Journal of Prosthetic Dentistry
Systematic Review| Volume 121, ISSUE 3, P398-403.e3, March 2019

Download started.


Influence of different implant-abutment connection designs on the mechanical and biological behavior of single-tooth implants in the maxillary esthetic zone: A systematic review

Published:November 23, 2018DOI:


      Statement of problem

      A consensus regarding which implant-abutment connection type would perform best in the anterior maxilla is lacking.


      The purpose of this systematic review was to determine the best implant-abutment connection type for anterior single-tooth implants considering esthetics, success, and survival rates.

      Material and methods

      An electronic search was conducted in MEDLINE, Scopus, Embase, and the Cochrane Library databases to identify clinical studies on single-tooth implants with external and internal hexagon, and/or Morse taper connections. These studies needed to describe at least one of the following outcomes: esthetic score, survival/success rate, or marginal bone loss. The included studies and reports were assessed for bias using the Cochrane risk of bias tool.


      Of the 891 articles identified, 29 were selected and analyzed. The most common technical complications were abutment screw loosening and crown-cement loosening, while dehiscence and recession were the most common biological complications. The most frequent complications were dehiscence for external hexagon, crown-cement loosening for the internal hexagon, and ceramic fracture for the Morse taper. Esthetics were favorable for all connections, but the internal hexagon performed better. However, better results for marginal bone loss, success, and survival were found for the Morse taper. The global annual failure rate was 0.90% and 0.2% for Morse taper, 0.3% for external hexagon, and 2.2% for internal hexagon.


      This review suggests that Morse taper performs better for survival, success, and marginal bone loss. Internal hexagon performed better for esthetic parameters. Additional controlled studies are needed to provide stronger evidence because the evidence generated in this study was considered low.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Prosthetic Dentistry
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Moraschini V.
        • Poubel L.A.
        • Ferreira V.F.
        • Barboza E.S.
        Evaluation of survival and success rates of dental implants reported in longitudinal studies with a follow-up period of at least 10 years: a systematic review.
        Int J Oral Maxillofac Surg. 2015; 44: 377-388
        • Jemt T.
        Modified single and short-span restorations supported by osseointegrated fixtures in the partially edentulous jaw.
        J Prosthet Dent. 1986; 55: 243-247
        • Albrektsson T.
        • Donos N.
        • Working G.
        Implant survival and complications. The Third EAO consensus conference 2012.
        Clin Oral Implants Res. 2012; 23 Suppl 6: 63-65
        • Klinge B.
        • Meyle J.
        • Working G.
        Peri-implant tissue destruction. The Third EAO Consensus Conference 2012.
        Clin Oral Implants Res. 2012; 23 Suppl 6: 108-110
        • Salvi G.E.
        • Bragger U.
        Mechanical and technical risks in implant therapy.
        Int J Oral Maxillofac Implants. 2009; 24 Suppl: 69-85
        • Misje K.
        • Bjornland T.
        • Saxegaard E.
        • Jensen J.L.
        Treatment outcome of dental implants in the esthetic zone: a 12- to 15-year retrospective study.
        Int J Prosthodont. 2013; 26: 365-369
        • Ricomini Filho A.P.
        • Fernandes F.S.
        • Straioto F.G.
        • da Silva W.J.
        • Del Bel Cury A.A.
        Preload loss and bacterial penetration on different implant-abutment connection systems.
        Braz Dent J. 2010; 21: 123-129
        • Pessoa R.S.
        • Muraru L.
        • Junior E.M.
        • Vaz L.G.
        • Sloten J.V.
        • Duyck J.
        • et al.
        Influence of implant connection type on the biomechanical environment of immediately placed implants - CT-based nonlinear, three-dimensional finite element analysis.
        Clin Implant Dent Relat Res. 2010; 12: 219-234
        • Coppede A.R.
        • Bersani E.
        • de Mattos M.G.
        • Rodrigues R.C.
        • Sartori I.A.
        • Ribeiro R.F.
        Fracture resistance of the implant-abutment connection in implants with internal hex and internal conical connections under oblique compressive loading: an in vitro study.
        Int J Prosthodont. 2009; 22: 283-286
        • Ribeiro C.G.
        • Maia M.L.
        • Scherrer S.S.
        • Cardoso A.C.
        • Wiskott H.W.
        Resistance of three implant-abutment interfaces to fatigue testing.
        J Appl Oral Sci. 2011; 19: 413-420
        • Zarb G.A.
        • Albrektsson T.
        Towards optimized treatment outcomes for dental implants.
        J Prosthet Dent. 1998; 80: 639-640
        • Albrektsson T.
        • Zarb G.
        • Worthington P.
        • Eriksson A.R.
        The long-term efficacy of currently used dental implants: a review and proposed criteria of success.
        Int J Oral Maxillofac Implants. 1986; 1: 11-25
        • Qian J.
        • Wennerberg A.
        • Albrektsson T.
        Reasons for marginal bone loss around oral implants.
        Clin Implant Dent Relat Res. 2012; 14: 792-807
        • Papaspyridakos P.
        • Chen C.J.
        • Singh M.
        • Weber H.P.
        • Gallucci G.O.
        Success criteria in implant dentistry: a systematic review.
        J Dent Res. 2012; 91: 242-248
        • Higgins J.P.
        Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011].
        The Cochrane Collaboration, London2011
        • Moher D.
        • Liberati A.
        • Tetzlaff J.
        • Altman D.G.
        • PRISMA Group
        Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
        J Clin Epidemiol. 2009; 62: 1006-1012
        • Cooper L.F.
        • Reside G.
        • Stanford C.
        • Barwacz C.
        • Feine J.
        • Abi Nader S.
        • et al.
        A multicenter randomized comparative trial of implants with different abutment interfaces to replace anterior maxillary single teeth.
        Int J Oral Maxillofac Implants. 2015; 30: 622-632
        • Andersson B.
        • Odman P.
        • Lindvall A.M.
        • Branemark P.I.
        Cemented single crowns on osseointegrated implants after 5 years: results from a prospective study on CeraOne.
        Int J Prosthodont. 1998; 11: 212-218
        • Andersson B.
        • Taylor A.
        • Lang B.R.
        • Scheller H.
        • Scharer P.
        • Sorensen J.A.
        • et al.
        Alumina ceramic implant abutments used for single-tooth replacement: a prospective 1- to 3-year multicenter study.
        Int J Prosthodont. 2001; 14: 432-438
        • Arlin M.L.
        Analysis of 435 Screw-Vent dental implants placed in 161 patients: software enhancement of clinical evaluation.
        Implant Dent. 2002; 11: 58-66
        • Artzi Z.
        • Dreiangel A.
        A screw lock for single-tooth implant superstructures.
        J Am Dent Assoc. 1999; 130: 677-682
        • Bae K.H.
        • Han J.S.
        • Seol Y.J.
        • Butz F.
        • Caton J.
        • Rhyu I.C.
        The biologic stability of alumina-zirconia implant abutments after 1 year of clinical service: a digital subtraction radiographic evaluation.
        Int J Periodontics Restorative Dent. 2008; 28: 137-143
        • Levine R.A.
        • Clem D.S.
        • Wilson T.G.
        • Higginbottom F.
        • Solnit G.
        Multicenter retrospective analysis of the ITI implant system used for single-tooth replacements: results of loading for 2 or more years.
        Int J Oral Maxillofac Implants. 1999; 14: 516-520
        • Montero J.
        • Manzano G.
        • Beltrán D.
        • Lynch C.D.
        • Suárez-García M.J.
        • Castillo-Oyagüe R.
        Clinical evaluation of the incidence of prosthetic complications in implant crowns constructed with UCLA castable abutments. A cohort follow-up study.
        J Dent. 2012; 40: 1081-1089
        • Tabrizi R.
        • Pourdanesh F.
        • Zare S.
        • Daneste H.
        • Zeini N.
        Do angulated implants increase the amount of bone loss around implants in the anterior maxilla?.
        J Oral Maxillofac Surg. 2013; 71: 272-277
        • Vermylen K.
        • Collaert B.
        • Linden U.
        • Bjorn A.L.
        • De Bruyn H.
        Patient satisfaction and quality of single-tooth restorations.
        Clin Oral Implants Res. 2003; 14: 119-124
        • Andersen E.
        • Saxegaard E.
        • Knutsen B.M.
        • Haanaes H.R.
        A prospective clinical study evaluating the safety and effectiveness of narrow-diameter threaded implants in the anterior region of the maxilla.
        Int J Oral Maxillofac Implants. 2001; 16: 217-224
        • Ormianer Z.
        • Schiroli G.
        Maxillary single-tooth replacement utilizing a novel ceramic restorative system: results to 30 months.
        J Oral Implantol. 2006; 32: 190-199
        • Vanlıoğlu B.A.
        • Kahramanoğlu E.
        • Yıldız C.
        • Ozkan Y.
        • Kulak-Özkan Y.
        Esthetic outcome evaluation of maxillary anterior single-tooth bone-level implants with metal or ceramic abutments and ceramic crowns.
        Int J Oral Maxillofac Implants. 2014; 29: 1130-1136
        • Vanlioglu B.A.
        • Özkan Y.
        • Evren B.
        • Özkan Y.K.
        Experimental custom-made zirconia abutments for narrow implants in esthetically demanding regions: a 5-year follow-up.
        Int J Oral Maxillofac Implants. 2012; 27: 1239-1242
        • Brown S.D.
        • Payne A.G.
        Immediately restored single implants in the aesthetic zone of the maxilla using a novel design: 1-year report.
        Clin Oral Implants Res. 2011; 22: 445-454
        • Canullo L.
        • Tallarico M.
        • Penarrocha-Oltra D.
        • Monje A.
        • Wang H.L.
        • Penarrocha-Diago M.
        Implant abutment cleaning by plasma of argon: 5-year follow-up of a randomized controlled trial.
        J Periodontol. 2016; 87: 434-442
        • Bonde M.J.
        • Stokholm R.
        • Schou S.
        • Isidor F.
        Patient satisfaction and aesthetic outcome of implant-supported single-tooth replacements performed by dental students: a retrospective evaluation 8 to 12 years after treatment.
        Eur J Oral Implantol. 2013; 6: 387-395
        • Buser D.
        • Wittneben J.
        • Bornstein M.M.
        • Grutter L.
        • Chappuis V.
        • Belser U.C.
        Stability of contour augmentation and esthetic outcomes of implant-supported single crowns in the esthetic zone: 3-year results of a prospective study with early implant placement postextraction.
        J Periodontol. 2011; 82: 342-349
        • Chappuis V.
        • Bornstein M.M.
        • Buser D.
        • Belser U.
        Influence of implant neck design on facial bone crest dimensions in the esthetic zone analyzed by cone beam CT: a comparative study with a 5-to-9-year follow-up.
        Clin Oral Implants Res. 2016; 27: 1055-1064
        • Furze D.
        • Byrne A.
        • Donos N.
        • Mardas N.
        Clinical and esthetic outcomes of single-tooth implants in the anterior maxilla.
        Quintessence Int. 2012; 43: 127-134
        • Guarnieri R.
        • Grande M.
        • Ippoliti S.
        • Iorio-Siciliano V.
        • Riccitiello F.
        • Farronato D.
        Influence of a Laser-Lok surface on immediate functional loading of implants in single-tooth replacement: three-year results of a prospective randomized clinical study on soft tissue response and esthetics.
        Int J Periodontics Restorative Dent. 2015; 35: 865-875
        • Guarnieri R.
        • Placella R.
        • Testarelli L.
        • Iorio-Siciliano V.
        • Grande M.
        Clinical, radiographic, and esthetic evaluation of immediately loaded laser microtextured implants placed into fresh extraction sockets in the anterior maxilla: a 2-year retrospective multicentric study.
        Implant Dent. 2014; 23: 144-154
        • Mangano F.
        • Mangano C.
        • Ricci M.
        • Sammons R.L.
        • Shibli J.A.
        • Piattelli A.
        Single-tooth Morse taper connection implants placed in fresh extraction sockets of the anterior maxilla: an aesthetic evaluation.
        Clin Oral Implants Res. 2012; 23: 1302-1307
        • Mangano F.G.
        • Mangano C.
        • Ricci M.
        • Sammons R.L.
        • Shibli J.A.
        • Piattelli A.
        Esthetic evaluation of single-tooth Morse taper connection implants placed in fresh extraction sockets or healed sites.
        J Oral Implantol. 2013; 39: 172-181
        • Raes F.
        • Cosyn J.
        • De Bruyn H.
        Clinical, aesthetic, and patient-related outcome of immediately loaded single implants in the anterior maxilla: a prospective study in extraction sockets, healed ridges, and grafted sites.
        Clin Implant Dent Relat Res. 2013; 15: 819-835
        • Belser U.C.
        • Grutter L.
        • Vailati F.
        • Bornstein M.M.
        • Weber H.P.
        • Buser D.
        Outcome evaluation of early placed maxillary anterior single-tooth implants using objective esthetic criteria: a cross-sectional, retrospective study in 45 patients with a 2- to 4-year follow-up using pink and white esthetic scores.
        J Periodontol. 2009; 80: 140-151
        • Buser D.
        • Martin W.
        • Belser U.C.
        Optimizing esthetics for implant restorations in the anterior maxilla: anatomic and surgical considerations.
        Int J Oral Maxillofac Implants. 2004; 19 Suppl: 43-61
        • Jung R.E.
        • Pjetursson B.E.
        • Glauser R.
        • Zembic A.
        • Zwahlen M.
        • Lang N.P.
        A systematic review of the 5-year survival and complication rates of implant-supported single crowns.
        Clin Oral Implants Res. 2008; 19: 119-130
        • Castro D.S.
        • Araujo M.A.
        • Benfatti C.A.
        • Araujo C.R.
        • Piattelli A.
        • Perrotti V.
        • et al.
        Comparative histological and histomorphometrical evaluation of marginal bone resorption around external hexagon and Morse cone implants: an experimental study in dogs.
        Implant Dent. 2014; 23: 270-276

      Supplemental References

        • Haas R.
        • Mensdorff-Pouilly N.
        • Mailath G.
        • Watzek G.
        Brånemark single tooth implants: a preliminary report of 76 implants.
        J Prosthet Dent. 1995; 73: 274-279
        • Malevez C.
        • Hermans M.
        • Daelemans P.
        Marginal bone levels at Brånemark system implants used for single tooth restoration. The influence of implant design and anatomical region.
        Clin Oral Implants Res. 1996; 7: 162-169
        • Palmer R.M.
        • Smith B.J.
        • Palmer P.J.
        • Floyd P.D.
        A prospective study of Astra single tooth implants.
        Clin Oral Implants Res. 1997; 8: 173-179
        • Lorenzoni M.
        • Pertl C.
        • Zhang K.
        • Wimmer G.
        • Wegscheider W.A.
        Immediate loading of single-tooth implants in the anterior maxilla. Preliminary results after one year.
        Clin Oral Implants Res. 2003; 14: 180-187
        • Henriksson K.
        • Jemt T.
        Measurements of soft tissue volume in association with single-implant restorations: a 1-year comparative study after abutment connection surgery.
        Clin Implant Dent Relat Res. 2004; 6: 181-189
        • Calvo-Guirado J.L.
        • Ortiz-Ruiz A.J.
        • Lopez-Mari L.
        • Delgado-Ruiz R.
        • Mate-Sanchez J.
        • Bravo Gonzalez L.A.
        Immediate maxillary restoration of single-tooth implants using platform switching for crestal bone preservation: a 12-month study.
        Int J Oral Maxillofac Implants. 2009; 24: 275-281
        • Calvo-Guirado J.L.
        • Gomez-Moreno G.
        • Lopez-Mari L.
        • Guardia J.
        • Negri B.
        • Martinez-Gonzalez J.M.
        Crestal bone loss evaluation in osseotite expanded platform implants: a 5-year study.
        Clin Oral Implants Res. 2011; 22: 1409-1414
        • Vanlioglu B.A.
        • Özkan Y.
        • Evren B.
        • Özkan Y.K.
        Experimental custom-made zirconia abutments for narrow implants in esthetically demanding regions: a 5-year follow-up.
        Int J Oral Maxillofac Implants. 2012; 27: 1239-1242
        • Berberi A.N.
        • Noujeim Z.N.
        • Kanj W.H.
        • Mearawi R.J.
        • Salameh Z.A.
        Immediate placement and loading of maxillary single-tooth implants: a 3-year prospective study of marginal bone level.
        J Contemp Dent Pract. 2014; 15: 202-208
        • Berberi A.N.
        • Sabbagh J.M.
        • Aboushelib M.N.
        • Noujeim Z.F.
        • Salameh Z.A.
        A 5-year comparison of marginal bone level following immediate loading of single-tooth implants placed in healed alveolar ridges and extraction sockets in the maxilla.
        Front Physiol. 2014; 5: 29
        • Calvo-Guirado J.L.
        • Gomez-Moreno G.
        • Delgado-Ruiz R.A.
        • Mate Sanchez de Val J.E.
        • Negri B.
        • Ramirez Fernandez M.P.
        Clinical and radiographic evaluation of osseotite-expanded platform implants related to crestal bone loss: a 10-year study.
        Clin Oral Implants Res. 2014; 25: 352-358
        • Vanlıoğlu B.A.
        • Kahramanoğlu E.
        • Yıldız C.
        • Ozkan Y.
        • Kulak-Özkan Y.
        Esthetic outcome evaluation of maxillary anterior single-tooth bone-level implants with metal or ceramic abutments and ceramic crowns.
        Int J Oral Maxillofac Implants. 2014; 29: 1130-1136
        • Crespi R.
        • Capparè P.
        • Polizzi E.
        • Gherlone E.
        Fresh-socket implants of different collar length: clinical evaluation in the aesthetic zone.
        Clin Implant Dent Relat Res. 2015; 17: 871-878
        • Canullo L.
        • Tallarico M.
        • Pradies G.
        • Marinotti F.
        • Loi I.
        • Cocchetto R.
        Soft and hard tissue response to an implant with a convergent collar in the esthetic area: preliminary report at 18 months.
        Int J Esthet Dent. 2017; 12: 306-323
        • Cardaropoli G.
        • Lekholm U.
        • Wennstrom J.L.
        Tissue alterations at implant-supported single-tooth replacements: a 1-year prospective clinical study.
        Clin Oral Implants Res. 2006; 17: 165-171
        • Koller C.D.
        • Pereira-Cenci T.
        • Boscato N.
        Parameters associated with marginal bone loss around implant after prosthetic loading.
        Braz Dent J. 2016; 27: 292-297
        • Santing H.J.
        • Raghoebar G.M.
        • Vissink A.
        • den Hartog L.
        • Meijer H.J.
        Performance of the Straumann Bone Level Implant system for anterior single-tooth replacements in augmented and nonaugmented sites: a prospective cohort study with 60 consecutive patients.
        Clin Oral Implants Res. 2013; 24: 941-948
        • Koller C.D.
        • Pereira-Cenci T.
        • Boscato N.
        Parameters associated with marginal bone loss around implant after prosthetic loading.
        Braz Dent J. 2016; 27: 292-297