Received: 11 April 2019 Accepted: 19 May 2019

DOI: 10.1111/jerd.12494

REVIEW ARTICLE

Mechanism of and factors associated with the loosening of the

implant abutment screw: A review

Yiqing Huang DDS, MDS1,2 | Jiawei Wang DDS, PhD1

1
Department of Prosthodontics, Hubei-MOST
KLOS & KLOBM, School and Hospital of
Stomatology, Wuhan University, Wuhan,
China
2 complications in implant-supported restorations, there is a lack of comprehensive lit-
Department of Stomatology, The Central
Hospital of Wuhan, Tongji Medical College,
Huazhong University of Science and
Technology, Wuhan, China
Correspondence
Jiawei Wang, Department of Prosthodontics,
School and Hospital of Stomatology, Wuhan
University, 237 Luoyu Road, Wuhan 430079,
China.
Email: wb000238@whu.edu.cn
Funding information
National Natural Science Foundation of China,
Grant/Award Numbers: 81570956, 81870744
Abstract
Objective: While the loosening of the abutment screw is one of the most common
eratures for mechanism of and factors associated with the loosening of the implant
abutment screw. The review was to summarize the mechanism of and factors associ-
ated with the loosening of the implant abutment screw.
Overview: A total of 99 relevant articles were included in the literature review. The
mechanism of the abutment screw loosening was explained. The factors contributed
to abutment screw loosening were divided into five aspects and then expounded
respectively.
Conclusions: The internal connection and abutments with anti-rotational and conical
designs have better resistance to screw loosening. Cantilevers increase the risk of
screw loosening. The effect of surface treatment of the abutment screw is unsure.
Clinicians need to tighten the abutment screw to the recommended torque while
avoiding repeated tightening and loosening, and increase the frequency of follow-ups
to retighten the loosened screws in time.
Clinical Significance: While the loosening of the abutment screw is one of the most
common complications in implant-supported restorations, there is a lack of compre-
hensive literatures for mechanism of and factors associated with the loosening of the
implant abutment screw. The review was to summarize the mechanism of and factors
associated with the loosening of the implant abutment screw, so that clinicians may
make better choices in clinical practice.

KEYWORDS
abutment screw, implant, mechanical complication, screw loosening

1 | I N T RO D UC T I O N However, implant restoration is not perfect. In addition to surgical

Since the end of the last century, the rapid development of oral
implant technology has opened up a new era of prosthodontics.
Compared with traditional restorations, the introduction of implant
technology has significantly improved the esthetic and functional out-
comes of definitive restoration, thereby greatly improving the quality
of life of the patients. It has also provided more choices for clinicians
and patients.
trauma, high cost, and long period of treatment, the implant-
supported restorations associated biological and mechanical complica-
tions are troublesome in clinical practice.1-7 These complications
mainly include peri-mucositis, peri-implantitis, loosening or fracturing
of the abutment screw, fracturing of the abutment or superstructure,
crown loosening, or porcelain cracking.8-12 Among these, the loosen-
ing of the abutment screw is one of the most common mechanical
complications.11,13,14 The incidence rate of abutment screw loosening

J Esthet Restor Dent. 2019;1–8. wileyonlinelibrary.com/journal/jerd © 2019 Wiley Periodicals, Inc. 1

2 HUANG AND WANG
reaches 5.3% in the first year after loading,15 and 5.8%-12.7% after
the 5-year follow-up.14,16-18 The loosening of the abutment screw is
likely to deteriorate into fracture of the screw or even fracture of the
implant without timely management. The instability of the prosthesis,
which is caused by the loosening of the abutment screw, changes the
distribution of the occlusal force during function, thus accelerating
the progress of the abutment screw loosening.19,20 Moreover, the
loosening of the abutment screw increases the micro-motion and
the micro-gap of the implant-abutment interface, thereby aggravating
the micro-leakage at the implant-abutment interface and causing bio-
logical complications in the end.10,21,22
2 | THE MECHANISM OF THE ABUTMENT
SCREW LOOSENING
The abutment screw is an integral part of the implant-abutment con-
nection in most implant systems. The screw presents elastic deforma-
tion and is elongated when tightened, thereby creating a tensile force
called preload.23-25 Another definition of the preload is the axial force
generated between the threads of the abutment screw and the inner
part of the implant along the direction of the long axis of the
implant.26-29 The screw acts like a tensioned spring, and the clamping
force it induces between the implant and the abutment holds the two
parts together. The preload determines the clamping force to a large
extent and is a crucial factor in the stability of the implant-abutment
connection.24,30-33
Bickford34 divided the process of screw loosening into two stages.
The initial tensile deformation of the screw is decreased under the
impact of external force primarily, thereby leading to a decrease in the
clamping force. In the second stage, with further decrease in clamping
force, the micro-motion of the implant-abutment interface intensifies,
and the instability of the connection finally leads to screw loosening.
The loss of the preload by external force causes the loosening of the
abutment screw.
The implant-supported restoration is subjected to external force
in complex ways when functioning in the mouth. The lateral loads of
25N in average are applied to the implant-supported restoration dur-
ing mastication, according to in vivo studies.35 The stress distribution
of the assembly under lateral force is more uneven than that of the
axial force; thus, it is harder to maintain the stability of the joint. As
many in vitro studies have reported, the friction between the abut-
ment screw and the inner of the implant decreases after cyclic loading,
and so does the torque.19,36,37 A higher preload means a stronger
resistance of the screw to loosening, and this slows down the process
38,39
of screw loosening.
The preload is positively correlated with the value of the screw
tightening torque. The abutment screw functions in its status of elas-
tic deformation; thus, larger tightening torque and preload does not
mean better. When the preload exceeds the yield limit of the abut-
ment screw's material, the screw is permanently deformed and loses
its function, thereby loosening or even fracturing screw. Therefore,
the ideal preload is usually 60%-80% of the yield strength of the
material.25,40-42
Only 10% of the torque is converted into the preload, whereas
the remaining 90% is used to overcome the friction between the
interfaces of the joint's components.40,42,43 The loss of preload was
observed 2-3 minutes26,33,44,45 or 15 hours29 after tightening, even
without external force. It might have been caused by the irregular sur-
face morphology of the contact interfaces of the joint at the micro-
scopic level. The high points tend to be flattened during the
installation process, thereby consuming some of the torque. The phe-
nomenon of the preload loss due to installation is called the settling
effect.42,46 Some researchers suggested that the screw should be
retightened at an interval of 10 minutes after the initial tighten-
ing.42,47 As Siamos et al42 demonstrated, retightening could reduce
torque loss by 17%-19%. However, in most studies, the preload was
believed to keep decreasing with the repeated tightening of the
screw.38,39,48 Cardoso et al38 found that the removal torque value con-
tinues decreasing with the same tightening torque along the cyclic tight-
ening and loosening of the abutment screw. After 10 cycles of
tightening and loosening, the resistance to screw loosening could not be
increased even if the abutment was changed to a new one. However,
some studies suggested that the preload would increase after repeated
tightening and loosening.41,49 This difference might be explained by the
differences in methods and materials used.38
3 | T H E F A C TOR S C O N T RI B U T ED T O
A B U T M E N T S C R E W L O O S E N I NG
3.1 | Types of implant-abutment connection
The stability of the implant-abutment connection is closely related to
its connection type, which has been confirmed by a large number of
studies.50,51 There are two types of implant-abutment connection in
two-piece implant system, namely, external connection and internal
connection. The protruded structure of a hexagon or an octagon with
1-2 mm height on the top of the implant connecting to the abutment
forms the external connection. The external connection has its advan-
tage in orientation of the abutment and anti-rotation. However, due
to the limited height and diameter of the contact parts of the joint, it
is vulnerable to the micro-motion of the implant-abutment interface
under external force, especially lateral force, and leads to instability of
the joint. According to Binon et al,52 in the external connection, the
external force is transmitted directly to the abutment screw and the
top of the implant at the joint, thereby causing stress concentration in
the areas and possibly resulting in the loosening or even fracturing of
the abutment screw. The internal connection is the connection
formed by the abutment, with a structure (4-6 mm) into the implant.
This design increases the contact area between the abutment and the
implant and also changes the stress distribution when loaded. Cibirka
et al53 have found in the internal connection that the inner part of
implant that is in contact with the abutment will withstand most of
the external force, thereby greatly reducing the stress at the screw,
HUANG AND WANG
effectively decreasing the torque loss, and maintaining the stability of
the implant-abutment connection.
The internal connection is reported to have advantages over
external connection in the stability of the implant-abutment connec-
tion and has better resistance of torque loss and screw loosening.54-59
According to a recent systematic review of Vetromilla et al, 60
abut-
ment screw loosening and abutment fracture occurred more often in
external hexagon connection comparing to internal hexagon or Morse
taper connections in clinical studies. There are also studies stating that
the difference in connection types does not have a significant influ-
ence on screw loosening. Vigolo et al61 compared the two connection
types by a retrospective study. In a follow-up period of at least 5 years
involving 2010 implants in 1159 patients, no significant difference
was found in the incidence of screw loosening between two connec-
tions, which was similar to the result of Chae et al.62 However, many
other factors may also affect the results in clinical practice. Moreover,
the difference in the loosening of abutment screw may not be obvi-
ous, even if there was a significant difference in torque loss.
3.2 | The geometrical morphology, material used,
and manufacturing method of the abutment
As the abutment plays an important role in the implant-abutment con-
nection, the difference of abutments may change the stability of the
joint. The relevant factors of the abutment mainly include its geomet-
rical morphology, material used, and manufacturing method.
The different geometric designs of the abutment are very likely to
alter the stress distribution at the implant-abutment connection and
have an effect on torque loss. In the study of Moris et al,63 with the
only difference being the diameter of the upper part of the abutment,
which was connected with the superstructure, the torque loss would
be different. Although there was no significant difference in the tor-
que loss between the two groups before loading, the torque loss of
the 3.8 mm-diameter group was significantly higher than that of the
4.8-mm group after cyclic loading.
It is often necessary to select the collar height of the abutment
depending on the thickness of the gingiva to achieve better esthetic
outcome. Siadat et al64 studied the influence of different abutment
collar heights on torque loss. There was no significant difference in
torque loss among the different abutment collar heights (1.5, 3.5, and
5.5 mm) before cyclic loading. However, after cyclic loading, the abut-
ment with higher collar height was more vulnerable to torque loss. An
increase in the collar height of the abutment increased the length of
the axial cantilever, which may explain this result.
Angled abutment is often used when the implant is not placed par-
allel to the axial force. Though provided convenience in prosthodontic
restoration, angled abutment is more prone to develop transverse
force under loads, thus resulting in off-axis forces. El-Sheikh et al65
have proved that increasing abutment angulation as well as collar
height had significant effect on removal torque value after dynamic
cyclic loading, so that screw loosening would increase.
In addition to the geometry of the upper part of the abutment
connecting with the superstructure, the geometry of the lower part of
3
abutment in contact with the inner implant is also associated with tor-
que loss. Rotational freedom between the implant and the abutment
is a critical factor related to the stability of the implant-abutment con-
nection. The implant-abutment connection is most stable when the
degree of rotational freedom is less than 2 ,66 and significant torque
loss occurs when the degree is greater than 5 .67-70 The anti-rotation
design of the abutment can limit the rotational freedom, thereby
maintaining well the stability of the joint. In the experiment of Yao
et al,71 all the abutments without anti-rotation design were rotated
after cyclic loading, and fatigue fracture was observed. In addition, the
anti-rotation design can also effectively reduce the incidence of abut-
ment screw loosening by increasing the preload.72 The abutment with
a taper design possibly increases the stability of the implant-abutment
connection. The tapered contact interface creates friction-locking
mechanism and has a wedge effect that could enhance the friction-
locking mechanism.73 in vitro studies proved that the connection with
a tapered abutment has higher resistance to torque loss than other
connections before and after cyclic loading.74,75 The taper design has
also better adaptation between the abutment and the implant than
other abutment designs, thereby reducing the micro-gap and micro-
motion at the implant-abutment interface and decreasing the torque
loss.51
Abutment material could also influence the stability of the implant-
abutment connection. Jo et al76 compared the stability of the joint of
three abutments made of commercially pure grade 3 titanium (group
T3), commercially pure grade 4 titanium (group T4), or Ti-6Al-4V (group
TA). It was found that preload and compressive bending strength values
were significantly higher in group TA in contrast to groups T3 and T4.
The result might be explained by higher strength and lower frictional
coefficient of Ti-6Al-4V.
The use of the porcelain abutment effectively overcame the draw-
back of the titanium abutment in esthetic outcome during the restora-
tion of upper anterior teeth. However, compared with the conventional
titanium abutment, both zirconia and alumina abutments had greater
brittleness and higher modulus of elasticity, thereby influencing the pre-
load and the torque loss. With more similar elastic modulus of the mate-
rial, the stress distribution of the joint under external force would be
more even. In the implant-abutment connection, the modulus of elastic-
ity of the porcelain abutment is higher than that of the implant and the
abutment screw. Thus, the stress would concentrate more on the
screw and the implant under external force, thereby increasing the
risk of screw loosening and implant fracture.77 Zirconia has higher
flexural strength and lower modulus of elasticity than alumina,78
making it a better choice for manufacturing porcelain abutments.
According to Dhingra et al,32 the torque loss of the zirconia abut-
ment was higher than that of the titanium abutment after cyclic
loading. However, there was no significant difference. Debris found
between the zirconia abutment and the screw, and between the
abutment and the implant, might contribute to retard further torque
loss and keep the joint stable. Therefore, zirconia abutment might
still be a choice for clinical applications.
Except for the difference that is possibly found after cyclic load-
ing, the micro-leakage and torque loss of the zirconia abutment was
4 HUANG AND WANG
significantly higher than that of the titanium abutment in the leakage
tests of Sahin et al,10 which might be explained by the poorer fitness
between the zirconia abutment and the implant. The different proper-
ties of the materials caused the differences between the manufactur-
ing processes of the porcelain abutments and the titanium abutments,
thereby leading to differences in manufacturing precision and fit dis-
crepancy between the two. As Vigolo et al79 have pointed out, the por-
celain abutment manufactured by computer-aided design/computer-
aided manufacturing (CAD/CAM) has lower precision than the titanium
abutment and has larger degree of rotational freedom, although without
significant difference and the rotational freedom of all the specimens
was less than 3 . Comparing the prefabricated titanium abutment with
the customized zirconia abutment, the latter is inferior to the former in
terms of the precision, degree of rotational freedom, and torque loss;
hence, it is more prone to the instability of the implant-abutment
connection.80,81
Along with the entrance of CAD/CAM and third-party prosthetic
components into the clinic, concern about the non-original abutments
82
is raised. Park et al compared the torque loss of four abutment
groups. The results showed that the torque loss of the original abut-
ments was significantly lower than that of the copy abutments. In
another in vitro study, Alonso-Pérez et al83 came to a similar conclu-
sion, verifying that the internal fit of the connection was crucial to the
mechanical behavior of the assembly, and so that the original compo-
nents excelled.
3.3 | The design and material of the abutment screw
As the most important part of the implant-abutment connection, the
abutment screw allows the preload to tightly connect the implant and
the abutment and maintains the stability of the implant-abutment
connection under external force. The characteristics of the material
used to make the screw, such as yield strength, modulus of elastic-
ity, and fatigue life, are important factors that affect the stability of
the implant-abutment connection.84 According to the research of
Shinohara et al,85 the screws made of grade 4 pure titanium led to
significantly more loosening than the screws made of titanium alloy
Ti-6Al-4V. The friction coefficient of the interface between the
screw and the internal surface of the implant is one of the main fac-
tors determining the preload value. With the same settling torque, a
smaller friction coefficient results in higher preload.86,87 When the
screw is being installed or subjected to external force, there is a rel-
ative sliding of the surfaces of the internal implant and the screw in
dry contact, and the metal with relatively low strength is worn on
the surface.88
48
In the study of Lee et al, the surface of the screw was contami-
nated with titanium nanoparticles to simulate the rough surface of the
screw with larger friction coefficient. The contaminated screws
exhibited a more significant torque loss than the untreated ones after
repeated insertion and removal. The increased friction coefficient of
the screw surface made it more susceptible to settling effect, thereby
resulting in greater loss of preload. As Anchieta et al89 have similarly
shown that the coated screws had significantly less torque loss than
the uncoated screws after cyclic loading. The coating of the screw on
the one hand has increased the fit of the screw to the internal implant,
and on the other hand, it has reduced the effect of wear. However,
Elias et al90 have found that the joint with Teflon coated abutment
screw was not as stable as that with uncoated screw after cyclic load-
ing. Although the coating increased the preload at a certain inserting
torque by reducing the coefficient of friction between the screw and
the implant, the removal torque was correspondingly reduced due to
smaller coefficient of friction. This result is in accordance with the
result of Wu.91 Wu et al treated the surface of the abutment screw
with different lubricants. The use of lubricant reduced the removal
torque before and after cyclic loading, and the lubricated screw was
more prone to loosening than the screw without lubricant.
The taper design is now widely used in the manufacturing of the
abutment. With the same mechanism, the taper design can also be
used for the screw head. Although the vertical dimension of taper and
the angle of taper vary at a limited axial distance, the conical-head
screw was experimentally confirmed to resist torque loss.34,92
3.4 | The design of the implant
It is quite common to use angled abutment to correct the angulation
of implant-supported restorations for a long time. While nowadays,
new angulation-correcting technique which the angled part is built
over the implant is available. Straight and 12 implants were tested in
the study of Hotinski et al.93 Dynamic cyclic loading at 18 to the long
axis of the implant was applied, and the torque loss of the angulation-
correcting implant group was significantly lower than that of the
straight group. It was suggested that the angulation-correcting implant
had better resistance to screw loosening because of the reduced angle
of abutment screw loading.
3.5 | Types of the restoration
Different types of restorations have different stress distributions
when loading. The implant-supported single crown is more prone to
screw loosening than the implant-supported fixed bridge, when the
retention modes of the superstructure are the same. The latter has
the incidence of screw loosening of 5.6% in the 5-year follow-up,
whereas the former has reached 12.7%.16 It is speculated that the
components of the implant-supported fixed bridge may bear more
evenly under external force and can act as a whole to work better in
anti-rotation. However, in the single crown, the stress concentrates
on the implant-abutment connection part, especially on the abutment
screw, thereby leading to a higher incidence of screw loosening.94
Cantilevers are also common in restorations, including both the
cantilever in the fixed partial denture and eccentric position of the
implant in the single crown. The cantilever would work as a lever that
amplifies the effect of external force and produces a torque.
Shinohara et al85 compared the loosening torque of two different
loading place after cyclic loading: loading at the eccentric point (9 mm
from screw center) and at the centric point (3 mm from screw center).
The results showed that eccentric point loading led to more loosening
HUANG AND WANG
than centric point loading with significant difference. In an in vitro
experiment of Goiato et al,95 photoelastic analysis was used to evalu-
ate the stress distribution of implant-supported restorations. A greater
concentration of force on the cervical part of the implant was
observed on the models with two crowns in the cantilever than on
the models with one crown in the cantilever, showing that the cantile-
ver length did have a direct influence on stress distribution. Suedam
96
et al drew a similar conclusion through their in vitro analysis, affir-
ming the greater length of cantilever could lead to greater concentra-
tion of stress. The findings of the in vitro studies might explain the
results of clinical studies. In the systematic review and meta-analysis
of Freitas da Silva et al,97 although cantilevers were not proved to
have negative influence on the marginal bone loss or the survival rate
of the implant-supported restorations, restorations with short cantile-
vers or without cantilevers did have minor complications like abut-
ment screw loosening or screw fracture.
3.6 | Human-associated factors
Human factors are inevitable in clinical practice. The tightening torque
and insertion technique clinicians used determine the preload value.
A suitable preload can better maintain the stability of the implant-
abutment connection. Excessive preload would lead to overload of
the connection part, thereby causing the fracturing of components.
The insufficient preload would increase the rotation freedom, thereby
resulting in instability of the assemblies.3,98 The different insertion
techniques used might influence the settling effect and change the
preload value. Although the insertion technique of retightening after
the first tightening before loading has been supported by some
studies,42,47 there is still no consensus on a recommended insertion
technique in clinical practice.
Moreover, in terms of the individual differences of patients, it has
been found in a retrospective comparative study that the bruxers
group had a significantly higher prevalence of mechanical complica-
tions including but not limited to screw loosening and screw fracture
in comparison with the non-bruxers group.99 So parafunctions such as
bruxism, excessive occlusal force, bad chewing habits, and others
which might be risk factors of screw loosening, should cause concern.
4 | CO NC LUSIO N
Screw loosening is one of the most common mechanical complications
of implant-supported restoration. Knowing the causes and relevant
factors can help clinicians make better choices in clinical practice.
According to this review, the following conclusions can be obtained:
1. The internal connection might have better resistance to torque
loss and screw loosening than external connection.
2. The geometrical morphology of the abutment including anti-
rotational and conical designs affects the stability of the implant-
abutment connection.
5
3. The original components are more stable than the non-original
ones in general.
4. The effect of the surface treatment of the abutment screw on
improvement of the stability of implant-abutment connection is
controversial.
5. Cantilevers lead to stress concentration and increase the risk of
screw loosening.
6. The abutment screw needs to be tightened to the recommended
torque by the manufacturer during insertion. Repeated tightening
and loosening of the screw need to be avoided. Retorquing of the
screw after the initial torquing with a time interval may be useful
in reducing the preload loss.
7. Individual differences of patients need to be paid attention to,
especially in terms of the parafunctions, such as bruxism, exces-
sive occlusal force, and bad chewing habits.
Moreover, the clinicians need to increase the frequency of follow-
ups, retighten the loosened screws in time, or replace the screws with
new ones to prevent further loosening or even fracture.
ACKNOWLEDG MENTS
This study was financially supported by grants from the National Nat-
ural Science Foundation of China (81570956 and 81870744). The
authors would like to thank Key Laboratory for Molecular Diagnosis
of Hubei Province, The Central Hospital of Wuhan, Tongji Medical
College, Huazhong University of Science and Technology.
CONFLIC T OF INT ER E ST
The authors do not have any financial interest in the companies
whose materials are included in this article.
OR CID
Jiawei Wang https://orcid.org/0000-0003-1405-4811
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How to cite this article: Huang Y, Wang J. Mechanism of and
factors associated with the loosening of the implant abutment
screw: A review. J Esthet Restor Dent. 2019;1–8. https://doi.
org/10.1111/jerd.12494