Influence of Prosthesis Type and Retention Mechanism on

Complications with Fixed Implant-Supported Prostheses:

A Systematic Review Applying Multivariate Analyses
Christopher Millen, BDS, MFDS, MClinDent, MPros1/
Urs Brägger, DMD, Dr Med Dent2/Julia-Gabriela Wittneben, DMD, Dr Med Dent, MMSc3

Purpose: To identify the influence of fixed prosthesis type on biologic and technical complication rates
in the context of screw versus cement retention. Furthermore, a multivariate analysis was conducted to
determine which factors, when considered together, influence the complication and failure rates of fixed
implant-supported prostheses. Materials and Methods: Electronic searches of MEDLINE (PubMed),
EMBASE, and the Cochrane Library were conducted. Selected inclusion and exclusion criteria were used
to limit the search. Data were analyzed statistically with simple and multivariate random-effects Poisson
regressions. Results: Seventy-three articles qualified for inclusion in the study. Screw-retained prostheses
showed a tendency toward and significantly more technical complications than cemented prostheses with
single crowns and fixed partial prostheses, respectively. Resin chipping and ceramic veneer chipping had
high mean event rates, at 10.04 and 8.95 per 100 years, respectively, for full-arch screwed prostheses. For
“all fixed prostheses” (prosthesis type not reported or not known), significantly fewer biologic and technical
complications were seen with screw retention. Multivariate analysis revealed a significantly greater incidence
of technical complications with cemented prostheses. Full-arch prostheses, cantilevered prostheses, and
“all fixed prostheses” had significantly higher complication rates than single crowns. A significantly greater
incidence of technical and biologic complications was seen with cemented prostheses. Conclusion: Screw-
retained fixed partial prostheses demonstrated a significantly higher rate of technical complications and
screw-retained full-arch prostheses demonstrated a notably high rate of veneer chipping. When “all fixed
prostheses” were considered, significantly higher rates of technical and biologic complications were seen for
cement-retained prostheses. Multivariate Poisson regression analysis failed to show a significant difference
between screw- and cement-retained prostheses with respect to the incidence of failure but demonstrated
a higher rate of technical and biologic complications for cement-retained prostheses. The incidence
of technical complications was more dependent upon prosthesis and retention type than prosthesis or
abutment material. Int J Oral Maxillofac Implants 2015;30:110–124. doi: 10.11607/jomi.3607

Key words: cement, complication, dental implants, fixed dental prostheses, multivariate analysis, screw

F
1ITIScholar, Department of Reconstructive Dentistry and
Gerodontology, School of Dental Medicine, University of Bern, ixed implant-supported prostheses may be either
Switzerland; Clinical Lecturer/Honorary Specialist Registrar in screw- or cement-retained. The success rate of
Restorative Dentistry, Edinburgh Dental Institute, University of these prostheses does not seem to be affected by the
Edinburgh, Edinburgh, United Kingdom. type of retention.1,2 However, both retention types
2Professor, Department of Reconstructive Dentistry and
have relative advantages and disadvantages3–7 and
Gerodontology, School of Dental Medicine, University of Bern,
Switzerland. may have an influence on the frequency of technical
3Assistant Professor, Department of Reconstructive Dentistry and biologic complications.8 A complication is defined
and Gerodontology, School of Dental Medicine, University in the Glossary of Oral and Maxillofacial Implants as an
of Bern, Switzerland; Lecturer in Restorative Dentistry and “Unexpected deviation from the normal treatment
Biomaterials Sciences, Harvard School of Dental Medicine,
outcome. It is generally classified as either technical
Cambridge, Massachusetts.
or biological, eg, surgical complication, hemorrhage,
Correspondence to: Dr Julia-Gabriela Wittneben, Department damage to the inferior alveolar nerve, infection, de-
of Reconstructive Dentistry and Gerodontology, Freiburgstrasse layed wound healing, or lack of osseointegration.”9
7, CH-3010 Bern, Switzerland. Fax: +41-31-632-49-31. Mechanical and technical risks affecting these compli-
Email: [email protected]
cations were elaborated upon and further defined by
©2015 by Quintessence Publishing Co Inc. Salvi and Brägger.10

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 Millen et al

A recent comprehensive systematic review on What is the clinical performance of implant-supported

the subject of screw- vs cement-retained prosthe- reconstructions (including complications and failures)
ses1 grouped event rates into cement- versus screw- in patients with edentulous sites treated with either
retained single crowns (SCs), fixed partial prostheses screw or cement retention?
(FPPs), and full-arch fixed dental prostheses (FAFDPs). Well-defined inclusion and exclusion criteria were ap-
No statistically significant differences were reported for plied to narrow the search. These criteria dictated that
fixed prosthesis survival. Estimated biologic complica- the study had to be prospective, with a mean follow-
tion rates (bone loss > 2 mm) were found to be higher up time of 3 years and a minimum of 10 patients. Ret-
with cemented prostheses, whereas screw-retained rospective studies were included if a follow-up clinical
prostheses exhibited more technical complications. examination had been conducted. The study also had to
Based on their improved retrievability, screw-retained clearly state the type of retention used (screw or cement)
prostheses were given preference. and had to have assessed implant-supported fixed
The subject was visited again by this group of au- prostheses. Data from patient cohorts used for multiple
thors at the recent ITI Consensus Conference in Bern, publications were limited to the most recent version.
Switzerland.2 The complication data in that study were After the search had been narrowed by the inclusion
not separated by prosthesis type, but it was similar to and exclusion criteria, a hand search was performed
the study of Sailer et al1 in that survival rates, technical of the bibliographies of recently published, relevant
complication rates, and biologic complication rates of review articles. This hand search was not limited by
all screw-retained and all cemented prostheses were date and included studies published earlier than the
analyzed. The results demonstrated no significant year 2000. The full texts of the remaining articles were
difference between retention types for survival but screened to determine their suitability for inclusion,
showed more technical and biologic complications for and data were extracted from each of the qualifying
cemented prostheses. articles during this process. Data extracted included:
In addition to the retention type, the particular com- author, year, type of study (prospective/retrospective),
ponents, superstructures, and materials are also likely planned number of patients, actual number of pa-
to influence complication rates. The resulting combi- tients, mean patient age, age range of patients, study
nation of these factors varies throughout the literature, setting (university/private practice), location (anterior/
and it is therefore difficult to determine the true reason posterior), fixed prosthesis type, abutment material,
for the results seen. An accepted method of statistically prosthesis material, retention type, cement type, im-
controlling for these factors in a systematic review is to plant brand, implant types, and total number of im-
apply a multivariate analysis. This was not carried out in plants. The total exposure time of the prostheses was
either of the aforementioned reviews. calculated, and survival of the prostheses was defined
Because a separate analysis of complications by as remaining in situ throughout the study period.
prosthesis type was not carried out in the previous Data regarding technical complications were also ex-
review,2 the aim of the current review was to identify tracted. Technical complications included loss of reten-
the influence of prosthesis type on technical and bio- tion, loosening of the occlusal/abutment screws, loss
logic complication rates in the context of screw versus of screw access fill material, fracture and/or chipping
cement retention. Furthermore, the authors used a of the veneer, and fracture of the implant/abutment/
multivariate analysis to determine which factors (from framework/screw. Biologic complications were defined
among retention type, prostheses type, prosthesis as bone loss > 2 mm, peri-implantitis, peri-implant muco-
material, and abutment material) influence the com- sitis, general soft tissue complications (including fistulae
plication and failure rates of implant-supported fixed and swelling), recession, loss of the implant, any esthetic
prostheses when considered together. complication, and any other reported complications.
The data were grouped and assessed according to
the prosthesis type. Namely, this encompassed SCs,
MATERIALS AND METHODS FPPs, FAFDPs, and cantilever FDPs (cFDPs). Studies that
did not report the prosthesis type or in which identi-
Study Selection fication of the prosthesis type was not possible were
An initial electronic search using medical subject grouped together as “all fixed prostheses.” Likewise,
headings and free-text terms related to the review top- studies that did not report on abutment or prosthetic
ic was conducted of EMBASE, MEDLINE (via PubMed), material were grouped as “all materials” and “all abut-
and the Cochrane Library. The search included articles ment materials,” respectively. Individual and summa-
published between 2000 and September 2012 and tive analyses, as well as a multivariate analysis, were
included articles in English, German, and French. This carried out to add to the information already present-
search was based on the following PICO question: ed by Wittneben et al.2

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Millen et al

complications were not considered were excluded

Initial electronic search: 4,324 articles
from this analysis. The summary analyses for technical
and biologic complications summarized the cumula-
tive rates of complications, excluding resin chipping
and implant loss, respectively.
Individual selection after The estimated event rate per 100 years was calcu-
applying inclusion/exclusion criteria
by two reviewers (abstract search) lated by using the observation time of the studies to-
(reviewer 1): 346; (reviewer 2): 333 gether with the number of prostheses observed (eg,
100 prostheses observed for 1 year each, with only one
failure, would have an event rate of 1 per 100 years).
Comparisons included differences in event rates per
Agreement on the selected articles by discussion
(reviewers 1 and 2): 302 100 prosthesis-years between cement- and screw-
retained prostheses, in total and when grouped ac-
cording to prosthesis type. In addition, a multivariate
random-effects Poisson regression was used to com-
Hand search
(reviewer 3): 19
pare the incidence rate ratios (IRR) of different groups,
with the IRR being the ratio between incidence rates of
two parameters. The threshold for significance was set
at .05 and P values were calculated using a Wald test.
Abstracts selected for full text review: 321

RESULTS
Full review of 321 studies by two reviewers
The titles and abstracts of 4,324 articles (initial search)
were screened independently by two authors (JW,
UB) to determine their suitability for inclusion in the
Data extraction into spreadsheet of 321 studies review (Fig 1). Following discussion, a consensus was
(reviewers 1 and 3) reached regarding disputed articles. Three hundred
two articles were obtained for screening. An additional
19 articles were obtained from a manual search of the
bibliographies of review articles identified within the
Individual selection of the
final articles by two reviewers: 73
initial search and recently published relevant reviews.
Two authors (JW, CM) independently reviewed the 321
articles. Of these articles, 73 qualified for inclusion in
Fig 1   Flow diagram describing the search design and strategy. the review.5,11–82
The qualifying articles included 52 prospective co-
hort studies (71.2%), 13 retrospective studies (17.8%),
2 split-mouth studies, and 6 randomized controlled tri-
Statistical Analysis als (8.3%). Most studies were carried out in a university
All statistical analysis was performed using Stata 11.2. setting (63%) (Tables 1 and 2). The types of prostheses
Random-effects Poisson regression analysis was used studied are summarized in Table 3.
to estimate the complication rate and calculated 95%
confidence intervals (CIs). For all analyses, the total ex- Findings of Simple Poisson Regression
posure time per study was used as an offset variable Analysis
(ln[exposure time]). When no complication occurred, Technical Complications by Prosthesis Type. The
no confidence intervals were calculated. Complication complications “loss of coverage of access hole” and
rates of individual studies were calculated by dividing “loosening of occlusal screw” could not be compared
the number of events by the total exposure time. Esti- statistically, as they were only applicable for screw-
mated complication rates and 95% CIs were calculated retained prostheses; however, they were included in
by assuming a Poisson distributed number of events the summary analyses. A statistical analysis was per-
and by assuming constant event rates. formed for the following observations: loss of reten-
Studies that reported on at least one of the com- tion, fracture and/or chipping, loosening of abutment,
plications examined were included in the overall fracture of abutment, fracture of framework, fracture
analysis. Where there were unreported complications, of implant, screw fracture, resin chipping and/or frac-
these were assumed to be zero. Studies in which ture, and “other.”

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 Millen et al

When comparing the summative overall technical Table 1 Design of Included Studies
complications between cement and screw retention
for each prosthesis type, the “resin chipping” catego- Study type No. of studies %
ry was removed. It could not be analyzed, because it Prospective cohort 52 71.2
was not reported in some of the cemented prosthesis Retrospective cohort 13 17.8
studies and represented a significant outlier for screw- Split mouth 2 2.7
retained complications. Randomized controlled 6 8.3
Single Crowns. Technical complications with SCs Total 73 100
are summarized in Table 4. There were no fractured
implants and no episodes of resin chipping associated
with SCs. “Loosening of abutment” showed a statisti- Table 2 Settings of Included Studies
cally significantly higher rate in screw-retained pros- Study setting No. of studies %
theses (P = .003), whereas the opposite was true for
Private practice 13 17.8
“framework fracture” (P < .001). Complication rates
University 46 63
per 100 years did not exceed 1, except for “loosening
of abutment” (2.07 [0.65 to 6.58] per 100 years) and Specialist clinic 6 8.2
“fracture of framework” (2.69 [1.59 to 4.54] per 100 Multicenter 6 8.2
years). Overall, there was no difference between re- Not reported 2 2.8
tention types; however, there was a tendency toward Total 73 100
more complications with screw-retained prostheses
(P = .071).
Fixed Partial Prostheses . Technical complications Table 3 Types of Implant-Supported
with FPPs are summarized in Table 5. There were no Prostheses Analyzed in Included
statistically significant differences with any of the in- Studies
dividual complications. However, the summary of all No. of
complications showed statistically significantly more Reported prosthesis type prostheses %
events in the screw-retained group (P = .009). Single crown 1,720 29.4
Full-Arch FDPs. Technical complications with Fixed partial 979 16.7
FAFDPs are summarized in Table 6. Only one included Full-arch FDP 928 15.8
study reported on cemented FAFDPs; however, it did Cantilever FDP 61 1.0
not report on any complications. Therefore, no statisti-
All fixed prostheses 2,170 36.2
cal comparison was possible. Resin chipping and ce-
Total 5,858 100
ramic veneer chipping had high event rates, at 10.04
(4.48 to 22.48) and 8.95 (1.25 to 64.13) per 100 years,
respectively.
Cantilever FDPs. Technical complications with Biologic Complications by Prosthesis Type. The
cFDPs are summarized in Table 7. The number of in- same method used for technical complications—
cluded studies reporting on complications for cFDPs excluding studies from analysis that did not report on
was low, with only 1 for cemented and 2 for screw-re- individual complications—was used to analyze biolog-
tained cFDPs. Because of the small numbers of studies, ic complications. The summary assessments for each
complications were rarely considered, and as such sta- prosthesis type did not include any data on implant
tistical comparisons were not possible. Rates of 10.33 loss.
and 11.59 for ceramic veneer chipping and abutment Single Crowns. Biologic complications with SCs are
loosening, respectively, were high in comparison to summarized in Table 9. Only the category “any esthetic
the calculated rates for other types of prostheses. A complications” showed a statistically significant result,
large difference in overall complication rates per 100 with a higher complication rate for screw-retained
years was reported between screw-retained (17.93) crowns (P = .01). Summary results showed no differ-
and cemented (0.59) cFDPs. ence in biologic complication rates between the two
All Fixed Prostheses. Technical complications in retention types.
the group “all fixed prostheses” are summarized in Fixed Partial Prostheses. Biologic complications
Table 8. There were statistically significantly higher with FPPs are summarized in Table 10. Overall, ce-
rates of retention loss and abutment loosening in the mented FDPs in the included studies reported no bio-
cemented groups (P < .001), which contributed to a logic complications, and screw-retained prostheses
greater number of complications with cemented pros- showed a complication rate of 4.18 (2.11 to 8.28) per
theses (P < .001). 100 years.

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Millen et al

Table 4 Technical Complications with SCs

No. of No. of Exposure No. of Complication rate*
Complication Retention studies prostheses time (y) complications (95% CI) P
Loss of retention Cement 22 1,193 6,155 23 0.55 (0.25–1.23)
.834
Screw 6 309 1,196 10 0.47 (0.12–1.79)
Exposure of access hole Cement 0 0 – – – (–)
N/A
Screw 6 309 1,196 1 0.08 (0.01–0.59)
Fracture and/or chipping Cement 22 1,126 5,770 23 0.41 (0.26–0.65)
.523
Screw 7 355 1,426 4 0.28 (0.10–0.79)
Loosening of occlusal screw Cement 0 0 – – – (–)
N/A
Screw 8 373 1,606 13 0.90 (0.20–4.09)
Loosening of abutment Cement 22 1,126 5,770 18 0.33 (0.15–0.71)
.003
Screw 6 309 1,196 23 2.07 (0.65–6.58)
Fracture of abutment Cement 22 1,126 5,770 0 0 (–)
> .999
Screw 6 309 1,196 1 0.08 (0.01–0.59)
Fracture of framework Cement 2 109 521 14 2.69 (1.59–4.54)
< .001
Screw 7 355 1,426 1 0.07 (0.01–0.50)
Fracture of implant Cement 22 1,126 5,770 0 0 (–)
N/A
Screw 6 309 1,196 0 0 (–)
Screw fracture Cement 22 1,126 5,770 0 0 (–)
> .999
Screw 7 355 1,426 4 0.31 (0.07–1.32)
Resin chipping and/or fracture Cement 1 12 36 0 0 (–)
N/A
Screw 6 309 1,196 0 0 (–)
Other Cement 20 958 4,611 33 0.60 (0.19–1.86)
.145
Screw 7 327 1,376 7 0.30 (0.08–1.14)
Summary of all complications except Cement 24 1,246 6,485 111 1.91 (1.25–2.94)
.071
“resin chipping and/or fracture” Screw 8 373 1,606 64 3.12 (1.79–5.42)
*Estimated complication rate per 100 years (95% confidence interval).

Table 5 Technical Complications with FPPs

No. of No. of Exposure No. of Complication rate*
Complication Retention studies prostheses time (y) complications 95% CI) P
Loss of retention Cement 3 61 318 4 0.94 (0.09–9.72) .500
Screw 9 460 2,697 16 0.37 (0.09–1.55)
Exposure of access hole Cement 0 0 – – – (–) N/A
Screw 9 460 2,697 21 0.46 (0.05–3.95)
Fracture and/or chipping Cement 3 61 318 1 0.30 (0.02–4.16) .112
Screw 11 649 4,299 98 2.80 (1.20–6.57)
Loosening of occlusal screw Cement 0 0 – – – (–) N/A
Screw 10 529 3,099 34 1.83 (0.47–7.02)
Loosening of abutment Cement 3 61 318 1 0.29 (0.02–3.44) .351
Screw 9 486 2,884 30 1.02 (0.40–2.57)
Fracture of abutment Cement 3 61 318 0 0 (–) > .999
Screw 8 340 1,497 1 0.07 (0.01–0.47)
Fracture of framework Cement 1 16 48 0 0 (–) > .999
Screw 10 529 3,099 1 0.03 (0.00–0.23)
Fracture of implant Cement 3 61 318 0 0 (–) > .999
Screw 9 486 2,884 8 0.43 (0.11–1.73)
Screw fracture Cement 3 61 318 0 0 (–) > .999
Screw 11 649 4,299 11 0.21 (0.08–0.53)
Resin chipping and/or fracture Cement 1 16 48 0 0 (–) > .999
Screw 9 486 2,884 6 0.46 (0.01–14.62)
Other Cement 3 61 318 0 0 (–) > .999
Screw 10 606 4,084 5 0.07 (0.01–0.58)
Summary of all complications except Cement 3 61 318 6 1.19 (0.36–3.86) .009
“resin chipping and/or fracture” Screw 11 649 4,299 225 6.60 (3.71–11.72)
*Estimated complication rate per 100 years (95% confidence interval).

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 Millen et al

Table 6 Technical Complications with FAFDPs

No. of No. of Exposure No. of Complication rate*
Complication Retention studies prostheses time (y) complications (95% CI)
Loss of retention Screw 16 851 6,508 30 1.13 (0.26–4.87)
Exposure of access hole Screw 14 778 6,252 106 1.54 (0.52–4.56)
Fracture and/or chipping Screw 14 778 6,252 60 8.95 (1.25–64.13)
Loosening of occlusal screw Screw 16 851 6,508 52 1.75 (0.63–4.87)
Loosening of abutment Screw 16 851 6,508 21 0.74 (0.10–5.33)
Fracture of abutment Screw 15 822 6,384 14 0.16 (0.05–0.52)
Fracture of framework Screw 15 822 6,384 55 0.61 (0.19–1.99)
Fracture of implant Screw 16 851 6,508 3 0.15 (0.00–4.35)
Screw fracture Screw 16 851 6,508 18 0.52 (0.15–1.88)
Resin chipping and/or fracture Screw 15 822 6,384 533 10.04 (4.48–22.48)
Other Screw 16 851 6,508 231 5.83 (2.77–12.27)
Summary of all complications except Screw 16 851 6,508 590 19.44 (11.08–34.09)
“resin chipping and/or fracture”
*Estimated complication rate per 100 years (95% confidence interval).

Table 7 Technical Complications with cFDPs

No. of No. of Exposure No. of Complication rate*
Complication Retention studies prostheses time (y) complications (95% CI)
Loss of retention Cement 1 15 169.5 0 0.00
Screw 1 23 69.0 0 0.00
Exposure of access hole Cement 0 0 – – N/A
Screw 1 23 69.0 0 0.00
Fracture and/or chipping Cement 1 15 169.5 0 0.00
Screw 2 46 184.0 19 10.33
Loosening of occlusal screw Cement 0 0 – – N/A
Screw 2 46 184.0 5 2.72
Loosening of abutment Cement 1 15 169.5 1 0.59
Screw 1 23 69.0 8 11.59
Fracture of abutment Cement 1 15 169.5 0 0.00
Screw 1 23 69.0 0 0.00
Fracture of framework Cement 0 0 – – N/A
Screw 2 46 184.0 0 0.00
Fracture of implant Cement 1 15 169.5 0 0.00
Screw 1 23 69.0 0 0.00
Screw fracture Cement 1 15 169.5 0 0.00
Screw 2 46 184.0 1 0.54
Resin chipping and/or fracture Cement 0 0 – – N/A
Screw 1 23 69.0 0 0.00
Other Cement 1 15 169.5 0 0.00
Screw 1 23 69.0 0 0.00
Summary of all complications except “resin Cement 1 15 169.5 1 0.59
chipping and/or fracture” Screw 2 46 184.0 33 17.93
*Estimated complication rate per 100 years (95% confidence interval).

Full-Arch FDPs. Biologic complications with complication rate for screw-retained FAFDPs was 7.61
FAFDPs are summarized in Table 11. As was seen with (4.55 to 12.72) per 100 years.
technical complications, there were no complications Cantilever FDPs. Only two studies reported on
reported for cemented FAFDPs. Bone loss, implant loss, biologic complications for cFDPs (Table 12). The most
and “other” represent the most frequently occurring commonly reported complication was peri-implantitis,
biologic complications for FAFDPs. The overall biologic with an event rate of 5.31 per 100 years.

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Millen et al

Table 8 Technical Complications for “All Fixed Prostheses”

No. of No. of Exposure No. of Complication rate*
Complication Retention studies prostheses time (y) complications (95% CI) P
Loss of retention Cement 6 746 3,751 68 20.49 (3.56–117.89)
< .001
Screw 5 1,098 4,932 21 1.72 (0.33–8.89)
Exposure of access hole Cement 0 0 – – – (–)
N/A
Screw 3 964 4,530 3 0.23 (0.01–4.90)
Fracture and/or chipping Cement 7 756 3,805 6 1.03 (0.22–4.89)
.507
Screw 6 1,173 5,267 31 1.58 (0.48–5.20)
Loosening of occlusal screw Cement 0 0 – – – (–)
N/A
Screw 6 1,224 5,634 97 3.82 (1.53–9.51)
Loosening of abutment Cement 7 756 3,805 66 1.79 (0.70–4.62)
< .001
Screw 5 1,117 5,313 3 0.06 (0.01–0.27)
Fracture of abutment Cement 7 756 3,805 4 0.06 (0.01–0.38)
.470
Screw 5 1,117 5,313 4 0.03 (0.00–0.26)
Fracture of framework Cement 0 0 – – – (–)
N/A
Screw 6 1,224 5,634 2 0.10 (0.01–1.85)
Fracture of implant Cement 7 756 3,805 2 0.13 (0.01–2.44)
.999
Screw 6 1,224 5,634 0 0 (–)
Screw fracture Cement 7 756 3,805 10 0.22 (0.03–1.52)
.286
Screw 6 1,224 5,634 13 0.14 (0.02–0.86)
Resin chipping and/or fracture Cement 0 0 – – – (–)
N/A
Screw 5 1,117 5,313 0 0 (–)
Other Cement 7 756 3,805 0 0 (–)
N/A
Screw 6 1,173 5,481 0 0 (–)
Summary of all complications except Cement 7 756 3,805 156 8.79 (5.20–14.88)
< .001
“resin chipping and/or fracture” Screw 8 1,307 5,883 174 4.70 (2.87–7.69)
*Estimated complication rate per 100 years (95% confidence interval).

Table 9 Biologic Complications with SCs

No. of No. of Exposure No. of Complication rate*
Complication Retention studies prostheses time (y) complications (95% CI) P
Bone loss (> 2 mm) Cement 20 1,111 6,028 34 0.41 (0.19–0.88)
.213
Screw 7 327 1,376 1 0.08 (0.01–0.94)
Peri-implantitis Cement 19 1,022 4,590 15 0.24 (0.08–0.71)
.999
Screw 6 309 1,196 0 0 (–)
Presence of fistula, suppuration Cement 20 1,044 5,633 20 0.41 (0.18–0.93)
.567
Screw 7 327 1,376 2 0.24 (0.04–1.49)
Peri-implant mucositis Cement 18 967 4,040 59 1.71 (0.53–5.57)
.687
Screw 6 309 1,196 2 1.16 (0.14–9.90)
Recession Cement 18 882 3,946 6 0.19 (0.05–0.69)
.704
Screw 7 327 1,376 1 0.12 (0.01–1.55)
Loss of implant Cement 20 1,075 5,565 15 0.27 (0.16–0.47)
.736
Screw 7 355 1,426 3 0.22 (0.07–0.72)
Any esthetic problem Cement 20 1,117 5,500 10 0.19 (0.06–0.58)
.010
Screw 6 309 1,196 14 1.09 (0.30–4.02)
Other Cement 20 1,142 5,960 43 1.22 (0.41–3.65)
.698
Screw 6 309 1,196 14 0.93 (0.28–3.11)
Summary of all complications except Cement 22 1,195 6,280 187 3.40 (1.98–5.82)
.425
“loss of implant” Screw 8 373 1,606 34 4.46 (2.07–9.58)
*Estimated complication rate per 100 years (95% confidence interval).

All Fixed Prostheses. Biologic complications with individual complication reached significance, but there
“all fixed prostheses” are summarized in Table 13. was a tendency toward more implant loss for cemented
There were statistically significantly more overall com- prostheses (P = .074).
plications with cemented prostheses (P < .001). No

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Table 10 Biologic Complications with FPPs

No. of No. of Exposure No. of Complication rate*
Complication Retention studies prostheses time (y) complications (95% CI) P
Bone loss (> 2 mm) Cement 2 25 150 0 0 (–)
> .999
Screw 8 435 2,572 28 1.35 (0.25–7.27)
Peri-implantitis Cement 2 25 150 0 0 (–)
> .999
Screw 8 461 2,759 10 0.42 (0.13–1.34)
Presence of fistula, suppuration Cement 2 25 150 0 0 (–)
> .999
Screw 8 461 2,759 11 0.38 (0.16–0.90)
Peri-implant mucositis Cement 1 16 48 0 0 (–)
.99
Screw 8 435 2,572 59 2.04 (0.83–5.02)
Recession Cement 1 16 48 0 0 (–)
N/A
Screw 7 315 1,372 0 0 (–)
Loss of implant Cement 2 25 150 0 0 (–)
> .999
Screw 10 624 4,174 33 0.76 (0.34–1.70)
Any esthetic problem Cement 2 25 150 0 0 (–)
> .999
Screw 9 581 3,959 9 0.17 (0.04–0.77)
Other Cement 2 25 150 0 0 (–)
> .999
Screw 9 581 3,959 32 0.98 (0.20–4.84)
Summary of all complications except Cement 2 25 150 0 0 (–)
> .999
“loss of implant” Screw 10 624 4,174 149 4.18 (2.11–8.28)
*Estimated complication rate per 100 years (95% confidence interval).

Table 11 Biologic Complications with FAFDPs

No. of No. of Exposure No. of Complication rate*
Complication Retention studies prostheses time (y) complications (95% CI)
Bone loss (> 2 mm) Screw 13 742 6,121 356 3.28 (1.14–9.44)
Peri-implantitis Screw 11 651 5,811 0 0 (–)
Presence of fistula, suppuration Screw 11 651 5,811 23 0.62 (0.06–6.97)
Peri-implant mucositis Screw 12 680 5,935 100 1.61 (0.56–4.62)
Recession Screw 11 651 5,811 0 0 (–)
Loss of implant Screw 13 729 6,045 70 2.21 (0.73–6.71)
Any esthetic problem Screw 11 651 5,811 1 0.03 (0.00–0.51)
Other Screw 12 713 5,997 161 2.94 (1.36–6.33)
Summary of all complications except Screw 14 758 6,169 641 7.61 (4.55–12.72)
“loss of implant”
*Estimated complication rate per 100 years (95% confidence interval).

Outcome of Multivariate Poisson fer significantly from that of porcelain-fused-to-metal

Regression Analysis (PFM) prostheses. The complication rates of gold
Prosthesis Failure and ceramic abutment materials did not differ sig-
The results and incidence rate ratios for this analysis nificantly from that of titanium abutments. Titanium
are presented in Table 14. There was no statistically abutments showed a tendency toward higher compli-
significant difference between the failure rates for ce- cation rates than the “all abutment materials” group
mented and screw-retained prostheses. (P = .051).
Technical Complications. The results are pre- Biologic Complications. The results are presented
sented in Table 15. There was a statistically signifi- in Table 1. There was a statistically significantly greater
cantly greater incidence of technical complications incidence of biologic complications in cemented than
in cemented compared to screw-retained prostheses in screw-retained prostheses (P = .001, IRR 1.73). “All
(P = .01). FAFDPs (P < .001), cFDPs (P < .001), and “all fixed prostheses” had a statistically significantly higher
fixed prostheses” (P = .003) had significantly higher complication rate than SCs (P = .032). Cantilever pros-
complication rates than SCs. The complication rates theses showed a tendency to have a higher complica-
of acrylic resin, ceramic, and “all materials” did not dif- tion rate than SCs (P = .051).

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Millen et al

Table 12 Biologic Complications with cFDPs

No. of No. of Exposure No. of Complication rate*
Complication Retention studies prostheses time (y) complications (95% CI)
Bone loss (> 2 mm) Cement 1 15 169.5 0 0.00
Screw 0 0 – – N/A
Peri-implantitis Cement 1 15 169.5 9 5.31
Screw 0 0 – – N/A
Presence of fistula, suppuration Cement 1 15 169.5 0 0.00
Screw 0 0 – – N/A
Peri-implant mucositis Cement 0 0 – – N/A
Screw 0 0 – – N/A
Recession Cement 0 0 – – N/A
Screw 0 0 – – N/A
Loss of implant Cement 1 15 169.5 2 1.18
Screw 1 23 115.0 1 0.87
Any esthetic problem Cement 1 15 169.5 0 0.00
Screw 0 0 – – N/A
Other Cement 1 15 169.5 0 0.00
Screw 0 0 – – N/A
Summary of all complications except “loss of Cement 1 15 169.5 9 5.31
implant” Screw 1 23 115.0 0 0.00
*Estimated complication rate per 100 years (95% confidence interval).

Table 13 Biologic Complications for “All Fixed Prostheses”

No. of No. of Exposure No. of Complication rate*
Complication Retention studies prostheses time (y) complications (95% CI) P
Bone loss (> 2 mm) Cement 6 629 3,149 5 2.89 (0.52–16.09)
.50
Screw 5 1,128 5,345 85 4.27 (1.11–16.39)
Peri-implantitis Cement 6 629 3,149 22 1.74 (0.38–7.94)
.18
Screw 5 1,128 5,345 38 1.19 (0.28–5.10)
Presence of fistula, suppuration Cement 6 629 3,149 35 1.27 (0.04–44.33)
> .999
Screw 5 1,128 5,345 0 0 (–)
Peri-implant mucositis Cement 6 629 3,149 1 0.06 (0.01–0.72)
.27
Screw 4 1,072 5,177 6 0.21 (0.04–1.18)
Recession Cement 6 629 3,149 0 0 (–)
N/A
Screw 4 1,072 5,177 0 0 (–)
Loss of implant Cement 6 629 3,149 40 2.29 (0.90–5.79)
.07
Screw 6 1,235 5,666 76 1.54 (0.65–3.63)
Any esthetic problem Cement 6 629 3,149 7 0.30 (0.02–4.77)
> .999
Screw 4 1,072 5,177 0 0 (–)
Other Cement 6 629 3,149 2 0.10 (0.01–1.07)
.99
Screw 5 1,128 5,345 0 0 (–)
Summary of all complications except Cement 6 629 3,149 72 12.89 (3.45–48.16)
< .001
“loss of implant” Screw 6 1,235 5,666 129 5.47 (1.53–19.59)
*Estimated complication rate per 100 years (95% confidence interval).

DISCUSSION influence the choice of retention. It is plausible to restore

a single edentulous gap with an implant-supported SC,
Restoring partially edentulous patients with the use of but to rehabilitate an extended edentulous gap, the use
dental implants has been reported as a successful treat- of several implants might be considered, depending on
ment approach, with high success and survival rates for the planned prosthetic outcome. In this situation, a fixed
both implants and implant-supported prostheses.83,84 prosthesis may consist of solely implant-supported FPP,
Many factors, including the clinician’s preference, a cFDP, an FAFDP, or several implant-supported SCs.

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 Millen et al

Table 14 Multivariate Analysis of Table 15 Multivariate Analysis of

Failure Technical Complications
Estimated Estimated
IRR 95% CI P IRR 95% CI P
Retention Retention
Cement vs screw 0.92 0.50–1.69 .794 Cement vs screw 1.36 1.08–1.72 .010
Type of prosthesis Type of prosthesis
FPD+cantilever vs SC 1.91 0.86–4.27 .113 FPP vs SC 1.58 0.88–2.84 .127
FAFDP vs SC 1.63 0.49–5.39 .424 FAFDP vs SC 9.80 3.64–26.38 < .001
All fixed prostheses vs SC 0.41 0.14–1.17 .096 cFDP vs SC 4.97 2.42–10.24 < .001
Prosthesis material
All fixed prostheses vs SC 2.42 1.09–5.37 .030
Acrylic vs PFM 0.60 0.16–2.29 .457
Prosthesis material
Ceramic vs PFM 1.34 0.38–4.74 .654
Acrylic vs PFM 0.99 0.36–2.67 .978
All materials vs PFM 3.45 1.44–8.26 .005
Ceramic vs PFM 2.28 0.82–6.30 .114
Abutment material
All materials vs PFM 1.38 0.68–2.79 .368
Gold vs titanium 2.24 0.71–7.05 .167
Abutment material
Ceramic vs titanium 1.58 0.43–5.83 .491
Gold vs titanium 0.98 0.42–2.30 .966
All abutment materials 0.58 0.19–1.78 .341
Ceramic vs titanium 0.60 0.24–1.51 .277
vs titanium
All abutment materials 0.44 0.19–1.01 .051
vs titanium

The purpose of this investigation was to identify Table 16 Multivariate Analysis of Biologic
the influence of fixed prosthesis and retention type on Complications
technical and biologic complication rates. The Europe-
an Association of Osseointegration (EAO) and the Inter- Estimated
IRR 95% CI P
national Team for Implantology (ITI) recently published
Retention
consensus statements and clinical recommendations
Cement vs screw 1.73 1.25–2.39 .001
regarding the question of whether screw or cement re- Type of prosthesis
tention is preferred for fixed prostheses.85,86 These two FPP vs SC 1.46 0.51–4.18 .486
sets of statements and recommendations complement FAFDP vs SC 2.31 0.59–9.06 .231
one another and indicate a preference for screw reten- cFDP vs SC 7.42 0.99–55.53 .051
tion based on retrievability and a higher frequency of All fixed prostheses vs SC 3.36 1.04–10.90 .043
biologic complications with cemented prostheses. Prosthesis material
The complication rates of each prosthesis type in the Acrylic vs PFM 1.43 0.35–5.80 .614
current review revealed a variety of different outcomes. Ceramic vs PFM 0.37 0.09–1.49 .162
There was a tendency toward more technical complica- All materials vs PFM 1.21 0.52–2.82 .664
tions with screw-retained SCs, without statistical signif- Abutment material
icance. More specifically, there were significantly more Gold vs titanium 0.95 0.31–2.87 .926
instances of abutment loosening with screw-retained Ceramic vs titanium 0.46 0.14–1.52 .205
crowns, which was in accordance with the results of the All abutment materials 0.43 0.16–1.19 .103
systematic review of Sailer et al.1 More framework frac- vs titanium
tures occurred with cemented SCs; however, this could
not be compared to Sailer et al, as data on framework
fracture were not presented in their published article.
No statistically significant differences were identified Regarding FPPs, there were statistically significantly
for biologic complications relative to retention type for more technical complications in the screw-retained
single implant–supported crowns, whereas in the pre- group. However, testing of individual complications
vious review from Sailer et al,1 more soft tissue com- failed to demonstrate any statistically significant dif-
plications were documented with screw-retained SCs. ferences. These findings are in contrast to the outcome
This difference may have resulted because of esthetic on FPPs in the review of Sailer et al,1 in which a trend
complications that, while not considered by Sailer et al, toward fewer technical complications with screw re-
contributed to the overall biologic complications in the tention was observed. This contrast is difficult to ex-
current review. Esthetic complications may be of par- plain, but it is of note that the current review includes
ticular importance to patients.87 more articles on the technical complications of FPPs.

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Millen et al

No statistically significant differences could be iden- Multivariate analysis takes into consideration the
tified for biologic complications with FPPs regarding effects of all the included variables on the outcome of
retention type. Whereas this review analyzed more interest, which included prosthesis failure and techni-
articles than Sailer et al, the number of studies includ- cal and biologic complications in the current review.
ing cemented prostheses was still limited. The result Parameters felt to exert an influence on these outcomes
regarding both technical and biologic complications that were regularly reported included retention type,
should therefore be interpreted with caution. prosthesis type, prosthesis material, and abutment
FDPs with a full-arch design showed high chipping material. This type of analysis has not been previously
rates with both resin and ceramic materials. High chip- carried out on data regarding this subject. The analysis
ping rates have been previously reported in clinical of failure confirms the result of previous studies stating
studies on implant prostheses.83 A possible explana- that there was no difference in failure rates between
tion for these high chipping rates may be the absence screw and cement retention or abutment material.1,2,92
of a periodontal ligament (PDL) around implants in Technical complications showed a slightly higher risk of
comparison to natural teeth. The PDL around teeth can occurrence in cemented prostheses, with a reasonably
serve as a shock absorber, transferring occlusal stresses narrow confidence interval. This finding is in agreement
along the axis of the tooth and thus distributing them with that of Wittneben et al.2 There was also a signifi-
evenly. The absence of the PDL allows concentration cantly higher risk of technical complications in FAFDPs
of the occlusal load at the crest of the surrounding and cFDPs in comparison to SCs—almost 10 times
bone and is further complicated by the relative lack greater for FAFDPs. This significantly higher risk demon-
of proprioception, meaning that tactile sensitivity is strates the predictability of SCs as well as highlighting
diminished with implants.88–90 Hyperocclusion will not a need for more evidence on other types of prostheses.
be felt by the patient, which may result in a chipping Surprisingly, there was little difference between pros-
event. This is especially critical if the fixed prostheses thesis materials and only a tendency toward more com-
are supported solely by implants in a full-arch design. plications with ceramic prostheses compared to PFM
The reported biologic complications presented higher prostheses (P = .114). This finding is in contrast with
event rates with FAFDPs compared to other prosthesis what one might expect, considering that a higher rate
designs; however, only studies of screw-retained pros- of ceramic fracture and chipping is seen with all-ceramic
theses were available for data extraction. prostheses compared to prostheses made with other
Cantilever extensions are frequently used with im- materials.93,94 The values presented in the current review
plant prostheses but should be handled with caution.83 are related to the overall number of complications, not
The results regarding cFDPs show that more evidence solely ceramic chipping, which suggests that all ceramic
is needed in this field; only three studies concerning restorations experience as many technical complica-
cFDPs met the inclusion criteria. A systematic review tions as PFM prostheses. Thus, the prosthesis and reten-
concerned solely with implant-supported cFDPs found tion types are of greater importance than the prosthesis
only five studies that met its inclusion criteria.91 The material in determining the overall number of complica-
findings presented by Aglietta et al91 were consistent tions. This finding has not been previously presented, to
with those in the current study. Screw loosening and the authors’ knowledge. Other authors have stated that
veneer fracture represent the most common techni- the incidence of complications for PFM FDPs is less than
cal complications among screw-retained prostheses, that of all-ceramic FDPs94,95; however, the methods used
whereas the most commonly reported biologic com- in those studies did not include a multivariate analysis,
plication is peri-implantitis with cemented prostheses. and the summative incidence of all complications was
Studies in which the identification of the type of not calculated. The summative incidence of all compli-
fixed implant-supported prosthesis was not avail- cations related to a prosthesis can be considered impor-
able in the included publications were grouped as “all tant, as it alludes to how often a prosthesis may require
fixed prostheses.” They were included in the analyses service and thus how cost-effective it may be.96
because of their high numbers in these studies (756 Abutment material demonstrated no statistically
cemented and 1,307 screw-retained). Overall, there significant differences in terms of technical complica-
were statistically significantly higher technical and tions between different materials. This finding is con-
biologic complication rates with cemented prosthe- sistent with the findings of other authors.92,97
ses than with screw-retained ones. The events “loss of Biologic complications appeared to be a greater
retention” and “loosening of abutment” occurred sig- factor in cemented than in screw-retained restora-
nificantly more frequently with cemented prostheses. tions. This is consistent with the findings of many au-
These results are in accordance with the findings of a thors, who have found and stated that cement rests
previous systematic review2 that also pooled recon- represent a significant risk for peri-implant disease if
struction types. not handled appropriately.98–101

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 Millen et al

The findings of these analyses should be interpret- CONCLUSIONS

ed with caution, as the number of studies available for
each element of the analysis varied as a result of poor According to simple Poisson regression analysis:
reporting of complications in the literature. Hetero-
geneity of the included studies is to be expected in a • Screw-retained fixed dental prostheses (FDPs) dem-
review of this kind but should be kept in mind when onstrated a significantly higher rate of technical
extrapolating conclusions from these results. Compli- complications than cemented FDPs.
cation event rates were assumed to be constant for the • Screw-retained full-arch FDPs demonstrated a nota-
current analyses. This assumption would pose statisti- bly high rate of veneer chipping.
cal problems should it prove untrue. However, there is • “All fixed prostheses” demonstrated a significantly
no evidence in the literature to the contrary, and many higher rate of biologic complications with cement
well-known systematic reviews have adopted a simi- retention than with screw retention.
lar approach.1,94,102–105 Therefore, the assumption of
constant event rates was considered justified. Further- According to multivariate Poisson regression analysis:
more, random-effects Poisson regression was used to
limit the possibility of overdispersion while maintain- • No significant difference was seen between screw-
ing comparability to the previously mentioned sys- and cement-retained prostheses with respect to the
tematic reviews of a similar nature. incidence of failure.
The PICO question used during the literature search • A higher incidence rate of technical and biologic
was designed for the previous review and did not complications was seen with cement-retained
entirely encompass the purposes of this review. As a prostheses.
result, this review included an “all fixed prostheses” • The incidence rate of technical complications was
group, which originated from those studies that failed dependent more upon prosthesis and retention
to report on or analyze different types of prostheses. type than prosthesis or abutment material.
Although it may seem desirable to remove this group
from the multivariate analysis, this would represent
data discrimination and result in the exclusion of ACKNOWLEDGMENTS
methodologically sound but incompletely reported
studies that were considered important for the assess- The authors reported no conflicts of interest related to this study.
ment of retention type. It is therefore recommended
that future researchers endeavor to report not only
clinical and technical methods accurately but also any REFERENCES
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