International Journal of
Environmental Research
and Public Health
Article
A Novel Technique Using Polytetrafluoroethylene Tape to Solve
Screw Loosening Complication in Implant-Supported
Single Crowns
Luis F. Félix 1, * , Michell Medina 1 , Cristina Gómez-Polo 2 , Rubén Agustín-Panadero 3 , Rocío Ortega 4
and Miguel Gómez-Polo 5






Citation: Félix, L.F.; Medina, M.;
Gómez-Polo, C.; Agustín-Panadero,
R.; Ortega, R.; Gómez-Polo, M. A
Novel Technique Using
Polytetrafluoroethylene Tape to Solve
Screw Loosening Complication in
Implant-Supported Single Crowns.
Int. J. Environ. Res. Public Health 2021,
18, 125. https://dx.doi.org/10.3390/
ijerph18010125
Received: 8 November 2020
Accepted: 22 December 2020
Published: 27 December 2020
Publisher’s Note: MDPI stays neu-
tral with regard to jurisdictional claims
in published maps and institutional
affiliations.
Copyright: © 2020 by the authors. Li-
censee MDPI, Basel, Switzerland. This
article is an open access article distributed
under the terms and conditions of the
Creative Commons Attribution (CC BY)
license (https://creativecommons.org/
licenses/by/4.0/).
Int. J. Environ. Res. Public Health 2021, 18, 125. https://dx.doi.org/10.3390/ijerph18010125
1 Department of Prosthodontics and Restorative Dentistry, School of Dentistry,
Complutense University of Madrid, 28040 Madrid, Spain; michellmd89@gmail.com
2 Department of Surgery, Faculty of Medicine, University of Salamanca, 37007 Salamanca, Spain;
crisgodent@hotmail.com
3 Department of Stomatology, Faculty of Medicine and Dentistry, University of Valencia, 46010 Valencia, Spain;
rubenagustinpanadero@gmail.com
4 Department of Prosthetic Dentistry, School of Dentistry, European University of Madrid, 28045 Madrid, Spain;
rocio.ortega@universidadeuropea.es
5 Department of Prosthetic Dentistry, Faculty of Dentistry, Complutense University of Madrid,
28040 Madrid, Spain; miguelodont@hotmail.com
* Correspondence: l.felix8952@gmail.com
Abstract: This study aimed to analyze a novel technique to make screws with greater untightening
resistance and to solve screw loosening in implant-supported single crowns. Thirty grade IV titanium
straight abutments were screwed onto 30 external hex implants using grade IV titanium screws
(30 Ncm). They were exposed to cyclic loading (300,000 cycles, 200 N). Samples were divided into
4 groups (15 samples per group): new screws (SCREW group) (control), reused screws (rSCREW
group), new screws wrapped with polytetrafluoroethylene (PTFE) tape (PTFE group), and reused
screws wrapped with PTFE tape (rPTFE group). Reverse torque values (RTVs) were recorded
with a digitally calibrated implant motor. Mean RTVs observed were 14.46 N (±1.10 N) for the
control group, 14.42 N (±1.22 N) for the rSCREW group, 19.97 N (±1.16 N) for the PTFE group,
and 19.13 N (±2.38 N) for the rPTFE group. Statistically significant differences were found between
RTVs of both groups employing screws without PTFE tape (SCREW and rSCREW groups) compared
with those using screws wrapped with PTFE tape (PTFE and rPTFE) (p < 0.001). These results
suggest that wrapping the implant–abutment screw with PTFE tape may effectively lower the risk of
loosening and even constitute a solution when this complication occurs in implant single crowns.
Keywords: screw loosening; implant single crowns; fixed dental prosthesis; polytetrafluorethylene;
mechanical complications
1. Introduction
Implant-supported fixed dental prostheses (FDPs) are the alternative of choice to
replace lost teeth, from a single crown to a complete arch [1–5].
Over time, dental implants have undergone considerable progress and change in
design to reduce the number and severity of the associated biological and mechanical
complications [6]. Nevertheless, screw loosening (SL) has been reported as one of the most
common mechanical complications [7–9], with incidence ranging from 5% to 43% after
the first year after placement [10–13]; these values denote wide variability in the clinical
findings reported in articles on the subject. Such differences may be attributable to the
broad spectrum of factors involved, which, among others, include the type of connection,
type of prosthesis (single crown, partial or full-arch FDP), force magnitude and angle,
and parafunctional habits. Complications with implant prostheses can cause physical,
https://www.mdpi.com/journal/ijerph
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social, and psychological issues for the patient, leading to additional time and cost. Patients’
perception of the prosthetic outcome can affect their satisfaction with their dental treatment,
their oral-health-related quality of life (OHRQoL), and ultimately, their general health [14].
SL has been described as a two-stage development [15], beginning with the onset of
external loads that reduce screw preload, inducing vibration and micromovements. When
preload subsequently drops below a critical value, the external forces and vibrations cause
the implant–abutment screw to turn or recede, inducing SL. These micromovements may
ultimately lead to biological complications due to the ingress of microorganisms that can
destroy the bone surrounding the implant [16].
A number of studies have been conducted to determine the factors affecting SL,
comparing implant connections, applying lateral loads, or varying the abutment angle or
tightening conditions [17–19]. The conclusion drawn from the findings is that all may have
an impact and that the etiology is therefore multifactorial. The approaches proposed to
lower the frequency of SL may be divided into three groups. First, related to prosthetic
design, includes centering occlusal contact, narrowing the buccolingual width of the crown,
or shortening the cantilever. Second, involves tightening techniques, such as ensuring the
right torque when tightening screws, the use of straight abutments, or screw retightening
during placement. Third, screw design, which entails manufacturing screws from different
materials or coating them with a material not used in their composition, such as steel
or gold [20–26]. None of those methods seems to wholly prevent the appearance of this
complication, however, because, given the multifactorial nature of the cause, a single
solution for all circumstances would appear to be elusive [27].
In light of the foregoing and given the significance of SL in the long-term success of
implant-supported FDP, more research is needed to find alternatives not only to reduce the
incidence of screw loosening but also to correct it when it arises. One of the techniques
addressed in earlier studies is to sheathe the screw in a material such as gold that would
raise the reverse torque value. That approach has proven to be only partially effective,
however, and very costly [18]. To date, no material has been described that would be
applicable by both the manufacturer in new screw design and clinicians when patients
present with loose prostheses.
One of the materials that might be used to that end, given its biocompatibility,
resistance to chemical agents, water repellence, ready adaptability, and durability, is
polytetrafluorethylene (PTFE) tape, used in dentistry for other purposes [28–30].
Previous studies carried out have revealed that the use of lubricants like saliva could
reduce friction and consequently increase the preload [31–33].
To the authors’ knowledge, no comparative data are available regarding the effect
of wrapping abutment screws in PTFE tape to lower the risk of screw loosening in
single-crown implants. This in vitro study explored wrapping screws in PTFE as a possible
approach to manufacturing screws with greater untightening resistance and solving SL-
associated clinical problems. The efficacy of the method was measured in terms of the
removal torque value (RTV) in abutments screwed to external hexagon connection implants.
External hexagon implants were intentionally chosen, as their design is where screws have
greater influence on SL [34]. The null hypothesis was that differences would be observed
between the RTVs for the control and experimental groups in the SL.

2. Materials and Methods

Thirty prefabricated milled titanium (grade IV) abutments (straight abutment Osseous
STD; TiCare® , Valladolid, Spain) were fixed onto 30 implants (Osseous STD 3.75 × 11.5 mm;
TiCare® , Valladolid, Spain) with a 4.1 mm platform diameter and external hexagonal
connection (2.7 × 0.7 mm) implants. Thirty original screws (grade IV titanium) (pros-
thetic screws; TiCare® , Valladolid, Spain) were employed for all the implant–abutment
specimens (Figure 1). The abutment screws had a hexagonal socket head. Samples were
divided into 4 groups: SCREW group (control group; n = 15) (new screws), rSCREW
group (reused screws without PTFE tape; n = 15), PTFE group (new screws wrapped with
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divided
divided into
into 44 groups:
groups: SCREW
SCREW group group (control
(control group;
group; n n == 15)
15) (new
(new screws),
screws), rSCREW
rSCREW group group
(reused
(reused screws without PTFE tape; n = ®15), PTFE group (new screws wrapped with
screws without PTFE tape; n = 15), PTFE group (new screws wrapped with poly-
poly-
polytetrafluorethylene
tetrafluorethylene
tetrafluorethylene tape tapetape (MIARCO
(MIARCO
(MIARCO
®, COD
®, COD , COD
269, 269,
269, 12
12 mm
mm 12 ××mm
12
12 m× ××120.1
m 0.1 × 0.1Valencia,
m mm,
mm, mm, Valencia,
Valencia, Spain)
Spain)
Spain)
(PTFE);(PTFE);
(PTFE); n
n == 15),
15),n and
=
and15),rPTFE
and rPTFE
rPTFE groupgroup
group (reused
(reused(reused
screws
screwsscrews
wrapped
wrappedwrapped
with with
with PTFE
PTFE PTFE
tape;tape;
tape; n n = 15).
n == 15).
15). The
The
The abutments were tightened using an implant motor (iChiroPro ® ; BienAir, Bienne,
abutments
abutments were were tightened
tightened usingusing anan implant
implant motor
motor (iChiroPro
(iChiroPro®;; BienAir,
®
BienAir, Bienne,
Bienne, Switzer-
Switzer-
Switzerland)
land) connected to a tablet computer (iPad; Apple Inc, California, CA, USA).
land) connected
connected to to aa tablet
tablet computer
computer (iPad;
(iPad; Apple
Apple Inc,Inc, California,
California, CA,CA, USA).
USA). This
This motor
motor
This
was motor
managed was managed
with an with
application an application
(iChiroPro (iChiroPro
APP v2.2; APP
Bien v2.2;
Air, Bien
Bienne, Air, Bienne,
Switzerland)
was managed with an application (iChiroPro APP v2.2; Bien Air, Bienne, Switzerland)
Switzerland)
where wherepreviously
torque was previously set. Theallscrewsgroups
of all the groups were tightened
where torque
torque was was previously set. set. The
The screws
screws of of all the
the groups werewere tightened
tightened clockwise
clockwise
clockwise
to toofa 30
torque of 30 Ncmto pursuant to manufacturer’s instructions. This device was
to a torque of 30 Ncm pursuant to manufacturer’s instructions. This device was
a torque Ncm pursuant manufacturer’s instructions. This device was previously
previously
previously
validated validated employing an Instronmachine
testing machine (Instron Corp, Norwood, model Mass,
validated employing
employing an an Instron
Instron testing
testing machine (Instron(Instron Corp,
Corp, Norwood,
Norwood, Mass, Mass, model
model
4204, 4204, Barcelona, Spain) by a specialized engineer in order to ensure its reliability.
4204, Barcelona,
Barcelona, Spain)
Spain) by by aa specialized
specialized engineer
engineer in in order
order toto ensure
ensure itsits reliability.
reliability.

Figure
Figure1.1.
Figure Original
1.Original grade
Originalgrade IV
gradeIV titanium
IVtitanium prosthetic
titaniumprosthetic screw.
prostheticscrew.
screw.

Four
Four different
Fourdifferent techniques
differenttechniques
techniques were
were employed
employed
were employed for
for the the
the screw
forscrew tightening.
tightening.
screw For theFor
tightening. the
the control
control
For group
control
group
group (SCREW group), all the steps were carried out following the manufacturer’s in-
(SCREW (SCREW
group), group),
all the all
steps the steps
were were
carried carried
out out
following following
the the manufacturer’s
manufacturer’s instructions. in-
structions.
New screwsNew
structions. were
New screws
used were
screws with used
were with
no PTFE
used no
withandno PTFE
in a dry
PTFE and in
in aa dry
dry environment.
andenvironment. For
For the
the exper-
For the experimental
environment. exper-
imental
PTFE
imental PTFE
group,
PTFEPTFEgroup,
group, PTFE
tape
PTFE(12 tape
mm (12
tape wide,
(12 mm
mm wide,
100 µm 100
wide, 100 μm
thick) μmwas thick) was
wound
thick) wound
was around
wound the around
screws
around the
the
screws
three three
times, times,
and the and
PTFEthe PTFE
tail at tail
the at the
bottom bottom
of the of
screwthe screw
was
screws three times, and the PTFE tail at the bottom of the screw was subsequently cut was subsequently
subsequently cut away cut
away
away (Figure
(Figure 2). The2).
(Figure The
screw
2). Thewas screw
screw was
was tightened
tightened using a using
tightened 1.25 aa 1.25
1.25 hexagonal
usinghexagonal point
point connected
point connected
hexagonal to
to an
to an implant
connected an
motor (iChiroPro ® ; BienAir, Bienne, Switzerland) and was programmed at a low speed
implant motor (iChiroPro
implant motor (iChiroPro ; BienAir, Bienne, Switzerland) and was programmed at a low
®; BienAir,
® Bienne, Switzerland) and was programmed at a low
(12 revolutions
speed
speed (12 per minute
(12 revolutions
revolutions per (rpm)).
per minute Then,
minute (rpm)).the
(rpm)). PTFEthe
Then,
Then, thetape
PTFE
PTFEedgetapewasedge
tape put in
edge was
wascontact
put
put inwith
in the
contact
contact
screw
with and
with the the
the screw implant
screw and
and the motor
the implant was
implant motor activated
motor was for 15
was activated s
activated for so the
for 15 screw
15 ss so
so thewas wound
the screw
screw was three
was wound times,
wound three
three
therefore
times, wrapping
therefore the
wrapping screwthe in three
screw layers
in three of PTFE.
layers
times, therefore wrapping the screw in three layers of PTFE. of PTFE.

Figure
Figure2.2. Prosthetic
2.Prosthetic screw
Prostheticscrew wrapped
screwwrapped in
wrappedin polytetrafluorethylene
inpolytetrafluorethylene (PTFE).
polytetrafluorethylene(PTFE).
(PTFE).
Figure

The same
The same
The methodology
same methodology
methodology from from
from the the SCREW
the SCREW
SCREW and and PTFE
andPTFE groups
PTFEgroups
groupswaswas developed
wasdeveloped
developedfor for the
forthe
the
rPTFE and
rPTFE and
rPTFE rSCREW
and rSCREW groups.
rSCREW groups. It is
groups. ItIt is necessary
is necessary to
necessary to highlight
to highlight
highlightthatthat the
thatthe screws
thescrews employed
screwsemployed
employedin in the
inthe
the
SCREW
SCREW and
SCREW and PTFE
and PTFE groups
PTFE groups were
groups were respectively
were respectively reused
respectively reused
reused forfor the
forthe experimental
theexperimental rSCREW
experimentalrSCREW
rSCREWand and
and
rPTFE groups,
rPTFEgroups,
rPTFE groups,so so all
soall the
allthe screws
thescrews
screwswere were previously
werepreviously loaded
previouslyloaded
loadedto to
to111year
year
yearofof simulated
ofsimulated mastication
simulatedmastication
mastication
(300,000
(300,000 cycles, 200
(300,000 cycles, 200 N)
200N) and
N)and intentionally
andintentionally
intentionally unscrewed.
unscrewed.
unscrewed. It must be
It must
It must highlighted that
that the
be highlighted
be highlighted reused
that
the the
reused
screws
reused of rPTFE
screws screws
of rPTFE specimens
ofspecimens were
rPTFE specimens wrapped
were wrapped again
were wrapped with
again withagain3 layers
with
3 layers of PTFE
of 3PTFE tape.
layers A
of A
tape. stereomi-
PTFE tape.
stereomi-
Acroscope (Leica
(Leica M80,
stereomicroscope
croscope M80, Wetzlar,
(Leica M80, Germany)
Wetzlar, at
at 60×
60× magnification
Wetzlar, Germany)
Germany) was
was used
at 60× magnification
magnification usedwasin
in order
used in
order to
to
order to visually determine if the use of PTFE tape created a gap between the implant and
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visually determine if the use of PTFE tape created a gap between the implant and implant
visuallyabutment.
implant determineAllif the
theuse of PTFEwere
specimens tape evaluated
created a gap between the implant(1and
perimplant
abutment. All the specimens were evaluated taking taking 4 measurements
4 measurements aspect)
(1 per aspect) (Me-
abutment.
(Mesial, All the
Distal, specimens
Vestibular andwere evaluated
Lingual) taking 4examiner.
by 1 blinded measurements (1 per aspect)
No changes (Me-
were found
sial, Distal, Vestibular and Lingual) by 1 blinded examiner. No changes were found (Fig-
sial, Distal,
(Figure 3). Vestibular and Lingual) by 1 blinded examiner. No changes were found (Fig-
ure 3).
ure 3).

Figure 3.
3. Implant–abutmentmisfit:
misfit: SCREW(control
(control(A))
(A))specimen
specimen with original prosthetic screws
andand rSCREW group
Figure 3.Implant–abutment
Figure Implant–abutment misfit:SCREW
SCREW (control (A)) specimenwith original
with prosthetic
original screws
prosthetic screws rSCREW
and group
rSCREW (B).
group
(B). PTFE (C) and rPTFE group (D) specimen with screws wrapped in PTFE tape.
PTFE (C) and
(B). PTFE (C)rPTFE groupgroup
and rPTFE (D) specimen with with
(D) specimen screws wrapped
screws in PTFE
wrapped tape. tape.
in PTFE

Each
Each sample was positioned on a frame with
with the implant
implant angulated 30 30°◦ to load
load the
Each sample
sample was
was positioned
positioned on on aaframe
frame withthethe implantangulated
angulated 30° to to loadthe
the
abutment
abutment relative to the implant following the ISO 14801 normative. A force of 200 N was
was
abutmentrelative
relativetotothe
theimplant
implantfollowing
followingthetheISO
ISO14801
14801normative.
normative.AAforce
forceof of200
200NN was
applied
applied at aa frequency of 22 Hz for 300,000
300,000 cycles, equivalent
equivalent to 11 year
year of mastication
mastication [35]
[35]
applied at
at a frequency
frequency ofof 2Hz
Hzfor
for 300,000cycles,
cycles, equivalentto to 1 yearof
of mastication [35]
using
using a cyclicloading
loadingmachine
machine (Chewing Simulator CS-4.2 economy
line line
® SD®;Mechatronik
® SD Mecha-
usingaacyclic
cyclic loading machine(Chewing
(Chewing Simulator CS-4.2
Simulator economy
CS-4.2 economy ;line ; SD Mecha-
tronik
GMBH, GMBH, Feldkirchen-Westerham,
Feldkirchen-Westerham, Germany)Germany)
(Figure(Figure
4). 4).
tronik GMBH, Feldkirchen-Westerham, Germany) (Figure 4).

Figure 4. Cyclic loading following ISO 14801.

Figure4.4. Cyclic
Figure Cyclic loading
loading following
followingISO
ISO14801.
14801.

Abutment tightening and recording of the RTVs for all the specimens were carried
Abutment tightening
Abutment tightening and and recording
recording ofof the
the RTVs
RTVs forforall
allthe
thespecimens
specimenswerewerecarried
carried
out with the same validated device used previously in their tightening (iChiroPro; Bien
out with
out with the
thesame
samevalidated
validated device
device used
usedpreviously
previouslyin intheir
theirtightening
tightening(iChiroPro;
(iChiroPro;BienBien
Air, California, CA, USA). The device managed by this software (iChiroPro APP v2.2; Bien
Air, California, CA, USA). The device managed by this software (iChiroPro
Air, California, CA, USA). The device managed by this software (iChiroPro APP v2.2; Bien APP v2.2; Bien
Air, Bienne, Switzerland) can not only obtain the RTV but also create a graphic showing
Air,Bienne,
Air, Bienne,Switzerland)
Switzerland)can cannotnotonly
only obtain
obtain thethe
RTVRTVbutbut also
also create
create a graphic
a graphic showing
showing its
its evolution (Figure 5). For the analysis of power for 4 groups (n = 15), the Neyman–
its evolution
evolution (Figure
(Figure 5). the
5). For Foranalysis
the analysis of power
of power for 4 groups
for 4 groups (n = 15),(nthe= Neyman–Pearson
15), the Neyman–
Pearson lemma was performed for a normalized size of the samples after assuming the
Pearsonwas
lemma lemma was performed
performed for a normalized
for a normalized size of the sizesamples
of the samples after assuming
after assuming the risk the
of
risk of 0.2 and a power of 0.8, resulting in 11.44 samples per group. Finally, a greater sam-
riskand
0.2 of 0.2 and a power
a power of 0.8, of 0.8, resulting
resulting in 11.44
in 11.44 samplessamples per group.
per group. Finally,
Finally, a greater
a greater sam-
sample
ple size was included (n = 15). All data were statistically analyzed by Kolmogorov–
size
ple was
size included (n = 15).
was included (n All data
= 15). were
All datastatistically analyzedanalyzed
were statistically by Kolmogorov–Smirnov
by Kolmogorov–
Smirnov and Shapiro–Wilk tests. These were done to test normality and homogeneity var-
and Shapiro–Wilk tests. These were done to test normality and homogeneity
Smirnov and Shapiro–Wilk tests. These were done to test normality and homogeneity variancesvar-of
iances of the data. Pairwise comparisons by Tukey’s test compared the RTVs between the
the data. Pairwise comparisons by Tukey’s test compared the RTVs between
iances of the data. Pairwise comparisons by Tukey’s test compared the RTVs between the the different
different groups at a 95% significance level.
groups at groups
different a 95% significance level.
at a 95% significance level.
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Figure5.5.5.Example
Figure
Figure Exampleof
Example ofreverse
of reversetorque
reverse torquevalue
torque value(RTV)
value (RTV)evolution
(RTV) evolution
evolution during
during
during the
the
the untightening
untightening
untightening procedure.
procedure.
procedure.

3.Results
3.3. Results
Results
TheTheShapiro–Wilk
The Shapiro–Wilktest
Shapiro–Wilk testfor
fornormal
for normaldistribution
normal distribution
distributionwas was conducted
wasconducted
conducted onon
on allall
all four
fourfour groups.
groups.
groups. All
All
Allthethe
the groups
groups
groups showed
showed
showed values
values
values higher
higher
higher than
than thethe
than p =pp0.05
the == 0.05
0.05 Shapiro–Wilk
Shapiro–Wilk
Shapiro–Wilk criterion.
criterion.
criterion. TheThe The null
nullnull
hy-
hypothesis
hypothesis
pothesis heldheld
held and and
and the
thethe samples
samples
samples studied
studied
studied could
be be
could
could be deemed
deemed
deemed to to
to be
be be normally
normally
normally distributed
distributed
distributed (p (p
=
= 0.448
(p0.448
= 0.448 SCREW
SCREWSCREW group, p =p 0.214
group,
group, = 0.214rSCREW
p = 0.214 rSCREWgroup,
rSCREW group,p p= =0.863
group, 0.863PTFE
p = PTFEgroup,
0.863 PTFEgroup,andandpp==0.471
group, and 0.471rPTFE
p = rPTFE
0.471
group).
rPTFE
group). group).
No Noabutment
No abutmentmobility
abutment mobilityor
mobility orscrew
or screwfracture
screw fracturewas
fracture wasperceptible
was perceptibletoto
perceptible tothe
thetouch
the touchor
touch ortoto
or tothe
thenaked
the naked
naked
eyeeyeafter
eye afterthe
after theseries
the seriesof
series of300,000
of 300,000cycles.
300,000 cycles.The
cycles. Therange
The rangeof
range ofvalues
of valuesobtained
values obtainedwere
obtained werehigher
were higherinin
higher ingroups
groups
groups
wherePTFE
where
where PTFEtape
PTFE tapewas
tape wasused
was used(PTFE
used (PTFE(17.7–21.9
(PTFE (17.7–21.9Ncm)
(17.7–21.9 Ncm)and
Ncm) andrPTFE
and rPTFE(14.6–23.5
rPTFE (14.6–23.5Ncm)
(14.6–23.5 Ncm)groups)
Ncm) groups)
groups)
thanin
than
than ininthe
theSCREW
the SCREWgroup
SCREW group(12.7–16.5
group (12.7–16.5Ncm)
(12.7–16.5 Ncm)and
Ncm) andrSCREW
and rSCREWgroup
rSCREW group(12.8–17.6
group (12.8–17.6Ncm).
(12.8–17.6 Ncm).The
Ncm). Themean
The mean
mean
RTVs were
RTVs
RTVs were 14.46
were 14.46 ±
14.46 ±± 0.99
0.99 Ncm
0.99 Ncm for
Ncm for the
for thethe SCREW
SCREW group
SCREW group (control),
group (control), 14.42
(control), 14.42 ±
14.42 ±± 1.22
1.22 Ncm
1.22 NcmNcmfor forthe
for the
the
rSCREWgroup,
rSCREW
rSCREW group,
group, 19.97
19.97
19.97 ±±±1.16
1.16Ncm
1.16 Ncmfor
Ncm forthe
for thePTFE
the PTFEgroup,
PTFE group,and
group, and
and 19.13
19.13
19.13 ±±±2.01
2.01Ncm
2.01 Ncmfor
Ncm forthe
for therPTFE
the rPTFE
rPTFE
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group(Figure
group (Figure6).
(Figure 6).
6).

25
25

20
20
(Ncm)
Torque (Ncm)

15
15
Torque

10
10

55

00
Control
Control rSCREW
rSCREW PTFE
PTFE rPTFE
rPTFE

Figure6.6.6.Boxplot
Figure
Figure Boxplotof
Boxplot ofRTVs
of RTVsfor
RTVs forcontrol
for control(n(n
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Thevalues
The
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values foundwith
found withthe
with theTukey’s
the Tukey’stest
Tukey’s testatat
test ataaasignificance
significancelevel
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0.0001 confirmed
confirmed
theexistence
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differences
differences between
between
between the the
the RTVs
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RTVs forthe
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andandandrSCREW
rSCREW rSCREW
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andPTFE PTFE
PTFE groups.
groups.
groups. No significant
Nosignificant
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differencesdifferences were between
were found
were found between
between the the
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control
group
group andgroup
and and rSCREW
rSCREW
rSCREW and
andrPTFE
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thePTFEto the
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(Table
(Table (Table 1).
1).1).
Int. J. Environ. Res. Public Health 2021, 18, 125 6 of 10

Table 1. Mean RTV, standard deviation (SD), and statistical significance (p) between SCREW (control)
and experimental groups.

Group Specimen No. Mean RTV (Ncm) SD p

SCREW (control) 15 14.46 ±0.99
rSCREW 15 14.42 ±1.22 p = 0.98
PTFE 15 19.97 ±1.17 p = 0.001
rPTFE 15 19.13 ±2.01 p = 0.001
RTV: reverse torque value; SD: standard deviation.
4. Discussion
The present study aimed to assess the efficacy of employing PTFE wrapping of the
prosthetic screws of implant-supported single crowns to lower the risk of SL and to solve
this complication when it appears. By accepting the assumption that the RTV is a measure
of the remaining preload in the abutment screw [9,18,19,35], the increase of postload reverse
torque of two experimental groups (PTFE and rPTFE) in the present study confirms the
research hypothesis, since the existence of significant differences between the RTVs for the
control and experimental groups were found.
SL has been reported as the most frequent mechanical complication of implant
restorations [36]. The gravity of SL as a biomechanical problem is attested to by the number
of studies assessing the factors that may affect its appearance. The methods used in those
studies may condition the findings, however, hampering the establishment of general
conclusions, such as the degree to which each factor determines the onset of loosening.
SL may be caused by inadequate tightening torque, settling of implant components,
inappropriate implant position, inadequate occlusal scheme or crown anatomy, poorly
fitting frameworks, improper screw design/material, type of implant connection, type of
abutment, and heavy occlusal forces [37]. To overcome screw loosening and joint instability,
many technical solutions have been suggested—for example, type of implant connection,
screw material/design, type of abutment, and number of load cycles.
This lack of methodological uniformity is visible, for instance, in the type of implant
connection studied or how cyclic loads are applied. The magnitude, frequency, and number
of loads reported in the literature also vary widely, with the number of cycles ranging from
16,667 to 5,000,000, the force from 20 to 420 N, and the frequency from 1 to 30 Hz [34,38–40].
The number of cycles (300,000) per sample applied in this study was used as representative
of 1 year of mastication [35], whereas the reference for the force used was the range found
in the literature for chewing force: 143–330 N [41].
The type of connection is indisputably one of the factors most frequently analyzed
in previous studies [20,38]. Most concluded that the Morse taper retains preload more
effectively than the external hex [35] and, to a lesser extent, even the internal hex
connection [20] because it reduces micromovements, thus enhancing screw stability and
stress dissipation [19]. Some authors’ recommendation to use internal hex and Morse
taper connections for this reason, particularly in single-crown implants, is reasonable.
That procedure would not eradicate the problem entirely, however. Moreover, one must
take into account the amount of external hex implants already placed in patients’ mouths
that are prone to such loosening. The present study consequently addressed the effect PTFE
tape wrapping on external hexagon connection implants. The type of implant connection
was intentionally chosen as the least favorable circumstance, as earlier studies found that
type of connection to exhibit the highest rate of screw loosening [42].
Despite the many prosthetic-design-related measures for lowering the incidence of this
complication, such as centering occlusal contact, narrowing the buccolingual width of the
crown, or shortening the cantilever, screw loosening rates continue to be high, particularly
in externally connected single-crown implants [19,43,44]. However, it is not always possible
to achieve such ideal conditions in the oral environment. The efficacy of such measures
would therefore appear to be limited.
Int. J. Environ. Res. Public Health 2021, 18, 125 7 of 10

Other recommendations have also been put forward to reduce SL by perfecting

tightening techniques, such as screw readjustment 10 min after tightening to enhance
screw stability [45,46], but the efficacy of this technique has not been proven in previous
research. Some studies conclude that retightening loosened screws induces a progressive
decline in the abutment–implant RTV with each new use [47], which they attribute to a
deformation-mediated loss of friction between screw and implant. They consequently
recommend using a new screw wherever definitive prostheses are involved. That finding is
pertinent to the present study, where for the experimental group with used screws wrapped
in PTFE, the RTV not only failed to decline but actually rose by 32% relative to the control.
One of the main causes of SL is the settling effect. It has been reported that 2–10%
of the initial preload is lost without being subjected to any type of load as a result of the
settling effect [48]. Preload depends of the following factors: (1) torque applied, which
influences the screw head friction, the thread friction, and the elastic/plastic deformation
of the screw; (2) screw head geometry, which influences the screw head friction; and (3) the
screw and abutment material, which influences the level of grip. From a biomechanical
point of view, the applied torque determines the preload, which in turn is responsible
for the clamping forces; such forces arise from both attrition between opposing surfaces
(screw and fixture) and elastic/plastic deformation occurring on the mating structures [49].
The application of cyclic loads was to simulate the dynamic conditions found in the
oral cavity. Due to micromovement as a result of functional or parafunctional load [47],
the use of PTFE tape might play a role in decreasing SL. The fact that the experimental
group RTV showed better results than the control group could mean that the use of
PTFE tape could reduce the loss of preload and maintain the initial force applied to the
abutment screws. Further investigations are required to verify the effects of the technique
planted in the present study.
Screw design unquestionably also has a heavy impact on SL [43]. The presence on the
marketplace of screws especially designed to prevent loosening, such as those plated in
gold, stands as proof of the importance attached to the problem. While some studies report
higher reverse torque values [19,33] with gold-plated screws [43,50,51], no consensus has
been reached in this regard [18,39]. The high cost of gold-plated screws is a significant
drawback that both precludes their routine use and determines their relegation to specific
clinical situations such as the loosening of a titanium screw. PTFE tape instead is an
inexpensive and readily available material that would not be subject to that disadvantage.
In the literature review on the occasion of this study, only one paper was found that
analyzed PTFE-plated screws [25]. Four different coated abutment screws groups were
used (TiC, TiCN, Teflon, and Parylene) to clarify the influence of the coating material on
abutment screw stability. The specimens were submitted to a series of three mechanical
tests: (1) measuring the torque to unscrew a previously tight screw, (2) tightening and
retightening six times the same screw, and (3) cyclic loading of the dental implant system.
The study showed that RTVs were found not to rise with PTFE but actually to decline after
the cyclic load measurement was performed. Nonetheless, the authors coated the screws
with PTFE, an approach that differed from the sheathing procedure adopted here.
Further to the present findings, wrapping screws in PTFE would appear to be a
convenient and viable solution for loosened screws, as it affords up to 32% higher reverse
torque values than new screws, with the added advantage of its comparatively low cost.
Further clinical studies are needed to determine whether this technique can effectively
prevent and solve screw loosening. Furthermore, wrapping prosthetic screws with PTFE
tape could be a new approach specially indicated to solve screw loosening, replacing gold
as a plating material.

5. Conclusions
This in vitro study showed that wrapping screws in three windings of 100 µm poly-
tetrafluorethylene tape raised the reverse torque value of loosened screws. Subject to
the limitations of such research, this procedure may be deemed to effectively lower the
Int. J. Environ. Res. Public Health 2021, 18, 125 8 of 10

likelihood of screw loosening in future implants and to be a viable solution when it appears
in those now in place.

Author Contributions: Conceptualization: C.G.-P. and R.A.-P.; Investigation: M.M., R.O., and M.G.-P.;
data curation: L.F.F. and R.O.; formal analysis: M.G.-P. and L.F.F.; methodology: L.F.F., M.G.-P., and
M.M.; supervision: R.A.-P. and R.O.; visualization: C.G.-P., R.O., and R.A.-P.; writing—original draft:
L.F.F., M.G.-P., and M.M.; writing—review and editing: M.G.-P., R.A.-P., M.M., L.F.F., C.G.-P., and
R.O. All authors have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not Applicable.
Informed Consent Statement: Not Applicable.
Data Availability Statement: The data presented in this study are available on request from the
corresponding author.
Conflicts of Interest: The authors declare no conflict of interest.

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