Fractures related to occlusal overload

with single posterior implants: A

clinical report
Heather J. Conrad, DMD, MS,a John K. Schulte, DDS, MSD,b
and Mark C. Vallee, BSc, DDSc
School of Dentistry, University of Minnesota, Minneapolis, Minn

This clinical report describes 2 patient situations in which fractures related to occlusal overload occurred with single
posterior implants. The initial clinical presentation of both patients appeared to be screw loosening, but upon further
examination, implant and abutment fractures were identified. Several factors are described that have been implicated
in the etiology of implant fractures, including occlusal overload, implant location, inadequate fit of the prosthesis,
design of the prosthesis, progressive bone loss, metal fatigue, implant diameter, manufacturing defects, and galvanic
activity. This article describes the management of implant and abutment fractures and discusses possible mechanisms
of failure for the patient situations presented. Careful treatment planning and execution of implant therapy is neces-
sary to minimize the risk of implant and component fractures. (J Prosthet Dent 2008;99:251-256)

Since the introduction of osseoin-
tegrated dental implants, long-term
clinical studies have confirmed the ef-
ficacy of implant therapy.1-6 Implants
were originally used for the treatment
of edentulous patients and are asso-
ciated with improved denture reten-
tion, stability, functional efficiency,
and quality of life.2,7 Implants are now
widely accepted for the prosthetic
restoration of completely or partially
edentulous patients.8,9
Implant failures or complications
may occur early, prior to integration,
often related to surgical problems
during placement, or they may occur
later, after integration.10,11 Although
loss of osseointegration is the most
common cause of failure, a less com-
mon but equally catastrophic cause
of failure is fracture of the implant
body.12,13 Implant fracture rates from
5-year clinical studies have ranged
from 0.2% to 3.5%.1,14,15 A long-term
15-year follow-up study reported an
implant fracture rate of 16% in the
maxilla and 4% in the mandible.2 Fac-
tors implicated in the etiology of im-
plant fractures include occlusal over-
load, implant location, inadequate fit
of the prosthesis, design of the pros-
thesis, progressive bone loss, metal
fatigue, implant diameter, manufac-
turing defects, and galvanic activ-
ity.14,16-20
Most studies associate occlusal
overload-induced implant fractures
with a history of parafunctional hab-
its and bruxism.14,19-24 Patients who
engage in bruxism are identified by
the presence of hypertrophic mastica-
tory muscles, wear of the occlusal sur-
faces, or through polysomnographic
analysis.22,23 The increased magnitude
of the occlusal load, duration, and
frequency, as well as increased buccal-
lingual mandibular movement, place
the implant at risk of fracture due to
bending overload.14,25 Excessive bend-
ing overload occurs when occlusal
forces on an implant prosthesis ex-
ert a bending moment at the crestal
bone, resulting in marginal bone loss
and/or fatigue fracture.22,25
Prosthetic load conditions may
be different for partially edentulous
patients compared to completely
edentulous patients and, also, for an-
terior regions compared to posterior
regions.25 Several studies reported
that the risk for implant component
fracture is higher for partially eden-
tulous patients and in posterior re-
gions.12,14,22,26-29 In a retrospective
study by Rangert25 analyzing 39 pa-
tients with implant fractures out of a
reference of 10,000 implants, it was
found that 90% of the fractures oc-
curred in the posterior region, 77% of
the prostheses were supported by 1 or
2 implants, and the implants were ex-
posed to occlusal overload. Another
study with single tooth implants re-
vealed that fractures occurred only
in the molar region and primarily in
the mandibular first molar area.30 In
the posterior region, the combination
of increased loading, buccal-lingual
mandibular movement, and cusp-
groove orientation leads to excessive
laterally directed forces.20 While the
average occlusal masticatory force in
a completely dentate individual is 450
N to 550 N in the second molar re-
gion, the force decreases to a level be-
tween 200 N and 300 N for patients
with a removable implant-supported

a
Assistant Professor, Division of Prosthodontics, Department of Restorative Sciences.
b
Associate Professor, Postdoctoral Prosthodontics, Department of Restorative Sciences.
c
Graduate student, Division of Prosthodontics, Department of Restorative Sciences.
Conrad et al
252
prosthesis.28,31
Inadequate fit of the prosthesis
causes stress in the screw joint and
constant shear load on the implant,
predisposing the implant to fracture
which may be preceded by screw
loosening.14 A nonpassive framework
creates undesirable forces which
have been implicated in implant
fractures.1,2,32 Overload can also re-
sult from prosthesis design, as can-
tilevered superstructures have been
linked to implant fractures.25,33 Au-
thors have recommended minimizing
or eliminating cantilevers to maintain
occlusal contact areas in line with the
long axis of the implant.33,34
The role of microorganisms in
the development of periimplantitis
is well documented in clinical stud-
ies.35-37 Marginal bone loss and the
loss of osseointegration have been at-
tributed not only to microorganisms
but also to biomechanical overload,38
and frequently precede implant frac-
ture.25 Metal fatigue is the most com-
mon cause of structural failure of the
implant.39 High local stresses are re-
quired for crack initiation and prop-
agation to result in sudden failure.39
When periimplant bone resorption ex-
tends to a level corresponding to the
end of the abutment screw, the cross-
section of the implant is converted
from a solid composite cylinder to a
tube.40 This loss of supporting bone
produces higher bending stresses un-
der loading in a region of the implant
where the resistance to bending is
reduced, and the implant may frac-
ture due to metal fatigue.14,25,40-42 Ad-
ditionally, stress concentration at the
sharp edges of the threads may result
in crack initiation and propagation
and sudden failure.22,40
Small diameter implants and de-
sign or manufacturing defects have
also been cited as reasons for implant
fracture.2,14,22,43 A clinical report of gal-
vanic activity of a semiprecious metal
restoration on a titanium implant was
believed to cause bone resorption
which ultimately lead to fracture of
the implant.20
Implant fracture is often preced-
The Journal of Prosthetic Dentistry
ed by mechanical problems such as
screw loosening or fracture and pro-
gressive bone loss.12,14,44 Although
the frequency of implant fractures is
low, treatment planning should be
directed towards preventing occlu-
sal overload,25 and when indicated,
protecting implant restorations from
bruxism with an occlusal splint.44 Sug-
gested guidelines for loading implants
within physiologic limits include: en-
suring optimal passive fit of the pros-
thesis, developing ideal preload in the
abutment screw, reducing prosthesis
cantilevers, narrowing the buccal-lin-
gual width of the crowns, flattening
the cuspal inclines, centering occlusal
contacts over the implant body, and
selecting adequate width, length, and
number of implants.22,25,27,32,45,46 Im-
provements in implant fracture rates
have been noted with the advent of
new implant designs and restorative
components.47 The internal hexagon
or octagon designs were found to
have a more stable screw joint assem-
bly and maintained a higher fatigue
strength compared to an external
hexagon design.48,49 Implant systems
that offer no protection against rota-
tion present with higher complication
rates.50,51
Management of a fractured im-
plant is complicated and usually in-
volves removal of the implant using a
trephine, followed by possible graft-
ing, replacement of the implant, and
refabrication of the prosthesis.14,52
Depending on the severity and loca-
tion of the fracture, it may be possible
to modify the implant and refabricate
the prosthesis if a sufficient number
of internal threads remain for con-
nection of a new custom abutment.14
Alternatively, the implant may be
buried and the prosthesis modified
to function without the fractured im-
plant.14 This clinical report describes
the treatment and management of
an implant fracture as well as a rare
abutment fracture, both related to
occlusal overload with single poste-
rior implants.
Volume 99 Issue 4
Clinical Report
Patient 1
A 42-year-old woman was re-
ferred to the Graduate Prosthodontic
Clinic at the University of Minnesota
for replacement of the mandibular
left first molar with an implant-sup-
ported restoration. An implant 3.7
mm in diameter and 13 mm in length
(Tapered Screw-Vent; Zimmer Den-
tal, Carlsbad, Calif ) was placed, and
healing was uneventful. The patient
returned 6 months later for second-
stage surgery in which the implant
head was exposed and a healing abut-
ment (Zimmer Dental) was placed. A
screw-retained metal-ceramic crown
was subsequently fabricated and in-
serted.
After 14 months, the patient re-
turned to the clinic complaining of a
loose crown on the implant. An ac-
cess to the retention screw was made,
the screw was tightened to 30 Ncm
with a mechanical torque limiting de-
vice (Dynatorq; Pro-Dex Micro Mo-
tors, Santa Ana, Calif ), and the ac-
cess was resealed. At this point, it was
also determined that the mandibular
left second premolar and second mo-
lar were unrestorable, and they were
subsequently removed. This resulted
in excessive occlusal load placed on
the implant-supported crown. Five
months later, the patient returned to
the clinic again complaining of a loose
crown on the implant. Upon clinical
examination it was apparent that the
internal hex platform was fractured
(Fig. 1), and this was confirmed ra-
diographically (Fig. 2). Under local
anesthesia, a flap entry exposed the
head of the fractured implant (Fig. 3)
and a trephine was used to create an
osteotomy by encircling the implant.
A periotome (Hu-Friedy, Chicago, Ill)
was inserted parallel to the implant
and gently rotated to release the api-
cal attachment of the implant and
remove it. The site was grafted with
processed human allograft tissue (Os-
teotech, Inc, Eatontown, NJ), covered
with a resorbable collagen membrane
Conrad et al
April 2008
(ACE Surgical Supply Co, Brockton,
Mass), and closed with sutures of a
nonabsorbable expanded polytetra-
fluoroethylene (GORE Medical, Flag-
staff, Ariz).
The patient returned 9 months
later for the placement of 3 implants
(Tapered Screw-Vent; Zimmer Den-
tal) in the site of the mandibular left
second premolar and first and second
molars. All 3 implants placed were
4.7 mm in diameter, while the length
varied from 13 mm for the second
premolar and first molar to 11.5 mm
for the second molar. Six months after
placement, all 3 implants were suc-
cessfully restored with custom abut-
ments (UCLA; Zimmer Dental) and
metal ceramic crowns (Figs. 4 and 5).
The crowns were cast with a high no-
253
ble alloy (Eclipse; Dentsply Ceramco,
Burlington, NJ), and the metal was
veneered with a low-fusing feldspath-
ic porcelain (VITA Omega 900 Metal
Ceramics; Vident, Brea, Calif ). Abut-
ment screws were tightened with a
friction-style mechanical torque limit-
ing device (Dynatorq; Pro-Dex Micro
Motors) to 30 Ncm, and the crowns
were cemented with noneugenol tem-

1 Fracture of internal hex platform. 2 Radiographic evidence of fracture.

3 Flap entry exposing head of fractured implant. 4 Radiograph of definitive prosthesis.

5 Occlusal view of definitive prosthesis on mandibular left second premolar and molars.
Conrad et al
254
porary resin cement (Premier Implant
Cement; Premier Dental Products
Co, Plymouth Meeting, Pa). Occlu-
sion was adjusted to have centric oc-
clusion contacts in line with the long
axis of the implant and no eccentric
contacts. The patient was referred
back to her general dentist for recall
examinations, with no further compli-
cations after 3 months.
Patient 2
A 62-year-old man was referred to
the Graduate Prosthodontic Clinic at
the University of Minnesota for im-
plant evaluation and treatment. The
patient received 3 implants (Tapered
Screw-Vent; Zimmer Dental) at the
position of the maxillary right pre-
molars and first molar. All 3 implants
were 13 mm in length while the diam-
eter varied from 4.7 mm for the first
molar and second premolar to 3.7
6 Fractured implant abutment.
8 Occlusal view of definitive prosthesis on maxillary right first molar.
The Journal of Prosthetic Dentistry
mm for the first premolar. The surgery
also involved a direct sinus elevation
using processed human allograft tis-
sue (Osteotech, Inc), a resorbable
collagen membrane (ACE Surgical
Supply Co), and closure with sutures
of a nonabsorbable expanded polytet-
rafluoroethylene (GORE Medical).
The patient returned 6 months
later for second-stage surgery, after
which single tooth custom abutments
(UCLA; Zimmer Dental) and metal
ceramic crowns made from a high no-
ble alloy (Eclipse; Dentsply Ceramco)
and veneered with a low-fusing feld-
spathic porcelain (VITA Omega 900
Metal Ceramics; Vident) were subse-
quently fabricated and inserted. Oc-
clusion was adjusted to have centric
occlusion contacts in line with the
long axis of the implant and no eccen-
tric contacts. The patient was referred
back to his general dentist for fabrica-
tion of an occlusal splint to assist in
7 Radiograph of definitive prosthesis.
Volume 99 Issue 4
the management of bruxism.
After 18 months, the patient re-
turned to the clinic complaining that
1 of his implant crowns was loose.
Clinical examination indicated that
the abutment screw of the first mo-
lar was loose. The patient admitted
that he did not have an occlusal splint
fabricated by his general dentist. To
retrieve the crown-abutment unit, an
access was made through the crown
to reach the screw head. Upon remov-
al, it became apparent that not only
had the screw loosened, but the hex
connection of the abutment had frac-
tured (Fig. 6). The crown-abutment
unit was not salvageable; therefore,
a definitive vinyl polysiloxane impres-
sion (Imprint II Garant; 3M ESPE, St.
Paul, Minn) of the first molar implant
was made, and a new prosthesis was
fabricated and inserted (Figs. 7 and
8). A maxillary heat-processed acrylic
resin (Lucitone Clear; Dentsply Intl)
Conrad et al
April 2008
occlusal device with a mutually pro-
tected articulation was subsequently
fabricated and inserted. The patient
was advised that continued wearing
of his maxillary occlusal device is criti-
cal to protect the restorations against
parafunctional habits. The patient was
referred back to his general dentist for
recall examinations, with no further
complications after 6 months.
Discussion
The clinical situations presented il-
lustrate complications that may occur
with the use of implants when occlu-
sal overload becomes a factor. Clini-
cal reports indicate that implant body
fracture is a rare complication,1,14,15
and abutment fractures are more
rare.11,23 Implant component frac-
tures are important clinical situations
to manage because of the significant
consequences to the patient.
In the first patient, the etiology
of the implant fracture was attrib-
uted to a combination of occlusal
overload,14,19-24 metal fatigue,39 and
small implant diameter.2,43 Mechani-
cal problems such as screw loosening
often precede implant fracture,12,14,44
as was the situation with this patient.
Moderate signs of parafunctional
habits were evidenced by hypertro-
phic masticatory muscles and wear of
the occlusal and incisal surfaces.22 The
additional loss of the adjacent teeth,
leaving a lone standing implant, may
have produced higher bending stress-
es under loading, resulting in implant
fracture due to metal fatigue.14,25,40-42
Replacement of the fractured implant
with a larger diameter implant and re-
placement of the adjacent teeth with
implants was recommended to sup-
port and distribute the occlusal load.
The etiology of the abutment frac-
ture in the second patient was attrib-
uted to a combination of occlusal
overload14,19-24 and metal fatigue.39
This patient had significant signs of
parafunctional habits evidenced by
hypertrophic masticatory muscles and
wear of the occlusal and incisal sur-
faces of the teeth and restorations.22
Conrad et al
The increase in the magnitude of the
occlusal load, duration, and frequen-
cy, as well as increased buccal-lingual
mandibular movement, presented an
opportunity for implant fracture due
to bending overload.14,25 Increased ef-
fort was made to ensure the patient
received an occlusal splint to protect
the teeth, implants, and restorations
from occlusal overload.
Summary
Implant and component fractures
in these 2 clinical situations were
preceded by screw loosening and at-
tributed to occlusal overload, metal
fatigue, and small implant diameter,
resulting in additional surgical and
prosthetic appointments for the pa-
tients. Careful treatment planning
and execution of implant therapy is
necessary to minimize the risk of im-
plant and component fractures.
references
1. Adell R, Lekholm U, Rockler B, Branemark
PI. A 15-year study of osseointegrated
implants in the treatment of the edentulous
jaw. Int J Oral Surg 1981;10:387-416.
2. Adell R, Eriksson B, Lekholm U, Branemark
PI, Jemt T. Long-term follow-up study of
osseointegrated implants in the treatment
of totally edentulous jaws. Int J Oral Maxil-
lofac Implants 1990;5:347-59.
3. Albrektsson T, Zarb G, Worthington P,
Eriksson AR. The long-term efficacy of
currently used dental implants: a review
and proposed criteria of success. Int J Oral
Maxillofac Implants 1986;1:11-25.
4. Albrektsson T, Blomberg S, Branemark
A, Carlsson GE. Edentulousness--an oral
handicap. Patient reactions to treatment
with jawbone-anchored prostheses. J Oral
Rehabil 1987;14:503-11.
5. Albrektsson T, Dahl E, Enbom L, Engevall S,
Engquist B, Eriksson AR, et al. Osseointe-
grated oral implants. A Swedish multicenter
study of 8139 consecutively inserted
Nobelpharma implants. J Periodontol
1988;59:287-96.
6. Albrektsson T. A multicenter report on
osseointegrated oral implants. J Prosthet
Dent 1988;60:75-84.
7. Adell R, Lekholm U, Grondahl K, Brane-
mark PI, Lindstrom J, Jacobsson M. Recon-
struction of severely resorbed edentulous
maxillae using osseointegrated fixtures in
immediate autogenous bone grafts. Int J
Oral Maxillofac Implants 1990;5:233-46.
8. Naert I, Koutsikakis G, Duyck J, Quirynen
M, Jacobs R, van Steenberghe D. Biologic
outcome of implant-supported restorations
in the treatment of partial edentulism. part
255
I: a longitudinal clinical evaluation. Clin
Oral Implants Res 2002;13:381-9.
9. Naert I, Koutsikakis G, Quirynen M, Duyck
J, van Steenberghe D, Jacobs R. Biologic
outcome of implant-supported restorations
in the treatment of partial edentulism. Part
2: a longitudinal radiographic study. Clin
Oral Implants Res 2002;13:390-5.
10.Tonetti MS, Schmid J. Pathogenesis
of implant failures. Periodontol 2000
1994;4:127-38.
11.Nedir R, Bischof M, Szmukler-Moncler S,
Belser UC, Samson J. Prosthetic complica-
tions with dental implants: from an up-to-
8-year experience in private practice. Int J
Oral Maxillofac Implants 2006;21:919-28.
12.Eckert SE, Meraw SJ, Cal E, Ow RK. Analy-
sis of incidence and associated factors with
fractured implants: a retrospective study.
Int J Oral Maxillofac Implants 2000;15:662-
7.
13.Schwarz MS. Mechanical complications
of dental implants. Clin Oral Implants Res
2000;11 Suppl 1:156-8.
14.Balshi TJ. An analysis and management of
fractured implants: a clinical report. Int J
Oral Maxillofac Implants 1996;11:660-6.
15.Jemt T, Lekholm U. Oral implant treatment
in posterior partially edentulous jaws: a 5-
year follow-up report. Int J Oral Maxillofac
Implants 1993;8:635-40.
16.Balshi TJ, Hernandez RE, Pryszlak MC,
Rangert B. A comparative study of one
implant versus two replacing a single molar.
Int J Oral Maxillofac Implants 1996;11:372-
8.
17.Cranin AN, Dibling JB, Simons A, Klein
M, Sirakian A. Report of the incidence
of implant insert fracture and repair of
Core-Vent dental implants. J Oral Implantol
1990;16:184-8.
18.Lanyon LE, Goodship AE, Pye CJ, MacFie
JH. Mechanically adaptive bone remodel-
ling. J Biomech 1982;15:141-54.
19.Quirynen M, Naert I, van Steenberghe
D. Fixture design and overload influence
marginal bone loss and fixture success in
the Branemark system. Clin Oral Implants
Res 1992;3:104-11.
20.Tagger Green N, Machtei EE, Horwitz J,
Peled M. Fracture of dental implants: litera-
ture review and report of a case. Implant
Dent 2002;11:137-43.
21.Naert I, Quirynen M, van Steenberghe
D, Darius P. A study of 589 consecutive
implants supporting complete fixed pros-
theses. Part II: Prosthetic aspects. J Prosthet
Dent 1992;68:949-56.
22.Piattelli A, Piattelli M, Scarano A, Monte-
sani L. Light and scanning electron micro-
scopic report of four fractured implants. Int
J Oral Maxillofac Implants 1998;13:561-4.
23.Tosun T, Karabuda C, Cuhadaroglu C.
Evaluation of sleep bruxism by polysom-
nographic analysis in patients with dental
implants. Int J Oral Maxillofac Implants
2003;18:286-92.
24.Nishimura RD, Beumer J 3rd, Perri GR,
Davodi A. Implants in the partially edentu-
lous patient: restorative considerations. J
Calif Dent Assoc 1997;25:866-71.
25.Rangert B, Krogh PH, Langer B, Van Roekel
N. Bending overload and implant fracture:
a retrospective clinical analysis. Int J Oral
256
Maxillofac Implants 1995;10:326-34.
26.Carlson B, Carlsson GE. Prosthodontic
complications in osseointegrated dental
implant treatment. Int J Oral Maxillofac
Implants 1994;9:90-4.
27.Sato Y, Shindoi N, Hosokawa R, Tsuga
K, Akagawa Y. A biomechanical effect of
wide implant placement and offset place-
ment of three implants in the posterior
partially edentulous region. J Oral Rehabil
2000;27:15-21.
28.Brunski JB, Puleo DA, Nanci A. Bioma-
terials and biomechanics of oral and
maxillofacial implants: current status and
future developments. Int J Oral Maxillofac
Implants 2000;15:15-46.
29.Taylor TD, Agar JR, Vogiatzi T. Implant
prosthodontics: current perspective and
future directions. Int J Oral Maxillofac
Implants 2000;15:66-75.
30.Levine RA, Clem DS 3rd, Wilson TG Jr, Hig-
ginbottom F, Solnit G. Multicenter retro-
spective analysis of the ITI implant system
used for single-tooth replacements: results
of loading for 2 or more years. Int J Oral
Maxillofac Implants 1999;14:516-20.
31.Mericske-Stern R, Assal P, Mericske E,
Burgin W. Occlusal force and oral tactile
sensibility measured in partially edentulous
patients with ITI implants. Int J Oral Maxil-
lofac Implants 1995;10:345-53.
32.Rangert B, Jemt T, Jorneus L. Forces and
moments on Branemark implants. Int J Oral
Maxillofac Implants 1989;4:241-7.
33.Balshi TJ. Preventing and resolving com-
plications with osseointegrated implants.
Dent Clin North Am 1989;33:821-68.
34.Weinberg LA. The biomechanics of
force distribution in implant-supported
prostheses. Int J Oral Maxillofac Implants
1993;8:19-31.
35.Rams TE, Roberts TW, Tatum H Jr, Keyes
PH. The subgingival microbial flora as-
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The Journal of Prosthetic Dentistry
sociated with human dental implants. J
Prosthet Dent 1984;51:529-34.
36.Salcetti JM, Moriarty JD, Cooper LF, Smith
FW, Collins JG, Socransky SS, et al. The
clinical, microbial, and host response char-
acteristics of the failing implant. Int J Oral
Maxillofac Implants 1997;12:32-42.
37.Becker W, Becker BE, Newman MG, Nyman
S. Clinical and microbiologic findings that
may contribute to dental implant failure.
Int J Oral Maxillofac Implants 1990;5:31-8.
38.Engel E, Gomez-Roman G, Axmann-Krcmar
D. Effect of occlusal wear on bone loss and
Periotest value of dental implants. Int J
Prosthodont 2001;14:444-50.
39.Patterson EA, Johns RB. Theoretical analy-
sis of the fatigue life of fixture screws in
osseointegrated dental implants. Int J Oral
Maxillofac Implants 1992;7:26-33.
40.Morgan MJ, James DF, Pilliar RM. Fractures
of the fixture component of an osseoin-
tegrated implant. Int J Oral Maxillofac
Implants 1993;8:409-14.
41.Linkow LI, Donath K, Lemons JE. Re-
trieval analyses of a blade implant after 231
months of clinical function. Implant Dent
1992;1:37-43.
42.Zarb GA, Schmitt A. The longitudinal clini-
cal effectiveness of osseointegrated dental
implants: the Toronto study. Part I: Surgical
results. J Prosthet Dent 1990;63:451-7.
43.Langer B, Langer L, Herrmann I, Jorneus L.
The wide fixture: a solution for special bone
situations and a rescue for the compro-
mised implant. Part 1. Int J Oral Maxillofac
Implants 1993;8:400-8.
44.Luterbacher S, Fourmousis I, Lang NP,
Bragger U. Fractured prosthetic abutments
in osseointegrated implants: a techni-
cal complication to cope with. Clin Oral
Implants Res 2000;11:163-70.
45.Binon PP. Implants and components:
entering the new millennium. Int J Oral
Volume 99 Issue 4
Maxillofac Implants 2000;15:76-94.
46.Bakaeen LG, Winkler S, Neff PA. The effect
of implant diameter, restoration design,
and occlusal table variations on screw
loosening of posterior single-tooth implant
restorations. J Oral Implantol 2001;27:63-
72.
47.Eckert SE, Wollan PC. Retrospective review
of 1170 endosseous implants placed in
partially edentulous jaws. J Prosthet Dent
1998;79:415-21.
48.Balfour A, O’Brien GR. Comparative study
of antirotational single tooth abutments. J
Prosthet Dent 1995;73:36-43.
49.Binon PP. Evaluation of machining accu-
racy and consistency of selected implants,
standard abutments, and laboratory ana-
logs. Int J Prosthodont 1995;8:162-78.
50.Behr M, Lang R, Leibrock A, Rosentritt
M, Handel G. Complication rate with
prosthodontic reconstructions on ITI and
IMZ dental implants. Internationales Team
fur Implantologie. Clin Oral Implants Res
1998;9:51-8.
51.Mollersten L, Lockowandt P, Linden LA.
Comparison of strength and failure mode
of seven implant systems: an in vitro test. J
Prosthet Dent 1997;78:582-91.
52.Muroff FI. Removal and replacement of
a fractured dental implant: case report.
Implant Dent 2003;12:206-10.
Corresponding author:
Dr Heather J. Conrad
Division of Prosthodontics, Department of
Restorative Dentistry
University of Minnesota, School of Dentistry
9-450a Moos Tower
515 Delaware St SE
Minneapolis, MN 55455
Fax: 612-626-1496
E-mail: conr0094@umn.edu
Copyright © 2008 by the Editorial Council for
The Journal of Prosthetic Dentistry.
Conrad et al