Principles of Fixed Implant Prosthodontics

Principles of Fixed Implant Prosthodontics:
Cement-Retained Restorations
…… By: Manar Abu Shady……
………..
What is cement- retained restorations?
They are a traditional design to attach a restoration (crown, bridge) to an
implant-retained abutment, similar to cementing a crown or bridge restoration
on a natural tooth.
Indications:
1. Areas where aesthetics are in concern
2. Indicated in cases of limited mouth opening (< 30 mm)
3. Presence of Implant prosthetic malposition
4. Short span bridges
5. For narrow diameter crowns
Advantages:
1) More passive casting & Easier correction of nonpassive ones:
Cement retained restorations fit passively over an abutment when compared to screw retained ones.
Stone expansion and die spacers are advantageous for a passive cement-retained prosthesis to
compensate for more cement space which helps seating the restoration more comfortably and passively.
If a cemented prosthesis is not passive, the casting or abutment may be modified slightly at the same
try-in appointment. High speed carbides with copious amounts of water may be used to modify the
abutment, adjust the internal aspect of the casting, or both and may provide an immediate solution. A
screw-in prosthesis that is not clinically passive requires casting separation and soldering of the casting
or a new impression.
2) Progressive loading
What is meant by progressive loading?
It is the gradual increase of bone strength due to gradual loading which
results in improved bone strength over time.
A cement-retained transitional prosthesis is easily fabricated to be used
before the delivery of the cement-retained final restoration in order to
achieve a progressive loading on the implant-to-bone interface to
gradually increase occlusal contacts over an extended time frame. This
protocol does not affect the properties of the final prosthesis retention
and leads to an increase in bone density
and strength.
3) Occlusion & Response to axial loads
The lack of screw holes in cemented prostheses provides a design
that enhances the physical strength of porcelain and acrylic resin,
resulting in less fracture. The occlusal surface is devoid of screw
holes, and as such, the occlusion can be developed so that it
responds to axial loading. The ideal location for an occlusal contact
is directly over the implant body so, in cement-retained restorations,
axial loads are directed on the primary occlusal contacts along implant
long axes. As a result, crestal bone loss is reduced.
Moreover, cemented restorations permit the design of narrow occlusal tables because no
minimum dimensions are required for screw holes and surrounding metal. This in turn proves a valuable
advantage to prevent over-contouring and promote the design of an emergence profile favourable to peri-
implant tissue health.
4) Reduced unretained restorations:

In clinical studies, reports of unretained cemented implant prostheses constitute fewer than 5% of cases.
Recurring uncemented prostheses are a more unusual occurrence compared with loose prosthetic
screws. Hence, when implant abutments are splinted together, it is safer to cement rather than screw
retain the restoration.
5) Enhanced aesthetics:
Cement-retained restorations offer superior aesthetics when compared to screw-
retained ones. The occlusal aspect of a cement-retained crown is all porcelain and
more aesthetic due to the absence of access holes. The emergence profile of an
anterior cemented crown does not require a facial porcelain ridge lap because the
implant may be placed under the incisal edge, rather than the cingulum. This
facilitates the achievement of an aesthetic result.
6) Improved accessibility:
cement retained restorations have greater accessibility in the posterior regions of
the mouth especially in patients with limited jaw opening. It is easier to place a cement-retained
restoration in cases of limited mouth opening (< 40 mm) than screw retained ones.
7) Reduced porcelain fracture:

One of most common complication for fixed prostheses on natural teeth is porcelain fracture. Occlusal
material fracture is more common with implants than natural teeth because of the lack of periodontal stress
relief with implants and a resultant higher impact force to the occlusal material. A decreased incidence of
porcelain or acrylic fracture of the prosthesis has been observed with
cement-retained restorations compared with screw-retained prostheses.
The screw hole may increase stress concentration to the restoring material
and more often leads to unsupported porcelain and then fracture.
8) Reduced cost:
The laboratory costs for cemented prosthesis are lower than those for screw-retained restoration that’s
because cemented ones do not require additional laboratory components such as impression transfers,
analogs, copings, and screws.
9) Less chair-time:
Fabrication of screw restorations cost a lot and are 1.5 to 2 times higher than cemented restorations.
Fewer and shorter prosthetic appointments are required to restore a patient with a cemented prosthesis
than with a screw-retained restoration
Disadvantages and limitations:

1) Subgingival excess cement:
Removal of cement residues is critical for peri-implant health

in cement retained prosthesis. Excess cement can cause
irritation to the surrounding tissues, increased plaque
retention, peri-implant inflammation associated with bleeding
and peri-implant bone loss. Removal of excess cement is
difficult especially when the margins of the restoration are
subgingival. To reduce the risk for cement trapping, it is
essential to position the height of the crown-abutment
interface at, or slightly below the gingival margin to allow
easy access and complete removal of luting agents.
However, removal of residual cement is extremely difficult especially when it is adherent to the micro-rough
surface of the implant leading to failure.
Case report:
In this case, the patient presented to a
graduate clinic with 5-mm to 7-mm probing
depths and bleeding on probing around
implant #8. Clinically, tissue inflammation
was noted on the gingival margin of #8.
Upon examination, residual cement was
noted in the subgingival area. This
represents the obvious etiologic factor for
peri-implant disease.
2) Bad oral hygiene:

One of the major negative aspects of cement retained restorations is the presence of residual cement
following delivery of the prosthesis that can lead to peri-implant mucositis and peri-implantitis. A clinical
trial has shown that approximately 80% of the cement-retained implant prostheses with radiological and
clinical signs of peri-implant disease had subgingival residual cement, thus, it was concluded that
residual cement might play an important role as a bacterial reservoir, leading to soft tissue irritation that
contributes to peri-implant tissue breakdown.
3) Difficult retrievability:
One of the main disadvantages of cement retained

prostheses is the difficult retrievability. When an abutment
loosens or any repair of the restoration become necessary,
the restoration may be destroyed during the removal
procedure if the cement seal cannot be easily broken. Any
force applied to a restoration on a loosened abutment has
the potential to damage the internal threads of the implant.
However, cementing the restoration with provisional cement allows a degree of retrievability. The cement
chosen is a controlling factor in the retention attained; either temporary cement or a mixture of temporary
cement and petroleum jelly (reduced strength) can be used to cement implant-supported prostheses. On the
other hand, there is another way to remove a cement retained prosthesis by creating an access hole through
the occlusal surface of the crown to reach the abutment screw and retighten it. This process depends on
guessing roughly where the screw channel is, then, excessive occlusal surface damage may occur. So,
generally cement retained prosthesis retrievability is difficult and complicated.
There is a viable protocol for management of screw

loosening in cement retained implant restorations by
using a vacuum formed clear stent to accurately
determining the position of the abutment screw in 3
dimensional relationships.
Clear vaccum formed sheet Orientation of the abutment Incorporation of the plastic
adabted onto the cast access path after removal of guide tubes
crowns
4) Not suitable for non-parallel implants:

When implant bodies are unparallel by more than 30
degrees, an abutment for cement retention cannot be
adequately prepared for a path of insertion. Anterior
abutments with slight labial angulation (<30o) can be
modified and prepared carefully to fit a cement retained
restoration {readymade angled abutments can be used}.
Common complications:
1) Residual Cement
The most common complication of a cement-retained implant restoration is residual cement left in the
gingival sulcus of the implant. Residual cement in the sulcus after cementation of the prosthesis is a
source of peri-implantitis.
Considerations in order to avoid formation of cement residues as possible:

1) Adequate cementation protocols and procedures should be
performed such as
• Placing retraction cords in the sulcus
• Applying controlled amount of cement.
2) Remnant cement was found on sites with a deeper
subgingival margin area so, using customized abutments with
≤1mm subgingival margin to allow easy access and complete
removal of luting agents.
2) Risk of uncementation:
The implant abutment is made of metal, so dental cements do not adhere to the interface as with dentin
of a natural tooth. So, any interceding space or marginal gap may expose the cement to oral fluids and
result in dissolution of the soluble cement and then restoration dislodgment. Uncementation in cases of
multi-unit cement retained restorations leads to significant complications and failure of restoration and
implant fracture. However, uncemented prostheses are a more unusual occurrence compared with loose
prosthetic screws.
Case reports:
1. Case 1:
a 54-year-old female was treated with
cement-retained implant-supported partial
denture at the mandibular right molars. After
several years of uneventful function, the
cement dissolved then the denture became
loose at the mesial abutments causing an
overloading of the distal implant leading to
implant fracture. The fractured implant apex
was removed, a short, larger diameter implant is then placed, and a new fixed partial denture
fabricated and cemented. The patient has been functioning uneventfully for 5 years.
2. Case 2:
A 59-year-old female patient had an implant placed which supported a cement retained single
crown in 2005. In 2016, the cement had dissolved and the crown dislodged. The crown and
abutment were cleaned, and the crown recemented in place.
3) Loss of retention in cases with low-profile
abutments:
A cement-retained restoration should ideally have 8 mm
or more of crown height space (CHS). This dimension
permits at least 1 mm for occlusal material on the crown
and 5 mm of abutment height for retention and
resistance form. Any reduction of CHS less than 5 mm
will decrease retention leading to failure.
4) Abutment screw loosening (difficult retrievability):

Loosening of an abutment screw is a challenging complication of cement-retained,
implant-supported prosthetic restorations. Often, the abutment screw becomes loose
from the implant body, whereas the crown remains cemented to the abutment. In such
situations, separating the cemented crown from the underlying abutment or locating
the abutment-screw access for removal of the restoration is a difficult task.

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Principles of Fixed Implant Prosthodontics:

4) Reduced unretained restorations:

7) Reduced porcelain fracture:

Disadvantages and limitations:

Removal of cement residues is critical for peri-implant health

2) Bad oral hygiene:

One of the main disadvantages of cement retained

There is a viable protocol for management of screw

4) Not suitable for non-parallel implants:

Considerations in order to avoid formation of cement residues as possible:

4) Abutment screw loosening (difficult retrievability):

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