Abstract
Purpose
This systematic review aimed to evaluate if the internal connection is more efficient than the external connection and its associated influencing factors.
Methods
A specific question was formulated according to the Population, Intervention, Control, and Outcome (PICO): Is internal connection more efficient than external connection in mechanical, biological, and esthetical point of views? An electronic search of the MEDLINE and the Web of Knowledge databases was performed for relevant studies published in English up to November 2013 by two independent reviewers. The keywords used in the search included a combination of “dental implant” and “internal connection” or “Morse connection” or “external connection.” Selected studies were randomized clinical trials, prospective or retrospective studies, and in vitro studies with a clear aim of investigating the internal and/or external implant connection use.
Results
From an 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. Morse taper connection has the best sealing ability. Concerning crestal bone loss, internal connections presented better results than external connections. The limitation of the present study was the absence of randomized clinical trials that investigated if the internal connection was more efficient than the external connection.
Conclusions
The external and internal connections have different mechanical, biological, and esthetical characteristics. Besides all systems that show proper success rates and effectiveness, crestal bone level maintenance is more important around internal connections than external connections. 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.
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References
Lin MI, Shen YW, Huang HL, Hsu JT, Fuh LJ (2013) A retrospective study of implant-abutment connections on crestal bone level. J Dent Res 92:202S–207S. doi:10.1177/0022034513510322
Mangano C, Mangano F, Piattelli A, Lezzi G, Mangano A, La Colla L (2010) Prospective clinical evaluation of 307 single-tooth morse taper-connection implants: a multicenter study. Int J Oral Maxillofac Implants 25:394–400
Coppedê AR, Bersani E, de Mattos MG, Rodrigues RC, Sartori IA, Ribeiro RF (2009) Fracture resistance of the implant-abutment connection in implants with internal hex and internal conical connections under oblique compressive loading: an in vitro study. Int J Prosthodont 22:283–286
Freitas-Júnior AC, Almeida EO, Bonfante EA, Silva NR, Coelho PG (2013) Reliability and failure modes of internal conical dental implant connections. Clin Oral Implants Res 24:197–202. doi:10.1111/j.1600-0501.2012.02443.x
Machado LS, Bonfante EA, Anchieta RB, Yamaguchi S, Coelho PG (2013) Implant-abutment connection designs for anterior crowns: reliability and failure modes. Implant Dent 22:540–545. doi:10.1097/ID.0b013e31829f1f2d
Almeida EO, Freitas AC Jr, Bonfante EA, Marotta L, Silva NR, Coelho PG (2013) Mechanical testing of implant-supported anterior crowns with different implant/abutment connections. Int J Oral Maxillofac Implants 28:103–108. doi:10.11607/jomi.2443
Ribeiro CG, Maia MLC, Scherrer SS, Cardoso AC, Wiskott HWA (2011) Resistance of three implant-abutment interfaces to fatigue testing. J Appl Oral Sci 19:413–420
Ricomini Filho AP, Fernandes FS, Straioto FG, da Silva WJ, Del Bel Cury AA (2010) Preload loss and bacterial penetration on different implant-abutment connection systems. Braz Dent J 21:123–129
Goiato MC, Bannwart LC, Pesqueira AA, Dos Santos DM, Haddad MF, Santos MR, Castilho PU (2014) Immediate loading of overdentures: systematic review. Oral Maxillofac Surg 18:259–264. doi:10.1007/s10006-013-0421-6
Annibali S, Bignozzi I, Cristalli MP, Graziani F, La Monaca G, Polimeni A (2012) Peri-implant marginal bone level: a systematic review and meta-analysis of studies comparing platform switching versus conventionally restored implants. J Clin Periodontol 39:1097–1113. doi:10.1111/j.1600-051X.2012.01930.x
Peñarrocha-Diago MA, Flichy-Fernández AJ, Alonso-González R, Peñarrocha-Oltra D, Balaguer-Martínez, Peñarrocha-Diago M (2013) Influence of implant neck design and implant-abutment connection type on peri-implant health. Radiological study. Clin Oral Implants Res 24:1192–1200. doi:10.1111/j.1600-0501.2012.02562.x
Koo KT, Lee EJ, Kim JY, Seol YJ, Han JS, Kim TI, Lee YM, Ku Y, Wikesjö UM, Rhyu IC (2012) The effect of internal versus external abutment connection modes on crestal bone changes around dental implants: a radiographic analysis. J Periodontol 83:1104–1109. doi:10.1902/jop.2011.110456
Perriard J, Wiskott WA, Mellal A, Scherrer SS, Botsis J, Belser UC (2002) Fatigue resistance of ITI implant-abutment connectors—a comparison of the standard cone with a novel internally keyed design. Clin Oral Implants Res 13:542–549
Ding TA, Woody RD, Higginbottom FL, Miller BH (2003) Evaluation of the ITI Morse taper implant/abutment design with an internal modification. Int J Oral Maxillofac Implants 18:865–872
Mangano C, Mangano F, Shibli JA, Tettamanti L, Figliuzzi M, d'Avila S, Sammons RL, Piattelli A (2011) Prospective evaluation of 2,549 Morse taper connection implants: 1- to 6-year data. J Periodontol 82:52–61. doi:10.1902/jop.2010.100243
Mangano C, Bartolucci EG (2001) Single tooth replacement by Morse taper connection implants: a retrospective study of 80 implants. Int J Oral Maxillofac Implants 16:675–680
Chou CT, Morris HF, Ochi S, Walker L, DesRosiers D (2004) AICRG, Part II: crestal bone loss associated with the Ankylos implant: loading to 36 months. J Oral Implantol 30:134–143
Mangano C, Mangano F, Piatelli A, Lezzi G, Mangano A, La Colla L, Mangano A (2008) Single-tooth Morse taper connection implants after 1 year of functional loading: a multicentre study on 302 patients. Eur J Oral Implantol 1:305–315
Mangano C, Mangano F, Shibli JA, Ricci M, Sammons RL, Figliuzzi M (2011) Morse taper connection implants supporting "planned" maxillary and mandibular bar-retained overdentures: a 5-year prospective multicenter study. Clin Oral Implants Res 22:1117–1124. doi:10.1111/j.1600-0501.2010.02079.x
Palmer RM, Smith BJ, Palmer PJ, Floyd PD (1997) A prospective study of Astra single tooth implants. Clin Oral Implants Res 8:173–179
Mangano F, Mangano C, Ricci M, Sammons RL, Shibli JA, Piattelli A (2012) Single-tooth Morse taper connection implants placed in fresh extraction sockets of the anterior maxilla: an aesthetic evaluation. Clin Oral Implants Res 23:1302–1307. doi:10.1111/j.1600-0501.2011.02307.x
Pessoa RS, Muraru L, Júnior EM, Vaz LG, Sloten JV, Duyck J, Jaecques SV (2010) Influence of implant connection type on the biomechanical environment of immediately placed implants—CT-based nonlinear, three-dimensional finite element analysis. Clin Implant Dent Relat Res 12:219–234. doi:10.1111/j.1708-8208.2009.00155.x
Balik A, Karatas MO, Keskin H (2012) Effects of different abutment connection designs on the stress distribution around five different implants: a 3-dimensional finite element analysis. J Oral Implantol 38(Spec No):491–496. doi:10.1563/AAID-JOI-D-10-00127
Segundo RM, Oshima HM, da Silva IN, Burnett LH Jr, Mota EG, Silva LL (2009) Stress distribution of an internal connection implant prostheses set: a 3D finite element analysis. Stomatologija 11:55–59
Nishioka RS, de Vasconcellos LG, de Melo Nishioka LN (2009) External hexagon and internal hexagon in straight and offset implant placement: strain gauge analysis. Implant Dent 18:512–520. doi:10.1097/ID.0b013e3181bcc621
Maeda Y, Satoh T, Sogo M (2006) In vitro differences of stress concentrations for internal and external hex implant-abutment connections: a short communication. J Oral Rehabil 33:75–78
Jaworski ME, Melo AC, Picheth CM, Sartori IA (2012) Analysis of the bacterial seal at the implant-abutment interface in external-hexagon and Morse taper-connection implants: an in vitro study using a new methodology. Int J Oral Maxillofac Implants 27:1091–1095
Tripodi D, Vantaggiato G, Scarano A, Perrotti V, Piattelli A, Iezzi G, DʼErcole S (2012) An in vitro investigation concerning the bacterial leakage at implants with internal hexagon and Morse taper implant-abutment connections. Implant Dent 21:335–339. doi:10.1097/ID.0b013e31825cd472
Teixeira W, Ribeiro RF, Sato S, Pedrazzi V (2011) Microleakage into and from two-stage implants: an in vitro comparative study. Int J Oral Maxillofac Implants 26:56–62
Koutouzis T, Wallet S, Calderon N, Lundgren T (2011) Bacterial colonization of the implant-abutment interface using an in vitro dynamic loading model. J Periodontol 82:613–618. doi:10.1902/jop.2010.100415
Steinebrunner L, Wolfart S, Bossmann K, Kern M (2005) In vitro evaluation of bacterial leakage along the implant-abutment interface of different implant systems. Int J Oral Maxillofac Implants 20:875–881
Tesmer M, Wallet S, Koutouzis T, Lundgren T (2009) Bacterial colonization of the dental implant fixture-abutment interface: an in vitro study. J Periodontol 80:1991–1997. doi:10.1902/jop.2009.090178
Nascimento C, Miani PK, Pedrazzi V, Gonçalves RB, Ribeiro RF, Faria AC, Macedo AP, De Albuquerque RF Jr (2012) Leakage of saliva through the implant-abutment interface: in vitro evaluation of three different implant connections under unloaded and loaded conditions. Int J Oral Maxillofac Implants 27:551–560
Kielbassa AM, Martinez-de Fuentes R, Goldstein M, Arnhart C, Barlattani A, Jackowski J (2009) Randomized controlled trial comparing a variable-thread novel tapered and a standard tapered implant: interim one-year results. J Prosthet Dent 101:293–305. doi:10.1016/S0022-3913(09)60060-3
Arlin ML (2002) Analysis of 435 screw-vent dental implants placed in 161 patients: software enhancement of clinical evaluation. Implant Dent 11:58–66
Akça K, Cehreli MC, Iplikçioğlu H (2003) Evaluation of the mechanical characteristics of the implant-abutment complex of a reduced-diameter morse-taper implant. A nonlinear finite element stress analysis. Clin Oral Implants Res 14:444–454
Scarano A, Assenza B, Piattelli M, Iezzi G, Leghissa GC, Quaranta A, Tortora P, Piattelli A (2005) A 16-year study of the microgap between 272 human titanium implants and their abutments. J Oral Implantol 31:269–275
Novaes AB Jr, de Oliveira RR, Muglia VA, Papalexiou V, Taba M (2006) The effects of interimplant distances on papilla formation and crestal resorption in implants with a morse cone connection and a platform switch: a histomorphometric study in dogs. J Periodontol 77:1839–1849
de Oliveira RR, Novaes AB Jr, Taba M Jr, Papalexiou V, Muglia VA (2009) Bone remodeling adjacent to Morse cone-connection implants with platform switch: a fluorescence study in the dog mandible. Int J Oral Maxillofac Implants 24:257–266
Tsuge T, Hagiwara Y, Matsumura H (2008) Marginal fit and microgaps of implant-abutment interface with internal anti-rotation configuration. Dent Mater J 27:29–34
Weng D, Nagata MJ, Bell M, Bosco AF, de Melo LG, Richter EJ (2008) Influence of microgap location and configuration on the periimplant bone morphology in submerged implants. An experimental study in dogs. Clin Oral Implants Res 19:1141–1147. doi:10.1111/j.1600-0501.2008.01564.x
Weng D, Nagata MJ, Bell M, de Melo LG, Bosco AF (2010) Influence of microgap location and configuration on peri-implant bone morphology in nonsubmerged implants: an experimental study in dogs. Int J Oral Maxillofac Implants 25:540–547
Weng D, Nagata MJ, Bosco AF, de Melo LG (2011) Influence of microgap location and configuration on radiographic bone loss around submerged implants: an experimental study in dogs. Int J Oral Maxillofac Implants 26:941–946
Weng D, Nagata MJ, Leite CM, de Melo LG, Bosco AF (2011) Influence of microgap location and configuration on radiographic bone loss in nonsubmerged implants: an experimental study in dogs. Int J Prosthodont 24:445–452
Steinebrunner L, Wolfart S, Ludwig K, Kern M (2008) Implant-abutment interface design affects fatigue and fracture strength of implants. Clin Oral Implants Res 19:1276–1284. doi:10.1111/j.1600-0501.2008.01581.x
Bernardes SR, de Araujo CA, Neto AJ, Simamoto Junior P, das Neves FD (2009) Photoelastic analysis of stress patterns from different implant-abutment interfaces. Int J Oral Maxillofac Implants 24:781–789
Novaes AB Jr, Barros RR, Muglia VA, Borges GJ (2009) Influence of interimplant distances and placement depth on papilla formation and crestal resorption: a clinical and radiographic study in dogs. J Oral Implantol 35:18–27. doi:10.1563/1548-1336-35.1.18
Barros RR, Novaes AB Jr, Muglia VA, Iezzi G, Piattelli A (2010) Influence of interimplant distances and placement depth on peri-implant bone remodeling of adjacent and immediately loaded Morse cone connection implants: a histomorphometric study in dogs. Clin Oral Implants Res 1(21):371–378. doi:10.1111/j.1600-0501.2009.01860.x
Rodríguez-Ciurana X, Vela-Nebot X, Segalà-Torres M, Rodado-Alonso C, Méndez-Blanco V, Mata-Bugueroles M (2009) Biomechanical repercussions of bone resorption related to biologic width: a finite element analysis of three implant-abutment configurations. Int J Periodontics Restor Dent 29:479–487
Nishioka RS, Nishioka LN, Abreu CW, de Vasconcellos LG, Balducci I (2010) Machined and plastic copings in three-element prostheses with different types of implant-abutment joints: a strain gauge comparative analysis. J Appl Oral Sci 18:225–230
Jesus Tavarez RR, Bonachela WC, Xible AA (2011) Effect of cyclic load on vertical misfit of prefabricated and cast implant single abutment. J Appl Oral Sci 19:16–21
Nishioka RS, de Vasconcellos LG, de Melo Nishioka GN (2011) Comparative strain gauge analysis of external and internal hexagon, Morse taper, and influence of straight and offset implant configuration. Implant Dent 20:e24–e32. doi:10.1097/ID.0b013e318211fce8
Pieri F, Aldini NN, Marchetti C, Corinaldesi G (2011) Influence of implant-abutment interface design on bone and soft tissue levels around immediately placed and restored single-tooth implants: a randomized controlled clinical trial. Int J Oral Maxillofac Implants 26:169–178
Freitas AC Jr, Bonfante EA, Rocha EP, Silva NR, Marotta L, Coelho PG (2011) Effect of implant connection and restoration design (screwed vs. cemented) in reliability and failure modes of anterior crowns. Eur J Oral Sci 119:323–330. doi:10.1111/j.1600-0722.2011.00837.x
Pessoa RS, Coelho PG, Muraru L, Marcantonio E Jr, Vaz LG, Vander Sloten J, Jaecques SV (2011) Influence of implant design on the biomechanical environment of immediately placed implants: computed tomography-based nonlinear three-dimensional finite element analysis. Int J Oral Maxillofac Implants 26:1279–1287
Oliva J, Oliva X, Oliva JD (2012) All-on-three delayed implant loading concept for the completely edentulous maxilla and mandible: a retrospective 5-year follow-up study. Int J Oral Maxillofac Implants 27:1584–1592
Diez JS, Brigagão VC, Cunha L, Neves AC, da Silva-Concilio LR (2012) Influence of diamondlike carbon-coated screws on the implant-abutment interface. Int J Oral Maxillofac Implants 27:1055–1060
Arnhart C, Kielbassa AM, Martinez-de Fuentes R, Goldstein M, Jackowski J, Lorenzoni M et al (2012) Comparison of variable-thread tapered implant designs to a standard tapered implant design after immediate loading. A 3-year multicentre randomised controlled trial. Eur J Oral Implantol 5:123–136
Freitas AC Jr, Bonfante EA, Martins LM, Silva NR, Marotta L, Coelho PG (2012) Reliability and failure modes of anterior single-unit implant-supported restorations. Clin Oral Implants Res 23:1005–1011. doi:10.1111/j.1600-0501.2011.02269.x
Tang CB, Liul SY, Zhou GX, Yu JH, Zhang GD, Bao YD, Wang QJ (2012) Nonlinear finite element analysis of three implant- abutment interface designs. Int J Oral Sci 4:101–108
Rack T, Zabler S, Rack A, Riesemeier H, Nelson K (2013) An in vitro pilot study of abutment stability during loading in new and fatigue-loaded conical dental implants using synchrotron-based radiography. Int J Oral Maxillofac Implants 28:44–50. doi:10.11607/jomi.2748
Kopp S, Behrend D, Kundt G, Ottl P, Frerich B, Warkentin M (2013) Dental implants and immediate loading: multivariate analysis of success factors. Rev Stomatol Chir Maxillofac Chir Orale 114:146–154. doi:10.1016/j.revsto.2013.02.004
Gehrke SA (2013) Importance of crown height ratios in dental implants on the fracture strength of different connection designs: an in vitro study. Clin Implant Dent Relat Res. doi:10.1111/cid.12165
Teixeira AB, Beja GB, Shimano AC, Macedo AP, Oliscovicz NF, Reis AC (2013) Influence of the ultimate torsion on the geometry of dental implants. Braz Dent J 24:213–217. doi:10.1590/0103-6440201302165
Jorge JR, Barao VA, Delben JA, Assuncao WG (2013) The role of implant/abutment system on torque maintenance of retention screws and vertical misfit of implant-supported crowns before and after mechanical cycling. Int J Oral Maxillofac Implants 28:415–422. doi:10.11607/jomi.2727
Das Neves FD, Verissimo AG, Da Silva Neto JP, Do Prado CJ, De Araújo CA (2013) Photoelastic stress analysis of different wide implant/abutment interfaces under oblique loading. Int J Oral Maxillofac Implants 28:e39-44. doi:10.11607/jomi.2157
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Goiato, M.C., Pellizzer, E.P., da Silva, E.V.F. et al. Is the internal connection more efficient than external connection in mechanical, biological, and esthetical point of views? A systematic review. Oral Maxillofac Surg 19, 229–242 (2015). https://doi.org/10.1007/s10006-015-0494-5
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DOI: https://doi.org/10.1007/s10006-015-0494-5