Various protocols are available to preclinically assess the fracture resistance of zirconia oral implants. The objective of the present review was to determine the impact of different treatments (dynamic loading, hydrothermal aging) and implant features (e.g., material, design or manufacturing) on the fracture resistance of zirconia implants. An electronic screening of two databases (MEDLINE/Pubmed, Embase) was performed. Investigations including > 5 screw-shaped implants providing information to calculate the bending moment at the time point of static loading to fracture were considered. Data was extracted and meta-analyses were conducted using multilevel mixed-effects generalized linear models (GLMs). The Šidák method was used to correct for multiple testing. The initial search resulted in 1864 articles, and finally 19 investigations loading 731 zirconia implants to fracture were analyzed. In general, fracture resistance was affected by the implant design (1-piece > 2-piece, p = 0.004), material (alumina-toughened zirconia/ATZ > yttria-stabilized tetragonal zirconia polycrystal/Y-TZP, p = 0.002) and abutment preparation (untouched > modified/grinded, p < 0.001). In case of 2-piece implants, the amount of dynamic loading cycles prior to static loading (p < 0.001) or anatomical crown supply (p < 0.001) negatively affected the outcome. No impact was found for hydrothermal aging. Heterogeneous findings of the present review highlight the importance of thoroughly and individually evaluating the fracture resistance of every zirconia implant system prior to market release.
