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 31

Clinical Recommendations for Implant Abutment

Selection for Single-Implant Reconstructions:
Customized vs Standardized Ceramic and Metallic Solutions

Cristina Zarauz, Med Dent1 The replacement of a single miss-

Joao Pitta, Med Dent1 ing tooth with an implant-supported
Guillermo Pradies, Prof Dr Med Dent, PhD2 single crown is considered a valid
Irena Sailer, Prof Dr Med Dent1 treatment option due to excellent
survival rates for both the implant
and its reconstruction.1,2 Yet, with
The present paper presents clinical guidelines for the selection of the abutment increasing patient expectations
material and level of customization for single-implant reconstructions. A systematic concerning the esthetic outcome of
literature search was conducted previous to a Consensus Conference, resulting anterior reconstructions,3 this treat-
in two systematic reviews. One review focused on esthetic clinical outcomes,
ment remains a clinical challenge.4
including esthetic indices and linear measurements, and the second focused on
peri-implant soft tissue color outcomes, evaluated with spectrophotometry. The Providing an implant-supported
outcomes of esthetic indexes and linear measurement were highly heterogenic, reconstruction that blends in to the
hence, a meta-analysis was not feasible. All-ceramic and customized solutions neighboring teeth and soft tissue
showed a trend for improved results of the esthetic outcomes. Regarding soft architecture, in a harmonious and
tissue color outcomes, all-ceramic abutments induced significantly less soft tissue pleasant manner, is only possible
color changes. Both metallic and all-ceramic abutments/standard and customized
after meticulous patient and site-
components may result in clinically and esthetically acceptable reconstructions.
Int J Periodontics Restorative Dent 2020;40:31–37. doi: 10.11607/prd.3913 specific risk analysis, consequent
decision-making (implant, abut-
ment, and reconstruction selection;
surgical technique; treatment plan-
ning sequence), and subsequent ex-
cellent treatment execution.4,5
It is the scope of this report to fo-
cus on recommendations for the use
of abutments made out of different
materials and the application of dif-
ferent types of implant-supported
solutions, ie, the customized and
standardized solutions.
Available materials for abut-
Division of Fixed Prosthodontics and Biomaterials, Clinic of Dental Medicine,
1
ments supporting single-implant
University of Geneva, Geneva, Switzerland.
2Department of Prosthodontics, Faculty of Dentistry, Complutense University of Madrid,
crowns include: metallic (titanium,
Madrid, Spain. precious/semi-precious alloys,2 non­
precious alloys6), all-ceramic2 (zir-
Correspondence to: Cristina Zarauz, Division of Fixed Prosthodontics and Biomaterials, conia, alumina), and resin-based
Clinic of Dental Medicine, University of Geneva, Switzerland, Rue Michel-Servet 1,
1211 Genève 4, Switzerland. Email: cristina.zarauz@unige.ch
materials (polyetheretherketone).7
Most published literature on
 Submitted May 9, 2018; accepted May 30, 2018.
 ©2020 by Quintessence Publishing Co Inc. implant abutments has focused on

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32
Table 1   Abutment Selection Decision Path
Anterior single-tooth implant abutment
Measured criteria Characteristics
Retention type
Screw-retained Cement-retained*
Biologic outcomes +++ ++
Mechanical outcomes ++ +++
Retrievability +++ + implant position (group 2), abut-
Level of Customization
Standardized Customized
Esthetic outcomes + +++
Cement removal + ++
Material
All-ceramic Metal Hybrid abutment
Esthetic outcomes +++ + ++
Soft tissue thickness < 2 mm > 2 mm > 2 mm
Occlusal forces expected + +++ ++
Space for material thickness + +++ ++
Criteria for abutment selection for single-implant reconstructions according to
type of retention, level of customization, and material. + = less recommended;
++ = recommended; +++ = strongly recommended.
*Only an option if the implant is not in a favorable three-dimensional position.
survival rates and the biologic and to help clinicians in their decision-
technical complications of titanium making between the different im-
and alumina/zirconia abutments.2 It plant restorative options, based on
is widely accepted that titanium and the current evidence (two system-
zirconia abutments exhibit excellent atic reviews and unpublished data)
biocompatibility2,8,9 and mechani- and paired with the clinical exper-
cal stability for the clinical applica- tise of those participating at the
tion.10–12 However, the degree to Consensus Conference.
which material selection affects the
esthetic outcome is still a recurrent
question for the clinician, especially Material and Methods
as there are several factors directly
associated with abutment material A systematic literature search was
selection that need to be consid- conducted previous to the Clinical
ered, like the level of customization Consensus Conference on Abut-
or the type of retention (cement- or ment/Crown Design for Single Tooth
screw-retained). Implant Restorations, held April 14
The objective is to provide and 15, 2017, at the New York Uni-
comprehensive clinical guidelines versity College of Dentistry (NYU).
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The Consensus Conference’s
objective was to investigate the
effect of different factors on the
esthetic outcomes of anterior im-
plant-retained single reconstruc-
tions. The factors evaluated were:
peri-implant soft tissue “frame-
work” (group 1), three-dimensional
ment insertion protocol (group 3),
and the abutment type and material
(group 4). Each participating group
completed systematic reviews on
their specific topic. The findings
were presented, discussed, and de-
bated with all the attending experts
in plenary sessions. After the re-
spective discussions, guidelines and
recommendations were developed
by the plenum.
The authors of the current
manuscript were integrated into
group 4, which aimed to evaluate
the influence of abutment material
selection and level of customization
on the esthetic outcomes of single-
implant–supported reconstructions.
The systematic literature search and
evaluation to address this topic re-
sulted in two systematic reviews on
single-implant reconstructions in
the anterior region reporting on the
abutment material and level of cus-
tomization. One review focused on
esthetic clinical outcomes, including
esthetic indices and linear measure-
ments, and the second focused on
the peri-implant soft tissue color
outcomes, evaluated with spectro-
photometry (both reviews in prepa-
ratory stages).
The recommendations and clin-
ical guidelines developed and dis-
cussed by the plenum on this topic
are presented herein.

Results
Summary of the Systematic
Reviews
Effect of Material and Level of
Customization on Esthetic Indices
The available results are based on
medium-term evaluation studies
(minimum of 3 years of follow-up)
composed of 16 included manu-
scripts.10,12–26 The selected esthetic
outcomes were the following esthet-
ic indices: (1) the Pink Esthetic Score
(PES),27 (2) the Papilla Index (PI),28
and (3) the linear measurement of
recessions.16 The results from the
included studies were heterogenic
in nature, which did not allow for a
meta-analysis of the data. Hence,
the weighted means were used for a
narrative evaluation. All-ceramic and
customized components showed
a tendency for better esthetic out-
comes as compared to metallic and
standardized/stock components
(outcome measure: PES). Mean-
while, the PI and recession values
were independent of abutment ma-
terial or level of customization to a
similar extent (based on review 1, in
preparation29).
Effect of Material on Peri-implant
Soft Tissue Color
The results are based in nine includ-
ed studies.11,30–34 In these studies,
soft tissue discoloration was evalu-
ated by means of spectrophotom-
etry. The data was extracted and a
meta-analysis comparing metallic
and all-ceramic abutments was per-
formed. All-ceramic components
demonstrated less soft tissue discol-
oration when compared to metallic
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Fig 1  Case 1.
Customized screw-
retained all-ceramic
solution. (a) Front
view. (b) Customized
screw-retained implant
crown. (c) Final implant
reconstruction in place.
a
b c
abutments (based on review 2, in
preparation).
Consensus Statements
In the presence of a thin phenotype,
all-ceramic materials should be used
for abutments and/or crowns.
When all-ceramic materials are
used, the use of a titanium base
abutment/connection is advised.
Customized abutments provide
improved soft tissue support and
should hence be preferred in es-
thetically demanding situations.
The customized abutments
improve site-respective cement-
line positions for cement-retained
crowns.
Crowns can be connected to
implants either by screw or cement
retention. However, when using a
cementation protocol, pronounced
care must be taken to remove resid-
ual excess cement to avoid biologic
complications.
33
Discussion and Clinical
Guidelines
The selection of the abutment for
single-implant reconstructions in-
volves several levels of decision-
making. The type of retention, the
customization level, and the type
of material are three relevant pa-
rameters to be considered, which
are shown in a comprehensive deci-
sion tree in Table 1 and illustrated in
Figs 1 to 4.
Type of Retention
Both screw- and cement-retained
single-implant–supported recon-
structions result in clinically accept-
able outcomes, exhibiting high
survival rates and low complica-
tion rates, as reported in previous
systematic reviews.35,36 It was dis-
cussed that it may not be clearly
Volume 40, Number 1, 2020
34
Fig 2  Case 2. Customized cemented
all-ceramic solution. (a) Front view.
(b) Customized abutments and implant
crowns. (c) Front view with abutments in
place. (d) Final crown placement.
a b
c d
recommended which retention
mode is advantageous over the
other, as both type of retention
systems have pros and cons. Both
types of retention present different
types of biologic and technical com-
plications. While cement-retained
implant reconstructions showed
higher biologic complications
such as fistulae, soft tissue inflam-
mation, or bone loss exceeding
2 mm, screw-retained implant re-
constructions exhibited higher
technical complication rates,35
with screw-loosening the most fre-
quently reported.35 The authors of
this systematic review concluded
that screw-retention is their recom-
mended primary retention mode, as
screw-retained reconstructions can
more easily be retrieved and techni-
cal problems more easily be solved
than the biologic complications
found at cement-retained implant
reconstructions.35
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Level of Customization
At cement-retained reconstructions,
it is highly recommended to use cus-
tomized abutments,37–39 as shown
in Fig 2. It is well documented37–39
that no matter how meticulous the
efforts to remove the excess ce-
ment are,37 cement remnants can be
found in subgingivally placed recon-
struction margins in both clinical38
and in vitro settings.37 The amount
of cement excess increased signifi-
cantly for each millimeter of depth
that the crown margin was placed
underneath the peri-implant mu-
cosal margin. It is for this reason
that, when cementing, it is highly
advisable to place the margin as
shallow as possible in the esthetic
area (ie, epi- or supramucosally in
the palatal/lingual aspect and 0.5
to 1 mm submucosal in the buccal
aspect of the implant-supported
reconstruction).37,38
Standardized/stock abutments
cannot satisfy the requirement of
remaining deep enough in the buc-
cal margin without being too deep
interproximally, and therefore cus-
tomized components are strongly
recommended in the presence of
highly scalloped soft tissue margins.
With respect to esthetic out-
comes, customized components
tended to lead to better PES re-
sults.13,16,19,21 The PI and recession
values were similar for customized
and standard abutments,10,12,18,22,26
and consensus between the experts
attending the Consensus Confer-
ence was present regarding this pa-
rameter. Customized components
provide improved tissue support,
in particular in situations with high
scalloped soft tissues and thin soft
tissue phenotypes.
Hence, in anatomically demand-
ing situations, combined with high
smile lines and high esthetic expec-
tations, the utilization of customized
components/solutions is advised.
Material
In respect to biocompatibility, tita-
nium- and zirconia surfaces showed
colonization patterns by a bacterial
community similar to those found
in the remaining adjacent teeth39 as
well as low clinical inflammation pa-
rameters in the clinical setting.8
Despite the good clinical per-
formance of zirconia abutments,10–12
caution should be taken when se-
lecting this restorative material.
Zirconia as a brittle ceramic abut-
ment material is mechanically weak-
er than metals like titanium.40,41 The
 35

a b c
Fig 3  Case 3. Screw-retained porcelain-fused-to-metal crown. (a) Front view of the initial situation. (b) Porcelain-fused-to-metal implant
crown. (c) Final implant reconstruction in place.

a b c
Fig 4  Case 4. (a) Hybrid abutment crown. (b) Titanium base and crown, not connected. (c) Final implant reconstruction in place.

zirconia abutments were more prone to metallic abutments. However, Conclusions

to fracture than titanium abutments,
as demonstrated in several in vitro
studies.41–43 In a 5-year follow-up
clinical prospective study, a 7.8%
abutment fracture rate was report-
ed, specifically at narrow implant
diameters (four of the five fractures
were narrow platforms).44 For good
clinical stability of the zirconia abut-
ments, the manufacturer recom-
mended respecting the material
thicknesses. Consequently, zirconia
abutments should be avoided when
high occlusal forces are expected or
in cases where a lack of space does
not allow for an adequate material
thickness.
Concerning the esthetic out-
comes, the results from this Con-
sensus Conference showed that
all-ceramic abutment materials
tended to lead to improved soft
tissue esthetics (PES) as compared
ceramic abutments lead to similar
papilla fill (PI) and recession occur-
rence as metallic abutments. At the
soft tissue color evaluation, per-
formed by means of the spectro-
photometry, all-ceramic abutments
showed significantly better results
compared to metallic abutments.
The Consensus Conference ex-
perts agreed with these findings. It is
evident that the beneficial influence
on soft tissue color is the most pro-
nounced advantage of all-ceramic
implant abutments and reconstruc-
tions. The PES includes color as one
of the evaluated parameters, which
explains the improved results for all-
ceramic abutments, while recession
and PI evaluations are influenced by
abutment shape rather than by ma-
terial, explaining the lack of differ-
ences between the all-ceramic and
the metallic abutments.
In clinical situations with high es-
thetic demands (high esthetic ex-
pectations, high smile line), with
anatomically demanding factors
(high scalloping of the soft tissues,
triangular teeth) and mechanically
low challenges (regular-platform im-
plant, low occlusal forces), custom-
ized all-ceramic implant abutments/
solutions are recommended.
In clinical situations with low
esthetic demands (esthetics of less
importance, low smile line) and me-
chanically challenging situations
(narrow-diameter platform, high
occlusal forces), metallic abutments
are recommended.
In high esthetic cases that are
also mechanically challenging,
the patient should be carefully in-
formed, as the decision has to be
mutually made between: (1) a more

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36
esthetic solution with compromised  2. Zembic A, Kim S, Zwahlen M, Kelly JR.
mechanical stability (all-ceramic Systematic review of the survival rate
and incidence of biologic, technical,
narrow-diameter abutment in a pa- and esthetic complications of single im-
tient with high occlusal forces), or (2) plant abutments supporting fixed pros-
theses. Int J Oral Maxillofac Implants
a possible esthetic challenge that 2014;29(suppl):s99–s116.
delivers more mechanical stability,   3. Vermylen K, Collaert B, Lindén U, Björn
ie, the application of a metallic abut- AL, De Bruyn H. Patient satisfaction and
quality of single-tooth restorations. Clin
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The use of titanium-base hybrid pression technique. Int J Periodontics
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abutments may help combine the  5. Martin WC, Pollini A, Morton D. The
advantages of all-ceramic and me- influence of restorative procedures on
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  8. Barwacz CA, Brogden KA, Stanford CM,
Acknowledgments Dawson DV, Recker EN, Blanchette D.
Comparison of pro-inflammatory cyto-
kines and bone metabolism mediators
The authors would like to thank the excellent around titanium and zirconia dental im-
work and contribution in the form of clinical plant abutments following a minimum
of 6 months of clinical function. Clin
cases of Master Dental Technician Vincent
Oral Implants Res 2015;26:e35–e41.
Fehmer and Dr Stefan Hicklin. The authors  9. Sanz-Martín I, Sanz-Sánchez I, Carrillo
also thank Dr Hyeonjong Lee for his valuable de Albornoz A, Figuero E, Sanz M. Ef-
support with photo conversion and editing. fects of modified abutment character-
The authors declare no conflicts of interest. istics on peri-implant soft tissue health:
A systematic review and meta-analysis.
Clin Oral Implants Res 2018;29:118–129.
10. Fenner N, Hämmerle CH, Sailer I, Jung
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Volume 40, Number 1, 2020