Retrospective Analysis of Prosthetic Complications of

Implant-Supported Fixed Partial Dentures After an

Observation Period of 5 to 10 Years
Burçin Vanlıoğlu, DDS, PhD1/Yaşar Özkan, DDS, PhD2/Yasemin Kulak-Özkan, DDS, Prof Dr3

Purpose: The purpose of this study was to evaluate the incidence of the most common technical problems
with implant-supported fixed partial dentures (FPDs) and to assess the survival and success rates (event-
free survival) after 5 to 10 years of function. Materials and Methods: All of the implants evaluated in
this study were from a single manufacturer (Institut Straumann). Follow-up examinations were scheduled
1 week after suprastructure placement, 6 months later, and annually thereafter. Prosthesis-based data
on survival/failure rates and technical complications were analyzed. Results: In 95 partially edentulous
patients, 231 Straumann implants were placed and restored with 177 implant-supported prostheses
(125 single crowns, 18 splinted crowns on two adjacent implants, and 34 three-unit FPDs). One hundred thirty-
one solid abutments and 100 synOcta abutments were inserted. The survival rate of prostheses supported
by implants was 97.7%. The prosthetic success rate (event-free survival) was 96.05%. After an observation
period of 5 years, the cumulative incidence of screw loosening was 0%. Fracture of the veneering porcelain
occurred in 3.95% of all restorations. Fractures of the superstructure framework were not observed. The
overall incidence of complications after 5 years was highest for splinted crowns, which showed the lowest
success rate (94.4%), followed by three-unit FPDs (96%) and single crowns (98.4%). Conclusions: Single-unit
restorations or short-span FPDs supported by both synOcta and solid abutments on Straumann implants
showed low rates of technical complications, the most common being fracture of the veneering porcelain. Int
J Oral Maxillofac Implants 2013;28:1300–1304. doi: 10.11607/jomi.2999

Key words: abutment, fixed partial dentures, implant, prosthetic outcome

T he use of dental implants is an established treat-

ment option for partially edentulous patients.1,2
Recent improvements in implant-supported fixed res-
torations for partially edentulous arches have resulted
in enhanced success rates.3,4 The longevity of pros-
thetic restorations on implants has been the subject of
1 Associate Professor, University of Marmara, Department of
Prosthetic Dentistry, Istanbul, Turkey.
2Professor, University of Marmara, Department of Oral Surgery,
Istanbul, Turkey.
3 Professor and Chairman, University of Marmara, Department
of Prosthetic Dentistry, Istanbul, Turkey.
Correspondence to: Dr Burçin Vanlıoğlu, University of
Marmara, Faculty of Dentistry, Department of Prosthodontics,
Büyükçiftlik Sokak No. 6, Güzelbahçe, 34365,
Nişantaşı, Istanbul, Turkey. Fax: +90-212-246-52-47.
Email: drburcinakoglu@hotmail.com
©2013 by Quintessence Publishing Co Inc.
numerous investigations.2–13 In earlier investigations,
only implant losses and thus the losses of crowns were
rated as failures.3,4 Clinical research activities in implant
dentistry have mainly focused on implant survival, and
the incidence of biologic and technical complications
has been addressed only to a minor extent. Technical
complications such as screw loosening, framework
fractures, and veneer fractures were usually ignored.
A more acceptable way of describing the susceptibil-
ity to complications is to report the complication-free
survival rate.2,12
There is still a lack of homogeneity in the dental
literature with regard to reporting complications at
both the implant and the prosthetic levels. A previous
systematic review showed that as many as 38.7% of
all implant-supported fixed partial dentures (FPDs) in
partially edentulous patients had some type of com-
plication during an observation period of 5 years.14
Pjetursson et al14 conducted a meta-analysis of the sur-
vival and complication rates of implant-supported FPDs
and reported a significantly lower 5-year risk of ceramic
fracture for tooth-supported versus implant-supported

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FPDs (2.9% versus 8.8%) and a 5-year failure rate for
implant-supported single crowns of 3.5%. They report-
ed that the incidence of prosthetic complications ap-
proached nearly 40% after 5 years. Kreissl et al recorded
a similar rate of incidence with respect to fracture of the
veneering porcelain (5.7% after an observation period
of 5 years).2 This highlights the importance of including
prosthetic outcomes in analyses of the overall success
of implant dentistry. Although the long-term success of
metal-ceramic crowns and FPDs in the natural dentition
is well established, the risk of failure for the implant-
supported prosthesis is less certain.
The synOcta abutment (Straumann) combines ta-
pered and octagonal shapes and offers a Morse ta-
per and repositioning. The impression is always taken
without an abutment and the dental technician works
directly on the actual components. Straumann solid
abutments have a Morse taper connection, and the im-
pression is taken over the inserted abutments. The null
hypothesis of the present study was that there would
be no difference between the patient-specific and
implant-specific variables as selected in terms of pre-
dicting prosthetic complications of implant-supported
restorations retained by two different types of abut-
ments. The purpose of this retrospective long-term
study was to assess the performance of implant-sup-
ported FPDs retained by solid or synOcta abutments
on Straumann implants by evaluating the incidence
of technical complications, namely screw loosening,
screw fracture, framework fracture, and fracture of ve-
neering material.
Material and Methods
Patient Selection
Information was given to each patient about treat-
ment options. All patients were treated at the Univer-
sity of Marmara (Istanbul, Turkey) in the departments
of oral surgery or prosthetic dentistry and signed the
appropriate informed consent form, which had been
approved by the institutional review board. All sub-
jects were also required to be at least 18 years old, able
to read and sign the corresponding informed consent
document, physically and psychologically able to toler-
ate conventional surgical and restorative procedures,
and willing to return for follow-up examinations as
outlined by the investigators. Exclusion criteria includ-
ed general health-compromising prognoses prohibit-
ing implant surgery, such as stroke, recent infarction,
severe bleeding disorders, diabetes, osteoporosis, or
cancer; a history of bruxism; or a surgical site with any
pathologic symptoms that might jeopardize the treat-
ment outcome.
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NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Vanlıoğlu et al
A number of patient-specific and implant-specific
variables were recorded. The type of restoration (single
crown, splinted crowns on two adjacent implants, or
three-unit FPD); number of supporting implants; type
of abutment; location in the dental arch; opposing
dentition (natural tooth, metal-ceramic restorations on
teeth, metal-ceramic restorations on implants, or acryl-
ic resin prosthetic teeth); type of occlusion (anterior
disclusion or group function); presence or absence of
bruxism; sex; and age were recorded for each patient.
To participate, patients needed to have an opposing
occlusion (natural teeth, FPD, or removable dentures).
Five of the patients had third molars distal to the im-
plants, but those teeth were not in occlusion.
Treatment and Follow-up
All of the implants evaluated in this study were from
a single manufacturer (Institut Straumann). Airborne
particle–abraded (sandblasted), large grit, acid-
etched (SLA) surfaces were used. All of the restora-
tions were fabricated by the same technician, who
was experienced with the fabrication of implant-sup-
ported restorations according to the manufacturer’s
instructions. Solid and synOcta abutments (Institut
Straumann) were used. A semiprecious alloy veneered
with feldspathic porcelain (VMK-95 Metal Keramik, Vita
Zahnfabrik) was used for all prostheses. The fit of the
restorations was checked with a light-body addition
silicone material (Affinis, Coltène/Whaledent) and ad-
justed as needed to ensure passive fit. The abutments
were tightened with the manufacturer’s torque driver.
The definitive metal-ceramic restorations were ce-
mented using a glass-ionomer luting agent (Fuji Plus,
GC). None of the implants were connected to natural
teeth. All of the implant-supported FPDs had rigid
connectors.
Follow-up examinations were scheduled 1 week af-
ter superstructure placement, 6 months later, and an-
nually thereafter.
Statistical Analysis
Success was defined as event-free survival. Survival and
success probabilities were predicted with Kaplan-Meier
estimates. An analysis was undertaken to characterize
both patient-specific and implant-specific variables and
to determine which variables might significantly pre-
dict complications. The data were listed and grouped
according to the type of superstructure and the type
of abutment. The statistical analyses included one-way
analysis of variance and post hoc multiple compari-
sons of the frequencies of technical failures and various
types of complications that occurred (P < .05).
The International Journal of Oral & Maxillofacial Implants 1301
Vanlıoğlu et al

Table 1  Implant-Related Parameters

Parameter No. Solid
1.0 + +
synOcta
Abutment type +
+ +
+ +
+ +
+

 Solid 131
0.8
 SynOcta 100

Survival rate
Superstructure type 0.6
  Single crown 125
  Splinted crown 18 0.4
  Three-unit FPD 34
0.2
Location and no. of implants
 Premolar 120 0
 Molar 111 5 6 7 8 9 10
Time (y)

Fig 1   FPD survival rate according to Kaplan-Meier estimate.

Table 2  Recorded Complications with Respect Table 3  Results of Comparative Analysis

to Jaw, Abutment Type, and Restoration Design Regarding Jaw, Restoration Type, and Abutment
Fracture, Source P value
No. of Fracture, restoration
incidents repaired replaced Corrected model .654

Jaw Intercept .000

 Maxilla 72 1 0 Jaw .281
 Mandible 105 2 4
Restoration type .999
Abutment type
 Solid 104 1 2 Abutment type .723
 SynOcta 73 2 2 Jaw × restoration type .995
Superstructure type Jaw × abutment .522
  Single crown 125 1 2
Restoration × abutment .398
  Splinted crown 18 1 1
  Three-unit FPD 34 1 1 Jaw × restoration × abutment .231
Multivariate analysis of variance.

Results was not observed. The overall complication incidence

Ninety-five partially edentulous patients (46 men and
49 women) with a mean age of 41.2 years participat-
ed in the study. In all, 231 Straumann implants were
placed, and they were restored with 177 implant-
supported restorations (125 single crowns, 18 splinted
crowns, 34 three-unit FPDs) (Table 1). No patient drop-
outs were experienced during the observation period.
A total of 131 solid abutments and 100 synOcta abut-
ments were used. The survival rate of the restorations
supported by implants was 97.7%. The success rate
(event-free survival) of the prostheses was 96.05%. The
cumulative incidence of screw loosening was 0%. Frac-
ture of the veneering porcelain occurred in 3.95% of
all FPDs. Fracturing of the superstructure framework
was highest for the splinted crowns, which showed
the lowest success rate (94.4%), followed by three-unit
FPDs (96%) and single crowns (98.4%). All of the resto-
rations showed only minor complications.
The FPD survival rate according to the Kaplan-Meier
estimate was 97.7% after a follow-up of 10 years (Fig 1).
One hundred seventy restorations remained free of any
complication and were rated as successful. There were
seven (3.95%) porcelain fractures of the implant-support-
ed restorations examined; three required repair and four
necessitated replacement of the restoration (Table 2).
No loose abutment screws or abutment fractures were
observed in the study. There were no statistically sig-
nificant differences with regard to type of abutments or
restorations, sex of the patient, or the jaw (Table 3).

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Discussion
In this study, low incidences of the surveyed techni-
cal complications were observed. With an FPD survival
rate of 97.7%, the results are well in line with those of
other investigations.6,7,14
In a systematic review, Pjetursson et al14 classified
technical complications into (1) major (eg, implant frac-
ture, loss of superstructure); (2) medium (eg, abutment
or abutment fracture, veneer or framework fracture, es-
thetic and/or phonetic complications); and (3) minor (eg,
abutment and screw loosening, loss of retention, loss of
screw hole sealing, veneer chipping [fixable via polish-
ing], and occlusal adjustments). They stated that, despite
the high survival rates of implant-supported FPDs (95%
after 5 years and 86.7% after 10 years), biologic and tech-
nical complications were frequent (38.7% after 5 years).
There are possible somatic causes that may account
for the differences in ceramic failure rates between res-
torations involving natural dentition versus those sup-
ported by implants, including the lack of neurologic
feedback and the absence of the periodontal reflex
mechanism as a protective mechanism in mastica-
tory force generation.12 Kinsel and Lin12 reported that
the risk of porcelain fracture of an implant-supported
metal-ceramic crown or FPD was greater than the risk
of fracture of the same types of prostheses supported
by the natural dentition. They also mentioned that
fractures were more frequent when the restoration op-
posed another implant-supported single crown or FPD
or when the patient had a bruxism habit.
A conventional review stated that technical com-
plications and failures frequently occur.14 Most of the
complications seemed to be associated with the oc-
clusal screws, followed by abutment screws and pros-
theses. Passive fit of a restoration plays a major role in
the long-term success and fracture of its components.
To minimize casting discrepancy and misfits, cementa-
tion of prostheses may be considered as an alternative
to screw retention. These complications are usually
more frequent in those with bruxism. Screw loosen-
ing could be minimized by cementation of the super-
structure.11,12 A systematic review of Pjetursson et al14
reported that, of the nine studies that reported on FPD
design, only 10% of FPDs were cemented and 90%
were screw retained. In the present study, all restora-
tions were cement retained to decrease cost, facilitate
fabrication, and prevent complications.
An implant-supported FPD with a short cantilever
extension (one tooth unit) is an acceptable restorative
therapy and might be considered as an alternative
to procedures that require more advanced surgery
(eg, sinus grafting) or for esthetic reasons. However, in
the present study, no restorations with mesial or distal
cantilevers were used.
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Vanlıoğlu et al
Porcelain fractures often occur as a result of insuf-
ficient support from the underlying framework, which
should be rigid enough to resist significant deforma-
tion under occlusal loads. Veneer failure can also be
caused by technical errors, such as incompatibility be-
tween an alloy and ceramic, poor alloy surface prepa-
ration, surface contamination, and improper ceramic
buildup or firing techniques. In this study there were
seven porcelain fractures among the 177 implant-sup-
ported restorations examined, which is consistent with
other reports.2,11,12 Of the fractures recorded, four re-
quired replacement of the restoration, a situation that
adversely impacts both the dentist and patient.
A limitation of this study was the inability to ac-
count for the potential influence of possible errors in
laboratory fabrication of the prostheses on porcelain
fracture.
In a systematic review, Sailer et al15 reported that
abutment fractures were rare, and the most frequent
technical complication was abutment screw loosening.
No abutment fractures were observed in the present
study. This may be a result of the attempts to provide
passive fit and ideal occlusion. Sailer et al15 compared
the rates of screw loosening found at abutments with
external and internal implant-abutment connections
and reported a trend toward fewer problems with in-
ternally connected abutments. In the present study,
all the implants and abutments had an internal-hex
connection. The abutments were tightened with a
torque driver of the manufacturer, and no abutment
screws loosened.
Conclusions
Fixed partial dentures supported by both synOcta and
Solid abutments on Straumann implants showed low
rates of technical complications.
Acknowledgment
The authors reported no conflicts of interest related to this study.
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