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Implant Abutment Types: A Literature Review – Part 1

Article · January 2010

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 Sadaqah et al
Implant Abutment Types:
A Literature Review – Part 1

Nsarin Sadaqah, BDS, MDSc1 • Ahed Al-Wahadni, BDS, MDSc, PhD2

Elham Abu Alhija, BDS, MDSc, PhD3

Abstract

Background: With the high rate of implant tion and angulated versus straight abutments.
success for edentulous, partially edentu-
lous, and single-tooth restorations the con- Methods: A Medline search was com-
cept of osseointegration and implant therapy pleted for the period from 1986 to 2009,
is now a highly predictable treatment modal- along with a manual search, to identify Eng-
ity. Several implant abutment designs are con- lish articles related to selected topic.
stantly evolving to meet esthetic and functional
requirements. This overview aims to discuss dif- Conclusion: The availability of the variety of abut-
ferent categories of implant abutments accord- ments described makes restoration using implants
ing to their designs, mechanics of implant relatively easy and predictable. Implant dentistry
abutment connection, method of abutments nowadays is almost a daily practice in every dental
fabrication, and the materials from which abut- clinic, because of that it is mandatory for the cli-
ments are made. Part one of this article series nician to get enough knowledge especially about
discusses screw versus cement retained abut- different implant components so as to achieve high
ments, mechanics of implant abutment connec- success rate of teeth replacement by implants.

KEY WORDS: Dental implants, abutments, cement retained, screw retained

1. Assistant Professor of Fixed and Removable Prosthodontics, Department of Restorative Dentistry, Faculty of Dentistry,
Arab American University, Jenin, Palestine
2. Professor of Fixed & Aesthetic Dentistry, Vice president of Jordan University of Science and Technology, Irbid, Jordan
3. Professor of orthodontics Dentistry, Jordan university of Science and Technology, Irbid/Jordan

The Journal of Implant & Advanced Clinical Dentistry • 93

Sadaqah et al

Background retained to the fixture or implant body.4-7 Within

It was not until the beginning of 1980’s when the first group the implant abutments are classi-
an implant prototype version with a removable fied as: an abutment that needs screw to retain
abutment was used clinically. Experiments the prosthesis, an abutment which needs dental
with two part implants had been carried out cement to retain suprastructures, and an abut-
in 1970’s. The use of the removable abutment ment which needs an attachment device such as
version allowed better handling of temporary magnet O-ring to retain a removable prosthesis.4-6
restoration and wider prosthetic choices espe- Within the second group the implant abutments
cially in conditions of single tooth replace- are classified as screw in, friction fit or cement.7
ments particularly in the anterior region of the Each of these types of abutments may be fur-
maxilla or in cases of misaligned implants ther subclassified as straight or angled abutments.
or difficult interocclusal space conditions.1 This describes the axial relationship between the
The implant supported prosthodontics intro- implant body and the abutment. In addition, these
duced by Branemark group was directed toward abutments can be further classified into either
the treatment of fully edentulous patients, so the stock or custom abutments. The stock abutments
abutments developed by Branemark team had are formed by preparation to create their final
a limited esthetic capability. As the osseointe- form while the custom abutments are prepared
grated implants were developed to treat partially by additive methods of waxing and casting.8
edentulous patient, there was a strong need to
introduce several modifications for the transmu- Cement vs. Screw Retained Implant
cosal abutments.2,3 Wide ranges of abutment Prosthesis
designs and materials are available to achieve Implant retained prosthesis can be screw
optimal results in various patient case types. retained, cement retained, or a combination of
both (cemented prosthesis with lingual or palatal
Materials and methods fastening screws).9 In 1989-1990, Swiss Bon-
A search of dental literature was conducted using efit implant system (later called ITI system) was
several electronic databases; specific terms were introduced to the USA market and depended
used for the database search which spanned exclusively on a cementable abutment for crown
the years 1968-2009. This search was supple- retention. After that many implants manufactur-
mented by manual searching of references and ers introduced cementable alternatives to screw
related journals. Related articles were reviewed retention.9 Since then cement retained pros-
including clinical and in-vitro experiences in addi- theses have become the restoration of choice
tion to review articles and clinical case reports. for the treatment of implant patients.10 This
rapid rise of popularity of cement retained pros-
Classification of Implant Abutments thesis has been attributed to several factors:
The classification of implant abutments depends
on two main categories: 1)method of retention of 1) Ease of fabrication and cost: The fabrication
prosthesis; 2)method by which the abutment is of cement retained prosthesis is easier than the

94 • Vol. 2, No. 3 • April 2010

 Sadaqah et al

screw retained prosthesis. This is because tra- of fastening screw.22 When the ill fitting parts
ditional techniques in fabrication of the cement are brought together by external preload screw,
retained prosthesis is followed. Also, they have tension will lead to screw loosening or fracture.23
less cost than screw retained prosthesis since
they utilize fewer prosthetic components.9, 11 Advantages / Disadvantages of Cement
and Screw Retained Implant Prosthesis
2) Passivity of the framework: Taylor et al12 stated The marginal opening in screw retained resto-
that cement retained implant suprastructures have rations is 8.8± 5.7μm while for those cement
the ability for being completely passive because retained prosthesis it equals 57.4 ± 20.2μm if
of the 25-30μm space provided for cement. The glass ionomer cement is used and 67.4± 15.9μm
poorly fitting screw retained suprastructures can for those cemented with zinc phosphate.11 The
be one of the main causes for screw loosening or marginal opening is associated with colonization
fractures.13-15 The second serious complication of microflora within this space that will produce
attributed to framework misfit is implant fracture.16 inflammation. In case of cement retained restora-
tions, there is a concern for cement dissolution.12
3) Retention: Retention in the cement retained Screw or cement retained restorations will
prosthesis is basically the same as those for affect the occlusion. The head of screws are
natural teeth. It depends on convergence about 3mm in diameter, so they require a screw
of axial walls, surface area, height, rough- access hole of 3mm diameter which will represent
ness of the surface and type of cement.17 at least 50% of occlusal table of molars and more
The retention of screw retained prosthesis is than 50% of that of premolars.24 This area which
obtained by the fastening screw. However, to is occupied by screw hole can be very critical to
avoid problems of fracture or loosening of screw reproduce ideal occlusion. To establish proper
it is important that screws be torqued to manu- occlusal contacts, this will be done on compos-
facturer’s specifications.18,19 Usually screws are ite which is used to cover the access holes.25
either gold or titanium. The friction resistance On the other hand, in cement retained restora-
developed between the internal threads of the tions, occlusal contacts can be established and
implant and the fastening screw will provide the remain stable over long period in porcelain.9,11
retention. If titanium screw is used, there will be The screw access hole is highly unaesthetic
a slight damage for both implants and fastening but this problem is a concern only in the man-
screw threads which will result in their joining dibular premolars and molars. The gray color
by a phenomenon called galling.20 However, of the screw can be decreased by adding
gold screws have smaller coefficient of friction opaque composite materials. Obviously this
allowing them to be tightened more effectively is not a problem in cemented restorations.9,11
than titanium without galling effect.9 Small misfit To verify the precise fit in case of screw
can produce deformation that alters the preload retained restorations, only a radiographic
torque relationship.21 Passive fit of the prosthesis examination is required while in cemented res-
and components is a request for optimal preload toration and radiographic examination care-

The Journal of Implant & Advanced Clinical Dentistry • 95

Sadaqah et al

ful removal of the cement remnants is required prostheses.30-33 The butt joint or the external
which is not an easy procedure especially if hex connection is prone to biomechanical com-
the margins of the restoration are subgingival 9. plications such as screw loosening, compo-
One more important factor that must not nent fracture and difficulty in seating abutments
be overlooked is the need for future removal in deep subgingival tissues.20, 34 To overcome
of the restoration26 which is necessitated by: the shortcomings of external hexagon Sutter
1. the need for periodic replacement of and coworkers35 proposed an 8 degree inter-
prosthodontic components nal taper connection known as Morse taper
2. loosening or fracture of the fastening screw between the implant and abutment. They
3. fracture of the abutment showed that this connection enhanced the
4. modification of prosthesis after implant loss ability of the system to resist bending forces.
5. surgical intervention The external hex and taper connection has
The main disadvantage of cement retained different mechanical principles of function. In
prosthesis is the difficulty of their retrievabil- the external hex, the screw alone holds the abut-
ity because of the provisional cements used ment to the implant and counteracts the effect of
for the cementation of these restorations since horizontal force. There is no form lock or posi-
they are weaker than definitive cements.9 tive locking by the external hex. On the other
hand in a taper connection; lock and friction
Mechanics of the Implant-Abutment are the basic principles. The taper interface
Connection prevents abutment tilting by restricting lateral
Implant abutment connection stability is an loading. The geometric locking will protect the
essential prerequisite for long term success abutment threads from excessive functional load
of dental implants.1 The abutment is mechani- and provide effective screw joint stability.29,36-38
cally attached to the implant surface and ide- Most root form implants nowadays have inter-
ally it should be fixed to the implant throughout nal abutment connection to implant because of its
life of implant, otherwise screw complications advantages over conventional external connec-
such as screw loosening and fracture may tion, although the original connection is available.39
occur. In addition to that, bacterial leakage
through implant abutment interface will occur Angled vs. Non-Angled Abutments
and affect long term stability of the implant.27 Bruggenkate et al40 presented certain fac-
There are two main types of abutment con- tors that may limit the possibilities of place-
nection to implant; the butt joint with an exter- ment of dental implant with proper angulation:
nal connection and internal connection or taper 1. Anatomic structures. The height and width
design lock.28,29 The initial purpose of external of the residual alveolar ridge, the mandibu-
hexagon was to transmit torque during surgical lar nerve and the nasal and maxillary sinus.
placement. Afterwards the external hexagon 2. Shape and angle of alveolar process. The
was shown to work as an anti-rotational mecha- shape of the jaws and the maxillomandibular
nism and to orient the abutment in single tooth relation may create problems either for place-

96 • Vol. 2, No. 3 • April 2010

 Sadaqah et al

ment of implants or for design and fabrica- ference between straight and angled abutments
tion of the suprastructure. Most problems are for deflection, rotation and torque required to
found in maxilla. The shape of the jaw deter- loosen abutment screws. Eger et al43 compared
mines the position of the implants that may the effect of angled and standard abutments on
produce angulation or non parallel implants. clinical outcomes and they stated that clinical
The solutions for these problems are surgi- examination revealed no significant differences.
cal correction or bone augmentation of alveolar
ridge, sinus elevation or nerve repositioning.41,42
The other alternative is the placement of Conclusion
implants in the area of greatest available bone Implant dentistry has seen rapid and remark-
and then to correct the implant alignment with able progress in recent years. Several ques-
the use of angled abutments since the morphol- tions have been raised concerning the materials
ogy and position of teeth are determined by used as well as the designs to achieve maximum
esthetic and functional considerations.43 The clinical success rate. One of the questions con-
use of angled abutment was suggested as the cerns the materials and design of implant abut-
treatment of choice in cases of anatomical limi- ments. The primary factor in determining the
tations that prevent axial implant placement.44 type of abutment selected is the clinical situa-
Currently, a wide range of pre-angled abut- tion and patient requests regarding esthetics. ●
ments are available at specified divergence
angles (15 degrees, 25 degrees, 35 degrees).
Correspondence:
In addition, in certain cases custom angled abut-
Dr. Sadaqa
ments may be casted to achieve acceptable
esthetic outcome.43 The main concern in using e-mail: [email protected],
angled abutments is the adverse effect of non axial [email protected].
forces on the survival of implants. Sethi et al45 Business telephone: 0097 0 42510801,
concluded in their five years clinical study of the ext: 517
angled abutments that there was no difference in Business fax: 0097 0 42510810
the survival rate of implants based on the use of
angulated abutments ranging from 0-45 degree.
Significant increase in stress and strain with
the increase in abutment angulations was found
by Clelland et al.46 However, they stated that
this stress and strain is within physiological limit
of bone. In a 3-D finite element analysis study
by Kao et al47 found that abutment angulation up
to 25 degrees can increase the stress in peri-
implant bone by 18% and the micromotion level
by 30%. Dixon et al48 found no significant dif-

The Journal of Implant & Advanced Clinical Dentistry • 97

Sadaqah et al

Disclosure 16. Lekholm U, van Steenberghe D, Herrmann 33. D

 avi L R, Golin A L, Bernardes S R, Araújo
The authors report no conflicts of interest with I. Osseointegrated implants in the treatment C A, Neves F D. In vitro integrity of implant
anything mentioned in this article. of partially edentulous jaws: A prospective external hexagon after application of surgical
5-year multicenter study. Int J Oral placement torque simulating implant locking.
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