Archives of Oral Biology 83 (2017) 153–160

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Archives of Oral Biology

journal homepage: www.elsevier.com/locate/archoralbio

Review

Influences of microgap and micromotion of implant–abutment interface on MARK

marginal bone loss around implant neck
⁎
Yang Liu, Jiawei Wang
Department of Prosthodontics, School of Stomatology, Wuhan University, Wuhan, 430079, China

A R T I C L E I N F O A B S T R A C T

Keywords: Objective: To review the influences and clinical implications of micro-gap and micro-motion of implant-abut-
Implant-abutment interface ment interface on marginal bone loss around the neck of implant.
Microgap Design: Literatures were searched based on the following Keywords: implant-abutment interface/implant-
Micromotion abutment connection/implant-abutment conjunction, microgap, micromotion/micromovement, microleakage,
Microleakage
and current control methods available. The papers were then screened through titles, abstracts, and full texts.
Marginal bone loss
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 micro-
motion 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 absorp-
tion finally occurs. We summarize the influences of microgap and micromotion at the implant-abutment in-
terface 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.

1. Introduction determined as, for instance, implant-abutment interface/implant-abut-

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 re-
sorption 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, mi-
croleakage, 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 con-
sidered the microgap responsible for the phenomenon, and others deem
it as the result of micromotion. In this article, the keywords were
ment connection/implant-abutment conjunction, microgap, micromo-
tion/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 ab-
stracts 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.

⁎
Corresponding author at: 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 addresses: whulyang@hotmail.com (Y. Liu), wangjwei@hotmail.com (J. Wang).

http://dx.doi.org/10.1016/j.archoralbio.2017.07.022
Received 19 February 2017; Received in revised form 19 July 2017; Accepted 27 July 2017
0003-9969/ © 2017 Elsevier Ltd. All rights reserved.
Y. Liu, J. Wang
2. Microgap, micromotion, and microleakage
2.1. 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 con-
nection 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 in-
cludes taper, butt joint, and hybrid connections (Fig. 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 re-
fers to the connecting area between the implant and the abutment
Fig. 1. (a) Butt joint connection. (b) Tapered connection. (c) Hybrid connection.
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Archives of Oral Biology 83 (2017) 153–160
without a taper, and it is only retained via a retaining screw. A hybrid
connection means that both Morse taper design and the regular poly-
gonal 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 distribu-
tion of the peri-IAI bone is reduced (Alvarez-Arenal et al., 2017; Liu
et al., 2014).
2.2. Microgap
The implant and the abutment cannot be accurately matched be-
cause 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 mi-
crogap between the titanium abutment and the titanium implant is
smaller than that between the zirconia abutment and the titanium im-
plant. Moreover, the IAI microgaps of zirconia abutments increase
significantly when torque values less than those of manufacturer-re-
commended 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 connec-
tion is sealed better than butt joint connection (Khorshidi, Raoofi,
Moattari, Bagheri, & Kalantari, 2016). Fixing of taper connection de-
pends on friction. Thus, the fitting degree of IAI connection mainly
relates with the taper degree and connecting area. When the taper
Y. Liu, J. Wang
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 be-
comes close with time, thereby achieving a metal–to–metal cold
welding (Norton, 1999). Currently, except for one type of taper con-
nection 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).
2.3. 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 micro-
motion 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 re-
lative to the implant (Fig. 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
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. (For interpretation of the references to colour
in this figure legend, the reader is referred to the web version of this article.)
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Archives of Oral Biology 83 (2017) 153–160
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 les-
sens 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.
2.4. 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 by-
products, and small molecules through the IAI microgap and penetra-
tion into the implant internal cavity or vice versa is defined as the IAI
microleakage (Ericsson et al., 1995; Gross, Abramovich, & Weiss, 1999;
Y. Liu, J. Wang
Quirynen, Bollen, Eyssen, & van Steenberghe, 1994; Quirynen & van
Steenberghe, 1993). Broggini et al. (2006) found that the infiltration of
neutrophils near IAI increased with increasing implanting depth; ad-
ditionally, 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 con-
nection. 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., 2016c). 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).
2.5. Disadvantage of microgap and micromovement
2.5.1. 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 im-
plant internal cavity (Broggini et al., 2006). Moreover, the internal
cavity of implant is characterized by easy entrance but difficult eradi-
cation 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 en-
dotoxins can penetrate gaps that are considerably smaller than a bac-
terium. 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 en-
dotoxin, 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 su-
pernatant of pyrogen-free water, which stores the inoculated and bolted
implants (Harder et al., 2010).
2.5.2. 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 (in-
cluding 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
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Archives of Oral Biology 83 (2017) 153–160
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.
2.5.3. 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 ex-
hibits 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 mi-
crogap. 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 30 μm, 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 dif-
ferent 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 in-
fluence 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).
2.6. 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
Y. Liu, J. Wang
the bacteria inside the implant internal cavity and causes them to mi-
grate from the implant internal cavity to the surrounding tissue con-
tinuously. Therefore, the bacteria around the IAI exist continually.
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 mi-
croleakage 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). Micro-
wear and plastic deformation will result in enlargement of microgap at
a load of 98 N within 1 million cycles, during which the highest in-
clination of increase of the microgap was within the first 200,000 cy-
cles, 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 in-
crease the degree of microleakage and damage the mechanical prop-
erties 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 de-
formation, 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 micro-
leakage. Both components influence and promote each other. Conse-
quently, 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 osseointe-
gration by causing mechanical damage (Fig. 3).
3. Clinical implications
3.1. 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 anti-
fungal 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 comple-
tion of prosthodontic restoration. The internal cavity of the implant was
filled with 1% chlorhexidine gel, and then the implant was connected
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Archives of Oral Biology 83 (2017) 153–160
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. Sub-
sequently, 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 evi-
dences. 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.
3.2. Selection of morse taper connection implants and corresponding
platform switching abutments
Mangano et al. (2009) evaluated the survival rate and related
clinical indexes of 1920 Morse taper connection implants. They re-
vealed 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 micro-
environment, 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 et al., 2007; Novaes, de Oliveira,
Muglia, Papalexiou, & Taba, 2006).
Fig. 3. Influences of microgap and micromotion of IAI on marginal bone
loss around implant neck.
Y. Liu, J. Wang
3.3. 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 sus-
ceptibility 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 (Nascimento et al., 2014; de
Oliveira et al., 2012) 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 micro-
leakage of IAI. When zirconia abutments should be selected, the man-
ufacturer-recommended torque values should be strictly followed
(Smith & Turkyilmaz, 2014). For the same reason, premachined abut-
ments, rather than custom abutments, are suggested because pre-
machined abutments show smaller microgaps than those of customized
abutments.
Regarding the retained mode of prosthetic suprastructure, all ad-
vantages 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-re-
tained 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 gin-
gival 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.
4. 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 mi-
croenvironment 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 ap-
propriate retain mode should be selected for suprastructure.
158
Archives of Oral Biology 83 (2017) 153–160
Conflicts of interest
None.
Acknowledgements
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).
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