Journal of

Oral Rehabilitation

Journal of Oral Rehabilitation 2011 38; 697711

Review Article

Prosthetic outcome of cement-retained implant-supported xed dental restorations: a systematic review

M. S. CHAAR, W. ATT & J. R. STRUB
Freiburg, Germany Department of Prosthodontics, School of Dentistry, Albert-Ludwigs University,

SUMMARY The aim of the article is to assess the current literature in terms of the prosthetic outcome of cement-retained implant-supported xed restorations, as well as to determine the type of cement that can be recommended for clinical application. A review of the literature published up to May 2010 was conducted to identify clinical studies about cement-retained implant-supported xed restorations. The search strategy applied was a combination of MeSH terms and free text words, including the following keywords: implants, implant-supported xed dental prostheses (FDPs), bridges, implant-supported single crowns (SCs), cement-retained, cement xation, cement, cementation, cement failure, retention, and loss of retention, technical complications, mechanical complications, prosthetic complication, retrievability and maintenance. Thirty-two studies met the inclusion criteria. The studies were divided into two categories: 15 short-term clinical studies with an observation period of less than 5 years, and 17 longterm clinical studies with an observation period of

5 years and more. The most common technical complications of cement-retained implant-supported xed restorations were loss of retention, chipping and abutment screw loosening. The results of the current review revealed no guidelines about cement or cementation procedures. It may be stated that despite the questionable retrievability of cement-retained implant-supported xed restorations, this treatment modality is a reliable and effective option, especially for implant-supported SCs and short-span FDPs. The literature does not provide accurate information about the clinical outcome of cement-retained implant-supported xed restorations nor about the ideal type of cement that facilitates stability and maintains retrievability. Standardised randomised clinical trials will provide valuable information to this issue. KEYWORDS: cement-retained, xed implant-supported restorations, prosthetic complications, clinical outcome Accepted for publication 23 January 2011

Introduction
Successful long-term prognosis of osseointegrated oral implants in the edentulous jaws has encouraged clinicians to extend their application to partial edentulism (1, 2). The initial experience with implant-supported restorations in partial edentulism was less favourable than those in edentulous patients (35). Recent improvements in understanding and manufacturing techniques of implant-supported xed restorations for partially edentulous arches have improved their success rates to a level equal to those for edentulous arches (68).
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Clinical research activities in implant dentistry have been focusing on implant survival, whereas the incidence of technical complications with implant components or restorations has been addressed only to a minor extent. To improve long-term stability and minimise complications, it is important to consider the mechanical stability of the implant-supported xed restorations. Indeed, mechanical complications may lead to increased rates of repairs and remakes that are time-consuming and require additional nancial resources (9). During prosthetic implant treatment planning, different prosthetic modalities should be considered and
doi: 10.1111/j.1365-2842.2011.02209.x

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M . S . C H A A R et al.
related to many factors, such as aesthetical outcome, nancial concerns, and probability of mechanical and biological complications (10). Implant-supported restorations can be screw-retained, cement-retained or a combination of both. The question of whether to fabricate cement- or screw-retained implant-supported xed restorations has been discussed extensively (1115). In a recent long-term clinical prospective study, both screw- and cement-retained implant restorations showed similar results in terms of clinician- and patient-assessed success parameters (16). Nevertheless, the choice of retention in xed implant prosthodontics seems to be based mainly on the clinicians preference in the absence of scientic evidence-based information (15). The main advantages of screw-retained restorations are retrievability (17, 18) and excellent marginal integrity (19). However, they represent some disadvantages, such as the need for an optimal implant positioning and open screw access holes, which have been proposed to compromise occlusion and the stability of the veneering material (20, 21). In addition, screw-retained restorations are associated with more sophisticated clinical and laboratory procedures, which increase the total cost of implant treatment (12, 14). Moreover, the retaining screw seems to be more prone to lateral bending, tipping and elongation forces, which may result in screw loosening or screw fracture (11). To eliminate such disadvantages as well as to broaden the material spectrum to include additional restorative materials, i.e. all-ceramic materials, cement-retained restorations can be used (15). However, several disadvantages have been mentioned in the literature for such restorations, such as the difcult retrievability (13, 22, 23), in addition to the demanding removal of excess cement. The permanency of residual cement in the soft tissues may result in peri-implant tissue inammation (24, 25). To overcome this problem, the use of customised abutments with the margins being positioned not deep into the sulcus has been suggested (26). Another disadvantage of cement-retained restorations is the reduced stability in situations where interocclusal space is limited, as the abutment lacks the important factors of height and surface area for the cement retention (27). Hence, it is obvious that there are no specic guidelines for when and how cement-retained restorations are indicated and used. Despite their increasing popularity as a treatment modality in implant prosthodontics, the long-term outcome of such restorations is still not clear. With the lack of sufcient knowledge, several important questions can be raised: What is the outcome of cementretained restorations? What are the complications associated with such restorations? And what is the most appropriate cement to retain these restorations? Therefore, the aim of this paper was to systematically review the current literature regarding the prosthetic outcome of cement-retained implant-supported xed restorations, as well as to determine the type of cement that can be recommended for clinical application.

Material and methods

Search strategy An electronic search was performed by two reviewers (M.S.C., W.A.) from 1991 to May 2010, using MEDLINE (PubMed) and Cochrane Library databases for English articles in dental journals. The search strategy applied was a combination of MeSH terms and free text words, including the following keywords: implants, implant-supported xed dental prostheses (FDPs), bridges, implant-supported single crowns (SCs), cement-retained, cement xation, cement, cementation, cement failure, retention, and loss of retention, technical complications, mechanical complications, prosthetic complication, retrievability and maintenance. The option of related articles was also used. Review articles, as well as references from different studies, were also used to identify relevant articles. Furthermore, a manual search was conducted in the following journals: Clinical Implant Dentistry and Related Research, International Journal of Oral and Maxillofacial Implants, International Journal of Oral and Maxillofacial Surgery, International Journal of Periodontics and Restorative Dentistry, International Journal of Prosthodontics, Journal of Dental Research, Journal of Prosthetic Dentistry, Journal of Oral Rehabilitation, Clinical Oral Implants Research (Fig. 1). Selection of studies The review process consisted of two phases. In the rst phase, titles and abstracts of the searches were initially screened for relevance, and the full text of the relevant abstracts was obtained and assessed. Any disagreement was resolved by discussion and a nal inter-reviewer consensus. Additionally, the hand search of the selected journals, as well as search of the references of the selected studies, was also implemented. The articles
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CEMENT-RETAINED IMPLANT-RESTORATIONS: A SYSTEMATIC REVIEW

699

First electronic and hand search 3594 articles

Independent selected by 2 reviewers 173 titles Abstracts obtained

Discussion discarded 72

Agreed by both 101 abstracts Full text obtained Further hand searching 2 studies 3 studies retrieved from references

Total full text 106, screened for inclusion/exclusion criteria for first phase

Discussion Agreed on 55 full text articles

23 Studies excluded in the second review phase

The 32 final included studies were further classified as following 17 long-term studies 5 years
Fig. 1. Search strategy used to identify the included studies.

15 short-term studies < 5 years

obtained were screened during the rst step of the review process using the following exclusion and inclusion criteria:

Inclusion criteria 1 Human subjects. 2 Observation period 1 year after delivery of nal restorations. 3 Studies on implant-supported FDPs and or implantsupported SCs. 4 Randomised controlled clinical trials, controlled clinical trials, retrospective and prospective studies. 5 Review articles that could help to identify relevant articles regarding cement-retained implant-supported restorations.

Exclusion criteria 1 Animal studies. 2 Finite element analysis studies. 3 In vitro studies.
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4 Case reports or case studies. 5 Clinical studies reported tooth implant-supported FDPs. 6 Clinical studies not providing detailed information about the characteristics of the implants and their supported restorations. 7 Clinical studies reporting only screw-retained implant-supported FDPs and SCs. The selected full texts were screened independently by the two reviewers in the second phase of the review process using the following exclusion criteria: 1 Review articles. 2 When multiple reports of the same study were identied, only the most recent study was included. 3 Clinical studies considering only cumulative implant success rate or only biological complications without considering technical complications were excluded. 4 Clinical studies with <10 cement-retained restorations were excluded. 5 When data regarding cement-retained xed restorations could not be extracted from the study.

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6 Clinical studies in which the restorations were cemented extraorally. 7 Clinical studies that used both types of retention, i.e. cement-retained and screw-retained, in the same implant-supported xed prostheses. All excluded studies in the second phase of the review are summarised in Table 1. nal included studies were tabulated, and the incidences of complications were calculated and analysed (Tables 2 and 3), and the following information was extracted: study design applied, mean observation period, number of patients examined, number of implants restored, implant system used and connection type (internal external), number and design of restorations, type of abutment, type of cement, prosthetic success rate and complications.

Results
The initial database search yielded 3594 titles. Fifty-ve studies passed the rst review phase, and 32 studies were nally selected (Fig. 1). All the identied studies were published in the past 14 years between 1996 and 2010. The included studies were classied into two categories: Clinical short-term studies with observation periods of <5 years and clinical long-term studies with observation periods of 5 years and more. Data of the

Short-term studies The literature search revealed fteen studies (Table 2) (2842). All studies were either prospective or retrospective, except for three randomised clinical trials (30, 40, 41). Implants with internal connection were employed in 10 studies (28, 3236, 3841), while ve studies employed implants with external connection (2931, 37, 42). Eleven studies reported only SCs

Table 1. Excluded studies at the second phase of the review Study Eckert & Wollan (70) Henry et al. (71) McGlumphy (72) Priest (73) Haas et al. (74) Andersson et al. (75) Levine et al. (76) Levine et al. (77) Mangano et al. (78) Jemt et al. (79) Fugazzotto et al. (80) Rodriguez et al. (81) Anitua et al. (82) Davarpanah et al. (83) Gibard & Zarb (84) Tawil et al. (85) Misch et al. (86) Mericske-Sternet et al. (59) Keller et al. (87) Bra gger et al. (56) Schropp & Isidor (88) Bischof et al. (89) Preiskel et al. (90) Year 1998 1993 2003 1999 2002 1999 1997 1999 2009 2009 2004 2000 2008 2005 2002 2006 2008 2001 1998 2001 2008 2006 2004 Reason for exclusion Data regarding cement-retained restorations could not be extracted Data regarding cement-retained restorations could not be extracted Data regarding cement-retained restorations could not be extracted Data regarding cement-retained restorations could not be extracted Data regarding cement-retained restorations could not be extracted Data was reported in a most recent study Data was reported in a most recent study Data was reported in a most recent study Data was reported in a most recent study Restorations were cemented extra orally Only cumulative implant success rate was considered without considering prosthetic complications Only cumulative implant success rate was considered without considering prosthetic complications Prosthetic complication rate was not considered Prosthetic complication rate was not considered Prosthetic complication rate was not considered Prosthetic complication rate was not considered Prosthetic complication rate was not considered Less than 10 cement-retained restorations were reported Less than 10 cement-retained restorations were reported Complications related to cement-retained restorations could not be extracted Complications related to cement-retained restorations could not be extracted Complications related to cement-retained restorations could not be extracted Each prosthesis in the study had at least 1 screw-retained element and 1 or more cement-retained telescopic units

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Table 2. Included short-term clinical studies

Study 4 years 295 Internal (Morse taper) 65 AC SCs 42 MC SCs Pre-fabricated metal abutments ZOE External 17 AC SCs 21 MC SCs RC GI 899% 9944% AL: 066%

Design

Observation period Connection Abutment Cement Complications

No. of patients

No. of implants

No. of restorations

Prosthetic success rate

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Mangano et al. 2010 (28)

PS

Sailer et al. 2009 (30)

RCT

1 year

20

307 Leone Leone implant system 38 Branemark Nobel Biocare

RS 14 years 4 years 20 Internal ZOE 66 Internal PC

16 years

49

Internal

PC

9655% 96% 100%

MCRS

Chipping: (167%) on MC SCs ASL: 0% Loss of retention: 345% Loss of retention: 4% No complications

Khraisat et al. 2008 (34) Jebreen et al. 2007 (33) Vigolo et al. 2006 (41)

RCT

87 ITI Straumann 141 ITI Straumann 40 3i Biomed 3i

MC SCs and MC FDPs MC SCs and FDPs 40 MC SCs

RCT 1 year 73 External 110 all-metal and MC SCs

4 years

12

Internal

12 MC SCs

ZOE CH

100% 991%

No complications ASL: 09%

Vigolo et al. 2004 (40) Drago. 2003 (31)

PS

12 3i Biomed 3i 110 Osseotite Biomed 3i

Duncan et al. 2003 (32) 3 years 18 41 ITI Straumann Internal

PS

18 customised zirconia abutments 20 customised titanium abutments Pre-fabricated titanium abutments Pre-fabricated titanium abutments 20 customised titanium abutments 20 customised gold-alloy abutments Customised gold abutments Customised gold abutments Customised titanium abutments Pre-fabricated titanium abutments ZP 100%

No complication

Krennmair et al. 2002 (35) 3 years 112* 93 Frialit-2 Friatec

RS

Internal

22 MC SCs 8 MC FDPs 1 cantilever MC FDP 66 MC SCs 27 AC SCs

Pre-fabricated titanium abutments

ZOE

836%

CEMENT-RETAINED IMPLANT-RESTORATIONS: A SYSTEMATIC REVIEW

Levine et al. 2002 (36)

MCRS

15 years 471* 600 ITI Straumann

Internal

600 SCs

Pre-fabricated titanium abutments

Ns

984%

ASL: 43% Chipping: 22% Loss of retention: 99% ASL: 0,3% Chipping: 02% Loss of retention 06% Other complications: 05%

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Table 2. (Continued)

Study 13 years 75* 74 Branemark Nobel Biocare External 67 AC SCs 7 MC SCs 96%

Design

Observation period Connection Abutment Cement

No. of patients

No. of implants

No. of restorations

Prosthetic success rate

Complications Other complications: 4%

Andersson et al. 2001 (29)

PS

Wannfors, Smedberg 1999 (42) 15 year 58* 65 Branemark Nobel Biocare External 65 SCs Pre-fabricated titanium abutments

PS

3 years

34

36 Branemark Nobel Biocare

External

27 MC SCs 9 AC SCs

Pre-fabricated titanium abutments Pre-fabricated alumina abutments Pre-fabricated titanium abutments

58 ZP. 7 GI. 6 ZOE 3 RC ZP

698%

McMillan et al. 1998 (37)

MCRS

59 GI 6 ZP

878%

Palmer et al. 1997 (38) 636 months 70 225 Spectra system Core-Vent Internal 17 SCs 75 FDPs

PS

2 years

15

15 Astra Astra Tech

Internal

15 SCs

Pre-fabricated titanium abutments Customised titanium abutments

ZOE

70%

Singer, Sefaty 1996 (39)

RS

ZOE

85%

ASL. 27% Chipping: 27% Other complications: 258% Chipping: 3% Loss of retention: 46% Other complications: 46% Chipping: 15% Loss of retention: 15% ASL: 33% Chipping 22% Loss of retention: 98%

PS, prospective study; RS, retrospective study; RCT, randomised clinical trial; MCRS, multicentre retrospective study; AL, abutment loosening; ASL, abutment screw loosening; SCs, single crowns; FDPs, xed dental prostheses; MC, metal-ceramic; AC, all-ceramic; ZP, zinc phosphate cement; ZOE, zinc oxide eugenol cement; GI, glassionomer cement; RC, resin cement; PC, polycarboxylate cement; CH, calcium hydroxide-based temporary cement; Ns, not specied. *Only data about cement-retained xed restorations were extracted. The implant and the abutment are joined together by a self-locking connection without the need for abutment screw.

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Table 3. Included long-term clinical studies

Study 10 years 139* Internal 31 MC SCs 64 MC FDPs Ns ZP 878%

Design

Observation period Connection Abutment Cement Complications

No. of patients

No. of implants

No. of restorations

Prosthetic success rate

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Arisan et al. 2010 (43)

RS

ASL: 03% Chipping: 43% Loss of retention: 168%

Krennmair et al. 2010 (44)

RS

5 years

216*

235 ITI Straumann* 81 Xive Dentsply -Friadent* 541* Camlog root-line Camlog Internal 112 SCs 68 FDPs Ns ZOE 828% for SCs 765% for FDPs

Romeo et al. 2009 (55) 5 years 54 78 ITI Straumann Internal 27 cantilever FDPs 22 SCs 5 FDPs

PS

8 years

45*

116 ITI* Straumann

Internal

41 cantilever FDPs

ZP or ZOE ZP or GI

na

ASL: 45% SCs, 59% FDPs Chipping: 45% SCs, 88% FDPs Loss of retention: 98% SCs, 88% FDPs Loss of retention: 73% 788% in cantilever group 963% in SCs & FDPs

Ha lg et al. 2008 (54)

RS

Pre-fabricated titanium abutment Pre-fabricated titanium abutments

De Boever et al. 2006 (10)

RS

5 years

105*

283 ITI* Straumann

Internal

80 SCs* 77 FDPs* 8 cantilever FDPs*

72 ZP 55 AU

78%

CEMENT-RETAINED IMPLANT-RESTORATIONS: A SYSTEMATIC REVIEW

Nedir et al. 2006 (48)

RS

8 years

146*

383 ITI* Straumann

Internal

93 MC FDPs* 172 MC SCs*

Pre-fabricated titanium abutments Customised titanium abutments Ns

ZP

896%

Chipping: 148% cantilever group Loss of retention: 37% cantilever group; 0% SCs & FDPs Other complications: 37% in each group Loss of retention: 157% Other complications: 63% Loss of retention: 19% Other complications: 85%

703

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Table 3. (Continued)

Study 10 years 77 * 138 ITI* Straumann Internal 67 SCs 25 FDPs Ns ZP 922% for SCs 562% for FDPs

Design

Observation period Connection Abutment Cement

No. of patients

No. of implants

No. of restorations

Prosthetic success rate

Complications

M . S . C H A A R et al.

Bra gger et al. 2005 (9)

PS

Wennstro m et al. 2005 (53) 5 years 20 20 Astra Astra Tech Internal 20 SCs

PS

5 years

40

45 Astra Astra Tech

Internal

45 SCs

ZP

944%

ASL: 15% in SCs, 212% in FDPs Chipping: 43% in SCs, 6% in FDPs Loss of retention: 3% in SCs, 16% in FDPs ASL: 66%

Gotfredsen 2004 (47)

PS

Pre-fabricated titanium abutments Customised titanium abutments

Ns

75%

Andersson et al. 2003 (45) 10 years 50* 126 Branemark* Nobel Biocare External

MCRCT

5 years

32*

105 Branemark* Nobel Biocare

External

19 AC FDPs

Ns

947%

Simon 2003 (51)

RS

101 SCs

82 ZOE 8 CH 11 ZP

72%

Vigolo, Givani 2000 (52) 5 years 21

PS

5 years

44

52 3i Biomed 3i 30 Branemark Nobel Biocare

Internal

52 MC SCs

ZOE

84%

ASL: 10% Chipping: 5% Loss of retention: 10% Other complications: 63% Loss of retention: 22% Other complications: 6% ASL: 2% Loss of retention: 14% External 30 MC SCs Ns 967% Loss of retention 33% Prefabricated alumina abutments Pre-fabricated titanium abutments or customised abutments Customised gold-alloy abutments Prefabricated titanium abutments

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Polizzi et al. 1999 (49)

PS

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Table 3. (Continued)

Study 5 years 183* 259 Branemark* Nobel Biocare External 174 AC SCs 34 MC SCs Prefabricated titanium abutments 112 ZP 73 ZOEF 23 GI 952%

Design

Observation period Connection Abutment Cement

No. of patients

No. of implants

No. of restorations

Prosthetic success rate

Complications

Scholander 1999 (50)

RS

Andersson et al. 1998 (46)

PS

5 years

57

65 Branemark Nobel Biocare

External

62 AC SCs 3 MC SCs

Prefabricated titanium abutments Prefabricated titanium abutments

Ns

937%

Scheller et al. 1998 (8)

MCPS

5 years

57

65 Branemark Nobel Biocare

External

65 MC and AC SCs

ZP GI ZOE

797%

Parein et al. 1997 (3)

RS

5 years

152*

392 Branemark* Nobel Biocare

External

35 SCs

Prefabricated titanium abutments

ZOE

77%

ASL: 096% Chipping: 23% in MC SCs Loss of retention: 19% Other complications: 17% ASL: 15% Other complications: 61% ASL: 6% Loss of retention: 36% Other complications: 107% ASL: 29% Other complications: 201%

CEMENT-RETAINED IMPLANT-RESTORATIONS: A SYSTEMATIC REVIEW

MCRCT, multicenter randomised clinical trial; MCPS, multicenter prospective study; ZOEF, eugenol-free zinc oxide cement; AU, acryl urethane-based cement. *Only data about cement-retained xed restorations were extracted.

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(2831, 3538, 4042), while four studies reported both SCs and FDPs (3234, 39). Conventional cements (zinc phosphate cement, glassionomer and polycarboxylate cement) were used in ve studies (3234, 37, 42). One study used either resin cement or glassionomer cement for all-ceramic crowns (30). Another study used either zinc phosphate cement or zinc oxide eugenol temporary cement (28). Temporary cements, particularly zinc oxide eugenol cement, were used in six studies (31, 35, 3841). In one study, the type of cement was not specied (36). Nevertheless, the results of the identied short-term studies revealed no information or guidelines about cement or cementation procedures implemented for cement-retained implant-supported restorations. The prosthetic success rate for the short-term studies ranged between 698% and 100% (Table 2). The incidence of abutment screw loosening ranged between 0% and 43% (35). Fracture of veneering porcelain, i.e. chipping, was also a common technical complication, which amounted to be up to 167% (30). Interestingly, the most common technical complication associated with cement-retained xed restorations in the majority of the included studies was loss of retention, which amounted up to 46% (3234, 37, 42) and up to 15% (31, 35, 3841) for permanent cements and temporary cements, respectively. cement or cementation procedures implemented for cement-retained implant-supported restorations. The prosthetic success rate for the long-term studies ranged between 562% and 967% (Table 3). The most common technical complication was loss of retention, which amounted to be up to 16% (810, 48, 50, 53) and up to 22% (3, 51, 52) for permanent cements and temporary cements, respectively. Moreover, the incidence of abutment screw loosening was reported to be up to 10% for SCs (47) and up to 212% for FDPs (9). Chipping of the veneering porcelain was also a common technical complication, which amounted to be up to 5% for SCs (47), and up to 88% for FDPs (44), and 148% for cantilever FDPs (54).

Discussion
The aim of the present systematic literature review was to assess the short- and long-term prosthetic outcome and mechanical technical complications of cementretained implant-supported xed restorations, as well as to try to determine the type of cement that can be recommended for clinical application. Unfortunately, because of the heterogeneity of the studies identied, it was not possible to carry out a meta-analysis of the data. Instead, the current article summarised the outcome and the complication rates of cement-retained implant-supported xed restorations. The start of the search was in 1991, because it was the year of the introduction of cement-retained restorations on CeraOne abutment (46). Although shortterm studies are not reliable to provide a valid evidence for a given treatment modality, the observation period was set at a minimum of 1 year. This was to provide more accurate information about the onset of technical complications of cement-retained implant-supported xed restorations. In addition, the separation between short-term and long-term studies attempted to provide information about the prognosis and the progress of such complications throughout the service time of the restorations. With the exception of one study, no RCTs were identied in the current review in terms of type of retention or type of cement (40). The identied prospective and retrospective studies were very heterogeneous in terms of objectives, designs, sample size, assessment of treatments outcomes and observation periods. The heterogeneity was further compounded by the variety of implant systems and component being
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Long-term studies The literature search revealed seventeen long-term studies with observation periods ranging between 5 and 10 years (Table 3) (3, 810, 4355). All studies were either prospective or retrospective, except for one randomised clinical trial (45). Implants with internal connection were employed in ten studies (9, 10, 43, 44, 47, 48, 5255), while seven studies employed implants with external connection (3, 8, 45, 46, 4951). SCs were reported in nine studies (3, 8, 46, 47, 4953), SCs and FDPs were reported in six studies (9, 10, 43, 44, 48, 54), while FDPs were reported in two studies (45, 55). Zinc phosphate cement was used for the majority of the restorations in nine studies (810, 43, 48, 50, 5355). Temporary cements, particularly zinc oxide eugenol cement, were employed in four studies (3, 44, 51, 52), and the type of the cement was not specied in four studies (4547, 49). In a similar manner to shortterm studies, the results of the identied long-term studies yielded no information or guidelines about

CEMENT-RETAINED IMPLANT-RESTORATIONS: A SYSTEMATIC REVIEW

used, placement site, as well as implant restorative techniques and designs. Therefore, it was difcult to draw a clear conclusion from the identied studies. This clearly reveals the need for randomised clinical trials in this eld. The prosthetic success rate amounted to be between 698% and 100% for the short-term studies (14 years), and between 562% and 967% for the long-term studies (510 years). More technical complications were reported in the long-term studies than in shortterm studies, which reect the increase in the incidence of technical complication with time. Obviously, more technical complications were reported for FPDs than those for SCs, especially for cantilever FPDs (9, 10, 44, 54, 55). Nevertheless, most of the reported complications were minor retrievable ones, such as loss of retention or minor chipping (9, 10, 38, 42, 51, 54). A number of studies that compared the technical complications between screw-retained and cementretained restorations reported more technical complications for screw-retained restorations. The most frequent complication was related to abutment screw loosening in the screw-retained groups (10555%), compared to (055%) in the cement-retained groups (3, 9, 10, 32, 36, 42). On the other hand, several studies found that both screw-retained and cement-retained restorations performed equally well, and they could not identify any signicant difference in terms of abutment screw loosening or even other technical complications, related to the type of xation (30, 35, 37, 40, 45, 48, 55, 56). The incidence of abutment screw loosening amounted to be up to 43% and up to 10% for the short-term and the long-term studies, respectively. Reviewing the data obtained, it can be observed in the more recent studies that there is a trend of a reduction in the incidence of abutment screw loosening (015%) (9, 28, 3034, 40, 41, 48, 54, 55). This may be explained by the learning curve over the years and the improvement in manufacture and mechanical characteristics of implant components, as well as implementation of controlled tightening with a torque-controlling instrument for abutment screw retention. Moreover, the inaccurately tting prostheses and implants components contributed in increasing the rate of technical complications, particularly abutment screw loosening (57). The present review could not identify complications in terms of abutment screw loosening related to the type of the implantabutment connection
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(internal external). This is in agreement with the results of another systematic review, which showed that abutment screw loosening is a rare event in implant-supported SCs, regardless of the implantabutment connection geometry. The authors emphasised that proper antirotational features and controlled torque should be employed to reduce the incidence of abutment screw loosening (58). Conversely, the particular benets of internal connection, especially with implant-supported SCs, have been described in other studies (53, 59), but could not be established by the presented data. Fracture of the veneering porcelain has been considered a common complication in implant-supported xed restorations (9, 60, 61). This complication was reported to be up to 167% in the present review. However, if two studies were excluded from the analysis, the incidence of chipping would be decreased to about 6% after an observation period of 510 years. The rst study reported on cantilever FPDs (54), and other one reported on small number of samples consisted of metal ceramic crowns in the posterior regions (30). Oral forces may contribute to increase in prosthetic complications in terms of chipping, with cantilevered designs and patients exhibiting parafunctional behaviour of particular concerns (57, 62). In this review, loss of retention was the main reason for prosthetic complications, particularly when temporary cements and short abutments were used (35). Loss of retention amounted to be up to 22% for temporary cements and up to 168% for permanent cements. Nevertheless, this complication can be considered as a minor retrievable complication, provided that recementation is a simple and cost-effective procedure. Ideally, cement should be strong enough to retain the restorations, yet weak enough so that restorations can be removed easily, if required. However, controversy exists in the literature about the ideal cement to be used (23, 27, 6366). The results of the current review revealed no standardised guidelines for cementation, because each study used different cements, different protocols and different implants and components systems. Remarkably, the mostly used cements in the identied studies were either zinc phosphate cement as permanent cement, or zinc oxide eugenol cement as a provisional one. Using zinc phosphate cement will reduce signicantly the loss of retention, in addition to the simplicity in removing cement rests, as zinc phosphate cement does not adhere strongly to the metal

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surface compared to polycarboxylate cement, glass ionomer cement or resin cement (67). On the other hand, provisional cements may assure retrievability. Nevertheless, it is probable that a cement that functions well as provisional cement for restorations cemented to teeth may indeed be a permanent cement for metal cemented to metal (65). Thus, the retrievability of cement-retained restorations is still questionable. Taking this in consideration, the clinician should carefully consider the choice of cement by evaluating the surface area, taper, degree of the abutments, cement type, as well as interocclusal space and occlusion. When cement-retained xed restorations are considered, the clinician should weigh the advantages and disadvantages of such treatment modality. This is particularly important, as potential costs may arise with the need for renewing the restoration in the event of biological or technical complications. In fact, many factors are involved in this assessment, including the number of dental implants, arch position, occlusion, costs of remaking a given restoration and the likelihood of complications. The principle of progressive cementation can be also advocated, whereby stronger cements are progressively used until adequate retention is achieved (65). Furthermore, the retrievability of these restorations could be most possibly maintained by implementing modication in the design of the restoration to ease removal without damaging the cemented superstructure (e.g. removing driver, removing screw or techniques for locating abutment screw) (26, 68, 69). Taking the results of this review in consideration, implant-supported SCs and short-span FDPs may be successfully cement-retained, where the probability of prosthetic complications is very low. However, longspan and full-arch FDPs, as well as cantilever FDPs are likewise best treated with screw-retained solution, as far as the complications of these restorations are more frequent. Furthermore, the retrievability of these reconstructions is less traumatic, more cost effective and more predictable than cemented reconstructions. arch FDPs and cantilever FDPs. The literature does not provide accurate information about the clinical outcome of cement-retained implant-supported xed restorations nor about the ideal type of cement that facilitates stability and maintains retrievability. Standardised RCTs will provide valuable information to this issue.

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Conclusions
It may be stated that despite the questionable retrievability of cement-retained implant-supported xed restorations, this treatment modality is a reliable and effective option in xed implant prosthodontics, especially for implant-supported SCs and short-span FDPs. However, it is not advocated for long-span FDPs, full-

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Correspondence: M. Sad Chaar, Department of Prosthodontics, School of Dentistry, Hugstetter Str. 55, 79106 Freiburg, Germany. E-mail: mohamed.sad.chaar@uniklnik-freiburg.de

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