Cono Morse

Review Article
Performance of conical abutment (Morse Taper) connection implants:

A systematic review
Christian M. Schmitt,1 Getulio Nogueira-Filho,2 Howard C. Tenenbaum,3 Jim Yuan Lai,3

Carlos Brito,2 Hendrik Do
€ ring,1,2 Jo
€ rg Nonhoff4
1
Department of Oral and Maxillofacial Surgery, University of Erlangen-Nuremberg, Erlangen, Germany
2
Department of Preventive Dentistry, University of Toronto, Toronto, Ontario, Canada
3
Department of Periodontology, University of Toronto, Toronto, Ontario, Canada
4
Clinical Research DENTSPLY Friadent, Mannheim, Germany
Received 7 January 2013; revised 20 February 2013; accepted 20 February 2013

Published online 9 May 2013 in Wiley Online Library (wileyonlinelibrary.com). 10.1002/jbm.a.34709
Abstract: In this systematic review, we aimed to compare abutments showed sufficient resistance to maximal bending
conical versus nonconical implant–abutment connection sys- forces and fatigue loading. However, conical abutments
tems in terms of their in vitro and in vivo performances. An showed superiority in terms of seal performance, microgap
electronic search was performed using PubMed, Embase, formation, torque maintenance, and abutment stability. In
and Medline databases with the logical operators: “dental vivo studies (human and animal) indicated that conical and
implant” AND “dental abutment” AND (“conical” OR “taper” nonconical systems are comparable in terms of implant suc-
OR “cone”). Names of the most common conical implant– cess and survival rates with less marginal bone loss around
abutment connection systems were used as additional key conical connection implants in most cases. This review indi-
words to detect further data. The search was limited to cates that implant systems using a conical implant–abutment
articles published up to November 2012. Recent publications connection, provides better results in terms of abutment fit,
were also searched manually in order to find any relevant stability, and seal performance. These design features could
studies that might have been missed using the search criteria lead to improvements over time versus nonconical connec-
noted above. Fifty-two studies met the inclusion criteria and tion systems. V C 2013 Wiley Periodicals, Inc. J Biomed Mater Res
were included in this systematic review. As the data and Part A: 102A: 552–574, 2014.
methods, as well as types of implants used was so heteroge-
neous, this mitigated against the performance of meta-analy- Key Words: systematic review, dental implant, dental abut-
sis. In vitro studies indicated that conical and nonconical ment, Morse Taper, implant–abutment connection
€ ring H, Nonhoff J. 2014. Performance of

How to cite this article: Schmitt CM, Nogueira-Filho G, Tenenbaum HC, Lai JY, Brito C, Do
conical abutment (Morse Taper) connection implants: A systematic review. J Biomed Mater Res Part A 2014:102A:552–574.
INTRODUCTION gap that permits bacterial invasion). It has been claimed

Implant systems differ in terms of the geometry of the that with conical implant–abutment attachment systems,
implant–abutment interface with particular differences this is not as much of a risk as the gap is much smaller
between both conical and nonconical connection systems with less leakage at the implant–abutment interface,1,2 thus
(indexed external or internal connections). The implant– retarding or preventing bacterial colonization. However, it
abutment connection represents the weakest point of dental must be recognized that as of now, there are no endosseous
endosseous implant fixtures, as it must resist maximal and dental implant systems that can provide a complete seal at
permanent masticatory forces as well as penetration by the implant–abutment interface1,3,4 and so this is still an im-
bacteria. portant clinical issue.
The formation of a marginal gap between the implant Regarding the mechanical properties of implant connec-
and abutment might lead to increased loss of marginal bone tions, it has been assumed that different abutment connec-
because of the penetration of bacteria into the implant– tions might provide greater resistance to displacement that
abutment interface (i.e., compared to an implant without a is caused by excessive occlusal forces.5 In this regard it has
Correspondence to: C. M. Schmitt; e-mail: christian.schmitt@uk-erlangen.de

Contract grant sponsor: Bavarian Association for Scientific Dentistry, Germany (VfwZ)
552 C 2013 WILEY PERIODICALS, INC.

V
REVIEW ARTICLE
been speculated that this displacement will increase stress/ resistance, bending moment/maximal load resistance and
strain on the endosseous implant thus promoting the accel- strain/stress distribution in and around the implant–
eration of marginal bone loss.6,7 Clearly then, there is need abutment interface with respect to the implant–abutment
for improvements in the connection systems currently in configuration.
use but at this time it is unknown as to whether one con- Additional inclusion criteria for in vivo studies:
nection system currently available, might be superior to
others. This review was undertaken to determine whether 1. Only comparative studies (animal and human trials),
there is any evidence to support the superiority of any con- with a minimum number of two groups, with one related
nection system over the other. Based on previous claims, it to the use of a conical (Morse Taper) and the other to a
was decided to focus more specifically on the performance nonconical implant–abutment connection system.
of conical (Morse Taper) implant–abutment connection sys- 2. In cases of clinical trials only prospective clinical com-
tems and to compare them with each other and to implant parative studies with a minimum follow-up of 12
systems with nonconical interfaces and to determine months.
whether there might be improved clinical outcomes with 3. Studies investigating marginal bone level changes and
one of these systems. implant survival rates.
MATERIAL AND METHODS

Publications not meeting all mentioned inclusion crite-
ria, using analytical formulas only, or dealing with case
This systematic review was conducted according to the Pre-
reports, case series, abstracts, letters, and narrative reviews
ferred Reporting Items for Systematic Reviews and Meta-
were excluded from this systematic review. In the presence
Analyses statement, the recommendations of the Cochrane
of duplicate publications, only the study with the most in-
Handbook for Systematic Reviews and known literature
clusive data was selected.
guidelines writing a systematic review.8–11 Several articles
related to the in vitro and in vivo performance of conical
Search strategy
implant–abutment connection systems were reviewed. The
The following electronic databases were searched:
central review questions were as follows:
1. The Cochrane Library (up to November, 15th, 2012):
1. Do implant systems with a conical (Morse Taper)
a. CDSR (Cochran Database of Systematic Review),
implant–abutment connection compared to nonconical
b. The Cochrane Central Register of Controlled Trials
implant–abutment connection systems in vitro show bet-
(CENTRAL),
ter performances in terms of implant–abutment seal and
c. The Cochran Review Groups.
under mechanical stress/loading?
2. MEDLINE (up to November, 15th, 2012).
2. Does the use of a conical (Morse Taper) implant–abut-
3. EMBASE (up to November, 15th, 2012).
ment connection system compared to a nonconical
implant–abutment connection system result in less mar-
Electronic search was carried out using the logical oper-
ginal bone level changes and higher implant survival
ators: (“dental implant”) AND (“dental abutment”) AND
rates?
[(“taper”) OR (“cone”) OR (“conical”)]. In order to detect
additional trials dealing with conical implant–abutment sys-
Inclusion and exclusion criteria tems, the databases were searched for major implant sys-
Studies were included according to the following general tems with a conical implant–abutment connection,
inclusion criteria: including: ITI/ Straumann Dental Implant System (Strau-
mann AG, CH-Basel/ Straumann GmbH, Freiburg, Switzer-
1. Publication in an international peer-reviewed journal. land), AnkylosV R (Dentsply FRIADENT GmbH, Mannheim,
2. Study published in English. Germany), BICON Dental Implants (BICON Europe, Sohren,
3. Publication not older than 15 years. Germany), AstraTech Implant System (AstraTech GmbH, Elz
Germany), ConelogV R (Camlog GmbH, Wimsheim, Germany),
Additional inclusion criteria for in vitro studies: NobelActiveV R (NobelBiocare Ag, Sweden), AlphatecV R BONI-
tex, AlphatecVR DUOtex (Henry Schein Dental Depot GmbH,
1. Only comparative studies with a minimum number of Langen, Germany), Neoss Implant System (Neoss GmbH,
two groups, with one related to the use of a conical K€oln Germany), Neodent Titamax CM, Neodent Alvim II Plus
(Morse Taper) implant–abutment connection and the IC (Neodent, Curitiba, Parana, Brazil), and TS Implant Sys-
other related to the use of another conical or nonconical tem (Osstem Implants GmbH, Eschborn Germany). Therefore
implant–abutment connection system. the name of the system, respectively, the manufacturer was
2. Studies investigating implant–abutment seal, particularly used as a logical operator and combined with the keywords
microgap formation and bacterial leakage. as follows: (“dental implant”) AND (“dental abutment”) AND
3. Studies investigating the performance of the implant– (“name of the system” OR “name of the manufacturer”).
abutment unit under loading conditions in vitro; In addition a hand search was carried out for the last
especially preload/torque loss, load fatigue performance/ six months in the following journals: Journal of Clinical
JOURNAL OF BIOMEDICAL MATERIALS RESEARCH A | FEB 2014 VOL 102A, ISSUE 2 553
Periodontology, Journal of Dental Research, Clinical Oral
Implants Research, Clinical Implant Dentistry and Related
Research, Journal of Periodontology, Journal of Periodontal
Research, The International Journal of Oral & Maxillofacial
Implants, Journal of Cranio and Maxillofacial Surgery,
Implant Dentistry, International Journal of Prosthodontics,
Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology
and Endodontology, The International journal of Periodon-
tics & Restorative Dentistry, The Journal of the American
Dental Association, The Journal of Prosthetic Dentistry,
American Journal of Dentistry, Journal of Esthetic and Re-
storative Dentistry, Quintessence International, Periodontol-
ogy 2000, British Journal of Oral and Maxillofacial Surgery,
Journal of Oral and Maxillofacial Surgery, Journal of Cranio
Maxillofacial Surgery, Journal of Canadian Dental Associa-
tion, and Journal of Oral Implantology.
The search and screening process was carried out by two
independent examiners (CS, GN) to minimize the potential
for reviewer biases. After electronic search all titles, key
words and abstracts were screened. Irrelevant studies or
studies not meeting the inclusion criteria were excluded. All
full texts of the remaining articles were acquired for the sec-
ond screening. The references of all selected publications
were additionally checked for further relevant data. In cases
of missing or insufficient data the corresponding authors
were contacted via e-mail. After detailed full text examination
and agreement between examiners further articles were
excluded. All remaining studies were included in this system-
atic review. The references were managed with specific bibli-
ographic software (EndNoteX4, ThomsonReutersV R , NY).
FIGURE 1. Study selection process. [Color figure can be viewed in the

online issue, which is available at wileyonlinelibrary.com.]
Data extraction
Data extractions were performed independently by the two
reviewers (CS, GN) using data extraction tables. In cases of
not investigate a conical implant–abutment connection, five
disagreements, the data were double checked with the origi-
studies did not meet primary objectives,25–29 one study had
nal data. The following data were extracted from the
a follow-up of only 6 months,30 one study had a retrospec-
selected articles: (1) authors, (2) title, (3) year of publica-
tive design,31 and four in vivo studies used implants with
tion, (4) journal name, (5) implant–abutment connection,
machined surfaces.32–35
(6) implant system, (7) number of implants per group, (8)
The remaining 52 studies were included in the review.
study design, (9) primary objective, (10) secondary objec-
Thirteen out of 52 studies dealt with implant–abutment seal
tives, (11) methods, and (12) results.
performance, particularly focusing on bacterial colonization,
saliva leakage, endotoxin ingress as well as overall micro-
RESULTS leakage based on dye penetration. Thirty studies concen-
The initial electronic literature search identified 468 publi- trated on stress and loading performance/resistance of the
cations (Fig. 1). Hand search did not provide any additional implant–abutment unit. Nine studies were carried out in
studies. Review of all titles, key words, and abstracts led to vivo, and there were five animal and four clinical (i.e.,
the exclusion of 345 studies, which left 123 studies for full human) trials. Regarding the secondary outcome of some in
text screening. After full text evaluation, 52 articles were vitro studies, there was overlap between groups.2,3,5,36,37 If
excluded, as they did not fulfill inclusion criteria. Reference applicable and meeting the inclusion criteria, a double
screening revealed eight additional studies. A total of 79 assessment was conducted concerning the secondary out-
studies were analyzed in detail for potential inclusion in the come.2,3,5,36,37 The study characteristics and outcomes for in
review. Twenty-seven additional studies were excluded for vitro studies are detailed in Tables I and II, and for in vivo
the following reasons: eight studies did not include a com- studies in Tables III and IV.
parable control group with another conical or nonconical
implant–abutment connection system,12–19 two studies used In vitro
implant and abutment replicas as a control group,20,21 three Seal performance. Eight trials studied the bacterial leakage
studies used analytical formulas only,22–24 three studies did of the implant–abutment interface.1,3,4,36,38–41 Following
554 SCHMITT ET AL. PERFORMANCE OF CONICAL IMPLANT–ABUTMENT CONNECTION SYSTEMS

TABLE I. Seal Performance
SEAL PERFORMANCE
Sec. Used Bacteria/

Author/ Year Connection System # Samples Insertion torque Pr. Objective Objectives Dyes Method Result
Nascimento Morse taper, SIN, Sistema de 20 per group, According to the Saliva leakage N.a. Human saliva Implant abutment Contamination:
et al., 2012 internal and Implante 10 loaded recommenda- into the implant– connection and External hex:
external hex Nacional and 10 tion of the man- abutment incubation in Loaded 10 out
unloaded ufacturer (20 interface under human saliva. of 10, unloaded
Ncm) loaded and Detecting saliva 3 out of 10 Inter-
unloaded leakage. Half of nal hex: Loaded
conditions the specimens: 10 out of 10,
Cycling with 120 unloaded 4 out
N, 500,000 of 10, Morse
cycles at 1.8 Hz taper: Loaded 9
out of 10,
unloaded 1 out
of 10
Tripodi et al., Internal cone, Universal II HI 10 per group, 5 According to the Bacterial leakage N.a. P. aeruginosa (PS), A. Bacterial inocula- For PS inocula-
2012 internal hex and CM, per bacterial recommenda- from the actinomycetemcomitans tion of the tion: 2 out of 5
(Implacil De species tion of the implant–abut- (AA) implant and in the conical
Bortoli) manufacturer ment interface abutment con- group and 2 out
nection and of 5 in the inter-
detecting bacte- nal hex group,
rial leakage for AA: 0 out of
five in the coni-
cal and 3 out of
5 in the internal
hex group
Assenza et al., Internal cone, Ankylos (Dents- 10 per system According to the Bacterial leakage N.a. P. aeruginosa, A. Bacterial inocula- Bacterial leakage:
2011 internal tri- ply Friadent), recommenda- from the actinomycetemcomitans tion of the internal conical
lobed, Replace Select tion of the implant-abut- implant and 1 out of 10, in-
cemented (Nobel Bio- manufacturer ment interface abutment con- ternal trilobed 6
care), Bone nection, and out of 10,
System measuring bac- cemented 0 out
terial leakage of 10
Teixeira et al., Internal cone, Titamax CM, 20 per system Titamax II Plus 20 Bacterial leakage Bacterial leakage S. aureus 1. Bacterial con- Into: Conical 70%
2011 internal hex Titamax II Plus (10 per Ncm, Titamax into the implant- from the tamination and internal hex
(Neodent) experiment) CM 32 Ncm, abutment implant-abut- before and 2. af- 100% leakage.
(recommended interface ment interface ter implant-abut- From: Conical
by the ment connec- 77.7% and inter-
manufacturer) tion, incubation nal hex 100%
and colony leakage
growth
calculation
TABLE I. Continued
SEAL PERFORMANCE
Sec. Used Bacteria/

Koutouzis Internal cone, Ankylos (Dents- 14 per system Ankylos 25 Ncm, Bacterial leakage Torque value loss E. coli Implant abutment Ankylos: 1 out of
et al., 2011 four groove ply Friadent), Bone level 35 into the implant- after loading connection, 14, mean CFUs
internal cone Bone level (ITI Ncm, (recom- abutment inter- loading in E. 14.07652.56,
Straumann) mended by the face during coli medium, torque increase
manufacturer) loading disconnection (2.8563.23
measuring loos- Ncm), Bone
ening torque, level (ITI): 12
incubation and out of 14, mean
measuring CFUs CFUs
184.646242.32,
torque decrease
(-5.0062.77
Ncm)
Ricomini Filho Internal cone 1 Not mentioned 11 per system Morse Taper 1: 35 Bacterial leakage Preload loss after S. sanguinis Connection, ther- Bacterial leakage
et al., 2010 (one piece), (6 with and 5 Ncm, Morse into the implant thermal cycling mal cycling and after loading:
internal cone without Taper 2 and abutment inter- and mechanical mechanical fa- Morse Taper 1
2 (two loading) external hexago- face subjected fatigue tigue testing, (67%), Morse
pieces), nal: 15 Ncm, to thermal cy- sterilization and Taper 2 (50%),
external hex, (recommended cling and me- contamination external hexago-
locking taper by the chanical fatigue. to bacterial me- nal (0%), locking
manufacturer) dium, detorque taper (60%) Pre-
measurements load loss after
and SEM cycling: Morse
analysis Taper 1
(12.5%), Morse
Taper 2
(-23.3%), exter-
nal hexagonal
(-23.1%).
Aloise et al., Internal cone, Bicon Implant 10 per system Ankylos 25 Ncm, Bacterial leakage N.a. S. sanguinis Inoculation S. san- Bactarial leakage:
2010 internal cone System Bicon tapped, from the guinis, connect- Ankylos 20%,
(Bicon), Anky- (recommended implant-abut- ing abutment Bicon 20%.
los (Dentsply by the ment interface. and implant,
Friadent) manufacturer) incubation and
proof of bacte-
rial presence or
absence
TABLE I. Continued
SEAL PERFORMANCE
Sec. Used Bacteria/

Harder et al., Internal cone, OsseoSpeed 8 per system According to the Molecular leakage N.a. LPS of Salmonella enterica Inoculation of Endotoxin detec-
2010 internal cone (AstraTech), recommenda- of endotoxin implant with tion in both
Ankylos tion of the along the LPS, connection groups after 5
(Dentsply manufacturer implant abut- to abutment and minutes. Signifi-
Friadent) ment interface incubation, en- cant less endo-
dotoxin detec- toxin concentra-
tion and tion (mean) for
measuring con- OsseoSpeed
centration over units over the
time (168h) whole examina-
tion period
Baixe et al., Internal cone Ankylos (Dents- 5 per system Nobel 35 Ncm, ITI Microgap between Microgap compar- N.a. Longitudinal cut- The mean micro-
2010 (2x), external ply Friadent), 15 Ncm, Astra implant and ing titanium and ting and scan- gap was larger
flat, internal OsseoSpeed 25 Ncm, Anky- abutment zirconia ning electron for flat-to-flat
flat (Astratech), los 15 Ncm (rec- abutments microscopy interface sys-
Standard ITI ommended by tems compared
(ITI Strau- the to conical inter-
mann, Nobel manufacturer) face systems,
Replace zirconia abut-
Tapered ments showed
Groovy (Nobel smaller micro-
Biocare) gaps than tita-
nium abutments
Tesmer et al., Internal cone, Ankylos and 10 per system Ankylos and Bacterial invasion N.a. A. actinomycetemcomitas, Implant abutment Bacterial contami-
2009 manipulated manipulated manipulated into the implant P. gingivalis connection, con- nation Ankylos:
internal Ankylos Ankylos 25 abutment tamination with (Aa 3/10, Pg 0/
cone, tri- (Dentsply Fria- Ncm, Nobel interface bacterial solu- 10, median
channel in- dent), Nobel Replace Select tion (Aa and CFUs; Aa 0, Pg
ternal Replace Select 35 Ncm, (recom- Pg), disconnec- 0), Nobel
connection (Nobel mended by the tion, incubation Replace select:
Biocare) manufacturer) and detecting (Aa 9/10, Pg 9/
bacterial 10, CFUs; Aa
contamination 24.5, Pg 12),
manipulated
Ankylos: (Aa 10/
10, Pg 10/10,
CFUs; Aa 81, Pg
55)
TABLE I. Continued
SEAL PERFORMANCE
Sec. Used Bacteria/

Coelho et al., Internal cone, Standard SLA 5 per system According to the Sealing capability N.a. Toluidin Blue dye Contamination of Total release after
2008 trilobed inter- implant (ITI, recommenda- of implant implant inter- 144h: ITI 55%,
nal, internal Straumann), tion of the system face, connection Intra-lock 22%
hex Replace Select manufacturer to abutment and and Replace
(Nobel Bio- measuring dye Select 100%.
care), Intra- leakage over
lock short col- time with spec-
lar implant trophotometric
(Intra-lock Int.) analysis
Gross et al., Internal cone, ITI (Straumann), 3 per system (1 10 Ncm, 20 Ncm Dye leakage over N.a. Gentian violet dye Contamination of Leakage increased
1999 external hex 3i, CeraOne per torque and according time implant inter- in all systems
(2x), spline and Steri-Oss group) to the recom- face, connection over time with
connection (Nobel Bio- mendation of to abutment and no significant
care), Spline the measuring dye differences after
(Sulzer manufacturer leakage over 80 minutes,
Calcitek), time with spec- leakage
trophotometric decreased sig-
analysis nificantly as
tightening tor-
que increased to
recommended
values
Jansen et al., Internal cone OsseoSpeed 10 per system According to the Bacterial seal from Microgap between E. coli Bacterial inocula- All systems
1997 (3x), div. (Astratech), recommenda- implant- abut- implant and tion of the inner showed bacte-
external flat Ankylos, Fria- tion of the ment interface abutment part of the rial leakage of
(7x), flat lit-2, IMZ manufacturer implant, abut- the implant
1internal (Dentsply Fria- ment connec- abutment inter-
cone, flat 1 dent), Bonefit tion, cultivation face after 5
internal sili- conical and and detection of days, the micro
con washer synOcta (ITI bacterial leakage gap was less
Straumann), over time (14 than 10 mm in
Branemark days), microgap all systems, con-
(Nobel Bio- detection with ical connection
care), Sema- SEM systems showed
dos (Bego the smallest
Semados), micro gap
HaTi (Leder-
mann), Calci-
tek Implants
TABLE II. Stress/Loading Performance
STRESS/LOADING PERFORMANCE
Author/ Year Connection System # Samples Insertion torque Pr. Objective Sec. Objectives Method Result
Load fatigue performance/ resistance

Seetoh et al., Internal cone, Ankylos (Dentsply 10 per system, 5 According to the Load fatigue perform- Fatigue perform- Fatigue loading No significant differ-
2011 internal hex1 Friadent), Life- per group (tita- recommendation ance/ resistance of ance of Ti and until failure of ence between the
cone, internal core PrimaCon- nium (Ti) and of the different implant- Zr abutments the implant Ti abutments tested
four groove1 nex (Keystone zirconia (Zr) manufacturer abutment connec- and determine abutment for the three sys-
cone Dental), Bone abutments) tion systems failure mode specimens or tems. Straumann
Level (ITI and region maximal cycles Zr abutments
Straumann) (10 Hz, 5 3 106 showed significant
cycles). SEM better load fatigue
analysis of resistance than
fracture region Ankylos and Prima-
Connex implants-
abutment systems.
Ribeiro et al., Internal cone, Conexao Implant 30 per system 30 Ncm Load fatigue perform- Determine the fail- Fatigue loading External hexagonal:
2011 internal hex, Systems (Con- ance/ resistance of ure mode and and calculating F50, 53.567.8 N,
external hex exao Sistemas three implant- abut- region of the F50 value internal conical:
de Protese) ment connection (at which 50% F50, 4462.49 N, in-
systems of the samples ternal hexagonal:
failed and 50% F50, 4563.40 N. In
ran out), stereo- 24 out of 30 cases
microscopy and fracture region was
SEM analysis of observed in the
fracture region threaded part of
the abutment.
Quek et al., External hex, Branemark 15 per system, (5 Branemark 28 Ncm, Load fatigue perform- Effect of decreas- Fatigue loading No statistical signifi-
2008 external hex, CeraOne (Nobel per group: rec- 3i 32 Ncm, ance/ resistance of ing/ increasing until failure or cant differences in
cam tube, Inter- Biocare), 3i ommended tor- Replace Select 35 different implant- tightening tor- maximal cycles the number of
nal cone Osseotite-STA que and -20% Ncm, Lifecore 30 abutment connec- que values (5 3 106 cycles). cycles to failure
(3i, Biomet), and 120% Ncm) Ncm (recom- tion systems and about 20% Examination of between the four
Replace Select- mended by the region and mode the fracture systems when rec-
Easy (Nobel manufacturer and of failure region and ommended torque
Biocare), -20%/ 120%) surface with values were used;
Lifecore Starge- SEM failure location is
1-COC (LC system specific and
Lifecore always occurs at
Biomedical) the weakest point
of the implant abut-
ment connection.
TABLE II. Continued
Cehreli et al., Internal cone, ITI Solid and Syn- 8 35 Ncm (recom- Load fatigue perform- Tightening torque Fatigue loading Solid abutments
2004 internal octagon Octa implants mended by the ance/resistance of loss after (500,000 cycles, showed significant
(ITI Straumann) manufacturer) different implant- loading Periotest value higher RTVs than
abutment connec- (PTVs) measure- synOcta abutments,
tion systems ments after ev- both implant abut-
ery 100,000 ment connections
cycles), after ter- showed compara-
mination re- ble high fatigue
moval torque resistances
value (RTV)
measurement
Khraisat et al., Internal cone, Branemark (Nobel 7 Branemark 32 Ncm, Load fatigue perform- Mode and region Fatigue loading ITI solid screw: no
2002 external hex Biocare), ITI ITI 35 Ncm (rec- ance/ resistance of of failure until failure of failures, Brane-
Solid screw (ITI ommended by two different the implant mark: fracture
Straumann) the manufacturer) implant- abutment abutment speci- between 1,778,023
connection systems mens or maxi- and 1,733,526
mal cycles cycles (significant
(1,800,000 difference); frac-
cycles), fracture tures occurred
surface analysis between the
with SEM threaded and
unthreaded parts of
the abutments
Perriard et al., Internal cone, in- ITI Standard (S) 20 specimens for 40 Ncm Load fatigue perform- Fracture mode Implant abutment S-O connection more
2002 ternal octagon and synOcta (O) O-O, 10 for O-S ance/ resistance of and region, connection and resistant to force
implants (ITI and 10 for S-S different ITI peak stresses in fatigue loading application; S-O
Straumann) 1 combination implant-abutment the implant- (step procedure, combination supe-
Solid (S) and (Abutment- connections abutment and calculating rior to O-O and S-
synOcta (O) Implant) connection F50), FEM detect- S; S-S- and O-O
abutments (ITI ing stress peaks comparable; in
Straumann) in implant-abut- cases of fracture no
ment preferential loca-
connection tion detectable in
all three groups;
stresses in the
implant-abutment
interface: O-O more
stresses than S-O
and S-S
TABLE II. Continued
Bending moment/ maximal load resistance

Coppede et al., Internal cone, in- Alvim II Plus 10 IH implants 10 Ncm, Resistance to bend- N.a. Maximal loading IC: 90.58 6 6.72 kgf
2009 ternal hex implants with IC implants 20 ing moment/ maxi- until failure, (MDF), no fracture,
internal hex (IH) Ncm (recom- mal fatigue measuring max- IH: 83.876 4.94 kgf
and with inter- mended by the resistance imal deforma- (MDF), 79.8664.77
nal cone (IC) manufacturer) tion force (MDF) kgf (FF), significant
(Neodent and fracture difference for MDF
Implants) force (FF)
Norton et al., Internal cone, in- OsseoSpeed 6 Astra 25 Ncm, ITI 35 Resistance to bend- N.a. 3 point bending Astra: Mean Pb 4176
2000 ternal cone (Astratech), Ncm (recom- ing moment/ maxi- test until failure Nmm, mean Mb
standard ITI (ITI mended by the mal fatigue or maximum 5507 Nmm, signifi-
Straumann) manufacturer) resistance load, measuring cant higher bend-
plastic bending ing moments at
moment (Pb) plastic deformation
and maximal and failure than ITI:
bending Mean Pb 2526
moment (Mb) Nmm, mean Mb
3269 Nmm
Norton et al., Internal cone, in- OsseoSpeed (1-pi- 6 1-piece abutment 15 Resistance to bend- N.a. 3 point bending Astra (1-piece): Mean
2000 ternal hex1 ece Uni-abut- Ncm, 2-piece ing moment/ maxi- test until failure Pb 4176 Nmm,
cone ment St and 2- abutment 25 Ncm mal fatigue or maximum mean Mb 5507
piece Profile- (recommended by resistance load, measuring Nmm; Astra (2-pi-
abutment ST) the manufacturer) plastic bending ece): Mean Pb 4049
(Astratech) moment (Pb) Nmm, mean Mb
and maximal 6281 Nmm, no sta-
bending tistical significant
moment (Mb) differences
Norton et al., Internal cone, OsseSpeed (Astra- 6 Astra 8 Ncm, Brane- Resistance to bend- N.a. 3 point bending Astra: Mean Pb 1315
1997 external hex tech), Brane- mark 20 Ncm ing moment/ maxi- test until failure Nmm, mean Mb
mark (Nobel (recommended by mal fatigue or maximum 2030 Nmm; Brane-
Biocare) the manufacturer) resistance load, measuring mark: Mean Pb
plastic bending mean 645 Nmm ,
moment (Pb) mean Mb 1262
and maximal Nmm , significant
bending difference between
moment (Mb) systems
Tightening/ loosening torque, cold welding
Park et al., Internal cone, in- Osstem Implant 10 per system, 5 30 Ncm Compression force N.a. Measuring com- All systems showed
2010 ternal cone1 Systems (US II, per group (tita- tightening abut- pression force preload loss after
external colar, SS II, GS II) nium and tung- ment to implant and tightening initial tightening.
external hex sten carbide and screw removal and removal tor- External hexagonal
carbon coated torque before and que before and connection showed
titanium after cycling after loading significantly higher
abutments) (106 cycles). preload loss after
loading than the
two conical
connections
TABLE II. Continued
Richiardi Internal cone, in- Alvim CM 34 per implant- 20 Ncm solid abut- Effect of loading on Effect of repeated Measuring re- Loading increased re-
Copedde ternal cone implants and abutment sys- ment, 10 Ncm the abutment re- insertion/ removal torque af- moval torque; two
et al., 2009 Universal abut- tem, 17 per two-piece abut- moval torque moval cycles on ter repeated piece system had
ment CM one- group (loading ment (recom- the abutment re- insertion/ re- to be removed in
and two-piece and no loading) mended by the moval torque moval and after two steps with tor-
(Neodent) manufacturer) loading (1,325 que gain of the sec-
cycles), SEM ond piece after
loading (cold weld-
ing); increasing
number of abut-
ment insertion/re-
moval decreased
removal torque
values
Piermatti et al., Internal cone, OsseoSpeed 10 32 Ncm Removal torque in N.a. Off axis loading of Astra showed signifi-
2006 external hex (Astratech), Bio- combination with the specimens cant higher torque
(2x), internal Lok (Bio-Lok), loading and recording loss than other sys-
hex1 cone Branemark (No- removal torque tems under loading
bel Biocare), every 250.000 conditions, screw
Screw-vent cycles up to 106 design seems so
(Zimmer Dental) cycles be an important
factor influencing
the loosing torque
Ding et al., Internal cone, in- Standard and syn- 12 ITI standard, 24 35 Ncm (recom- Repeated torque/ Maximal failure Measuring Initial removal torque
2003 ternal octagon Octa ITI (ITI synOcta (12 mended by the reverse torque val- load repeated in/ out of solid abutments
Straumann) with solid and manufacturer) ues of each system torque values combined with
12 with synOcta and implant-abut- and maximal standard and syn-
abutment) ment combination bending Octa implants were
moment, SEM significantly higher
than the initial tor-
que removal of the
synOcta implant1
abutment, solid
abutments with
both implant types
showed significant
higher load
resistance
TABLE II. Continued
Weiss et al., Internal cone (2x), Standard ITI (ITI 3 According to the Comparison of torque N.a. 200 repeated con- Significant higher
2000 external hex Straumann), recommendation loss as a result of secutive closing/ maintaining torque
(3x), internal oc- SpectraClone of the multiple consecu- opening cycles values in either
tagon, flat rim (Alpha Bio), manufacturer tive closures within and measuring conical frictional
Spline, Integral and between the the torque elements or inter-
and Omnitek systems values locking lines, re-
(Calcitek), Ster- moval torque
iOss, Branemark declined for all sys-
(Nobel Biocare) tems progressively
up to 200 c/o cycles
Norton et al., Internal cone, in- Astratech (diame- 5 for Astra, 4 for Group 1: low torque Torque loss after dif- N.a. Measuring differ- All combination
1999 ternal cone, in- ters 3.5 and 5.0), ITI (4-50 Ncm), ferent tightening ent tightening showed compara-
ternal cone standard ITI (ITI Group 2: high tor- torques in wet and and the result- ble removal tor-
Straumann) que (100- 300 dry environment ing removal torques in wet and
Ncm) for different ques in wet and dry environments;
implant-abutment dry cold welding did
connections environments not occur between
20 and 40 Ncm;
surface area of
interface seems to
influence torque
loss
Stress/ strain distribution
Yamanishi External hex, inter- N.a. (simulation) N.a. N.a. Effect of implant N.a. Fenite element External hex connec-
et al., 2012 nal cone, inter- abutment design analysis method tion: Largest
nal straight on abutment micro- (FEM), simulat- amount of abut-
movement, ing an oblique ment movement,
implant- abutment load higher labial bone
interface and peri- stresses; Internal
implant stress conical: Lowest
distribution abutment move-
ment and low labial
peri-coronal bone
stresses
Saidin et al., Internal cone, tri- N.a. (simulation) N.a. N.a. Effect of implant- N.a. Fenite element Stress concentrates
2012 lobe, internal abutment connec- analysis method at vertices of non-
hex, internal tion on micromo- (FEM), simulat- conical abutments;
octagon tion and abutment ing axial and conical abutments
stress distribution oblique loads showed more uni-
formly distributed
stresses; internal
hex connection
showed the great-
est stresses, fol-
lowed by internal
conical, octagonal
and the trilobed
connection.
TABLE II. Continued
Pellizzer et al., Internal hex, exter- Conexao Implant 5 According to the Strain/ stress distribu- N.a. Photoelastic analy- Axial load: Greatest
2011 nal hex, internal System (Con- recommendation tion around sis under verti- stress concentra-
octagon 1cone, exao Systemas of the implants cal and oblique tion in the cervical
internal cone, de Protese), ITI manufacturer loading and apical thirds.
internal locking (Straumann), Oblique load: At
taper Bicon the implant apex
and in the cervical
adjacent to the
load direction. In-
ternal octagon1
cone presented the
lowest stress con-
centrations, exter-
nal hex exhibited
the greatest
stresses.
Nishioka et al., Internal cone, in- Conexao Implant 3 According to the Strain/ stress distribu- Effect of implant- Strain gauge Statistically signifi-
2011 ternal hex, System (Con- recommendation tion around abutment con- analysis cant difference
external hex exao Systemas of the implants nection and comparing the
de Protese) manufacturer implant fixture implant- abutment
alignment connections, Morse
Taper and internal
hexagon did not
reduce strain
around implants,
no statistical signif-
icance in the place-
ment configuration
Pessoa et al., Internal cone, in- Neodent Implant N.a. N.a. Stress/ strain in peri- Influence of con- Fenite element Conical connection
2010 ternal hex, System implant bone and nection type on analysis method showed a signifi-
external hex influence on abut- bone-to-implant (FEM), simulat- cant higher abut-
ment and implant relative dis- ing non-axial ment stability, the
stability (before placement and loading for im- smallest microgap
and after abutment mediate loaded and the lowest
osseointegration) microgap and osseointe- stress in the abut-
grated implants ment screw; mar-
ginal bone stresses
were comparable
for the simulation
of immediate
placed implants
and lower for
Morse Taper con-
nection implants af-
ter
osseointegration
TABLE II. Continued
Bernardes Internal cone, in- Neodent Implant 4 Not mentioned Peri-implant stress N.a. Photoelastic strain No significant differ-
et al., 2009 ternal hex, System fields generated analysis under ence under cen-
external hex, from four different different vertical tered axial loading,
one-piece implant-abutment center and off- smallest peri-
implant interfaces center loading implant stress field
conditions for internal hexago-
nal connection
under off-center
loads; Internal-
taper interfaces
presented interme-
diate results
Quaresma Internal cone, in- Frialit-2, Ankylos N.a. N.a. Strain/ stress distribu- N.a. Fenite element Conical abutment
et al., 2008 ternal hex (Dentsply tion in the prosthe- analysis method showed lower
Friadent) sis, abutment, (FEM), simulat- stresses on alveolar
implant and sur- ing different ver- bone and prothesis
rounding alveolar tical occlusal and higher stresses
bone under differ- forces on abutment. Inter-
ent loading nal hexagonal abut-
conditions ment showed
higher bone
stresses and lower
abutment stresses
Akca et al., Internal cone, in- synOcta, Mono- 2 per system Not mentioned Force transmission in N.a. Photoelastic and The internal cone-
2008 ternal cone, in- block ITI (ITI the peri-implant strain-gauge implants showed
ternal cone, Straumann), bone region of analysis under similar interface
one-piece Bicon Implants implants with dif- vertical and force transfer char-
implant (Bicon), Osseo- ferent conical oblique forces acteristics that
Speed implant-abutment resemble a one-pi-
(AstraTech) connections ece implant system
Lin et al., 2007 Internal cone, in- Frialit-2 (Dentsply N.a. N.a. Strain/ stress distribu- N.a. Fenite element Internal conical con-
ternal hex, inter- Friadent), Bicon, tion around analysis method nection performed
nal cone standard ITI implants influenced (FEM), simulat- better as a force-
Straumann by implant-abut- ing different oc- transmission mech-
ment connection clusal loads anism than other
systems, conical
systems showed
lower interface and
marginal bone
stresses than inter-
nal hexagonal con-
nection system
TABLE II. Continued
Cehreli et al., Internal cone, in- ITI Straumann, 2 per system Not mentioned Force transfer charac- N.a. Photoelastic and Strains around Brane-
2004 ternal cone, Astratech, Bra- teristics of different strain gauge mark implants were
external hex nemark (Nobel implant abutment analysis with lower than around
Biocare) connections vertical and Astra and ITI
oblique load implants particu-
application larly under vertical
loads
Alkan et al., Internal cone, Branemark (Nobel N.a. Simulated Stress distribution of N.a. 3-dimensional fen- In all systems maxi-
2004 external hex, in- Biocare), ITI according to the preloaded dental ite element anal- mum stress was
ternal octagon solid, synOcta manufacturers implant screws in ysis method examined between
(ITI Straumann) recommendations different implant- (FEM), 3 simu- the shank and first
abutment joint sys- lating occlusal thread of the abut-
tems under simu- loads (horizon- ment; stress
lated occlusal tal, vertical, increased in all sys-
forces oblique) tems under loading
conditions
Merz et al., Internal cone, ITI and hypotheti- N.a. Simulated with tor- Mechanics of two dif- N.a. Fenite elment Significant higher
2000 external hex cal butt joint ITI que of 35 Ncm ferent implant- analysis method stress in the butt
(ITI Straumann) according to the abutment (FEM), simulat- joint connection
recommendation connections ing vertical and tightening the abut-
of the different off-axis ment to the
manufacturer loads implant, taper con-
nection compen-
sated high forces,
butt joint showed
more stress in the
implant abutment
connection
Hansson et al., Internal cone, N.a. (simulation) N.a. N.a. Stress distribution N.a. Fenite element Significant decrease
2000 external flat top around implants analysis method in the peak bone-
with conical and (FEM), simu- implant interfacial
external flat lated axial shear stress in con-
implant abutment loading ical implant abut-
connections ment connections,
external flat top
showed high mar-
ginal peri-implant
stress peaks, coni-
cal system showed
lower marginal
stress peaks
Kitagawa et al., Internal cone, Ankylos (Dentsply N.a. Ankylos 20 Ncm, Dynamic behavior N.a. Fenite element The external type-
2005 external hex Friadent), Brane- Branemark 32 (screw loosening) analysis method joint model showed
mark (Nobel Ncm (recom- of different (FEM) compar- rotation movement,
Biocare) mended by the implant-abutment ing the move- the taper type-joint
manufacturer) connections ment of the showed no
taper-and exter- movement
nal type-joint
model
TABLE III. Animal Studies
ANIMAL STUDIES
Animal Primary Secondary

Author/Year Connection System model # Animals # Implants Healing Loading objective objective Results
Weng et al., Internal cone, Ankylos (Dentsply Mongrel 6 4 groups a 6 nonsubmerged No Radiographical N.a. Marginal bone
2011a external hex Friadent), Brane- dog implants (coni- marginal bone loss Conical:
mark (Nobel cal equicrestal loss equicrestal
Biocare) and subcrestal, (0.6860.59 mm),
external hexago- subcrestal
nal crestal and (0.7660.49 mm)
subcrestal) External: equi-
crestal
(1.3260.49 mm),
subcrestal
(1.8860.81mm)
Weng et al., Internal cone, Ankylos (Dentsply Mongrel 8 4 groups a 8 submerged No Radiographical N.a. Marginal bone
2011b external hex Friadent), Brane- dog implants (coni- marginal bone loss Conical:
mark (Nobel cal equicrestal loss equicrestal
Biocare) and subcrestal, (0.4860.66 mm),
external hexago- subcrestal
nal crestal and (0.7960.93 mm)
subcrestal) External: equi-
crestal
(0.6960.43mm),
subcrestal
(1.5660.53 mm)
Berglundh Internal cone, Astratech, Beagle dog 6 24 implants per submerged Yes Radiographical Histological Marginal bone
et al., 2005 external hex Branemark system marginal bone observation loss: Astratech
(Nobel Biocare) loss 0.0960.16 mm,
Branemark
0.7760.42 mm
Abrahamsson Internal cone, Astratech, Brane- Beagel dos 5 9 implants per submerged No Histological obser- Soft tissue Marginal bone
et al., 1998 external hex mark (Nobel system vation peri- response loss: Astratech
Biocare) implant tissue, around 0.6460.44 mm,
marginal bone implants to Branemark
loss plaque 0.6460.72 mm
formation
Abrahamsson Internal cone, Astratech, Beagle dog 5 10 implants per submerged No Histological obser- Soft tissue Marginal bone
et al., 1996 external hex Branemark system vation peri- around loss: Astratech
(Nobel Biocare) implant tissue, implants 0.5760.44 mm,
marginal bone Branemark
loss 0.6260.12 mm
TABLE IV. Human Studies
568
HUMAN STUDIES
Author/
Year Connection System Study Design Follow-up # Patients # Implants Placed Healing Loading Objective Results
Pieri et al., Internal Samo Smiler RCT 12 month 40 40 (20 per immediately nonsubmerged immediately Clinical and Marginal bone
2011 cone, Implants, group) radio- loss: Conical
internal Biospark graphical 0.260.17
SCHMITT ET AL.
hex outcome mm, internal
(marginal hex
bone 0.5160.24
loss), mm Implant
implant success: Con-
success ical 94.7%,
internal hex
100%
Bilhan Internal Astratech, Bra- CT 24 month 26 42 (Astra), 36 delayed submerged delayed Soft tissue, Marginal bone
et al., cone, nemark (No- (Branemark), marginal loss: Astra-
2010 external bel Biocare), 29 (ITI) bone loss, tech 0.6660.1
hex ITI implant mm, ITI
(Straumann) survival 0.860.1 mm,
Branemark
1.160.1 mm,
Implant sur-
vival: all
100%
Crespi Internal Ankylos (Dents- CT 24 month 45 34 (Branemark), Immediately nonsubmerged Immediately Marginal Marginal bone
et al., cone, ply Friadent), 30 (Ankylos) bone loss, loss: Conical
2009 external Seven Swe- implant 0.7360.52
hex den and survival mm, external
Martina hexagonal
Implants 0.7860.45
mm Implant
survival:
both 100%
Kielbassa Internal Nobel Active RCT 12 month 177 117 (internal delayed nonsubmerged immediately Marginal Implant sur-
et al., cone, (NA) internal multicenter NA), 82 bone loss vival: Internal
2009 external and study (external and soft NA 96.6%,
cone external, No- NA), 126 tissue external NA
external bel Replace (NR) behavior, 96.3%, NR
trilobe (NR, implant 97.6% Mar-
Nobel survival ginal bone
Biocare) rate loss: Internal
NA
0.9561.37
mm, external
NA
0.6460.97
mm, NR
PERFORMANCE OF CONICAL IMPLANT–ABUTMENT CONNECTION SYSTEMS

0.6361.18
mm
REVIEW ARTICLE
bacterial species were used: Escherichia coli, Aggregatibacter Stress/load performance. All studies dealing with stress or
actinomycetemcomitans (Aa), Porphyrmonas gingivalis (Pg), loading performance of the implant–abutment unit were
Streptococcus sanguinis (Ss), Pseudemonas aeruginosa (Pa), included in this part of the review. Depending on the pri-
and Streptococcus aureus (Sa). One study examined micro- mary outcome, the studies were summarized under the fol-
bacterial endotoxin leakage from the implant–abutment lowing subtopics: (1) load/fatigue performance, respectively,
interface using lipopolysaccharides (LPS) from Salmonella and resistance. There were six studies in this category,47–52
enterica (Se).42 Only Nascimento et al. examined human sa- (2) bending moment/ maximal load resistance (4 studies53–
liva leakage of the implant–abutment interface.43 Outcome 56
, (3) preload loss (tightening/ loosening torque) and cold
of included studies showed that 100% seal of the implant– welding, consisting of six studies,57–62 and (4) stress and
abutment interface to the outside could not be achieved strain distribution in and around the implant–abutment
regardless of the implant–abutment connection used.4,38,39 interface, consisting of 14 studies.2,5–7,37,63–71 Regarding the
Even if an abutment was tightened to an implant under secondary objectives, there was an overlapping between the
sterile conditions, bacterial invasion into the interface was four subtopics in few studies. The studies were assessed for
still demonstrated in most cases (Table I).1,40 both objectives if applicable and meeting the inclusion crite-
Only one study demonstrated 100% bacterial seal using ria (Table II).
the Ankylos implant–abutment unit to ingress/colonization
with Pg. However, when another organism, Aa, was tested it Load fatigue performance/ resistance. In the investigation
was demonstrated that this particular bacterial species of load fatigue performance, specifically resistance of the
could still penetrate into the AnkylosV implant–abutment
R
different implant–abutment connection systems, five trials
interface.1 Bacterial leakage was also shown in all implant– studied the mode of abutment failure using stereomicro-
abutment connection systems under loading in vitro.36 In scopy or SEM.47–52
contrast, Ricomini Filho et al. reported no leakage at all Although primary outcomes were different in the stud-
when testing the external hex implant–abutment connection ies, they all focused on the issue of load fatigue perform-
system using Ss.3 ance/resistance. In relation to this Seetoh et al., Quek et al.,
Two studies evaluated the implant–abutment seal using and Khraisat et al. measured the fatigue loading of the
dyes (toluidine blue and gentian violet) by measuring parti- specimens until failure or to a maximum number of cycles
cle absorption with spectrophotometric analysis.28,44 Coelho (5 3 106, 5 3 106 and 1.8 3 106 cycles).47,49,51 Cehreli
et al. documented significantly lower dye leakage with the et al. tested implant–abutment performance using a maxi-
Morse Taper and internal hexagonal connection as com- mum number of 500,000 cycles and used the PeriotestV R
pared to the tri-lobed internal connection system. Leakage system to measure the so-called PeriotestV R Values (PTVs)
was recorded in all systems and decreased significantly as over 100,000 cycles of loading/unloading. Ribeiro et al. and
tightening torque was increased to the values recommended Perriard et al. calculated the F50 value at which 50% of the
by the manufacturers.28 samples failed and 50% run out.48,50,52 Cehreli et al. were
In summary: the performance of the seal was (1) differ- unable to demonstrate failure of either the Morse Taper or
ent in every implant system in vitro regardless of the con- the internal octagonal attachments used for implant–abut-
nection, and (2) there appeared to be significantly less ment connections, even after 500,000 loading/unloading
bacterial contamination in implant systems using a pure cycles. There was a trend towards increased values for PTV
conical implant–abutment connection as compared to other for both implant–abutment connection designs and there
connection systems.1,4,36,40,41 However, although conical was no significant difference between either connection sys-
implant–abutment connection systems were able to reduce tems in this regard.50 After the application of 1.8 3 106 to
bacterial contamination significantly, they were still unable 5 3 106 cycles, several failures occurred.47,49,51 Khraisat
to prevent leakage of microbial endotoxin into the seal/gap et al. reported a significant difference between the Morse
area.42 Nascimnento et al. showed siginficant less human sa- Taper (ITI Straumann) and external hexagonal connection
liva penetration to the implant–abutment interface in coni- system (Branemark), in that no fractures were noted for the
cal conncetion systems.43 Morse Taper group while the mean fracture rate for the
Microgaps were detected in all systems with the scan- external hexagonal groups was somewhere between 1733
ning electron microscope (SEM), but were generally less and 1778 cycles.51 After 5 3 106 maximum cycles, there
than 10 mm for all connections tested in this manner.39 The were no statistically significant differences relating to fa-
mean microgap was significantly larger for flat-to-flat inter- tigue resistance for the various abutment systems and this
face systems compared to conical interface systems.45 Using was also not altered by different manufacturer-recom-
finite element analysis (FEM),46 Merz et al. documented the mended tightening torques.47,49 When focusing on the F50
formation of a microgap for external hexagonal connection value, Ribeiro et al. demonstrated superior fatigue resist-
systems on the tension side of the implant under oblique or ance for external hexagonal implant–abutment systems (F50:
horizontal loading simulation. Pessoa et al. also demon- 53.5 6 7.8 N), with no statistically significant differences
strated microgap formation on tension sides for internal between the conical (F50: 44 6 2.49 N) and internal hexago-
hexagonal and external hexagonal connection systems. Coni- nal (F50: 45 6 3.40 N) interfaces.48 Failure of the abutments
cal implant–abutment systems did not appear to develop was system-dependent and occurred primarily in the region
microgaps.2,37 of the weakest point, the screws, respectively, the threaded
parts, or between the threaded or unthreaded parts of the et al. and Park et al. documented torque loss following ini-
abutments.48,49,51 tial tightening of the abutment to the implant but without
loading, and this was done with several internal conical and
Bending moment/ maximal load resistance. All four trials external hexagonal implant–abutment connections.3,57
focused on bending moment/maximal load resistance of the Ding et al. showed that there was initial loss of torque
implant–abutment connection used similar methods.53–56 after tightening; however, this loss was significantly less in
Coppede et al. measured maximum deformation force the internal conical group in comparison to the internal oc-
(MDF) and fracture force (FF) of the specimens under a tagonal group.62 As well, Norton et al. documented no cold
compressive load delivered at 45! from the vertical (500 welding measuring on the removal torque for ITI and Astra-
gkf load cell with 1 mm/min dislocation) for internal coni- tech Morse Taper implant–abutment connection systems
cal (one-piece) and internal hexagonal (two-piece) implant– with applied torque values between 20 and 40 Ncm. Higher
abutment connection systems.53 Higher MDF values were insertion torque values (>100 Ncm) increased the rate of
demonstrated for the internal conical implant–abutment cold welding, but also the rate of fractures.60 The environ-
connection (90.58 6 6.72 kgf) as compared to the internal ment (dry and wet) did not influence these outcomes.60 Tor-
hexagonal connection with a two-piece abutment (83.72 6 que loss was also measured as a result of multiple
4.94 kgf). Fractures only occurred in the internal hexagonal consecutive closures using different implant–abutment con-
group at the weakest point; the threaded part of the screw. nections. It was shown that when tightening and removal
No fractures were detected in the abutments or implants.53 cycles were increased in number, there were concomitant
Norton et al. studied the resistance of different internal con- reductions in the torque forces required for removal of the
ical implant–abutment connections and systems (ITI and abutment.58,59 Using this approach, Weiss et al. documented
Astratech with solid abutments), an external hexagonal con- significantly higher maintenance of torque values for both
nection (Branemark, Nobel Biocare) and an internal hexago- conical frictional or interlocking elements.59
nal connection with cone and a two-piece abutment The effect of loading on torque required for abutment
(Astratech).54–56 The findings were published in three removal was studied. This demonstrated that internal coni-
papers where comparable loading approaches were used. cal implant–abutment connection systems had significantly
High load tests were run with increasing force and at a con- less torque loss compared to internal octagonal connection
stant velocity of 1 mm/min until the applied load caused a systems3 as well as external hexagonal57 connection sys-
failure of the unit or maximal load was achieved. tems. It was also shown that loading can cause cold welding
Plastic bending (PB) and maximal bending (Mb) moments to occur between the implant and abutment in conical sys-
were measured and compared between systems and connec- tems.3,36,58 Alternatively, it was shown that there was more
tions. The internal conical implant–abutment connection with loss of torque in the conical connection group compared to
a one-piece abutment (AstratechV R ) and the internal hexagonal the external hexagonal or internal hexagonal groups after
connection with cone and a two-piece abutment (AstratechV R) cycling.61 However, they concluded that the design of the
had the highest resistance to bending forces. No statistically connection was not a significant factor in loss of torque but,
significant differences were observed for any of the parame- rather, the screw design such that the use of a screw with a
ters studied in any of the implant systems.55 In comparing dif- thick stem and a journal provided the least loss of torque
ferent internal conical one-piece abutment systems after several cycles or tightening and loosening.
(AstratechV R and ITIVR ) it was shown that there was signifi-
cantly higher resistance to bending forces for the AstratechV R Stress/strain distribution. Fourteen studies dealt with
implant–abutment connection system54 as compared to the stress/strain distribution around dental implants and
ITI system. The Branemark system (Nobel BiocareV R ), with an implant–abutment interfaces. Stress transmission from the
external hexagonal connection demonstrated the least resist- implant–abutment interface to peri-implant bone was
ance (Norton 1997) to bending. Another study62 also docu- detected using FEM.6,7,37,63,71 Similar data were shown
mented significantly higher resistance to bending forces for using photoelastic and strain gauge analysis.65–68,70 FEM
systems using internal conical implant–abutment connections was also used to examine peaks of stress distribution at the
in comparison to those using internal octagonal connections.62 implant–abutment interface.
Four trials evaluated the stresses that occur in the peri-
Tightening/loosening torque and cold welding. Six trials implant and interface regions (implant–bone inter-
studied changes in preload, specifically tightening torque face)6,7,37,63 and three evaluated only interface stresses, and
loss or gain of the implant–abutment system.57–62 The prin- others tried to mimic occlusal loading and assessed the
ciple objectives were to assess the changes in torque after stresses at three interfaces.2,64,69 One study from the load
initial tightening and how this was influenced by the follow- fatigue performance/resistance subgroup also investigated
ing: (1) Increased/decreased initial tightening torque,60 (2) the effects of the addition of more force to the implant–
Repeated tightening and removal cycles,58,59,62 and (3) Fa- abutment interface, but this was more or less a secondary
tigue loading.57,58,61 Two investigations addressed seal per- research objective.52 Of the papers included here for analy-
formance, whereas others were focused on stress/load sis it was found that only two looked at the influence of the
performance, particularly dealing with load fatigue perform- implant–abutment joint design on abutment screw loosen-
ance of the implant–abutment unit.3,36,50 Ricomini Filho ing using FEM (which of course would lead to movement at

REVIEW ARTICLE
the abutment–implant interface).5,69 When photoelastic documented implant success and bone level changes around
strain gauge analysis was used to assess peri-implant immediately placed and loaded conical and nonconical
stresses under different loading conditions, it was demon- implant–abutment connection implants.77,78 Further studies
strated that internal conical connections did not reduce followed delayed implant placement protocols with sub-
stresses around implants compared with internal or exter- merged or nonsubmerged healing and delayed or immediate
nal hexagonal connections.67,68 loading protocols.79,80 Regarding implant survival and suc-
Cehreli et al. showed that the strain around Brånemark cess rates of included data revealed that conical and non-
implants with an external hexagonal connection was lower conical implant–abutment connection systems do not differ
than around ITI and Astratech implants with an internal coni- statistically. However, three studies documented less mar-
cal connection, particularly under vertical loads.65 However, ginal bone level changes for conical connection systems,
the force distribution around the implants systems was similar two out of these with a significant difference.77,78,80 Only
and it was concluded that the implant–abutment mating one study documented higher marginal bone losses around
design is not the decisive factor affecting stress and strain conical implant–abutment connection systems compared to
magnitudes in a bone model.65 Comparing several conical nonconical ones (Table IV).79
implant–abutment connection systems (ITI, Bicon, Astratech)
with a one piece ITI implant revealed that internal-conical con- DISCUSSION
nection implants have similar force transfer characteristics This review found some relevant in vitro and in vivo evi-
than one-piece implants and the connection may not be the de- dence for the use of conical implant–abutment connection
cisive factor influencing stress distribution around implants.66 system as it seems superior to nonconical connection sys-
Pessoa et al. documented lower marginal peri-implant bone tems. Reviewing the current literature concerning the per-
stresses around an internal conical connection implant com- formance of conical implant–abutment connection systems
pared with internal and external hexagonal connection revealed a large number of comparative studies dealing
implants for osseointegrated implants using FEM.37 with in vitro investigations. However, only few studies com-
Also Quaresma et al. showed lower stresses in bone in pared conical with nonconical connection implants in vivo.
the conical group compared to the internal hexagonal In vitro data revealed that most systems have a gap
group.6 Additionally, Lin et al. and Hansson et al. reported smaller than 10 mm.39,45 The smallest gap among all con-
that conical implant–abutment connection systems per- nections showed the Astra implants followed by the Ankylos
formed better as a force transmission system than internal implants that have conical interface geometry.39,45 There-
hexagonal and external flat top systems. This resulted in fore, the conical interface geometry seemed to provide a
reduced peak stresses and force transmission to the mar- better fit, but may not completely eliminate the gap
ginal and apical peri-implant bone regions.7,63 Concerning between the implant and abutment. One may say that a
stress distribution at the implant–abutment interface, sev- more import factor is the abutment performance under me-
eral groups documented higher stresses when external hex- chanical stress as abutment movement promotes gap
agonal implant–abutment connection systems were used as enlargement and bacterial penetration. Whether this has
compared to when internal conical and internal hexagonal any clinical impact remains questionable.
connection systems were utilized.2,37 Additionally, with the For conical connection systems no rotational abutment
use of conical-connection systems there was even more sta- movement or microgap enlargement was detected under
bility of the abutment, also with the smallest microgap in vertical and oblique occlusal loading.2,5,37,71 External and in-
comparison to external and internal hexagonal connection ternal hexagonal connection systems were more susceptible
systems.2,5,37,71 Rotational abutment movements and micro- to abutment micromovements.2,5,37,71 Another factor for
gap formation were shown most often with implant systems long-term implant–abutment stability may have the mainte-
using the external hexagonal connection system.2,5 nance of torque value between implant and abutment after
tightening. Obviously this can prevent abutment screw loos-
In vivo ening or movement and also microgap formation. All tested
Animal studies. This part of the review included five stud- connection systems showed torque loss after initial
ies. Weng at al. compared radiographic marginal bone level tightening.53,57,62
changes around conical and nonconical implant–abutment Mechanical stress showed impact on torque values. In
connection systems for submerged and nonsubmerged most cases, conical systems showed either higher resistance
implants. Marginal bone level changes were statistically sig- to torque loss or resulted in cold welding between implant
nificant, with less bone loss around conical connections of and abutment.3,36,53,57 No cold welding was reported for
submerged and nonsubmerged implants.72,73 Berglundh systems without cone. Multiple consecutive closing and re-
et al. documented similar outcomes for submerged healing moval cycles showed impact on torque loss for all connec-
implants.74 Other included studies reported either compara- tion systems.59,62 With the increasing number of cycles the
ble or less nonsignificant marginal bone loss around conical torque value decreased significantly.59,62 Before final inser-
connection implants (Table III).75,76 tion of the superstructure, the number of cycles should be
minimized in order to avoid further torque loss.
Human studies. The included studies differ in terms of All factors promoting the formation of a microgap
their implant placement and loading protocols. Two studies between implant and abutment may compromise seal
performance. As demonstrated, an absolute overall bacterial protocols.77–80 Such variation makes it difficult, albeit not
seal between implant and abutment cannot be achieved. impossible to compare the outcomes of the different inves-
However, most of the results indicate a statistically higher tigations to one another. Loss of marginal bone loss was
bacterial seal for conical implant–abutment connections sys- observed for all implant systems regardless of whether the
tems.1,4,36,40,41 In order to keep bacterial penetration as low implants had been placed using a submerged or nonsub-
as possible, conical connection systems with small micro- merged placement protocol. Similarly the placement of im-
gaps and resistance against abutment movement should be mediate or delayed implants (including early or late
favored. Abutments should be tightened to the implants loading) had no effect on the loss of marginal bone. How-
according to the manufacturer’s recommendations. ever, when marginal bone loss was assessed for implants
To guarantee long-term implant success, the number of with conical connection systems versus those with noncon-
mechanical complications under loading must be minimized. ical connection systems, it was shown that there was less
The implant–abutment connection may well be regarded as a bone loss about the former in most cases.72,73,75,77,80
key point to success. The region and mode of abutment frac- Nevertheless, given the state of the literature in this area
ture also seems to be system specific but quite comparable it must still be recognized that there are probably several
between systems. It was documented that fractures usually factors that might work in concert or singly that influence
occur at the weakest point of the construction.48,49,51 It should marginal heights of bone. However, at the very least it
be recognized then, that it is not only the geometry of the would appear that the conical implant connection system
implant–abutment interface that might influence abutment is more favorable insofar as maintenance of marginal bone
fracture resistance, but other components and design factors is concerned.
as well. These could include the number of components (one-
piece or two-piece abutment connections), screw-length and CONCLUSION
diameter; thread design, material as well as contact area. Out- Within the limitations of the present review the following
comes of this review suggest that the literature is inconclusive conclusions were drawn:
as to what connection is superior insofar as resistance of frac-
ture of the fixture is concerned after loading. Studies that In vitro
investigated the effects of maximal bending forces on implant
" No connection has a 100% bacterial seal. However, evi-
systems suggested that implants with a conical implant/abut-
dence showed that conical connection systems seem to
ment connection system were more resistant to fracture than
be superior in terms of bacterial seal.
other designs.53–55,60 This was particularly noteworthy with
" Conical implant–abutment connection systems seem more
respect to the one- piece conical abutment connection, which
resistant to abutment movement and microgap enlarge-
provided greater deformation and fracture resistance to the
ment under loading. Internal and external hexagonal con-
implant–abutment assembly under oblique compressive load-
nection systems seem inferior in terms of abutment
ing when compared to internal hexagonal and external hexago-
movement and microgap formation.
nal connection systems.53,56
" Conical connection systems have higher torque loss re-
High stress peaks at the implant–abutment interface,
sistance than other systems.
particularly the abutment screw, may also explain how
" Conical connection systems have high resistance to fa-
some systems fracture or fail. Given these data it would
tigue loading and maximum bending.
appear that the geometry of the interface might have an im-
" Conical connection systems seem to have lower abutment
portant impact on stress distribution and peak stress forma-
screw stresses than external hexagonal connection sys-
tion in and around implants, and effects that transcends
tems and are comparable to internal hexagonal systems.
mere positioning of the implant and even the condition of
The cone compensates high stresses and protects the
the bone into which the fixture has been placed.7 Studies
screw from overloading.
included in this review clearly showed that there were sig-
" The implant–abutment interface geometry seems to be an
nificantly lower stress values in the implant–abutment inter-
influencing factor for stress and strain transmission
face of conical implant systems as compared to external
around the implant.
hexagonal connections.2,37,64 However, the stresses were not
critical for all connections under loading simulation.
Despite the comments above, some authors have con- In vivo
cluded that the implant–abutment mating design is not a " Conical and nonconical connection systems are compara-
decisive factor insofar as the effects this might have on the ble in terms of implant success and survival.
magnitudes of stress and strain bone. In relation to this, for " In most cases conical connection systems seem to pro-
example, it has also been suggested that the diameter of the duce a lower marginal bone loss.
implant could play an important role insofar as resistance
to fracture or failure of integration is concerned.64,65 ACKNOWLEDGMENTS
Regarding study characteristics of the clinical studies The first author was supported by grants from the Bavarian
(animal and human) included in this review it was found Association for Scientific Dentistry, Germany (VfwZ) and
that many different experimental approaches were utilized, Dentsply Friadent. The authors declare that there is no conflict
particularly in the implant placement and loading of interest associated with this systematic literature review.

REVIEW ARTICLE
REFERENCES cone-screw internal connection, as a function of tightening tor-

1. Tesmer M, Wallet S, Koutouzis T, Lundgren T. Bacterial coloniza- que. Int J Oral Maxillofac Implants 2009;24:251–256.
tion of the dental implant fixture–abutment interface: An in vitro 21. Coelho Goiato M, Pesqueira AA, Falcon-Antenucci RM, Dos San-
study. J Periodontol 2009;80:1991–1997. tos DM, Haddad MF, Bannwart LC, Moreno A. Stress distribution
2. Merz BR, Hunenbart S, Belser UC. Mechanics of the implant–abut- in implant-supported prosthesis with external and internal
ment connection: An 8-degree taper compared to a butt joint con- implant–abutment connections. Acta Odontol Scand 2012.
nection. Int J Oral Maxillofac Implants 2000;15:519–526. 22. Bozkaya D, Muftu S. Mechanics of the tapered interference fit in
3. Ricomini Filho AP, Fernandes FS, Straioto FG, da Silva WJ, Del dental implants. J Biomech 2003;36:1649–1658.
Bel Cury AA. Preload loss and bacterial penetration on different 23. Bozkaya D, Muftu S. Efficiency considerations for the purely
implant–abutment connection systems. Braz Dent J2010;21:123– tapered interference fit (TIF) abutments used in dental implants. J
129. Biomech Eng 2004;126:393–401.
4. Assenza B, Tripodi D, Scarano A, Perrotti V, Piattelli A, Iezzi G, 24. Bozkaya D, Muftu S. Mechanics of the taper integrated screwed-in
D’Ercole S. Bacterial leakage in implants with different implant– (TIS) abutments used in dental implants. J Biomech 2005;38:87–
abutment connections: An in vitro study. J Periodontol 2011. 97.
5. Kitagawa T, Tanimoto Y, Odaki M, Nemoto K, Aida M. Influence 25. Chu CM, Huang HL, Hsu JT, Fuh LJ. Influences of internal tapered
of implant/abutment joint designs on abutment screw loosening abutment designs on bone stresses around a dental implant:
in a dental implant system. J Biomed Mater Res B Appl Biomater three-dimensional finite element method with statistical evalua-
2005;75:457–463. tion. J Periodontol 2011.
6. Quaresma SE, Cury PR, Sendyk WR, Sendyk C. A finite element 26. Pappalardo S, Milazzo I, Nicoletti G, Baglio O, Blandino G, Scalini
analysis of two different dental implants: Stress distribution in L, Mastrangelo F, Tete S. Dental implants with locking taper con-
the prosthesis, abutment, implant, and supporting bone. J Oral nection versus screwed connection: microbiologic and scanning
Implantol 2008;34:1–6. electron microscope study. Int J Immunopathol Pharmacol
7. Lin CL, Chang SH, Chang WJ, Kuo YC. Factorial analysis of varia- 2007;20(1 Suppl 1):13–17.
bles influencing mechanical characteristics of a single tooth 27. Mollersten L, Lockowandt P, Linden LA. Comparison of strength
implant placed in the maxilla using finite element analysis and and failure mode of seven implant systems: An in vitro test. J
the statistics-based Taguchi method. Eur J Oral Sci 2007;115:408– Prosthet Dent 1997;78:582–591.
416. 28. Gross M, Abramovich I, Weiss EI. Microleakage at the abutment-
8. Moher D, Liberati A, Tetzlaff J, Altman DG, Group P. Preferred implant interface of osseointegrated implants: A comparative
reporting items for systematic reviews and meta-analyses: The study. Int J Oral Maxillofac Implants 1999;14:94–100.
PRISMA statement. Int J Surg 2010;8:336–341. 29. Freitas-Junior AC, Almeida EO, Bonfante EA, Silva NR, Coelho
9. Higgins JPT, Green S, editors. Cochrane Handbook for Systematic PG. Reliability and failure modes of internal conical dental
Reviews of Interventions Version 5.1.0 [updated March 2011]. The implant connections. Clin Oral Implants Res 2012.
Cochrane Collaboration, 2011. Available from www.cochrane- 30. Ho DS, Yeung SC, Zee KY, Curtis B, Hell P, Tumuluri V. Clinical
handbook.org. and radiographic evaluation of NobelActive(TM) dental implants.
10. Mulrow C, Langhorne P, Grimshaw J. Integrating heterogeneous Clin Oral Implants Res 2011.
pieces of evidence in systematic reviews. Ann Intern Med 31. Eliasson A, Blomqvist F, Wennerberg A, Johansson A. A retro-
1997;127:989–995. spective analysis of early and delayed loading of full-arch man-
11. Cook DJ, Mulrow CD, Haynes RB. Systematic reviews: Synthesis dibular prostheses using three different implant systems: Clinical
of best evidence for clinical decisions. Ann Intern Med results with up to 5 years of loading. Clin Implant Dent Relat Res
1997;126:376–380. 2009;11:134–148.
12. Rack A, Rack T, Stiller M, Riesemeier H, Zabler S, Nelson K. In 32. Astrand P, Engquist B, Dahlgren S, Grondahl K, Engquist E, Feld-
vitro synchrotron-based radiography of micro-gap formation at mann H. Astra Tech and Branemark system implants: A 5-year
the implant–abutment interface of two-piece dental implants. J prospective study of marginal bone reactions. Clin Oral Implants
Synchrotron Radiat 2010;17:289–294. Res 2004;15:413–420.
13. Hansson S. A conical implant–abutment interface at the level of 33. Puchades-Roman L, Palmer RM, Palmer PJ, Howe LC, Ide M, Wil-
the marginal bone improves the distribution of stresses in the son RF. A clinical, radiographic, and microbiologic comparison of
supporting bone. An axisymmetric finite element analysis. Clin Astra Tech and Branemark single tooth implants. Clin Implant
Oral Implants Res 2003;14:286–293. Dent Relat Res 2000;2:78–84.
14. Zielak JC, Rorbacker M, Gomes R, Yamashita C, Gonzaga CC, Gio- 34. Jacobs R, Pittayapat P, van Steenberghe D, De Mars G, Gijbels F,
vanni AF. In vitro evaluation of the removal force of abutments in Van Der Donck A, Li L, Liang X, Van Assche N, Quirynen M, Naert
frictional dental implants. J Oral Implantol 2011;37:519–523. I. A split-mouth comparative study up to 16 years of two screw-
15. Deconto MA, Salvoni AD, Wassall T. In vitro microbiological bac- shaped titanium implant systems. J Clin Periodontol
terial seal analysis of the implant/abutment connection in morse 2010;37:1119–1127.
taper implants: A comparative study between 2 abutments. 35. Engquist B, Astrand P, Dahlgren S, Engquist E, Feldmann H,
Implant Dent 2010;19:158–166. Grondahl K. Marginal bone reaction to oral implants: a prospec-
16. Dibart S, Warbington M, Su MF, Skobe Z. In vitro evaluation of tive comparative study of Astra Tech and Branemark System
the implant–abutment bacterial seal: The locking taper system. Int implants. Clin Oral Implants Res 2002;13:30–37.
J Oral Maxillofac Implants 2005;20:732–737. 36. Koutouzis T, Wallet S, Calderon N, Lundgren T. Bacterial coloniza-
17. Broggini N, McManus LM, Hermann JS, Medina R, Schenk RK, tion of the implant–abutment interface using an in vitro dynamic
Buser D, Cochran DL. Peri-implant inflammation defined by the loading model. J Periodontol 2011;82:613–618.
implant–abutment interface. J Dent Res 2006;85:473–478. 37. Pessoa RS, Muraru L, Junior EM, Vaz LG, Sloten JV, Duyck J,
18. Piattelli A, Vrespa G, Petrone G, Iezzi G, Annibali S, Scarano A. Jaecques SV. Influence of implant connection type on the biome-
Role of the microgap between implant and abutment: A retro- chanical environment of immediately placed implants—CT-based
spective histologic evaluation in monkeys. J Periodontol nonlinear, three-dimensional finite element analysis. Clin Implant
2003;74:346–352. Dent Relat Res 2010;12:219–234.
19. Hermann JS, Schoolfield JD, Schenk RK, Buser D, Cochran DL. 38. Aloise JP, Curcio R, Laporta MZ, Rossi L, da Silva AM, Rapoport
Influence of the size of the microgap on crestal bone changes A. Microbial leakage through the implant–abutment interface of
around titanium implants. A histometric evaluation of unloaded Morse taper implants in vitro. Clin Oral Implants Res 2010;21:328–
non-submerged implants in the canine mandible. J Periodontol 335.
2001;72:1372–1383. 39. Jansen VK, Conrads G, Richter EJ. Microbial leakage and mar-
20. Dailey B, Jordan L, Blind O, Tavernier B. Axial displacement of ginal fit of the implant–abutment interface. Int J Oral Maxillofac
abutments into implants and implant replicas, with the tapered Implants 1997;12:527–540.
40. Teixeira W, Ribeiro RF, Sato S, Pedrazzi V. Microleakage into and 60. Norton MR. Assessment of cold welding properties of the internal
from two-stage implants: An in vitro comparative study. Int J Oral conical interface of two commercially available implant systems.
Maxillofac Implants 2011;26:56–62. J Prosthet Dent 1999;81:159–166.
41. Tripodi D, Vantaggiato G, Scarano A, Perrotti V, Piattelli A, Iezzi 61. Piermatti J, Yousef H, Luke A, Mahevich R, Weiner S. An in vitro
G, D’Ercole S. An in vitro investigation concerning the bacterial analysis of implant screw torque loss with external hex and inter-
leakage at implants with internal hexagon and Morse taper nal connection implant systems. Implant Dent 2006;15:427–435.
implant–abutment connections. Implant Dent 2012;21:335–339. 62. Ding TA, Woody RD, Higginbottom FL, Miller BH. Evaluation of
42. Harder S, Dimaczek B, Acil Y, Terheyden H, Freitag-Wolf S, Kern the ITI Morse taper implant/abutment design with an internal
M. Molecular leakage at implant–abutment connection—in vitro modification. Int J Oral Maxillofac Implants 2003;18:865–872.
investigation of tightness of internal conical implant–abutment 63. Hansson S. Implant–abutment interface: Biomechanical study of
connections against endotoxin penetration. Clin Oral Investig flat top versus conical. Clin Implant Dent Relat Res 2000;2:33–41.
2010;14:427–432. 64. Alkan I, Sertgoz A, Ekici B. Influence of occlusal forces on stress
43. do Nascimento C, Miani PK, Pedrazzi V, Goncalves RB, Ribeiro distribution in preloaded dental implant screws. J Prosthet Dent
RF, Faria AC, Macedo AP, de Albuquerque RF, Jr. Leakage of sa- 2004;91:319–325.
liva through the implant–abutment interface: In vitro evaluation of 65. Cehreli M, Duyck J, De Cooman M, Puers R, Naert I. Implant
three different implant connections under unloaded and loaded design and interface force transfer. A photoelastic and strain-
conditions. Int J Oral Maxillofac Implants 2012;27:551–560. gauge analysis. Clin Oral Implants Res 2004;15:249–257.
44. Coelho PG, Sudack P, Suzuki M, Kurtz KS, Romanos GE, Silva 66. Akca K, Cehreli MC. A photoelastic and strain-gauge analysis of
NR. In vitro evaluation of the implant abutment connection seal- interface force transmission of internal-cone implants. Int J Perio-
ing capability of different implant systems. J Oral Rehabil dont Restorative Dent 2008;28:391–399.
2008;35:917–924. 67. Bernardes SR, de Araujo CA, Neto AJ, Simamoto Junior P, das
45. Baixe S, Fauxpoint G, Arntz Y, Etienne O. Microgap between zir- Neves FD. Photoelastic analysis of stress patterns from different
conia abutments and titanium implants. Int J Oral Maxillofac implant–abutment interfaces. Int J Oral Maxillofac Implants
Implants 2010;25:455–460. 2009;24:781–789.
46. McGuff HS, Heim-Hall J, Holsinger FC, Jones AA, O’Dell DS, Hafe- 68. Nishioka RS, de Vasconcellos LG, de Melo Nishioka GN. Compar-
meister AC. Maxillary osteosarcoma associated with a dental ative strain gauge analysis of external and internal hexagon,
implant: report of a case and review of the literature regarding Morse taper, and influence of straight and offset implant configu-
implant-related sarcomas. J Am Dent Assoc 2008;139:1052–1059. ration. Implant Dent 2011;20:e24–e32.
47. Seetoh YL, Tan KB, Chua EK, Quek HC, Nicholls JI. Load fatigue 69. Saidin S, Abdul Kadir MR, Sulaiman E, Abu Kasim NH. Effects of
performance of conical implant–abutment connections. Int J Oral different implant– connections on micromotion and stress distri-
Maxillofac Implants 2011;26:797–806. bution: Prediction of microgap formation. J Dent 2012;40:467–474.
48. Ribeiro CG, Maia ML, Scherrer SS, Cardoso AC, Wiskott HW. Re- 70. Pellizzer EP, Carli RI, Falcon-Antenucci RM, Verri FR, Goiato MC,
sistance of three implant–abutment interfaces to fatigue testing. J Villa LM. Photoelastic analysis of stress distribution with different
Appl Oral Sci. Revista FOB. 2011;19:413–420. implant systems. J Oral Implantol 2011.
49. Quek HC, Tan KB, Nicholls JI. Load fatigue performance of four 71. Yamanishi Y, Yamaguchi S, Imazato S, Nakano T, Yatani H. Influen-
implant–abutment interface designs: Effect of torque level and ces of implant neck design and implant–abutment joint type on peri-
implant system. Int J Oral Maxillofac Implants 2008;23:253–262. implant bone stress and abutment micromovement: Three-dimen-
50. Cehreli MC, Akca K, Iplikcioglu H, Sahin S. Dynamic fatigue resist- sional finite element analysis. Dent Mater 2012;28:1126–1133.
ance of implant–abutment junction in an internally notched 72. Weng D, Nagata MJ, Leite CM, de Melo LG, Bosco AF. Influence
morse-taper oral implant: Influence of abutment design. Clin Oral of microgap location and configuration on radiographic bone loss
Implants Res 2004;15:459–465. in nonsubmerged implants: An experimental study in dogs. Int J
51. Khraisat A, Stegaroiu R, Nomura S, Miyakawa O. Fatigue resist- Prosthodont 2011;24:445–452.
ance of two implant/abutment joint designs. J Prosthet Dent 73. Weng D, Nagata MJ, Bosco AF, de Melo LG. Influence of micro-
2002;88:604–610. gap location and configuration on radiographic bone loss around
52. Perriard J, Wiskott WA, Mellal A, Scherrer SS, Botsis J, Belser submerged implants: An experimental study in dogs. Int J Oral
UC. Fatigue resistance of ITI implant–abutment connectors—A Maxillofac Implants 2011;26:941–946.
comparison of the standard cone with a novel internally keyed 74. Berglundh T, Abrahamsson I, Lindhe J. Bone reactions to long-
design. Clin Oral Implants Res 2002;13:542–549. standing functional load at implants: An experimental study in
53. Coppede AR, Bersani E, de Mattos Mda G, Rodrigues RC, Sartori dogs. J Clin Periodontol 2005;32:925–932.
IA, Ribeiro RF. Fracture resistance of the implant–abutment con- 75. Abrahamsson I, Berglundh T, Wennstrom J, Lindhe J. The peri-
nection in implants with internal hex and internal conical connec- implant hard and soft tissues at different implant systems. A com-
tions under oblique compressive loading: An in vitro study. IntJ parative study in the dog. Clin Oral Implants Res 1996;7:212–219.
Prosthodont 2009;22:283–286. 76. Abrahamsson I, Berglundh T, Lindhe J. Soft tissue response to
54. Norton MR. In vitro evaluation of the strength of the conical plaque formation at different implant systems. A comparative
implant-to-abutment joint in two commercially available implant study in the dog. Clin Oral Implants Res 1998;9:73–79.
systems. J Prosthet Dent 2000;83:567–571. 77. Pieri F, Aldini NN, Marchetti C, Corinaldesi G. Influence of implant–
55. Norton MR. An in vitro evaluation of the strength of a 1-piece and abutment interface design on bone and soft tissue levels around im-
2-piece conical abutment joint in implant design. Clin Oral mediately placed and restored single-tooth implants: A randomized
Implants Res 2000;11:458–464. controlled clinical trial. Int J Oral Maxillofac Implants 2011;26:169–
56. Norton MR. An in vitro evaluation of the strength of an internal 178.
conical interface compared to a butt joint interface in implant 78. Crespi R, Cappare P, Gherlone E. Radiographic evaluation of mar-
design. Clin Oral Implants Res 1997;8:290–298. ginal bone levels around platform-switched and non-platform-
57. Park JK, Choi JU, Jeon YC, Choi KS, Jeong CM. Effects of abut- switched implants used in an immediate loading protocol. Int J
ment screw coating on implant preload. J Prosthodont Oral Maxillofac Implants 2009;24:920–926.
2010;19:458–464. 79. Kielbassa AM, Martinez-de Fuentes R, Goldstein M, Arnhart C, Bar-
58. Ricciardi Coppede A, de Mattos Mda G, Rodrigues RC, Ribeiro RF. lattani A, Jackowski J, Knauf M, Lorenzoni M, Maiorana C, Mericske-
Effect of repeated torque/mechanical loading cycles on two differ- Stern R, Rompen E, Sanz M. Randomized controlled trial comparing
ent abutment types in implants with internal tapered connections: a variable-thread novel tapered and a standard tapered implant: In-
An in vitro study. Clin Oral Implants Res 2009;20:624–632. terim one-year results. J Prosthet Dent 2009;101:293–305.
59. Weiss EI, Kozak D, Gross MD. Effect of repeated closures on 80. Bilhan H, Kutay O, Arat S, Cekici A, Cehreli MC. Astra Tech, Bra-
opening torque values in seven abutment-implant systems. J nemark, and ITI implants in the rehabilitation of partial edentu-
Prosthet Dent 2000;84:194–199. lism: Two-year results. Implant Dent 2010;19:437446.

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Review Article

Performance of conical abutment (Morse Taper) connection implants:

Christian M. Schmitt,1 Getulio Nogueira-Filho,2 Howard C. Tenenbaum,3 Jim Yuan Lai,3

Received 7 January 2013; revised 20 February 2013; accepted 20 February 2013

€ ring H, Nonhoff J. 2014. Performance of

INTRODUCTION gap that permits bacterial invasion). It has been claimed

Correspondence to: C. M. Schmitt; e-mail: christian.schmitt@uk-erlangen.de

552 C 2013 WILEY PERIODICALS, INC.

MATERIAL AND METHODS

tex, AlphatecVR DUOtex (Henry Schein Dental Depot GmbH,

FIGURE 1. Study selection process. [Color figure can be viewed in the

554 SCHMITT ET AL. PERFORMANCE OF CONICAL IMPLANT–ABUTMENT CONNECTION SYSTEMS

Sec. Used Bacteria/

Sec. Used Bacteria/

Sec. Used Bacteria/

Sec. Used Bacteria/

Load fatigue performance/ resistance

Bending moment/ maximal load resistance

Animal Primary Secondary

PERFORMANCE OF CONICAL IMPLANT–ABUTMENT CONNECTION SYSTEMS

570 SCHMITT ET AL. PERFORMANCE OF CONICAL IMPLANT–ABUTMENT CONNECTION SYSTEMS

572 SCHMITT ET AL. PERFORMANCE OF CONICAL IMPLANT–ABUTMENT CONNECTION SYSTEMS

REFERENCES cone-screw internal connection, as a function of tightening tor-

574 SCHMITT ET AL. PERFORMANCE OF CONICAL IMPLANT–ABUTMENT CONNECTION SYSTEMS

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