A microstrain comparison of passively

fitting screw-retained and cemented

titanium frameworks
Diego Klee de Vasconcellos, DDS, PhD,a
Alberto Noriyuki Kojima, DDS, PhD,b
Alfredo Mikail Melo Mesquita, DDS, PhD,c
Marco Antonio Bottino, DDS, PhD,d and Mutlu zcan, DMD, PhDe
Sao Paulo State University Dental School (UNESP), Sao Jos dos
Campos, Brazil, Paulista University (UNIP), So Paulo, Brazil, and
University of Zrich, Zrich, Switzerland
Statement of problem. An imprecise t between frameworks and supporting dental implants in loaded protocols increases
the strain transferred to the periimplant bone, which may impair healing or generate microgaps.
Purpose. The purpose of this study was to investigate the microstrain between premachined 1-piece screw-retained
frameworks (group STF) and screw-retained frameworks fabricated by cementing titanium cylinders to the prefabricated
framework (group CTF). This procedure was developed to correct the mist between frameworks and loaded implants.
Material and methods. Four internal hexagon cylindrical implants were placed 10 mm apart in a polyurethane block by using
the surgical guides of the corresponding implant system. Previously fabricated titanium frameworks (n10) were divided into
2 groups. In group STF, prefabricated machined frameworks were used (n5), and, in group CTF, the frameworks were
fabricated by using a passive t procedure, which was developed to correct the mist between the cast titanium frameworks
and supporting dental implants (n5). Both groups were screw-retained under torque control (10 Ncm). Six strain gauges
were placed on the upper surface of the polyurethane block, and 3 strain measurements were recorded for each framework.
Data were analyzed with the Student t test (a.05).
Results. The mean microstrain values between the framework and the implants were signicantly higher for group STF (2517
m) than for group CTF (844 m) (P<.05).
Conclusions. Complete-arch implant frameworks designed for load application and fabricated by using the passive t
procedure decreased the strain between the frameworks and implants more than 1 piece prefabricated machined frameworks.
(J Prosthet Dent 2014;112:834-838)

Clinical Implications
Frameworks fabricated by using a passive-t procedure developed for
correcting a mist between titanium frameworks and supporting dental
implants reduced the stress transferred to the periimplant tissues more
than prefabricated machined frameworks.

Oral rehabilitation with osseointegrated titanium implants may be

regarded as a treatment option with a

positive prognosis when indicated and

properly planned.1 In the original protocol for osseointegrated implant-

supported prosthodontic treatment for

the complete arch, the implants
remained submerged under the soft

Professor, Department of Dental Materials and Prosthodontics, Sao Paulo State University Dental School (UNESP).
Professor, Department of Dental Materials and Prosthodontics, Sao Paulo State University Dental School (UNESP).
c
Professor, Department of Dental Materials and Prosthodontics, Paulista University (UNIP).
d
Professor, Department of Dental Materials and Prosthodontics, Sao Paulo State University Dental School (UNESP).
e
Professor, Dental Materials Unit, Center for Dental and Oral Medicine, Clinic for Fixed and Removable Prosthodontics and
Dental Materials Science, University of Zrich, Zrich, Switzerland.
b

The Journal of Prosthetic Dentistry

de Vasconcellos et al

October 2014
tissues for a period of 3 to 6 months. In
principle, they should heal without being
exposed to occlusal forces or bacterial
contamination.1,2 Such forces might
interfere with the osseointegration process.3 In most patients, a complete or
partial removable interim prosthesis is
required to reestablish function during
this healing period.3 This type of transitional prosthesis is a limitation that
some prospective patients must accept
when considering this treatment.4,5
Implant therapy might be more
appealing to these prospective patients
as an alternative treatment option if the
implants are loaded immediately after
implant surgery.4,5
Several protocols for the immediate
loading of implants in edentulous jaws
have been proposed.3-7 These protocols
allow a patient to have a xed prosthesis during the osseointegration
period. The reported procedures aim for
a less protracted treatment protocol.
Some methods use surgical guides and
prefabricated prosthodontic frameworks that allow the placement of the
implants and prosthesis on the same
day. Within a few hours after the
implant surgery, a xed prosthesis
fabricated on a premanufactured titanium framework is attached to the implants. An analysis of the biomechanics
of conventional implantesupported
rehabilitation, namely a 2-stage implant
approach, reveals that, when considering the ankylotic nature of osseointegration, any mist introduced in the
prosthesis-implant system may yield
stresses that will not be dissipated with
time.8 Therefore, mists may lead to
problems such as screw loosening,
fracture of the prosthodontic component or even of the implant itself, and
bone loss around the implants.9 For this
reason, the need for passively tting a
implant prosthesis is essential for
maintaining osseointegration in conventional protocols.
However, in immediate loading procedures, such concepts undergo important alterations. According to Skalak,10
the static stresses caused by prosthodontic mist may be dissipated during
the rst weeks of osseointegration in the

de Vasconcellos et al

835
immediate loading procedure, which is
not possible with completely osseointegrated implants. When implants are
placed, the lamellar bone that is present
initially maintains the stresses. As this
bone is resorbed, the newly formed bone
will most likely not reintroduce the initial
stresses. Consequently, the residual
stresses caused by prosthodontic mist
may be relieved by the sequence of
remodeling processes, which results in
osseointegration. In that respect, the
level of microstrain (m) generated between the framework and the implant is
more important than that typically
measured with strain gauges in simulated settings.11 One thousand microstrains reportedly correlate to a cell
elongation of 0.1%. The strain gauge is
an electric sensor that quanties deformation; its working principle is based on
electrical resistance transformed into
deformation levels.12 Frost13 distinguished a minimum effective strain of
500 m needed for bone maintenance
from the supraphysiologic strain
(>4000 m), which would lead to a
long-term implant failure because of
overload. Higher strains may favor bone
healing when applied in the single-step
procedure,14-17 provided that they are
within acceptable levels (between 100
m and 2000 m).18
The purpose of this study was to
investigate the m on the cervical region
of the implants, between premachined 1piece screw-retained frameworks (STF)
and screw-retained frameworks fabricated by cementing titanium cylinders to
the prefabricated framework (CTF). The
null hypothesis was that STF and CTF
systems would not show signicant differences in terms of m.

MATERIAL AND METHODS

A polyurethane block (F 16; Axson
Technologies) (3512545 mm) was
used to represent the edentulous
mandible. A surgical guide template
(Speed Master; Conexo Prosthetic Systems) was attached to the block with 3
temporary stabilization screws. This
template has 4 orices into which a surgeon places and removes metal inserts

that guide the direction of implant site

preparations. These drill guides are color
coded, each color represents different
diameters that correspond to each drill
used (silver, pilot drill and 2.0-mm twist
drill; blue, 3.0-mm twist drill; yellow,
3.15-mm twist drill; and purple, 3.35mm twist drill). The preparation for
implant placement was gradually
increased by using the following twist drill
diameters: 2.0 mm, 3.0 mm, 3.15 mm,
and 3.35 mm. Finally, 4 internal hexagon
cylindrical implants (Connect AR
513413; Conexo Prosthetic Systems)
(diameter, 4 mm; length, 13 mm) were
placed on the polyurethane block 10 mm
apart. The temporary xation screws and
surgical guide were then removed.
Abutments were connected to the
implants (no. 022001; Conexo Prosthetic Systems) by fastening the screws
with a mechanical torque wrench (no.
400000; Conexo Prosthetic Systems)
calibrated by electronic torque controllers with 20 Ncm torque (Fig. 1).
The 10 prefabricated titanium frameworks used in this study were distributed as follows: group STF comprised
1-piece machined bars (n5) ready
for use (no. 001010; Conexo Prosthetic Systems); group CTF comprised
bars (n5) fabricated with the passive
t method (no. 001009; Conexo Prosthetic Systems) (Fig. 2). The CTF system
was cemented rst in the nal cast and
then screw retained to the implants.
Square impression copings for
direct impressions were secured to the
abutments with an open tray technique
(no. 023001; Conexo Prosthetic Systems). The screws of the impression
copings were fastened with a mechanical torque wrench (no. 400000; Conexo Prosthetic Systems) calibrated
with electronic torque controllers by
using 10 Ncm torque. Autopolymerizing acrylic resin (GC pattern resin; GC
Dental Industrial) was applied to rigidly
connect the impression copings (2.0mm high and 2.0-mm wide). The
acrylic resin device was then sectioned
equidistant from the implants with a
0.3-mm double-faced diamond disk
(no. 40601 001; Microdont), and the
segments were reconnected.

836

Volume 112 Issue 4

1 Screw-retained prefabricated titanium framework xed on

prosthodontic abutments, and screws tightened to 10 Ncm
with mechanical torque device before microstrain
measurements.

The impression was recorded with

addition silicone (Aquasil; Dentsply Intl)
and an acrylic resin custom open top
tray. The screws of the impression copings were loosened to disengage each
impression coping from the implants,
and the impression was gently removed.
Abutment analogs (no. 101001; Conexo Prosthetic Systems) were attached
to the impression copings, and the
impression was poured with dental Type
IV stone (Durone; Dentsply Intl) to
create the denitive cast.
E
D
C

2 Left, Cross section of passively

tting cemented titanium framework
with prefabricated titanium cylinder
screw (A) xed on prosthodontic
abutment (B, C) and cemented (D) to
prefabricated titanium framework (E).
Right, Cross section of screw-retained
prefabricated titanium framework (E)
xed on prosthodontic abutment
(B, C).

Four prefabricated titanium cylinders (no. 105015; Conexo Prosthetic

Systems) were attached to the analogs
of the denitive cast and were screw
tightened with a mechanical torquecontrolling device at a preload of
10 Ncm (no. 400000; Conexo Prosthetic Systems). The premanufactured
titanium framework used for this procedure had 4 orices on its lower surface, which corresponded to the cylinder
positions, which were secured on the
denitive cast in such a way as to avoid
lateral contacts or contact with the upper surface. Alloy primer was applied to
the metal surfaces inside the framework
orices and outside the cylinders (Alloy
Primer; Kuraray Medical Inc). A thin and
uniform coat of adhesive resin cement
(Panavia 21; Kuraray Medical Inc) was
placed inside these framework orices,
and the framework was gently seated
over the cylinders on the denitive
cast. To avoid excess cement in the
screw sites, these areas were covered
with a thin lm of glycerin oxygen inhibition gel (Oxyguard II; Kuraray Medical
Inc). Excess material was removed, and
the cement was photopolymerized
(light output, 600 mw/cm2, Optilux
501; Kerr Corp) at each site for 40
seconds from a distance of approximately 2 mm, according to the manufacturers instructions. This procedure
was repeated for all bars (n5) in this
group.

The Journal of Prosthetic Dentistry

For the m measurement, 6 strain

gauges (PA-06-060CA-120L; Excel
Sensors Ltd) were bonded to the upper
surface of the polyurethane block
(Fig. 3) with a cyanoacrylate adhesive
(Super Bonder; Loctite) 1 mm away
from the implant platforms. The strain
gauges were numbered 1 to 6 from left
to right. The frameworks (Fig. 4) were
seated onto the polyurethane block,
and the screws (no. 011014; Conexo
Prosthetic Systems) were tightened to
10 Ncm with a mechanical torque device (no. 400000; Conexo Prosthetic
Systems), with the screws secured in the
following order: 2, 3, 1, and 4 (2 and 3
denote the central implants, and 1 and
4 denote the terminal implants).11 The
same operator placed all frameworks.
The strain gauge device was calibrated
at 10 m before the specimens were
seated onto the polyurethane blocks,
and the screws were tightened. The
magnitude of m at each strain gauge
was recorded when the fourth screw
was tightened. Data on the 6 sensors
were amplied and transferred with a
signal amplier (ADS 2000IP; Lynx).
The m measurements were recorded 3
times for each framework. The recorded
data were analyzed with a software
program (AqDados and AqAnalysis;
Lynx). The mean values of the 6 strain
gauges, which represented the behavior
of the whole assembly, were used for
the statistical analysis.
The statistical analysis was performed with statistical software (SPSS
15.0 for Windows; SPSS Inc). The data
were found to be normally distributed,
with equal variance (KolmogorovSmirnov and Shapiro-Wilk, a.05).
The means of the m values obtained
from the 2 framework designs (CTF,
STF) were statistically analyzed with the
Student t test for independent samples
(a.05).

RESULTS
The mean (SD) values of the 6
strain gauges for each framework type
are displayed in Table I. The mean m
values between the framework and the
implants were higher for STF (2517

de Vasconcellos et al

October 2014

837

3 Polyurethane block with 4 internal hexagon cylindrical

implants and prosthodontic abutments attached. Six strain
gauges bonded to upper surface of polyurethane block for
microstrain measurements.

4 External aspect of prefabricated titanium framework for

both groups.
Mean microstrain (m) values of 6 strain gauges for each framework
design (n5).

Table I.

Strain Gauge No.

Framework Type

01

02

03

04

05

STF
CTF

06

966.3

4966.6

1090.4

3079.2

3306.6

1694.3

699.5

1734.3

900.4

663.6

472.3

595.6

STF, premachined 1-piece screw-retained frameworks; CTF, screw-retained frameworks fabricated by

cementing titanium cylinders to prefabricated framework.

1553 m) than for CTF (844 458

m) (P<.05).

DISCUSSION
The present study was an in vitro
investigation of the static m transmitted from the 2 different premanufactured frameworks, STF and

de Vasconcellos et al

CTF, provided for the immediate load

system.12 Based on the signicant differences in m generated between the
framework and the implants in the 2
systems, the null hypothesis was rejected. The relative elongation of cells may
be calculated as m, the unit of strain
measurement used in the present
investigation. The CTF system created

less m than STF, but the values achieved by both systems were far less than
the physiologic threshold (>4000 m),
which, according to Frost,13 could lead
to long-term implant failure. However,
according to Smukler-Moncler et al,6 a
critical threshold of micromotion does
exist, above which brous encapsulation prevails over osseointegration.
When the amount of micromotion at
the bone-implant interface is maintained beneath this threshold during
the healing phase, immediate occlusal
loading procedures can be successful.
Only excessive micromotion is directly
implicated in the formation of brous
encapsulation. This critical level, however, is not the absence of micromotion
because it is generally interpreted.
Instead, the tolerated micromotion
threshold was found to lie somewhere
between 50 and 150 mm.6 The system
investigated in the present study comprises a rigid metal structure that joins
the implants, which should reduce
these micromotions and which allow
osseointegration to occur.3,5 Tarnow
et al3 also recommended a rigid metal
structure to avoid micromotion, thus
providing resistance to forces in all directions. However, the metal-free
design of the prostheses during the
healing phase does not appear to
jeopardize osseointegration.7
An analysis of the m values for the
individual strain gauges revealed that
the mean value for strain gauge no. 2
with the STF system was higher than the
physiologic threshold. The consequence
of this excessive strain at this specic site
may not be as harmful for the immediate
load protocol as it would be for the
conventional protocol. However, this
aspect needs to be veried in clinical
studies. In an attempt to minimize
variations during the study, the same
operator performed all laboratory procedures, and a calibrated mechanical
torque device was used to ensure a
consistent torque of 10 Ncm during the
attachment of the frameworks before
the m measurements. Measuring each
specimen in both groups 3 times was
intended to minimize errors. A high
standard deviation was observed in this

838

Volume 112 Issue 4

investigation, which agreed with the
ndings of Inturregui et al14 and may
have resulted from the high sensitivity of
strain gauges compared with the forces
generated in the system. This result
could also be attributed to the in vitro
model that simulated human bone.
Certainly, the experimental design of
strain gauge analysis in a static state
does not simulate the physiologic
remodeling that would normally occur
in an immediate loading protocol.15 In
the present study, a polyurethane base,
an isotropic material, was used because
of its uniform elastic properties.11,15
Moreover, its modulus of elasticity is
similar to that of human medullar bone
(polyurethane, 3.6 GPa; medullar bone,
4.0-4.5 GPa).11,16 However, this represents a limitation for this study because
natural anatomic structures and the
anisotropic properties of the mandible
were not considered so to achieve a
more accurate stress prediction. Because of its nonuniform elastic properties, human bone presents more
complexities when remodeling occurs
during the healing period.13 Bone quality is one factor that inuences treatment with implants. The bone that
surrounds implants does not constitute
a homogeneous substrate, and its
physical properties vary with age and the
functional and systemic factors of the
patient.13
The procedure of cementing the CTF
has been recommended by the manufacturer of the tested system to achieve
a better passive t between the framework and the abutments. The present
results reveal that the m values generated by the CTF system were nearly 65%
lower than the values produced in STF.
Note that a cement interface is at risk
over time because of the fatigue load
effects that lead to the loosening and
possible compromise of the framework.
Therefore, further laboratory studies
should submit the bonded and screwed

structures to thermal and mechanical

cycling, which simulates the situation
found in the oral cavity. In addition,
clinical trials should report on the longterm safety and efcacy of the procedures compared in this study.

CONCLUSION
Complete-arch implant frameworks
designed for immediate load application and constructed by cementing CTF
created less strain between the framework and the implants than STFs.

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Corresponding author:
Dr Alberto Noriyuki Kojima
So Paulo State University (UNESP)
Dental Material and Prosthodontics
Av. Eng Francisco Jos Longo, no 777
So Jos dos Campos
BRAZIL
E-mail: kojima@fosjc.unesp.br
Copyright 2014 by the Editorial Council for
The Journal of Prosthetic Dentistry.

de Vasconcellos et al