Screw-Retained Implant Restorations

in the Aesthetic Zone: Biological, 13 1

Functional, and Aesthetic 3

Considerations 4

Tomas Linkevicius and Algirdas Puisys 5

Abstract 6
One of the choices to rehabilitate dental implant in aesthetic zone can be cement-­ 7
screw-­retained restoration, usually referred as hybrid prosthesis. It combines 8
some features from cemented and screwed way of restoring implants. The sys- 9
tem consists of the crown with palatinal opening, which is cemented to special 10
retentive metal base on the working model. The cement excess is cleaned and 11
restoration is screwed to the implant in the mouth. Retrievability is also a very 12
important factor for success in implant restorations. 13
In addition this approach is good for peri-implant tissues, as it combines tita- 14
nium as material for retentive base, which is good for connective tissue part of 15
peri-implant tissues. Highly polished zirconia is appropriate material for epithe- 16
lial adhesion of more coronal peri-implant tissues. 17

It is obvious that traditionally clinician can select between cemented or screw-­ 18

retained restorations, when the time to restore implant in aesthetic zone occurs. 19
Choosing between these constructions is mostly dependent on clinical situation and 20
clinician’s preference because there is no definite superiority of either of these 21
means of retention. Some clinicians have better outcome with screw-retained, while 22
others enjoy success with cemented implant-supported restorations (Fig. 13.1). 23
There are myriad factors to discuss in order to make an informed choice. The 24
factors that are affected by different methods of retention of the prostheses to the 25
implants include ease of fabrication, cost, aesthetics, access, occlusion, retention, 26

T. Linkevicius (*)
AU1 Faculty of Medicine, Institute of Odontology, Vilnius University, Vilnius, Lithuania
A. Puisys
Vilnius Implantology Center, Vilnius, Lithuania

© Springer International Publishing AG, part of Springer Nature 2019

Todd R. Schoenbaum (ed.), Implants in the Aesthetic Zone,
https://doi.org/10.1007/978-3-319-72601-4_13
 T. Linkevicius and A. Puisys

Fig. 13.1 Screw-retained
restorations on anterior
segment

27 incidence of loss of retention, retrievability, passivity of fit, restriction of implant

28 position, effect on peri-implant tissue health, provisionalization, immediate load-
29 ing, impression procedures, porcelain fracture, and clinical performance [1].
30 Although the purpose of this chapter is not to show the inferiority or superiority of
31 each module, it is a must to say that current systematic reviews show significantly
32 more bone loss around cemented restorations compared to screw-retained solution
33 [2]. That being said, of course, might be due to different reasons; however, the main
34 disadvantage of cemented restorations is of course possible cement extrusion into
35 peri-implant tissues and difficulties to remove the remnants [3]. Recent clinical
36 study by Wasyliuk et al. has shown that even 1 mm below gingival margin on indi-
37 vidual abutments was not possible to remove all cement remnants [4]. Additional
38 problem is created, if cemented crown becomes mobile due to abutment screw loos-
39 ening, as then occlusal perforation must be made to reach the screw and tighten it
40 back [5]. According to Wittneben et al.’s systematic review in 2014, total rate of
41 biological and technical complications of cemented restorations was greater com-
42 pared to screw-retained prosthesis [6]. On the other hand, rate of ceramic fracture
43 and chipping appeared to be higher in screw-retained metal-ceramic restorations.
44 This brings us to the other choice—to use screw-retained restorations, a cement-­
45 free solution, free from residual cement risk, and offering long-term predictable
46 outcome.

47 13.1 Indications and Advantages/Contraindications

48 and Disadvantages

49 Generally, strict indications for screw-retained restorations are not that numerous.
50 Generally, a lack of interocclusal space is strong indication to have one-piece screw-­
51 retained restoration while other being rather choice of the clinician, not strict indica-
52 tions. It is considered that if interocclusal clearance is less than 4 mm, screw-retained
53 solution should be considered. Also, if the peri-implant tissue is poorly keratinized
54 or irregular, screw-retained restorations are preferred.
55 Two major advantages of this approach can be listed: (1) screw-retained design
56 of implant-based restorations allows for easy and nondestructive retrievability of the
57 restoration for maintenance or repair procedures and (2) no risk of residual
 13  Screw-Retained Implant Restorations in the Aesthetic Zone

Fig. 13.2  Palatinal screw

access channel after
5 years of delivery.
Discoloration and
microleakage of the
composite are obvious

subgingival cement excess. A screw-retained design is a contribution toward healthy 58

peri-­implant tissues. 59
Occlusal or, in case of anterior teeth, palatal access to the screw opening is usu- 60
ally considered as the biggest disadvantage, which sometimes can compromise the 61
treatment (Fig. 13.2). If the implant is angled to the facial, the screw access presents 62
an aesthetic contraindication for traditional screw retention. 63
Screw-retained prosthesis on implants is impossible without the screw access 64
channel, which must be sealed after delivery. Usually a screw access channel is 65
closed with direct restoration that may affect aesthetics; however there is a quick 66
and convenient way to finish the treatment with better control of aesthetics and 67
occlusion. This alternative to a screw hole closure with composite restorations is the 68
implant crown adhesive plug (ICAP), proposed by Wadhawi et al. [7]. The plug is 69
made of custom-pressed porcelain that matches the same shape of the hole and same 70
shade of the crown. The procedure is similar to inlay cementation: porcelain plug is 71
etched, silanized, and bonded with composite resin luting cement into the crown. 72
This type of restoration can eliminate the poor aesthetics of the screw channel and 73
provide better control of the occlusal contacts. On the other hand, not all clinical 74
situations warrant such sophisticated treatment. 75

AU3 13.2 Fabrication of Screw-Retained Restorations 76

Fabrication of the screw-retained restoration can be achieved in several ways: (1) 77

casted with the use of plastic sleeves (gold alloy or Cr-Co) and (2) milled one-piece 78
(titanium, zirconium, Cr-Co) and (3) milled two-piece hybrid (milled zirconium 79
coping connected to titanium base). 80
AU4 Casting, as a method, already belongs to the past; poor qualities of gold or Cr-Co 81
in terms of biocompatibility, casting irregularities, and increasing and fluctuating 82
costs make this method less applicable than it once was. 83
One-piece screw-retained frameworks can be milled, thus eliminating inner 84
tension problems inherent in the investment and casting process [8]. However it 85
 T. Linkevicius and A. Puisys

86 is not advisable to use titanium in aesthetic area, as the major drawback of these
87 abutments is that their dark color shines through soft peri-implant tissues, creat-
88 ing a grayish appearance of the peri-implant mucosa, which is aesthetically
89 unacceptable [9].
90 In contrast zirconia frameworks offer a much better aesthetic outcome, espe-
91 cially in thinner peri-implant mucosa cases [10]). Nevertheless, its brittleness might AU5
92 be considered as one of the shortcomings of zirconium framework. Fractures of
93 one-piece zirconia abutments with internal connection were reported in short-term
94 studies [11] and in longer follow-up observations [12]. In addition, it was reported
95 that zirconia hexagon could damage the implant, as it is stiffer than titanium alloy.
96 Therefore, it is clear that there should be a more convenient and contemporary
97 way to produce screw-retained restoration. The use of a two-piece system, where
98 the restoration superstructure is produced separately and later by means of cement
99 or mechanical adaptation is connected to a titanium base, is the way to restore in
100 aesthetic area. We can distinguish two most commonly used systems to connect
101 the titanium base to the restoration: (1) cementation and (2) mechanical
102 adaptation.
103 The most currently used and predictable is cement-screw-retained restoration of
104 hybrid solution, where the zirconia-based restoration is fabricated and glazed,
105 cemented on an appropriate titanium base in the laboratory, and then screw-retained
106 to the implant intraorally. This construction eliminates the cement remnants, as
107 crown is cemented to abutment on the model and technician can easily remove
108 cement excess. Biomechanically this kind of restoration is cement-retained; thus,
109 passive fit is achieved due to the layer of the cement between abutment and the
110 crown.
111 This method has its roots from modification of Rajan and Gunaseelan. They
112 described very similar technique of cement-screw-retained restoration [13]. They
113 also proposed to use standard abutments (predecessor of titanium base) and metal
114 ceramic restoration with occlusal opening; however, their cementation procedure
115 was to be performed intraorally. After that, abutment-restoration complex was
116 retrieved, cement remnants cleaned, and restoration returned to the mouth. Currently
117 proposed technique has several advantages. First, the cementation procedure is
118 more controlled on the model, than on the mouth, especially if the implant is placed
119 deeply. In the latter case, it is difficult to fully seat the crown on the implant in the
120 mouth, due to resistance of the peri-implant tissues. Secondly, less clinical time is
121 spent, as cementation and excess cleaning procedures are done in the laboratory.
122 Despite these clear advantages, there are some clinicians who still prefer to cement
123 crowns of cement-screw-retained restorations in the mouth.
124 The sequence of fabrication can be seen in Fig. XXX. AU6
125 The question arises: what is the success and long-term data of this approach of
126 screw-retained restorations? Indeed, long-term in vivo evidence is still being gath-
127 ered; however, we can extrapolate from the data of individual prosthetic abutments
128 for cemented restorations. These reports in increased loading situations showed
129 100% success [14, 15]. It is interesting to note that these excellent-outcome studies
130 used zirconium abutment with external connection or internal hexagon two-piece
 13  Screw-Retained Implant Restorations in the Aesthetic Zone

construction, where zirconium abutment-like coping is cemented on a titanium 131

base. Finally, Zembic et  al. showed no fractures of zirconium abutment glued to 132
titanium substructures in an 11-year prospective clinical trial [16]. 133
The other way to connect zirconia to titanium base is via metallic adapter. 134
This is a more unique way, when zirconia is connected to titanium base during 135
the process of tightening. This eliminates the cement line, and connection relies 136
on mechanical precision and adaptation. This system is unique to a few manu- 137
facturers. And we do not yet know if the unfilled micro-gap between the tita- 138
nium base and the zirconia superstructure will prove to be a problematic 139
reservoir of pathogenic bacteria (Figs. 13.3, 13.4, 13.5, 13.6, 13.7, 13.8, 13.9, 140
AU7 13.10, and 13.11). 141

Fig. 13.3  Grayish appearance of soft peri-implant tissues when metal framework is used

a b

Fig. 13.4 (a) Luting of finished restoration to titanium base on the model. This allows to com-
AU8 pletely clean cement remnants. (b) Completely finished hybrid restoration free of residual cement
 T. Linkevicius and A. Puisys

a b c

d e

Fig. 13.5 (a) Zirconia framework temporary glued to titanium base. (b) Clinical verification of
the framework. (c) Zirconia framework within Ti base without ceramic layering. (d) Finished res-
toration screw-retained to the implant. (e) Radiological image of finalized treatment

Fig. 13.6  Titanium bases with different height of the gingival part

142 13.3 Material Selection

143 The very important factor for the screw-retained restorations is selection of material
144 because part of the restoration ends up subgingivally and plays a direct role in
145 establishment and maintenance of biologic width around implants. Thus, material
146 selection has direct influence on soft tissue stability and functioning of the implant.
 13  Screw-Retained Implant Restorations in the Aesthetic Zone

Fig. 13.7  Surface of

polished zirconia, achieved
with hand polishing

Fig. 13.8 Schematic
drawing of peri-implant
tissues. It can be seen that
connective tissue direct
contact is with titanium
base, while moving coronal
connective tissues are lined
with epithelium, which
contacts zirconia

a b

AU13 Fig. 13.9  (a) “Zirconia without zirconia” restorations. Zirconia framework is covered with
veneering porcelain and hidden from peri-implant tissues. (b) Restoration with zirconia not cov-
ered with feldspathic porcelain
 T. Linkevicius and A. Puisys

Fig. 13.10 Schematic
visualization of angulated 0°
25°
screw access possibilities
up to 25°

Fig. 13.11  The case, there screw angulation could be used—individual abutment and screw hole AU9
is on incisal; therefore, regular screw-retained restoration would compromise aesthetics

147 It is in closest contact with the peri-implant tissues, which is the first and only bar-
148 rier from oral bacteria—a threat to osseointegration.
149 Before going into details, we need to distinguish three main parts of the screw-­
150 retained restoration—framework material, veneering material, and metallic base
151 material. If we are using cement-screw-retained restoration, we have the fourth
152 component—adhesive resin cement, which is used to connect the superstructure to
153 the titanium base.
 13  Screw-Retained Implant Restorations in the Aesthetic Zone

Metallic base is usually titanium alloy, which is a biocompatible material with 154
sufficient strength to withstand loading. Recently, manufacturers started to offer 155
titanium bases with different height not only for retention of suprastructure but also 156
with different heights for subgingival part. The base with higher subgingival part 157
might be used in case we want to move the cementation line further from the bone 158
and also in case we are using metal-ceramic crown for restoration of the implant. 159
This reduces the exposure of peri-implant tissues to feldspathic ceramics, gold 160
alloys, and Cr-Co, as more titanium surface is gained from the base. 161
Currently, various materials are used for fabrication of individually screw-­ 162
retained restorations, like metals, ceramics, and composites. For many years, cast 163
gold alloy was considered as the state of the art in customized prosthetic solutions; 164
however, their use recently is rapidly decreasing due to lack of biocompatibility and 165
higher pricing. It was shown in animal studies that peri-implant soft tissues do not 166
form sufficient seal with gold abutments; as such, significant soft tissue recession 167
and crestal bone loss can be expected. Similarly, dental porcelain appeared not to be 168
a proper material for establishment of reliable soft tissue adherence. In fact the out- 169
come with feldspathic ceramics was least favorable, as soft tissue recession and 170
bone loss were highest among the tested materials [17]. 171
Properties of zirconium allow achieving good and stable clinical results. One of 172
the major justifications for zirconia as prosthetic material for implants restorations 173
is biocompatibility. This reason for zirconium oxide’s high biocompatibility is its 174
ability to evoke positive reaction of the host tissues. It has been suggested that the 175
biocompatibility is influenced by the following features of zirconia—chemical 176
composition, polishing properties, adhesion of fibroblasts, and bacteria. Zirconia is 177
an inert material, structurally stable, with almost no corrosion, producing side prod- 178
ucts, thus no threat to the host tissues. 179
Polishing properties are also very important to the maintenance of the peri-­ 180
implant tissues. It has been shown that it is possible to polish zirconia to a mirror-­ 181
AU10 like finish (Fig.  16). Many studies show that fibroblasts and epithelial cells have 182
better proliferation and retention to a polished zirconium surface when compared to 183
a rough one. Additionally, it has been shown that fibroblasts have better prolifera- 184
tion and adhesion to polished zirconia, while bacteria seem to be least attracted to 185
smooth zirconia. It has been shown clinically that zirconia-healing abutments 186
evoked less inflammation when compared to titanium. This leads to the conclusion 187
that this material is best material currently available for framework fabrication. 188
Although a systematic review did not confirm the superiority of zirconium abut- 189
ments for crestal bone preservation over titanium abutments, reaction of soft tissues 190
seem to be more favorable clinically. 191
To completely understand the role of framework and veneering materials on peri-­ 192
implant tissues, we need to look at the schematic picture of a screw-retained 193
restoration. 194
It is well known that vertical biologic width consists of connective tissue portion 195
(CT) and the epithelial attachment (JE). An overwhelming number of studies show 196
that the connective tissue is approximately 1 mm in length, despite the design of an 197
implant, depth of the placement, and roughness of the abutment. Therefore, it is 198
 T. Linkevicius and A. Puisys

199 rather constant figure. In contrast, the epithelial portion varies from 2–3 mm and is
200 formed of a small layer of epithelial cells. It has been shown that the apical part of
201 the epithelium is very thin and attaches to implant surface with hemidesmosome-­
202 like structures. Thus, if we are using titanium bases, which are 1 mm in height, we
203 have fibroblasts in contact with titanium, while there is no direct interaction between
204 zirconia and fibroblasts, as connective tissue is lined with epithelial cells that adhere
205 to zirconia surface via hemidesmosomes. This is very important to understand, as
206 majority of in vitro studies study interaction of Zr with fibroblasts, as in fact this
207 interaction usually does not occur intraorally. The zirconia in this design is only in
208 contact with epithelial cells.
209 Additionally, we must address the interaction between the framework and the
210 veneering materials. One of the common protocols is to completely cover the frame-
211 work with feldspathic porcelain. Screw retaining of the finished restoration on the
212 implant results in placement of the feldspathic veneering porcelain under the peri-­
213 implant mucosa (Fig.). If this protocol is followed, the zirconia framework is
214 blocked from the tissues by the veneering porcelain, and the reconstruction becomes
215 so called Zr02 without ZrO2, where no direct or only minimal contact between ZrO2
216 and soft tissues is achieved (Fig.).
217 Finally, patients do not receive the benefits of zirconia, as the major part of peri-­
218 implant tissues has contact with dental porcelain, which is much less biocompatible.
219 The rational for masking zirconia with feldspathic ceramics may be based on the
220 notion that ZrO2 can age and subsequently become weaker when confronted by oral
221 environment [10]. Therefore, veneering porcelain protects ZrO2 from contact with
222 saliva and precludes weakening of the material. However, recent studies do not
223 confirm the idea that saliva can make ZrO2 weaker with time [11]. Therefore it can
224 be speculated that if Zr2O screw-retained restoration is designed in the traditional
225 way, no difference in peri-implant soft tissue response will occur, compared to
226 metal-ceramic restorations, since biological properties of veneering porcelain for
227 zirconia and metal are the same.
228 The scaffold of such restorations can be divided into two areas: (1) peri-implant
229 tissue area with pure ZrO2 and (2) ceramic area, where only porcelain is applied
230 (Fig. 13.5). It is designed in such a manner that the veneering ceramics would start
231 only from emergence point of the restoration from peri-implant tissues and do not
232 go into the subgingival area. Subsequently feldspathic porcelain is layered on the
233 ZrO2 framework without touching the soft tissue area.
234 It could be suggested that this novel Zr2O screw-retained restoration, when zir-
235 conia is maximally exposed to peri-implant tissues, offers significant advantages,
236 compared to implant-supported crowns, which subgingival parts are covered with
237 veneering porcelain. The benefits of biocompatibility can be obtained only if soft
238 tissues have direct contact with zirconia. This is why we have less soft tissue reces- AU11
239 sion due to integration of the implant.
240 One of the restrictions to screw-retained restorations has been incorrect 3D implant
241 position because that usually results in an access hole through the facial surface of the
242 crown, which leaves aesthetically unacceptable results. Using custom-­milled abut-
243 ments and cemented restorations solves this problem. However, recent advances have
 13  Screw-Retained Implant Restorations in the Aesthetic Zone

made it possible to have screw-retained restoration with angulated access, thus avoid- 244
ing cemented solution. Angulated screw channel systems with a gimbaled screw/ 245
screwdriver construction, allowing an angulation of the screw channel and screw- 246
driver axis of up to 25°. This solution is not available for all implant systems. 247
In conclusion it can be stated that screw-retained restoration is viable solution for 248
prosthetic rehabilitation of implants in aesthetic region, if a cementless solution is 249
desired. 250

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 Author Queries
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