materials

Review
Scientific Trends in Clinical Research on Zirconia
Dental Implants: A Bibliometric Review
Felice Lorusso 1,2 , Sammy Noumbissi 1,2 , Inchingolo Francesco 3 , Biagio Rapone 4 ,
Ahmad G. A. Khater 5 and Antonio Scarano 1,2, *
1 Department of Medical, Oral and Biotechnological Sciences, University of Chieti-Pescara, Via dei Vestini, 31,
66100 Chieti, Italy; [email protected] (F.L.); [email protected] (S.N.)
2 Zirconia Implant Research Group (Z.I.R.G), International Academy of Ceramic Implantology,
Silver Spring, MD 20910, USA
3 Department of Interdisciplinary Medicine, University of Bari Aldo Moro, 70121 Bari, Italy;
[email protected]
4 Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari Aldo Moro,
70121 Bari, Italy; [email protected]
5 Faculty of Oral and Dental Medicine, Ahram Canadian University, 6th of October City, 8655 Giza, Egypt;
[email protected]
* Correspondence: [email protected]; Tel.: +39-0871-355-4084; Fax: +39-0871-355-4099




Received: 18 October 2020; Accepted: 2 December 2020; Published: 4 December 2020


Abstract: Background: The clinical use of zirconia implants has been shown to increase steadily due to
their biological, aesthetic, and physical properties; therefore, this bibliometric study aimed to review
the clinical research and co-authors in the field of zirconia dental implant rehabilitation. Methods:
We searched Scopus and Web of Science databases using a comprehensive search strategy to 5 October
2020, and independently paired reviewers who screened studies, and collected data with inclusion
criteria restricted to clinical research only (either prospective or retrospective). Data on article title,
co-authors, number of citations received, journal details, publication year, country and institution
involved, funding, study design, marginal bone loss, survival rate, failure, follow-up, and the author’s
bibliometric data were collected and evaluated. Results: A total of 29 clinical studies were published
between 2008 and 2020 as 41.4% were prospective cohort studies and 48.3% originated from Germany.
Most of the included studies had been published in Clinical Oral Implant Research (n = 12), and the
most productive institution was the Medical Center of University of Freiburg. The author with the
largest number of clinical studies on zirconia implants was Kohal R.J. (n = 10), followed by Spies B.C.
(n = 8). Conclusions: This study revealed that zirconia implants have been more prominent in the last
ten years, which is a valuable option for oral rehabilitation with marginal bone loss and survival rate
comparable to titanium dental implants.

Keywords: zirconia implant; bibliometrics; citations; scientometric

1. Introduction
The clinical application of dental implant rehabilitation represents consolidated effectiveness in the
literature due to long-term predictability and high-level satisfactory functioning and aesthetics [1–4].
Titanium alloys are the most widely used biomaterials for dental implant fixtures due to their physical,
chemical, and thermal properties, which produce the osseointegrating ability of the fixture placed to
replace the natural teeth [2,5–12].
Recently, the use of zirconia as an implant material has become more prevalent due to its high
aesthetic characteristics, particularly in the rehabilitation of the compromised anterior jaw area,
where there is fine soft-tissue biotype and the metal sensibility of the patients [13–15].

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Materials 2020, 13, 5534 2 of 19

In fact, the literature reports that the titanium ion dissolution related to the implant corrosion could
alter the natural oral microbiome and the homeostatic functional balance of the oral tissues [16–20].
On the contrary, it has been shown in vitro that the zirconia surface can lead to a significant
decrease in periodontal pathogen adhesion compared to the titanium surface [21], alongside similar
bone–implant contact compared to the titanium fixture with an almost overlapping range [22].
Additionally, Scarano et al. reported in a rabbit study that zirconia implants had about 68.4%
bone–implant contact with evidence of contact osteogenesis without fibrous tissue interposition [23].
Zirconia material is distinguished by its clear ivory appearance, which is very similar to the
natural color of the teeth and is characterized by an intrinsic strength and physical resistance to the
loading [24–26]; as a result, it has been introduced as a restorative material for dental crowns, bars,
abutments, and specially designed drills and burs [26–34]. Therefore, zirconia has recently gained
further attention in the scientific community by growing research activities to confirm the clinical
effectiveness of zirconia as a dental implant material.
Although citations are not an infallible metric to determine whether research is beneficial to
researchers and clinicians, citations and citation analysis can quantify an article’s influence, author,
subject of debate, country, journal, or a specialty [35,36]. Based on citation analysis, the bibliometric
analysis aims to provide information about the trend in a research field and demonstrates its growth
and development [37]; the number of citations received, researcher H-index, and journal impact factor
are the most common bibliometric evaluation variables and considered as a scientific productivity
score for the scientometric evaluation [38].
With the significant increase in the published articles on dental implants, recognizing trends
and advances in a research field is critical and relevant to the needs of dental practitioners and
researchers [39,40]. In this sense, bibliometric analysis is a useful tool for this purpose [41,42].
As far as we know, the trends and advances in zirconia dental implants have not been studied
before; hence this study aimed to evaluate the bibliometric output of clinical research and co-authors
in the field of zirconia dental implant rehabilitations.

2. Materials and Methods

We reported this bibliometric study in compliance with the Standards for Reporting Qualitative
Research (SRQR) [43] and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses
(PRISMA) guidelines [44].

2.1. Search Strategy

An online literature search was conducted in Elsevier’s Scopus and Clarivate Analytics’ Web of
Science (WoS) until 5 October 2020. We used the medical terms (MeSH) feature in the Cochrane Library
to obtain the available synonyms for our search terms to create a detailed search strategy (Table 1).

Table 1. Search strategy used for each database.

TITLE-ABS-KEY (“Zirconia” OR “Zirconium” OR “Zircon*”) AND TITLE-ABS-KEY

(“Dental implant” OR “Dental implants” OR “Oral implant” OR “Oral implants” OR
“Implant dentistry” OR “Dental implantology” OR “Dental Implantation” OR
“Osseointegrated” OR “Osseointegrated Dental Implantation”) AND TITLE-ABS-KEY
(“Intervention Study” OR “Clinical Trial” OR “Controlled Clinical Trial” OR “Randomized
Scopus Controlled Trials OR “Non-Randomized Clinical Trial” OR “Nonrandomized Clinical Trial”
OR “Quasi-Experimental” OR “Observational Study” OR “Prospective Study” OR
“Prospective” OR “Retrospective Study” OR “Retrospective” OR “Comparative Study” OR
“Multicenter Studies” OR “Epidemiologic Study” OR “Epidemiological Studies” OR
“Cohort Study” OR “Case Studies” OR “Follow-Up Study” OR “Case-Control Study” OR
“Case Report” OR “Case Series” OR “Pilot Study”)
Materials 2020, 13, 5534 3 of 19

Table 1. Cont.

TS = (“Zirconia” OR “Zirconium” OR “Zircon*”) AND TS = (“Dental implant” OR

“Dental implants” OR “Oral implant” OR “Oral implants” OR “Implant dentistry” OR “Dental
implantology” OR “Dental Implantation” OR “Osseointegrated” OR “Osseointegrated Dental
Implantation”) AND TS = (“Intervention Study” OR “Clinical Trial” OR “Controlled Clinical
Trial OR “Randomized Controlled Trials” OR “Non-Randomized Clinical Trial” OR
“Nonrandomized Clinical Trial” OR “Quasi-Experimental” OR “Observational Study” OR
Web of Science
“Prospective Study” OR “Prospective” OR “Retrospective Study” OR “Retrospective” OR
“Comparative Study” OR “Multicenter Studies” OR “Epidemiologic Study” OR
“Epidemiological Studies” OR “Cohort Study” OR “Case Studies” OR “Follow-Up Study” OR
“Case-Control Study” OR “Case Report” OR “Case Series” OR “Pilot Study”)
Timespan: All years. Databases: WOS, ARCI, BCI, KJD, MEDLINE, RSCI, SCIELO, ZOOREC.
Search language = Auto.

2.2. Data Extraction and Bibliometric Parameters

We used a specially built Excel file (Microsoft, Redmond, WA, USA) to collect the findings of the
literature search. The file contained the following information: abstracts, year of publication, indexed
keywords, journal name, citations as well as all co-author bibliometric data (H-index, number of papers
related to zirconia implant, the total number of papers, citation of paper regarding zirconia implant,
and citation of paper regarding zirconia implant). Authors with the highest quantity of clinical studies
regarding zirconia dental implants were evaluated and measured the average, the standard deviation,
minimum and maximum of topic paper, total papers, topic citations, overall citations, and H-index.
Moreover, we evaluated the scientific trend of the included study according to the year of publication
and journal details (full title, the impact factor (IF), and rank) based on the Clarivate Analytics report
for 2019 with selected categories: “Dentistry, Oral Surgery & Medicine”, study design, number of
citations received, marginal bone loss, survival rate, failure, and study follow-up.

2.3. Study Selection

We screened the literature search results in two steps, where the first phase was the screening of the
title and abstract by paired reviewers separately. Then, the second phase was a full-text assessment by
two expert reviewers (L.F and A.S). The reference list of the studies included in the full-text screening
was hand-screened for potential additional studies. In this bibliometric study, inclusion criteria were
only clinical studies (either prospective or retrospective) without time restrictions. Exclusion criteria
were animal studies, in vitro studies, literature reviews, systematic reviews, short communications,
personal opinion, letters, book chapters, and non-English studies.

2.4. Data Analysis

We used VOSviewer software (version 1.6.8; Leiden University, Leiden, The Netherlands) to
visualize a term map analyzing keywords from the data obtained. “Create Map” function was used to
analyze the data by using the “Citation” type and setting the unit of analysis as a “number of citations.”
In the keyword map, the node’s size reflects the number of received citations, as the larger size indicates
the author with the highest citations. Furthermore, keywords that often appeared together were
classified as the same color in network visualization mode [45,46].

3. Results

3.1. Study Selection

A total of 1159 references were collected from electronic databases in which (n = 185) were omitted
due to duplication. By title and abstract, 968 articles were screened and 841 excluded as irrelevant topics.
By the full-text screening of 127 papers, 29 studies were included in this bibliometric study [47–75]
excluding the remaining 98 articles because they did not meet our inclusion criteria (Figure 1).
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Materials 2020, 13, x FOR PEER REVIEW 4 of 21

Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow chart
demonstrates the process of literature search and study selection.
Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow chart
3.2. Study Characteristics
demonstrates the process of literature search and study selection.
The included studies showed wide variability in the study design, presence/absence of a control
3.2.group,
Studyexperimental
Characteristicssite, type of prosthetic rehabilitation, prosthetic connection (one-piece or two-piece),
follow-up period, and different methods for evaluating the effectiveness of research. Although these
The included studies showed wide variability in the study design, presence/absence of a control
differences exist, most studies reported favorable outcomes for the use of zirconia implants in oral
group, experimental site, type of prosthetic rehabilitation, prosthetic connection (one-piece or two-
rehabilitation. The main characteristics of the included studies are summarized in Table 2.
piece), follow-up period, and different methods for evaluating the effectiveness of research. Although
A total of 21 studies evaluated monolithic or one-piece zirconia implants [47–49,51–54,56–58,60,
these differences exist, most studies reported favorable outcomes for the use of zirconia implants in
62,64,66,70–74,76], two of which had titanium implants as their control and showed no significant
oral rehabilitation. The main characteristics of the included studies are summarized in Table 2.
difference in survival rate and marginal bone loss between groups (p > 0.05) [64,70]. Two studies
A total of 21 studies evaluated monolithic or one-piece zirconia implants [47–49,51–54,56–
evaluated the immediate loading of zirconia implants [53,64]: one study compared it to the non-occlusal
58,60,62,64,66,70–74,76], two of which had titanium implants as their control and showed no
loading procedure [64], while the other study compared it with the standard loading protocol [57].
significant difference in survival rate and marginal bone loss between groups (p > 0.05) [64,70]. Two
Furthermore, 26 papers assessed the cylindrical microgeometry of zirconia implants [47–65,67,70–75],
studies evaluated the immediate loading of zirconia implants [53,64]: one study compared it to the
while three studies evaluated the root-analog zirconia implants obtained by a three-dimensional
non-occlusal loading procedure [64], while the other study compared it with the standard loading
scan [66,68,69]. However, Akça et al. and Pirker et al. reported the lowest marginal bone loss after
protocol [57]. Furthermore, 26 papers assessed the cylindrical microgeometry of zirconia implants
two years (0.31 ± 0.24 and 0.5 ± 0.7 mm, respectively), in which Akça et al. used specially designed
[47–65,67,70–75], while three studies evaluated the root-analog zirconia implants obtained by a three-
titanium–zirconia alloy implants [47], and Pirker et al. used specially designed root-analog zirconia
dimensional scan [66,68,69]. However, Akça et al. and Pirker et al. reported the lowest marginal bone
implants with a micro-retention surface in a fresh extraction socket [69].
loss after two years (0.31 ± 0.24 and 0.5 ± 0.7 mm, respectively), in which Akça et al. used specially
designed titanium–zirconia alloy implants [47], and Pirker et al. used specially designed root-analog
zirconia implants with a micro-retention surface in a fresh extraction socket [69].
Materials 2020, 13, 5534 5 of 19

Table 2. Main characteristics of the clinical research included (Zir: Zirconia implant group, Tit: Titanium implant group, IF: impact factor, RCT: Randomized
controlled trial).

Authors Journal Study Patients Marginal Bone Loss Follow

Cited By Test Control Survival Rate Failure
(Year) [Ref] Full Title Rank IF Design (Implants) (Mean ± SD) Up

Microretention and
International Journal of
Pirker et al. sandblasted
Oral and Maxillofacial 33 2.068 50 Case report 1 (1 Implant) - - 100% - 2 years
(2008) [68] root-analogue
Surgery
zirconia implant
Microretention and
International Journal of Sandblasted Test:
Pirker et al. Prospective sandblasted Test: 92%
Oral and Maxillofacial 33 2.068 58 18 (18 Implants) root-analogue 0.5 ± 0.7 mm 1 implant 2 years
(2009) [69] Case Series root-analogue Control: 0%
Surgery zirconia implants Control: All implants (6)
zirconia implants
Test:
Immediate occlusal Immediate 5 implants (12.5%): Test:
Cannizzaro et al. European Journal of Multicenter 0.90 ± 0.48 mm
- - 69 40 (40 Implants) loading zirconia non-occlusal loading 88.50% 3 Implants Control: 1 year
(2010) [54] Implantology RCT Control:
Implants zirconia Implants 2 Implants
0.72 ± 0.59 mm
One-piece yttrium
Borgonovo et al. Prospective 1 Implant
Minerva Stomatologica - - 21 16 (26 Implants) stabilized zirconia - - 96.16% 2 years
(2011) [51] Case Series osseointegration failure
implants
Payer et al. Clinical Oral Implants Prospective One-piece zirconia 1 Implant
8 3.723 61 20 (20 Implants) - 1.29 ± 0.73 mm 95% 2 years
(2012) [66] Research Case Series implants osseointegration failure
International Journal of
Akça et al. Prospective
Oral and Maxillofacial 24 2.32 8 23 (52 Implants) - - 0.32 ± 0.24 mm 100% No failure 2 years
(2013) [47] Case Series
Implants
One-piece yttrium
Borgonovo et al. Prospective
Minerva Stomatologica - - 10 6 (14 Implants) stabilized zirconia - 0.67 ± 0.51 mm 100% No failure 4 years
(2013) [52] Case Series
implants
One-piece
Kohal et al. Journal of Clinical Prospective yttria-stabilized 1 Implant
2 5.241 47 28 (56 Implants) - 1.95 ± 0.65 98.20% 1 year
(2013) [59] Periodontology Case Series tetragonal zirconia osseointegration failure
implants
One-piece zirconia
Osman et al. International Journal of
61 1.49 6 Pilot study 4 (28 Implants) implants for ball - - 85.70% 4 Implants 1 year
(2013) [63] Prosthodontics
abutment
Zir:
Zir:
One-piece zirconia One-piece titanium 21Implants
Osman et al. Clinical Oral Implants 19 (129 0.42 ± 0.40 Zir: 90.9%Tit:
8 3.723 34 RCT implants for implants for (3 fractured) 1 year
(2014) [64] Research Implants) Tit: 95.8%
ball-abutment ball-abutment Tit:
0.18 ± 0.47
10Implants
Becker et al. Clinical Oral Implants Prospective Two-piece zirconia
8 3.723 15 52 (52 Implants) - - 95.80% 2 Implants 2 years
(2015) [50] Research Cohort Study implants
Cionca et al. Clinical Oral Implants Prospective Two-piece zirconia
8 3.723 43 32 (49 Implants) - - 87% 6 Implants 1 year
(2015) [55] Research Case Series implants
Materials 2020, 13, 5534 6 of 19

Table 2. Cont.

Authors Journal Study Patients Marginal Bone Loss Follow

Cited By Test Control Survival Rate Failure
(Year) [Ref] Full Title Rank IF Design (Implants) (Mean ± SD) Up

Jung et al. Clinical Oral Implants Prospective Immediate one-piece 1 implant

8 3.723 27 60 (71 Implants) - 0.78 ± 0.79 mm 98.30% 1 year
(2015) [56] Research Cohort Study zirconia implants osseointegration failure
Zir: Zir:
Zir: 93.3%
Payer et al. Clinical Oral Implants Two-piece zirconia Two-piece titanium 1.48 ± 1.05 1 Implant
8 3.723 41 RCT 22 (31 Implants) Tit: 2 years
(2015) [67] Research implants implants Tit: Tit:
100%
1.43 ± 0.67 No failure
Zir: Zir:
Clinical Implant One-piece zirconia Titanium implants Zir: 67.6%
Siddiqi et al. 22 (150 2.23 ± 0.69 16 Implants
Dentistry and Related 9 3.396 17 RCT implants for for one-piece Tit: 1 year
(2015) [70] Implants) Tit: Tit:
Research ball-abutment ball-abutment 66.7%
1.59 ± 0.33 7 Implants
One-piece
Spies et al. Journal of Dental Prospective 3 Implants
3 4.914 22 40 (53 Implants) alumina-toughened - 0.79 ± 0.47 mm 94.2% 3 years
(2015) [73] Research Cohort Study osseointegration failure
zirconia implant
Microretention and
Patankar et al. Journal of Maxillofacial sandblasted
- - 3 Case report 1 (1 Implant) - - 100% - 1.5 year
(2016) [65] and Oral Surgery root-analogue
zirconia implant
Immediate one-piece
Spies et al. Clinical Oral Implants Prospective 3 Implants
8 3.723 13 27 (27 Implants) alumina-toughened - 0.77 ± 0.31 mm 88.90% 1 year
(2016) [74] Research Cohort Study osseointegration failure
zirconia implant
International Journal of
Kniha et al. Prospective 81 (105
Oral and Maxillofacial 33 2.068 9 Zirconia implants - 0.66 ± 0.33 mm 100% No failure 3 years
(2017) [58] Cohort Study Implants)
Surgery
Immediate: Immediate:
International Journal of Immediate loading
Kniha et al. Prospective Delayed one-piece 0.76 ± 1.13 mm 100%
Oral and Maxillofacial 33 2.068 9 78 (82 Implants) one-piece zirconia No failure 1 year
(2017) [57] Cohort Study zirconia implants Delayed: Delayed:
Surgery implants
0.83 ± 0.65 mm 100%
Spies et al. Prospective One-piece zirconia
Journal of Dentistry 10 3.242 6 60 (71 Implants) - - 100% No failure 3 years
(2017) [71] Case Series oral implants
Spies et al. Clinical Oral Implants Prospective One-piece zirconia
8 3.723 11 13 (26 Implants) - - 100% No failure 5 years
(2017) [75] Research Case Series implants
Prospective One-piece immediate
Balmer et al. Clinical Oral Implants 1 Implant
8 3.723 11 Multicenter 60 (71 Implants) loading zirconia - 0.70 ± 0.72 mm 98.50% 3 years
(2018) [49] Research osseointegration failure
Cohort Study implants
Prospective
Bormann et al.
BMC Oral Health 38 1.911 7 Multicenter 44 (44 Implants) Zirconia implants - 0.97 ± 0.88 mm 97.50% 1 Implant 3 years
(2018) [53]
Cohort Study
Immediate loading
Kohal et al. Journal of Clinical Prospective
2 5.241 5 65 (65 Implants) one-piece zirconia - 1.45 ± 1.96 mm 90.80% 6 Implants 3 years
(2018) [60] Periodontology Cohort Study
implants
Materials 2020, 13, 5534 7 of 19

Table 2. Cont.

Authors Journal Study Patients Marginal Bone Loss Follow

Cited By Test Control Survival Rate Failure
(Year) [Ref] Full Title Rank IF Design (Implants) (Mean ± SD) Up

Clinical Implant No failure one

Lorenz et al. Prospective
Dentistry and Related 9 3.396 4 28 (83 Implants) Zirconia implants Natural teeth 1.2 ± 0.76 mm 100% peri-implantitis resistant 7.8 years
(2019) [62] Cohort Study
Research to therapies
Prospective Chipping (n = 19)
Spies et al. Clinical Oral Implants
8 3.723 5 Multicenter 45 (45 Implants) Zirconia implants - - 97.5 ± 2.47%. occlusal roughness 5 years
(2019) [72] Research
Cohort Study (n = 35)
Prospective Single crown Multiple prostheses
Balmer et al. Clinical Oral Implants
8 3.723 4 Multicenter 60 (71 Implants) one-piece zirconia one-piece zirconia 0.7 ± 0.6 mm 98.4% 1 Implant 5 years
(2020) [48] Research
Cohort Study implant implant
Zir:
Zir:
Koller et al. Clinical Oral Implants Two-piece zirconia Two-piece titanium Zir: 87.5%Tit: 2 Implants
8 3.723 0 Pilot RCT 22 (31 Implants) 1.38 ± 0.81 Tit: 6.67 years
(2020) [61] Research implants implants 93.3% Tit:
1.17 ± 0.73 mm
1 Implant
Materials2020,
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2020, 13, FOR PEER REVIEW 10 8ofof21
19

3.3. Growth
3.3. GrowthofofPublications
Publications
Intotal,
In total,29
29clinical
clinicalstudies
studieswere
werepublished
publishedbetween
between2008
2008and
and2020,
2020,ininwhich
which1919papers
papers(65.5%)
(65.5%)were
were
published in the last five years and ten papers published before 2015. The highest number of
published in the last five years and ten papers published before 2015. The highest number of published published
studieswas
studies wasinin2015
2015(n (n==6,6,20.6%)
20.6%)followed
followedbyby 2013
2013 and
and 2017
2017 (n(n = 13.7%
= 4, 4, 13.7%
forfor each)
each) (Figure
(Figure 2). 2).

Growth of publications
6

4
Papers

0
08

09

10

11

12

13

14

15

16

17

18

19

20
20

20

20

20

20

20

20

20

20

20

20

20

Year 20
Figure
Figure2.
2.Publication
Publicationtrend
trendof
ofthe
theclinical
clinicalstudies
studieson
onthe
thezirconia
zirconia implants.
implants.

3.4. Journal
3.4. JournalofofPublication
Publication
The clinical
The clinical studies
studies on
on the
the use
use of
ofzirconia
zirconia dental
dental implants
implants for
for oral
oralrehabilitation
rehabilitation were
were published
published
across ten
across ten peer-reviewed
peer-reviewedjournals.
journals.TheThejournal
journalwith
withthe largest
the number
largest numberof publications waswas
of publications “Clinical Oral
“Clinical
Implants Research” (n = 12, 41%), followed by “International Journal of Oral and Maxillofacial
Oral Implants Research” (n = 12, 41%), followed by “International Journal of Oral and Maxillofacial Surgery”
(n = 4, 13.7%)
Surgery” (Figure
(n = 4, 13.7%)3).
(Figure 3).
The majority of publications
The majority of publications were were published
published in
in Q1
Q1 journals (n ==25,
journals (n 25,86%),
86%),while
while the
the journal
journal with
with
the highest impact factor was “Journal of Clinical Periodontology” (IF = 5.241), which
the highest impact factor was “Journal of Clinical Periodontology” (IF = 5.241), which had two had two articles.
articles.
Materials 2020, 13, 5534 9 of 19
Materials 2020, 13, x FOR PEER REVIEW 11 of 21

Distribution of scientific journals

BMC Oral Health
Clinical Implant Dentistry
and Related Research
Clinical Oral Implants Research

European Journal of Implantology

International Journal of
Oral and Maxillofacial Implants
International Journal of
Oral and Maxillofacial Surgery
International Journal of Prosthodontics

Journal of Clinical Periodontology

Journal of Dental Research

Journal of Dentistry
Journal of Maxillofacial
and Oral Surgery
Minerva Stomatologica

0 2 4 6 8 10 12

Figure 3. Contribution journals in clinical research on zirconia implants.

Figure 3.

3.5. Study Design and Level of Evidence

3.5. Study Design and Level of Evidence
All included studies were prospective, while the most common study design of clinical research on
All included studies were prospective, while the most common study design of clinical research
zirconia implants was cohort study (n = 12, 41.4%), followed by case series (n = 9, 31%), and RCT (n = 5,
on zirconia implants was cohort study (n = 12, 41.4%), followed by case series (n = 9, 31%), and RCT
17%). According to the hierarchy of evidence levels (Is) [77,78], the available evidence supporting the
(n = 5, 17%). According to the hierarchy of evidence levels (Is) [77,78], the available evidence
use of zirconia implants is 17% level II, 41.4% EL IV, and the remaining EL VI.
supporting the use of zirconia implants is 17% level II, 41.4% EL IV, and the remaining EL VI.
3.6. Contribution of Countries and Institutions
3.6. Contribution of Countries and Institutions
The majority of the studies originated from institutions in Germany (n = 14, 48.3%), followed
The majority of the studies originated from institutions in Germany (n = 14, 48.3%), followed by
by Switzerland, (n = 6, 20.7%), and Austria (n = 5, 17%), where the most productive institution
Switzerland, (n = 6, 20.7%), and Austria (n = 5, 17%), where the most productive institution was the
was the Medical Center of University of Freiburg (n = 8, 27.6%), followed by the Center of Dental
Medical Center of University of Freiburg (n = 8, 27.6%), followed by the Center of Dental Medicine,
Medicine, University of Zürich (n = 5, 17%). While many of the included studies were funded, the
University of Zürich (n = 5, 17%). While many of the included studies were funded, the most funding
most funding support for included research was provided by VITA Zahnfabrik—H. Rauter GmbH &
support for included research was provided by VITA Zahnfabrik—H. Rauter GmbH & Co. KG, Bad
Co. KG, Bad Säckingen, Germany (n = 5, 17%) (Table 3).
Säckingen, Germany (n = 5, 17%) (Table 3).
Materials 2020, 13, 5534 10 of 19

Table 3. Contribution of countries and institutions to clinical studies on zirconia implants.

Country Institution Study [Ref] Funding

Universitätsklinikum Düsseldorf, Düsseldorf Becker et al., 2015 [50] ZV3 Zircon Vision GmbH, Wolfratshausen, Germany
University Hospital Aachen, Aachen Kniha et al., 2017 [57]
Friedrich-Alexander-University Erlangen-Nürnberg Kniha et al., 2017 [58] No Funding
Johann-Wolfgang Goethe University, Frankfurt/Main Lorenz et al., 2019 [62]
Hannover Medical School, Hannover Bormann et al., 2018 [53] Institut Straumann AG, Basel, Switzerland
Germany
School of Dentistry, Albert-Ludwigs University, Freiburg Kohal et al., 2013 [59]
Nobel Biocare AB, Göteborg, Sweden
Kohal et al., 2018 [60]
Spies et al., 2015 [73]
Medical Center of University of Freiburg, Freiburg Metoxit AG (Thayngen, Switzerland)
Spies et al., 2016 [74]
Spies et al., 2017 [75] Ivoclar Vivadent
Spies et al., 2017 [71]

Medical Center of University of Freiburg, Freiburg and Balmer et al., 2018 [49]
Germany and Switzerland VITA Zahnfabrik—H. Rauter GmbH & Co. KG, Bad Säckingen, Germany
Center of Dental Medicine, University of Zürich, Zürich Spies et al., 2019 [72]
Balmer et al., 2020 [48]
School of Dental Medicine, University of Geneva, Geneva Cionca et al., 2015 [55] Dentalpoint AG, Zürich, Switzerland
Switzerland
Center of Dental Medicine, University of Zürich, Zürich Jung et al., 2015 [56] VITA Zahnfabrik—H. Rauter GmbH & Co. KG, Bad Säckingen, Germany
Pirker et al., 2008 [68]
Alfred Kocher, Medical University Vienna, Vienna No Funding
Pirker et al., 2009 [69]
Austria Payer et al., 2012 [66] Bredent medical GmbH, Senden, Germany
School of Dentistry, Medical University Graz, Graz Payer et al., 2015 [67]
Ziterion GmbH, Uffenheim, Germany
Koller et al., 2020 [61]
Private practice Cannizzaro et al., 2010 [54] Partially supported by Z-systems
Italy Borgonovo et al., 2011 [51]
School of Dentistry, University of Milan, Milan Not reported
Borgonovo et al., 2013 [52]
Osman et al., 2013 [63]
Oral Implantology Research Group, Sir John Walsh Oral Implantology Research Group, Sir John Walsh Research Institute,
New Zealand Osman et al., 2014 [64]
Research Institute, School of Dentistry, University of Otago School of Dentistry, University of Otago and Southern Implants
Siddiqi et al., 2015 [70]
India BV Dental College and Hospital, Pune Patankar et al., 2016 [65] No Funding
Turkey Faculty of Dentistry, Hacettepe University Akça et al., 2013 [47] No Funding
Materials 2020, 13, x FOR PEER REVIEW 13 of 21
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13 of 19
21

3.7. Bibliometric Assessment

3.7.
3.7. Bibliometric
Bibliometric Assessment
A total of 29Assessment
articles with total citations[Scopus] ranged from 0 to 176 (mean 57.28 ± 42.18), while
A total
the number of 29 articles
citations
A total of 29 articles with
[Scopus]
with total
received
totalcitations
by each paper
[Scopus]
citations ranged
ranged from 0 to 0176
from to (mean
69 (mean57.28 ± 42.18),
21.3
[Scopus] ranged from 0 to 176 (mean 57.28 ± 42.18), while
± 20). while the
The top-
number
cited of citations
study was
the number the[Scopus] received
RCT[Scopus]
of citations of Cannizzaro by each
received byeteach paper
al. (2010)ranged
paper(n from 0 to 69 (mean 21.3 ± 20). The
[Scopus] = 69) [54], followed by the prospective
ranged from 0 to 69 (mean 21.3 ± 20). The top- top-cited
study
cited study was the RCT of Cannizzaro et al. (2010) (n[Scopus] =[54],
case was
series the
of RCT
Payer of
et Cannizzaro
al. (2012) (n et al.
[Scopus] = (2010)
61) (n
[66], and =
Pirker
[Scopus] 69)et al. followed
69)(2009) by the
(n[Scopus]
[54], followed = by prospective
58) case
[69].prospective
the
series of Payer
However, et
theal. (2012)
author (n
with the
[Scopus] = 61)
highest [66], and
number Pirker
of et al.
clinical (2009)
research(n on = 58)
zirconia
[Scopus]
case series of Payer et al. (2012) (n[Scopus] = 61) [66], and Pirker et al. (2009) (n[Scopus] = 58) [69]. [69].
implants was
However,
KohalHowever, the
R.J. (n = 10), author
the followed
author withwith the
by Spies highest number
B.C. (n number
the highest = 8) and of of clinical
Vach research
K. (n research
clinical = 6), whileon
onthezirconia implants
top-cited
zirconia authorwas
implants of
was
Kohal
clinical R.J. (n
studies = 10),
on followed
zirconia by Spies
implants was B.C. (n
Kohal = 8)
R.J. and
(n Vach
[WoS] = K.
155), (n =
Kohal R.J. (n = 10), followed by Spies B.C. (n = 8) and Vach K. (n = 6), while the top-cited author of
6),
followed while
by the top-cited
Arnetzl G. (n author
[WoS] = 91),
of
clinical
Koller studies
clinicalM. (n[WoS]on
studies zirconia
= 87),
on Payer
zirconia implants
M., andwas
implants wasKohal
Jakse N. (nR.J.
Kohal [WoS](n
R.J.=(n86
[WoS] for= each)
155), followed
(Figures by Arnetzl
4 and 5). G. (n[WoS]
[WoS] = 155), followed by Arnetzl G. (n
= 91),
[WoS] = 91),
Koller
Koller M.
M. (n(n[WoS] = 87), Payer M., and Jakse N. (n[WoS]= =
[WoS] = 87), Payer M., and Jakse N. (n[WoS] 8686forfor each)
each) (Figures
(Figures 4 and
4 and 5).5).

Figure 4. Network analysis of the authors with the largest number of clinical studies on zirconia
implants.
Figure4.4.Network
Networkanalysis
analysis of the authors
Figure of the authors withwith the largest
the largest numbernumber of studies
of clinical clinicalon
studies onimplants.
zirconia zirconia
implants.
Topic papers
Topic citations[Scopus]
Topic papers
Topic citations[WoS]
Topic citations[Scopus]
Topic citations[WoS]
M. M.
A. A.

C.H.F.
G. G.

Butz F.

Jakse N. N.
R. R.
W. W.

Jung R.E.

H. H.
R.J. R.J.

I.

F. F.
Spies B.C. B.C.
M. M.

K. K.
Vavassori V. V.
Koller M. M.

SailerSailer
Schwarz

Vach Vach
Vavassori
CensiCensi
Borgonovo
Arnetzl

Jakse

KnihaKniha
Duncan
Balmer

PayerPayer
Koller
KohalKohal

Spies
Butz F.

C.H.F.

I.
Jung R.E.
Hämmerle

Schwarz
Borgonovo
Arnetzl

Duncan
Balmer

Hämmerle

Figure 5.
Figure Bibliometricvariables
5. Bibliometric variables for
for authors
authors with
with the
the highest
highest number
number of
of topic
topic papers.
papers.
Figure 5. Bibliometric variables for authors with the highest number of topic papers.
The authors’
The authors’ H-indexScopus
H-index rangedfrom
Scopusranged fromone
onetoto79
79(mean 22.67±±19.96),
(mean22.67 19.96),and
andthetheauthor
author with
with the
the
most bibliometric
most The
bibliometric characteristics was Hämmerle C.H.F., who had 364 publications (two of which were
authors’ characteristics was Hämmerle
H-indexScopus ranged from one to C.H.F., who22.67
79 (mean had ±364 publications
19.96), (two ofwith
and the author whichthe
clinical
were studies
clinical on zirconia
studies on implants)
zirconia withwith
implants) 83118311
total citations
total and
citations andH-index
H-index = 79 (Table 4 and
Scopus = 79 (Table 4 and
Scopus
most bibliometric characteristics was Hämmerle C.H.F., who had 364 publications (two of which
Figure 6).
Figure 6).
were clinical studies on zirconia implants) with 8311 total citations and H-indexScopus = 79 (Table 4 and
Figure 6).
Materials 2020, 13, 5534 12 of 19

Table 4. General bibliometric variables for authors with the largest number of topic papers.

Topic Topic Total Topic/Total

Topic Topic/Total Total Citation H-index H-index
Author Total Papers Citations Citations Citations Citations %
Papers Papers % [WoS] [Scopus] [WoS]
[Scopus] [WoS] [Scopus] [Scopus-WoS]
Kohal R.J. 10 109 9.17% 176 155 3053 2975 [5.76–5.21%] 30 29
Spies B.C. 8 47 17.02% 70 64 452 448 [15.49–14.29%] 14 14
Vach K. 6 73 8.22% 54 51 661 820 [8.17–6.21%] 15 16
Balmer M. 5 13 38.46% 44 31 256 130 [17.19–23.84%] 7 5
Jung R.E. 5 202 2.48% 23 19 8359 9126 [0.28–0.21%] 47 57
Jakse N. 3 70 4.29% 99 86 1114 981 [8.89–8.77%] 18 18
Kniha H. 3 28 10.71% 21 13 664 726 [3.16–1.779%] 11 13
Koller M. 3 9 33.33% 99 87 166 312 [59.64–27.88%] 5 5
Payer M. 3 48 6.25% 99 86 770 1484 [12.86–5.79%] 15 23
Sailer I. 3 113 2.65% 35 31 6027 5713 [0.58–0.54%] 34 33
Arnetzl G. 2 40 5.00% 99 91 437 183 [22.65–49.72%] 11 6
Butz F. 2 24 8.33% 48 45 1248 1441 [3.85–3.12%] 18 19
Censi R. 2 18 11.11% 31 29 169 95 [18.34–30.52%] 8 4
Duncan W. 2 87 2.30% 38 35 2163 1356 [1.76–2.58%] 20 19
Hämmerle C.H.F. 2 364 0.55% 16 14 18,311 16,032 [0.09–0.08%] 79 72
Schwarz F. 2 261 0.77% 17 15 9093 9169 [0.19–0.16%] 57 57
Vavassori V. 2 12 16.67% 31 27 136 96 [22.79–28.12%] 7 5
Borgonovo A. 2 51 3.92% 31 28 535 449 [5.79–6.23%] 12 11
Summary
3.61 ± 2.33 87.17 ± 96.37 10.07 ± 0.11% 57.28 ± 42.18 50.39 ± 37.68 2978.56 ± 4750.05 2863.11 ± 4386.90 - 22.67 ± 19.96 22.56 ± 20.14
(Mean ± SD)
Materials
Materials2020,
2020,13,
13,x5534
FOR PEER REVIEW 1513ofof21
19

260 25%~75%
Range within 1.5IQR
240
Median Line
220 Mean
200 Outliers

180

160
Range

140

120

100

80

60

40

20

0
s}
s%

s]

]
rs

oS

oS
er

pu

pu
pe

er

[W
ap

[W
co
pa

co
ap
lp

[S

ns

[S

x
lp
c

de
ta
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tio
ns

x
ta
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-in
To

tio

ita
To

-in

H
ita

C
c/

H
pi

c
cC

pi
To

To
pi
To

Box plots
Figure6.6. Box
Figure plots summarize
summarizethe
thebibliometric variables
bibliometric of the
variables of authors with with
the authors the largest number
the largest of studies.
number of
studies.
4. Discussion
The present study carried out a bibliometric evaluation of clinical research on zirconia implant
4. Discussion
rehabilitation, highlighting the significant heterogeneity of the included studies, which revealed
The present study carried out a bibliometric evaluation of clinical research on zirconia implant
considerable variations in methodology, technical approaches, follow-up, and control group
rehabilitation, highlighting the significant heterogeneity of the included studies, which revealed
involvement. Our findings indicate that there is a trend for zirconia implants in oral rehabilitation as
considerable variations in methodology, technical approaches, follow-up, and control group
there has been an increase in about 180% of the studies published in the last five years.
involvement. Our findings indicate that there is a trend for zirconia implants in oral rehabilitation as
The included studies reported a survival rate for zirconia implants ranging from 87% to 100% with
there has been an increase in about 180% of the studies published in the last five years.
follow-up periods from one to 7.8 years, while the least survival rate reported in RCT by Siddiqi et al.
The included studies reported a survival rate for zirconia implants ranging from 87% to 100%
was 67.6% after one-year follow-up (i.e., 16 zirconia implants failed out of 68) [70]. This RCT aimed
with follow-up periods from one to 7.8 years, while the least survival rate reported in RCT by Siddiqi
to study the effectiveness of zirconia vs. titanium implants restored with one-piece ball-abutment in
et al. was 67.6% after one-year follow-up (i.e., 16 zirconia implants failed out of 68) [70]. This RCT
mandibular and maxillary overdentures, while this high decrease in the survival rate was for both
aimed to study the effectiveness of zirconia vs. titanium implants restored with one-piece ball-
groups (i.e., 67.6% for zirconia implants and 66.7% for titanium implants); the outcomes of maxillary
abutment in mandibular and maxillary overdentures, while this high decrease in the survival rate
rehabilitation were worse than the mandible, while no mechanical fractures of the fixtures were
was for both groups (i.e., 67.6% for zirconia implants and 66.7% for titanium implants); the outcomes
reported [70].
of maxillary rehabilitation were worse than the mandible, while no mechanical fractures of the
Although one-piece and two-piece zirconia implants have been evaluated, the lower marginal
fixtures were reported [70].
bone loss and higher survival rates were observed in studies of one-piece zirconia implant rehabilitation
Although one-piece and two-piece zirconia implants have been evaluated, the lower marginal
on a single tooth or three element prosthetic rehabilitation [59,61]. However, the studies did not report
bone loss and higher survival rates were observed in studies of one-piece zirconia implant
any differences in the marginal bone loss and survival rate between the single crown and the fixed
rehabilitation on a single tooth or three element prosthetic rehabilitation [59,61]. However, the studies
multiple zirconia implant recovery, while the prosthetic connection appears to have no apparent effect
did not report any differences in the marginal bone loss and survival rate between the single crown
on these parameters [48]. Additionally, Lorenz et al. showed no significant difference in marginal bone
and the fixed multiple zirconia implant recovery, while the prosthetic connection appears to have no
loss with a total of 83 zirconia implants compared to natural teeth after 7.8 years of function [47], and the
apparent effect on these parameters [48]. Additionally, Lorenz et al. showed no significant difference
marginal bone loss was similar in the other studies, which was less than 1 mm in the first year and
in marginal bone loss with a total of 83 zirconia implants compared to natural teeth after 7.8 years of
Materials 2020, 13, 5534 14 of 19

stabilized in subsequent functional loading [47–49,52,56–58,64,69,73,74]. Moreover, the prospective

study by Kniha et al. contained the largest sample size of the included studies involving 81 patients
with 105 implants for fixed rehabilitation, who reported a significant decrease of 0.66 ± 0.30 mm with a
survival rate of 100% after three years [58].
However, the most common complication (70%) was the failure of implant osseointegration as
17 studies reported a loss of at least one implant in the first six months [48–51,53–56,59–61,63,64,66,67,
69,70,72–74].
As previously reported for titanium dental implant threads, microgeometry appears to have a
significant effect on the osseointegration of zirconia implants [79,80], whereas a more retentive surface
resulted in an increased survival rate compared to a sandblasted surface only [68,69].
Although all clinical research included in this analysis was screened and selected from the Scopus
and Web of Science databases, which may avoid restriction in each database [39,81], our investigation
has further limitations. First, the year of publication, which is a reliable indicator of the number
of citations received, as older papers receive more citations than recent publications because there
is more time to cite them, regardless of their impact [82,83]. Second, open access policies have a
significant influence on the citations received in the evaluated papers [84–86], as a result, we found
large heterogeneity in Topic/Total Citations% and co-authors’ H-index.

5. Conclusions
This was the first study highlighting bibliometric output of clinical research and co-authors in the
field of zirconia dental implants and shows a strong interest in the development of research into the
clinical application of zirconia dental implants, as evidenced by the increase in the number of scientific
papers published in the last ten years.

Author Contributions: Conceptualization, F.L. and A.S.; Methodology, F.L. and A.G.A.K.; Software, F.L.;
Validation, F.L. and A.S.; Formal analysis, F.L. and A.G.A.K.; Investigation, A.S., F.L. and B.R.; Data curation, F.L.,
A.G.A.K. and A.S.; Writing—original draft preparation, F.L. and A.S.; Writing—review and editing, F.L., A.G.A.K.
and S.N.; Visualization, A.S., B.R. and I.F.; Supervision, A.S. and I.F. All authors have read and agreed to the
published version of the manuscript.
Funding: This research received no external funding.
Conflicts of Interest: Authors declare no conflicts of interest.

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