Zirconia vs titanium at 3 years: same bone, more chipping and two losses

Zirconia implants keep coming back into the conversation: metal-free, tooth-coloured, attractive to patients who ask for them by name. The question for the clinician is plainer. Placed side by side with titanium in the same mouth, do they behave the same over time?

This randomized controlled trial used a within-subject design. Forty-two patients each received one zirconia (Zr) and one titanium (Ti) implant in posterior sites, so every patient served as their own control. Clinical and radiographic outcomes were recorded at crown delivery and at one and three years: marginal bone levels (MBL), bleeding on probing, plaque, probing depth, keratinized mucosa, technical complications, colour differences (ΔE), visual analogue scale scores and patient-reported measures. Thirty-nine patients reached the three-year visit, with 37 zirconia and 39 titanium implants still in function.

Survival was 100% for titanium and 94.9% for zirconia: two zirconia implants were lost during follow-up. Marginal bone remained stable after the initial remodelling phase, with no clinically relevant difference between materials. Soft-tissue conditions were similar. Peri-implantitis was diagnosed in 7.9% of implants, three titanium and three zirconia, so neither material was spared. The real difference was technical: chipping of the veneering ceramic was significantly more frequent on zirconia-supported crowns. Titanium sites recorded two screw-loosening events, zirconia sites two decementations. Aesthetic and patient-reported outcomes were comparable, with low perceived mucosal colour differences and, where patients could tell at all, a slight preference for zirconia.

Clinical relevance. In posterior sites, zirconia implants matched titanium on bone stability, soft-tissue health and patient satisfaction at three years. They did not match it on survival and prosthetic robustness: two implants lost and more chipping. With small numbers, the survival gap is a signal rather than a verdict. For the patient who explicitly asks for a metal-free solution, zirconia is a defensible option; for everyone else, titanium remains the reference, and the consent conversation should mention the higher rate of ceramic chipping. Peri-implantitis affected both materials equally, a useful reminder that the material does not replace maintenance.