C O N T I N U I N G E D U C A T I O N 2 5

THE EVOLUTION OF EXTERNAL AND

INTERNAL IMPLANT/ABUTMENT CONNECTIONS
Israel M. Finger, DDS, MS*
Paulino Castellon, DDS

FINGER
Michael Block, DMD
Nicolas Elian, DDS

15
8

SEPTEMBER
The indications for implant dentistry continue to increase, enabling the restora-
tion of partially and totally edentulous patients with greater success and pre-
dictability. Recent goals for implant dentistry include simplifying the involved
procedures, reducing the duration of therapy for the patient and clinician, and
enabling the use of conventional prosthodontic techniques for implant-supported
restorations. This article reviews key developments in implantology and highlights
the various design characteristics of internal abutment connection implants, demon-
strating their clinical application in a detailed case presentation.

Learning Objectives:
This article discusses recent advancements in implant therapy. Upon reading
this article, the reader should:
Understand the various design characteristics associated with internal
abutment connections.
Be aware of the clinical application of contemporary implant designs.

Key Words: implant, abutment, internal, connection, aesthetics, hex

*Professor, Department of Prosthodontics, LSU School of Dentistry, New Orleans, Louisiana.

Assistant Professor, Department of Prosthodontics, LSU School of Dentistry, New Orleans,
Louisiana.
Professor, Department of Oral and Maxillofacial Surgery, LSU School of Dentistry,
New Orleans, Louisiana.
Director, International Implant Program and Professor, Department of Implant Dentistry,
New York University, School of Dentistry, New York, New York.
Israel M. Finger, DDS, MS, 1100 Florida Avenue, Box #222, New Orleans, LA 70119
Tel: 504-619-8528 Fax: 504-619-8741 E-mail: ifinge@lsuhsc.edu

Pract Proced Aesthet Dent 2003;15(8):625-632 625

Practical Procedures & AESTHETIC DENTISTRY

Compromised abutment position

T he long-term success of dental implants has been

well established in the literature, and numerous inves-
tigators have documented the biological factors, surgi-
cal procedures, and restorative principles that influence
the outcome of implant-supported restorations.1-3 As a
result, implant dentistry has, as a natural extension of
Brnemarks initial success with edentulous patients,
evolved considerably from the Brnemark protocol that
was first introduced to the United States in the 1980s.
The indications for implant dentistry have expanded to
include the restoration of single or multiple missing teeth.4,5
As the biological parameters influencing implant
function have been appreciably defined, emphasis
throughout the industry has shifted to include aesthetics
and simplification of treatment as concomitant goals of
implant dentistry.6-8 In all settings, clinicians pursue implant
protocols and materials that further expand their use in
the fixed replacement of natural teeth. This has contributed
in part to the evolution of restoration-driven implant den-
tistry. This article reviews key developments in implant
9
therapy and highlights the design principles of internal
connection implants, emphasizing their application in a
clinical presentation.
Abutment Connections
The original Brnemark protocol required several exter-
nally hexed implants to restore fully edentulous arches,
linking them together via a metal bar with a fixed pros-
thesis. 2,10
In this protocol, the external hex design was
Standard- Straight-
shaped cement-
screw- retained
retained abutment
abutment
Abutment Connecting
screw screw
A B
Figure 1A. Illustration of standard abutment for a screw-
retained implant. 1B. Abutment for a cement-retained
restoration.
Buccally inclined implant
Figure 2. Premachined abutments can have positioning
limitations due to the number of rotational positions within
the internal connection implant design.
present to help screw the implant into place. In fact, for
the fully edentulous, fixed prostheses abutments that were
screwed down onto the implants, the hex was not
engaged as an antirotation device.11 When the implants
were later placed in single-tooth or partially edentulous
cases, the hex had to be used to prevent rotation of the
abutment and the single crown. This external hex, which
was only 0.7 mm in height, was not designed to with-
stand the forces directed on the crowns intraorally.12-15
Therefore, implant manufacturers had to compensate for
this by changing the type of screw used (eg, geometry,
height, surface area), the precision of the fit over the hex,
and the amount of torque used to secure the new screws.
These changes have allowed externally hexed implants
to be utilized with great confidence, although such efforts
still require the clinician to radiographically verify that
the abutments are fully seated.
New interface designs are utilized on a variety of
implants to improve the original external hex implant/
abutment interface. The goals of new designs are to
improve connection stability throughout function and
placement, and simplify the armamentarium necessary
for the clinician to complete the restoration. There are
at least 20 different implant/abutment interface varia-
tions on dental implants that are cleared for marketing
by the FDA (Figure 1). The implant/abutment interface
determines joint strength, stability, and lateral and rota-
tional stability. As implant design evolves, different require-
ments are incorporated into the interface design.

626 Vol. 15, No. 8

 Finger

Improved rotational position for

preangled abutment

Buccal
inclination

Buccally inclined implant

Figure 3. Illustration demonstrates ideal rotational position Figure 4. Preangled abutment in place redirects path of
of a pre-angled implant abutment (GingiHue, 3i Implant insertion for buccally inclined implant.
Innovations, Inc, Palm Beach Gardens, FL).

One of the first internally hexed implants was
designed with a 1.7-mm-deep hex below a 0.5-mm
wide, 45 bevel.16,17 Its features were intended to
distribute intraoral forces deeper within the implant to
protect the retention screw from excess loading, 17,18
and
to reduce the potential of microleakage.14 Internally con-
nected implants also provide superior strength for the
implant/abutment connection. 17,19,20
Since the introduction of the internal connection con-
cept, further design enhancements have been made in
an attempt to enhance the implant/abutment connection
(Table).21-23 Included in such efforts is the Morse taper,
wherein a tapered abutment post is inserted into the
nonthreaded shaft of a dental implant with the same
taper.23,24 Other internal connection designs have fol-
lowed, frequently with variations in their use of joint
designs (eg, bevel, butt), or the numbers of hexes pre-
sent for the restorative phase.21-23 When using these
implant/abutment connections, clinicians had to be mind-
ful of their application in the intraoral environment, an

Table
Comparison of Internal Connection Systems

Nobel Alatec 3i
CenterPulse Astra Tech Straumann Biocare Technologies Friadent (Osseotite
Feature (Screw-Vent) (Astra) (ITI) (Replace Select) (Camlog) (Frialit 2) Certain)
Length of 1.2 mm 2.4 mm 2 mm 3.8 mm 5.4 mm 3.4 mm 4 mm
internal
connection
Type of 6-point 12-point 8-point 3-point 3-point 6-point 6- or 12-
retention internal hex conical seal Morse taper internal internal internal hex point
(with friction tripod tripod internal hex
fit)
Verification X-ray X-ray X-ray X-ray X-ray X-ray X-ray or
of seating audible click
Abutment 60 30 45 120 120 60 30 or 60
positioning

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Practical Procedures & AESTHETIC DENTISTRY
Figure 5. Preoperative buccal view of the patients missing
left mandibular premolar.
Figure 7. Fabrication of abutment on model for delivery of
provisional crown at the time of implant placement.
often challenging region due to the involved bone topog-
raphy, soft tissue contours, rotational forces, and the req-
uisite prosthetic components particularly for aesthetic,
single-implant restorations.
A new internal connection implant design (eg,
Osseotite Certain, 3i Implant Innovations, Inc., Palm Beach
Gardens, FL) has recently been introduced to the pro-
fession, demonstrating how interface design has con-
tinued to evolve. The internal connection implant design
incorporates an audible and tactile click when the
components are properly seated. This unique feature
eases placement for the clinician and may reduce the
need for radiographs following placement of the restora-
tive components.
The implants internal connection allows 4 mm of
internal engagement, with contact along a significant
628 Vol. 15, No. 8
Figure 6. Preoperative radiograph of the edentulous
space at tooth #20(35).
Figure 8. Illustration demonstrates the placement of an
implant (Osseotite Certain, 3i, Palm Beach Gardens, FL)
into prepared osteotomy.
length that provides lateral stability from off-axis
forces.17,19,20 The deep, 4-mm multilevel engagement zone
of this internal connection achieves a precise, secure
connection with low torque. No more than 20 Ncm is
required to maintain screw retention without loosening.
The design of the internal connection allows the height
of the screw to be only 1.95 mm from the top of the
screw to the seating surface, allowing flexibility in abut-
ment preparation without damaging the head of the
screw. From the restorative perspective, an internal con-
nection with retentive features allows the placement of
transfer copings and abutments with secure seating and
ease of use. The click confirms positive seating and
allows the abutment to remain in place in the maxillary
arch even prior to placement of the retaining screw.

Figure 9. Once a soft tissue flap was elevated, the
osteotomy was completed and the 4 mm  11.5 mm
implant (Osseotite Certain, 3i, Palm Beach Gardens, FL)
was seated.
Figure 11. Clinical view demonstrates the healing around
provisional crown at 6 weeks postsurgery. An impression
would be taken at 12 weeks postsurgery.
This internal connection design incorporates a
6-point hex and a 12-point, double-hex internal design.
The 6-point internal hex provides a stable base for
the use of straight abutments. The 12-point, double-hex
of the internal connection allows 30-degree increments
of rotational flexibility for placement of machined pre-
angled abutments to correct the off-axis emergence of
the implant (Figures 2 through 4). This feature provides
flexibility for the restorative dentist and enables the
surgeon to place the implant in any rotational position
without concern for orienting the flats of a hex during
surgery. This decreases the involved expenses for the
case and simplifies the laboratory and restorative pro-
cedures for an implant-supported prosthesis. Addition-
ally, if a provisional crown is fabricated prior to implant
placement for delivery at the time of implant surgery
Finger
Figure 10. The implant abutment was delivered at the
same surgical visit. The site was provisionalized but not
loaded at this stage.
Figure 12. Master model shows the position of the
prepared abutment and the replication of the soft tissues
for fabrication of the definitive restoration.
(ie, in lieu of a cover screw), the implant can be oriented
by the hex flats on the implant placement driver tip.
This internal connection design adapts well to abut-
ments that provide a large variety of prosthetic options
using the same implant for multiple clinical situations.
The audible and tactile confirmation of seating the com-
ponents into the implant, combined with the 12-point,
double-hex design that enables simple alignment for
angled abutments, allows ease of placement for the trans-
fer copings and abutments.
Case Presentation
A 61-year-old female patient presented for the replace-
ment of tooth #20(35) (Figures 5 and 6). The patients
medical and dental histories were unremarkable, and
the patients periodontal status was stable. Clinical
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Practical Procedures & AESTHETIC DENTISTRY

examination revealed multiple sound restorations. Radio-

graphic and clinical examination revealed 13 mm of bone
superior to the inferior alveolar canal and 6 mm of crestal
width, thus adequate for placement of a dental implant.
There was 3 mm of attached keratinized gingiva pre-
sent on the edentulous crest. A single-tooth, implant-
supported restoration was recommended to the patient.
The patient was advised of different treatment
options. As tooth #19(36) had a sound restoration and
#21(34) did not have prior restorations, the patient
decided that an implant-supported restoration would be
the treatment of choice. The treatment plan consisted of Figure 13. Occlusal view of the implant site following two months
implant placement and immediate provisionalization, of healing. Note the height and contour of the gingival tissues.

which would be followed by placement of a cement-

retained, metal-ceramic crown restoration approximately
three months after implant placement.

Surgical Phase
Diagnostic casts were mounted, and a waxup of the
planned restoration was fabricated. Based on a peri-
apical radiograph, an analog of the implant was placed
into the diagnostic cast to place the top of the implant
level with the bone. A fixed abutment (GingiHue Post,
3i, Palm Beach Gardens, FL) was placed into the implant
analog, and the abutment was prepared in the labora-
tory. A hollowed acrylic denture tooth was retrofitted to
the implant abutment, leaving 0.5 mm of clearance at
Figure 14. Try-in of the prepared implant abutment. Accurate fit
the mesial and distal marginal ridges. A surgical guide was verified by an audible click and eliminated the need to verify
template was made on the diagnostic model with the with radiographs.
analog present to guide the surgical placement of the
implant (Figure 7).
The implant selected was 4 mm in diameter
(due to the 6-mm crestal width) and 11.5 mm in length.
After administration of local infiltration anesthesia, a cre-
stal incision was made with a vertical release to expose
the crestal bone. The drilling sequence recommended
by the manufacturer was followed for single-stage implant
placement, and an internal connection implant (Osseotite
Certain, 3i, Palm Beach Gardens, FL) was placed level
with the crestal bone (Figures 8 and 9). The prepared
abutment was placed (Figure 10), and the provisional
crown was tried in place. After determining that a mini-
mal occlusal clearance of 0.5 mm was present in all
Figure 15. Buccal view demonstrates the insertion of the gold
excursions, the abutment was tightened, and the crown abutment screw (Gold-tite, 3i, Palm Beach Gardens, FL).

630 Vol. 15, No. 8


Figure 16. Buccal view shows the use of the square driver to
facilitate seating of the abutment in the implant.
Figure 17. Eight-week postrestoration radiograph of the full-
coverage porcelain-fused-to-metal crown.
Figure 18. Buccal view of the definitive implant-supported restoration
harmoniously integrated with the natural dentition.
Finger
was secured with temporary cement. The incisions were
closed using 4-0 chromic sutures on a tapered needle.
The patient was placed on antibiotics for 7 days, and
mild analgesics were prescribed.
Restorative Phase
Following a 6-week healing period, the patient was
recalled for evaluation (Figure 11). Clinical and radi-
ographic examination revealed healthy gingival tissue,
no radiolucencies, and no evidence of clinical mobility.
At 12 weeks, the provisional crown and abutment were
removed. An impression for the fabrication of the defin-
itive restoration was made using a transfer-type, implant
impression coping, with the audible click confirming
proper transfer coping seating. A soft tissue cast was
poured, and the depth of the gingival sulcus gauged on
the cast. The angulation of the implant was evaluated
and a new abutment selected. Once the abutment was
prepared to ideal dimensions, a porcelain-fused-to-metal
crown was fabricated and delivered within 2 weeks of
impression making approximately 14 weeks follow-
ing implant placement (Figures 12 through 18). Periodic
recall of the patient confirmed successful integration of
the implant within the patients mandible and the adap-
tation of the gingival contour to the definitive restoration.
Conclusion
The success of implant dentistry has increased its popu-
larity as a restorative option for the treatment of edentu-
lous patients. Its indications, once limited to edentulous
mandibles, have been expanded to include single-tooth
replacement and the reconstruction of both partially and
fully edentulous mandibular and maxillary arches. While
clinicians continue to identify grafting procedures, sur-
gical protocols, and implant materials that simplify the
application of implant dentistry, the results to date are
promising. This presentation has reviewed the evolution
of internal implant/abutment connections and internal
connection implants, focusing principally on the latest
advances currently available to the clinician.
Acknowledgment
The authors receive research support from 3i Implant
Innovations, Inc.
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