ROBERTO ADRIAN MARKARIAN

ANÁLISE POR MEV DA ADAPTAÇÃO DE PILARES UNITÁRIOS

APARAFUSADOS FABRICADOS POR QUATRO MÉTODOS CAD/CAM APÓS
CICLAGEM MECÂNICA

CAMPINAS
2016
 ROBERTO ADRIAN MARKARIAN

ANÁLISE POR MEV DA ADAPTAÇÃO DE PILARES UNITÁRIOS

APARAFUSADOS FABRICADOS POR QUATRO MÉTODOS CAD/CAM APÓS
CICLAGEM MECÂNICA

Tese apresentada ao Centro de Pós

Graduação / CPO São Leopoldo Mandic,
para obtenção do título de Doutor em
Odontologia
Área de concentração: Implantodontia
Orientadora: Profª. Drª. Fabiana
Mantovani Gomes França

CAMPINAS
2016
 Folha de Aprovação

A dissertação intitulada: ANÁLISE POR MEV DA ADAPTAÇÃO DE PILARES

UNITÁRIOS APARAFUSADOS FABRICADOS POR QUATRO MÉTODOS
CAD/CAM APÓS CICLAGEM MECÂNICA apresentada ao Centro de Pós-
Graduação, para obtenção do grau de Doutor em Odontologia, área de
concentração: Implantodontia em 06/03/2017, à comissão examinadora abaixo
denominada, foi aprovada após liberação pelo orientador.

___________________________________________________________________
Profª. Drª. Fabiana Mantovani Gomes França – Orientadora

___________________________________________________________________
Profª. Drª. Flávia Lucisano Botelho do Amaral

___________________________________________________________________
Prof. Dr. Flávio Henrique Baggio Aguiar

___________________________________________________________________
Prof. Dr. Mario Alexandre Coelho Sinhoreti

___________________________________________________________________
Profª. Drª. Roberta Tarkany Basting
 Tu vedi un blocco, pensa all'immagine:
l'immagine è dentro basta soltanto spogliarla
- Michelangelo Buonarotti-

There are no secrets to success. It is the result of

preparation, hard work, and learning from failure
- Colin Powell -

Todo pasa y todo queda,

pero lo nuestro es pasar,
pasar haciendo caminos,
caminos sobre el mar.

Nunca persequí la gloria,

ni dejar en la memoria
de los hombres mi canción;
yo amo los mundos sutiles,
ingrávidos y gentiles,
como pompas de jabón.

Me gusta verlos pintarse

de sol y grana, volar
bajo el cielo azul, temblar
súbitamente y quebrarse...

Nunca perseguí la gloria.

Caminante, son tus huellas

el camino y nada más;
caminante, no hay camino,
se hace camino al andar.

Al andar se hace camino

y al volver la vista atrás
se ve la senda que nunca
se ha de volver a pisar.

Caminante no hay camino

sino estelas en la mar...
- Antonio Machado -
 À minha esposa Bella e minha filha
Isabelinha, amorosas e companheiras,
dedico esta obra
 AGRADECIMENTOS

Neste momento realizo um retrospecto de minha trajetória profissional e

científica, e tantas pessoas me veem à memória. São aqueles que em maior ou
menor grau contribuíram para minha chegada a este ponto emblemático de minha
vida. Com a finalização deste trabalho, obtenho um título acadêmico que muito me
orgulha, e me remete à admiração que sentia pelos grandes Mestres que tive
oportunidade de conviver durante meu período de estudante, alguns dos quais cito a
seguir:

Prof. Dr. Rafael Yague Ballester, Depto. de Materiais Dentários da FOUSP -

pelo ensino do Método Científico e pela orientação em trabalhos de iniciação
científica.

Prof. Dr. Carlos Francci, Depto. de Materiais Dentários da FOUSP - pelo

exemplo científico e profissional, e pelo incentivo em meu início de atividade clínica.

Prof. Dr. Matsuyohi Mori, Depto. de Prótese da FOUSP - pelo ensino de

sólidos fundamentos de Reabilitação Oral e Oclusão, e pelas inúmeras
oportunidades de aprendizado em estágios, cursos e em seu próprio consultório.

Prof. Dr. Claudio Sendyk, Depto. de Prótese da FOUSP - pelo aprendizado

dos princípios que fundamentam uma implantodontia segura e pela orientação em
meu Mestrado.

Profª. Drª. Fabiana Mantovani Gomes França, Univ. SL Mandic – sua

orientação de forma brilhante e precisa neste trabalho, resultou em um trabalho de
grande relevância científica, a ponto de ser rapidamente aceito em um periódico com
alta relevância internacional. Agradeço também o convite para continuarmos com a
linha de pesquisa.

Agradeço a todos os meus Colegas de Turma, em especial ao Prof. Dr.

Kunihiro Saito, exemplo de pessoa e profissional.
 Agradeço e Parabenizo a Universidade SL Mandic, na pessoa do
coordenador de pós Graduação Prof. Dr. Marcelo Napimoga, pela criação e
desenvolvimento de uma instituição de excelência para a odontologia brasileira e
internacional.

Agradeço ao Prof. Dr. Marcelo Sperandio pelo auxílio com a versão em língua
inglesa deste trabalho.

Agradeço a todos os membros da Clínica ImplArt, meu local de trabalho diário,

em especial à Luciana Carvalho pela inestimável ajuda com a editoração deste
trabalho.

Agradeço à empresa SIN Implantes pelo fornecimento de componentes e

materiais utilizados nesta pesquisa.

Agradeço ao CEME – UNIFESP pela realização das microscopias nesta

pesquisa.

Agradeço a meus pais Gloria e Roberto pelo constante incentivo ao estudo

desde muito cedo em minha vida, e pelos sacrifícios que fizeram para que eu
chegasse mais longe. Também agradeço a minha irmã, Na, pelo constante incentivo
e amizade.

Por fim, agradeço à minha esposa Deborah, que tanto me apoiou desde a
ideia de realizar este curso. Aceitou minhas ausências, me ajudou a superar as
dificuldades na elaboração da metodologia e quando precisei, seu pensamento
rápido e ponderado me ajudou a encontrar soluções para minhas dúvidas. Nestes
últimos anos além do papel de companheira, acabou se tornando também Profª.
MSc Deborah Galles, coautora deste trabalho, contribuindo para sua qualidade e
finalização no prazo adequado.

À todos, meu sincero obrigado.

 RESUMO

O objetivo deste trabalho foi mensurar a fenda na interface entre implantes dentários
e pilares customizados (interface pilar-implante IPI) fabricados com diferentes
métodos CAD/CAM, antes e após ciclagem mecânica, utilizando Microscopia
Eletrônica de Varredura (MEV), além de realizar uma avaliação morfológica dos
pilares. Um software CAD (Dental System, 3shape, Dinamarca) foi utilizado para
projetar um pilar personalizado para uma coroa aparafusada unitária, compatível
com um implante dentário com conexão protética tipo hexagono externo diâmetro de
plataforma 4.1mm. Um mesmo arquivo de estereolitografia resultante foi enviado
para fabricação usando quatro métodos CAD/CAM (n=10): fresagem e sinterização
de dióxido de zircônio (ZI), Co-Cr sinterizado a laser (SL), liga de Co-Cr denso
fresado (MF); fresagem e sinterização de liga de Co-Cr em pó aglutinado (MA).
Pilares de titânio pré-fabricados foram utilizados como controle (TI, AI 4151-Q, SIN -
São Paulo, Brazil). Cada pilar foi instalado sobre um implante dentário de 4.1x11 mm
(SA411, SIN, Brasil) inserido em bloco de alumínio. As medições foram realizadas
utilizando-se MEV (4000X) em quatro regiões da interface implante-pilar (IPI) com
distância relativa de 90° entre si. A média entre essas quatro medidas correspondeu
ao valor da amostra. Os espécimes foram envelhecidos mecanicamente (1.000.000
ciclos, 2 Hz, 100 N, 37° C) e a largura da IPI foi novamente medida utilizando a
mesma metodologia. Os dados foram analisados por Analise de variância com dois
fatores, seguido do teste de Tukey, com nível de significância de 5% (p<0,05). Antes
da ciclagem mecânica, os menores valores de fenda na IPI foram obtidos do grupo
TI (1,10 ± 0,31 µm), MA (1,1 ± 0,72 µm). Houve resultado significativamente maior
para o grupo MF (2,61 ± 1,13 µm). Medidas de fenda significativamente maiores
foram encontrados nos grupos SL (24,71 ± 15,29 µm) e ZI (11,75 ± 0,61 µm).
Após ciclagem mecânica, os menores valores de fenda foram obtidos do grupo TI
(2,29 ± 1,13 µm), MA (3,58 ± 1,80 µm) e MF (1,89 ± 0,98 µm). Observou-se um
resultado de adaptação significativamente maior para os grupos SL (18,40 ± 20,78
µm) e ZI (10,42 ± 0,80 µm). A ciclagem mecânica teve efeito estatisticamente
significante apenas nos espécimes MA, com o aumento da fenda na IPI. Os pilares
personalizados fabricados com MF e MA demonstraram menor fenda na IPI,
semelhantes aos obtidos com os pilares comerciais de titânio pré-fabricados após
ciclagem mecânica. A fenda de pilares personalizados elaborados pelos métodos SL
ou ZI, apresentaram resultados estatisticamente semelhantes entre si, e
permaneceram em níveis mais elevados, antes e depois da ciclagem mecânica. O
grupo SL apresentou deformações morfológicas e rugosidades que poderiam
interferir em seu desempenho clínico. O grupo MF apresentou resultados e
morfologia semelhantes ao resultados do grupo controle (TI). Conclui-se que o
método CAD/CAM, bem como os materiais utilizados podem influenciar na
morfologia dos pilares resultantes, bem como na precisão da adaptação na interface
implante-pilar.

Palavras-chave: CAD/CAM. Conexão de hexágono externo. Implante dentário.

Interface implante-pilar. Desajuste.
 ABSTRACT

The purpose of this work was to measure the microgap between dental implants and
custom abutments fabricated using different CAD/CAM methods, before and after
mechanical cycling, using Scanning Electron Microscopy (SEM). The CAD software
(Dental System, 3shape, Denmark) was used to design a custom abutment for a
single-unit screw-retained crown, compatible with a 4.1 external hexagon dental
implant. The same resulting stereolithography file was sent for manufacturing using
four CAD/CAM methods (N=40): milling and sintering of zirconium dioxide (ZO), Co-
Cr sintered by selective laser melting (SLM), fully sintered machined Co-Cr alloy
(MM); machined and sintered agglutinated Co-Cr alloy powder (AM). Prefabricated
titanium abutments were used as control (TI). Each abutment was installed onto a
dental implant measuring 4.1 x 11 mm (SA411, SIN, Brazil) inserted into an
aluminum block. Measurements were taken using SEM (4,000X) on four regions of
the implant-abutment interface (IAI), and relative distance of 90° from each other.
The specimens were mechanically aged (1,000,000 cycles, 2 Hz, 100N, 37°C) and
the IAI width was measured again using the same approach. Data were analyzed
using two-way ANOVA, followed by the Tukey test. After mechanical cycling, the best
adaptation results were obtained from group TI (2.29 ± 1.13 µm), AM (3.58 ± 1.80 µm)
and MM (1.89 ± 0.98 µm). A significantly worse adaptation outcome was observed
for the groups SLM (18.40 ± 20.78 µm) and ZO (10.42 ± 0.80 µm). Mechanical
cycling had a marked effect only on the AM specimens, which significantly increased
the microgap at the IAI. Custom abutments fabricated using MM and AM
demonstrated lower adaptation levels at the IAI, similar to those obtained with
commercial prefabricated titanium abutments after mechanical cycling. The
adaptation of custom abutments made by SLM or ZO methods remained in higher
levels, both before and after mechanical cycling.

Key words: CAD/CAM. Microgap. External abutment connection. Dental implant.

Implant-abutment interface. Misfit.
 DIVULGAÇÃO E TRANSMISSÃO DO CONHECIMENTO

O uso de sistemas computadorizados para a elaboração de próteses dentárias é

uma tendência atual na implantodontia. Este trabalho objetivou medir o encaixe

entre implantes dentários e pilares (coroa dentária), elaborados por técnicas

computadorizadas em diferentes materiais (zircônia, metal denso, metal em pó

endurecido a laser, metal em pó aglutinado), sendo comparadas a peças em titânio

pré-fabricadas. O encaixe entre implante-pilar foi medido inicialmente e após o seu

envelhecimento artificial. As peças desmontadas foram inspecionadas por meio de

um microscópio. As menores medidas de encaixe foram obtidas com os pilares pré-

fabricados de titânio, metal denso e metal em pó aglutinado; enquanto que as

maiores medidas foram obtidas nos pilares em zircônia e em metal em pó

endurecido a laser. Os pilares em metal endurecido a laser apresentaram

deformações e rugosidades. Conclui-se que métodos e materiais computadorizados

podem apresentar resultados diferentes tanto na precisão de encaixe como na

aparência microscópica. .
 SUMÁRIO

1. INTRODUÇÃO ................................................................................................ 09

2. OBJETIVOS .................................................................................................... 14

3. ARTIGO .......................................................................................................... 15

4. CONSIDERAÇÕES FINAIS ............................................................................ 51

ANEXO A – PARECER DO COMITÊ DE ÉTICA E PESQUISA ........................ 56

ANEXO B – DECLARAÇÃO DA EDITORA ....................................................... 57

 9

INTRODUÇÃO

A rapidez de elaboração das restaurações e a melhora do custo-benefício

proporcionado pelos sistemas CAD/CAM impulsionam a maior utilização destas

tecnologias (Joda & Brägger, 2015). As principais técnicas utilizadas para a

elaboração de próteses em CAD/CAM se baseiam em estratégias aditivas ou

subtrativas, sendo as últimas mais comuns. As estratégias subtrativas

envolvem a escultura de blocos de material por brocas ou pontas diamantadas

até atingirem a forma planejada por computador. Por outro lado, as estratégias

aditivas envolvem a escultura tridimensional do objeto pela deposição de

camadas sucessivas (Van Noort, 2012; Abduo et al., 2014). Diferentes

materiais, metálicos e não metálicos, são disponibilizados pela indústria para

confecção de componentes e próteses pela tecnologia CAD/CAM, sendo que a

opção pelo material a ser utilizado em cada caso depende do tipo de trabalho a

ser realizado, da aplicabilidade clínica e do plano de tratamento traçado pelo

cirurgião dentista.

O óxido zircônia é indicado nas reabilitações implanto-suportadas

CAD/CAM, sendo elaborado por técnica subtrativa de fresagem, e pode ser

utilizado clinicamente como pilar para restaurações cimentadas,

como material estrutural para revestimento estético direto ou como

mesoestrutura (Yüzügüllü et al., 2008; Baldassarri et al., 2012; Zembic et al.,

2013; Mühlemann et al., 2014; Joda et al., 2015). A zircônia favorece

resultados estéticos, apresenta boa biocompatibilidade, estabilidade de cor,

baixo acúmulo de biofilme, boa resistência à abrasão, baixa condução térmica

(Volpato et al., 2011); porém em alguns casos com maior exigência mecânica, há
 10

preferência dos clínicos em utilizar estruturas sobre implante em metais como o

titânio, ligas metálicas básicas ou nobres (Linkevicius & Vaitelis 2015; Svanborg

et al. 2015; Abduo et al. 2012; Vigolo et al. 2006).

A liga de Cobalto-Cromo (Co-Cr) é utilizada na elaboração de estruturas

para prótese, por suas propriedades mecânicas, como a sua elevada resistência

flexural, e propriedades químicas favoráveis, facilidade de uso e bom custo

benefício quando comparadas a ligas de metais nobres (Al Jabbari, 2014). Ligas

de Co-Cr podem ser utilizadas em estruturas para próteses sobre implante com

variadas extensões, de elementos unitários a próteses fixas extensas, e em

casos nos quais o desafio biomecânico seja mais acentuado, como em próteses

com pônticos em balanço, ou pilares com paredes finas. O Co-Cr é utilizado de

forma mais frequente em processos laboratoriais de fundição, porém

desenvolvimentos recentes permitiram aplicações dessas ligas com tecnologias

CAD/CAM por meio de estratégias subtrativas em máquinas fresadoras (de

França et al. 2015), ou por estratégia aditiva (Koutsoukis et al., 2015; Tuna et al.,

2015).

Apenas algumas máquinas fresadoras industriais CNC (Computer

Numeric Control), ou fresadoras especiais CAD/CAM de grande porte para

laboratório de prótese dentária são capazes produzir estruturas por usinagem de

blocos sólidos de Co-Cr em larga escala, devido à resistência ao desgaste do

material (Stawarczyk et al., 2014). Para aumentar o acesso à esta tecnologia,

uma liga de Co-Cr para CAD/CAM foi desenvolvida (Ceramill Sintron,

AmannGirrbach, Áustria), apresentada sob a forma de blocos do metal em pó

prensado em conjunto com polímeros aglutinantes para aumentar sua

estabilidade (Lee et al., 2015). O método de fabricação utilizando o Co-Cr

 11

aglutinado permite usinar o material a seco por técnicas subtrativas em

máquinas menos robustas (Stawarczyk et al., 2014). As etapas de

processamento desse material são comparáveis com as da zircônia, pois o

material deve ser usinado em dimensões aumentadas, e logo em seguida,

sinterizado em um forno especial sob a presença do gás argônio, para atingir

suas propriedades químicas e mecânicas finais que seriam comparáveis com as

ligas fundidas de Co-Cr (Becker et al., 1995; Dourandish et al., 2008; Stawarczyk

et al., 2014; Lee et al., 2015; Li et al., 2015).

A estratégia aditiva Selective Laser Melting (SLM), também conhecida

como sinterização a laser, utiliza como matéria prima metais como o Titânio e

Co-Cr em grânulos finos que são fundidos por um laser direcionado a

coordenadas tridimensionais indicadas pelo projeto computadorizado, sendo que

após a sinterização de camadas verticais sucessivas de material a estrutura irá

atingir as dimensões volumétricas finais (Koutsoukis et al. 2015; Lu et al. 2015;

Takaichi et al. 2015). A técnica SLM é capaz de produzir corpos mais complexos

tridimensionalmente do que aqueles obtidos por técnicas subtrativas (Van Noort,

2012). As tecnologias SLM e a de fresagem de Co-Cr aglutinado vem sendo

estudadas para a elaboração de estruturas protéticas sobre dentes naturais

(Oyagüe et al., 2012; Tuna et al., 2015), e pilares para implantes unitários

(Fernández et al., 2015).

Os sistemas CAD/CAM permitem a construção de pilares protéticos que

podem ter interface pilar-implante (IPI) por duas estratégias: i- Cimentando o pilar

personalizado sobre um pilar pré-fabricado em titânio (Ti-based), para garantir que

o ajuste IAI seja ótimo, já que as peças são produzidas sob as especificações

originais do fabricante, resultando em adequada resistência mecânica (Joda et al.,

 12

2015); ii - Projetando diretamente o pilar personalizado incluindo a IPI. Neste caso,

o pilar poderia ser fabricado em qualquer material e estratégia disponível em

máquinas laboratoriais. Diante dessas técnicas, surge a preocupação com a

precisão alcançada no nível da IPI e a resistência dos pilares obtidos por esses

métodos de customização (Baldassarri et al., 2012; Mühlermann et al., 2014;

Fernández et al., 2014; Joda et al., 2015). Enquanto que o primeiro método (i) é

mais frequentemente indicado pelos fabricantes de implantes, o segundo (ii)

também pode ser utilizado segundo a preferência do clínico (Mühlermann et al.,

2014, Joda et al., 2015).

Há um número limitado de acompanhamentos in vivo de longo prazo de

reconstruções unitárias sobre implante elaboradas por CAD/CAM (Zembic et al.,

2013; Patzelt et al., 2015). Clinicamente pilares personalizados unitários

elaborados por fresagem em CAD/CAM em titânio ou zircônia para a reabilitação

de implantes na região anterior tem mostrado um bom desempenho, sendo

relacionados a uma melhor estabilidade dos tecidos moles, quando comparados a

pilares pré-fabricados (Borges et al., 2014; Lops et al., 2015).

Sabe-se que durante a função clínica de próteses sobre implantes, forças

induzem tensões nos componentes protéticos, nos implantes e nos tecidos de

suporte, que podem ser potencializadas caso exista uma desadaptação na interface

pilar-implante (Markarian et al., 2007), podendo resultar em infiltração e proliferação

bacteriana peri-implantar (Jansen et al., 1997). Medidas de adaptação da fenda na

interface implante-pilar tem sido realizadas com sucesso por meio do microscópio

eletrônico de varredura (MEV) (Dias et al., 2012; Coelho et al., 2007; Solá-Ruíz et

al., 2013), bem como para exibir desgastes em componentes protéticos e em

implantes (Stimmelmayr et al., 2012).

 13

É possível simular in vitro o envelhecimento de corpos de prova pela

ação de forças externas e estimar seu comportamento durante função clínica

por meio de máquinas de ciclagem mecânica (Stimmelmayr et al. 2012; Hecker

et al. 2006; Cibirka et al. 2001; Assunção et al. 2009; Dittmer et al. 2012). Dado

que fabricantes oferecem continuamente novos materiais e técnicas para uso

em sistemas CAD/CAM, e há poucos estudos que demonstrem seu uso em

pilares unitários sobre implantes, torna-se importante realizar investigações

para caracterizá-los in vitro, para que possam ser utilizados clinicamente de

forma segura.
 14

2 OBJETIVOS

O objetivo deste trabalho foi avaliar por MEV a fenda entre implantes com

hexágono externo e componentes personalizados unitários aparafusados,

elaborados por quatro métodos CAD/CAM: fresagem de zircônia, sinterização a

laser liga de Co-Cr em pó, fresagem de liga de Co-Cr denso, fresagem de liga de

Co-Cr em pó aglutinado por polímeros; submetidos a ciclagem mecânica, além de

observar a morfologia dos componentes protéticos e analisar os efeitos

qualitativos da ciclagem mecânica sobre eles.

 15

3 ARTIGO

SEM analysis of the adaptation of single-unit screw-retained CAD/CAM

abutments after mechanical cycling

Roberto Adrian Markarian DDS, MS, PhD student, Deborah Pedroso Galles

DVM, MS, Fabiana Mantovani Gomes França DDS, MS, PhD

International Journal of Oral & Maxillofacial Implants 2017 (In Press)

ABSTRACT

Purpose: To measure the microgap between dental implants and custom abutments

fabricated using different CAD/CAM methods, before and after mechanical cycling,

using Scanning Electron Microscopy (SEM).

Materials and Methods: The CAD software (Dental System, 3shape, Denmark) was

used to design a custom abutment for a single-unit screw-retained crown, compatible

with a 4.1 external hexagon dental implant. The same resulting stereolithography file

was sent for manufacturing using four CAD/CAM methods (N=40): milling and

sintering of zirconium dioxide (ZO), Co-Cr sintered by selective laser melting (SLM),

fully sintered machined Co-Cr alloy (MM); machined and sintered agglutinated Co-Cr

alloy powder (AM). Prefabricated titanium abutments were used as control (TI). Each

abutment was installed onto a dental implant measuring 4.1 x 11 mm (SA411, SIN,

Brazil) inserted into an aluminum block. Measurements were taken using SEM

(4,000X) on four regions of the implant-abutment interface (IAI), and relative distance

of 90° from each other. The specimens were mechanically aged (1,000,000 cycles, 2
 16

Hz, 100N, 37°C) and the IAI width was measured again using the same approach.

Data were analyzed using two-way ANOVA, followed by the Tukey test.

Results: After mechanical cycling, the best adaptation results were obtained from

group TI (2.29 ± 1.13 µm), AM (3.58 ± 1.80 µm) and MM (1.89 ± 0.98 µm). A

significantly worse adaptation outcome was observed for the groups SLM (18.40 ±

20.78 µm) and ZO (10.42 ± 0.80 µm). Mechanical cycling had a marked effect only

on the AM specimens, which significantly increased the microgap at the IAI.

Conclusion: Custom abutments fabricated using MM and AM demonstrated lower

adaptation levels at the IAI, similar to those obtained with commercial prefabricated

titanium abutments after mechanical cycling. The adaptation of custom abutments

made by SLM or ZO methods remained in higher levels, both before and after

mechanical cycling.

Key words: CAD/CAM, microgap, external abutment connection, dental implant,

Implant-abutment interface, misfit.

INTRODUCTION

The efficiency relating to CAD/CAM restorations as well as the cost-

effectiveness of CAD/CAM systems have driven the increased use of such

technologies.1 The main techniques used to create CAD/CAM restorations are

based on additive or subtractive manufacturing, the latter being more common.

Subtractive strategies involve computer-assisted sculpting of restorative material

blocks by drills or diamond burs until they have reached the desired shape.

Additive strategies involve three-dimensional sculpting of the object by deposition

 17

of successive layers.2,3 Different materials are available for the manufacturing of

components and prostheses for CAD/CAM technology.

Zirconium oxide is indicated for implant-supported CAD/CAM

rehabilitations and is prepared via subtractive milling to produce abutments for

cemented restorations, structural copings for direct esthetic layering and

mesostructures4-8. Zirconia offers good esthetics, biocompatibility, shade stability,

low accumulation of plaque, good resistance to abrasion and low thermal

conductivity;9 however when high mechanical resistance is required, clinicians

would rather use metal-alloy structures, such as titanium or precious metals.10,13

Cobalt-chrome (Co-Cr) alloys are used in prosthetic structures, due to their

favorable mechanical and chemical properties, ease of use and cost

effectiveness when compared to precious metal alloys.14 Co-Cr is frequently

used in laboratory casting processes, however recent developments have

enabled the use of such alloys with CAD/CAM technologies via subtractive

strategies, by milling machines,16 or additive approaches.17,18

Only a few industrial CNC (Computer Numeric Control) milling machines, or

specially large CAD/CAM milling machines for dental laboratories are able to

produce structures from fully sintered blocks of Co-Cr on a large scale, due to the

hardness of the material.19 In order to widen access to this technology, a Co-Cr

alloy for CAD/CAM has been developed (Ceramill Sintron, AmannGirrbach,

Austria) and presented in the form of metal blocks composed of pressed powder

and binding polymers to increase stability.20 The manufacturing method using

agglutinated Co-Cr allows machining of dry material by subtractive techniques

using less robust equipment.19 The processing steps involved in Co-Cr alloy

preparation are comparable to those of zirconia, since the material needs to be

 18

machined into relatively high dimensions, then immediately sintered in a special

furnace in the presence of argon so as to achieve its chemical and mechanical

properties, which are comparable to those of cast Co-Cr alloys. 15,19-22

The additive strategy of selective laser melting (SLM), also known as laser

sintering, uses fine granules of metals such as titanium and Co-Cr as raw

material, which are fused by a laser beam guided by three-dimensional

coordinates obtained from a computerized prototype. After sintering of

successive vertical layers of material, the structure will reach its final volumetric

dimensions.17,23,24 The SLM technique is capable of producing more complex

three-dimensional specimens than those obtained by subtractive techniques.2

The SLM and sintered metal milling technologies have been studied for the

development of prosthetic structures over natural teeth,18,25 as well as abutments

for single implants.26

There is only a limited number of long-term follow-up studies in vivo on

implant-supported single-unit CAD/CAM abutments.4,27 Clinically, customized

single-unit abutments prepared by CAD/CAM milling in titanium or zirconia for

implants in the anterior region have shown good performance, which has been

associated to superior soft tissue stability when compared to prefabricated

abutments.28,29 It is therefore important to simulate aging in vitro by applying

external forces and estimate their clinical behavior, which can be achieved by

means of mechanical cycling.30-34

Dental CAD/CAM systems allow the implant-abutment interface (IAI) to be

created by two strategies. i- cementing the customized abutment onto a prefabricated

titanium based (Ti-based) abutment ; ii- directly designing the customized abutment

including the IAI. Meanwhile the former is more often indicated by implant
 19

manufacturers, the latter could be used for some clinical solutions. 5,7

The use of prefabricated Ti-based abutments is recommended to ensure that

the IAI fit would be optimal, as parts are produced under original manufacturer’s

specifications, resulting in high mechanical stiffness and failure load.7 However, a

customized CAD/CAM abutment including the IAI could be manufactured under any

material and strategy used in desktop laboratory machines. Within these approaches,

concern may arise regarding the precision achieved at the IAI level and the

resistance of the abutments obtained by these nonoriginal methods, which is

increasing the interest on the subject in the literature. 5,7,8,26

It is known that during function, masticatory forces generate stress not only

in the abutment, but also in the implant and supporting tissues, which can be

potentiated should the IAI be ill-fitting,35 thus resulting in bacterial leakage and

peri-implant colonization.36 Scanning electron microscopy (SEM) has been

proven successful not only at measuring the IAI adaptation,37-39 but also at

revealing wear spots on both abutments and implants.30

The objective of this study was to evaluate by SEM the IAI adaptation of

customized single-unit CAD/CAM abutments manufactured by four different

methods and subjected to mechanical cycling, while qualitatively observing the

effects of mechanical cycling on the abutments. The null hypothesis was that

mechanical cycling and the type of material used to fabricate CAD/CAM

abutments do not interfere with implant/abutment adaptation.

 20

MATERIALS AND METHODS

Abutments

A flowchart of the experimental stages is shown as Figure 1. The samples

were prepared as single-unit abutments with a 4.1-mm diameter external hexagon

and anti-rotation platform. A 4.1 external hex implant analog (AN 4100, SIN - São

Paulo, Brazil) was scanned (D700, 3Shape A/S, Copenhagen, Denmark) and used

as the prototype connection. Using drawing software (Dental System, 3Shape A/S,

Copenhagen, Denmark), a digital custom abutment was designed for a single-unit

screwed-on restoration in the premolar region measuring 4.1 x 9.6 mm. The

abutment was meant to engage the implant hexagon and would require further

porcelain application (Fig 2). The same resulting stereolithography file format (STL)

was used to manufacture abutments using four different methods and, for each group,

ten identical abutments were made (Table 1). Titanium cylinders with anti-rotation

hexagon (AI 4151-Q, SIN - São Paulo, Brazil) were used as control abutments. Once

the abutments were obtained from the manufacturer, they were cleaned in a

ultrasonic bath containing 96% ethanol for 5 minutes.

For specimen preparation in the ZO Group, a CNC (computer numeric control)

milling machine (Roders, RXD5, Germany) was used. Zirconia milling was performed

in a pre-sintered stage with dimensions increased by 25%. This step was followed by

sintering of the structures in a specific furnace (In Fire, Sirona, Bensheim, Germany),

which caused the structure to shrink.

For the abutments in the SLM Group, the project was sent to a machining

center (CUBO, São Paulo, Brazil), which used an SLM machine (EOSINT M270 EOS

GmbH, Germany) and a Co-Cr alloy powder (EOS Cobalt Chrome SP2, EOS GmbH)
 21

as raw material. The samples were then separated from their base using a diamond

disc.

For the preparation of the Co-Cr specimens (MM group), the STL file was sent

to a CNC machining center (Neoshape, Neodent, Brazil). The abutments were

carved directly on a block of dense and completely sintered Co-Cr alloy, which

needed no further treatment of the material.

The specimens in the AM group were prepared on a lab-based machining

equipment (Ceramill Motion II, AmannGirrbach, Austria). The alloy was machined into

a bonded phase (Ceramill Sintron, AmmannGirrbach, Austria), with dimensions

increased by 10%. The abutments were then sintered as recommended by the

manufacturer in a specific furnace in the presence of argon gas at 1300 degrees

Celsius, according to the manufacturer's instructions (Ceramill ArgoTherm,

AmmannGirrbach, Austria). The appearance of the abutment samples obtained

using CAD/CAM methods are showed as Figure 3.

Test specimens set-up

For the final assembly of the specimens, 50 external hexagon titanium

implants (n = 10) were used, measuring 4mm in diameter, 11mm in length and a

4.1-mm platform (SA411, SIN - Brazil). The implants were inserted individually

into 50 aluminum blocks measuring 7 x 7 x 11 mm featuring a 3.5 mm diameter

and 8-mm deep central orifice, using an implant insertion key (CCIT 20, SIN -

Brazil) and a manual ratchet (TMECC, SIN - Brazil).

The implants were inserted to leave 3 mm exposed to comply with the

ISO14801 standard (Dentistry fatigue test for endosseous dental implants,

 22

International Organization for Standardization 2005, Geneva, Switzerland) for

simulation of vertical bone loss.

Then each abutment was fixed onto the implant using a square-headed

retaining screw (PTQ 2008 - SIN - Brazil) and manual torque of 32Ncm, using a

dedicated key (CQTM20, SIN - Brazil), manual a ratchet (TMEC, SIN, Brazil) and

a digital torque wrench (TQ-8800, Lutron, Taiwan) (Fig 4).

Mechanical Cycling

To simulate masticatory forces, the implant-abutment sets were subjected to

a million mechanical fatigue cycles at a frequency of 2Hz under 100 N and 30-

degree angulation on a mechanical cycling equipment (Byocycle, Biopdi, São

Carlos, Brazil). The specimens were kept in saline solution at 37°C throughout

the experiment.

SEM analysis of abutment fit

Adaptation measurements were taken at the IAI before and after mechanical

cycling at 4000x magnification using SEM. Each specimen received four markings

with relative distances of 90 degrees so that vertical misfit measurements could be

taken, corresponding to the distance between the bottom edge of each abutment and

the top edge of the implant. These measurements were always taken by the same

calibrated observer. The average of the four measurements (µm) for each specimen

was used as the reference value for each sample.

 23

SEM analysis of the internal hexagon surfaces

Following the evaluation of marginal adaptation, all abutments were

observed qualitatively at the fitting face of the hexagon, before and after

mechanical cycling, by scanning electron microscopy - SEM (Quanta FEG 250,

FEI, Hillsboro, United States), at 50x magnification. Subsequently, one of the

edges was chosen at random to be inspected at 250x magnification.

Statistical analysis

Quantitative evaluation of the implant-abutment interface

The assumptions of normality and homoscedasticity for the adaptation values

between implants and abutments were evaluated by Shapiro-Wilk and Levene tests,

respectively. Repeated measures two-way analysis of variance was applied to

determine whether the mismatch between implants and abutments was influenced by

abutment type and mechanical cycling. For the breakdown of interactions, the Tukey

test was applied. Statistical calculations were performed on SPSS 20 (SPSS Inc.,

Chicago, IL, USA), adopting a significance level of 5%.

RESULTS

Quantitative evaluation of the implant-abutment interface

The Shapiro-Wilk and Levene tests indicated that the data did not conform to a

normal distribution (p <0.05) nor did they show homoscedasticity (p <0.001),

respectively. A normal distribution was achieved, however, by applying a logarithmic

transformation of the data (p> 0.05).

 24

The repeated measures two-way analysis of variance applied to the

transformed data revealed a significant interaction between abutment type and

mechanical cycling (p> 0.001, 83.8% test power).

Breaking down the interactions using the Tukey test, it was observed that prior

to mechanical cycling lower adaptation values were found for control group (TI) and

AM, which were not significantly different between each other (Table 2). The highest

adaptation values were found in the zirconium oxide (ZO) and selective laser melting

(SLM) groups, which were not found to be significantly different from each other. The

adaptation values obtained from the machined fully sintered Co-Cr abutments (MM

group) showed intermediate values, which were significantly different from those

found for the other abutments types.

Upon completion of mechanical cycling, the Tukey test indicated that lower

adaptation values were obtained for the abutments from the MM, TI and AM groups,

with no significant differences between them. The zirconium oxide and laser sintered

Co-Cr abutments showed the highest misfit values and were not significantly different

between each other. Mechanical cycling had a significant effect on adaptation values

only for the agglutinated Co-Cr abutments, leading to a significant increase in misfit.

Qualitative evaluation via SEM

When inspecting adaptation at the IAI and hexagons by SEM, the lateral wall of

the titanium abutments (TI) appeared flattened and containing some grooves (Fig 5A).

These specimens had regular and well-defined edges that were not affected by

mechanical cycling (Figs 5B, 6C and 6D).

 25

At 4000x magnification, evidence of mild roughness and unevenness was

observed on the lateral wall of the abutments from the ZO group, with loss of

definition of the abutment edges (Fig 5C). After mechanical cycling, the abutment

edges did not change, however a smear layer could be seen on the hexagonal

surface of the interface (Figs 5D and 7D).

The specimens from the SLM group showed moderate surface roughness as

well as irregularities on their walls and edges (Figs 5E and 5F). Inspection of the

interface revealed deformation of the abutment edges and the presence of lumps and

beads of material. There were not perceptive qualitative changes after mechanical

cycling (Figs 8A, 8B, 8C, 8D).

The lateral surface of the abutments from the MM group was flattened and

contained slight grooves and dimples inherent to the machining process, which was

very similar to the TI group (Fig 5G). The specimens presented regular and well-

defined edges, and were not apparently affected by mechanical cycling (Figs 5H and

9D). At the hex connection interface, some artifacts were observed such as chippings

and beads of material (Figs 9A and 9C). After mechanical cycling, these beads

disappeared leaving a smear layer deposited onto the interface surface (Fig 9D).

The abutments from the AM group showed a markedly rough lateral surface

with rounded edges (Fig 5I). Inspection of the interface revealed microtexture

patterns and loss of definition of the dihedral angles, despite the abutment appearing

smooth and containing no artifacts macroscopically (Fig 10A). The characteristics of

the interface did not change after mechanical cycling (Figs 5J and 10D).
 26

DISCUSSION

CAD/CAM permits abutment designs of customized dimensions using a variety

of materials.1 CAD/CAM abutments are designed to produce a highly accurate

implant-abutment interface, however some manufacturing factors may interfere with

such high standard adaptation, including the use of additive or subtractive strategies,

the quality of the milling machine and the intrinsic properties of the preparation

material.3

The manufacturing process did influence the adaptation of single-unit

CAD/CAM abutments in this study and the null hypothesis was therefore rejected.

The abutments from the TI group (control group) were machined by the same

manufacturer as the implants. This process followed strict specifications for maximum

precision of the implant-abutment set, obtaining average values in the order of 1 µm.

Similar mean values were obtained with the abutments from the agglutinated Co-Cr

powder (AM) group, which under inspection by SEM, were free from internal

irregularities and debris (Fig 10C). Intermediate adaptation values around 2.5 µm

were obtained for the fully sintered machined metal (MM) group, whose abutments

were prepared on a CNC machine and showed artifacts such as beads and debris at

the interface, which may have interfered with the quality of the initial adaptation (Fig

9C). The abutments from the groups made with selective laser melting (SLM) and

zirconium oxide (ZO) had the highest misfit values, greater than 10 µm. In the case of

ZO abutments, no evidence of changes was observed at the interface using SEM

(Fig 7C), but for the SLM abutments, a marked morphological change was observed,

such as roughness throughout the abutment surface at the interface region (Fig 8C)

when compared to the control group (TI) (Fig 6B).

 27

Solá-Ruíz et al. (2013)39 investigated the baseline adaptation of external

hexagon titanium abutments, interchanging components between different

commercial systems and classified the adaptation level as acceptable, good and

excellent, with values typically below 10 µm and average values below 4 µm. Results

below 10 µm were also found in the literature for fixed prostheses prepared by

CAD/CAM in zirconia,12 in titanium and in Co-Cr.11 In the present study, after

mechanical loading, the abutments from the groups TI, MM, and AM showed similar

adaptation values to each other and all within the same levels as those reported in

the literature for external hex implant abutments.37,39 Apparently, metal abutments

made by CAD/CAM systems using subtractive milling techniques provide highly

accurate results. Moreover, although the abutments from groups ZO and SLM have

shown a decrease in average misfit, this was not significant and remained at high

levels, possibly because the causal factors of the initial misfit were maintained.

Fernández et al. (2014)26 investigated the adaptation of single-unit abutments

for external hexagon implants made in Co-Cr by CAD/CAM using SLM and milling

techniques, comparing them with cast abutments. They reported average adaptation

values in the order of 11.3 µm, 0.73 µm and 9.09 µm, respectively. They found that

the abutments prepared by SLM showed high superficial roughness and loss of

definition of the edges, with a positive correlation between internal roughness and

abutment adaptation.26

Such results corroborate those found in this study using SEM, which

demonstrated considerable roughness on the abutments from the SLM group, which

did not change after mechanical cycling, similarly to the agglutinated metal powder

abutments (AM). Clinically, this roughness could translate into greater bacterial

colonization on the unpolished inner surfaces of the abutment and enhance bacterial
 28

count at the IAI (Figs 8C and 10C). The relevance of such bacterial accumulation

must be investigated thoroughly because contamination at the IAI always occurs to

some extent.37 Jansen et al. studied microbial infiltration on thirteen different implant-

abutment configurations and reported that a good marginal seal of implant

components can reduce bacterial leakage, though no system was able to prevent it

altogether.36

The lateral surface of the abutments from the MM group contained some

grooves and undulations, similarly to group TI (Fig 5G). The interface showed well-

defined geometry and angles (Fig 9A). The artifacts initially found at the IAI of the

MM abutments were probably secondary to overheating during milling, considering

the high wear resistance of the material.3,14 The friction between the components

during mechanical cycling was probably the cause of the smear layer and the small

chippings seen on the surface of the components. The same friction could have

caused the beads of material to disappear (Fig 9D).

The titanium abutments in control group showed well-defined margins and

some grooves on their walls from the CNC tools (Fig 5A), which apparently suffered

no qualitative changes after mechanical cycling (Fig 5B). The good results for the

titanium abutments observed in this study may encourage the use of Ti-based

abutments in CAD/CAM systems. Some manufacturers propose digital systems for

which Ti-based abutments are used and onto which a monolithic crown7 or a

mesostructure4,5 can be designed. Therefore, at least in theory, the fit between the

implant and the prosthetic system would always be the best possible and less

susceptible to aging by mechanical fatigue. The use of Ti-based abutments, however,

brings out further questions in terms of their mechanical stability, the strength of the

cement layer between the interface and the mesostructure and bacterial colonization
 29

of the cementation zone.5 According to the results from this study, theoretically, these

intermediate structures could also be adequately designed with good adaptation

outcomes using techniques and materials from the groups MM and AM.

Mechanical cycling methods vary widely in the literature, both in number of

masticatory cycles, force applied, specimen angulation and frequency.33 In general,

studies seem to show no change in adaptation levels of single-unit abutments after

mechanical cycling, as observed for single-unit cast abutments,31 abutments

prepared through CAD/CAM alumina, zirconia and titanium.6 Moreover, Cibirka32

observed macroscopic changes on implant and abutment hexagons after a number

of cycles (five million), despite no change in counter-torque or loosening of the

screws.

In this study, the simulation of 15 months of clinical use was performed on the

abutments,34 which did not affect the level of marginal fit in any of the groups, except

for group AM, thus causing the null hypothesis to be rejected. It is a novel material,

into which only few in vitro15,19,20 and no clinical studies have been performed. No

one knows for sure if the presence of organic agglutinating substances influence on

their ultimate strength, or the degree of porosity resulting from sintering. One of the

possible reasons for such findings could be the sintering process, which can cause

dimensional changes.21 In addition, the images from the interfaces suggest a certain

degree of horizontal misalignment of the components from this group (Fig 5J), which

has not been further investigated in this study.

The abutments fabricated in zirconia (ZO) presented a regular and well-defined

macroscopic shape on SEM at 250x magnification (Fig 7A), however irregularities

could be detected at 4000x (Fig 5C). After mechanical cycling, no further damage to

the abutments was detected (Figs 7B and 5D), though smear deposits were
 30

observed at the hexagonal interface of all zirconia abutments, probably caused by

friction between components (Fig 7D), whose contents could not be determined. This

finding corroborate those by a study that reported debris, irregularities and increased

wear on the implant interface connected to zirconia abutments compared to titanium

abutments after mechanical cycling.30

Custom ceramic abutments prepared by CAD/CAM systems provide good

results due to their structural stability.9 Linkevicius & Vaitelis10 found that single-unit

titanium and zirconia abutments behave well clinically with esthetic advantages to

zirconia. The authors state that titanium should be the material of choice for stability

over time, but other materials may be used for restorations with direct application of

porcelain to zirconia and Co-Cr. The results from the present study corroborate these

previous findings since the best qualitative and quantitative results for adaptation

were obtained from titanium abutments. Conversely, reports show that single-unit

abutments made of zirconia for CAD/CAM systems performed just as well as their

prefabricated titanium counterparts,6,12,13 while others reported worse performance.8

In the present study, zirconia abutments had significantly poorer adaptation values

than the control group. Possible reasons for such difference may be related to certain

stages of the manufacturing process and intrinsic properties of the material.3 The

abutments from the titanium control group were processed on a large CNC milling

machine and no comparisons were made with other machines on the market.

Zirconium oxide is machined at an increased volume, which requires a special

heating furnace at high temperature to achieve the final sintering. Therefore, the

sintering stage could distort the marginal adaptation of Zirconia abutments,

secondary to abutment shrinkage.16

 31

Milling and direct metal laser sintering using SLM strategies would be preferable

to conventional casting techniques.25 Theoretically, the low ductility of casting Co-Cr

would not allow for finely detailed structures and, therefore, milling would be more

suitable to reproduce details.15 On the other hand, criticism to milling techniques may

include equipment vibrations and the use of drills that may become worn and unable

to reproduce all required detail in prosthetic structures.2,18

Hypothetically, marginal adaptation of abutments prepared by SLM would be

equal or slightly better than metal casting and certainly better compared to milling.25

However, in this study the laser sintered material showed high internal distortion and

sharp marginal surface roughness as well as irregularities of the walls and edges that

generated the most significant misfit seen in this study. Also the specimens in SLM

group presented not only higher fit measurements, but also a low consistency of the

manufacturing process evidenced by a noticeable higher standard deviation, which

would hinder its clinical application for prosthetic structures over implants.

There were no significant additional changes to the abutments after mechanical

cycling. One possible explanation for the distortions observed in the SLM group could

be the intensity of the laser. A study found that different laser intensities can generate

completely different microstructures and, therefore, an optimal level of energy could

be investigated in order to optimize accuracy for implant structures.24 Another

variable that may have influenced this group was the fact that the SLM process

generates residual stresses within the material due to rapid heating and cooling of

the alloy, which may even affect the accuracy of the final structure.23 For this reason,

an additional heating step should be necessary so that this residual stress could be

released, which can also alter the microstructure of the alloy.24

 32

The vertical misfit of the components found in this study may not be the only

type of distortion in custom abutments prepared by CAD/CAM, since it is a three-

dimensional displacement and, as such, can be classified as vertical, horizontal,

angular and rotational.33 They ought to be as low as possible to prevent overloading

of the components and supporting tissues.35 The quality of the internal adaptation to

the abutment-implant system and the horizontal mismatch should also be further

investigated, which could be achieved using cross sections or longitudinal sections of

the specimens.37,39

One may infer, therefore, that titanium remains the gold standard for single-unit

implant abutments, but machined Co-Cr or agglutinated Co-Cr may be an alternative

in select cases, especially when ceramics should be applied directly onto the coping

surface. The selective laser melting technique should be further investigated prior to

intensive clinical use for implants.

CONCLUSION

This work aimed to measure the microgap between external connection dental

implants and CAD/CAM abutments made in different materials: milled zirconia, Co-Cr

alloy sintered by selective laser melting, machined Co-Cr alloy fully sintered,

machined Co-Cr alloy agglutinated powder, when compared to titanium prefabricated

abutments, before and after mechanical cycling.

Based on the findings as well as the limitations of this study, the following

conclusions can be drawn:

1. Custom abutments prepared in fully sintered machined Co-Cr by CAD/CAM

or agglutinated Co-Cr demonstrated levels of adaptation similar to those obtained

with prefabricated titanium abutments after mechanical cycling.

 33

2. The adaptation levels of CAD/CAM abutments obtained from selective laser

melting and zirconia remained in highest levels among the tested groups before and

after mechanical cycling.

3. Mechanical cycling increased the misfit values of agglutinated Co-Cr

abutments, which remained within the lowest levels among the tested groups, having

no effect on other types of abutments.

ACKOWLEDGEMENTS

The authors acknowledge the dental laboratory EsteticArt, São Paulo, Brazil, for

digital abutment design. Furthermore, they thank SIN, São Paulo, Brazil, for their

support by donating the implants and prosthetic components; and CEME/UNIFESP,

São Paulo, Brazil, for the SEM analyses.

The authors declare no conflict of interest, directly or indirectly, with regards to

any entity that is commercially related to the products mentioned in this article.

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23. Lu Y, Wu S, Gan Y, Li J, Zhao C, Zhuo D, et al. Investigation on the

microstructure, mechanical property and corrosion behavior of the selective laser

melted CoCrW alloy for dental application. Materials Science and Engineering: C.

2015;49:517-25.

24. Takaichi A, Nakamoto T, Joko N, Nomura N, Tsutsumi Y, Migita S, et al.

Microstructures and mechanical properties of Co–29Cr–6Mo alloy fabricated by

selective laser melting process for dental applications. Journal of the mechanical

behavior of biomedical materials. 2013;21:67-76.

25. Oyagüe RC, Sánchez-Turrión A, López-Lozano JF, Suárez-García MJ.

Vertical discrepancy and microleakage of laser-sintered and vacuum-cast implant-

supported structures luted with different cement types. Journal of dentistry.

2012;40(2):123-30.
 37

26. Fernández M, Delgado L, Molmeneu M, García D, Rodríguez D. Analysis of

the misfit of dental implant-supported prostheses made with three manufacturing

processes. The Journal of prosthetic dentistry. 2014;111(2):116-23.

27. Patzelt SBM, Spies BC, Kohal RJ. CAD/CAM-fabricated implant-supported

restorations: a systematic review. Clinical oral implants research. 2015;26(S11):77-

85.

28. Lops D, Bressan E, Parpaiola A, Sbricoli L, Cecchinato D, Romeo E. Soft

tissues stability of cad-cam and stock abutments in anterior regions: 2-year

prospective multicentric cohort study. Clinical oral implants research.

2015;26(12):1436-42.

29. Borges T, Lima T, Carvalho Á, Dourado C, Carvalho V. The influence of

customized abutments and custom metal abutments on the presence of the

interproximal papilla at implants inserted in single-unit gaps: a 1-year prospective

clinical study. Clinical oral implants research. 2014;25(11):1222-7.

30. Stimmelmayr M, Edelhoff D, Güth J-F, Erdelt K, Happe A, Beuer F. Wear at

the titanium–titanium and the titanium–zirconia implant–abutment interface: A

comparative in vitro study. Dental Materials. 2012;28(12):1215-20.

31. Hecker DM, Eckert SE, Choi Y-G. Cyclic loading of implant-supported

prostheses: comparison of gaps at the prosthetic-abutment interface when cycled

abutments are replaced with as-manufactured abutments. The Journal of prosthetic

dentistry. 2006;95(1):26-32.

32. Cibirka RM, Nelson SK, Lang BR, Rueggeberg FA. Examination of the

implant-abutment interface after fatigue testing. The Journal of prosthetic dentistry.

2001;85(3):268-75.
 38

33. Assunção WG, Dos Santos PH, Delben JA, Gomes ÉA, Barao VAR, Tabata

LF. Effect of misfit on preload maintenance of retention screws of implant-supported

prostheses. Journal of materials engineering and performance. 2009;18(7):935-8.

34. Dittmer MP, Dittmer S, Borchers L, Kohorst P, Stiesch M. Influence of the

interface design on the yield force of the implant–abutment complex before and after

cyclic mechanical loading. Journal of prosthodontic research. 2012;56(1):19-24.

35. Markarian RA, Ueda C, Sendyk CL, Laganá DC, Souza RM. Stress

distribution after installation of fixed frameworks with marginal gaps over angled and

parallel implants: a photoelastic analysis. Journal of Prosthodontics. 2007;16(2):117-

22.

36. Jansen VK, Conrads G, Richter E-J. Microbial leakage and marginal fit of the

implant-abutment interface. International Journal of Oral & Maxillofacial Implants.

1997;12(4).

37. Dias ECLdC, Bisognin EDC, Harari ND, Machado SJ, da Silva CP, de Almeida

Soares GD, et al. Evaluation of implant-abutment microgap and bacterial leakage in

five external-hex implant systems: an in vitro study. International Journal of Oral &

Maxillofacial Implants. 2012;27(2).

38. Coelho A, Suzuki M, Dibart S, Da Silva N, Coelho P. Cross-sectional analysis

of the implant–abutment interface. Journal of oral rehabilitation. 2007;34(7):508-16.

39. Solá-Ruíz MF, Selva-Otaolaurruchi E, Senent-Vicente G, González-de-Cossio

I, Amigó-Borrás V. Accuracy combining different brands of implants and abutments.

Medicina oral, patologia oral y cirugia bucal. 2013;18(2):e332.

Fig 1 Study flowchart.
39
 40

Fig 2 (A) Digital format of the morphological characteristics of the customized

abutment designed for this study. (B) Characteristics of the interface of the
customized abutment.
 41

Table 1 Description of experimental groups, materials and their composition

(n=10)
Fig 3 Samples of the components obtained using CAD/CAM methods. (A) TI-prefabricated titanium. (B) ZO-zirconia. (C)
SLM-selective laser melting. (D) MM-machined metal. (E) AM-agglutinated metal.
42
 43

Fig 4 Test specimen following implant placement into aluminum blocks and abutment
adaptation.
 44

Table 2 Mean and standard deviation of the adaptation values (µm) between implant
and the different abutments tested before and after mechanical cycling.

Uppercase and lowercase letters by the means represent the multicomparison of the
data by the Tukey test. Means followed by different uppercase letters indicate a
significant difference between types of abutments, considering the conditions before
and after mechanical cycling (comparisons within columns). Means followed by
different lowercase letters indicate a significant effect of mechanical cycling,
considering each type of abutment separately (comparison within rows).
Fig 5 Example of interfaces prior and after mechanical cycling for the different materials tested. (A) TI group before cycling. (B)
TI group after cycling. (C) ZO group before cycling. (D) ZO group after cycling. (E) SLM group before cycling. (F) SLM group
after cycling. (G) MM group before cycling. (H) MM group after cycling. (I) AM group before cycling. (J) AM group after cycling.
45
 46

Fig 6 Qualitative analysis of an abutment from group TI before and after mechanical
cycling. (A) Hexagon before (50X). (B) Hexagon after mechanical cycling (50X). (C)
Hexagon before (250X). (D) Hexagon after mechanical cycling (250X).
 47

Fig 7 Qualitative analysis of an abutment from group ZO before and after mechanical
cycling. (A) Hexagon before (50X). (B) Hexagon after mechanical cycling (50X). (C)
Hexagon before (250X). (D) Hexagon after mechanical cycling (250X).
 48

Fig 8 Qualitative analysis of an abutment from group SLM before and after
mechanical cycling. (A) Hexagon before (50X). (B) Hexagon after mechanical cycling
(50X). (C) Hexagon before (250X). (D) Hexagon after mechanical cycling (250X).
 49

Fig 9 Qualitative analysis of an abutment from group MM before and after

mechanical cycling. (A) Hexagon before (50X). (B) Hexagon after mechanical cycling
(50X). (C) Hexagon before (250X). (D) Hexagon after mechanical cycling (250X).
 50

Fig 10 Qualitative analysis of an abutment from group AM before and after

mechanical cycling. (A) Hexagon before (50X). (B) Hexagon after mechanical cycling
(50X). (C) Hexagon before (250X). (D) Hexagon after mechanical cycling (250X).
 51

4 CONSIDERAÇÕES FINAIS

Com base nos resultados e limitações deste estudo, as seguintes conclusões

podem ser tiradas:

1. Pilares customizados e elaborados por CAD/CAM em Co-Cr usinado, ou Co-Cr

aglutinado obtiveram os melhores resultados níveis de adaptação entre os grupos

testados, e similares aos obtidos com pilares de titânio pré-fabricados após ciclagem

mecânica.

2. Os níveis de adaptação de Pilares CAD/CAM elaborados por Sinterização a laser

e em Zircônia permaneceram com os maiores níveis de desajuste entre os grupos

testados antes e após ciclagem mecânica.

3. A ciclagem mecânica aumentou a fenda de adaptação de pilares de Co-Cr

aglutinado, que mesmo assim, permaneceram entre as menores medidas de

adaptação, não tendo efeito sobre os demais tipos de pilares estudados.

4. A estratégia CAD/CAM, e os materiais utilizados podem influenciar na morfologia

dos pilares resultantes.

 52

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 56

ANEXO A – PARECER DO COMITÊ DE ÉTICA E PESQUISA

 57

ANEXO B – DECLARAÇÃO DA EDITORA

58