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Your Guide on the path of Dentistry

16
Prosthodontics
Nov 2013
PROSTHODONTICS
Prosthodontics
ZIRCONIA - THE NEW CHOICE FOR
IMPLANT ABUTMENTS
Dr. Rajat Dang
Reader
Dr. Ashu Kakkar
P.G. Student
Dr. Nikita Garg
P.G. Student
Department of Prosthodontics
MMCDSR Mullana (Ambala), India
Dental implants are considered as an essential treatment modality
which has demonstrated high success rates for replacement of both
single and multiple teeth. However, this approach of rehabilitation
is a clinical challenge especially in the anterior segment where
esthetics has prime importance. One of the most challenging
scenarios is to satisfy the patient expectations both functionally and
esthetically. The high esthetic demands lead to the fabrication of
metal free restorations using ceramic that exhibits ideal properties
of biocompatibility and esthetics.
1
The abutment is the portion of the implant that supports or retains a
prosthesis or implant superstructure. The abutments are commonly
made from materials, such as titanium, surgical stainless steel and
gold. Of these, titanium has been the gold standard and continues its
impeccable service with respect to biocompatibility and its physical
property. In spite of the success of these materials there has never
been a dearth in the efforts to formulate the right ceramic material
to overcome the inherent esthetic compromise in the use of metals,
especially with regard to anterior restorations.
The increased demand from patient for high esthetic result,
and clinicians need to achieve better treatment outcome, has
considerably contributed to the development of a new generation
of ceramic abutments. The materials of preference for ceramic
abutments are densely sintered high purity alumina and yttria-
stabilized tetragonial zirconia polycrystal ceramics. Alumina-based
ceramics rst broke into this metal bastion and brought about the
change that was so long desired and looked forward to. But as the
rst comer, its Achilles heel was that it possessed the risk of fracture
during laboratory procedures and following abutment connection.
To rein in this weakness, yttrium-oxide stabilized zirconia was
introduced. It brought along several advantages like high exural
strength (900-1400 Mpa)
2
and desirable optical properties. This
To restore oral functions in patients with missing teeth,
single tooth implants are a well documented treatment
option. The selection of the restorative materials
should thus be based on the esthetic characteristics
in addition to the biocompatibility and the strength
characteristics. A focus of interest in implant
dentistry; is the application of ceramic materials for
the fabrication of the implant abutments as well as
for prosthesis. Improved material characteristics,
complying with clinicians and patients increased
demands for highly esthetic results, have contributed
signicantly to the development of new generation
of ceramic abutments. In the all-ceramic category,
zirconia implant abutments provide a highly desirable
option. The focus of this systematic review was to
assess the published data concerning zirconia dental
implant abutments from various aspects.
Keywords : Zirconia, Implant, Abutments, Esthetics,
Transformation toughening.
material proved its worth in mechanical properties and reliability
as a result of its stress-induced transformation toughening. Most
modern abutments made from zirconia are now introduced in order
to overcome the shortcomings and better complement the esthetics
of a dental implant restoration.
Prosthodontics
Your Guide on the path of Dentistry
| GUIDENT 17
Prosthodontics
Nov 2013
PROSTHODONTICS
results in a compressive stress as the result of volume expansion
and slows down further crack propagation, resulting in improvement
of the mechanical properties (i.e. transformation toughening).
1
It has
been assumed that the phenomenon of transformation toughening
contributes to this high fracture strength and the self-repairing
properties of zirconium that prevent crack propagation.
It is the general understanding that ceramic abutments should
demonstrate adequate resistance against the masticatory
forces that rise during chewing or swallowing . To achieve a ne
restoration, the abutment should present resistance to fracture
to ensure long term success. In this aspect, zirconia abutments
exhibit enhanced resistance. In addition, a cyclic fatigue pattern
and stress corrosion fatigue caused by oral environment must be
considered. In the oral environment, the inherent aws of ceramic
materials have been considered to induce propagation of crack to
a critical size. A failure ultimately results from a nal loading cycle
that exceeds the mechanical capacity of the ceramics. A a rule of
thumb, the endurance limit for fatigue cycling that can be applied
to dental ceramics is approximately 50% of the maximum fracture
strength. Consequently, it is reasonable to demand an initial fracture
resistance within a safety range of 650 N for the anterior region and
1,000 N for the posterior region of maxilla and mandible, to ensure
a favourable clinical prognosis of zirconium implant abutments and
their all-ceramic restorations.
Further in vitro and in vivo studies are necessary to prove that
this claim can be transferred to clinical situations. The zirconium-
ceramic abutments investigated in a study conducted by Gehrke et
al
6
exhibited a maximum fracture strength of 672 N during a static
loading and 269 N and 403 N during cyclic loading. This provides
evidence that zirconium abutments can safely be used in the incisor
region of the maxilla and mandible, while caution is recommended
in the molar regions.
Yttria-stabilized tetragonal zirconia polycrystals (Y-TZP) implant
abutments offer enhanced biocompatibility, metal-like radiopacity
for better radiographic evaluation, and, ultimately reduced bacterial
adhesion, plaque accumulation, and inammation risk. Moreover,
Y-TZP abutments may promote soft tissue integration, while peri-
implant soft tissues may be clinically achieved adjacent to zirconia
or alumina-zirconia abutments and zirconia healing caps.
Y-TZP abutments are available in two types: prefabricated and
custom made. Prefabricated zirconia abutments are a reliable and
practical solution but CAD/CAM technology is also benecial in
designing fully individualized zirconia abutments for ideal soft-
tissue integration and esthetics. Both types of abutments give the
opportunity for further customization either by extra-oral or intra-
oral preparation.
The incidence of complications associated with zirconia abutments
was determined by evaluating data from three studies.
7,8,9
Glauser
et al reported the clinical success of 36 experimental zirconia
In an in-vitro study by Yildrim
3
et al the fracture resistance of such
restorations were evaluated. Alumina and zirconia abutments were
prepared and restored with glass-ceramic crowns and placed on
Branemark implants (Nobel Biocare, Gathenburg, Sweden). No
articial aging was applied to the test specimens. The statistical
analysis showed signicant differences between both groups, with
mean fracture load values of 280.1 N for the group with alumina
abutments and 737.6 N for the group with zirconia abutments. The
fracture resistance in the zirconia abutment was more than twice
that in the alumina abutment group.
Ceramic abutments which were developed are available in
prefabricated or customizable forms and can be prepared in the
dental laboratory either by the technician or by utilizing computer
aided design (CAD) manufacturing units.
ESTHETICS AND ZIRCONIA ABUTMENTS
Zirconia posesses maximal opaquing effect due to scattering of
light by dispersed particles of zirconium oxide which are greater in
size than wavelength of light and with a different refractive index
to the matrix. Zirconia, though being a metal, has a very appreciable
esthetic appeal due to its tooth color and this factor alone takes it
a long way in making it a very good choice as an implant abutment
in the anterior region.
According to Watkin
4
, tissue discoloration in the cervical third of
anterior implant restorations may result from implant abutment
material show-through. As an alternative to metal abutments that
may compromise the appearance of tissue color in the esthetic
zone, zirconia abutments can be used. When zirconia abutments
are combined with all-ceramic crowns, the appearance of the peri-
implant tissue can be noticeably improved.
Also, the mechanical properties of zirconia are in a league of its own
and poses a signicant advantage over other esthetic abutment. This
combination of more than acceptable esthetics and its far reaching
mechanical properties make this the gold standard of esthetic
material of all the ceramic materials available today.
Zirconia is a high strength ceramic, the yttria stabilized zirconia
ceramic has twice the exural strength of alumina ceramic (900-1400
MPa), a fracture toughness of upto 10 MPa/m
0.5
, and a modulus of
elasticity value of 210 GPa. The enhanced strength of zirconia (ZrO
2
)
can be explained by the microstructural differences, such as higher
density, smaller particle size and polymorphic mechanism against
aw propagation.
2,5

The main reason for the superior resistance of zirconia lies in the
stabilizing effect of yttria, which allows the processing of zirconia in
the metastable tetragonal crystalline structure at room temperature
(18C23C). The tetragonal phase at room temperature allows for
transformation to the monoclinic phase under stress and represents
an efcient mechanism against aw propagation. The transformation
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Your Guide on the path of Dentistry
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Prosthodontics
Nov 2013
PROSTHODONTICS
abutments on single-tooth implants, after a minimum observation
period of 49.2 months. No abutment fractures were observed during
clinical loading, resulting in a cumulative survival rate of 100%.
Healthy peri-implant mucosa and stable marginal bone levels were
documented at zirconia abutments.
7
In another study, 30 zirconia
abutments on single-tooth implants were observed after a follow-
up period of 40 months. No abutments fractures or screw loosening
were reported, resulting in a cumulative survival rate of 100%.
8
Finally, a third study evaluated the success rate of 37 zirconia-
alumina composite abutments (ZirAce, Acucera Inc., Reno, NV). Nine
implants were single teeth, and 28 implants were FPDs. After a 12-
month follow-up, no abutments fractures, cracks, screw loosening,
or peri-implant infection signs were reported. In this study, neither
zirconia-alumina abutment failures nor adverse soft tissue reactions
were observed at 12 months.
9
These studies indicate that zirconia
abutments are suitable for clinical use.
Zirconia abutments may also represent a material surface less
attractive for early plaque retention compared to titanium. Scarano
et al reported a coverage by bacteria of 12.1% on zirconia as
compared to 19.3% on titanium.
10
Kou et al compared different
polishing systems for zirconia and concluded that polishing creates
surfaces similar to the just sintered ones and smoother than only
grinding surfaces.
11
These studies indicate that zirconium oxide can
be suitable for implant abutment but more clinical and mechanical
trials are necessary for a complete understanding of behaviour of
zirconia abutments.
CONCLUSION
The diversity of contemporary materials and of methods available
for the fabrication of implant supported, all-ceramic restorations
makes it difcult to select the most appropriate treatment modality.
New products are constantly being added to the wide range of
existing products. For example, efforts are being made to produce
low-temperature, degradation- free zirconiaalumina composites
for dental implant abutments. The rst short-term results are
encouraging. Zirconia ceramics and abutments are being intensively
investigated and are gaining in popularity. Future improvements in
the ceramic will focus on its color and long-term stability. Attempts
are being made to add coloring oxides to zirconia ceramic before the
sintering process; this would change its whitish color and enhance
the aesthetic outcome. It remains important, however, to verify the
effectiveness of a suggested method before its recommendation.
Advances in computer-aided designcomputer aided manufacturing
technologies, which have made the fabrication procedures of
ceramic abutments and implant-supported, all-ceramic restorations
faster, easier, and more efcient, are playing a major role in the
growing use of ceramic abutments. Future developments will make
it possible to produce more resistant abutments and restorations
with higher quality and lower fabrication time and costs.
12

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