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    Irena Sailer Sven MühlemannMarcel ZwahlenChristoph H. F. Hämmerle

    David Schneider 

    Cemented and screw-retained implantreconstructions: a systematic review ofthe survival and complication rates

    Authors’ affiliations:Irena Sailer, Sven Mühlemann, Christoph H. F.Hämmerle, David Schneider, Clinic of Fixed andRemovable Prosthodontics and Dental MaterialScience, University of Zurich, SwitzerlandMarcel Zwahlen, Institute of Social and PreventiveMedicine, University of Bern, Bern, Switzerland

    Corresponding author:PD Dr. med. dent. Irena Sailer 

    Clinic of Fixed and Removable Prosthodontics andMaterial ScienceCenter of Dental MedicineUniversity of ZurichPlattenstr. 11CH 8032 Zurich, SwitzerlandTel.: +41 44 634 3260Fax: +41 44 634 4305e-mail: [email protected]

    Conflicts of interest:Dr Irena Sailer has a consultancy agreement withVITA and research collaborations with 3M ESPE,Straumann, Astra, Ivoclar, DeguDent, Sirona. Theremaining authors have no potential conflicts todeclare.

    Key words:   biological complications, bridges, cemented, complication rates, failures, fixed,

    fixed dental prostheses, full-arch, implant reconstruction, screw-retained, single crowns,

    survival, systematic review, technical complications

    Abstract

    Objectives:   To assess the 5-year survival rates and incidences of complications of cemented and

    screw-retained implant reconstructions.

    Methods:   An electronic Medline search complemented by manual searching was conducted toidentify randomized controlled clinical trials (RCTs), and prospective and retrospective studies

    giving information on cemented and screw-retained single-unit and multiple-unit implant

    reconstructions with a mean follow-up time of at least 1 year. Assessment of the identified studies

    and data abstraction were performed independently by three reviewers. Failure rates were

    analyzed using Poisson regression models to obtain summary estimates and 95% confidence

    intervals of failure rates and 5-year survival proportions.

    Results:   Fifty-nine clinical studies were selected from an initial yield of 4511 titles and the data

    were extracted. For cemented single crowns the estimated 5-year reconstruction survival was 96.5%

    (95% confidence interval (CI): 94.8 – 97.7%), for screw-retained single crowns it was 89.3% (95% CI:

    64.9 – 97.1%) (P  =  0.091 for difference). The 5-year survival for cemented partial fixed dental

    prostheses (FDPs) was 96.9% (95% CI: 90.8 – 99%), similar to the one for screw-retained partial FDPs

    with 98% (95% CI: 96.2 – 99%) (P  =  0.47). For cemented full-arch FDPs the 5-year survival was 100%

    (95% CI: 88.9 – 100%), which was somewhat higher than that for screw-retained FDPs with 95.8%(95% CI: 91.9 – 97.9%) (P  =  0.54). The estimated 5-year cumulative incidence of technical

    complications at cemented single crowns was 11.9% and 24.4% at screw-retained crowns. At the

    partial and full-arch FDPs, in contrast, a trend to less complication at the screw-retained was found

    than at the cemented ones (partial FDPs cemented 24.5%, screw-retained 22.1%; full-arch FDPs

    cemented 62.9%, screw-retained 54.1%). Biological complications like marginal bone loss  >2 mm

    occurred more frequently at cemented crowns (5-year incidence: 2.8%) than at screw-retained ones

    (5-year incidence: 0%).

    Conclusion:   Both types of reconstructions influenced the clinical outcomes in different ways, none

    of the fixation methods was clearly advantageous over the other. Cemented reconstructions

    exhibited more serious biological complications (implant loss, bone loss  >2 mm), screw-retained

    reconstructions exhibited more technical problems. Screw-retained reconstructions are more easily

    retrievable than cemented reconstructions and, therefore, technical and eventually biological

    complications can be treated more easily. For this reason and for their apparently higher biologicalcompatibility, these reconstructions seem to be preferable.

    Introduction

    Fixed implant reconstructions like single-

    implant crowns and multiple-unit fixed den-

    tal prostheses (partial FDPs) are well docu-

    mented in the literature and nowadays fully

    accepted as a treatment option for the

    replacement of single or multiple missing

    teeth (Pjetursson et al. 2007; Jung et al.

    2008). The establishment of the osseointegra-

    tion of dental implants has been thoroughly

    investigated and found to be highly predict-

    able (Esposito et al. 1998; Berglundh et al.

    2002). Even more, the implant-borne recon-

    structions themselves exhibit excellent clini-

    cal survival rates. In a recent systematic

    review, the implant-borne crowns and partial

    FDPs exhibited high survival rates resem-

    bling the ones of tooth-borne reconstructions,

    amounting to 95% at 5-years (Pjetursson

    et al. 2007). Albeit, the clinical success of

    Date:Accepted 04 June 2012

    To cite this article:

    Sailer I, Mühlemann S, Zwahlen M, Hämmerle CHF,Schneider D. Cemented and screw-retained implantreconstructions: a systematic review of the survival andcomplication rates.Clin. Oral Implants Res. 23(Suppl. 6), 2012, 163–201doi: 10.1111/j.1600-0501.2012.02538.x

    ©  2012 John Wiley & Sons A/S   163

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    dental reconstructions depends not only on

    the survival rates but also on the amount of

    technical or biological complications occur-

    ring during clinical function. To improve the

    clinical success, debates about the best mate-

    rials and techniques for the implant-borne

    reconstructions are constantly raised (Pjeturs-

    son et al. 2007; Jung et al. 2008). One of

    those actual debates deals with the ideal fixa-

    tion method between the implant and the

    reconstruction.

    The fixation of an implant reconstruction

    can either be accomplished by screw-retain-

    ing the reconstruction on the implant or on a

    screw-onto implant abutment, or by cement-

    ing the reconstruction on standardized or cus-

    tomized abutments. Initially, screw-retention

    was used for full-arch FDPs in edentulous

    patients (Adell et al. 1981, 1990; Albrektsson

    et al. 1986). Single-unit reconstructions were

    generally cemented on prefabricated cement-

    onto abutments (Sharifi et al. 1994). Both

    types of reconstructions exhibited satisfactory

    clinical long-term outcomes (Adell et al.

    1981; Jemt 2009). However, due to the need

    for customized prosthetic components to

    improve the aesthetic outcomes or a possible

    misangulation of the implant, new compo-

    nents like the cast-on UCLA abutment were

    developed (Lewis et al. 1988, 1992). These

    cast-on abutments allowed for both single-

    unit screw-retained and cement-retained

    reconstructions.

    Both cementation and screw-retention

    seem to have their benefits and shortcomings

    in their clinical application (Michalakis et al.

    2003; Chee & Jivraj 2006). Cemented implant

    reconstructions clinically and technically

    resemble the procedures used for tooth-borne

    reconstructions. They might, therefore, be

    easier to fabricate and to manipulate in the

    patients’ mouths. Specific prefabricated

    cement-onto or even customized abutments

    are needed, though. Nowadays, the CAD/

    CAM (Computer-aided design / Computer-

    aided manufacturing) procedures enable a

    broad application of customized abutments

    and, as a consequence, the cemented recon-

    structions have become the reconstruction of

    choice in many clinical situations. One

    shortcoming of cemented crowns and FDPs

    is the difficulty with the removal of the

    excess cement.   In-vitro   investigations have

    shown that excess cement always remained

    at the tested specimens, irrespective of sub-

    mucosal position of the crown margin (Agar

    et al. 1997; Linkevicius et al. 2011). More

    distressing, in the clinical situation excess

    cement was proven to cause peri-implantitis

    (Wilson 2009). Another significant shortcom-

    ing of the cemented reconstructions is that,

    in case of problems, they are difficult or

    impossible to remove without destruction,

    for example, in cases of technical complica-

    tions.

    In contrast, the major benefit of the screw-

    retained reconstructions is their retrievability

    (Zarb & Schmitt 1990; Chee et al. 1998). Fur-

    thermore, biological problems are rather unli-

    kely to occur, provided that the

    reconstruction exhibits a good fit (Keith et al.

    1999). The horizontal and angular positioning

    of the implant, however, is more delicate and

    harbors less tolerance than when using

    screw-retained reconstructions, because the

    position of the screw access hole and the sur-

    rounding material dimensions of the supra-

    structure need to be considered. The opening

    for the fixation screw should be preferably

    placed in non-visible palatal or oral areas,

    which is only possible if a respective implant

    position and angulation is provided. Further-

    more, the technical fabrication of screw-

    retained reconstructions is more complex

    because a customization of the reconstruc-

    tion core is always needed. Technical compli-

    cations like loosening of retaining screws or

    fracture of the veneering ceramic have been

    reported (Torrado et al. 2004).

    Until today, very little scientific informa-

    tion is available comparing the pros and cons

    of cement-retention and screw-retention

    (Michalakis et al. 2003; Sherif et al. 2011).

    The decision between the two types of recon-

    structions is difficult and rather a matter of

    personal preference than scientific evidence.

    To be applicable as alternatives in every clin-

    ical situation the cemented and screw-

    retained reconstructions need to exhibit simi-

    lar survival and complications rates, though.

    The objectives of this review, therefore,

    were the following:

    1) To obtain robust estimates of the 5-year

    survival rates of cemented and screw-

    retained single-unit and multiple-unit

    reconstructions and their supporting

    implants.2) To obtain robust estimates of the bio-

    logical and technical complication rates

    of the cemented and screw-retained

    single-unit and multiple-unit reconstruc-

    tions.

    Materials and Methods

    The focused PICO (problem, intervention,

    comparison, outcome) question of the present

    systematic review was, whether or not the

    clinical survival and complication rates of

    cemented implant reconstructions are similar

    to the ones of screw-retained reconstructions.

    The focused question was separately ana-

    lyzed for three different kinds of fixed

    implant-supported reconstructions: single

    crowns, partial FDPs, and full-arch FDPs.

    This review was performed by three review-

    ers (IS, SM, and DS).

    Search strategy and study selectionA general MEDLINE (PubMed search form

    search from 1990 up to and including August

    2011 was conducted for English- and Ger-

    man-language articles in dental journals by

    the three reviewers. For this purpose Mesh

    terms and free text words were used. The

    detailed search terms were as follows

    “implant*”, “cement*” or “screw*”, “fix*”

    or “retain*”, “single-crown”, “single crown”,

    “FPD”, “FDP”, “bridge”, “reconstruct*”, and

    “suprastruct*”. Furthermore, the terms

    “long-term”, “long term”, “longterm”, “lon-

    gitud*”, “survival” or “failure”, “compli-cat*”, “technical”, or “biological” were used

    in the search. The search was limited to:

    “human, clinical trial, RCT, case report, clin-

    ical trial phase 1-4, comparative study, con-

    trolled clinical trial, English abstract,

    English, German.” In addition, Cochrane

    Library and Embase searches were performed

    applying the same search terms. The litera-

    ture search was supported by a specialized

    librarian.

    Finally, the electronic search was comple-

    mented by manual search of the bibliogra-

    phies of recent reviews (Michalakis et al.2003; Weber & Sukotjo 2007; Chaar et al

    2011).

    All titles obtained were checked for rele-

    vant clinical studies.

    Inclusion criteria

    The first aim of this extensive search was to

    find randomized controlled clinical trials

    (RCTs) comparing cemented and screw-

    retained implant reconstructions.

    The systematic review of the clinical liter-

    ature, furthermore, included clinical studies

    from all levels of evidence, that is, prospec-tive or retrospective cohort studies. The addi-

    tional inclusion criteria for study selection

    were as follows:

    •   the studies included a minimum of 10

    patients;

    •   the studies reported on outcomes of final

    reconstructions;

    •   the studies had a mean follow-up time of

    the final reconstructions 1 year or more;

    •   the studies reported details of the fixation

    mode of the respective final reconstruc-

    tions; and

    164 |   Clin. Oral Implants Res. 23 (Suppl. 6), 2012/163–201   © 2012 John Wiley & Sons A/S

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    •   the studies reported on partially or fully

    dentate patients receiving implant-sup-

    ported single crowns and/or FDPs (partial

    or full-arch FDPs).

    Studies were excluded where the patients

    had not been examined clinically at the fol-

    low-up visit, that is, publications based on

    patient records, questionnaires, or interviews.

    Selection of studies

    Titles and abstracts of the searches were ini-

    tially screened independently by the three

    reviewers (IS, SM, and DS) for possible inclu-

    sion in the review. The full text of all possi-

    bly relevant studies was then obtained for

    independent assessment by the reviewers.

    Any disagreement regarding inclusion was

    resolved by discussion.

    Figure 1 describes the process of identify-

    ing the 59 full-text articles on the clinical

    performance of the cemented and screw-retained reconstructions selected from the

    initial yield of 4511 titles.

    For the analysis, the articles were divided by

    the fixation method (cemented, screw-retained)

    and into studies reporting on the following:

    -single crowns

    -multi-unit partial FDPs (including two to

    four splinted crowns, three- to five-unit

    partial FDPs, partial FDPs with/without can-

    tilevers)

    -full-arch FDPs (10 units or more)

    Excluded Studies

    Of the 520 full-text articles examined, 461

    were excluded from the final analysis for

    different reasons (for detailed information, see

    reference list of excluded articles). Amongthose articles, unfortunately, one RCT com-

    paring cemented and screw-retained crowns

    (Vigolo et al. 2004) had to be excluded as well,

    due to the fact that the report of the outcomes

    of the reconstructions was based on patient

    interviews and not on a clinical examination.

    The main reasons for exclusion were as fol-

    lows: no detailed information on the recon-

    struction design or the clinical outcomes at

    the follow-up visits, no detailed information

    on the fixation method, a mean observation

    period of the final reconstructions less than

    1 year, no detailed analysis of the data andcase descriptions of failures without relevant

    information on the entire patient cohort,

    mixed reconstructions in one patient cohort,

    and no detailed information on the respective

    reconstructions and multiple publications on

    the same patient cohorts.

    Data extraction

    Information on the survival proportions and

    on the biological and technical complications

    of the abutments and reconstructions was

    extracted from the included studies. The

    number of events and the corresponding totalexposure time of the reconstructions were

    calculated.

    Survival was defined as the implant and/or

    the reconstruction remaining   in situ   for the

    observation period with or without modifica-

    tion.

    The analysis of the  technical complications

    included loosening of the abutment/recon-

    struction screws, fracture of the abutment/

    reconstruction screws, de-cementation, chip-

    ping/fracture of the veneer/reconstruction,

    presence of a gap at the junction between

    implant and abutment, and finally the totalnumber of technical complications.

    The analysis of the   biological complica-

    tions   encompassed bone loss of more than

    2 mm, general soft tissue complications like,

    for example, peri-implant infections, fistulas

    or swelling, mucosal hypertrophy, and soft

    tissue recession.

    Data from allthe studies were extracted inde-

    pendently by three reviewers (IS, SM, and DS),

    using data extraction forms. Disagreement

    regarding data extraction was resolved by con-

    sensus.

    Statistical analysis

    Failure and complication rates were calculated

    by dividing the number of events (failures or

    complications) as the numerator by the total

    time of the reconstructions being under obser-

    vation as the denominator. The numerator

    could usually be extracted directly from the

    publication. If all patients/reconstructions had

    a fixed follow-up time point, this was taken asthe observation period for all.

    The total observation time was calculated

    by taking the sum of the following:

    1) Exposure time of reconstructions that

    could be followed for the whole observa-

    tion time.

    2) Exposure time up to failure of the recon-

    structions that were lost due to failure

    during the observation time.

    3) Exposure time up to the end of observa-

    tion time for reconstructions that did not

    complete the observation period for rea-sons such as death, change of address,

    refusal to participate, nonresponse,

    chronic illnesses, missed appointments,

    and work commitments.

    If all three components for the calculation

    of the total exposure time were not available,

    the total exposure time was estimated by

    multiplying the mean follow-up time by the

    number of constructions under observation.

    For each study, event rates for the recon-

    structions were calculated by dividing the

    total number of events by the total recon-

    struction exposure time in years. For further

    analysis, the total number of events was con-

    sidered to be Poisson distributed for a given

    sum of abutment exposure years, and Poisson

    regression with a logarithmic link-function

    and total exposure time per study as an offset

    variable was used (Kirkwood & Sterne

    2003a). To assess heterogeneity of the study-

    specific event rates, the Spearman goodness-

    of-fit statistics and associated   P-value were

    calculated. If the goodness-of-fit   P-value was

    below 0.05, indicating heterogeneity, robust

    Poisson regression (by calculating robust

    standard errors for the summary rates) was

    used to obtain a summary estimate of the

    event rates, which incorporated the heteroge-

    neity among studies. Five-year survival pro-

    portions were calculated through the

    relationship between event rate and survival

    function S, S(T)   =  exp(-T   *event rate), by

    assuming constant event rates (Kirkwood &

    Sterne 2003b). Five-year cumulative failure

    rates were calculated by subtracting the five-

    year survival proportion from one. The 95%

    confidence intervals for the survival and

    cumulative failure rates were calculated by

    First electronic search:4511 titles selected

    3714 articles excluded(titles not topic related)

    797 abstracts independentlyselected by three reviewers

    277 articles excluded(268 not topic related, 6 no

    abstract available, 3 reviews)

    520 full text articles

    461 articles excluded

    59 articles included for review

    Fig. 1.  Article selection.

    ©  2012 John Wiley & Sons A/S   165 |   Clin. Oral Implants Res. 23 (Suppl. 6), 2012/163–201

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    Table 1.   Included articles  –  Overview

    Study Authors Year Study design Center Implant system Reconstruction Jaw

    Region of

     jaw

    Type of

    fixation

    1 Abboud et al. 2005; 2005 Prospective University Ankylos Single crown Maxilla

    Mandible

    Posterior Cement

    2 Akca & Cehreli 2008; 2008 Prospective University ITI FDP Maxilla

    Mandible

    Nr Cement

    3 Andersen et al. 2001; 2001 P rospective University Implant

    Innovations

    Single crown Maxilla Anterior Screw

    4 Andersson et al.1998a;

    1998 Prospective Specialized clinic Branemark Single crown MaxillaMandible

    AnteriorPosterior

    Cement

    5 Andersson et al.

    1998b;

    1998 Prospective Private practices

    Specialized clinic;

    multicenter

    Branemark Single crown Maxilla Anterior

    Posterior

    Cement

    6 Astrand et al. 2000; 2000 Prospective University ITI Full arch Maxilla Full arch Screw

    7 Astrand et al. 2004a; 2004 Prospective

    split mouth

    Private practices;

    multicenter

    Branemark

    ITI

    FDP Maxilla Posterior Screw

    8 Astrand et al. 2004b; 2004 RCT Nr Astra Tech

    Branemark

    Full arch Maxilla

    Mandible

    Full arch Screw

    9 Bambini et al. 2001; 2001 Retrospective Nr Threadloc

    Spine

    Single crown

    FDP

    Mandible Poster ior Screw

    10 Bragger et al. 2005; 2005 Prospective University ITI Single crown Nr Nr CementA

    1 1 Cannizza ro e t al.

    2008a;

    2008 RCT Nr Zimmer Tapered

    SwissPlus

    Single crown Maxilla

    Mandible

    Anterior,

    posterior

    Cement

    1 2 Cecchinato et a l.

    2008;

    2008 RCT

    multicenter

    University Astra FDP Maxilla

    Mandible

    Canine to

    molar

    Screw

    13 Cho et al. 2004; 2004 Prospective University Nr Single crown

    FDP

    Maxilla

    Mandible

    Anterior

    Posterior

    Screw

    14 Cooper et al. 2007; 2007 Prospective University Astra Tech Single crown Maxilla Anterior Cement

    15 Crespi et al. 2010 2010 Prospective Nr Outlink Single crown Maxilla Posterior Cement

    16 Crespi et al. 2007; 2007 Prospective Nr Outlink Single crown

    FDP

    full arch

    Maxilla

    Mandible

    Anterior

    Posterior

    Cement

    17 Drago 2003; 2003 Prospective Specialiced clinic Osseotite Single crown Maxilla

    Mandible

    Nr Cement

    1 8 Drago & Lazzara

    2006;

    2006 Prospective Private practices;

    multicenter

    Osseotite Sull arch Mandible Full arch Cement

    Screw

    1 9 Duncan et al. 2003; 2 003 Prospective

    multicenter

    Nr ITI Single crown

    FDP

    Maxilla

    Mandible

    Anterior

    Posterior

    Screw

    Cement

    20 Eliasson et al. 2006; 2006 Retrospective University Branemark FDP Maxilla

    Mandible

    Anterior

    Posterior

    Screw

    21 Eliasson et al. 2010; 2010 Prospective University Paragon Full arch Mandible Full arch Screw

    22 Fischer et al. 2008; 2008 RCT HospitalSpecialized clinic

    Straumann Full arch Maxilla Full arch Cement

    23 Froberg et al. 2006; 2006 Prospective Nr Branemark

    TiUnite

    Full arch Maxilla Full arch Screw

    2 4 Fugazzott o et al.

    2004;

    2004 Retrospective Private practices;

    multicenter

    ITI TPS+SLA Single crown

    FDP

    full arch

    All All Cement

    Screw

    25 Gallucci et al. 2009; 2009 Prospective University;

    multicenter

    Straumann FDP with

    cantilevers

    All Posterior Screw

    26 Gallucci et al. 2011a; 2011 RCT University Straumann SP Single crown Maxilla Anterior Screw

    27 Glauser et al. 2004;. 2004 P rospective University Branemark Mk II Single crown All Anterior to

    premolar

    Cement

    28 Gotfredsen 2004; 2004 Prospective University Astra Tech ST Single crown Maxilla Anterior Cement

    29 Guncu et al. 2008; 2008 RCT University Branemark Mk

    III TiUnite

    Single crown Mandible Posterior Cement

    3 0 Halg et al. 2008; 2008 Ret rospective Pr ivat e practice St raumann FDP with/without

    cantilevers

    All Posterior Cement

    3 1 Hellden et al. 2 003; 2003 Prospective Univers ity

    Private practice;

    multicenter

    Cresco Ti API

    syste,

    FDP All All Screw

    3 2 Henriks son & J emt

    2004;

    2004 Prospective University Branemark Mk

    III

    Single crown Maxilla Anterior Cement

    33 Henry et al. 1995; 1995 Prospective Private practices Branemark Single crown All All Cement

    34 Hjalmarsson et al.

    2011;

    2011 Retrospective Specialized clinic Astra Tech

    Straumann

    Biomet 3i

    Branemark

    Full arch Maxilla Full arch Screw

    35 Jemt 2009 2009 Retrospective University Branemark

    machined

    Single crown Maxilla Anterior

    Premolar

    Screw

    Cement

    3 6 Johns on & Pe rss on

    2001;

    2001 Prospective University Genetics

    implant system

    Single crown All All Cement

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    using the 95% confidence limits of the event

    rates. Multivariable Poisson regression was

    used to formally compare reconstruction fixa-

    tion types and to assess other study charac-

    teristics. In case of zero events in all studies

    of one group, exact Poisson regression with-

    out robust standard errors was used. All   P-

    values are two-sided and analyses were per-

    formed using Stata®, version 12 (StataCorp.

    2011. Stata Statistical Software: Release 12.

    College Station, TX: StataCorp LP http://

    www.stata.com/support/faqs/resources/citing-

    software-documentation-faqs/).

    Results

    Included studies

    A total of 59 studies were included in the

    analysis, giving information on the clinical

    performance of cemented and screw-retained

    implant-supported fixed reconstructions. The

    characteristics of the selected studies are

    shown in Table 1.

    Unfortunately, no RCT comparing cemen-

    ted and screw-retained fixed implant recon-

    structions matching the inclusion criteria

    was available. Solely nine RCTs comparing

    different types of implants or prosthetic

    materials were found, however, using the

    same fixation method for the tested groups

    (Astrand et al. 2004b; Cannizzaro et al.

    2008a; Cecchinato et al. 2008; Fischer et al.

    2008; Guncu et al. 2008; Schropp & Isidor

    2008; Zembic et al. 2009; Larsson & Vult

    von Steyern 2010; Gallucci et al. 2011a).

    In addition 38 prospective and 12 retro-

    spective studies were included in this

    review. Among them were six studies,

    which were included because they gave

    detailed information on the survival of the

    implants supporting cemented or screw-

    retained reconstructions, although these

    studies did not report on the reconstruction

    outcomes (Naert et al. 2001; Murphy et al.

    2002; Fugazzotto et al. 2004; Froberg et al.

    2006; Guncu et al. 2008; Ortorp & Jemt

    2009b) (Table 2).

    All the studies chosen were published

    within the past 14 years.

    The studies were mainly conducted in an

    institutional environment. Thirty-seven stud-

    ies were performed at universities, eight at

    specialized clinics or hospitals, and seven

    were performed in private practices. In the

    seven studies, the study setting was not

    reported. Nine of the investigations were per-

    formed as multicenter studies.

    Table 1.   (continued)

    Study Authors Year Study design Center Implant system Reconstruction Jaw

    Region of

     jaw

    Type of

    fixation

    37 Jung et al. 2008; 2008 Prospective University Straumann

    Nobel Biocare

    TiUnite

    Single crown Mandible Posterior Screw

    Cement

    38 Karlsson et al. 1997; 1997 Prospective Specialized clinics;

    multicenter

    Astra Single crown All All Cement

    3 9 Kemppainen et al.

    1997;

    1997 Prospective University ITI

    Astra

    Single crown All All Screw

    Cement4 0 Lar sson & Vult von

    Steyern 2010;

    2010 RCT University Astra FDP All All Cement

    41 Levine et al. 1999; 1999 Retrospective Private practices;

    multicenter

    Straumann Single crown All All Cement

    Screw

    42 Murphy et al. 2002; 2002 Prospective University Astra Full arch Mandible Full arch Screw

    43 Naert et al. 2001; 2001 Prospective University Branemark

    Nobel Biocare

    FDP Maxilla

    Mandible

    Nr Screw

    44 Nordin et al. 2007; 2007 Retrospective Private practice Straumann Full arch Maxilla Full arch Screw

    45 Ortorp & Jemt 2008; 2008 Retrospective University Branemark FDP Mandible Nr Screw

    46 Ortorp & Jemt

    2009b;

    2009 Prospective University Branemark Full arch Maxilla

    Mandible

    Full arch Screw

    47 Ortorp & Jemt 2009a; 2009 Retrospective University Branemark Full arch mandible Full arch Screw

    48 Palmer et al. 2000; 2000 Prospective Hospital Astra Single crown Maxilla Anterior Cement

    4 9 Ras mus son et al.

    2005;

    2005 Prospective University TiOblast Astra Full arch Maxilla

    Mandible

    Nr Screw

    5 0 Roma nos & Ne ntwig

    2000;

    2000 Retrospective University NobelBiocare Single crown Maxilla

    Mandible

    Molar Cement

    51 Scholander 1999; 1999 Retrospective University Branemark Single crown Maxilla

    Mandible

    Nr CementB

    52 Scheller et al. 1998; 1998 Prospective University

    Private practice;

    multicenter

    Biomet3i

    SPI Thommen

    Single crown Maxilla

    Mandible

    Nr Cement

    53 Schneider et al. 2011; 2011 Prospective University Biomet 3i Single crown Maxilla Anterior Cement

    5 4 Schr opp & Isidor

    2008;

    2008 RCT University Osseotite 3i Single crown Maxilla

    Mandible

    Anterior

    Premolar

    CementC

    55 Schwarz et al. 2010; 2010 P rospective University FRIA-LOC-

    System

    Full arch Mandible Nr Screw

    56 Turkyilmaz 2006; 2006 Prospective University Branemark MK

    III

    Single crown Maxilla All Cement

    5 7 Van Steenberghe

    et al. 2005;

    2005 Prospective University Branemark MK

    III

    Full arch Maxilla Full arch Screw

    58 Wannfors &

    Smedberg 1999;

    1999 Prospective Hospital NobelBiocare Single crown Maxilla

    Mandible

    Anterior Screw

    Cement59 Zembic et al. 2009 2009 RCT University Branemark RP Single crown Maxilla

    Mandible

    Nr Cement

    A) 67 single crowns cemented, 2 single crowns screw-retained

    B) 256 single crowns cemented, 2 single crowns screw-retained

    C) 40 single crowns cemented, 2 single crowns screw-retained

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    Table 2.  Summary of results for outcome “implant survival”

    Study Authors Year

    Total no. of

    loaded

    implants

    Total no. of

    drop-outs

    Mean

    follow-up

    time (y)

    Total no. of

    failures after

    load

    Total

    exposure

    time

    Estimated failure

    rate (per 100 years) 95% CI

    Single crown

    Cement 1 Abboud

    et al.

    2005 20 0 1 1 20 5 0.13 – 27.86

    4 Andersson

    et al. 1

    1998 65 5 5 1 307.5 0.33 0.01 – 1.81

    5 Anderssonet al. 2

    1998 34 4 5 0 170 0 0 – 2.17

    10 Bragger

    et al.

    2005 69 Nr 10 5 665 0.75 0.24 – 1.75

    11 Cannizzaro

    et al.

    2008 108 0 3 0 327 0 0 – 1.13

    14 Cooper et al. 2007 43 11 3 3 120.6 2.49 0.51 – 7.27

    15 Crespi et al. 2010 30 0 3 0 90 0 0 – 4.1

    16 Crespi et al. 2007 147 0 1.5 0 220.5 0 0 – 1.67

    19 Duncan

    et al.

    2003 22 0 3 0 66 0 0 – 5.59

    24 Fugazzotto

    et al.

    2004 2615 Nr 2 30 5200 0.58 0.39 – 0.82

    28 Gotfredsen 2004 20 0 5 0 100 0 0 – 3.69

    29 Guncu et al. 2008 24 0 1 1 23.83 4.2 0.11 – 23.38

    32 Henriks son &

    Jemt

    2004 18 0 1 0 18 0 0 – 20.49

    33 Henry et al. 1995 50 1 1 0 50 0 0 – 7.38

    36 Johnson &

    Persson

    2001 77 2 3 0 228 0 0 – 1.62

    38 Karlsson

    et al.

    1997 43 4 2 0 86 0 0 – 4.29

    39 Kemppainen

    et al.

    1997 86 1 1 0 87 0 0 – 4.24

    48 Palmer et al. 2000 15 1 5 0 72.5 0 0 – 5.09

    50 Romanos &

    Nentwig

    2000 58 0 2.44 2 139.08 1.44 0.17 – 5.19

    51 Scholander 1999 258 Nr 5 2 1285 0.16 0.02 – 0.56

    52 Scheller

    et al.

    1998 97 Nr 5 2 480 0.42 0.05 – 1.51

    53 Schneider

    et al.

    2011 16 1 1 0 16 0 0 – 23.06

    54 Schropp &

    Isidor

    2008 34 11 5 0 170 0 0 – 2.17

    56 Turkyilmaz 2006 34 Nr 3 0 102 0 0 – 3.62

    58 Wannfors &

    Smedberg

    1999 36 2 3 0 105 0 0 – 3.51

    59 Zembic et al. 2009 40 12 3 0 102 0 0 – 3.62

    Summary estimate 0.46 0.32 – 0.66

    5 – year survival rate (%) 97.7 96.8 – 98.4

    Screw 3 Andersen

    et al.

    2001 59 5 3 1 167 0.6 0.02 – 3.34

    9 Bambini

    et al.

    2001 32 0 3 0 96 0 0 – 3.84

    19 Duncan

    et al.

    2003 10 0 3 0 30 0 0 – 12.3

    24 Fugazzotto

    et al.

    2004 102 Nr 2 1 203 0.49 0.01 – 2.74

    26 Gallucci

    et al.

    2011 20 0 2 0 40 0 0 – 9.22

    39 Kemppainen

    et al.

    1997 25 Nr 1 0 25 0 0 – 14.76

    58 Wannfors &

    Smedberg

    1999 44 2 3 0 129 0 0 – 2.86

    Summary estimate 0.29 0.12 – 0.69

    5-year survival rate (%) 98.6 96.6 – 99.4

    Partial Fixed dental prosthesis

    Cement 2 Akca &

    Cehreli

    2008 30 0 2.2 0 66 0 0 – 5.59

    16 Crespi et al. 2007 147 0 1.5 0 220.5 0 0 – 1.67

    19 Duncan

    et al.

    2003 19 0 3 0 57 0 0 – 6.47

    24 Fugazzotto

    et al.

    2004 889 Nr 2 9 1769 0.51 0.23 – 0.97

    30 Halg et al. 2008 78 6 5.3 3 389.55 0.77 0.16 – 2.25

    Summary estimate 0.48 0.35 – 0.65

    5-year survival rate (%) 97.6 96.8 – 

    98.3

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    The studies reported on 14 different

    implant systems.

    Numbers of included reconstructions and respectivefollow-up times (Table 3)

    Single crowns (SCs)

    The 59 studies included 35 studies reporting

    on a total of 1692 single crowns, of which

    1408 were cemented and 284 were screw-

    retained. The weighted mean follow-up time

    of the crowns was 3.8 years for cemented and

    2.4 years for screw-retained.

    Partial FDPs

    Fifteen studies reported on 740 partial FDPs,

    118 cemented, and 622 screw-retained. The

    weighted mean follow-up time of the cemen-

    ted FDPs amounted to 4.2 years, and that of

    the screw-retained FDPs to 6.2 years.

    Full-arch FDPs

    Sixteen studies reported on 681 full-arch

    FDPs, 50 cemented, and 631 screw-retained.

    The weighted mean follow-up time of the

    cemented full-arch FDPs was 1.4 years and

    for the screw-retained FDPs 6.1 years.

    Table 2.   (continued)

    Study Authors Year

    Total no. of

    loaded

    implants

    Total no. of

    drop-outs

    Mean

    follow-up

    time (y)

    Total no. of

    failures after

    load

    Total

    exposure

    time

    Estimated failure

    rate (per 100 years) 95% CI

    Screw 7 Astrand

    et al. 1

    2004 148 2 3 2 439.5 0.46 0.06 – 1.64

    9 Bambini

    et al.

    2001 64 0 3 0 192 0 0 – 1.92

    12 Cecchinato

    et al.

    2008 321 35 5 3 1510 0.2 0.04 – 0.58

    19 Duncan

    et al.

    2003 32 2 3 0 93 0 0 – 3.97

    20 Eliasson

    et al.

    2006 371 4 9.5 10 3477 0.29 0.14 – 0.53

    24 Fugazzotto

    et al.

    2004 33 Nr 2 0 66 0 0 – 5.59

    25 Gallucci

    et al.

    2009 237 0 5 0 1185 0 0 – 0.31

    31 Hellden

    et al.

    2003 190 21 3.7 3 699.9 0.43 0.09 – 1.25

    43 Naert et al. 2001 305 Nr 5.8 1 2030.5 0.05 0 – 0.27

    45 Ortorp &

    Jemt

    2008 351 Nr 8.6 10 1426 0.7 0.34 – 1.29

    Summary estimate 0.26 0.14 – 0.48

    5-year survival rate (%) 98.7 97.6 – 99.3

    Full-arch reconstruction

    Cement 16 Crespi et al. 2007 147 0 1.5 0 220.5 0 0 – 1.67

    22 Fischer et al. 2008 139 6 5 4 690 0.58 0.16 – 1.48

    24 Fugazzotto

    et al.

    2004 518 Nr 2 19 1017 1.87 1.12 – 2.92

    Summary estimate 1.19 0.49 – 2.89

    5-year survival rate (%) 94.2 86.5 – 97.6

    Screw 6 Astrand

    et al.

    2000 157 10 1 2 156 1.28 0.16 – 4.63

    8 Astrand

    et al. 2

    2004 371 Nr 5 13 1822.5 0.71 0.38 – 1.22

    21 Eliasson

    et al.

    2010 167 30 5 0 760 0 0 – 0.49

    23 Froberg

    et al.

    2006 89 Nr 1.5 0 133.5 0 0 – 2.76

    24 Fugazzotto

    et al.

    2004 71 Nr 2 8 134 5.97 2.58 – 11.76

    34 Hjalmar ssonet al.

    2011 242 Nr 5 0 1210 0 0 – 0.3

    42 Murphy

    et al.

    2002 123 8 5 0 615 0 0 – 0.6

    44 Nordin et al. 2007 110 7 2 2 258.53 0.77 0.09 – 2.79

    46 Ortorp &

    Jemt 1

    2009 719 Nr 7.8 15 2725 0.55 0.31 – 0.91

    47 Ortorp &

    Jemt 2

    2009 1093 740 9 6 7914 0.08 0.03 – 0.17

    49 Rasmusson

    et al.

    2005 199 Nr 10 0 3397 0 0 – 0.11

    55 Schwarz

    et al.

    2010 185 Nr 4.5 19 789.75 2.41 1.45 – 3.76

    57 Van

    Steenberghe

    et al.

    2005 184 20 1 0 174 0 0 – 2.12

    Summary estimate 0.32 0.12 – 0.85

    5-year survival rate (%) 98.4 95.8 – 99.4

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    Implant survival

    Data on implants lost in function were

    reported in 33 patient cohorts (29 studies) on

    single crowns (26 cemented, 7 screw-

    retained), 15 patient cohorts (13 studies) on

    partial FDPs (5 cemented, 10 screw-retained),

    and 16 patient cohorts (15 studies) on full-

    arch FDPs (3 cemented, 13 screw-retained).

    The estimated 5-year survival rates of theimplants supporting the implant reconstruc-

    tions ranged from 94.2% (cemented full-arch

    FDPs) to 98.7% (screw-retained partial FDPs).

    Detailed information on the included studies

    for this analysis and the respective implant

    survival rates at the different types of recon-

    structions is given in Table 2 and Figs 2 – 7.

    When comparing screw-retained with

    cemented single crowns no statistically sig-

    nificant difference was found with respect to

    implant failure (event rate ratio   =  0.63,

    P   =  0.32).

    At partial FDPs a trend was observed

    toward less implant failures at screw-retained

    FDPs compared to cemented FDPs (event rate

    ratio   =  0.54,  P   =  0.07).

    In the group with full-arch FDPs signifi-

    cantly less implant failures were found at the

    screw-retained bridges compared to the

    cemented reconstructions (event rate

    ratio   =  0.27,  P   =  0.04).

    Reconstruction survival

    From 59 studies a total of 35 patient cohorts

    (29 studies) provided data on single crown

    survival (27 cemented, 10 screw-retained), 14

    patient cohorts (12 studies) on FDP survival

    (5 cemented, 9 screw-retained), and 17patient cohorts (13 studies) reported on the

    survival of full-arch FDPs (3 cemented, 14

    screw-retained).

    Table 3 and Figs 8 – 13 give detailed infor-

    mation on the included studies for this analy-

     .46 (95% CI: .32 - .66)Zembic et al.,2009

    Wannfors & Smedberg,1999

    Turkyilmaz,2006

    Schropp & Isidor,2008

    Scholander ,1999

    Schneider et al.,2011

    Scheller et al.,1998

    Romanos & Nentwig,2000

    Palmer et al.,2000

    Kemppainen et al.,1997

    Karlsson et al.,1997

    Johnson & Persson,2001

    Henry et al.,1995

    Henriksson & Jemt,2004

    Guncu et al.,2008

    Gotfredsen,2004

    Fugazzotto et al.,2004Duncan et al.,2003

    Crespi et al.,2010

    Crespi et al.,2007

    Cooper et al.,2007

    Cannizzaro et al.,2008

    Bragger et al.,2005

    Andersson et al. 2,1998

    Andersson et al. 1,1998

    Abboud et al.,2005

    0 5 10 15 20 25 30 35

    Event rate per 100 years

    Fig. 2.   Implant survival rate for cemented single crowns.

     .28 (95% CI: .12 - .69)

    Wannfors & Smedberg,1999

    Kemppainen et al.,1997

    Gallucci et al. ,2011

    Fugazzotto et al.,2004

    Duncan et al.,2003

    Bambini et al. ,2001

    Andersen et al.,2001

    0 5 10 15 20Event rate per 100 years

    Fig. 3.  Implant survival rate for screw-retained single crowns.

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    sis and the survival rates of the cemented

    and the screw-retained reconstructions.

    In general, the estimated 5-year survival

    rates of the reconstructions ranged from

    89.3% (screw-retained crowns) to 98.0%

    (cemented full-arch FDPs).

    Altogether 49 (3.2%) single crowns, 18

    (2.7%) partial FDPs, and 32 (7.0%) full-arch

    FDPs failed during follow-up. The main

    reported reasons for the loss of the recon-

    structions were loss of the supporting

    implant (Schropp & Isidor 2008; Ortorp &

    Jemt 2009a; Schwarz et al. 2010), fractures of

    the reconstructions/frameworks (Scheller

    et al. 1998; Jemt et al. 2003; Abboud et al.

    2005; Gallucci et al. 2009), other technical

    complications like chipping of the veneering

    ceramic (Palmer et al. 2000; Bragger et al.

    2005; Rasmusson et al. 2005), and, finally,

    aesthetic problems not acceptable by the cli-

    nician and/or the patient (Wannfors & Smed-

    berg 1999).

    At the single crowns more reconstructions

    failed in the group with the screw-retained

    crowns compared to cemented ones, how-

    ever, this observation did not reach statistical

    significance (event rate ratio   =  3.22,

    P   =  0.09).

    At the partial FDPs, in contrast, a tendency

    toward less reconstruction failure was found

    at the screw-retained FDPs compared to the

    cemented ones (event rate ratio   =  0.64,

    P   =  0.47).

    In the group with full-arch FDPs three

    studies contained data on cemented full-arch

    FDPs and did not report on any failures (Dra-

    go & Lazzara 2006; Crespi et al. 2007; Elias-

    son et al. 2010). In contrast, 8 of the 14

    studies on screw-retained full-arch FDPs

     .48 (95% CI: .35 - .65)

    Halg et al.,2008

    Fugazzotto et al.,2004

    Duncan et al.,2003

    Crespi et al.,2007

    Akca & Cehreli,2008

    0 5 10Event rate per 100 years

    Fig. 4.   Implant survival rate for cemented partial FDPs.

     .26 (95% CI: .14 - .48)

    Ortorp & Jemt,2008

    Naert et al.,2001

    Hellden et al.,2003

    Gallucci et al.,2009

    Fugazzotto et al.,2004

    Eliasson et al.,2006

    Duncan et al.,2003

    Cecchinato et al. ,2008

    Bambini et al. ,2001

    Astrand et al. 1,2004

    0 5 10Event rate per 100 years

    Fig. 5.   Implant survival rate for screw-retained partial FDPs.

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    reported on reconstruction failures (event rate

    ratio   =  1.9,  P   =  0.54).

    Technical complications

    Altogether 44 patient cohorts (34 studies)

    reported on technical complications at single

    crowns (30 cemented, 14 screw-retained), 16

    patient cohorts (14 studies) reported on tech-

    nical problems of partial FDPs (5 cemented,

    11 screw-retained), and 20 patient cohorts (14

    studies) reported on the technical outcomes

    of full-arch FDPs (3 cement, 17 screw-

    retained).

    Table 4 gives detailed information on the

    included studies for this analysis and the

    technical complication rates of the cemented

    and the screw-retained reconstructions.

    The data extracted from these studies are

    only allowed for statistical comparison of the

    total number of technical complications, the

    number of abutment and/or reconstruction

    screw loosening, the number of screw frac-

    tures, and the number of chipping of the

    veneering ceramic. Other technical problems

    were not reported or did not occur in the

    investigations.

    For single crowns, significantly more tech-

    nical complications occurred at the screw-

    retained reconstructions compared to the

    cemented ones (event rate ratio   =  2.2,

    P   =   0.01). Loosening of the abutment and/or

    reconstruction screws was the most frequent

    technical problem at single crowns, occurring

    significantly more often at screw-retained

    than at cemented crowns (event rate

    ratio   =  6.0,   P   <  0.005). Screw fracture (abut-

    ment screw) tended to occur more often at

    cemented crowns. For this parameter 18

    studies (14 cemented, 4 screw-retained) were

     1.19 (95% CI: .49 - 2.89)

    Fugazzotto et al.,2004

    Fischer et al.,2008

    Crespi et al.,2007

    0 5 10Event rate per 100 years

    Fig. 6.   Implant survival rate for cemented full-arch FDPs.

     .32 (95% CI: .12 - .85)

    van Steenberghe et al.,2005

    Schwarz et al.,2010

    Rasmusson et al.,2005

    Ortorp & Jemt 2,2009

    Ortorp & Jemt 1,2009

    Nordin et al.,2007

    Murphy et al.,2002

    Hjalmarsson et al.,2011

    Fugazzotto et al.,2004

    Froberg et al.,2006

    Eliasson et al.,2010

    Astrand et al. 2,2004

    Astrand et al.,2000

    0 5 10 15Event rate per 100 years

    Fig. 7.  Implant survival rate for screw-retained full-arch FDPs.

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    Table 3.   Summary of results for outcome “reconstruction survival”

    Study Authors Year

    Total no. of

    included

    reconstructions

    Total no. of

    drop-outs

    Mean

    follow-up

    time (y)

    Total no.

    of failures

    Total

    exposure

    time

    Estimated failure

    rate (per 100 years) 95% CI

    Single crown

    Cement 1 Abboud et al. 2005 20 0 1 1 19.04 5.25 0.13 – 29.26

    4 Andersson

    et al. (1)

    1998 65 6 5 4 294 1.36 0.37 – 3.48

    5 Andersson

    et al. (2)

    1998 38 4 5 1 181.75 0.55 0.01 – 3.07

    10 Bragger et al. 2005 69 5 10 2 655 0.31 0.04 – 1.1

    11 Cannizzaro

    et al.

    2008 108 0 3 0 324 0 0 – 1.14

    14 Cooper et al. 2007 51 8 3 0 141 0 0 – 2.62

    15 Crespi et al. 2010 30 30 3 0 90 0 0 – 4.1

    16 Crespi et al. 2007 9 0 1.5 0 13.5 0 0 – 27.33

    17 Drago 2003 110 6 1 0 107 0 0 – 3.45

    19 Duncan et al. 2003 22 0 3 0 66 0 0 – 5.59

    27 Glauser et al. 2004 54 18 4.1 0 184.5 0 0 – 2

    28 Gotfredsen 2004 20 0 5 1 97.5 1.03 0.03 – 5.71

    32 Henriks son &

    Jemt

    2004 18 0 1 0 18 0 0 – 20.49

    33 Henry et al. 1995 50 0 1 1 49.5 2.02 0.05 – 11.26

    35 Jemt 2009 23 5 5 1 100 1 0.03 – 5.57

    36 Johnson &

    Persson

    2001 78 1 3 1 231 0.43 0.01 – 2.41

    38 Karlsson et al. 1997 47 4 2 0 90 0 0 – 4.1

    48 Palmer et al. 2000 15 1 5 1 70 1.43 0.04 – 7.96

    50 Romanos &

    Nentwig

    2000 58 2 1.72 2 96.32 2.08 0.25 – 7.5

    51 Scholander 1999 258 5 5 8 1257.5 0.64 0.27 – 1.25

    52 Scheller et al. 1998 97 32 5 8 382 2.09 0.9 – 4.13

    53 Schneider

    et al.

    2011 16 1 1 0 15.5 0 0 – 23.8

    54 Schropp &

    Isidor

    2008 42 5 5 3 193 1.55 0.32 – 4.54

    56 Turkyilmaz 2006 34 0 3 1 100.5 1 0.03 – 5.54

    58 Wannfors &

    Smedberg

    1999 27 1 3 0 79.5 0 0 – 4.64

    58 Wannfors &

    Smedberg

    1999 9 1 3 0 25.5 0 0 – 14.47

    59 Zembic et al. 2009 40 12 3 0 102 0 0 – 3.62

    Summary estimate 0.70 0.46 – 

    1.085-year survival rate (%) 96.5 94.8 – 97.7

    Screw 3 Andersen

    et al.

    2001 28 2 3 1 79.5 1.26 0.03 – 7.01

    3 Andersen

    et al.

    2001 31 3 3 1 87 1.15 0.03 – 6.4

    9 Bambini et al. 2001 32 0 3 0 96 0 0 – 3.84

    19 Duncan et al. 2003 10 0 3 0 30 0 0 – 12.3

    26 Gallucci et al. 2011 10 0 2 0 20 0 0 – 18.44

    26 Gallucci et al. 2011 10 0 2 0 20 0 0 – 18.44

    35 Jemt 2009 18 5 5 0 77.5 0 0 – 4.76

    39 Kemppainen

    et al.

    1997 101 0 1 0 101 0 0 – 3.65

    58 Wannfors &

    Smedberg

    1999 36 2 3 10 86 11.63 5.58 – 21.38

    58 Wannfors &Smedberg 1999 8 0 3 2 22 9.09 1.1 – 

    32.84

    Summary estimate 2.26 0.59 – 8.65

    5-year survival rate (%) 89.3 64.9 – 97.1

    Partial Fixed dental prosthesis

    Cement 2 Akca &

    Cehreli

    2008 15 0 2.2 0 33 0 0 – 11.18

    16 Crespi et al. 2007 15 0 1.5 0 22.5 0 0 – 16.4

    19 Duncan et al. 2003 9 0 3 0 27 0 0 – 13.66

    30 Halg et al. 2008 54 2 5.3 3 272.95 1.1 0.23 – 3.21

    40 Lars son & Vult

    von Steyern

    2010 25 0 5 0 125 0 0 – 2.95

    Summary estimate 0.62 0.20 – 1.93

    5-year survival rate (%) 96.9 90.8 – 99.0

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    analyzed, showing 2 studies reporting on

    screw fractures in the cemented group (Karls-

    son et al. 1997; Romanos & Nentwig 2000)

    and no screw fractures in the screw-retained

    group. Finally, chipping of the veneering cera-

    mic tended to occur more frequently at the

    screw-retained reconstructions (event rate

    ratio   =  3.6,  P   =  0.08).

    At FDPs a trend to less total technical

    complications was observed at the screw-

    retained reconstructions compared to the

    cemented ones (event rate ratio   =  0.89,

    P   =   0.85). Loosening of the abutment and/or

    reconstruction screws was only reported in

    studies on screw-retained FDPs and did not

    occur on cemented FDPs. Due to the lack of

    events for cemented FDPs, a statistical com-

    parison (regression) was not possible. The

    same applies to the technical parameter, the

    screw fractures. Fractures of the retaining

    screws were reported in five of the seven

    included studies on screw-retained FDPs and

    in none of the three studies included on

    cemented FDPs. Finally, chipping of the

    veneering ceramic tended to occur more fre-

    quently at the screw-retained FDPs (event

    rate ratio   =  0.5).

    At full-arch FDPs a trend to less total tech-

    nical complications was observed at the

    screw-retained reconstructions compared to

    the cemented ones (event rate ratio   =  0.62,

    P   =   0.18). Loosening of the abutment and/or

    reconstruction screws tended to occur more

    frequently at screw-retained FDPs (event rate

    ratio   =  3.1,  P   =  0.09). Screw fracture was only

    reported in five of the seven studies with

    screw-retained full-arch FDPs; no screw frac-

    tures occurred at the cemented ones (two

    studies). Due to the zero events of cemented

    full-arch FDPs, again a statistical comparison

    (regression) was not possible. Chipping of the

    veneering ceramic was significantly less fre-

    quently observed at the screw-retained FDPs

    (event rate ratio   =  0.24,  P   <  0.005).

    Biological complications

    Altogether 29 patient cohorts (25 studies)

    reported on biological complications at single

    crowns (22 cemented, 7 screw-retained), 9

    patient cohorts (8 studies) reported on techni-

    cal problems of partial FDPs (2 cemented, 7

    Table 3.   (continued)

    Study Authors Year

    Total no. of

    included

    reconstructions

    Total no. of

    drop-outs

    Mean

    follow-up

    time (y)

    Total no.

    of failures

    Total

    exposure

    time

    Estimated failure

    rate (per 100 years) 95% CI

    Screw 7 Astrand et al.

    1

    2004 56 4 3 0 162 0 0 – 2.28

    9 Bambini et al. 2001 64 0 3 0 192 0 0 – 1.92

    12 Cecchinato

    et al.

    2008 115 11 5 2 542.5 0.37 0.04 – 1.33

    19 Duncan et al. 2003 16 1 3 0 46.5 0 0 – 7.9320 Eliasson et al. 2006 146 0 9.5 4 1368 0.29 0.08 – 0.75

    25 Gallucci et al. 2009 45 0 5 2 218.55 0.92 0.11 – 3.31

    31 Hellden et al. 2003 60 8 3.7 1 205.35 0.49 0.01 – 2.71

    45 Ortorp & Jemt 2008 60 22 8.47 0 508 0 0 – 0.73

    45 Ortorp & Jemt 2008 60 16 8.83 6 530 1.13 0.42 – 2.46

    Summary estimate 0.40 0.20 – 0.78

    5-year survival rate (%) 98.0 96.2 – 99.0

    Full-arch reconstruction

    Cement 16 Crespi et al. 2007 11 0 1.5 0 16.5 0 0 – 22.36

    18 Drago &

    Lazzara

    2006 15 0 1.5 0 22.5 0 0 – 16.4

    22 Fischer et al. 2008 24 1 5 0 117.5 0 0 – 3.14

    Summary estimate 0 0 – 2.36

    5-year survival rate (%) 100 88.9 – 100%

    Screw 6 Astrand et al. 2000 28 1 1 0 27.5 0 0 – 13.41

    8 Astrand et al.

    2

    2004 66 3 5 1 322.5 0.31 0.01 – 1.73

    18 Drago &

    Lazzara

    2006 12 0 1.5 0 18 0 0 – 20.49

    21 Eliasson et al. 2010 29 5 5 0 132.5 0 0 – 2.78

    34 Hjalmar sson

    et al.

    2011 40 0 5 1 197.5 0.51 0.01 – 2.82

    44 Nordin et al. 2007 19 1 2.51 0 46.435 0 0 – 7.94

    45 Ortorp & Jemt

    1

    2009 62 25 7.67 1 475.5 0.21 0.01 – 1.17

    45 Ortorp & Jemt

    1

    2009 67 32 7.82 2 524 0.38 0.05 – 1.38

    46 Ortorp & Jemt

    2

    2009 53 40 6.81 0 361 0 0 – 1.02

    46 Ortorp & Jemt

    2

    2009 51 31 8.02 8 409 1.96 0.84 – 3.85

    46 Ortorp & Jemt

    2

    2009 104 72 7.19 14 748 1.87 1.02 – 3.14

    49 Rasmusson

    et al.

    2005 36 8 10 1 315 0.32 0.01 – 1.77

    55 Schwarz et al. 2010 37 0 4.5 4 157.5 2.54 0.69 – 6.5

    57 Van

    Steenberghe

    et al.

    2005 27 3 1 0 25.5 0 0 – 14.47

    Summary estimate 0.85 0.43 – 1.70

    5-year survival rate (%) 95.8 91.9 – 97.9

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    screw-retained), and 17 patient cohorts (12

    studies) reported on the technical outcomes

    of full-arch FDPs (1 cement, 16 screw-

    retained).

    5 gives detailed information on the

    included studies for this analysis and the bio-

    logical complication rates of the cemented

    and the screw-retained reconstructions.

    Bone loss exceeding 2 mm occurred in 6 of

    the 23 studies on single crowns that were

    included for this analysis. In all these six stud-

    ies cement-retained crowns were used. Since

    the event rate was 0 at the screw-retained

    crowns, a statistical regression analysis

    between the two groups was not possible.

    Screw-retained single crowns, however,

    exhibited statistically more soft tissue com-

    plications like peri-implant infections, fistu-

    las or swelling, and mucosal hypertrophy

    (event rate ratio   =  6.3,   P   <  0.005). Finally,

    soft tissue recession tended to occur more

    frequently at cemented crowns. Five of the

    eight studies on cemented crowns reported

    soft tissue recessions, in contrast, none of

    the two studies on screw-retained crowns

    observed that problem.

    At partial FDPs, bone loss occurred signifi-

    cantly less frequently at screw-retained

    reconstructions than at cemented ones (event

    rate ratio   =  0.38,   P   =   0.01). Soft tissue com-

    plications were only reported in the studies

    on screw-retained FDPs. One study reporting

    on cemented FDPs showed no soft tissue

    complications (Duncan et al. 2003). Reces-

    sions were not reported nor analyzed in the

    studies on partial FDPs.

    A similar observation was made at the full-

    arch FDPs. Bone loss occurred significantly

    less frequently at the screw-retained bridges

     2.25 (95% CI: .59 - 8.65)

    Wannfors & Smedberg,1999

    Wannfors & Smedberg,1999

    Kemppainen et al.,1997

    Jemt,2009

    Gallucci et al. ,2011

    Gallucci et al. ,2011

    Duncan et al.,2003

    Bambini et al. ,2001

    Andersen et al.,2001

    Andersen et al.,2001

    0 5 10 15 20 25 30 35 40Event rate per 100 years

    Fig. 9.  Reconstruction survival rate for screw-retained single crowns.

     .7 (95% CI: .46 - 1.08)Zembic et al.,2009

    Wannfors & Smedberg,1999

    Wannfors & Smedberg,1999

    Turkyilmaz,2006

    Schropp & Isidor,2008

    Scholander ,1999

    Schneider et al.,2011

    Scheller et al.,1998

    Romanos & Nentwig,2000

    Palmer et al.,2000

    Karlsson et al.,1997

    Johnson & Persson,2001

    Jemt,2009

    Henry et al.,1995Henriksson & Jemt,2004

    Gotfredsen,2004

    Glauser et al.,2004

    Duncan et al.,2003

    Drago,2003

    Crespi et al.,2010

    Crespi et al.,2007

    Cooper et al.,2007

    Cannizzaro et al.,2008

    Bragger et al.,2005

    Andersson et al. (2),1998

    Andersson et al. (1),1998

    Abboud et al.,2005

    0 5 10 15 20 25 30 35Event rate per 100 years

    Fig. 8.  Reconstruction survival rate for cemented single crowns.

    ©  2012 John Wiley & Sons A/S   175 |   Clin. Oral Implants Res. 23 (Suppl. 6), 2012/163–201

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    (event rate ratio   =  0.28,   P   <   0.005). For the

    analysis of soft tissue complications only

    studies on screw-retained reconstructions

    were available. In 13 of the included 15 stud-

    ies, soft-tissue problems were reported.

    Recessions were not analyzed nor reported in

    the studies on full-arch FDPs.

    Discussion

    This systematic review of the literature indi-

    cated interesting differences in the perfor-

    mance of cemented and screw-retained

    implant reconstructions, depending on the

    extension of the reconstructions.

    With respect to the implant survival, no

    differences were found regarding the

    estimated 5-year survival rates of implants

    supporting single crowns when cemented and

    screw-retained crowns were compared.

    However, in case of partial FDPs a trend was

    found to more implant failures at cemented

    reconstructions. At full-arch FDPs signifi-

    cantly more implant failures occurred with

    cemented reconstructions compared to

    screw-retained ones. Hence, the incidence of

    implant loss appeared to be higher at the

    cemented reconstructions and increased with

    the size of the reconstruction.

    The respective reconstruction survival

    rates of the different reconstruction types

    exhibited a contrary behavior than the

    implant survival rates. Screw-retained single

    crowns showed lower estimated 5- year

    survival rates than cemented crowns. The

    difference, however, did not reach statistical

    significance. The survival rates of the screw-

    retained multi-unit reconstructions did not

    differ from the ones of the cemented recon-

    structions.

    Technical complications were generally

    more often observed with screw-retained

    reconstructions than with cemented recon-

     .4 (95% CI: .2 - .78)

    Ortorp & Jemt,2008

    Ortorp & Jemt,2008

    Hellden et al.,2003

    Gallucci et al.,2009

    Eliasson et al.,2006

    Duncan et al.,2003

    Cecchinato et al. ,2008

    Bambini et al. ,2001

    Astrand et al. 1,2004

    0 5 10

    Event rate per 100 years

    Fig. 11.  Reconstruction survival rate for screw-retained partial FDPs.

     .62 (95% CI: .2 - 1.93)

    Larsson & Vult von Steyern,2010

    Halg et al.,2008

    Duncan et al.,2003

    Crespi et al.,2007

    Akca & Cehreli,2008

    0 5 10 15 20Event rate per 100 years

    Fig. 10.  Reconstruction survival rate for cemented partial FDPs.

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    structions. More specifically, higher rates for

    loosening of abutment/ reconstruction screws

    and chipping of the veneering ceramic were

    found at screw-retained reconstructions com-

    pared to cemented ones.

    In contrast, the incidence of serious biolog-

    ical complications, like bone loss exceeding

    2 mm, was higher with cemented reconstruc-

    tions. This complication was specifically

    present at the multi-unit reconstructions.

    Soft tissue inflammation was found at both

    types of reconstructions, however, signifi-

    cantly more often with screw-retained recon-

    structions. This complication was reported to

    be associated with excess cement (Bornstein

    et al. 2003; Abboud et al. 2005) or, more pre-

    dominantly, with loose abutment screws

    (Andersen et al. 2001).

    Hence, while the screw-retained recon-

    structions suffered from more technical prob-

    lems and needed more often repair or

    replacement of the reconstructions, the

    cemented reconstructions more frequently

    experienced serious biological problems like

    bone loss   >2 mm or loss of the implant,

    which may be more difficult to resolve clini-

    cally. None of the two types of fixation, how-

    ever, was clearly advantageous over the

    other.

    In the following sections, the findings

    regarding the parameters will be interpreted

    individually with aid of published results of

    other reviews or clinical studies.

    Implant survival

    In general, the estimated 5-year survival rates

    of the implant crowns and FDPs in this sys-

    tematic review were in accordance with the

    results of previous systematic reviews. In a

     0 (95% CI: 0 - 2.36)

    Fischer et al.,2008

    Drago & Lazzara,2006

    Crespi et al.,2007

    0 5 10 15 20 25

    Event rate per 100 years

    Fig. 12.  Reconstruction survival rate for cemented full-arch FDPs.

     .85 (95% CI: .43 - 1.7)

    van Steenberghe et al.,2005

    Schwarz et al.,2010

    Rasmusson et al.,2005

    Ortorp & Jemt 2,2009

    Ortorp & Jemt 2,2009

    Ortorp & Jemt 2,2009

    Ortorp & Jemt 1,2009

    Ortorp & Jemt 1,2009

    Nordin et al.,2007

    Hjalmarsson et al.,2011

    Eliasson et al.,2010

    Drago & Lazzara,2006

    Astrand et al. 2,2004

    Astrand et al.,2000

    0 5 10 15 20 25Event rate per 100 years

    Fig. 13.  Reconstruction survival rate for screw-retained full-arch FDPs.

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        4

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        N   a

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        2    0    0    8

        7    8

        3 .    6

        2    8    0 .    8

        4 .    2

        7

        N   a

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        J   u   n   g   e    t   a    l .

        2    0    0    8

        9    7

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        3    4    9 .    2

        0 .    8

        6

        N   a

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        3    8

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        4    1

        L   e   v    i   n   e   e    t   a    l .

        1    9    9    9

        8    2

        3 .    3

        2    6    0 .    7

        3 .    0

        7

        1 .    5

        3

        N   a

        N   a

        4    8

        P   a    l   m   e   r   e    t   a    l .

        2    0    0    0

        1    5

        5

        7    0

        2 .    8

        6

        0

        N   a

        1 .    4

        3

        5    0

        R   o   m   a   n   o   s    &

        N   e   n    t   w    i   g

        2    0    0    0

        5    8

        1 .    7

        2

        9    6 .    3

        2

        1 .    0

        4

        N   a

        1 .    0

        4

        N   a

        5    1

        S   c    h   o    l   a   n    d   e   r

        1    9    9    9

        2    5    8

        5

        1    2    5    7 .    5

        1 .    8

        3

        0 .    8

        N   a

        0 .    0

        8

        5    2

        S   c    h   e    l    l   e   r   e    t   a    l .

        1    9    9    8

        9    7

        5

        3    8    2

        1 .    8

        3

        1 .    0

        5

        N   a

        N   a

        5    3

        S   c    h   n   e    i    d   e   r

       e    t   a    l .

        2    0    1    1

        1    6

        1

        1    5 .    5

        0

        N   a

        N   a

        N   a

        5    4

        S   c    h   r   o   p   p    &

        I   s    i    d   o   r

        2    0    0    8

        4    2

        5

        1    9    3

        3 .    1

        1

        0

        0

        0

        5    6

        T   u   r    k   y    i    l   m   a   z

        2    0    0    6

        3    4

        3

        1    0    0 .    5

        1 .    9

        9

        N   a

        N   a

        1

        5    8

        W   a   n   n    f   o   r   s    &

        S   m   e    d    b   e   r   g

        1    9    9    9

        2    7

        3

        7    9 .    5

        1    2 .    5

        8

        1 .    2

        6

        N   a

        1 .    2

        6

        5    8

        W   a   n   n    f   o   r   s    &

        S   m   e    d    b   e   r   g

        1    9    9    9

        9

        3

        2    5 .    5

        0

        0

        N   a

        0

        5    9

        Z   e   m    b    i   c   e    t   a    l .

        2    0    0    9

        4    0

        3

        1    0    2

        1 .    9

        6

        0

        N   a

        1 .    9

        6

        S   u   m   m   a   r   y   e   s    t    i   m   a    t   e    (    9    5    %

        C    I    )

        2 .    5

        3    (    1 .    8

        5   –    3 .    4

        8    )

        0 .    7

        9    (    0 .    5

        6   –    1 .    1

        2    )

        0 .    0

        8    (    0 .    0

        2   –    0 .    3

        7    )

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        8   –    1 .    1

        4    )

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        1    1 .    9

        %

        (    8 .    8

        %   –    1    6 .    0

        %    )

        3 .    9

        %    (    2 .    8

        %   –    5 .    4

        %    )

        0 .    4

        %

        (    0 .    1

        %   –    1 .    8

        %    )

        2 .    8

        %

        (    1 .    4

        %   –    5 .    5

        %    )

    178 |   Clin. Oral Implants Res. 23 (Suppl. 6), 2012/163–201   © 2012 John Wiley & Sons A/S

    Sailer et al Systematic review of cemented and screw-retained implant reconstructions

  • 8/19/2019 Cementadas vs Atornilladas, Haemmerle

    17/39

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