Received: 30 December 2019 | Revised: 2 May 2021 | Accepted: 17 June 2021

DOI: 10.1111/clr.13849

ORIGINAL ARTICLE

Cemented versus screw-­retained posterior implant-­supported

single crowns: A 24-­month randomized controlled clinical trial

Stefan Wolfart1 | Anne Rittich1 | Karin Groß1 | Oliver Hartkamp1 |

Annabelle von der Stück1 | Stefan Raith1,2 | Sven Reich1

1
Department of Prosthodontics and
Biomaterials, RWTH University Hospital, Abstract
Aachen, Germany
Objectives: To compare the incidence of biological and technical complications of ce-
2
Clinic for Oral and Maxillofacial Surgery,
Aachen, Germany
mented and screw-­retained monolithic lithium-­disilicate implant-­supported posterior
single crowns.
Correspondence
Sven Reich, Department of Prosthodontics
Material and Methods: Forty-­one subjects with a total of 56 implants received ran-
and Biomaterials, RWTH University domly allocated 28 cemented and 28 screw-­retained crowns. In the screw-­retained
Hospital, Pauwelsstrasse 30, D-­52074
Aachen, Germany.
group, monolithic lithium-­disilicate restorations were luted to titanium bases ex-
Email: sreich@ukaachen.de traorally. In the cemented group, monolithic lithium-­disilicate crowns were cemented

Funding information
The study was funded by Ivoclar Vivadent.
The ceramic, luting, and composite
materials were provided by Ivoclar
Vivadent. The implants and the metal
components for the suprastructures
were funded by the Oral Reconstruction
Foundation (ref# CF41308)
on individualized titanium abutments intraorally. All restorations were examined ac-
cording to modified FDI criteria within 2 weeks of inserting the crowns (baseline) and
after 12 (n = 46) and 24 (n = 43) months. Bone loss was evaluated by standardized
radiographs at baseline and 12 months.
Results: After 12 months, the incidence of mucositis (positive bleeding on probing)
was 14.2% (screw-­retained) and 17.9% (cement-­retained). The gingival and plaque
index and a mean marginal bone loss between 0.03–­0.15 mm showed no significant
difference between the groups. In the cemented group, cement residues were de-
tected at baseline at two restorations (6.9%) by radiographic examination. A complete
digital workflow was realized in most cases (85.7%). At 24 months, no restoration
had failed, and no chipping of the ceramic had occurred. In the screw-­retained group,
screw loosening occurred in one implant. In both groups, there was obvious deteriora-
tion in the quality of 32% of the occlusal and of 18% of the proximal contact points.
Conclusions: The type of retention mode of monolithic implant-­retained lithium-­
disilicate posterior crowns had no influence on the biological and technical complica-
tion rate.

KEYWORDS
bone implant interactions, clinical research, clinical trials, material sciences, prosthodontics,
soft tissue-­implant interactions

This is an open access article under the terms of the Creat​ive Commo​ns Attri​bution-NonCo​mmercial License, which permits use, distribution and reproduction
in any medium, provided the original work is properly cited and is not used for commercial purposes.
© 2021 The Authors. Clinical Oral Implants Research published by John Wiley & Sons Ltd.

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wileyonlinelibrary.com/journal/clr Clin Oral Impl Res. 2021;32:1484–1495.

WOLFART et al.
1 | I NTRO D U C TI O N
The biocompatibility of implant-­supported restorations is an essen-
tial factor for their long-­term success. In health, the peri-­implant site
is characterized by an absence of erythema, bleeding on probing
(BOP), swelling, and suppuration (Berglundh et al., 2018). On the
other hand, peri-­implant diseases are of infectious origin and are
observed in two clinical phases. In peri-­implant mucositis, the in-
flammatory cell infiltrate is limited to the soft tissue, whereas in peri-­
implantitis, it extends to the adjacent bone bed (Lindhe & Meyle,
2008).
An optimally designed and processed prosthetic restoration
is a prerequisite (Kordbacheh Changi et al., 2019) to prevent peri-­
implant disease. Thus, the quality of the restoration is an important
benchmark when estimating the risk of a patient to develop peri-­
implantitis. This refers especially to the fit and cleansability of the
restoration and the type of retention: screw-­retained or cemented
in combination with the risk of excess cement (Heitz-­Mayfield et al.,
2020). Even though the survival rate did not differ statistically be-
tween cemented and screw-­retained restorations (Lemos et al.,
2016; Sailer et al., 2012; Wittneben et al., 2014), the complication
rates of both treatment modalities are significantly different (Sailer
et al., 2012).
An analysis of the biological complications of cemented resto-
rations revealed a marginal bone loss of >2 mm with a 5-­year in-
cidence of 2.8% (Sailer et al., 2012). A more apical localization of
the margin (1, 2, or 3 mm subgingival) leads to a greater amount of
undetected residual cement (Linkevicius, Vindasiute, et al., 2013). To
minimize the risk of undetected cement excess, it is recommended
to place the finish line of the abutment at the gingival level (Staubli
et al., 2017). In contrast to cemented restorations, a marginal bone
loss of >2 mm within 5 years was not observed for screw-­retained
restorations (Sailer et al., 2012). This difference in outcomes be-
tween both types of retention was confirmed by another review and
meta-­analysis (Lemos et al., 2016).
In terms of technical complications, cement-­retained resto-
rations showed a 5-­year complication rate of 11.9%. Screw loos-
ening occurred in 3.9% and chipping of the veneering ceramic in
2.8% of all cases. In contrast, technical complications were more
frequent for screw-­retained reconstructions with a 5-­year inci-
dence of 24.4%. Screw loosening occurred in 21.2% of the cases
and was the most frequently seen technical issue in single crowns.
Chipping of the veneering ceramic occurred in 9.6% cases (Sailer
et al., 2012).
To minimize biological and technical complications while meet-
ing the requirements of future-­oriented dentistry, the application of
digital methods for clinical prosthetic implant dentistry has gained
significant interest and need to be investigated further (Joda et al.,
2017). In this regard, there are insufficient scientific data to show
whether a digital workflow, especially for single-­unit monolithic im-
plant suprastructures, can be implemented in every clinical situation
or whether a conventional workflow must be used in critical situa-
tions to ensure the desired quality standards.
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1485
To summarize, there are serious indications that cement-­retained
restorations may have a higher probability of developing peri-­implant
mucositis and peri-­implantitis than screw-­retained restorations and
that this may be associated with the cement excess seen in relation
to cemented restorations. On the contrary, technical complications
may be seen more often with screw-­retained restorations. A recent
review emphasized the necessity to strengthen the evidence on
such potential risk factors for peri-­implant diseases (Heitz-­Mayfield
& Salvi, 2018).
Therefore, the primary aim of the study was to compare the in-
cidence of biological complications of cemented and screw-­retained
monolithic lithium-­disilicate implant-­supported posterior single
crowns fabricated with a digital workflow. The secondary aims of
the study were the analysis of the longevity and technical complica-
tions of these restorations.
2 | M ATE R I A L A N D M E TH O DS
2.1 | Ethical approval
The present study received approval from the ethics committee of
the Uniklinik RWTH Aachen (no. EK 211-­13) and was registered at
the German Clinical Trials Register (Deutsches Register Klinischer
Studien, reg.no. DRKS00005452). This study was conducted in ac-
cordance with the ethical standards of the ethics committee of the
Uniklinik RWTH Aachen and with the 1964 Helsinki declaration and
its later amendments or comparable ethical standards. Written in-
formed consent was obtained from all participants on a form ap-
proved by the ethical committee of the Medical Faculty of the
RWTH-­Aachen University.
2.2 | Study design
This prospective study was designed as a single-­center randomized
clinical trial.
2.3 | Patient selection
The study was carried out at the Department of Prosthodontics and
Biomaterials, Uniklinik RWTH Aachen, Germany. Patients with an
indication for posterior single implants were recruited consecutively.
The inclusion criteria were as follows:
• Only dentate patients were included who showed the indication
for a maximum of three posterior single implant-­supported res-
torations. The bony conditions for the prospective implant sites
were defined as follows: clinically healed after extraction, man-
dibular alveolar ridge height of at least 11 mm above the inferior
alveolar nerve, and a maxillary alveolar ridge height of at least
10 mm on a panoramic radiograph.
 |
1486
• a natural dentition or at least a restored dentition with fixed pros-
theses in the opposing jaw.
• patients with a good health status (American Society of
Anesthesiologists Physical Status (ASA PS) I or II (Dripps, 1963))
The exclusion criteria were as follows:
• heavy smokers (>20 cigarettes a day),
• the need for significant bone augmentation,
• untreated periodontitis,
• insufficient oral hygiene,
• psychological disorders,
• craniomandibular disorders such as muscular pain and/or pain of
the temporomandibular joint according to anamnesis or clinical
examination,
• and history of drug abuse.
Patients were informed about the risks of and alternatives to the
proposed therapy. Once a patient had given informed consent, the
treatment was performed.
2.4 | Implant therapy
The implants (diameter 3.8–­5.0 mm, length 9–­11 mm, Screw-­Line-­
Implants, Promote Plus, Camlog Biotechnologies) were placed using
a navigated drilling template. The implants were inserted such that
occlusal screw retention was feasible. If necessary, minor bone aug-
mentation procedures were performed with autogenous bone from
the surrounding area, using Safescraper® Twist (Meta), bovine bone
graft substitutes (Bio-­Oss®, Geistlich Biomaterials), and a collagen
membrane (Bio-­Gide®, Geistlich Biomaterials). After a healing pe-
riod of 3 months (mandible) and 6 months (maxilla), the second-­stage
surgery was performed, and the implants were connected to healing
abutments.
2.5 | Groups and randomization
After second-­stage surgery, it was randomly decided whether the
implant received a cemented or a monolithic suprastructure, using
the following process:
1. If two posterior single implant restorations were indi-
cated, the Excel random generator was used to decide
which implant received a cemented or a screw-­retained
superstructure.
2. If one posterior single implant restoration was indicated, the pro-
spective maximum height of the future restoration was calculated
using 3D optical impressions (Cerec Omnicam, version 4.2 and
higher; Dentsply Sirona) measuring the shortest distance from the
healing abutment to the fissure line of the antagonist tooth. Two
subjects with a similar prospective height were paired and the
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WOLFART et al.
type of suprastructure (cement-­or screw-­retained) was randomly
assigned to those implants using the Excel random generator.
3. One subject first received two implants, that were treated as de-
scribed in (1). Later, the same subject received another implant
that was allocated to the randomization process (2).
2.6 | Treatment procedure
2.6.1 | Cemented group
In the cemented group, standard titanium abutments (Camlog
Esthomic Abutment straight, gingiva heights 1.0–­1.8 mm or 3.0–­
4.5 mm, Camlog) were customized chairside. For this purpose, they
were inserted intraorally, and the potential height reduction required
and correct finish line were marked with a pencil. The modifications
were immediately performed chairside by fixing the abutments to
a laboratory implant analogue. The preparation margin was located
slightly subgingival (≤1.0 mm) in the visible area. The abutments
were re-­inserted, and optical impressions served as virtual casts
for the fabrication of the cemented lithium-­disilicate crowns. The
workflow employed in this study has been described in detail earlier
(Reich et al., 2019). Prior to insertion, the maximum height of the
abutment and the entire height of the abutment and crown together
were measured with a slide gauge. For cementation, the abutments
were sandblasted extraorally using a laboratory sandblaster in-
stalled in the treatment room, with a 50 µm grain size and a pressure
of 2 bars. They were screwed intraorally with a force of 20 N/cm,
and the screw canal was rinsed with ethanol, dried, and covered with
a foam pellet. The abutment was silanized (Monobond Plus, Ivoclar
Vivadent). Next, the intaglio surface of the crystallized, stained, and
glazed crown was treated with fluoric acid for 20 s and with silane
for 60 s. Finally, the crown was adhesively luted intraorally using
Multilink Implant (Ivoclar Vivadent) (Figure 2). Cement residues were
removed with hand scalers using a magnifying glasses at a 2.5-­fold
magnification (Figures 1–­3).
2.6.2 | Screw-­retained group
For the optical impression, a corresponding scan post (Camlog
scan posts for Dentsply Sirona scanbodies, Camlog) and scan body
(Cerec scan bodies for Omnicam, Dentsply Sirona) were inserted.
Optical scans were performed and the buccal bite was registered.
After virtually designing the monolithic restoration, it was milled
from a lithium-­disilicate block with a prefabricated hole and a notch
(IPS e.max CAD LT A16). After try-­ins (before and after crystalliza-
tion, staining, and glazing) the monolithic restoration was adhe-
sively luted extraorally to the corresponding titanium base (Camlog
Titanium base CAD/CAM crown, Camlog), Ivoclar Vivadent) accord-
ing to the manufacturer´s recommendations. The total height of the
restoration, including the seat of the titanium base, was measured.
Furthermore, the coronal part of the occlusal screw canal was etched
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WOLFART et al. 1487

F I G U R E 3 Example of a standardized radiograph of a cemented

implant-­supported restoration

F I G U R E 1 Individualized titanium abutment under relative

exsiccation prior to cementation [Colour figure can be viewed at
wileyonlinelibrary.com]

F I G U R E 4 Example of an occlusally screw-­retained

suprastructure [Colour figure can be viewed at wileyonlinelibrary.
com]

with fluoric acid. Then, the restoration was inserted definitively with
a torque of 20 N/cm. The screw canal was rinsed with ethanol, dried,
and covered with a foam pellet. The screw canal was silanized, and
the occlusal access was closed with flowable composite (Tetric Evo
Flow, Ivoclar Vivadent) (Figures 4 and 5).

2.7 | Clinical examinations at baseline and

follow-­up

F I G U R E 2 Cemented lithium-­disilicate crown [Colour figure can The clinical examination was performed at baseline and after
be viewed at wileyonlinelibrary.com] 12 and 24 months. The baseline was defined as the first control
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1488 WOLFART et al.

appointment after the insertion of the crowns and was scheduled
within 2 weeks of inserting the suprastructure. The clinical examina-
tion was performed by two independent examiners using the modi-
fied criteria for indirect and direct restorations proposed by Hickel
et al. (2010). In principle, every parameter was assessed using five
possible scores: clinically excellent (score 1), clinically good (score 2),
clinically sufficient (score 3), clinically unsatisfactory (score 4), and
clinically poor (score 5). For all parameters, the distinction between
“clinically unsatisfactory,” or “clinically poor” restorations was based
on whether the restoration could be repaired (score 4) or whether
it had to be replaced completely (score 5). The parameter that was
assigned the worst score was decisive for the overall rating of the
restoration. The parameters, occlusion (qualitative) and approximal
contact point, were modified (refer Table 1 for details).
A repaired restoration was documented as a “relative failure” and
its replacement as an “absolute failure.”
2.8 | Biological parameters

Periodontal parameters such as plaque index (PI) (Silness & Löe,

1964), gingival index (GI) (Löe, 1967), probing depth, and BOP around
the implant, were assessed. A standardized pressure-­sensitive den-
tal probe was used. The assessment of BOP was dichotomous (pre-
sent/ absent) and was not based on the number of bleeding points.

2.9 | Radiographic examination

F I G U R E 5 Example of a standardized radiograph of an occlusally Radiographs (dental film) were taken at baseline (Figures 3 and
screw-­retained suprastructure 5) and after 12 months. At baseline, especially the proximal areas

TA B L E 1 Definition of the scores of

Occlusion (qualitatively) Approximal contact point
the modified parameters occlusion and
Clinically A shimstock filma is held by antagonist A 50 µm matrix band can proximal contact
excellent suprastructures/an antagonist pair and pass approximally with
(score 1) by the antagonist pairs adjacent to the resistance
implant reconstruction
There is an absence of dynamic
supra-­contacts
Clinically good Not applicableb The contact is too strong;
(score 2) the matrix band
cannot be placed in
the interproximal
contact area
Clinically A shimstock film can be removed with A double (100 µm)
sufficient resistance during intercuspation, matrix band can pass
(score 3) whereas the adjacent antagonist pairs approximally with
keep the film resistance
Clinically There is an absence of occlusal static There is a visible gap
unsatisfactory contacts (>100 µm) between
(score 4) or the proximal surfaces
static premature contact of two adjacent teeth/
restorations
potential, with a risk of
food impaction
Clinically poor Not applicablec There is evident damage
(score 5) of the gingiva caused
by food impaction

aShimstock film: Arti-­Fol 12 µm BK 30 black (Dr. Jean Bausch).

bScore 2: not applicable because between scores 1 and 3, no clinically feasible sub-­item could be
defined.
cScore 5: not applicable because the removal of a restoration with an absent occlusal contact but
otherwise acceptable clinical parameters would be overtreatment with respect to a single-­unit
restoration. Therefore, score 5 (= immediate removal of the restoration) was not applied for the
parameter occlusion.
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WOLFART et al. 1489

were checked, if there were cement residues. Changes in the
marginal bone level were evaluated between baseline and at the
12-­month follow-­up using standardized radiographs. To achieve
the same orthoradial perspective on the implants, customized ra-
diographic positioning jigs were used. After importing screenshots
of the radiographs, a semiautomatic self-­developed program was
used to measure the bone loss (Blender, Blender Foundation). The
implant threads and the cylindrical coronal part of the implant,
which could clearly be identified, were used as reference. The ref-
erence was used to measure the distance to the crest of the sur-
rounding bone along the axis of the cylindrical part. The distance
of at least five threads was used to calibrate the measurement pro-
cedure in every radiograph. The marginal bone loss was calculated
by subtracting the baseline measurement from the measurement
after 12 months.
2.10 | Statistics
2.10.1 | Sample size calculation
Asymptotic relative efficiency method was used for Wilcoxon
matched pairs sample size calculation software G*Power (Heinrich-­
Heine-­Universität Düsseldorf). The parameters were set as effect
size d = 0.6, p-­value = .05 and statistical power = 0.8. The calcula-
tion showed that a sample size of at least 26 implant restorations in
each group was necessary.
All outcomes for both groups were analyzed descriptively.
Differences between groups were individually analyzed for each time
point. Comparison within groups over time and between groups was
made using generalized linear mixed models. A random patient effect
was added to consider dependencies between different study resto-
rations placed in the same patient. A random matching effect was added
to consider the matched pairs design between groups. For ordinal data
(e.g., PI and GI), an ordinal logistic regression model was used; for bi-
nary data (e.g., BOP), a binary logistic regression model was used; and
for continuous data (e.g., probing death and bone loss), a linear model
was used. The level of significance was set at 5%. Outcomes which had
no variability within time points (e.g., fracture and retention) were de-
scribed descriptively.

The main objective of this study was defined as the evaluation of
the incidence of biological complications (peri-­implant mucositis or
peri-­implantitis) in screw-­retained versus cemented restorations.
To calculate the power, a 60% probability for cement residue can
be assumed (Korsch et al., 2018), which leads to peri-­implantitis in
85% (Linkevicius, Puisys, et al., 2013) of all cases. Since there are no
cement residues in a screw-­retained restoration, a peri-­implantitis
risk of 7.6% can be expected (Schwarz et al., 2017). Based on these
different probabilities for peri-­implantitis, the sample size was calcu-
lated. Due to the high estimated differences in the peri-­implantitis
rate in combination with missing standard deviation data in previ-
ously described studies, we estimated a mean rate of effect size.
2.11 | EQUATOR guidelines
This manuscript was prepared in accordance with the CONSORT
2010 statement (Appendix S1).
3 | R E S U LT S
From January 2014 to May 2016, 41 subjects (24 females, 17 male)
received 56 implants with 28 cemented suprastructures and
28 screw-­retained restorations. One subject received three im-
plants, 13 subjects received two implants, and 27 subjects received

TA B L E 2 Number and type of FDI Group 17 16 15 14 24 25 26 27

suprastructures per implant site listed
Upper jaw Cemented 3 1 2 3
according FDI world dental federation
notation Screw-­retained 2 3 1 1 2
Lower jaw SCREW-­ 1 4 2 1 1 2 7 1
retained
Cemented 1 7 3 1 2 1 4
FDI 47 46 45 44 34 35 36 37

TA B L E 3 Details of the implants used:

Type of implants
diameter, number, and mean heights of Mean height of restoration (standard
the restorations (n = 28 for each group) Diameter Number deviation)

Cemented 5.0 3 11.3 mm (±1.0)

4.3 9 11.0 mm (±1.9)
3.8 16 11.1 mm (±2.1)
Screw-­retained 5.0 3 10.4 mm (±0.9)
4.3 11 9.6 mm (±1.6)
3.8 14 11.1 mm (±2.2)
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1490 WOLFART et al.

staining, color match and translucency, and esthetic anatomical form. The scores range from excellent to poor: clinically excellent (score 1), clinically good (score 2), clinically sufficient (score 3),
one implant each. The allocation of the implants is summarized in

NA

1
1
2
2

2
1
2
1
TA B L E 4 Results of the clinical examination at baseline, 12, and 24 months, according to modified FDI criteria: Category: Esthetic properties comprising the parameters of surface luster,
Table 2. The average age of the subjects on the date of implant
placement was 47 years (minimum: 26 years; maximum: 80 years;

5
SD ± 14 years).
Details regarding the implant diameters used and the mean total

4
height of the restorations are presented in Table 3.
For three cemented and five screw-­retained restorations, con-

1
ventional gypsum casts with implant analogs were used for the
prostheses fabrication process. The production process of these

18*,a
restorations was analogus to the intraoral, model-­free approach

9*
1
2
4

7
4
using an intraoral scanner.

24 months

2
All subjects participated in the baseline and 12-­month follow-­up

8*, a
18*
27
26
24
22

19
22
examinations. Two subjects did not participate in the 24-­month

Note: NA, number of implant structures which could not be evaluated, because the subjects were unable to attend the follow-­up appointment at 24 months.
1
follow-­up examination. Of them, one subject had received one ce-
mented and one screw-­retained restoration, and the other patient

5
had received a cemented restoration. All examined restorations
were still in place at the 24-­month follow-­up.

Statistically significant difference within one group (cemented or screw-­retained group) over time between the different follow-­up intervals.
4
3.1 | Esthetic and functional properties and

1a
3

1
technical complications

*Statistically significant difference between the cemented and the screw-­retained groups at a certain follow-­up examination.
The descriptive statistics of the modified criteria according to Hickel

12a
1
2
3

7
3

6
9
et al. (2010) are displayed in Tables 4 and 5. Regarding esthetic
12 months

2
properties (Table 4), the color match was significantly better for the

15a
screw-­retained than for the cemented restorations at the 24-­month

27
26
25
25

21
22
18
1
follow-­up. Furthermore, in the cemented group, the color match
showed significant deterioration over time (p < .05). In relation to
5

the functional properties (Table 5), there were no significant differ-

ences in the contact points of both groups. However, in both groups,
4

there was a significant deterioration in the quality (increase in the

score from 1 or 2 to 3 or 4) in 32% of all occlusal contact points. A
3

1
decline (increase in the score from 1–­3 to 4 or 5) was observed in
18% of all proximal contact points.
Screw loosening was observed in one implant (3%) in the
6a
1

2
10
6
2

screw-­retained group one month after insertion and was tightened

Baseline
clinically unsatisfactory (score 4), and clinically poor (score 5)

again.
22a
27
28
28

24
28

18
21

No chipping of the ceramic occurred during the observation pe-

1

riod of 24 months.
Screw-­retained
Screw-­retained

Screw-­retained

Screw-­retained
suprastructure

Cemented
Cemented

Cemented
Cemented

3.2 | Cement residues and marginal bone loss

Type of

In the cemented group, mesial and distal cement residues were de-
tected on the radiographs at two restorations (6.9%) at baseline.
Color match and translucency

They could be removed directly after taking the radiographs. All

Esthetic anatomical form

other dental films showed no cement residues. During the follow-

­up period, no further cement residues were detected or removed
clinically. The mean bone loss was between 0.03 and 0.15 mm. On
Surface luster

comparing the bone loss between both groups, on the distal surface,
Parameter

there was significantly less bone loss in the cemented group after
Staining
Score

12 months (p < .001). For the mesial surface, no difference was seen
between the two groups (Table 6).
a
 WOLFART et al.

TA B L E 5 Results of the clinical examination at baseline, 12, and 24 months according to the modified FDI criteria: Category: Functional properties comprising the parameters of fracture and
retention, margin, occlusion (qualitative and quantitative), approximal mesial and distal contact point, and approximal contour. The scores range from excellent to poor: clinically excellent (score
1), clinically good (score 2), clinically sufficient (score 3), clinically unsatisfactory (score 4), and clinically poor (score 5)

Parameter Baseline 12 months 24 months

Type of
Score suprastructure 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 n.a.

Fracture and retention Cemented 28 28 26 2

Screw-­retained 28 28 27 1
Margin (only cement-­retained) Cemented 27 1 28
Screw-­retained
Occlusion (qualitative) Cemented 28a 20a 4a 4a 18a 6a 2a 2
a a a a a a a a
Screw-­retained 27 1 21 2 5 16 6 5 1
Occlusion (quantitative) Cemented 28 27 1 25 1 2
SCREW-­retained 28 25 1 2 26 1 1
Approximal contact (mesial) Cemented 14 13 1 21a 3a 2a 1a 15*,a 1*,a 4*,a 6*,a 2
Screw-­retained 14a 10a 4a 16a 3a 7a 2a 5*,a 4*,a 10*,a 8*,a 1
Approximal contact (distal) Cemented 14 7 3 10 7 7 11 5 3 3 2
Screw-­retained 13 4 4 1 12 6 3 11 1 4 3 1
Approximal contour Cemented 28 22 4 1 22 4 2
Screw-­retained 22 6 26 2 22 3 1 1

Due to absence of distal adjacent teeth, four distal proximal contacts in the cemented group and six distal proximal contacts in the screw-­retained group could not be assessed.
a
Statistically significant difference within one group (cemented or screw-­retained group) over time between the different follow-­up intervals.
*Statistically significant difference between the cemented and the screw-­retained groups at a specific follow-­up examination at p ≤ .05.
| 1491

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1492
3.3 | GI, PI, and BOP
No significant differences were found in the GI and BOP of the two
groups. Only the parameter PI was significantly higher for screw-­
retained (96.6%) than for cemented restorations (64.3%) after
12 months (p = .016) (Table 7).
4 | DISCUSSION
The primary aim of this study was to evaluate the biological com-
plications of cemented and screw-­retained restorations. Under the
condition of a slightly subgingivally located finish line (≤1.0 mm),
cement-­retained implant-­supported monolithic single crowns in the
posterior region showed good biological results, similar to those
seen with monolithic screw-­retained restorations. Except for the PI
and small differences in bone resorption, no significant differences
were observed in the biological outcomes after 12 months and no
significant differences were seen in the technical complication rates
after 24 months. Based on these short-­term results, both cemented
and screw-­retained restorations can, therefore, be recommended.
These results do not reflect the results of an earlier systematic
review, where an increased bone loss was seen with cemented res-
torations (Sailer et al., 2012). However, in that review, the depth
of the cementation line was not considered, and studies with sub-
gingival and supragingival cementation lines were pooled. These
drawbacks underline the importance of studies that make a direct
comparison between cemented and screw-­retained restorations
while also defining the exact position of the cementation line. In this
context, Linkevicius, Vindasiute, et al. (2013) measured the relation
between the area of cement remnants and the total area of soft tis-
sue contour. A cementation line at the gingival level showed cement
remnants on 1.4% of the total area of the soft tissue contour level. A
1-­mm subgingival cementation line showed a 5.2% affected surface,
2 mm showed 5.7%, and 3 mm showed 7.1%. In general, a more api-
cal placement of the margin led to a greater amount of undetected
residual cement (Linkevicius, Vindasiute, et al., 2013). To obtain the
best possible results for the cemented restorations, the cementation
line was set 0–­1 mm subgingivally in the current study. With this pre-
requisite condition and a baseline radiograph to control any cement
residues, the current study showed a marginal bone loss between
0.03 mm and 0.15 mm after 12 months without any difference be-
tween the groups. These results are in line with another prospective
study evaluating cemented versus screw-­retained single crowns on
customized zirconia abutments in the anterior area of the maxilla
and mandible, also in combination with an only slightly subgingival
finishing line (Heierle et al., 2019). They report a marginal bone loss
of 0.1 mm for the cemented and 0.0 mm for the screw-­retained
restorations, respectively, after a 3-­year observation period. Even
though the two studies only report short-­term results, these results
can already be regarded as substantial, because biological responses
to cement residues and suboptimal cementation margins can be ex-
pected after a short observation period (Korsch et al., 2018).
16000501, 2021, 12, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/clr.13849 by Cochrane Romania, Wiley Online Library on [26/11/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
WOLFART et al.
Due to good visibility of the epigingival cementation margin in
the current study, the presence of cement residues could be safely
avoided. Nevertheless, in the cement-­retained group, mesial and dis-
tal cement residues were detected on the dental films in two cases
(6.9%) and had to be removed later. This shows that complete re-
moval of cement residues is never guaranteed. This is especially true
for the mesial and distal areas, where the cementation line often
runs slightly subgingival due to pronounced papillae. The type of
cement also plays an important role. With the adhesive cementa-
tion performed in this study, the removal of the cement residues is
particularly demanding. In this regard, it was shown that temporary
cements can be removed to a greater extent than definitive cements
and adhesive cementation systems (Korsch et al., 2018).
In the current study, the static and dynamic occlusion at base-
line were chiefly rated as “excellent" in both groups (Table 5). The
assessment of the proximal contact points also showed results
ranging from “excellent” to “sufficient.” For both, occlusal and
proximal contact points, the ratings deteriorated, sometimes even
significantly at the 12-­ and 24-­month follow-­ups (Table 5). A de-
tailed comparison of this aspect with the data from other studies
is not possible, because similar prospective and short-­term studies
are lacking.
In the current study, in 32% of all cases, the occlusal contact
points were lost after 24 months. A retrospective analysis had
showed the loss of 73% occlusal contact points after 5–­20 years
(Cocchetto et al., 2019). Furthermore, the current study showed a
loss of 18% of the proximal contact points after 24 months. A re-
cent review had reported a loss of 50.5% occlusal contact points and
46.3% proximal contact points after a follow-­up period of 18.5 years
(Papageorgiou et al., 2018). Due to the different observation times,
the comparison of the results of the present study with those of
other studies is possible to a limited extent. However, the trend in
the literature and the results of the current study point in the same
direction, and the evaluated parameters must be investigated fur-
ther. This is particularly important because the quality of evidence of
the included study in this systematic review was rated very low due
to bias (Papageorgiou et al., 2018).
In the literature, a radiograph is recommended after cementa-
tion to ensure that all cement residues have been removed, at least
with regard to the mesial and distal areas, even if this radiograph
TA B L E 6 Marginal bone level changes in [mm] between baseline
and the 12-­month follow-­up (negative values imply bone loss and
positive values bone gain)
Cemented Screw-­retained
Surface Mesial Distal Mesial Distal
N 27 27 26 26
*
Mean −0.11 −0.03 −0.11 −0.15*
SD± 0.27 0.20 0.15 0.17
Abbreviation: SD, standard deviation
*Statistically significant difference between the cemented and screw-­
retained groups (p < .001).
 |

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WOLFART et al. 1493

does not provide sufficient information on the residual cement

present on the buccal and lingual aspects (Linkevicius, Vindasiute,
et al., 2013). In line with this recommendation and the standard

0
0

0
0
procedure of the Department of Prosthodontics of our institu-
tion (Wolfart, 2016), radiographic examination was performed in

4 (14.3)
the current study at baseline and after 12 months. According to
2 (7.7)

1 (3.9)
0
0

0
a guideline valid in Germany, additional radiographs are only rec-
1

2 ommended in case of signs of inflammation and increased pocket

depth (Schwarz and Becker, 2016). This led to a limitation of the
study: The radiographic data could not be acquired at the 24-­month

4 (14.3)
5 (19.2)
1 (3.8)
follow-­up.
0
1

As pairing criterion, the prospective abutment height was cho-

sen. Although the crown-­to-­implant ratio seems to play a minor
24 months

role in clinical success (Meijer et al., 2018), the height of the res-
24 (92.3)
24 (85.7)

23 (85.7)
25 (96.2)

20 (76.9)
27 (100)

toration was considered of importance in the current study. This

TA B L E 7 Bleeding on probing and gingival and plaque index of the cemented and screw-­retained groups at baseline, 12, and 24 months

is due to the design of the screw-­retained restorations using a

0

standardized titanium base, which were available only in one stan-

dard height. Therefore, the height of the intaglio surface of the
3

0
0

0
0

titanium base was always 4.7 mm, regardless of the total height
of the monolithic crown. Additionally, the use of intraoral optical
impressions might be more difficult in cases in which the distance
4 (14.2)
5 (17.9)

between the occlusal surfaces of adjacent teeth and the implant

shoulder is high. To take these aspects related to biomechanics and
1

0
0

0
0

accuracy into account, implant crowns of the same height were

10 (35.7)
4 (14.3)

paired with each other.

1 (3.6)

1 (3.6)

Based on the sample size calculation, a sample of at least 26 im-

1

plant crowns was required in each group. The actual sample size ex-
ceeded this number at baseline and at 12 months. However, due to
*Statistically significant difference between the cemented and screw-­retained groups (p = .016).
12 months

the dropout rate, this number decreased to n = 26 in the cemented

24 (82.8)
23 (82.1)

18 (64.3)*
*
24 (85.7)
27 (96.4)

27 (96.4)

and n = 27 in the screw-­retained groups at 24 months. However, the

overall results over the three time points meet the requirements of
0

the power analysis.

The limitations of the study are the short follow-­up period of only
24 months, and the fact that the standardized X-­rays were taken
3

0
0

0
0

only after 12 months and not after 24 months because of ethical rea-
sons. With regard to the power analysis, the limitation of the study
1

0
0

0
0

0
0

is that the analysis is based on an estimated effect size and not on a

calculated effect size carried out by a pilot study. Furthermore, parts
of the analysis consist of many pair-­wise comparisons. This approach
1 (3.6)
1 (3.6)

involves the risk of type I error.

0
0
1

5 | CO N C LU S I O N
Abbreviation: BOP, bleeding on probing.
Baseline

28 (100)
28 (100)

27 (96.4)
27 (96.4)
28 (100)
28 (100)

With respect to biological complications, there were no clini-

0

cally relevant differences between posterior cemented implant-­

0

supported monolithic crowns with a finish line placed maximally

Gingiva index [N/(%)]

1 mm subgingivally and screw-­retained monolithic crowns after

Plaque index [N/(%)]
Screw-­retained

Screw-­retained

Screw-­retained

12 months. With respect to the technical complications, there

Date follow-­up

Cemented

Cemented

Cemented

were no significant differences between the two groups after

BOP [N/(%)]

24 months. However, there was a significant loss in the occlusal

Scales

Scales

and approximal contact points in both groups during the observa-

tion time of 24 months.
 |
1494
AC K N OW L E D G M E N T S
The authors would like to thank the study nurse Kornelia Schmitz for
her thorough assistance with data documentation.
C O N FL I C T O F I N T E R E S T
The authors S. Wolfart and S. Reich did oral presentations and/
or courses for the funding institutions and received an adequate
honorarium.
AU T H O R C O N T R I B U T I O N S
Stefan Wolfart: Conceptualization (equal); Data curation (equal);
Project administration (supporting); Writing-­original draft (lead);
Writing-­review & editing (lead). Anne Rittich: Data curation (equal);
Formal analysis (equal); Writing-­original draft (supporting); Writing-­
review & editing (supporting). Karin Gross: Investigation (equal).
Annbelle von der Stück: Data curation (supporting); Formal analysis
(equal). Stefan Raith: Software (lead). Sven Reich: Conceptualization
(lead); Data curation (equal); Formal analysis (equal); Funding ac-
quisition (lead); Methodology (equal); Project administration (lead);
Writing-­original draft (equal); Writing-­review & editing (equal).
E T H I C S A P P R OVA L S TAT E M E N T
The present study received approval from the ethics committee of
the Uniklinik RWTH Aachen (no. EK 211-­13).
PAT I E N T C O N S E N T S TAT E M E N T
Written informed consent was obtained from all participants on a
form approved by the ethical committee of the Medical Faculty of
the RWTH-­Aachen University.
C L I N I C A L T R I A L R EG I S T R AT I O N
This study was registered at the German Clinical Trials Register
(Deutsches Register Klinischer Studien, reg.no. DRKS00005452).
DATA AVA I L A B I L I T Y S TAT E M E N T
The data of this study are available upon reasonable request from
the corresponding author.
ORCID
Sven Reich https://orcid.org/0000-0002-2693-9118
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