Clinical applications of angled abutments

a literature review
MING-LUN HSU 1 TAI-FOONG CHUNG 1 HUNG-CHAN KAO 2
1
Graduate Institute, School of Dentistry, National Yang-Ming University, Taipei, Taiwan, ROC.
2
Biomechanics Research Laboratory, Medical Research Department, Mackay Memorial Hospital, Taipei, Taiwan, ROC.

Dental implants have been proven to be an effective way of restoring the masticatory ability to
completely or partially edentulous patients. But when clinicians deal with undesirable implant
orientation caused by poor bone conditions, an angled abutment is often the treatment of choice for
prosthodontic restorations. A search of articles related to the success rate, stress analysis, and bone
response to loading of angled abutments was performed in order to understand the rationale for their
current clinical applications. Evidence shows that the clinical performance of angled abutments is
comparable to that of straight abutments with respect to both soft-tissue responses and general survival
rates. However, in vitro studies of stress/strain analyses of angled abutments can only agree that
stress/strain levels increase as abutment angulation increases. Three analytical techniques including the
photo elastic technique, strain gauge analysis, and finite element analysis have been applied for analyzing
angled abutments. Further comparative studies are required using these three techniques because some
quantitative aspects are still inconclusive such as how much stress is introduced upon a certain degree of
abutment angulation. Chin Dent J, 24(1)15-20, 2005

Key words: dental implant, angled abutment, survival rate, literature review, stress analysis.

Implant prostheses often offer a more-redictable
treatment course than traditional restorations1. It was
proven that osseointegrated implants can successfully
be used to restore the completely or partially
edentulous patients with long-term success2-4. But in
some real clinical situations, severely resorbed bone
may result in inappropriate implant alignment, which
can cause disparities between the implant long axis
and the abutment long axis. Under such circumstances,
difficulties will be certainly encountered in future
prosthesis fabrication. Two options are available to
overcome such problems: the angled implant5 and,
the angled abutment. As early as 1990 Kallus et al.6
demonstrated prototype angled abutments of the
Branemark (Nobel Biocare, Gteborg, Sweden)
Received: December 18, 2004
Accepted: February 25, 2005
Reprint requests to: Dr. Ming-Lun Hsu, School of Dentistry, National
Yang Ming University, No. 155, Li-Nong Street, Sec.
2, Taipei, Taiwan 11221, ROC.
implant system. The advent of angled abutments has
simplified the management of situations when
implant placements are suboptimal. Gelb et al.7
presented 3 cases restored with pre-angled abutments
to fulfill the esthetic demands and functional
objectives of patients. Until the present time, no
thorough review of the information on angled
abutments can be found in the literature which can
elaborates both the efficacy and biomechanical
mechanisms of this treatment modality.
Dentists understand the risks involved when
restored prostheses are subjected to non-axial loading.
It has always been recommended to direct occlusal
loads as close to the long axis of the fixture as
possible1,8,9. However, it is known that the loading on
angled abutments is mostly off-axis, which raises the
concern of how angled abutments generally perform
with such an unfavorable loading regimen. The
purposes of this article were to determine the general
clinical success rate of angled abutments through a
literature review, to understand the current
methodology used to analyze the stress and strain of

Chin Dent J 2005Vol 24No 1 15

M.L. Hsu, T.F. Chung and H.C. Kao.
bone, and to review the responses of the bone toward
the loading around implants restored with angled
abutments.
Clinical performance
In the early design of angled abutments which is
published by Kallus et al.6, a prototype of an angled
abutment was introduced. Because of the lack of
diversity of shoulder height and form in the early
developed Branemark angled abutments, such
concerns as with the soft-tissue health induced by
misfiting between the soft-tissue thickness and
abutment shoulder heights were encountered. Other
than the minor aforementioned shortcomings, 14
patients showed favorable results in improved
esthetics and structural integrity with prosthetic
reconstruction. An animal study with histological
observations of angled abutments was done by
Celletti et al.10. In their study, 20 implants (3i, Implant
Innovations, Palm Beach, FL, USA) were placed in 2
subhuman primates and were later restored with 25
and 35 angled abutments. After 1 year in service,
they discovered that the quality of the
osseointegration proved to be histologically excellent
either in both the straight and angled abutments.
Soft-tissue performance
A retrospective study investigated the possible
peri-implant mucosal complications around angled
abutments11. In that study, 421 Branemark implants
placed in 71 patients were restored with angled
abutments or a combination of angled and straight
abutments (209 angled abutments and 212 straight
Table 1. Comparison chart for survival rates
11
Balshi et al.
Duration of evaluation
3 5
(years)
No. of angled abutments
209
reviewed
No. of straight abutments
202
reviewed
Abutment angulation
30
evaluated
Supported prosthesis
fixed prostheses
type
Success rate of angled maxilla, 94.8%
abutments mandible, 94.1%
16
abutments). The overall gingival problems in the
areas around the angled abutments were comparable
or lower than those with standard abutments. Another
soft-tissue evaluation of angled abutment was done
by Eger et al.12. In that study, 81 implants (56 restored
with angled abutments, 25 with straight abutments) in
24 patients were evaluated for the parameters of
probing depth, gingival level, gingival index, and
mobility. The final data revealed no significant
differences between angled and straight abutments
for any of the clinical variables measured, and no
significant difference was found in gingival
inflammation or implant mobility between the two
groups as well.
Overall success rate
In a study by Balshi et al.11, the cumulative
survival rates for angled abutments were 94.8% and
94.1% for the maxilla and mandible respectively.
These are comparable to those of straight abutments
which were 91.3% in the maxilla and 97.4% in the
mandible. Sethi et al. reported a 5-year mean survival
probability of 98.6% and a 10-year survival probability
of 98.2% with a 95% confidence interval for angled
abutments13, 14. In their observations, 3101 implants
restored with angled abutments ranging from 0 to
45 were included. They reported that the magnitude
of the angles did not significantly influence the
survival rate. A comparison chart is listed for all of
the reviewed survival analyses (Table 1).
Stress analysis
Due to the unfavorable loading direction that
angled abutments have, it is important to understand
13 14
Sethi et al. Sethi et al.
14
2261 3101
N/A N/A
0~45 0~45
fixed and removable fixed and removable
prostheses prostheses
survival probability of mean survival probability of
> 98.6% > 97.5%
Chin Dent J 2005Vol 24No 1
 Angled abutments

the stresses transferred through various abutment
angulations to the surrounding bone, through which
we can prevent less-than-ideal stress transfer
conditions. Current techniques employed to evaluate
the biomechanical loads on implants consist of
photoelastic stress analysis, finite element analysis,
and strain-gauge analysis15-17. Two studies conducted
by Clelland et al.18,19 used both photoelastic analysis
and a strain gauge technique. Abutment angulations
of 0, 15, 25, 30, and 35 (0, 15, and 20 for the
study published in 1993) were tested with 178 N
applied along the long axis. The stresses obtained
from the photoelastic fringe order conversion showed
a significant increase as abutment angulation
increased. The highest fringe order was found near
the implant apex, which indicated the highest stress
concentration. Strain gauge values were also obtained
from a point 4 mm away from the implant surface.
The compressive stresses and tensile stresses were
calculated from the strain gauge readings and
subsequently converted to compressive stress and
tensile stresses of the bone by Hookes law. Results
showed that all converted bone strain data were
within the physiological zone as proposed by Frost20.
A comparison of strain gauge data and the photoelastic
fringe order data also showed consistency between
these two analytical methods.
Another study conducted to test the stress
distribution on the bone-implant interface for different
abutment angulations by means of photoelastic and
strain gauge analyses was carried out by Brosh et al.17.
In that study, three strain gauges were attached to the
implants surface on each side and then embedded in a
photoelastic resin. Abutment angulations of 0, 15,
and 25 were tested with a loading of up to 350 N
along the implant long axis. Photoelastic models
were similarly prepared without strain gauges
attached and then loaded with 100, 200, and 300 N.
The results of the strain gauge models showed that
the loading side had significant higher strain response
to force (SRF) (instead of using strain data, they used
SRF, which is strain produced per loading unit) than
those on the contralateral side. The results showed
significantly higher SRFs when abutment angulation
was increased. On the implant surface, the more
apical the location was, the smaller was SRF ratio
which was generated. By comparing the data
obtained from the photoelastic model, they found that
strain measurement distribution data showed a
pronounced decrease in value along the implant
compared to those of photoelastic models. The
discrepancies were more pronounced when the
influence of abutment angulation was compared.
They concluded that when the abutment angulation
increased, stress and strain increased, and the
comparison between the two analytical techniques
could only be made qualitatively rather than
quantitatively due to tendencies of the discrepancies
in the stresses/strains to increase. The conclusions
concerning comparisons of the two techniques were
not compatible with Clelland et als. data published in
1993.

Table 2. Comparison between Clelland et al. and Brosh et al.'s Studies

19 17
Clelland et al.s study (1993) Brosh et al.s study (1998)

Abutment angulation 0, 15, 20 0, 15, 25

Loading magnitude (N) 178 0-300 (for the strain gauge model)
100, 200, 300 (for the photoelastic model)

Loading direction along the abutment long axis along the implant long axis

Implant size (mm) 3.8 10 4 13

Strain gauge location
Conclusions about the effect of
increasing abutment angulation
Conclusions about the comparison of
the two study techniques
4 mm away from the implant surface
significant increase in stresses and strains
as abutment angulation increases
strain gauge data provided results consistent
with the visual interpretation of fringe order
on the implant surface, loading and
contralateral side
stresses and strains (SRF) increase as
abutment angulation increases
strain gauge measurements showed
more-pronounced changes than did the
photoelastic analysis

Chin Dent J 2005Vol 24No 1 17

M.L. Hsu, T.F. Chung and H.C. Kao.
Since both Brosh et al.s study and Clelland et
al.s study were mainly aimed at the two analytical
techniques for angled abutments, a comparison table of
related issues is made for these two studies (Table 2).
The only 3-dimensional finite element analysis
of angled abutments was done by Clelland et al.16. A
premaxilla model was developed through a computed
tomographic scan of a dry human skull. A simulated
implant was subsequently inserted. The elastic
properties of the cancellous bone were calculated
from density values determined from related CT
numbers. The model was loaded with 178 N along
the abutment axis and analyzed. The results showed
that peak stress/strain values generally increased
as abutment angulation increased. These data
qualitatively substantiated the results from the strain
gauge and photoelastic studies. However the amounts
of increment were not quite the same between the
different analytical techniques. Further studies are
required.
Bone response to biomechanical loading
In 1892, Wolff observed that every change in
the form and function of bone or of their function
alone is followed by certain definite changes in
their internal architecture and in their external
conformation, in accordance with mathematical
laws20-22. This is Wolffs law. At that time, not much
was understood about the mechanisms responsible
for this effect, until 1987, when mechanostat theory
made a connection between mechanical loading and
the responses of the bone23. This theory postulated
some threshold data about which the bones
physiological modeling and remodeling responses
accordingly can be switched on or off. Long-term
implant interfaces can only be maintained through
these dynamic modeling and remodeling processes15.
More time and studies are required to test the validity
of the mechanostat theory. However, the threshold
data from the mechanostat theory21 (Table 3) can be
Table 3. Threshold windows for the mechanostat theory21
Strain range (microstrain)
Disuse window < 50
Adapted window 50 ~ 1500
Mild overload window 1500 ~ 3000
Pathologic overload window > 3000
Fracture > 25000
18
used as references when performing stress/strain
analyses around implant/bone interfaces. The finite
element analytical data for angled abutments in the
premaxilla area were compared with mechanostat
theory threshold by Clelland et al.16. The peak
compressive strains (1950 microstrains) and peak
tensile strains (1500 microstrains for 20 angled
abutments) were reported to be within the threshold
of the adapted window and the mild overload
window in the mechanostat theory. According to
Frost21, the strain level in the adapted window tends
to conserve bone, maintain its strength, and prevent a
osteopenia; likewise, strain levels in the mild
overload zone can add and strengthen bone.
DISCUSSION
In one study which implants placed in subhuman
primates were loaded for 1 year, Celletti et al.10
demonstrated that the quality of osseointegration was
so excellent that overloading can only cause
abutment screw breakage rather than loss of bone
or failure of the implants. Using histological
examinations, they found that no osteoblasts or
osteroclasts were present in the bone adjacent to the
implants, leading them to the conclusion that no
active remodeling had taken place. This finding is
inconsistent with the theory that long-term implant
interfaces can only be maintained through dynamic
modeling and remodeling processes15. This should
apply to angled abutments as well.
Other types of failure related to angled
abutments in reviewed articles included fracture of
the occlusal material11, fracture in parts of the
framework11, loosening or fracture of abutment
screws10,11, and loss of osseointegration11,12. Most of
the articles claiming high success/survival rates did
not take abutment screw loosening, occlusal material,
or framework fracture into account in calculating the
success/survival rates. These complications might not
Description
Bone is weakenrd by active remodeling
Bone is conserved and strength is maintained
Modeling bone strenthening
Unrepaired microdamage begin to accumulate
Exceeds bones fracture strength
Chin Dent J 2005Vol 24No 1

eventually lead to implant failure, but can still
frustrate both dentists and patients and should be
major concerns from a biomechanical point of view.
Careful examination and documentation of such
events to be included in future success/survival
analyses are essential.
The most tapered pre-angled abutment reviewed
was 45. It was stated that the magnitude of the angle
did not influence the survival rate13. However, 3-D
finite element data showed that a 45 angle of loads
on an implant tripled the compressive stress24. They
also increased tensile stresses from almost zero to
4000 Psi in the bone. No other in vitro stress/strain
data were found for such an extreme angle. Clinical
application of angled abutments with such angulation
should be used with great caution before the
scientific evidence approves its feasibility.
When off-axis loading is applied to an implant,
the magnitude of the stress will be increased 3 times
or more1. Hoshaw et al.25 also reported that
overloading can cause bone loss around the implant
neck. Other studies showed that excessive stresses
may cause implant failure, component fracture,
and/or crestal bone loss around the implant neck22,26-28.
It may seem dangerous to use angled abutments
which maybe subjected to off-axis loading. However,
with all the clinical successes and survival rate from
the articles in this review, it seemed reasonable to
assume that stress distributions around the bone
surrounding implants restored with angled abutments
are favorable or at least comparable to those of
straight abutments, even though the loading
mechanisms of angled abutments in anterior teeth and
posterior teeth differ in terms of force direction and
magnitude. Most of the success/survival rate analyses
in the literature combined anterior and posterior data
together, which renders it impossible to determine the
exact performance of anterior angled abutments.
Researchers have tried to analyze stress/strain
distributions generated from angled abutments with
different analytical techniques8,16-19. We only know
that stresses and strains increase as the abutment
angulation increases16-19. There is no general
consensus about how much stresses/strains increase
with regard to the unit increase in abutment
angulation to date. Further studies are required for
clarification.
When comparing finite element analytical data
with those of animal studies or to the threshold data
from mechanostat theory16,19, it should be noted that
Chin Dent J 2005Vol 24No 1
Angled abutments
finite element analysis makes a lot of assumptions
during model construction, parameter selection, and
load simulation29,30. All those can reduce the
credibility of the resultant data. In order to make the
model meaningful, validation of finite element
models can be done by using the data from
strain-gauge analysis as suggested by Brosh et al.17.
In the reviewed finite element study done for
angled abutments16, loading was applied along the
long axis of the abutments in the anterior maxilla area.
However, the real loading condition for anterior teeth
is mostly at a certain angle toward the long axis of
the abutments/restorations. Stresses/strains generated
through such loading may be more detrimental to the
surrounding bone since it is more off-axis. When
future finite element analytical studies are conducted,
this factor should be considered and carefully
designed.
CONCLUSIONS
Based on the literature reviewed, several
conclusions can be drawn.
The clinical performance of angled abutments is
comparable to that of straight abutments.
The stresses/strains generated through off-axis
loading increase as the abutment angulation
increases, but there is no consensus as to what
extent of angle increase will cause implant or bone
failure. The data from mechanostat theory are used
in the literature as a certain threshold reference to
predict possible bone failure.
Off-axis loads are said to be detrimental to the
surrounding bone. However, the clinical
performances of angled abutments have mostly
been satisfactory. Further studies are needed to
clarify the discrepancies between the favorable
clinical success/survival rates and the unfavorable
in vitro biomechanical research data.
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Chin Dent J 2005Vol 24No 1
W.P. Chen, B.S. Lee and C.P. Lin.

Chin Dent J 2005Vol 24No 1 21