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In Vitro Study of the Influence of the Type of

Connection on the Fracture Load of
Zirconia Abutments with Internal and External
Implant-Abutment Connections
Irena Sailer, Dr Med Dent1/Thomas Sailer, Dr Med Dent2/Bogna Stawarczyk, Dipl Ing3/
Ronald Ernst Jung, Dr Med Dent1/Christoph Hans Franz Hämmerle, Prof Dr Med Dent4

Purpose: To determine whether zirconia abutments with an internal connection exhibit similar fracture
load as zirconia abutments with an external connection. Materials and Methods: The following zirconia
abutments were divided into four groups of 20 each: StraumannCARES abutments on Straumann
implants (group A), Procera abutments on Brånemark implants (group B), Procera abutments on Nobel-
Replace implants (group C), and Zirabut SynOcta prototype abutments on Straumann implants (group
D). The abutments were fixed on their respective implants either internally via a secondary abutment
(A) or a metallic coupling (C) (two-piece) or directly externally (B) and internally (D) (one-piece). In each
group, 10 abutments were left unrestored (A1 to D1). Ten received glass-ceramic crowns (A2 to D2).
Static loading was performed according to the ISO norm 14801 until failure. The bending moment was
calculated for comparison of the groups and subjected to statistical analysis (Student t test). Results:
The mean bending moments of the unrestored abutments were 371.5 ± 142.3 Ncm (A1), 276.5 ± 47.6
Ncm (B1), 434.9 ± 124.8 Ncm (C1), and 182.5 ± 136.5 Ncm (D1). Two-piece internally connected abut-
ments exhibited higher bending moments than one-piece internally (C1 versus D1 P = .003, A1 versus
D1 P = .03) or externally (C1 versus B1 P = .004) connected abutments. The groups with restorations
did not show different bending moments than those without restorations. The mean bending moments
of the restored abutments were 283.3 ± 44.8 Ncm (A2), 291.5 ± 31.7 Ncm (B2), 351.5 ± 58 Ncm (C2),
and 184.3 ± 77.7 Ncm (D2). Group C2 exhibited the highest bending moment (P < .05). Internally con-
nected one-piece abutments (D2) were weaker than all other groups (D2 versus A2 P = .002; D2 versus
B2 P = .001; D2 versus C2 P = .0003). Conclusions: The type of connection significantly influenced the
strength of zirconia abutments. Superior strength was achieved by means of internal connection via a
secondary metallic component. INT J ORAL MAXILLOFAC IMPLANTS 2009;24:850–858

Keywords: ceramic abutments, connection, fixation, implant reconstructions, stability, zirconia

he good long-term clinical results of dental

1Assistant Professor, Clinic for Fixed and Removable Prosthodon-
tics and Dental Material Science, Center for Dental and Oral
Medicine, University of Zurich, Switzerland.
2Private Practice, Ludwigsburg, Germany.
3Dental Technologist, Clinic for Fixed and Removable Prosthodon-
tics and Dental Material Science, Center for Dental and Oral
Medicine, University of Zurich, Switzerland.
4Professor and Head, Clinic for Fixed and Removable Prosthodon-
tics and Dental Material Science, Center for Dental and Oral
Medicine, University of Zurich, Switzerland.
Correspondence to: Dr Irena Sailer, Clinic for Fixed and Remov-
able Prosthodontics and Dental Material Science, Center for Den-
tal and Oral Medicine, University of Zurich, Plattenstrasse 11,
8032 Zurich, Switzerland. Fax: +41-44-634-43-05.
Email: irena.sailer@zzmk.uzh.ch
T implants allow their application in various regions
of the arches and for diverse indications.1 Following
the functional and biologic success of implant-sup-
ported reconstructions, additional criteria, primarily
esthetic aspects, gain importance.
Standardized titanium abutments exhibit high sur-
vival rates because of their excellent physical proper-
ties. 2 However, their application can impair the
esthetic result. In case of soft tissue recession, expo-
sure of the gray titanium abutment can lead to a fail-
ure of the reconstruction in highly visible anterior
regions.3 Furthermore, when titanium abutments are
used in patients with a thin labial mucosa, a grayish
discoloration of the mucosa can occur owing to the
gray metal color showing through it.3,4

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The esthetic shortcomings of titanium led to the
development of ceramic materials as an alternative
for esthetically demanding anterior and premolar
regions. The first all-ceramic implant abutments were
developed in 1993 and were made of alumina, a high-
strength ceramic. Among the ceramics, alumina
exhibits favorable physical material properties.5,6 The
bending strength of alumina reaches 547 MPa and its
fracture toughness is 3.55 MPa m 1/2. 7 These early
abutments were customized manually to meet the
anatomical requirements of each individual site. In
vitro studies demonstrated high fracture resistance of
alumina abutments.8 In clinical investigations, how-
ever, abutment fractures were observed in 7% of sin-
gle-implant crowns and 1.9% of implant-supported
fixed dental prostheses.9,10 In the search for a ceramic
abutment material with improved physical proper-
ties, yttria-stabilized zirconia was introduced in
1996.11 This high-strength ceramic exhibits fracture
toughness and bending strength that are almost
twice as high as alumina ceramic7,12: The bending
strength of zirconia is 900 MPa and its fracture tough-
ness reaches 9 MPa m 1/2 . 13 Zirconia abutments
showed resistance to high loads of up to 738 N in one
in vitro study.14 In comparison, the naturally occur-
ring mean inciso-occlusal loads in anterior regions
amount to 110 N for teeth and 370 N for implants.15,16
With these data from in vitro studies, zirconia was
expected to reduce the risk of fracture. Indeed, no
fractures of zirconia abutments were reported after 4
years of clinical service in one study.17
Because of its different material properties, the
mechanism of ceramic abutment failure differs from
that seen with titanium abutments. Ceramics are brit-
tle and therefore do not withstand tensile forces very
well. Fracture occurs when the tensile forces exceed
the limits given by the fracture toughness. In contrast,
metals are ductile. Their ductility enhances the toler-
ance for both compressive and tensile forces. Prior to
fracture, first elastic deformation followed by plastic
deformation occurs. This property is the reason for
the excellent loading capacity of metals.
The nature and the direction of the load have a
major influence on the stability of ceramic implant
abutments. During occlusal loading of an implant-
supported reconstruction, the region around the
abutment screw head is the area of the highest
torque and stress concentrations, and it has been
demonstrated to be the most critical region for the
stability of ceramic abutments. 14,18,19 High tensile
forces occurring in this region during function were
the most frequent origin of fracture of ceramic abut-
ments in several in vitro studies.14,18 At metal abut-
ments, the same forces first led to deformation and
then to fracture of the abutment screws.20 Conse-
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Sailer et al
quently, the type and architecture of the implant-
abutment connection might have a substantial influ-
ence on the stability and fixation of brittle ceramic
abutments.
Implants are designed with different types of
implant-abutment connections. The abutments can
either be fixed onto an external connecting part of
the implant (eg, an external hexagon) or internally
into the implant (eg, an internal cone). The internal
connection of zirconia abutments can be accom-
plished either by the abutment itself (one-piece) or
by means of secondary components (two-piece).
One-piece abutments are made entirely of ceramic,
whereas for two-piece abutments the internal con-
necting part can be either a secondary titanium abut-
ment (eg, CARES, Straumann) or a separate metallic
insert (eg, Replace, Nobel Biocare) mounted on the
implant together with the abutment and fixed by
means of one abutment screw.
The influence of the type of connection on the
long-term stability of the abutment-implant complex
has been analyzed for titanium abutments in several
studies. With this type of abutment, mechanical prob-
lems such as loosening or fracture of the abutment
screw can occur with external connections.21–23 In
one clinical study of an external-connection implant
system, loosening of the abutment screw was the
most frequent technical complication observed after
3 years of service.22 In contrast, the internal conical
connection was demonstrated to exhibit significantly
higher strength in vitro than the external hexagonal
connection owing to its higher resistance to bending.
The occurrence of abutment screw fracture was lower
with an internal connection.24–26 In one clinical study
analyzing an internal-connection implant system, the
cumulative survival rate for the abutment screws and
the restorations supported by titanium abutments
was 100% after 18 months, and no screw loosening or
fracture occurred.27
The stability of zirconia abutments with external
connections has been analyzed in detail.14,28 In con-
trast, to date, the stability of internally connected
ceramic abutments has not been specifically investi-
gated. It might be expected that one- and two-piece
internally connected zirconia abutments exhibit dif-
ferent resistance to loading as a result of a different
distribution of the loading forces. The aim of this
study was to determine whether or not zirconia abut-
ments with an internal connection, provided in either
a one-piece or a two-piece design, exhibit a fracture
strength similar to that of one-piece zirconia abut-
ments with an external connection.
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Sailer et al

Table 1 Types of Zirconia Abutments and Their Corresponding Implants, Connection Designs, and Torque
Used for Fixation of the Abutments
Groups Abutments Implants Type of connection Secondary components Fixation torque

A1 and A2 CARES RN Straumann Standard Plus RN, Internal connection 1.5-mm titanium SynOcta 35 Ncm
4.1 ⫻ 12 mm (cone and octagon)
B1 and B2 Procera RP Brånemark MK III TiUnite RP, External connection None 35 Ncm
3.75 ⫻ 13 mm (hexagon)
C1 and C2 Procera RP NobelReplace Select Straight Internal connection Metallic insert 35 Ncm
TiUnite RP, 4.3 ⫻ 13 mm (triangle)
D1 and D2 Zirabut Straumann Standard Plus RN, Internal connection None 35 Ncm
SynOcta RN 4.1 ⫻ 12 mm (cone and octagon)
RN = regular neck; RP = regular platform.

Two-piece One-piece Two-piece One-piece

internal external internal internal
(CARES, (Procera, (Procera, (Zirabut,
Straumann) Brånemark) Replace) Straumann)

Fig 1 Master cast of the clinical situation used for the production Fig 2 Detailed view of the four types of zirconia abutments and
of the master abutment. The abutment shoulder was designed to their methods of implant-abutment connection.
follow the scalloping of the peri-implant mucosa.

MATERIALS AND METHODS
Four types of zirconia abutment-implant combina-
tions were included in this study and divided into
four groups of 20 each: Straumann CARES abutments
for Straumann implants (Straumann), Procera abut-
ments for Brånemark implants (Nobel Biocare), Pro-
cera abutments for NobelReplace implants (Nobel
Biocare), and Zirabut SynOcta prototype abutments
(Wohlwend) for Straumann implants (Table 1).
A clinical case in which the maxillary left central
incisor had been replaced with a Straumann RN
implant (Straumann) was selected for the design of a
master abutment. In this patient the peri-implant
mucosa had been conditioned by means of an
implant-supported provisional prosthesis, resulting in
a scalloped soft tissue margin. The master zirconia
abutment was digitally designed for this patient’s sit-
uation using three-dimensional abutment fabrication
software (Infinident, Sirona). To achieve this, a scan
abutment was mounted on the implant replica of the
master cast and scanned (Cerec InEos scanner,
Sirona). The abutment was designed in such a way
that the prospective crown margin would follow the
soft tissue scallop with a slightly submucosal shoul-
der (Fig 1). The shape of this master abutment was
transferred to all other abutments as follows (Fig 2):
• Group A: Two-piece, connected internally (Strau-
mann CARES abutments on Straumann RN
implants). The data from the master abutment
were used for production of an additional 20 iden-
tical zirconia abutments. For the internal connec-
tion, corresponding secondar y titanium
abutments were used (SynOcta 1.5-mm titanium
abutment, Straumann).
• Group B: One-piece, connected externally (Procera
abutments on Brånemark implants). The external
form of the master abutment was mechanically
scanned (Procera Forte 1.1 scanner, Nobel Biocare).
Subsequently, this copy of the master abutment
was transferred to the Brånemark MK III Regular-
Platform (RP) hexagonal platform and by means of
computer-aided design (CAD) software (Procera
CAD Design C3D version 1.1.0, Nobel Biocare).
Twenty identical abutments were produced.

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• Group C: Two-piece, connected internally (Procera
abutments, NobelReplace implants). The scan of
the master abutment, which had been done previ-
ously for implants of the Brånemark implant sys-
tem, was transferred to the NobelReplace RP
platform, again by means of CAD software (Procera
CAD Design C3D version 1.1.0, Nobel Biocare) and
20 abutments were fabricated. The zirconia abut-
ments were identical to those produced for the
Brånemark implants. For internal connection into
the Replace implants a corresponding removable
metallic insert was added.
• Group D: One-piece, connected internally (Zirabut
SynOcta Regular-Neck [RN] 1.5 abutments on
Straumann RN implants). The 20 Zirabut abut-
ments were produced by copy milling (Copy-
Milling Machine, Wohlwend), which transferred the
shape of the master abutment to densely sintered
zirconia blanks (Metoxit). These one-piece proto-
type zirconia abutments were designed with a
cone and an octagon that fit the internal part of
the Straumann RN implants.
All abutments were fixed on their corresponding
implants using a torque controller with the torque
recommended by the manufacturers. In each group,
10 abutments were left unrestored to receive infor-
mation on the influence of the type of connection
with emphasis on the abutments (A1 through D1),
whereas the other 10 received glass-ceramic crowns
to more closely resemble the clinical loading situa-
tion (A2 to D2) (Table 1).
For the fabrication of the crowns, the master abut-
ment was fixed on the implant replica of the master
cast and scanned (Cerec InEos scanner, Sirona). The
missing central incisor crown was designed virtually
(Cerec 3D software, Sirona). Forty identical crowns
were milled out of leucite-reinforced glass-ceramic
ingots (ProCAD, Ivoclar Vivadent) by means of a
milling machine (Cerec InLab, Sirona). After the
milling, the crowns were fitted onto the abutments as
necessary and all crowns were glazed (ProCAD Glaze,
Ivoclar Vivadent) according to the manufacturer’s
instructions. The crowns were adhesively cemented
to the abutments. The internal side of the crowns was
etched with a 9% hydrofluoric etching gel (Ultradent
Porcelain Etch, Ultradent) and silanized according to
the manufacturer’s instructions (Clearfil Porcelain
Bond Activator and Clearfil SE Bond Primer, Kuraray).
The zirconia abutments of groups A2 through D2
were cleaned with alcohol and silanized using the
same silane. The crowns were cemented with a chem-
ically curing resin cement (Panavia 21 TC, Kuraray)
according to the manufacturer’s instructions.
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Sailer et al
Fig 3 Sample with glass-ceramic crown mounted in the steel
holder of the universal testing machine at an angle of 30
degrees. To ensure an even distribution of the static force, tin foil
was applied between the sample and the indenter.
All samples (A1 through D1 and A2 through D2)
were embedded according to ISO Norm 14801. 29
According to this norm, the implants were embedded
in an acrylic resin holder with 3 mm of vertical dis-
tance from the most coronal bone-to-implant border
to the top of the holder, thereby simulating vertical
bone resorption of 3 mm (Fig 3). According to this
requirement, cylindric acrylic glass holders (diameter
16.4 mm) with a modulus of elasticity of more than 3
GPa were custom made for each implant system. The
implants were placed in a corresponding drill hole in
the center of the specific holders and fixed with a
self-curing acrylic resin ( Technovit 4071, Haereus
Kulzer). Likewise, the modulus of elasticity of this
acrylic resin was within the requirements of the ISO
norm. 29,30 The flowable acrylic resin was applied
through a lateral drill hole using a syringe (Fig 4). Any
overflow was meticulously removed. The cement was
left to set for 24 hours before the test. In groups A1 to
D1, the screw access hole was filled with a light-cur-
ing composite (Tetric Ceram, Ivoclar Vivadent).
The embedded specimens were mounted in a 30-
degree angled steel holder of a universal testing
machine (Z 010, Zwick/Roell) (Fig 3). A piece of tin (Sn)
foil with a thickness of 0.5 mm was applied between
the indenter of the testing machine and the abut-
ments/crowns. With this procedure, an even distribu-
tion of the load that avoided stress peaks was sought.
A static load was applied on the palatal side of the
specimens, 2 mm below the incisal edge of the abut-
ments in groups A1 through D1 and of the crowns in
groups A2 through D2, until fracture or deformation
occurred. The feed motion of the indenter was 1
mm/min. The fracture load was captured in Newtons
by means of a specific software (testXpert V.11.02,
Zwick/Roell).
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F Fig 4 Schematic drawing of the setup for the static testing and
detailed information on the parameters needed for the calcula-
tion of the bending moment in Ncm. a = midline; b = direction of
load application; c = total length of sample incuding holder; l =
distance from acrylic resin holder to center of load; F = load; 1 =
b indenter; 2 = sample; 3 = acrylic resin holder.
30°
1

Bending Moments in the Unrestored

2 nent (A1, C1) showed higher bending moments com-
3 pared to one-piece externally (B1) and internally fixed
l zirconia abutments (D1) (Table 4, Fig 5). The mean
a c
Because of the different location of the crestal
bone–implant border of the examined implant sys-
tems, the distance from the acrylic resin to the loca-
tion of the indenter was not uniform for all groups,
resulting in different lever arms. As a consequence,
the bending moment was calculated using the for-
mula M = 0.5 ⫻ F ⫻ l (ISO Norm 14801) (Fig 4) and
used for comparison.24 The distance l was measured
for each implant-abutment combination in all groups
(Tables 2 and 3).
Statistical Analysis
The data were analyzed descriptively using SPSS 12.0
for Windows (SPSS Inc), visualized using box plots with
whiskers and outliers, and checked for normal distrib-
ution. The fracture load within the groups as well as
the bending moments of the groups A1 through D1
and A2 through D2 were compared. Statistical signifi-
cance was tested by means of the Student t test. The
level for significance was set at 5% (P < .05).
RESULTS
The mean fracture load of groups A1 through D1
ranged from 292 ± 218.4 N to 724.9 ± 207.9 N. In
groups A2 through D2, the fracture load ranged from
245.7 ± 103.6 N to 484.9 ± 80.0 N (Tables 2 and 3).
Abutments
The internal fixation via a metallic secondary compo-
bending moments were 371.5 ± 142.3 Ncm (A1),
276.5 ± 47.6 Ncm (B1), 434.9 ± 124.8 Ncm (C1), and
182.5 ± 136.5 Ncm (D1). Two-piece internally con-
nected zirconia abutments exhibited significantly
higher bending moments than one-piece internally
(C1 versus D1 P = .003, A1 versus D1 P = .03) or exter-
nally (C1 versus B1 P = .004) connected abutments.
Furthermore, zirconia abutments manufactured in
the same way showed significantly higher bending
moments with the internal connection by means of a
metallic insert (C1 versus B1 P = .004). No difference
in the bending moments was found between one-
piece internally and externally connected abutments.
Analysis of the samples after the test revealed that
the abutments represented the “locus minoris
resistentiae” (area of least resistance) in both groups
with one-piece external (B1) and internal connections
(D1). Fracture of the abutments occurred prior to
deformation of the abutment screws or the implants
in this group. Interestingly, the internal fixation was
associated with varying types of failures. In 20% of
the samples of groups A1 and C1 (two-piece internal
connections), the metallic secondary component
failed because of plastic deformation prior to the
fracture of the ceramic abutment. In 10% of the sam-
ples of group C1, the deformation occurred in combi-
nation with a fracture of the abutment. In the
remaining 70%, the abutments fractured without
metal deformation.
Bending Moments in the Restored Abutments
The mean bending moments for the restored abut-
ments were 283.3 ± 44.8 Ncm (A2), 291.5 ± 31.7 Ncm
(B2), 351.5 ± 58 Ncm (C2), and 184.3 ± 77.7 Ncm (D2)
(Table 5, Fig 6). The restoration of the abutments with
adhesively fixed ceramic crowns (A2 through D2) did
not lead to significant changes of the bending
moments compared to the unrestored abutments
(A1 through D1). In the groups with a restoration,
group C2 exhibited a significantly higher bending
moment (P < .05) than the other groups (A2, B2, D2).

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Table 2 Fracture Loads (Individual Values, Means, Table 3 Fracture Loads (Individual Values, Means,
and Standard Deviations, in N) for Unrestored and Standard Deviations, in N) for Restored
Abutments Abutments
Sample Group A1 Group B1 Group C1 Group D1 Sample Group A2 Group B2 Group C2 Group D2

1 677.5 557.5 600.1 163.7 1 242.4 349.7 433.6 134.4

2 1158.0 373.9 596.7 253.6 2 338.7 423.1 444.3 117.2
3 561.9 389.4 551.9 151.9 3 358.5 386.9 560.4 255.5
4 538.0 390.5 1038.4 220.4 4 383.1 399.0 505.2 210.4
5 507.9 465.5 582.9 234.2 5 457.6 427.5 650.8 175.4
6 475.3 493.4 594.5 279.0 6 411.3 491.6 542.2 408.2
7 515.5 632.3 756.4 215.9 7 380.7 466.6 385.1 178.7
8 738.5 514.9 1157.0 157.8 8 434.6 356.7 444.4 289.5
9 351.6 534.2 664.3 887.9 9 407.5 415.3 464.0 275.2
10 420.6 457.3 706.5 355.7 10 362.8 447.6 418.8 412.6
Mean 594.5 480.9 724.9 292.0 Mean 377.7 416.4 484.9 245.7
SD 227.7 82.8 207.9 218.4 SD 59.7 45.3 80.0 103.6
Mean l (mm) 12.5 11.5 12.0 12.5 Mean / (mm) 15.0 14.0 14.5 15.0
The distance from the top of the acrylic holder to the center of the sta- The distance from the top of the acrylic holder to the center of the sta-
tic load (l) was measured for each group (in mm). By means of l and tic load (l) was measured for each group in mm. By means of l and the
the fracture strength, the bending moment for each group was calcu- fracture strength, the bending moment for each group was calculated
lated and used for comparison. (in Ncm) and used for comparison.

Table 4 Bending Moments (Individual Values, 800

Means, and Standard Deviations, in Ncm) for
Unrestored Abutments Bending moment (Ncm)
600
Sample Group A1 Group B1 Group C1 Group D1

1 423.5 320.6 360.0 102.3

2 723.8 215.0 358.0 158.5 400
3 351.2 223.9 331.1 94.9
4 336.3 224.6 623.0 137.7
5 317.5 267.7 349.8 146.4 200
6 297.1 283.7 356.7 174.4
7 322.2 363.6 453.8 135.0
8 461.6 296.1 694.2 98.6 0
9 219.8 307.2 398.6 555.0 A1 B1 C1 D1
10 262.9 262.9 423.9 222.3 Group
Mean 371.5 276.5 434.9 182.5
SD 142.3 47.6 124.8 136.5 Fig 5 Box plots with whiskers and outliers of the bending
moments for the groups A1 through D1 (unrestored groups). A1 =
two-piece internal connection (Straumann CARES abutments and
Straumann implants); B1 = one-piece external connection (Pro-
cera abutments and Brånemark implants); C1 = two-piece inter-
nal connection (Procera abutments and NobelReplace implants);
D1 = one-piece internal connection (Zirabut SynOcta prototype
abutments and Straumann implants).

The internally connected one-piece zirconia abut-
ments exhibited the lowest bending moment (D2
versus A2 P = .002; D2 versus B2 P = .001; D2 versus
C2 P = .0003).
In 70% of the samples of the two groups with
internal connection via a metallic secondary compo-
nent (A2 and C2), a plastic deformation of the metallic
components (metallic insert, abutment screw,
implant shoulder) was found in addition to or prior to
the abutment fracture. In 50% of the group A2 sam-
ples and in 20% of group C2 samples, only deforma-
tion of the metallic parts (implant and/or secondary
abutment/metallic insert) was found. This resulted in
loosening of the abutment screw. Fracture of the
abutment was the reason for failure in 100% of the
one-piece externally or internally connected abut-
ments (B2, D2).
DISCUSSION
Two-piece zirconia abutments with a secondary cou-
pling abutment or a metallic insert exhibited signifi-
cantly higher bending moments than one-piece
internally or externally connected abutments. Fur-
thermore, the internal connection via a metallic

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Table 5 Bending Moments (Individual Values, 500

Means, and Standard Deviations, in Ncm) for
Restored Abutments

Bending moment (Ncm)

400
Sample Group A2 Group B2 Group C2 Group D2

1 181.8 244.8 314.4 100.8 300

2 254.0 296.1 322.1 87.9
3 268.9 270.8 406.3 191.7 200
4 287.3 279.3 366.3 157.8
5 343.2 299.3 471.8 131.6
100
6 308.4 344.1 393.1 306.1
7 285.5 326.6 279.2 134.0
8 326.0 249.7 322.2 217.1 0
9 305.7 290.7 336.4 206.4 A2 B2 C2 D2
10 272.1 313.3 303.7 309.4 Group
Mean 283.3 291.5 351.5 184.3
SD 44.8 31.7 58.0 77.7 Fig 6 Box plots with whiskers and outliers of the bending
moments for the groups A2 through D2 (restored groups). A2 =
two-piece internal connection (Straumann CARES abutments and
Straumann implants); B2 = one-piece external connection (Pro-
cera abutments and Brånemark implants); C2 = two-piece inter-
nal connection (Procera abutments and NobelReplace implants);
D2 = one-piece internal connection (Zirabut SynOcta prototype
abutments and Straumann implants).

insert showed a significantly increased bending
moment compared to the external fixation of the
same abutment type. The restoration of the abut-
ments with adhesively cemented all-ceramic crowns,
however, did not influence the bending moment in
any of the groups.
Therefore, it can be concluded that the type of
connection to the implant influences the stability of
ceramic abutments regardless of the presence or
absence of restorations. This finding has been
observed for titanium abutments before. The stability
of the implant-abutment complex of titanium abut-
ments was significantly higher with internal com-
pared to external connection.24,26
Internal connection has also been associated with
a more favorable load distribution in the connection
area.31 A finite element analysis demonstrated high
tensile stresses in the abutment screw threads upon
lateral loading of an externally connected abutment
(butt joint design), whereas with a tapered internal
connection, lateral loading was taken up by the taper,
thus protecting the thread portion of the abutment
from load transfer.32
The results of the present study demonstrate a
superior distribution of the load with an internal
implant-abutment connection for zirconia abut-
ments. A metallic secondary component, however,
seems to be advantageous to transfer the forces. In
contrast to the two-piece internally connected abut-
ments, the one-piece internally connected abutments
exhibited the lowest bending moment in the present
study. It has to be considered, though, that this type
of zirconia abutment was in a prototype stage,
whereas all other abutments were already developed.
In many studies the analysis of the stability of zir-
conia abutments has been limited to externally con-
nected abutments. In a recent investigation,
unrestored externally connected zirconia abutments
exhibited a mean fracture load of 294 ± 53 N after
chewing simulation.28 In the present study, externally
connected zirconia abutments exhibited a mean load
of 553 ± 95.3 N under static loading. When recon-
structed with an all-ceramic crown, the fracture load
was not different. In a comparable investigation, the
fracture load of the same type of abutments with
adhesively luted crowns amounted to 738 ± 245 N
under static force application.14 The results of these
investigations are not consistent. Generally, data on
the fracture stability of zirconia abutments are diffi-
cult to compare between studies because of different
study designs. In the present study the implants and
abutments were embedded in the acrylic resin hold-
ers, simulating horizontal bone loss, whereas in the
other investigations the implant-supported recon-
structions were embedded up to the implant shoul-
der. 14 As a result, the loads were applied with
different lever arms. Furthermore, variations in the
angle of the applied load, static or dynamic testing
methods, and the size and shape of the abutments
and reconstructions can have an important influence
on the results.
In the present study, zirconia abutments with
internal fixation by means of a metallic insert exhib-
ited the highest bending moment. The fracture load

856 Volume 24, Number 5, 2009

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850_Sailer.qxp 9/17/09 12:31 PM Page 857
of the abutments with the metallic insert and the
ceramic crowns was within the range of the values
reported in other studies. In these studies the stability
of zirconia, alumina, and titanium abutments was
analyzed after connection to the same type of
implants.19,20 The mean fracture load of the zirconia
abutments was 457 ± 252 N in one study20 and 470 ±
152 N in the other.19 However, in contrast to the pre-
sent investigation, the samples were artificially aged
before loading, making the results only partly compa-
rable.
In the groups with internal connection via a sec-
ondary metallic component, plastic deformations of
the metallic insert/abutment, the abutment screw,
and/or the implant shoulder of several samples were
observed. These might be one reason for the higher
standard deviations of the bending moments in
these groups. In these groups, the failure pattern
encompassed fracture of the ceramic abutment,
deformation of the metal parts, and/or loss of reten-
tion of the reconstruction. A variation in the fracture
pattern was also observed in other studies reporting
on alumina, zirconia, and titanium abutments with
internal connection.19,20 In only one of those studies,
however, an implant neck distortion was found in a
specimen bearing a titanium abutment.19
The abutment screw was identified as the weakest
component in a previous study examining titanium
abutments.20 In another investigation testing alu-
mina and zirconia abutments, fracture of the abut-
ment and/or fracture of both the abutment and
crown were the main reasons for failure.19 In contrast
to these results, both ceramic and metal components
failed by fracture or deformation in the groups with
metallic internal connections in the present study.
One reason for the differences found in these investi-
gations may be the difference in force application.
Whereas dynamic loads were used in the two previ-
ous studies,19 static loads were applied in the present
study, allowing higher loads before failure. Neverthe-
less, naturally occurring forces in patients remain far
below the forces recorded in these in vitro studies.15
In clinical situations, therefore, a plastic deformation
of the metallic components is unlikely to occur.
CONCLUSIONS
Internally connected abutments using a secondary
metallic component exhibited the highest bending
moments, whereas internally connected one-piece
zirconia abutments were the weakest of those inves-
tigated. Restoration of the abutments with adhesively
cemented reconstructions had no influence on the
bending moment in any of the groups.
© 2009 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE
MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Sailer et al
Efforts should be made to conduct in vitro studies
based on ISO norms and standardizations to allow
better comparison of results. Clinical studies are nec-
essary to support the present findings.
ACKNOWLEDGMENTS
The authors gratefully acknowledge Mr Christian Lüscher for the
fabrication of the cylindric acrylic glass holders and Drs Andreas
Ender, Daniel Wolf, and Jörg Michel for their technical support dur-
ing the fabrication of the Cerec crowns. Furthermore, they thank
the companies Straumann, Wohlwend, and Ivoclar Vivadent for
the support of the study with implants, abutments, and ceramic
ingots.
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