Journal of Dental Research

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Theoretical Optimum of Implant Positional Index Design

W. Semper, S. Kraft, T. Krger and K. Nelson J DENT RES 2009 88: 731 DOI: 10.1177/0022034509341243 The online version of this article can be found at: http://jdr.sagepub.com/content/88/8/731

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RESEARCH REPORTS
Biomaterials & Bioengineering

W. Semper, S. Kraft, T. Krger, and K. Nelson*

Dept. of Oral and Maxillofacial Surgery, Clinical Navigation and Robotics, Charit-Campus Virchow Clinic, Augusten burger Platz 1, 13353 Berlin, Germany; *corresponding author, katja.nelson@charite.de J Dent Res 88(8):731-735, 2009

Theoretical Optimum of Implant Positional Index Design

Abstract
Rotational freedom of the implant-abutment connection influences its screw joint stability; for optimization, influential factors need to be evaluated based on a previously developed closed formula. The underlying hypothesis is that the manufacturing tolerances, geometric pattern, and dimensions of the index do not influence positional stability. We used the dimensions of 5 commonly used implant systems with a clearance of 20 m to calculate the extent of rotational freedom; a 3D simulation (SolidWorks) validated the analytical findings. Polygonal positional indices showed the highest degrees of rotational freedom. The polygonal profile displayed higher positional stability than the polygons, but less positional accuracy than the cam-groove connection. Features of a maximal rotation-safe positional index were determined. The analytical calculation of rotational freedom of implant positional indices is possible. Rotational freedom is dependent on the geometric design of the index and may be decreased by incorporating specific aspects into the positional index design.

INTRODUCTION
plethora of studies evaluating implant-abutment connection features has been performed in recent years (Bozkaya and Mft, 2004; Tan et al., 2004; Maeda et al., 2006; Coelho et al., 2007; Meng et al., 2007). Prosthetic complications are highly correlated with the implant-abutment connection (Goodacre et al., 2003); they are still frequent, despite the high success rate (Jung et al., 2008). By enhancement of conventional laboratory techniques, a fit of 4.9 m between the joining surfaces of the prosthesis and the abutment is achievable (Weigl et al., 2000), but, to date, a passive fit of implant-supported superstructures has not been demonstrated (Jemt, 1995; Heckmann et al., 2004; Karl et al., 2004). Finite Element Analysis showed that prosthesis misfit influences the stress distribution in all implant components (Kunavisarut et al., 2002). The parameters responsible for this inability to achieve a passive fit have been investigated (Al-Turki et al., 2002; Heckmann et al., 2004). Although inaccuracies in repositioning of the abutment may cause prosthetic misfit, multiple repositionings of the abutment are necessary during the fabrication process (Gallucci et al., 2005; Nelson et al., 2008). Manufacturing tolerances of the implant components may be an influence in this inaccuracy phenomenon. It has been shown that manufacturing tolerances influence the extent of the clearance fit between the implant components; the clearance fit ensures that a mating will occur (Lang et al., 2003). The manufacturing-related tolerances could amount to 100 m between the mating parts (Niznick, 1991; Ma et al., 1997); no further information has so far been available from the implant manufacturers or the literature. An increased manufacturing tolerance has been described as resulting in an increased likelihood of complications (Schulte, 1994). Due to the clearance between the mating parts, a rotational movement of the abutment is possible (Binon, 1995). Rotational freedom in external hexagonal connections has been studied (Binon, 1996; Vigolo et al., 2006). This knowledge led to the development of different positional indices (Binon, 2000). The degree of rotational misfit in torque-tightened (Binon, 1996; de Barros Carrilho et al., 2005; Vigolo et al., 2006) and manually tightened (Semper et al., unpublished observations) implant-abutment complexes has been evaluated for several designs. An earlier analytical investigation (Semper et al., unpublished observations) showed that rotational freedom in different positional indices depends on their geometric design. Idealized equations were formulated to calculate the extent of rotational freedom mathematically in various untightened implant-abutment complexes. The present analysis evaluates the fit of commonly used positional index principles in dependence on manufacturing tolerances. After measuring the

KeY WorDs: implant-abutment connection, positional index, rotation, geometric design, 3D simulation.

DOI: 10.1177/0022034509341243 Received October 24, 2008; Last revision March 23, 2009; Accepted March 23, 2009

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dimensions of the geometric pattern, we performed an analytical calculation and a 3D simulation to refer theoretical findings to clinically relevant dimensions by inserting the measured values. The influences of manufacturing tolerances, geometric pattern, and the dimensions of the implant positional index principle on rotational freedom of the abutment are evaluated. A design based on the calculated theoretical optimum is described.

MATERIALS & METHODS

Previously calculated idealized equations for the possible rotational freedom of regular polygons, rounded polygonal patterns, and other patterns were utilized (Semper et al., unpublished observations).

Regular Polygonal Pattern (Steri Oss, Astra Tech, Straumann)

The previously developed closed-form formula for the rotational freedom a in polygons was used.
= 360 180 C 2 arccos cos + n n R

(1)

Rounded Polygonal Pattern (Replace Select)

The rotational freedom a in polygon profiles can be obtained by means of the following equations:
D2 + d2 K + R + C 2 = arccos 2dD ! D2 + d2 K + R2 = arccos 2dD !

(2)

a = 2 . (g b )

Universal Approach (CAMLOG and Other Geometric Principles)

Rotational freedom in other positional index designs can be calculated by C = 2 arcsin sin + . (3) R To demonstrate the clinical relevance of these idealized formulas, we inserted the parameters of the positional index design of commercially available implant systems. Geometric data from Straumann (Straumann AG, Waldenburg, Switzerland), Steri Oss (Nobel Biocare, Gteborg, Sweden), CAMLOG (CAMLOG Biotechnologies AG, Basel, Switzerland), Astra Tech (Astra Tech Dental, Mlndal, Sweden), and Replace Select (Nobel Biocare, Gteborg, Sweden) implants were included in the study (Table). One randomly selected implant and the corresponding abutment of each investigated system were measured by a coordinate reading machine (Video Check IP 400x200, Werth Messtechnik, Giessen, Germany). At a temperature of 20C 5.0C and with

a measurement accuracy of (1.40 + L/300) m, the dimensions of the particular design were measured (Figs. 1A-1E). The coordinate reading machine performs a non-contact probing by automatic measuring of basic elements in incident and transmitted light. Shade contours are identified at up to 250x magnification. The measuring of all arcs is performed by projection of a second arc with a defined radius onto the measuring object, or by calculation of the radius based on user-defined points on the arc. The centers of the circles are determined by automatic calculation. SEM micrographs (SUPRA 40VP, Carl Zeiss AG, Oberkochen, Germany) were used to illustrate the measuring points. The width across vertices V and the width across flats F were evaluated as described for regular polygonal positional index designs (Figs. 1A-1C). We used these measurements to construct idealized geometric forms, without taking abrasion or manufacturing inaccuracies into account. For other positional index designs, the diameter S was determined (Figs. 1D, 1E). All parameters were measured at the implant (Vi, Fi, Si) and the abutment (Va, Fa, Sa). In regular polygons, the length R of the abutment was obtained by Vi /2 (Va /2 for the external hexagon), adjusted for the gap between the vertices of implant and abutment. The gap resulted from multiplying the given clearance C with the corresponding cosine. Measuring the radius of R in the cam-groove connection, we used the most external points of the straight part of each groove to construct a circle (Fig. 1E). The determined values were used to generate 3D-CAD models corresponding to the idealized designs. These were constructed with SolidWorks (SolidWorks Office Premium 2007, Concord, MA, USA), with the rotations simulated to verify the calculated results. The components had the same rotation axis; the implant-abutment contact point was determined, given by the positional index design. Maximal rotational freedom of the abutment was simulated from the starting position with maximal symmetric rotation possibilities to the stop position. The resulting angle of maximal rotation was determined. Since the clearance between implant and abutment is an important parameter for the calculation and simulation of rotational freedom, the difference between Fi and Fa or Si and Sa, respectively, was determined and divided by 2. Mean value of the clearance of the different systems was 22.1 m (Steri Oss, 21 m; Astra Tech, 23 m; Straumann, 24 m; Replace Select, 27.5 m; CAMLOG, 15m). To ensure comparability of the different designs and their rotational freedom, we set the clearance at 20m.

RESULTS
Regular Polygonal Pattern (Steri Oss, Astra Tech, Straumann)
When the values of the radius R = 1.55mm, the number of vertices n = 6, and the approximated clearance C = 20m are inserted, the calculation and simulation result in a theoretical rotational freedom of 3.0 for the Steri Oss implant (Fig. 1F). With the parameters R = 1.41mm, n = 6, and C = 20 m, a rotational freedom of 3.3 results for the design of the Astra Tech implant system (Fig. 1G). With R = 1.68mm, n = 8, and C = 20 m, a rotational freedom of 3.7 can be calculated for the dimensions of the Straumann implant (Fig. 1H).

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J Dent Res 88(8) 2009 Rounded Polygonal Pattern (Replace Select)

The construction of the geometric principle is based on tangentially connected arcs; their radius and center can be determined by the coordinate reading machine. The formula and the simulation for the Replace Select System with the radius of the bulge K = 0.49mm, the radius of the outer arc at the notch of the implant R = 1.24mm, the distance from the center of the outer arc of the implant to the rotational axis D = 2.61mm, the distance from the center of the inner arc to the rotational axis d = 1.35 mm, and the clearance C = 20 m result in a rotational freedom of 1.9 (Fig. 1I).

Anti-rotational Index Design 733

Table. Description of the Components Used System Steri Oss Nobel Biocare AB, Gteborg, Sweden Astra Tech Astra Tech dental, Mlndal, Sweden Straumann Institut Straumann AG, Basel, Switzerland Replace Select Nobel Biocare AB, Gteborg, Sweden CamLog CamLog Biotechno logies AG, Basel, Switzerland Implant TPS Coated Implant 4.5mm Implant Item No. 4610TPS Implant Charge No. 322450 Abutment Item No. 31709 Abutment Charge No. 376055

Osseo SpeedTM 4.5mm

24632

36571

22968

0610375

Standard Implantat 4.1 mm

043.033S

1260

048.605

C7561

Universal Approach (CAMLOG and Other Geometric Principles)

The developed formula and the simulation show a maximal rotation of 1.4 for the dimensions of the CAMLOG implant (Fig. 1J) when the distance of the contact point to the rotational axis R = 1.6mm, the angle between R and the implant wall = 8.8, and the clearance C = 20m are inserted.

Nobelplaced Tapered Groovy 4.3 mm Schraubenim plantat, Promote 4.3 mm

32217

668188

29036

39294

J1042.4311

FF05001349

J2210.4300

FF06000679

Theoretical Optimum
As previously shown, the formula for the universal approach verifies that decreasing reduces rotational freedom. This leads to the assumption that minimal rotational freedom is achieved by = 0. In this case, the implant wall is orthogonal to the path of the rotating contact point.
= 2 arcsin C R

(4)

For small angles, the formula can be simplified with:

a arcsin a
This results in a relation where the rotational freedom is solely dependent on two parameters.

Figure 1. Rotational freedom of regular polygonal patterns, polygon profiles, and other patterns. (A) Measuring points and measuring results of the hexagonal positional index (Steri Oss). (B)Measuring points and measuring results of the dodecagrammal positional index (Astra Tech). (C)Measuring points and measuring results of the octagonal positional index (Straumann). V = width across corners, F = width across flats demonstrated at the implant positional index. (D) Measuring points and measuring results of the polygonal profile positional index (Replace Select). K = radius of the bulge, R = radius of the outer arc at the notch of the implant, D = distance from the center of the outer arc of the implant to the rotational axis, d = distance from the center of the inner arc to the rotational axis, S = diameter demonstrated at the implant positional index. (E) Measuring points and measuring results of the cam-groove connection (CAMLOG). S = diameter, R = distance of the contact point to the rotational axis, = angle between R and the implant wall demonstrated at the implant positional index. (F) 3D simulation: rotational freedom of the Steri Oss system (hexagon). (G)3Dsimulation: rotational freedom of the Astra Tech system (dodecagram). (H)3Dsimulation: rotational freedom of the Straumann system (octagon). (I) 3D simulation: rotational freedom of the Replace Select system. (J) 3Dsimulation: rotational freedom of the CAMLOG system.

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rotational freedom demonstrates a dependency on the manufacturing tolerance regardless of the geometric design. We performed calculation and simulation for untightened implantabutment complexes to demonstrate the possible displacement of the differently designed components. Theoretical analysis and 3D simulation showed consistent results, proving the formulated ana lytical equations (Semper et al., unpublished observations). The present study aimed to refer analytical aspects to clinically relevant dimensions. We measured randomly selected implants to assign them to an approximated geometric model. This approach cannot Figure 2. Comparison of the rotational freedom of different positional index designs. Calculated and analyze the rotational stability of commercially available implant simulated relation of rotational freedom and manufacturing tolerances of the systems tested (implant diamsystems, but allows the geometric eter and length: Straumann, 4.1mm/12mm; Steri Oss, 4.5mm/10mm; CAMLOG, 4.3mm/11mm; Astra Tech, 4.5mm/11mm; Replace Select, 4.3mm/13mm) and a theoretically considered maximal patterns to be compared. Drawing rotation-safe pattern. conclusions to the manufacturing tolerance of particular implantabutment connections would have required a larger number of C 2 (5) samples. R Regular polygonal implant-abutment connections displayed a higher degree of rotational freedom than polygonal profiles. The only parameters left are the clearance C, which depends Experimental rotational freedom in torque-tightened hexagonal on the tolerance of the manufacturing process, and the distance connections has reportedly decreased in recent decades. Binon of the contact point to the rotational axis R, which is dependent observed a rotational freedom of up to 14.87 in 10 external on the size of the abutment. hexagons (Binon, 1996); recent investigations showed a lower By insertion of an assumed radius of R = 2 mm and the possible hexagonal rotational movement (de Barros Carrilho specified clearance C = 20m, a minimal rotational freedom of et al. , 2005; Vigolo et al., 2006; Semper et al., unpublished 1.1 would be possible for two-dimensional position stability. observations). This might be partly due to a more precise fabrication of the implant components. Increasing rotational freedom Comparison of Rotational Freedoms among the Systems was demonstrated in 5 internal hexagonal connections compared with 5 external hexagons (de Barros Carrilho et al., 2005). This A coherence between rotational freedom and clearance was verican probably be attributed to the different radii of the hexagons; fied regardless of the positional index pattern (Fig. 2). Increasing a smaller radius increases the extent of rotational freedom, as has the number of vertices from the hexagon (Steri Oss) or dodecabeen shown in the present and a previous investigation (Semper gram (Astra Tech) to an octagon (Straumann) resulted in a higher et al., unpublished observations). These observations can be rotational freedom based on all assumed manufacturing tolerconfirmed for manually tightened implant-abutment complexes: ances. The polygonal profile connection (Replace Select) consisSix Astra Tech implants with a smaller radius (internal dodecatently showed an increased rotational freedom compared with that gram, rotation up to 4.89) showed a higher rotational freedom of the cam-groove connection (CAMLOG). than 6 Steri Oss implants with a larger radius (external hexagon, The theoretical optimum with d = 0 for an assumed radius rotation up to 3.88) (Semper et al., unpublished observations). of 2mm resulted in a minimized rotational freedom. These results correspond to the findings of the analytical Analogous to the analytical calculation, the abutments were approach, with higher values for the Astra Tech design. Increasing varied in the 3D simulation by changing the clearance. The the number of vertices resulted in a higher rotational freedom. In results are also pictured and show a high correlation with the contrast to the theoretical findings, octagons showed a reduced calculated values (Fig. 2). rotational freedom of up to 3.28 in the experimental investigation with manually tightened implant-abutment comp lexes DISCUSSION (Semper et al., unpublished observations). The analysis and simulation of the influence of the geometric Manually tightened Replace Select implants displayed a rota principle on rotation possibilities at the index level showed that tional freedom of up to 4.49 in the experimental investigation

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J Dent Res 88(8) 2009

Anti-rotational Index Design 735

Binon PP (2000). Implants and components: entering the new millennium. Int J Oral Maxillofac Implants 15:76-94. Bozkaya D, Mft S (2004). Efficiency considerations for the purely tapered interference fit (TIF) abutments used in dental implants. J Biomech Eng 126:393-401. Coelho AL, Suzuki M, Dibart S, DA Silva N, Coelho PG (2007). Crosssectional analysis of the implant-abutment interface. J Oral Rehabil 34:508-516. de Barros Carrilho GP, Dias RP, Elias CN (2005). Comparison of external and internal hex implants rotational freedom: a pilot study. Int J Prosthodont 18:165-166. Gallucci GO, Bernard JP, Belser UC (2005). Treatment of completely edentulous patients with fixed implant-supported restorations: three consecutive cases of simultaneous immediate loading in both maxilla and mandible. Int J Periodont Rest Dent 25:27-37. Goodacre CJ, Bernal G, Rungcharassaeng K, Kan JY (2003). Clinical complications with implants and implant prostheses. J Prosthet Dent 90:121-132. Heckmann SM, Karl M, Wichmann MG, Winter W, Graef F, Taylor TD (2004). Cement fixation and screw retention: parameters of passive fit. An in vitro study of three-unit implant-supported fixed partial dentures. Clin Oral Implants Res 15:466-473. Jemt T (1995). Three-dimensional distortion of gold alloy castings and welded titanium frameworks. Measurements of the precision of fit between completed implant prostheses and the master casts in routine edentulous situations. J Oral Rehabil 22:557-564. Jung RE, Pjetursson BE, Glauser R, Zembic A, Zwahlen M, Lang NP (2008). A systematic review of the 5-year survival and complication rates of implant-supported single crowns. Clin Oral Implants Res 19:119-130. Karl M, Winter W, Taylor TD, Heckmann SM (2004). In vitro study on passive fit in implant-supported 5-unit fixed partial dentures. Int J Oral Maxillofac Implants 19:30-37. Kunavisarut C, Lang LA, Stoner BR, Felton DA (2002). Finite element analysis on dental implant-supported prostheses without passive fit. J Prosthodont 11:30-40. Lang LA, Sierraalta M, Hoffensperger M, Wang RF (2003). Evaluation of the precision of fit between the Procera custom abutment and various implant systems. Int J Oral Maxillofac Implants 18:652-658. Ma T, Nicholls JI, Rubenstein JE (1997). Tolerance measurements of various implant components. Int J Oral Maxillofac Implants 12:371-375. Maeda Y, Satoh T, Sogo M (2006). In vitro differences of stress concentrations for internal and external hex implant-abutment connections: a short communication. J Oral Rehabil 33:75-78. Meng JC, Everts JE, Qian F, Gratton DG (2007). Influence of connection geometry on dynamic micromotion at the implant-abutment interface. Int J Prosthodont 20:623-625. Nelson K, Hildebrand D, Mehrhof J (2008). Fabrication of a fixed retrievable implant-supported prosthesis based on electroforming: a technical report. J Prosthodont 17:591-595. Niznick G (1991). The implant abutment connection: the key to prosthetic success. Compendium 12:932, 934-938. Schulte JK (1994). External hex manufacturing tolerances of six implant systems: a pilot study. Implant Dent 3:51-53. Semper W, Heberer S, Mehrhof J, Schink T, Nelson K (2009). Effects of repeated manual disassembly and reassembly on the position stabi lity of various implant-abutment complexes: an experimental study. Int J Oral Maxillofac Implants (in press). Tan BF, Tan KB, Nicholls JI (2004). Critical bending moment of implantabutment screw joint interfaces: effect of torque levels and implant diameter. Int J Oral Maxillofac Implants 19:648-658. Vigolo P, Fonzi F, Majzoub Z, Cordioli G (2006). An in vitro evaluation of titanium, zirconia, and alumina procera abutments with hexagonal connection. Int J Oral Maxillofac Implants 21:575-580. Weigl P, Hahn L, Lauer HC (2000). Advanced biomaterials used for a new telescopic retainer for removable dentures. J Biomed Mater Res 53:320-336.

(Semper et al., unpublished observations). This does not correspond to the findings of the present study, which demonstrated increased positional stability of polygonal profiles compared with regular polygons. The rotational freedom of the implants used in the experimental study might be referred to higher manufacturing tolerances (Fig. 2). The manually tightened cam-groove connection showed a reduced rotational freedom of up to 1.50 (Semper et al., unpublished observations); this corresponds to the analytical findings demonstrating that cam-groove connections show low degrees of rotational freedom and a lower influence of the manufacturing tolerances on positional stability. The least influence of the manufacturing tolerances on rotational freedom was observed in the theoretical optimum. The difference of the values of the experimental set-up and the analytical approach is influenced by the differing test conditions. Theoretical analysis was performed with untightened implantabutment complexes; in the experimental set-up, the implantabutment complexes were hand-tightened. Maximal rotational freedom of the different indices was determined in the mathematical approach, while the experimental set-up showed the variability of abutment position. Analysis was based on approximated, idealized geometric models. Potential shape irregularities of the implant components in the experimental set-up might have influenced the results. The experimental results can also differ from the analytical outcomes because the individual manufacturing tolerances affect the clearance between the components. Rotational freedom was determined at the two-dimensional positional index level; consequences on three-dimensional changes of position of the abutment were not elucidated. To summarize, optimal positional stability in two-dimensional positional indices could be achieved by optimizing the following parameters: The contact point of the implant and the abutment must occur in maximal distance to the rotation axis, while the index rotates perpendicularly to the implant wall. The extent of the clearance at the contact area must be minimized, and standardized manufacturing tolerances should be established. The findings of the present study might contribute to the enhancement of implant positional index design.

ACKNOWLEDGMENTS
Wiebke Semper is the recipient of a post-doctoral grant from the CAMLOG Foundation (Basel, Switzerland). This project was supported by Humboldt University Internal Research Funding (No. 89511156).

REFERENCES
Al-Turki LE, Chai J, Lautenschlager EP, Hutten MC (2002). Changes in prosthetic screw stability because of misfit of implant-supported prostheses. Int J Prosthodont 15:38-42. Binon PP (1995). Evaluation of machining accuracy and consistency of selected implants, standard abutments, and laboratory analogs. Int J Prosthodont 8:162-178; erratum in Int J Prosthodont 8:284, 1995. Binon PP (1996). The effect of implant/abutment hexagonal misfit on screw joint stability. Int J Prosthodont 9:149-160.

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