REVIEW ARTICLE

Clinical Outcomes of Implant Abutments in the Anterior

Region: A Systematic Review
AVINASH S. BIDRA, BDS, MS*, PATCHANEE RUNGRUANGANUNT, DDS, MSD†

ABSTRACT
Statement of Problem: The clinical outcomes of anterior implant abutments are not well reported.
Purpose of the Study: To systematically review the existing literature to identify survival, mechanical, biological, and
esthetic outcomes of anterior implant abutments.
Material and Methods: An electronic search was performed using PubMed/MEDLINE with specific search terms and
predetermined criteria. After application of inclusion and exclusion criteria, the final list of articles was reviewed
in-depth to meet the objectives of this review.
Results: Systematic application of inclusion and exclusion criteria resulted in identification of 27 studies that described
outcomes of anterior implant abutments. Because of substantial heterogeneity of data, true survival, or cumulative
survival of abutments could not be calculated. However, the mean failure of abutments was 1.15%, attributable to
fractures restricted to ceramic abutments. Mechanical complications included abutment screw loosening, primarily
restricted to external hex implants. Biological complications included fistulas and mucosal recession. Esthetic outcomes
showed lesser gingival discoloration for zirconia abutments compared with metal abutments.
Conclusions: Minimal anterior abutment fractures have been reported and are restricted to ceramic abutments. Studies
using spectrophotometry showed lesser gingival discoloration with zirconia abutments, but there is no evidence for
difference in patient’s esthetic satisfaction between ceramic and metal abutments.

CLINICAL SIGNIFICANCE
For the anterior region, selection of an implant with internal connection and a customized metal abutment (titanium or
cast metal) can have the least mechanical complications. Limited existing clinical data indicate reduced peri-implant
mucosal discoloration from zirconia abutments, which may be preferable over metal abutments, in patients with thinner
mucosal tissues or patients with high or gummy smiles.
(J Esthet Restor Dent 25:159–176, 2013)

INTRODUCTION surrounding soft tissues. This is especially important for

implant therapy in maxillary and mandibular anterior
Current paradigms for treatment success in implant regions, where esthetics play a predominant role in
dentistry are based not only on true clinical outcomes treatment success. A variety of implants, abutments,
such as implant survival, restoration survival, and and restorations differing in design and biomaterials
patient satisfaction but also on surrogate clinical have been introduced to achieve optimal mechanical,
outcomes such as dentogingival esthetics, rate of biological, and esthetic treatment outcomes.1–27 The
mechanical complications, bone levels, and health of choice of an implant abutment in the anterior region is

*Assistant Professor and Assistant Program Director, Post-Graduate Prosthodontics, Department of Reconstructive Sciences, University of Connecticut Health Center,
Farmington, CT, USA
†
Associate Professor, Department of Reconstructive Sciences, University of Connecticut Health Center, Farmington, CT, USA

© 2013 Wiley Periodicals, Inc. DOI 10.1111/jerd.12031 Journal of Esthetic and Restorative Dentistry Vol 25 • No 3 • 159–176 • 2013 159
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IMPLANT ABUTMENTS IN THE ANTERIOR REGION Bidra and Rungruanganunt

primarily governed by: (1) patient’s smile line (low, patients. These were prefabricated machined
medium, high, or gummy smile), (2) nature of components made of titanium and veneered primarily
peri-implant mucosa (thick or thin), (3) angulation with acrylic resin resulting in a one-piece
of the implant, (4) choice of crown material, abutment-crown restoration.27,28 In order to improve
(5) availability of restorative space, (6) type of esthetics, this approach was later replaced by a
restoration (screw- or cement-retained), (7) clinician’s two-piece restoration with a prefabricated titanium
preference, and (8) treatment expenses. Different types abutment supporting a cemented metal-ceramic
of implant abutments have been described in the crown.28 This was followed by the introduction of the
literature for use in the anterior region. They can be University of California Los Angeles (UCLA) abutment
categorized based on method of connection to in 1988, which for the first time allowed customized
restoration, material, method of fabrication, and color cast metal component to be directly screwed into the
(Table 1). Different characteristics of the abutment add dental implant.29 This abutment continues to be
to unique advantages and disadvantages. popular, for screw- and cement-retained restorations.
With evolution in esthetic implant dentistry, it was
Use of implants for single tooth restorations was first recognized that the metal abutments lead to a
reported in 1986 by Jemt28 and is rapidly emerging as blue-grayish discoloration of the peri-implant soft tissue
the standard of care for partially edentulous patients. at the gingival margins that was considered
Historically, the prosthetic components such as objectionable by some clinicians for treatment success.
abutment and retaining screw were directly derived
from those being used to rehabilitate edentulous A solution to this problem was the introduction of a
densely sintered alumina ceramic abutment in 1993 by
Prestipino and Ingber.30–32 The alumina ceramic
TABLE 1. Categorization of different implant abutment
designs
abutment was an important breakthrough and was used
in multiple clinical studies and was further improvised
Category Options
by using computer-aided design–computer-aided
1. Method of One-piece screw-retained abutment-crown
manufacturing (CAD-CAM) technology for
connection to complex
restoration Two-piece design with screw-retained crown fabrication.23 Then, in 2004, Glauser and colleagues first
over the abutment described the densely sintered yttrium-stabilized
Two-piece design with cemented crown
over the abutment zirconia as an alternative ceramic abutment.22 They
used a manually guided copy-milling technique to
2. Material Titanium
produce their abutment as a copy of a customized resin
Cast metal (noble, high noble, or base metal
alloy) pattern. This was eventually followed by CAD-CAM
Cast metal with porcelain fused at the base technology for producing zirconia abutments. Since
Alumina
Complete zirconia then, significant advancements in biological
Zirconia with a titanium base understanding has resulted in improved treatment
(zirconia-titanium hybrid abutment)
protocols such as palatal placement of implants,
3. Method Prefabricated (unmodified or modified) surgical augmentation of thin soft tissues, and soft
of fabrication Customized cast abutment tissue development with interim restorations and
Customized copy-milled abutment
Customized CAD-CAM abutment platform switching, all of which now enable
replacement of a missing anterior tooth to ideal
4. Color Gold
Silver (metallic finish)
esthetics and function.
Pure white
Customized white Previous systematic reviews incorporating implant
Customized pink/gingival shade at the
cervical region abutments have all combined treatment outcomes for
anterior and posterior abutments.33–35 Additionally,
CAD-CAM = computer-aided design–computer-aided manufacturing.
some systematic reviews have combined laboratory and

160 Vol 25 • No 3 • 159–176 • 2013 Journal of Esthetic and Restorative Dentistry DOI 10.1111/jerd.12031 © 2013 Wiley Periodicals, Inc.
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IMPLANT ABUTMENTS IN THE ANTERIOR REGION Bidra and Rungruanganunt

clinical results to arrive to their conclusions. It is well (4) review/technique articles without associated clinical
known that biting/occlusal forces have different vectors trial and data, (5) case reports/series/studies with less
and are significantly higher in the posterior regions than four abutments, (6) patients or data being repeated
than anterior regions because of the class III lever in other included articles, and (7) articles that did not
system in the human mandible.36,37 When compared provide the required data or did not allow extraction of
with the incisor region, occlusal forces are almost two the required data on anterior implant abutments.
times higher in the premolar region and three times
higher in the molar region. Therefore, the clinical The electronic search was conducted in three stages in
outcomes between anterior and posterior abutments a hierarchical order. At stage 1, a list of titles was
may be significantly different. Additionally, esthetic obtained from the electronic databases, and each
parameters governing the selection of an anterior examiner independently analyzed pertinent titles based
abutment may not necessarily apply to posterior on the predetermined inclusion criteria. The examiners
regions. It is important that studies evaluating then debated the exclusion of these titles, and any
outcomes of prosthetic components delineate anterior disagreement was resolved by discussion. In case of any
and posterior regions, as their complications and doubt, the title of the article was appropriately included
survival outcomes may be significantly different. for consideration in the next stage. At stage 2, both
Therefore, the purpose of this study is to evaluate examiners independently screened the abstracts of all
clinical outcomes including survival outcomes, selected titles. Abstracts to be included for further
mechanical outcomes, and biological and esthetic scrutiny were again independently selected by the two
outcomes of implant abutments used exclusively in the authors. Any discrepancies between the authors were
maxillary and mandibular anterior regions. discussed until a consensus was reached. When in
doubt, an abstract was incorporated for the next stage
of full-text analysis of articles. At stage 3, both
MATERIAL AND METHODS examiners carefully studied the full text of all included
articles. A manual search complemented this stage by
An electronic search of the English language literature inclusion of additional full-text articles from citations
between the periods of January 1970 and August 2012 that were reviewed in stage 3. Thereafter, exclusion
was performed by using PubMed/MEDLINE with criteria were applied, and the final list of articles was
predetermined inclusion criteria. Key terms included in reviewed in-depth to meet the objectives of this
the search were: zirconia abutments, zirconium systematic review. In this systematic review, survival
abutments, alumina abutments, gold abutments, was defined as presence of an implant abutment in
ceramic abutments, porcelain abutments, esthetic function after placement. Failure was defined as absence
abutments, CAD-CAM abutments, metal-free or complete loss of the abutment requiring replacement
abutments, titanium abutments, and custom abutments. by a new abutment. Complication was defined as
The inclusion criteria were: (1) English language article introduction of an unplanned and unwanted event
in a peer-reviewed journal, (2) any clinical study on during treatment, which did not require replacement of
humans involving any of the search terms listed, and the entire abutment, implant, or crown.
(3) articles describing clinical studies on partially
edentulous humans involving implant abutments in the
maxillary and mandibular canine to canine region. The RESULTS
exclusion criteria were: (1) articles that did not pertain
to abutments described in the inclusion criteria, The search from the electronic database resulted in a
(2) articles that described implants with a one-piece total of 2,205 titles, out of which abstracts of only 64
design (without a separate abutment), (3) articles that titles were applicable to the study. Application of the
described the use of abutments solely for purposes predetermined exclusion criteria led to a total of 31
of interim/provisional/transitional treatment, articles for full-text analysis. An in-depth manual search

© 2013 Wiley Periodicals, Inc. DOI 10.1111/jerd.12031 Journal of Esthetic and Restorative Dentistry Vol 25 • No 3 • 159–176 • 2013 161
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IMPLANT ABUTMENTS IN THE ANTERIOR REGION Bidra and Rungruanganunt

of citations from these 31 articles led to addition of 25 disilicate), (3) porcelain veneered directly to cast metal
more articles resulting in a total of 57 full-text articles abutment, titanium abutment, or ceramic abutment,
that were studied in detail. Further application of and (4) acrylic resin veneered directly to cast metal or
exclusion criteria resulted in elimination of 30 full-text titanium abutment.
articles38–67 (Table 2). This lead to a total of 27 studies
from which qualitative and quantitative data were Only 11/27 studies reported exclusively on abutments
extracted for analysis (Tables 3 and 4). Of the 27 in the anterior region. Consequently, the authors
studies, 4 were randomized clinical trials, 14 were extracted data from the remaining 16 studies to
prospective studies, 8 were retrospective studies, and 1 compute a total of 951 anterior abutments from all 27
was a cross-sectional study. Majority of studies (20/27) studies combined (Table 5). Because of substantial
were published during the recent 5-year period. heterogeneity of data reporting, unclear data on
follow-up (range 0.08–13 years), and lack of life table
All 27 studies reported use of abutments in the anterior survival analysis, calculation of true survival or
maxilla, with 12 of them also reporting use of cumulative survival rate of the abutments was
abutments in the anterior mandible as well. The impossible. Additionally, two studies were descriptive in
number of implant abutments reported in the anterior nature that compared esthetic outcomes and did not
mandible was very low in all 12 studies. Almost all report any survival data. An unrefined mean survival
studies reported use of abutments to support single estimate calculated for a total of 11 reported fractures
crown restorations, and only one study reported use of resulted in a mean failure of 1.15%. All 11 fractures
abutments to support fixed partial dentures.5 Majority were reported for ceramic abutments with 8 fractures
of studies (17/27) reported exclusively on internal on alumina abutments and the remaining 3 fractures
connection between the abutment and the implant, involving zirconia abutments. No abutment
nine studies reported exclusive use of external hex fractures were reported on titanium or cast metal
implants, and one study incorporated both types of abutments. Studies reporting mechanical outcomes
implants. Majority of studies (22/27) reported use of listed abutment screw loosening as the primary
cement-retained restorations making them appear as complication, but the majority of these studies used
the popular choice for anterior implant restorations. external hex implants, for which abutment loosening
The one-piece screw-retained restoration was reported is a well-recognized complication. Abutment screw
in eight studies, and three studies reported on fracture was reported in only one study,27 making
two-piece screw-retained restorations. it appear to be a rare complication for anterior
abutments. Complications for crowns over the
For abutment material, 16 studies reported use of abutments were reported in 14 studies, with most
titanium abutments, 4 studies on cast metal alloy common complications being minor fracture/chipping
abutments, 4 studies on alumina abutments, 13 studies of porcelain, prosthetic screw loosening, and loss of
on complete zirconia abutments, and 2 studies on crown retention.
zirconia abutments with a titanium base. For method of
abutment fabrication, 16 studies reported on For biological outcomes, occurrence of fistulas was
prefabricated abutments (zirconia and titanium), 4 reported as the most common complication, both in
studies on UCLA-type customized abutments, 8 studies screw-retained restorations (4/6) and cement-retained
on CAD-CAM customized abutments (zirconia and restorations (2/6). Another biological complication
titanium), and 4 studies reported on special methods reported in six studies9,15,17,23,24,27 was peri-implant
for customization including copy-milled technique. mucosal recession. This complication was
Different types of restorative materials were used for predominantly reported in studies using prefabricated
crown fabrication over the abutments ranging from abutments (titanium). All other biological surrogate
(1) metal-ceramic cemented crowns, (2) all-ceramic treatment outcomes such as plaque index, marginal
cemented crowns (zirconia alumina and lithium bone loss, and tissue health were unremarkable across

162 Vol 25 • No 3 • 159–176 • 2013 Journal of Esthetic and Restorative Dentistry DOI 10.1111/jerd.12031 © 2013 Wiley Periodicals, Inc.
 17088240, 2013, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jerd.12031 by Egyptian National Sti. Network (Enstinet), Wiley Online Library on [22/01/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
IMPLANT ABUTMENTS IN THE ANTERIOR REGION Bidra and Rungruanganunt

TABLE 2. Summary of 30 excluded articles at full-text stage and reason for exclusion (30 total)
No. Authors Year of Criteria for exclusion
publication

1. Wolleb et al.38 2012 Did not allow data extraction

2. Brown and Payne39 2011 Did not allow data extraction

3. Sailer et al.40 2009 Repeated data from another included article

4. Jung et al.41 2008 Did not allow data extraction

5. Bae et al.43 2008 Number of anterior abutments was less than 4.

6. Kreissl et al.42 2007 Did not pertain to anterior abutments and did not allow data extraction

7. Bischof et al.44 2006 Did not pertain to anterior abutments

8. De Boever et al.45 2006 Did not allow data extraction

9. Vigolo et al.46 2006 Did not pertain to anterior abutments

10. Brägger et al.47 2005 Did not pertain to anterior abutments

11. Romeo et al.48 2004 Did not allow data extraction

12. Preiskel and Tsolka49 2004 Did not allow data extraction

13. Andersson et al.50 2003 Did not allow data extraction

14. Romeo et al.51 2003 Did not pertain to anterior abutments and did not allow data extraction

15. Jemt et al.52 2003 Did not pertain to anterior abutments

16. Krennmair et al.53 2002 Did not allow data extraction

17. Behneke et al.54 2000 Did not allow data extraction

18. Bianco et al.55 2000 Did not allow data extraction

19. Eger et al.56 2000 Did not allow data extraction

20. Sethi et al.57 2000 Did not allow data extraction

21. Andersson et al.58 1999 Did not allow data extraction

22. Wannfors and Smedberg59 1999 Did not allow data extraction

23. Wyatt and Zarb60 1998 Did not allow data extraction

24. Behr et al.61 1998 Did not allow data extraction

25. Scheller et al.62 1998 Did not allow data extraction

26. Andersson et al.63 1998 Did not allow data extraction

27. Kastenbaum et al.64 1998 Did not allow data extraction

28. Chapman and Grippo65 1996 Did not allow data extraction

29. Henry et al.66 1996 Did not allow data extraction

30. Lewis et al.67 1992 Did not allow data extraction

© 2013 Wiley Periodicals, Inc. DOI 10.1111/jerd.12031 Journal of Esthetic and Restorative Dentistry Vol 25 • No 3 • 159–176 • 2013 163
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IMPLANT ABUTMENTS IN THE ANTERIOR REGION Bidra and Rungruanganunt

TABLE 3. Summary of 27 included studies with qualitative data

Study name Nature of Setting Abutment Type of implant Type of Abutment
the study location restoration connection of manufacturer
(single crown abutment to information
or FPD) implant

Camargos et al.1 Retrospective Independent clinic Maxilla and Single crown External Neodent
mandible

Cabello et al.2 Prospective Private practice Maxilla Single crown Internal Straumann

Hosseini et al.3 Prospective University Maxilla Single crown Internal Astra Tech

4
Canullo and Götz Prospective Not reported Maxilla Single crown Internal Sweden & Martina

Kim et al.5 Prospective University Maxilla and Single crown and External Zir-Ace, Acucera,
mandible fixed partial Pocheon, Koria
dentures

Furze et al.6 Prospective Private practice Maxilla Single crown Internal Straumann

Gallucci et al.7 RCT University Maxilla Single crown Internal Synocta 1.5
screw-retained
abutment, Straumann

Happe et al.8 Retrospective Private practice Maxilla Single crown Internal Cercon, Dentsply,
Friadent

Cosyn et al.9 Prospective University Maxilla Single crown Internal Esthetic abutment, Nobel
Biocare

Ekfeldt et al.10 Retrospective Private practice Maxilla and Single crown Internal and external Procera, Nobel Biocare
mandible

van Brakel et al.11 Cross-sectional University Maxilla Single crown Internal Astra

Bressan et al.12 Prospective Multicenter study Maxilla Single crown Internal Astra

13
Redemagni et al. Retrospective Private practice Maxilla and Single crown Internal Not reported
mandible

Zembic et al.14 RCT University Maxilla and Single crown External Procera, Nobel Biocare
mandible

Jemt15 Retrospective University Maxilla Single crown External TiAdapt and CeraOne,
Nobel Biocare

Lee and Hasegawa16 Prospective Not reported Maxilla Single crown Internal Zimmer Contour
all-ceramic abutment,
Zimmer

Chen et al.18 RCT Not reported Maxilla and Single crown Internal and external CerAdapt and zirconia
mandible abutments, Nobel
Biocare

Cooper et al.17 Prospective University Maxilla Single crown Internal Astra abutment ST
titanium

Rompen et al.19 Prospective University and private Maxilla and Single crown Internal Experimental abutments
practice mandible and Procera, Nobel
Biocare

Canullo20 Prospective Private practice Maxilla and Single crown Internal ProUnic abutment,
mandible impladent with
Zirkonzahn

Zarone et al.21 Retrospective University Maxilla Single crown Internal Procera Alumina and
stock titanium
abutments, Nobel
Biocare

164 Vol 25 • No 3 • 159–176 • 2013 Journal of Esthetic and Restorative Dentistry DOI 10.1111/jerd.12031 © 2013 Wiley Periodicals, Inc.
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IMPLANT ABUTMENTS IN THE ANTERIOR REGION Bidra and Rungruanganunt

TABLE 3. Continued
Study name Nature of Setting Abutment Type of implant Type of Abutment
the study location restoration connection of manufacturer
(single crown abutment to information
or FPD) implant

Glauser et al.22 Prospective University Maxilla and Single crown External Wohlwend
mandible

Henriksson and Prospective Independent clinic Maxilla Single crown External Procera, Nobel Biocare
Jemt23

Andersson et al.24 RCT Multicenter study Maxilla and Single crown External CerAdapt and CeraOne,
mandible Branemaek System,
Nobel Biocare

Levine et al.26 Retrospective Multicenter study Maxilla and Single crown Internal Octa-abutment and
mandible conical-abutment,
Straumann

Jemt25 Retrospective Independent center Maxilla and Single crown External Experimental adjustable
mandible titanium abutments,
Nobel Biocare

Avivi-Arber and Prospective University Maxilla and Single crown External Prefabricated standard
Zarb27 mandible abutments and
CeraOne abutments,
Nobel Biocare

FPD = Fixed partial denture; RCT = randomized, controlled trial.

all studies. However, two studies examining an anterior abutments were followed during a specific time
experimental concave-shaped abutment showed soft interval and did not clarify when the abutment failures
tissue stability, minimal soft tissue recession, and even a occurred, (3) most studies (19/27) described follow-up
gain in soft tissue height.13,19 For esthetic outcomes, periods of less than 5 years, and (4) few studies allowed
change in color of peri-implant soft tissues because of generation of a life table survival analysis, impeding
the abutment was the commonly studied outcome. In calculation of interval, or cumulative survival rates.
general, studies using spectrophotometric analysis Lack of similar outcome criteria and time periods made
showed lesser peri-implant mucosal discoloration for it difficult to draw conclusions on survival of anterior
zirconia abutments compared with metal abutments; implant abutments. Furthermore, two studies were
studies using subjective-/objective-scoring criteria descriptive in nature that compared esthetic outcomes
showed no difference in patient’s esthetic satisfaction and did not report any survival data. Therefore, only a
between the two kinds of abutments. gross estimate of mean failures could be calculated for
the 11 reported failures, which was 1.15%.

DISCUSSION Out of 11 fractures, 4 alumina abutments were reported

to have fractured at the time of insertion and 4 alumina
Survival Outcomes abutments and 3 zirconia abutments fractured after
crown cementation. Although none of the studies
Analyzing abutment survival outcomes was one of the reported fracture of zirconia abutments at the time of
primary objectives of this systematic review. However, insertion, this incidence cannot be ruled out and is a
multiple challenges in extraction of survival data from very important consideration in future reporting to
the included studies were: (1) majority of studies allow true assessment of the zirconia abutments. It is
reported a broad follow-up period (range 0.08–13 important to note that no abutment fractures were
years), (2) most studies did not report how many reported on titanium or cast metal abutments. Because

© 2013 Wiley Periodicals, Inc. DOI 10.1111/jerd.12031 Journal of Esthetic and Restorative Dentistry Vol 25 • No 3 • 159–176 • 2013 165
 166
TABLE 4. Summary of 27 included studies with their clinical outcomes
Study name Nature of Mechanical Biological Esthetic complications Nature of restoration Crown material Prosthetic
abutment and complications complications complications
material

Camargos et al.1 Prefabricated titanium Abutment screw Not reported Not reported One-piece Metal-ceramic and Prosthetic screw
abutment and UCLA-type loosening screw-retained, metal-acrylic resin loosening

Vol 25 • No 3 • 159–176 • 2013

cast metal abutment (3 UCLA-type cast two-piece
metal abutments) screw-retained, and
cement-retained

Cabello et al.2 UCLA-type cast metal Abutment screw None None One-piece Metal-ceramic and None
abutment and loosening screw-retained (12) zirconia-ceramic
prefabricated zirconia (1 abutment) and cement-retained
abutment (2)

Hosseini et al.3 UCLA-type cast metal None Fistulas because of None (although the mucosal Cement-retained Metal-ceramic, Loss of retention of one
abutment (38) residual cement in discoloration of zirconia zirconia-ceramic, and metal-ceramic crown,
prefabricated zirconia cement-retained abutments was lesser than lithium disilicate poor-marginal
abutment (19) and crowns titanium abutments) adaptation of one
prefabricated titanium all-ceramic crown, and
abutment (11) minor chipping of

Journal of Esthetic and Restorative Dentistry

porcelain of one
crown

Canullo and Götz4 Prefabricated titanium Not reported Plasma cleaning None Cement-retained Metal-ceramic Not reported
abutment treatment of
titanium
abutments favored
hard tissue levels
IMPLANT ABUTMENTS IN THE ANTERIOR REGION Bidra and Rungruanganunt

Kim et al.5 Prefabricated alumina- Abutment fracture None Not reported One-piece Metal-ceramic and Not reported
toughened zirconia (1) and abutment screw-retained and zirconia-ceramic
abutment screw loosening cement-retained
(1 abutment)

Furze et al.6 CAD-CAM zirconia None None None Cement-retained Zirconia-ceramic Multiple fractures of
abutment provisional abutment

Gallucci et al.7 Prefabricated titanium None None None Two-piece screw-retained Metal-ceramic and Minor chipping of
abutment coupled with In-ceram alumina porcelain (2)
In-ceram alumina or cast

DOI 10.1111/jerd.12031
gold alloy

Happe et al.8 Customized zirconia Not reported Not reported Minimal discoloration between Cement-retained Zirconia-ceramic Not reported
abutment with fluorescent peri-implant mucosa and the
orange ceramic collar natural tooth gingiva.

Cosyn et al.9 Prefabricated titanium None Midfacial recession of None Cement-retained Metal-ceramic Loss of retention of one
abutment mucosa metal-ceramic crown

© 2013 Wiley Periodicals, Inc.

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 Ekfeldt et al.10 CAD-CAM zirconia Fracture of the Fistulas because of None One-piece Zirconia-ceramic and Minor chipping of
abutment abutments (2) residual cement in screw-retained and alumina-ceramic porcelain (three
(one at insertion cement-retained cement-retained crowns), loss of
and one after 2 crowns retention (one crown)
months); abutment
screw loosening
(1)

van Brakel et al.11 Experimental titanium and Not reported Not reported Soft tissue discoloration was Did not place a Did not place a crown N/A

© 2013 Wiley Periodicals, Inc.

zirconia abutments similar for metal and restoration
ceramic abutment when
tissue thickness was greater
than 2 mm

Bressan et al.12 UCLA-type cast metal Not reported Not reported Soft tissue discoloration was Cement-retained and Zirconia-ceramic N/A
abutment (20), least for zirconia followed screw-retained
prefabricated CAD-CAM by gold and then titanium
zirconia abutment (20), and abutments

DOI 10.1111/jerd.12031
CAD-CAM titanium
abutment (20)

Redemagni et al.13 Customized concave titanium None None, but the None Cement-retained Zirconia-ceramic None
and customized concave concave
zirconia abutments abutments showed
minimal recession
and stable soft
tissue levels

Zembic et al.14 CAD-CAM titanium and None None None Cement-retained and Metal-ceramic and Minor chipping of
CAD-CAM zirconia one-piece zirconia, alumina, or porcelain
abutments screw-retained glass-ceramic

Jemt15 Prefabricated titanium Multiple abutment Buccal fistulas and None One-piece Metal-ceramic None
abutments screw loosening buccal mucosal screw-retained (16)
(exact site and recession and externally
number not cemented crowns with
reported) single abutment screw
(21)

Lee and Prefabricated zirconia None None None Cement-retained Zirconia-ceramic None
Hasegawa16 abutment with a titanium
interface ring

Chen et al.18 Prefabricated alumina and Alumina abutment None None Cement-retained Empress II Loss of retention (2) and

Journal of Esthetic and Restorative Dentistry

zirconia abutment fractures (2) crown fracture (1)

Cooper et al.17 Prefabricated titanium None Tenderness of buccal None Cement-retained Not reported Loss of retention of two
abutments mucosa and metal-ceramic crown
peri-implant and minor chipping of
mucosal defect porcelain (3)

Rompen et al.19 CAD-CAM titanium and None None None Cement-retained Alumina-ceramic Not reported
zirconia abutment
IMPLANT ABUTMENTS IN THE ANTERIOR REGION Bidra and Rungruanganunt

Vol 25 • No 3 • 159–176 • 2013

167
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 168
TABLE 4. Continued

Study name Nature of Mechanical Biological Esthetic complications Nature of restoration Crown material Prosthetic
abutment and complications complications complications
material

Vol 25 • No 3 • 159–176 • 2013

Canullo20 CAD-CAM zirconia None None None Cement-retained All-ceramic material Minor chipping of
abutment on a (exact type not porcelain (1)
prefabricated titanium base reported)

Zarone et al.21 Prefabricated titanium None None None Cement-retained Procera all-ceram alumina Minor chipping of
abutments and CAD-CAM porcelain (1)
alumina abutments

Glauser et al.22 Customized experimental Abutment screw None None Cement-retained Empress I Minor chipping of
zirconia abutments by loosening (2) porcelain (2)
manually guided
copy-milling machine

Henriksson and CAD-CAM alumina None Buccal fistulas (1) None One-piece Alumina crowns and None
Jemt23 abutment and buccal screw-retained and porcelain directly

Journal of Esthetic and Restorative Dentistry

mucosal recession cement-retained veneered to alumina
(2) abutment

Andersson et al.24 Prefabricated titanium Fracture of alumina Papillary recession None One-piece Metal-ceramic, Fracture of all-ceramic
abutments and alumina abutments (2 and buccal fistula screw-retained and titanium-veneered with crown (1) placed on
abutments during the first cement-retained ceramic, and titanium abutment
year; 4 fractures at all-ceramic
placement and 2
IMPLANT ABUTMENTS IN THE ANTERIOR REGION Bidra and Rungruanganunt

chipping at
placement)

Levine et al.26 Prefabricated titanium None Not reported Not reported Two-piece screw-retained Metal-ceramic Prosthetic screw
abutments and cement-retained loosening

Jemt25 Prefabricated titanium Abutment screw Buccal fistula (1) None One-piece Titanium veneered with None
abutment loosening (1) screw-retained ceramic

Avivi-Arber and Prefabricated titanium Abutment screw Buccal fistulas (3), None Cement-retained and Metal-ceramic and Loss of retention of
Zarb27 abutment and UCLA-type loosening, inflammation (6) screw-retained metal-acrylic resin metal-ceramic crown

DOI 10.1111/jerd.12031
cast metal abutment abutment screw and buccal and fracture of
fracture mucosal recession porcelain
(1)

CAD-CAM = computer-aided design–computer-aided manufacturing; N/A = not applicable; UCLA = University of California Los Angeles.

© 2013 Wiley Periodicals, Inc.

17088240, 2013, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jerd.12031 by Egyptian National Sti. Network (Enstinet), Wiley Online Library on [22/01/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
 TABLE 5. Summary of 27 included studies with quantitative data
Study name Number of Total number Total number Number of Total failures Total mechanical Range of follow-up in years
patients of implants of abutments in anterior abutments reported complications
in the study the study in the study reported

Camargos et al.1 44 73 73 23 0 3 2 to 13 years

2
Cabello et al. 14 14 14 14 0 1 1 year

© 2013 Wiley Periodicals, Inc.

3
Hosseini et al. 59 98 98 68 0 0 3 years

Canullo and Götz4 5 5 5 5 0 0 1.5 years

Kim et al.5 213 611 611 60 1 1 0.08 to 12.8 years

6
Furze et al. 10 10 10 9 0 0 1 year
7
Gallucci et al. 20 20 20 20 0 0 2 years

DOI 10.1111/jerd.12031
8
Happe et al. 12 12 12 12 0 0 N/A

Cosyn et al.9 25 25 25 25 0 0 1–3 years

Ekfeldt et al.10 130 185 185 165 2 1 Variable range up to 5 years

11
van Brakel et al. 11 15 30 30 N/A N/A N/A
12
Bressan et al. 20 20 60 60 N/A N/A N/A
13
Redemagni et al. 28 33 33 13 0 0 0.5 to 4.1 years
14
Zembic et al. 22 40 40 4 0 0 2.6 to 4.4 years

Jemt15 35 41 41 37 0 Not reported 10 years

Lee and Hasegawa16 9 9 9 9 0 0 1 year

18
Chen et al. 23 35 35 35 2 0 1 to 4 years
17
Cooper et al. 39 43 43 43 0 0 3 years
19
Rompen et al. 41 54 54 44 0 0 1 to 2 years

Canullo20 25 30 30 16 0 0 3 to 3.6 years

Zarone et al.21 44 58 58 58 0 0 4 years

22
Glauser et al. 27 54 54 39 0 2 4 years

Journal of Esthetic and Restorative Dentistry

23
Henriksson and Jemt 20 24 24 23 0 0 1 year
24
Andersson et al. 75 89 89 70 6 1 to 3 years

Levine et al.26 110 157 157 22 0 0 2 years or more

Jemt25 14 17 17 16 0 1 2 years
27
Avivi-Arber and Zarb 41 49 49 31 0 Not reported 1 to 8 years

N/A = not applicable.

IMPLANT ABUTMENTS IN THE ANTERIOR REGION Bidra and Rungruanganunt

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169
17088240, 2013, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jerd.12031 by Egyptian National Sti. Network (Enstinet), Wiley Online Library on [22/01/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
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IMPLANT ABUTMENTS IN THE ANTERIOR REGION Bidra and Rungruanganunt

of paucity of data, the outcomes of abutments used in and mechanical bond between the zirconia and
the anterior mandible and for fixed partial dentures titanium components in these hybrid abutments may
remain unknown. also be of additional concern.

Mechanical Outcomes Biological Outcomes

Irrespective of the abutment material, abutment screw Buccal fistulas were reported by 6/27 studies and
loosening was the most commonly reported mechanical involved both screw- and cement-retained restorations.
complication; this was primarily noted in studies using In screw-retained restorations, this was only seen in
external hex implants for single implant restorations. external hex implants probably because of a gap
This finding is consistent with the systematic review of between an ill-fitting abutment and implant, where soft
Sailer and colleagues.33 Although abutment screw tissue could have invaginated to result in fistulas. In
loosening may not be a catastrophic failure, repeated cement-retained restorations, the fistulas were
screw loosening can affect the success of implant attributed to uncleaned residual cement. In all studies,
therapy and patient satisfaction. Therefore, it may be the complication was resolved by appropriate
preferable to use implants with internal connection for intervention. Another biological complication reported
single implant restorations, which showed very minimal in six studies was peri-implant mucosal recession. This
abutment screw loosening in this systematic review. complication was predominantly reported in studies
The number of abutment screw fractures was minimal using prefabricated titanium abutments. This
across all studies. The most common mechanical association could be purely coincidental or probably
complication of restorations over the implant related to the fact that (1) prefabricated abutments
abutments was minor chipping of porcelain and loss of provide less optimal support of gingival tissues
retention of cemented crowns possibly because of use compared with customized abutments, (2) titanium
of temporary cement. These minor complications were abutments have been reported in more studies because
noted irrespective of the material of the crown. of their longer period of usage, and (3) recession related
to titanium abutments can more easily be seen and
There were two studies identified in this systematic recorded compared with ceramic abutments. All other
review that described a combination of zirconia and biological surrogate treatment outcomes such as plaque
titanium abutments (zirconia-titanium hybrid index, marginal bone loss, and tissue health were
abutment). One study described the use of a thin unremarkable irrespective of the type of abutment used.
titanium ring over the zirconia abutment at the point of This finding is consistent with a systematic review by
interface with the implant.16 Another study described a Sailer and colleagues who reported no differences in
titanium base onto which a customized zirconia core biological outcomes between metal and ceramic
was cemented.22 However, there were no clinical studies abutments.33
identified in this systematic review that described the
differences in mechanical or esthetic outcomes of Two studies investigated the use of experimental
complete zirconia abutments and zirconia-titanium concave-shaped implant abutments and their effect on
hybrid abutment. A couple of recent in vitro studies gingival level. Rompen and colleagues19 used 49 concave
have examined wear of the softer titanium intaglio titanium abutments and 5 concave zirconia abutments
surface of implants because of the harder zirconia on 54 implants for single crown restorations. Digital
abutments.68,69 These studies have expressed concern photographs were made at 1, 3, 6, 12, 18, and 24
about deterioration of the intaglio surface of the months, enlarged and vertical changes in soft tissue
titanium implant and potential for future complications. levels were measured, and the definitive esthetic result
These preliminary observations are not yet clinically was evaluated subjectively on a scale. Their results
validated but require future research. On the other showed that 87% of the sites showed facial soft tissue
hand, the strength and performance of the chemical stability or a vertical gain, whereas recession in the

170 Vol 25 • No 3 • 159–176 • 2013 Journal of Esthetic and Restorative Dentistry DOI 10.1111/jerd.12031 © 2013 Wiley Periodicals, Inc.
 17088240, 2013, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jerd.12031 by Egyptian National Sti. Network (Enstinet), Wiley Online Library on [22/01/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
IMPLANT ABUTMENTS IN THE ANTERIOR REGION Bidra and Rungruanganunt

remaining 13% of the sites was never greater than abutments, either all-ceramic crowns or metal-ceramic
0.5 mm. These results suggested that using concave crowns were cemented over them. Although this study
transmucosal profiles for implant components allowed did not report many tenets of an RCT such as
for more predictable soft tissue stability in esthetic allocation concealment, follow-up, and control of bias,
areas. There was no difference in soft tissue stability it was reported that all patients in the test and control
between titanium and zirconia concave abutments. groups were fully satisfied with the achieved esthetic
Redemagni and colleagues13 used 28 concave complete results at the 1-year follow-up. However, there was no
zirconia abutments on implants for single crown mention of change in color of peri-implant soft tissues
restorations. Digital photographs were made, and because of either abutment. Zembic and colleagues14
patients were followed for a mean interval of 20.8 compared CAD-CAM fabricated zirconia abutments
months. Their results were similar to Rompen and against CAD-CAM fabricated titanium abutments in an
colleagues,19 and concluded that buccal gingival soft RCT, which included only four anterior abutments that
tissues showed minimal recession, stability, and were all on canine sites. For zirconia abutments, either
increased volume of connective tissue. Long-term data all-ceramic crowns were cemented over them or
with a randomized, controlled design are needed to porcelain was fused directly to the abutment to result in
validate this promising design of implant abutments. a one-piece screw-retained restoration. For titanium
abutments, metal-ceramic crowns were cemented over
Esthetic Outcomes them. The difference of color (delta E) of the
peri-implant mucosa as well as the gingiva of control
Esthetic outcomes in general pose challenges for natural teeth was assessed with a spectrophotometer
comparison of treatment outcomes across populations over all abutments. They reported that both zirconia
and studies. This is obviously because of variations in and titanium abutments induced a visible discoloration
subjective assessments not only among clinicians but of the peri-implant soft tissues compared with the
also because of variations between clinicians and gingiva of the control teeth. The amount of
patients. The predominant esthetic outcome discoloration induced by zirconia and titanium
attributable to the abutment in anterior implant abutments was not significantly different. Gallucci and
restorations is the change in color of the peri-implant colleagues7 compared titanium abutments with an
soft tissues. Previous authors have implicated that the in-ceram ceramic coping (test group) against titanium
blue-grayish shimmering effect of titanium abutments, abutments (control) in 20 patients, all of whom were
especially over thin peri-implant mucosal tissues can indicated for two-piece screw-retained restorations.
compromise the esthetic result.3,28,70,71 This was one of Although the test group abutments received a ceramic
the primary reasons for development of alumina and veneering, the control group received a metal-ceramic
zirconia abutments.22,30–32 crown. Specific subjective and objective criteria were
used for esthetic evaluation by independent clinicians
There were 4 randomized, controlled trials (RCTs) and patients. Their results showed that metal-ceramic
identified in this systematic review, and 3 of them and all-ceramic restorations were indistinguishable
compared esthetic outcomes between metal and from each other and the investigator’s concluded that
ceramic abutments. Andersson and colleagues24 in a the choice of material per se does not ensure an optimal
multicenter trial compared prefabricated alumina esthetic outcome.
abutments (test group) against prefabricated titanium
abutments (control group) on 70 anterior abutments on Four additional observational studies identified in this
external hex implants. The majority of abutments were systematic review examined the peri-implant mucosal
in the anterior maxilla. For alumina abutments, either discoloration because of abutments.3,8,11,12 Bressan and
all-ceramic crowns were cemented over them or colleagues12 compared three types of abutments
porcelain was fused directly to the abutment to result in (CAD-CAM titanium, cast gold alloy, and CAD-CAM
a one-piece screw-retained restoration. For titanium zirconia) on each of 20 patients in a random fashion.

© 2013 Wiley Periodicals, Inc. DOI 10.1111/jerd.12031 Journal of Esthetic and Restorative Dentistry Vol 25 • No 3 • 159–176 • 2013 171
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IMPLANT ABUTMENTS IN THE ANTERIOR REGION Bidra and Rungruanganunt

An all-ceramic crown was temporarily cemented over abutment sites and the natural teeth sites. Hosseini and
each of the abutments to simulate a clinical situation. A colleagues3 in a 3-year prospective study including 68
spectrophotometer was then used to measure anterior implants with cast metal, titanium, and
peri-implant mucosal color changes for each abutment zirconia abutments used clinician and patient’s
and mucosa adjacent to a contralateral natural tooth. subjective analysis to analyze esthetic outcomes.
Their results showed that all three abutments induced a Although the peri-implant mucosal discoloration was
color change in the peri-implant mucosa that was not significantly different between metal and zirconia
different than the natural tissue color, but zirconia abutments, slightly less discoloration was noted by
abutments induced the least color change, which was clinicians at sites with zirconia abutments. In general,
not significantly different than the cast gold abutment. patients reported no difference in esthetic satisfaction
However, titanium abutments were associated with of all-ceramic and metal-ceramic restorations.
significantly higher differences in color. They also
concluded that the thickness of the peri-implant tissues Another specific study that was excluded in this
was not a crucial factor for color change. van Brakel systematic review because of lack of retrievable data on
and colleagues11 compared two types of specially anterior abutments, but is applicable for discussion on
designed abutments (titanium and zirconia) that were this topic, is an RCT by Jung and colleagues.41 They
not intended for clinical use. They compared both used a spectrophotometer to compare the color
abutments on each of the 15 implants and used difference in peri-implant mucosa before and after
spectrophotometric measurements at each of the insertion of a metal abutment (titanium or cast gold
abutments. Their results showed that the difference in alloy) and an alumina abutment. Alumina all-ceramic
peri-implant mucosal discoloration between zirconia crowns were cemented over the alumina abutments,
and titanium abutments was imperceptible to the and metal-ceramic crowns were cemented over the
human eye when the mucosal thickness was greater metal abutments. They also compared the mucosal
than 2 mm. They also stated that the peri-implant color difference at each implant site and a
mucosa in general is about 2 mm thick when measured corresponding neighboring natural tooth site. Like
1 mm below the gingival margin. However, some previous studies, their results showed that there was a
methodological issues in this study limit its clinical difference in color of the peri-implant mucosa before
applicability. First, the experimental abutments used and after insertion of all types of abutments, without
were not representative of clinical conditions; second, any significant differences. However, when the mucosal
no crown was placed over the abutment before discoloration induced by each abutment was compared
spectrophotometric measurements were made; and with the mucosa around natural teeth sites, the alumina
finally, the spectrophotometric measurements only abutments showed lesser discoloration than the metal
compared differences in tissue color between titanium abutments, and this difference was significant.
and zirconia abutments but not between natural tissues
before abutment placement or natural tissues on the In summary, it appears that studies using
contralateral side. spectrophotometric analysis showed higher sensitivity
to detect peri-implant mucosal discoloration, whereas
Happe and colleagues8 used spectrophotometric studies using subjective/objective scoring criteria
measurements on 12 implant abutments to compare a reported minimal differences in esthetic outcomes and
specially fabricated zirconia abutment against the patient satisfaction. Future studies should examine the
natural gingival tissue of unrestored adjacent or validation of spectrophotometry with respect to
contralateral natural teeth. The zirconia abutment had clinician and patient-reported esthetic outcomes and
been veneered with a 2 mm wide collar of an treatment satisfaction.
experimental fluorescent light orange ceramic material.
They concluded that there were minimal differences in The focused question of this systematic review using
the peri-implant mucosal color between the implant the patient-intervention-control-outcome (PICO)

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IMPLANT ABUTMENTS IN THE ANTERIOR REGION Bidra and Rungruanganunt

format was: in patients requiring anterior implant primarily derived from short-term research on
restorations, does use of a specific abutment (metal or implant-supported single crowns. There is limited
ceramic) have better survival, mechanical, biological, data for anterior implant-supported fixed partial
and esthetic treatment outcomes? Systematic reviews of dentures. No data could be assimilated for
RCTs are generally considered to offer the highest level long-term survival of abutments because of
of evidence for decision making in clinical practice.72 heterogeneity of reporting.
However, depending upon on the nature of the focused 2. Among all fractures, the highest fractures were
question in a systematic review, RCTs might not always reported for alumina abutments followed by
be available for analysis. This is generally common in zirconia abutments. There are no reported fractures
implant dentistry where it is difficult to perform RCTs, on titanium and cast metal alloy abutments for the
given the nature of the treatment, cost, and the limited anterior region.
opportunity for randomization. Therefore, 3. Irrespective of the type of abutment, screw
observational studies may also need to be incorporated loosening was the most common mechanical
into a systematic review to help better answer the complication, but this finding is derived primarily
focused question by assessment and summarization of from studies using external hex implants. Loss of
all existing data.73 They also aid in highlighting the retention for cemented crowns and minor chipping
deficit in the existing body of knowledge and help to of porcelain were the most common prosthetic
guide future research. complications reported.
4. Buccal fistulas and mucosal recession were the most
Like any systematic review, there are some limitations common biological complications and were
to this study. First, there could be multiple implant reported in screw-retained and cemented
abutments whose outcomes were unaccounted for restorations.
mainly because of omission of those studies from which 5. Clinical studies using spectrophotometric analysis
data could not be extracted. This is primarily because of showed lesser peri-implant mucosal discoloration
the manner of data reporting by the authors of those with zirconia abutments, but there is no evidence
studies where anterior and posterior abutments were for difference in patient’s esthetic satisfaction
grouped together or studies where the outcomes were between ceramic and metal abutments.
not reported at all. Moreover, some studies defined the
anterior region up to the second premolar teeth but did
not provide specific number of abutments for each DISCLOSURE
implant site, making it impossible to isolate the data,
and therefore, such studies were excluded. The authors The authors have no financial interest in any of the
of this systematic review defined the anterior region as companies whose products may be included in this
canine to canine with the previously described rationale paper.
of significantly different occlusal forces from anterior to
posterior region. It is important that future studies on
implant abutments differentiate anterior and posterior REFERENCES
abutments, and describe number of abutments followed
for different time intervals. Such long-term studies with 1. Camargos Gde V, do Prado CJ, das Neves FD, Sartori IA.
adequate sample sizes will allow better understanding Clinical outcomes of single dental implants with external
of clinical outcomes of various abutments. connections: results after 2 to 13 years. Int J Oral
Maxillofac Implants 2012;27:935–44.
2. Cabello G, Rioboo M, Fábrega JG. Immediate placement
CONCLUSIONS and restoration of implants in the aesthetic zone with a
trimodal approach: soft tissue alterations and its relation
1. Minimal fractures have been reported for implant to gingival biotype. Clin Oral Implants Res 2012. doi:
abutments in the anterior region, but this data is 10.1111/j.1600-0501.2012.02516.x [Epub ahead of print].

© 2013 Wiley Periodicals, Inc. DOI 10.1111/jerd.12031 Journal of Esthetic and Restorative Dentistry Vol 25 • No 3 • 159–176 • 2013 173
 17088240, 2013, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jerd.12031 by Egyptian National Sti. Network (Enstinet), Wiley Online Library on [22/01/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
IMPLANT ABUTMENTS IN THE ANTERIOR REGION Bidra and Rungruanganunt

3. Hosseini M, Worsaae N, Schiødt M, Gotfredsen K. implants in canine and posterior regions: 3-year results.
A 3-year prospective study of implant-supported, Clin Oral Implants Res 2009;20:802–8.
single-tooth restorations of all-ceramic and 15. Jemt T. Cemented CeraOne and porcelain fused to
metal-ceramic materials in patients with tooth agenesis. TiAdapt abutment single-implant crown restorations: a
Clin Oral Implants Res 2012. doi: 10-year comparative follow-up study. Clin Implant Dent
10.1111/j.1600-0501.2012.02514.x [Epub ahead of print]. Relat Res 2009;11:303–10.
4. Canullo L, Götz W. Peri-implant hard tissue response to 16. Lee CY, Hasegawa H. Immediate load and esthetic zone
glow-discharged abutments: prospective study. considerations to replace maxillary incisor teeth using a
Preliminary radiological results. Ann Anat new zirconia implant abutment in the bone grafted
2012;194:529–32. anterior maxilla. J Oral Implantol 2008;34:259–67.
5. Kim SS, Yeo IS, Lee SJ, et al. Clinical use of 17. Cooper LF, Ellner S, Moriarty J, et al. Three-year
alumina-toughened zirconia abutments for evaluation of single-tooth implants restored 3 weeks after
implant-supported restoration: prospective cohort study 1-stage surgery. Int J Oral Maxillofac Implants
of survival analysis. Clin Oral Implants Res 2007;22:791–800.
2013;24:517–22. doi: 10.1111/j.1600-0501.2011.02413.x. 18. Chen ZF, Nang PH, Wang Y, Luo ZB. Clinical evaluation
6. Furze D, Byrne A, Donos N, Mardas N. Clinical and of ceramic implant abutments in anterior restorations.
esthetic outcomes of single-tooth implants in the anterior Ann R Australas Coll Dent Surg 2008;19:67–70.
maxilla. Quintessence Int 2012;43:127–34. 19. Rompen E, Raepsaet N, Domken O, et al. Soft tissue
7. Gallucci GO, Grütter L, Nedir R, et al. Esthetic outcomes stability at the facial aspect of gingivally converging
with porcelain-fused-to-ceramic and all-ceramic abutments in the esthetic zone: a pilot clinical study.
single-implant crowns: a randomized clinical trial. Clin J Prosthet Dent 2007;97(Suppl 6):S119–25.
Oral Implants Res 2011;22(1):62–9. doi: 20. Canullo L. Clinical outcome study of customized zirconia
10.1111/j.1600-0501.2010.01997.x abutments for single-implant restorations. Int J
8. Happe A, Schulte-Mattler V, Fickl S, et al. Prosthodont 2007;20:489–93.
Spectrophotometric assessment of peri-implant mucosa 21. Zarone F, Sorrentino R, Vaccaro F, et al. Retrospective
after restoration with zirconia abutments veneered with clinical evaluation of 86 Procera AllCeram anterior single
fluorescent ceramic: a controlled, retrospective clinical crowns on natural and implant-supported abutments.
study. Clin Oral Implants Res 2011. doi: Clin Implant Dent Relat Res 2005;7(Suppl 1):
10.1111/j.1600-0501.2011.02361.x [Epub ahead S95–103.
of print]. 22. Glauser R, Sailer I, Wohlwend A, et al. Experimental
9. Cosyn J, Eghbali A, De Bruyn H, et al. Immediate zirconia abutments for implant-supported single-tooth
single-tooth implants in the anterior maxilla: 3-year restorations in esthetically demanding regions: 4-year
results of a case series on hard and soft tissue response results of a prospective clinical study. Int J Prosthodont
and aesthetics. J Clin Periodontol 2011;38: 2004;17:285–90.
746–53. 23. Henriksson K, Jemt T. Evaluation of custom-made
10. Ekfeldt A, Fürst B, Carlsson GE. Zirconia abutments for procera ceramic abutments for single-implant tooth
single-tooth implant restorations: a retrospective and replacement: a prospective 1-year follow-up study. Int J
clinical follow-up study. Clin Oral Implants Res Prosthodont 2003;16:626–30.
2011;22:1308–14. 24. Andersson B, Taylor A, Lang BR, et al. Alumina ceramic
11. van Brakel R, Noordmans HJ, Frenken J, et al. The effect implant abutments used for single-tooth replacement: a
of zirconia and titanium implant abutments on light prospective 1- to 3-year multicenter study. Int J
reflection of the supporting soft tissues. Clin Oral Prosthodont 2001;14:432–8.
Implants Res 2011;22:1172–8. 25. Jemt T. Customized titanium single-implant abutments:
12. Bressan E, Paniz G, Lops D, et al. Influence of abutment 2-year follow-up pilot study. Int J Prosthodont
material on the gingival color of implant-supported 1998;11:312–6.
all-ceramic restorations: a prospective multicenter study. 26. Levine RA, Clem DS 3rd, Wilson TG Jr, et al. Multicenter
Clin Oral Implants Res 2011;22:631–7. retrospective analysis of the ITI implant system used for
13. Redemagni M, Cremonesi S, Garlini G, Maiorana C. Soft single-tooth replacements: results of loading for 2 or
tissue stability with immediate implants and concave more years. Int J Oral Maxillofac Implants
abutments. Eur J Esthet Dent 2009;4:328–37. 1999;14:516–20.
14. Zembic A, Sailer I, Jung RE, Hämmerle CH. 27. Avivi-Arber L, Zarb GA. Clinical effectiveness of
Randomized-controlled clinical trial of customized implant-supported single-tooth replacement: the Toronto
zirconia and titanium implant abutments for single-tooth Study. Int J Oral Maxillofac Implants 1996;11:311–21.

174 Vol 25 • No 3 • 159–176 • 2013 Journal of Esthetic and Restorative Dentistry DOI 10.1111/jerd.12031 © 2013 Wiley Periodicals, Inc.
 17088240, 2013, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jerd.12031 by Egyptian National Sti. Network (Enstinet), Wiley Online Library on [22/01/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
IMPLANT ABUTMENTS IN THE ANTERIOR REGION Bidra and Rungruanganunt

28. Jemt T. Modified single and short span restorations evaluation. Int J Periodontics Restorative Dent
supported by osseointegrated fixtures in the partially 2008;28:137–43.
edentulous jaw. J Prosthet Dent 1986;55:243–6. 44. Bischof M, Nedir R, Abi Najm S, et al. A five-year
29. Lewis S, Beumer J 3rd, Hornburg W, Moy P. The “UCLA” life-table analysis on wide neck ITI implants with
abutment. Int J Oral Maxillofac Implants 1988;3:183–9. prosthetic evaluation and radiographic analysis: results
30. Prestipino V, Ingber A. Esthetic high strength implant from a private practice. Clin Oral Implants Res
abutments. Part I. J Esthet Dent 1993;5:29–36. 2006;17:512–20.
31. Prestipino V, Ingber A. Esthetic high strength implant 45. De Boever AL, Keersmaekers K, Vanmaele G, et al.
abutments. Part II. J Esthet Dent 1993;5:63–8. Prosthetic complications in fixed endosseous
32. Prestipino V, Ingber A. All-ceramic implant abutments. implant-borne reconstructions after an observations
Esthetic indications. J Esthet Dent 1996;8:255–62. period of at least 40 months. J Oral Rehabil
33. Sailer I, Philipp A, Zembic A, et al. A systematic review of 2006;33:833–9.
the performance of ceramic and metal implant abutments 46. Vigolo P, Givani A, Majzoub Z, Cordioli G. A 4-year
supporting fixed implant reconstructions. Clin Oral prospective study to assess peri-implant hard and soft
Implants Res 2009;20(Suppl 4):4–31. tissues adjacent to titanium versus gold-alloy abutments
34. Nakamura K, Kanno T, Milleding P, Ortengren U. in cemented single implant crowns. J Prosthodont
Zirconia as a dental implant abutment material: a 2006;15:250–6.
systematic review. Int J Prosthodont 2010;23: 47. Brägger U, Karoussis I, Persson R, et al. Technical and
299–309. biological complications/failures with single crowns and
35. Abt E, Carr AB, Worthington HV. Interventions for fixed partial dentures on implants: a 10-year prospective
replacing missing teeth: partially absent dentition. cohort study. Clin Oral Implants Res 2005;16:326–34.
Cochrane Database Syst Rev 2012;(2)CD003814. 48. Romeo E, Lops D, Margutti E, et al. Long-term survival
36. Garner LD, Kotwal NS. Correlation study of incisive and success of oral implants in the treatment of full and
biting forces with age, sex, and anterior occlusion. J Dent partial arches: a 7-year prospective study with the ITI
Res 1973;52:698–702. dental implant system. Int J Oral Maxillofac Implants
37. Kumagai H, Suzuki T, Hamada T, et al. Occlusal force 2004;19:247–59.
distribution on the dental arch during various levels of 49. Preiskel HW, Tsolka P. Cement- and screw-retained
clenching. J Oral Rehabil 1999;26:932–5. implant-supported prostheses: up to 10 years of follow-up
38. Wolleb K, Sailer I, Thoma A, et al. Clinical and of a new design. Int J Oral Maxillofac Implants
radiographic evaluation of patients receiving both tooth- 2004;19:87–91.
and implant-supported prosthodontic treatment after 5 50. Andersson B, Glauser R, Maglione M, Taylor A. Ceramic
years of function. Int J Prosthodont 2012;25:252–9. implant abutments for short-span FPDs: a prospective
39. Brown SD, Payne AG. Immediately restored single 5-year multicenter study. Int J Prosthodont
implants in the aesthetic zone of the maxilla using a novel 2003;16:640–6.
design: 1-year report. Clin Oral Implants Res 51. Romeo E, Lops D, Margutti E, et al. Implant-supported
2011;22:445–54. fixed cantilever prostheses in partially edentulous arches.
40. Sailer I, Zembic A, Jung RE, et al. Randomized controlled A seven-year prospective study. Clin Oral Implants Res
clinical trial of customized zirconia and titanium implant 2003;14:303–11.
abutments for canine and posterior single-tooth implant 52. Jemt T, Henry P, Lindén B, et al. Implant-supported
reconstructions: preliminary results at 1 year of function. laser-welded titanium and conventional cast frameworks
Clin Oral Implants Res 2009;20:219–25. in the partially edentulous law: a 5-year prospective
41. Jung RE, Holderegger C, Sailer I, et al. The effect of multicenter study. Int J Prosthodont 2003;
all-ceramic and porcelain-fused-to-metal restorations on 16:415–21.
marginal peri-implant soft tissue color: a randomized 53. Krennmair G, Schmidinger S, Waldenberger O.
controlled clinical trial. Int J Periodontics Restorative Single-tooth replacement with the Frialit-2 system: a
Dent 2008;28:357–65. retrospective clinical analysis of 146 implants. Int J Oral
42. Kreissl ME, Gerds T, Muche R, et al. Technical Maxillofac Implants 2002;17:78–85.
complications of implant-supported fixed partial dentures 54. Behneke A, Behneke N, d’Hoedt B. The longitudinal
in partially edentulous cases after an average observation clinical effectiveness of ITI solid-screw implants in
period of 5 years. Clin Oral Implants Res 2007;18:720–6. partially edentulous patients: a 5-year follow-up report.
43. Bae KH, Han JS, Seol YJ, et al. The biologic stability of Int J Oral Maxillofac Implants 2000;15:633–45.
alumina-zirconia implant abutments after 1 year of 55. Bianco G, Di Raimondo R, Luongo G, et al.
clinical service: a digital subtraction radiographic Osseointegrated implant for single-tooth replacement: a

© 2013 Wiley Periodicals, Inc. DOI 10.1111/jerd.12031 Journal of Esthetic and Restorative Dentistry Vol 25 • No 3 • 159–176 • 2013 175
 17088240, 2013, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jerd.12031 by Egyptian National Sti. Network (Enstinet), Wiley Online Library on [22/01/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
IMPLANT ABUTMENTS IN THE ANTERIOR REGION Bidra and Rungruanganunt

retrospective multicenter study on routine use in private 65. Chapman RJ, Grippo W. The locking taper attachment
practice. Clin Implant Dent Relat Res 2000;2(3):152–8. for implant abutments: use and reliability. Implant Dent
56. Eger DE, Gunsolley JC, Feldman S. Comparison of angled 1996;5:257–61.
and standard abutments and their effect on clinical 66. Henry PJ, Laney WR, Jemt T, et al. Osseointegrated
outcomes: a preliminary report. Int J Oral Maxillofac implants for single-tooth replacement: a prospective
Implants 2000;15:819–23. 5-year multicenter study. Int J Oral Maxillofac Implants
57. Sethi A, Kaus T, Sochor P. The use of angulated 1996;11:450–5.
abutments in implant dentistry: five-year clinical results 67. Lewis SG, Llamas D, Avera S. The UCLA abutment: a
of an ongoing prospective study. Int J Oral Maxillofac four-year review. J Prosthet Dent 1992;67:509–15.
Implants 2000;15:801–10. 68. Stimmelmayr M, Edelhoff D, Güth JF, et al. Wear at the
58. Andersson B, Schärer P, Simion M, Bergström C. titanium-titanium and the titanium-zirconia
Ceramic implant abutments used for short-span fixed implant-abutment interface: a comparative in vitro study.
partial dentures: a prospective 2-year multicenter study. Dent Mater 2012;28(12):1215–20. pii:
Int J Prosthodont 1999;12:318–24. S0109-5641(12)00385-5. doi: 10.1016/j.dental.2012.08.008.
59. Wannfors K, Smedberg JI. A prospective clinical 69. Klotz MW, Taylor TD, Goldberg AJ. Wear at the
evaluation of different single-tooth restoration designs on titanium-zirconia implant-abutment interface: a pilot
osseointegrated implants. A 3-year follow-up of study. Int J Oral Maxillofac Implants 2011;26:970–5.
Brånemark implants. Clin Oral Implants Res 70. Park SE, Da Silva JD, Weber HP, Ishikawa-Nagai S.
1999;10:453–8. Optical phenomenon of peri-implant soft tissue. Part I.
60. Wyatt CC, Zarb GA. Treatment outcomes of patients Spectrophotometric assessment of natural tooth gingiva
with implant-supported fixed partial prostheses. Int J and peri-implant mucosa. Clin Oral Implants Res
Oral Maxillofac Implants 1998;13:204–11. 2007;18:569–74.
61. Behr M, Lang R, Leibrock A, et al. Complication rate with 71. Sailer I, Zembic A, Jung RE, et al. Single-tooth implant
prosthodontic reconstructions on ITI and IMZ dental reconstructions: esthetic factors influencing the decision
implants. Clin Oral Implants Res 1998;9:51–8. between titanium and zirconia abutments in anterior
62. Scheller H, Urgell JP, Kultje C, et al. A 5-year multicenter regions. Eur J Esthet Dent 2007;2:296–310.
study on implant-supported single crown restorations. Int 72. Needleman IG. A guide to systematic reviews. J Clin
J Oral Maxillofac Implants 1998;13:212–8. Periodontol 2002;29(Suppl. 3):6–9.
63. Andersson B, Odman P, Lindvall AM, Brånemark PI. 73. Bidra AS, Huynh-Ba G. Implants in the pterygoid region:
Cemented single crowns on osseointegrated implants a systematic review of the literature. Int J Oral Maxillofac
after 5 years: results from a prospective study on Surg 2011;40:773–81.
CeraOne. Int J Prosthodont 1998;11:212–8.
64. Kastenbaum F, Lewis S, Naert I, Palmquist C. The
EsthetiCone abutment: three-year results of a prospective Reprint requests: Avinash S. Bidra, BDS, MS, University of Connecticut
multicenter investigation. Clin Oral Implants Res Health Center, 263 Farmington Avenue, L6078, Farmington, CT 06030,
1998;9:178–84. USA; email: [email protected]

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