of Restorations 13 Stability of the connections between the different parts of the overall implant system is a significant factor in the clinical success of the reconstruction. This is especially true for single‐tooth restorations, where there is a need for a strong interlock between abutment and implant. The implant‐abutment connection stability is influenced by factors such as component fit, machining accuracy, saliva contamination and screw preload. Attaching the final restoration to the abutment by a screw or dental cement was addressed briefly in Chapters 3, 6, and 11. Which approach is “better” is still a matter of debate. Some clinicians prefer screw‐retention and others choose to use a resin‐based or adhesive resin “cement” to retain the restoration, Fig. 13.1.
Cement Retention of Restorations
The present international consensus is that cement retention may be recommended for the following situations:
• For short‐span prostheses with margins at or above the tissue level
• To enhance esthetics when the screw access passes through the buccal aspect of a restoration • In cases of malpositioned implants • To reduce initial treatment costs • Situations in which access is severely restricted or the patient has limited ability to maximize opening of the jaws.
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Cemented Crown Screw-Retained
Crown
Figure 13.1 Cement and screw‐retention of crowns (Source: Courtesy of Implant Direct).
Using cement retention will often simplify laboratory fabrication procedures
for the restoration. Resorting to cement retention of the restoration to the abut- ment may be the only approach to satisfactorily join restoration and implant, particularly if access to the implant is restricted. Finally, in some instances, there is an esthetic benefit in having intact restorative surfaces, for example, screw access traversing the buccal aspect on an anterior tooth. However, there can be problems associated with cement‐retained restorations, notably if the restoration should fail or need to be replaced. In such cases, removing the cemented restoration from the abutment can present a far greater challenge than simply unscrewing it. Another and important factor regarding cement‐retained restorations is that there is always a finite thickness of cement film between restoration and abutment. One consequence of this is that if a viscous cement was used or there is a thick cement film, the restoration may not seat completely down on the abutment. Consequently, there can be a gap between the margins of the restoration and the abutment collar, (Fig. 13.2). Inability to completely seat restorations is well‐known in prosthodontics, and the gap at the external line angle can be quite large [1, 2]. The presence of such a gap can result in a multitude of issues, including leaching out of the cement. The latter will permit ingress of fluids and bacteria which may lead to quite significant problems, namely peri‐implant bone loss. It should also be noted that one cause of peri‐implantitis is implant‐related cement sepsis, which is often a result of excess cement extruding into the peri‐ implant tissue. Consequences of the latter include increased bleeding on probing, suppuration, and possibly peri‐implant attachment loss. Clinical studies indicate that excess cement in the peri‐implant tissue may be exacerbated with larger diameter implant fixtures. It appears, however, that the presence of excess cement is often dependent upon the type of cement and, for example, a specialized
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Figure 13.2 Gap between restoration and abutment due to cementation.
methacrylate implant cement favored the development of suppuration and the
growth of periodontal pathogens. This subject is discussed again in Chapter 14. It is of utmost importance that if a cement‐retained restoration is indicated, the abutment must be at, or only slightly below, the tissue level (0.5 mm). This will allow for proper removal of any excess cement.
Screw‐Retained Restorations One area of constant concern for implant clinicians is the potential for peri‐ implantitis associated with cemented crowns and which occasionally leads to implant failure. In order to reduce this risk and eliminate possible complications from cement fixation, many dentists advocate the use of screw‐retained crowns and bridges, Fig. 13.3. Screw retention of restorations may be recommended for the following situations:
• In situations of minimal inter‐arch space
• To avoid a cement margin and thus the possibility of cement residue • When retrievability of the restoration is important or potentially necessary • In the esthetic zone, to facilitate tissue contouring and conditioning in the transition zone (i.e., developing the emergence profile)
It should be mentioned that to facilitate screw retention, it is recommended that
the implant be placed in a prosthetically driven position. Various mechanisms have been proposed to connect the dental implant abut- ment to the implant body or fixture and the different systems vary in connection geometry, materials, and overall screw mechanics. Some of these differences were indicated in Chapter 3. It is not uncommon, however, for clinicians to be con- cerned that the abutment screw can loosen over time. However, the literature [3]
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Figure 13.3 Screw‐retention of a crown.
indicates that abutment screw loosening is a rare event in single‐implant restora-
tions and the survival rate of single‐implant restorations after 5.2 years was 98.4% [4]. One reason for this remarkably high success rate is the mechanics involved in attaching the restoration screw to the abutment. Regardless of the precise screw and abutment design, contaminants such as salivary fluids and blood can seep into the abutment screw hole as well as coat the screw threads during the restoration attachment process. This effect, together with the presence of surface coatings, will change the coefficients of friction for the surfaces being screwed together in the implant complex. Such changes in fric- tional behavior can affect resistance to screw loosening through their effect on the preload, residual, and removal torque. Recent studies, however, indicate that the amount of removal torque required to loosen the abutment screw was less than the insertion torque at all frictional conditions. On the other hand, decreasing the coefficient of friction at the mating surfaces increases the resistance to screw loos- ening by its effect on increasing the remaining or residual torque. In other words, if clinicians deliberately contaminate the abutment screw with biologically‐ compatible lubricants, then removal torque may be increased, reducing the risk of screw loosening. There are also indications that the use of gold‐coated screws could also be preferred over non‐coated screws because their use would decrease the coefficient of friction at the screw‐abutment interface, thereby enhancing resistance to screw loosening by increasing the residual torque. There is, however, one important issue regarding screw‐retained crowns and that is the effect of the screw access hole on the strength of the crown. Screw access holes will disturb the continuity of the occlusal surface and reduce restora- tion strength, this reduction, depending on the crown material, can be as great as
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50%. The lowered restoration strength may result in a susceptibility to fracture in
patients with heavy bites, and parafunctional habits such as bruxers. It should be noted that a problematic implant crown that has been placed with a temporary cement or a low‐retention adhesive can be removed and repaired or temporarily replaced with a readily fabricated temporary crown until the permanent replacement is available. In contrast, if problems develop with a screw‐retained crown, the latter can be more difficult and expensive to repair or replace, and temporization may present greater difficulties than with a cemented crown. This dichotomy has led to the development of hybridized screw‐retained crowns (screw‐mentable) with prefabricated, lab‐placed screw access holes in a zirconia or lithium silicate/disilicate material that are cemented to the implant fixture (Ti‐base), but which may be cleaned extra‐orally. The underlying concept is that such hybrids may reduce the risk of future complications with pure screw‐ retained or cemented crowns. Despite this seeming controversy between the two approaches to crown‐ implant retention, it appears from clinical reports that the success rates of screw‐ and cement‐retained restorations are equivalent in the anterior maxillae [5]. The overall implant survival rate was 96.4% and there was no statistically significant difference in survival between the screw‐ and cement‐retained groups. Further, the majority of clinician‐ and patient‐assessed outcomes were similar. The results of this study indicate that for the majority of clinician‐ and patient‐assessed success parameters, screw and cement‐retained restorations are equivalent in the anterior maxilla. Consequently, the subject of restoration selection for screw retention is discussed in some detail in Chapter 14.
Conclusions The main two restorative options for the implant prosthesis are the screw‐retained prosthesis and cement-retained prosthesis. The screw‐retained prosthesis is a “one‐piece” prosthesis that is directly torqued to the implant through an access hole in the restoration. Generally, the access hole is filled in with a material to protect the screw (Teflon tape, cotton pellet, or polyvinyl siloxane [PVS]) and com- posite. The major benefits of the screw‐retained prosthesis are ease of retrievabil- ity and avoiding a cement margin. Cement residue in the sulcus of the implant is known to cause peri‐mucositis and peri‐implantitis. The cement‐retained prosthe- sis is a two‐piece prosthesis consisting of an abutment and the restoration. The abutment is torqued to the implant and then the restoration is cemented to the abutment. Generally, the screw is protected by placing Teflon tape, a cotton pellet, or PVS in the abutment prior to cementation. The main benefit of the cement‐ retained prosthesis is keeping the restorative material intact.
References 1. McLean, J.W. and von Fraunhofer, J.A. (1971). The estimation of cement film thickness by an in vivo; technique. Br. Dent. J. 131: 107–111. 2. Dimashkieh, M.R., Davies, E.H., and von Fraunhofer, J.A. (1974). Measurement of the cement film thickness beneath full crown restorations. Br. Dent. J. 137: 281–284.
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3. Theoharidou, A., Petridis, H.P., Tzannas, K., and Garefis, P. (2007). Abutment screw loosening in single‐implant restorations: a systematic review. Int. J. Oral Maxillofac. Implants 23 (4): 681–690. 4. Tey, V.H.S., Phillips, R., and Tan, K. (2017). Five‐year retrospective study on success, survival and incidence of complications of single crowns supported by dental implants. Clin. Oral Implants Res. 28 (5): 620–625. 5. Sherif, S., Susarla, S.M., Hwang, J.W. et al. (2011). Clinician‐ and patient‐reported long‐term evaluation of screw‐ and cement‐retained implant restorations: a 5‐year prospective study. Clin. Oral Investig. 15 (6): 993–999.
