Accepted Manuscript

Title: Influences of microgap and micromotion of

implant–abutment interface on marginal bone loss around
implant neck

Authors: Yang Liu, Jiawei Wang

PII: S0003-9969(17)30243-1
DOI: http://dx.doi.org/doi:10.1016/j.archoralbio.2017.07.022
Reference: AOB 3960

To appear in: Archives of Oral Biology

Received date: 19-2-2017

Revised date: 19-7-2017
Accepted date: 27-7-2017

Please cite this article as: Liu Yang, Wang Jiawei.Influences of microgap and
micromotion of implant–abutment interface on marginal bone loss around implant
neck.Archives of Oral Biology http://dx.doi.org/10.1016/j.archoralbio.2017.07.022

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 Influences of microgap and micromotion of implant–
abutment interface on marginal bone loss around
implant neck

Running title: Microgap and micromotion of IAI

Author names：

Yang Liu, MD; E-mail: whulyang@hotmail.com.

Jiawei Wang, PhD; E-mail: wangjwei@hotmail.com.

Authors’ affiliation: Department of Prosthodontics, School of Stomatology, Wuhan

University, Wuhan, 430079, China.

Corresponding author: Prof. Jiawei Wang, The State Key Laboratory Breeding Base of

Basic Science of Stomatology (Hubei-MOST), Key Laboratory of Oral Biomedicine Ministry

of Education, School & Hospital of Stomatology, Wuhan University, 237 Luoyu Road,

Wuhan 430079, China; e-mail: wangjwei@hotmail.com.

Conflicts of interest: none

Highlights

 Elaborated respectively the influence mechanisms of the microgap and micromotion

between the implant and the abutment on implant marginal bone loss in detail;
 The relationship between microgap, micromotion, microleakage and mechanical
damage, and their influences on bone resorption around implant neck are particularly
explained;
 Some feasible clinical methods to reduce the bone resorption engendered by the
microgap and micromotion at the IAI are recommended.

ABSTRACT

Objective: To review the influences and clinical implications of micro-gap and micro-motion
of implant-abutment interface on marginal bone loss around the neck of implant.

Design: Literatures were searched based on the following Keywords: implant-abutment

interface/implant-abutment connection/implant-abutment conjunction, microgap,
micromotion/micromovement, microleakage, and current control methods available. The
papers were then screened through titles, abstracts, and full texts.

Results: A total of 83 studies were included in the literature review. Two-piece implant
systems are widely used in clinics. However, the production error and masticatory load result
in the presence of microgap and micromotion between the implant and the abutment, which
directly or indirectly causes microleakage and mechanical damage. Consequently, the degrees
of microgap and micromotion further increase, and marginal bone absorption finally occurs.
We summarize the influences of microgap and micromotion at the implant-abutment interface
on marginal bone loss around the neck of the implant. We also recommend some feasible
methods to reduce their effect.

Conclusions: Clinicians and patients should pay more attention to the mechanisms as well as
the control methods of microgap and micromotion. To reduce the corresponding detriment to
the implant marginal bone, suitable Morse taper or hybrid connection implants and platform
switching abutments should be selected, as well as other potential methods.

Keywords: Implant-abutment interface, Microgap, Micromotion, Microleakage, Marginal

bone loss

KEYWORDS: Implant-abutment interface; Microgap; Micromotion; Microleakage;

Marginal bone loss
INTRODUCTION
Marginal bone loss around the neck of dental implant is one of the most common
complications after implantation and exerts remarkable influence on the future success and
long-term stability of the implant. Generally, when the implant is placed into the alveolar
bone, the resorption of marginal bone usually begins from the bone cortex (Branemark et al.,
1969). Factors contributing to the loss of marginal bone include surgical trauma, peri-
implantitis, occlusal overload, microleakage, biologic width, and implant anatomy on the
crest area (Macedo et al., 2016; Oh, Yoon, Misch, & Wang, 2002). The phrase microleakage
of the implant-abutment interface (IAI) was coined in the 1990s, and it describes a microbial
leakage between the implant and the abutment, which is attributed to the microgap and
micromotion of the IAI. Efforts have been exerted over the last two decades to explore the
discrepancy in the microleakage level within different implant systems and the reasons behind
this phenomenon. Some scholars considered the microgap responsible for the phenomenon,
and others deem it as the result of micromotion. In this article, the keywords were
determined as, for instance, implant-abutment interface/implant-abutment
connection/implant-abutment conjunction, microgap, micromotion/micromovement,
microleakage, and current control methods available. The literatures were searched based on
the keywords up to February 2017.To be analyzed in the review, papers had to (i) be written
in English, (ii) be published in an international peer-reviewed journal, and (iii) have a clear
definition for microleakage and related keywords. The titles and abstracts for eligible papers
were screened. If eligibility aspects were present in the title, the paper was selected for further
reading. If none of the eligibility aspects were mentioned in the title, the abstract was read in
detail and screened for suitability. After selection, full-text papers were read in detail. The
search resulted in 4350 records of titles and abstracts. Screening of these titles and abstracts
initially resulted in 264 articles. Based on detailed reading of full texts, 181 articles were
excluded and 83 studies were identified eligible for inclusion in the literature review. The
influences of microgap and micromotion existing between the implant and the abutment-
interface on marginal bone loss are reviewed and clearly illustrated, and their clinical
significances are discussed.

MICROGAP, MICROMOTION, AND MICROLEAKAGE

Two-piece implant system

Given the protection of implant from unwanted load during bone healing phase and the
beneficial potential to adjust the prosthetic angle, the two-piece implant system is widely used
in clinics. The IAI connection of the two-piece implant system includes two types: external
and internal connections. In a typical external connection, the implant convex extends outside
by 1–2 mm, thereby forming an external structure similar to a hexagon or an octagon, which
connects to the abutment. External connection is incorporated in some systems and once
commonly used worldwide during the period when two-piece implant system was initially
used because of its superior antirotational mechanism and ability to orient the abutment in the
implant (Davi, Golin, Bernardes, Araujo, & Neves, 2008; Gracis et al., 2012). However, the
short and narrow external geometry is particularly vulnerable when off axis loads are applied,
which consequently leads to the deformation of the IAI (Binon, 2000; Gracis, et al., 2012).

Along with the rapid development of two-piece implant system, internal connection including
but not limited to internal hex connection gradually occupies a larger share in the market.
Internal connection refers to the abutment stretches of 4–6 mm into the implant cavity.
Subsequently, this abutment fixes with the implant and forms a conical, octagonal, hexagonal,
trilobe, or spline design. Internal connection includes taper, butt joint, and hybrid connections
(Figure 1). The taper connection originates from the concept of Morse taper in mechanical
engineering and simply means a cone within another cone (Hernigou, Queinnec, & Flouzat
Lachaniette, 2013; Oh, et al., 2002). Therefore, this connection is also called conical
connection. Butt joint connection refers to the connecting area between the implant and the
abutment without a taper, and it is only retained via a retaining screw. A hybrid connection
means that both Morse taper design and the regular polygonal shape of antirotational or
guiding grooves are present. Compared with the external connection, internal connection
remarkably lowers the rotation center and improves the mechanical stability (Sailer, Sailer,
Stawarczyk, Jung, & Hammerle, 2009). Furthermore, when internal connection adopts the
form of platform switching, the stress distribution of the peri-IAI bone is reduced (Alvarez-
Arenal et al., 2017; Liu et al., 2014).

Microgap
The implant and the abutment cannot be accurately matched because of the precision limit
during production (Alves, de Carvalho, Elias, Vedovatto, & Martinez, 2016). The IAI
microgap, defined as the microscopic space between implant and corresponding abutment,
exists (Scarano, Mortellaro, Mavriqi, Pecci, & Valbonetti, 2016). The microgap between the
titanium abutment and the titanium implant is smaller than that between the zirconia abutment
and the titanium implant. Moreover, the IAI microgaps of zirconia abutments increase
significantly when torque values less than those of manufacturer-recommended values are
applied (Hernigou, et al., 2013; Rack, Zabler, Rack, Riesemeier, & Nelson, 2013).
Concerning the manufacturing technique, the premachined abutments exhibit smaller
microgaps than those of cast on and castable abutments (Harder et al., 2010; Rismanchian,
Hatami, Badrian, Khalighinejad, & Goroohi, 2012).
From the perspective of IAI connection style, Morse taper connection is sealed better than
butt joint connection (Khorshidi, Raoofi, Moattari, Bagheri, & Kalantari, 2016). Fixing of
taper connection depends on friction. Thus, the fitting degree of IAI connection mainly relates
with the taper degree and connecting area. When the taper degree of the internal cone is larger
than 5.8°, the removing force is smaller than the tightening force (Bozkaya & Muftu, 2004).
On the contrary, the small taper degree results in large removing force and tight IAI.
Additionally, the IAI under cyclic loading increases and becomes close with time, thereby
achieving a metal–to–metal cold welding (Norton, 1999). Currently, except for one type of
taper connection that is totally fixed by 1.5° Morse taper and a large contact surface of the
implant and the respective abutment (Broggini et al., 2003; Dibart, Warbington, Su, & Skobe,
2005), all other connections need a certain preloaded screw to achieve and maintain the close
connection of IAI (Aloise et al., 2010).

Micromotion/micromovement
For two-piece implant system, although the micromotion in the IAI connections decreases due
to a precise fabrication of the implant and the abutment, the current production process cannot
avoid the micromotion when chewing between the abutment and the implant (Binon, 1996;
Vigolo, Fonzi, Majzoub, & Cordioli, 2006). The micromotion of IAI includes the
microabrasion and relative microshift between the implant and the abutment and the
microrotation of the abutment relative to the implant (Figure 2). The micromotion size
generally ranges from 1.52 µm to 94.00 µm (Karl & Taylor, 2014).

According to the IAI connection style point, butt joint connection tends to fret, and taper
connection is likely to rotate. In addition, oral environment and liquid also influence the wear
mechanism to a certain extent. The peri-implant microenvironment (Ericsson et al., 1995),
which is composed of blood, saliva, and biofilm, acts as a lubricant (Karl & Taylor, 2014) that
connects the implant internal cavity and the peri-implant oral environment and decreases the
friction resistance. In an antirotation study, the rotational micromotion degree of the internal
trilobe connection and internal taper connection is the lowest and highest, respectively;
moreover, such degree of internal hexagonal and octagonal connections, which produce
similar patterns of micromotion and stress distribution, is the middle value (Saidin, Abdul
Kadir, Sulaiman, & Abu Kasim, 2012). Consequently, for single implant without adjacent
teeth, the increased number of guiding polygons lessens the resistant to rotational
micromotion. Furthermore, Semper and colleagues (Semper, Kraft, Kruger, & Nelson, 2009)
found that regular polygons display lower antirotation than that of rounded polygonal profile.
Compared with the taper connection, butt joint connection exhibits better antirotational
micromotion, but is more prone to fretting wear.

Microleakage
For most two-piece implant systems, the microgap size ranges from 0.1 µm to 10 µm after
connection of the two components and prior to loading; this size may increase after cyclic
loading. However, most oral bacteria are within the width of 0.2–1.5 µm and length of 2–10
µm (Nascimento et al., 2016). Therefore, bacteria and endotoxin can freely pass through the
IAI microgap and enter the implant internal cavity, which results in the biomaterial exchange
between the implant internal cavity and the peri-implant oral environment (Teixeira, Ribeiro,
Sato, & Pedrazzi, 2011). The passing of bacteria, bacterial toxic byproducts, and small
molecules through the IAI microgap and penetration into the implant internal cavity or vice
versa is defined as the IAI microleakage (Ericsson, et al., 1995; Gross, Abramovich, & Weiss,
1999; Quirynen, Bollen, Eyssen, & van Steenberghe, 1994; Quirynen & van Steenberghe,
1993). Broggini and colleagues (Broggini et al., 2006) found that the infiltration of
neutrophils near IAI increased with increasing implanting depth; additionally, the peak
concentration of neutrophils was constantly around the IAI, regardless of the implant position.
The authors believed that the IAI microleakage could cause a persistent inflammatory
process, which ultimately led to alveolar bone destruction (Oh, et al., 2002; Siar et al., 2003).

Whether under static condition without load (Tesmer, Wallet, Koutouzis, & Lundgren, 2009)
or under dynamic cyclic load condition (Koutouzis, Wallet, Calderon, & Lundgren, 2011), the
microleakage of the Morse taper connection is smaller than that of the butt joint connection.
Along with the taper degree, the connecting area considerably affects the IAI connection
intimacy (Baggi, Di Girolamo, Mirisola, & Calcaterra, 2013; Blum et al., 2015; do
Nascimento, Pedrazzi, Miani, Moreira, & de Albuquerque, 2009). In different implant
systems, the taper degree and connecting area are different, which are mostly responsible for
the differences in bacterial penetration (Scarano et al., 2016). The torque value applied is also
important (Ranieri et al., 2015). Commonly, a large connecting area results in small taper
degree, and a large torque value translates to the low microleakage level of bacteria (Ranieri,
et al., 2015).

Disadvantage of microgap and micromovement

Microgap leads to microleakage
The internal cavity of implant is similar to a reservoir (Nayak et al., 2014; Orsini et al., 2000;
Proff et al., 2006). When the abutment is removed and replaced, bacteria can enter the implant
internal cavity, where they reside and proliferate. The bacteria with their toxic by-products
and small nutritious molecules can freely penetrate into the implant internal cavity or reverse
through the IAI microgap. Thus, for two-piece implants, bacteria come from both the peri-
implant and implant internal cavity (Broggini, et al., 2006). Moreover, the internal cavity of
implant is characterized by easy entrance but difficult eradication for bacteria, thereby leading
to the continuous existence of bacteria and their toxic by-products around the IAI. In addition
to the toxic bacterial by-products, endotoxin, which is a small molecule complex of
lipopolysaccharides and a component of gram-negative bacterial cell walls, plays an
important toxic role on marginal bone resorption processes (Nair et al., 1996). With smaller
sizes, these endotoxins can penetrate gaps that are considerably smaller than a bacterium.
After its release from the implant internal cavity, endotoxin can induce alveolar bone
destruction via the osteoclast-activating pathway. Furthermore, a detectable immunological
response in human whole blood has been observed (Harder, Quabius, Ossenkop, & Kern,
2012). The internal cavity of each implant system was inoculated with endotoxin, and the
implant and corresponding abutment were connected together and stored under static
conditions. Endotoxin contamination could be observed immediately at 5 min after
inoculation in the supernatant of pyrogen-free water, which stores the inoculated and bolted
implants (Harder, et al., 2010).

Micromotion destroys the stability of hard and soft tissues and

aggravates microleakage
The destruction of the IAI micromotion is mainly displayed in two aspects. First,
micromotion interferes the attachment of soft tissue around the implant neck and disrupts the
stability of soft tissue that has completed integration (Passos, Gressler May, Faria, Ozcan, &
Bottino, 2013). Second, micromotion causes a micropumping effect (Ericsson, et al., 1995),
which intensifies the leakage of bacteria and their toxic by-products and accelerates the blood,
saliva, and proteoglycans (including the extracellular matrix and mucus layer) into the
internal cavity of implant (Baixe, Tenenbaum, & Etienne, 2016). The latter provides nutrients
for bacteria, aggravates bacteria colonization and proliferation, and decreases the removal
torque values of abutment by creating a slippery environment (Sahin & Ayyildiz, 2014). King
and colleagues (King, Hermann, Schoolfield, Buser, & Cochran, 2002) welded abutment and
implant into a whole piece and observed that marginal bone absorption was considerably
reduced. Relative to the non-welded two-piece implants, the size of the IAI microgap of the
welded whole piece showed no change, but the micromotion was eliminated. Hence,
micromotion is also an important cause of bone destruction.

Microgap synergizes with micromotion and causes mechanical

damage
Mechanical damages of microgap and micromotion include fretting wear, adhesive wear, and
screw loosening (Jorn, Kohorst, Besdo, Borchers, & Stiesch, 2016; Sakamoto et al., 2016).
Fretting wear refers to microfracture and chipping between the IAI, whereas adhesive wear is
defined as the plastic deformation in the IAI (Blum, et al., 2015).

Generally, for most of two-piece implants, the abutments should be fixed with implants
through a screw according to the recommended torque value. Both of the implants and the
abutments will transfer the occlusal loads from prosthetic suprastructure to the surrounding
bone tissue through the IAI. Nevertheless, the IAI connection with poor margin fitness can
cause undesired rapid stress, consequently leading to the loosening of the screw when
masticating (Binon, 2000; Jung et al., 2008). Furthermore, Sahin and colleagues (Sahin &
Ayyildiz, 2014) demonstrated that large IAI microgap resulted in high microleakage degree
and small removal torque value. The removal torque value should be the same as or higher
than the tightening torque value (Barbosa et al., 2008; Spazzin et al., 2010), and it should be
maintained at this state as long as possible. The reduction of removal torque values means
that screws are prone to loosen, that is, the IAI microgap will promote the loosening of screw
through causing microleakage (Sahin & Ayyildiz, 2014).

In addition, during chewing, the IAI of all two-piece implants exhibits chipping and plastic
deformation, which suggested that both fretting wear and adhesive wear occur (Blum, et al.,
2015). In a study carried by Blum and colleagues, particles were found to be embedded in the
layer of the IAI connecting surfaces or suspended within the microgap. The size and form of
the wear particles varied depending on its location of IAI and which implant system it
belonged to. In general, the sizes ranged from 2 to 30µm, and presented in various formations
such as flat shape or round shape, etc. Meanwhile in all implant systems examined, plastic
deformation could be observed in different degree (Blum, et al., 2015). In view of the Morse
taper degree point, the small taper degree will result in close IAI connection and low level of
fretting wear and plastic deformation when functioning (Rack, et al., 2013). In the perspective
of material properties, when zirconia abutment is fixed on the titanium implant and functions
together, the deformation energy further tends to distribute to the component with low
Young’s modulus, that is, the implant (Saidin, et al., 2012; Stimmelmayr et al., 2012).
Consequently, zirconia abutments are more likely to cause fretting wear and deformation on
the implants than those of titanium abutments. The overall amount of microwear debris
generated by zirconia abutments is also more than that of the titanium abutments
(Stimmelmayr, et al., 2012). This observation may be attributed to that the interface of
different rigidity materials is inclined to incur pure fretting wear, which is in contrast to that
of the same rigidity material tends to cause both fretting wear and deformation. Furthermore,
the bone mode might influence the mechanism of the wear at the IAI when under fatigue
loading because the surrounding bone with different resiliencies will provide different
buffering effects; afterward, the force transferred to the bone might change (Blum, et al.,
2015).

Relationship between microgap, micromotion, and

microleakage
Under static condition, the bacteria can enter and proliferate in the implant internal
cavity. The microgap provides the nutrition supply for the bacteria inside the implant
internal cavity and causes them to migrate from the implant internal cavity to the
surrounding tissue continuously. Therefore, the bacteria around the IAI exist
continually. Rismanchian and colleagues (Rismanchian, et al., 2012) conducted a
research on the microleakage of four ITI abutments with different microgap sizes.
They observed that the bacterial microleakage of the abutments after 5 h differs, but
were not significantly different after 24 h. This result indicated that with extension of
time, the influence of the microgap size on bacterial microleakage is gradually
reduced, until no significant difference exists.

Moreover, when functioning, the mismatch of the abutment and the implant, namely, the
microgap, will incur a relative microwear and microshift between two components, which is
collectively known as micromotion. The micromotion will in turn lead to fretting wear and
plastic deformation, which further reduces the precise adaptation and increases the microgap
size between them (Blum, et al., 2015). Microwear and plastic deformation will result in
enlargement of microgap at a load of 98 N within 1 million cycles, during which the highest
inclination of increase of the microgap was within the first 200,000 cycles, and then gradually
increased (Blum, et al., 2015). Under cyclic loading, the microgap size would increase, the
micromotion level would expand, and the interaction between the two factors would increase
the degree of microleakage and damage the mechanical properties of the IAI connection
(Rack, et al., 2013).
In summary, microgap permits the bacterial microleakage to persist around the IAI
(Scarano, Lorusso, Di Giulio, & Mazzatenta, 2016) and further aggravates the
micromotion when in function. Additionally, micromotion and microleakage both
lead to fretting wear, plastic deformation, and screw loosening. These mechanical
destructions will increase the micromotion and microgap (Gratton, Aquilino, &
Stanford, 2001), thereby increasing the microleakage and mechanical damage and
causing a malignant circulation. Thus, microgap is the fundamental cause of
microleakage, and micromotion is the key factor for microleakage. Both components
influence and promote each other. Consequently, they synergize the microleakage of
bacteria and endotoxins around the IAI, which ultimately induces the marginal bone
loss around the neck of the implant. Micromotion will also destruct the
osseointegration by causing mechanical damage (Figure 3).

CLINICAL IMPLICATIONS

Appropriate application of chlorhexidine

As a surface-active agent with strong effects of broad-spectrum bacteriostasis and
sterilization, chlorhexidine is generally used for treating periodontal diseases (Koutouzis,
Gadalla, Kettler, Elbarasi, & Nonhoff, 2015), due to its efficient antimicrobial and antifungal
function (Sheen & Addy, 2003). In a research conducted by Paolantonio and colleagues
(Paolantonio et al., 2008), clinical and microbiological parameters were recorded three
months after completion of prosthodontic restoration. The internal cavity of the implant was
filled with 1% chlorhexidine gel, and then the implant was connected with the abutment.
After six months, the clinical and microbiological parameters were re-examined. The test
group effectively prevented bacterial colonization and caused significant improvements for
clinical parameters in contrast with the control group. Similarly, Groenendijk and colleagues
(Groenendijk, Dominicus, Moorer, Aartman, & van Waas, 2004) reported that 0.2% of
chlorhexidine solution inhibited bacterial growth, and the beneficial effect could last for six
weeks. Conversely, some scholars held that only irrigation by chlorhexidine solution exerted
no significant effect on bacterial penetration into IAI (Romanos, Biltucci, Kokaras, & Paster,
2016; Wennstrom, Dahlen, Grondahl, & Heijl, 1987). For instance, Koutouzis and colleagues
(Koutouzis, et al., 2015) inoculated the internal cavity of the implant with 0.2% chlorhexidine
solution and sterile saline respectively. Subsequently, the abutments were replaced, and the
implants were cyclic loaded. Endotoxins were detected in both groups, and no statistically
significant differences were observed at all of the testing points.

The differences in the above results may be due to the different exposure time to
chlorhexidine when located in the implant internal cavity and subgingival area (Ready et al.,
2015). To summarize, the benefit of chlorhexidine is hard to justify in light of the opposing
evidences. Therefore, the using of chlorhexidine in the oral implantation is suggested with
possible benefits, and the appropriate dosage and form of chlorhexidine which could make its
bactericidal effect more durable still need further studies.

Selection of Morse taper connection implants and

corresponding platform switching abutments

Mangano and colleagues (Mangano et al., 2009) evaluated the survival rate and related
clinical indexes of 1920 Morse taper connection implants. They revealed that the use of
tapered abutments minimized the IAI microgaps and enhances the mechanical stability, which
eventually reduced the crestal bone loss and prosthetic complications.

Furthermore, the use of platform switching abutments keeps the microleakage and
micromotion at the IAI distant from the alveolar ridge. This technique directly reduces the
pollution of bacteria and endotoxins (Canullo, Pace, Coelho, Sciubba, & Vozza, 2011; Wang,
Kan, Rungcharassaeng, Roe, & Lozada, 2015) and transfers the microenvironment, which is
detrimental to the integration of implant and peri-implant tissue away from the IAI and close
to the implant center (Passos, et al., 2013). The large platform width results in improved peri-
implant tissue repair and rebuilding. For the same implant system and abutment, the larger
implant diameter, i.e., wider platform, results in less marginal bone loss (Cumbo et al., 2013),
which is also beneficial for the formation of a relatively thin and uniform connective tissue
sealing (Canullo, Fedele, Iannello, & Jepsen, 2010). Therefore, Morse taper connection
implants and platform switching abutments could be used to reduce the resorption of the
alveolar crest (Canullo, et al., 2010; Farronato et al., 2012; Hurzeler, Fickl, Zuhr, & Wachtel,
2007; Novaes, de Oliveira, Muglia, Papalexiou, & Taba, 2006).
Selection of abutments and retained mode
As for the biofilm mass on the surfaces of abutments, some scholars regarded that zirconia
abutments accumulate small amounts of biofilm mass and bacteria because the zirconia
material can lower the susceptibility to microorganism adhesion (Hisbergues, Vendeville, &
Vendeville, 2009; Nascimento et al., 2014; Nascimento, et al., 2016; Scarano, Piattelli,
Caputi, Favero, & Piattelli, 2004). However, within this clinical research, either the implants
are tested without prosthetic suprastructure and load (de Oliveira et al., 2012; Nascimento, et
al., 2014) or zirconia abutments are placed in the anterior region; additionally, titanium
abutments are placed in the posterior region, despite the availability of prosthetic
suprastructures (Nascimento, et al., 2016). Thus, a defect exists since the effect of masticatory
force on the microleakage of IAI is not compared when these two abutments are functioning.
Consequently, unless necessary, such that the missing teeth are in the esthetic zone (usually in
anterior region), or the patients express high aesthetic requirements, zirconia abutments are
not recommended to reduce the microgap and microleakage of IAI. When zirconia abutments
should be selected, the manufacturer-recommended torque values should be strictly followed
(Smith & Turkyilmaz, 2014). For the same reason, premachined abutments, rather than
custom abutments, are suggested because premachined abutments show smaller microgaps
than those of customized abutments.

Regarding the retained mode of prosthetic suprastructure, all advantages and disadvantages of
cement-retained and screw-retained modes should be synthetically considered to connect the
abutment and prosthetic suprastructure appropriately. Regardless of whether the test is in vivo
(Keller, Bragger, & Mombelli, 1998) or in vitro (Passos, et al., 2013; Penarrocha-Oltra et al.,
2016), the microleakage at the IAI of cement-retained prosthesis is smaller than that of screw-
retained prosthesis. Lemos and colleagues (Lemos et al., 2016) conducted a systematic review
and meta-analysis and concluded that cement-retained prosthesis exhibited less marginal bone
loss and higher survival rate than those of screw-retained prosthesis during follow-up, which
ranges from 12 months to 180 months. Nevertheless, some deficiencies associated with
cement-retained prosthesis still exist. Among these deficiencies, the most important is the
difficulty in clearing residual cement, which would promote biofilm formation (Busscher,
Rinastiti, Siswomihardjo, & van der Mei, 2010), increase the peri-implant gingival sulcus
bacterial loads (Penarrocha-Oltra, et al., 2016), and lead to peri-implantitis (Korsch, Obst, &
Walther, 2014). In general, when the IAI is deep in subgingival, such as when implants are
placed deep, or the gingival tissue is thick, screw retained prosthesis is preferred, especially
when the patient presents a history of periodontal disease. On the contrary, when the IAI is
not deeply located, cement-retained prosthesis is favored provided that the remaining cement
can be cleared away meticulously.

SUMMARY AND CONCLUSIONS

To date, two-piece implant systems are widely used in the clinic. However, microgap and
micromotion inevitably exist at the IAI. This phenomenon results in both microleakage and
mechanical damage, which finally incur bone resorption around the implant neck. Clinicians
should sufficiently recognize and understand the characteristics of the two-piece structures.
To reduce the bone resorption engendered by the microgap and micromotion at the IAI, the
first and most important thing is to select suitable Morse taper or hybrid connection implants
and platform switching abutments, which not only reduce the pollution of bacteria and
endotoxins directly, but also transfer the harmful microenvironment away from the IAI and
close to the implant center. Moreover, chlorhexidine solution or gel may provide some
benefits, zirconia and custom abutments should be chosen sparingly, and appropriate retain
mode should be selected for suprastructure.

ACKNOWLEDGEMENT
This study was financially supported by the grants from National Natural Science Foundation
of China (81570956) and the Bureau of Science and Technology of Wuhan ([2014]160,
2015060101010051).
REFERENCES
Aloise, J. P., Curcio, R., Laporta, M. Z., Rossi, L., da Silva, A. M., & Rapoport, A.
(2010). Microbial leakage through the implant-abutment interface of
Morse taper implants in vitro. Clin Oral Implants Res, 21(3), 328-335.
Alvarez-Arenal, A., Segura-Mori, L., Gonzalez-Gonzalez, I., DeLlanos-Lanchares, H.,
Sanchez-Lasheras, F., & Ellacuria-Echevarria, J. (2017). Stress distribution
in the transitional peri-implant bone in a single implant-supported
prosthesis with platform-switching under different angulated loads.
Odontology, 105(1), 68-75.
Alves, D. C., de Carvalho, P. S., Elias, C. N., Vedovatto, E., & Martinez, E. F. (2016). In
vitro analysis of the microbiological sealing of tapered implants after
mechanical cycling. Clin Oral Investig, 20(9), 2437-2445.
Baggi, L., Di Girolamo, M., Mirisola, C., & Calcaterra, R. (2013). Microbiological
evaluation of bacterial and mycotic seal in implant systems with different
implant-abutment interfaces and closing torque values. Implant Dent,
22(4), 344-350.
Baixe, S., Tenenbaum, H., & Etienne, O. (2016). [Microbial contamination of the
implant-abutment connections: Review of the literature]. Rev Stomatol
Chir Maxillofac Chir Orale, 117(1), 20-25.
Barbosa, G. A., Bernardes, S. R., das Neves, F. D., Fernandes Neto, A. J., de Mattos
Mda, G., & Ribeiro, R. F. (2008). Relation between implant/abutment
vertical misfit and torque loss of abutment screws. Braz Dent J, 19(4), 358-
363.
Binon, P. P. (1996). The effect of implant/abutment hexagonal misfit on screw
joint stability. Int J Prosthodont, 9(2), 149-160.
Binon, P. P. (2000). Implants and components: entering the new millennium. Int J
Oral Maxillofac Implants, 15(1), 76-94.
Blum, K., Wiest, W., Fella, C., Balles, A., Dittmann, J., Rack, A., et al. (2015). Fatigue
induced changes in conical implant-abutment connections. Dent Mater,
31(11), 1415-1426.
Bozkaya, D., & Muftu, S. (2004). Efficiency considerations for the purely tapered
interference fit (TIF) abutments used in dental implants. J Biomech Eng,
126(4), 393-401.
Branemark, P. I., Adell, R., Breine, U., Hansson, B. O., Lindstrom, J., & Ohlsson, A.
(1969). Intra-osseous anchorage of dental prostheses. I. Experimental
studies. Scand J Plast Reconstr Surg, 3(2), 81-100.
Broggini, N., McManus, L. M., Hermann, J. S., Medina, R., Schenk, R. K., Buser, D., et
al. (2006). Peri-implant inflammation defined by the implant-abutment
interface. J Dent Res, 85(5), 473-478.
Broggini, N., McManus, L. M., Hermann, J. S., Medina, R. U., Oates, T. W., Schenk, R.
K., et al. (2003). Persistent acute inflammation at the implant-abutment
 interface. J Dent Res, 82(3), 232-237.
Busscher, H. J., Rinastiti, M., Siswomihardjo, W., & van der Mei, H. C. (2010).
Biofilm formation on dental restorative and implant materials. J Dent Res,
89(7), 657-665.
Canullo, L., Fedele, G. R., Iannello, G., & Jepsen, S. (2010). Platform switching and
marginal bone-level alterations: the results of a randomized-controlled
trial. Clin Oral Implants Res, 21(1), 115-121.
Canullo, L., Pace, F., Coelho, P., Sciubba, E., & Vozza, I. (2011). The influence of
platform switching on the biomechanical aspects of the implant-abutment
system. A three dimensional finite element study. Med Oral Patol Oral Cir
Bucal, 16(6), e852-856.
Cumbo, C., Marigo, L., Somma, F., La Torre, G., Minciacchi, I., & D'Addona, A.
(2013). Implant platform switching concept: a literature review. Eur Rev
Med Pharmacol Sci, 17(3), 392-397.
Davi, L. R., Golin, A. L., Bernardes, S. R., Araujo, C. A., & Neves, F. D. (2008). In vitro
integrity of implant external hexagon after application of surgical
placement torque simulating implant locking. Braz Oral Res, 22(2), 125-
131.
de Oliveira, G. R., Pozzer, L., Cavalieri-Pereira, L., de Moraes, P. H., Olate, S., & de
Albergaria Barbosa, J. R. (2012). Bacterial adhesion and colonization
differences between zirconia and titanium implant abutments: an in vivo
human study. J Periodontal Implant Sci, 42(6), 217-223.
Dibart, S., Warbington, M., Su, M. F., & Skobe, Z. (2005). In vitro evaluation of the
implant-abutment bacterial seal: the locking taper system. Int J Oral
Maxillofac Implants, 20(5), 732-737.
do Nascimento, C., Pedrazzi, V., Miani, P. K., Moreira, L. D., & de Albuquerque, R. F.,
Jr. (2009). Influence of repeated screw tightening on bacterial leakage
along the implant-abutment interface. Clin Oral Implants Res, 20(12),
1394-1397.
Ericsson, I., Persson, L. G., Berglundh, T., Marinello, C. P., Lindhe, J., & Klinge, B.
(1995). Different types of inflammatory reactions in peri-implant soft
tissues. J Clin Periodontol, 22(3), 255-261.
Farronato, D., Santoro, G., Canullo, L., Botticelli, D., Maiorana, C., & Lang, N. P.
(2012). Establishment of the epithelial attachment and connective tissue
adaptation to implants installed under the concept of "platform
switching": a histologic study in minipigs. Clin Oral Implants Res, 23(1),
90-94.
Gracis, S., Michalakis, K., Vigolo, P., Vult von Steyern, P., Zwahlen, M., & Sailer, I.
(2012). Internal vs. external connections for abutments/reconstructions:
a systematic review. Clin Oral Implants Res, 23 Suppl 6, 202-216.
Gratton, D. G., Aquilino, S. A., & Stanford, C. M. (2001). Micromotion and dynamic
fatigue properties of the dental implant-abutment interface. J Prosthet
 Dent, 85(1), 47-52.
Groenendijk, E., Dominicus, J. J., Moorer, W. R., Aartman, I. H., & van Waas, M. A.
(2004). Microbiological and clinical effects of chlorhexidine enclosed in
fixtures of 3I-Titamed implants. Clin Oral Implants Res, 15(2), 174-179.
Gross, M., Abramovich, I., & Weiss, E. I. (1999). Microleakage at the abutment-
implant interface of osseointegrated implants: a comparative study. Int J
Oral Maxillofac Implants, 14(1), 94-100.
Harder, S., Dimaczek, B., Acil, Y., Terheyden, H., Freitag-Wolf, S., & Kern, M. (2010).
Molecular leakage at implant-abutment connection--in vitro investigation
of tightness of internal conical implant-abutment connections against
endotoxin penetration. Clin Oral Investig, 14(4), 427-432.
Harder, S., Quabius, E. S., Ossenkop, L., & Kern, M. (2012). Assessment of
lipopolysaccharide microleakage at conical implant-abutment
connections. Clin Oral Investig, 16(5), 1377-1384.
Hernigou, P., Queinnec, S., & Flouzat Lachaniette, C. H. (2013). One hundred and
fifty years of history of the Morse taper: from Stephen A. Morse in 1864 to
complications related to modularity in hip arthroplasty. Int Orthop,
37(10), 2081-2088.
Hisbergues, M., Vendeville, S., & Vendeville, P. (2009). Zirconia: Established facts
and perspectives for a biomaterial in dental implantology. J Biomed Mater
Res B Appl Biomater, 88(2), 519-529.
Hurzeler, M., Fickl, S., Zuhr, O., & Wachtel, H. C. (2007). Peri-implant bone level
around implants with platform-switched abutments: preliminary data
from a prospective study. J Oral Maxillofac Surg, 65(7 Suppl 1), 33-39.
Jorn, D., Kohorst, P., Besdo, S., Borchers, L., & Stiesch, M. (2016). Three-
Dimensional Nonlinear Finite Element Analysis and Microcomputed
Tomography Evaluation of Microgap Formation in a Dental Implant Under
Oblique Loading. Int J Oral Maxillofac Implants, 31(3), e32-42.
Jung, R. E., Pjetursson, B. E., Glauser, R., Zembic, A., Zwahlen, M., & Lang, N. P.
(2008). A systematic review of the 5-year survival and complication rates
of implant-supported single crowns. Clin Oral Implants Res, 19(2), 119-
130.
Karl, M., & Taylor, T. D. (2014). Parameters determining micromotion at the
implant-abutment interface. Int J Oral Maxillofac Implants, 29(6), 1338-
1347.
Keller, W., Bragger, U., & Mombelli, A. (1998). Peri-implant microflora of implants
with cemented and screw retained suprastructures. Clin Oral Implants Res,
9(4), 209-217.
Khorshidi, H., Raoofi, S., Moattari, A., Bagheri, A., & Kalantari, M. H. (2016). In
Vitro Evaluation of Bacterial Leakage at Implant-Abutment Connection:
An 11-Degree Morse Taper Compared to a Butt Joint Connection. Int J
Biomater, 2016, 8527849.
King, G. N., Hermann, J. S., Schoolfield, J. D., Buser, D., & Cochran, D. L. (2002).
Influence of the size of the microgap on crestal bone levels in non-
submerged dental implants: a radiographic study in the canine mandible. J
Periodontol, 73(10), 1111-1117.
Korsch, M., Obst, U., & Walther, W. (2014). Cement-associated peri-implantitis: a
retrospective clinical observational study of fixed implant-supported
restorations using a methacrylate cement. Clin Oral Implants Res, 25(7),
797-802.
Koutouzis, T., Gadalla, H., Kettler, Z., Elbarasi, A., & Nonhoff, J. (2015). The Role of
Chlorhexidine on Endotoxin Penetration to the Implant-Abutment
Interface (IAI). Clin Implant Dent Relat Res, 17(3), 476-482.
Koutouzis, T., Wallet, S., Calderon, N., & Lundgren, T. (2011). Bacterial
colonization of the implant-abutment interface using an in vitro dynamic
loading model. J Periodontol, 82(4), 613-618.
Lemos, C. A., de Souza Batista, V. E., Almeida, D. A., Santiago Junior, J. F., Verri, F. R.,
& Pellizzer, E. P. (2016). Evaluation of cement-retained versus screw-
retained implant-supported restorations for marginal bone loss: A
systematic review and meta-analysis. J Prosthet Dent, 115(4), 419-427.
Liu, S., Tang, C., Yu, J., Dai, W., Bao, Y., & Hu, D. (2014). The effect of platform
switching on stress distribution in implants and periimplant bone studied
by nonlinear finite element analysis. J Prosthet Dent, 112(5), 1111-1118.
Macedo, J. P., Pereira, J., Vahey, B. R., Henriques, B., Benfatti, C. A., Magini, R. S., et
al. (2016). Morse taper dental implants and platform switching: The new
paradigm in oral implantology. Eur J Dent, 10(1), 148-154.
Mangano, C., Mangano, F., Piattelli, A., Iezzi, G., Mangano, A., & La Colla, L. (2009).
Prospective clinical evaluation of 1920 Morse taper connection implants:
results after 4 years of functional loading. Clin Oral Implants Res, 20(3),
254-261.
Nair, S. P., Meghji, S., Wilson, M., Reddi, K., White, P., & Henderson, B. (1996).
Bacterially induced bone destruction: mechanisms and misconceptions.
Infect Immun, 64(7), 2371-2380.
Nascimento, C., Pita, M. S., Fernandes, F. H., Pedrazzi, V., de Albuquerque Junior, R.
F., & Ribeiro, R. F. (2014). Bacterial adhesion on the titanium and zirconia
abutment surfaces. Clin Oral Implants Res, 25(3), 337-343.
Nascimento, C., Pita, M. S., Santos Ede, S., Monesi, N., Pedrazzi, V., Albuquerque
Junior, R. F., et al. (2016). Microbiome of titanium and zirconia dental
implants abutments. Dent Mater, 32(1), 93-101.
Nayak, A. G., Fernandes, A., Kulkarni, R., Ajantha, G. S., Lekha, K., & Nadiger, R.
(2014). Efficacy of antibacterial sealing gel and O-ring to prevent
microleakage at the implant abutment interface: an in vitro study. J Oral
Implantol, 40(1), 11-14.
Norton, M. R. (1999). Assessment of cold welding properties of the internal
 conical interface of two commercially available implant systems. J Prosthet
Dent, 81(2), 159-166.
Novaes, A. B., Jr., de Oliveira, R. R., Muglia, V. A., Papalexiou, V., & Taba, M. (2006).
The effects of interimplant distances on papilla formation and crestal
resorption in implants with a morse cone connection and a platform
switch: a histomorphometric study in dogs. J Periodontol, 77(11), 1839-
1849.
Oh, T. J., Yoon, J., Misch, C. E., & Wang, H. L. (2002). The causes of early implant
bone loss: myth or science? J Periodontol, 73(3), 322-333.
Orsini, G., Fanali, S., Scarano, A., Petrone, G., di Silvestro, S., & Piattelli, A. (2000).
Tissue reactions, fluids, and bacterial infiltration in implants retrieved at
autopsy: a case report. Int J Oral Maxillofac Implants, 15(2), 283-286.
Paolantonio, M., Perinetti, G., D'Ercole, S., Graziani, F., Catamo, G., Sammartino, G.,
et al. (2008). Internal decontamination of dental implants: an in vivo
randomized microbiologic 6-month trial on the effects of a chlorhexidine
gel. J Periodontol, 79(8), 1419-1425.
Passos, S. P., Gressler May, L., Faria, R., Ozcan, M., & Bottino, M. A. (2013). Implant-
abutment gap versus microbial colonization: Clinical significance based on
a literature review. J Biomed Mater Res B Appl Biomater, 101(7), 1321-
1328.
Penarrocha-Oltra, D., Monreal-Bello, A., Penarrocha-Diago, M., Alonso-Perez-
Barquero, J., Botticelli, D., & Canullo, L. (2016). Microbial Colonization of
the Peri-Implant Sulcus and Implant Connection of Implants Restored
With Cemented Versus Screw-Retained Superstructures: A Cross-Sectional
Study. J Periodontol, 87(9), 1002-1011.
Proff, P., Steinmetz, I., Bayerlein, T., Dietze, S., Fanghanel, J., & Gedrange, T. (2006).
Bacterial colonisation of interior implant threads with and without
sealing. Folia Morphol (Warsz), 65(1), 75-77.
Quirynen, M., Bollen, C. M., Eyssen, H., & van Steenberghe, D. (1994). Microbial
penetration along the implant components of the Branemark system. An
in vitro study. Clin Oral Implants Res, 5(4), 239-244.
Quirynen, M., & van Steenberghe, D. (1993). Bacterial colonization of the internal
part of two-stage implants. An in vivo study. Clin Oral Implants Res, 4(3),
158-161.
Rack, T., Zabler, S., Rack, A., Riesemeier, H., & Nelson, K. (2013). An in vitro pilot
study of abutment stability during loading in new and fatigue-loaded
conical dental implants using synchrotron-based radiography. Int J Oral
Maxillofac Implants, 28(1), 44-50.
Ranieri, R., Ferreira, A., Souza, E., Arcoverde, J., Dametto, F., Gade-Neto, C., et al.
(2015). The bacterial sealing capacity of morse taper implant-abutment
systems in vitro. J Periodontol, 86(5), 696-702.
Ready, D., Theodoridis, G., Green, I., Ciric, L., Pratten, J., Tay, W., et al. (2015). In
 vitro evaluation of the antibiofilm properties of chlorhexidine and
delmopinol on dental implant surfaces. Int J Antimicrob Agents, 45(6),
662-666.
Rismanchian, M., Hatami, M., Badrian, H., Khalighinejad, N., & Goroohi, H. (2012).
Evaluation of microgap size and microbial leakage in the connection area
of 4 abutments with Straumann (ITI) implant. J Oral Implantol, 38(6), 677-
685.
Romanos, G. E., Biltucci, M. T., Kokaras, A., & Paster, B. J. (2016). Bacterial
Composition at the Implant-Abutment Connection under Loading in vivo.
Clin Implant Dent Relat Res, 18(1), 138-145.
Sahin, C., & Ayyildiz, S. (2014). Correlation between microleakage and screw
loosening at implant-abutment connection. J Adv Prosthodont, 6(1), 35-38.
Saidin, S., Abdul Kadir, M. R., Sulaiman, E., & Abu Kasim, N. H. (2012). Effects of
different implant-abutment connections on micromotion and stress
distribution: prediction of microgap formation. J Dent, 40(6), 467-474.
Sailer, I., Sailer, T., Stawarczyk, B., Jung, R. E., & Hammerle, C. H. (2009). In vitro
study of the influence of the type of connection on the fracture load of
zirconia abutments with internal and external implant-abutment
connections. Int J Oral Maxillofac Implants, 24(5), 850-858.
Sakamoto, K., Homma, S., Takanashi, T., Takemoto, S., Furuya, Y., Yoshinari, M., et
al. (2016). Influence of eccentric cyclic loading on implant components:
Comparison between external joint system and internal joint system. Dent
Mater J, 35(6), 929-937.
Scarano, A., Lorusso, C., Di Giulio, C., & Mazzatenta, A. (2016). Evaluation of the
Sealing Capability of the Implant Healing Screw by Using Real Time
Volatile Organic Compounds Analysis: Internal Hexagon Versus Cone
Morse. J Periodontol, 87(12), 1492-1498.
Scarano, A., Mortellaro, C., Mavriqi, L., Pecci, R., & Valbonetti, L. (2016).
Evaluation of Microgap With Three-Dimensional X-Ray Microtomography:
Internal Hexagon Versus Cone Morse. J Craniofac Surg, 27(3), 682-685.
Scarano, A., Piattelli, M., Caputi, S., Favero, G. A., & Piattelli, A. (2004). Bacterial
adhesion on commercially pure titanium and zirconium oxide disks: an in
vivo human study. J Periodontol, 75(2), 292-296.
Scarano, A., Valbonetti, L., Degidi, M., Pecci, R., Piattelli, A., de Oliveira, P. S., et al.
(2016). Implant-Abutment Contact Surfaces and Microgap Measurements
of Different Implant Connections Under 3-Dimensional X-Ray
Microtomography. Implant Dent, 25(5), 656-662.
Semper, W., Kraft, S., Kruger, T., & Nelson, K. (2009). Theoretical optimum of
implant positional index design. J Dent Res, 88(8), 731-735.
Sheen, S., & Addy, M. (2003). An in vitro evaluation of the availability of
cetylpyridinium chloride and chlorhexidine in some commercially
available mouthrinse products. Br Dent J, 194(4), 207-210; discussion 203.
Siar, C. H., Toh, C. G., Romanos, G., Swaminathan, D., Ong, A. H., Yaacob, H., et al.
(2003). Peri-implant soft tissue integration of immediately loaded
implants in the posterior macaque mandible: a histomorphometric study.
J Periodontol, 74(5), 571-578.
Smith, N. A., & Turkyilmaz, I. (2014). Evaluation of the sealing capability of
implants to titanium and zirconia abutments against Porphyromonas
gingivalis, Prevotella intermedia, and Fusobacterium nucleatum under
different screw torque values. J Prosthet Dent, 112(3), 561-567.
Spazzin, A. O., Henrique, G. E., Nobilo, M. A., Consani, R. L., Correr-Sobrinho, L., &
Mesquita, M. F. (2010). Effect of retorque on loosening torque of
prosthetic screws under two levels of fit of implant-supported dentures.
Braz Dent J, 21(1), 12-17.
Stimmelmayr, M., Edelhoff, D., Guth, J. F., Erdelt, K., Happe, A., & Beuer, F. (2012).
Wear at the titanium-titanium and the titanium-zirconia implant-
abutment interface: a comparative in vitro study. Dent Mater, 28(12),
1215-1220.
Teixeira, W., Ribeiro, R. F., Sato, S., & Pedrazzi, V. (2011). Microleakage into and
from two-stage implants: an in vitro comparative study. Int J Oral
Maxillofac Implants, 26(1), 56-62.
Tesmer, M., Wallet, S., Koutouzis, T., & Lundgren, T. (2009). Bacterial colonization
of the dental implant fixture-abutment interface: an in vitro study. J
Periodontol, 80(12), 1991-1997.
Vigolo, P., Fonzi, F., Majzoub, Z., & Cordioli, G. (2006). An in vitro evaluation of
titanium, zirconia, and alumina procera abutments with hexagonal
connection. Int J Oral Maxillofac Implants, 21(4), 575-580.
Wang, Y. C., Kan, J. Y., Rungcharassaeng, K., Roe, P., & Lozada, J. L. (2015). Marginal
bone response of implants with platform switching and non-platform
switching abutments in posterior healed sites: a 1-year prospective study.
Clin Oral Implants Res, 26(2), 220-227.
Wennstrom, J. L., Dahlen, G., Grondahl, K., & Heijl, L. (1987). Periodic subgingival
antimicrobial irrigation of periodontal pockets. II. Microbiological and
radiographical observations. J Clin Periodontol, 14(10), 573-580.
Figure Caption
Figr-1
Figr-2
Figr-3
Figr-4Fig 1. (a) Butt joint connection. (b) Tapered connection. (c) Hybrid connection.

Fig 2. Green arrow refers to the microabrasion and relative microshift between the implant
and the abutment; blue arrow refers to microrotation of the abutment relative to the implant.
(a) Fretting wear means the microfracture and chipping between the IAI. (b) Adhesive wear is
defined as the plastic deformation in the IAI.

Fig 3. Influences of microgap and micromotion of IAI on marginal bone loss around implant
neck.