8 th International Conference and Exhibition on Dentistry & Oral Care D U B A I µm? Lecture: Microgap, Micromovements and Bacterial Penetration on Different Implant - Abutment Connection System: A Litterature Review April 18 2016 Cesare D’Orsogna DDS

C e m e n t & S c r e w R e t a i n e d M i c r o g a p M i c r o m o v e m e n t s B a c t e r i a l P e n e t r a t i o n

Implant - Abutment connection system CEMENTED VERSUS SCREW RETAINED IMPLANT PROSTHESES Advantages Easy access to the screw No cement required Disadvantages Cosmetic appearance may not be ideal Advantages Looks like a natural tooth Disadvantages Cement can cause inflammation and bone loss

PROBLEM RELATED TO CEMENTED RETAINED

B I O L O G Y Cementing crowns > 100 years on teeth without issue Why is an implant more vulnerable? WELL DEVELOPED WITH TRANSVERSAL FIBER BUNDLE INSERTION ATTACHMENT “ STRONG ATTACHMENT “ SEAL HEMIDESMOSOMAL ATTACHMENT ONLY. NO DIRECT INSERTION ATTACHMENT CUFF

Implant - Abutment connection system SCREW RETAINED EXTERNAL INTERNAL CONE MORSE Flat to Flat Tube in Tube - Flat to Flat - Tube in Tube Maurillo Sucena Pita; Rodollfo Bruniera Anchieta; Valentin Adelino Ricardo Barao; Idelmo Rangel Garcia Journal of Craniofacial Surgery & Volume 22, Number 6, November 2011 Prosthetic Platforms in Implant Dentistry

Mechanical Problems of Internal & External Connection SEM imaging (longitudinal section) of a fixture - screw connection complex subjected to a non axial overloading Maurillo Sucena Pita; Rodollfo Bruniera Anchieta; Valentin Adelino Ricardo Barao; Idelmo Rangel Garcia Journal of Craniofacial Surgery & Volume 22, Number 6, November 2011 Prosthetic Platforms in Implant Dentistry

Incidence of 12% after 5 years of follow-up Screw Loosening From a mechanical perspective it has been identified in a systematic review that the most common technical complication of a single-unit implant-supported reconstruction is abutment or occlusal screw loosening. Incidence of 12% after 5 years of follow-up Jung RE, Pjetursson BE, Glauser R, Zembic A, Zwahlen M, Lang NP. Oral Implants Res. 2008 Feb;19(2): 119-30. Epub 2007 Dec 7. A systematic review of the 5-year survival and complication rates of implant-supported single crowns.

Screw Loosening 76 implants 12 screw loosening (16%) 55 implants Haas R, Mensdorff-Pouilly N, Mailath G, Watzek G. Branemark single tooth implants: a preliminary report of 76 implants. J. Prosthet Dent. 1995;73;274-9 76 implants 12 screw loosening (16%) 55 implants 7 screw loosening (10%) Haas R, Polak C, Furhauser R, Mailath-Pokorny G, Dortbudak O, Watzek G. A long-term follow-up of 76 Branemark’s single-tooth implants. Clin Oral Implants Res 2002;13;38-43

- Wide diameter 5% screw loosening - Standard diameter implants showed 14% screw loosening after insertion with only hand torquing. Cho SC, Small PN, Elian N, Tarnow D. Screw loosening for Standard and Wide Diameter Implants in partially edentulous cases: 3 - to 7 - year longitudinal data. Implant Dent. 2004;13:245-250

Screw Fracture The rescrewing of a loosened screw should not be done because it can increase the risk of a fracture of the abutment Scarano A, Quaranta M, Piattelli M, Piattelli A. J Immunopathol Pharmacol. 2007 Jan-Mar;20(1 Suppl 1); 19-22 SEM and fractography analysis of screw thread loosening in dental implants.

MICROGAP Holmes 1989 Between 1 to 5 µm in vitro A) Vertical Discrepancy B) Horizontal Discrepancy MICROGAP Between 1 to 5 µm in vitro Takuma TSUGE, Yoshiyuki HAGIWARA and Hideo MATSUMURA Materials Journal 27(1):29-34, 2008 Marginal Fit and Microgaps of Implant-abutment Interface with Internal Anti-rotation Configuration

Size of Microgap Between 2 µm and 9 µm Between 3 µm and 7 µm Callan DP, O’Mahony A, Cobb CM. Loss of crystal bone around dental implants: A retrospective study Implant Dent 1998;7:258-266 Between 2 µm and 9 µm Dellow AG, Driessen CH, Nel HJ. Scanning electron microscopy evaluation of the interfacial fit interchanged components of four dental implant system Int J Prosthodontic 1997; 10:216-221 Between 3 µm and 7 µm Jansen VK, Conrads G, Richter EJ. Microbial leakage and marginal fit of the implant-abutment interface Int J Oral Maxillofac Implants 1997; 12:527-540 Between 1µm and 10 µm

Micro or Macrogap?

Microgap: SRA vs CRA Research: Results: Conclusions: Piattelli A, Scarano, Paoloantonio M, Assenza B, Leghissa GC, Di Bonaventura G, Catamo G, Piccolomini R. Fluids and microbial penetration in the internal part of cement-retained versus screw-retained implant-abutment connections. J. Periodontol. 2001 Sep;72(9): 1146-50 12 dental implants CRA Research: 12 dental implants SRA - Scanning electron microscopic (SEM) - Fluid penetration analysis (FPA) - Bacterial penetration analysis (BPA) Results: SRA CRA SEM Microgap: 2 to 7µm 6 µm FPA Toloudine blue No Toloudine blue BPA Yes No Conclusions: …CRA implants offer better results relating to fluid and bacterial permeability compared to SRA implants

Microgap & Bone Loss Conclusions: Piattelli A, Vrespa G, Petrone G, Iezzi G, Annibali S, Scarano A. Role of the microgap between implant and abutment: A retrospective histologic evaluation in monkeys J. Periodontal. 2003 Mar;74(3):346-52 Group 1 (15 Implants) Group 2 (12 Implants) Group 3 (13 Implants) 1 to 2 mm above alveolar crest Level of the alveolar crest 1 to 1.5 mm below the alveolar crest Conclusions: …if the microgap was moved coronally away from the alveolar crest, less bone loss would occur and if the microgap was moved apical to the alveolar crest, greater amounts of bone resorption were present. Group 1 (15 Implants) Group 2 (12 Implants) Group 3 (13 Implants) 0.13 +/- 0.12 mm bone increase in a coronal direction 2.1 +/- 0.29 mm vertical bone loss was present 3.6 +/- 0.46 mm vertical bone loss extending in an apical direction

Clereance fit: Between 0.8 to 1 µm Micromovements Fk: Masticatory force Clereance fit: Between 0.8 to 1 µm …the largest possible microgap will also be created during non-axial loading by the length of the parallel-wall connection, by the size of the clearance fit, and by elastic deformation of the implant components. Holger Zipprich, Paul Weigl, Bodo Lange, Hans-Christoph Lauer Micromovements at the Implant-Abutment Interface: Measurement, Causes, and Consequences Implantologie 2007; 15(1): 31-46

Micromovements …the static friction of the implant platform and the abutment floor would be the only factor counteracting rotation of the abutment. However, this static friction is not enough to safely avoid rotation in the presence of masticatory forces. Holger Zipprich, Paul Weigl, Bodo Lange, Hans-Christoph Lauer Micromovements at the Implant-Abutment Interface: Measurement, Causes, and Consequences Implantologie 2007; 15(1): 31-46

INFLAMATION / INFECTION HEALTH

Tissue Reaction 1° Micromovements between abutments and implants can be considered one of numerous causes of crestal bone resorption 2° Cycling opening and closing of the microgap will exert a pumping effect on the liquid contained in the implant cavities Holger Zipprich, Paul Weigl, Bodo Lange, Hans-Christoph Lauer Micromovements at the Implant-Abutment Interface: Measurement, Causes, and Consequences Implantologie 2007; 15(1): 31-46

Tissue Reaction 3° This liquid emanates a bad smell and contains endotoxins of bacterial origin. It may be assumed that the crestal bone is being contaminated with this liquid due to the pumping effect 4° The extend of bone resorption is limited by the radius of the contaminated tissue Holger Zipprich, Paul Weigl, Bodo Lange, Hans-Christoph Lauer Micromovements at the Implant-Abutment Interface: Measurement, Causes, and Consequences Implantologie 2007; 15(1): 31-46

Cone Morse Connection Mechanical friction between the external wall of the abutment and the internal wall of the implant “Cold Welding” No rotation of the abutment Convergent angle from 8 to 11 degrees of the internal walls The Journal of Craniofacial Surgery & Volume 22, Number 6, November 2011 Prosthetic Platforms in Implant Dentistry Maurillo Sucena Pita; Rodollfo Bruniera Anchieta; Valentin Adelino Ricardo Barao; Idelmo Rangel Garcia

Cone Morse Connection May 2014 Results: Survival 97 % Between January 1992 and December 2002 58 fixed reconstructions (15 single crowns, 29 partial prostheses, 14 full-arches) 49 patients 178 Morse-taper connection implants 10 years follow up Results: Survival 97 % Biological complication (3 %) Mechanical complication (10 %) Conclusion: … Morse Taper connection implants presents low incidence of biological complication and a very high cumulative implant survival rate

Conclusion Implants materials, connection system, and surface properties have all relevant impact on the initial formation of biofilm and on the characteristics of the peri- and intra- implant microbiota. The external hexagon is indicated for multiunit restoration. On the other hand, the internal hexagon and the Morse cone are more favorable in single-unit restoration and aesthetic regions. Cone Morse connection, is considered mechanically more stable and efficient in preventing bacterial leakage (Merz et al.,2000) Microbiological evaluation show that there is a more efficient bacterial sealing between the Cone Morse connection implant and its abutment, revealed by lower bacterial counts in comparison to other connection system (Pautke et al., 2009; Aloise et al., 2010)

T H A N K Y O U