Selecting And Customizing Implant

Abutments For Cemented Restorations

Dr/ Amr Elkhadem
Assistant Professor- Prosthodontics- Cairo University
Program coordinator-Master Degree of Implantology- Cairo University
Diplomat/Fellow ICOI
Regional Director Of Global Dental Implant Academy (GDIA)
Types of Implant- Abutment
Connections
 1. Threaded abutments
• 1The abutment is a one piece structure with the threaded portion
• Commonly used for overdenture abutments and screw retained
trans-mucosal element. (less common with cemented
restorations)

• Disadvantages:
1. Easy unscrewing under shear forces
2. Only straight abutments available because
it is difficult to control the angular
orientation
3. Indirect abutment transfer is not possible
because abutment position depends on the
tightening torque which is not easily
repeatable
 2. Abutments with anti-rotational features and
retaining screw
• It is a 2 piece abutment with separate retaining screw
• The abutment anti-rotational feature fits on the
implant counter part to resist shear forces
• The retaining screw is then tightened to the required
torque
 Types of anti rotational features

External
Connection

Internal
Connection
 External connection
• It is a projection from the implant body
(usually less then 1 mm)
• Commonly a hex (original Branemark
design) or a spline
• Advantage: does not weaken the implant
body (ideal with narrow and short
implants)
• Disadvantage: questionable efficiency
due to short height (high rate of screw External Hex Spline connection
loosening (up t0 48%). Micro movement
is easy
 Internal Connection
• The antirotational feature is a projection from
the abutment that fit on a precise recess in the
implant body

• Have many shapes (trilobe, hex, octagon, torx)

• Advantage:

1. Can be made longer than external connection

(less micromovement, fewer screw loosening)

2. Bring the retaining screw head at a lower level

(better in angle abutment cases)
 Shapes for internal connection & no. of orientation
positions

Trilobe connection (3 positions) Cross fit connection (4 positions)

 Shapes for internal connection & no. of
orientation positions

Internal hex (6 positions) Torx connection (6 positions)

 Shapes for internal connection & no. of
orientation positions

Octagonal connection (8 positions) Double hex “Dodecagonal” (12 positions)

 Maximum
resitance

Relation of geometry to anti

rotational potential
Least
resistance
 4 position
every 90°

6 positions
every 60 °

Why to use Only 3

position
abutments every 120°

with many
walls?? No limitation
8 positions
every 45°
in 360°
abutment
position 12
positions
every 30°
 How to increase the potential
abutment positions without increasing
the number of walls??
7
A distinctive 6 1
feature of the
12 8
R-types is an
indentation in
the screw canal. 5 2

11 9 Regular
4 3 R-Type
10

6 positions Regular abutment (1 to 6)

Regular R-Type + 6 positions R-Type abutment (7 to 12)
Abutment Abutment
12 positions
 What is slip fit Connection??

Machining Rotational
tolerance gap misfit
(Clearance fit)
 External versus internal connections
External connection Internal connection

Short projection from implant body Longer projection from abutment

Design
0.7-1.2 mm 1.5-5mm

Rotational
3-10 degrees Less then 2 degrees
Misfit
Incidence of
screw 6-48% Can be as low as 3.5%
loosening
Can be poor due to labial metal bulk
Esthetics Better esthetics
and high level of retaining screw

Usually the bone interface

Weak link Usually the screw
Blame for increasing crestal one loss
 3. Friction fit Connections
• Depend on the Morse taper
concept (cone in a cone). The true
taper is usually below 7 degrees
• Cold welding process between
implant and abutment post is
achieved during implant seating
• Implant seating is achieved with
hammering (Bicon system) or by
screwing (Ankylos)
 3a-The true friction fit design

• Offered originally by
bicon sytem
• 1.5 degree morse
taper with no
connecting screw
• Seating is achieved by
hammering the
abutment in place
 3b-Screw derived friction fit
• The morse taper
cone is about 5-6
degrees
• The abutment
seating and friction
fit is obtained by
tightening an
abutment screw
• Originally offered by
Ankylos system
 4. Combining friction and locks
• The concept was developed to provide extra
security by combining both methods
• Obtained either by:
1. Combining a short anti-rotational
connection with exact friction fit
(Zimmer friction fit abutments)
2. Taper lock design: long abutment cone
with 8-14 degree taper with short apical
antirotational lock (Astra system)
 How to remove
frictionally fitting
abutments??

Abutment retrieval
tool
Flat versus conical connection

Large Micro-movement
Micro gap formed at No Micro-movement
interface No Micro gap
Micro-pumping of No Micro pumping
fluids
 Important parameters for ideal self locking

1. Cone angle
2. Cone length
3. Manufacturing tolerance
4. Tightening torque
 Does the connection type really matters??
Is the internal connection more efficient than external connection in mechanical, biological,
and esthetical point of views? A systematic review
Goiato MC et al , Oral Maxillofac Surg (2015) 19:229–242
• Initial screening yield of 674 articles, 64 potentially relevant articles were
selected after an evaluation of their titles and abstracts. Full texts of these
articles were obtained with 29 articles fulfilling the inclusion criteria.
• Conclusions:
1. Crestal bone level maintenance is more important around internal
connections than external connections.
2. The Morse taper connection seems to be more efficient concerning biological
aspects, allowing lower bacterial leakage and bone loss in single implants,
including aesthetic regions. Additionally, this connection type can be
successfully indicated for fixed partial prostheses and overdenture planning,
since it exhibits high mechanical stability.
 Platform switching
Refers to the use of an abutment

which has a diameter narrower then

the underlying implant

Platform Matching Platform Switching

abutment abutment
 Suggested Mechanism of action (1)
Platform Switching medialize the implant-abutment microgap
(horizontal offset) carrying it far from the crestal bone.
 Suggested Mechanism of action (2)
• In matched abutments the
peak implant stress
concentration was found to
be adjacent to the bone
interface
• In platform switched design
the peak stress is at the
switch zone (more medial)
protecting the interface
from overload
 Is there evidence on the efficiency of
Platform switching???
Strietzel FP, Neumann K, Hertel M. Impact of platform switching on marginal
peri-implant bone level changes. A systematic review and meta-analysis. Clin.
Oral Impl. Res. 26, 2015, 342–358
• 22 eligible publication 15 RCTs and 7 PCCS . A meta-analysis including 13 RCTs
revealed a significantly less mean MBL change (0.49 mm [CI95% 0.38; 0.60]) at PS
implants, compared with PM implants (1.01 mm [CI95% 0.62; 1.40] (P < 0.0001).

• Conclusions: The meta-analysis revealed a significantly less mean MBL change at

implants with a PS compared to PM-implant-abutment configuration. Studies
included here in showed an unclear as well as high risk of bias mostly, and relatively
short follow-up periods. Due to heterogeneity of the included studies, their results
require cautious interpretation
 The retaining screw
• A simple mechanical device used to clamp the implant and
abutment together
• Any screw is composed of head, shaft, and threads
 Screw preload
• Preload refers to the linear force, which a stretched prosthetic screw
transmits to the abutment and implant body, holding the
components together.
• As the prosthetic screw is tightened, the torque applied is
transferred to the threads of the prosthetic screw and internal
threads of the implant. This force clamps the abutment to the
implant body.
• Preload is determined by
1. Applied tightening Torque
2. Screw head geometry.
3. Materials of the screw and abutment, which influence the level of
grip
 How to generate preload???
• Manual tightening can generate clamping moment ranging from 5-20 Ncm
only
• Usually titanium abutment screws require 30-35 Ncm torque to generate
sufficient preload
• This require the use of electronic or manual torque wrenches
 Type of manual torque wrench

Multiple separate Toggle type Swivel type

wrenches wrench wrench
 Material of abutment screw
• The screw may be made of
commercially pure titanium, coated
titanium or gold

• They differ in their coefficient of

friction and thus in the torque
required to generate the sufficient
preload

• Titanium screws require the highest

torque while gold require the least
 Screw settling
• This is a decrease in preload as a result of creep and stress
relaxation, of the components. (embedment relaxation)

• It is recommended that the prosthetic screws be

retorqued 10 minutes after initial placement and
periodically thereafter to compensate for initial settling.

• Torque loss will also occur over longer periods of time. It

is recommended to retorque the prosthetic screw at each
recall visit. This has not been shown to have any harmful
effects on the implant joint stability
Selecting the suitable stock
abutment
Stock abutment selection parameters

Abutment Collar Abutment

Restorative post
platform
 Abutment collar
Collar (cuff height):
• Depend on the soft tissue
height
• Short cuff heights in thick
mucosa will make excess
cement removal difficult
and might encroach on
biological width
 Abutment collar
Surface configuration:
• Usually stock abutments
have flat configuration
• Some manufacturers
produce abutments with
concave collar profile to
promote soft tissue growth
 Abutment collar
Surface coating:
• Some manufacturer supply
abutments with golden color
collars. It is made of titanium
nitride coating
• Golden color enhance good
esthetics with thin soft tissue
biotype
 Restorative platform
Platform geometry:
• Usually manufacturer
supply abutments with
cylindrical restorative
platform
• Some manufacturers
provide anatomical
restorative platforms
 Restorative platform
Restorative platform diameter:
• Is the diameter of the abutment at
the cervical portion of the restoration
• The selection depends on the size of
the tooth to be restored (Emergence
profile)
 Restorative platform (finish line)

No finish line Flat finish line Scalloped finish line

 Abutment post
Post height:
• Manufacturers provides abutments with different post heights to
accommodate different crown height space
• The minimum height is 4-5 mm
• Usually there is a mark to delineate the lowest level of abutment height
reduction to avoid damage of the screw head
 Abutment post
Abutment angle:
• Manufactures supply
straight abutments as well
as abutment with
difference angle (usually
less than 30 degree)
• The number of possible
abutments positions
depend on the connection
design (trilobe, hexagon,
octagon or cylindrical)
 Free mill abutments
• Abutments provided with sufficient bulk to
allow free preparation in the lab to the
desired collar height, direction contour,
and finish line position
 How to select the suitable stock abutment?
• Trial abutments are plastic autoclavable parts
similar to the manufacturer stock abutments

• The operator gets to try the plastic abutments

till he find the perfect abutment regarding cuff
height, post height, restorative platform
diameter and angle
Customizing abutments for
cemented restorations
 Why to custom your abutment?

• The ideal solution for:

1. Malpositioned implant
2. Modelling soft tissue around abutments by controlling the
emergence profile
3. Constructing esthetic tooth colored abutments in the esthetic zone
 Techniques for making custom abutments
1. Cast custom abutment
2. Custom abutment on machined titanium base:
a) Cast-to abutment
b) Press-to abutments
c) Screw-to abutments
• Using conventional multi units (2 screws)
• Using one connecting screw
d) CAD CAM abutment cemented to ti base
3. One piece milled CAD CAM abutment
 1- Cast custom abutments (UCLA)
• Supplied as plastic sleeves with a retaining screw
• Supplied as engaging abutments for single custom abutments or screw
retained crown, or as non engaging for screw retained bridges
• The plastic is shaped with grinding and wax addition. The final pattern is cast
in to gold or base metal alloy
 Problems with castable abutments
• Casting in accuracies of the connection specially with non precious alloys can
cause:
1. Large microgap at implant interface (Per-implantitis and bone loss)
2. Large rotational misfit (transfer inaccuracy and easy screw loosening),
3. The surface roughness cause high friction during torqueing. Most of
torque is lost. (Insufficient preload) + easy loss of preload due to screw
settling
 2a- Cast-to abutments
• The abutment is supplied as a machined metal base with serration and a
plastic sleeve
• Also supplied in engaging and non engaging types
• Originally made for precious alloy casting, but now available for base metal
applications
 2b-Press to abutments
• The supplied abutments and waxing procedure are similar to the cast to technique
• The abutment material is an esthetic pressable material which is glass ceramic or ceramic
filled peek
• After wax elimination from the pressing ring abutment material is pressed with special
pressing machine under vaccum. Upon cooling the ceramic or peek bind mechanically to
the undercuts on the metal base
 2c- Screw to abutments
• The abutment is compose of a metal base and a plastic sleeve
• The sleeve is cut and modified as UCLA and then cast.
• The produced cast abutment is attached to the machined base using a short prosthetic
screw
• There is a variety whereby the cast abutment and machined base and the implant are
attached together with one long screw
 2d-Cement to abutment

• The Ti base is scan directly with an optical

scanner or virtual placed on the model
after scan the model with scan jigs

• The virtual abutment is designed and

milled from the material of choice

• The produced abutment is cemented to the

Ti base with special resin cement
 3- One piece milled CAD CAM abutment
• A scan body is needed for this technique
• Direct intra oral scan or scan over the model can be do
• The designed abutment with its connection is milled from
titanium blocks or free milling prefabs
Totally milled abutment with the connection
 Take home message
• Implant abutment connection is a critical
choice in implant cases
• Abutment selection is mandatory in all cases
based on needed collar height, post height,
finish line configuration, and abutment
inclination
• Professional prosthodontist would never use
the all in one packs
• Custom abutments is your magical stick to
solve many problems. CAD CAM technology is
a great breakthrough in this field
Thanks