Probability of Failure of Internal Hexagon and

Morse Taper Implants with Different Bone Levels:

A Mechanical Test and Probabilistic Fatigue
María Prados-Privado, PhD1/Sérgio A. Gehrke, PhD, DDS2/Rosa Rojo, PhD, DDS3/
Juan Carlos Prados-Frutos, PhD, MD, DDS3

Purpose: The goal of this study was to foresee the fatigue life of two implant connections, evaluate the
failure probability with several bone levels, and compare the in vitro test results with finite element results.
Materials and Methods: Mechanical tests were done with 60 implants (Ø3.50 mm), and abutments were
used. These implants were divided into two groups with 30 implants each: internal hexagon and Morse
taper. Three bone levels and 10 implants for each level were analyzed. The first level was considered at
the platform level, the second at 3 mm, and the last level at 5 mm above the platform resin. A quasi-static
loading at 30 degrees was applied to the axis of the implant in a universal machine. Six models were
created and assembled to reproduce the conditions used in the laboratory testing. All models had restricted
all displacement at the bone (bottom and lateral). Loads employed in the numerical test were obtained
experimentally. Loads and material properties were supposed to be random. Then, failure probability was
calculated by the probabilistic methodology. Results: The internal hexagon group obtained the following
mean fracture strengths: 2,092 N at the first level, 1,041 N at the second level, and 898 N at the third level.
The mean fracture strengths for the Morse taper group were as follows: 1,687 N at the first level, 1,644
N at the second level, and 1,159 N at the third level. Results obtained by the finite element analysis are in
accordance with the in vitro mechanical test results. The Morse taper group obtained a better behavior at
bone levels 2 and 3 than the internal hexagon group. An important dependency between failure probability
and bone level was found in the internal hexagon group. However, a similar behavior in levels 2 and 3 was
obtained for the Morse taper group. Conclusion: In view of the mechanical results, the Morse taper group
has a better behavior in bone levels 2 and 3 than the internal hexagon group. This is also in accordance
with the probabilistic fatigue outcomes. Int J Oral Maxillofac Implants 2018;33:1266–1273. doi:10.11607/
jomi.6426

Keywords: abutment, bone level, dental implant, failure probability, fracture strength, probabilistic approach

T he use of dental implants has increased in the

last few years in different clinical situations.1 This
has more than a 90% success rate,2 but occasionally,
1Professor, Carlos III University, Department of Continuum
Mechanics and Structural Analysis, Leganés, Madrid, Spain;
ASISA Dental SA (I+D Department), Madrid, Spain; Biotecnos -
Technology and Science, Montevideo, Uruguay;
2Professor, Director of Biotecnos Research Center, Biotecnos -
Technology and Science, Montevideo, Uruguay; Department
of Implantology, Catholic University of Uruguay, Montevideo,
Uruguay.
3 Professor, Department of Medicine and Surgery (Stomatology
Area), Rey Juan Carlos University, Madrid, Spain.
Correspondence to: Dr María Prados-Privado, Carlos III
University, Avenida de la Universidad 30, 28911 Leganés,
Madrid, Spain. Email: mprados@ing.uc3m.es
©2018 by Quintessence Publishing Co Inc.
prosthetic implants fail because of mechanical or bio-
logic causes.3 Long-term evaluation of dental implants
is essential for acquiring as much information as pos-
sible about the causes of implant success and failure.
A high number of studies deal with the mechanisms
to retrieve fractured implants4–6 and the causes of that
failure. As detailed by Tiossi et al,7 biomechanical be-
havior of implant-supported prostheses has been ana-
lyzed with various techniques, such as photoelasticity,
strain gauges, and finite element analysis.
An adequate crestal bone level is very important in
the success of dental implants.8 Several factors such
as excessive occlusal forces, the loss of peri-implant
crestal bone, infections, implant-abutment gap, and
surgical procedure, to name a few, can compromise
the implant treatment.2
The finite element method (FEM) is the most
common technique used in dental and orthopedic

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Table 1   Characteristics of Each Implant and Abutment Used in This Study
Group Connection Implant diameter × length (mm)
1 Internal hexagon
2 Conical Morse taper
10
3.5
3.5
13
a b
Fig 1   Internal hexagon implants tested. (a) Schematic drawing.
(b) Transverse cut.
biomechanics.9 Physiologic loads are very difficult to
reproduce in experimental studies. Also, in vivo stud-
ies have limitations due to the ethical and technical
restrictions.10 Although FEM has fewer limitations
than in vivo and in vitro techniques, the accuracy of
the predictions of these methods depends strongly
on the quality of the mesh, the precision of the mate-
rial data, boundary conditions, and assumed loading
configuration.7
A wide variety of implant designs are available now-
adays in the market, and most of them comply with the
quality requirements defined by ISO 14801. This stan-
dard details how the fatigue test of dental implants
must be conducted to get the certification.11 Accord-
ing to ISO 14801, fatigue testing should be done by
applying alternative loading (worst-case conditions)
on the examined structures at several load levels until
a lower load limit is reached (endurance limit). Below
this limit, no fatigue failure is expected to occur.12
Nowadays, it is possible to estimate the fatigue life
of a component with different testing methods. The
most common method is the “total fatigue life ap-
proach,” which is carried out to evaluate how many
cycles can support a component until fracture.13 The
results are synthetized in what is known as the Wöhler
curve or S-N curve.
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Prados-Privado et al
Abutment diameter × length (mm)
3.5 × 13 3.5 × 10
3.5 × 13 3.5 × 10
10 3.5
3.5
13
a b
Fig 2   Morse taper implants tested. (a) Schematic drawing. (b)
Transverse cut.
This study presents an alternative to the tradi-
tional fatigue life approach. This study employed
a probabilistic fatigue in silico model on dental im-
plants and their components, considering as random
variables the material data and the loading configu-
rations from an in vitro study. The main novelty of
this study is that, unlike most of the previous finite
element analyses, this study was done with a proba-
bilistic point of view, based on the probabilistic FEM
and a cumulative damage model, which is based on
Markov chains.14
The impact of the variability of multiple variables
can be measured by probabilistic models. The goal of
this study was to foresee the fatigue life of two implant
connections, evaluate the failure probability with sev-
eral bone levels, and compare the in vitro test results
with finite element results.
MATERIALS AND METHODS
Two dental implant models and their components
(abutments and screws) were employed in this study.
These implants are manufactured by Implacil De Bor-
toli, and their characteristics are described in Table 1
and shown in Figs 1 and 2.
The International Journal of Oral & Maxillofacial Implants 1267
Prados-Privado et al
Level 1: 0 mm
Fig 3   Bone levels examined in this study.
Each group was studied with three different bone
levels, as shown in Fig 3.
Mechanical Test with Static Compressive
Forces
Sixty dental implants (Ø3.50 mm) and 60 abutments
were manufactured by Implacil De Bortoli (Brazil).
The geometric characteristics of these implants are
detailed in Table 1. Two implant models were used in
the final analysis: internal hexagon and conical Morse
taper. International Organization for Standardization
(ISO) guidelines were followed to test the static fatigue
strength of the dental implants; these guidelines rec-
ommend the use of the smallest diameter of implant
available for each model due to the adverse impact on
the efficacy of the implant. The load was applied with
an angle of 30 degrees with respect to the implant.
Ten implants per level and group were fixed in epoxy
resin. These levels were as follows: surface level (L1); 3
mm above surface level (L2); and 5 mm above surface
level (L3), simulating various marginal bone levels (Fig
3). The epoxy resin had a Young’s modulus of elasticity
like the cortical bone. All abutments received a torque
of 25 Ncm, as recommended by the product manu-
facturer. A metal hemisphere was elaborated and ce-
mented on the abutment. Then, a quasi-static load
test until fracture was carried out to all implants in a
properly calibrated universal testing machine (model
AME-5kN, Técnica Industrial Oswaldo Filizola Ltda)
with a test capacity of 5.0 kN. Tests were carried out
at the Testing Laboratory of Biomechanics (Biotecnos).
The test speed was set at 1 mm/min.
Once the quasi-static loading test was finished, all
fractured implants were ultrasonically cleaned in 96%
isopropanol and observed under low-power magnifi-
cation. Digital photographs were taken using a high-
resolution camera (Sony Cyber-shot DSC-H9, Sony),
and the data were reported descriptively. Then, the
samples were completely embedded in a metallo-
graphic resin to cut. All samples were cut in the center
portion of the longitudinal axis of the sets (implants
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Level 2: 3 mm Level 3: 5 mm
plus abutments) using a metallographic cutter (Isomet
1000), and a diamond disk was used to produce cuts
at the center of the longitudinal joint. The joints were
then polished using a sequence of papers that were
240-, 320-, 400-, 600-, and 1,200-grit abrasive (Poli-
pox), plus a rag wheel to provide appropriate surface
smoothness.
Finite Element Model
Six three-dimensional models were created using the
computer-aided design (CAD) software SolidWorks
2016 (Dassault Systèmes, SolidWorks). Three different
marginal bone levels were represented in each group
with the aim of reproducing the experimental results
obtained in a study by Gehrke et al.2 All geometries
of the model were provided by the manufacturer
except the cylinder, which was created employing
SolidWorks.
All assembled models were imported into ANSYS
Workbench 16 and analyzed. A change of less than 5%
in von Mises stress in the model was considered as a
criterion of convergence.15 Due to the stress singulari-
ties in sharp corners, it is crucial to have a good mesh
in the model. The number of elements and nodes em-
ployed in this study are summarized in Table 2.
Material Properties
The elastic properties of the materials used in the mod-
els were taken from the literature, as shown in Table 3.
Implants and bone were modeled with linear, elastic,
isotropic, and homogenous properties.16 Cylindrical
geometry was modeled with cortical bone properties
due to its similarities to this material.2 To develop this
model, the stochastic values (mean and standard de-
viation) of the material properties and loads should be
known. In this case, stochastic values of materials and
loads are shown in Tables 3 and 4, respectively.
The ultimate stress is an important value to know
the limits of behavior of a material. The ultimate stress
of cortical bone has been described as 170 MPa in
compression and 100 MPa in tension.17
 Prados-Privado et al

Table 2   Number of Nodes and Elements Used in Finite Element Models
Internal hexagon group Morse taper group
Implant group Nodes Elements Nodes Elements
Level 1 380,950 236,900 613,822 429,047
Level 2 279,565 190,770 544,982 380,422
Level 3 259,679 176,456 526,139 365,374

Table 3   Mechanical Properties of Materials θ

Used in This Study F
Young’s modulus
Abutment
Material (GPa) Poisson’s ratio
Titanium alloy 100 ± 20 0.32
L
Cortical bone 13.7 0.3 M
All DOFs Screw
restrained Cortical bone

Fig 4  (Right) Cross section of the finite element model. F = Bonded Implant
force; M = moment; L = bone level; θ = angle; DOFs = degrees
of freedom.

Boundary Conditions and Loading

Configuration Boundary conditions and
Geometry and mesh loading configuration
Osseointegrated screw implants with various mar-
ginal bone levels were simulated in the present study:
surface level (L1), 3 mm above surface level (L2), and Material
Probabilistic finite
5 mm above surface level (L3). element method fatigue
properties
A torque of 25 Ncm was applied in the abutment, as
recommended by the product manufacturer.
All models employed in the present study were con- Cumulative damage
model
strained as detailed in Fig 4: all degrees-of-freedom in
the bottom and lateral surfaces of the bone were re-
strained. To simulate an osseointegrated condition, the Mean fatigue life
implants were rigidly bonded in the bone. Cumulative probability function

Probabilistic Fatigue Model Fig 5   Scheme of the probabilistic model.

In addition to the previous deterministic finite element
analysis, a probabilistic fatigue model was also per-
formed. Load and Young’s modulus were considered
as random variables, and they were handled via first-
order Taylor series expansion.14 Once all the sensitivi- A summary of the probabilistic methodology is de-
ties of the random variables are known, it is possible tailed in Fig 5.
to apply the mean and variance operator. All the sensi-
tivities of the random fields involved, such as displace-
ment field, strain field, and stress field, can be obtained RESULTS
as described in Prados-Privado et al.14
The aim of this model is to compute the random
output variable and fatigue life, and obtain the mean Mechanical Tests
life and variance. Now, the use of a damage model, Different static loads, depending on the bone level,
based on Markov18 chains, is necessary. were obtained with 30 degrees to the implant axis as
Finally, the probabilistic transition matrix (PTM) can shown in Table 4. Images were captured using a digital
be obtained from the mean value and variance of the microscope to evaluate the fractures (Figs 6 and 7).
fatigue life, and from this PTM, it is possible to calculate Experimental fracture loads obtained in the me-
the failure probability.14 chanical test were used to check that the failure area

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Prados-Privado et al
Table 4   Mean ± SD of Resistance Values Obtained in Mechanical Quasi-static Test
Implant group Level 1
Internal hexagon group 2,092 ± 200
Morse taper group 1,687 ± 200
Level 1 Level 2 Level 3
Fig 6   Cross section after mechanical test of internal hexagon
group in the three proposed levels, respectively.
0 mm 3 mm 5 mm
Fig 8   von Mises stress values in internal hexagon group with
different bone levels.
corresponded with the results calculated by the finite
element model, and then, the probabilistic fatigue
model was computed to compare the effect of differ-
ent levels of marginal bone in the long-term fatigue in
dental implants.
Internal hexagon implants obtained the highest
loads at level 1, with a mean load of 2,092 N. However,
Morse taper obtained more resistance at levels 2 and 3
than internal hexagon.
A fracture of the abutment appeared in all bone
levels for internal hexagon implants. However, a simi-
lar behavior in levels 2 and 3 was obtained for the
Morse taper group. A deformation in the cervical
portion of the implant, with a mean load of 1,687 N,
appeared at the first level. In the second level, there
was also a deformation of the implant, with a mean
reduction of 2.5% of loads and a fracture of the abut-
ment. At level 3, a deformation of the implants ap-
peared, and the load was reduced 29.5% in relation
to level 2.
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Force (N)
Level 2 Level 3
1,041 ± 100 898 ± 50
1,644 ± 180 1,159 ± 300
Level 1 Level 2 Level 3
Fig 7  Cross section after mechanical test of Morse taper
group in the three proposed levels, respectively.
0 mm 3 mm 5 mm
Fig 9   von Mises stress values in Morse taper group with dif-
ferent bone levels.
Finite Element Method and In Vitro Study
In this study, von Mises stress on implants, screws, and
abutments was used to assess the effect of the margin-
al bone in the fatigue behavior. Results obtained in an
in vitro study2 matched with the results obtained with
the three-dimensional finite element model detailed
in the present study. Figures 8 and 9 show a macro
picture of dental implant failure after the mechanical
tests. Internal hexagon at level 1 showed the highest
stress value in the hexagon. At level 2, the maximum
stress appeared near the area of the implant insertion
into the bone, and, at level 3, the maximum value ap-
peared, again, in the hexagon. The conical Morse ta-
per implants at level 1 showed a higher stress level in
the cervical part of the implant. At level 2, the maxi-
mum stress value also appeared in the first thread of
the implant and, finally, at level 3, the highest stress
values obtained with this finite element model were
concentrated in the body of the implant, where the
bone appears.
 Prados-Privado et al

Probabilistic Fatigue Table 5   PTM Values for Each Case

Failure probability of two different implant designs
with three different marginal bone levels was obtained Internal hexagon
group Morse taper group
employing the probabilistic methodology. To calculate
p q p q
the probability of failure, it is necessary first to obtain
the PTM, which is a matrix that represents the prob- Dimension 6 3
ability of moving from one damage cycle to the next Level 1 0.15 0.85 0.208 0.792
in a one-time step. Level 2 0.135 0.865 0.115 0.885
Table 5 shows the data to construct the PTM in each Level 3 0.132 0.868 0.195 0.805
case: where dimension represents the size of the ma- PTM = probabilistic transition matrix.
trix. In this case, all matrixes are rectangular, which
means that the number of rows and columns is the
same. This matrix depends on the p (probability of re-
maining in the same damage cycle) and q (probability 1.0
of jumping to the next damage cycle). More details are
included in the Prados-Privado et al study.14 0.8

Failure probability
The probability of failure in the internal hexagon 0.6
group was obtained from 1 million loading cycles to 10
million cycles. As explained by Gibbs et al,19 1 year of in 0.4
vivo service corresponds with, approximately, 1 million Level 3
cycles. In Fig 10, the probability of failure in the inter- 0.2
Level 2
nal hexagon group shows an important dependency Level 1
of the bone level, while in the Morse taper group, the 1 2 3 4 5 6 7 8 9 10
implant and its superstructures have a similar behavior Million cycles
when the bone loss is small (Fig 11). With this method-
ology, the probability of failure in a system can be de- Fig 10  Cumulative Probability Function in internal hexagon
termined for a specific number of loading cycles (Figs group.
10 and 11). In level 1, the internal hexagon group has
a better fatigue behavior in terms of probability of fail-
ure than the Morse taper group because the probabil- 1.0
ity of failure in this level remains equal to zero until 5
million cycles, while for a Morse taper, this probability 0.8
Failure probability

is equal to zero until 3 million cycles. At levels 2 and 3,

the probability of failure remains equal to zero for few- 0.6
er cycles in internal connections than in Morse taper 0.4
implants, which means that internal connections have
a higher risk of failure than Morse taper connections. Level 3
0.2
Level 2
The probability of failure remains equal to zero until 3 Level 1
million cycles in Morse taper implants at levels 1 and 2;
1 2 3 4 5 6 7 8 9 10
however, once the failure probability is different than Million cycles
zero, level 2 has fewer cycles for the same probability
than level 1.
Fig 11   Cumulative Probability Function in Morse taper group.

DISCUSSION
This in vitro study examined the maximum fracture of
load of two dental implant connections with three dif-
ferent bone levels. The methodology proposed in the
present study was applied with two dental implants
with different internal connections (hexagon and
Morse taper) and three marginal bone levels (L1= 0
mm, L2 = 3 mm, and L3 = 5 mm). The results obtained
in this mechanical test were used to compute the finite
element analysis and the probabilistic study.
Fracture loads obtained in the in vitro mechanical
test, similar to a previous study published by Gehrke
et al,2 which were employed to compare the results
obtained by the three-dimensional finite element
model employed here, are in accordance with the re-
sults obtained by the mechanical test. Therefore, the
worst scenario in terms of loads was simulated with
the goal of obtaining the probability of failure of the
implants analyzed in the present study. In view of
the mechanical results, the Morse taper group had a

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Prados-Privado et al
better behavior in bone levels L2 and L3 than the inter-
nal hexagon group. This is also in accordance with the
probabilistic fatigue outcomes.
Several assumptions have been made in the present
study. Bone has been modeled as isotropic, although it is
anisotropic.20,21 All implants were assumed to be 100%
osseointegrated. In the present study, bone has been
modeled as a cylinder and considered as a compact
bone.
Thus, this finite element analysis has limitations.
Only forces in one direction have been applied; how-
ever, combined loads should appear for a more realis-
tic analysis, but here, due to a comparison between the
in vitro analysis and FEM, it is not necessary to consider
load components in more directions. Another limita-
tion is that this study does not include other factors,
different from biomechanical ones, that can interfere
in bone loss.
To the best of the authors’ knowledge, there are no
studies in the literature analyzing internal hexagonal
connection and Morse taper implant behavior from a
probabilistic point of view or their behavior under dif-
ferent bone loss levels.
Since the fatigue resistance of implants is very im-
portant for long-term clinical success, the present
study employed a probabilistic methodology to ana-
lyze the probability of failure in dental implants, abut-
ments, and screws, keeping in mind the influence of
different random variables, such as material properties
and loads. The model proposed in this study allows for
obtaining the influence of the uncertainty of mechani-
cal factors on implant behavior with different marginal
bone levels. Mastication habits cannot be considered
as deterministic because different patients cause dif-
ferent loads on implants.22,23 Thus, the study of dental
implants requires a probabilistic approach as the mod-
el employs here. However, most of the finite element
studies on dental implants available in the literature
are deterministic.24–28
Marginal bone level is a key criterion of long-term
success in dental implant treatment, and this bone
level position is influenced by numerous variables re-
lated to surgical trauma,29 prosthetic considerations,30
implant design,31 bone substratum,32 patient habits,33
implant-abutment connection,34,35 and the general
health of the patients.
Von Mises stress is widely used in dental implant
analysis because, as Erkmen et al explained in their
study,36 these values are defined as the beginning of
deformation for ductile materials.
FEM has been widely used in dental implant stud-
ies37,38 because it is considered to be an excellent
tool to analyze realistic biomechanical problems
and because it is a powerful tool to simulate dental
restorations.39
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Further studies simulating different random vari-
ables and considering the anisotropic and regenera-
tive properties of bone are needed.
From the clinical point of view, it is generally ob-
served that implants with internal hexagonal40 and
Morse taper41 connections present a better behav-
ior in front of the hexagonal external connections in
terms of marginal bone loss. This study suggests that
the clinical results would be more favorable for the
Morse taper connection. Likewise, the behavior of the
best connections available in the clinical field for dif-
ferent bone insertions was evaluated, but only from
the biomechanical point of view.
CONCLUSIONS
Although some assumptions have been employed in
the three-dimensional finite element model and even
though it is very difficult to exactly reproduce the
natural behavior, this mathematical model has more
repeatability and controllability than in vitro stud-
ies.42 Results obtained by finite element analysis can
provide more in-depth information than mechanical
tests,39 and the probabilistic model employed here
can be used to predict the long-term behavior of
dental implants, which is helpful in reducing redun-
dant clinical experiments. In view of the mechanical
results, the Morse taper group has a better behavior
in bone levels L2 and L3 than the internal hexagon
group. This is also in accordance with the probabilistic
fatigue outcomes.
ACKNOWLEDGMENTS
This work was supported by Grant A-285 (Proclinic-URJC, Princi-
pal Researcher JC Prados-Frutos). The authors declare no con-
flicts of interest.
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