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Cemented versus screw-retained implant-supported single-tooth crowns: a

10-year randomised controlled trial

Article in European Journal of Oral Implantology · December 2012

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 RANDOMISED CONTROLLED CLINICAL TRIAL „ 355

Paolo Vigolo, Sabrina Mutinelli, Andrea Givani, Edoardo Stellini

Cemented versus screw-retained

implant-supported single-tooth crowns:
a 10-year randomised controlled trial
Paolo Vigolo, DMD,
MScD
Assistant Professor, Depart-
ment of Clinical Odonto-
Key words cement-retained crowns, dental implants, screw-retained crowns, single implant- stomatology, University of
Padua, Institute of Clinical
supported crowns Dentistry, Padua, Italy

Sabrina Mutinelli,
Purpose: The purpose of this randomised controlled trial was to compare the long-term clinical out- DMD
Private practice, Trento, Italy
come of cemented and screw-retained implant-supported single-tooth crowns.
Materials and methods: Eighteen consecutive patients presenting with single-tooth bilateral edentu- Andrea Givani, MD,
DDS
lous sites in the canine/molar region with adequate bone width, similar bone height at the implant Private practice, Vicenza,
sites, and an occlusal scheme that allowed for the establishment of identical occlusal cusp/fossa con- Italy

tacts were treated. Each patient received two identical implants according to a split-mouth design. Edoardo Stellini,
One side was randomly selected to be restored with a cemented implant-supported single crown, DMD
Professor and Chairman,
and the other was restored with a screw-retained implant-supported single crown. Outcome meas- Department of Clinical
ures were implant success, complications, marginal bone levels and peri-implant soft tissue health. Odontostomatology, Uni-
versity of Padua, Institute
Results: Ten years after initial loading, 2 patients moved away and were lost to follow-up. Two of Clinical Dentistry, Padua,
Italy
implants placed in the same patient failed 5 years after their insertion; the remaining 30 implants sur-
vived, resulting in a cumulative implant success rate of 93.7%. No complication occurred. The mean Correspondence to:
Paolo Vigolo
marginal bone resorption at 10 years after implant placement, measured on intraoral radiographs, Via Vecchia Ferriera, 13
was 1.1 ± 0.2 mm for both types of restorations. There were no statistically significant differences 36100 Vicenza, Italy
Fax: +39 0444 964545
between the two groups with respect to peri-implant marginal bone level at the 10-year follow-up Email: paolovigolo@virgilio.it
appointment (T2) (P = 0.58); at the 4-year follow-up appointment (T1) a statistically significant
difference was observed (P = 0.01), but this was not considered clinically relevant (mean difference:
-0.06 mm). The status of the soft tissue around the implants remained stable over the evaluation
period. No statistically significant difference was identified for the facial keratinised gingiva between
the two groups at T1 (P = 0.10) or at T2 (P = 0.07).
Conclusions: Within the limitations of this study, the results indicate that there was no evidence of a
significant difference in the clinical behaviour of the peri-implant marginal bone or of the peri-implant
soft tissues when cemented or screw-retained single-tooth implant restorations were provided.

Conflict-of-interest statement: The authors declare that they do not have any conflict of interest and
that they purchased all of the materials used in the study.

Eur J Oral Implantol 2012;5(4):355–364

356 „ Vigolo et al Cemented versus screw-retained implant-supported crowns
„ Introduction
Prosthetic reconstruction involving endosseous
implants can include screw-retained or cement-
retained restorations, or both1,2. The choice of
cementation versus screw retention seems to be
mainly based on the clinician’s preference3. Some
authors have advocated that the screw-retained
prosthesis, as established by Adell and coworkers4,
offers retrievability and more stability and security at
the implant–abutment prosthetic interface5-11. Dur-
ing the life of an implant prosthesis, the clinician
may need to remove the restoration for hygiene,
repairs and abutment screw tightening12, and screw-
retained designs make all of these procedures easily
achievable. Screw-retained restorations, however,
require precise implant placement for optimal loca-
tion of the screw access hole; deviations from the
optimal position and angulation can lead to an
unaesthetic restoration13.
Many authors have emphasised the advan-
tages of the cement-retained prosthesis, including
its greater versatility for aesthetics and simplicity of
the technique14-18. Another advantage might be the
potential for complete passivity when a cemented
restoration is placed on the implants19,20. The
absence of a screw to draw inadequately fitting com-
ponents together with a clamping force would be
likely to eliminate strain that the tightening force of
the screw would introduce into the restoration/im-
plant assembly. This potential advantage, together
with the others mentioned, has made cement-
retained implant restorations increasingly popular3.
Some authors still stress the importance of main-
taining the retrievability of cement-retained implant
restorations21. For this purpose, provisional cement
is commonly used. Unfortunately, it is probable that
a cement that functions well as a provisional cement
for restorations cemented to teeth may indeed be
a permanent luting agent for metal cemented to
metal22. Because of the clinical abutment height,
implant crowns retained by temporary cement can
be very difficult to remove23. Should an abutment
screw loosen or any repair become necessary, the
restoration may be damaged during the removal
procedure if the cement seal cannot be broken easily.
Prestipino et al24 and Bastos Valbao et al25 intro-
duced two similar slot designs to be used during
Eur J Oral Implantol 2012;5(4):355–364
the fabrication of custom implant abutments and
followed through to the definitive prosthesis. Their
techniques would allow the clinician to remove the
cemented crown in a simpler and safer way. The
introduction into the market of components that
require infrequent abutment screw tightening26-29
have reduced the need to retrieve cement-retained
implant restorations.
Various studies have reported on the predict-
ability of single implant restorations30-36. However,
there is a paucity of articles comparing the cemented
and the screw-retained approaches. In a previous
4-year follow-up of the current study, the results on
a group of 12 patients indicated that there was no
evidence of a clinically relevant difference in behav-
iour of the peri-implant marginal bone or of the peri-
implant soft tissue when cemented or screw-retained
single-tooth implant restorations were provided37. A
systematic review38 evaluated the scientific evidence
on the effect of prosthodontic design features on
the long-term outcomes of implant therapy in par-
tially edentulous patients. For the method of reten-
tion (screw-retained versus cemented), data were
obtained that were not sufficiently consistent to pro-
vide reliable conclusions. Jemt39 compared, with a
retrospective study design on a group of 35 patients,
the clinical and radiographic performance of single-
implant crowns made by either directly baked porce-
lain onto custom-made TiAdapt titanium abutments
(Nobel Biocare AB, Göteborg, Sweden) (test) or
cement crowns onto CeraOne (Nobel Biocare AB)
abutments (control) after 10 years in function. He
did not find clear clinical or radiographic differences
between the test and control single-implant restor-
ations during 10 years of follow-up.
In a recent article, Nissan and coworkers40 com-
pared the long-term outcome and complications
of cemented versus screw-retained implant restor-
ations in partially edentulous patients. Thirty-eight
consecutive patients (16 male and 22 female) with
bilateral partial posterior edentulism comprised this
study group. Implants were placed, and cemented or
screw-retained restorations were randomly assigned
to the patients in a split-mouth design. Follow-up
(up to 15 years) examinations were performed every
6 months in the first year and every 12 months in
subsequent years. The mean age of the patients was
58 ± 6 years (range, 38 to 70 years). A total of 221
 Vigolo et al Cemented versus screw-retained implant-supported crowns
internal-hex implants (104 in the maxilla, 117 in the
mandible) were placed. All 221 implants survived
the second surgical phase and loading with the de-
finitive restoration. All patients regularly returned to
the clinic for recall for up to 15 years. No implant
failures were reported during the follow-up period.
The mean follow-up periods were 66 ± 47 months
for the screw-retained restorations (range, 18 to 180
months) and 61 ± 40 months for the cemented res-
torations (range, 18 to 159 months). Ceramic frac-
ture, abutment screw loosening, metal frame fracture,
gingival index (GI) and marginal bone loss were evalu-
ated and recorded at each recall appointment. Follow-
up examinations revealed that the long-term outcome
of cemented implant-supported restorations was
superior to that of screw-retained restorations, both
clinically and biologically. Ceramic fracture occurred
at a statistically significantly higher rate in screw-
retained (38% ± 0.3%) than in cement-retained
(4% ± 0.1%) restorations (P < 0.001). Abutment
screw loosening occurred statistically significantly
more frequently in screw-retained (32% ± 0.3%)
than in cemented (9% ± 0.2%) restorations
(P = 0.001); furthermore abutment screw loosen-
ing occurred in most (86%) cases that presented with
ceramic fractures. There were no metal frame frac-
tures for either type of restoration. The mean GI was
statistically significantly higher for screw-retained
(0.48 ± 05) than for cemented (0.09 ± 0.3) restor-
ations (P < 0.001). The mean marginal bone loss
(MBL) at the end of the observation period was simi-
lar (1.4 ± 0.6 mm) for both mesial and distal sides of
the screw-retained restorations. The mean MBL was
similar for both sides of the cemented restorations
(0.69 ± 0.5 mm) and statistically significantly lower
than that seen for the screw-retained restorations
(P < 0.001). There was no statistically significant
influence (P > 0.05) of the different implant types on
biologic or biomechanical complications.
Cutrim et al used the Pink Esthetic Score (PES)
to evaluate gingival aesthetics around implants in
the anterior maxilla rehabilitated with cemented or
screw-retained prosthesis41. Forty implants placed in
the anterior maxilla, and rehabilitated with prosthetic
crowns for a minimum period of 1 year, were evalu-
ated. The study showed that the type of crown reten-
tion did not influence the health and quality of the
soft tissues around implants. The survival and success
„ 357
of screw- versus cement-retained implant crowns
over a 5-year period was evaluated in a multi-centre
prospective cohort study, consisting of patients who
had one or more dental implants placed and restored
in the anterior maxilla42. Information was collected
for 102 patients who had 214 implants placed during
the study period. Outcome measures were modified
plaque index (MPI), sulcular bleeding index (SBI),
keratinised mucosa and gingival levels, and a subjec-
tive measurement of aesthetic quality. Restorative
outcome variables were subjectively evaluated by
the treating clinicians and included retention, stabil-
ity and aesthetics. The results of that study showed
that for the majority of clinician- and patient-assessed
success parameters, screw- and cement-retained res-
torations were equivalent in the anterior maxilla.
The purpose of this randomised controlled trial was
to compare cemented and screw-retained implant-
supported single-tooth crowns up to 10 years after
prosthetic rehabilitation. This study was reported fol-
lowing the consort statement (http://www.consort-
statement.org/)43. One previous article describing
materials and results of the first 12 patients of the
same studied group has been published37.
„ Materials and methods
During the years 1998 to 2002, 18 consecutive
patients were recruited and treated from a patient
population attending the Implantology Department
at the University of Padua, according to the follow-
ing criteria:
t
no systemic contraindication for oral surgical
therapy
t
single-tooth bilateral edentulous sites in the
canine/premolar/molar region
t
presence of adequate bone width precluding the
need for bone augmentation procedures
t
similar bone height at the implant sites allowing
for the placement of implants of identical height
and diameter
t
occlusal scheme allowing for the establishment
of identical occlusal cusp-fossa contacts.
The study was approved by the Clinical Medical Ethi-
cal Committee of the University of Padua, Medical
and Dental School (Prot. 128/1997). A randomised
Eur J Oral Implantol 2012;5(4):355–364
358 „ Vigolo et al Cemented versus screw-retained implant-supported crowns

Table 1 Distribution of single-tooth edentulous sites treated with implants. „ Prosthetic procedures

Location No. of implants for No. of implants At second-stage surgery, 4 months after placement
cemented single-tooth for screw-retained of the implants, titanium healing caps were con-
crowns single-tooth crowns
nected. The final impression was made 3 weeks after
Maxillary canine region 3 3
second-stage surgery, and a single impression served
Maxillary premolar region 3 3
for both implants of each patient45. For the impres-
Mandibular premolar region 5 5
sion phase, 2 mm-thick custom impression trays were
Mandibular molar region 7 7
fabricated with Palatray LC resin (Heraeus Kulzer,
Wehrheim, Germany) mixed in accordance with the
manufacturer’s instructions. The impression trays
Table 2 Dimensions of implants used.
had two windows to allow access for both coping
Dimensions (diameter × length) No. of implants for No. of implants
screws and were previously coated with Impregum
cemented single- for screw-retained polyether adhesive (ESPE Dental-Medizin, Seefeld,
tooth crowns single-tooth crowns Germany). Prior to every impression procedure,
3.75 × 11.5 mm (OSS 311) 2 2 a square impression coping (pick-up type; 3i/Im-
3.75 × 13.0 mm (OSS 313) 5 5 plant Innovations) was secured to the implant. The
3.75 × 15.0 mm (OSS 315) 5 5 impression material was machine-mixed (Pentamix;
4.00 × 13.0 mm (OSS 413) 5 5 ESPE), and part of it was meticulously syringed all
4.00 × 15.0 mm (OSS 415) 1 1 around the impression coping to ensure complete
coverage of the coping itself. Five minutes were
allowed for setting of the impression material, after
which the coping screws were unscrewed and the
controlled trial of split-mouth design was carried impressions removed. An implant replica (3i/Implant
out44. At the end of the first visit, each patient Innovations) was screwed on top of the impression
was asked to flip a coin twice: with the first flip, coping, and the impression was poured with type
the type of implant-supported single-tooth crown IV artificial stone (New Fujirock; GC Corporation,
was decided (cemented or screw-retained); with the Tokyo, Japan) following the manufacturer’s instruc-
second flip, the edentulous site was chosen (right or tions. All laboratory procedures were performed by
left). All patients were informed about the purposes the same technician. Thirty-six gold machined UCLA
and the details of the study and their consent was abutments were used (SGUCA1C; 3i/Implant Inno-
obtained prior to implant placement. vations). All prostheses were provided by the same
prosthodontist.
In the cemented crowns group, custom screwed
„ Implant placement
abutments were fabricated for all 18 implants. The
A single clinician performed all clinical procedures gold UCLA-type abutments were screwed on top of
(surgical and restorative). Thirty-six cylindrical the implant replicas using waxing posts and wax was
external-hexagon implants (3i/Implant Innovations, added directly to the gold cylinders following standard
Palm Beach Gardens, FL, USA) were positioned waxing procedures. The total occlusal convergence
using a two-stage surgical technique. The implant (TOC) angle of the abutments was 12 degrees. The
diameter was 3.75 mm for mandibular sites and 4.0 waxed-up cylinders were then invested in a carbon-
mm for maxillary sites. The edentulous sites treated free phosphate-bonded investment (Ceramicor; Cen-
and the length and diameter of the implants used dres & Métaux, Biel-Bienne, France) and cast using a
are summarised in Tables 1 and 2. The surgeries, all noble alloy (Al Med; Cendres & Métaux). The custom
of which were performed by the same practitioner, abutments were screwed on top of the implants in
were carefully accomplished with the guidance of the patients’ mouths using a gold screw (Gold-Tite;
a template to decrease the risk of damage to the 3i/Implant Innovations) and a torque wrench cali-
adjacent teeth roots. brated at 30 Ncm (Torque Driver CATDO; 3i/Implant

Eur J Oral Implantol 2012;5(4):355–364

 Vigolo et al Cemented versus screw-retained implant-supported crowns „ 359

Innovations); regular porcelain-fused-to-metal de- Fig 1 Master cast with

a cemented implant-
finitive crowns with porcelain occlusal surfaces were supported single tooth
fabricated. A noble alloy (Valcambi, Balerna, Swit- crown (left side) and a
screw-retained implant-
zerland) was used for the metal copings and porce- supported single tooth
lain (Noritake EX-3; Noritake, Nagoya, Japan) was crown (right side).
applied in layers to them. The occlusal surfaces of
the restorations were designed to avoid premature
contacts during lateral and protrusive movements. All
definitive restorations were cemented with temporary
cement (Temp Bond NE; Kerr Italia, Scafati, Salerno,
Italy) and the crowns were loaded with cement using
a spatula (Figs 1 and 2a).
In the screw-retained crowns group, gold UCLA
type abutments were screwed on top of the implant
replicas using waxing posts and wax was added
directly to the gold cylinders following standard
waxing procedures. The waxed-up cylinders were
then invested in a carbon-free phosphate-bonded
investment (Ceramicor; Cendres & Métaux) and cast
using a noble alloy (Valcambi). Porcelain (Noritake
EX-3; Noritake) was applied in layers to the cast
abutments, carved and then baked according to the
manufacturer’s recommendations. The occlusal sur-
faces of the restorations were designed to avoid pre-
mature contacts during lateral and protrusive move-
ments. Definitive crowns were screwed on top of the
implants in the patients’ mouths using a gold screw
(Gold-Tite; 3i/Implant Innovations) and a torque
wrench calibrated at 30 Ncm (Torque Driver CATDO;
3i/Implant Innovations). The screw access holes on
the occlusal surfaces of the restorations were closed Fig 2a Occlusal view of the cemented Fig 2b Occlusal view of the screw-
with composite resin (Tetric Ceram; Ivoclar Vivadent, implant-supported single-tooth crown. retained implant-supported single-tooth
crown.
Schaan, Liechtenstein) (Figs 1 and 2b).

visually and manually detected by percussing

„ Follow-up procedures and outcome
measures
After prosthetic treatment, a follow-up program was
designed for all patients. This provided the opportu-
nity to check the patients every 3 months in the first
year, every 6 months in the subsequent 4 years and
every 12 months in the subsequent 6 years. Out-
come measures were:
t
Implant failure: the implant survival was judged
on absence of painful symptoms or paraesthe-
sia, absence of peri-implant radiolucency during
radiographic evaluation and clinical absence of
mobility46. The clinical absence of mobility was
them vertically and horizontally with a metallic
instrument and obtaining a nice ‘crystal’ sound
for both. No electronic devices were used to
monitor initial degrees of implant mobility.
t
Any biological or prosthetic complications.
t
Peri-implant soft tissue health: supragingival
plaque was assessed with the Lindquist scale
(score 0: no visible plaque; score 1: local plaque
accumulation; score 2: general plaque accumu-
lation greater than 25%)47; gingival inflamma-
tion with the simplified GI proposed by Apse et al
(score 0: normal mucosa; score 1: minimal inflam-
mation with colour change and minor oedema;

Eur J Oral Implantol 2012;5(4):355–364

360 „ Vigolo et al Cemented versus screw-retained implant-supported crowns
Fig 3 The digital
micrometer used with
a probe to measure the
amount of peri-implant
keratinised gingiva.
score 2: moderate inflammation with mucosal
margin redness, oedema, and glazing; score 3:
severe inflammation with redness, oedema,
ulceration, and spontaneous bleeding without
probing)48; bleeding on probing; amount of peri-
implant keratinised gingiva measured with a probe
and a digital micrometer (Model 293, Mitutoyo,
Tokyo, Japan) (see Fig 3: each measurement was
made from the gingival margin to the mucogingi-
val junction); and probing depth from the gingival
margin. Ten years after implant placement, at the
last follow-up appointment, all patients were seen
and periodontal parameter data were compiled
on the peri-implant mucosal response (records
for four surfaces of each restoration type). All
cemented crowns were carefully removed using
GC removal pliers (Type KY; GC Corporation) to
avoid damaging the porcelain. The custom posts
and the screwed crowns were unscrewed to allow
measurement of the mucosal channel; a periodon-
tal probe was used to record the length from the
marginal gingiva to the head of the implant.
t
Bone levels were assessed on radiographic films
using a 6× magnifying lens and measurements
were rounded to the nearest 0.1 mm. The base-
line measurement of the marginal bone levels was
recorded at the time of definitive prosthetic res-
toration insertion. The apical end of the smooth
collar of the implants was considered the coronal
reference point while the crestal bone level was
considered the apical reference point. Once a
year, intraoral radiographic examinations were
performed (see Figs 4a, 4b, 5a and 5b) using
the paralleling technique and an adjusted film-
holding device. This device was designed to con-
trol imaging geometry by consistently placing the
films at a standard distance from the x-ray cone,
parallel to the long axis of the implant and perpen-
dicular to the central ray and allowed standardi-
Eur J Oral Implantol 2012;5(4):355–364
sation of consecutive radiographs (Fig 6)30,49-54.
All radiographic measurements were performed
by the same investigator who was not involved
in patient treatment and ignored if a crown was
cemented- or screw-retained. Radiographic
measurements were performed at the time of de-
finitive prosthetic restoration insertion (T0), after
4 years from the final delivery (T1) and at the last
follow-up appointment 10 years after implant
placement (T2), always by the same assessor.
„ Methodological aspects
All data were statistically analysed with STATA 11
(StataCorp, College Station, TX, USA) to determine
whether there was a significant difference in peri-
implant marginal bone levels and soft tissue param-
eters between the cemented and the screw-retained
implant-supported single crowns using a paired t test.
To compare the pre-treatment and the post-treat-
ment measures (T0 = at the time of definitive crown
insertion; T1 = at the 4-year follow-up appointment;
and T2 = at the 10-year follow-up appointment) the
paired t test was applied. The missing values of the
patient lost to the last follow-up (T2) were substi-
tuted with her measures recorded at T1. The _ level
of significance was selected at 0.05. No sample size
calculation was performed.
„ Results
The study ended at the time of the 10-year follow-up
appointment of the last patient. At implant place-
ment, patient age ranged from 27 to 42 years (mean
age 33); 10 patients were females and 8 males. Six-
teen patients completed the study; 2 patients moved
to different cities and did not respond to repeated
attempts to contact them to schedule regular follow-
up appointments after the definitive crown insertion
phase: they were lost to follow-up. Two implants
placed in the same patient in type 3 bone (maxil-
lary second premolar region) failed 5 years after their
insertion. The patient refused another implant pro-
cedure and she was treated with two partial cov-
erage three-unit fixed restorations. The remaining
30 implants were successful. During the surgeries,
the postoperative periods and at the follow-up visits,
 Vigolo et al Cemented versus screw-retained implant-supported crowns „ 361

Fig 4a Radiographic view of the cemented implant- Fig 4b Radiographic view of the cemented implant-
supported single-tooth crown at the time of abutment and supported single-tooth crown at the 10-year follow-up
prosthetic restoration insertion. appointment.

Fig 5a Radiographic view of the screw-retained implant- Fig 5b Radiographic view of the screw-retained implant-
supported single-tooth crown at the time of abutment and supported single crown at 10-year follow-up appointment.
prosthetic restoration insertion.

no patient showed any biological complications such Fig 6 The individual

resin stent (Duralay, Reli-
as mucosal recession, peri-implantitis, peri-implant ance Dental Manufac-
mucositis, fistula, or any prosthetic complications turing, Worth, IL, USA)
used with the long-cone
such as loosening of the custom screwed abutment or technique designed to
the screwed crown, fracture of the porcelain, or loos- control imaging geom-
etry by consistently
ening of provisionally cemented definitive crowns. placing the films at a
The mean marginal bone resorption at 10 years standard distance from
the x-ray cone.
after implant placement was 1.1 ± 0.2 mm for
both types of restorations. The difference between
the two groups was significant at T1 (at the 4-year
follow-up appointment; P = 0.01) and not at T2
(at the 10-year follow-up appointment; P = 0.58).
However, this statistically significant difference at T1
(mean difference: -0.06 mm) was considered not to (general plaque accumulation greater than 25%)
be clinically relevant (Table 3). was present on 14% of the considered surfaces on
The status of the soft tissue around crowns and both types of restorations, and gingival inflammation
adjacent teeth remained stable over the evaluation involved 4.7% of the cemented crowns and 4.5% of
period. Dental plaque at score 2 of the Lindquist scale the screw-retained crowns at score 1 of the simplified

Eur J Oral Implantol 2012;5(4):355–364

362 „ Vigolo et al Cemented versus screw-retained implant-supported crowns

Table 3 Amount of keratinised facial attached gingiva and of marginal bone resorption for cemented and screw-retained
single-tooth crowns (paired t test).

Cemented single- Screw-retained Difference Level of

tooth crowns single-tooth crowns significance (P)
(n = 16) (n = 16)
Time Mean (SD), mm Mean (SD), mm (95% CI), mm
Facial keratinised T0 1.84 (1.18)§ 1.73 (1.13)§
gingiva T1 1.67 (1.23) 1.55 (1.14) 0.12 (-0.03 to 0.26) 0.10
T2 1.61 (1.23) 1.49 (1.13) 0.12 (-0.009 to 0.26) 0.07
Marginal bone T1 0.78 (0.23) 0.83 (0.20) -0.06 (-0.10 to -0.01) 0.01*
resorption T2 1.11 (0.20) 1.12 (0.20) -0.01 (-0.06 to 0.03) 0.58

*Statistically significant difference judged to not be clinically relevant.

§This data included two patients lost to follow-ups after the definitive crown insertion phase (n = 18).
T0 = definitive crown insertion; T1 = 4-year follow-up; T2 = 10-year follow-up

GI scale proposed by Apse et al (minimal inflamma-
tion with colour change and minor oedema).
The facial keratinised gingiva, measured with a
probe and a digital micrometer, was 1.6 ± 1.2 mm
at the 10-year follow-up appointment for cemented
implant-supported single-tooth crowns and
1.5 ± 1.1 mm for the screw-retained implant-
supported single-tooth crowns. No statistically
significant difference was identified for the facial
keratinised gingiva between the two groups at T1
(P = 0.10) or at T2 (P = 0.07) (Table 3).
A mean probing depth of 3.1 mm was recorded
for both types of restorations, the mucosal canal
measurements were the same as probing and 6.9%
of sites had bleeding on probing for both types of
restorations.
„ Discussion
This 10-year randomised controlled trial provided
the results from 32 implants (16 patients) used for
single-tooth crowns retained with either cement or
screws. The comparison of these two types of res-
torations with respect to peri-implant marginal bone
levels, peri-implant soft tissue, and biological and
prosthetic complications did not reveal any clinically
different outcome at the end of the evaluation period.
A mean probing depth of 3.1 mm was recorded for
both types of restorations, which is less than that
reported in other studies30,55,56. No screw loosening
was found with either the cemented crowns or the
screw-retained crowns. In Table 3, it can be observed
that there was a statistically significant difference
between the two groups with respect to peri-implant
marginal bone level at the 4-year follow-up appoint-
ment (P = 0.01), however this difference was mini-
mal (mean difference: -0.06 mm) and for this reason
it was not considered clinically relevant.
Two implants placed in the same patient failed 5
years after their insertion; the patient was a female
who received two implants in the second maxil-
lary premolar regions at the age of 35. The patient
refused another implant procedure and she was
treated with two partial coverage three-unit fixed
restorations (from first premolar to first molar). The
remaining 30 implants survived, resulting in a cumu-
lative implant success rate of 93.7% at the end of
10 years of function, a result that is similar to results
reported by other authors30-36.
Screw-retained implant restorations may have
the advantage of predictable retrievability, but they
demand precise placement of the implant for optimal
location of the screw access hole. Deviation from
this optimal direction can lead to an unaesthetic res-
toration if screw retention is used. Screw-retained
implant restorations may also present a screw access
opening that can weaken the porcelain around the
openings and at the cusp tips, resulting in unstable
occlusal contacts.
One limitation of this study was that the TOC
angle of the abutments of the included cemented
restorations was 12 degrees. Further studies should
be performed to compare the effect of different
TOCs on the success of cement-retained implant-
supported restorations56.

Eur J Oral Implantol 2012;5(4):355–364

 Vigolo et al Cemented versus screw-retained implant-supported crowns
Cementation of implant restorations eliminates
unaesthetic screw access holes and problems related
to the development of stable occlusal contacts. With
the introduction of more precise abutments, which
improve abutment-to-implant fit26-29, the argu-
ments against cementation (i.e. fear that the abut-
ment complex may loosen) may be questioned. In
the present study, these more precise components
were used, which, with careful and selective equili-
bration to achieve optimal occlusion and the avoid-
ance of contact in lateral and protrusive movements,
may also explain the lack of complications related to
screw loosening during this investigation. Accurate
evaluation of the occlusal scheme and the provision
of appropriate variations to the occlusal contacts,
both static and dynamic, may also explain the lack
of prosthetic complications, such as porcelain frac-
ture and loosening of provisionally cemented defini-
tive crowns. Furthermore, it should be noted that
cemented crowns require particular attention to the
removal of all subgingival cement at the cementa-
tion phase, so that problems associated with peri-
implant gingival tissues may be prevented37,57. In this
study, only one type of cementation was used: all
crowns were loaded with cement using a spatula. In
a recent article it was emphasised that in the current
literature there is a lack of consensus regarding the
type of cement, the appropriate quantity of cement
and the placement method for a cement-retained
implant crown (e.g. gross application of the cement
with a regular spatula, brush-on application and mar-
gin application)58. It should also be emphasised that
in this study only external-hexagon implants were
used. Further studies should be performed to assess
the behaviour of internal connection implants when
cemented or screw-retained implant-supported sin-
gle-tooth crowns are used.
„ Conclusions
There was no evidence that one method of retention
was superior to another in this limited patient popu-
lation, therefore the choice of cementation versus
screw retention seems to be primarily related to the
clinician’s preference.
„ 363
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