G 2022	nRCT	9.0	Zirconia	30 (11/19)	49	30	Partial edentulous (SCs)	Posterior (maxilla and mandible)	Y-TZP	Two-piece implant	Diameter: 4.5 and 5.0 mm Length: 9, 11, and 13 mm	Patent™, Zircon Medical^®
Grassi, FR 2015	nRCT	5.0	Zirconia	17 (8/9)	52.3	32	Partial edentulous (SCs)	Both (maxilla and mandible)	Y-TZP	One-piece implant	Diameter: 3.5, 4.0, and 4.5 mm Length: 8, 10, 12, 14, and 16 mm	WhiteSKY, Bredent Medical^®
N. Cionca 2021	nRCT	6.0	Zirconia	24 (-/-)	–	39	Partial edentulous (SCs)	Both (maxilla and mandible)	Y-TZP	Two-piece implant	Diameter: 3.5, 4.2, and 5.5 mm Length: 8, 10, and 12 mm	Zeramex^® T
B. C. Spies 2015	nRCT	5.0	Zirconia	63 (32/31)	–	79	Partial edentulous (SCs (N = 47); FDPs (N = 16))	Both (maxilla and mandible)	Y-TZP	One-piece implant	Diameter: 4.3 mm Length: 10 mm	ZiUnite, Nobel Biocare^®
Lorenz J 2019	RCT	7.8	Zirconia	28 (13/15)	63.5	83	Partial edentulous (SCs)	Both (maxilla and mandible)	Y-TZP	One-piece implant	Diameter: 3.25 to 5 mm Length: 8 to 14 mm	Z-Systems, Oensingen^®
Kiechle S 2023	nRCT	8.0	Zirconia	39 (-/-)	58.8	67	Partial edentulous (SCs)	–	ZrO₂	One-piece implant	Diameter: 4.1 mm Length: 8, 10, and 12 mm	Straumann^®
Kohal RJ 2023	nRCT	5.0	Zirconia	48 (-/-)	–	57	Partial edentulous (SCs)	Both (maxilla and mandible)	Y-TZP	One-piece implant	Diameter: 4.3 and 5.0 mm Length: 10, 13, and 16 mm	Nobel Biocare^®

Table 2. Titanium studies’ output.

Study	Study Variables
	Periodontal					Esthetic	Rates (%)
	BoP (%)	PPD (mm)	GR (mm)	PI (%)	MBL (mm)	PINK	Success	Survival
Koller 2020	14.50 ± 7.66 (Median ± SD)	–	1.03 ± 0.72 (Median ± SD)	8.50 ± 8.11 (Median ± SD)	1.03 ± 0.72 (Median ± SD)	12.00 ± 1.01 (Median ± SD)	–	95.8% (mandible) 71.9% (maxilla)
S. Ma DClinDent 2018	–	–	0.08 ± 0.20 (mm ± SD)	–	0.10 ± 0.25 (mm ± SD)	–	92.9%	–
Cochran D.L. 2011	–	–	–	–	–	–	92.5%	87%
N. Ravald 2013
Astra Tech	45 ± 12 (maxilla) 36 ± 16 (mandible) (Mean ± SD)	–	–	18 ± 22 (maxilla) 35 ± 32 (mandible) (Mean ± SD)	0.30 ± 0.76 (Mean ± SD)	–	–	95.5%
Branemark	54 ± 18 (maxilla) 39 ± 17 (mandible) (Mean ± SD)	–	–	28 ± 31 (maxilla) 44 ± 40 (mandible) (Mean ± SD)	0.16 ± 0.52 (Mean ± SD)	–	–	94.7%
F. Müller 2015	–	–	–	–	0.61 ± 0.83 (Mean ± SD)	–	92.6%	97.8%
van Velzen FJ 2015	–	3.71 ± 1.12 (Mean ± SD)	–	–	0.16 ± 0.46 (Mean ± SD)	–	–	99.7%	* mPLI DIB value * mSBI
Buser D 2012	1.32 ± 0.57 * (Mean ± SD)	3.27 ± 1.06 (Mean ± SD)	0.42 ± 1.27 (Mean ± SD)	0.65 ± 0.64 *** (Mean ± SD)	3.32 ± 10.73 (Mean ± SD) **	–	97%	98.8%	* mPLI DIB value * mSBI

* mSBI. ** Dichotomous variable: 0—absence of plaque; 1—presence of plaque. *** mPLI.

Table 3. Zirconia studies’ output.

Study	Study Variables
	Periodontal					Esthetic	Rates (%)
	BoP (%)	PPD (mm)	GR (mm)	PI (%)	MBL (mm)	PINK	Success	Survival
Koller 2020	18.00 ± 6.16 (Median ± SD)	–	1.27 ± 0.81 (Median ± SD)	20.5 ± 6.09 (Median ± SD)	1.27 ± 0.81 (Median ± SD)	11.00 ± 1.27 (Median ± SD)	–	90.9% (mandible) 55% (maxilla)
Balmer, M 2020	48.0 ± 33.1 (Mean ± SD)	3.3 ± 0.6 (Mean ± SD)	0.8 ± 0.4 (Mean ± SD)	26.2 ± 27.5 (Mean ± SD)	0.7 ± 0.6 (Mean ± SD)	–	–	98.4%
Brunello, G 2022	12.9 ± 15.8 (Mean ± SD)	3.0 ± 0.6 (Mean ± SD)	0.1 ± 0.2 (Mean ± SD)	0.33 ± 0.28 * (Mean ± SD)	–	–	–	96.7%
Grassi, FR 2015	0.47 ± 0.51 ** (Mean ± SD)	2.2 ± 0.53 (Mean ± SD)	10.64 ± 0.86 (Mean ± SD)	0.40 ± 0.56 *** (Mean ± SD)	1.23 ± 0.29 (Mean ± SD)	–	96.9%	96.8%
N. Cionca 2021	–	3.5 ± 1.0 (Mean ± SD)	–	–	0.43 ± 0.76 **** (Mean ± SD)	–	63%	83%
B. C. Spies 2015	–	–	–	–	–	–	51.7%	–
Lorenz J 2019	22.16 ± 33.21 (Mean ± SD)	2.57 ± 1.10 (Mean ± SD)	0.43 ± 0.80 (Mean ± SD)	25.0 ± 26.41 (Mean ± SD)	1.2 ± 0.76 (Mean ± SD)	–	–	100%
Kiechle S 2023	–	–	–	–	–	–	89.6%	100%
Kohal RJ 2023	–	–	–	–	–	–	–	78.2%

* mSBI. ** Dichotomous variable: 0—absence of plaque; 1—presence of plaque. *** mPLI. **** DIB value.

Table 4. Risk of bias.

Study	Design	ROB Tool
Koller 2020	RCT	ROB2
S. Ma DClinDent 2018	nRCT	ROBINS-9
Cochran, D.L. 2011	nRCT	ROBINS-9
N. Ravald 2013	RCT	ROB2
F. Müller 2015	RCT	ROB2
van Velzen FJ 2015	nRCT	ROBINS-9
Buser D 2012	nRCT	ROBINS-9
Balmer, M 2020	nRCT	ROBINS-9
Brunello, G 2022	nRCT	ROBINS-9
Grassi, FR 2015	nRCT	ROBINS-9
N. Cionca 2021	nRCT	ROBINS-9
B. C. Spies 2015	nRCT	ROBINS-9
Lorenz J 2019	RCT	ROB2
Kiechle S 2023	nRCT	ROBINS-9
Kohal RJ 2023	nRCT	ROBINS-9

Caption:

Low risk;

some concerns; Surgeries 06 00020 i007

high risk; Surgeries 06 00020 i008

the domain is not part of ROB2. ROB2 domains—D1, randomization; D2, deviations from intended intervention; D3, missing data; D4, outcome measurement; D5, selection of reported result; ROBINS-9 domains—D1, confounding; D2, selection of participants; D3, classification of interventions; D4, deviations from intended interventions; D5, missing data; D6, measurement of outcomes; D7, selection of the reported result.

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© 2025 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).

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Abreu, F.; Correia, F.; Caetano, T.; Faria-Almeida, R. The Survival Rate of Zirconia Versus Titanium Dental Implants: A Systematic Review. Surgeries 2025, 6, 20. https://doi.org/10.3390/surgeries6010020

AMA Style

Abreu F, Correia F, Caetano T, Faria-Almeida R. The Survival Rate of Zirconia Versus Titanium Dental Implants: A Systematic Review. Surgeries. 2025; 6(1):20. https://doi.org/10.3390/surgeries6010020

Chicago/Turabian Style

Abreu, Francisca, Francisco Correia, Tiago Caetano, and Ricardo Faria-Almeida. 2025. "The Survival Rate of Zirconia Versus Titanium Dental Implants: A Systematic Review" Surgeries 6, no. 1: 20. https://doi.org/10.3390/surgeries6010020

APA Style

Abreu, F., Correia, F., Caetano, T., & Faria-Almeida, R. (2025). The Survival Rate of Zirconia Versus Titanium Dental Implants: A Systematic Review. Surgeries, 6(1), 20. https://doi.org/10.3390/surgeries6010020

Article Menu

The Survival Rate of Zirconia Versus Titanium Dental Implants: A Systematic Review

Abstract

1. Introduction

1.1. Titanium Implants

1.2. Zirconia Implants

1.3. Objective

2. Materials and Methods

2.1. Research Conduct

2.2. Study Selection

2.3. Inclusion Criteria

2.4. Exclusion Criteria

2.5. Screening Method

2.6. Data Extraction and Outcomes

2.7. Quality Assessment and Risk of Bias

3. Results

3.1. Studies Characteristics

3.2. Implant Characteristics

3.3. Output Measurement Methods and Results (Table 2 and Table 3)

3.3.1. Survival Rate Criteria (SR)

3.3.2. Success Rate Criteria (ScR)

3.3.3. Bleeding on Probing (BoP)

3.3.4. Peri-Implant Probing Depth (PPD)

3.3.5. Gingival Recession (GR)

3.3.6. Plaque Index (PI)

3.3.7. Marginal Bone Loss (MBL)

3.3.8. Aesthetic Score (PINK)

3.4. Risk of Bias Assessment

4. Discussion

5. Conclusions

Author Contributions

Funding

Conflicts of Interest

Appendix A

References

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