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Journal of Prosthodontic Research 57 (2013) 219223

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Original article

The effect of fatigue loading on the screw joint stability

of zirconium abutment
Mitsuyoshi Tsumita DDS, PhDa,*, Yuji Kokubo DDS, PhDb,
Takamitsu Kano DDS, PhDb, Keita Sasaki DDS, PhDb
a

Division of Oral and Maxillofacial Implantology, Tsurumi University, School of Dental Medicine, 2-1-3 Tsurumi, Tsurumi-ku, Yokohama City, Japan
b
Department of Fixed Prosthodontics, Tsurumi University, School of Dental Medicine, 2-1-3 Tsurumi, Tsurumi-ku, Yokohama City, Japan
Received 7 April 2012; received in revised form 27 November 2012; accepted 25 February 2013
Available online 21 June 2013

Abstract
Purpose: This study evaluated the effect of fatigue loading on the screw joint stability of a zirconium abutment connected to an external hexagon
implant in vitro.
Materials and methods: Fifteen titanium and 15 zirconia abutments of 3 different heights (5, 8, and 11 mm) were connected to external titanium
implants with titanium screws. A torque gauge was used to measure the reverse torque values before and after loading. An air cylindrical loading
device was used to simulate mastication at a 45-degree angle to the longitudinal axis of the implant.
Results: There were significant differences (P < 0.05) before and after the loading of titanium (5 mm) and zirconia (5, 8, and 11 mm) abutments.
Conclusion: Zirconia abutments for external hexagon implants had durability rates similar to those of titanium abutments after repeating load on
the reverse torque of the abutment screw, indicating that the zirconia abutment could be reliably used instead of the titanium abutment.
# 2013 Japan Prosthodontic Society. Published by Elsevier Ireland. All rights reserved.
Keywords: Zirconia abutment; Screw; Implant; External hexagon

1. Introduction
Recently, implant-supported restorations have become
increasingly popular, and patients are demanding a more
natural-looking outcome in not only the anterior but also the
posterior regions. Among the major concerns are darkness of
soft tissue around the implant margin and unexpected soft tissue
recession around the implant, results of the thickness of soft
tissue and an inappropriate position or direction of implant
placement. In such cases, the use of tooth-colored abutments
and crowns without metal is recommended. To improve esthetic
results, all-ceramic materials are frequently used for implants,
abutments, and crowns. The abutment material has been
changing from titanium to zirconia, which has high translucency and mechanical strength and could create an ideal
emergence profile and crown margin.
Screw joint failures have been reported by many clinical
researchers, especially in cases of single-tooth replacement

* Corresponding author. Tel.: +81 45 581 1001; fax: +81 45 573 9599.
E-mail address: tsumita-mitsuyoshi@tsurumi-u.ac.jp (M. Tsumita).

using a titanium abutment with a titanium implant [15]. The

introduction of the zirconia abutment based on CAD/CAM
technology has provided new opportunities for esthetic implant
restorations. The Dental CAD/CAM GN-I (GC, Tokyo, Japan),
introduced to the market in 1999, can produce titanium,
aluminum, and zirconia copings and abutments [6]. Kokubo
et al. [7] have shown that the technology can fabricate clinically
acceptable copings on the marginal fit to the natural teeth.
As far as the authors know, only six kinds of zirconia
abutments are available from companies such as Nobel Biocare
and Astra Tech. There have been no reports on the durability of
zirconia abutments with titanium implants. Abutments connected with implants inherently receive high stress in the
cervical area, where abutment screws apply high bending
stress, the reported cause of prosthetic and osseointegration
failure [8].
In this study, the effect of fatigue loading simulated in the
oral environment and caused by masticatory movement on
screw joint stability was analyzed. An air cylindrical cyclic
loading device was used to simulate mastication.
The purpose of this study was to evaluate the stability of
abutment screws connected to external hexagon implants and

1883-1958/$ see front matter # 2013 Japan Prosthodontic Society. Published by Elsevier Ireland. All rights reserved.
http://dx.doi.org/10.1016/j.jpor.2013.02.004

M. Tsumita et al. / Journal of Prosthodontic Research 57 (2013) 219223

220

Fig. 1. Titanium and zirconium abutments used in this study.

Fig. 2. Air cylindrical cyclic loading device to simulate mastication (Upper).

Specimen holder mounted in position under loading stylus (Lower).

zirconia abutments of different heights. The reverse torque of

the abutment screw was measured before and after loading. The
reverse torque values were also compared at various loading
points. Titanium abutments were used as controls for
comparison.
2. Materials and methods
Thirty titanium implants (GC implant Re, GC) with an
external hexagon shape (length, 12 mm; diameter, 3.8 mm)
were positioned in an acrylic block with a center hole 5 mm in
diameter and 13 mm in depth. The implants were embedded in
the center hole with autopolymerizing resin (Pattern resin, GC)
using a surveyor so that the platform of the implant was 1 mm
above the edge of the acrylic block, which was perpendicular to
the surveyor arm. The implants were divided into two groups.
The master abutments, the heights of which were 5, 8, and
11 mm, were waxed up using a temporary plastic cylinder
(GC). Then, custom-made titanium abutments were fabricated
using a CAD/CAM system (Dental CAD/CAM GN-I, GC).
Zirconia abutments were milled from presintered zirconia
block and then were completely sintered. Fifteen titanium and
15 zirconia abutments of 3 different heights were made from
each type of block (Fig. 1). Each group was divided into three
subgroups of five specimens each. Each abutment and implant
was connected with titanium screws (UCLA abutment screw,
GC) at 35 N cm using a torque wrench (Ratchet wrench, GC).
A torque gauge (Tohnichi Mfg, Tokyo, Japan) was used to
measure the reverse torque value of each abutment, which
showed the load value to screw loosening. Each abutment was

Fig. 3. Mean reverse torque values before and after loading.

measured, and the average value was obtained as before

loading. Then, each specimen was retightened using the same
torque wrench. An air cylindrical cyclic loading device was
used to simulate mastication (Fig. 2). According to the method
reported by Nishimura [9], each specimen was firmly mounted
in a stainless holder, which was loaded at a 45-degree angle to
the longitudinal axis of the implant abutment, and dynamic
vertical loading was applied on the top of each abutment with
250 N (from 0 to 250 N). Then, up to 100,000 loads were
conducted with a contact time of 0.2 seconds at a frequency of
1 Hz, as reported by Lee et al. [10]. The temperature of each
specimen was maintained at 37 8C by means of a thermostatically controlled water-circulating device. After the
repeating loads were finished, the reverse torque value of
each abutment was measured, and the average value was
calculated.

M. Tsumita et al. / Journal of Prosthodontic Research 57 (2013) 219223

221

Fig. 4. Fractured zirconium abutment after loading and magnification image.

After loading, all implant platform surfaces, hexagons, and

circular forms of loading groups were observed through an
optical microscope (SZH 10, Olympus, Tokyo, Japan).
The differences between the groups were calculated by using
SPSS Base 10.0 software (SPSS, Chicago, IL, USA) with
ANOVA and were compared with each other using the Games
Howell test at a significance level of 0.05 for comparisons
among individual mean values of the test groups.
3. Results
The mean reverse torque values before and after repeating
load with different abutment materials and heights are shown in
Fig. 3. There were no screw loosenings during repeating load,
and all abutment screws for titanium and zirconia abutments
were stable. After repeating load, all abutments showed
decreased values compared to those before loading, and
zirconia abutment tended to show a high degree of decrease.
For the zirconia abutment group, minor chipping was
detected in 4 specimens at the abutment margin of the loading
side (Fig. 4). There were no deformations such as pressure spots
around the implant platform.
There were significant differences before and after the
loading of titanium (5 mm) and zirconium (5, 8, and 11 mm).
However, there were no significant differences among abutment
heights after repeating loads.
4. Discussion
In this study, the repeating loads were applied to the
abutment screws through the abutments in order to simulate the
oral condition for the anterior segment. During testing, no
screws were loosened; however, in clinical studies, the most
frequent problem after functioning was screw failure [15]. The
use of a torque wrench to tighten the screws with the
recommended force to prevent screw loosening is strongly
recommended by the manufacturer [11]. With old implant
systems, clinicians tightened screws using only a hand driver.
When a hand driver was used, the maximum torque to the

abutment in a limited access space was up to 12.913.5 N cm.

There were no statistical differences in the clinicians years of
clinical practice [12]. Low torque was one of the main reasons
for screw loosening; another reason was physical characteristics of the screw materials, which prevented the flexure and
deformation of screws. Screw stability is influenced by the
geometry of the screw, the contact between the screw head and
abutment screw bore, material properties of the screw, and
similar factors. The screws used in this implant system must be
predictable in severe conditions. The abutment screw of the GC
implant system was made of grade 2 titanium alloy. When gold
abutment is used, screw loosening may be reduced [13]. Some
abutment screws have a surface treatment which could erode
and lead to screw loosening. Martin et al. [14] reported different
preload values among abutment screw materials. In this study,
new abutments were always used in order to avoid errors in data
collection. Some manufacturers have recommended that the
abutment screw and implant should be tightened after a 10-min
wait and that retorquing to the same value should be performed
[15,16]. The implant used in this study did not come with such a
recommendation.
Many factors will affect the stability of a screw joint:
excursive contacts, off-axis centric occlusal contacts, interproximal contacts, and cantilever contacts. Preload is determined by the tightening torque and any misfit between the
abutment and the external hexagon [17]. One report showed a
correlation between implant/abutment rotational misfit and
screw joint failure [1821]. The rotational misfits of the GC
implant system with titanium and zirconia abutments were 1.08
and 1.68, respectively, within the improvement range of the
screw joint stability. The fit of the external hexagon of the
implant and the internal hexagon of the abutment should be less
than 5 degrees of the rotational movement [20]. Reducing misfit
between abutment external hexagons will eliminate the
problem of screw loosening [21].
The external hexagon design of an implant was first
introduced by Branemark. These kinds of implant systems have
been in common use longer than the taper joint system has, but
the latter has greater abutment stability [22]. The GC implant

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M. Tsumita et al. / Journal of Prosthodontic Research 57 (2013) 219223

system also has a 0.65 mm high external hexagon. English [23]

reported that the optimal height of the external hexagon was
1.2 mm, which might protect the screw from the bending effect.
Further studies will be needed to evaluate the effect of the
differences of implant/zirconia abutment interface on the
durability of the implant/abutment connection.
The repeating load applied on a single implant in this study,
as in other studies, simulated the lateral force of the oral
environment, which would affect screw stability [16,24].
Functional loading, such as repeating load, will gradually lead
to the effective erosion of the preload of the screw joint and
then decrease the reverse torque values. After the repeating
load, four specimens of zirconia abutment, 5, 8, and 11 mm in
height, fractured from the cervical area of the loading side.
However, optical microscope observation revealed that after
loading there were no defects on the surfaces of the implant
platforms and the external hexagons of both abutments. This
result indicates that yttrium-stabilized zirconia has high
compressive strength but low tensile strength, so the fracture
area might have been exposed to tensile force from the external
hexagon due to repeating load. The abutment screw was not
able to bend in a group of higher abutments. In general, the
greater the abutment height, the greater the bending force. In
this study, for the titanium group, only the 5 mm abutment
decreased significantly, whereas for the zirconia group, all
heights of abutment groups decreased significantly. Titanium
is not fragile material different from zirconium. Therefore, it
seemed that the titanium abutment imbibed repeating load.
However, the 5 mm abutment decreased significantly. This
may be from a reason that repeating load applied to implant/
abutment connection directly. There were no significant
differences among the 3 groups. These results indicate that
abutment height, or loading point, did not affect the implant/
abutment stability.
The implant/abutment complex was bent as a single unit, as
described by Khraisat et al. [25]. This study was conducted
without final restoration; in a clinical situation, the abutment
would be protected by the prosthesis-like ferrule effect.
The abutments used in this study were made using CAD/
CAM technology and were designed to engage the implant
hexagon directly. Vigolo et al. [26] evaluated Procera
abutments with a hexagonal connector and concluded that
the hexagonal misfit of the Procera abutment on the implant
hexagon may be implicated in screw joint loosening. If
micromotion occurs between the titanium implant and
zirconia abutment, the implant hexagon will be abraded
and wear; as a result, the screw will loosen. Concerning the
misfit of recently introduced ceramic abutments, Garine et al.
[27] showed that the presence of a metal collar in the zirconia
abutment improved the rotational misfit compared with the
all-ceramic abutment, which might resist screw loosening. In
the present study, fitting between the implant platform and
abutment could not be identified. Further studies will be
needed to investigate the vertical and hexagonal misfit before
and after repeating load.
Breeding et al. [15] evaluated the effect of the adhesion
sealant on the torque required to loosen the screws. However,

they did not comment on the reaming sealant used when

abutment screws were changed.
Because of their esthetic value, zirconia abutments and
zirconia crowns will become more popular in implant
restorations. There has been only one clinical report on the
evaluation of zirconia abutments of single-tooth restorations.
Glauser et al. [28] reported that two abutments were loosened in
the restorations, which was in agreement with similar studies on
titanium abutments. Furthermore, they emphasized the need for
information concerning an adequate fit for ceramic abutments
because if there is no rotational freedom between the ceramic
abutment and the implant, the ceramic material could fracture
when it is fit tightly. Long-term clinical research will be needed
to determine the predictability of zirconia abutments.
The hypothesis that lateral cyclic loading for zirconia
abutments would affect the reverse torque values of the
abutment screw was confirmed.
5. Conclusions
The data obtained from this study support the following
conclusions:
1. Zirconia abutments for external hexagon implants had
durability rates similar to those of titanium abutments after
repeating load on the reverse torque value of the abutment
screw, and zirconia abutment could reliably be used instead
of titanium abutment.
2. No damage was detected on the platform and external
hexagon after repeating load for both abutments.
3. The loading point did not affect the reverse torque value.
4. After repeating load, the reverse torque value of the zirconia
abutment showed a tendency to decrease greatly.

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