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Volume 17; 2007

Dental Updates ™

"CUTTING EDGE INFORMATION FOR THE DENTAL PROFESSIONAL "

200 SEMINARS AND 30 JOURNALS REVIEWED YEARLY FOR THE LATEST, CUTTING EDGE INFORMATION

Excerpted Article e-mail: re777@comcast.net

Why Implant Screws Loosen

Part 2
Recent research shows that tightening during
try-ins can increase chances of screw loosening

Richard Erickson, MS, DDS

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Incorporated
Volume 16; 2007
Bond strength testing results using SurpassTM to Z-250
composite are shown in the graph below:
Crown and Bridge
Abfractions - Where Do They Come From?
As we noted in a previous issue (Vol. 14, pg. 16), abfraction
lesions do not seem to be related to occlusal interferences or
bruxism. As that study found, when all interferences to the
abfracted tooth were removed,
the abfraction lesion continued
to progress and become larger.
Another research group4
has confirmed this in a
separate study involving 65
adults. They found that there
was no relationship between
abfraction lesions and occlusal
enamel wear OR lateral excur-
sive interferences.
Again stating the abfrac-
tion conundrum, if abfractions are caused by lateral excursive
forces and B-L bending of the tooth, then why are lesions not
found on the lingual surfaces? Good question and one that makes
the origin of abfractions all the more mysterious.
Does the Luting Shade and Stump Shade Really Matter?
Much debate has been made in esthetic seminars concerning
the recording of “stump shades” of the prepared teeth so the lab
can correctly match the final restoration to the surrounding teeth.
This is normally of concern and recommended when using
EmpressTM veneers and crowns. Some have suggested that even
the luting cement can alter the shade slightly of these type resto-
rations.
A new study was of particular interest because it would
appear to render these concerns of underlying shade moot. In this
study5, 1mm thick Empress disks (shade A2) were luted to
various shade composite disks (A3, B3, C3, and D3) using both
A3 and Transparent luting cement (Variolink II). Quite a wide
variety of underlying shades and cements to be sure. The
4
Koster W: IADR Meeting, 2006; abstract #2015
5
Shereen S: J Prosthet Dent, 2006;96:397-40
6
Choquet V, Tarnow D: J Periodontol, 2001;72:1364-71
5
resulting shade of the “luted Empress restoration” was measured
electronically using a colorimeter. Even with all these variations
in “stump shade” and luting cement shade, there was not a clini-
cally perceptible difference in the final end shade (CIE L*a*b*
parameters). This result is in direct contradiction with Crispin
and others who have implied that core translucency was one of
the primary factors in controlling esthetics and color.
Implants and Papillae
For interproximal papillae in the esthetic zone to be estheti-
cally attractive enough to not have the dreaded “black triangle”,
Choquet et al, have determined that the distance from the proxi-
mal contact point of the restoration to the crest of the bone should
be ≤ 5mm6. Therefore, when doing implants in the esthetic zone
with severe bone loss from extraction following traumatic injury
or periodontal disease, the restoration may need to have tissue
colored porcelain added to the gingival area to fill in the defect as
shown in the photo below.
Implant Preload Force: Essential Data
for Anyone Restoring Implants
Screw loosening in implants continues to be a problem for
both patients and clinicians. When an implant screw is tightened,
the implant abutment is “clamped” to the implant by the tension
exerted by the screw. This tension force of the screw is known as
“preload”. One might think that if screws made of different
materials were all tightened with the same force (torque) using
the same wrench, the PRELOAD would be the equal in all the
screws. It is not and is
very dependent on what
the screws are made of.
To put it another
way, as the screw is
being tightened, a
tension force (preload)
is being developed
between the abutment
and the implant. This
tension also acts on the
screw threads them-
selves and eventually,
the frictional force of
Volume 16; 2007
the screw threads equals the torque value of the torque wrench
and further tightening ceases. Now, imagine if the threads were
made of a material which caused less friction. Can you now see
how the preload (tension) from this type of screw would be
higher on the implant? In other words, lower thread friction
allows the screw to be turned slightly more before the desired
torque is reached, thus achieving a higher tension. Higher tension
on the screw results in better “clamping” of the abutment and less
screw loosening. The following paper 7 elaborates this further:
“Optimal preload for a screw is achieved when the screw
is elongated but not to a point where the yield strength is
exceeded. Implant abutment screws are most often made
from titanium alloys or gold alloys. Friction on screw
threads can result in lower preloads generated in screws
for any given insertion torque. To minimize friction, dry
lubricant coatings have been developed such as pure gold
(Gold-Tite, 3i Implant Innovations, Inc., West Palm
Beach, FL) and amorphous carbon (TorqTite; Nobel
Biocare UK, Ltd., County Wicklow, Ireland).”
The above paper cited another reference8 which studied the
other side of the coin, the force required to loosen a screw once it
had been tightened and loosened repeatedly. This has a clinical
application in that often times, implant abutments and prostheses
may be tried in repeatedly during their fabrication. What does all
this screw tightening and loosening have on the potential loosen-
ing of the final restoration? The Weiss study found that repeated
tightening and loosening of implant screws to a constant torque
caused the force required to loosen the screw to decrease. Stated
another way, repeated try-ins of the implant screw made it easier
for the screw to loosen. The researchers theorized that this was
due to decrease in friction between the thread surfaces.
The Byrne group noted that screw loosening can also occur
as a result of “settling” of the implant. Minor surface irregulari-
ties in the screw or the implant-abutment mating surface will
become worn over time with functioning of the implant. The
abutment can then “settle” more on the mating surface and the
tension on the screw (preload) will thereby decrease, making it
easier to loosen.
The engineering reality which was a revelation to me is that
if you tighten different screws with the same torque (35Ncm), the
clamping force (preload) of the screws will NOT be equal. This
study further confounds one’s intuitive “logic” by observing that
for gold screws and the gold-coated screws, repeated tightening
of the SAME screw to the SAME torque results in a decreasing
preload each time the screw was tightened.. This may fly in the
face of logic but it is fact.
The Bottom Line: This study is of particular interest to
those of you who restore implants. Other observations were
made regarding abutment types but for the sake of clarity, we will
only concern ourselves with the types of screws and how they
differ in their ultimate preloads, or clamping force of the prefabri-
cated abutment to the implant. Several interesting conclusions
from the Byrne study are summarized below:
7
Byrne D: J Prosthodont, 2006; 15: 164-171
8
Weiss EI: J Prosthet Dent. 2000 Aug;84(2):194-9
9
Dunham D: J Prosthet Dent, 2006; 95: 323-6
6
ƒ Of the three implant screw types: titanium, gold and gold
coated, the gold coated resulted in the HIGHEST preloads for
any given torque. For a torque of 35Ncm, the preload force for
the three screws were: titanium (142N); gold (134N); gold
coated (386N). These numbers are from the first tightening of
the screws. The gold coated screw was significantly higher in
clamping force that the other two even after repeated tighten-
ings (see Table below). Again, the higher the clamping force,
the more resistant the screw is to loosening.
ƒ The titanium screw’s preload force did not change much or
decrease with repeated tightening to 35N then loosened.
ƒ The gold and gold coated screw’s preload force DECREASED
significantly when repeatedly tightening and loosening to 35N.
ƒ Of the three screws, the gold coated screw’s preload force
decreased the most with repeated tightening and loosening but
it’s preload force was always significantly higher than the
other two:
titanium gold gold coated
preload (N) preload (N) preload (N)
1st tightening 142 134 386
to 35Ncm
3rd tightening 142 124 266
to 35Ncm
Of all the screw types, the gold screw exerted the lowest
preload of all, throughout the testing range. This is probably due
to the lower tensile strength of gold and its ductile nature.
Because of the high clamping force (preload) of the gold coated
screws, it would appear to have the best chance of resisting screw
loosening.
One other caveat is that while repeated try-ins of the
abutment parts may be necessary, both the Byrne and the Weiss
study show that repeated tightening and loosening of the fasten-
ing screws result in an increased probability of the screw becom-
ing loose after final placement. Obviously, this type of
mechanical connection on which implants depend needs to be
rethought.
Partial Clasp Fit - More Reasons For Implants
We’ve all had episodes of “grinding in” a new partial denture
during the initial try-in of the framework or delivery appointment.
It is a real exercise in frustration. It became so frustrating to me
that I began using a lab in California whose only business was
making partial frameworks for other labs. They were the only
frameworks which would snap into place with almost never an
adjustment. Then my local lab would process the framework
with teeth and acrylic and all bets on fitting at the delivery were
off. It seems to be the nature of the beast as a current study
makes clear.
In this study9, both new and existing removable partial
dentures (RPD) were examined for fit. The new RPDs were
adjusted to what was deemed an acceptable fit before empirically
measuring the fit of the clasps and rest seats using impression
material. The authors noted that, unlike single crowns, an RPD is