title: Fracture strength of implant abutments after fatigue testing: A systematic review and a meta-analysis.
abstract: The use of implants and their respective suprastructures to replace missing teeth has become a common therapeutic option in dentistry. Prior to their clinical application, all implant components have to demonstrate suitable durability in laboratory studies. Fatigue tests utilising cyclic loading typically simulate masticatory function in vitro. The objectives of this systematic review were to assess the loading conditions used for fatigue testing of implant abutments and to compare the fracture strength of different types of implant abutment and abutment-connection types after cyclic loading.
  
  
  
  Original scientific papers published in MEDLINE (PubMed) and Embase database in English between 01/01/1970 and 12/31/2014 on cyclic loading on implant abutments were included in this systematic review. The following MeSH terms, search terms and their combinations were used: "in vitro" or "ex vivo" or experimental or laboratory, "dental implants", "implants, experimental", "dental prosthesis, implant-supported", "fatigue", "dental abutments", "cyclic loading", "cyclic fatigue", "mechanical fatigue", "fatigue resistance", "bending moments", and "fracture". Two reviewers performed screening and data abstraction. Only the studies that reported, static fracture values before and after fatigue cycling of implant abutments, were included that allowed comparison of aging effect through cyclic loading. Data (N) were analyzed using a weighted linear regression analysis (α=0.05).
  
  
  
  The selection process resulted in the final sample of 7 studies. In general, loading conditions of the fatigue tests revealed heterogeneity in the sample but a meta-analysis could be performed for the following parameters: a) abutment material, b) implant-abutment connection, and (c) number of fatigue cycles. Mean fracture strength of titanium (508.9±334.6N) and for zirconia abutments (698.6±452.6N) did not show significant difference after cyclic loading (p>0.05). Internal implant-abutment connections demonstrated significantly higher fracture strength after cyclic loading compared to external ones (internal: 774.0±582.3N; external: 481.2±137.5N; p=0.022). The mean fracture strength of all abutment types decreased significantly when number of loading cycles exceeded 1,000,000 cycles (<1×10(-6): 1047.0±751.3N; >1×10(-6): 556.7±317.6N; p=0.032).
  
  
  
  The results of this meta-analysis, favour the use of internal implant-abutment connections in combination with either titanium or zirconia abutment materials. Number of cycles had a significant impact on the fracture strength after cyclic loading.
authors.affiliation: University of Zürich, Dental Materials Unit, Center for Dental and Oral Medicine, Clinic for Fixed and Removable Prosthodontics and Dental Materials Science, Plattenstrasse 11, CH-8032 Zurich, Switzerland.
authors.forename: Rafaela
authors.initials: R
authors.lastname: Coray
authors.affiliation: University of Zürich, Dental Materials Unit, Center for Dental and Oral Medicine, Clinic for Fixed and Removable Prosthodontics and Dental Materials Science, Plattenstrasse 11, CH-8032 Zurich, Switzerland.
authors.forename: Marco
authors.initials: M
authors.lastname: Zeltner
authors.affiliation: University of Zürich, Dental Materials Unit, Center for Dental and Oral Medicine, Clinic for Fixed and Removable Prosthodontics and Dental Materials Science, Plattenstrasse 11, CH-8032 Zurich, Switzerland. Electronic address: mutluozcan@hotmail.com.
authors.forename: Mutlu
authors.initials: M
authors.lastname: Özcan
mesh_terms: D000044:Dental Abutments; D059605:Dental Implant-Abutment Design; D019232:Dental Restoration Failure; D003799:Dental Stress Analysis; D006801:Humans; D008422:Materials Testing; D015040:Zirconium
chemical_list: D015040:Zirconium
keywords: Cyclic loading; Dental abutments; Dynamic loading; Fatigue; Fatigue resistance; Mechanical test