Review Article

Phoebus Tsaousoglou The effect of rigid and non-rigid

Konstantinos Michalakis
Kiho Kang
connections between implants and
Hans-Peter Weber teeth on biological and technical
Anton Sculean
complications: a systematic review
and a meta-analysis

Authors’ affiliations:
Phoebus Tsaousoglou, Anton Sculean, Department
of Periodontology, School of Dental Medicine,
University of Bern, Bern, Switzerland
Konstantinos Michalakis, Department of
Prosthodontics, School of Dentistry, Aristotle
University of Thessaloniki, Thessaloniki, Greece
Kiho Kang, Hans-Peter Weber, Konstantinos
Michalakis, Department of Prosthodontics, School
of Dental Medicine, Tufts University, Boston, MA,
USA
Corresponding author:
Phoebus Tsaousoglou, Department of
Periodontology,
School of Dental Medicine, University of Bern
Freiburgstrasse 7, CH-3010 Bern, Switzerland
Tel.: +41 31 632 25 89
Fax: +41 31 632 49 15
e-mail: phtsaouso@yahoo.com
Key words: attachment, biological complication, dental implant, non-rigid connection, partial
FDP, rigid connection, survival, technical complication, tooth–implant connection
Abstract
Objective: To assess survival, as well as technical and biological complication rates of partial fixed
dental prostheses (FDPs) supported by implants and teeth.
Method: An electronic Medline search was conducted to identify articles, published in dental
journals from January 1980 to August 2015, reporting on partial FDPs supported by implants and
teeth. The search terms were categorized into four groups comprising the PICO question. Manual
searches of published full-text articles and related reviews were also performed.
Results: The initial database search produced 3587 relevant titles. Three hundred and eighty-six
articles were retrieved for abstract review, while 39 articles were selected for full-text review. A
total of 10 studies were selected for inclusion. Overall survival rate for implants ranged between
90% and 100%, after follow-up periods with a mean range of 18–120 months. The survival of the
abutment teeth was 94.1–100%, while the prostheses survival was 85–100% for the same time
period. The most frequent complications were “periapical lesions” (11.53%). The most frequent
technical complication was “porcelain occlusal fracture” (16.6%), followed by “screw loosening”
(15%). According to the meta-analysis, no intrusion was noted on the rigid connection group,
while five teeth (8.19%) were intruded in the non-rigid connection group [95% CI (0.013–0.151)].
Conclusion: The tooth–implant FDP seems to be a possible alternative to an implant-supported
FDP. There is limited evidence that rigid connection between teeth and implants presents better
results when compared with the non-rigid one. The major drawback of non-rigidly connected FDPs
is tooth intrusion.

Date:
Accepted 7 May 2016
To cite this article:
Tsaousoglou P, Michalakis K, Kang K, Weber H-P, Sculean A.
The effect of rigid and non-rigid connections between
implants and teeth on biological and technical complications:
a systematic review and a meta-analysis.
Clin. Oral Impl. Res. 28, 2017, 849–863.
doi: 10.1111/clr.12890
The biomechanical differences between natu-
ral teeth and implants have been recognized
in the early 1980s. However, connection
between teeth and implants has been advo-
cated as an alternative method for provision
of prosthetic reconstructions when anatomi-
cal restrictions or financial limitations are
present, or when splinting of periodontally
involved teeth with practically ankylosed
implants is desired (Ericsson et al. 1986;
Richter 1989; Rangert et al. 1991, 1995;
Gross & Laufer 1997; Fugazzotto et al. 1999;
Lindh et al. 2001b). This approach was pro-
posed both for short-span fixed partial den-
tures and full-arch fixed prostheses (Cordaro
et al. 2005).
A key factor in a tooth–implant (T-I) fixed
prosthesis is the difference in mobility
between the tooth and the osseointegrated
implant. It has been demonstrated in the past
that natural teeth have a normal micromobil-
ity because of the presence of the periodontal
ligament (M€ uhleman 1951a,b). It has been
found that teeth mobility is around 10 times
greater than the mobility of the implants, if
it is assumed that an “ankylosed” implant
has a micromobility (Lukas et al. 1980;
Cohen & Orenstein 1994). Implant’s lack of
mobility is referred to the direct and func-
tional integration of the superficial layer of
bone with the implant surface, which has
been defined as “osseointegration” or

© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd 849
Tsaousoglou et al
Outcomes of teeth/implants connections
“functional ankylosis” (Br anemark et al.
1969; Schroeder et al. 1976, 1981).
The need for retrievability that implant
prostheses should possess and the danger of
microleakage and recurrent decay that natu-
ral teeth – serving as abutments – have, com-
plicates the implant–tooth connection.
Therefore, the prosthesis should be defini-
tively cemented on the tooth, permitting at
the same time access to the implant if a need
arises in the future. This can be accom-
plished by either using telescopic crowns or
attachments. Both of these connections can
be rigid or non-rigid depending on whether a
locking screw is used or not. Both connec-
tions have advantages and disadvantages, and
a debate has arisen as to which one of these
two types of attachment is superior to the
other, regarding the survival/success and fail-
ure rates of fixed dental prostheses (FDPs),
the marginal bone loss around implant and
tooth, the phenomenon of tooth intrusion, as
well as the technical and mechanical compli-
cations.
Tooth–implant FDPs have been shown to
be a successful therapeutic modality (Eric-

sson et al. 1986; Astrand et al. 1991; Cavic-
chia & Bravi 1994; Fugazzotto et al. 1999;
Hosny et al. 2000; Lindh et al. 2001a). Previ-
ous studies comparing implant–implant (I-I)
and tooth–implant FDPs have demonstrated
comparable results regarding the technical
and biological complications between these
two treatments (Ericsson et al. 1986; van

Steenberghe 1989; Astrand et al. 1991; Gunne
et al. 1992; Olsson et al. 1995; Br€agger et al.
2001). Naert et al. (2001a) have concluded
that the cumulative success rate for the free-
standing implant and the tooth–implant-con-
nected FDPs was 98.4% and 94.9%,
respectively, without reaching a statistically
significant difference. However, there are
studies with different and discordant results
(Hosny et al. 2000; Naert et al. 2001b). It
seems that the rate of prosthetic (technical)
complications is affected by the type of pros-
thesis attachment (rigid/non-rigid), with a
higher rate occurring in non-rigid connection,
and by the type of fixation system (screw
retained/cemented), with a higher rate seem-
ing to occur in non-rigid screw-retained pros-
theses (Nickenig et al. 2006). These
complications include tooth intrusion;
implant and teeth bone loss; implant and
teeth mobility; prosthetic and/or abutment
screw loosening; screw, abutment and
implant fractures; abutment and/or frame-
work deformation; veneering and/or frame-
work fracture; and decementation.
850 | Clin. Oral Impl. Res. 28, 2017 / 849–863
Generally, most authors conclude that they
prefer the rigid connection (Olsson et al.
1995; Gross & Laufer 1997; Lindh et al.
2001b; Naert et al. 2001a,b; Block et al. 2002;
Tangerud et al. 2002; Lang et al. 2004;
Cordaro et al. 2005) as intrusion of teeth has
been shown to occur more often with non-
rigid connections (Block et al. 2002; Lang
et al. 2004). Additionally, promising evidence
from an animal study showed that the rigid
tooth–implant connection has no detrimental
effects on the periodontium of the tooth
(Pesun et al. 1999). Nevertheless, greater
bone loss around implants has been demon-
strated with rigid tooth–implant connection
(Naert et al. 2001a).
Both the rigid and non-rigid methods of
connection between teeth and implants have
been employed in the past. However, their
efficacy has not been thoroughly evaluated.
Therefore, the decision as to which method
of connection should be adopted is some-
times difficult and very often a matter of per-
sonal preference and cost, than of scientific
evidence. In order for the clinicians to be able
to employ both methods, rigid and non-rigid
connections need to exhibit similar results.
The purpose of this systematic review,
therefore, was to identify studies in which
either rigid or non-rigid connection has been
used when implants were connected to teeth,
and compare the biologic and technical out-
comes of these two approaches.
Material and methods
The present systematic review was written
according to the PRISMA (Preferred Report-
ing Items for Systematic reviews and Meta-
Analyses) guidelines for reporting studies
evaluating healthcare interventions (Liberati
et al. 2009). The focused PICO (population,
intervention, control, outcome) question of
the present systematic review was whether
or not the different types of connection (rigid
vs. non-rigid) between natural teeth and
osseointegrated implants had an effect on the
biological, functional and/or the prosthetic
(technical) complication rates (Fig. 1). A pilot
initial PubMed search followed by a system-
atic evaluation of five potentially eligible ran-
domly selected studies was performed to
establish the study protocol. As it was evi-
dent from this initial search that the random-
ized control studies would be scarce or even
not existing, an eligibility evaluation of non-
randomized studies, following a thorough
quality assessment protocol, was decided.
© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Types of outcome measures: Primary
outcome measures: biological and/or pros-
thetic (technical) complication rates. Second-
ary outcome measures:
Population: “Dental Implants” [MeSH]
AND “Jaw, Edentulous, Partially” [MeSH]
(dental AND implant*) OR (endosseous
AND implant*) OR (implant*) OR (root-
form implant*) OR (fixture) OR (partial
AND edentulism) OR (partially AND
edentulous AND jaw) OR (tooth AND
free end) OR (tooth AND distal gap) OR
(tooth AND mesial gap)
Intervention: “Denture, Partial, Fixed”
[MeSH] AND “Non-rigid connection”
[MeSH]
(denture* AND partial AND fixed) OR
(prosthes* AND fixed) OR (bridge AND
fixed) OR (bridge* AND fixed) OR (non-
rigid attach*) OR (non rigid attach*) OR
(tooth-implant AND non-rigid connection)
OR (tooth-implant AND non rigid con-
nection)
Control: “Denture, Partial, Fixed” [MeSH]
AND “Rigid connection” [MeSH]
(denture* AND partial AND fixed) OR
(prosthesis AND fixed) OR (prostheses
AND fixed) OR (bridge* AND fixed) OR
(bridge* AND fixed) OR (rigid attach*) OR
(tooth-implant AND rigid connection)
Outcome: “Survival” [MeSH] OR “Sur-
vival Analysis” [MeSH] OR “Survival
Rates” [MeSH]
(“Complications” [Subheadings] AND [bi-
ologic OR functional OR technical]) OR
“Dental, Restoration, Failure” [MeSH])
(implant AND survival) OR (implant
AND success) OR (implant AND failure)
OR (complications) OR (fail*) OR (techni-
cal) OR (prosthetic) OR (biological) OR
(screw fracture) OR (screw loosen*) OR
(implant fracture) OR (framework fracture)
OR (porcelain fracture) OR (abutment
intrusion) OR (tooth intrusion).
Search strategy
An electronic Medline search was conducted
to identify English language articles pub-
lished in dental journals from January 1980
to August 2015, by two independent review-
ers (PT and KM) (Fig. 1). An additional elec-
tronic searching was performed in EMBASE,
Google Scholar Beta and Cochrane databases.
Specific key words and a variety of combina-
tions with the key words were used to iden-
tify the appropriate studies, which were
recorded within the characteristics of the
specific PICO question above. The electronic
 Tsaousoglou et al
Outcomes of teeth/implants connections

Fig. 1. Focused PICO question.

© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd 851 | Clin. Oral Impl. Res. 28, 2017 / 849–863
Tsaousoglou et al
Outcomes of teeth/implants connections
search which was complemented by a hand
search of the same time period issues of the
following journals was performed: Journal of
Prosthetic Dentistry, International Journal of
Prosthodontics, Journal of Prosthodontics,
Journal of Periodontology, Journal of Clinical
Periodontology, Periodontology 2000, Interna-
tional Journal of Periodontics and Restorative
Dentistry, International Journal of Oral and
Maxillofacial Implants, Clinical Oral
Implants Research, Clinical Implant Den-
tistry and Related Research, Implant Den-
tistry, and Journal of Oral Implantology.
Eligibility criteria
Inclusion criteria
Only clinical studies, randomized clinical tri-
als (I–IV), prospective and retrospective
cohort studies were included in this system-
atic review. Additionally, inclusion criteria
were the following:
• That the studies reported on partially
edentulous patients – in the anterior and/
or the posterior regions of either jaw –
rehabilitated by non-immediately loaded
fixed dental prostheses connecting
implants to teeth.
• That the studies included detailed infor-
mation on the connection/attachment
mode (rigid or non-rigid).
• That the studies included a clinical and/
or radiographic evaluation of the outcome
with a mean follow-up of at least
12 months.
• That the studies reported on the presence
or absence of biologic, functional and/or
prosthetic (technical) complications at
the follow-up.
Exclusion criteria
All studies which did not satisfy the above-
mentioned criteria, that is, in vitro studies,
in silico studies, animal studies, reviews, sys-
tematic reviews, case reports, clinical studies
with <1-year follow-up, as well as clinical
studies which relied on questionnaires and
interviews were excluded. Studies with sap-
phire- and hydroxyapatite-coated implants as
well as IMZ dental system were excluded.
Also studies were excluded whether they
reported on removable partial dentures or
overdentures, as well as whether it was not
referred whether the attachments were rigid
or non-rigid.
Selection of studies
Use of specific key words by two of the par-
ticipating authors (PT and KM) resulted in
852 | Clin. Oral Impl. Res. 28, 2017 / 849–863
the first selection of the papers, based only
on the titles. Then, the abstracts of the ini-
tially retrieved articles were obtained, inde-
pendently, by the two principal investigators
(PT and KM) for possible selection in the
review, based on the inclusion criteria for-
merly set. Any disagreement was resolved by
discussion with the other reviewers (AS, KK,
HPW). During the search strategy, all partici-
pating authors were informed about the
authors and the institutions of the selected
papers. After that, the abstracts of all titles
approved by both investigators (PT and KM)
were downloaded and individually evaluated.
If the abstract met the inclusion criteria, the
full text was obtained. Additionally, if not
enough information was included in either
the title or the abstract, the full text was
obtained in an effort to include all relevant
articles. Also, the relevant papers of refer-
ences of the included articles were searched.
After the collection of all full texts, the eligi-
bility criteria were used to identify the final
articles, which would be used for this sys-
tematic review. The two principal investiga-
tors (PT, KM) agreed on the final selection of
the articles (Cohen’s kappa score = 0.90). Fol-
lowing that, a final control was conducted by
the other reviewers (AS, KK, HPW), who ran-
domly picked up the selected papers and
checked them for their eligibility according
to the set criteria (Fig. 2).
From a same group of scientists who pub-

lished four papers (Astrand et al. 1991;
Gunne et al. 1992, 1999; Olsson et al. 1995)
on that topic, only the last one was consid-
ered for inclusion in this systematic review,
as it was the most recent and it had the long-
est observational period. Furthermore, as far
as the technical complications are concerned,
it was not possible to safely extract data from
the first three papers. Similarly, from three
papers (Naert et al. 1992, 2001a,b) only the
second one (Naert et al. 2001a) was selected,
as it was not clear whether the authors used
partially the same cohort with the first one
(1992), while in the last one (2001b) they
focused on the radiographical parameters
only with the same cohort as in the second
one.
Extraction of data
Four prospective and six retrospective studies
were finally included. The data regarding the
following parameters were retrieved by the
two reviewers (PT and KM): lead author; year
of publication; study design; connector (at-
tachment) type; study aim (main objective);
sample size; study setting; treatment tested;
method of allocation/recruitment procedure;
© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
jaw/region of implant placement; implant
system. Additionally, the following parame-
ters regarding the T-I FDPs were recorded:
short and long span (number of units);
implant number/loss; tooth number/loss;
prosthesis number/loss after prosthesis; fol-
low-up. As short-span T-I prostheses were
considered, the FDPs ≤3 units. Space saving
and data plethora purposes led to the mainte-
nance of only the most important parameters
in the tables of the included studies.
Quality assessment of individual included
studies
As there is not a unanimous systematic
approach or scale for the assessment of the
quality of evidence of the non-randomized
clinical trials, the tool of the Cochrane Col-
laboration from Cochrane handbook was
used for assessing risk of bias of randomized
clinical trials (Higgins et al. 2011). This tool
basically consists the “Risk of bias” table,
which is available in RevMan software.
According to this, each included study was
judged based on seven items/characteristics/
entries and categorized as ‘low risk’ of bias,
‘high risk’ of bias or ‘unclear risk’ of bias.
The ended result of this judgment is the gen-
eration of the ‘Risk of bias summary’ figure.
Due to the fact that all the included studies
would be non-randomized clinical trials (ob-
servational), it was decided not to include in
the judgment the “Random sequence genera-
tion (selection bias)” and “Allocation con-
cealment (selection bias)” items/entries and
to default these as “Unclear”. Therefore, a
modified figure was presented, which has
been used, also, by other authors (Gkantidis
et al. 2014).
Results
The flowchart of article selection is shown in
Fig. 2. A total of 387 articles were selected
from an initial yield of 3587 studies follow-
ing the initial electronic and hand literature
search. After the abstracts’ review, 39 studies
were agreed for full-text evaluation. Ten arti-
cles were finally selected for inclusion in this
systematic review, whereas the rest 29 arti-
cles were excluded for different reasons (Sul-
livan 1986; Jemt et al. 1989; van Steenberghe

1989; Astrand et al. 1991; Gunne et al. 1992;
Naert et al. 1992, 2001b, 2002a,b; Rieder &
Parel 1993; Olsson et al. 1995; Garcia & Oes-
terle 1998; Fugazzotto et al. 1999; Lee et al.
2000; Br€agger et al. 2001, 2005; Kronstr€ om
et al. 2004; Romeo et al. 2004; Palmer et al.
2005; Akcßa et al. 2006; Heinemann et al.

Fig. 2. Article selection flowchart.
2006; Krennmair et al. 2007; Ozkan et al.
2007; Nickenig et al. 2008; Bernhart et al.
2012; Wolleb et al. 2012; Joda 2013; Ram-
melsberg et al. 2013; Pettersson & Sennerby
2015). Data extraction was performed in all
ten articles, which fulfilled the inclusion cri-
teria set. The basic characteristics of the
selected studies are shown in Table 1. Addi-
tionally, the main objectives of the studies,
the results and the outcome data are pre-
sented in Table 2, while the overall quality
assessment is demonstrated in Fig. 3. With
one exception (Ericsson et al. 1986), all
included articles were published between
1999 and 2006 (Table 3).
Four of the included studies have a control
group comparing the outcomes of tooth–im-
plant with freestanding supported FDPs
(Gunne et al. 1999; Hosny et al. 2000; Lindh
et al. 2001a; Naert et al. 2001a). The first
three of them were conducted with a split
mouth, while the last one was carried out
with a parallel group as a control.
Three studies (Gunne et al. 1999; Lindh
et al. 2001b; Tangerud et al. 2002) included
only rigid fixed reconstructions, while six
studies reported on both rigid and non-rigid
© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Tsaousoglou et al
Outcomes of teeth/implants connections
implant to tooth connection fixed dental
prostheses and could have been included in a
meta-analysis (Leandro 2005). One more
study (Kindberg et al. 2001) reported on both
methods of connection, but all but one of the
prostheses included were rigid and exact
extraction of data could not be performed.
Additionally, one or more fruitless attempts
were made to contact through email the lead
authors of three studies (Lindh et al. 2001b;
Naert et al. 2001a; Nickenig et al. 2006),
which reported on rigid and non-rigid
implant to tooth connection fixed dental
prostheses, in order to retrieve information
regarding the number of natural teeth acted
as abutments in the examined groups. As in
the study of Lindh et al. (2001a) was not
clear the natural teeth abutment, the 188
teeth number was taken into account. There-
fore, the data synthesis and examination per-
mitted the implementation of a meta-
analysis only for three studies, which clearly
reported the required information (Ericsson
et al. 1986; Hosny et al. 2000; Cordaro et al.
2005).
In all studies, the rigid connection mainly
involved a vertical or horizontal locking
screw, while the non-rigid involved tele-
scopic crowns or sliding type attachments.
The studies were mainly conducted in uni-
versity or hospital clinics, with the exception
of one study which took place in a federal
military dental clinic (Nickenig et al. 2006).
Another study (Lindh et al. 2001b) does not
clearly specify whether only university clin-
ics were involved in the investigation.
A total of 481 patients received 526 FDPs
supported by 981 abutment teeth connected
with 1072 implants. In seven studies (Eric-
sson et al. 1986; Gunne et al. 1999; Hosny
et al. 2000; Kindberg et al. 2001; Lindh et al.
2001a; Naert et al. 2001a; Tangerud et al.
2002), the Br anemark implant system was
used exclusively, while in two studies (Lindh
et al. 2001b; Nickenig et al. 2006), the Br
ane-
mark and the Straumann system were
mainly used. In one study (Cordaro et al.
2005), the Straumann and the Biomet 3i sys-
tems were used. Other implant systems used
included Replace, Friadent, Ankylos, Astra
and others, which were not specified.
Dropouts ranged between 0% (Nickenig
et al. 2006) and 11.71% (Lindh et al. 2001b).
All studies had a mean follow-up range of
853 | Clin. Oral Impl. Res. 28, 2017 / 849–863
 Table 1. Characteristics of included studies grouped according to chronological order, from the most recently to the earliest. The data in the 10th column regard only the tooth–implant
groups

854 |
Implant
Jaw/region of number/loss;
implant placement, tooth number/
Method of not tooth loss; prosthesis Follow-up
Sample data: size allocation/ abutment/short-* number/loss of after
Connector Study aim/ (sex; age)dropouts/ recruitment vs. long-span T-I T-I group after prosthesis
Authors Study design (attachment)type main objective subjects’ setting Treatment tested procedure used FDPs Implant system prosthesis (mean)
Nickenig Retrospective Rigid and non-rigid To review the 83; 45.4 T-I with rigid and Not referred/not Maxilla and 43.5% 142/0; 132/3; 26.4–99.6m
et al. biological and 0 dropouts/federal non-rigid referred mandible/anterior anemark†,
Br 84/2 (56.76)m
(2006) technical military dental and posterior/33 41.2%
complications in clinic short and 51 long Straumann †,
T-I-supported span Replace†,
FDPs Friadent§,
Ankylos§,
Others
Cordaro Retrospective Rigid and non-rigid To evaluate 20 (9 F/11 M); 56.4 T-I complete-arch Not referred/ Maxilla and Biomet 3i**, 90/1; 72/0; 19/0 24–94 m

Clin. Oral Impl. Res. 28, 2017 / 849–863

et al. (sliding precision implant success 1 dropout/ FDPs with normal unclear mandible/anterior Straumann ‡ (36.5 m)
(2005) attachment rate, prosthetic hospital and or reduced (consecutive) and posterior/only
[Interlock-type complications and university periodontal long span
cylindrical¶) or tooth intrusion of support with rigid
telescopic crown T-I complete-arch and non-rigid
Tsaousoglou et al
Outcomes of teeth/implants connections

design] FDPs attachments

Tangerud Prospective Rigid (screws with To evaluate T-I- 30; 40–89 T-I with rigid. Not referred/ Maxilla and anemark†
Br 85/2; 86/1; 29/0 36 m
et al. additional lingual supported FDPs 1 dropout/ No group recruitment mandible/unclear
(2002) arm) university according to units number
predefined
criteria
Kindberg Retrospective All but one rigid To evaluate 37 (16 F/21 M); 60.6 T-I FDPs supported Not referred/not Maxilla and anemark†
Br 115/6; 85/5; 41/ 14–106.8 m
et al. (primarily copings treatment 1 dropout/ by one tooth and referred mandible/anterior 2
(2001) with vertical locking outcome of T-I hospital implant, and and posterior/11
screws). FDPs supported by complete-arch short and 30 long
Non-rigid 1 tooth and 1 prostheses span
(McCollum’s implant as well as supported by
precision complete-arch multiple teeth
attachments) FDPs and implants
Lindh et al. Retrospective Rigid and non-rigid To investigate the 111 (71 F/40 M); 65 T-I with rigid and Not referred/ Maxilla/anterior Mainly 184/17; 188/ 36 m
(2001a) implant survival 13 dropouts/6 non-rigid. unclear and posterior anemark†,
Br unclear;
rate, marginal clinics (including No group (consecutive) Mandible/ Straumann ‡ 138/0
bone loss and university) posterior/101
complications of short and 37 long
T-I FDPs span
Lindh et al. Prospective Rigid (custom-made To evaluate the 26 (15 F/11 M; 67) T-I vs. I-I Non-random/ Maxilla/posterior/ anemark†
Br 26/1; 26/1; 26/1 24 m
(2001a) (Split mouth) or modified biological and 2 dropouts/ consecutive only short span
McCollum mechanical university according to
attachment with consequences of predefined
locking screws). T-I-supported criteria
FDPs and compare
with I-I-supported
FDPs
Naert et al. Retrospective Rigid [C&M screw††, To compare Total: 246 (142 F/ T-I-supported Not referred/ Maxilla and anemark†
Br 339/10; 313/5; Test group:
(2001a) (Parallel screw retained on freestanding and 104 M); 52.05 prostheses vs. unclear mandible/not 140/0 18–180 m
groups) telescope††, T-I prostheses in Test group: 123 freestanding referred/unclear (78 m)
cemented retained the treatment of (67 F/56 M); 51.8 units number Control
on telescope††, partially Control group: group:
I.M.Z.-T block‡‡, edentulous 123 (75 F/48 M); 15.6–174 m
cements without patients 52.3/university (74.4 m)
telescope].
Non-rigid (Ney-
slot§§)

© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
 Tsaousoglou et al
Outcomes of teeth/implants connections

18–120 months. The mean follow-up period

*As short-span T-I prostheses were considered, the FDPs ≤3 units; †Nobel Biocare AB, Gothenburg, Sweden; ‡Straumann AG, Waldenburg, Switzerland; §Dentsply GmbH, Mannheim, Germany; ¶Bredent,
taux, Bienne, Switzerland; ‡‡Friedrichsfeld, Mannheim, Germany; §§Ney-slot, Ney Incorporation,
of the three studies which were eligible for

Follow-up

prosthesis

15–168 m
inclusion in the meta-analysis (Ericsson et al.

(78 m)

(18 m)
6–30 m
(mean)

120 m
1986; Hosny et al. 2000; Cordaro et al. 2005)

after
ranged from 18 to 78 months.
All but two studies (Gunne et al. 1999;

30/0; 30/0; 18/0

20/2; 20/1; 20/3

41/0; 29/0; 10/0

number/loss of
T-I group after
tooth number/
loss; prosthesis
number/loss;

Lindh et al. 2001a) treated partial

prosthesis
edentulisms located in both jaws and
Implant

regions. Gunne et al. (1999) included

patients who needed treatment in the
mandibular posterior areas, while Lindh
Implant system
anemark†

anemark†

anemark†
et al. (2001a) reported on the results of par-
tial fixed dental prostheses placed in the
maxillary posterior areas.
Br

Br

Br
For the majority of the studies, the method
Mandible/posterior/
implant placement,

mandible/anterior

mandible/anterior
short and 12 long

of allocation and the recruitment procedure

short and 9 long

abutment/short-*

only short span

and posterior/6

and posterior/1
vs. long-span T-I

used are either not reported or are unclear.

Jaw/region of

Maxilla and

Maxilla and

Only two studies (Lindh et al. 2001a; Tan-

not tooth

gerud et al. 2002) stated that the recruitment

span

span
FDPs

was performed according to predefined crite-

ria, without however giving more details on
that issue.
Not referred/not

Not referred/not
procedure used

Random/not
recruitment

Span of prostheses
Method of
allocation/

referred

referred

referred

Two studies (Naert et al. 2001a; Tangerud

et al. 2002) did not report on the number of
units included in the T-I FDPs, another two
(Gunne et al. 1999; Lindh et al. 2001a)
T-I with rigid and
Treatment tested

reported only on short-span FDPs, while one

Senden/Witzighausen, Germany; **3i Implant Innovations, Inc., Palm Beach Gardens, FL; ††Cendres & Me

study (Cordaro et al. 2005) examined only

non-rigid
T-I vs. I-I

T-I vs. I-I

long-span T-I FDPs. The rest of the included

studies reported on both short- and long-span
FDPs. The total number of short-span FDPs
10 (7 F/3 M; 31–60)/
18 (12 F/6 M); 49.5/
(sex; age)dropouts/

23 (15 F/8 M; 57.7)

is bigger than that of the long-span ones (198

Sample data: size

subjects’ setting

vs. 158).
3 dropouts/
university

university

university

Survival rates
With the exception of two studies (Ericsson
et al. 1986; Hosny et al. 2000), all investiga-
and compare with
I-I-supported FDPs

whether implants

tions were referred to survival using different

and I-I-supported

could be used as

T-I, tooth–implant; I-I, implant–implant; FDPs, fixed partial dentures.

abutments with
outcome of T-I-

supported FDPs
To compare the

To evaluate T-I-
main objective

definitions of “rate,” such as “prosthesis sta-

teeth in FDPs
To evaluate

combined

bility and survival rate”; “implant survival

Study aim/

and success rates”; “cumulative prosthesis

FDPs

and implant survival and success rates”; “ab-

solute number of implants and teeth sur-
Rigid and non-rigid¶¶
(different connector

vival.” This fact alone made the pooling of

Rigid and Non-rigid

horizontal locking
Rigid (McCollum T-
attachment) with
(attachment)type

the data unfeasible, as far as the results and

the meta-analysis procedure were concerned.
Connector

All included studies reported on survival

screw
type)

€nga, Sweden.

for implants, teeth and prostheses with the

exception of the trial by Lindh et al. (2001a)
that did not provide information regarding
(split mouth)

(split mouth)
Retrospective
Study design

Prospective

Prospective

the survival rates of the abutment teeth. The

USA; ¶¶J. Sjӧding, Spa

overall survival rate for implants ranged

Table 1. (continued)

between 90% and 100%, after follow-up peri-

ods with a mean range of 18–120 months.
Gunne et al.
Hosny et al.

The survival of the abutment teeth ranged

Authors

Ericsson

between 94.1% and 100%, while the prosthe-

(2000)

(1999)

(1986)
et al.

ses survival ranged between 85% and 100%

for the same time period.

© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd 855 | Clin. Oral Impl. Res. 28, 2017 / 849–863
 856 |
Table 2. Results of the studies, outcomes data and overall quality assessment grouped according to the type of attachment
Study Type of attachments Main objective-aim
Nickenig et al. Rigid and non-rigid Survival, and technical and
(2006) biological complications of
implants, teeth and FDPs
Clin. Oral Impl. Res. 28, 2017 / 849–863
Cordaro et al. Rigid and non-rigid Evaluation of complete-arch T-I-
(2005) supported FPDs in patients with
normal or reduced periodontal
support by comparing the
prosthetic and biological
complications.
[Implant survival and success rate,
prosthetic complications, peri-
implant crestal bone levels,
occurrences of tooth intrusion and
caries
(Comparisons were made between
patients with normal and reduced
periodontal support)]
Tangerud et al. Rigid Evaluation of combined T-I-
(2002) supported FPDs in both jaws and
in a variety of clinical situations.
(Marginal bone level, presence of
plaque, bleeding on probing,
probing pocket depths, mobility of
the implants and prostheses)
Kindberg et al. All but one rigid Evaluation of combined FPDs with
(2001) different numbers of teeth and
implants
(Implant survival rate marginal
bone loss)
© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Main outcome data
Survival: 0 of 142 functionally loaded
implants and 3 of 132 abutment teeth
were lost because of a periodontal
inflammation/abscess. Complication
rates after 5 years: 10% T-I FPD, >1%
implant abutments (<1 biological and
unclear percentage of technical
complications), 8% abutment teeth.
The complication rate of T-I FPD non-
rigid is significantly increased as
compared with a rigid connection
(P = 0.05). The incidence of
complications of T-I-supported
prostheses is significantly associated
with the type of attachment with
increased among non-rigid
attachments (P = 0.05)
Implant survival rate 99% % and
implant success rate 96%.
Four prosthetic complications with
non-rigid connection and normal
periodontal support. Four abutment
tooth intrusions with non-rigid
connection and normal periodontal
support (P = 0.03). Stable crestal bone
levels for all but three implants. No
recurrent caries of abutment teeth
No prosthesis mobility after 3 years.
Cumulative implant survival rates
91.0% (maxilla)- 95.5% (mandible)
(3 years). Plaque: 32 (implants) – 22%
(tooth abutments) (3 years). Bleeding:
41% (implants) and 40% (tooth
abutments). Probing depths (mm):
40% ≥4 (implants) – 19% ≥4 (tooth
abutments) (3 years). Marginal bone
loss (mm): 0.8 (implants) 0.1 (tooth
abutments) (3 years). Total: 38
complications
Cumulative implant survival rate 89.8%
and implant survival rate 100% after
5 years.
Marginal bone loss of implants
around 50% from 1 thread to 3
threads (3 years) and 3 abutment
teeth with 2 mm loss (5 years)
Complication of T-I group after prosthesis except for implant losses
Biological
Tooth abutments: Therapeutic
measures in 8%, 1 abutment
tooth removal.
Implant abutment: <1%
5.6% intrusions of the total
tooth abutments or 13% of
the teeth with non-rigid
connection and normal
periodontal support
1 tooth lost because of root
fracture, 1 tooth fistula, 2
teeth with pocket depth
>5 mm
5 teeth lost because of fractures
and endodontic reasons, 3.5%
tooth intrusions
Quality
Technical assessments
FDPs: 2 renewal due to 1 Unclear
superstructure loosening and 4
reintegrations, 2 FPDs
fractures, 7 veneer fractures.
5.35% of the rigidly and 35%
of the non-rigidly connected
required modification
(statistically significant).
Implants:
7 screw loosening and 4
decementations
Tsaousoglou et al
Outcomes of teeth/implants connections
Non-rigid connection and High
normal periodontal support
group: 2 prostheses remakes, 1
entire veneering material
replacement, 1 occlusal
adjustments
5 occlusal porcelain fracture, 3 Unclear
fracture of facing, 3
replacement of composite
“plug”
1 implant prosthetic screw High
loosening, 3 superstructure
locking screw loosenings, 4
veneer fractures, 1 severe
prosthesis wear, 2 occlusal
adjustments
 Table 2. (continued)
Study Type of attachments Main objective-aim
Lindh et al. Rigid and non-rigid Evaluation of the success of
(2001a) treatment of T-I-supported
prostheses and comparison with
published results from treatment
with I-I-supported prostheses.
(Implant survival rate, marginal
bone loss, complications,
indications)
Lindh et al. Rigid Comparison between T-I-supported
(2001a) and freestanding implant FPDs
placed in the posterior maxilla.
(Biological and technical
complications, marginal bone
level, cumulative survival rates for
Main outcome data
Cumulative implant survival rate 95.4%
after 3 years. Marginal bone level
lower in the maxilla compared to the
mandible (P = 0.015). Secondary
outcomes: 34 complications [peri-
implantitis, tooth intrusion (only with
non-rigid attachments), locking screw
in attachment loosening, fracture of
veneering material and 6
osseointegration failures and implant
losses]
Cumulative prostheses survival rates
96% for T-I & 95% for I-I FPDs
(2 years) (no difference). Marginal
bone loss between the baseline and
24 months of the posterior implant:
0.42 mm for I-I (P = 0.005) and
Complication of T-I group after prosthesis except for implant losses
Biological
5% tooth intrusions, endodontic
treatment, carious lesions, 4
peri-implant infections, 5
implants lost osseointegration
1 tooth lost because of fracture,
3 devitalized, 1 fistula at
abutment level.
Quality
Technical assessments
Abutment and prosthetic screw High
loosening, attachment fracture,
attachment locking screw
loosening and fracturing,
veneering material fracture,
sensory disturbances
Decementation of 2 abutment Unclear
teeth, 1 prosthesis screw
fracture, mobility of 2
prostheses due to screw
loosening, 1 excessive occlusal
wear

© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
the implants and the prostheses, 0.09 mm for T-I FPDs (P = 0.45).
plaque accumulation and bleeding Plaque and bleeding variables showed
of peri-implant mucosa) no difference between T-I & I-I FPDs.
Six complications at the abutment
teeth, 5 complications at the implants
of T-I FPD & 7 of I-I FPD
Naert et al. Rigid and non-rigid Comparison between T-I-supported Cumulative implant success rate 94.9% 2 tooth fractures 25 crown cement failures, 3 High
(2001a) and freestanding implant FDPs (15 years) for T-I and 98.4% (13 years) 3 teeth extracted due to decay patients with framework
(Results are according to implant, tooth and for I-I FDPs (P > 0.05). Complications in or periodontitis, 11 periapical fracture, 4 implant fractures, 3
combined prostheses complications. T-I FPDs:6 implant mobilities, lesions, 3.4% (11) tooth abutment screw fractures
with Naert periapical lesion 3.5%, tooth removal intrusions, 6 implants with
et al. (2001b) 1.8%, crown cement failure 8% and mobility
tooth intrusions 3.4%. Complications
in I-I FPDs:1 implant fracture and 2
abutment screws fractures (13 implant
complications for T-I FDPs whereas 3
implant complications for I-I FDPs.
16.7% tooth complications for T-I
FDPs)

857 |
Marginal bone loss around implants:
T-I FPDs 0.07 mm/year, rigidly
connected T-I FPDs 0.09 mm/year, non-
rigidly connected T-I FPDs 0.04 mm/
year, multi-connector T-I FDPs
0.08 mm/year, freestanding FPDs 0.02
mm/year. Not significant difference
only between non-rigidly connected T-
I and freestanding FDPs

Clin. Oral Impl. Res. 28, 2017 / 849–863

Tsaousoglou et al
Outcomes of teeth/implants connections
 858 |
Table 2. (continued)
Study Type of attachments Main objective-aim
Hosny et al. Rigid and non-rigid Long-term outcome of comparison
(2000) between T-I-supported and
freestanding implant FPDs
(Implant, tooth and FPDs
complications, marginal bone
level)
Clin. Oral Impl. Res. 28, 2017 / 849–863
Gunne et al. Rigid Evaluation of I-I- versus T-I-
(1999) supported FPDs; changes in the
marginal bone level; use of short
implants in the posterior mandible
(Implant stability, tooth mobility,
marginal bone loss, bleeding on
probing, tightness of prosthetic
screws and abutment screws)
Ericsson et al. Rigid and non-rigid Investigation whether titanium
(1986) fixtures could be used as combined
abutments with teeth in FPDs.
(CDA criteria system for quality,
presence of plaque, bleeding on
probing, probing pocket depths,
marginal bone level, biological
and technical complications)
FDP, fixed dental prostheses.
© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Complication of T-I group after prosthesis except for implant losses
Quality
Main outcome data Biological Technical assessments
No significant difference in marginal 1 periapical lesion 6 months – High
bone loss regarding T-I and I-I FPDs after
and connector types. Mean marginal
bone loss 3–6 months after loading
1.08 mm and 6 months to 14 years
0.015 mm annually for T-I and I-I FPDs.
No one complication regarding FPDs,
implant and tooth abutments
(including tooth intrusion) except for
one periapical tooth lesion
I-I FPDs stability: 80% and T-I FPDs 1 tooth lost because of caries 3 prosthetic screw loosenings High
stability: 85% (10 years). 8 implant and endodontic reasons, 1
losses tooth with increased mobility
Cumulative success rate 88.4%
Tsaousoglou et al
Outcomes of teeth/implants connections
(10 years). No difference regarding
implant failures between I-I- and T-I-
supported FPDs. Same failure rate for
short (7 mm) and 10-mm implants.
Bleeding on probing: around 3
implants of I-I FPDs and 1 abutment
tooth. Marginal bone loss: 0.6–0.7 mm
I-I FPDs and 0.5 mm T-I FPDs
(statistically significant). Prosthetic
screw loosening in 5 cases: 2 I-I FPDs
and 3 T-I FPDs, sensory dysfunction of
the mental region (unclear in which
group)
According to CDA criteria excellence in The tooth segment of 1 T-I High
10 of 11 prostheses. Plaque: 15% bridge intruded
around implants and 13% around
tooth abutments (not statistically
significant). Bleeding: 7.8% around
implants and 4.3% around tooth
abutments (not statistically
significant). Probing depths (mm): 3.3
in implants and 2.3 in tooth
abutments (statistically significant).
Marginal bone loss around all
implants (but in most cases <1 mm),
whereas no marginal bone loss
around tooth abutments. Assessment
of the variables, except for CDA
criteria, for an average of 18 months
(range 6–30 months)
 Tsaousoglou et al
Outcomes of teeth/implants connections

analysis for tooth intrusion. From a total of

20 abutment teeth rigidly and 10 teeth non-
rigidly connected with implants, no intrusion
was noted by Hosny et al. (2000), showing no
difference between the two treatment modal-
ities. However, different results have been
reported by Ericsson et al. (1986) and Cordaro
et al. (2005), whose research includes a total
of 89 abutment teeth. Of those, 28 were
rigidly and 61 were non-rigidly connected
with implants. While no intrusion was noted
on the rigid connection group, five teeth
(8.19%) were intruded in the non-rigid con-
nection group [95% CI (0.013–0.151)] (Fig. 4).

Quality assessment
The overall quality of evidence is low as all
the included studies are observational with-
out any randomized controlled trials (RCTs),
which are assessed with high-quality evi-
dence (Fig. 3).

Discussion

The main purpose of this study was to assess

the biological and technical outcomes, as
well as the survival rates of fixed dental pros-
theses supported by natural teeth and
implants. Furthermore, possible outcome dif-
ferences between the two different connec-
tion modalities (rigid vs. non-rigid) were also
investigated. Thus, a systematic search of the
literature was conducted in order to identify
high-level evidence.
This systematic review was conducted in
accordance with the guidelines of PRISMA
(Liberati et al. 2009) and the Cochrane Col-
Fig. 3. Risk of bias summary. Review authors’ judgments about each risk of bias item for each included study. The
plus and minus inside the circle denote low and high risk of bias, respectively, whereas the question mark the circle laboration’s tool for assessing risk of bias in
inside the circle denotes unclear risk of bias. The overall assessment of a study with at least one minus or one ques- randomized trials (Higgins et al. 2011). How-
tion mark is considered high or unclear risk of bias, respectively, whereas a study with only plus low risk of bias. ever, a modification deemed necessary, as no
The first two domains are not applicable (default: unclear) as all the included studies are non-randomized/observa-
RCT satisfying the inclusion criteria was
tional studies.
found.
After an electronic and a hand search strat-
Biologic complications remake” with 10.52%, “facing fracture” and egy were conducted, a total of 10 observa-
All ten included articles reported on biologi- “replacement of composite plug” with 10%, tional studies were included in the analysis.
cal complications. In detail, the most fre- “cement failure” and “screw fractures” with It should be mentioned, however, that most
quent complications were “periapical 7.98%, “need for occlusal adjustment” and of the included studies suffered from a small
lesions” with an occurrence of up to 11.53%, “material replacement” with 5.26%. The sample size. Additionally, the mean follow-
followed by “caries” with 5%, “tooth intru- authors of one article (Nickenig et al. 2006) up period of the available studies is surpris-
sion” with also up to 5%, “tooth fractures” pointed out that when the modification of ingly low. Summarizing the studies’ data, an
with 3.84%, “loss of osseointegration” with the prostheses was examined, a statistical overall failure rate of 1.7%, 3.64% and 1.63%
2.7%, “periodontal pathology” with 2.32% significant difference was found between of utilized FDPs, implants and teeth was
and “fistulas” with 1.16%. rigidly (5.35%) and non-rigidly (35%) con- found, respectively. The failure rates demon-
nected restorations. strate that loses of implants and teeth were
Technical complications very scarce.
The most frequent technical complication Tooth intrusion The overall complication rate (biological
was “porcelain occlusal fracture” with an As already mentioned, three articles (Ericsson and technical) was estimated to be almost
occurrence of up to 16.6%, followed by et al. 1986; Hosny et al. 2000; Cordaro et al. 19% for tooth–implant-supported FDPs, after
“screw loosening” with 15%, “prosthesis 2005) qualified for inclusion in a meta- a mean loading period of 6.5 years. Teeth

© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd 859 | Clin. Oral Impl. Res. 28, 2017 / 849–863
 Table 3. Non-included studies and the exclusion reasons
Study Exclusion reasons

860 |
Sullivan (1986)
Jemt et al. (1989)
van Steenberghe (1989)

Astrand et al. (1991)
Gunne et al. (1992)
Naert et al. (1992)
Rieder & Parel (1993)
Olsson et al. (1995)
Garcia & Oesterle (1998)
Fugazzotto et al. (1999)
Lee et al. (2000)
Bra
€gger et al. (2001)
Naert et al. (2001b)
Naert et al. (2002a)
Review and case reports study
A small number on prostheses were connected with teeth; however, the results were incomplete, insufficient and confusing regarding the T-I FDPs
Τhe type of attachments was not referred
The sample size data were the same as Gunne et al. (1999) but with shorter follow-up
The sample size data were the same as Gunne et al. (1999) but with shorter follow-up
The study was not clear whether the authors used partially the same cohort with Naert et al. (2001a)
The study was based on survey forms.
The sample size data were the same as Gunne et al. (1999) but with shorter follow-up
Based on a questionnaire survey
IMZ with intramobile element (Friatec, Mannheim, Germany)
Case reports study
The type of the attachments was not referred. There was no clear distinction among the 3 groups regarding all parameters and complications
The sample size data were the same as Naert et al. (2001a). Therefore, it was excluded as double and only the results regarding the radiographic evaluation were
considered
The type of the attachments was not reported. It was not clear in which group the complications occurred. In same implants, membrane and/or graft were applied

Clin. Oral Impl. Res. 28, 2017 / 849–863

Naert et al. (2002b)
Kronstro
€ m et al. (2004)
Romeo et al. (2004)
Τhe type of attachments was not referred. It was not clear in which group the complication occurred. In same implants, membrane and/or graft were applied. Also, same
sample data as Naert et al. (2002a)
The study was based on questionnaires
The type of the attachments was not reported
Tsaousoglou et al
Outcomes of teeth/implants connections

Bra
€gger et al. (2005)
Palmer et al. (2005)
Bra
€gger et al. (2005)
Palmer et al. (2005)
Krennmair et al. (2007)
Ozkan et al. (2007)
Nickenig et al. (2008)
Bernhart et al. (2012)
Wolleb et al. (2012)
Joda (2013)
Rammelsberg et al. (2013)
Pettersson & Sennerby (2015)
The type of the attachments was not clear, namely if they included FDPs only with rigid connection. It was not clear whether the authors used the same cohort as Bra
€gger
et al. (2001)
The type of the attachments was not referred
The type of the attachments was not clear, namely if they included FDPs only with rigid connection. It was not clear whether the authors used the same cohort as Bra
€gger
et al. (2001)
The type of the attachments was not referred
The type of the attachments was not reported. Telescopic T-I prostheses
The type of the attachments was not reported, and the number of teeth and implant abutments was not clear as well
The study was referred partially to tooth–implant-supported removable partial dentures
The type of attachments was not reported
The type of the attachments was not reported. Only one case with T-I FDP
The type of the attachments was not reported. Telescopic-retained removable T-I prostheses
The type of attachments was not totally clear. The number of abutment teeth and implants as well as the rate and type of T-I FDPs was not given
The type of the attachments was not reported and the number of teeth and implant abutments is not clear as well

FDP, fixed dental prostheses.

utilized.

fixation screws.

tal ligament (Cordaro et al. 2005).


support the rigid connection (Astrand

ity, type of attachments, operator experience,

© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
behavior between the bone and the periodon-
Many theories have been formulated to
prostheses should be connected rigidly or

et al. (1999) have reported that in rigid con-

FDPs with non-rigid connections and on
ing from 3.4 to 5.6%. It should be mentioned

reduced) or differences in the biomechanical

nomenon depends on the level of periodontal
reported that all intrusions were noticed in
parable outcomes with implant-supported

explain the etiology of teeth abutment intru-

daro et al. 2005) has shown that all cases with
(1986) have found that the tooth segment of
sson et al. 1986; Kindberg et al. 2001; Lindh

the status of periodontal support (normal or

non-rigid connections than with rigid ones,
that the risk of tooth intrusion is higher with
The meta-analysis performed demonstrated
Ackermann 1986; Sullivan 1986; Ylantz &
2005) while others the non-rigid one (Kirsh &

with reduced periodontal support. Further-

abutment teeth with normal periodontal sup-
tooth intrusion occurred in patients having
sions at 13%. Additionally, Ericsson et al.
support, increasing the rate of tooth intru-
FDPs but only when rigid attachments are
1999; Kindberg et al. 2001; Cordaro et al.
fer 1997; Fugazzotto et al. 1999; Gunne et al.
non-rigidly is a topic of debate. Some authors

sion. These may include parafunctional activ-

support of the abutment teeth. A study (Cor-
nection cases all observed intrusions were
teeth intruded vs. no tooth intrusion in the
tooth–implant-supported FDPs present com-
Nickenig et al. (2006) have confirmed that
Nyman 1986). It should be emphasized that
1995; Fartash & Arvidson 1997; Gross & Lau-
2001a; Quirynen et al. 1992; Olsson et al.
et al.
1991; Rangert et al. 1991; Naert et al. 1992,
et al. 2005) with very low percentages, rang-
abutment intrusions were reported – as bio-

more, it seems that intrusion of the abutment

It also seems that the intrusion phe-
that whether the tooth–implant-supported
logical complications – in five papers (Eric-

et al. 2001b; Naert et al. 2001a; Cordaro

ing prostheses loading (Cordaro et al. 2005).

associated with broken or lost attachment
abutment teeth having normal periodontal
as 8.19% of the total non-rigidly connected

teeth occurred within the initial period follow-

port, while no intrusion occurred in patients
attachment was intruded, while Fugazzotto
rigid connection group. Cordaro et al. (2005)

one tooth–implant FDPs with non-rigid


Fig. 4. Standard plot for tooth intrusion.
It is remarkable that in some cases tooth
intrusions were observed together with tech-
nical/mechanical complications. Almost 50%
of tooth intrusions occurred in patients with
crown cement failures (Naert et al. 2001a).
However, Lindh et al. (2001a) reported dece-
mentation of two tooth abutments without
any tooth intrusion.
A technical/mechanical complication rate
of approximately 10% of the tooth–implant-
supported FDPs has been estimated, and it
seems that at least one technical modifica-
tion will be needed after 5–6.5 years (Naert
et al. 2001a; Nickenig et al. 2006). Most fre-
quently observed technical complications
include screws’ loosening and/or fractures
and restorative/veneering material fractures.
It should be mentioned, however, that these
complications occurred very scarcely and
there is an agreement among the studies’
results (Gunne et al. 1999; Hosny et al. 2000;
Kindberg et al. 2001).
The studies suggest that technical compli-
cations are highly affected from the type of
connector/attachment. The non-rigid connec-
tion of tooth–implant-supported FDPs has
been shown to implicate significantly more
technical complications than the rigid one
(Nickenig et al. 2006). Therefore, the use of a
rigid connection in T-I FDPs should be pre-
ferred, although its fabrication is much more
technically demanding than that of a non-
rigid T-I FDP.
Regarding periodontal parameters, Lindh
et al. (2001a) found that there was no differ-
ence in plaque and bleeding indices between
the two types of prostheses. A statistically
significant increase in probing depth mea-
surements around the abutment teeth and
implants was demonstrated after 3 years of
T-I prostheses loading (Palmer et al. 2005).
© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Tsaousoglou et al
Outcomes of teeth/implants connections
Naert et al. (2001a,b) have demonstrated
that rigidly connected implants lose more
bone than non-rigidly connected implants.
Additionally, it seems that a greater number
of problems occur to teeth than to implants,
with either type of connection. Regarding the
marginal bone loss differences between T-I
and I-I FDPs, there is no unanimous conclu-
sion. No significant difference in implant
marginal bone loss between tooth–implant
and freestanding supported FDPs (Hosny
et al. 2000), as well as, between non-rigidly
connected and freestanding implants (Naert
et al. 2001b) has been shown. Significantly
more bone loss was found around implants of
tooth–implant FDPs in relation to freestand-
ing supported FDPs after 6 months of loading
(Naert et al. 2001b). Contrary results have
been published by Gunne et al. (1999) and
Lindh et al. (2001a) showing statistically sig-
nificant higher marginal bone loss around
implants of freestanding FDPs in comparison
with those of tooth–implant-supported FDPs.
Regarding implant survival rates, conflict-
ing results can be found in the literature.
Two studies (Hosny et al. 2000; Lindh et al.
2001a) presented comparable results for free-
standing and tooth–implant-supported FDPs,
while another study (Gunne et al. 1999)
showed that tooth–implant-supported pros-
theses exhibited higher survival rates than
freestanding implant-supported FDPs. At
prosthesis level, the survival rate was higher
for the freestanding FDPs compared to that of
tooth–implant FDPs.
The crucial time for implant failures in
tooth–implant-connected FDPs is still
unclear. Early implant loss – within the first
6 months – after loading of tooth–implant
FDPs has been observed by Lindh et al.
(2001a). Other studies have shown implant
failures within the first 2 years after loading,
which is considered to be a relatively early
failure, as well as between the 4th and the
9th year of loading (Gunne et al. 1999; Naert
et al. 2001a). The different findings may be
due to the different study design and connec-
tion type. Gunne et al. (1999) employed only
rigid attachments, whereas Naert et al.
(2001a) have used both rigid and non-rigid
attachments.
As far as the quality of evidence of the 10
included studies is concerned, this was
found to be low. Thus, the results of the
present studies do not possess strong evi-
dence and no definitely conclusions could be
extracted. This is in agreement with another
study, where the same assessment tool was
used for observational studies (Gkantidis
et al. 2014).
A limitation of the present systematic
review was the heterogeneity among the
included studies, namely type of study, sam-
ple size, follow-up periods and span of the
prostheses. Due to this fact, a clear outcome
regarding the span of the T-I FDPs and the
biological and technical complications was
not possible. It should be mentioned that in
the present study as short prostheses were
considered those with ≤3 units. Another limi-
tation was that only two studies directly
comparing the two types of connection –
rigid vs. non-rigid – were identified (Ericsson
et al. 1986; Cordaro et al. 2005). Moreover, in
the vast majority of the selected studies the
method of allocation and the recruitment
procedure were unclear.
As most of the included trials in this
review were not designed for answering the
set question, the results and conclusions
have to be interpreted with caution. There-
fore, properly designed RCTs should be
861 | Clin. Oral Impl. Res. 28, 2017 / 849–863
Tsaousoglou et al
Outcomes of teeth/implants connections
conducted in future in order to draw safe
conclusions.
Conclusion
Within the limitations of this systematic
review and meta-analysis, the following con-
clusions can be drawn:
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