Ziconia implants as preferred treatment method for health-conscious patients – German S3 guideline
Spreitenbach, 9 August 2023 – For a long time, titanium was considered the implant material of choice and showed reliable long-term results. The question of possible material-related risks such as metal incompatibility was often left aside. Several studies have shown that titanium releases abrasion particles as a result of mechanical insertion (Meyer et al. 2006) which together with microbial milieu influences can trigger mucositis and peri-implantitis (Scridhar et al. 2015). The new German S3 guideline now provides recommendations for cases with material intolerance.
With the growing number of titanium implants placed worldwide, the risk of peri-implant inflammation is also increasing. The often cited meta-analysis by Derks & Tomasi already showed worrying prevalence averages of 43% for peri-implant mucositis and 22% for peri-implantitis in 2014. It was also proven that there is a positive correlation between implant function time and peri-implantitis prevalence.
Poor oral hygiene, smoking and incorrect loading of the implant can result in implant loss. The material-related immunological reaction of patients to titanium oxide particles, which should be called titanium intolerance because of its non-specific character (Jacobi-Gresser 2017) is also an important factor. Dr. Volker von Baehr assumes that about 15% of the population may have a metal-related hypersensitivity. The new study by Stolzer et al. (2022) shows a statistically significant correlation between a positive TiO2 stimulation test and peri-implantitis with an overall frequency of positive TiO2 stimulation tests of 28.3%.
For all the qualities of titanium as an implant material, the literature also shows clear advantages of zirconium dioxide. For example, zirconia demonstrates less plaque accumulation, less bacterial adhesion (Scarano et al. 2004, Ichikawa et al. 1992) and less biofilm thickness (Roehling et al. 2016). Circular blood flow in the peri-implant soft tissue is similar to that of the natural tooth for zirconia and significantly reduced for titanium (Kajiwara et al. 2015). Better circular blood flow means a healthier gingiva which not only results in better aesthetic outcomes (Tartsch 2018). Peri-implantitis with ceramic implants has not been observed (Cionca N, Mombelli A et al. 2016, Spies et al. 2018, Janner et al. 2018, Roehling et al. 2018).
German S3 guideline on titanium hypersensitivity in implant dentistry: consensus statements and recommendations
The new German S3 guideline (short report) which was published at the end of 2022 shows the relevance of the topic. It recommends that zirconia implants can be considered as a treatment option if a local titanium-related inflammatory reaction is suspected. Metals or impurities present in the superstructures or alloys can also cause an intolerance reaction. "It is a right step to open the doors to immunological health for many compromised patients," says Dr Elisabeth Jacobi-Gresser, oral surgeon and co-author of the S3 guideline.
The Zeramex XT implant system
The future of implant dentistry is based on new standards - better biological compatibility and aesthetic advantages of zirconia, a two-piece implant design with reliable metal-free internal connection as well as diverse prosthetic possibilities thanks to the digital workflow.
Zeramex XT is a completely metal-free two-piece zirconia implant system that has shown a survival rate of 98% (Jank & Hochgatterer 2016). Thanks to the two-piece design of the system, its reversible screw connection and compatibility with the conventional and digital workflows, Zeramex XT offers excellent surgical and prosthetic flexibility.
Zeramex Demobox
With the Zeramex Demobox, dentists can learn more about the Zeramex XT implant system hands-on. The Zeramex Demobox contains the most important surgical and prosthetic components and offers the possibility to perform a test implantation in the artificial bone as well as the prosthetic restoration with the support of our advisors.
References
Cionca N, Mombelli A et al.: Pro-inflammatory cytokines at zirconia implants and teeth. A cross-sectional assessment. Clin Oral Investig (2016).
Derks J, Tomasi C (2014): Peri-implant health and disease. A systematic review of current epidemiology. J Clin Periodontol 2014
Ichikawa Y, Akagawa Y, Nikai H, Tsuru H: Tissue compatibility and stability of a new zirconia ceramic in vivo. J Prosthet Dent 68, 322-326
(1992).
Jacobi-Gresser E: Titanüberempfindlichkeit oder Titanunverträglichkeit? Wissenschaftliche Fakten und klinische Konsequenzen. Quintessenz 2017; 68: 1413–1420
Jank S, Hochgatterer G. Success Rate of Two-Piece Zirconia Implants: A Retrospective Statistical Analysis. 2016 Apr;25(2):193-8. doi: 10.1097/ID.0000000000000365.
Janner S, Gahlert M, Bosshardt D, Roehling S, Milz S, Higginbottom F, Buser D, Cochran DL: Bone response to functionally loaded, two-piece zirconia implants: A preclinical histometric study. Clin Oral Implants Res 29 (3), 277-289 (2018).
Kajiwara Net al.: Soft tissue biological response to zirconia and metal implant abutments. Implant Dentistry 24 (1), (2015).
Meyer U, Bühner M, Büchter A, Kruse-Lösler B, Stamm T, Wiesmann H P. Fast element mapping of titanium wear around implants of different surface structures. Clin. Oral Impl. Res. 2006; 17,206-211
Roehling, S.; Schlegel, K.A.; Woelfler, H.; Gahlert, M. Performance and outcome of zirconia dental implants in clinical studies: A meta-analysis. Clin Oral Implants Res 2018, 29 Suppl 16, 135-153.
Roehling S et al.: In vitro biofilm formation on titanium and zirconia implant surfaces. | Periodontol 88 (3), 298-307 (2016).
Scarano A, Piattelli M, Caputi S, Favero GA, Piattelli A: Bacterial adhesion on commercially pure titanium and zirconium oxide disks: An in vivo human study. J Periodontol 75, 292-296 (2004).
Scridhar S, Wilson Jr TG, Palmer KL, Valderrama P, Mathew MT, Prasad S, Jacobs M, Gindri IM, Rodrigues DC. In Vitro Investigation of the Effect of Oral Bacteria in the Surface Oxidation of Dental Implants. Clin Impl Dent 2015; 17:562-75
Spies C, Vach K, Kohal RJ, Hämmerle CHF, Jung RE: Three-year analysis of zirconia implants for single-tooth replacement and three-unit fixed dental prostheses. Clin Oral Implants Res 29 (3), 290-299 (2018).
Stolzer C, Müller M, Gosau M, Henningsen A, Fuest S, Aavani F, Smeets R. Do Titanium Dioxide Particles Stimulate Macrophages to Release Proinflammatory Cytokines and Increase the Risk for Peri-implantitis? J Oral Maxillofac Surg. 2023 Mar;81(3):308-317. doi: 10.1016/j.joms.2022.10.019. Epub 2022 Nov 1. PMID: 36442535.
Tartsch J: Keramikimplantate - Exoten oder sinnvolle Erweiterung des Behandlungsspektrums. ZMK 34-11 (2018).
v. Baehr V: Die Immunologie des Titans – Titanunverträglichkeit – Mythos oder Realität. Internet: https://dentalplus.info/wp-content/uploads/2017/11/ti-unvertraeglichkeit.pdf
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