What does the research say about ceramic implants after five years?

The short version

Zirconia, the ceramic that "metal-free" implants are made from, has a much shorter clinical history than titanium, and most of the published research is short. Pooled reviews report survival in the mid-ninety-percent range, and the best five-year cohorts land in the same territory. Other five-year cohorts, mostly of early one-piece designs, report survival well below ninety percent. Randomized trials against titanium exist, but they are few and small, and most report only one to two years of follow-up. So when a patient asks what happens "after five years," the honest answer is that the record becomes sparse rather than bad: the studies that reach five years are few, small, and not consistent with each other.

Titanium, by contrast, has decades of follow-up across many designs. That does not make ceramic a poor choice. It means the two materials carry different amounts of evidence, and a choice between them should be made knowing that. Our companion guide, Ceramic versus titanium dental implants: compare evidence, design, and fit, covers the design and fit questions; this one looks only at what the studies say.

How to read an implant study

A few questions turn a headline percentage into something you can interpret.

• Survival or success? Survival means the implant is still in the mouth. Success is stricter: the implant is in place, the bone and gum around it are healthy, and there have been no significant complications. A study can report high survival and noticeably lower success. A cumulative survival figure adds up losses year by year over the whole follow-up period.
• How many implants, in how many people? Many zirconia cohorts contain fewer than a hundred implants. A single failure in a cohort of fifty moves the survival figure by two percentage points.
• How long, and how many came back? Five-year results are only as good as the share of the original patients who were actually examined at five years. Ask how many were lost to follow-up.
• Is the design still sold? Several implants in the zirconia literature were early one-piece designs that differ from what is placed today. Their results shaped the pooled figures but may not describe what is placed today.
• Who placed them, and who paid? University cohorts placed by experienced surgeons under study protocols can produce different results from everyday practice, and industry funding is worth noting even when the methods are sound.
• Pooled or single-cohort? A meta-analysis averages studies of different designs, surgeries and follow-up lengths. The average can be more precise and, at the same time, less relevant to any one implant.

What the reviews report

Pooled reviews across all designs

An early systematic review found 14 eligible studies among more than 1,500 screened titles. Pooling one- and two-piece zirconia implants, it estimated survival of 92 percent (95 percent confidence interval 87 to 95) after one year of function, with considerable variation between studies. Its authors judged the long-term evidence insufficient to justify routine use at that time, while noting that zirconia could be a non-metallic alternative to titanium.

A 2023 meta-analysis took in 25 studies covering 4,017 implants in 2,083 patients and estimated a ten-year cumulative survival of 95.1 percent. Two caveats matter. Only seven of the 25 studies followed patients beyond 60 months, so the ten-year estimate rests on a thin base of long studies. And of 172 failed implants, 47 were early failures and 26 were fractures, most of them in narrow-diameter implants. Survival was lower for implants whose upper portion had been adjusted with drills, and for two-piece compared with one-piece designs.

Randomized comparisons with titanium

Randomized trials are the fairest comparison, but there are few, and most are short. A 2023 meta-analysis located four randomized trials. Survival of zirconia implants was lower than titanium, but the difference was not statistically significant (risk ratio 0.91, 95 percent confidence interval 0.82 to 1.02), while the success rate was significantly lower (risk ratio 0.87, confidence interval 0.78 to 0.98). Probing depth, bleeding and plaque did not differ meaningfully, and the authors reported no meaningful difference in bone loss, although the 2024 analysis below did find one at twelve months.

A 2024 meta-analysis of six randomized trials, 152 patients and 448 implants (267 zirconia, 181 titanium) found that survival favored titanium, and that marginal bone loss (bone lost around the top of the implant, measured on X-rays) at 12 months was 0.42 mm around zirconia against 0.18 mm around titanium. The authors limit their conclusion to one-year follow-up. Whether a difference of about a quarter of a millimeter in the first year matters at five or ten years is one of the open questions.

Five-year prospective cohorts

Three five-year prospective studies, all of one-piece zirconia implants restored with ceramic crowns or bridges, show how widely results vary.

• Single crowns and three-unit bridges, 94.3 percent. One cohort reported cumulative five-year survival of 94.3 percent with marginal bone loss of 0.81 mm from placement to five years; 35 patients were examined at five years, and patients reported improvements in function, esthetics, speech and self-esteem.
• Single teeth with immediate temporaries, 78.2 percent. A second cohort placed 66 single-tooth implants in 65 patients, each fitted with a temporary crown right away and later with an all-ceramic crown. Fourteen implants were lost, for cumulative survival of 78.2 percent, and bone loss averaged 1.12 mm.
• Three-unit bridges with immediate temporaries, 66.67 percent. A third cohort placed 54 implants in 27 patients to support three-unit bridges, again provisionalized immediately. Eighteen implants were lost by five years, a cumulative survival of 66.67 percent, and surviving implants had lost a mean of 1.89 mm of bone. The authors described the survival as low.

The lesson is not that one set of figures is "right." It is that the specific design, the loading protocol and whether the implant carried a bridge or a single tooth changed the outcome more than the word "ceramic" did.

Two-piece ceramic implants

Two-piece designs, with a separate abutment attached to the implant as in most titanium systems, are the newest part of the zirconia literature. A 2025 systematic review found six eligible studies and 298 two-piece zirconia implants, with pooled survival of 96.31 percent, follow-up ranging from about 18 to 111 months, and success rates between 63 and 100 percent. The authors call them a possible alternative to titanium while warning that the small evidence base limits how far the findings can be generalized.

What tends to lower reported survival, and what tends to raise it

The research so far associates these features with poorer results:

• One-piece implants adjusted with a drill at the chairside, which showed lower survival in pooled analysis.
• Narrow diameters, where most of the reported fractures clustered. Zirconia is strong under compression but, unlike a metal, does not bend before it breaks, so fracture is the failure mode researchers watch most closely.
• Immediate temporaries in some series. The two lowest five-year cohorts above both used immediate provisionalization, although differences in design mean loading alone cannot be blamed.
• Bridges rather than single teeth in one cohort, although the study did not establish why.
• Smoking and poor oral hygiene. The FDA notes that smoking may affect healing and decrease the long-term success of an implant of any material, and that cleaning around the implant as instructed matters. Bone volume is a separate planning question, covered in the candidacy guide linked below.

Features associated with better results are, unsurprisingly, the mirror image: adequate diameter for the site, a design that does not need chairside drilling, careful case selection, and a maintenance program. The FDA advises that an implant of any material needs ongoing care, including cleaning around it as instructed and regular check-ups.

What is not known

• Ten years and beyond for current designs. The pooled ten-year estimate leans on a handful of long studies, most of them of older one-piece implants.
• Two-piece connections over time. The six studies pooled in the 2025 review covered fewer than 300 two-piece zirconia implants, and the longest follow-up among them was just over nine years.
• Full-arch use. Most of the studies above concern single teeth and short bridges, so the pooled figures say little about ceramic implants supporting a whole arch.
• Whether early bone-loss differences persist. The one-year gap seen in randomized trials has not been studied for long enough, in enough patients, to show whether it persists or closes.
• How ceramic implants behave once gum disease around them sets in, since most cohorts are too small to study complications in detail.

What this means at Loul Dental Studio

The practice lists computer-guided implant placement, including metal-free ceramic (zirconia) implants, among its services. This guide presents the evidence as it stands: ceramic implants have a shorter and less uniform record than titanium, and neither material is described here as superior. A preference for a metal-free material is a legitimate reason to choose a ceramic implant, in the same way a patient may prefer a tooth-colored filling, but it is a material choice, not a health treatment. The practice does not claim that a ceramic implant prevents disease, improves general health, or that a titanium implant harms it.

Whether a ceramic implant is sensible for a particular site depends on bone volume, the width available for an adequate implant diameter, bite forces, and the restoration planned, which is why the questions in Who may be a good candidate for a dental implant? come before the material question. Ask the office whether both materials are suitable options for your case and which design would be used, so that you can match it to the kind of study described here.

The next step

Bring your questions about evidence to the consultation and ask that the written plan name the material, the design (one-piece or two-piece) and the loading approach. Our guide Dental implants in Santa Barbara: what should a complete consultation include? lists what else that visit should cover. You can request an appointment online; a request is not a confirmed appointment, and the team will follow up to schedule.