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Mechanical Testing of Implant-Supported Anterior Crowns with Different

Implant/Abutment Connections

Article in The International journal of oral & maxillofacial implants · February 2013
DOI: 10.11607/jomi.2443 · Source: PubMed

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 Mechanical Testing of Implant-Supported Anterior Crowns
with Different Implant/Abutment Connections
Erika O. Almeida, DDS, MSc1/Amilcar C. Freitas Jr, DDS, MSc1/
Estevam A. Bonfante, DDS, MS, PhD2/Leonard Marotta, CDT, MDT, PhD 3/
Nelson R.F.A. Silva, DDS, MS, PhD4/Paulo G. Coelho, DDS, BS, MS, MSMtE, PhD3,5

Purpose: This study evaluated the reliability and failure modes of anterior implants with internal-hexagon (IH),
external-hexagon (EH), or Morse taper (MT) implant-abutment interface designs. The postulated hypothesis
was that the different implant-abutment connections would result in different reliability and failure modes
when subjected to step-stress accelerated life testing (SSALT) in water. Materials and Methods: Sixty-three
dental implants (4 × 10 mm) were divided into three groups (n = 21 each) according to connection type: EH,
IH, or MT. Commercially pure titanium abutments were screwed to the implants, and standardized maxillary
central incisor metallic crowns were cemented and subjected to SSALT in water. The probability of failure
versus number of cycles (95% two-sided confidence intervals) was calculated and plotted using a power-law
relationship for damage accumulation. Reliability for a mission of 50,000 cycles at 150 N (90% two-sided
confidence intervals) was calculated. Polarized-light and scanning electron microscopes were used for failure
analyses. Results: The beta values (confidence intervals) derived from use-level probability Weibull calculation
were 3.34 (2.22 to 5.00), 1.72 (1.14 to 2.58), and 1.05 (0.60 to 1.83) for groups EH, IH, and MT, respectively,
indicating that fatigue was an accelerating factor for all groups. Reliability was significantly different between
groups: 99% for MT, 96% for IH, and 31% for EH. Failure modes differed; EH presented abutment screw
fracture, IH showed abutment screw and implant fractures, and MT displayed abutment and abutment screw
bending or fracture. Conclusions: The postulated hypothesis that different implant-abutment connections to
support anterior single-unit replacements would result in different reliability and failure modes when subjected
to SSALT was accepted. INT J ORAL MAXILLOFAC IMPLANTS 2013;28:103–108. doi: 10.11607/jomi.2443

Key words: cementation, dental implants, fractography, implant-supported prostheses, reliability, step-stress
accelerated life testing

S ingle-tooth replacement involving osseointegrated

implants is among the most popular and successful
treatment options, presenting 89.4% estimated survival
rates after 10 years in function.1 However, despite the
high success rates reported for dental implant treat-
ment,2 mechanical complications in the prosthetic
components, such as loosening and/or fracture of the
abutment screws, have been reported and remain un-
1Research Scholar, Department of Biomaterials and der investigation.3–5 Once osseointegration has been
Biomimetics, New York University College of Dentistry, New achieved and maintained, the stability of the implant-
York, New York, USA. abutment connection becomes a key factor for the
2 Assistant Professor, Postgraduate Program in Dentistry,
success of the restoration, especially in single-tooth
UNIGRANRIO University, Duque de Caxias, RJ, Brazil.
3Assistant Professor, Department of Biomaterials and
replacements, where the incidence of mechanical com-
Biomimetics, New York University College of Dentistry, New plications is highest.6 Therefore, failures should be ex-
York, New York, USA. plored to gain insight into the mechanical behavior of
4 Assistant Professor, Department of Prosthodontics, different implant-abutment connection configurations,
Department of Restorative Dentistry, Federal University of since they may compromise function and quality of
Minas Gerais, UFMG, Belo Horizonte, MG, Brazil.
5Director for Research, Department of Periodontology and
life.7,8
Implant Dentistry, New York University College of Dentistry, From a biomechanical point of view, one major con-
New York, NY, USA cern among different implant-abutment connection
designs is the external force exerted on components
Correspondence to: Dr Erika O. Almeida, 345 E. 24th Street, via oral function, which is concentrated mainly on the
Room 804S, New York, NY 10010, USA. Fax: +212-995-4244.
abutment screw, especially in external-hexagon (EH)
Email: [email protected]
connections.9,10 In contrast, internal-hexagon (IH) con-
©2013 by Quintessence Publishing Co Inc. nections have been claimed to be more mechanically

The International Journal of Oral & Maxillofacial Implants 103

Almeida et al

a b c
Fig 1 Implant connection configurations tested. (a) EH, (b) IH, (c) MT.

stable, since the load is distributed deep within the The aim of this study was to evaluate the reliabil-
implant, where engagement with a long internal wall ity and failure modes of implant-supported anterior
shields the abutment screw.10–12 High rates of mechan- crowns restored with different implant connections
ical complications (6% to 48%) have been reported for (IH, EH, and MT). The postulated hypothesis was that
EH implants,13–15 whereas fewer episodes of abutment different implant connections used as anterior single-
loosening (3.6% to 5.3%) seem to occur in Morse taper unit replacements would show different rates of reli-
(MT) connections.16 ability and different failure modes when subjected to
The maintenance and stability of screw-type con- step-stress accelerated life testing (SSALT).
nections are challenged by forces exceeding that of
the torqued abutment/crown system.17 However,
lower physiologic forces, applied repeatedly, although MATERIALS AND METHODS
they do not necessarily surpass the failure threshold of
the assembly, may potentially lead to gradual loosen- Sample Preparation
ing of the implant-abutment connection and/or fail- Sixty-three commercially pure titanium dental im-
ure as a result of fatigue.5,18,19 The ensuing misfit of a plants (4 mm in diameter, 10 mm in length, Emfils, Co-
loose abutment connected to an implant may not only losso Evolution System) were divided into three groups
impose taxing stresses in the crestal bone, potentially (n = 21) according to the implant/abutment connec-
leading to resorption,20,21 but it may also serve as a tion design: EH (HEE Evolution; Fig 1a), IH (ECI Evolution;
bacterial reservoir, contributing to peri-implant tissue Fig 1b), and MT (Fig 1c). All implants were vertically em-
inflammation.22 bedded in acrylic resin (Orthoresin, Degudent) that had
Laboratory fatigue studies have shown improved been poured into a 25-mm-diameter plastic tube. The
mechanical behavior for prostheses supported by top platform was left at the level of the resin surface.
implants with an internal connection versus implants A maxillary central incisor crown was waxed into an
with external connections.5,23 A specific evaluation anatomical shape and cast in cobalt-chromium alloy
comparing EH and IH connections to MT connections (BEGO). To reproduce the anatomy of the crowns, an
was performed in a finite element investigation; the impression was taken from the first waxed pattern and
results showed the lowest stress concentration in the used by the technician as a guide during waxing of the
abutment screw of the MT connection.10 Whereas that remaining crowns. The respective prefabricated abut-
study provided insight about the stress concentrations ments (commercially pure titanium; Emfils, Colosso
of different implant/abutment configurations, the Evolution System) were tightened with a torque gauge
clinical significance of the presence of stresses per se according to the manufacturer’s instructions (30 Ncm)
requires further validation by mechanical testing, such using titanium alloy abutment screws (titanium-alu-
as fatigue. Because comparisons have frequently been minum-vanadium). Following connection of the corre-
made between different implant systems comprising sponding abutments to the implants, the cementation
different implant geometry, an evaluation of the me- surface of the crowns was blasted with aluminum oxide
chanical behavior and failure patterns of EH, IH, and (particle size ≤ 40 µm; 276 KPa of compressed air pres-
MT connections within the same implant system is sure), cleaned with ethanol, dried with air free of water
warranted. and oil, and then cemented (RelyX Unicem, 3M ESPE).

104 Volume 28, Number 1, 2013

 Almeida et al

Table 1 Calculated Reliability for a Protocol of 50,000 Cycles at a Load of 150 N

Output EH IH MT
Upper 0.4650 0.9912 1.0000
Reliability 0.3187* 0.9687** 0.9994***
Lower 0.1812 0.8917 0.9922
Beta 3.34 (2.22–5.00) 1.72 (1.14–2.58) 1.05 (0.60–1.83)
Different numbers of asterisks denote statistically significant differences.

Mechanical Testing and Reliability Analysis identify fractographic markings and characterize the
For mechanical testing, the specimens were subjected origin of failure and direction of propagation, the
to 30-degree off-axis loading. Three specimens of each most representative failed samples of each group were
group underwent single-load-to-failure (SLF) testing at a inspected first under a polarized light microscope
crosshead speed of 1 mm/min in a universal testing ma- (MZ-APO stereomicroscope, Carl Zeiss MicroImaging)
chine (INSTRON 5666); a flat tungsten carbide indenter and then by scanning electron microscopy (SEM)
was used to apply the load at the incisal edge of the (Model S-3500N, Hitachi).26
crown. Based upon the mean values from SLF testing,
three SSALT profiles were determined for the remain-
ing 18 specimens of each group, which were assigned RESULTS
to mild (n = 9), moderate (n = 6), or aggressive (n = 3)
fatigue profiles (ratio 3:2:1, respectively).24–26 These pro- SLF and Reliability
files were named based on the stepwise load increase by The SLF values (means ± standard deviations) were
which they were fatigued along the cycles. Hence, in the 468 ± 97 N for IH, 486 ± 51 N for EH, and 759 ± 52 N
mild profile, a specimen was cycled longer to reach the for MT.
same load level as that allocated in the moderate pro- The beta value means (confidence intervals) and
file and even longer in the aggressive profile. The data associated upper and lower bounds derived from use-
collected during testing at different stress profile levels level probability Weibull calculation (probability of fail-
were used to estimate the parameter that best fit the ure vs number of cycles) were 3.34 (2.22 to 5.00), 1.72
data by means of commonly used life distributions, such (1.14 to 2.58), and 1.05 (0.60 to 1.83) for groups EH, IH,
as log normal, exponential, or Weibull. and MT, respectively. These indicate that fatigue was
The prescribed fatigue method was SSALT under an accelerating factor in all groups (Table 1).
water at 9 Hz with a servo–all-electric system (Test- The step-stress–derived probability Weibull plots
Resources 800L); the indenter contacted the incisal and summary statistics at a 150-N load are presented
edge, applied the prescribed load within the step in Fig 2 and Table 1, respectively. The SSALT permitted
profile, and lifted off the incisal edge. Fatigue testing estimates of reliability at a given load level (Table 1).
was performed until failure (bending or fracture of the The calculated reliability with 90% confidence intervals
fixation screw and/or bending, partial fracture, or total for a mission of 50,000 cycles at 150 N showed that the
fracture of the abutment) or survival (no failure at the cumulative damage from loads reaching 150 N would
end of step-stress profiles, where maximum loads were lead to implant-supported restoration survival of only
up to 600 N).27–29 31% of EH assemblies, whereas 96% of the IH group
Use-level probability Weibull curves (probability of specimens and 99% of the MT specimens would sur-
failure versus number of cycles) with a power law re- vive. The lack of overlap between the upper and lower
lationship for damage accumulation were calculated limits of reliability values emphasizes the statistically
(Alta Pro 7, Reliasoft).30 Reliability (the probability of an significant differences between groups; the MT group
item functioning for a given amount of time without presented the highest reliability, the EH the lowest, and
failure) for completion of a mission of 50,000 cycles at a IH was positioned intermediate to the other groups.
load of 150 N (90% two-sided confidence bounds) was
calculated for group comparisons. Failure Modes
All specimens failed after SSALT. When component
Failure Analysis failures were evaluated together, failures comprised a
The failed samples were visually inspected and classi- combination of abutment screw bending or fracture,
fied according to the proposed failure criteria (bend- abutment bending or fracture, and implant fracture.
ing, fracture) for comparisons between groups. To Observed failure modes are described in Table 2.

The International Journal of Oral & Maxillofacial Implants 105

Almeida et al

Fig 2 Use-level probability Weibull

for tested groups showing the prob-
ability of failure as a function of num-
99 EH* ber of cycles (time) given a mission of
Data points 50,000 cycles at 150 N. Use level CB
90 Use level line at 90% two-sided. *Cumulative dam-
Top CB-I age Weibull = 175; F = 18, S = 0.
Bottom CB-I

50 IH*
Data points
Probability of failure

Use level line

Top CB-I
Bottom CB-I
MT*
10 Data points
Use level line
Top CB-I
5 Bottom CB-I

1
100 10,000 1.000E+6 1.000E+8 1.000E+10
1,000 100,000 1.000E+7 1.000E+9
No. of cycles

Table 2 Modes of Failure of Screws, Abutments, and Implants in Each Group

Test type EH IH MT
SLF Abutment screw: 1 bent, 2 fractured Abutment screw: 1 bent, 2 fractured Abutment screw: 3 bent
(n = 3) Abutment: 3 intact Abutment: 3 intact Abutment: 3 bent
Implant: 3 intact Implant: 3 intact Implant: 3 intact
SSALT Abutment screw: 18 fractured Abutment screw: 18 fractured Abutment screw: 9 fractured, 9 bent
(n = 18) Abutment: 18 intact Abutment: 18 intact Abutment: 9 fractured, 9 bent
Implant: 18 intact Implant: 15 fractured, 3 intact Implant: 18 intact

a b c
Fig 3 SEM images of the fractured surfaces of the abutments and abutment screws together (a) EH, (b) IH, (c) MT. The white
arrows indicate compression curls, which indicate the direction of crack propagation (black arrow) and evidence of fracture origin at
the opposing tensile side (yellow arrows).

For the EH group, most failures involved abutment fracture were the main failure modes. All abutments and
screw fractures, whereas the abutments and implants re- their screws fractured or bent, whereas the implants re-
mained intact after mechanical testing. For the IH group, mained intact in this group (Fig 3, Table 2).
abutment screw and implant fractures were the chief Observation of the polarized-light and SEM images
failure modes. This group was the only one that showed of the fractured surfaces of the abutment screws al-
longitudinal fractures in the implant neck area. Similarly lowed the consistent identification of fractographic
to the EH group, the abutments were also intact. In the markings (eg, compression curl), fracture origins, and
MT group, abutment and abutment screw bending or the direction of crack propagation (Fig 3).

106 Volume 28, Number 1, 2013

 Almeida et al

DISCUSSION positive or geometric locking, and are assumed to be

responsible for protecting the abutment threads from
Because of the relevance of the mechanical character- excessive functional load.18
ization and failure patterns of different implant-abut- The analysis of the failed implant components al-
ment configurations in clinical practice, the present lowed the identification of fractographic markings
study used SSALT in single-unit anterior crowns ce- and the tracing of the fracture origin and the direction
mented to implants with EH, IH, and MT connections of crack propagation. The ductile fractures, which oc-
to gain insight into the reliability of each interface. The curred as a result of stresses surpassing the material’s
use of accelerated life testing in dental research has yield or flow stress,42 showed a consistent crack path-
been reported for several prosthetic restorative sys- way from lingual to buccal, where forces naturally oc-
tems, where close similarity with the failures observed cur and as was simulated in the present study.
clinically could be simulated with this methodology The restoration of single-unit anterior spaces with
in the laboratory.31–34 Its use in testing a variety of implant-supported crowns is a challenging scenario in
implant-abutment systems and scenarios has also been terms of longevity and esthetics. With regard to me-
reported.35–38 The rationale is to reduce testing time by chanical testing, the MT implant-abutment connection
causing the samples to fail more quickly, yet with rel- presented the highest reliability in maxillary central
evant failure mechanisms compared to SLF tests. The incisor replacements, followed by IH and EH connec-
MT group presented the highest reliability, followed tions. Although EH implants have been used success-
by IH and EH. These findings are in agreement with fully for splinted full-arch rehabilitations, it seems that
previous fatigue studies, which observed improved fa- they should be avoided in the anterior maxilla because
tigue behavior for IH relative to EH connections.5,23 The of potential long-term complications.
stress magnitude was the highest in abutment screws
of EH, followed by IH and MT connections10; therefore
the present findings of fracture in all EH and IH abut- CONCLUSIONS
ment screws but only half of the MT abutment screws
are in agreement with Pessoa et al10 and suggest the The postulated hypothesis that implants with different
relevance of the potential outcome (fracture) of such abutment connections used as anterior single-unit re-
stresses when translated to laboratory fatigue testing. placements would show different reliability and failure
The reported cumulative incidence of screw or modes when subjected to step-stress accelerated life
abutment loosening in single-unit implant-supported testing was accepted. The Morse taper implant con-
crowns with internal (whether IH or MT) connections nection showed the highest reliability, followed by the
is 12.7% after 5 years of clinical service.39 Specific to internal hexagon and the external hexagon.
the MT connection, a recent prospective evaluation
of more than 2,500 implant-supported prostheses in
function for up to 6 years reported a very different inci- ACKNOWLEDGMENTS
dence of abutment loosening of 0.37% for single-unit
crowns.40 It has been suggested that, in the MT connec- The authors are thankful to Emfils, Colosso Evolution System
(SP, Brazil), and Marotta Dental Studio (Farmingdale, New York)
tion, lateral loading is resisted mainly by the tapered
for their support. The authors reported no conflicts of interest
design, which hinders abutment micromovement. In related to this study.
addition, a high pressure is normally maintained in the
matching area because of the tapered design, allow-
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