Ceramic implants – a real alternative to titanium?
- Sep 5
- 6 min read
Updated: Sep 10
Introduction: Dentists are increasingly faced with the question of whether new materials and technologies truly deliver on their promises. The current focus is on the metal-free zirconium oxide implant , which is being touted as a potential alternative to the proven titanium implant. Patients are increasingly concerned about the potential health risks of titanium (and its alloys) and are asking for "metal-free" solutions. Accordingly, an evidence-based view of hard data from clinical studies—with clear methodology and transparency regarding potential bias—is crucial. We therefore assess study quality using a traffic light system and openly identify conflicts of interest.
Traffic light system for study evaluation:
Green: Methodologically high-quality, independent studies
Yellow: Solid methodology, but with uncertainties or possible bias
Red: Obvious methodological weaknesses or strong industry bias
Development of ceramic implants
Ceramic implants are not a completely new idea. The first sapphire implants made of aluminum oxide were tested around 30–40 years ago. However, these early ceramics exhibited mechanical weaknesses —they were highly susceptible to fractures and had lower survival rates than titanium implants. As a result, such implants disappeared from the market.
With the advent of yttrium-stabilized zirconium dioxide (Y-TZP) as an implant material, the concept of ceramic implants experienced a revival. Zirconium oxide exhibits significantly better physical properties than alumina: it has higher flexural strength, greater fracture toughness, and a lower modulus of elasticity. In particular, the so-called transformation toughening gives Y-TZP a unique crack-stopping effect – small cracks in the material are halted by phase transformation. These improvements fueled hopes that modern ceramic implants could withstand the stresses in the mouth over the long term.
Zirconium also sounded promising from a biological perspective. Animal studies demonstrated comparable osseointegration of zirconium oxide implants to titanium. Furthermore, initial clinical reports indicated that less plaque accumulates on zirconium and that the soft tissue appears healthy. Above all, ceramic implants promised a solution for patients with metal allergies or phobias – without any gray sheen at the gum line.
Study situation: Titanium vs. ceramic
How does the zirconium implant compare directly to the titanium screw? The current evidence paints a mixed picture . On the one hand, some studies show short-term success rates similar to those of titanium implants. For example, a three-year evaluation (74 patients, one- and two-piece zirconium implants) revealed a cumulative survival rate of 96.5% after 3 years – a value in the range of common titanium results. The "surviving" ceramic implants exhibited healthy soft tissue conditions; probing depths and bleeding indices were low and comparable to those of natural teeth. Such findings indicate that ceramic implants can function in the short term ( study rating: yellow-green ).
On the other hand, other studies report notable early failures . In some cohorts, significantly more early failures occurred than is known for titanium. According to a systematic review, failure rates in the first year ranged from approximately 2% to 100%, depending on the study (in one extreme case, all inserted zirconium implants failed). Overall, most losses occurred very early—often before or shortly after the denture was inserted. Such alarming results usually come from older, methodologically weaker reports ( red ); however, they underscore that zirconium implants may have a narrower success rate than titanium.
A direct head-to-head comparison was provided by a randomized clinical study by Osman et al. (2014). In this study, 24 edentulous patients received either zirconium oxide or titanium implants (one-piece design) for prosthetic restorations. After one year, a differentiated picture emerged: In the lower jaw, the survival rates were almost identical (zirconium 90.9% vs. titanium 95.8%), but in the upper jaw, only 55% of the zirconium implants survived compared to 71.9% of the titanium implants. Additionally, three implant fractures occurred in the zirconium group, and significantly greater bone loss was measured at the implant neck. The authors draw a clear conclusion: caution with generalized recommendations – for the time being, one-piece zirconium implants should only be used in exceptional cases (e.g., in cases of confirmed titanium allergy). ( Study rating: Yellow – randomized and scientifically valuable, but small sample size and short follow-up.)
What about the newer two-piece ceramic implants (with removable abutments)? Initial data from clinical series are available. A prospective study with 49 two-piece zirconium implants (Zeramex T) reported an 87% survival rate after 1 year , which dropped to approximately 83% by year 6. All losses were due to loosening without infection ; no material fractures occurred in this series. Nevertheless, the 17% failure rate within a few years remains significantly higher than is usual for modern titanium systems. For comparison: In large long-term studies, rough titanium implants achieve 99% survival after 10 years – including minimal complication rates (2% peri-implant infections over 10 years). To date, no such comprehensive long-term study exists for zirconium implants. ( Study rating: Yellow – important real-life data, but still limited case numbers.)
Systematic evidence is also still limited. A comprehensive review (2016) aggregated the available clinical studies with a duration of ≥1 year and reached a cautiously optimistic conclusion. According to this review, zirconium implants could, in principle, be an alternative for metal-free restorations— but reliable long-term data are still pending. In particular, randomized studies with newer two-piece zirconium systems are lacking to directly compare success and risks with titanium. The authors of the review—a methodologically high-quality, independent study ( Green )—emphasize the need for further knowledge: Until sufficient studies are available, titanium remains the gold standard .
Observations regarding peri-implant health are also interesting: To date, no case of peri-implantitis involving zirconium implants has been documented in publications. At least clinically, zirconium implants do not appear to be affected by the inflammatory complications known from titanium. Zirconium may exhibit greater biocompatibility or promote a different biofilm colonization. However, caution must be exercised here—the small number of cases and follow-up time could simply mean that cases of peri-implantitis have not (yet) been recorded. Long-term comparisons are pending.
Study situation: Titanium vs. ceramic
Short-term results
Some studies show similar success rates to titanium .
Example: Brüll et al. 2014 (121 implants, up to 3 years follow-up) – cumulative survival rate 96.5% after 3 years, stable soft tissue conditions.
🟡 Assessment: methodologically sound, but short duration and mixed cohort.
Early failures
Other studies report strikingly high early losses .
Systematic reviews describe first-year failure rates between 2% and 100% , with particularly high rates in older systems.
🔴 Rating: mostly older, methodologically weak studies with small collectives.
Head-to-head comparison
A randomized clinical trial by Osman et al. (2014) :
24 edentulous patients, zirconia vs. titanium, one-piece design.
Lower jaw: Zirconia 90.9% vs. Titanium 95.8%.
Upper jaw: Zirconia only 55% vs. titanium 71.9%.
In addition, there were three implant fractures in the zirconium group and more marginal bone loss .
🟡 Assessment: RCT with clear methodology, but small sample size and short follow-up.
Two-piece zirconium implants
Cionca et al. 2015 (49 two-part implants, Zeramex T):
Survival 87% after 1 year, ~83% after 6 years.
Main problem: loosening without infection.
🟡 Assessment: important clinical data, but limited number of cases.
Systematic reviews
Hashim et al. 2016 (Clin Oral Invest.) : 14 studies ≥1 year duration.
Result: 92% survival after 1 year , high heterogeneity.
Clear statement: Titanium remains the gold standard , long-term data are missing.
🟢 Assessment: high-quality, independent systematic review.
Periimplantitis
To date , no cases of periimplantitis on zirconium implants have been documented in clinical publications.
Possible explanation: higher biocompatibility or short observation time.
⚠️ Caution: missing long-term data → evidence currently uncertain .
Conclusion for practice
Are ceramic implants a viable alternative? Yes and no. Currently, it can be stated that zirconium implants can osseointegrate and achieve acceptable short- to medium-term success rates. Modern ceramic implants represent an option , particularly for patient groups with titanium intolerance or a strong desire for metal-free implants. They also offer promising approaches in terms of soft tissue aesthetics and biocompatibility.
At the same time, reality cannot be sugarcoated. The quality of the evidence is predominantly poor – manageable case numbers, short durations, and, in some cases, manufacturer involvement limit its significance. The few high-quality studies available advise caution: The clinical success rates of zirconium are (still) lower than those of titanium, especially with longer-term observation. Specific risks such as material fractures or pronounced bone loss around zirconium implants have been reported. Accordingly, the conservative recommendation is: Titanium implants remain the gold standard , while zirconium implants should currently be used primarily in selected cases – for example, when titanium is truly not an option.
Future studies could change this picture. It's crucial for practice to critically monitor new research. A vigilant eye for potential bias helps: Are studies sponsored by manufacturers? Are the results consistently positive? Our transparent author evaluation provides additional value by highlighting authors who frequently publish exceptionally positive or negative results on certain topics. This helps evidence-oriented dentists maintain perspective – in the interest of making the best decision for their patients.
Bibliography
Brüll F, van Winkelhoff AJ, Cune MS. Zirconia dental implants: a clinical, radiographic, and microbiologic evaluation up to 3 years. Int J Oral Maxillofac Implants. 2014;29(4):914–920. doi:10.11607/jomi.3293. 🟡
Osman RB, Swain MV, Atieh M, Ma S, Duncan WJ. Ceramic implants (Y-TZP): are they a viable alternative to titanium implants for the support of overdentures? A randomized clinical trial. Clin Oral Implants Res. 2014;25(12):1366–1377. doi:10.1111/clr.12272. 🟡
Cionca N, Müller N, Mombelli A. Two-piece zirconia implants supporting all-ceramic crowns: a prospective clinical study. Clin Oral Implants Res. 2015;26(4):413–418. doi:10.1111/clr.12370. 🟡
Hashim D, Cionca N, Courvoisier DS, Mombelli A. A systematic review of the clinical survival of zirconia implants. Clin Oral Invest. 2016;20:1403–1417. doi:10.1007/s00784-016-1853-9. 🟢
