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Dental implants CLINICAL

One-piece versus two-piece ceramic dental implants

Curd Bollen,*1 Gagik Hakobayan2 and Martin Jörgens3,4

Key points
Ceramic implants are a valuable One-piece zirconia implants can be Abutments of two-piece ceramic Zirconia implants offers the
alternative for titanium implants. restored as natural teeth. implants can be attached with teflon, solution for patients requesting a
titanium, gold or ceramic screws. complete metal-free restoration.

Abstract
In this narrative review, a structured comparison between one-piece and two-piece zirconia dental implants is
highlighted. Ceramic dental implants have long ceased to be hype; on the contrary, they can offer a significant
addition to the daily dental implant practice. Not only do their favourable aesthetics play a significant role, but their
ability to work completely metal-free is of added value, particularly for patients with a proven allergy for Grade 5
titanium. Furthermore, the fact that peri-implantitis seems to appear only incidentally is an important supporting
argument for their use as well. Whereas the original design of zirconia implants was formerly always of a one-piece/
one-phase structure (the monobloc design), nowadays, two-piece/two-phase designs (the so-called hybrid concept)
are also widely utilised to restore missing teeth. Both concepts have advantages and disadvantages, scientifically as
well as clinically.
For this paper, relevant articles from the recent scientific literature were selected from PubMed. The aim was to
identify and summarise what has previously been published on one-piece versus two-piece ceramic implants. This
article will compare the benefits and drawbacks of one-piece versus two-piece ceramic implants based on clinical-
(design, different sizes, surgical protocol, prosthetics), scientific- (loading and eventual complications) and patient-
related (costs and long-time perspectives) criteria.

Introduction the past, ceramic implants were predominantly showing post-op allergy compatible responses
made of aluminium oxide (Al2O3), which was (allergic symptoms after implant placement or
In the dental implant community, there is still a far too brittle material for oral rehabilitation, unexplained implant failures).8
a lot of discussion on the place of ceramic leading to multiple implant fractures, causing a These implants also have a lower thermal
dental implants in the rehabilitation of (partial) widespread rejection in their application, and conductivity compared to metal implants,
edentulous patients. A majority still considers to a global stigmatisation of ceramic dental which can reduce sensitivity and discomfort
zirconia implants as a transient phenomenon, implants.3 in the mouth, often experienced as unpleasant
whereas others consider it as the ultimate Recently, ceramic dental implants are by the patient.9
breakthrough in implant dentistry.1 becoming increasingly popular again due to Whereas ceramic implants are still relatively
Ceramic dental implants are a relatively new their aesthetic appeal and biocompatibility.4,5 new, research has shown promising results in
type of dental implant made from the ceramic Unlike traditional titanium implants, ceramic terms of their long-term success rates and
material zirconia (zirconium dioxide [Zro2]).2 In implants have a whitish colour, making them durability.
virtually indistinguishable from natural teeth, The choice between a one-piece/one-phase
1
Professor, Ulster University, College of Medicine and
especially when the patient presents with a thin implant versus a two-piece/two-phase implant
Dentistry, Birmingham, UK; 2Professor and Head of gingival biotype.6 In such cases, the hint of grey is a more recent phenomenon. At the early days
Department of Oral and Maxillofacial Surgery, Yerevan
titanium in combination with a high smile line of ceramic dental implants, all these implants
State Medical University after Mkhitar Heratsi, Yerevan,
Armenia; 3Professor, University of Sevilla, Spain; 4MUHAS is an aesthetic letdown. were produced as a monobloc, that is, an
University, Dar es Salaam, Tanzania. Additionally, ceramic implants are implant with an integrated abutment (Fig. 1).10
*Correspondence to: Curd Bollen
Email address: [email protected] hypoallergenic, making them a suitable On one-piece/one-phase implants, there
Refereed Paper.
option for patients with metal allergies.7 are more studies published since they have
Submitted 10 June 2023 Titanium allergy can be detected in dental already been on the market much longer. In
Revised 5 September 2023 implant patients, even though its estimated the seventies, Sammy Sandhaus and Thomas
Accepted 18 September 2023 prevalence is quite low (0.6%). A higher risk of Driskell were publishing groundbreaking
https://doi.org/10.1038/s41415-024-7123-3
positive allergic reaction was found in patients work. Both proved separately the great

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 CLINICAL Dental implants

opportunities of working with ceramic one-

piece implants.11,12
Only more recently have two-piece/two-
phase ceramic implants entered the dental
implant market (Fig. 2, Table 1).
Due to their later release on the market,
these two-piece/two-phase implants have less
scientific data available and the existing data
span up to ten years.13,14 Although the medium-
term results are excellent after 5–6 years, the
German Society for Implantology made a
warning in their recent S3 guideline.15,16 Thiem
and co-workers confirm the feasible use of
one-piece zirconia implants as an addendum/
alternative to titanium implants. However, no
conclusion regarding the application of two-
piece ceramic implant systems can be drawn
based on the existing data. So, they suggest
recommending these implants only after the
patient has been informed in detail about the
Fig. 1 a, b) One-piece ceramic dental implants (Z-Systems: Z5m & Z5mt, Oesingen, Switserland)
lack of long-term clinical data.

Criteria

Based on eight different criteria, the differences,

and advantages/disadvantages between one-
piece and two-piece ceramic dental implants
will be discussed.

Design
With a one-piece implant, the implant and the
abutment are fused to one simple monobloc.
Therefore, there can’t be any bacterial leakage
between the implant and the abutment because
there is no joint as with the two-piece implants,
where there is always a gap detected between
the implant and the abutment.17 This means
furthermore that the temporary or final crown
must ultimately be cemented on top of the
implant. There is a wide range of these implants
commercially available (Table 2). Fig. 2 a, b) Two-piece ceramic dental implants (Z-Systems: Z5-TL & Z5-BL, Oesingen, Switserland)
The more complex two-piece implants
consist of two or three parts: the implant body
itself, the abutment, and the abutment retention Considering the design, there are parallel one-piece implants, a flapless approach can be
screw. In case of a cementable abutment, there and tapered implants available. Most of the appropriate. The flapless technique for one-
is, of course, no abutment screw. The retention implants are not self-tapping. Therefore, in piece implants shows, however, statistically
screw can be fabricated out of titanium, gold, almost all situations, bone tapping is advised significantly more bone loss, which might be
carbon, or zirconia. If the patient wants a before implant installation. indicative for future problems.18
complete metal-free restoration, an internal For the two-piece implants, there is a large Only in a two-stage approach for two-
ceramic abutment screw is required (Fig. 3). variety of internal connections. Not every piece implants is a second surgery necessary,
It is important to follow the manufacturers‘ connection offers the same stability. An internal connecting the healing abutment to the
instructions for applying correct torque on conical connection with anti-rotational apex is implant. Healing abutments are mostly made
these screws: titanium screw is 25 Ncm; carbon preferred (Fig. 4). from PEEK (polyetheretherketone) or PEKK
screw is 25 Ncm; zirconia screw is 12 Ncm; and (polyetherketoneketone).
gold screw is 15 Ncm. Currently, there are only Surgery Because it is not always allowed to prep one-
a limited number of two-piece implants on the The first-stage surgical procedure for both piece zirconia implants (always carefully look
dental market (Table 2). implant types is identical, although for at the manufacturer recommendations), their

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Table 1 Detailed overview of the two-piece/two-phase ceramic implants and their

components

Brand Product Cemented Screwed Screw

Z-Systems Z5-BL/Z5-TL No Yes Ceramic or titanium

Zeramex XT/P6 No Yes Carbon

Nobel Biocare NobelPearl No Yes Carbon

Straumann Pure No Yes Titanium

Zircon Medical Patent Yes No -

WITAR AWI No Yes Direct*

Neodent Zi No Yes Titanium

Camlog Ceralog No Yes Titanium or gold

SDS Swiss Dental Solutions Bright/Value Yes Yes Peek or titanium

TAV Dental W No Yes Titanium
Key:
* = Ceramic abutment directly screwed into the implant (no additional screw)

Table 2 Overview of one-piece and two-piece ceramic dental implants

One-piece ceramic implants Two-piece ceramic implants Fig. 3 Ceramic abutment screw (Z-Systems,
Oesingen, Switserland)
Z-Systems: Z5m/Z5m(t) Z-Systems: Z5-BL/Z5-TL

Straumann: Pure Monotype Straumann: Pure

Camlog: Ceralog Monobloc Camlog: Ceralog Hexalobe

Zircon Medical: Patent one-piece Zircon Medical: Patent two-piece

SDS Swiss Dental Solutions: Bright SDS Swiss Dental Solutions: Bright/Value

TAV Dental: W-1 TAV Dental: W-2

WITAR: AWI one-piece WITAR: AWI two-piece

ZiBone ZiBone

Medical Instinct: BoneTrust Neodent: Zi

Fair Implant: Fair White Zeramex: XT/P6

CeraRoot Nobel Biocare: NobelPearl

Tree-Oss Ceramic SIC invent: SICwhite

Bredent: WhiteSKY

immediate correct surgical positioning is of lead to implant failure but induces significant
utmost importance.19 crestal bone loss during healing and a final Fig. 4 Conical internal connection with anti-
Therefore, it can be advantageous to initially lower percentage of bone-to-implant contact.22 rotational apex (BL, Z-Systems, Oesingen,
use guided surgery for these procedures, These drilling speeds start around 800 rpm for Switserland)
helping to avoid incorrect inclination of the the first drills, reducing to 400 rpm for the last
abutment component of the implant.20 For two- drills. The advised tapping for D1–D2 (and
piece implants this problem is less significant D3) bone should be performed at 15 rpm.23 It direct loading.24 Therefore, delayed, or late
since most commercial brands offer angulated is of utmost importance to check the individual loading are mostly recommended for two-
or preparable abutments in their portfolio. recommendations of the manufacturer before piece implants. Moreover, in the anterior
Whether one-piece or two-piece implants are using the respective drill sequences. aesthetic area, a two-phase technique can help
installed, low drilling speeds should always be to improve the gingival aesthetic outcome, as
applied, assuredly when ceramic implant drills Loading shown by Suchetha and co-workers.25
are applied. Drills made of ceramics do not Since for ceramic implants bone tapping is One-piece implants are, due to their design,
conduct the warmth, leading to overheating of almost always utilised, the primary stability directly loaded. To reduce these immediate
the bone in the osteotomy.21 The latter doesn’t of these implants is often insufficient for loading forces, most brands offer silicone

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or PEEK protection caps to place over the

abutment after installing the implant. These
shock absorbers also protect against gingival
overgrowth during the required healing time
(Fig. 5).

Prosthetics
The prosthetic procedure of a one-piece implant
is almost completely identical to the prosthetic
process for natural teeth. Both analogue and
digital impressions are possible. Due the high
affinity of the soft tissue towards zirconia, often, Fig. 5 PEEK protection caps for one-piece implant (Z-Systems Z5m, Oesingen, Switserland)
excess gingiva must be controlled by retraction
cords or (diode) laser.26 Implant analogues are Table 3 Range in diameters and lengths of different commercially available ceramic
not really required in this method. dental implant systems
For two-piece implants, the procedures are
Brand Range of diameters Range of lengths
identical as for titanium two-piece implants:
analogue or digital impressions; open or closed Z-Systems 3.6–5 mm 8–12 mm
tray. Different brand-related scan bodies are Zeramex 3.5–5.5 mm 8–14 mm
available and here an implant analogue is
Straumann 3.3–4.8 mm 8–14 mm
always needed for the further laboratory
handling. It is still of the highest importance Nobel Biocare 3.5–5.5 mm 8–14 mm
to use the original components, delivered by Camlog 4 mm 8–12 mm
the respective manufacturers, since printing
Zircon Medical 4.1–5 mm 7–13 mm
of these individual components does not yet
offer the same accuracy.27 SDS Swiss Dental Solutions 3.2–7 mm 6–17 mm

TAV Dental 3.6–4.8 mm 8–14 mm

Sizes
Bredent 3.5–4.5 mm 8–16 mm
The offer in diameters and lengths is rather
limited for one-piece compared to two-piece ZiBone 3.6–5 mm 8–14.5 mm
ceramic implants, but there is no structural
Tree-Oss 3.7–4.3 mm 10–13 mm
difference in portfolio between both types of
implants: sizes are similar. Table 3 shows the CeraRoot 3.5–6.5 mm 8–14 mm
ranges in diameters and lengths of the actual Neodent 3.75–4.3 mm 10–13 mm
most commonly used ceramic dental implants.
WITAR 3.9–6 mm 8–14 mm
The available diameter ranges from 3.3
(Straumann) to 7 mm (SDS). The lengths range Fair Implant 3.5–5 mm 8–13 mm
from 6 mm (SDS) to 16 mm (Bredent). The Medical Instinct 4–5 mm 10–13 mm
average diameter is 4.2 mm and the average
SIC invent 3.5–5.5 mm 8–14 mm
length is 10.8 mm. With these sizes, almost all
indications are properly covered.
Complications can remain present subgingivally. These
Costs The main complication for oral implants is the toxic cement rests can easily induce peri-
The use of one-piece implants is relatively absence or lack of osseointegration. With the implantitis. 30 Therefore, the meticulous
less expensive since there is only need for a actual ceramic materials, the success rates of removal of all excess cement after cementation
full ceramic crown that can be cemented on zirconia implants are comparable with those of the crown is of utmost importance.31
top of the implant-abutment complex. For of titanium implants. After all, zirconia and As mentioned before, the incorrect positioning
two-piece implants there is always the need titanium implants show a similar soft and (that is, inclination) of a one-piece implant that
for extra components: ceramic abutments hard tissue integration capability. Titanium, may not be ground post-operatively is a major
and abutment retention screws. These extra however, tends to demonstrate an accelerated problem. Here, the only solution is explantation.
components mean not only an extra cost in initial osseointegration compared to zirconia. Two-piece ceramic implants can offer different
their purchase from the manufacturer, but It is meanwhile also clear that zirconia implants complications. Abutment screw loosening
also an extra cost in the laboratory handling, do not show better clinical results as titanium and abutment screw fracture are the main
making the final cost of a two-piece ceramic implants.28,29 So both systems seem to have problems.32 Therefore, it is essential to apply the
implant substantially higher. The latter is the comparable clinical outcomes. exact prescribed torque value when installing the
case for all brands who offer both one-piece With one-piece implants, the cementation abutment or the crown. The more components
and two-piece zirconia implants. of the crown can cause cement rests that used, the higher the risk for complications.

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As far as scientific literature is concerned, Ethics declaration 18. Bömicke W, Gabbert O, Koob A, Krisam J, Rammelsberg
P. Comparison of immediately loaded flapless-placed
there seems to be less peri-implantitis There are no conflicts of interest. None of the authors one-piece implants and flapped-placed conventionally
around ceramic in comparison with titanium received funding from any company mentioned in loaded two-piece implants, both fitted with all-ceramic
single crowns, in the posterior mandible: 3-year results
implants. 33,34 A peer explanation on this this article. None of the authors holds a consultation from a randomised controlled pilot trial. Eur J Oral
phenomenon is still awaited. Although there or advisory position in any company mentioned in Implantol 2017; 10: 179–195.
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