EAO POSITION

PAPERS
EAO Position Paper: Material Selection for
Implant-Supported Restorations
Bjarni Elvar Pjetursson, Prof, DDS, Dr Med Dent, MAS Perio, PhD
Department of Reconstructive Dentistry, Faculty of Odontology, University of Iceland, Reykjavik, Iceland;
Division of Fixed Prosthodontics and Biomaterials, University Clinics for Dental Medicine,
University of Geneva, Geneva, Switzerland.

Vincent Fehmer, MDT

Irena Sailer, Prof Dr Med Dent
Division of Fixed Prosthodontics and Biomaterials, University Clinics for Dental Medicine,
University of Geneva, Geneva, Switzerland.

In recent years, numerous new dental materials have been introduced as alternatives to metal-ceramics
for restorations on teeth and implants. This position paper presents the current evidence and respective
clinical recommendations of the European Association for Osseointegration (EAO), one of the scientific
partners of the International Journal of Prosthodontics, on material selection for single crowns (SCs) and
multiple-unit implant-supported fixed dental prostheses (FDPs). Metal-ceramic restorations can be utilized in
most clinical indications and are preferred to ceramic restorations in incidences such as long clinical implant
crowns; cantilever implant restorations where one implant is supporting two crowns; implant-supported FDPs
with extension units extending more than 7 to 8 mm (premolar size); implant-supported FDPs with more
than two pontics; and implant-supported FDPs with small connector diameters due to limited intraocclusal
space. Veneered or monolithic zirconia-ceramic and veneered or monolithic reinforced glass-ceramic implant-
supported SCs are indicated for most SC cases in both the anterior and posterior areas. Today, implant-
supported zirconia-ceramic FDPs that are conventionally veneered cannot be considered the material of first
priority due to the pronounced risk for fracture of the framework and catastrophic fracture of the veneering
material. Monolithic zirconia FDPs are a promising alternative to veneered implant-supported zirconia-ceramic
FDPs. The mechanical stability of the translucent and shaded zirconia differs significantly between the grades
of translucency. This must always be considered when clinical indications are recommended. As this specific
area of prosthodontics is evolving fast, numerous studies evaluating different material options in implant
prosthodontics are currently performed worldwide, and future consensus meetings will refine the present
recommendations. The EAO will therefore regularly publish updated position papers on relevant topics. Int J
Prosthodont 2022;35:7–16. doi: 10.11607/ijp.8013

I
n recent years, numerous new esthetic dental materials have been introduced as
alternatives to metal-ceramics for restorations on teeth and implants. Specifically,
the ceramics lithium disilicate and zirconia have gained interest. The cost efficiency
Correspondence to:
of these all-ceramic options and the diversity of their possible applications through Dr Bjarni E. Pjetursson
CAD/CAM processing technologies have shifted fixed implant-supported restora- Department of Reconstructive
tions away from metal-ceramics toward all-ceramics. Furthermore, a new abutment Dentistry
Faculty of Odontology
type, the titanium base abutment with a special antirotational configuration and a University of Iceland
parallel abutment wall for increased cement retention, has been introduced, further Vatnsmyrarvegi 16
expanding the use of ceramics for implant prosthodontics. This abutment can be 101 Reykjavik, Iceland
Email: [email protected];
used for the support of chairside or labside monolithic or veneered ceramic implant- [email protected]
supported restorations. These recent developments are already frequently applied in
daily clinical practice. Researchers and clinicians have been investigating the evidence Submitted September 11, 2021;
accepted November 18, 2021.
behind these new concepts in order to select the most appropriate material for the ©2022 by Quintessence
respective clinical indication. Publishing Co Inc.

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 EAO Position Papers

Fig 1   Three-unit implant-supported metal-

ceramic FDP.

For clinicians, it is not only good survival rates that A pair of systematic reviews1,2 analyzed the clinical
are relevant for general satisfaction with restorations, outcomes of metal-ceramic implant-supported restora-
but also the complications that may occur with a spe- tions. The review analyzing metal-ceramic SCs1 included
cific type of restorative material. Complications can be 30 studies reporting on a total of 4,542 crowns, 83%
biologic, technical, or, in the worst case, a combination of which were cement retained and 17% of which were
of both. screw retained. The review analyzing metal-ceramic
The European Association for Osseointegration (EAO), multiple-unit FDPs2 included 16 studies reporting on
one of the scientific partners of the International Journal 993 FDPs supported by 2,289 implant abutments, 73%
of Prosthodontics, regularly performs Consensus Con- of which were cement retained and 27% of which were
ferences with the aim of elaborating the evidence on screw retained.
relevant clinical topics. Hence, the majority of evidence available on implant-
In the present position paper, the current evidence supported metal-ceramic restorations is evaluating intra-
and the respective clinical recommendations of the orally cemented restorations.
EAO on material selection for single crowns (SCs) and The meta-analyses included with these reviews esti-
multiple-unit implant fixed dental prostheses (FDPs) mated an annual failure rate of 0.35% (95% CI: 0.19% to
are given. 0.66%), translating into a 5-year survival rate of 98.3%
for metal-ceramic implant-supported SCs,1 and an an-
Metal-Ceramic Implant-Supported Restorations nual failure rate of 0.26% (95% CI: 0.10% to 0.64%),
Metal frameworks or cores veneered with feldspathic translating into a 5-year survival rate of 98.7% for FDPs2
ceramic are a long-existing, well-documented mate- (Table 1). Even though the 5-year survival rate for metal-
rial combination for single- and multiple-unit implant- ceramic restorations was high, the respective complica-
supported restorations (Fig 1).1,2 Metals provide high tion rates were 13.3% for metal-ceramic SCs1 and 15.1%
strength as a core, so the relatively weak veneering layer for FDPs,2 meaning that 1 out of every 6 to 8 restorations
is protected against tensile stress during function. The experienced some kind of biologic, technical, or es-
framework of metal-ceramic restorations can be pro- thetic complication or failure. Hence, only 86.7% of the
duced from different alloys by casting, milling, or laser metal-ceramic implant-supported SCs and 84.9% of the
melting. The main advantage of metals is their plastic metal-ceramic implant-supported FDPs were free of all
behavior under stress. complications over the entire 5-year observation period.

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 Pjetursson et al

Table 1   Annual Failure Rates of Different Types of Implant-Supported Restorations

Type of implant-supported restoration No. of restorations evaluated Estimated annual failure rates, % (95% CI)
Metal-ceramic SC 4,542 0.35 (0.19–0.66)
Zirconia-ceramic SC 912 0.49 (0.21–1.18)
Reinforced glass-ceramic SC 484 1.02 (0.51–2.05)
Metal-ceramic FDP 993 0.26 (0.10–0.64)
Zirconia-ceramic FDP 175 1.45 (1.06–1.98)

Fig 2   Implant-supported metal-ceramic SC

showing significant ceramic chipping.

The 5-year rate of peri-implantitis or soft tissue com- easier and faster, and the restorations are less expensive
plications was estimated to be 5.1%. Furthermore, sig- and more predictable with respect to shape, occlusion,
nificant bone loss, defined as marginal bone levels more and function.
than 2 mm, below what can be expected as normal To compensate for the slight distortion that often oc-
bone remodeling, was reported for 3.3% of the im- curs with traditionally manufactured metal frameworks,
plants supporting metal-ceramic SCs.1 The respective screw-retained multiple-unit metal-ceramic implant-
figures for metal-ceramic FDPs were 8.5% and 2.6%.2 supported restorations should preferably be made using
Fracture of abutments, abutment screws, or occlusal customized computer-aided milling from industrially fab-
screws were rare complications, reported for 0.2% of ricated base-metal alloy blanks (Fig 3) or made with ad-
the metal-ceramic SCs1 and 1.3% of the FDPs2 during a ditive methods via selective laser technology to achieve
5-year observation period. Abutment or occlusal screw passive fit of the restoration. The traditional workflow
loosening was more frequent, with a 5-year complica- is better suited for cemented multi-unit restorations, as
tion rate of 3.6% for metal-ceramic SCs1 and 5.3% for the cement gap can compensate for the distortion of
metal-ceramic FDPs.2 The incidence of ceramic fractures the framework. The metal framework and the implant
or chipping was over a 5-year period was 2.9% for im- abutment should preferably be milled as one piece. Com-
plant-supported metal-ceramic SCs,1 compared to 11.6% puter-aided design (CAD) allows for the ideal thickness
for FDPs2 (Fig 2). Framework fractures, however, were of the ceramic veneer.
only reported for 0.2% of the metal-ceramic SCs1 and Single- and multiple-unit metal-ceramic restorations
0.5% of the FDPs.2 An overview is shown in Table 2.3 have been extensively researched and have shown excel-
The traditional way of processing precious and base- lent long-term outcomes. In conclusion, metal-ceramic
metal alloy frameworks and cores is casting using the restorations can be utilized in most clinical indications
lost-wax technique. This is a costly and technique-sen- and are preferred to ceramic restorations in incidences
sitive procedure. Even though the clinical outcomes of such as long clinical implant crowns (eg, as a result of a
traditionally manufactured metal-ceramic implant-sup- lack of vertical bone, making the titanium base concept
ported restorations are quite good, application of tra- less favorable); cantilever implant restorations where
ditional methods was reduced with the introduction of one implant is supporting two crowns (Fig 4); implant-
computer-aided manufacturing (CAM) techniques. Com- supported FDPs with extension units extending more
pared to the manual approach, CAD/CAM processes are than 7 to 8 mm (premolar size); implant-supported FDPs

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 EAO Position Papers

Table 2   Estimated 5-Year Failure and Complication Rates for Different Types of Implant-Supported Restorations
and Number of Implant Abutments or Restorations Analyzed
Implant-supported Implant-supported Implant-supported Implant-supported
metal-ceramic SCs zirconia-ceramic SCs metal-ceramic FDPs zirconia-ceramic FDPs
5-y 5-y 5-y 5-y
No. complication No. complication No. complication No. complication
Complication failure analyzed rate, % analyzed rate, % analyzed rate, % analyzed rate, %
Total complications, n 1,300 13.3 76 16.2 371 15.1 NA
Total technical NA NA NA NA
complications, n
Implant fracture 2,394 0.2 NA 3,207 0.5 NA
 Abutment or occlusal 3,954 3.6 694 1.0 2,804 5.3 NA
crew loosening
 Abutment or occlusal 3,998 0.2 790 0.4 2,941 1.3 169 0
screw fracture
 Fracture of core or 2,592 0.2 371 2.1 966 0.5 175 4.7
framework
Total ceramic fractures 4,090 2.9 694 2.8 781 11.6 NA
and chipping, n
 Ceramic fractures NA NA 427 4.7 102 2.5
(Repair needed)
Ceramic chipping 1,538 3.5 NA 747 7.8 NA
Loss of retention 2,211 2.0 115 0 476 1.9 NA
 Loss of the access hole 159 0 NA 545 5.4 NA
restoration
Total biologic NA NA NA NA
complications, n
 Soft tissue complications 2,118 5.1 234 5.3 871 8.5 73 10.1
 Marginal bone loss 3,254 3.3 670 4.3 1,621 2.6 NA
(> 2 mm)
 Abutment tooth NA NA NA NA
intrusion
Esthetic failures 627 1.7 224 0 94 0 73 0
 Esthetic complications 610 7.1 NA NA NA

Fig 3  Framework for a four-unit implant-

supported metal-ceramic FDP milled from in-
dustrially fabricated base-metal alloy blank.

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 Pjetursson et al

Fig 4   Metal-ceramic cantilever restoration

with one implant supporting two units.

Fig 5   Monolithic zirconia implant-supported

SC in the position of the first molar.

with more than two pontics; and implant-supported material due to its excellent biocompatibility and im-
FDPs with small connector diameters due to limited in- proved mechanical properties,11 which are supported
traocclusal space. by the promising outcomes of many studies on the
properties of zirconia.12–16 Until recently, zirconia was
Zirconia-Ceramic Implant-Supported Restorations only available as yttria-stabilized tetragonal zirconia
The desire for materials with the appearance of natural polycrystals, a rather opaque whitish framework mate-
dental tissues led to the development and use of zirconia rial that had to be veneered with ceramic to achieve an
ceramic as restorative material.4 Zirconia is the strongest acceptable esthetic outcome. Lately, new variations of
of all ceramics and was adapted to dental applications zirconia exhibiting tooth-like color and more translu-
in line with the development of CAD/CAM technology.5 cency have been developed, allowing for a monolithic
As previously mentioned, these developments coupled application of zirconia5 (Fig 5).
with the high demand for esthetics have opened up a A pair of systematic reviews analyzed studies reporting
range of possibilities for ceramic restorations, allow- on zirconia-ceramic implant-supported SCs1 and FDPs.2
ing for less costly and more time-effective production The review by Pjetursson et al1 included 8 studies report-
workflows.6,7 The design and subsequent milling of ing on 912 zirconia implant-supported SCs followed for
high-strength ceramics with an adequate fit and ac- an average period of 5 years, and a review by Sailer et al2
ceptable clinical outcome are now possible.8–10 In the included 3 studies reporting on a total of 175 zirconia-
last decade, zirconia has emerged as a very popular ceramic FDPs followed for an average of 5.1 years. Of

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 EAO Position Papers

Fig 6   Zirconia implant-supported FDP that

fractured in the connector because of insuf-
ficient material thickness.

Fig 7   Implant-supported ceramic SC and a

customized zirconia abutment.

the included SCs, 51% were cement retained and 49% (2.8%), fracture of the core or framework (2.1%) (Fig 6),
were screw retained; for FDPs, the respective values and abutment screw loosening (1.0%). Other complica-
were 15% and 75%. The annual failure rates for implant- tions, such as abutment or occlusal screw fracture, loss
supported zirconia-ceramic SCs and FDPs were estimated of retention of cemented crowns, and esthetic failures,
to be 0.49% (95% CI: 0.21% to 1.18%)1 and 1.45% were less frequent.1 For implant-supported zirconia-
(95% CI: 1.06% to 1.98%), respectively,2 translating into ceramic FDPs, the most frequent complications were soft
respective 5-year survival rates of 97.6%1 and 93.0%2 tissue complications (10.1%) and framework fractures
(Table 1). However, the estimated 5-year complication (4.7%).2 An overview is shown in Table 2.3
rate for zirconia-ceramic SCs was 16.2%, meaning that The clinical indications for veneered or monolithic
83.8% of the SCs were free of any complication over zirconia-ceramic implant-supported SCs cover most SC
the entire 5-year observation period.1 The most frequent cases, both in the anterior and posterior areas. Zirconia-
complications reported for SCs were peri-implantitis and ceramic is mainly used in combination with CAD/CAM
soft tissue complications (5.3%), marginal bone loss technology, and standardized or customized abutments
more than 2 mm (4.3%), ceramic fractures or chipping can be used as support (Fig 7).

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 Pjetursson et al

Fig 8   Monolithic zirconia implant-supported

three-unit FDP.

Today, implant-supported zirconia-ceramic FDPs that translucency. This must always be considered when clini-
are conventionally veneered cannot be considered the cal indications are recommended. Five factors must be
material of first priority due to the pronounced risk for considered when choosing between veneered or mono-
fractures of the framework and catastrophic fracture of lithic zirconia restorations: (1) esthetic requirements; (2)
the veneering material, leading to loss of the restoration. position in the dental arch; (3) material-specific limita-
Moreover, chipping of the zirconia ceramic veneer has tions; (4) possibility for surface modification; and (5)
been a frequently reported problem since the introduc- abrasion/wear properties.
tion of veneered zirconia-based restorations.17 Studies
on implant-supported zirconia FDPs have reported ce- Reinforced Glass-Ceramic Implant-Supported
ramic fracture and chipping rates up to 50%.18 Further Restorations
developments of the zirconia ceramic veneers and of the To influence the strength, thermal expansion, and con-
veneering procedures have helped to lower the initially traction behavior of glass-ceramic, crystalline fillers
high incidences of chipping. The remaining problem is such as leucite or lithium have been added.20 Today the
the predominant technical complications associated with main filler material is lithium forming a crystalline phase
veneered zirconia restorations. Recently, however, more (lithium disilicate, Li2Si2O5), which makes up about 70%
translucent and/or colored types of zirconia ceramics of the volume of the glass-ceramic. Lithium disilicate–
were introduced, reducing the need for ceramic veneer- reinforced glass-ceramic restorations can be produced
ing. When using zirconia as a monolithic restoration, the with heat pressing, which is performed in an investment
weakest link of the traditional restoration—the ceramic mold, or with computer-aided milling from prefabricated
veneer—is eliminated. Furthermore, the diameter of lithium disilicate blanks. Glass-ceramic reinforced with
the monolithic framework has pronounced dimensions, lithium or leucite fillers has been used for manufactur-
reducing the risk for ceramic chipping and framework ing both implant-supported SCs and short-span FDPs.
fracture. Hence, monolithic zirconia FDPs are a promis- A recent systematic review19 evaluated the survival
ing alternative to veneered implant-supported zirconia- and complication rates of monolithic and veneered
ceramic FDPs (Fig 8). Unfortunately, literature on this reinforced glass-ceramic implant-supported SCs. Of
topic is still scarce. the included studies, 5 reported on veneered leucite
A more recent systematic review19 evaluated the or lithium disilicate–reinforced glass-ceramic implant-
3-year survival and complication rates of veneered and supported SCs (n = 110) and 14 on monolithic leucite
monolithic zirconia-ceramic implant-supported SCs. The or lithium disilicate–reinforced glass-ceramic implant-
survival rates of veneered and monolithic zirconia crowns supported SCs (n = 484). The mean follow-up time for
were similar, but the incidence of failure due to core the veneered crowns was 8.1 years, compared to 2.6
fractures or catastrophic veneer fractures was higher for years for the monolithic crowns. The annual failure rate
the veneered zirconia SCs. Furthermore, the incidence was estimated at 0.80% (95% CI: 0.14% to 4.64%) for
of ceramic chipping was also higher for the veneered the veneered and reinforced glass-ceramic crowns and
zirconia SCs. at 1.02% (95% CI: 0.51% to 2.05%) for the monolithic
The mechanical stability of translucent and shaded reinforced glass-ceramic crowns, translating into respec-
zirconia differs significantly between the grades of tive 3-year survival rates of 97.6% and 97.0% (Table 1).

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 EAO Position Papers

Fig 9  Monolithic reinforced glass-ceramic

SC cemented extraorally to a titanium base
abutment.

Fig 10   Comprehensive prosthetic planning

allows for the screw access holes to be posi-
tioned in the center of the occlusal surfaces.

The review19 also compared the overall complication Considering the available evidence, veneered or mono-
rates of different types of ceramic implant-supported SCs lithic reinforced glass-ceramic cannot be recommended
and concluded that monolithic reinforced glass-ceramic for implant-supported multiple-unit FDPs, as they suffer
crowns had the lowest annual complication rate (1.7%), from high rates of framework fracture.
with veneered reinforced glass-ceramic crowns the sec-
ond lowest (2.6%), compared to an annual complication Titanium-Base Abutment Concept
rate of 3.6% for monolithic zirconia SCs and 4.5% for Traditionally, implant-supported restorations are either
veneered zirconia-ceramic implant-supported SCs. The screw retained directly onto the implant or through an
respective annual complication rate for metal-ceramic intermediate abutment, or they are cemented intra-
implant-supported SCs was 2.7%.1 orally onto standardized or customized abutments. 21
In conclusion, the clinical indications for veneered or Current evidence demonstrates that screw-retained
monolithic reinforced glass-ceramic implant-supported restorations have a lower risk of developing biologic
SCs are similar to those for zirconia-ceramic crowns or complications (eg, marginal bone loss or peri-implant
most single-unit situations located in the anterior and disease) and therefore should be preferred over intra-
posterior areas (Fig 9). The main disadvantage of rein- orally cemented restorations. 21,22 Furthermore, the
forced glass-ceramic implant-supported SCs is that the retrievability of the restoration makes the handling
prefabricated ceramic blanks have integrated titanium of complications easier if they do occur. To allow for
base abutments, which does not allow the flexibility of a screw retention and to achieve a reasonable clinical
preferred abutment choice by the clinician, and that the outcome, comprehensive prosthetic planning is man-
heat-pressed manufacturing procedure does not allow datory, followed by a correct 3D implant position and
for the full benefits of the CAD/CAM manufacturing axis (Fig 10).
procedure.

14 The International Journal of Prosthodontics

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 Pjetursson et al

The development of titanium base abutments allows lithium disilicate, implant-supported crowns cemented
for full utilization of the digital workflow producing to titanium base abutments was influenced by different
implant-supported restorations. Different titanium base types of cement.37 More opaque cements led to less
abutment configurations are available according to each discoloration for both APA and non-APA abutments.
clinical indication, and this configuration is usually in- Hence, the application of an opaque resin cement is rec-
tegrated into the milling program. These prefabricated ommended for good esthetic outcomes. For the titanium
titanium base abutments appear to be a promising solu- base concept, appropriate pretreatment of the different
tion, as they combine a metallic implant connection with ceramics and the titanium-base abutment before the
a ceramic outer part, thereby offering good esthetics adhesive cementation is crucial for the bond strength
and mechanical stability at the same time.23–25 Follow- values. Following manufacturer recommendations is
ing a digital workflow, the monolithic restoration can be crucial for achieving good outcomes.
designed, milled, and adhesively cemented to the tita-
nium base abutment extraorally and then directly screw CONCLUSIONS
retained to the implant as a conventional one-piece,
screw-retained restoration.26–28 This type of restoration This position paper presents the current state of the art
has shown positive results in laboratory and short-term regarding the selection of restorative materials and op-
clinical investigations.23,29,30 tions for fixed implant restorations. As this specific area
Different configurations of titanium base abutments of prosthodontics is evolving fast, numerous studies
are available from different manufacturers according to evaluating different material options in implant prosth-
the indication, whether for single-unit or multiple-unit odontics are currently performed worldwide, and future
restorations. Cylindrical titanium base abutments should consensus meetings will refine the present recommenda-
be preferred to conical for both SCs and FDPs, as resto- tions. The EAO will therefore regularly publish update
rations supported by conical abutments have a higher position papers on relevant clinical subjects.
risk of debonding compared to cylindrical ones.31 This,
however, requires better 3D treatment planning and ACKNOWLEDGMENTS
relatively parallel placement of the supporting implants.
Notwithstanding all advantages of the titanium base The authors report no conflicts of interest.
abutment concept, its success is highly dependent on
the bonding stability between the titanium base and REFERENCES
the ceramic components. It has been shown that there
is a significant risk of incomplete cementation, partial 1. Pjetursson BE, Valente NA, Strasding M, Zwahlen M, Liu S, Sailer I. A sys-
tematic review of the survival and complication rates of zirconia-ceramic
decementation, or degradation of the cement, which and metal-ceramic single crowns. Clin Oral Implants Res 2018;29(suppl
could lead to microleakage, increased plaque accumula- 16):199–214.
tion, and peri-implant infections, especially when the ce- 2. Sailer I, Strasding M, Valente NA, Zwahlen M, Liu S, Pjetursson BE. A
systematic review of the survival and complication rates of zirconia-
ment gap is placed deeply under the mucosal margin.32 ceramic and metal-ceramic multiple-unit fixed dental prostheses. Clin
Hence, the position of the cementation margin and a Oral Implants Res 2018;29(suppl 16):184–198.
proper cementation protocol when using the titanium 3. Sailer I, Fehmer Vincent, Pjetursson B. Fixed Restorations: A Clinical
Guide to the Selection of Materials and Fabrication Technology. Berlin:
base abutment concept are crucial. In order to achieve Quintessesce, 2021.
a high and durable adhesive retention, several surface 4. Filser F, Kocher P, Weibel F, Lüthy H, Schärer P, Gauckler LJ. Reliability and
pretreatments have been proposed. Considering the strength of all-ceramic dental restorations fabricated by direct ceramic
machining (DCM). Int J Comput Dent 2001;4:89–106.
outcomes of studies, airborne particle abrasion (APA) of 5. Zhang Y, Lawn BR. Novel zirconia materials in dentistry. J Dent Res
titanium base abutments with 50-μm aluminum oxide 2018;97:140–147.
is recommended. Besides pretreatment of the titanium 6. Joda T, Brägger U. Time-efficiency analysis of the treatment with mono-
lithic implant crowns in a digital workflow: A randomized controlled trial.
base abutment, selection of the resin cement also plays Clin Oral Implants Res 2016;27:1401–1406.
a crucial role in clinical success with the titanium base 7. Sailer I, Benic GI, Fehmer V, Hämmerle CHF, Mühlemann S. Random-
abutment concept. It has been reported that titanium ized controlled within-subject evaluation of digital and conventional
workflows for the fabrication of lithium disilicate single crowns. Part II:
abutments can cause a change in the color appearance CAD-CAM versus conventional laboratory procedures. J Prosthet Dent
of the peri-implant mucosa, especially in a clinical situ- 2017;118:43–48.
ation with a mucosa thickness of 2 mm or less.33–36 8. Freire Y, Gonzalo E, Lopez-Suarez C, Suarez MJ. The marginal fit of CAD/
CAM monolithic ceramic and metal-ceramic crowns. J Prosthodont
The abutment color can also influence the color of the 2019;28:299–304.
ceramic restoration, depending on the ceramic thickness. 9. Lopez-Suarez C, Gonzalo E, Pelaez J, Serrano B, Suarez MJ. Marginal
It is reasonable to speculate that the cement bonding a vertical discrepancies of monolithic and veneered zirconia and metal-
ceramic three-unit posterior fixed dental prostheses. Int J Prosthodont
ceramic restoration to a titanium base abutment could 2016;29:256–258.
also contribute to the color outcome. A recent in vi-
tro study showed that the color outcomes of ceramic,

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 EAO Position Papers

10. Zeltner M, Sailer I, Mühlemann S, Özcan M, Hämmerle CH, Benic GI. 24. Sailer I, Asgeirsson AG, Thoma DS, et al. Fracture strength of zirconia
Randomized controlled within-subject evaluation of digital and conven- implant abutments on narrow diameter implants with internal and ex-
tional workflows for the fabrication of lithium disilicate single crowns. ternal implant abutment connections: A study on the titanium resin base
Part III: Marginal and internal fit. J Prosthet Dent 2017;117:354–362. concept. Clin Oral Implants Res 2018;29:411–423.
11. Denry I, Kelly JR. State of the art of zirconia for dental applications. Dent 25. Pitta J, Hicklin SP, Fehmer V, Boldt J, Gierthmuehlen PC, Sailer I. Me-
Mater 2008;24:299–307. chanical stability of zirconia meso-abutments bonded to titanium bases
12. Guazzato M, Albakry M, Ringer SP, Swain MV. Strength, fracture tough- restored with different monolithic all-ceramic crowns. Int J Oral Maxil-
ness and microstructure of a selection of all-ceramic materials. Part II. lofac Implants 2019;34:1091–1097.
Zirconia-based dental ceramics. Dent Mater 2004;20:449–456. 26. Joda T, Brägger U. Complete digital workflow for the production of
13. Guazzato M, Proos K, Quach L, Swain MV. Strength, reliability and implant-supported single-unit monolithic crowns. Clin Oral Implants Res
mode of fracture of bilayered porcelain/zirconia (Y-TZP) dental ceramics. 2014;25:1304–1306.
Biomaterials 2004;25:5045–5052. 27. Kurbad A, Kurbad S. CAD/CAM-based implant abutments. Int J Comput
14. Guazzato M, Quach L, Albakry M, Swain MV. Influence of surface and Dent 2013;16:125–141.
heat treatments on the flexural strength of Y-TZP dental ceramic. J Dent 28. Reich S. Tooth-colored CAD/CAM monolithic restorations. Int J Comput
2005;33:9–18. Dent 2015;18:131–146.
15. Studart AR, Filser F, Kocher P, Gauckler LJ. In vitro lifetime of dental 29. Elsayed A, Wille S, Al-Akhali M, Kern M. Effect of fatigue loading on
ceramics under cyclic loading in water. Biomaterials 2007;28:2695–2705. the fracture strength and failure mode of lithium disilicate and zirconia
16. Studart AR, Filser F, Kocher P, Lüthy H, Gauckler LJ. Mechanical and implant abutments. Clin Oral Implants Res 2018;29:20–27.
fracture behavior of veneer-framework composites for all-ceramic dental 30. Stimmelmayr M, Heiss P, Erdelt K, Schweiger J, Beuer F. Fracture
bridges. Dent Mater 2007;23:115–123. resistance of different implant abutments supporting all-ceramic single
17. Heintze SD, Rousson V. Survival of zirconia- and metal-supported crowns after aging. Int J Comput Dent 2017;20:53–64.
fixed dental prostheses: A systematic review. Int J Prosthodont 31. Calderon U, Hicklin S, Mojon P, et al. The influence of the titanium base
2010;23:493–502. abutment design on monolithic zirconia multiple-unit implant fixed den-
18. Larsson C, Vult von Steyern P. Ten-year follow-up of implant-supported tal prostheses: A laboratory study. Int J Oral Maxillofac Implants. In press.
all-ceramic fixed dental prostheses: A randomized, prospective clinical 32. Mattheos N, Vergoullis I, Janda M, Miseli A. The implant supracrestal
trial. Int J Prosthodont 2016;29:31–34. complex and its significance for long-term successful clinical outcomes.
19. Pjetursson BE, Sailer I, Latyshev A, Rabel K, Kohal RJ, Karasan D. A Int J Prosthodont 2021;34:88–100.
systematic review and meta-analysis evaluating the survival, the failure 33. Happe A, Schulte-Mattler V, Fickl S, Naumann M, Zöller JE, Rothamel D.
and the complication rates of veneered and monolithic all-ceramic Spectrophotometric assessment of peri-implant mucosa after restoration
implant-supported single crowns. Clin Oral Implants Res 2021;32(suppl with zirconia abutments veneered with fluorescent ceramic: A con-
21):254–288. trolled, retrospective clinical study. Clin Oral Implants Res 2013;24(suppl
20. Kelly JR, Denry I. Stabilized zirconia as a structural ceramic: An overview. A100):28–33.
Dent Mater 2008;24:289–298. 34. Jung RE, Holderegger C, Sailer I, Khraisat A, Suter A, Hämmerle CH.
21. Staubli N, Walter C, Schmidt JC, Weiger R, Zitzmann NU. Excess cement The effect of all-ceramic and porcelain-fused-to-metal restorations on
and the risk of peri-implant disease—A systematic review. Clin Oral marginal peri-implant soft tissue color: A randomized controlled clinical
Implants Res 2017;28:1278–1290. trial. Int J Periodontics Restorative Dent 2008;28:357–365.
22. Sailer I, Mühlemann S, Zwahlen M, Hämmerle CH, Schneider D. Cement- 35. Lops D, Stellini E, Sbricoli L, Cea N, Romeo E, Bressan E. Influence of
ed and screw-retained implant reconstructions: A systematic review of abutment material on peri-implant soft tissues in anterior areas with thin
the survival and complication rates. Clin Oral Implants Res 2012;23(suppl gingival biotype: A multicentric prospective study. Clin Oral Implants Res
6):163–201. 2017;28:1263–1268.
23. Joda T, Ferrari M, Brägger U. Monolithic implant-supported lithium 36. Thoma DS, Brandenberg F, Fehmer V, Knechtle N, Hämmerle CH, Sailer
disilicate (LS2) crowns in a complete digital workflow: A prospec- I. The esthetic effect of veneered zirconia abutments for single-tooth im-
tive clinical trial with a 2-year follow-up. Clin Implant Dent Relat Res plant reconstructions: A randomized controlled clinical trial. Clin Implant
2017;19:505–511. Dent Relat Res 2016;18:1210–1217.
37. Liu X, Fehmer V, Sailer I, Mojon P, Liu F, Pjetursson BE. Influence of dif-
ferent cements on the color outcome of titanium-based lithium disilicate
all-ceramic crowns and the peri-implant soft tissue. Int J Prosthodont
2020;33:63–73.

Literature Abstract

Two Short Implants Versus One Short Implant with a Cantilever: 5-year Results of a Randomized Clinical Trial
The aim of this study (ClinicalTrials.gov: NCT01649531) was to test whether the use of a short implant with a cantilever results in similar
clinical and radiographic outcomes when compared to two adjacent short implants with single-tooth restorations. A total of 36 patients
with two adjacent missing teeth in the posterior region were randomly assigned to receive either a single 6-mm implant with a cantilever
(ONE-C) or two 6-mm implants (TWO). Fixed reconstructions were inserted 3 to 6 months after implant placement, and patients were
re-examined at up to 5 years (FU-5). A total of 26 patients were available for re-examination at FU-5. The survival rate amounted to 84.2%
in ONE-C and to 80.4% in TWO (intergroup P = .894). Technical complication rates amounted to 64.2% in ONE-C and to 54.4% in TWO
(intergroup P = 1.000). From baseline to FU-5, the median changes of the marginal bone levels were 0.13 mm in ONE-C and 0.05 mm
in TWO (intergroup P = .775). Probing depth, bleeding on probing, and plaque control record values showed no significant differences
between the two treatment modalities (P > .05). Short implants with a cantilever rendered similar clinical and radiographic outcomes
compared to two adjacent short implants at 5 years; however, they tended to fail at earlier time points, suggesting an overload of the
implants. Considering the modest survival rates, the clinical indication of either treatment option needs to be carefully evaluated.
Thoma DS, Wolleb K, Schellenberg R, Strauss FJ, Hämmerle CHF, Jung RE. J Clin Periodontol 202;48:1480–1490. References: 44. Reprints: Daniel
Thoma, [email protected] —Diana Rodriquez, Colombia

16 The International Journal of Prosthodontics

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