Professional perspective
Clinical relevance
- Patient counseling when a ceramic restoration is desired or titanium intolerance is suspected
- Differentiating between implant body, abutment, and crown when addressing material inquiries
- Framing the growing but still smaller data on two-piece systems within case planning
- Realistic framing of commercial claims about ‘bioactive’ or ‘metal-free’ implant systems
Material and classification
Many clinically used zirconia implants are made of yttria-stabilized tetragonal polycrystalline zirconia (Y-TZP); material composition and generation can vary by system, however. The German S3 guideline on the use of dental ceramic implants (Thiem et al., 2022; German Society of Implantology, DGI) recognizes zirconia implants as a clinically usable alternative to titanium while emphasizing limitations in the long-term evidence base, particularly for two-piece implant systems.
As an oxide ceramic, zirconia does not undergo the same electrochemical corrosion processes as metallic implant materials. Its long-term behavior is instead influenced by other material-dependent processes, including surface changes, hydrothermal aging, and mechanical fatigue.
Clinical survival data
A systematic review with meta-analysis (Roehling, Gahlert, Bacevic, Woelfler, Laleman, 2023), part of the proceedings of the Seventh ITI Consensus Conference, identified six clinical cohort studies (four prospective, two retrospective) with at least five years of follow-up. The meta-analysis found a mean implant survival rate of 97.2% at five years (range 93.8-100%; 95% CI 94.7-99.1%), a mean marginal bone loss of 1.1 mm, and a mean probing depth of 3.0 mm; these figures fall within the range of published titanium values, but are based on an indirect comparison with published titanium data rather than an extensive body of direct head-to-head studies. At the time of this review, robust conclusions related predominantly to one-piece zirconia implants for single crowns and three-unit bridges.
A prospective multicenter study published in 2026 (Roehling, Bormann, Bornstein, Laval, Thieringer, Gahlert, 2026) investigated the long-term performance of a commercially available one-piece zirconia implant system (Y-TZP, sandblasted and acid-etched surface) at three clinical centers in Germany over ten years. Of the original 44 patients with 44 implants, 35 patients with 35 implants were available for evaluation after ten years. The estimated ten-year survival rate was 97.7% (95% CI 97.27-98.13%); in addition to survival and success rates and peri-implant bone levels, esthetic outcomes were also assessed using the Pink Esthetic Score (PES) and White Esthetic Score (WES). This study thus provides prospective multicenter ten-year data for a commercially available one-piece zirconia system, but relates to a limited cohort size and a single implant system; broad generalizability to other systems, surfaces, and particularly two-piece configurations cannot be drawn from it.
A systematic review (Bazal-Bonelli, Castro-Janeiro, Ríos-Barbero, Cano Sánchez de Tembleque, López-Quiles, Meniz-García, Cortés-Bretón Brinkmann, 2025) specifically evaluated two-piece zirconia implants: six studies covering a total of 298 implants, with follow-up periods averaging roughly 18 to over 111 months, found a survival rate of 96.3%. These data point to an encouraging development for two-piece systems; robust ten-year data on the scale of the newer one-piece study are not yet available for two-piece systems, however.
Earlier studies also show that material generation, manufacturing process, and surface modification can influence clinical outcomes. Results from one system therefore cannot automatically be transferred to all zirconia implants.
Implant body, abutment, and crown: a necessary distinction
For the correct interpretation of studies and patient inquiries, a strict distinction must be made between three levels: the zirconia implant body (anchored in bone), the zirconia abutment (transmucosal connecting component), and the zirconia crown (prosthetic restoration). Peri-implant parameters for zirconia versus titanium abutments may prove comparable; this is a separate question, however, independent of the implant body material itself. Many patients who speak of a ‘zirconia implant’ actually have a titanium implant with a zirconia abutment or crown.
Titanium intolerance as an indication
Where there is a well-founded clinical suspicion of a hypersensitivity reaction to components of a titanium-based system, a ceramic implant body can be considered. This choice does not replace structured dental or specialist diagnostic assessment, however; in addition, two-piece zirconia systems can contain additional metallic connecting or screw elements, which should be taken into account during counseling.
What current evidence supports
- Zirconia osseointegrates and functions clinically as an implant material
- High five-year survival rates across multiple independent cohorts, consistently in the range of published titanium figures
- Robust ten-year data for a one-piece system with a high survival rate (97.7%) from a prospective multicenter study
- Encouraging, growing evidence also for two-piece systems, though with smaller cohorts overall
Why this matters
A material can be a clinically valid alternative without having the same depth of evidence as the historical standard. Distinguishing ‘works clinically’ from ‘has an equally broad long-term evidence base’ prevents both unjustified skepticism and unjustified claims of equivalence.
What the data currently doesn't show
- Only limited direct long-term comparative data between zirconia and titanium implant bodies from head-to-head studies
- Despite a growing evidence base, still markedly fewer long-term studies on two-piece zirconia implants; longer observation periods have been reported for individual systems, but the cohorts are small, and the evidence base overall remains considerably narrower than for one-piece systems or titanium
- No sufficient clinical evidence for generally lower biofilm accumulation or a reduced peri-implantitis risk compared to titanium across different surfaces and systems; corresponding in vitro and surface studies cannot be directly translated into clinical outcomes
- No sufficient transferability of results from individual systems and surfaces, including the new ten-year data, to zirconia implants in general
Evidence summary
Thiem, Stephan, Kniha, Kohal, Röhling, Spies, Stimmelmayr, Grötz (2022): German S3 guideline on the use of dental ceramic implants. International Journal of Implant Dentistry, 8, 43. German S3 guideline from the DGI; consensus recommendations on indication, material, and limitations of ceramic implants.
Roehling, Gahlert, Bacevic, Woelfler, Laleman (2023): Clinical and radiographic outcomes of zirconia dental implants, a systematic review and meta-analysis. Clinical Oral Implants Research, 34(Suppl 26), 112-124. Basis of the ITI consensus statements on survival rates and peri-implant parameters at five years.
Bazal-Bonelli, Castro-Janeiro, Ríos-Barbero, Cano Sánchez de Tembleque, López-Quiles, Meniz-García, Cortés-Bretón Brinkmann (2025): Clinical behavior of two-piece zirconia implants. A systematic review. Medicina Oral Patología Oral y Cirugía Bucal, 30(3), e313-e321. Recent review focused specifically on two-piece systems; supplements the limited data body from earlier consensus reports.
Roehling, Bormann, Bornstein, Laval, Thieringer, Gahlert (2026): Long-Term Clinical, Radiographic and Esthetic Outcomes of Zirconia Dental Implants, a 10-Year Prospective Multicenter Study. Clinical Oral Implants Research, 37(4), 439-452. Prospective multicenter study with robust ten-year data for a one-piece zirconia system; also captures esthetic outcomes (PES/WES).
