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Introduction
Dental implant therapy is a fast growing and promising aspect in the
rehabilitation of completely and partially edentulous arches. Study of
implants has become indispensable and so is the biomechanics related
to dental implant therapy. Implant abutment connection is a crucial
synapse between the implant and the abutment. It is an important
determinant of the strength and stability of an implant supported
restoration, and play a major role in the success of the implant. 1
The implant abutment interface determines joint strength, stability, and
lateral and rotational stability of the joint.2
A DENTAL IMPLANT ABUTMENT is formally defined as ―that portion
of a dental implant that serves to support and/or retain a prosthesis. 3

(Fig1)
CREST MODULE is that portion of implant fixture that provides
connection to abutment and consists of a platform & anti rotational
features.4 (Fig 2)
Particularly, the connection between implant and abutment is a key
junction because it is the primary determinant of long term stability and
strength of implants which in turn determines the final outcome of
implant therapy. The implant abutment interface ensures optimal load
distribution along with lateral and anti-rotational stability. Currently,
ͳ
Introduction
there are some 20 different implant/abutment interface geometric
variations available.5
The original Brånemark protocol involves a two-stage surgical
procedure and was designed to restore a completely edentulous
mandibular arch.4 In this protocol, the implant-abutment interface was
an external hexagon of 0.7 mm height. This external hex served the
purpose of a torque transfer coupling device (fixture mount) during the
initial placement of the implant into the bone and the subsequent
connection of the trans mucosal extension, which when used in series
could effectively restore the completely edentulous arch. Although the
external hex served the aforementioned purposes, it was not an
effective anti-rotation device6 and was not designed to withstand the
forces directed on the crowns intraorally7. Hence, mechanical problems
including screw loosening and fractures led to the development of
newer connections.
These limitations have led to the development of various implant
abutment connection systems to address these issues. Many
contemporary implant systems now have an internal — rather than an
external — connection.
The goals of the internal connection were to improve connection
stability throughout the placement and functional periods, and to
ʹ
Introduction
simplify the armamentarium necessary for the clinician to complete the
restoration
Since the introduction of the internal connection concept, further design
enhancements have been made in an attempt to enhance the implant
/abutment 8,9,10 connection. Included in such efforts is the “Morse”
taper, wherein a tapered abutment post is inserted into the non-
threaded shaft of a dental implant 10,11 with the same taper. Other
internal connection designs have followed, frequently with variations in
their use of joint designs (e.g. bevel, butt), or the numbers of 'hexes'
8,9,10 present for the restorative phase.
Although the internal hex reigns as the most predominant
abutment/implant connection, it is not the most stable. The tapered
connection, especially the true Morse taper, provides a much more
stable abutment/implant interface. It virtually eliminates any micro
gaps and provides a hermetic seal that prevents bacterial invasion of
the abutment/implant juncture.
Implants designed with Morse taper interface engage their abutments
by using angulated friction fit internal wall into which an abutment with
a rounded male extension is placed. The abutments achieve the anti-
rotational properties due to the cold-weld phenomenon that occurs
after placing and torqueing the abutment.4
͵
Introduction
Cold or contact welding is a solid state welding process in which joining
takes place without fusion at the interface of the two parts to be
welded.
Morse taper abutments are considered superior in terms of sealing
because the intimate contact between the implant and the abutment
diminishes the possibility of microorganism passage
They differ with respect to design features and capability. The
consequences of choosing a less-than-ideal interface are mechanical
and biological, with potential problems resulting in fatigue failures
and/or peri-implantitis.12 Furthermore, some of the latest IACI systems
allow for innovative and advanced restorative options. 13,14
When using these implant/abutment connections, clinicians had to be
mindful of their application in the intraoral environment, an often
challenging region due to the involved bone topography, soft tissue
contours, rotational forces, and the requisite prosthetic components
particularly for aesthetic, single-implant restorations.15
The requirements for an optimal implant abutment connection can be
summarized as follows: precise rotational orientation for Single tooth
restorations, maximum mechanical stability instead of optimal fatigue
resistance minimized micro gap, overload protection.
Ͷ
Introduction
Park et al stated that dental implants are potentially subject to failure
in the screw connection areas of an implant system, which can occur
due to screw loosening or fracture.16
Binon et al reported that the instability between the components of an
implant system may cause not only frequent screw loosening and
chronic fracture of the screws but can also cause the accumulation of
plaque, an unfavorable soft tissue response, and the failure of Osseo
integration,
Several published studies have shown that crestal bone loss occurs
following implant placement and its connection to the abutment.19
Research by Hermann et al demonstrated that crestal bone loss
typically occurs approximately 2 mm apical to the implant-abutment
junction (IAJ).This position appears to be constant, regardless of where
the IAJ is situated relative to the original level of the bony crest.20
Investigations by various researchers offered explanations on why the
presence of the IAJ appears to trigger resorption in the adjacent bone.
Ericsson et al found histological evidence of inflammatory cell infiltrate
associated.
The gap between implant and abutment is an ideal place for bacterial
proliferation and fluid micro leakage what can lead to peri-implantitis .It
ͷ
Introduction
is important to say that the force applied in the tightening torque is only
valid if the machining and adjustment degree between abutment and
implant were proper because high levels of tightening torque would not
produce the desired result on components that do not have proper
mortise. Decisions regarding dental implant abutments are essential
aspects of clinical dental implant excellence.
This library dissertation discusses in detail about the implants,
abutments, various types of connections and there biomechanical
perspectives.
͸
Review of Literature
Lang LA et al (1999)21, studied and examined the tightening force
transmitted to the implant with and without the use of a counter-torque
device during the tightening of the abutment screw.
Forty Brânemark implants and 10 CeraOne, Estheticone, Procera, and
Aur Adapt abutments formed the experimental populations. Samples in
each group were further divided into 2 groups, 1 group was tightened
with a torque controller without the use of a counter-torque device,
whereas the other used the counter-torque device. Samples were
positioned in a special holder within the grips of a Tohnichi BTG-6
torque gauge for measuring transmitted forces.
There were significant differences (P =. 0001) in the tightening forces
transmitted to the implant with and without the use of a counter-torque
device when tightening the abutment screws.
An average of 91% of the recommended preload tightening torque was
transmitted to the implant-bone interface in the absence of a counter-
torque device. In all abutment systems, less than 10% of the
recommended preload tightening torque was transmitted to the implant
when the counter-torque device was used. When the counter-torque
device was used, the magnitude of the torque force that was
transmitted to the bone was significantly reduced. Although the
uncontrolled force transmitted as a result of tightening without a
͹
counter-torque device is only speculative at this point in time, it may
lead to premature loss of implants. The allowable magnitude of force
that the implant-bone interface can withstand is presently unknown.
Beat R. Merz et al (2000)22 presented a comparison between the 8-
degree Morse Taper and the butt joint as connections between an
implant and an abutment. Three-dimensional, non-linear finite element
models were created to compare the 2 connection principles under
equal conditions. The loading configuration was thereby modeled
according to a test setup actually used for the dynamic long-term
testing of dental implants as required for regulatory purposes. The
results give insight into the mechanics involved in each type of
connection and are compared to actual findings with the testing
machine. The comparison indicates the superior mechanics of conical
abutment connections and helps to explain their significantly better
long-term stability in the clinical application.
Yoshinobu Maeda et al (2007)23, examined the biomechanical
advantages of platform switching using three-dimensional (3D) finite
element models.
Within the limitations of this study, it was suggested that the platform
switching configuration has the biomechanical advantage of shifting the
stress concentration area away from the cervical bone–implant
ͺ
interface. It also has the disadvantage of increasing stress in the
abutment or abutment screw.
Zipprich et al (2008)24, studied in vitro and examined the dynamic
behavior of different designs of implant-abutment connections.
Abutments were loaded at an angle of 30° with a force of up to 200 N.
The distance of the point of force application from the implant platform
was 8 mm; the gradation of the force was 0.3 N/m s. The interface of
the implant-abutment connection was examined and measured radio
logically using a professional high speed digital camera (1,000 images
per second).
The results showed that, under simulated clinical conditions, complex
mechanisms are responsible for the presence or absence of a micro-
motion. All implant-abutment (SIC®; Replace Select®; Camlog®;
XIVE®; Straumann synOkta®; Bego-Semados®; Straumann massive
conical abutment®) connections with a clearance fit exhibit a micro-
motion Precision conical connections (implant systems: Ankylos®;
Astra Tech®) show no micro-motion.
Most of two-component or multi-component implant systems use an
implant-abutment connection with a clearance fit. The clinical impact is
assumed as high according to the following factors:
ͻ
Implant systems consisting of two or several components are much
more widespread than single component systems because they offer a
number of well-known clinical and technical advantages.
Unconnected crowns in the posterior region are more susceptible to
technical failure of the implant-abutment interface.
Crestally or subcrestally placed implant-abutment interfaces are
frequently subjected to crestal bone resorption following abutment
connection.
Anna Theoharidou et al (2008)25, reviewed systematically the clinical
studies on the incidence of abutment screw loosening in single-implant
restorations with different implant-abutment connection geometries.
The results show that abutment screw loosening is a rare event in
single-implant restorations regardless of the geometry of implant-
abutment connection, provided that proper anti-rotational features and
torque are employed. More than 97% of SIR studied maintained a
stable implant-abutment connection after 3 years of service. This is in
agreement with results from in vitro studies, which have demonstrated
stable abutment screw joints for internal-connection implants as well as
for external-connection implants with improved screw materials and
preload. This study did not look into other types of mechanical
ͳͲ
complications, such as screw fracture, where implant abutment
connection geometry might play a role.
C. do Nascimento et al (2008)26 conducted in-vitro study to
investigate leakage of Fusobacterium Nucleatum through the interface
between implants and premachined or cast abutments. Both
premachined (n = 10) and cast (n = 10) implant–abutment assemblies
were inoculated with 3.0 mL of microbial inoculum. The assemblies
were completely immersed in 5.0 mL of tryptic soy broth culture
medium to observe leakage at the implant–abutment interface after 14
days of anaerobic incubation. Bacterial growth in the medium,
indicative of microbial leakage, was found only in 1 out of 9 samples
(11.1%) in each group. This implied that both premachined and cast
abutments connected to external hexagonal implants provide low
percentages of bacterial leakage through the interface in in vitro
unloaded conditions if the manufacturer’s instructions and casting
procedures are properly followed.
E. T. Quaresma et al (2008)27, evaluated the influence of 2
commercially available dental implant systems on stress distribution in
the prosthesis, abutment, implant, and supporting alveolar bone under
simulated occlusal forces, employing a finite element analysis. The
implants and abutments evaluated consisted of a stepped cylinder
implant connected to a screw-retained, internal, hexagonal abutment
ͳͳ
(system 1) and a conical implant connected to a solid, internal, conical
abutment (system 2 Within the limits of this investigation, the stepped
cylinder implant connected to a screw-retained, internal hexagonal
abutment produces greater stresses on the alveolar bone and
prosthesis and lower stresses on the abutment complex. In contrast,
the conical implant connected to a solid, internal, conical abutment
furnishes lower stresses on the alveolar bone and prosthesis and
greater stresses on the abutment.
Syafiqah Saidin et al (2010)28, analyzed micro motion and stress
distribution on mating surface of internal conical and internal hexagonal
implant-abutment connections. Three dimensional (3D) model of
mandible around the first molar was reconstructed from two
dimensional (2D) CT data scan. Dental implant body and two-piece
abutment with different implant-abutment connection were designed
and inserted separately to simulate the replacement of the first molar.
Axial load were applied on the top center of the prosthesis and on the
adjacent teeth to simulate occlusal force. Micro motion was observed
to be lower around internal hexagonal abutments compared to internal
conical. However, internal hexagonal connection produce stress
concentration at its vertices, thus increase the possibility to be
fractured.
ͳʹ
Park et al (2010)29, investigated the effects of tungsten carbide carbon
(WC/CTa) screw surface coating on abutment screw preload in three
implant connection systems in comparison to noncoated titanium alloy
(Ta) screws. Preload of WC/CTa abutment screws was compared to
noncoated Ta screws in three implant connection systems.( US II, SS
II, and GS II ) Within the limits of present study, the following
conclusions were made: (1) WC/CTa screws provided higher preload
than noncoated Ta screws in all three implant connection systems. (2)
The initial removal torque for Ta screws required higher force than
WC/CTa screws, whereas post load removal torque for Ta screws was
lower than WC/CTa screws. Calculated Ta screw preload loss percent
was higher than for WC/CTa screws, indicating that the WC/CTa screw
was more effective in maintaining preload than the Ta screw. Internal
conical connections were more effective in maintaining the screw
preload in cyclic loads than external-hex butt joint connections.
Pattapon Asvanund et al (2011)29 compared the load transfer
characteristics of a complete-arch restoration supported by 4 implants
with external and internal implant-abutment connections. Loads were
applied to the prostheses in 3 positions. Two-dimensional photo elastic
models were used to simulate bone. Two types of implants (Replace
Select
ͳ͵
Internal-Interface Tapered Implants and Replace Select External-
Interface Tapered Implants) were placed in the photo elastic models.
Complete-arch metal frameworks were fabricated on the abutments.
Artificial teeth were arranged on the framework, and the prosthesis was
screwed onto the abutments. The specimens were analyzed at 2 levels
(implant-abutment level and apical to the implant level) with 3 loading
conditions (4-point load; 2-point anterior load; and 2-point lateral load).
The numbers of fringe orders were recorded and compared.
With the 4-point load, no stress differences occurred between the
external-implant abutment connection and internal-implant abutment
connection at the connection level and at the apical level. With the 2-
point anterior load, the internal-implant abutment connection resulted in
lower stresses at the connection level both in the loaded and non-
loaded areas. With the 2-point lateral load, the internal-implant
abutment connection resulted in lower stresses at the connection level
at the non-loaded area.
It was concluded that when loaded off-center, the internal-implant
abutment connection produced less stress when compared with the
external-implant abutment connection.
Yasufumi Yamanishi et al (2012)30 conducted 3D FEA with
simulation of the complex structure of dental implants, and the
ͳͶ
influences of neck design and connections with an abutment on peri-
implant bone stress and abutment micro movement were investigated.
Three types of two-piece implant CAD models were designed: external
joint with a conical tapered neck (EJ), internal joint with a straight neck
(IJ), and conical joint with a reverse conical neck (CJ). 3D FEA was
performed with the setting of a “contact” condition at the component
interface, and stress distribution in the peri-implant bone and abutment
micro movement were analyzed. It was concluded that the shear stress
was concentrated on the mesiodistal side of the cortical bone for EJ.
EJ had the largest amount of abutment micro movement. While the von
Mises and shear stresses around the implant neck were concentrated
on the labial bone for IJ, they were distributed on the mesiodistal side
of the cortical bone for CJ. CJ had the least amount of abutment micro
movement. Implants with a conical joint with an abutment and reverse
conical neck design may effectively control occlusal overloading on the
labial bone and abutment micro movement.
Khraisat et al (2012)31, evaluated the influence of abutment screw
preload through the implant collar on marginal bone stress without
external load application. It can be concluded that, without any external
load application, abutment screw preload exerts stresses on the
implant collar and the marginal bone. These findings should help guide
ͳͷ
the development of new implant/abutment joint designs that exert less
stress on the marginal bone.
João Paulo da SILVA-NET et al (2012)32, evaluated the micro leakage
at the implant/abutment interface of external hexagon (EH) implants
and abutments with different amounts of bacteria and tightening
torques. A bacterial suspension was prepared to inoculate the
implants. The first phase of this study used nine EH implants and
abutments that were divided into three groups with different amounts of
bacterial suspension and tightened to the manufacturer’s
recommended torque. The second phase of this experiment used 27
assemblies that were similar to those used in the first phase. These
samples were inoculated with 0.5 μ L of bacterial suspension and
divided into 3 groups. The samples were evaluated according to the
turbidity of the broth every 24 hours for 14 days, and the bacteria
viability was tested after that period. The statistical evaluation was
conducted by Kruskal-Wallis testing (p<.05). Results: During the first
phase, groups V1.0 and V1.5 was presented with bacterial
contamination in all samples after 24 h. During the second phase, two
samples from group T10 and one from T20 presented positive results
for bacterial contamination. Different amounts of bacterial solution led
to overflow and contamination during the first 24 h of the experiment.
The tightening torques did not statistically affect the micro leakage in
ͳ͸
the assemblies. However, the group that was tightened to 32 N cm
torque did not show any bacterial contamination. It was concluded that
after 14 days of experimentation, the bacteria were proven to remain
viable inside the implant internal cavity.
Amilcar C. Freitas-Júnior et al (2012)33, assessed the effect of
abutment’s diameter shifting on reliability and stress distribution within
the implant-abutment connection for internal and external hexagon
implants. The postulated hypothesis was that platform-switched
implants would result in increased stress concentration within the
implant-abutment connection, leading to the systems’ lower reliability
Eighty-four implants were divided in four groups (n = 21): REG-EH and
SWT-EH (regular and switched-platform implants with external
connection, respectively); REG-IH and SWT-IH (regular and switched-
platform implants with internal connection, respectively). The
corresponding abutments were screwed to the implants and
standardized maxillary central incisor metal crowns were cemented
and subjected to step-stress accelerated life testing. The Beta values
for groups SWT-EH (1.31), REG-EH (1.55), SWT-IH (1.83) and REG-
IH (1.82) indicated that fatigue accelerated the failure of all groups. The
higher levels of σ (v M) implants (groups SWT-EH and SWT-IH) were
in agreement with the lower reliability observed for the external hex
implants, but not for the internal hex implants.
ͳ͹
Ali Balik et al (2012)34, investigated the strain distributions in the
connection areas of different implant-abutment connection systems
under similar loading conditions. According to the analysis, the implant-
abutment connection system with external hexagonal connection
showed the highest strain values, and the internal hexagonal implant-
abutment connection system showed the lowest strain values. Conical
and internal hexagonal and screw-in implant abutment connection
interface is more successful than other systems in cases with
increased vertical dimension, particularly in the posterior region
Aashritha Shenava (2013)35 studied biological and mechanical
implant-abutment connection complications and failures are still
present in clinical practice, frequently compromising oral function.
Abutment screw loosening has occurred with many of other designs
used for single tooth implant and concluded that with a conical implant–
abutment interface at the level of the marginal bone, in combination
with retention elements at the implant neck, and with suitable values of
implant wall thickness and modulus of elasticity, the amount of micro
motion can be reduced to a greater extend thereby improving joint
stability and success of the implant therapy. The tightening torque is an
important factor to improve mechanical and biological properties of the
interface between implant and abutment and the use of the torque
recommended from the manufacturer may potentially reduce the
ͳͺ
adverse effects of micro leakage. The concept of platform switching
appears to limit crestal resorption and seems to preserve peri-implant
bone levels.
M.-I. Lin et al (2013)36 compared the effects of external hex, internal
octagon and internal Morse taper implant–abutment connections on the
peri-implant bone level before and after the occlusal loading of dental
implants. First, the level of peri-implant crestal bone does not differ
significantly during either the healing phase or the loading phases
among 3 different implant– abutment connection designs (external hex,
internal octagon, and internal Morse taper). Second, the level of
periimplant crestal bone changes significantly with the time interval
(healing phase, loading phase 1, and loading phase 2), with it being
slightly greater before the application of occlusal loading.
Saeed Raoofi et al (2013)37, determined the stress patterns within an
implant and the effect of different types of connections on load transfer.
Three different types of implant-abutment connections were selected
for this study. Sample A: 1.5-mm deep internal hex corresponding to a
lead-in bevel; sample B: a tri-channel internal connection; and sample
C: internal Morse taper with 110 degrees of tapering and 6 anti-
rotational grooves. Four types of loading conditions were simulated in a
finite element model, with the maximum von Mises stress set as output
variables. The maximum stress concentration at the inner surface of
ͳͻ
the fixtures was higher than the stress value in bone in all of the
samples. Stress values in sample B were the lowest amongst all of the
models. Any alterations in the amount and direction of the 100-N axial
load resulted in an increase in fixture surfaces stress. Overall, the
highest amount of stress (112 M Pa) was detected in sample C at the
inner surface of the fixture under a non-axial load of 300 N. Stress
concentration decreased when the internal surface area increased.
Creating three or six stops in the internal surface of the fixtures
resulted in a decrease in stress.
Manoj Shetty et al (2014)38, described the biomechanics of this crucial
connection. The requirements for an optimal implant abutment
connection can be summarized as follows: precise rotational
orientation for Single tooth restorations, maximum mechanical stability
instead of optimal fatigue resistance minimized micro gap, overload
protection. High surface compression in the critical perimeter area of
the connection results in a minimal micro gap between the implant and
the abutment, which in turn reduce the occurrence of bacterial
contamination. The misfit between abutment and implant interface has
many clinical implications as: abutment overload; screw loosening or
fracture or even of the implant itself; incorrect transmission of force to
implant and marginal bone and microbial proliferation. These factors
can lead to a persistent inflammation around peri-implant tissue. The
ʹͲ
gap between implant and abutment is an ideal place for bacterial
proliferation and fluid micro leakage what can lead to peri-implantitis. It
is important to say that the force applied in the tightening torque is only
valid if the machining and adjustment degree between abutment and
implant were proper because high levels of tightening torque would not
produce the desired result on components that do not have proper
mortise. Decisions regarding dental implant abutments are essential
aspects of clinical dental implant excellence.
Hyon - Mo Shin et al (2014)39, conducted a study to evaluate the
influence of the implant-abutment connection design and diameter on
the screw joint stability. The results of this study showed that the
external butt joint was more advantageous than the internal cone in
terms of the post load removal torque loss. For the difference in the
implant diameter, a wide diameter was more advantageous in terms of
the torque loss rate.
Frank Schwarz et al (2014)40, assessed the impact of implant–
abutment connection, positioning of the machined collar/micro gap, and
platform switching on crestal bone level changes. Two comprehensive
systematic reviews were prepared in advance of the meeting.
Consensus statements, practical recommendations, and implications
for future research were based on within group as well as plenary
scrutinization and discussions of these systematic reviews and I was
ʹͳ
observed that placing the smooth part of the implant below the alveolar
crest may lead to bone loss. Despite a more pronounced bone
remodeling, the subcrestal positioning of the micro gap may help to
retain the bony coverage of the rough surface. Crestal bone
remodeling has been observed for either internal and external, or
conical and butt–joint connections. There was a trend favoring the
bone loss.
Cem Sahin et al (2014)41, evaluated the correlation between micro
leakage and screw loosening at different types of implant-abutment
connections and/or geometries measuring the torque values before
and after the leakage tests. Three different abutment types (Internal
hex titanium, internal hex zirconium, Morse tapered titanium) with
different geometries were connected to its own implant fixture. All the
abutments were tightened with a standard torque value then the
composition was connected to the modified fluid filtration system. After
the measurements of leakage removal torque values were re-
measured. Kruskal-Wallis test was performed for non-parametric and
one-way ANOVA was performed for parametric data. The correlation
was evaluated using Spearman Correlation Test (α=0.05). Significantly
higher micro leakage was found at the connection of implant internal
hex zirconium abutment. Observed mean torque value loss was also
significantly higher than other connection geometries. Spearman tests
ʹʹ
revealed a significant correlation between micro leakage and screw
loosening. Micro leakage may provoke screw loosening. Removing
torque values rationally decrease with the increase of micro leakage.
Greison Rabelode Oliveira et al (2014)42, evaluated bacterial
contamination along the implant-abutment interface in relation to the
size of the interface. 80 brand name implants were used, 40 internal-
hex and 40 external-hex. The implants were handled in a sterile
atmosphere inside a box, where they were inoculated with 0.3 μ l of the
Streptococcus sanguis ATCC10556 bacterium in the interior and the
abutment was immediately installed with a torque of 30 N cm for the
external-hex and 20 N cm for the internal-hex; the system was included
in an Eppendorf control for 30 seconds and then placed in an
Eppendorf control for 30 days. The implants were removed and
assessed under a scanning electron microscope while the Eppendorf
controls were bred in blood agar to analyze the colonies formed. The
data were analyzed using the Chi-squared, Kruskal-Wallis and Mann-
Whitney tests, considering a value of p<0.05 to obtain statistical
significance. Five implants were excluded due to probable external
contamination. Micro spaces of up to 86.8 μ m were observed in the
external-hex implants and up to 53.9 μ m in the internal-hex implants
with no significant differences between the different systems being
observed (p>0.05). The contamination observed was produced mainly
ʹ͵
in the external-hex implants and statistically significant differences
were observed between the different hex systems from the same
company. No significant differences were observed between interface
size and bacterial contamination. Within our limitations, there was no
relation between the size of the implant-abutment interface and
bacterial contamination with Streptococcus sanguis ATCC10556.
Siyu liu et al (2014)43, investigated quantitatively the interfacial stress
and stress distribution in implant bone in 2 implant abutment designs
(platform-switched design and conventional diameter matching) by
using a nonlinear finite element analysis method.
The finite element analysis found that the Ankylos implant system has
a higher maximum von Mises stress in the implant abutment
connection section and a lower maximum von Mises stress in the
periimplant bone. The opposite results were found in the Anthogy
implant system.
Lower stress levels in the periimplant bone with a more uniform stress
distribution were found for the Ankylos implant system with a platform-
switched configuration. Although relatively higher stress was found in
the abutment, premature implant failure is not anticipated because of
the high strength of titanium alloy.
ʹͶ
Hassam I. Nasser et al (2015)44, evaluated the bacterial leakage of
two different internal implant abutment connections in vitro.Twenty
dental implants divided into two equal groups were compared; Group 1
fixtures with an internal hexagonal geometry; Group 2 fixtures with a tri-
lobe internal connection. A bacterial suspension of Staphylococcus
aureus was prepared to obtain a density of 0.5 McFarland standards.
All implant abutment assemblies were submerged in sterile tubes
containing 4mL of S. aureus broth culture and were incubated at 37 _C
for 14 days. The specimens were disassembled and the inner surfaces
of the implants were sampled by sterile paper points. Then the paper
points were immersed in test tubes containing sterile BHI broth. From
the broth, culture was done on blood agar plates and incubated at 37
_C for 24 h. The resulting colonies were identified by Gram's stain and
biochemical reactions. Internal hexagon implants showed statistically
significant higher mean Log10 CFU than Tri-lobe implant .Bacterial
leakage seems to be inevitable but fixture abutment interface geometry
plays an important role in the amount of leakage.
Kai Blum et al (2015)45, evaluated the micro gap formation and wear
pattern of different implants in the course of cyclic loading. Several
implant systems with different conical implant–abutment interfaces
were purchased. The implants were first evaluated using synchrotron
X-ray high-resolution radio-graphy (SRX) and scanning electron
ʹͷ
microscopy (SEM). The implant–abutment assemblies were then
subjected to cyclic loading at 98 N and their micro gap was evaluated
after 100,000,200,000 and 1 million cycles using SRX, synchrotron
micro-tomography (CT). Wear mechanisms of the implant–abutment
connection (IAC) after 200,000 cycles and 1 million cycles were further
characterized using SEM. All implants exhibit a micro gap between the
implant and abutment prior to loading. The gap size increased with
cyclic loading with its changes being significantly higher within the first
200,000 cycles. Wear was seen in all implants regardless of their
interface design. The wear pattern comprised adhesive wear and
fretting. Wear behavior changed when a different mounting medium
was used (brass vs. polymer).
Caroline H. Odo et al (2015)46, evaluated the stress distribution
around external hexagon (EH) and Morse taper (MT) implants with
different prosthetic systems of immediate loading (distal bar (DB),
casting technique (CT), and laser welding (LW)) by using photo elastic
method. Methods: Three infrastructures were manufactured on a model
simulating an edentulous lower jaw. All models were composed by five
implants (4.1 mm _ 13.0 mm) simulating a conventional lower protocol.
The samples were divided into six groups. G1: EH implants with DB
and acrylic resin; G2: EH implants with titanium infrastructure CT; G3:
EH implants with titanium infrastructure attached using LW; G4: MT
ʹ͸
implants with DB and acrylic resin; G5: MT implants with titanium
infrastructure CT; G6: MT implants with titanium infrastructure attached
using LW. After the infrastructures construction, the photo elastic
models were manufactured and a loading of 4.9 N was applied in the
cantilever. Five pre-determined points were analyzed by Fringes
software. Results: Data showed significant differences between the
connection types ( p < 0.0001), and there was no significant difference
among the techniques used for infrastructure. Conclusion: The
reduction of the stress levels was more influenced by MT connection
(except for CT). Different bar types submitted to immediate loading not
influenced stress concentration.
G.E. MANCINI et al (2015)47 , evaluated the effectiveness of Ditron
implants abutment connection (IAC) to sealing the gap between two
pieces.
To identify the efficacy of a new IAC, the passage of genetically
modified bacteria across IAC was evaluated. A total of five Ditron
Implants were used. All implants were immerged in a bacterial culture
for forty-eight hours and then bacteria amount was measured inside
and outside IAC with Real-time PCR. Bacterial quantification was
performed by Real-Time Polymerase Chain Reaction using the
absolute quantification with the standard curve method. In all the
tested implants, bacteria were found in the inner side, with a median
ʹ͹
percentage of 1.35%. The analysis revealed that, in untreated implants,
bacteria grew (internally and externally). Moreover, the difference
between outer and inner bacteria concentration was statistically
significant at each time point. Ditron Implant IAC (MPI, Ditron Dental,
Israel) is efficacy in reducing bacterial leakage.
Regalin et al (2015)48 ,evaluated the influence of tightening technique
and the screw coating on the loosening torque of screws used for
Universal Abutmentfixation after cyclic loading.The tightening
techniquedidnotshowsignificantinfluenceonthe loosening torqueof scre
ws (P=.509).Conventional titanium screws showed significant
higher loosening torque values than DLC (P=.000). The use of
conventional titanium screw is more important than the tightening
techniques employed in this study to provide long-term stability to
Universal Abutment screws.
Josu Aguirrebeitia et al (2016)49, elucidated the influences of design
and clinical parameters on the removal force for implant systems that
use tapered interference fit (TIF) type connections by measuring the
force needed to remove an abutment from an implant. Ninety-six
implants with tapered abutment-implant interfaces specifically built for
an unreplicated factorial design were tested on a custom-built
workbench for removal force. Four levels were chosen for the preload,
FP, and the taper mismatch D q; 3 levels for the wait time t; and 2
ʹͺ
levels for the saliva presence s at the interface. A regression model
was used based on physical reasoning and a theoretical understanding
of the interface. A 4-way ANOVA was used to evaluate the influence of
the main effects and interactions (a=.05). The experiments strongly
indicated that preload, taper mismatch, and saliva presence are
relevant variables in removal force. The wait time becomes important
when its effect is evaluated along with the preload.
The results of this study can be used for decision making in the design
and use of TIF type systems. The study supports the use of artificial
saliva in any implant design experiment because of its significance in
the removal force of the abutment.
Helen Mary Abraham et al (2016)50, evaluated the effect of implant
and abutment diameter on stress distribution in the peri-implant area.
Three-dimensional finite element models created to replicate
completely Osseo integrated end osseous titanium implants and were
used for the purpose of stress analysis. It was concluded that
RP(regular platform) model yielded a positive result with regard to
lowering of peri-implant bone stress levels, in healthy as well as
compromised bone qualities when compared to NP(narrow platform)
designs.
ʹͻ
Load transfer mechanisms from the implant to surrounding bone and
failure of Osseo integrated implants are affected by implant geometry
and mechanical properties of the site of placement as well as crestal
bone resorption. Estimation of such effects allows for a correct design
of implant geometry to minimize crestal bone loss and implant failure.
Rhoodie Garrana et al (2016)51, stated that endotoxin initiates
osteoclastic activity resulting in bone loss. Endotoxin leakage through
implant abutment connections negatively influences peri-implant bone
levels. There study aimed to determine if, endotoxin can traverse
different implant abutment connection (IAC) designs; to quantify the
amount of endotoxins traversing the IAC; to compare the in vitro
comportments of different IACs).
Within the parameters of this study, it was concluded that endotoxin
leakage is dependent on the design of the IAC. Straumann Synocta,
Straumann Cross-fit, and Ankylos displayed the best performances of
all IACs tested with undetectable leakage after 7 days. Each of these
IACs incorporated a Morse like component in their design. Speculation
still exists over the impact of IAC endotoxin leakage on peri-implant
tissues in vivo; hence, further investigations are required to further
explore this.
͵Ͳ
Zeno et al (2016)52 ,compared the removal of torque values of
machined implant abutment connections (internal and external) with
and without soft tissue entrapment using an in vitro model.. In all
specimens, tissue did not completely dissolve after 48 hours. External-
connection implants were significantly affected by tissue entrapment;
the thicker the tissue, the lower the reverse torque values noted.
Internal-connection implants were less affected by tissue entrapment.
José Paulo Mace do et al (2016)53, conducted a literature review on
the potential benefits with the use of Morse taper dental implant
connections associated with small diameter platform switching
abutments. Results indicated a reduced occurrence of peri-implantitis
and bone loss at the abutment/implant level associated with Morse
taper implants and a reduced-diameter platform switching abutment.
Extrapolation of data from previous studies indicates that Morse taper
connections associated with platform switching have shown less
inflammation and possible bone loss with the peri-implant soft tissues.
However, more long-term studies are needed to confirm these trends.
Two types of implant-abutment systems with tube-in-tube interfaces
were tested.
Within the limitations of this study, the results indicate the possibility
that repeated closing/opening cycles of the implant-abutment unit may
͵ͳ
influence bacterial/yeast leakage, most likely as a consequence of
decreased precision of the coupling between the abutment and the
internal part of the dental implant. These findings suggest that a one-
time abutment technique may avoid microbiologic leakage in cases of
implant-abutment systems with tube-in-tube interfaces.
Calcaterra et al (2016)54, investigated the impact of abutment screw
retightening on the leakage of two different types of bacteria,
Streptococcus sanguinis and Fusobacterium nucleatum, and of the
yeast Candida albicans. Within the limitations of this study, the results
indicate the possibility that repeated closing/opening cycles of the
implant-abutment unit may influence bacterial/yeast leakage, most
likely as a consequence of decreased precision of the coupling
between the abutment and the internal part of the dental implant These
findings suggest that a one-time abutment technique may avoid
microbiologic leakage in cases of implant-abutment systems with tube-
in-tube interfaces.
Sunil Kumar Mishra et al (2017)55, evaluated the sealing capability of
different implant connections against micro leakage An electronic
search of literature was performed, in Medline, EBSCO host and Pub
med data base. The search was focused on ability of different implant
connections in preventing micro leakage. . Almost all the studies
showed that there was some amount of micro leakage at abutment
͵ʹ
implant interface. Micro leakage was very less in Morse taper implants
in comparison to other implant connections. Majority of studies showed
less micro leakage in static loading conditions and micro leakage
increases in dynamic loading conditions. External hexagon implants
failed completely to prevent micro leakage in both static and dynamic
loading conditions of implants. Morse taper implants were very
promising in case of static loading and also showed less micro leakage
in dynamic loading conditions. Torque recommended by manufacturer
should be followed strictly and zirconia abutments were more prone to
micro leakage than titanium abutments and should be avoided.
Beatriz Pardal-Peláez et al (2017)56, reviewed systematic literature of
the causes of preload loss of the abutment screws, of internal and
external connection implants, tightened to different torque values and
subjected to cyclic loading. A systematic search was conducted in
PubMed, EMBASE, and Cochrane Library databases with reference to
in vitro studies in which internal and external connection implants were
subjected to cyclic loads to determine the degree of loosening of the
abutment screws after loading. It was concluded that most of the
studies indicate that the internal connection, together with the Morse
taper, best resists cyclic loading in terms of screw loosening in single-
tooth implants.
͵͵
Dimitar Kirov et al (2017)57, established the influence of various
factors upon the loosening of abutment screw. The current study has
analyzed the factors leading to loosening of the abutment screws
implant-supported restorations.
Abutment screw loosening has been registered in 6.8% of the
monitored cases. Regarding the type of connection between the
implant and abutment a higher prevalence has been reported in
connection with an internal octagon - 4.7% compared to the conical
connection - 2.1%. It was found that the type of prosthesis, bruxism,
cantilevers, non-balanced occlusion, crestal bone resorption and time
of this complication setting in are factors of statistically significant
influence.
It has been concluded that the optimal choice and number of implant
positions, the design of prosthesis, achieving optimal occlusion as well
as reporting cases of bruxism, leading to functional overload of dental
implants are of particular importance in order to avoid bio-mechanical
long-term complications.
Kannan A et al (2017)58, assessed the effectiveness of screw coating
in minimizing abutment screw loosening in dental implants in literature.
This meta-analysis inferred that there is no difference between the
coated and noncoated screws with respect to screw loosening.
͵Ͷ
Noncoated screws are equally effective as coated screws with respect
to abutment loosening in end osseous implants. Hence, the additional
cost and technique sensitivity incurred with powdered screws may not
drastically improve the rate of failure due to screw loosening.
Jeng et al (2017)59, evaluated the load fatigue performance of
different abutment-implant connection implant types-retaining-
screw (RS) and taper integrated screwed-in (TIS) types under 3
applied torque levels based on the screw elastic limit. The static
fracture resistance results showed that the fracture resistance in the
TIS-type implant significantly increased (P < .05) when
the abutment screw was inserted tightly This study concluded that the
static fracture resistance and dynamic endurance limitation of the TIS-
type implant (1-piece solid abutment) increased when torque was
applied more tightly on the screw. Less torque loss was also found
when increasing the screw insertion torque.
Kose et al (2017)60, assessed screw loosening and bending/torsional
moments applied by clinicians of various specialties following
application of manual tightening torque to combinations of implants and
abutments. The implants that deformed in this test were examined
using an optical microscope to assess deformities. Manual tightening
did not yield the manufacturer-recommended preload values. Dynamic
͵ͷ
loading testing suggested early screw loosening/fracture in samples
with insufficient preload.
Demircan et al (2017)61,assessed screw loosening and bending/
torsional moments applied by clinicians of various specialties following
application of manual tightening torque to combinations of implants
and abutment. The implants that deformed in this test were examined
using an optical microscope to assess deformities. Manual tightening
did not yield the manufacturer-recommended preload values. Dynamic
loading testing suggested early screw loosening/fracture in samples
with insufficient preload.
Katsuhiro Tsuruta,et al (2018)62,studied that ,there are some spaces
between abutment and implant body which can be a reservoir of toxic
substance, and they can penetrate into subgingival space from
microgap at the implant–abutment interface. This penetration may
cause periimplantitis which is known to be one of the most important
factors associated with late failure. In this study, three kinds of
abutment connection system, external parallel connection (EP), internal
parallel connection (IP), and internal conical connection (CC), were
studied from the viewpoint of microleakage from the gap between the
implant and the abutment and in connection with the loosening of
abutment screw.
͵͸
Dye leakage was observed from abutment screw hole to outside
through microgap under the excessive compressive and tensile load
and evaluated the anti-leakage characteristics of these connection
systems.
The results of microleakage of toluidine blue from implant–abutment
connection indicated that microleakage generally increased as loading
procedure progressed.. Throughout the experiment, the amount of
microleakage in EP was largest, but no statistical difference was
indicated due to the high standard deviation.
Within the limitation of the study, CC was stable even after the loading
in the RTV of abutment screw and it prevented microleakage from the
microgap between the implant body and the abutment, among the
three tested connections.
Butkevica et al (2018)63,evaluated the effect of repeated tightening
and loosening of implant/abutment screws on the loosening torque of
implant/abutmentconnections of commercially available implant
systems. Seven different implant/abutment connections and their
modifications were tested.Repeated tighteningand loosening of
implant/abutment screws caused varying torque level changes among
the different systems. These observations can probably be attributed to
connection design. Limiting the number of tightening/loosening cycles
͵͹
in clinical and laboratory procedures is advisable for most of the
implant systems tested.
Hasan Sarfaraz et al (2018)64, evaluated the influence of four different
implant abutment connection designs on the amount of stress
dissipated on the implant, abutment screw, implant abutment interface
and the bone when subjected to various loading conditions. The result
showed that vertical loads closer to the implant long axis produced
much lower Von Mises stresses than when loads applied away to the
long axis of implant. The two types of conical connections dissipated
the least amount of stress to the surrounding bone and most of the
stresses were recorded at the implant abutment interface of these
connections. The parallel hex connection showed a great amount of
stress being dissipated to the abutment screw on vertical loading and
most of these stresses were located at the 1st thread of the implant.
All the four implant abutment designs studied showed the least
amount of stress on the various areas of the assembly and the
surrounding bone, when the loads applied were close to the long axis
of the implant. Both the conical connections proved to be the most
favorable connections, and the parallel hex connection was the least
favorable design. The tri-channel cylindrical connection design was
stable on loads applied along and closer to the implant axis, but
͵ͺ
produced high amount of stress on the bone on oblique loads applied
at a distance from the long axis of the implant.
Krishna Chaitanya Kanneganti et al (2018)65, compared the effect of
implant-abutment connections, abutment angulations, and screw
lengths on screw loosening (SL) of preloaded abutment using three
dimensional (3D) finite element analysis.
The present study suggests selecting appropriate implant-abutment
connection based on the abutment angulation, as well as preferring
long screws with more number of threads for effective preload retention
by the screws.
Wagner Moreira et al (2018)66, evaluated the mechanical behavior of
two different straight prosthetic abutments (one- and two-piece) for
external hex butt-joint connection implants using three-dimensional
finite element analysis (3D-FEA The regions with the highest von Mises
stress results were at the bottom of the initial two threads of both
prosthetic abutments that were tested. The one-piece prosthetic
abutment presented a more homogeneous behavior of stress
distribution when compared with the two-piece abutment.
Under the simulated chewing loads, the von Mises stresses for both
tested prosthetic-abutments were within the tensile strength values of
͵ͻ
the materials analyzed which thus supports the clinical use of both
prosthetic abutments.
Krishna Prasad D et al (2018)67, reviewed and discussed the literature
dealing with the platform switching concept to preserve the crestal
bone, the mechanism by which it contributes to maintenance of
marginal bone, its clinical applications, advantages and disadvantages,
in order to assess its survival rates. It was concluded that platform
switching helps preserve crestal bone around the implants and this
concept should be followed when clinical situations in implant
placement permit.
ͶͲ
Discussion
What Is An Implant?
A dental implant is an artificial root that replaces the natural tooth root.
(Fig. 3)
Dental implant abutments:
A dental implant abutment is formally defined as “that portion of a
dental implant that serves to support and/or retain a prosthesis”.3 It
functions to physically connect the clinical crown (i .e. prosthesis) to
the implant.
IAC is the point of contact between the surgical and prosthetic phase
and is required to provide adequate joint strength, rotational stability,
prosthetic indexing, and resistance to microbial penetration.
Screw Head Design and Mechanism
A screw is tightened by applying torque. The applied torque develops a
force within the screw called the preload. It is defined as the tension
generated in an abutment screw upon tightening and is a direct
determinant of clamping force. As a screw is tightened, it elongates,
producing tension. Elastic recovery of the screw pulls the 2 parts
together, creating a clamping force. (Fig. 4)
Ͷͳ
Discussion
In an effort to minimize clinical complications, the features of the screw
have been enhanced to maximize preload and minimize the loss of
input torque to friction. The head of the screw is wider than the thread
diameter and for an abutment most often is flat. Tapered head design
reduces the clamping effect and reduces the tensile force in the
threads of the screw. The tapered screw head distorts and aligns
nonpassive components and gives a nonpassive casting the
appearance of proper fit, but the super structure is not deformed
permanently and leads to stress in the system. Even a 10 N/cm torque
force applied to an inclined plane of a screw can distort a
superstructure and result in significant stress at the crestal bone
region. In addition, most of the force within the tapered screw is
distributed to the head rather than to the fixation screw component. A
flat-head screw distributes forces more evenly within the threads and
the head of the screw and is less likely to distort a nonpassive casting.
As a result, the dentist can identify and correct the nonpassive casting.
As such the abutment head also should be flat on top to increase the
clamping force in the screw head and the tensile force in the threads.
Thread Design and Number
The thread design and number of threads are also primary factors
influencing the risk of screw loosening. The most common abutment
screw design used by implant manufacturers is a fixture that is a V-
Ͷʹ
Discussion
shaped 30 degree angle .The fixture design allows the preload torque
applied to the screw to stretch the male component down the 30
degree angle of the female component of the screw to help fixate the
metal components. As a result, most manufacturers only have a few
threads on their abutment screw designs. The most common design is
a flat head, long-stem length with six threads to achieve optimal
elongation. (Fig. 5 & 6)
Screw Diameter
The diameter of the screw may affect the amount of preload applied to
the implant system before deformation. The greater the diameter, the
higher the preload that may be applied and the greater the clamping
force on the screw joint. As a general rule, abutment screws loosen
less often and can take a higher preload compared with coping screws.
In addition, coping screws do not engage an antirotatonal hexagon,
and therefore antitorque devices cannot be used. 68
In order to prevent screw loosening, macroscopic structures such as
the length of the screw, the thread and groove shape, the number of
screw threads, etc. can be altered; additionally, microscopic factors
such as the roughness of the screw surface, the interposition of
lubricant, etc. should also be designed properly. 29
Ͷ͵
Discussion
In an effort to reduce frictional resistance even more, dry lubricant
coatings have been applied to abutment screws. (Fig 7)
A number of implant-abutment connection designs are commercially
available and the clinician is often perplexed as to which implant
system and which connection design to choose.
Particularly, the connection between implant and abutment is a key
junction because it is the primary determinant of long term stability and
strength of implants which in turn determines the final outcome of
implant therapy. The implant abutment interface ensures optimal load
distribution along with lateral and anti-rotational stability.
TYPES OF IMPLANT ABUTMENT INTERFACE:
The implant abutment interface can be categorized into the following
types.69
1. Whether Or Not There Exists An Extension Of A Geometric
Figure Above The Body Of The Implant:(Fig. 8)
External Hex: There is an extension above the implant surface.
Internal Hex: the connection is recessed into the implant body.
2. Depending on the space between the connecting parts:
ͶͶ
Discussion
Slip fit: slight space exists between the connecting parts, and the
connection is passive.(Fig. 9)
Friction Fit: no space exists between the components and the parts
are literally forced together. (Fig.10 )
3. Angulation between the connecting parts:
Butt Joint: the connecting surfaces are at 90 degrees to one another.
Bevel Joint: The connecting surfaces are at an angle internally or
externally.
4. According to the geometrical configuration: (Fig 11 & 12)
a. Octagonal,
b. Hexagonal,
c. Conical,
d. Cylinder hex and
e. Spline, etc
Ͷͷ
Discussion
The implant/abutment connection, by convention, is generally
described as an internal or external connection. These two implant-
abutment connections can be distinguished by whether or not there
exists an extension of a geometric figure above the body of the implant.
In external connection implants, we observe a distinct projection
external to the body of the implant, whereas in internal connection
implants the implant-abutment connection is recessed into the body of
the implant . (Fig 13)
The history of abutment connections began with Branemark’s landmark
discovery of the dental implant. Branemark’s original implant was
composed of a 0.7 mm ex0ternal hex with a butt joint. Initially there
was little interest in anti-rotational features of the abutment connection
because implants were used to treat fully edentulous patients and were
connected together with a one-piece metal substructure.22
Why external hex…
The external hex portion of the implant was added to the design to
enable surgical placement of the implant.
This external hex served the purpose of a torque transfer coupling
device (fixture mount) during the initial placement of the implant into
the bone and the subsequent connection of the trans mucosal
extension.
Ͷ͸
Discussion
Although the external hex served the aforementioned purposes, it was
not an effective anti-rotation device and was not designed to withstand
the forces directed on the crowns intra orally.
Dental implants have now been used for a myriad of applications:
From the restoration of the completely edentulous arch, to partial
edentulous situations, single tooth replacements and fixed bridges.70,71
Thus, with the ever increasing applications of implant dentistry, the
requirements of the implant-abutment connection have also increased.
The implant-abutment connections must now serve the purpose of anti-
rotation and prosthetic indexing.4 These functions are most important in
the restoration of single posterior teeth by implants, as they are the
most difficult to retain.72
Thus, there was a need to modify the Branemark’s external hexagon
implant-abutment connection to prevent complications, such as
abutment screw loosening and fracture, which occurred commonly
when the external hexagon was used in single tooth implant
restorations. Thus, design modifications, such as increasing the height
and flat to flat width of the mating surfaces of the implant-abutment
connection have been tried by various manufacturers.4
Ͷ͹
Discussion
Chronological Development of Abutment Connections:
The abutment modifications that have occurred are vast and complex.
For example, the external hex underwent several modifications of
height and width. Besides altering the size, other modifications were
also made in an effort to improve upon the original external hex design.
A major paradigm shift came with the evolution of the internal
connection. Each implant system has developed their own design of
the internal connection, resulting in a wide variation in terminology and
types of connections.
The initial relationship between the abutment and implant body was
mainly associated with external connections. Over time the simple butt
joint has evolved into slip-fit and friction-fit joints.
Prosthetic success remains high with the external connection but the
most common prosthetic complication is screw loosening when
implants are used to replace a missing single tooth. Multiple studies
have shown screw loosening to be anywhere from 6% to 48% with
external connection devices.
Screw loosening can create serious challenges for the clinician and
patient and diminishes a practitioner’s chair side time, which is the
most valuable asset a practitioner has.
Ͷͺ
Discussion
When an external hex implant is used to replace a single tooth, the
weakest link between the implant, abutment connection, screw, and
bone is the screw.
This is because with this connection type the screw alone secures the
abutment.
THE EXTERNAL CONNECTION
The initial 0.7 mm external connection, being short in length, provided
only limited screw engagement. The original narrow platform
associated with the external hex connection created a short fulcrum
arm, which also increased screw loosening due to adverse tipping
forces. Consequently, the short and narrow external connections made
screw loosening a common occurrence. Research clearly indicates that
screw loosening is more common with external connections. The
seriousness of screw loosening resulted in manufacturers
implementing major modifications to the external hex connection. (Fig.
14)
There are a number of advantages and disadvantages of the
external hex connection.
Advantages of the external hex connection
x Long-term follow-up data are available
Ͷͻ
Discussion
x Compatibility among multiple implant systems
x Solutions to complications are found throughout the literature
due to their extensive use
Disadvantages of the external hex connection
x Higher prevalence of screw loosening
x Higher prevalence of rotational misfit
x Less esthetic results
x Inadequate microbial seal
Modifications of External Connection:
The first solution to overcome the adverse force distribution and
instability of the abutment connection was increasing the width and
height of the external hex connection.
Currently available external hex heights range from 0.7 to 1.2 mm and
widths from 2.0 to 3.4 mm, depending on the manufacturer. These
adjustments increased the fulcrum arm and deepened the abutment
screw engagement, thus limiting the tipping forces on abutment screws
and reducing the prevalence of screw loosening. (Table1 and Fig 15 )
ͷͲ
Discussion
Also, a variety of modifications of the external hexagon, such as the
tapered hexagon, external octagon and the spline dental implant are
now available
THE INTERNAL IMPLANT-ABUTMENT CONNECTION
To overcome the clinical complications with external implant-abutment
connections, internal connection implants were developed. The goals
of new designs were to improve connection stability throughout
function and placement and simplify the armamentarium necessary for
the clinician to complete the restoration. One of the first internally
hexed implants was designed with a 1.7 mm-deep hex below a 0.5 mm
wide, 45° bevel. This was the corevent implant developed by Nickzick
implant manufacturers in the year 1986.73,74 (Fig 16 & 17)
The design has been proven to distribute intraoral forces deep within
the implant and thus improve the implant-abutment joint stability.
The internal interface designs offer a reduced vertical height platform
for restorative components, distribution of lateral loading deep within
the implant, a shielded abutment screw, long internal wall
engagements that create a stiff, unified body that resists joint opening,
wall engagement with the implant that buffers vibration, the potential for
a microbial seal, extensive flexibility and the ability to lower the
restorative interface to the implant level esthetically.
ͷͳ
Discussion
Internal friction fit/interference fit connections have no space existing
between mating components and abutment actually wedges into the
implants internal recess due to friction, resulting in a virtual ‘cold weld’
between the two which provides superb microbial seal and joint
stability.
Advantages:
x Reduced vertical height which resulted inBetter esthetics
x Distribution of lateral loading deep within the implant
x Shielded abutment screw that caused less abutment screw
loosening
x Internal wall engagement: less freedom of rotation.
x Wall engagement with the implant that buffers vibration, the
potential for a microbial seal
x Extensive flexibilty
The Internal Connection Implants Can Be Divided Into The
Following Group: (Table 2)
1. Passive Fit/Slip Fit Joint (space exists between mating
components)
ͷʹ
Discussion
2. Friction Fit (no space between mating components)
Locking taper/morse taper:
6-Point Internal Hexagon Design
This is the most common type of commercially available, internal
implant abutment connection. It has a six-sided geometric figure, that
is, a hexagon recessed into the body of the implant. As the internal
geometry is a hexagon, the abutment can fit over the implant at every
60 degree rotation
of the implant over the abutment, but not at any other intermediate
angle. Thus, abutment positioning is possible at six different positions
of the implant over the abutment.
It is available from Central pulse (Screw-vent) implants with a 1.2 mm
length of the internal connection. This implant has evolved from the
original core vent implant, with a hollow basket design to the tapered
screw vent
implant.. The design has been proven to distribute intraoral forces deep
within the implant and thus improve the implant-abutment joint stability
as compared to the traditional external hexagon. 73,74
ͷ͵
Discussion
12-Point Internal Hexagon
The 12-point double internal hex provides an opportunity to place the
abutment on the implant for every 30 degree rotation, thus useful when
we use angled abutments. It provides us with a greater opportunity to
correct the off-axis angulation of the abutment with respect to the
implant.
The 12-point internal hexagon system offers more freedom of
positioning the abutment over the implant as well as a better
distribution of stresses at the implant-abutment interface.
3-Point Internal Tripod
This type of implant to abutment connection represents a triangular
internal geometry. A major disadvantage of this system is that it allows
for positioning of the abutment over the implant at only 120 degree of
rotation. This type of implant-abutment connection was introduced by
Nobel Bio care, which was the replace select system. It represents the
trichannel implant system. It is available in four diameters: 3.5, 4.3, 5
and 6 mm and is color-coded for ease of identification.
Camlog implant system (Alatech technologies) represents an internal
tripod implant-abutment connection. The length of the internal
connection is 5.4 mm. It is claimed to have a ‘tube in tube effect’ which
ͷͶ
Discussion
is claimed to provide an accurate, mechanically secure implant to
abutment connection with anti-rotational stability.
Internal Octagon Implant
The internal octagonal implant represents an 8-sided internal geometry
connecting the implant and the abutment allowing for positioning of the
implant over the abutment at every 45 degree rotation. The internal
octagon connection was introduced by Omniloc, Sulzer Calcitek. The
octagonal connection, because of its thin walls, 0 to 6 mm length and a
small diameter that presented a geometry profile similar to that of a
circle, offered minimal rotational and lateral resistance during function.4
Due to these disadvantages, it is no longer marketed.
Friction Fit (Morse Taper Implants)
The concept of Morse taper implant-abutment connection design
includes a tapered projection from the implant abutment, which fits into
a tapered recess in the implant. There is a friction fit and cold welding
at the implant–abutment interface. This implant-abutment connection
depends on this friction fit for elimination for rotation at the implant-
abutment interface and subsequent abutment screw loosening.22 ( Fig
18)
ͷͷ
Discussion
8 Degree Morse Taper Implants
In dentistry, the concept of this morse taper or cone screw tapered
connection was first utilized by the ITI group in Switzerland. 75
The rationale was that a tapered connection would yield a mechanically
stable, sound and self-locking interface. It basically creates a friction
lock similar to themorse taper used in mechanical engineering and
related industries.
A further modification of the ITI-Straumann implant design is the
Synocta design. Though the original implant design allowed for a
precise fit between the implant and the abutment, it did not allow for
rotation of the abutment over the implant and fit at a different
angulation. Wiskott and Belser supplemented the morse taper
connection by introducing a internal hexagon in the middle of the
morse taper connection, thus allowing for repositioning of the abutment
and also precise transfer of the implant position to the master cast. As
a result, only one transfer system and one analog are required.
11.5 Degree Morse Taper Implant
This implant is marketed by Astra Tech. The fixture and abutment are
strongly connected at an 11.5 degree angle by the conical seal design.
The conical design seals off the connection and decreases micro
ͷ͸
Discussion
movement and micro leakage. This thread has a micro threaded
conical neck and TiO blast surface. Micro threads on the fixture top
prevent concentration of the stress around the alveolar ridge crest and
decrease marginal bone loss.
1.5 Degree Morse Taper Implants
This is a true morse taper implant with an angle of taper: 1.5 degree is
available from Bicon implants. The Bicon locking taper abutment has
no screw, but like a screwretained abutment, it relies on friction to keep
it intact. Assembly is achieved by driving the 1.5 degree morse taper
into the matching socket in the implant. A high clamping force between
abutment and implant is generated by this action.
The high friction force is the result of relative slip between the two
friction surfaces occurring at high contact pressure. This results in the
surface oxide layers breaking down and causing cold welding at the
implant-abutment interface. (Fig 19)
Thus, there was a need to modify the Branemark’s external hexagon
implant-abutment connection to prevent complications, such as
abutment screw loosening and fracture, which occurred commonly
when the external hexagon was used in single tooth implant
restorations. Thus, design modifications, such as increasing the height
and flat to flat width of the mating surfaces of the implant-abutment
ͷ͹
Discussion
connection have been tried by various manufacturers. The
development of the tapered hexagon and the spline dental implant
have been other attempts toward overcoming the limitations of the
Branemark’s external hexagon. The search for a new implant-abutment
connection design, to overcome the limitations of the external hexagon
led to the development of the internal hexagon design. This has further
been modified to the 3-point internal tripod, 12-point internal hexagon
and the internal octagon implantabutment connection. The basic
clinical significance of these various implant-abutment connections is
the freedom of positioning the abutment over the implant, which is
maximum for the 12-point internal hex and minimum for the 3-point
internal tripod.
The implant–abutment interface determines the lateral and rotational
stability of the implant-abutment joint which in turn determines the
prosthetic stability of the implant supported restoration.
ͷͺ
Discussion
BIOMECHANICAL FACTORS AFFECTING IMPLANT
ABUTMENT INTERFACE (EVIDENCE BASED DECISION
MAKING)
1. Implant Abutment Interface Geometry/Design
The implant / abutment interface connection, is generally described as
an internal or external connection. The distinctive factor that separates
the two groups is the presence or absence of a geometric feature that
extends above the coronal surface of the implant. The connection can
be further characterized as a slip fit joint, where a slight space exists
between the mating parts and the connection is passive or, as a
friction fit joint, where no space exists between the mating
components and the parts are literally forced together. The joined
surfaces may also incorporate a rotational resistance and indexing
feature and / or lateral stabilizing geometry. This geometry is further
described as octagonal, hexagonal, cone screw, cone hex, cylinder
hex, 13 spline, cam, cam tube and pin / slot.
Dr. Gerald A Niznick was the first one to suggest modification to the
Implant abutment design in the form of internal hex.
In internal hex connection the mating components are situated inside
the implant body which was believed to help in better stress distribution
ͷͻ
Discussion
and provide better and more prosthetic options. Almost all vitro studies,
with the exception of one, have demonstrated that internal connections
have greater stability than external hex connections.
The next major advancement in terms of geometry of the connection
was the introduction of tapered connections. Tapered connections are
believed to give better marginal seal and reduce the micro movements
between the implant and the abutment.
A conical implant-abutment interface at the level of the marginal bone
is also believed to improve the distribution of the load into the
supporting bone. In reduced-diameter conical connections, the neck of
this implant is a potential zone for fracture when subjected to high
bending forces. The joined surfaces may also incorporate a rotational
resistance and indexing feature and/or lateral stabilizing geometry.
This geometry is further described as octagonal, hexagonal, cone
screw, cone hex, cylinder hex, cam tube, and pin/slot.
Combination of morse taper with other features such as internal hex is
also being tried in newer implant systems. Some screw less implant
systems which rely entirely on the friction fit for their
tapered mating hexagon.
͸Ͳ
Discussion
2. Micro gap And Micro motion
Most dental implant systems consist of two main parts: the abutment
and the implant body.5
Micro gaps between the implant–abutment interface may cause
microbial leakage as microorganisms can penetrate through a gap as
small as 10 micrometer.76,77 This penetration will result in bacterial
colonization through plaque formation at the interface of the implant–
abutment complex, leading to inflammation in peri-implant soft and
hard tissues.78-80
In the worst-case scenario, such inflammation will cause gingivitis,
bone loss, and eventually, implant failure. Although peri-implant
therapy can be used to treat peri-implant disease, bone loss that has
already occurred is irreversible, and implant failure is still a common
complication following therapy. It is therefore prudent to prevent
bacterial colonization by having a tight seal at the implant–abutment
interface.81
Three main factors have been identified as possible causes for the
formation of micro gaps:
x occlusal load during physio-logical function,82 .
x manufacturing tolerance and.83
͸ͳ
Discussion
x micro motion between the implant–abutment connections.
Different types of abutment connections have been reported to
produce different magnitudes of micro motion. 82,84 Two major types of
abutment connections are the conical and the butt-joint, the latter type
of connection being available in at least three different forms:
hexagonal, octagonal and trilobe.5 The design configuration of the
abutment connection also plays a vital role in uniformly transferring
occlusal stresses to the bone, thus eliminating potential micro gap
formation due to uneven loading. The sharp angles and vertices at
abutment connections induce high stresses, causing wear, and
therefore causing micro gap formation.
Micro motion and stress are believed to play pivotal roles in micro gap
formation and microbial leakage. Different designs of implant–abutment
connections are predicted to induce different patterns of micro motion
and stress distribution under occlusal loading.
Internal hexagonal and octagonal abutments produced similar patterns
of micro motion and stress distribution due to their regular polygonal
design. The internal conical abutment produced the highest magnitude
of micro motion.
͸ʹ
Discussion
Unlike the internal conical abutment, the trilobe abutment produced the
lowest magnitude of micro motion, which was mainly caused by the
polygonal profile.
Non-cylindrical abutments showed lower micro motion, but the
tendency of stress to concentrate at the vertices increased the risk for
micro fracture, and therefore for micro gap formation. Micro motion is
an important parameter that has received relatively little attention in the
field of prosthodontic implants. This parameter needs to be addressed
for long-term success of implants as it can predict the primary stability
of implants within the bone and the secondary stability of their
components.85,86
Micro motion has been regarded as one of the parameters that
contribute to the formation of micro gaps between the mating surfaces
of dental implants.76,82
Occlusal forces produced during clenching, chewing and jiggling
movements are typically transferred through dental implant systems,
resulting in movement between the implants and the abutments. 87,88.
Do Nascimento C et al., evaluated the bacterial leakage in an
External Hexagon (EH) implant connection in non-loaded condition
using DNA checkerboard and culture methods. They found that
bacterial leakage from the IAI was same in both the methods 89
͸͵
Discussion
Verdugo CL et al., used external connection implant and conical
internal connection (Morse taper) implants in their study. The results of
the study showed that less micro leakage was shown by Morse taper
connection implants them external connection implants.
A gap of 10 μ m was presented by external connection implant which
was more than Morse taper implants with gap of 2-3 μ m. When 30 N
cm torque was applied to tighten the abutments there was decrease in
microleakage.90
Canullo L et al., conducted a five year follow up study on human for
different implant connections under functional loading. Result showed
that microbial contamination was seen in all the connections. IH and
conical connections implant showed less leakage of bacteria at the
peri-implant sulcus and inside the connection than external hexagon
implants91.
3. Screw Mechanics
The screw is a simple machine that follows the mechanics of a spiral
inclined plane and therefore is highly efficient.
A screw design is the most commonly used implant body to initially
fixate an implant into bone and load the bone after hard tissue healing.
͸Ͷ
Discussion
A screw almost always is also used to connect the abutment
components into the implant body.
In addition, a screw may be used to fixate the prosthesis into the
abutment or directly into the implant body. (Fig 20)
Abutment and prosthetic screw loosening is one of the most common
complications for implant prosthetics.
Hence, dentists should have an understanding of implant screw
mechanics rather than solely depending on an implant manufacturer to
fulfill the needs of the profession.
The primary use of screws in implant restorations is to fasten prosthetic
components together. In almost all implant systems, a screw is used to
fixate the abutment component (i.e., abutment for cement retention,
abutment for screw retention and abutment for attachment) to the
implant body. (Fig 21)
Screw loosening of the abutment also presents some potential
problems.
The abutment-to-implant body connection approximates the level of
bone and is several millimeters below the margin of the tissue. It may
not be completely hermetically sealed and may contribute to bacterial
infection, especially when the abutment screw becomes loose.
͸ͷ
Discussion
Chronic screw loosening can be costly and time consuming. 92 Any
discrepancy in occlusion, casting fit, or force may result in vibration
during function and screw loosening or breakage where the force is
greatest or the metal dimension is weakest.
The increased risk of prosthetic or abutment screw loosening may be
decreased by understanding metal screw mechanics.
Screw Parameters Affecting Screw Loosening:
1. Preload
2. Component fit
3. Platform dimension
4. Hex height
Settling or Torque Loss
This is a decrease in preload as a result of burnishing of both the
internal implant threads and the prosthetic screw threads. Unlike screw
loosening, the prosthetic screw does not “unscrew.” The frictional
forces between the components are decreased as a result of creep and
stress relaxation, which eventually will cause a decrease in preload.
This is a normal occurrence which should be anticipated and corrected
by retorqueing the prosthetic screw to the recommended moment force
͸͸
Discussion
after a period of time. It is recommended that the prosthetic screws be
retorqued 10 minutes after initial placement and periodically thereafter
(Winkler et al. 2003; Cantwell and Hobirk 2004). Torque loss will
also occur over longer periods of time. It is recommended to retorque
the prosthetic screw at each recall visit. This has not been shown to
have any harmful effects on the implant joint stability (Delben et
al. 2011).
Preload
Preload of an abutment or prosthetic screw is the initial load created by
the application of a torque and causes elongation of the screw. Preload
places the screw in tension and leads to an over clamping force
between the parts of the implant system. Preload is primarily
dependent on the applied torque and secondarily on the component
material, screw head and thread design and surface roughness 93-95.
The aim of tightening a screw using preload stress is to maximize the
fatigue life of the screw yet provide satisfactory resistance to loosening.
The preload is affected by seven factors:
(1) torque magnitude,
(2) screw head design,
(3) thread design and number,
͸͹
Discussion
(4) composition of metal,
(5) component fit,
(6) surface condition, and
(7) diameter of the screw
1. Screw head: The head contains the driver fitting site, which is
used to rotate the screw into position. Various driver fitting site
types are available, including slot (flat-head), Phillips, Robertson
(square), hex, and star. By far, the most common type used in
implant dentistry is the hex type. It is critically important to use the
appropriate corresponding driver to prevent screw head stripping.
2. Shank: The shank is the unthreaded portion of the screw below
the head. It is variable in length depending on the geometry of the
components that are being held together.
3. Thread: Without going into too much complexity, the thread can
come in a myriad of different dimensions. This portion of the screw
engages the internal threads of the implant and provides the
surfaces onto which force is transmitted and converted to preload.
The internal threads of the implant and those of the prosthetic
retaining screw must be 100% compatible. (Fig 22)
͸ͺ
Discussion
4. Connection Geometry:
Connection geometry influences the amount of screw loosening. They
influence the amount of micro motion, stress distribution and micro gap
formation. Internal hexagon and octagonal abutments have similar
pattern of micro motion and stress distribution96.The internal conical
abutment produced the highest magnitude of micro motion. The trilobe
connection showed lowest magnitude of micro motion. Internal
hexagonal connection required greater detorque values than the
external hex and internal octagon connections. Morse taper connection
provided reduced incidence of abutment screw loosening and also help
in distributing the load more favorably in the bone. 97-99
Mc Glumphy et al100 defined the screw joint as 2 parts tightened
together by a screw, such as an abutment and implant being held
together by a screw. A screw is tightened by applying torque. The
applied torque develops a force within the screw called the pre-load. As
a screw is tightened, it elongates, producing tension. Elastic recovery
of the screw pulls the 2 parts together, creating a clamping force. The
preload in the screw, from elongation and elastic recovery, is equal in
magnitude to the clamping force.Opposing the clamping force is a joint
separating force, which attempts to separate the screw joint. Screw
͸ͻ
Discussion
loosening occurs when the joint-separating forces acting on the screw
joint are greater than the clamping forces holding the screw unit
together.Excessive forces cause slippage between threads of the
screw and threads of the bore,resulting in a loss of preload.When the
clinician applies a torque to a screw to tighten its components together,
the tightening torque creates a preload in the screw. The preload is
determined by the applied torque and other factors, such as the screw
alloy, screw head design, and abutment surface. The established
preload is proportional to the applied torque. The torque value can be
controlled by the clinician and can be reproduced from implant
prosthesis to implant prosthesis.Too little torque may allow separation
of the joint and result in screw fatigue, loosening, and failure. Too large
a torque may strip the screw threads.Increasing the torque will increase
the preload. Increasing the preload maximizes the stability of the screw
joint by increasing the clamping threshold that separating forces must
overcome to cause screw loosening.
The amount of torque than can be applied is limited by the ultimate
strength of the screw. McGlumphy et al have stated that the optimal
torque value is 75% of the torque needed to cause screw
failure.Another variable in the amount of torque that can be applied is
how the torque is produced by the clinician.Torque can be applied
manually or with a mechanical device. Until the introduction of
͹Ͳ
Discussion
mechanical torquing devices to the profession, implant components
were tightened manually. The inexperienced clinician often
undertightened the screws in an implant system.
Dellinges and Tebrock found that the average torque applied with a
screwdriver is only 10 N-cm.
Carr et al.101 and Byren et al102. reported that the fitting of the implant-
abutment interface is important for obtaining joint stability of the implant
system. Moreover, under such conditions, the preload also reaches the
maximum value.
Jaarda et al found that test subjects with little implant experience were
not generally able to provide the recommended torque to implant
prosthesis–retaining slotted gold screws. micromotion.
4. Effects of Different Abutment Connection Designs on the
Stress Distribution
The stability of the bone-implant interface is required for the long-term
favorable clinical outcome of implant supported prosthetic
rehabilitation. The implant failures that occur after the functional
loading are mainly related to biomechanical factors. Micro movements
and vibrations due to occlusal forces can lead to mechanical
complications such as loosening of the screw and fractures of the
͹ͳ
Discussion
abutment or implants. The reliability and stability of the implant-
abutment connection design and the surface properties of the fixture
are crucial factors in maintaining the long-term functioning of the
implant-bone interface.103 The basic knowledge concerning possible
mechanical failures that may occur following prosthetic rehabilitation is
an important part of treatment planning as it provides predictable
success rates.
Animal experiments and clinical studies have shown that implant
failures in the absence of plaque-related gingivitis might be associated
with the disequilibrium of the forces acting on implants. 104-106
These adverse occlusal forces resulting from the functional
components of mastication and nonfunctional occlusal contacts may
result in mechanical malfunctions in the implant systems, particularly at
the level of implant-abutment connection.107.
There are various biomechanical techniques to evaluate the stress
distribution of occlusal forces in bone around dental implants.
The finite element method (FEM) is a mathematical model analysis that
gives detailed qualitative solution of the interaction between prosthesis,
implant, and surrounding bone.108 The design configuration of the
abutment connection also plays a vital role in uniformly transferring
occlusal stresses to the bone, thus eliminating potential micro gap
͹ʹ
Discussion
formation due to uneven loading.109 The sharp angles and vertices at
abutment connections induce high stresses, causing wear, and
therefore causing micro gap formation. 110 Micro motion and stress are
believed to play pivotal roles in micro gap formation and microbial
leakage. Different designs of implant–abutment connections are
predicted to induce different patterns of micro motion and stress
distribution under occlusal loading, the parameters of which were
analyzed with Finite Element Modelling (FEM). 111-118
Chewing forces of adult individuals with natural dentition and those with
prosthetic rehabilitation are between 50 N and 2440 N, showing a
decreasing pattern from molars to incisors.
In FEM studies, the application of such forces generally varies from 35
N to 178N119-125.
Based on these observations, we used the vectoral oblique force load,
resulting from 100 N and 50 N of vertical and horizontal components,
respectively. Combinations of the axial and horizontal forces that lead
to maximum stress load in cortical bone should be taken into account
in preclinical studies evaluating the stability of the implant-abutment
connections since these are more realistic than using occlusal forces
alone122,126.
͹͵
Discussion
In the external hexagonal connection systems, Jemt et al127 observed
that the connection screw receives all static and dynamic lateral force
loads, which distribute throughout the surface. The authors concluded
that such forces can cause loosening and/or fracture of the connection
screw.
Similarly, Levine et al128 . demonstrated that the external hexagonal
connection system is more susceptible to screw loss than the solid
conical abutment connection. These findings suggest that the highest
stresses are concentrated in the screw of the external hexagonal
connection system, and the tension in the neck of the screw shows the
maximum values.
Sutter et al129. had shown that the conical angled design could reduce
screw loosening by creating a friction lock. In addition, they found that
the screw rotation is minimal in the Morse taper integrated screwed-in
thread abutment system when compared with the external hexagonal
connection.
Merz et al130. considered the internal conical design and the use of 1-
piece abutment as the main factors influencing the amount and
distribution of the stress in implant systems.
Hasan Sarfaraz et al131 evaluated the influence of four different
implant abutment connection design :
͹Ͷ
Discussion
1. Tri-channel cylinder (TCC): The tri-channel cylinder connection of
Nobel replace.
2. Conical connection (CC2): The two piece CC of Nobel active.
3. Conical connection (CC1): The single piece CC (without the
abutment screw) of Osstem Implant system.
4. Parallel hex connection (PHC): The parallel 6 point hex connection
of Frialit II Implant system. ] on the amount of stress dissipated on the
implant, abutment screw, implant abutment interface and the bone
when subjected to various loading conditions. They concluded that, all
the four implant abutment designs showed the least amount of stress
on the various areas of the assembly and the surrounding bone, when
the loads applied were close to the long axis of the implant. Both the
conical connections proved to be the most favorable connections, and
the parallel hex connection was the least favorable design. The tri-
channel cylindrical connection design was stable on loads applied
along and closer to the implant axis, but produced high amount of
stress on the bone on oblique loads applied at a distance from the long
axis of the implant.
͹ͷ
Discussion
5. Platform Switching
Platform switching is an IAC modification to control crestal bone loss
around dental implants. This term was coined by Gardner in 2005 and
expanded by Lazzara in 2006 . This concept uses prosthetic
abutments with reduced diameter in relation to implant platform
diameter, thus moving the implant abutment junction and supposedly
the inflammatory reaction medially, away from the crestal bone and
may thus, minimize crestal bone loss.
Step, created between abutment and implant allows the biologic width
to be established horizontally. This means, less vertical bone
resorption is required to compensate for biologic seal. Significant
decrease in crestal bone loss was noted if implant abutment diameter
difference was greater or equal to 0.4mm.132. It can reduce crestal
bone loss around 1.56 ±0.7mm32,33133,134 and facilitates superior
aesthetics with preservation of interdental papilla, better bone-implant
contact and improved primary stability. It necessitates components with
similar design and enough soft tissue depth (>3mm) to develop
adequate emergence profile. Platform switching can be achieved by
using abutments with a diameter smaller than the implant neck or body
width, using an implant design where neck diameter is increased with
respect to the implant body width, using inherently platform switched
implants and conical emergence abutments freeing extension of the
͹͸
Discussion
implant platform between 0.5- 0.75mm or bone platform switching
which involves an inward bone ring in the coronal part of the implant
that is in continuity with the alveolar bone crest.135 (Fig 23)
• The design details of a platform switched implant are mentioned
below and Figure depicts the same. (Fig 24)
• The collar bevels medially into a smaller-diameter prosthetic
platform
• Restoring the 4.8-mm diameter collar (implant restorative
platform) with the 4.1-mm prosthetic component medializes the
IAJ.
Applications of platform switching:
• In situations where larger implant is desirable but prosthetic
space is limited.
• In the esthetic zone
• Where preservation of crestal bone can lead to improved
esthetics
• Where shorter implants must be utilized.
͹͹
Discussion
Advantages of platform switching:
• The inflammatory cell infiltrate, which surrounds the IAJ in a
collar like fashion, is contained within the angle formed at the
interface and thus prevented from spreading further apically
along the implant where it would otherwise result in
inflammatory changes to the bone crest136-138 (Fig. 25 )
• The horizontal dimension of the step allows for an additional
area where biologic attachment may take place, thus limiting the
extent of physiologic remodeling of the bone crest needed to
accommodate the biological zone.139
• Optimal management of restorative space. With the crestal bone
preserved both horizontally and vertically, support is thus
retained for the interdental papillae. Maintenance of midfacial
bone height helps to maintain facial gingival tissues.
• Improved bone support for shorter implants.
• The possible influence of the microgap on bone resorption may
be diminished by moving the junction inwards from the bone
crest.
͹ͺ
Discussion
Disadvantages
• Need for the components that have similar design
• Need for sufficient space to develop proper emergence profile.
6. Effect of Abutment Material
Earlier the abutments were made of titanium until the recent
introduction of ceramic abutments. The problems with titanium
abutments are the micro gap, consecutive fatigue and wear at the
interface.
Yuzugullu et al assessed the implant-abutment interfaces after the
dynamic loading of titanium, alumina, and zirconia abutments. After the
dynamic loading, there was no significant difference between the
aluminum oxide, zirconium oxide, and titanium abutment groups
regarding the micro gap.
Yuong Jo et al evaluated the influence of abutment materials on the
stability of the implant-abutment joint in internal conical connection type
implant systems using abutments fabricated with commercially pure
grade 3 titanium (group T3), commercially pure grade 4 titanium (group
T4), or Ti-6Al-4V (group TA). Provided that biological risks can be
excluded, it would be recommendable to use abutment materials with
͹ͻ
Discussion
high strength and low frictional coefficients to improve the mechanical
stability of the implant-abutment etc..
ͺͲ
Conclusion
The requirements for an optimal implant abutment connection can be
summarized as follows: precise rotational orientation for Single tooth
restorations, maximum mechanical stability instead of optimal fatigue
resistance minimized micro gap, overload protection. High surface
compression in the critical perimeter area of the connection results in a
minimal micro gap between the implant and the abutment, which in turn
reduce the occurrence of bacterial contamination. The misfit between
abutment and implant interface has many clinical implications as:
abutment overload; screw loosening or fracture or even of the implant
itself; incorrect transmission of force to implant and marginal bone and
microbial proliferation. These factors can lead to a persistent
inflammation around peri-implant tissue. The gap between implant and
abutment is an ideal place for bacterial proliferation and fluid micro
leakage what can lead to peri-implantitis .It is important to say that the
force applied in the tightening torque is only valid if the machining and
adjustment degree between abutment and implant were proper
because high levels of tightening torque would not produce the desired
result on components that do not have proper mortise. Decisions
regarding dental implant abutments are essential aspects of clinical
dental implant excellence.
The implant–abutment interface determines the lateral and rotational
stability of the implant-abutment joint, which in turn determines the
ͺͳ
Conclusion
prosthetic stability of the implant- supported restoration. Internal
connections have better prosthesis retention and consequently higher
stability, which decrease the stress on the cervical region of the
implants and retention screws. Conical implant–abutment interface in
combination with retention elements at the implant neck reduce the
amount of micro motion. All types of prosthetic platforms can provide
high success rate of the implant treatment by following a strict criteria
of their indication and limitation. Therefore, a reverse planning of
implant treatment is strongly indicated to reduce implant overload.
ͺʹ
References
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References
135. Carinci F, BrunelliG, Danza M. Platform switching and bone
platform switching. J Oral Implantol 2009; 35:245-250.
136. Abrahamsson I, Berglundh T, Lindhe J. Soft tissue response to
plaque formation at different implant systems. A comparative
study in the dog. Clin Oral Implants Res 1998; 9:73-9.
137. Ericsson I, Persson LG, Berglundh T, Marinello CP, Lindhe
J,Klinge B. Different types of inflammatory reactions in peri-
implant soft tissues. J Clin Periodontol 1995; 22:255-61.
138. Lazzara RJ, Porter SS. Platform switching: A new concept in
implant dentistry for controlling post restorative crestal bone
levels. Int J Periodontics Restorative Dent 2006; 26:9-17.
139. Baumgarten H, Cocchetto R, Testori T, Meltzer A, Porter S. A
new implant design for crestal bone preservation: Initial
observations and case report. Pract Proced Aesthet Dent
2005; 17:735-40
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Dental implant therapy is a fast growing and promising aspect in the

rehabilitation of completely and partially edentulous arches. Study of

implants has become indispensable and so is the biomechanics related

to dental implant therapy. Implant abutment connection is a crucial

synapse between the implant and the abutment. It is an important

determinant of the strength and stability of an implant supported

restoration, and play a major role in the success of the implant. 1

The implant abutment interface determines joint strength, stability, and

lateral and rotational stability of the joint.2

A DENTAL IMPLANT ABUTMENT is formally defined as ―that portion

of a dental implant that serves to support and/or retain a prosthesis. 3

CREST MODULE is that portion of implant fixture that provides

connection to abutment and consists of a platform & anti rotational

Particularly, the connection between implant and abutment is a key

junction because it is the primary determinant of long term stability and

strength of implants which in turn determines the final outcome of

implant therapy. The implant abutment interface ensures optimal load

distribution along with lateral and anti-rotational stability. Currently,

there are some 20 different implant/abutment interface geometric

The original Brånemark protocol involves a two-stage surgical

procedure and was designed to restore a completely edentulous

mandibular arch.4 In this protocol, the implant-abutment interface was

an external hexagon of 0.7 mm height. This external hex served the

purpose of a torque transfer coupling device (fixture mount) during the

connection of the trans mucosal extension, which when used in series

could effectively restore the completely edentulous arch. Although the

external hex served the aforementioned purposes, it was not an

effective anti-rotation device6 and was not designed to withstand the

forces directed on the crowns intraorally7. Hence, mechanical problems

including screw loosening and fractures led to the development of

These limitations have led to the development of various implant

abutment connection systems to address these issues. Many

contemporary implant systems now have an internal — rather than an

The goals of the internal connection were to improve connection

stability throughout the placement and functional periods, and to

simplify the armamentarium necessary for the clinician to complete the

Since the introduction of the internal connection concept, further design

enhancements have been made in an attempt to enhance the implant

/abutment 8,9,10 connection. Included in such efforts is the “Morse”

taper, wherein a tapered abutment post is inserted into the non-

internal connection designs have followed, frequently with variations in

Although the internal hex reigns as the most predominant

abutment/implant connection, it is not the most stable. The tapered

connection, especially the true Morse taper, provides a much more

stable abutment/implant interface. It virtually eliminates any micro

gaps and provides a hermetic seal that prevents bacterial invasion of

the abutment/implant juncture.

Implants designed with Morse taper interface engage their abutments

a rounded male extension is placed. The abutments achieve the anti-

rotational properties due to the cold-weld phenomenon that occurs

after placing and torqueing the abutment.4

Cold or contact welding is a solid state welding process in which joining

takes place without fusion at the interface of the two parts to be

Morse taper abutments are considered superior in terms of sealing

diminishes the possibility of microorganism passage

They differ with respect to design features and capability. The

consequences of choosing a less-than-ideal interface are mechanical

and biological, with potential problems resulting in fatigue failures

and/or peri-implantitis.12 Furthermore, some of the latest IACI systems

allow for innovative and advanced restorative options. 13,14

When using these implant/abutment connections, clinicians had to be

mindful of their application in the intraoral environment, an often

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