Screw vs cement retained implant prosthesis

Implant success
rates highly
predictable
Implant borne
crowns exhibited
high success rates –
95%
Clinical success
depends not only on
survival rates but
also the amount of
technical and
biological
complicationsDebates to improve
clinical success -
materials and
techniques
One of the debates
deals with the ideal
fixation method
between implant and
the prosthesis

Periodontology 2000, Vol. 73, 2017, 141–151
Presented by :
Apurva Thampi

Aboutthe
article
•Screw retained vs cement retained
implant supported prosthesisTitle
•Julia-Gabrielle Wittenben, tim
joda, Hans-Peter WebberAuthors
•Narrative review
Type of
study
•2017Year
•Periodontology 2000Journal

Purposeofthe
study
To present an overview of factors
influencing the overall outcome of screw
vs cement retention for implant
supported fixed partial dentures

Introduction
 Implants are well established treatment option -
standard of care
 Success/failure – dependent on osseointegration
 Refined surgical techniques – better prognosis
 Life long prophylactic measures

Introduction
 10 yr survival rate of
 Implants – 98.8%
 Implant prosthesis – 95.5%
 WHY??
Buser D, Janner SF, Wittneben JG, Brägger U, Ramseier CA, Salvi GE. 10‐Year Survival and Success Rates of 511 Titanium Implants with a
Sandblasted and Acid‐Etched Surface: A Retrospective Study in 303 Partially Edentulous Patients. Clinical implant dentistry and related research.
2012 Dec 1;14(6):839-51.

Wittneben JG, Millen C, Brägger U. Clinical Performance of Screw-Versus Cement-Retained Fixed Implant-Supported Reconstructions-A
Systematic Review. International journal of oral & maxillofacial implants. 2014 Jan 2;29.
Accordingtoanotherstudy whichconducted5yrsurvivalratesof
Screwretainedprosthesis–95.55%
Cementretainedprosthesis–96.03%
“Thetotalrateoftechnicalandbiologicalcomplicationswashigherincemented
prostheses”

Choiceofretentiontypemightnot
haveacrucialinfluenceonthe
overallprosthesisbutmay
increasechancesofcomplications
Cement retained or screw retained?

Cement
retained
prosthesis
Factorsaffecting
amountofretention
Taper or parallelism
Surface area or height
Surface finish or
roughness
Type of cement
Hebel KS, Gajjar RC. Cement-retained versus screw-retained implant restorations: achieving optimal occlusion and esthetics in implant dentistry.
The Journal of prosthetic dentistry. 1997 Jan 31;77(1):28-35.

Taper
• Taper is
inversely
proportiona
l to
retention
•JØRGENSEN K. The relation
between retention and angle of
convergence in cemented veneer
crowns. Tandlaegebladet. 1955
Feb;59(2):94-8.
• Machined
abutments
have exact
6֯ taper
Surface area
•Increase in
surface area
and height
increases
retention
•Machined
implants are
placed 2-3mm
lower than
the gingival
crest
Surface finish
•Rough axial
walls provide
increased
mechanical
retention
•Machined
posts provide
superior
retention
Roughness
•Definitive
cements –
strong and
lasting
•Provisional –
short term
use
•Provisional
cement for
long term –
control
retrievability

Whendowe
choosecement
retention?
Adequate inter-ridge space
Areas where esthetics are
of concern
Implant is not placed in the
prosthetically ideal location

Screwretained
prosthesis
Screw retention was validated
by the Branemark system
Screws used to attach
prosthesis to implant and
abutment to implant
Different screws have different
properties, size, design and
metallurgic composition

Screwretained
prosthesis
Long span – screw
retained – easier
maintainance
Initially used only
for full arch
prostheses
UCLA Gold
custom abutment
– 1988 – retention
of prosthesis
directly on or
inside the implant
4 times cost of the
components than
cement retained

Mechanicsof
screwretention  Screws tightened upto 50% to 75% of yield strength –
clamping force
 Torque applied – tensile force – clamping force
 Accurate fit – vertical loading – does not stress the
screw

Mechanicsof
screwretention
 Inaccurate casting – vertical loading not over the
implant head
 Offset loading – overcomes the clamping force of the
screw – stretches/breaks/loosens

Whendowe
choosescrew
retention??
Limited inter ridge space (minimum
4mm)
Chee W, Jivraj S. Screw versus cemented implant supported restorations. British
dental journal. 2006 Oct 21;201(8):501-7.
Implant is placed in
in the prosthetically
ideal position

“Choice of retention type may NOT have a crucial role in the
overall survival of the prosthesis but may be responsible for the
development of certain complications.”

Typesof
cementation
PROVISIONAL CEMENTATION
 Allows retrievablility
 Risk of leakage and loss of retention is higher
DEFINITIVE CEMENTATION
 Very difficult to retrieve
 May result in the loss of the prosthesis in case of
failure

Factorstobe
considered during
decision making
Retrievability
Esthetics and provisionalisation
Clinical performance
Occlusion
Retention
Implant placement
Passivity

Retrievability
New high strength
ceramics – less
risk of fracture or
chipping BUT
difficult to
separate if needed
Removal becomes
time consuming
and uncomfortable
FPD will most
likely be destroyed
in separation
Wittneben JG, Joda T, Weber HP, Brägger U. Screw retained vs. cement retained implant‐supported fixed dental prosthesis.
Periodontology 2000. 2017 Feb 1;73(1):141-51.
KEY ARTICLE

Chee W, Jivraj S. Screw versus cemented implant supported restorations. British dental journal. 2006 Oct 21;201(8):501-7.

Retrievablity
CEMENT RETAINED PROSTHESIS
Abutment screw loosening – FPD needs
to be destroyed to be retrieved
Retrievable provisional (ideal inter-arch
space)– no marginal seal
SCREW RETAINED PROSTHESIS
Predictable retrievability
Implant should be placed in the exact location
Sealed with polyfluoroethylene tape
Can be removed during maintenance
Wittneben JG, Joda T, Weber HP, Brägger U. Screw retained vs. cement retained implant‐supported fixed dental prosthesis. Periodontology 2000.
2017 Feb 1;73(1):141-51.

Retrievabillity
 The process of removal of excess cement – tedious
 Residual cement – predisposing factor for peri-
implantitis
 More common where the implants were placed 2-3mm
submucosally
Wilson TG Jr. The positive relationship betweenexcess cement and peri-implant
disease: a prospective clinical endoscopic study. J Periodontol 2009: 80: 1388–1392
2017 Feb 1;73(1):141-51.

Provisionalisation
and esthetics
 Mimics the esthetic details of previous tooth
 Facilitate soft tissue conditioning – facilitate mucosal
conditioning
 Individualize the position of future definitive crowns
2017 Feb 1;73(1):141-51.
Requirements of provisionalisation
• Supported directly on the implant
• Crown margins should be accessible
• Residual cement avoided

Provisionalisation
andesthetics
 Submucosal crown margin should be in an accessible
position – complete removable of margins becomes
unpredictable
 Subginigval margins – difficult to access  complete
removal not predictable
 Deeper the margins, more amount of undetected cement
Cement retained prosthesis
Linkevicius T, Puisys A, Vindasiute E, Linkeviciene L, Apse P. Does residual cement around implant‐supported restorations cause peri‐implant
disease? A retrospective case analysis. Clinical oral implants research. 2013 Nov 1;24(11):1179-84.
2017 Feb 1;73(1):141-51.

Review 2013 by Linkevicius et al
Clinical oral implantology research
77 patients with 129 implants
Linkevicius T, Puisys A, Vindasiute E, Linkeviciene L, Apse P. Does residual cement around implant‐supported restorations cause peri‐implant
disease? A retrospective case analysis. Clinical oral implants research. 2013 Nov 1;24(11):1179-84.
Conclusion : Cement remnants should be considered
as an additional pre-disposing factor in development
of chronic peri implantitis
During cementation, cement does not escape due to
lack of attachment to the implant.
Instead it gets pushed further down  acute
reaction of peri implant tissues

Provisionalisation
andesthetics
 Ideal mode of retention for anteriors
 Easy retrievability
Screw retained prosthesis

Clinical
performance
Gages survival of
implant
prosthesis
Presence of
technical and
biological
complications
Choice of
retention may
affect the
frequency of
complications

Systematic Review 2015 by Millen et al
Int J Oral Maxillofac Implants
Electronic searches of MEDLINE,
EMBASE and Cochrane library
Type Multivariate Poissons
regression Outcome
Prosthesis failure No statistically significant
difference in failure rates
Technical
considerations
Statistically significant
greater incidence of
complications in cemented
compared to screw retained
Biological
complications
Statistically significant
greater complications in
cemented to screw retained
Type Simple Poissons regression
Outcome
Prosthesis
failure
No statistically significant
difference in failure rates
Technical
considerations
Screw retained
demonstrated a higher
rate of complications
Biological
complications
Cement retained
demonstrated a higher
rate of complications
Millen C, Brägger U, Wittneben JG. Influence of prosthesis type and retention mechanism on complications with fixed implant-supported
prostheses: a systematic review applying multivariate analyses. International journal of oral & maxillofacial implants. 2015 Jan 1;30(1).
The incidence rate of complications
is dependent more on prosthesis
and retention type than prosthesis
or abutment material

Systematic Review 2012 by Sailer et al
Clin Oral Implants Res
Type of prosthesis Type of
retentio
n
5 yr
survival
rate
Single crown Cement 97.7%
Screw 98.6%
Partial fixed dental
prosthesis
Cement 97.6%
Screw 98.7%
Full arch prosthesis Cement 94.2%
Screw 98.2%
Type of prosthesis Type of
retentio
n
5 yr
survival
rate
Single crown Cement 96.5%
Screw 89.3%
Partial fixed dental
prosthesis
Cement 96.9%
Screw 98%
Full arch prosthesis Cement 100%
Screw 95.8%
Sailer I, Mühlemann S, Zwahlen M, Hämmerle CH, Schneider D. Cemented and screw‐retained implant reconstructions: a systematic review of the
survival and complication rates. Clinical oral implants research. 2012 Oct 1;23(s6):163-201.
Technical complication
• Screw : loosening of screw and
ceramic chipping  minor clinical
significance
• Cement : De-cementation
Biological complication
• Screw : soft tissue inflammation
screw loosening
• Cement : bone loss of >2mm
Conclusion : None of the fixation method is clearly advantageous over the other

Systematic Review 2007 by Weber et al
Int J Oral and Maxillofac Implants
74 articles  7 were studies that evaluated
cemented and screw retained prosthesis
• Abutment type
• Retention type
• Support type
• Restorative material
Does the
method of
retention
influence the
outcome??
Conclusion:
• Screw and cement retained
prosthesis both performed well 
implant success or survival
• Prosthetic success for cement
retained was better (93%) when
compared to screw retained (83%)
Weber H, Sukotjo C. Does the type of implant prosthesis affect outcomes in the partially edentulous patient?. International Journal of Oral and
Maxillofacial Implants. 2007 Jan 1;22:140.

Systematic Review 2014 by Wittneben et al
Int J Oral and Maxillofac Implants
73 articles qualified for the study
CONCLUSION
• 5 year survival rate of screw retained prosthesis is similar to that of cement retained prosthesis
• Total event rate of complications was more in cement retained prosthesis when compared
to screw retained prosthesis

Shadid R, Sadaqa N. A comparison between screw-and cement-retained implant prostheses. A literature review. Journal of Oral Implantology. 2012
Jun;38(3):298-307.
Occlusion
CEMENT RETAINED
 Ideal and stable occlusal contacts
 No occlusal screw access holes
SCREW RETAINED
 Obliterates occlusal anatomy
 Screw access hole - <50% of occlusal table
 Interfere with protrusive and excursive movements
 Affects the direction of occlusal loads

Retention
CEMENT RETAINED
De
cementation
Taper,
surface area,
and height,
surface
roughness,
cement
Adequate
interocclusal
space 
adequate
retention
SCREW RETAINED
Screw
loosening
Insufficient
clamping force,
biomechanical
overload, off-
axial forces,
components
misfit
Inadequate
inter occlusal
space (<4mm)
Jun;38(3):298-307.

Implant
placement
CEMENT RETAINED
Greater freedom
of implant
placement
SCREW RETAINED
Trajectories of
the implant is
limited
Cannot be used
on malaligned
implants
Jun;38(3):298-307.

Passivity
CEMENT RETAINED
 More passive due to cement space
 One of the advantages of cement retained prosthesis
SCREW RETAINED
 Less strain to bone implant interface
 Difficult to achieve
 Electric discharge machining

Summary
Situations that prefer
screw retention
Situations that prefer
cement retention
Large, full arch
reconstructions 
complications are more
common
Single, short span
Cantilevered prosthesis 
may require maintenance
Narrow diameter crowns
screw access may
compromise crown’s
integrity
Pts at high risk of gingival
recession may be
required
Occlusal surface may be
compromised due to
restorative material sealing
the access

summary
Situations that require
screw retention
Situations that require
cement retention
Periodontally
compromised expected to
lose more teeth
Restoring malaligned
implants
Minimal occlusal space
exists (<4mm)
Situations in which
removal of excess cement is
difficult
Cases in which biologic
complications are
anticipated

Conclusion
 There is no clear evidence that one type of retention is
better than the other, nevertheless, some authors
suggest the use of screw retained prosthesis over
cement retained prosthesis
 The type prosthesis retention does not dictate the
overall survival of the implant, but may be a
predisposing factor for certain technical and biological
complications
Proper handling of cement retained prosthesis
provides adequate retrievability

Bibliography
 Buser D, Janner SF, Wittneben JG, Brägger U,
Ramseier CA, Salvi GE. 10‐Year Survival and Success
Rates of 511 Titanium Implants with a Sandblasted
and Acid‐Etched Surface: A Retrospective Study in 303
Partially Edentulous Patients. Clinical implant
dentistry and related research. 2012 Dec 1;14(6):839-
51.
 Wittneben JG, Millen C, Brägger U. Clinical
Performance of Screw-Versus Cement-Retained Fixed
Implant-Supported Reconstructions-A Systematic
Review. International journal of oral & maxillofacial
implants. 2014 Jan 2;29.
 Hebel KS, Gajjar RC. Cement-retained versus screw-
retained implant restorations: achieving optimal
occlusion and esthetics in implant dentistry. The
Journal of prosthetic dentistry. 1997 Jan 31;77(1):28-
35.

Bibliography
 Chee W, Jivraj S. Screw versus cemented implant
supported restorations. British dental journal. 2006
Oct 21;201(8):501-7.
 Wittneben JG, Millen C, Brägger U. Clinical
Performance of Screw-Versus Cement-Retained Fixed
Implant-Supported Reconstructions-A Systematic
Review. International journal of oral & maxillofacial
implants. 2014 Jan 2;29.
 Wittneben JG, Joda T, Weber HP, Brägger U. Screw
retained vs. cement retained implant‐supported fixed
dental prosthesis. Periodontology 2000. 2017 Feb
1;73(1):141-51. (KEY ARTICLE)

Bibliography
 Linkevicius T, Puisys A, Vindasiute E, Linkeviciene L,
Apse P. Does residual cement around
implant‐supported restorations cause peri‐implant
disease? A retrospective case analysis. Clinical oral
implants research. 2013 Nov 1;24(11):1179-84.
 Millen C, Brägger U, Wittneben JG. Influence of
prosthesis type and retention mechanism on
complications with fixed implant-supported prostheses:
a systematic review applying multivariate analyses.
International journal of oral & maxillofacial implants.
2015 Jan 1;30(1).
 Sailer I, Mühlemann S, Zwahlen M, Hämmerle CH,
Schneider D. Cemented and screw‐retained implant
reconstructions: a systematic review of the survival
and complication rates. Clinical oral implants research.
2012 Oct 1;23(s6):163-201.

Bibliography
 Weber H, Sukotjo C. Does the type of implant
prosthesis affect outcomes in the partially edentulous
patient?. International Journal of Oral and
Maxillofacial Implants. 2007 Jan 1;22:140.

Thank You
And
Have A Pleasant Day!

Screw vs cement retained implant prosthesis

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