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W
ith the high rate of im-
plant success for edentu- ses, which has long been discussed, but the
lous, partially edentulous, best type of implant prosthesis remains
and single tooth restora- controversial among practitioners.
tions, the concept of im- There are few publications that compre-
plant therapy is now a highly predictable hensively compare the 2 types of retention.
treatment modality. The aim of this review of the literature was to
Implant dentistry has seen rapid and provide an overview of the advantages and
remarkable progress in recent years. Several disadvantages of the cement- and screw-
questions have been raised concerning retained restorations, and also to suggest
some clinical situations that advocate for
materials as well as designs of both implants
one method of retention over the other.
and implant abutments to achieve maximum
The factors that are affected by different
clinical success rates.
methods of retention of the prostheses to
the implants are: ease of fabrication and cost,
Department of Prosthodontics, Arab American Univer-
sity, Jenin, Palestinian Territory. esthetics, access, occlusion, retention, incidence
* Corresponding author, e-mail: rola_shadeed@yahoo.
com
of loss of retention, retrievability, passivity of
DOI: 10.1563/AAID-JOI-D-10-00146 fit, restriction of implant position, effect on
taper depending on the concept of ideal misfit, differences in screw material and
tapering proposed by Jorgensen for natural design, and finally hex height and implant
teeth.14 diameter will affect the amount of retention
Regarding surface area and height, the of screw-retained restorations.1,22–33
subgingival placement of the implants pro- To achieve sufficient clamping force the
vides longer implant abutment walls and screws should be torqued 50% to 75% of
usually more surface area than prepared their yield strength, so it is imperative that all
natural teeth.1,15 The minimum abutment screws be tightened to manufacturers’ spec-
height to use cement-retained restorations ifications using a torque control wrench in
with predictable retention was documented the initial phase of screw tightening.1,22
to be 5 mm.15 Therefore, when the interoc- Screw settling or embedment relaxation
clusal space is as little as 4 mm, screw- will occur shortly after screw tightening due
retained restorations may be used,6 since to compressing the microscopically rough
these restorations can be attached directly to areas of the screw threads and opposing
implants without intermediate abutment.18 flanges during screw tightening23; therefore,
Increased surface roughness will offer retorquing the screw 5 minutes after initial
increased mechanical retention for ce- torquing and again a few weeks later is
ments,17 and so roughening the implant recommended.26
abutments using diamond burs or grit During function and biomechanical over-
blasting will provide higher retention.1 How- load, both compressive and tensile forces
ever, because of the ideal 6u taper and long will cause screw loosening. The compressive
surface provided by implant abutments, forces will cause disengagement of mating
there will usually be no need for roughening threads when applied in amount equal to or
abutment surface to increase retention.1 greater than the preload, the tensile forces
Cement selection is one of the most may cause plastic deformation of the screw,
important factors controlling the amount of thereby decreasing the clamping forces that
retention attained for cement-retained res- hold the components together.23,24
torations.17 The cement used with implant Off-axis centric forces are detrimental to
restorations can be either permanent or screw-retained restorations. Therefore, ex-
provisional, and it is the clinician’s decision cessive implant angles, cantilever prosthesis,
to choose a certain type of cement based on and connecting implant to natural teeth
the clinical situation.1,19–21 The concept of using fixed partial dentures should be
using provisional cementation is considered evaluated and eliminated whenever possible
to achieve restoration retrievability without to prevent screw loosening.22
endangering the implant restoration com- Screw loosening is also affected by implant
ponents when loose restoration or abutment component and prosthesis misfit. Poor fit
screw loosening occurs.17 between implant and components could
With regard to screw-retained restora- increase stress in the screw leading to screw
tions, retention is obtained by a fastening loosening.25–27 The same is applied to non-
screw. The loss of retention in screw-retained passive prosthesis that will apply additional
restorations is demonstrating itself as screw load to the system leading to bending
loosening.22 Factors including insufficient moments constantly loading the implant
clamping force, screw settling, biomechanical components and surrounding bone tissue.28,29
overload, off-axis centric forces (forces that To prevent screw loosening, various
are not directed along the long axis of the modifications to the screw and implant were
implant), implant components and prosthesis reported.26,30–33 It was found that gold
screws can be tightened more effectively restorations will enable assessing the preload
than titanium ones and therefore will pro- of implant abutment screws over time,
vide better retention.31 since the preload is not constant with on-
The screw design will affect screw reten- going application of forces associated with
tion, so it has been shown that screw heads occlusion.
with internal hexagon remain tighter than
those with slots.32 Tapered head screws have
RETRIEVABILITY
been abandoned because the head/shaft
load ratio was found to be 4:1 as opposed to The main advantage of screw-retained resto-
flat head screws using a 1:1 head/shaft ratio, rations is the predictable retrievability that
and this will lead to strained interfaces when can be achieved without damaging the
using tapered screws that will increase the restoration or fixture.1,4 Therefore, the prosth-
susceptibility of screw loosening.27 odontic components can be adjusted, the
In addition, increasing the screw diame- screws can be refastened, and the fractured
ter will increase the preload and therefore components can be repaired44 with less time
the retention of screw-retained restorations. and at lower cost than would be the case with
Also, enhancing the implant design by cement-retained restorations.2,45,46
increasing hex height and diameter of Several suggestions and techniques have
implant platform can increase stability and been introduced to facilitate the removal of
resistance to screw loosening.26,33 cement-retained restorations.
One of the techniques described is the
incorporation of screw into the cemented
INCIDENCE OF LOSS OF RETENTION
restoration to be used later to lift the res-
The screw loosening is a major problem with toration off the abutment if activated. Com-
screw-retained restorations.34–37 The inci- pared with conventional screw retention, this
dence of screw loosening was 65% for single technique improves esthetics and occlusion
tooth implant restorations in one study,34 since the access hole can be placed in
whereas the incidence of unretained ce- the most ideal position without regard to
mented implant restorations was reported to implant position.47 Another method pro-
be less than 5% in other studies.38,39 posed is to prepare a cylindrical guide hole
However, the improvements in implant on the lingual surface of the abutment
systems, including the advent of internal and an access hole in the lingual side of
implant-abutment connections, enhance- the restoration. Then, by inserting a remov-
ment of torque drivers, and screw materials ing driver into the guide hole through the
and design, led to reduction in the incidence access hole and turning it to generate a
of screw loosening.4,35,36,40,41 shear force, the cement will disintegrate
On the other hand, the screw loosening of and, in turn, the restoration can be easily
screw-retained restorations can be considered removed.48
as an important advantage since the weakest Other techniques that have been sug-
component within the implant-supported gested depend mainly on locating the screw
restoration will be the prosthetic screw; this access opening of the abutment screw in
will allow for assessing the implant-supported cement-retained restoration, in turn, to allow
restoration before more serious complications access to the abutment screw with least
develop, such as implant fracture at screw damage in the future. These techniques are
level especially in implant systems using in- achieved by using abutment screw access
ternal connections.42,43 Using screw-retained guide or placement of a well-defined small
However, the use of cement-retained resto- surface on the abutment analogue extra-
rations allows for greater freedom in implant orally before the restoration is cemented
placement.6 intraorally can be used to reduce the excess
As the manufacturers have not provided cement.68
angled abutments of less than 17u for screw Creating a lingual vent hole in the
retention until now, malaligned implants with implant-supported crowns is another tech-
divergence axis less than 17u have to be nique to reduce the amount of excess
restored with cement-retained restorations.10,67 cement being lodged in the sulcus.74
In general with good treatment planning The gingival response is found to be
and precision surgery using surgical guides, the better when using screw-retained crowns
implant can be placed at its ideal position.6 since no cement is used. However, if pros-
thetic retaining screws and abutment screws
become loose, granulation tissue accumu-
EFFECT ON THE HEALTH OF PERI-IMPLANT TISSUE
lates between the prosthesis and the abut-
Some authors reported gingival inflamma- ment and also between implant and abut-
tion when using cement-retained prosthesis ment leading to fistulae formation, plaque
because of difficulty in removing excess deposition, and screw fracture. Therefore, it is
cement, especially when the restoration recommended to retighten the screws in full
margin is greater than 3 mm subgingivally. arch fixed prosthesis every 5 years.32
This is particularly common in the anterior
region when it is recommended to place the
PROVISIONALIZATION
implant 3 to 4 mm apical to the cemento-
enamel junction or the facial gingival margin Provisional restorations are frequently used
of adjacent teeth to develop proper emer- for immediate or early implant loading to
gence profile.68 achieve better esthetics and to mold soft
It has been shown that incomplete tissue for proper emergence profile for
removal of cement may result in peri-implant definitive restorations.75
inflammation, soft tissue swelling, soreness, Using screw-retained provisional restoration
bleeding or exudation on probing, and is preferred over cement-retained restoration
resorption of peri-implant bone.10,68–70 The because the screw can be used to seat the
solution for these clinical situations is using provisional restoration and to expand peri-
either screw-retained restorations or custom implant mucosa.6,76 Also, screw-retained provi-
abutments for cement restoration with mar- sional restoration can be screwed into the
gin following the anterior gingival contours.68 master impression to translate additional infor-
One of the techniques proposed for mation to the technician about the contours.6
removal of excess cement is using plastic The major disadvantage of cement-
scalers, but even this may result in scratches retained provisional restoration is the difficul-
on the implant surfaces which may encour- ty associated with removing excess cement
age plaque accumulation and compromised and managing bleeding at the same time.
soft tissue health.71–73 Moreover, cement residues may cause gingi-
Reducing the amount of cement placed val inflammation.6
in the restoration before cementation can be
achieved by placing a luting agent only on
IMMEDIATE LOADING
the occlusal half of the intaglio of the
restoration. In addition, seating the restora- Screw-retained restoration is considered the
tion after placing the cement on the fitting restoration of choice for immediate loading;
TABLE
Summarization of the situations that prefer screw retention
and those that prefer cement retention
Situations That Prefer Screw Retention Situations That Prefer Cement Retention
Large, full-arch implant reconstructions are Single-unit and short-span implant restorations, assuming
preferred to be screw-retained, because that implant table size, implant numbers, and abutment
complications in these long-span screw torque can be optimized, are preferred to be
prostheses are more common than those cement-retained.10 The only reason for using screw
of short-span ones.10 retention in such cases would be if the implant’s long axis
Cantilevered prostheses are preferred to be was too palatal in the anterior region.10
screw-retained, because some maintenance Cases involving narrow diameter crowns in which the
of restorative structures or implants would screw access may compromise the crown’s integrity are
probably be needed during the lifetime of preferred to be cement-retained.82
such prostheses.10,53 Situations in which the occlusal surface will be
With patients who are at a high risk of compromised with regard to esthetics or occlusal stability
developing gingival recession, screw- due to the presence of a restorative material sealing the
retained restorations are preferred. This is screw access are preferred to be cement-retained.82
to allow for their uncomplicated removal In situations of restoring malaligned implants, if the
and then for the modification of the divergence of the implant axis and the retaining screw of the
restorations according to the new angled abutment which is to receive the restoration is less
situation.82 than 17u, conventional screw retention of the restoration
With patients who are expected to lose more using premachined abutments is not possible.10,67
teeth in the future, screw-retained
restorations are preferred. This is to allow
for easy removal of the restorations, thereby
modifying the restorations.
In situations where minimal interocclusal space
exists, it may not be possible to achieve
adequate retention for cement-retained
restorations because these restorations
require a vertical component of at least 5 mm
to provide retention and resistance form.15
However, as little as 4 mm of interocclusal
space is sufficient to use screw-retained
restorations.6 Additionally, screw-retained
restorations can be attached directly to
implants without an intermediate abutment,
therapy reducing the interocclusal space
needed for these restorations.18
In situations in which removal of excess
cement is difficult or impossible (eg, if the
final restorative margin will be greater than
3 mm subgingivally, the use of screw-
retained restoration is indicated).10,68 An
alternative to screw-retained restoration in
this situation would be to fabricate a
custom abutment for cement retention
with a restorative margin following the
outline of the gingival contours.68
Cases in which technical or biologic
complications are anticipated, screw-
retained restorations are preferred to allow
for easy removal of the restorations, thereby
managing the problems.
this is because using this restoration elimi- components is superior to any cement
nates the need for cement and the associated margin that can be developed.60
difficulty in removing excess from the peri- In addition, screw retention provides the
implant area that may interfere with healing most definitive and rigid splinting when
and implant integration.71 In addition it has multiple implants are used and therefore
been shown that the interface of machined enhances implant primary stability.6
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