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Stefano Gracis Internal vs.

external connections
Konstantinos Michalakis
Paolo Vigolo
for abutments/reconstructions:
Per Vult von Steyern a systematic review
Marcel Zwahlen
Irena Sailer

Authors’ affiliations: Key words: external connection, implant connection, internal connection, systematic review
Stefano Gracis, Konstantinos Michalakis, Division
of Postgraduate Prosthodontics, Tufts University,
School of Dental Medicine, Boston, MA, USA Abstract
Paolo Vigolo, Department of Clinical Objectives: The objectives of the review were (1) to evaluate the accuracy of implant-level
Odontostomatology, University of Padova, Institute
impressions in cases with internal and external connection abutments/reconstructions, and (2) to
of Clinical Dentistry, Padova, Italy
Per Vult von Steyern, Department of Prosthetic evaluate the incidence of technical complications of internal and external connection metal- or
Dentistry, Faculty of Odontology, Malmö, Sweden zirconia-based abutments and single-implant reconstructions.
Marcel Zwahlen, Institute of Social and Preventive
Materials and methods: A MEDLINE electronic search was conducted to identify English language
Medicine, University of Berne, Bern, Switzerland
Irena Sailer, Clinic of Fixed and Removable publications in dental journals related to each of the two topics by inserting the appropriate
Prosthodontics and Dental Material Sciences, keywords. These electronic searches were complemented by a hand search of the January 2009 to
Center for Dental Medicine, University of Zurich,
Zurich, Switzerland January 2012 issues of the following journals: Clinical Oral Implants Research, The Journal of
Prosthetic Dentistry, The International Journal of Prosthodontics, The International Journal of
Corresponding author: Periodontics and Restorative Dentistry, The International Journal of Oral Maxillofacial Implants,
Stefano Gracis
Via Brera, 28/a 20121 Milan, Italy Clinical Implant Dentistry and Related Research.
Tel.: +39 02 72094471 Results: Seven in vitro studies were included in the review to evaluate the accuracy of implant-
Fax: +39 02 86997426 level accuracy. No clinical study was found. There was no study that directly compared the
e-mail: sgracis@dentalbrera.com
influence of internal and external implant connections for abutments/reconstructions on the
accuracy of implant-level impressions. All in vitro studies reported separately on the two
Conflict of interest
connection designs and they did not use same protocol and, therefore, the data could not be
IS has acted as an advisor for VITA, and the
University Department has research collaborations compared.
with 3M ESPE, Straumann, Astra, Ivoclar, Fourteen clinical studies on metal-based abutments/reconstructions and five clinical studies on
DeguDent and Sirona. The remaining authors have
zirconia-based abutments/reconstructions satisfied the inclusion criteria and, therefore, were
no potential conflicts to declare.
included in the review to evaluate the incidence of technical complications. The most frequent
mechanical complication found in both implant connection design when employing metal
abutments/reconstructions was screw loosening.
Conclusions: Implant-level impression accuracy may be influenced by a number of variables
(implant connection type, connection design, disparallelism between multiple implants, impression
material and technique employed). Implant divergence appears to affect negatively impression
accuracy when using internal connection implants.
Based on the sparse literature evaluating the incidence of technical complications of metal or
zirconia abutments/reconstructions, it was concluded that:
• The incidence of fracture of metal-based and zirconia-based abutments and that of abutment
screws does not seem to be influenced by the type of connection.
• Loosening of abutment screws was the most frequently occurring technical complication. The
type of connection seems to have an influence on the incidence of the screw loosening: more
loose screws were reported for externally connected implant systems for both types of
materials. However, proper preload may decrease the incidence of such a complication.

Date: Since the introduction of the Brånemark sys- Albrektsson et al. 1986; Babbush 1986). One
Accepted 3 June 2012
tem to the scientific community in the of the features that has been the object of
To cite this article: 1960s and 1970s, a large number of implant debate among the systems is the design of
Gracis S, Michalakis K, Vigolo P, Vult von Steyern P,
Zwahlen M, Sailer I. Internal vs. external connections for systems have been developed and have the connection that allows the prosthetic su-
abutments/reconstructions: a systematic review.
become available to the dental profession prastructure to be attached to the implants.
Clin. Oral Implants Res. 23(Suppl. 6), 2012, 202–216
doi: 10.1111/j.1600-0501.2012.02556.x (Kirsch 1983; Brånemark et al. 1985; From the beginning, the Brånemark system

202 © 2012 John Wiley & Sons A/S


Gracis et al.  Internal vs. external connections for abutments/reconstructions

was characterized by an external hexagon chanical features and understand their impli- topic. These papers point out and analyze the
which was developed to facilitate implant cations to make a rational choice between an major factors that may cause mechanical
insertion rather than to provide clinicians external and an internal connection system. complications:
with an antirotational device (Brånemark The two aspects which were investigated by
• screw material (Tsuge & Hagiwara 2009),
et al. 1985). This external hexagon configura-
tion has served well over the years and it has
this review are implant-level impression tak-
ing and fixture-abutment/reconstruction joint
• screw preload (Martin et al. 2001; Siamos
et al. 2002; Otorp et al. 2005; Park et al.
been incorporated in a number of competing stability.
2010),
systems. However, it has some drawbacks
due to its limited height and, as a conse-
When making an impression of dental
implants, the goal is to produce a master cast
• abutment material (Apicella et al. 2011;
Kim et al. 2011),
quence, limited effectiveness when subjected
to off axis loads (Weinberg 1993). Hence, it
that is the replica of the clinical situation.
To this end, the technique and materials
• abutment rotational misfit (Binon 1995,
1996; Binon & McHugh 1996; Vigolo et
has been speculated that, under high occlusal employed must allow the clinician to capture
al. 2008),
loads, the external hexagon might allow for
micromovements of the abutment, thus caus-
the three dimensional spatial relationship of
the fixtures (or abutments). This is important
• implant-abutment connection configura-
tion (Perriard et al. 2002; Maeda et al.
ing instability of the joint which may result especially when splinting multiple implants
2006; Vigolo et al. 2008),
in abutment screw loosening or even fatigue with a fixed dental prosthesis (FDP). Conse-
• implant angulation (Ha C-Y et al., 2011),
fracture (Adell et al. 1990; Jemt et al. 1991;
Becker & Becker 1995).
quently, a primary goal to fulfill when fabri-
cating such a restoration is to ensure that the
• thickness of implant neck walls (Meng
et al. 2007; Lee et al. 2011),
Internal connections have been introduced
to lower or eliminate these mechanical com-
reconstruction is passively adapted to all fix-
tures or abutments.
• single vs. splinted crowns (Clelland et al.
2010; Nissan et al. 2010).
plications and reduce stress transferred to the Factors that might generate impression dis-
crestal bone (Sutter et al. 1993; Norton 1997; tortion are premature removal of the impres- In particular, after the change of the abut-
Merz et al. 2000; Finger et al. 2003). A pri- sion from the oral cavity, deformation due to ment screw material in the 1990s, and the
mary question is whether or not this may be rigidity of the impression material, number recommendation of system-specific torque
true for all internal connection systems (Bal- and degree of undercuts present in the arch, values for these screws, the type of implant-
four & O’Brien 1995; Norton 1999; Steineb- lack of parallelism between the implants, abutment connection configuration has been
runner et al. 2008) since, unlike the external depth and intimacy of the coupling between pointed out as the most relevant variable that
hexagon connection, the internal connection impression coping and fixture, direction of can ensure implant-abutment joint stability.
configurations adopted by different compa- impression tray removal with respect to It has already been postulated that internal
nies are not alike. When analyzing the implant axis, undue torque applied to the implant-abutment connections demonstrate
implant-abutment coupling of internal con- impression coping screw when connecting higher resistance to bending and improved
necting systems, many differences have been the implant or abutment analogue to the cop- force distribution over external configura-
described (Wiskott et al. 2007; Steinebrunner ing itself embedded in the set impression. tions (Asvanund & Morgano 2011; Freitas
et al. 2008; Bernardes et al. 2009; Coppedè A recent literature review (Lee et al. 2008) et al. 2011) because of their:
et al. 2009; Tsuge & Hagiwara 2009): has looked at the influence that reported
• ability to dissipate lateral loads deeply
• intimacy of approximation between the
impression techniques (splint, pick up and
transfer) and other clinical factors have on the
within the implant and to resist joint
abutment’s surface and the internal walls opening due to the deep and rigid connec-
accuracy of implant impressions. Forty-one in
of the implant fixture (no friction vs. tion which creates a unified body, thus
vitro studies were selected and their data com-
Morse taper), displaying a more favorable load distribu-
• depth of penetration of the abutment in
pared. However, the majority of the studies in
this review evaluated abutment-level impres-
tion in the connection area (Steinebrunner
the fixture, et al. 2008; Bernardes et al. 2009; Sailer
• presence of antirotational interlocking,
sions. Usually, there is no antirotational
et al. 2009a; Seetoh et al. 2011); and
• number and shape of antirotational or guid-
configuration in these abutments. Therefore,
there was a need for a new literature review to
• improved shielding of the abutment
ing grooves (hexagon, trilobe, spline, etc.), screw from stress (Norton 1997).
• abutment diameter at the platform level
investigate whether or not the different types
of external and internal implant connection The use of high-strength ceramics, previ-
(matched vs. narrower, to generate a plat-
configurations influence the accuracy of fix- ously alumina and nowadays zirconia, has
form shift or switch),
• abutment screw dimension and material,
ture-level impressions of multiple implants provided an alternative to metal abutments

• screw preload,
and, thus, of the resulting definitive cast. (Happe et al. 2011). When using polycrystal-

• abutment materials allowed (titanium,


When fabricating an implant-supported
FDP, one of the concerns of the clinician to
line ceramic implant abutments in the clini-
cal situation, there are concerns about the
precious metal alloys, full zirconia, zirco-
ensure its longevity is to minimize mechani- risk of fracture due to the material’s brittle
nia with metal inserts).
cal complications. Many publications in the nature. This is especially true in internal
These differences might have profound international literature deal with the inci- connection systems, where the interlocking
impact on the clinical procedures and proto- dence of screw loosening or fracture, as well portion may be particularly thin. As a matter
cols, chair-time dedicated to the patient, as with the incidence of abutment and of fact, several manufacturing companies do
number of appointments, laboratory and implant fracture. Four literature reviews not provide zirconia abutments for their nar-
component costs, maintenance intervals, and (Pjetursson et al. 2004; Jung et al. 2008; row platform implants. In vitro studies have
incidence of complications. Therefore, the Theoharidou et al. 2008; Sailer et al. 2009b) provided some insight into the behavior of
clinician has to analyze the different biome- have provided an in depth analysis of the ceramic abutments in different types of

© 2012 John Wiley & Sons A/S 203 | Clin. Oral Implants Res. 23(Suppl. 6), 2012/202–216
Gracis et al.  Internal vs. external connections for abutments/reconstructions

implant systems (Vigolo et al. 2006; Sailer that, in this short- to medium-period of eval- provide any additional references: Clinical
et al. 2009a; Nothdurft et al. 2010a; Klotz uation, no relevant mechanical complications Oral Implants Research, The Journal of Pros-
et al. 2011; Seetoh et al. 2011; Truninger occurred. Still, they cautioned that the num- thetic Dentistry, The International Journal of
et al. 2011), but it is difficult to draw from ber of abutments followed was too small for Prosthodontics, The International Journal of
them clinically relevant recommendations. them to recommend a wide use of this pros- Periodontics and Restorative Dentistry, The
One of the difficulties in ascribing clinical thetic solution, also taking into consideration International Journal of Oral Maxillofacial
value to the results of in vitro studies has to the fact that much still needs to be clarified Implants, Clinical Implant Dentistry and
do with the lack of evidence for the diverse about zirconia’s aging process. Related Research.
methods of loading implant abutments. They Thus, the aims of the present systematic The second focused PICO question was
differ for: type of loading (static loading or review were to update the literature and to whether or not an internal connection of the
dynamic fatigue loading, lateral-oblique load- investigate the following: implant-supported prostheses can influence
ing [Tsuge & Hagiwara 2009] or rotational the technical complication rates when com-
1. if there is any significant difference in
fatigue loading [Wiskott et al. 2007]); loading pared to an external connection for patients
accuracy between implant-level impres-
angle (from 0 to 90°); loading point (incisal with single implants to be restored with
sions made on internal or external con-
edge or a non specified point on the palatal metal-based and/or zirconia-based FDPs. A
nection implant systems;
surface); applied load (light forces or forces MEDLINE electronic search was initially
2. if there is any clinical evidence that abut-
which exceed the maximum bite force conducted to identify English language publi-
ments/prostheses for internal connection
recorded in humans). It is debatable which is cations in dental journals by inserting the fol-
implant systems have less incidence of
the most clinically relevant method. There- lowing keywords: “implant internal
technical complications compared to
fore, it is the analysis of the clinical perfor- connection” OR “implant external connec-
abutments/prostheses for external con-
mance that can best demonstrate the tion” OR “implant abutment connection”
nection implant systems in patients with
reliability of this prosthetic device. Two very OR “implant abutment interface” OR
implants to be restored with single
thorough systematic reviews on the perfor- “implant abutment” OR “screw loosening”
metal-based and/or zirconia-based restora-
mance of ceramic and metal implant abut- OR “screw fracture” OR “screw retention”
tions.
ments (Sailer et al. 2009b) and on zirconia OR “screw complication” OR “mechanical
abutments only (Nakamura et al. 2010) have complication” OR “technical complication”
been published recently. The former review OR “failure” OR “load fatigue” AND
includes 29 clinical and 22 laboratory studies Materials and methods “implant”. The following limits were acti-
selected from an initial pool of 7136 papers. vated: humans, clinical trial, meta-analysis,
The clinical studies were composed by The first focused PICO question of the pres- randomized controlled trial, review, clinical
RCT’s, prospective and retrospective cohort ent systematic review was whether or not trial, phase I, clinical trial, phase II, clinical
studies with more than 3 years of follow-up the different types of external and internal trial, phase III, clinical trial, phase IV, com-
time (Sailer et al. 2009b). Of this group, only implant connections for abutments/recon- parative study, controlled clinical trial, mul-
five analyzed the clinical behavior of ceramic structions influence the accuracy of implant- ticenter study. As for PICO question 1, also
abutments, two made of densely sintered alu- level impressions of multiple implants and, this electronic search was complemented by
mina (Andersson et al. 2001, 2003) which is therefore, of the resulting master cast. A analyzing the reference list of previous litera-
no longer available on the market, two of zir- MEDLINE electronic search was conducted ture reviews and by hand search of the Janu-
conia (Glauser et al. 2004; Zembic et al. to identify English language publications in ary 2009 to January 2012 issues of the same
2009), and one of zirconia with a titanium dental journals from 1990 to January 2012 journals.
insert (Canullo 2007), for a total number of related to fixture-level impressions by insert- The general electronic search produced
166 abutments. In comparing the outcome of ing the following keywords: “internal con- 1336 titles. After the initial screening of
the studies on ceramic abutments to the one nection” OR “external connection” OR these titles, the search was narrowed by fur-
of the studies on metal abutments (which “implant abutment connection” OR ther defining terms and limits that would
analyzed 4807 abutments), the authors con- “implant abutment interface” OR “implant help identify pertinent clinical studies inves-
cluded that no difference in the clinical per- divergence” OR “implant-level impression” tigating the performance of, on one side,
formance of the two types of abutments OR “impression*” AND “implant”. To be metal abutments/reconstructions and, on the
could be noticed. included in this review, the study had to ana- other, zirconia abutments/reconstructions.
The review by Nakamura et al. (2010), on lyze implant-level impressions of two or For the search on metal abutments, the fol-
the other hand, looked specifically at four dif- more fixtures. Exclusion criteria were, there- lowing keywords were inserted: “dental
ferent areas of interest on zirconia abut- fore, the following: single implants, and abut- implant” OR “implant abutment” AND
ments: mechanical properties, soft tissue ment-level impressions. “metal”. This produced 422 abstracts. After
response, plaque accumulation, and results The initial search yielded 1127 titles. After analyzing these abstracts, 22 articles were
from clinical studies. For this last search, the initial screening, the search was nar- selected for full text reading.
only clinical studies with a minimum num- rowed to 120 abstracts. After evaluation of For the search on zirconia abutments,
ber of 20 subjects at baseline and at least a 1- these abstracts, 15 articles were selected for instead, the following keywords were used:
year follow-up were identified and, eventu- full text reading and only 7 for inclusion in “dental implant” AND “implant abutment”
ally, only 3 were included (Glauser et al. the review (Table 1). All are in vitro studies AND “zirconia”. This search produced 104
2004; Canullo 2007; Zembic et al. 2009). The since no clinical study was found. A manual titles. It was then narrowed down by limiting
authors reached the same conclusions as in search of the January 2009 to January 2012 it to clinical studies and RCT’s on humans,
the previous review, highlighting the fact issues of the following journals did not and by specifying the time frame to the

204 | Clin. Oral Implants Res. 23(Suppl. 6), 2012/202–216 © 2012 John Wiley & Sons A/S
Table 1. In vitro studies on implant-level impression accuracy
Degree of
Authors No. of Distance implant No. of
and year implants to between divergence impressions
of Implant brand Connection be implants or and Splinting Impression Evaluation
publication (manufacturer) type connected (mm) convergence technique Coping type method material method Outcome
Vigolo Certain Internal Four in a Posterior Almost 0° 15 SquareSquareSquare None Medium Profile Improved accuracy was
et al. (Biomet 3i) fully implants 15 Floss and viscosity PE projector (2-D) achieved when the square
(2004) edentulous (#1 and #4): 15 resin copings joined by resin
arch 28.2 Abraded and were used

© 2012 John Wiley & Sons A/S


Anterior adhesive-
implants coated
(#2 and #3): copings
12.9
Cabral and SIN (Sistema Internal 2 20 0° 15 Tapered None VPS (putty Profile No statistically significant
Guedes de Implante (parallel 15 Square None soft and projector (2-D) differences
(2007) Nacional) hex) 15 Square Resin light body Technique with square
15 Square Resin in 1-step copings with resin
sectioned and procedure) sectioned and welded
welded produced a model that
was more similar to the
master metal framework
Square copings splinted
with resin showed the
worst accuracy
Choi et al. Astra ST Internal, 2 10 0° 10 Square Resin Low Framework Accuracy of impressions
(2007) (Astra Tech) with a 11° 8° 10 Square sectioned and viscosity deformation was similar for splinted
taper and 10 Square welded VPS (3-D evaluation and non splinted copings,
hexagon 10 Square None with strain and for parallel and 8°
Resin gauges) divergent implants
sectioned and
welded
None
Assuncao Conexao External 2 n.r. 25° 10 Square Floss and Medium Digitalization Square copings abraded
et al. (Conexao 10 Square resin in bulk viscosity PE of model and by aluminum oxide
(2008) Prosthesis 10 Square Abraded 2-D produced the most
System) copings measurement accurate master casts
Abraded and of implant Implants perpendicular to
adhesive- analogues’ the surface tend to

205 |
coated inclination generate less
copings displacement of the
transfer coping than
inclined implants
Filho et al. Conexao External 2 n.r. 25° 6 Square None Medium Digitalization All replicas were different
(2009) (Conexao 6 Square Resin in bulk viscosity PE of model and from the reference model,
Prosthesis 6 Square Resin 2-D especially for the
System) 6 Square sectioned and measurement angulated implant
welded of implant Best techniques: copings
Prefabricated analogues’ splinted either with a
resin bar inclination prefabricated resin bar or
a direct resin bridge,
sectioned and then
welded again

Clin. Oral Implants Res. 23(Suppl. 6), 2012/202–216


Gracis et al.  Internal vs. external connections for abutments/reconstructions
Gracis et al.  Internal vs. external connections for abutments/reconstructions

period from January 2009 to January 2012

difference was found for


implants, VPS resulted in
produced more accurate

A statistically significant
since the reviews by Sailer et al. (2009b) and

connections were used


and use of polyethers,
With parallel implants

especially when 1 mm
more accurate casts,
Nakamura et al. (2010) had examined the

2 mm connections

the 20° divergent


With nonparallel
previous years’ publications very thoroughly.
In this way, the number was reduced to six
papers whose full text was read. The manual
Outcome

implants
search produced four additional newly pub-

casts
lished studies on zirconia abutments (Noth-
durft & Pospiech 2010b; Ekfeldt et al. 2011;
projector (2-D)

projector (2-D)

projector (2-D)
Hosseini et al. 2011; Kim et al. 2012).
Evaluation

Only clinical studies, RCTs, prospective and


method

retrospective cohort studies, were included in


Profile

Profile

Profile
this review. Furthermore, these studies had to
fulfill the following inclusion criteria:
viscosity PE

viscosity PE

viscosity PE

viscosity PE

viscosity PE
Impression


Medium

Medium

Medium

Medium

Medium

Medium

Medium

Medium

Medium
material

a mean follow-up of at least 3 years for


viscosity

viscosity

viscosity

viscosity
metal abutments/reconstructions and
VPS

VPS

VPS

VPS
1 year for zirconia abutments/reconstruc-
tions;
• the abutments had to support single res-
Splinting
method

torations;

None

None

None
the patients had to be examined clinically
at the follow-up intervals;
• detailed information about the connec-
hex
hex
hex
hex

hex
hex
hex
hex

tion type and the type of abutments being


mm
mm
mm
mm

mm
mm
mm
mm

used had to reported;


Coping type

• abutment and prosthetic complications


1
2
1
2

1
2
1
2
Square,
Square,
Square,
Square,

Square,
Square,
Square,
Square,

Square

had to be reported.

The exclusion criteria applied were the fol-


lowing:
impressions

10 for each
angulation
technique

• alumina based abutments/reconstruc-


No. of

and

tions;
10
10
10
10

10
10
10
10

• insufficient information about the con-


convergence

nection type and/or the type of abutments


divergence
Degree of

used;
implant

• splinted FDPs.
10°

10°
15°
20°
or


The alumina-based abutments/reconstruc-


21.4Anterior
(#1 and #4):

(#2 and #3):

(#1 and #4):

(#2 and #3):

tions were excluded since they are no longer


Posterior

Posterior
between
implants

implants

implants

implants

implants

available on the market.


Distance

anterior
(mm)

21.3

14.5
8.7

8.7

Statistical analysis
Failure and complication rates were calcu-
implants to

edentulous
connected

n.r., not reported; PE, polyether; VPS, vinylpolysiloxane.

lated by dividing the number of events (fail-


partially
No. of

ures or complications) as the numerator by


4 in a

arch
be

the total time of the reconstructions being


2

under observation as the denominator. The


Connection

numerator could usually be extracted directly


walls and

engaging
Internal,

Internal
parallel

from the publication. The total exposure


apical
with
type

hex

time was estimated by multiplying the mean


follow-up time by the number of construc-
(manufacturer)
Winsix Implant
Implant brand

tions under observation.


Implantium
(Dentium)

For each study, event rates for the recon-


(BioSAF)
System

structions were calculated by dividing the


Table 1. (continued)

total number of events by the total recon-


struction exposure time in years. For further
publication
Sorrentino

Jang et al.

analysis, the total number of events was con-


and year
Authors

sidered to be Poisson distributed for a given


(2010)

(2011)
et al.

sum of construction-years and Poisson regres-


of

sion with a logarithmic link-function and

206 | Clin. Oral Implants Res. 23(Suppl. 6), 2012/202–216 © 2012 John Wiley & Sons A/S
Table 2. Clinical studies on complications of single-implant metal abutments and metal-based reconstructions
Authors and Mean No. of No. of No. of

© 2012 John Wiley & Sons A/S


year of follow-up Implant system No. of No. of abutments at Abutment screw screw abutment
publication Study design Setting (years) (manufacturer) abutments end of time interval material Location in arch loosenings fractures fractures
Internal connections
Wennstrom Prospective University 5 Astra 41 32 Titanium Maxilla and mandible 3 0 0
et al. (2005) (Astra Tech)
Bragger Prospective University 10 ITI (Straumann) 69 64 Titanium n.r. 1 0 0
et al. (2005)
Cooper Prospective University 3 Astra 54 43 Titanium Anterior maxilla 0 0 0
et al. (2007) (Astra Tech)
Gotfredsen Prospective University 10 Astra 20 19 Titanium Anterior and premolar 2 0 0
(2012) (Astra Tech) maxilla
Total 184 158 6 0 0
External connections
Henry et al. Prospective Private 5 Brånemark 107 86 Titanium Anterior maxilla 28 1 0
(1996) practice (Nobel Biocare)
Andersson Prospective Private 5 Brånemark 65 58 Titanium Maxilla and mandible 0 0 0
et al. (1998) practice (Nobel Biocare)
Scheller Prospective University 5 Brånemark 99 97 Titanium Maxilla and mandible 0 0 0
et al. (1998) Private (Nobel Biocare)
practice;
multicenter
Wannfors & Prospective Hospital 3 Brånemark 80 76 34 Maxilla and mandible 14 0 0
Smedberg (Nobel Biocare) Titanium,
(1999) 44 Gold
Cho et al. Prospective University 3.2 Brånemark 213 213 Gold Posterior mandible/ 24 0 n.r.
(2004) (Nobel Biocare) maxilla
Vigolo et al. Prospective University 4 Osseotite 40 40 20 16 max. premolar, 16 0 0 0
(2006) (Biomet 3i) Titanium, max. molar, 8 mand.

207 |
20 Gold molar
Jemt (2008) Retrospective University Up to 15 Brånemark 47 32 Titanium Maxilla and mandible 20 0 0
(Nobel Biocare)
Schropp & RCT University 5 Osseotite 42 34 Titanium Maxilla and mandible 0 0 0
Isidor (2008) (Biomet 3i) or Gold
Zembic et al. RCT University 3 Brånemark 40 28 Titanium Maxilla and mandible 0 0 0
(2009) (Nobel Biocare)
Jemt (2009) Retrospective University 10 Brånemark 18 13 Titanium Anterior and premolar 2 0 0
(Nobel Biocare) regions
Total 751 677 88 1 0

n.r., not reported.

Clin. Oral Implants Res. 23(Suppl. 6), 2012/202–216


Gracis et al.  Internal vs. external connections for abutments/reconstructions
Gracis et al.  Internal vs. external connections for abutments/reconstructions

total construction-time per study as an offset

Abutment
fractures
variable were used (Kirkwood & Sterne 2003).
Robust Poisson regression (by calculating

0
0
robust standard errors for the summary rates)
were used to obtain a summary estimate and
fractures
Screw
95% confidence intervals of the event rates,

n.r.

n.r.
which incorporated possible heterogeneity

0
among studies. Three-year survival propor-

27 months)
loosening

8 months tions were calculated via the relationship


and at
Screw

between event rate and survival function S,


2 (at

0 SðTÞ ¼ expðT  event rateÞ, by assuming

0
0
premolars and constant event rates. Cumulative incidence

10 premolars,
estimates were calculated as 1S(T). Multivar-
15 premolars

2 canines, 11
Location in

12 incisors,
14 canines
25 incisors

4 canines,

Premolars
iable Poisson regression was used to formally

Posterior
4 molars
5 molars

compare different types of reconstructions


arch

(with internal or with external connection


design). All P-values are two-sided and analy-
retained

ses were performed using Stata®, version 12


Screw

(Stata Corp., College Station, TX, USA).


0

0
2
retained
Cement

Results
108
160
36

16

52

30

40

38

Table 1 illustrates the results of the search to


Reconstruction

17 all ceramic

PICO question 1. Seven in vitro studies were


(leucite glass
All ceramic

All ceramic

All ceramic

supported)
Table 3. Clinical studies on complications of single-implant zirconia abutments and zirconia-based reconstructions

identified (Vigolo et al. 2004; Cabral &


(zirconia
Subtotal

Subtotal
ceramic)
material

1 metal-

Zirconia
ceramic

Guedes 2007; Choi et al. 2007; Assunção et al.


Total

2008; Filho et al. 2009; Jang et al. 2011; Sor-


rentino et al. 2011). The ones by Vigolo et al.
Abutment

(2004), Cabral & Guedes (2007) and Sorrentino


titanium
material

Zirconia

Zirconia

Zirconia

Zirconia

Zirconia
insert

et al. (2011) analyzed the outcome of impres-


with

sion techniques on parallel implants, while


that by Sorrentino et al. (2011) and the
abutments at
end of time

remaining four looked into the problem of


impression distortion of non parallel implants.
interval
No. of

All studies used a setup with two implants


108
162
36

18

54

30

40

38

embedded in a reference model, with the


exception of the ones by Vigolo et al. (2004)
abutments

and Sorrentino et al. (2011) which used a full


No. of

arch model with four implants. The studies by


108
182
54

20

74

30

40

38

Assunção et al. (2008) and Filho et al. (2009)


(Astra Tech)
(Impladent)

were conducted on the same external connec-


XiVE S plus
Brånemark

Brånemark

Subtotal

Subtotal
Biocare)

Biocare)

(Friatec)

tion implant system (Conexao; Conexao Pros-


Implant

(Nobel

(Nobel
system

Astra

Total

thesis System, Sao Paolo, Brazil), whereas the


TSA

other five on internal connection implants


(months)

(Certain, 3i Biomet, Palm Beach Gardens, FL,


Follow-

(mean)

(mean)

(mean)

USA; SIN, Barcelona, Spain; Sistema de Imp-


49.2
up

36

40

12

12

lante Nacional; Astra ST, Astra Tech, Möln-


dal, Sweden; Winsix Implant System, BioSAF,
University

University

University
practice

practice

London, UK; Implantium, Dentium, Seoul,


Setting

Private

Private

Korea).
The studies either tested specimens with
internal or specimens with external implant-
Prospective

Prospective

Prospective

Prospective

abutment connections. None of the studies


design
External connection

Internal connection
Study

compared the influence of internal vs. exter-


n.r., not reported.
RCT

RCT

nal connections on distortion in impression


publication

making. The parameters that were analyzed


& Pospiech
Nothdurft
Canullo
Glauser

Zembic
and year

Hosseini
Authors

included implant divergence (none vs. up to


(2010b)
(2004)

(2009)

(2007)

(2011)
et al.

et al.

et al.

20°) (Choi et al. 2007; Jang et al. 2011; Sor-


of

rentino et al. 2011), coping type (square vs.

208 | Clin. Oral Implants Res. 23(Suppl. 6), 2012/202–216 © 2012 John Wiley & Sons A/S
Gracis et al.  Internal vs. external connections for abutments/reconstructions

Cooper et al. with 3 years follow-up

Wennstrom et al. with 5 years follow-up

Bragger et al. with 10 years follow-up

Gotfredsen with 10 years follow-up

0 5 10
Annual rate in percent

Fig. 1. Annual rate (per 100 years) of metal abutment/reconstruction screw loosening in internal configuration implants.

Wannfors & Smedberg with 3 years follow-up

Zembic et al. with 3 years follow-up

Cho et al. with 3.2 years follow-up

Vigolo et al. with 4 years follow-up

Andersson et al. with 5 years follow-up

Henry et al. with 5 years follow-up

Scheller et al. with 5 years follow-up

Schropp & Isidor with 5 years follow-up

Jemt with 10 years follow-up

Jemt with 15 years follow-up

0 5 10 15
Annual rate in percent

Fig. 2. Annual rate (per 100 years) of metal abutment/reconstruction screw loosening in external configuration implants.

tapered) (Cabral & Guedes 2007), depth of material (medium viscosity polyether vs. sion copings joined by resin were used.
engagement of the internal hexagon by the polyvinylsiloxane) (Sorrentino et al. 2011). Cabral & Guedes (2007) did not find statisti-
square impression coping (1 vs. 2 mm) Due to a lack of standardized comparable cally significant differences between the vari-
(Sorrentino et al. 2011), coping splinting studies, this part of the review had to be per- ous techniques employed; however, the
method (none, adhesive coating, abraded formed narrative. technique which used square impression cop-
copings, floss and resin in bulk, resin sec- Dissimilar final outcomes resulted from ings with sectioned and welded resin pro-
tioned and welded) (Vigolo et al. 2004; Cabral the seven studies. In the study by Vigolo duced a model that was more similar to the
& Guedes 2007; Choi et al. 2007; Assunção et al. (2004), improved accuracy of the defini- master metal framework compared to the
et al. 2008; Filho et al. 2009) and impression tive casts was achieved when square impres- technique which used square copings simply

© 2012 John Wiley & Sons A/S 209 | Clin. Oral Implants Res. 23(Suppl. 6), 2012/202–216
Gracis et al.  Internal vs. external connections for abutments/reconstructions

splinted with resin. In the Choi et al. study Schropp & Isidor (2008), which were made out fractures of 0.0% (95% CI: 0.0–2.0%) both for
(2007), the accuracy of impressions was simi- of gold alloy. These abutments were all manu- external and internal connection designs.
lar for splinted- and non-splinted copings, factured for the external connection. The number of abutments taken into consid-
and for parallel and 8° divergent implants. The most frequent mechanical complica- eration was very small. At the end of the
Assunção et al. (2008) demonstrated that tion found in both implant connection design time interval analyzed, only 54 zirconia abut-
square copings abraded by aluminum oxide was screw loosening. Screw fracture was a ments for the external and 108 for the inter-
produced the most accurate definitive casts. rare event (one event reported in all identi- nal configuration were available for analysis.
In the study by Filho et al. (2009), all replicas fied studies), while no abutment fracture was While the number of abutments for the inter-
were different from the reference model, reported. Only 2 studies on the internal con- nal connection implants had not changed
especially for the angulated implant. The best nection and 2 on the external connection fol- from the start of the investigations, that for
technique was the one which used copings lowed up their patients for 10 years or longer the external connection implants had chan-
splinted either with a prefabricated resin bar while all the others were 5 years or shorter. ged due to patient dropout: 36 out of 54 in
or with a direct resin bridge, sectioned and The summary estimates for the 3-year cumu- the Glauser et al. study, and 18 out of 20 in
then welded again. In the Sorrentino et al. lative incidence of abutment fracture were the Zembic et al. study. The only complica-
study (2011), the use of polyether impression 0.0% (95% CI: 0.0–0.9%) for the internal con- tion reported was loosening of 2 screws (at 8
material and of square impression copings nection design and 0.0% (95% CI: 0.0–0.3%) and at 27 months intervals) in the former
with 2 mm inserts produced more accurate for the external one. The 3-year cumulative study. However, the incidence of screw loos-
definitive casts in case of parallel implants; incidence of screw fracture was 0.0% (95% ening in the dropouts was not reported. Based
on the other hand, the vinylpolysiloxane CI: 0.0–0.9%) for the internal and 0.1% (95% on the available data, the annual rate of
(VPS) impression material resulted in more CI: 0.0–0.5%) the external connection design, screw loosening between internal (summary
accurate casts, especially when square respectively. Finally, a 3-year cumulative estimate of annual rate = 0.0%, 95% CI: 0.0–
impression copings with 1 mm inserts were screw loosening incidence of 1.5% (95% CI: 2.1%) and external designs (summary esti-
used in case of nonparallel implants. Finally, 0.4–5.3%) and 7.5% (95% CI: 4.2–13.1%) was mate of annual rate = 0.8%, 95% CI: 0.1–
Jang et al. (2011) showed that a statistically recorded for the internal and the external 3.0%) was observed.
significant difference in impression accuracy connection design, respectively. The annual All abutments were one-piece zirconia,
was found for the 20° divergent implants. rate of screw loosening was highly heteroge- with the exception of the 30 TSA abutments
The final outcome of the review concern- neous in reconstructions with internal con- which had a titanium insert, and were sup-
ing PICO question 2, consists of 16 pertinent figurations (Fig. 1) and 5.1 times higher (95% ported with either single cemented restora-
clinical studies on metal abutments and CI: 1.4–18.6%) than for reconstructions with tions (160) or single screw-retained
metal-based reconstructions and of five clini- external design (Fig. 2), but not clearly lower restorations (2). No statistically significant
cal studies on zirconia abutments and zirco- in university settings compared to other clin- difference (P = 0.66 for difference) has been
nia-based reconstructions, which have ical settings (rate ratio = 0.6, 95% CI (0.16– found based upon abutment material (full zir-
reported on screw loosening, screw fracture 2.37%), P = 0.47). conia vs. zirconia with metal insert) or reten-
and abutment fracture (Tables 2 and 3). Of tion of the restoration (screwed abutment
the included studies, 4 were RCTs, 13 were Zirconia abutments and zirconia-based with cemented crown vs. screw-retained
prospective and 2 retrospective studies. No reconstructions implant restoration).
A total of five studies were included in the
RCT was found directly comparing internal Almost all crowns cemented on the zirco-
review on zirconia abutments and zirconia-
and external connection implant systems. nia abutments were made of metal-free mate-
based reconstructions, two on the same
rials (leucite glass ceramic or zirconia
external connection implants (Brånemark
Metal abutments and metal-based supported). Only one was made of metal-
reconstructions System, Nobel Biocare) (Glauser et al. 2004;
ceramics. Some authors have specified that
All the studies on metal abutments and metal- Zembic et al. 2009) and three on different
the crowns were provided with occlusal con-
based reconstructions were RCTs or prospec- internal connection implants: TSA System
tact in centric, and that there were no con-
tive with the exception of two on the external (Impladent) (Canullo 2007), XIVE S Plus (Fria-
tacts in excursive movements. The only
connection which were retrospective. Ten tec) (Nothdurft & Pospiech 2010b), and Astra
mechanical complication reported in relation
were on the same external hex connection (Astra Tech) (Hosseini et al. 2011) (Table 3).
to the crowns was minor chipping of the
configuration (Biomet 3i, Brånemark System, Except for the last two, the other studies had
veneering ceramic.
Nobel Biocare, and Osseotite) and four on two been included in the previous reviews. The
internal connections which were considered studies by Glauser et al. (2004), Zembic et al.
very similar in design (ITI, Straumann, and (2009) and Canullo (2007) reported on follow- Discussion
Astra, Astra Tech). Therefore, the authors up periods of 3 years or longer, while the
have pooled the numbers in order for compari- remaining two only of 1 year. The publica- Impression taking of multiple implants with
sons to be made. The total numbers of abut- tion by Nothdurft & Pospiech (2010b), how- an internal connection differs in many
ments which were included in the clinical ever, illustrates a prospective study run in a respects from that of implants with an exter-
analysis for the external and internal connec- University setting that is supposed to con- nal connection. Some internal connection
tions are 751 and 184, respectively, which tinue for 5 years. configurations have an intimate fit with the
became 677 and 158 at the end of the follow- No abutment and screw fractures were respective impression copings which may
up intervals. The abutments applied were in reported in studies describing external and make withdrawal of the impression more diffi-
titanium, except 277 plus an undisclosed internal connection designs resulting in an cult and, therefore, may generate a higher
number for the pool of 34 implants reported by estimated annual rate of screw and abutment degree of distortion. Furthermore, external

210 | Clin. Oral Implants Res. 23(Suppl. 6), 2012/202–216 © 2012 John Wiley & Sons A/S
Gracis et al.  Internal vs. external connections for abutments/reconstructions

connection implants can accommodate a lar- cast. The same authors, in another study forces that may influence negatively the
ger degree of divergence than internal connec- (Vigolo et al. 2004), stated that the removal implant-abutment stability and screw reten-
tion systems due to the limited height of the of the impression from internal connection tion, thus potentially exposing in a more
external hex. Thus, depending on the degree of implants is likely to produce a higher level of effective manner the role of the connection
divergence and internal connection configura- stress between the impression material and design. In this respect, implant location in
tion, variables such as impression technique the impression copings, than from external the arch may also have an influence on the
(rigid splint vs. no splint), impression material hexagon implants. This stress may hypotheti- incidence of screw loosening or fracture.
(more rigid vs. more elastic), and choice of cally induce permanent deformation of Unfortunately, not enough information has
impression copings (engaging vs. non engag- impression material or movement of the been provided by those authors regarding
ing) will influence impression accuracy. impression copings inside the impression complication rates in order for meaningful
If part or all of the configuration of the material. conclusions to be drawn.
internal connection has parallel walls, two Distortion of an impression which is The abutment materials were either tita-
types of impression copings are usually pro- attempting to capture the relative positions nium or gold alloy. Since in the reporting of
vided by the manufacturer: one that is well of two or more implants in the same arch the mechanical complications, no indication
adapted and captures the internal antirota- manifests itself as a change in the position, was given as to which abutment material
tional feature, which is necessary to make orientation or relative inclination of the was affected, no attempt has been made to
individualized abutments (engaging or non implant analogues in the stone model pro- differentiate them.
rotational impression coping), and one that duced. Any study evaluating distortion only Screw loosening was by far the mechanical
may contact just the shoulder area, avoiding in two dimensions is, by definition, of lim- complication that occurred more frequently
contact with the inner walls to allow for eas- ited clinical value. The fact that a study may with metal SIRs, regardless of the fact that
ier withdrawal (non engaging or rotational demonstrate little or no linear change of the they were made for an external- or an inter-
impression coping). The latter type can be implant analogues in one plane is of limited nal connection fixture. The incidence, how-
used only when fabricating fixture-level clinical significance. This is why the study ever, was statistically significantly lower for
screw-retained FPD’s. Use of the engaging by Choi et al. (2007) is of interest since it is the latter than it is for the former. It is inter-
impression copings in these instances will the only one that attempted to evaluate esting to note that many of the earlier stud-
probably result in a misfit of the framework impression distortion three-dimensionally in ies did not apply standardized protocols for
due to the rigid fit of the components. With- the 2-implant setup. To do so, the authors the tightening of the screws at predetermined
drawal of an impression with multiple single used a metal framework which was passive torque levels (Henry et al. 1996; Wannfors &
implants requires flexure of the impression on the master model. After applying to it Smedberg 1999; Cho et al. 2004; Jemt 2008)
material, whether using the closed- or open- strain gauges, they connected it to the and, even if it was done, the material of such
tray impression copings. implant analogues enclosed in the study screws (titanium) did not allow reaching high
Choi et al. (2007) have limited the degree models produced by two different VPS preloads. This has been shown to be a major
of divergence to 8° because the system that impression techniques, one where the factor that can explain such complications.
was used in their study (Astra ST, Astra- squared impression copings were left non For example, in the study by Jemt (2008), 47
Tech), according to what is stated by the splinted and one where the same copings single external connection implants placed in
authors, does not allow for a greater diver- were joined with a standardized autopolymer- the anterior maxilla were followed up for as
gence if the engaging copings are employed izing acrylic resin splint, sectioned 15 min long as 15 years. The incidence of mechani-
since it can introduce strain in the impres- before impression making and then welded cal complications in this group of patients
sion material. Therefore, the path of insertion again with the same resin. The results of the was relatively high: 20 of the crowns required
(or path of removal) of the implants to be study showed no difference in the outcome retightening of the abutment screw. In the
restored should be known before the restor- of the two techniques. As a matter of fact, materials and methods section, the author
ative procedures are initiated. Furthermore, both were equally distorted and no samples stated that the titanium screws had been
unlike other investigators who have showed perfect fit with the metal framework. hand tightened. As a consequence, when
employed polyethers, Choi et al. have loosening occurred, 15 of the 20 titanium
employed a low viscosity VPS with the idea Metal abutments and metal-based screws were replaced by gold screws. Once
of reducing permanent deformation of the reconstructions that was done, the problem was resolved.
The great majority of the studies included in
impression due to the more elastic behavior One of the major advancements for the sta-
the review on metal abutments and metal-
of this material. However, since no other bility of the abutment-fixture joint has been
based reconstructions were either RCTs (2) or
material was used with the same setup and, the change of the screw’s material and sur-
prospective (10) and only two were retrospec-
thus, no comparison was made, it is not pos- face treatment to allow a sensible increase in
tive. This implies that the data that can be
sible to infer that the low degree of deforma- preload, along with the recommendation to
extracted are of an acceptable quality. How-
tion cannot be matched by other elastomeric always tighten the screw with torque control-
ever, there was no RCT that directly com-
impression materials as well. ler that applies a calibrated force (for an abut-
pared implant-abutment stability in external
In a study on multiple external hexagon ment screw, generally, from 25 to 35 Ncm).
vs. internal connection implants.
implants on which standard abutments had This is particularly important with an exter-
In selecting the studies for this review, a
been placed, Vigolo et al. (2003) warned of nal connection implant.
decision was made to include only those that
the importance of avoiding any movement of One study (Cho et al. 2004) demonstrated
reported on single-implant-supported restora-
the impression copings inside the impression that implant diameter has an influence on
tions (SIR). The reason for this was that sin-
material throughout the procedures that are screw loosening only when the screws are
gle-implant crowns are subjected to torsional
carried out when fabricating the definitive hand torqued. Of 213 implants restored with

© 2012 John Wiley & Sons A/S 211 | Clin. Oral Implants Res. 23(Suppl. 6), 2012/202–216
Gracis et al.  Internal vs. external connections for abutments/reconstructions

SIRs, 68 were wide diameter and 145 were with metal inserts (for the Replace fixtures) tion failed. Secondly, there is no indication of
standard diameter implants. The former had broken, one at delivery and one after the time at which the different complications
showed 5.8% screw loosening, whereas the 2 months of function, and one screw-retained have taken place. For these reasons, the arti-
latter showed a 14.5% incidence in a 3– crown had become loose, after 8 months. cle was excluded from the current review.
7 year longitudinal study. When these loose Twenty-five patients who had been treated Implant companies provide zirconia
screws were tightened with a torque driver, over 3 years before were recalled for a clinical abutments for both external and internal
the authors did not observe loosening of reexamination. These 25 patients had been connection systems, but, for the latter con-
screws any longer. treated with 40 implant supported restora- figuration, some companies have chosen to
tions, of which 25 were zirconia-supported offer abutments with metal inserts to
Zirconia abutments and zirconia-based crown screw-retained to the fixture itself. At decrease the risk of fracture of what would
reconstructions the 3 year recall, none of the abutments be the thinnest portion of the abutment. In
The use of zirconia implant abutments is exhibited fractures or screw loosening. one of only two clinical studies that recorded
increasing, mainly due to aesthetic motiva- The most recent study (Kim et al. 2012) is abutment fracture (Ekfeldt et al. 2011), the
tions. The aims of the review on zirconia a prospective cohort study in a University two abutments that failed, one at delivery
abutments and zirconia-based reconstructions setting that assessed the 5-year survival of and the other after 2 months of function, had
were to assess the scientific evidence that alumina-toughened zirconia abutments pro- a metal insert. This is in apparent contradic-
justifies their use, analyze the mechanical duced by one company used for implant-sup- tion with the results of in vitro studies that
complications that can be encountered with ported restorations. A total of 611 external suggest that two-piece zirconia abutments
their clinical application, and to investigate hex implants of different brands were placed with a secondary coupling abutment or a
whether there is a difference in behavior in 213 patients to support 328 fixed restora- metallic insert withstand higher bending
when a zirconia abutment is used with an tions and were followed from a minimum of moments than one-piece internally or
external or with an internal connection sys- 1 month to a maximum of 12.8 years (mean externally connected abutments (Sailer et al.
tem. From the data analyzed, it seems that of 42 months). According to the data pub- 2009a; Truninger et al. 2011). In the
the incidence of mechanical complications lished, about half of the restorations have Nothdurft & Pospiech paper (2010b), the
with zirconia abutments ranges from very been followed for more than 3 years and authors specified that nearly all 40 full
low to absent, irrespective of the platform. about 20 for more than 8 years. It appears zirconia abutments had to be custom-shaped
With respect to the situation photographed that 20 restorations were lost to follow-up, in the occlusal aspect and along the chamber.
by the previous two systematic reviews deal- but, apparently, they were counted as surviv- For that purpose, they were reshaped with
ing with ceramic abutments (Sailer et al. als. Two-hundred-seventy-four restorations diamond grinding tools under water irriga-
2009b; Nakamura et al. 2010), only four new did not experience any complication and tion. It is worthwhile to mention that no
studies have appeared, three prospective were accounted for, wheras 31 had mechani- fracture has ensued after 12 months.
(Nothdurft & Pospiech 2010b; Hosseini et al. cal complications: 23 screw loosening, 2 A publication with the results of a scan-
2011; Kim et al. 2012) and one retrospective abutment screw fractures, 6 abutment frac- ning electron microscopy analysis of five
(Ekfeldt et al. 2011). The Nothdurft & tures. An interesting finding is that of the 25 clinically fractured one-piece zirconia abut-
Pospiech (2010b), Hosseini et al. (2011) and screw loosening and fracture, 22 were single ments suggests that fractures may occur
the Ekfeldt et al. (2011) studies have a units (20.5% of 107 single units) and 3 multi- because of friction stresses generated by the
follow-up of only 1 year, except for a small ple units (1.6% of 190 multiple units), 24 fixation screw or to overpreparation and thin-
group of patients of the last publication who were posterior (10% of 239 posterior restora- ning of the lateral walls (Aboushelib & Sala-
were recalled for a retrospective analysis after tions) and only 1 anterior restoration (1.7% meh 2009). The retrieval of the fractured
3 years of function; the fourth study, instead of 58 anteriors). Of the six abutment frac- portion of a zirconia abutment from an inter-
(Kim et al. 2012) reports the results after a tures, four were single units (3.7% of 107 nal connection implant systems with a spe-
median time period of 42 months. However, abutments) whereas five were located in the cially modified back-action tapper has even
the publications by Ekfeldt et al. (2011) and posterior area (2.1% of 239 units). Therefore, been the object of a short communication
Kim et al. (2012) had to be excluded from the these complications were shown to be signif- (Roe et al. 2011). In their study, Glauser
current review due to lack of data on the icantly associated with the restoration’s et al. (2004) mentioned that a minimum
patient population clinically examined. number of prosthodontic units and the type thickness of 0.5 mm should be maintained;
The Ekfeldt et al. study (2011) was a retro- of prostheses (single crown vs. FPD). The otherwise, the abutment may fracture.
spective analysis of 185 implants followed for authors of that study have concluded that The main problem with the studies
at least 1 year and restored with either a zir- care must be taken in the use of alumina- reviewed is that the number of zirconia
conia abutment and a cemented all ceramic toughened zirconia abutments for single abutments is limited and the observation
crown or a zirconia-supported crown screw- molar restorations. Unfortunately, there were periods are rather short. Larger samples and a
retained to the fixture itself. The implants two relevant shortcomings in this study: longer follow-up are needed for final conclu-
were subdivided in 124 external connections firstly, there was no clear indication of the sion, especially in view of the fact that zirco-
(Brånemark system), 53 internal connections number of abutments belonging to the multi- nia, like all ceramics, is prone to aging and
(Replace Select), and 8 non specified implant unit prosthetic groups. Since the authors accumulative damage, thus inducing a
systems. At the 1 year interval, 172 implant often referred to the number of restorations decrease in the physical properties (Zembic
restorations were examined since 10 patients and not to the number of abutments, confu- et al. 2009). The consequences of zirconia’s
were lost due to a patients’ change in resi- sion ensues and it is not possible for the low temperature degradation may also
dence. The mechanical complications reader to understand how many zirconia require a longer time interval to be exposed
recorded are limited: two zirconia abutments abutments were actually lost when a restora- (Deville et al. 2005). It is highly desirable

212 | Clin. Oral Implants Res. 23(Suppl. 6), 2012/202–216 © 2012 John Wiley & Sons A/S
Gracis et al.  Internal vs. external connections for abutments/reconstructions

that future research projects will address this between multiple implants, the impres- 3. Loosening of abutment screws was the
issue comparing not only implants with sion material, and the technique most frequently occurring technical com-
internal and external connections, but also employed. plication. The type of connection seems
the different designs of connections. 2. It appears that implant divergence influ- to have an influence on the incidence of
ences the impression accuracy when the screw loosening: more loose screws
using internal connection implants. were reported for externally connected
Conclusions of focused question 1
implant systems for both types of materi-
als. To minimize the screw loosening
No in vivo nor in vitro study was found that
Conclusions of focused question 2 incidence of both external- and internal
directly compared the influence of internal
connection abutment/reconstructions, it
vs. sexternal implant connections for abut-
Within the limitations of the low number of is highly recommended to tighten the
ments/reconstructions on implant-level
studies included in the present review, the retention screws at the recommended tor-
impression accuracy. All in vitro studies
following consensus statements can be made: que level.
reported separately on the two connection
designs and used different protocols. There- 1. The incidence of fracture of metal-based
fore, the data cannot be compared and no and zirconia-based abutments does not
clinical recommendation can be made. seem to be influenced by the type of con- Acknowledgement: The first author
On the basis of the studies reviewed, the nection. wishes to thank Luca Fumagalli, DDS, for
following considerations can be mentioned: 2. The incidence of abutment screw fracture his valuable assistance in the electronic
does not seem to be influenced by the searches.
1. Implant-level impression accuracy may
type of connection, neither with metal-
be influenced by the implant connection
based nor with zirconia-based abutments.
type (internal vs. external), the design of
the connection, lack of parallelism

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cement: the Toronto study. The International Crespi, R., Capparè, P., Gherlone, E. & Romanos, study. Clinical Oral Implants Research 22: 1308–
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unit. A 3-year controlled follow-up study. Clini-

© 2012 John Wiley & Sons A/S 215 | Clin. Oral Implants Res. 23(Suppl. 6), 2012/202–216
Gracis et al.  Internal vs. external connections for abutments/reconstructions

–245. Reason for exclusion: mean follow-up less Research. Accepted for publication. Reason for Moberg, L.E., Köndell, P.A., Sagulin, G.B., Bolin,
than 3 years. exclusion: not enough data on abutment popula- A., Heimdahl, A. & Gynther, G.W. (2001) Bråne-
Gallucci, G.O., Grütter, L., Nedir, R., Bischof, M. tion. mark System and ITI Dental Implant System for
& Belser, U.C. (2011b) Esthetic outcomes with Krennmair, G., Schmidinger, S. & Waldenberger, O. treatment of mandibular edentulism. A compara-
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implant crowns: a randomized clinical trial. Clin- system: a retrospective clinical analysis of 146 Oral Implants Research 12: 450–61. Reason for
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exclusion: mean follow-up less than 3 years. Maxillofacial Implants 17: 78–85. Reasons for edentulous jaws.
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spective study of a single-tooth implant. Prosth- dence of complications related to time of func- restorations in the posterior jaws: maintenance of
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of Prosthodontics 14: 183–89. Reason for exclu- crown fixation methods. implant-abutment microgap. The International
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Jung, U.W., Choi, J.Y., Kim, C.S., Cho, K.S., Chai, tive analysis of the ITI implant system used for tion and data on abutments.
J.K., Kim, C.K. & Choi, S.H. (2008b) Evaluation single-tooth replacements: results of loading for 2 Palmer, R.M., Palmer, P.J. & Smith, B.J. (2000) A 5-
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Kemppainen, P., Eskola, S. & Ylipaavalniemi, P. replacement by morse taper connection implants: Romanos, G.E. & Nentwig, G.H. (2000) Single
(1997) A comparative prospective clinical study of a retrospective study of 80 implants. The Interna- molar replacement with a progressive thread
two single-tooth implants: a preliminary report of tional Journal of Oral & Maxillofacial Implants design implant system: a retrospective clinical
102 implants. The Journal of Prosthetic Dentistry 16: 675–680. Reason for exclusion: insufficient report. The International Journal of Oral & Max-
77: 382–7. Reason for exclusion: only 1 year fol- information on abutments. illofacial Implants 15: 831–6. Reason for exclu-
low-up. Mericske-Stern, R., Grütter, L., Rösch, R. & sion: mean follow-up less than 3 years.
Kim, S.-S., Yeo, I.-S., Lee, S.-J., Kim, D.-J., Jang, B. Mericske, E. (2001) Clinical evaluation and Scholander, S. (1999) A retrospective evaluation of
M., Kim, S.-H. & Han, J.-S. (2012) Clinical use of prosthetic complications of single tooth replace- 259 single-tooth replacements by the use of
alumina-toughened zirconia abutments for ments by non-submerged implants. Clinical Oral Brånemark implants. The International Journal of
implant-supported restoration: prospective cohort Implants Research 12: 309–18. Reason for exclu- Prosthodontics 12: 483–91. Reason for exclusion:
study of survival analysis. Clinical Oral Implants sion: mean follow-up less than 3 years. insufficient information and data on abutments.

216 | Clin. Oral Implants Res. 23(Suppl. 6), 2012/202–216 © 2012 John Wiley & Sons A/S

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