Titanium in Dental Implants

Titanium is used in several parts of implant treatment. The parts are made to fit each other as one system.

• The implant. The screw placed in the jawbone. Once it has fused with the bone, it carries everything above it.
• The abutment. The connecting part between the implant and the crown. Abutments can be made of titanium or of other materials such as zirconia. In one trial, crowns were cemented onto individually made titanium abutments⁴.
• The titanium base. A short titanium part onto which a ceramic crown is bonded outside the mouth. The crown is then screwed onto the implant. In the same trial, the screw-retained crowns were bonded to titanium bases in this way.
• Screws. A small screw holds the abutment, or a screw-retained crown, on the implant. It belongs to the implant system.
• Frameworks for full-arch bridges. A fixed bridge on several implants, such as All-on-4, has a framework inside it. Frameworks can be made of different materials; this page does not compare them. Ask what yours is made of.
• Bone grafting. Small screws are sometimes used to hold a block of bone graft in place while it heals. A Cochrane review of bone augmentation trials noted that titanium screws may be preferable to resorbable screws⁵ for this. See bone grafting.

This page covers implants and their parts. Metals used in crowns and bridges on natural teeth are covered under metal-ceramic restorations and dental alloys.

Implants are made either of commercially pure titanium or of a titanium alloy. The figures in this section are handbook values for the materials, not measurements of any implant.

• Commercially pure titanium comes in four grades, numbered 1 to 4. They differ chiefly in how much oxygen the metal contains¹. Strength rises with the grade. A 2015 review compiled handbook values for tensile strength (resistance to being pulled apart). They are about 240 megapascals (MPa) for grade 1 and 550 MPa for grade 4.
• Titanium alloy. The main alloy described for implants in the same review is titanium with aluminium and vanadium, written Ti-6Al-4V. Its handbook tensile strength is about 930 MPa. You may see an alloy described by a grade number or by its composition; ask which one your implant is made of.
• Titanium-zirconium alloy. Some narrow implants are made of an alloy of about 83 to 87 per cent titanium and 13 to 17 per cent zirconium. Its strength figures come partly from the manufacturer¹. It is still a metal. It is not zirconia, the white ceramic described under "Alternative materials" below.

What the grade does and does not tell you

A consensus paper on implant systems found that the implants with the most clinical documentation are screw-shaped and made of commercially pure grade 4 titanium⁶. Clinical comparisons between grades or alloys are few and short; the one we cite, for narrow titanium-zirconium implants, is described below. A higher grade number or a stronger alloy does not by itself mean a longer-lasting implant.

Strength matters most for narrow implants. An older study cited in the 2015 review found implant fractures most often in 3.75 mm implants made of grade 1 titanium¹, the lowest-strength grade. The review names metal fatigue as the proposed cause.

For narrow titanium-zirconium implants, a review pooled studies of 256 implants carrying single crowns, followed for up to 36 months. It reported 97.5 per cent survival and 97.2 per cent success⁷. Survival means the implant was still in the mouth; success means it also met the studies' criteria. Bone loss showed no statistically significant difference from commercially pure titanium implants. The authors say the studies and follow-up are not enough to determine the real benefit.

Surfaces

Implant surfaces are treated to change their texture. Surface types studied over ten years or more include machined (turned) surfaces and rougher ones, such as titanium plasma-sprayed and anodised surfaces.

• A review covered 62 clinical studies with at least ten years of follow-up. Implant survival ranged from 82.9 to 100 per cent⁸ across the studies. Average bone loss was under 2 mm for every surface type. Most studies did not compare surfaces directly. The authors concluded that very good long-term results are possible with all the surface types included.
• A review of 87 papers found that the effect of surface roughness alone on bone loss seems rather limited and of minimal clinical importance⁹. A history of gum disease and smoking were associated with more bone loss.
• A 2014 Cochrane review of randomised trials found no evidence that any particular type of implant had superior long-term success¹⁰. Three years after loading, machined implants had a 20 per cent lower risk of peri-implantitis than implants with much rougher surfaces. They tended to fail early more often, though. The evidence was limited. Cochrane withdrew the review in 2019 as out of date, while stating that it was correct when it was published.

How the parts join

The abutment joins the implant either inside it (an internal connection) or on top of it (an external connection). A review of 11 studies found 0.44 mm less bone loss on average¹¹ with internal connections. It found no statistically significant difference in implant survival or complications, and the certainty of the evidence was very low to moderate. A randomised trial in 120 patients found no significant differences after five years¹².

Documentation and original parts

A consensus paper advises dentists to make sure an implant system is appropriate and supported by scientific evidence⁶. It also advises caution with non-genuine parts, which may fit poorly and lead to technical and biological complications. A review of 40 studies, most of them laboratory studies, compared abutments made by the implant's own manufacturer with non-original ones. Original abutments generally fitted better, though some non-original ones were comparable, and the authors recommend using original abutments¹³.

Regulatory marks

Under the EU Medical Device Regulation, the CE mark is a marking by which a manufacturer indicates¹⁴ that a device conforms with the Regulation's requirements. EU classification guidance places dental implants without bioactive coatings, and abutments, in class IIb¹⁵. A notified body takes part in assessing implantable devices. A CE mark is a statement of conformity: it does not rank implants or tell you how long one lasts. Long-term clinical studies do that.

Osseointegration means that the bone heals in close, firm contact with the implant surface. Once it has happened, the implant can carry a crown, a bridge or a denture. It is a biological process, and it does not happen in the same way for everyone.

• It takes time. How long depends on the bone, the implant's position, any graft and how you heal. As a guide, the Cochrane review of loading times calls a crown fitted more than two months after placement¹⁶ conventional loading. Fitting it earlier is done only in selected cases. Your dentist sets your own healing period after examining you.
• It can fail early. In a national Swedish sample of patients treated in 2003, early implant loss affected 4.4 per cent of patients¹⁷ (1.4 per cent of implants). Smoking, gum disease, implants shorter than 10 mm and certain brands were associated with higher odds of early loss.
• It can be lost later. One Swiss university cohort of titanium implants was followed for 25 years. There, loss of osseointegration accounted for about 60 per cent of implant failures¹⁸, all at premolar or molar sites. Of the 252 implants followed up to 25 years, 94 per cent were still in place. Peri-implantitis rose from 3.5 per cent of implants at 10 years to 9.1 per cent at 25. About half the implants could not be re-examined after year 10, and the results come from one centre and one implant type.

Fusion with bone is a starting point, not a promise for life. Keeping it depends on the health of the gum and bone around the implant, and on care and reviews (see "Maintenance around titanium implants" below).

The figures below come from published studies, not from our own records.

Benefits

• A long clinical record. A review pooled 18 prospective studies of contemporary implant systems (solid screws with roughened surfaces). It estimated that 96.4 per cent of implants were still in place after ten years¹⁹. When the authors allowed for patients who stopped attending, the estimate fell to 93.2 per cent. The range they expect in other settings then reached down to 76.6 per cent. In that analysis, people aged 65 or over had a ten-year survival of 91.5 per cent.
• A system of matching parts. The implant, abutment and screws are made to fit each other. When a crown on top is damaged, it can be repaired or replaced.
• No neighbouring teeth ground down. Like any implant, it fills a gap without reducing the teeth either side.

Limitations

• Inflammation around the implant. Peri-implantitis is inflammation with loss of the supporting bone. A 57-study review reported it in about 20 in 100 patients and about 12 in 100 implants²⁰. The rates vary widely with the definition used.
• The metal can show. At the front of the mouth, the gum can recede over time, and the metal edge of the implant can then show.
• Problems with the parts. Screws can loosen and crowns can come loose or chip (see "Corrosion and wear" below).
• Not interchangeable. Abutments and screws are made for a particular system, and non-original parts call for caution (see "Surface and manufacturing considerations" above).
• Not for life by default. Being in place is not the same as being trouble-free. An offer that promises a lifetime result is not based on evidence.

Titanium surfaces can wear and corrode in the mouth. A critical review was written for the 2018 consensus conference of the European Association for Osseointegration. It found that titanium particles and breakdown products of titanium have been detected²¹ in tissues in and outside the mouth. Particles are released from the implant surface by tribocorrosion. That is mechanical wear combined with chemical factors, including contact with substances produced by the bacterial film (plaque) on the implant and by inflammatory cells.

What this means for patients is not settled:

• In laboratory studies, titanium particles can interfere with cell function and promote inflammation.
• Particles are commonly found in healthy and diseased gum around implants alike, and at low levels even in the gums of people without titanium implants.
• Higher titanium levels in peri-implantitis could be the consequence of the bacterial film and inflammation²¹, rather than the trigger.
• The review found an association between corrosion, titanium particles and complications around implants, but not enough evidence to prove cause and effect.

Because substances from the bacterial film are among the factors involved, keeping plaque off the implant matters here as well as for the gum.

Wear and loosening of the parts

The parts that join the crown to the implant are under load every time you bite. A review of 46 studies looked at single crowns on implants. Over five years, the cumulative rates were screw loosening 8.8 per cent, the crown coming loose 4.1 per cent and chipped porcelain 3.5 per cent²². The review does not say what caused them. A loose screw can be tightened and a damaged crown repaired or replaced. Regular reviews are needed to find these problems.

Some people worry about a metal allergy before getting an implant. The German guideline on titanium hypersensitivity says titanium intolerance is not adequately documented²³, and that other metals must be considered as well. The 2018 critical review found tissue reactions suggesting hypersensitivity in a limited number of cases²¹. Other factors linked to placing the implant could also have caused them.

• Testing. The guideline says skin patch tests and blood (lymphocyte) tests do not help to assess titanium intolerance. It advises against patch testing people before treatment just in case.
• If intolerance is suspected. The guideline says a ceramic (zirconia) implant may be considered. That recommendation rests on low-level evidence.
• Implants that are working well. The guideline says removing an implant for suspected intolerance should be decided on very strict grounds. We have found no evidence supporting the replacement of healthy titanium implants with ceramic ones.
• Other metals. Titanium alloys contain other metals, and the crown or bridge on an implant may contain other alloys. Tell your dentist about any reaction to metals you have had, and ask what each part is made of.

An implant cannot decay, but the gum and bone around it can become inflamed. Peri-implant mucositis is inflammation of the soft tissue around an implant. It is reversible but can evolve into peri-implantitis²⁴ if it is not properly addressed. A review for the 2017 World Workshop found strong evidence²⁵ linking peri-implantitis with a history of chronic periodontitis, poor plaque control and no regular maintenance.

Daily care

• Brush twice a day with a soft brush and fluoride toothpaste. Pay particular attention to the line where the implant meets the gum.
• Clean between the teeth every day with interdental brushes, floss or a water flosser. Your dentist shows you which works in your mouth.
• Smoking has been associated with more bone loss⁹ around implants. If you smoke, tell your dentist.

Reviews

• When the crown or bridge is complete, a consensus report recommends that an X-ray and probing measurements be taken as a baseline³. Later changes are compared with this record.
• The European Federation of Periodontology guideline calls for a structured supportive care programme²⁶ once implants are in use. It includes periodic checks of the tissues around them.
• The NICE guideline on dental recall covers check-ups in general, not implants. It recommends that the interval between reviews be set for each patient²⁷, based on a risk assessment. So there is no single interval that suits everyone.
• Tell any dentist or hygienist who treats you that you have implants, and give them your implant record and baseline X-ray.

When to see a dentist

See a dentist without waiting for your next review if the gum around an implant bleeds, swells, recedes or releases pus. The same applies if the implant or the tooth on it feels loose, a screw feels loose, or a piece cracks or breaks.

Zirconia (ceramic) implants

Ceramic implants are made of zirconia (zirconium dioxide), a white ceramic. A 2026 review pooled 9 studies that compared the two materials directly, with 435 implants. It found no significant difference in implant survival²⁸ at one year, three years and five years or more. The authors limit their conclusion to healthy patients, follow-up of up to five years and older implant systems, part of which are no longer sold. Beyond five years there is too little comparative data, and "no significant difference" does not mean "just as good".

• Where they are used. An international expert consensus states that ceramic implants can be an alternative to titanium in selected cases²⁹. A position paper for the European Association for Osseointegration found comparable evidence for one-piece implants replacing one to three missing teeth with fixed crowns or a small bridge³⁰.
• One-piece or two-piece. In a one-piece ceramic implant, the part in the bone and the part that carries the crown are a single piece. There is little room to correct its angle or position afterwards, which calls for precise planning and an experienced team³⁰. Most of the research is on one-piece implants; the evidence for two-piece implants is limited²⁹. A German guideline says a two-piece ceramic implant should be used only after the patient has been told in detail² that long-term data are missing.
• Removable dentures held by implants. Results were weaker. In one review, about 70 in 100 ceramic implants holding removable dentures were in place after an average of 12 months³¹. The authors called this less predictable.
• Gum health. A review of comparative studies found no statistically significant difference in biological complications³² between the two materials, with moderate certainty. A ceramic implant does not prevent peri-implantitis and needs the same cleaning and reviews.

More about zirconia, including crowns, is on the zirconium (zirconia) page.

Ceramic parts on titanium implants

The implant can be titanium while the abutment is ceramic. An international consensus suggests, as expert opinion, that ceramic parts passing through the gum might be preferred where appearance matters most²⁹. This page cites no study showing a better appearance.

Not having an implant

A bridge, a partial or complete denture, or leaving the gap are alternatives to an implant of any material. They are compared on the dental implants page. Implants and all of these options are also available from dentists in the UK. A UK dentist can give you an independent opinion before you decide. Other materials used around implant treatment, such as bone grafting materials, are described under other dental materials.

Ask before treatment, in writing

• Which implant system is planned: the manufacturer, the system and product name, the diameter and the length
• What the implant is made of: commercially pure titanium and its grade, a titanium alloy, or titanium-zirconium
• Whether the abutment and screws are original parts of the same system, and what the crown and any framework are made of
• Where the crown or bridge is made
• What the written terms say if the implant fails or a part loosens or breaks, and who pays for repairs and travel

Bring home for your UK dentist

• An implant card or a written record for each implant: manufacturer, system, model, diameter, length and the lot (batch) or reference number
• The abutment and screw details, and the crown material
• Copies of your X-rays and scans, including the baseline X-ray and probing measurements
• Your review interval, in writing

Aftercare once you are home

Later problems are usually first seen by your own UK dentist. The GDC suggests speaking to your own dentist³³ before you consider treatment abroad. The NHS website for England says the NHS is not liable for negligence or failure of treatment³⁴ you receive abroad. Scotland, Wales and Northern Ireland run their own health services, with their own rules, which this page does not cover; if you live there, ask your dentist. The full list of questions the GDC and the NHS suggest you ask is on the dental implants page.