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Two-piece zirconia implant concepts are appropriate for clinical application

A review of the evaluation by ESCI of two-piece ceramic implant designs.

While the first generations of zirconia implants were limited to a one-piece design the preference for two-piece implants amongst clinicians has pushed the development also for two-piece ceramic designs. The European Society for Ceramic Implantology (ESCI) has recently reviewed the available scientific literature to evaluate the performance of the latest generation of two-piece ceramic implants in comparison with one-piece ceramic designs and with two-piece titanium designs.

The ESCI considered clinical studies evaluating

  • the survival rate and clinical data of two-piece implants,
  • the reliability and stability of screw-retained implant-abutment connections and
  • the usage in clinical applications.

Their conclusion:

“Based on the currently available scientific data, the two-piece zirconia implant concept can be recommended for clinical application after correct diagnostic evaluation and appropriate patient information.”

The authors of the statement rely on studies showing that Zirconia implant survival rates have significantly increased between 2004 and 20171. The fracture incidence of zirconia oral implants has significantly reduced from 3.4% to 0.2%. Commercially available zirconia implants show survival rates of 95% at a follow-up of 5 years. 2, 3, 4, 5, 6

No statistically significant differences were found regarding the reliability and stability of the implants. The two-piece zirconia implants have been proven to withstand clinically relevant masticatory forces.13-18 Also, one-piece and two-piece micro-roughened ceramic implant concepts showed a similar level of osseointegration to their titanium counterparts. 7,8-12 The results refer to individual evaluations of studies and implant systems, as the clinical outcome depends on the material used and the type of connection.

In some indications, two-piece implant designs offer distinct advantages, for example regarding prosthetic flexibility and “reversibility”. Additionally, depending on some individual clinical situations, the ESCI concluded that the use of a two-piece implant design is beneficial compared to a one-piece design. For example:

  • In a completely edentulous jaw
  • In soft bone conditions
  • When bone augmentations are performed simultaneously with implant placement
  • When primary implant stability is hard to achieve

Ultimately, two-piece implants offer the possibility of implant axis corrections with individually designed abutments.

The choice for a one- or two-piece implant depends mainly on the patients’ clinical situation. Overall, there seems to be a trend towards two-piece implant concepts, whether ceramic or titanium is used as implant material. The evaluation conducted by ESCI presents zirconia implants as a reliable alternative to titanium with comparable results in terms of survival rates, stability and osseointegration.  

At a glance

  • Two-piece zirconia implants offer advantages regarding prosthetic flexibility and clinical indications.
  • Two-piece zirconia implants withstand clinically relevant masticatory forces
  • Manufacturing processes, material properties, implant geometries and prosthetic connection concepts may influence the fracture resistance and the mechanical stability of two-piece implants
  • One- and two-piece zirconia implants show equal levels of osseointegration and biologic integrity.


Read the full statement here



1. Roehling S, Schlegel KA, 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.

2. Gahlert M, Kniha H, Weingart D, Schild S, Gellrich NC, Bormann KH. A prospective clinical study to evaluate the performance of zirconium dioxide dental implants in single-tooth gaps. Clin Oral Implants Res 2016;27:e176-e184.

3. Balmer M, Spies BC, Kohal RJ, Hammerle CH, Vach K, Jung RE. Zirconia implants restored with single crowns or fixed dental prostheses: 5-year results of a prospective cohort investigation. Clin Oral Implants Res 2020.

4. Kohal RJ, Spies BC, Vach K, Balmer M, Pieralli S. A Prospective Clinical Cohort Investigation on Zirconia Implants: 5-Year Results. J Clin Med 2020;9.

5. Grassi FR, Capogreco M, Consonni D, Bilardi G, Buti J, Kalemaj Z. Immediate occlusal loading of one-piece zirconia implants: five-year radiographic and clinical evaluation. Int J Oral Maxillofac Implants 2015;30:671-680.

6. Bormann KH, Gellrich NC, Kniha H, Schild S, Weingart D, Gahlert M. A prospective clinical study to evaluate the performance of zirconium dioxide dental implants in single-tooth edentulous area: 3-year follow-up. BMC Oral Health 2018;18:181.

7. Roehling S, Schlegel KA, Woelfler H, Gahlert M. Zirconia compared to titanium dental implants in preclinical studies-A systematic review and meta-analysis. Clin Oral Implants Res 2019;30:365-395.

8. Bormann KH, Gellrich NC, Kniha H, Dard M, Wieland M, Gahlert M. Biomechanical evaluation of a microstructured zirconia implant by a removal torque comparison with a standard Ti-SLA implant. Clinical oral implants research 2012;23:1210-1216.

9. Gahlert M, Roehling S, Sprecher CM, Kniha H, Milz S, Bormann K. In vivo performance of zirconia and titanium implants: a histomorphometric study in mini pig maxillae. Clin Oral Implants Res 2012;23:281-286.

10. Gahlert M, Roehling S, Wieland M, Sprecher CM, Kniha H, Milz S. Osseointegration of zirconia and titanium dental implants: a histological and histomorphometrical study in the maxilla of pigs. Clinical oral implants research 2009;20:1247-1253.

11. Gahlert M, Rohling S, Wieland M, Eichhorn S, Kuchenhoff H, Kniha H. A comparison study of the osseointegration of zirconia and titanium dental implants. A biomechanical evaluation in the maxilla of pigs. Clin Implant Dent Relat Res 2010;12:297-305.

12. Janner SFM, Gahlert M, Bosshardt DD, Roehling S, Milz S, Higginbottom F, et al. Bone response to functionally loaded, two-piece zirconia implants: A preclinical histometric study. Clin Oral Implants Res 2018;29:277-289.

13. Bethke A, Pieralli S, Kohal RJ, Burkhardt F, von Stein-Lausnitz M, Vach K, et al. Fracture Resistance of Zirconia Oral Implants In Vitro: A Systematic Review and Meta-Analysis. Materials (Basel) 2020;13.

14. Joda T, Voumard B, Zysset PK, Bragger U, Ferrari M. Ultimate force and stiffness of 2- piece zirconium dioxide implants with screw-retained monolithic lithium-disilicate reconstructions. J Prosthodont Res 2018;62:258-263.

15. Spies BC, Fross A, Adolfsson E, Bagegni A, Doerken S, Kohal RJ. Stability and aging resistance of a zirconia oral implant using a carbon fiber-reinforced screw for implant-abutment connection. Dent Mater 2018;34:1585-1595.

16. Spies BC, Nold J, Vach K, Kohal RJ. Two-piece zirconia oral implants withstand masticatory loads: An investigation in the artificial mouth. J Mech Behav Biomed Mater 2016;53:1-10.

17. Zhang F, Meyer Zur Heide C, Chevalier J, Vleugels J, Van Meerbeek B, Wesemann C, et al. Reliability of an injection-moulded two-piece zirconia implant with PEKK abutment after long-term thermo-mechanical loading. J Mech Behav Biomed Mater 2020;110:103967.

18. Spies BC, Maass ME, Adolfsson E, Sergo V, Kiemle T, Berthold C, et al. Long-term stability of an injection-molded zirconia bone-level implant: A testing protocol considering aging kinetics and dynamic fatigue. Dent Mater 2017;33:954-965.