Examination of the implantabutment interface after fatigue testing

Roman M. Cibirka, DDS, MS,a Steven K. Nelson, DMD,b Brien R. Lang, DDS, MS,c and
Frederick A. Rueggeberg, DDS, MSd
School of Dentistry, Medical College of Georgia, Augusta, Ga., and School of Dentistry, University of
Michigan, Ann Arbor, Mich.
Purpose. This study examined potential differences in detorque values of abutment screws after fatigue
testing when the dimensions between external implant hexagon and internal abutment hexagon were
altered or the implant external hexagonal shape was eliminated.
Material and methods. Three subsets (N = 10) of NobelBiocare implants were assessed: (1) standard
external hexagon (R), (2) modified hexagon (M), and (3) circular (C) platform geometry. Thirty Procera
machined abutments with 25-degree angulated loading platforms were manufactured. Abutments were
retained with gold Unigrip abutment screws tightened to 32 N/cm with an electronic torque controller.
Vertical scribes across the implantabutment interface allowed longitudinal displacement evaluation. A
carousel-type fatigue testing device delivered dynamic loading forces between 20 and 200 N for
5,000,000 cycles, or the approximate equivalent of 5 years in vivo mastication, through a piston to the
abutment platform. Macroscopic and radiographic examination of the implant/abutment specimens was
performed. The abutment screws were removed and the detorque values recorded. Bearing surfaces were
examined microscopically.
Results. No abutment looseness or longitudinal displacements at the implantabutment interface were
noted. Radiographic examination demonstrated no indication of screw bending or displacement. The mean
detorque values for R, M, and C were 14.40 1.84 N/cm, 14.70 1.89 N/cm, and 16.40 2.17 N/cm,
respectively. The analysis of variance demonstrated significant differences between only designs R and C
(P=.031).
Conclusion. Increasing the vertical height, or degree of fit tolerance, between the implant external
hexagon and the abutment internal hexagon or completely eliminating the implant external hexagon did
not produce a significant effect on the detorque values of the abutment screws after 5,000,000 cycles in
fatigue testing, or the equivalent of 5 years of mastication for the implant/abutment specimens evaluated.
(J Prosthet Dent 2001;85:268-75.)

CLINICAL IMPLICATIONS
Clinicians using implant and abutment systems with an external hexagonal design
and gold alloy screw requiring 32 N/cm tightening torque may infer that implant
hexagons only aid surgical placement into bone and perhaps orientation of the abutment to the implant. The implant hexagon may not influence force distribution or
rotation resistance and may therefore affect the attainment of optimum preload during initial abutment screw tightening.

uccessful implant therapy requires a dynamic equilibrium between biologic and mechanical factors. The
biologic factors are generally considered multifactorial,

Presented before the 2000 Academy of Prosthodontics Annual

Session, Quebec City, Quebec, Canada.
Supported by NobelBiocare and the University of Michigan Center
of Excellence.
aAssistant Professor, Department of Oral Rehabilitation, Medical
College of Georgia.
bAssociate Professor, Department of Oral Rehabilitation, Medical
College of Georgia.
cProfessor Emeritus, Department of Prosthodontics, University of
Michigan.
dProfessor, Section of Dental Materials, Medical College of Georgia.
268 THE JOURNAL OF PROSTHETIC DENTISTRY

whereas mechanical failure has been associated with

screw joint instability between the abutment and the
implant. In tightening the abutment screw, a compressive force is generated that maintains contact between
the implant-bearing surface and the bearing surface of
the abutment. The success of this screw joint is directly related to the stretch of the abutment screw or the
preload achieved from the tightening torque and
maintenance of this preload over time. If the screw
loosens and the preload falls below a critical level, joint
stability may be compromised and may potentiate clinical failure.
Bickford1 described the process of screw loosening in
2 stages. Initially, external forces, such as mastication,
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CIBIRKA ET AL

applied to the screw joint cause thread slippage, contributing to release of the stretch, or preload, of the
screw. The second stage of loosening involves continual preload reduction below a critical level, allowing
threads to turn and loss of intended screw joint function. Screw loosening has been reported as a function
of implant and prosthetic component design.2,3
Loosening with hexagonal screw joint design ranged
between 6% and 48%.4-17 The fit tolerance between
the external implant hex and the internal abutment
hex has been suggested as a primary cause of screw
loosening by clinicians and researchers.
Numerous investigators have examined the
implantabutment screw joint.15-47 Many studies have
dealt with the assembly mechanisms and reported that
an inaccurate interface places excessive stresses on the
abutment screw joint, creating instability.29,45
Binon29,46,47 stated that rotational movement or stability of the abutment screw was directly correlated
with the fit tolerances of the flat-to-flat of the implant
hexagon to the abutment internal hexagon walls.
Binon29,46,47 further suggested that a 0.005 mm mean
flat-to-flat measure on the same hex and a total flat-toflat range of less than 0.015 mm for the entire
hexagonal design would result in a more stable screw
joint. It has also been suggested that the hexagon
height extending from the implant-bearing surface
may contribute to screw joint stability. Ohrnell et al26
recommended that the external hexagon connection
be a minimum of 1.2 mm in height to provide both
lateral and rotational stability, particularly in
single-tooth applications.
Conceptually, a more accurate hex-to-hex fit tolerance will improve force distribution to the supporting
bone, allow less relative movement of the abutment to
the implant fixture, and reduce the potential for screw
loosening and bending. Likewise, a higher hexagon
has been suggested to reduce screw loosening and
bending. Short, narrow external geometry of the
hexagon appears to be particularly vulnerable to loosening because of the limited engagement of the
external member and the presence of a short fulcrum
point.24,25 Overall, most investigators claim the better
the maintenance of preload, the better the long-term
stability of the joint.
Fatigue testing with different fit tolerances may be
used to evaluate the hexagonal screw joint stability. In
this type of assessment, the abutment screw is tightened using the recommended or optimum torque.
After fatigue testing, the screw is detorqued, and the
measured value of the specimen is recorded. In this
protocol, 3 assumptions are necessary: (1) the abutment screws are all loaded with the same preload after
initial tightening; (2) the detorque value is a measure
of the remaining preload in the abutment screw; and
(3) any differences in the detorque value from speciMARCH 2001

THE JOURNAL OF PROSTHETIC DENTISTRY

Fig. 1. Bearing surface view of experimental implant design

R.

men to specimen after fatigue testing are related to fit

tolerances between the dimensions of the internal and
external screw joint hexagons.
By accepting these assumptions as true, a study was
initiated to examine the following null hypothesis:
There are no differences in the detorque values of the
abutment screws after fatigue testing when the
dimensions between implant hexagon and abutment
hexagon are altered or the implant hexagonal shape is
eliminated.

MATERIAL AND METHODS

Three experimental implant designs were custom
machined for this study, with 10 implants created for
each design group. The first test design, labeled R,
was a 3.75-mm regular platform implant with a standard
external hexagon having a mean hexagon flat-to-flat
surface measurement of 2.700 mm (SD 0.004 mm).
For this design, the hexagon height was 0.633 mm
(SD 0.005 mm) (Fig. 1). The second test design,
labeled M, was a 3.75-mm regular platform implant
with a modified external hexagon having a mean flat-toflat measurement of 2.664 mm (SD 0.016 mm) and a
height of 0.608 mm (SD 0.003 mm) (Fig. 2). The third
test design, labeled C, was a 3.75-mm implant with the
hexagon removed by machine milling to create a circular
form having a diameter of 2.668 mm (SD 0.003 mm)
and a height of 0.668 mm (SD 0.003 mm) (Fig. 3).
Compared with design R, the width of the hexagon in
design M was decreased 0.04 mm, and the height was
decreased 0.03 mm. The hexagon form of C was eliminated to create the circular column with a diameter
decrease of 0.03 mm and a height increase of 0.03 mm
over the hexagon of design R (Table I).
Thirty Procera CAD/CAM custom abutments (Nobel
Biocare AB, Goteborg, Sweden) were manufactured with
a 25-degree offset angulated loading platform (Fig. 4).20
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CIBIRKA ET AL

Fig. 2. Bearing surface view of experimental implant design

M.

Fig. 3. Bearing surface view of experimental implant design

C.

Table I. Width and height comparisons for specimens (n = 10 per experimental group)
Specimen

R
M
C
A
*Parentheses

Width mean (mm)

2.700
2.664
2.668
2.718

(0.004)
(0.016)
(0.003)
(0.041)

Width difference (mm)*

0.000
0.035
0.031
(0.018)

0.633
0.608
0.668
0.905

(0.005)
(0.003)
(0.003)
(0.005)

Height difference (mm)*

0.000
0.025
(0.034)
(0.272)

denote a negative value relative to the R measurement.

The loading platform was a 2.0-mm square area that

permitted contact with the piston of the fatigue testing device. This design simulated a harsh stress vector
configuration due to the extreme clinical offset. Each
Procera abutment was retained with a gold alloy
Unigrip abutment screw (No. DCA 1045, Nobel
Biocare AB). The mean flat-to-flat dimension of the
abutment internal hexagon (A) was 2.720 mm (SD
0.041mm) with a height of 0.910 mm (SD
0.005mm) (Table I).
Each implant was rigidly held in a special holding
device during abutment screw tightening to ensure
solid fixation without rotation during the tightening
(Fig. 5). Individual abutments were positioned onto
the implants, and the respective hexagons or circular
column were mated. The abutment screw was initially
tightened with a screwdriver (Nobel Biocare AB) until
the bearing surfaces of the abutment and the implant
were in light contact. Final tightening was completed
with an electronic torque controller with a countertorque device (Nobel Biocare AB). Each abutment
screw was tightened with a single activation of the
electronic torque controller set at 32 N/cm.
After tightening, a vertical line was scribed across
the implantabutment interface to evaluate longitudinal displacements. All specimens were secured within a
specially designed split metal mold, allowing approximately 2.0 mm of the implant to project above the
mold. Individual molds were placed on a load cell
270

Height mean (mm)

within a carousel-type cyclic fatigue testing apparatus

having 10 identical stations. A computer continually
monitored both applied force and temperature for each
station. The temperature of each specimen was maintained at 37C by means of a thermostatically
controlled water-circulating device. Temperature monitoring was accomplished using K-type thermocouples
positioned at the implantabutment interface. The
carousel was attached to a hydraulically driven, computer-controlled universal testing machine (Instron,
model 8501, Instron Corporation, Canton, Ohio)
(Fig. 6). Dynamic loading was applied to the platform
of each abutment by a unidirectional vertical piston and
was calibrated under displacement control, cycling
between 20 and 200 N (4.5 and 45 lb). Force application was not randomized and was cyclically ramped
between 2 limits. A sinusoidal waveform at 8 cycles per
second was applied to simulate values found in human
mastication.48 Cyclic loading continued for 5,000,000
cycles, or the approximate equivalent of 5 years of in
vivo mastication.49
On test completion, each specimen was removed
from the carousel and macroscopically inspected for
longitudinal displacement, abutment looseness, or
screw fracture. Each specimen then was placed in a
holder designed to provide repeatable orientation of
individual implant/abutment specimens to dental
radiographic film. The x-ray cone was oriented perpendicular to the long axis of the specimens with the
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THE JOURNAL OF PROSTHETIC DENTISTRY

B
Fig. 4. A, Custom Procera abutment, Unigrip screw, and regular platform Branemark implant
fixture. B, Loading platform of custom Procera abutment.

center of the beam directed through the implant

abutment interface. The x-ray cone was held in a fixed
position for imaging of all specimens. Implants were
positioned identically to produce 1 image perpendicular to the offset bearing table of the abutment and
the other 90 degrees, or in line with the table.
Radiographic images were recorded with conventional
film (Eastman Kodak, Rochester, N.Y.) using an exposure of 0.4 seconds and a voltage of 70 kVp (Fig. 7).
The exposed images were examined for qualitative
assessment of the abutment screws and the implant-toabutment interface.
Specimens then were replaced in the rigid holding
device to ensure solid fixation without rotation for
detorque of the abutment. The Unigrip screwdriver
was placed into a torque gauge (Tohnichi BTG-6,
Tohnichi American Corporation, Northbrook, Ill.)
and carefully oriented in the long axis of the implant
with the driver seated in the screw head. Abutment
screws were removed and detorque values recorded in
Newton/centimeters (N/cm) (Table II).
After the detorque values were measured, the bearing surfaces, hexagons, and circular forms of the
respective implant groups were examined microscopically (Nikon SMZ-U microscope, Nikon, Japan). The
internal hexagons of the respective abutments were
also visualized.

RESULTS
Examination of specimen interfaces within each
design group demonstrated no abutment loosening or
rotational displacement at the implantabutment
interface when the vertically scribed lines were evaluated under high resolution (25) (Fig. 8). Radiographic examination demonstrated no indication of
screw bending or displacement after fatigue testing.
Space was visually confirmed between the implant
geometry and the walls of the abutments when assessMARCH 2001

ing radiographs for all specimens. Neither the hexagons for designs R and M nor the circular form of
design C was in contact with the floor of the internal
abutment hexagons (Fig. 7).
Mean detorque values and standard deviations
are presented in Table II. For design R, the mean
detorque value was 14.40 N/cm (SD 1.84 N/cm);
for design M, the mean value was 14.70 N/cm
(SD 1.89 N/cm); and for design C, the mean
value was 16.40 N/cm (SD 2.17 N/cm). The
analysis of variance demonstrated significant differences between only designs R and N (P=.031).

DISCUSSION
The effect of interface design on stability of the
screw joint connecting implant and abutment remains
uncertain, as is evidenced by the many configurations
that exist in todays market. There is no compelling
evidence to support 1 interface design over another.
The external hexagon geometry remains the most
common design in use. However, the crucial issue with
any design, be it hexagonal or otherwise, is the effect
of the design and its machining tolerances in maintaining stability of the screw joint.
Developers reported that 1 purpose of the implant
external hexagon was for driver fixation to assist with
surgical placement. Others indicate that this design
merely assists in orientation of the abutment onto the
implant. Still others suggest that the hexagon provides
an important relationship for the abutment to the
implant and the eventual force transfer to the implant
and supporting bone. Many of those who support this
latter role of hexagons further state that lack of precision
fit between the 2 hexagons will generate screw joint
instability over time. This premise suggests that instability between components ultimately may result in screw
loosening, restoration failure, and possibly the loss of
the bony attachment at the implantbone interface.
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THE JOURNAL OF PROSTHETIC DENTISTRY

Fig. 5. Holding device for electronic torque control tightening of abutment screws.

CIBIRKA ET AL

Fig. 6. Instron carousel-type cyclic fatigue testing device

(left) and view of split metal mold securing implant/abutment specimens during cyclic loading by piston (right).

Fig. 7. A, Radiographic image perpendicular to offset bearing table of abutment after loading.
B, Radiographic image in line with offset bearing table of abutment after loading.

Bickford1 described the screw as a spring stretched by

preload that is maintained by the frictional fit of the
threads. The greater the joint preload (up to the ultimate
strength), the greater will be the resistance to loosening.
External forces can create a vibratory movement and cause
the threads to back off. The backing off of the threads
leads to a reduction in the effective preload and diminishes ability of the screw to maintain the joint stability.
The development of optimum preload in the abutment
screw is premised on the bearing surfaces mating perfectly.50 A small-scale misfit, such as a misalignment of the
screw and its bore or interference between the walls or
the apices of the hexagons, may affect the preload.
272

In this study, the 32 N/cm initial tightening force

delivered to the gold alloy abutment screw by the electronic torque controller may not have developed an
identical preload in every implant/abutment specimen. A previous test that used an electronic torque
controller indicated that 65% to 80% of the set torque
at the low-speed setting was achieved.51 This finding
may be an inherent problem in the torque controller
itself or due to other interface conditions that may
have prevented the torque controller from delivering
consistent and equal preloads to each test specimen.
The implant and abutment screw joint is a dynamic,
3-dimensional interaction of width and height variables
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CIBIRKA ET AL

influencing joint stability. Recognizing this complex

interface, this investigation compared a standard implant
hexagon design (R) with 2 distinctly different designs. In
1 design (M), both the hexagon width and height were
reduced to create a less precise fit. In the other design
(C), a circular column was created and extended above
that of the standard hexagon in design R.
In this testing, it was assumed that the screw
detorque value recorded when loosening the abutment
screw after fatigue testing was a measure of the preload
remaining in the screw just before detorquing. It was
also assumed that the initial tightening preload
achieved with the new electronic torque controller
before the start of the experiment was consistent and
the same value for each implant/abutment specimen.
The detorque value is not exactly the tightening preload; rather, it is an indirect measure. It was also
assumed that differences in detorque values after
fatigue testing were related to fit tolerances between
the internal abutment dimension and external hexagon
dimension. Other variables, including contact surface
area and machined component imprecision, could have
affected the measured detorque values.
The stroke pattern of the Instron was not identical
to that of the human masticatory stroke, although it
was relevant in force magnitude. After completion of
5,000,000 cycles, the effect of hexagon width on the
maintenance of the preload was not evident. When the
width and height between the hexagons were significantly decreased, as they were in design M compared
with R, the mean detorquing value after fatigue testing
in design M (14.7 N/cm) was greater than that of
design R (14.4 N/cm). However, the difference was
not statistically significant. From the detorque data, a
less precise fit in both height and width did not significantly reduce the preload after the specimen was
subjected to fatigue testing.
When the hexagon form was completely removed
and a circular form existed on the top of the
implant, as in design C, the mean detorquing value
(16.4 N/cm) was statistically greater than that for
design R (14.4 N/cm) (P=.0315) but not design M
(14.7 N/cm) (P=.736). When design M was compared with design C, no statistically significant
differences were found. These results suggest that a
less precise fit in the width of the hexagon space, as
in design M, or the total elimination of the hexagon
form, as in design C, did not adversely affect the
preload after fatigue testing.
Detorquing values immediately after tightening are
always lower than the initial tightening torque of the
abutment screw.23,50,52 To some extent, this change
accounts for the lower relative values of the detorque
data recorded after fatigue testing. However, it still
does not account for the significant difference in the
values for designs R and C after fatigue testing. The
MARCH 2001

THE JOURNAL OF PROSTHETIC DENTISTRY

Fig. 8. Microscopic view of vertically scribed line on specimen at implantabutment interface.

Table II. Detorque values for specimens

R-experiment
M-experiment
C-experiment

Mean (N/cm)

SD

14.40
14.70
16.40

1.84
1.89
2.17

experimental conditions of the interface relationships

between these 2 designs clearly demonstrated width,
height, and geometry differences. No hexagon existed
in design C, yet the detorque value after fatigue testing was higher, indicating less preload loss.
The potential for binding of the hexagon still
existed in design M, whereas in design C, when the
hexagon was eliminated in creating the circular form,
the detorque values for R and C were significantly
different. In design C, the potential for binding was
eliminated; however, the height of the circular form
above the implant-bearing surface was greater than
the height of the hexagon in model R.
In design N, the distance from the top of the circular form to the bottom of the internal hexagon of
the abutment was 0.238 mm (SD 0.004 mm). In
design R, the distance from the top of the hexagon to
the bottom of the internal hexagon of the abutment
was 0.272 mm (0.004 mm). The smaller the distance
between the top of the implant geometry and the bottom of the internal abutment hexagon, the fewer the
possibilities for screw bending during function. Thus,
there was a reduced potential for screw loosening
and potential preload loss after fatigue testing.
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THE JOURNAL OF PROSTHETIC DENTISTRY

Likewise, the greater length of the screw positioned

within the internal bore of the implant, the greater the
resistance of the screw to lateral bending forces. In this
study, the length of the abutment screw supported by
the implant bore differed with each design because of
the hexagon configuration. The bore in design C supported a greater amount of the screw length.
Therefore, this design was influenced less by lateral
forces and movement of the abutment during fatigue
testing. This fact may help explain the relative increase
in detorque values of design C compared with designs
R and M.
Macroscopic examination of all implant/abutment
specimens demonstrated no apparent problems with
regard to looseness or longitudinal displacements
between the abutment and the implant. In light of the
detorque findings discussed earlier, it could be hypothesized that alignment in the x- and y-axes may be
related more to the machining tolerances among the
abutment screw, the abutment bore, and the screw
bore in the implant than to the precision of fit between
the hexagons at the implantabutment interface.
Microscopic examination revealed no signs of
damage to any aspect of the implant/abutment
geometry. It was apparent from these observations
that, clinically, the stability of the screw joint had
been maintained throughout the experiment. Even
though there was a significant difference between the
after-fatigue-testing preloads for designs R and C,
the preload had not been reduced to a critical level
resulting in a loose joint. These findings could be
important for clinicians using implant/abutment systems that require 32 N/cm tightening torque and
are an external hexagon design.
The results from this investigation support the contention that the hexagon is merely present for
placement of the implant into the bone and perhaps
orientation of the abutment onto the implant. This
external hexagon design may have little to do with
force distribution and may have influenced the attainment of optimum preload during initial screw
tightening. These concepts need to be addressed in
future studies. Determinations of quantitative critical
threshold values for preload loss to induce screw loosening with varied abutment and screw designs should
be investigated further.

CONCLUSIONS
Within the limits of this study, the following conclusions were drawn:
1. Increasing the distance between the implant
external hexagon width and the internal hexagon of an
abutment did not produce a statistically significant
effect on the detorque values of the abutment screw
after 5,000,000 cycles in fatigue testing.
2. Eliminating the implant external hexagon and
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CIBIRKA ET AL

increasing the circular height form resulted in a significant effect on the gold alloy abutment screw detorque
values after 5,000,000 cycles (P=.034) compared with
implants having regular hexagons.
3. After 5,000,000 fatigue testing cycles of
implant/abutment specimens with and without an
external hexagon design, no subjective clinical signs of
screw instability or loosening were observed.
We would like to thank Mr Rui Wang, Ms Beth Lang, and Mr
Don Mettenburg for their invaluable support in the completion of
this project.

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