Michael Korsch Cement-associated peri-implantitis:

Ursula Obst
Winfried Walther
a retrospective clinical observational
study of fixed implant-supported
restorations using a methacrylate
cement

Authors’ affiliations: Key words: cement-retained dentures, excess cement, implants, peri-implantitis
Michael Korsch, Winfried Walther, Dental
Academy for Continuing Professional
Development, Karlsruhe, Germany Abstract
Ursula Obst, Institute of Functional Interfaces, Background: Cement-retained fixed implant-supported restorations involve the risk of excess
Karlsruhe Institute of Technology (KIT), Karlsruhe,
cement, which can associate peri-implantitis. In connection with routine therapy using a
Germany
methacrylate cement (Premier Implant Cement, Premierâ Dental Products Company, Plymouth
Corresponding author: Meeting, PA, USA) to retain fixed implant-supported restorations, complications, that is,
Michael Korsch
Dental Academy for Continuing Professional
inflammations, were developed in some cases. After removing the suprastructure and the
Development abutment, residual excessive cement was found. For this reason, all implant-supported restorations
Sophienstrasse 39 a, 76133 Karlsruhe, Germany that had been fixed with this type of methacrylate cement were reevaluated and retreated.
Tel.: 0049/7219181200
Fax: 0049/7219181222 Methods: In a retrospective clinical observational study including 71 patients with 126 implants,
e-mail: michael-korsch@za-karlsruhe.de the findings made during retreatment were documented. In all cases, the suprastructure and the
abutment were removed. For recementation, Temp Bond (Kerr Sybron Dental Specialities,
Washington, D.C., USA) was used. If an inflammation had developed, a follow-up appointment was
scheduled 3–4 weeks later.
Results: In 59.5% of the implants, cement residues were identified. Bleeding on probing was
diagnosed at 80% of the implants with excess cement and suppuration at 21.3% of the implants.
After removal of the excess cement and recementation with Temp Bond, a 76.9% reduction in
bleeding on probing was found at follow-up. Suppuration was not found around any of the
implants at follow-up.
Conclusion: Excess cement left in the implant–mucosal interface caused bleeding on probing in most
cases and suppuration in some. The removal of excess cement after cementation should be given
high priority. In this retrospective observational study, an unusually high number of implants with
excess cement after cementation was found with the methacrylate cement applied in the study.

Compared with cement-retained restorations,
screw-retained restorations on implants pro-
vide a better marginal fit (Keith et al. 1999;
Guichet et al. 2000) and, in addition, are eas-
ier to remove. A disadvantage is the risk of
screw loosening (Michalakis et al. 2003), lim-
ited esthetics (sometimes severely) and less
primary retention (Lee et al. 2010). Moreover,
screw-retained restorations are more compli-
cated to fabricate in the dental laboratory and
therefore may be more costly (Lee et al.
Date: 2010). In view of these disadvantages, many
Accepted 17 March 2013 dentists consider cement-retained implant-
To cite this article: supported restorations the better option,
Korsch M, Obst U, Walther W. Cement-associated peri- especially in the esthetically relevant zone
implantitis: a retrospective clinical observational study of
fixed implant-supported restorations using a methacrylate (Michalakis et al. 2003). This type of dental
cement.
restoration offers the chance of creating ante-
Clin. Oral Impl. Res. 25, 2014, 797–802
doi: 10.1111/clr.12173 rior crowns with a natural looking marginal
contour and avoiding the perforation of the
occlusal ceramic surface. According to clini-
cal studies, cement-retained restorations have
a lower bleeding index and less peri-implant
bone loss (Nissan et al. 2011). Their draw-
back, however, is the wider marginal gap
between the abutment and the restoration,
which favors bacterial colonization (Quirynen
& van Steenberghe 1993). Besides, compared
to screw-retained restorations, cemented res-
torations are more difficult to remove after
cementation (Michalakis et al. 2003).
Another very significant risk when insert-
ing cement-retained restorations is the excess
cement that might be left in the peri-implant
soft tissue (Pauletto et al. 1999). Several
authors have dealt with this complication
(Gapski et al. 2008; Callan & Cobb 2009;

© 2013 John Wiley & Sons A/S. Published by Blackwell Publishing Ltd 797
Korsch et al
Cement-associated peri-implantitis
Wilson 2009). Wilson found a correlation of
81% between excess cement left in the soft
tissue and the occurrence of sulcular bleeding
and/or suppuration (Wilson 2009). Therefore,
this risk should be carefully borne in mind,
and the danger caused by excess cement
should be minimized as much as possible. A
biofilm may form on the cement left in the
peri-implant tissue (Busscher et al. 2010). For
this reason, excess cement should be com-
pletely removed immediately after inserting
the restoration to avoid iatrogenic peri-im-
plantitis with bone loss (Shapoff & Lahey
2012).
There are still very few clinical studies
dealing with this problem, which indicates
that it may possibly be underestimated.
Some contributions suggest a clinical
protocol for the cementation process (Dum-
brigue et al. 2002; Schwedhelm et al. 2003;
Wadhwani & Pineyro 2009; Santosa et al.
2010). Mostly, the hazards of excess cement
left in the mouth are only mentioned in a
cursory way.
In the Dental Academy for Continuing Pro-
fessional Development, Karlsruhe, Germany,
a temporary 2-component methacrylate
cement (Premier Implant Cement, Premierâ
Dental Products Company, Plymouth Meet-
ing, PA, USA) was used for the insertion of
fixed restorations on implants from April
2009 until February 2010. According to the
manufacturer, the option of easy atraumatic
removal of the restoration in case corrections
has to be made on the abutment or fixture is
one of the favorable characteristics of the
material. This cement is particularly recom-
mended for implants. In some of the cases
cemented with it, the patients presented after
a period of one to several month(s) and com-
plained about bleeding at the site of the
implant-supported restoration. Upon exami-
nation, the dentist found bleeding on probing
and suppuration from the peri-implant tissue.
For an analysis of the cause of the problem,
the fixed restorations including the abut-
ments were removed from the implants. In
all such cases, cement was found below the
abutments in the area of the implant collar
(Figs 1–3). When the excess cement was
removed, the patients’ condition improved
considerably within a few days or weeks.
Bleeding on probing and suppuration stopped.
As a consequence of these observations, the
Karlsruhe Dental Academy for Continuing
Professional Development has completely
discontinued using this methacrylate cement
from March 2010. To safely exclude any
cement-induced complications, all patients
treated in the period from April 2009 to
798 | Clin. Oral Impl. Res. 25, 2014 / 797–802
Fig. 1. Single crown after removal with excess cement
at the crown margin.
Fig. 2. Abutment after removal of the crown: excess
cement in the peri-implant tissue is clearly visible.
Fig. 3. Abutment unscrewed: circumferential excess
cement which could neither be removed by instrumen-
tation nor without abutment revision treatment.
February 2010 with a fixed implant-supported
restoration cemented with the Premier
Implant Cement were reevaluated. In all
cases, the fixed implant-supported restora-
tions including the abutments were taken
out and any excess cement was removed.
Then, the implant-supported restorations
were recemented with Temp Bond. During
this procedure and at the follow-up appoint-
ments, bleeding on probing and suppuration
were documented.
This study wants to contribute to making
the clinical step of cementation safer by
describing the clinical implications after
cementation with a methacrylate cement.
© 2013 John Wiley & Sons A/S. Published by Blackwell Publishing Ltd
Table 1. Material composition of Premier
Implant Cement
Premier
Implant
Cement
Base Methacrylate monomers
paste 2-hydroxyethylmethacrylate
Triethylenglycoldimethacrylate
Aliphatic urethane diacrylate
resilient oligomer
Pigments
Stabilizers
Catalyst Methacrylate monomers
paste Benzoyl peroxide
Triethylenglycoldimethacrylate
Aliphatic urethane diacrylate
resilient oligomer
Pigments
Stabilizers
Material and methods
In the period from April 2009 to February
2010, 105 patients were treated with fixed,
implant-supported cement-retained restora-
tions in the outpatient department of the
Karlsruhe Dental Academy for Continuing
Professional Development. In this process,
198 crowns were placed on implants. The
position of the abutment shoulder was placed
orally epigingival and mesially, distally and
vestibulary subgingival, not deeper than
1.5 mm. In all cases, a methacrylate cement
was used for fixing the suprastructures to the
implants. The methacrylate cement used was
a temporary 2-component cement consisting
of a catalyst and a base material (Table 1).
The cement was applied as recommended by
the manufacturer. The protocol for the
cementation of implant-supported crowns in
the Karlsruhe Dental Academy for Contin-
uing Professional Development was standard-
ized and applied by every clinician. The
crowns were not filled completely with
cement. Instead, the internal surfaces of the
crowns were wetted with cement using a
brush. After cementation of the suprastruc-
ture, any excess cement possibly left in the
tissue was removed. Supragingivally, it was
removed with a dental probe and dental floss.
Excess cement left subgingivally was
removed with a plastic curette.
When suppuration was observed in the
peri-implant tissue, the patients affected
were thoroughly examined by the dentist. In
all cases, cement was found between peri-
implant tissue and abutment at the site of
the implant collar.
As a result, from April 2010, all patients
who had been treated with an implant-
supported restoration cemented as described

above in the period mentioned were asked to
present for an examination and revision of
the suprastructure. The cases were clinically
documented in the period from April 2010 to
November 2010. Later revisions of supra-
structures were not included in the study,
this is why a total of only 71 of the 105 cases
treated were documented.
The patients were informed about the rea-
sons for the retreatment and documentation.
At the time of the revision therapy for
recementation, Temp Bond (Temp Bond, Kerr
Sybron Dental Specialities, Glendora, CA,
USA) was used, which was applied before the
input of Premier Implant Cementâ. The rea-
son for the reintroduction was that there
were no known inflammations in our clinic
after cementation by use of Temp Bond.
Study population
In the period from April 2010 to November
2010, 126 implants were examined in 71
patients. Sixty-nine implants had been placed
in female and 57 in male patients. The
implant-supported restorations consisted of
single crowns and multiple-unit bridges. The
patients’ age was between 32 and 81 years,
and the mean age was 60.7 years.
At the time of implant insertion, three dif-
ferent systems were used by the clinicians
(Astra OsseoSpeedTM, Astra Tech Dental,
M€ olndal, Sweden; CAMLOGâ SCREW-LINE
Promoteâ plus, ALTATEC GmbH, Wims-
heim, Germany, and SKY classic, bredent
medical GmbH & Co.KG, Senden, Germany).
In all, 53 Astra, 52 Camlog and 21 SKY
implants were examined. The fixed cement-
retained restorations had been placed by 9
prosthodontists working at the Karlsruhe
Dental Academy for Continuing Professional
Development. Each prosthodontist examined
and retreated the implant-supported restora-
tions he/she had inserted himself/herself
(Table 2).
Table 2. Documentation at the time of revision therapy: the table shows all implants without and
with excess cement for each prosthodontist
Implants without
Prosthodontist excess cement
1 4
2 4
3 3
4 22
5 0
6 12
7 4
8 1
9 1
Total number 51
of implants
© 2013 John Wiley & Sons A/S. Published by Blackwell Publishing Ltd
Korsch et al
Cement-associated peri-implantitis
Documentation and revision – clinical crowns per prosthodontist. The restorations
procedure
were in the anterior and posterior part of the
1. Before removal of the suprastructure, the
mouth. The time interval between cementa-
peri-implant tissue around each implant
tion of the crown and reevaluation was
was probed at six different sites. The
between 116 and 640 days with a mean per-
presence or absence of bleeding upon
iod of 261 days.
probing and pocket suppuration were doc-
At follow-up after 3–4 weeks, 73 of the 126
umented.
implants were reevaluated.
2. Then, the suprastructure and the abut-
ment were removed.
Findings on the day of crown revision therapy
3. After removal, the presence or absence of For 69 (54.8%) of the 126 implant-supported
cement in the peri-implant tissue was crowns, bleeding on probing was documented
documented. before revision treatment of the suprastruc-
4. Any residual cement was removed from ture (Fig. 4). Suppuration was diagnosed
the crown and abutment, and the
around 16 of the 126 implants (12.7%)
peri-implant tissue was rinsed with (Fig. 5). In the retreatment of the implant-
chlorhexidine 0.12% (GUMâ PAROEXâ supported crowns and abutments, cement
non-alcohol rinse 0.12%, Sunstar Suisse was found between abutment and peri-
S.A., Etoy, Switzerland). In the hollow implant tissue at 75 implants (59.5%) (Fig. 6).
spaces of the implants, chlorhexidine gel The implant systems were involved to vary-
0.2% was placed. Finally, the abutments ing degrees. In 28 of the 53 Astra implants
were reinserted, and the suprastructure (52.8%), excess cement was found. The Cam-
was recemented with Temp Bond. log system was involved in 35 of the 52 cases
5. If bleeding on probing or pocket suppura- (67.3%) (Fig. 7), and 12 of the 21 SKY
tion had been found, a follow-up exami- implants (57.1%) were found to have residual
nation was scheduled 3–4 weeks later. cement. The patients of all nine clinicians
6. To check the result of this clinical were affected (Table 2).
procedure, the patients were asked to
present for a follow-up examination to
see whether the retreatment had been
successful. At follow-up, bleeding on
probing and pocket suppuration were
again examined at six sites per implant
and documented. The time interval
between retreatment and follow-up was
3–4 weeks.
Results
In all, 126 implants were examined in 71
patients. The number of implants per patient
varied between 1 and 5. Table 2 lists the Fig. 4. The graph shows the distribution of all implants
number of implants/implant-supported with and without bleeding on probing in percentages.
Total number of
Implants with implants per
excess cement prosthodontist
8 12
9 13
6 9
17 39
2 2
20 32
10 14
2 3
1 2
75 126
Fig. 5. The graph shows the distribution of all implants
with and without suppuration in percentages.
799 | Clin. Oral Impl. Res. 25, 2014 / 797–802
Korsch et al
Cement-associated peri-implantitis
Fig. 6. The graph shows the distribution of all implants
with and without excess cement in percentages.
Fig. 7. Comparison of the three implant systems Astra,
Camlog and SKY: the graph shows the implants with-
out and with excess cement.
Findings on the day of follow-up, 3–4 weeks
after revision therapy
At follow-up, 73 of the 126 implants were
reevaluated. Only nine implants (12.3%)
demonstrated bleeding on probing. Suppura-
tion could not be detected at any of the
implants.
Correlation between bleeding on probing and
the presence of excess cement
Altogether, bleeding on probing was diag-
nosed at 69 of the 126 implants, and at 75
implants, cement was found. Forty-two
implants (33.3%) did not demonstrate any
bleeding nor was cement found (Fig. 8). At
nine implants (7.1%), bleeding was found,
but no cement. At 15 implants (11.9%), no
bleeding was found although excess cement
was present. Sixty implants (47.7%) demon-
strated both bleeding and cement. This
means that in 80% of the cases in which
excess cement was present, also bleeding on
probing could be diagnosed.
Correlation between suppuration and excess
cement
At 59 implants (44.4%), excess cement was
found, but no suppuration (Fig. 9). Suppura-
tion was diagnosed at 16 implants (12.7%),
800 | Clin. Oral Impl. Res. 25, 2014 / 797–802
Fig. 8. Correlation between bleeding on probing and excess cement during revision therapy.
Fig. 9. Correlation between excess cement and suppuration during revision therapy.
and in each of these cases, excess cement checked. None of the implants previously
was also present. Thus, suppuration only affected and no other implant showed suppu-
occurred in the presence of excess cement. ration.
Consequently, 21.3% of the implants with
excess cement were affected by suppuration.
Discussion
Findings at follow-up
One disadvantage of cement-retained
At follow-up, 73 of the 126 implants were
implant-supported restorations is the risk of
reevaluated. At 34 of them (46.6%), neither
excess cement left in the mouth after the
bleeding nor excess cement was found at
incorporation of the suprastructure. There are
crown revision. At follow-up, no bleeding
very few publications dealing with this sub-
was found at these implants either. Thirty-
ject (Pauletto et al. 1999; Tomson et al. 2004;
nine of the 73 implants (53.4%) demonstrated
Gapski et al. 2008; Callan & Cobb 2009; Wil-
bleeding on probing and cement residues at
son 2009; Shapoff & Lahey 2012). Many of
the time of crown retreatment. Only 9 of the
them are case reports (Pauletto et al. 1999;
73 implants (12.3%) demonstrated bleeding
Tomson et al. 2004; Gapski et al. 2008; Shap-
at follow-up. This equals a 76.9% reduction
off & Lahey 2012). Therefore, this problem
in bleeding.
presents itself as a rare event in the litera-
Before the revision therapy of the implant-
ture, but has serious consequences.
supported crowns, suppuration was docu-
The basis for the present study was the
mented in 16 of the 126 cases. At follow-up,
observation that after cementation with a
6 of the 16 implants with suppuration were
© 2013 John Wiley & Sons A/S. Published by Blackwell Publishing Ltd

methacrylate-based cement, clinical compli-
cations developed that were associated with
excess cement. A controlled study for the
evaluation of the corresponding clinical phe-
nomena has to be ruled out. The participat-
ing dentists were surprised by the fact that
from their own personal point of view, they
had proceeded with utmost care in removing
the residual cement and yet had not achieved
an adequate clinical result in more than 50%
of the cases. As the problem occurred in the
patients of all clinicians participating in the
study, it is unlikely that individual variations
in the technique applied played any major
role. Instead, the question arises whether the
mechanical removal of excess cement can
actually be achieved by means of conven-
tional instruments. The excess cement could
only be reliably identified and removed when
the abutment was unscrewed, which means
that the inspection of the cementation
required its destruction – this can be declared
as a clinical paradox.
Also, when a temporary cementation is
replaced by a permanent one, the abutments
are usually not removed so that excess
cement as described here cannot be detected.
The handling recommendations described in
the literature for the purpose of avoiding
excess cement were followed to the greatest
possible extent in the clinical protocol of the
outpatient department of the Karlsruhe Acad-
emy. It is recommended, for instance, to mini-
mize the risk of excess cement by reducing
the amount of cement used. Several tech-
niques are described in the literature in this
connection (Dumbrigue et al. 2002; Wolfart
et al. 2006; Wadhwani & Pineyro 2009). More-
over, deep subgingival restorations should be
avoided because they would make it difficult
to remove possible cement residues (Agar
et al. 1997; Linkevicius et al. 2011). These rec-
ommendations were taken into consideration
as much as possible in the treatment of the
patients described here. Clinical studies on
natural teeth showed that supragingival crown
margins are positive according to gingival
health compared with subgingival position
(Orkin et al. 1987; Kosyfaki et al. 2010).
A follow-up radiograph after cementation
and removal of excess cement is one option
for a better diagnosis of cement residues left
in the mouth. However, cements differ in ra-
diopacity. The methacrylate cement used in
this study had no radiopacity at the time
when it was applied (Wadhwani et al. 2010),
so that a follow-up radiograph would not have
produced any result. In addition, the question
arises for the usefulness of cement radiopaci-
ty as a criterion for the presence or absence of
© 2013 John Wiley & Sons A/S. Published by Blackwell Publishing Ltd
excess cement, as excess cement can only be
made visible in the interproximal part of the
cement gap. In the facial/buccal or lingual
part, the shadow of the implant makes a reli-
able diagnosis impossible. Moreover, as
described above, the complete destruction of
the cementation was the only effective mea-
sure for the removal of cement residues.
Whether the subsequent recementation was
free of defects cannot be determined.
In the present study, 59.5% of the implants
revealed cement residues in the peri-implant
tissue at revision of the suprastructure
including the abutment. At follow-up
appointments, Wilson found excess cement
at 34 inspected implants in a period of
5 years (Wilson 2009). He did not give any
details as to the total cohort so that nothing
can be said about the incidence of this com-
plication expressed in percentages.
According to Nissan et al., cement-retained
implant-supported restorations have a signifi-
cantly lower bleeding index and less peri-
implant bone loss than screw-retained
implant-supported restorations (Nissan et al.
2011). However, excess cement left in the
mouth can cause a higher bleeding index or
even suppuration. In the present study, 80% of
the implants demonstrated bleeding on
probing, if cement residues were left in the tis-
sue. Wilson (Wilson 2009) arrived at the same
result, he mentions an incidence of 81%.
76.9% of the tissue around implants that
had demonstrated bleeding at revision did
not bleed any more at the follow-up appoint-
ment 3–4 weeks later. Wilson stated that in
75.7% of the cases, inflamed areas initially
diagnosed were no longer found 4 weeks after
cement removal (Wilson 2009).
Even without reference to a validated com-
parative figure, the number of crowns with
excess cement and bleeding on probing identi-
fied in the present study appears to be very
high. It justifies without any doubt the outpa-
tient department’s policy of asking all patients
to present for a revision of the cementation.
The numbers stated here also illustrate how
difficult it is to follow up a defined patient
cohort completely. Despite the invitation, not
all patients had presented at the outpatient
department 7 months later. This shows that
as far as possible, clinical systems without
any inherent risks should be used.
To check the result of the revision treat-
ment, follow-up appointments were sched-
uled, which, however, could only be
implemented for 57.9% of the retreated resto-
rations. This is why the results have to be
evaluated with caution. Yet, they show that
bleeding on probing could be markedly
Korsch et al
Cement-associated peri-implantitis
reduced. Suppuration did no longer occur at
all in the group that was retreated. With
regard to minimizing the clinical risks by the
selection of dental materials, the outpatient
department of the Dental Academy is con-
vinced that its decision to stop using the
methacrylate luting cement discussed in this
study was justified.
In the authors’ opinion, the methacrylate-
based cement discussed here has a very low
viscosity. This property of the material seems
to be the reason for the high number of
implants with excess cement.
Besides the mechanical causes of the com-
plications described, the biological ones must
also be taken into account. There are indica-
tions that methacrylate-based materials favor
the formation of a biofilm (Busscher et al.
2010). Acrylate-containing dental restorations
are considered to be susceptible to the coloni-
zation by both, bacteria (Verran & Motteram
1987) and candida (Ramage et al. 2004).
Whereas bacteria can be found within just a
few hours on exposed acrylate surfaces, yeast
cannot be detected before a few days have
passed (Avon et al. 2007). C. albicans in the
oral cavity can often be found in mixed bio-
films together with bacteria (Holmes et al.
1995). Moreover, various strains of bacteria
could be identified in the biofilms of acrylate-
containing dental restorations. They include
Streptococcus, Veillonella, Lactobacillus,
Prevotella, and Actinomyces spp. (Koopmans
et al. 1988). This shows that additional stud-
ies dealing with the biological characteristics
of this type of cement may be required.
After the complications by use of that
methacrylate-based cement, Temp Bond was
reintroduced, which was applied before the
input of this cement. The reason therefore
was that there were no documented and
known inflammations by use of Temp Bond
in our clinic. There could be two factors for
this advantage. At first that the viscosity of
Temp Bond is higher than that of Premier
Implant Cementâ. Low-viscosity cements are
assumed to spread more easily in the peri-
implant sulcus than high-viscosity materials,
although the clinical proof of this assump-
tion has yet to be furnished. This may result
in more leftover excess cement. At second,
we may consider the material composition.
Temp Bond contains eugenol, which manners
antibacterial (Boeckh et al. 2002; Queiroz
et al. 2009). Further advantages of Temp
Bond were that dentures could be removed
easily and the high gray level value radio-
graphically. At that time, Premier Implant
Cementâ had no radiopacity (Wadhwani
et al. 2012).
801 | Clin. Oral Impl. Res. 25, 2014 / 797–802
Korsch et al
Cement-associated peri-implantitis
The surface of the methacrylate cement in
the peri-implant tissue is rougher than the
abutment and crown surfaces, and this may
also support the formation of a biofilm (Bus-
scher et al. 2010). Biofilm on metallic sur-
faces has a low vitality (less than 8%)
(Auschill et al. 2002). In comparison, oral
biofilm on enamel surfaces has a very high
vitality of 41–56% (van der Mei et al. 2006).
Usually implants are colonized by the trans-
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fer of biofilm from adjacent teeth (Aoki et al.
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Summary
In more than 50% of the cases, residues of the
methacrylate cement used in this study could
not be removed without retreatment of the
crown including the abutment. Excess cement
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