Peri-implant Soft Tissue Response to Direct Zirconia-Based Composite Customized Healing Abutment: A Randomized Controlled Clinical Study With Biochemical Analysis
Phase: NA
Conditions: Missing Tooth
Sponsor: Ain Shams University

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Document date: 6\1\2025 
Peri-implant Soft Tissue Response to Direct Zirconia-
Based Composite Customized Healing Abutment: A 
Randomized Controlled Clinical study with Biochemical 
Analysis 
 
Thesis Protocol 
Submitted to the Department of Oral Medicine, Periodontology and Oral Diagnosis,  
Faculty of Dentistry, Ain Shams University 
In partial fulfillment of the requirements of the master’s degree in Periodontology 
 
 
 
By 
Ahmed Assem El Sayed Abd El Motaleb 
Master’s degree student in the Department of Oral Medicine, Periodontology & 
Oral Diagnosis, Faculty of Dentistry, Ain Shams University. 
BDS 2020 
(Faculty of Dentistry, Ain Shams University) 
 
ahmed.abdelmoteleb.std@dent.asu.edu.eg 
 
 
 
 
 
 
 

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Under the Supervision of: 
Prof Dr. Nevine Hassan Kheir El Din 
Professor and Head of Oral Medicine, Periodontology and Oral 
Diagnosis department 
 Faculty of Dentistry, Ain-Shams University 
 
 
Dr. Hadeel Gamal Salem Al Malahy 
Lecturer of Oral Medicine, Periodontology and Oral Diagnosis 
Faculty of Dentistry, Ain Shams University 
 
 
Prof Dr. Olfat Gamil Shaker  
Professor of Medical Biochemistry and Molecular Biology 
 Faculty of Medicine Cairo University 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
Ain Shams University 
Faculty of Dentistry 
2025 
 
 

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Table of Contents 
 
Topic 
Page 
I. Abstract 
4 
II. Background 
5 
III. Research Question 
6 
IV. Aims (Objectives) 
7 
V. Hypothesis 
8 
VI. Ethical Considerations 
9 
VII. Study design 
9 
VIII. Materials and Methods 
• Study setting  
• Sample Size 
• Study Procedures 
10-13 
IX. Statistical Analysis 
14 
X. Funding of the Study 
14 
XI. References 
15 
 
 
 
 
 
 
 
 
 
 
 
 
 

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I-Abstract 
Statement of problem: Light-cured direct zirconia-based composite has many 
potential uses in dentistry, because of mechanical and biological reasons 
maintaining the health of peri-implant soft tissues during healing. Direct zirconia-
based composite customized healing abutments have superior properties such as 
biocompatibility, chemical stability, antibacterial and mechanical properties. 
Aim of the study: This study will be carried out to compare zirconia-based 
composite customized healing abutments vs conventional composite customized 
healing abutment placed simultaneously with delayed dental implant placement. 
Materials and Methods: This will be done by clinical evaluation of peri-implant 
soft tissue changes. Moreover, peri‑implant sulcus fluid (PISF) will be measured 
for the level of Interleukin-1 beta (IL-1β) in the gingival crevicular fluid. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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II. Background 
In the field of dental implantology, healing abutments play a critical role in peri-
implant tissue healing and are traditionally designed as prefabricated 
components, typically made of titanium. 
These abutments have been effective but are limited by their cylindrical shape, 
which may not mimic natural soft tissue profiles, leading to less favorable 
aesthetic and functional outcomes.  
To address these limitations, the use of customized healing abutments as a 
treatment strategy, was potentially able to give better results in terms of both soft 
and hard tissues (Almadani et al., 2023).                                                                               
Customized healing abutments can be fabricated by advanced materials like 
PEEK, PMMA, zirconia, resin composite, and titanium have been explored 
(Chokaree et al., 2022). 
Composite materials with nano-zirconium fillers are gaining attention for their 
ability to combine both biological and mechanical advantages (Hu et al., 2019). 
Nano-zirconium fillers, embedded within the resin composite matrix, enhance the 
material’s strength, durability, and wear resistance while maintaining its 
biocompatibility and chemical stability (Bannunah, 2023). 
Long-term randomized clinical controls have shown excellent soft tissue texture, 
quality and health when zirconia is used subgingivally and supragingivally and 
shows a qualitatively improved level of interaction between oral tissues and 
ceramic dental components made from ZrO2  (Kunrath et al., 2021). 
Additionally, these nano-zirconium filler-based composites offer improved 
aesthetic outcomes due to their tooth-like translucency, making them ideal for 
anterior regions where appearance is critical.  
From a biological perspective, compared to TiO2 particles, ZrO2 particles caused 
reduced toxicity and inflammatory cytokine production (Ramenzoni et al., 2021). 
Monitoring inflammatory markers like interleukin-1 beta (IL-1β) can provide 
valuable insights into the peri-implant tissue response and help compare the 
performance of these novel materials to traditional titanium healing abutments 
(Khatri et al., 2022). 
Understanding the comparative benefits of these materials could inform clinical 
decisions and improve patient outcomes in dental implant therapies could inform 
clinical decisions and improve patient outcomes in dental implant therapies. 

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II-Research Question 
 
“Do direct zirconia-based composite customized healing abutments have a 
favorable effect on peri implant soft tissue that may be related to the superior 
biological properties of zirconium nano particles regarding increased 
biocompatibility and decreased inflammatory response?” 
 
                                   PICOTS Elements: 
Patient/Problem 
Patients that are eligible for implant 
placement within inclusion criteria. 
Intervention 
Zirconia-based 
composite 
customized 
healing abutment. 
Comparator  
Conventional 
composite 
customized 
healing abutment. 
Outcome  
Clinical evaluation of peri-implant soft 
tissue changes via pink esthetic score 
and papilla index. 
Biochemical assessment of IL-1β level in 
the 
gingival 
crevicular 
fluid 
using 
Periopaper strip. 
Time  
Baseline, 1,2 and 3 months after 
implantation. 
Setting 
Faculty 
of 
Dentistry, 
Ain 
Shams 
University. 
 
 
 
 
 
 
 
 
 

7 
 
 
 
 
 
 
 
IV.Aim of the study 
This study will be carried out to compare between direct zirconia-based 
composite customized healing abutments vs conventional composite 
customized healing abutments placed simultaneously with delayed dental 
implant placement. 
 
Primary outcome: 
Clinical evaluation of Pink Esthetic Score (PES) and Papilla Index. 
 
Secondary outcome: 
Determine the impact of the customized healing abutment on the level of 
Interleukin-1 beta (IL-1β) in the gingival crevicular fluid. 
 
Clinical Relevance: 
The result will affect the gold standard in choosing the customized healing 
abutment material for implant patients, regarding which one offers better peri-
implant soft tissue results, healing stimulation, and less inflammatory response. 
 
 
 
 
 

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• Hypothesis: 
Direct zirconia-based composite customized healing abutments do not have a 
significantly different effect on peri-implant soft tissue compared to 
conventional composite customized healing abutment in terms of biological 
properties or biocompatibility or inflammatory response. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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VI.Ethical consideration 
•Risk and discomfort of patients: This research will be conducted with 
consideration of patient safety and with attempts to reduce discomfort to patient, 
risks include postoperative pain, edema that can be controlled with medication. 
•Minimization of the risk: Patient baseline vitals will be taken before any 
medical procedure to ensure patients safety. Moreover, all medical operation 
will be conduct under standardized infection control procedure. 
•Criteria for Discontinuation of Study/patient: patient will be allowed to 
leave study if developed any complications either related to the study 
intervention or related to the general condition of the patient. The patient will 
have the right to withdraw from the study at any time.  
•Benefits to the Patients and to the Community: patients will receive an 
aesthetically and functionally implant with no cost. The community will benefit 
from this study by having a wider range of healing abutments to choose from. 
•Privacy: All patients identification including patient data and pictures will be 
locked and not shared.  
•Confidentiality: patient’s data will be treated with utmost confidentiality. In 
which no personal other than the researchers will be able to view the patient’s 
data. 
•Data Management: All patient’s data will be saved on researcher’s personal 
laptop that are not connected to any intranet connections and no copies will be 
made in any kind of database. 
•Consent Procedures if Applicable: any medical procedures and photographs 
will have a printed written consent form. 
•Patient Informed Consent Form: a proper consent form will be formulated 
&signed by the patient before starting any procedure. 
 
 
VII. Study Design: 
Randomized, controlled, parallel design, two arms clinical trial. 
 

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VII. Materials and Methods: 
 
• Study Setting: Faculty of Dentistry, Ain Shams University. 
 
 
• Sample Size Calculation: A power analysis was designed to have 
adequate power to apply a two-sided statistical test of the null hypothesis 
that there is no difference would be found between different tested groups 
regarding pink esthetic score. By adopting alpha (α) and beta (β) levels of 
(0.05) (i.e. power=95%) and an effect size (d) of (1.87) calculated based 
on the results of a previous study1; the total required sample size (n) was 
found to be (18) cases (i.e., 9 cases per group).  Sample size was increased 
to account for possible dropout during different follow up intervals to be 
(22) cases (i.e., 11 cases per group). Sample size calculation was performed 
using R statistical analysis software version 4.3.2 for Windows. 
 
• Eligibility criteria: 
Inclusion Criteria: 
1.Patients should be systematically free from any disease as according to 
Cornell Medical Index-Health Questionnaire (Pendleton et al., 2004). 
2.Both genders. 
3.Age from 20-50 years. 
4.Missing tooth to be restored with standard implant, with no need for 
additional bone and soft tissue augmentation procedures (Beretta et al., 
2019). 
5.Implants primary stability ISQ ≥ 70 unites using the Osstell Mentor 
(Baltayan et al., 2016). 
6.Sound Mesial and distal neighboring teeth. 
7.At least 6 natural teeth remaining in the same arch . 
8.Mouth opening   ≥ 30mm. 
9.Thick phenotype. 
 
 
 
 

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Exclusion Criteria: 
1)Poor oral hygiene condition. 
2)Pregnant and lactating females. 
3)Smokers. 
4)Vulnerable groups (Prisoners and handicaps). 
Justification for Exclusions: 
To reduce any confounding factors and biases that may affect the results of this 
study. 
 
Study procedures: 
1- Randomization and allocation concealment technique: Patients will be 
randomly allocated according to predetermined computer-generated 
randomization using www.Randomizer.org  
 
 
2- Details of the interventions, testing and follow up: 
• Group I (Customized Zirconia-Based Composite Healing Abutment):  
11 patients will receive delayed implant and a customized zirconia-
based composite healing abutment placed simultaneously with 
implant surgery. 
 
• Group II (Customized Conventional Composite Healing Abutment): 
11 patients will receive delayed implant and a customized 
conventional composite healing abutment placed simultaneously 
with implant surgery. 
 
 
 
 
 
 
 
 

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Study protocol and surgical steps: 
This protocol will be reviewed by the Research Ethical Committee at 
Faculty of Dentistry,Ain Shams University. 
A) Presurgical procedures: 
1)Detailed clinical examination, full history, and radiographic 
examination (CBCT) will be performed initially to aid in patients’ 
selection. 
2)After enrollment, all participants will sign the informed consent.  
3)All participants will be subjected to periodontal phase I treatment 
including periodontal supra- and sub-gingival debridement and oral 
hygiene instructions. 
 
B) Surgical procedures: 
1)After local anesthesia administration, flap is raised, osteotomy site 
preparation, and implant will be placed. 
2)Check the ISQ to exceed or equal 70 unit. 
3)A customized Light-cured Direct Zirconia-Based Composite or A 
customized Light-cured Direct Convential Composite  Healing Abutment 
will be placed. 
 
       Assessment: 
• 
Clinical assessment. 
• 
Biochemical assessment. 
 
Clinical Parameters Included: 
 
1-Clinical evaluation of soft tissue: 
Pink Esthetic Score (PES) and The Papilla Index will be evaluated and 
changes between the two groups will be compared at baseline, 1,2 and 3 
months (Almadani et al., 2023). 
 
 
 
 
 

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 Pink esthetic Score : 
  
 
 
 
 
 
 
 
 
           Papilla index : 
 
           
 
 
 
2-Peri-implant sulcular fluid samples: 
Peri-implant sulcular fluid sampling will be performed at the dental implant 
sites after 2 months of implant placement (Lashkarizadeh et al., 2022). 
Using standardized Periopaper paper strips. Paper strips will be placed at the 
entrance of the peri‐implant sulcus and will be inserted to a standardized depth 
of 1 mm at each site regardless of the PD. In order not to affect the actual fluid 
volume, sampling time will also standardize as 30 s. Samples with evidence of 
gingival bleeding were not included. The PISF samples will then be placed in 
sterile, wrapped Eppendorf tubes and stored until the day of laboratory analysis 
(Tözüm et al., 2007). 
 
3- Blinding techniques: Single blinding (The data analysts are unaware of the 
treatment the participant receives). 
Variables 
0 
1 
2 
Papilla – M 
Missing 
Incomplete 
Complete 
Papilla – D 
Missing 
Incomplete 
Complete 
Tissue contours 
Unnatural 
Virtually natural 
Natural 
Gingival level 
>2 mm 
1—2 mm 
<1 mm 
Alveolar process Clearly resorbed 
Slightly resorbed No difference 
Coloring 
Clear difference 
Slight difference No difference 
Soft tissue 
texture 
Clear difference 
Slight difference No difference 
Description 
Variables 
No papilla 
0 
Less than half of the height 
1 
Half or more of the height 
2 
Papilla fills entire proximal space 
3 
Papilla is hyperplastic 
4 

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IX. Statistical Analysis: 
Statistical methods: 
Categorical data will be represented as frequency (n) and percentage (%) and will 
be analyzed using chi square test. Numerical data will be explored for normality 
by checking the data distribution, calculating the mean and median values and 
using Shapiro-Wilk tests. If the data is found to be normally distributed, it will be 
presented as mean and standard deviation values and independent t-test will be 
used for the analysis. If the assumption of normality is found to be violated; the 
data will be presented as median and range values and will be analyzed using 
Mann-Whitney U test. The significance level will be set at p<0.05 for all tests. 
Statistical analysis will be performed with R statistical analysis software version 
4.3.2 for Windows. 
 
 
X. Funding of the Study : 
This study will be personally funded by the researcher. 
 
 
 
 
 
 
 
 
 
 
 

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XI. References 
Almadani, T. M., Amer, A.-F. M., Abdallah, H. M., & El Sayed, I. S. 
Clinical and radiographic evaluation of peri-implant tissue changes 
associated with use of standard versus customized healing abutments. Al-
Azhar Journal of Dental Science (2023), 26(2), 229–239.  
Baltayan, S., Pi-Anfruns, J., Aghaloo, T., & Moy, P. K. The predictive value 
of resonance frequency analysis measurements in the surgical placement 
and loading of endosseous implants. Journal of Oral and Maxillofacial 
Surgery (2016), 74(6), 1145–1152. 
Bannunah, A. M. Biomedical Applications of Zirconia-Based Nanomaterials: 
Challenges and Future Perspectives. Molecules (Basel, Switzerland) (2023), 
28(14).  
Beretta, M., Poli, P. P., Pieriboni, S., Tansella, S., Manfredini, M., Cicciù, 
M., & Maiorana, C. Peri-implant soft tissue conditioning by means of 
customized healing abutment: A randomized controlled clinical trial. 
Materials (2019), 12(18).  
Chokaree, P., Poovarodom, P., Chaijareenont, P., Yavirach, A., & 
Rungsiyakull, P. Biomaterials and Clinical Applications of Customized 
Healing Abutment—A Narrative Review. Journal of Functional 
Biomaterials (2022), 13(4), 291.  
Hu, C., Sun, J., Long, C., Wu, L., Zhou, C., & Zhang, X. Synthesis of nano 
zirconium oxide and its application in dentistry. Nanotechnology Reviews 
(2019), 8(1), 396–404.  
Khatri, M., Bansal, M., Puri, K., Mehrotra, S., Kumar, A., & Rehan, M. 
Evaluation of the correlation between interleukin 1β levels in peri-implant 
crevicular fluid as an adjunctive diagnostic marker with clinical and 
radiographic parameters for assessing the peri-implant health status. 
National Journal of Maxillofacial Surgery (2022), 13(3), 421.  
Kunrath, M. F., Gupta, S., Lorusso, F., Scarano, A., & Noumbissi, S. Oral 
Tissue Interactions and Cellular Response to Zirconia Implant-Prosthetic 
Components: A Critical Review. Materials (2021), 14(11), 2825.  

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       Lashkarizadeh, N., Foroudisefat, M., Abyari, S., Mohammadi, M., & 
Lashkarizadeh, L. Is It Safe to Reuse Healing Abutments? An 
Experimental Study on IL-1β and TNF-α Cytokine Levels in Peri-Implant 
Crevicular Fluid. Journal of Prosthodontics (2022), 31(5), 399–404.  
       Pendleton, N., Clague, J. E., Horan, M. A., Rabbitt, P. M. A., Jones, 
M., Coward, R., Lowe, C., & McInnes, L. Concordance of Cornell 
medical index self-reports to structured clinical assessment for the 
identification of physical health status. Archives of Gerontology and 
Geriatrics (2004), 38(3), 261–269.  
Ramenzoni, L. L., Flückiger, L. B., Attin, T., & Schmidlin, P. R. Effect 
of Titanium and Zirconium Oxide Microparticles on Pro-Inflammatory 
Response in Human Macrophages under Induced Sterile Inflammation: An 
In Vitro Study. Materials (2021), Vol. 14, Page 4166, 14(15), 4166.