Narroline and review about titanium hybrid dental abutments complications and clinical outcomes


In the present days the substitution of a particular missing tooth with a single crown is considered to be a significant measure within the treatment approach due to the associated high rate of survival of both the implants and its reconstruction (Zarauz, 2020). However, with the enhancement of the hopes of the patients with regard to the esthetic outcome, the procedure of treatment is facing difficulties. The implant supported reconstruction which will smoothly fit with the nearby teeth and the soft tissue muscles depends on certain parameters such as scrupulous analysis of the patient, site specific evaluation, and thereafter taking the decision based on the factors for instances choice of the abutment, implant and reconstruction, the technical procedure during surgery, planning sequence of the treatment, and its further successful execution (Zarauz, 2020). Therefore, with the introduction of dental implants within the market provided a scope for restoration of the functioning capacity and the esthetics of the partial or complete edentulous patients (Turkoglu, 2019). The appropriate prosthodontic treatment is considered to be the most desired restorative options to achieve the prolonged success, and continued existence of especially the osseointegrated implants (Turkoglu, 2019).

The restorative options on the implant support can be ornamented with varied techniques (Sailer, 2009). In this regard, it must be mentioned that the pre ornamented abutments which are acquired from varied implant production companies are usually considered as the “gold standard” due to their mechanical properties and the biochemical composition (Sailer, 2009). However, it should be mentioned that especially for the anterior restorations, the arrangements are being highly substituted with the custom abutments which are most preferably formulated by the application of CAD/CAM techniques (Henriksson, 2003). Past scientific evidences have detailed about certain drawbacks associated with the pre ornamented abutments such as the mechanical inadequacy, esthetic defects those may turn up following the placement of the implant, any emerging profile that might be considered objectionable, and the development of any kind of unhygienic reactions which might crop up with respect to the angled abutments (Jung, 2008).

According to the highlights of a systemic review on the results of implant abutments specifically in the anterior region, few or diminished levels of fractures is observed with regard to ceramic abutments. Moreover, the findings also reported about the spectrophotometric analysis of the reduced level of gingival discolouration when the zirconia abutments were used (Jung, 2008). However, the study could not report any significant difference of the parameter of esthetic contentment in between the ceramic and metal abutments application among the patient population (Jung, 2008).

The clinical importance of this investigation is that the choice of implants for the anterior region should be an implant with interior connections that is attached with a customized metal abutment such as the cast metal or titanium might results in the formation of reduced level of mechanical impediments (Park, 2007). Constrained availability of the scientific evidences based on clinical findings pointed towards the diminished level of peri-implant mucosal staining with the application of zirconia abutments that can be considered to be better in comparison to metal abutments among patients having thin layer of mucosal tissues and among patients possessing high gummy smiles (Park, 2007; Jung, 2008).

Therefore the present work will detail about the formulations of the varied types of abutments, their usage efficacy and along with the rate of success of survival of the different abutments that were utilised within the anterior restorations. The study will also critically evaluate the distinguished materials used for the varied implants such as the zirconia and the glues and their mechanical efficacy along with their clinical outcomes. The assignment will also review about the cost expenditures, availability and the time required for these implants in a literature review structure.

The second half of the study will detail about the methodology adopted for the literature search and selection via the exclusion and inclusion criteria which will be based on the formulated research project title and questions assigned. Then the next half will detail about the results and the discussion section of the whole study undertaken highlighting about the essential points within the summary section. This methodology is adopted for the correlating the study investigation to the prior conducted scientific research in terms of statistics. The methodology justifies the uniqueness of the research area undertaken to comprehend the gravity of the proposed investigation (Neely, 1995).

Literature Review:

The literature background evaluates the different types of abutments, their usage efficacy, and the scientific evidences on the rate of survival of the abutments used for the purpose of anterior restorations or single crown restoration. In this respect, it is essential to mention in the beginning that the selection of abutments depends on certain major criteria which acts as hallmarks for the success of the process such as the biological and the mechanical outcomes, esthetic outcomes, retrivability, removal of cement, thickness of the soft tissues, anticipated occlusal forces, and the space required for thickness of the material used (Zarauz, 2020). The For the purpose of restoration of the single tooth with the aid of abutment-crown complex, was initially developed in the year, 1981 (Jemt, 1986).

This particular one piece complex was initially formulated with chemical acrylic resin, which was coated on pre-ornamented machined titanium (Jemt, 1986). Following this procedure for the accomplishments of better results with regard to esthetics, the overall complex was altered into a two parts restoration made up of metallic ceramic crown which was given support with the help of pre-ornamented titanium abutment (Avivi-Arber, 1996). Moreover, it is now widely known that abutments made up of titanium and zirconium demonstrates excellent biocompatibility along with mechanical strength with respect to clinical administration. However, still the physicians’ faces the difficulty due to the esthetic outcomes which is very much related to the material used for the abutments, along with the degree of customization and category of retention. Therefore, the clinicians follow the recommended guidelines with regard to the esthetic outcomes with a follow up span of minimum 3 years. The indices are the Pink Esthetic Score (PES), the Papilla Index (PI) and the linear calculations of the recessions (Zarauz, 2020). Then after this development, the University of California Los Angeles (UCLA) designed an abutment in the year, 1988 (Lewis, 1988).

This abutment was designed using the custom cast metal constituent which can be fitted into the implant structure (Lewis, 1988). Moreover, this particular category had achieved immense recognition with time, and therefore it is still considered for the purpose of cement holder implant-supported and screw fitted restorations (Lewis, 1988). It was also observed that even now in the present days, a varied number of clinical speculations have demonstrated appropriate rate of survival, with regard to metal abutments utilised for the anterior and posterior regions (Zembic, 2009). On the contrary there are certain drawbacks associated with the metal abutments on the aspect of esthetic outcomes (Zembic, 2009). As per the reports of clinical investigation, the metal abutments have revealed the blue-grayish color reflection from the site of implant gingival (Bressan, 2011; Park, 2007; Jung, 2008).

This aspect poses a threat to the treatment or therapy of the individuals who have an elevated gummy smile lines. Moreover, as per the records of the scientific investigation, maximum of the patient population are in between 40 to 50 years of age, therefore when they are provided with a prosthetic implants they need to show a prolonged rate of survival, i.e., up to five years of follow up (Bidra, 2013). With regard to this aspect, a recently conducted systematic review had highlighted that a solitary implant is considered to be an effective method of treatment procedure and demonstrating the rate of survival of about 97.2% within five years and 95.2% within the span of 10 years (Zembic, 2014). But it should be also noted that the survival rates of the implants is not the only matter of concern while offering patients with varied options for treatment. The results of the treatment need to be considered as well. It has been also noted that as a replacement of gold standard metal abutments, with the resilient zirconia abutments are getting utilized more rapidly and widely as an alternative to the metal abutments (Zembic, 2014).

However, it should be also noted that zirconia is a relatively weak ceramic material than titanium and it is very much prone to fractures. To prevent fracture the thickness of the material should be considered. Therefore, studies also suggested that titanium hybrid abutments might provide the benefit of all metallic and ceramic abutments with regard to esthetic outcomes and mechanical strength (Pitta, 2019). The above mentioned results were also found to be matching for both the metal and ceramic abutments (Zembic, 2014). But it should be also noted that the results of the investigation must be analysed and illustrated with caution as there are different abutments that were utilised among varied studies with variable outcomes (Zembic, 2014). With the upcoming evidences on greater rate of success with regard to implant abutments, the situation pointed towards the utilization of endosseous implants for the highly clinically difficult situations that would promote the volume of bone for the anchorage of the implant and would reduce the compromise of the patients in terms of overall health and well being conditions (Egilmez, 2015). The development of the implant surfaces have led to the reduction of time of healing along with the enhanced level of osseointegration (Egilmez, 2015).

There is a lot of development observed in terms of formation newer alloys that possess augmented level of mechanical properties and allowed smaller diameter implants to be fixed and situated even in the clinically challenging anatomical conditions which would in further expand the signs for restorative implants (Pjetursson, 2012). Moreover, another important feature of the implant that should be taken into account that it should possess a “back off” scheme if there is a requirement of urbane restitution with reduced retentive property for the patients receiving the end of life care (Pjetursson, 2012). Therefore with regard to the previously mentioned case, a two piece implants demonstrates few advantages such as the abutment can be get rid of and replaced with a lower retentive capacity abutment or with a healing cap that would provide solution to the challenging situation of diminished functional capacity of management of denature and wearing (Atsü, 2019).

Aged patients often shows diminished amount of neuroplasticity which is considered to be normal with respect to age, the treatment options includes certain following conditions such as avoidance of complicated modifications of dental restoration procedure, and as a substitute adaptable and transformable prosthodontic restorations are suggested (Bidra, 2017). Scientific evidences have confirmed that titanium is considered as a gold standard for the purpose of dental implants as it is associated with certain advantages (Atsü, 2019). The benefits titanium dental implants are resistance to corrosion, and the biocompatibility (Atsü, 2019). However, the titanium alloy that comprises zirconium demonstrates comparatively better weariness power and tensile than pure forms of titanium (Atsü, 2019). The strength of the small diameter comprising two parts implants can be enhanced with the utilization of titanium-zirconium (TiZr) alloy and this have been introduced with the SLActive® surface (Müller, 2015).

Roxolid® implants when utilised for 36 months as a mandibular overdentures reported non inadequacy in a randomised control trial (RCT) (Müller, 2015). In this regard, the outcomes of another clinical investigation should be mentioned that aimed to compare the overall rate of survival and success for five years of the dental implants having 3.3 mm diameter and it is composed of titanium-zirconium (TiZr) alloy or Grade IV titanium in case of mandibular removable overdentures. The study design was a randomised control double blinded split mouth clinical trial involving multiple centre for a period of thirty six months. The patients were with edentulous mandibles and they were provided with Straumann Bone Level implants of diameter 3.3 mm and having the SLActive® property and the composition of two implants are of TiZr and Ti Grade IV (control group). The study follow up aspect also acquired patients from the core study population and examined certain aspects such as the indices of sulcus bleeding, the radiographic estimation of crestal bone level, along with the rate of survival and success following sixty months of the placement of the implant. The total number of patients who received the implants in the introductory phase is 91, among them 75 patients had undergone the 36 months follow up study and 49 of them have participated in the 60 month follow up examination. The observation highlighted that up till 36 month of the follow up study no implants were absent, the overall rate of survival of the TiZr implants was 98.9 % whereas for the Ti Grade IV group it was 97.8 %. The level of changes observed for the crestal bone following 60 months was not distinguished among the experimental and the control group.

The statistical validation with p value of the TiZr – is 0.60 ± 0.69 mm and for Ti Grade IV is 0.61 ± 0.83 mm; p = 0.96. Moreover, the overall success rates of the implant following 60 months of the placement were 92.6 %and 95.8% with regard to the Ti Grade IV and TiZr respectively (Müller, 2015). Therefore, following 60 months of the investigation the positive findings obtained at the 36 months for the two different compositions namely Ti Grade IV and TiZr were confirmed. There were no certain changes observed for the clinical parameters as well along with the rate of survival and success rate (Müller, 2015). The study findings also highlighted that the TiZr implants demonstrated excellent performance in comparison to the Ti Grade IV implants of 3.3mm diameter small implants utilised for the removable mandibular overdentures (Müller, 2015).

Even clinical preliminaries findings also highlighted that both forms of periodical and fixed complete arch prostheses are associated with elevated rate of survival (Long, 2017). However, it was also observed that there were certain weariness which might be due to the post maintenance complications and other prosthetic intricacies. All these were considered to be unanticipated events which demands additional therapeutic regime. It is evident that implant overdentures are in relation with elevated amount of maintenance and also certain intricacies in comparison to the permanent prosthesis (Abou-Ayash, 2017). Moreover studies have also ascertained that placement following the residual ridge re-absorption was found to be elevated in association with the implant overdentures. With regard to the satisfaction level of the patients, it was found to be enhanced with both the type of prosthesis, whereas the implant overdentures were seen to be comparatively more cost benefitting (Abou-Ayash, 2017).

Several other clinical investigations have already demonstrated that zirconia implants is considered to be the most effective in terms of resilience in comparison to the other three ceramic materials utilized for oral health treatment (Conejo, 2017). As per past confirmations there are several types and designs of zirconia prosthesis are available such as monolithic zirconia, veneered zirconia i.e., conservative, gingival or minimum or a framework of zirconia with cemented crowns individually (Conejo, 2017). Review study about zirconia implants highlighted that there were certain problems associated with it which might be due to the absence of vertical prosthetic space that can act as a risk factor as because it was associated with repetitive fractures (Priest, 2014). Few complications also came up due to the different categories of zirconia used for the purpose therefore, the synthesizing process of the zirconia is considered to be a pertinent factor (Priest, 2014). However this must be noted that hardly any investigation reported about the negative impact of the zirconia implants such as demonstrating resistance to the natural dentition process, to the soft and hard tissues, to the temporo-mandibular joints and also causing dissatisfaction to the patients because of the utilization of permanent zirconia complete dentures for rehabilitations of the single and double jaws (Priest, 2014).

Another investigation was conducted by the researchers on the significance of the prosthetic material used for the mid and long term outcome of the implants used for single crowns and permanent dental prostheses (Thalji, 2014). The study included varied material such as metal alloys of coated base, coated expensive alloys, coated zirconia, coated alumina, coated or monolithic lithium-disilicate, and also another one that was utilised is ceramic matrix were included within the investigation. However, the results demonstrated that the varied prosthetic materials actually have no impact upon the survival rates of the prosthetic during fixed restorations (Thalji, 2014). When the subgroup were analysed for the analysis of the rate of prosthetic impediments no such statistical significance was observed for the loosening of the screws, fracturing of the abutments, and in terms of chipping in between one of the two gatherings (Thalji, 2014). One clinical investigation also proposed that the rate of incidence of de-cementation was found to be extremely higher within one of the study with regard to the resin ceramic matrix group in comparison to all the other groups, having statistical significance of P value < 0.0001 (Thalji, 2014). Similarly, another meta-analysis on the topic of ceramic versus metal base partial denatures were conducted (Tourah, 2014).

The study included varied ceramic prostheses, another two metal prostheses coated with facial resin and metal prostheses coated with ceramics. For the estimation of the rate of survival of both the prostheses and implants, no significant difference was observed among the two dissimilar materials used. The rate of incidence of loosening of screw and the fractures of the abutments were observed and was found to be similar. However, it was also noted that the rate of incidence is higher for chipping was potentially elevated with respect to the metal composite resin group in comparison to the other metallic ceramic and other metal groups (Tourah, 2014). Studies on the influence of the ornamentation of abutments with regard to the clinical outcomes highlighted that there are certain materials which are used to ornament the abutments which also have a strong impact upon the clinical findings. The investigation was pointed towards the impact of CAD/CAM produced abutments and their outcome of treatment on the peri – implant tissues. The factors that were assessed were the rate of survival and success, pink or white aesthetic scores along with loss of bones (Warreth, 2013).

The findings of the study highlighted that the CAD/CAM abutments demonstrated a better rate of survival and success, and also revealed better clinical outcomes in comparison to the other traditional abutments. The study also reported comparatively good aesthetic outcome following one year and reduced recession of soft tissues after the span of two years in comparison to traditional abutments (Warreth, 2013). Moreover, several clinical examinations have demonstrated that especially Titanium inserts augments cumulatively the fracture strength of the ceramic composed crown and abutments, also offer protection to the connection of implant from weariness, and most importantly it provides a fitting marginally when compared with all the other ceramic abutments (Henriksson, 2003; Thalji, 2014; Atsü, 2019).

The researchers also mentioned that for the purpose of recommendation of this category of prosthetic design within the routine clinical practice, several independent clinical preliminaries that will demonstrate the prolonged efficacy is required (Atsü, 2019). Several experts also expressed that the cost and the probable requirement to solder and section which would help to achieve a passive structure fitting highly influences the selection of structure materials. Interesting information revealed by the several authors that the framework synthesized by material cobalt-chromium produces the diminished amount of strain over the implants which contribute to the accurate fittings of the structural frameworks.

However another clinical investigation also demonstrated that though beneficial results were obtained by the procedure of prosthetic rehabilitations with implants certain complications occurs very recurrently in terms of biological, surgical and technical intricacies for instances the loss of implants and bones, complications with the peri – implant soft tissues, varied types of mechanical difficulties, along with frequent phonetic or aesthetic intricacies. In this regard, specialist also detailed that such kinds of complications occurs due to several factors such as the skill of the specialist, the decision taken with regard to the planning of the treatment, the design of the prosthesis, the material utilized, the specific parameters of the patients, the systemic and the nearby situations, along with other associated habits for instance smoking, bruxism, and the presence of the periodontal disease conditions along with the maintenance (STATEMENTS, 2017).

Moreover, the correspondence in between the surgeon and the prosthodontist is considered to be decisive to determine the adequacy of the varied prosthetic devices, accurate angulations of the implants, and for the reduction of cantilevers. As evident from the past scientific reports the hybrid implants demonstrates varied types of benefits starting from the reduction of pressure of dynamic occlusal weights, for the cost effective fabrication, and ultimately for the elevated level of esthetic re-establishments (STATEMENTS, 2017). The investigation conducted by the Pitta, et al., (2019) was to comprehend the bending moments and failure modes of zirconia a meso abutment which is bounded to the titanium base and that had been restored with all monolithic ceramic crowns in comparison to titanium abutment similarly restored with all ceramic crowns after ageing. The study findings highlighted that the value of bending moments in mean were 356.4 ± 20.8 Ncm (T1), 357.7 ± 26.3 Ncm (T2), 385.5 ± 21.2 Ncm (T3), and 358.8 ± 25.3 Ncm (C).

The authors also highlighted that particularly group T3 revealed comparatively much higher mean bending moments with a statistical significance of P value < 0.05 in relation to the other groups of the investigation. Moreover, no such significant differentiation was observed in between the zirconia meso abutment in support of titanium base and the customized forms of titanium abutments where lithium disilicate crowns were used for the process. The authors also added that all the 3 ceramic crown materials that were used, i.e., zirconia, PICN, and the lithium disilicate demonstrated excellent stability when it was utilized in the monolithic state.

Therefore, this study also pointed out that the zirconium and the titanium abutments generally shows identical rate of success and survival even after five years of follow up. However, the crown materials have an impact upon the bending moments as the monolithic zirconia abutments demonstrated with enhanced fracture stability values in comparison to the PICN or the lithium disilicate glass ceramic crowns. It was surprising to the authors that the zirconia abutments showed enhanced bending moments in comparison to the lithium disilicate and the possible illustration given by the researchers to this finding that microscopic cracks were observed under the fracture loads with regard to the other two materials except the zirconia abutments (Pitta, 2019).

However, it must be noted that the selection of the restorative material depends on the clinical experience of the physicians and the rate of acceptance of the patients with the proposed plan of treatment. It is also evident from the study that the metal ceramic restorations were considered to be of gold standard for the purpose of treatment of teeth and implants. With the introduction of ceramic materials which also confer enhanced strength, it was considered to be an excellent alternative with regard to the patients showing higher esthetic requirements (Lemos, 2019). A study showed that zirconia has enhanced level of flexibility and strength against fractures in comparison to the other ceramic materials. This particular characteristic eventually resulted in lower mechanical complications with regard to restoration (10.27%) which was more or less similar to metal ceramic restorations (9.03%) (Lemos, 2019). Another study by also revealed that titanium demonstrated higher resistance to fracture when compared with materials like zirconia and ceramic reinforced PEEK (with titanium base). Therefore, this finding was found to be in accordance to the other studies. The study also revealed that the physiological occlusal force lies within the range of 10 to 120 N while chewing or swallowing the food items while other studies have reported the occlusal force within the incisor area to be within the range of 150 to 300 N and 90 to 370 N (Atsü, 2019). The present study also revealed that all the specimens used can resist the clinical occlusal forces as the failure load of all the specimens was found to be higher than 418 N (Atsü, 2019). These findings are also matching with the findings of the other studies investigated on varied designs of ceramic abutments. Another most important feature is that one should choose the abutment material that is similar in colour of the tooth. The titanium on the other hand reveals grayish colour and its biological and mechanical properties are not similar to the natural tooth materials. In the case of fixed implant restorations the cement system reveals benefits over the screw retained system with respect to the following parameters such as the compliance of the patient passively, esthetic outcomes, and the distribution of load at the time of function. Moreover the study also reported that the load bearing capacity of the cement system is comparatively much higher than the screw system (Atsü, 2019).

Thus, ultimately it can be said that titanium abutments are thought as gold standard because of the rate of clinical success and enhanced degree of physical properties (Atsü, 2019). But few reports are also there that it causes reflection and gray colour of the mucosa nearby the implant. Another category of zirconia polycrystals namely tetragonal shaped stabilized Yttrium- are getting used as abutment material because of their longevity and bio-composition for the purpose of implant support permanent dentures (Osman, 2015). It can be also taken into consideration that zirconia abutment demonstrate extreme resistance to corrosion and diminishes the formation of plaque. The abutment also revealed reduced infection by the bacteria on the surface in comparison to the titanium (Osman, 2015). Moreover, in certain cases where titanium abutments caused abrasions and fractures zirconia abutment has been implanted in the neck region of the connection. The reason behind the fracture and the weariness is the hardness of the metal titanium. Therefore, because of all these complications a “hybrid abutments” has been developed, i.e., zirconia abutment comprising titanium neck. The overall system allowed the presence of both the resilience of the titanium, along with the esthetic qualities of the zirconia which can be utilized as an alternative treatment for individual patients (Osman, 2015).


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