Screw Retained vs Cement Retained

Implant-Supported Fixed Dental Prosthesis

Guided by:
Dr. Mukesh Kumar Goyal
Dr. Isha Saxena
Presented by :
Dr. Surabhi Vashistha
Dr. Shalini Chauhan Dr. Shivangi Bhatnagar
 Contents

• Introduction • CAD-CAM Custom

• Indications Abutment
• Advantages of cement & screw retained • Implant Abutment
prosthesis Margin
• Types of Cement retained prosthesis • Screw Retained
Prosthesis
• Multi Unit Abutment
• Force Factors
• Guidelines to Reduce Complication with • Counter Torque
cement retained prosthesis Technique
• Non Parallel Abutment • Abutment Connection
• References
 Introduction
• Implant supported restorations can be
retained to implants with---
• Screws or cement via abutments.

• Which retention system is appropriate for

the individual patient depends on diverse
factors.
Indications for Cement Retained Prosthesis

• For short-span prosthesis with margins at or above the mucosa level.

• For cases where an easier control of occlusion without an access hole is
desired – for example with narrow diameter crowns
• Cement restoration can be adopted for misaligned implant restoration.
Indications for Screw Retained Prosthesis

• In the presence of restricted inter arch space (minimum 4 mm)

• For fixed prostheses with a cantilever design.

• For long-span fixed prosthesis.
• When retrievability is desired.
CEMENT RETAINED PROSTHESIS
Categories of Abutments for Cement Retention:

•One-Piece Abutments:
• Do not engage the implant's antirotational feature.
• Fit flush with the implant platform.
• Used for multiple restorations where implants are within 20 degrees of
ideal alignment.

•Two-Piece Abutments:
• Include an abutment screw and a component engaging the antirotational
feature.
• Used for single-tooth implants, angled implants, and indirect laboratory
procedures.
Two categories of abutments are used for cemented restorations. The one-piece abutment (far
left) may be used in multiple restorations when the implant bodies are within 20 degrees of
ideal. The two-piece abutments may be used for single teeth, angled implants, and with
laboratory transfers or for custom abutments.
ADVANTAGES AND DISADVANTAGES FOR
ONE PIECE ABUTMENT

Advantages : :
Disadvantages
 No torque wrench needed
 Only for
 multiple
Strongerabutments
 Not
 for
Nosingle-tooth restoration
screw loosening
Not forcomplete
Easy angled abutments
seating
 to
 No' need Weaker to fracture
retighten under restoration
 Less expensive
 Thicker walls to allow great freedom of preparation
ADVANTAGES AND DISADVANTAGES FOR
TWO PIECE ABUTMENT
Disadvantages
Advantages : :

 Anti  Screw under

rotational loosening
shear forces
 Abutment
 Angled
loosening under restoration
Abutments
 Torque and countertorque devices needed for preload
 Proper seating with radiograph must be checked
 Thinner walls limit freedom of preparation
Multi Unit Abutment
 Types of multi-unit abutments: straight vs. angled.

 Provides the greatest range of angulation correction and least lateral offset,
ensuring uncompromised strength, versatility and simplicity.
Multi Unit Straight Multi Unit Angled Multi Unit Angled
Abutment Abutment (15 degrees) Abutment (35 degrees)
GUIDELINES TO REDUCE COMPLICATIONS:

ABUTMENT RETENTION

Applying the principles of retention and resistance ensures the stability of fixed
restorations on implant abutments, emphasizing the importance of precise
abutment preparation and appropriate cement selection.
 Factors affecting Abutment retention:

Surface
Taper Height
area

Resistance Path of Surface

form Insertion texture
NON PARALLEL ABUTMENTS
•Preparation of a Straight One-Piece Abutment:
•Suitable for divergence <20°.
•Uses a crosscut fissure bur with water and intermittent contact.
•Flat sides and grooves added for resistance and retention.
•Disadvantage: Reduces surface area and precision compared to
laboratory-fabricated abutments.

•Angled Implant Abutments:

•Available in angles of 15°–30°, ideal for anterior implants.
•Two-piece angled abutments engaging the antirotational hexagon are preferred.
•Disadvantages: Reduced fracture resistance with increased angle and potential
visibility of the metal due to gingival recession.
Other Options Include:
Use of a Coping:
•Fabricated to align with the fixed prosthesis path of
insertion.
•Provides increased surface area, retention, and
resistance.
•Allows the use of soft-access cement for retrievability.
•Commonly used for distally inclined posterior
implants, less often for anterior implants.

Inverted Tapered Bulk Abutment:

•Features a coronal taper with bulk on one side.
•Requires preparation or custom laboratory fabrication.
•Provides improved retention but relies heavily on precise
preparation.
• Custom Abutments:

• Advantages:
• Highly customizable for angulation,
emergence profile, and esthetics.
• Facilitates subgingival margin preparation
and precise crown seating.
• Disadvantages:
• Sensitive laboratory procedures, higher
A two-piece custom
cost, and risk of inaccuracies in hexagon
angled abutment may be
engagement. fabricated in the
laboratory using a
transfer impression of
Types of Custom Abutments

1. Plastic Pattern Cast in Metal:

Low cost but prone to misfit and screw
loosening.
2. Premachined Titanium Sleeve with Cast
Precious Alloy:
Accurate hexagon fit but risk of crevice
breakdown at material junction.
Three different coping
3. Combination of Plastic Sleeve and Metal designs are available for a
Coping: laboratory: all-plastic, all
Provides secure fit and allows porcelain for metal, and a metal coping
with a plastic housing.
esthetics but is the most expensive.
CAD/CAM Custom Abutments

•CAD/CAM abutments improve clinical outcomes by

enhancing esthetics, function, and peri-implant
mucosal health.
•They provide advantages over stock and
conventional cast abutments, including better design
and reduced micromotion, which helps maintain bone One-piece zirconia custom-
levels and prevents screw loosening. milled abutment

De Kok, I. J., Katz, L. H., & Duqum, I. S. (2018). CAD/CAM Custom Abutments for Esthetic Anterior Implant-
Supported Restoration: Materials and Design. Current Oral Health Reports, 5(2), 121–126.
History of CAD/CAM Abutments

•Introduced to dentistry in 1971 for ceramic restorations; applied to implant

abutments in the 1990s.
•The first CAD/CAM abutment, Atlantis™ (1999), eliminated the need for wax
patterns and allowed virtual designs.
•Systems like Procera® and Encode® followed, evolving into open systems
supporting multiple implant platforms.
Categorization of Implant Abutments
1.Connection Methods:
1. Most CAD/CAM abutments support cement-retained restorations.
2. Innovative designs, such as angulated screw channels and "Crown
Abutments," address esthetic and functional challenges.
2.Materials:
1. Titanium and zirconium oxide are the primary materials.
2. Hybrid abutments combine titanium bases with zirconium for esthetic and
biological advantages.
3.Design Considerations:
1. Customized features such as emergence profiles, margin designs, and
angulated screw channels improve esthetics and fit.
 Advantages of CAD/CAM Abutments
• High precision
Disadvantages reduces human
of CAD/CAM error and misfits.
Abutments
• Integrates
•Initial seamlessly
investment withand
in software digital workflows
milling forisconsistent
equipment high. manufacturing
and long-term
•Requires archival
a learning curve of
fordesigns.
technicians.
•Weaknesses at the prostheticdesigns
• Provides patient-specific interface
forcan lead to
superior complications,
esthetics asstability.
and tissue restorations
must be cemented onto the abutment.
IMPLANT ABUTMENT MARGIN

Most common : knife edge margin

•Knife-edge margins minimize abutment/tooth reduction.

•Preferred for situations where bulk reduction is contraindicated.
•Alternative margin designs (e.g., chamfers) are easier to prepare and manage but
require more reduction.
•Advantages:
•Preserves abutment/tooth structure.
•Avoids unnecessary bulk reduction while ensuring adequate hygiene.

•Disadvantages:
•Difficult to capture and identify in impressions.
•May complicate laboratory fabrication.
•Excess cement in subgingival preparations poses risks
SCREW RETAINED PROSTHESIS
• Challenges with Cement-Retained Abutments:

1. Hydrostatic Pressure:
Prevents complete seating of components, causing a cement margin at the bone
crest.
2. Difficult Cement Removal:
Excess cement located below the tissue margin is nearly impossible to remove
without surgery.
3. Small Abutment Diameter:
a. Typical 2-3 mm diameter is too small for predictable cementation.
b. Increases the risk of incomplete seating and abutment fatigue fracture.
4. Composite Resin Cement:
Provides strong retention but is difficult to remove and may contribute to
crestal bone loss.
5. Fracture Risk:
If the abutment fractures, removal is complex and risks overheating or
damaging the implant, leading to failure.
6. Limited Use:
Cemented posts are generally used as a last resort when screw retention is not
feasible.
Disadvantages :
• Screw loosening
• Fracture
• Improper seal
Force factors
• External forces that act on a screw joint greatly increase the risk of screw
loosening. These forces may be called joint separating forces.
• The force holding the screws together, called clamping forces.
• Joint separating force are greater than clamping force, screw loosening is
seen.
 Causes of Screw Loosening :

a) Forces: occlusion interferences

Parafunction: bruxism
Crown height
Masticatory dynamics
b) Cantilever: offset loads
Component
Dimension
Design
Preload
Material failure
Material type
c) Prosthesis: nonpassive fit
Preload
• Torque force applied to a screw joint causes strain, or elongation.
• Excessive torque can lead to plastic deformation (permanent change in the
screw material) or fracture, compromising the joint.
• To ensure safety and retrievability, the recommended torque should be 75% of
the threshold at which permanent deformation occurs.
• Consistent and adequate preload is essential to create sufficient strain within
the screw threads for a stable joint.
• High-torque wrenches are commonly used.
Counter Torque Technique
• Torque forces are also transmitted to the
bone–implant body interface.
• The amount of torque to break the interface
of an osseointegrated implant depends on
implant design, surface condition, and bone
density but may be less than 20 N-cm in soft
bone types.
• Therefore, the use of a counter-torque
procedure is advocated, especially in soft
bone.
• A simple counter-torque method is to use a modified hemostat to hold the
abutment while the torque wrench tightens the screw.
• Because the abutment engages the antirotational component of the implant
body and the abutment cannot rotate with the hemostat in position, the
rotational forces applied to the abutment screw do not transmit to the implant–
bone interface.
• To use this counter-torque technique the abutment must engage the hex or
antirotational design of the implant. To ensure that the abutment seats
completely on the implant body and fully engages the hexagon or
antirotational feature of the implant body, a radiograph is often necessary.
Factors Affecting Preload

Torque Magnitude

Screw Head Design

Thread Design & Number

Surface condition
The number of threads on an abutment or
coping screw varies depending on the
Screw Diameter manufacturer.
 Abutment Connection is Influenced by :
Height of Hexagon

 Impacts the force on the abutment screw during

lateral loading.
 A lateral force, resisted by the hexagon height and
screw.
 If the hexagon height is below the arc of tipping
forces, the screw bears the entire load, increasing the The higher (or deeper)
the antirotational
risk of loosening. hexagon component (x
 For a 4-mm diameter implant, a 1-mm hexagon component on the graft),
height is ideal, but most manufacturers use a 0.7-mm the less the
hexagon, directing excessive force to the abutment force applied to the
abutment screw (Fs) on
screw and contributing to screw loosening.
the y-axis
Platform Diameter

 Influences the stability of the abutment and the

forces applied to the abutment screw.
 A wider platform reduces the arc of tipping forces
and distributes the load more effectively.
 Narrow platforms with short fulcrums are more A 5-mm diameter
vulnerable to tipping forces. implant (far right) has a
 Larger-diameter implants with wider platforms, such larger platform on the
crest module than a 3.5-
as those used for bruxing patients.
mm diameter implant
(far left). Larger-
diameter implants are
suggested in bruxing
patients in whom force
Component Fit

 Screw loosening is influenced by implant and prosthetic design, particularly

the stability of implant-abutment connections.
 Tight tolerances in the flat-to-flat dimensions of external hexagons improve
stability, while misfit components, machining inaccuracies, and settling
increase stress on screws, causing loosening.
 Accurate machining, sandblasting, chemical devesting, and polishing improve
component fit and reduce settling.
 Plastic burnout copings, while cost-effective, often have greater fit issues due
to irregularities.
Comparison between Screw and Cement retained
Cementation Protocol
• The crown is painted internally with a water-
soluble lubricant such as KY jelly (Vaseline
can be used but it must be adequately cleaned
later). Complete the adaptation by gently
pushing the abutment into the crown and then
carefully removing it.
• Inside of crown has a PTFE tape adapted to it.

Implant Cementation Step by Step; Manual of Nobel Biocare

• Further adapt the PTFE against the walls
of the crown by gently placing the
abutment. When complete, remove the
abutment and make sure that the tape is
even.
• To make the CCA (Chair side Copy Abutment):
Using a fast-setting impression or bite
registration (Blu-Mousse) material, fill the
inside of the crown and continue to overfill
until a “handle” is produced. (Hint: Use a fine-
tip nozzle).
• Remove the CCA, then remove the
PTFE and clean out the inside of the
crown (important!) to remove the KY
jelly or Vaseline.
• Now you have a chair-side copy
abutment. The CCA is 50 microns
smaller than the inside of the
crown! Inspect it, compare it to the
actual abutment, and make sure you
know the orientation
• Load the crown with any amount of
cement you wish—the CCA will
subsequently be pushed into the
crown, and the excess cement will be
extruded chair-side and easily
removed. (This is done outside of the
mouth.)
• Inspect the inside of the crown for an
even cement layer. If you find any “bare”
areas, just add a little extra. Then seat the
crown in the mouth.

• A fast, inexpensive, simple technique,

this approach limits excess cement to an
absolute minimum, and makes cleanup
quicker and easier. The CCA can be used
for custom, stock and even multiple
abutments!
 References

• Shadid R, Sadaqa N. A comparison between screw-and cement-retained implant prostheses. A literature

reviews. J Oral Implantol. 2012;38: 298–307.
• Misch CE. Dental Implant Prosthetics. 2nd ed. St. Louis: Elsevier; 2015.
• Chee W, Jivraj S. Screw versus cemented implant supported restorations. British dental journal. 2006
Oct;201(8):501-7.
• De Kok, I. J., Katz, L. H., & Duqum, I. S. (2018). CAD/CAM Custom Abutments for Esthetic Anterior
Implant-Supported Restoration: Materials and Design. Current Oral Health Reports, 5(2), 121–126.
• Implant Cementation Step by Step; Manual of Nobel Biocare
THANK YOU