Journal of Dental Reports

Chawali F, et al., 2020-J Dent Report

Case Report

Management of Implant Abutment screw

Fracture Using A Non-Invasive Department of Fixed Prosthodontics and
Esthetic Dentistry, Faculty of dental
Technique: 9 Months Follow Up Case medicine, Monastir, Tunisia

Report Research Laboratory of Occlusodontics

and Ceramic Prostheses LR16ES15, Faculty
Farah Chawali, Nissaf Daouahi, Mohamed Ben Khelifa, Belhassen of Dental Medicine, University of
Monastir, Monastir, Tunisia
Harzallah, Mounir Cherif, Dalenda Hadyaoui *Corresponding Author: Farah Chawali,
Department of Fixed Prosthodontics and
Abstract Esthetic Dentistry, Faculty of dental
medicine, Monastir, Tunisia
This article describes a case of a 65-year-old male patient who
Received Date: 08-17-2020
presented with a chief complain of missing teeth avulsed since 2 years.
Published Date: 09-02-2020
He was asking for its replacement. The treatment plan included
implant supported crown associated with bone grafting technique. The Copyright© 2020 by Chawali F, et al. All
abutment screw was fractured during its insertion in the final rights reserved. This is an open access
article distributed under the terms of the
appointment. A conservative and non-invasive technique based on Creative Commons Attribution License,
converting the healing abutment into prosthetic abutment was which permits unrestricted use,
illustrated. A follow up after 9monthswasrecorded and satisfactory distribution, and reproduction in any
results were maintained. Thanks to a well-planned approach, the medium, provided the original author and
source are credited.
patient was satisfied.

Keywords: Implant Supported Crown, Management, Failure, Fracture,

Implant Abutment Screw, Healing Abutment

Introduction

Osseointegrated implant- supported restorations are widely used

for the replacement of missing teeth. It represents a safe
technique with high rate of success which is estimated, according
to studies, to be about 97% to 99% [1 -2]. However, failure or
complications may occur [1].The failure of dental implants is due
not only to unsuccessful osseointegration or the development of
periimplantitis, but also it can result from technical
complications which can be divided into two groups : Those
related to implant components and those related to the
prosthesis [3].

The abutment screw fracture, which is among the common

Chawali F| Volume 1; Issue 1 (2020) | Mapsci-JDR-1(1)-001 | Case Report

Citation: Farah Chawali, Nissaf Daouahi, Mohamed Ben Khelifa, Belhassen Harzallah, Mounir Cherif, Dalenda Hadyaoui.
Management of Implant Abutment screw Fracture Using A Non-Invasive Technique: 9 Months Follow Up Case Report. J Dent
Report. 2020;1(1):1-7.
mechanical complication, presents a rare Figure 1: Radiographic Examination.
but a serious problem which can be caused
by defects in design or material ,non-
passive fit of the prosthetic framework,
metal fatigue due to biomechanical
overloadingand parafunctional habits or
unfavorable superstructure. It is observed
consequently to screw loosening and
undetected micro-movements of the
abutment under functional loading [3].

For management of damaged or fractured

screw retainer, various techniques have Comprehensive examination revealed a
been described for screw retrieval [4]. In dehisence of the buccal alveolar bone with
some cases, the only solution for the vertical defect (fig .1). it was managed ,
abutment screw fracture is removing the during implant placement (Osstem TS IV
implant itself. And, in a majority of these implant), by guided bone
cases additional surgical procedures could regeneration(GBR) using synthetic
be necessary ; increasing cost, time and osteoplastic material (Klipdent GL,
morbidity if a new implant is to be “Vladmiva” Russia); The grafted site was
placed[5]. Fractured end can be retrieved secured with a non-resorbable membrane
and replaced by a new abutment screw. (Oss Builder,Osstem, Seoul, Korea)(fig .2 :
But sometimes, it cannot be conservatively a,b). Aperiod of 9 months was considered
removed using rotary instruments where as necessary for predictable
internal threads of the screw may be osseointegration.The non-resorbable
damaged conducting to useless membrane was, then, taken-off and
implant.Non invasive techniques are highly healing abutment was placed (fig .3 :a,b).
considered in such situations.
Figure 2(a,b): Surgical procedure using a
The purpose of this report was to describe bone grafting technique associated with
a non-invasive technique for the non resorbable membrane.
management of fractured abutment screw.
It is based on converting the healing
abutment into prosthetic abutment.

Clinical Presentation

A non smoker 65 year-old male patient

presented to the department of fixed
prosthodontics ; with a chief complaint of After 2weeks, the impression was taken
missing teeth. He was asking for the using pick up technique. The working cast
replacement of the first maxillary premolar was performed and desired modifications
avulsed since 2 years. The decision of were done in the rigid abutmentin favor of
implant supported crown was discusssed placing a ceramo-metal crown.
with the patient and retained.
Chawali F| Volume 1; Issue 1 (2020) | Mapsci-JDR-1(1)-001 | Case Report
Citation: Farah Chawali, Nissaf Daouahi, Mohamed Ben Khelifa, Belhassen Harzallah, Mounir Cherif, Dalenda Hadyaoui.
Management of Implant Abutment screw Fracture Using A Non-Invasive Technique: 9 Months Follow Up Case Report. J Dent
Report. 2020;1(1):1-7.
 During the final appointment, the
abutment was placed using a 30Ncm
controlled tightening. The abutment screw
was fractured (fig .4: a,b) . Radiologic
examination confirmed that, the screw
fracture occured in the depth of the
implant (fig .5).
Figure 3 (a,b): Placement of the healing
abutment.
Figure 4 (a,b): Fracture of the abutment
screw.
Figure 5: Radiographic examination
showing the level of screw fracture.
The patient was informed and the
modalities of removal of fractured screw
were discussed.Firstly, we attempt to
remove the fractured screw using a
Chawali F| Volume 1; Issue 1 (2020) | Mapsci-JDR-1(1)-001 | Case Report
Citation: Farah Chawali, Nissaf Daouahi, Mohamed Ben Khelifa, Belhassen Harzallah, Mounir Cherif, Dalenda Hadyaoui.
Management of Implant Abutment screw Fracture Using A Non-Invasive Technique: 9 Months Follow Up Case Report. J Dent
Report. 2020;1(1):1-7.
retriever tool. A special fragment
instrument was used in reverse torque to
engage on the rugged top portion of the
fractured screw and retrieve fractured
screw fragment. However, sufficient area,
which is required to work as intended, was
not available.
For the same reason, the ultrasonic insert
couldn’t be used ; it can’t be introduced
between the implant and the wedged screw
fragment.
Retrieval approach was impossible,
however, the healing abutment was the
only piece that holds to the implant. A
conservative technique of management was
retained; it consists on converting the
healing abutment to aprosthetic abutment
because the level of fracture does not
interfere with the placememnt of the
healing screw.
A healing abutment with an important
gingival height (H=7mm, D=4,5mm)was
selected and placed into the implant(fig
.6).
Figure 6: Abutment healing converted to
prosthetic abutment.
To control the adaptation between the
fixture and the healing abutment,
periapical radiograph was necessary. A
perfect adaptation was obtained (fig .7).
Figure 7: Radiographic examination
showing a good adaptation between the
fixture and the healing abutment.
As, it was not possible to fix any impression
coping because of the screw fragment, the
impression could only be performed
referring to the conventional technique
used in dental supported restorations. This
step aimed to reproduce the details of the
healing abutment previously transformed
to an abutment to supportthe final
prosthesis.
The final crown was carried out using the
master cast duplicating the customized
abutment. Occlual adjusments were
performed according to new concepts of
occlusion. Final crown was cemented using
provisional cement(fig .8).
A follow up after 9 months was recorded in
this case study and satisfactory results were
maintained (fig .9).
Figure 8: Final result.
Chawali F| Volume 1; Issue 1 (2020) | Mapsci-JDR-1(1)-001 | Case Report
Citation: Farah Chawali, Nissaf Daouahi, Mohamed Ben Khelifa, Belhassen Harzallah, Mounir Cherif, Dalenda Hadyaoui.
Management of Implant Abutment screw Fracture Using A Non-Invasive Technique: 9 Months Follow Up Case Report. J Dent
Report. 2020;1(1):1-7.
Figure 9: Radiographic examination after a
period of 9 months.
Discussion
Despite the high success rate of 97% to
99% of implant supported prostheses,
technical and biological problems may be
encountered [6,7]. They conduct to the
failure of the implant therapy. Technical
problems are related to implant
components or prosthesis components and
include abutment screw loosening and
fracture. According to litterature,
abutment screw fracture is considered to
be a rare complication occuring less than
0,5% [8] ; But the most common and
disturbing technical complication
estimated, for some other studies, to be
around 8% of technical complications
[1,4,9, 10].
Undetected screw loosening, which can be
related to ill fitting superstructure or
overloading is considered as the primary
reason for screw fracture. The load is
transmitted through the abutment and its
retaining screw ; The abutment screw will
receive then tensile and bending moments
that can induce a fatigue fracture.
Abutment screw has various shapes, sizes
and is manufactured from different
materials including gold, titanium or
sufrace treated titanium alloys. The part of
abutment screw located at the junction
between the neck and the threads is prone
to fracture because of its design. Defects in
the screw itself may result in increased
stress [4,11,12].
Fracture may, also, occcur when it is over
torqued on tightening. In the same
context, the fracture may happen in
situation where the abutment may not
have been fully seated when the torque is
applied [5].
To avoid the risk of fracture, maintaining a
correct torque during screwing is of
concern [5]. Authors recommend, also, an
increased diameter of screw. But, it
depends on the diameter of prosthetic
abutment and the implant itself and
consequently on the clinical situation [12].
According to recent studies, A modified
design of the abutment screw can be
intorduced as a concept for easy retrieval.
Conventional abutment screw measures
2 mm in diameter, 7.8 mm in length, and
0.4 mm in screw thread pitch. Meanwhile,
the hollow abutment screw was made with
the same system but modified by creating a
hole of 0.5 mm in diameter from the lower
end of the abutment screw up to the 1st
thread. It has been shown that the hollow
abutment screw may be an alternative to
the conventional abutment screws because
this is designed for easy retrieval. Its
mechanical strengths was also compared
with conventional abutment screws; No
significant difference in the mechanical
tests was shown [13,14,15].
It has also been confirmed that the risk of
fracture can be increased with the
customization of prosthetic abutment
because of the lack of precision and the
consequent low strength.Therefore,
prefabricated abutment should be prefered
whenever it is possible [16].
Chawali F| Volume 1; Issue 1 (2020) | Mapsci-JDR-1(1)-001 | Case Report
Citation: Farah Chawali, Nissaf Daouahi, Mohamed Ben Khelifa, Belhassen Harzallah, Mounir Cherif, Dalenda Hadyaoui.
Management of Implant Abutment screw Fracture Using A Non-Invasive Technique: 9 Months Follow Up Case Report. J Dent
Report. 2020;1(1):1-7.
Abutment screw fracture is challenging
and timely ; But necessary to provide an
adequate rehabilitation plan. Otherwise,
we will be faced with results in several
irreversible damages that can conduct to
useless implant. In addition, till nowno
consensus for its management is
confirmed.So, there is no universal method
that can be applied.
Once it occurs, the fractured segment
inside the implant has to be removed
without damaging the internal threads of
the implant maintaining the ability of the
implant to retain the prosthetic abutment.
Several techniques for the removal of
fractured screw have been documented.
They involved screw retrieval systems
supplied by various implant manufacturers.
The technique is selected according to the
location of fractured screw. When it is
fractured above the head of the implant ;
an explorer, a straight probe or hemostats
might be successuful. Whereas, when the
fractured part is located below the head of
the implant other methods are required
including Ultrasonic scaler, High pull out
or seperation forse which can expose the
bone interface to risk [17]. The clinician
must understand not only the technique of
retrieval but also identify the associated
risks and degree of difficulty and the
patient should be also informed about risks
[2].
As fractured abutment screw must be
removed without damaging the implant
body in order to maitain a useful implant
[18], Ultrasonic scaler would be the initial
method of choice to retrieve the apical
portion [1,5,10]. In the present case study,
the fractured part is located apically.
Ultrasonic technique was not sucessfully
done. Another conservative technique
providing a minimal risk was adopted; the
healing abutment was converted into
prosthetic abutment as the healing
abutment has a height permitting the
retention of the crown. It seems to be safer
than other techniques, however it requires
a healing abutment with sufficient height;
This makes this technique restricted to
some implant systems. Implant with short
abutment healing are excluded.
Conclusion
of the wedged fragment without damaging
the internal threads of the implant. If
conservative retrieval fails, then the
technique explained in this article can be
employed without sacrificing the
osseointegrated implant. Eventhe proposed
technique has a few disadvantages such as
technical difficulty and the lack of
precision. Further long-term clinical trials
are required to confirm its success in the
long run.

When screw fracture occur, the first

approach should be a conservative retrieval

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Chawali F| Volume 1; Issue 1 (2020) | Mapsci-JDR-1(1)-001 | Case Report
Citation: Farah Chawali, Nissaf Daouahi, Mohamed Ben Khelifa, Belhassen Harzallah, Mounir Cherif, Dalenda Hadyaoui.
Management of Implant Abutment screw Fracture Using A Non-Invasive Technique: 9 Months Follow Up Case Report. J Dent
Report. 2020;1(1):1-7.
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Chawali F| Volume 1; Issue 1 (2020) | Mapsci-JDR-1(1)-001 | Case Report

Citation: Farah Chawali, Nissaf Daouahi, Mohamed Ben Khelifa, Belhassen Harzallah, Mounir Cherif, Dalenda Hadyaoui.
Management of Implant Abutment screw Fracture Using A Non-Invasive Technique: 9 Months Follow Up Case Report. J Dent
Report. 2020;1(1):1-7.