Zirconia, titanium, and polyetheretherketone implant abutments show equal long‐term clinical success—A systematic review and network meta‐analysis

Hundreds of millions of people have one or more missing teeth. Consequently, a substantial number of patients undergo implant therapy each year. However, technical complications and soft tissue inflammation associated with the implant abutment or the type of restoration can lead to bone loss and, ultimately, implant failure. Using the methodology of network meta-analysis to rigorously compare and contrast the clinical performance of the three commonly used abutment materials: titanium (Ti), zirconium (Zr), and polyetheretherketone (PEEK) polymer. Until May 2025, a systematic search was performed in MEDLINE (PubMed), EMBASE, Scopus, and CENTRAL to find clinical studies comparing Ti, Zr, and PEEK implant abutments. Case reports, case series, in vitro, and in vivo studies were excluded. The Risk of Bias Tool 2, ROBINS-I, and GRADE approaches were used for quality and certainty assessment. Thirty-four articles (950 patients) were included, with various follow-ups. All abutments had high survival rates and no significant differences in marginal bone loss (BL), probing depth (PD), bleeding on probing (BOP), and plaque index (PI). There was no significant difference between Zr and Ti for papillary index (PAP), with a general trend toward better results in Zr, which may be of clinical significance. There was a statistically significant difference in soft tissue discoloration (ΔE) values and technical complications of Zr versus Ti [MD: -2.03, CI: -3.89 to -0.18] and [OR: 0.26, CI: 0.09 to 0.72], respectively, indicating better esthetics and fewer technical complications in Zr. Both Ti and Zr are clinically successful and biologically acceptable. PEEK abutments demonstrated comparable characteristics with both Ti and Zr. However, more studies about PEEK and cost-effectiveness analyses should also be performed to find the best options for clinical applications. PEEK can be a good alternative to Ti and Zr abutments for single-tooth replacement in the anterior and premolar regions.