Mechanical Stability of Zirconia Meso-abutments

Bonded to Titanium Bases Restored with

Different Monolithic All-Ceramic Crowns
João Pitta, Dr Med Dent1/Stefan P. Hicklin, Dr Med Dent1/Vincent Fehmer, MDT1/
Johannes Boldt, Dr Med Dent2/Petra C. Gierthmuehlen, Prof Dr Med Dent2/Irena Sailer, Prof Dr Med Dent1

Purpose: To evaluate the bending moments and failure modes of zirconia meso-abutments bonded to
titanium bases restored with different monolithic all-ceramic crowns after aging, and to compare them to
titanium abutments restored with all-ceramic crowns. Materials and Methods: Forty-eight internal conical
connection implants (CONELOG, Camlog Biotechnologies GmbH 4.3 mm diameter) were restored with four
different computer-aided design/computer-aided manufacturing (CAD/CAM) abutment-crown combinations
(n = 12). Thirty-six customized zirconia meso-abutments were bonded to titanium bases (CONELOG Titanium
Base CAD/CAM crown, Camlog Biotechnologies GmbH) and divided into three groups according to the
different crown materials: (T1) monolithic lithium disilicate (e.max CAD, Ivoclar), (T2) monolithic PICN (polymer-
infiltrated ceramic network [Enamic, Vita]), and (T3) monolithic zirconia (Lava Plus, 3M ESPE). Twelve titanium
customized abutments restored with monolithic lithium disilicate (e.max CAD, Ivoclar) crowns served as the
control group (C). The crowns were equal maxillary central incisors and were adhesively bonded with a resin-
based cement (Panavia 21, Kuraray). All samples were embedded in acrylic holders. After aging (1,200,000
cycles, 49 N, 1.67 Hz, 5°C to 50°C, 120 seconds), static load was applied until failure. Bending moments were
calculated for comparison of the groups. Data were statistically treated with one-way analysis of variance
(ANOVA) followed by Tukey post hoc test (P < .05). Failure modes were analyzed descriptively. Results: The
means of the bending moments were 356.4 ± 20.8 Ncm (T1), 357.7 ± 26.3 Ncm (T2), 385.5 ± 21.2 Ncm
(T3), and 358.8 ± 25.3 Ncm (C). Group T3 revealed significantly higher mean bending moments than the
other groups (P < .05). No differences were found between zirconia meso-abutments supported by titanium
bases and customized titanium abutments when lithium disilicate crowns were used (P > .05). No failures
were identified during and after aging. After static load, failures occurred due to fracture of the abutment in
the internal connection in all the groups. Conclusion: Zirconia meso-abutments bonded to titanium bases
showed similar mechanical stability compared with customized titanium abutments. Regarding the crown
material, all three tested ceramics (lithium disilicate, PICN, and zirconia) revealed very good stability when
used in the monolithic state. Int J Oral Maxillofac Implants 2019;34:1091–1097. doi: 10.11607/jomi.7431

Keywords: aging, bending moments, CAD/CAM, monolithic crowns, titanium base, zirconia abutments

1Division of Fixed Prosthodontics and Biomaterials,
University Clinics of Dental Medicine, University of Geneva,
Switzerland.
2Department of Prosthodontics, School of Dentistry, Heinrich-
Heine University, Düsseldorf, Germany.
Previously presented at EAO-SEPES joint meeting 2017, Madrid,
Spain, October 5–7, 2017.
Correspondence to: João Pitta, Division of Fixed
Prosthodontics and Biomaterials, University Clinics of Dental
Medicine, University of Geneva, 1 Rue Michel-Servet, 1211
Genève 4, Switzerland. Fax: +4122 379 40 52.
Email: joao.pitta@unige.ch
Submitted October 21, 2018; accepted February 10, 2019.
©2019 by Quintessence Publishing Co Inc.
T
itanium and zirconia are well-established mate-
rials for implant abutment reconstructions, with
similar survival and success rates after 5 years.1–3
From a mechanical point of view, titanium abut-
ments have proven to be efficient and durable due
to their loading capacity.4 In contrast, zirconia abut-
ments, which offer better optical properties than
metal, 5 might have some mechanical limitations.6–9
Taking the brittle nature of ceramics into account,
one might expect fatigue fractures over time.10,11
Furthermore, the possible effect of wear and fret-
ting at the implant-zirconia interface12,13 and low-
temperature degradation should be considered as
potential mechanical risk factors.14

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Pitta et al
LiDISi LiDISi
Ti abutment
Ti base
Ti base
Zr meso-
abutment
C T1
Fig 1  Four study groups with different combinations of abut-
ments and crown material.
A possible alternative to solve this problem might
be the choice of a hybrid abutment that consists of
an all-ceramic customized meso-abutment, bonded
to a standardized titanium base, to be screw-retained
to the implant as one complex.15–17 This new hybrid
concept encompasses the combination of the excel-
lent mechanical stability of metals with the esthetic
advantages of ceramic abutments. Moreover, the
customization of the ceramic meso-abutment allows
the placement of the crown margins at mucosal level,
facilitating the removal of the excess cement after
cementation.
The stability of the implant crowns is an additional
factor influencing the clinical outcomes of implant-
borne reconstructions. High fracture resistance of the
prosthetic materials is important. Traditionally, a stable
framework made out of metal gave the stability of the
crown, and the esthetic was provided by the veneering
ceramic. More recently, high-strength ceramic materi-
als are used for the fabrication of implant-borne recon-
structions, either covered by a veneering ceramic or in
the monolithic state.18–20 The prevailing ceramics for
monolithic crowns are lithium disilicate glass-ceramic
and zirconia.21–23 More recently, computer-aided
design/computer-aided manufacturing (CAD/CAM)
blocks of a polymer-infiltrated ceramic network (PICN),
also called hybrid ceramic, have been introduced. Due
to its dual network, this material presents reduced brit-
tleness, lower hardness, and lower elastic modulus,24
which can help to distribute stress more favorably.25
Moreover, this hybrid material provides a faster milling
process with smoother margins and easier polishing
properties than other ceramic materials.26,27
Considering the aforementioned advantages of the
hybrid abutment concept with promising properties of
the new all-ceramic CAD/CAM monolithic crowns, one
might assume that a combination of both may lead
to outcomes similar to or even better than the con-
ventional concept of customized metallic abutments
supporting esthetic implant crowns. However, the
available literature evaluating this new hybrid abut-
ment concept is limited, and it remains to be clarified
1092 Volume 34, Number 5, 2019
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whether or not there are differences in outcomes be-
tween all-ceramic and hybrid-ceramic crowns when
PICN Zr
supported by hybrid abutments.
The purpose of this in vitro study, therefore, was to
assess the mechanical stability, ie, the bending mo-
Ti base
Zr meso- Zr meso-
ments and failure modes of zirconia meso-abutments
abutment abutment bonded to titanium bases and restored with different
T2 T3 crown materials after artificial aging. The tested null
hypotheses were: (1) the abutment type does not influ-
ence the bending moments; and (2) the crown material
does not affect the bending moments.
MATERIALS AND METHODS
Forty-eight implants with an internal conical con-
nection (diameter 4.3 mm, length 13 mm; CONELOG,
Camlog Biotechnologies GmbH) were included and
divided into three test groups and one control group
(n = 12) (Fig 1). The sample size was based on previous
published studies with similar methodology.6,9 The
groups were as follows:
• Test group 1 (T1): zirconia customized meso-
abutment bonded to a titanium base (CONELOG
Titanium Base CAD/CAM crown, gingival height 0.8
mm, Camlog Biotechnologies GmbH) and restored
with a monolithic lithium disilicate crown (e.max
CAD, Ivoclar Vivadent)
• Test group 2 (T2): zirconia customized meso-
abutment bonded to titanium base (CONELOG
Titanium Base CAD/CAM crown, gingival height
0.8 mm, Camlog Biotechnologies GmbH) and
restored with a monolithic PICN crown (Enamic,
VITA Zahnfabrik).
• Test group 3 (T3): zirconia customized meso-
abutment bonded to titanium base (CONELOG
Titanium Base CAD/CAM crown, gingival height 0.8
mm, Camlog Biotechnologies GmbH) and restored
with a monolithic zirconia crown (Lava Plus, 3M
ESPE).
• Control group (C): customized titanium abutment
(DEDICAM, Camlog Biotechnologies GmbH)
restored with a monolithic lithium disilicate crown
(e.max CAD, Ivoclar Vivadent).
Fabrication of the Abutments and Crowns
Following the procedures described in previous pub-
lications,6–9 a master abutment was selected, and its
outer shape was replicated for all the customized
titanium abutments and zirconia meso-abutments
used in the present study by a central milling cen-
ter (DEDICAM, Camlog). This master abutment was
scanned (inEos X5, Dentsply Sirona), and a maxillary
central incisor crown was designed using dedicated
 Pitta et al

Table 1   Surface Pretreatments Previous to Bonding

Bonding surface C T1 T2 T3
Titanium abutment/ 50-µm aluminum 50-µm aluminum 50-µm aluminum 50-µm aluminum
Ti base oxide abrasion + oxide abrasion + oxide abrasion + oxide abrasion +
Alloy Primer Alloy Primer Alloy Primer Alloy Primer
Zirconia Inner surface CoJet (30-µm ) + CoJet (30-µm ) + CoJet (30-µm ) +
meso-abutment Outer surface Clearfil Ceramic Clearfil Ceramic Clearfil Ceramic
Primer Primer Primer
Crown inner surface IPS Ceramic Etching IPS Ceramic Etching IPS Ceramic Etching CoJet (30-µm ) +
Gel (20s) + Clearfil Gel (20s) + Clearfil Gel (60s) + Clearfil Clearfil Ceramic
Ceramic Primer Ceramic Primer Ceramic Primer Primer
Materials used for surface pretreatment and respective manufacturers: Alloy Primer (Kuraray); Clearfil Ceramic Primer (Kuraray); IPS Ceramic
Etching Gel (Ivoclar Vivadent); CoJet (3M ESPE).

software (CEREC inLab 16.1, Dentsply Sirona). The Aging

crowns were milled (CEREC MC XL, Dentsply Siro-
na) out of the corresponding ceramic block for the
groups with lithium disilicate and PICN (T1, T2, and
C). Then, lithium disilicate crowns were polished,
crystallized, and glazed, while PICN crowns were just
polished. For the production of the zirconia crowns
(T3), the STL file was transferred to another milling
machine (Zenotec Select Hybrid, Wieland Dental).
After milling and sintering, the zirconia crowns were
high gloss polished.
The samples were aged by means of simultaneous
thermal cycles (5°C to 50°C, dwelling time 120 sec-
onds) and chewing simulation (1,200,000 cycles, 49
N, 1.67 Hz, chewing simulator CS-4.9, SD Mechatron-
ic). A steatite ball (≤ 6 mm), with similar hardness to
enamel was used as an antagonist indenter. The speci-
mens were loaded 2 mm below the incisal edge at a
30-degree angle of the indenter to the implant axis.
The vertical indenter movement for each chewing act
was 2 mm.

Preparation of Specimens Fracture Load Test

All implants were embedded into custom-made acryl-
ic resin holders using a self-curing acrylic (Technovit
4071, Heraeus Kulzer) according to the recommen-
dations of the ISO-Norm 14801 (“Dentistry-Implants-
Dynamic fatigue test for endosseous dental implants,”
International Organization for Standardization 2007).
A vertical distance of 3 mm was left from the implant
shoulder to the top of the acrylic holder in order to
simulate vertical bone loss (ISO 14801). The excesses
of resin were carefully removed from the top of the
acrylic resin holders.
According to each group, the titanium abutments
(C) and the titanium bases (T1, T2, and T3) were mount-
ed to their corresponding implants and fixed with the
respective abutment screw with a torque of 20 Ncm,
as recommended by the manufacturer. In this study,
titanium bases with a prosthetic height of 5.5 mm
and a gingival height of 0.8 mm were selected. The
respective bonding surfaces were mechanically and/
or chemically treated (Table 1), and the zirconia meso-
abutments were bonded to the titanium bases using
resin cement (Panavia 21, Kuraray). The abutment-
screw access holes were closed with Teflon and a resin-
based composite filling material (Tetric EvoCeram,
Ivoclar Vivadent). Finally, the crowns were adhesively
cemented on the abutments with an MDP-containing
resin cement (Panavia 21, Kuraray), after the respective
surface pretreatments (Table 1).
After aging, a static load was applied in a 30-degree
angle to the implant axis (ISO 14801) using a universal
testing machine (Shimadzu AGS-X series, Shimadzu)
until failure. To ensure even force distribution to the
crown/abutment during loading, a 0.5-mm-thick tin
foil (Dentaurum) was used in between the specimens
and the indenter.6,9
Failure was defined either as visible fracture of the
abutment/crown, or after a 20% decrease of the maxi-
mum load during the fracture strength test if no obvi-
ous fracture was observed. For each group, the fracture
load was recorded using specific software (TRAPEZIUM
X, V.1.4.4, Shimadzu).
For comparison of the groups, the bending mo-
ments (M) were calculated in Ncm according to the
formula M = 0.5 × F × l (ISO Norm 14801, 2007), with
“F” corresponding to the maximum load (N) and “l” cor-
responding to the vertical distance from the simulated
bone level to the center of load (cm).
Analysis of Failure
After aging and fracture load test, all samples were
analyzed for determining the mode of failure. Failures
at implant, abutment, and/or crown level were docu-
mented, including fractures, visible crack lines, plastic
deformation, or debonding of components (Olympus
SZX9, Olympus). To be able to visualize the patterns
of the abutment/crown failures after loading, one

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Pitta et al
500
Bending moments (N)
400
300
200
100
0
Ti abutment + Ti base + LiDiSi
LiDiSi (C) (T1)
Groups (abutment + crown)
a b
a b
Fig 4   Sectional cut with a visible fracture of the abutment and
screw after applying static load until failure. (a) Titanium abut-
ment. (b) Zirconia meso-abutment bonded to titanium base.
specimen of each abutment type (titanium abutment
or titanium base) was embedded and sectioned with a
diamond saw in the bucco-oral direction through the
center of the sample (Well Diamond Wire Saws). The
embedded cross sections were examined by means
of a microscope (Leica DM LM, Leica Microsystems) for
further visualization of failure origin.
Statistical Analysis
Bending moments data were statistically analyzed
with software (IBM SPSS Statistics v20, IBM Corp). A
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Fig 2  Bending moments (MPa) (mean ± SD)
for the four study groups. Note that * refers
*
to statistically significant difference (P < .05).
Ti base + PICN Ti base +
(T2) zirconia (T3)
Fig 3   Samples of the groups (a) C, (b) T1, (c)
T2, and (d) T3, respectively, after aging. No fail-
ure was detected.
c d
one-way analysis of variance (ANOVA) was performed,
and multiple comparisons between groups were made
using Tukey HSD post hoc tests (α = .05). Failure modes
were analyzed descriptively.
RESULTS
The means of the bending moments were
356.4 ± 20.8 Ncm (T1), 357.7 ± 26.3 Ncm (T2),
385.5 ± 21.2 Ncm (T3), and 358.8 ± 25.3 Ncm (C). Group
T3 exhibited significantly higher mean bending mo-
ments than all the other groups (P < .05). No differ-
ences were found between zirconia meso-abutments
bonded to titanium bases and the customized tita-
nium abutments when lithium disilicate crowns were
used (T1 and C) (P > .05) (Fig 2).
No failures were detected during and consequently
to the aging procedure (Fig 3). In all groups, failures
occurred due to fracture of the abutment screw in the
internal connection (Fig 4). A plastic deformation of
the abutment and implant head was visible in all the
samples. Under the microscopic analysis, incomplete
crack lines in the crowns were detected in four sam-
ples of group C, four samples of group T1, and seven
samples of group T2. All of these crack lines followed a
similar pattern distribution in the palatal aspect of the
crown (Table 2).
 Pitta et al

Table 2   Failure Analysis After Fracture Load

Crowns Abutments Fractured Fractured Plastic
Groups with cracks with cracks crowns abutments/screw Debonding deformation
C 4 0 0 12 0 12
T1 4 0 0 12 0 12
T2 7 0 0 12 0 12
T3 0 0 0 12 0 12
C = customized titanium abutment restored with a monolithic lithium disilicate crown; T1 = zirconia customized meso-abutment bonded to a
titanium base and restored with a monolithic lithium disilicate crown; T2 = zirconia customized meso-abutment bonded to titanium base and
restored with a monolithic PICN crown; T3 = zirconia customized meso-abutment bonded to titanium base and restored with a monolithic zirconia
crown.

DISCUSSION
The present study showed that the abutment type
did not influence the bending moment values. Thus,
the first null hypothesis cannot be rejected. However,
the crown material influenced the bending moments,
as the monolithic zirconia revealed higher fracture
strength values than lithium disilicate glass-ceramic
or PICN crowns. Therefore, the second null hypothesis
was rejected.
In the present study, the titanium base with a zir-
conia meso-abutment performed similarly to the con-
ventional titanium abutments in terms of bending
moment values and failure modes, corroborating pre-
vious findings.28,29 After static loading, all the samples
suffered the same plastic deformation characteristic
of titanium abutments, with the bending of the im-
plant head. Even though cracks were detected in some
crowns a posteriori under the microscope, they were
not evident during the testing procedure. Therefore,
the test was only stopped when an evident fracture
was noticed or the load decreased by 20%. This led to
an extreme plastic deformation due to the lever cre-
ated by the increased loading in a 30-degree-axis an-
gulation. As a consequence, an ultimate fracture of the
abutment screw occurred, which has already been de-
scribed as the weakest component in abutments made
out of titanium.9,30 Nevertheless, this plastic deforma-
tion of the metallic components is unlikely to occur in
a clinical situation. In incisor regions, masticatory forc-
es may range between 90 and 270 N.31 In the present
investigation, all the specimens resisted higher forces,
even after being subjected to artificial aging. If poste-
rior regions are considered, higher masticatory forces
can be expected. However, the direction of these forc-
es are more axial and, therefore, more favorable for the
implant and the prosthetic components. This results in
very high fracture strength values, which have been
reported in previous investigations using a posterior
tooth-like shape.32–34
The use of a titanium base appears to be a very
promising alternative, which offers the possibility to
combine an all-ceramic superstructure with a metallic
connection to the implant. In the present study, zirco-
nia was successfully used as a meso-structure material,
with 100% survival integrity from the mechanical and
bonding point of view. Some authors also reported
lithium disilicate as possible material for this purpose,
showing similar stability.17,29,34 In another study, zir-
conia showed better reliability when compared with
lithium disilicate or CAD/CAM resin-based compos-
ite.35 Different methodologies used might explain the
differences found between studies.
The second variable analyzed in this in vitro study
was the crown material. As the chewing simulation did
not visibly affect the structural integrity of the recon-
struction and bonding interface, it may be presumed
that the complex of abutment and crown would be-
have as a solid one-piece during static load testing.
Hence, the bending moment values would be expect-
ed to be similar, independently of the crown materials.
Surprisingly, the zirconia group revealed significantly
higher bending moment values than the lithium
disilicate (P = .025) and PICN (P = .04) groups. A pos-
sible explanation might be related to the crack lines
observed under the microscope after fracture load, for
some lithium disilicate and PICN samples, but not at
all for the zirconia ones. Even if these crack lines were
not detected after chewing simulation, they could al-
ready be present at that time, and under the increas-
ing static load, they might have propagated on the
surface and became more visible. This explanation was
also suggested in a previous investigation,16 and can
be linked to the higher initial failure load of zirconia.20
Even though these differences were very small (less
than 30 Ncm), and although they were statistically sig-
nificant (P < .05), the P values were close to .05. Hence,
a statistical error type I cannot be discarded.
Concerning the bonding aspect, no failures were
registered. This finding is in agreement with previous
studies.16,29 A recent investigation on narrow implant
connections did not find any debonding on titani-
um resin bases after an identical aging simulation.16

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Pitta et al
Despite limited evidence concerning the bonding sta-
bility on titanium bases after chewing simulation,36,37
these outcomes appear to be promising for this con-
cept, as the fixation is merely based on the adhesive
cementation.
The methodology used in this study is mostly ad-
equate to test the whole implant-abutment-crown
complex. The selection of different crown materials
aimed to validate their respective use applied to the
titanium base abutment concept, and not to test the
fracture strength of the materials per se. Although
fracture tests may contribute to assess the durability
of prosthetic components, continuous fatigue is often
one of the main causes that leads to a structural failure
of the reconstructions. In that respect, dynamic load-
ing might be considered a more clinically relevant test-
ing approach.38 However, clinical extrapolation of the
results must be done carefully, as it is not possible to
fully replicate the oral cavity conditions through an in
vitro study.
In this study, all tested samples based on the tita-
nium base concept survived the dynamic loading. No
mechanical failures were registered, either at abutment
or at crown level. Moreover, titanium bases revealed a
similar stability and mechanical behavior of titanium
abutments, which is still considered the “golden stan-
dard” for implant-supported single reconstructions.
The outcomes of this study demonstrate very good
perspectives for application in an oral environment,
yet they must be confirmed in long-term clinical trials
to prove the predictability of this concept over time.
CONCLUSIONS
Zirconia meso-abutments bonded to titanium bases
were demonstrated to be a stable combination when
compared with customized titanium abutments,
which are still considered the golden standard. With
respect to the crown material, all three tested ceram-
ics (lithium disilicate, zirconia, and PICN) revealed very
good stability when used in its monolithic form.
ACKNOWLEDGMENTS
The authors would like to thank Dr A. Worni for the contribu-
tions for the study design, Dr P. Mojon for advice in the statisti-
cal analysis, and Eng E. Vittecoq for support with the testing
setup. The authors also thank Oral Reconstruction Foundation
(formerly Camlog Foundation) and Ivoclar Vivadent, VITA Zahn-
fabrik, and 3M ESPE for the support of this study. The authors
reported no conflicts of interest related to this study.
1096 Volume 34, Number 5, 2019
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