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Purpose: The purpose of this study was to systematically review clinical studies on the incidence of
abutment screw loosening in single-implant restorations with different implant-abutment connection
geometries. Materials and Methods: The literature search was conducted using several electronic
databases. Specific terms were used for the database search, which spanned the years 1990 to
2006. The search was augmented by using the option of “related articles” as well as hand searching
of references and relevant journals. Relevant studies were selected according to predetermined inclu-
sion and exclusion criteria. Agreement between reviewers was determined by using Cohen’s kappa
coefficients. Three-year complication-free rates (survival proportions) were calculated with the aid of a
survival function, assuming constant failure rates. Summary estimates per group for complication-free
rate after 3 years (M-estimator) were calculated using Tukey’s biweight estimator. Results: The initial
database search yielded 1,526 relevant titles. After the subsequent filtering process, 27 studies were
finally selected. Interexaminer agreement ranged from good to perfect. The external-connection group
comprised 12 studies following 586 single-implant restorations for a mean follow-up time that ranged
from 3 to 5 years. The estimated percent of complication-free single-implant restorations after 3 years
was 97.3% (95% CI: 95.6–98.3). The internal connection group comprised 15 studies following 1,113
single-implant restorations for a mean follow-up time that ranged from 3 to 10 years. The estimated
percentage of complication-free single-implant restorations after 3 years was 97.6% (95% CI:
96.5–98.3). Conclusion: The results show that abutment screw loosening is a rare event in single-
implant restorations regardless of the geometry of implant-abutment connection, provided that proper
antirotational features and torque are employed. INT J ORAL MAXILLOFAC IMPLANTS 2008;23:681–690
Key words: implant complications, implant geometry, meta-analysis, screw loosening, single implants
he stability of the connection between different the reconstruction. This is especially true for single-
T implant parts is important for the overall success of tooth restorations, where a strong interlock between
the abutment and implant is necessary. Various mech-
anisms have been proposed to connect the dental
1Doctoral Candidate, Department of Fixed Prosthesis and Implant implant abutment to the implant body. Different sys-
Prosthodontics, School of Dentistry, Aristotle University of Thes- tems vary in connection geometry, materials, and over-
saloniki, Thessaloniki, Greece. all screw mechanics. The implant-abutment connec-
2Lecturer, Department of Fixed Prosthesis and Implant Prostho-
tion stability is also influenced by factors such as
dontics, School of Dentistry, Aristotle University of Thessaloniki, component fit, machining accuracy, saliva contamina-
Thessaloniki, Greece.
3Statistician, DCS Company, Thessaloniki, Greece. tion, and screw preload.1–8 Most in vitro studies,9–12
4Professor and Chair, Department of Fixed Prosthesis and with the exception of one,13 have demonstrated that
Implant Prosthodontics, School of Dentistry, Aristotle University internal connections are more mechanically stable
of Thessaloniki, Thessaloniki, Greece. than external flat (hex-type) connections. Loosening of
abutment screws, particularly with the “classic” exter-
Correspondence to: Dr Haralampos P. Petridis, Department of
Fixed Prosthesis and Implant Prosthodontics, School of Dentistry, nal-hex implant systems, has been a well-known tech-
Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece. nical problem, occurring mainly during the first 2 years
Fax: +302310999575. E-mail: Lpetridi@dent.auth.gr after delivery of the crown.14–17 The stability of the
external implant-abutment connection was subse-
Presented as an oral presentation during the annual Interna-
tional Association for Dental Research-Continental European quently improved by altering the screw alloys and
Division (IADR-CED) meeting, which took place in Thessaloniki, their surfaces and applying proper torque values to
Greece, September 26–29, 2007. establish higher initial preloads.3,18–21
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All selected studies25–51 were published in the last able implant systems. Most of the external-connec-
12 years. The publication date of the external-con- tion implant systems included in the final studies
nection implant systems ranged from 1996 to 2004 were either 3i (Biomet 3i, Palm Beach Gardens, FL) or
with half of the studies published after 2000. The Nobel Biocare (Nobel Biocare, Göteborg, Sweden),
publication date of the internal-connection implant which essentially have similar geometry for their
systems ranged from 1998 to 2006, with the majority respective regular platforms. The exception was 1
of the studies published after 2000. No study directly study that utilized Threadlock/Spline (Sulzer Calcitek,
compared the incidence of screw loosening between Carlsbad, CA) implants. The internal-connection sys-
internal- and external-connection implant systems. tems were Straumann (Straumann, Basel, Switzer-
Most of the studies were classified as category C land), Astra (Astra Tech, Mölndal, Sweden), Frialit (Fri-
according to the strength of the evidence, and most atec, Mannheim, Germany), Mac System (Cabon,
were implemented in a university setting. Milan, Italy), Bicon (Bicon, Boston, MA), and Ankylos
The studies included a total of 2,038 patients with (Degussa Hulls, Hanau, Germany). Due to the possible
an age range of 13 to 90 years. The demographics of effect of the variability of internal-connection geom-
the included studies are depicted in Tables 3 and 4. etry on the stability of the implant-abutment inter-
The studies reported on various commercially avail- face, the internal connection group of studies was
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further categorized into 3 categories: “Straumann,” The design of the study (prospective versus retro-
“Astra,” and “Other.” The information on implants and spective) did not have any effect on the outcome.
SIR is depicted in Tables 5 and 6. The estimated percentage of complication-free SIR
The external-connection group comprised 12 after 3 years was as follows: external connection/
studies following 586 SIR for a mean follow-up time prospective 97.2% (95% CI: 94.9–98.5), external con-
that ranged from 3 to 5 years (Table 7). The estimated nection/retrospective 97.1% (95% CI: 93.6–98.7),
percentage of complication-free SIR after 3 years was internal connection/prospective 97.6% (95% CI:
97.3% (95% CI: 95.6–98.3). 95.9–98.6), and internal connection/retrospective
The internal-connection group comprised 15 stud- 97.6% (95% CI: 95.8–98.6).
ies following 1,113 SIR for a mean follow-up time that
ranged from 3 to 10 years (Table 8). The estimated
percentage of complication-free SIR after 3 years was DISCUSSION
97.6% (95% CI: 96.5–98.3). The complication-free per-
centage of SIR for the 3 groups was as follows: Strau- Systematic reviews differ from other types of reviews
mann 98.2% (95% CI: 96.8–99.0), Astra 97.0% (95% CI: in that they adhere to a strict scientific design to
94.4–98.4), and Other 97.1% (95% CI: 94.7–98.5). make them more comprehensive to minimize the
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Table 8 Abutment Screw Loosening Rates of Internal-Connection Implants (per Implant Type and Total)
Estimated Estimated
Total Mean No. of minimum failure rate Estimated
Type of no. of follow-up failure time (per 100 complication-free:
Study Year implant implants time (y) (loosen) exposure (y) implant years) % after 3 y
Behneke et al39 2000 Straumann 19 5.4 1 103 0.97 97.1
Brägger et al44 2005 Straumann 65 10 2 650 0.31 99.1
Duncan et al43 2003 Straumann 34 3 0 102 0.00 100
Mericske-Stern et al45 2001 Straumann 106 4.2 0 445 0.00 100
Nedir et al51 2006 Straumann 155 3 2 465 0.43 98.7
Levine et al37 1999 Straumann 157 3.3 5 518 0.97 97.1
Total 536 10 2,283
Summary estimate (95% CI) 0.59 (0.33–1.07) 98.2 (96.8–99.0)
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chance of bias and to ensure their reliability. Rather authors’ intention to try to include as many clinical
than reflecting the views of the authors or being studies as possible in order to reach a stronger con-
based on only a (possibly biased) selection of the clusion. Had the cutoff point for mean follow-up time
published literature, they contain a comprehensive been set at 5 years, 17 more studies would have been
summary of the available evidence with strict inclu- excluded. Furthermore, it has been shown that most
sion and exclusion criteria. Methodologies for under- of mechanical problems take place in the first years
taking systematic reviews have been described.87,88 after abutment connection.14–17 The mean follow-up
The gold standard for systematic reviews is to study time for the included studies ranged between from 3
randomized clinical trials (RCT), which are the studies to 10 years. However the results do not provide safe
with the most robust design. Most of the studies conclusions regarding the long-term stability of vari-
included in this review were retrospective. They were ous implant-abutment connections.
classified in category C according to the strength of The results of this review showed that abutment
evidence and clearly indicate a lower quality of data screw loosening is a rare event in SIR regardless of the
compared with prospective studies. 24 This clearly implant-abutment connection geometry, provided
points out the need for clinical studies with better that proper antirotational features and torque are
designs. No RCTs existed which directly compared employed. More than 97% of SIR studied maintained
the incidence of abutment screw loosening between a stable implant-abutment connection after 3 years
external and internal connection implant systems. of service. This is in agreement with results from in
The effect of study design (prospective versus retro- vitro studies,18–21 which have demonstrated stable
spective) was not significant; therefore, the results abutment screw joints for internal-connection
could be pooled together. implants as well as for external-connection implants
Two reviewers were used to ensure that tasks such with improved screw materials and preload. This
as selection of studies for inclusion and data extrac- study did not look into other types of mechanical
tion could be performed independently, increasing complications, such as screw fracture, where implant-
the chance that errors were detected. The interexam- abutment connection geometry might play a role.
iner agreement ranged from good to perfect agree- The results of this systematic review are in agreement
ment. Database search was also augmented by hand with the results of a previous systematic review92 that
searching to minimize selection bias.89 examined the incidence of biological and technical
The exclusion of papers in languages other than complications in implant therapy reported in
English may have led to the omission of some papers. prospective longitudinal studies of at least 5 years.
This is problematic for 2 reasons: (1) the precision of That study found a very low incidence of complica-
summary estimates could be reduced if a substantial tions affecting implant-connection components after
number of additional studies published in other lan- 5 years of clinical service. Another systematic review91
guages existed; (2) bias may have been introduced if of single implants stated that maintenance treat-
the results of studies published in English differed sys- ments were quite common with approximately 1 out
tematically from those published in other languages. of 5 single-tooth implants in need of maintenance,
However, a recent empirical study found little effect of varying from abutment screw retightening to crown
the inclusion/exclusion of trials published in language remake. The study did not look specifically at the inci-
other than English on combined effect estimates in dence of abutment screw loosening.
meta-analyses of RCTs.90 Moreover, it is difficult to have No attempt was made to distinguish between
access to non-English journals all over the world, and it anterior and posterior SIR, even though one could
is hard to establish the features of the peer-review assume that the vector of force is different. The rea-
processes of these journals. When these non-English sons were that most of the studies did not specify
papers are selected, based on their abstracts, the con- the number of posterior versus anterior SIR and that
tents must be translated. This includes the risk of inter- the incidence of abutment screw loosening reported
pretation problems.91 was extremely low. The same holds true for the possi-
The majority of the studies included in this review ble effect of restorative implant platform diameter
were conducted in a university setting. The results and method of crown retention. In the majority of
may therefore not be applicable to all practice set- included studies, implants with a regular-diameter
tings. The papers originating from private practice restorative platform and cement-retained restora-
settings showed a tendency for a slightly higher inci- tions were used. The method of reporting did not
dence of abutment screw loosening, especially permit the statistical analysis of the possible effect of
regarding internal-connection implant systems. the aforementioned clinical factors on the incidence
The follow-up time chosen was set at a minimum of abutment screw loosening.
of 3 years which could be considered small. It was the
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CONCLUSION 19. Drago CJ. A Clinical study of the efficacy of gold-tite square
abutment screws in cement-retained implant restorations. Int
J Oral Maxillofac Implants 2003;18:273–278.
The results show that abutment screw loosening is a
20. Tan KB, Nicholls JI. Implant-abutment screw joint preload of 7
rare event in SIR regardless of the geometry of hex-top abutment systems. Int J Oral Maxillofac Implants
implant-abutment connection, provided that proper 2001;16:367–377.
antirotational features and torque are employed. 21. Siamos G, Winkler S, Boberick KG. Relationship between
implant preload and screw loosening on implant-supported
prostheses. J Oral Implantol 2002;28:67–73.
22. Millennium Research Group. US markets for dental implants:
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