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CLINICAL ARTICLE

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Carlo Mangano, Francesco Mangano, Adriano Piattelli, Giovanna Lezzi, Alberto Mangano, Luca La Colla, Alessandro Mangano

Single-tooth Morse taper connection implants after 1 year of functional loading: a multicentre study on 302 patients Carlo Mangano Professor of Biomaterials Science, Dental School, University of Varese, Italy

Key words

implant–abutment connection, Morse taper connection implants, prosthetic complications, single-tooth restorations

Francesco Mangano Private Practice, Gravedona (CO), Italy

Adriano Piattelli

Purpose: This prospective clinical study evaluated the survival rate and the implant-crown success of 314 Morse taper connection implants, used for single-tooth replacement, after 1 year of functional loading. Materials and methods: Over a 4-year period (January 2003 to January 2007), 314 implants (168 maxilla, 146 mandible) were inserted in 302 patients (128 males, 174 females, aged between 23 to 79 years) in six different clinical centres. The sites included anterior (n = 118) and posterior (n = 196) teeth. To evaluate implant-crown success, the following clinical, prosthetic and radiographic parameters were assessed: modified plaque index (mPI), modified sulcus bleeding index (mBI), probing depth (PD), distance from the implant crown margin to the coronal border of the peri-implant mucosa (DIM), width of keratinised mucosa (KM), prosthesis function, and the distance between the implant shoulder and first crestal bone-implant contact (DIB). Success criteria included: absence of suppuration and mobility, PD1. For 258 implants (83.8%), PD value (based on the average of the four measured sites) did not exceed 3.0mm; for 48 implants (15.6%) PD was between 3.0mm and 5.0mm; for 2 implants (0.6%), PD was greater than 5.0mm. In 293 implants (95.1%) the DIM (based on the average of the four measured sites) was between -1mm and -2mm (the DIM was recorded as negative in the presence of a subgingival implant crown margin). Twelve implants (3.9%) showed a DIM between 0mm and -1mm, and just 3 implants (1.0%) showed minimal soft tissue recession with a reported DIM >0mm. Only 7.8% of the sites investigated (24 implants) did not exhibit KM, as they were localised within mobile, non-keratinised tissue. The remaining sites revealed the presence of KM with a width of 1mm or more. Two prosthetic abutments (in the posterior area of the mandible) became loose. These abutments were reinserted and no further loosening was observed in the period of this study. The overall incidence of abutment loosening was 0.6%. No other prosthetic complications (such as abutment fracture or ceramic-crown fracture) were evident. The radiographic evaluation of the implants revealed a DIB of 0.887 ± 0.308 mm, after 1 year of functional loading. When compared with bone level around implants seen in immediately post-operative radiographs, this value showed little modification. For this reason, all implants that survived completely fulfilled the radiographic success criteria. With regard to these data, among 308 survival implants, only 4 (of 308) did not fulfil the established clinical, prosthetic and radiographic success criteria (2 implants with PD>5.0mm and 2 implants with implant–abutment disconnection), to give an overall implant-crown success rate of 98.7% (Table 1; Figs 1 to 6).

 Discussion Together with proper design of the occlusion and stable osseointegration, a reliable connection between implant and abutment is a fundamental condition for the appropriate functioning and stability of

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Regarding implant survival rate, an implant has been classified as a ‘survival implant’ if it was still functioning at the end of the study. Implant losses were categorised as failures. The conditions where implant removal was indicated included peri-implant infections with persistent pain or implant loss due to mechanical overload. To achieve implant-crown success, the following clinical, prosthetic and radiographic success criteria should be fulfilled: • absence of pain and suppuration • absence of clinically detectable implant mobility • PD < 5.0 mm (for each implant) • absence of any prosthetic complications • absence of continuous peri-implant radiolucency • DIB < 1.5 mm after 12 months of functional loading45.

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Mangano et al Single-tooth Morse taper connection implants

Mangano et al Single-tooth Morse taper connection implants

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Fig 1 Implant in the posterior area of the mandible (46). Radiograph at the time of implant–abutment connection.

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Fig 2 The crown in situ after 1 year of functional loading.

Fig 3 Control radiograph after 1 year of functional loading.

Fig 4 Implant in the anterior area of the mandible (41).

Fig 5 The crown in situ after 1 year of functional loading.

Eur J Oral Implantol 2008;1(4):305–315

Fig 6 Control radiograph after 1 year of functional loading.

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Ant = anterior; Man = mandibular; Max = maxillary; Pos = posterior. All clinical centres were private practices. * In centre number 1, one drop-out was present (reason: patient moved to another city). In addition, among all survived implants (188), two implants could not fulfil the parameters for implant-crown success ** In centre number 2, among all survived implants (71), two implants could not fulfil the parameters for implant-crown success Table 1 Number of patients treated and distribution of implants inserted in the study, for each clinical centre.

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pyrig No Co t fo rP ub lica Fig 7 Drawing of the implant–abutment connection of the tio n tein this study. implant system (Leone Implant System ) used ss e n c e

Mangano et al Single-tooth Morse taper connection implants

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implant restorations27-29. The high mechanical stability of Morse taper implant–abutment connections can reduce prosthetic complications affecting single-tooth restorations on dental implants46-50. A lower percentage of implant–abutment loosening has been seen with single-tooth Morse taper connection implants, when compared with the external hex connections, or buttjoint design46-50. This can result in a better long-term stability in the clinical application29-32,47-50. In a 6-year study on 233 Morse taper connection single-tooth implant crowns in the posterior areas, Weigl49 reported a very low incidence (1.3%) of abutment loosening. No other mechanical complications, such as abutment fracture or ceramic crown fracture were described49. In an 8-year study on 275 single-tooth Morse taper connection implants, Doring et al50 found no abutment loosening. In a 3-year study, with 58 single tooth implants with Morse taper implant–abutment connection, Romanos and Netwig48 demonstrated evidence of little prosthetic complications (two abutment fractures). These data are confirmed by the authors’ previous 3-year retrospective study on 80 Morse taper connection implants, mainly positioned in the posterior areas of both arches, with a very low incidence of prosthetic complications (3.75%, with only two abutment fractures and one abutment loosening)47. In a taper connection, form lock and friction are the basic principles27,28. The tapered fit implant–abutment connection system used in this study (Fig 7) is composed of a fixture and an abutment joined together by a self-locking connection due to a Morse taper guided by an internal

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hexagon. The Morse taper presents a taper angle of 1.5 degrees, and it is able to induce a self-locking connection between the parts. In the present study, with 314 implant supporting single-tooth restorations, only two prosthetic abutments (0.6%) located in the posterior area of the mandible became loose after 1 year of functional loading. These two abutments were reinserted and no further loosening was observed during the study. No other prosthetic complications (such as abutment or ceramic fracture) were observed. With screw-type implant–abutment connections, the marginal bone crest level around twopiece dental implants is generally located 1.5 to 2.0 mm below the implant–abutment connection after the first year of functional loading51,52. Although precise mechanisms of bone loss around dental implants are still poorly understood53, some authors have suggested that micro-movements at the implant– abutment interface could lead to bone resorption54. In this context, Morse taper implant–abutment connection, owing to its higher mechanical stability27,28,46, could reduce crestal bone loss around implants. It is noteworthy that all implants with screw-type implant– abutment connections show a micro-gap of variable dimensions (40 to 100μm) at the implant–abutment interface. This micro-gap is colonised by bacteria, capable of penetrating the internal aspect of implant components55-57. As the implant–abutment connection is located near the alveolar crest, the bacterial leakage and persistent colonisation of the micro-gaps at the implant–abutment interface are responsible for generating a chemotactic stimulus, which initiates

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ations. The lower incidence of prosthetic complications (0.6% of abutment loosening) demonstrates evidence for the high mechanical stability of the Morse taper implant–abutment connection.

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Based on these results and within the limits of this study (i.e. lack of control and statistics calculated at implant level instead of at patient level), it can be concluded that single-tooth Morse taper connection implants can represent a successful treatment option for single-tooth replacement, even in the posterior areas of both arches. The overall implant survival (98.4%) and the implant-crown success (98.7%)

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and sustains recruitment of inflammatory cells. This finally results in the development of a persistent periimplant inflammation and increased alveolar bone loss58-63. If the absence of an implant–abutment micro-gap should be associated with reduced periimplant inflammation and minimal bone loss, the Morse taper implant–abutment connection could provide an efficient seal against microbial penetration64. The tapered interference fit significantly reduces micro-gap dimensions (1 to 3 μm) at the implant–abutment interface, providing an adequate biological seal and avoiding any kind of bacterial leakage65. This contributes to a minimal level of periimplant soft tissue inflammation and can guarantee adequate bone crest stability. Furthermore, it has been demonstrated that the vertical height of bone around an implant depends largely on the formation of the biological width at the implant–abutment interface, to provide space for the connective tissue66. With tapered interference fit, the abutment emergence geometry leads to the platform switching advantages67,68 increasing the distance between the microgap and the bone crest level. This is a very important aspect, as bacteria are more distant from the bone and it is possible to minimise bone loss69-71. Moreover, another consequence is excellent soft tissue healing, with thicker, larger, better-organised peri-implant soft tissues. This trans-mucosal seal can protect bone crest from resorption72-75. In the present study, the bone level of the fixture was situated 0.887±0.308mm from the reference point, after 1 year of functional loading. Good soft tissue healing was present, with 268 implants (87.0%) with an mBI score value (based on the average of the four values obtained from the sites) between 0 and 1. These data were confirmed by PD values, with only 2 implants (0.6%) showing PD>5.0mm.

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