Factors Affecting the Decision to Use Cemented or

Screw-Retained Fixed Implant-Supported Prostheses:

A Critical Review
Miguel Gómez-Polo, DDS, PhD1/Rocio Ortega, DDS, PhD2/Cristina Gómez-Polo, DDS, PhD3/
Alicia Celemin, MD, PhD4/Jaime Del Rio Highsmith, MD, PhD4

Purpose: This review aimed to compile and enumerate all the factors described in the literature
that may affect the decision to use either cemented or screw-retained restorations and to
determine the relative weights of each factor by type of retention and prosthesis. Materials and
Methods: The literature was reviewed, and the factors were classified as either determining
(present in a clinical situation in which one of the retention mechanisms was clearly more
suitable than the other) or conditioning (present in clinical situations in which one type of
restoration was not clearly more advantageous than the other). Results: Three determining
factors (esthetic outcome, retention, and biologic risk) and five conditioning factors (passive fit,
fracture strength, occlusal area, complications, and retrievability) were identified. Conclusion:
Although there is not a clearly better alternative for all clinical situations, determining factors
in certain scenarios can render one of the two approaches more recommendable. For esthetic
reasons, when the implant angle cannot be corrected to conceal the access hole, cementation
is more suitable; however, screw retention is the better option when the occlusal space is under
6 mm or margins cannot be located supra- or equigingivally. In the absence of determining
factors, the decision should be based on conditioning factors, which carry different weights
depending on the type of prosthesis. Int J Prosthodont 2018;31:43–54. doi: 10.11607/ijp.5279

T he two main systems for installing an implant-sup-

ported fixed dental prosthesis (FDP) are cemen-
tation and screw retention. Although all FDPs were
initially retained with screws, they began to be secured
to abutments with the cements used in tooth-sup-
ported restorations around 20 years after the discov-
ery of osseointegration.1–4 These two approaches to
retention have been compared in a number of in vitro
and in vivo studies, although no clear consensus has
been reached on when one or the other should be
used. Most of the articles and reviews addressing the
issue conclude that neither mechanism is obviously
better than the other.5–13
1Part-time Professor, Department of Prosthetic Dentistry, School of
Dentistry, Complutense University of Madrid, Madrid, Spain.
2Part-time Professor, Department of Prosthetic Dentistry, School of
Dentistry, European University of Madrid, Madrid, Spain.
3Part-time Professor, Department of Surgery, Medicine, University of
Salamanca, Salamanca, Spain.
4Full-time Professor, Department of Prosthetic Dentistry, School of
Dentistry, Complutense University of Madrid, Madrid, Spain.
Correspondence to: Dr Miguel Gómez-Polo, Department of
Prosthetic Dentistry, Complutense University of Madrid,
Pza Ramon y Cajal s/n, 28040 Madrid, Spain.
Email: mgpolo@odon.ucm.es; miguelodont@hotmail.com
©2018 by Quintessence Publishing Co Inc.
Nonetheless, given the specific characteristics of
each type of prosthesis, as well as the presence of
an access hole in screw-retained restorations and
the need for cement in cement-retained restorations,
each has its own advantages and drawbacks. The ab-
sence of an access hole in cemented systems affords
a more uniform surface, which is structurally stronger
and obviates the need for restoration material to cover
the hole. Moreover, the space provided for the dental
cement may contribute to a more satisfactory passive
fit. For advocates of screw-retained prostheses, the
most prominent advantages include the absence of
excess cement (and hence the need for its removal)
and easy retrievability, with ready access to the reten-
tion screw and its simple removal when necessary for
hygiene reasons or to treat complications.
As the advantages and disadvantages of each ap-
proach make it more or less suitable depending on
the circumstances, attempting to determine which
is the most universally appropriate option would ap-
pear to be a futile exercise.14,15 As pointed out in sev-
eral reviews,5,7 although many factors may influence
the choice of one retention procedure over another,
they do not all carry the same weight in the ultimate
decision. Their relative influences depend largely on
the prevailing circumstances, which in turn revolve
around the type of prosthesis. In other words, not all
factors affect the final decision equally, for some are

Volume 31, Number 1, 2018 43

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Factors in Using Cemented or Screw-Retained Fixed Implant-Supported Prostheses
Fig 1   Abutment with insufficient height, raising the risk of decemen-
tation.
of considerable significance while others are of scant
significance.
Hence, a classification of retention systems that
describes the effect of each type of prosthesis and
specifies the clinical significance of their mechanical
or biologic implications would be useful. Such a classi-
fication would help clinicians opt for one retention sys-
tem over the other depending on the clinical situation.
The objectives of the present study were as follows:
•• To compile and enumerate all the factors described
in the literature that may affect the decision to ap-
ply cement or screw retention and to establish a
classification based on the weight that each factor
carries in the end result.
•• To determine the effect of factors by type of resto-
ration and prosthesis (ie, single crown [SC], fixed
partial denture [FPD], or full-arch restoration).
Materials and Methods
The literature was analyzed to identify all the factors
described that might affect the final decision to use
cement or screw retention when installing an FDP.
The terms searched on PubMed/Medline, Scopus,
and Cochrane were: screw-retained dental implant
prostheses; cement-retained dental implant prosthe-
ses; screw-retained dental implant; cement-retained
dental implant; screw-retained implant single crown;
cement-retained dental single crown; screw-retained
implant fixed partial denture; cement-retained fixed
partial denture; screw-retained implant full-arch reha-
bilitation; and cement-retained full-arch rehabilitation.
In this first phase, systematic and critical reviews
were examined to identify all of the factors described
by the various authors. Systematic and critical reviews
in the English language comparing screw- vs cement-
retained fixed dental prostheses in permanent pros-
theses only were included. Clinical and in vitro studies
and systematic and critical reviews on temporary
restorations were excluded. Papers published prior to
2000 were also excluded from the search.
44 The International Journal of Prosthodontics
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In the second part of the search, the literature was ex-
plored in greater detail for articles that contained any of the
aforementioned search terms in addition to one of the fol-
lowing factors: esthetic outcome screw‑retained implant
prostheses; esthetic outcome cement-retained implant
prostheses; retention screw‑retained implant prostheses;
retention cement-retained implant prostheses; biologic
risk screw-retained implant prostheses; biologic risk
cement-retained implant prostheses; passive fit screw-
retained implant prostheses; passive fit cement-retained
implant prostheses; fracture strength screw-retained im-
plant prostheses; fracture strength cement-retained im-
plant prostheses; occlusal area screw-retained implant
prostheses; occlusal area cement-retained implant pros-
theses; complications screw-retained implant prosthe-
ses; complications cement-retained implant prostheses;
retrievability screw-retained implant prostheses; and re-
trievability cement-retained implant prostheses.
Although meta-analyses, systematic reviews, and
randomized clinical trials (RCTs) were preferred, ar-
ticles with a lower level of scientific evidence, such
as in vitro or finite element analysis studies, were in-
cluded if these were not available for certain factors.
The criteria used to classify the factors were as
follows:
•• Determining factors: Factors present in a clinical
situation in which one of the retention mechanisms
was clearly more suitable than the other.
•• Conditioning factors: Factors that influenced the
end result but did not make the choice of one type of
retention clearly more advantageous than the other.
Results
Eight factors were identified in the studies analyzed:
esthetic outcome, retention, biologic risk, passive fit,
fracture strength, occlusal area, complications, and
retrievability.
Esthetic Outcome
The absence of a screw access hole affords cemen-
tation a clear esthetic advantage over screw reten-
tion. The situation may vary depending on whether the
restoration is located anterior or posterior and on the
implant angle (ie, favorable [palatal], corrigible, or in-
corrigible). Both can determine the importance of this
factor in decision-making.
Retention
Decementation is one of the most common compli-
cations in permanent cemented implant-supported
prostheses.16–20 As in tooth-supported prostheses,

Fig 2   Subgingival margins that hinder the removal of subgingival residue.
abutment wall height is one of the most instrumental
factors in retention: the lower the height, the less ef-
fective the resistance to dislodgment.21–23 Retention
therefore depends on the occlusal space between the
implant platform and the occlusal face of the oppos-
ing tooth (Fig 1).
Biologic Risk
Cemented prostheses have been regarded to pose
higher biologic risk than screw-retained prostheses.
After the appearance of several studies reporting no
difference in the microflora present in restorations
with the two retention mechanisms,24 the conclusion
drawn appears to be that the risk lies not in the type
of microflora, but in the existence of excess subgin-
gival cement. Such excess matter may penetrate the
gingiva more deeply in implants than in teeth due to
the arrangement of the fibers in the peri-implant mu-
cosa25–27 and because the cement flows to the area
where resistance is lowest.28 In light of these findings,
several authors contend that clinicians may leave
more subgingival cement than they realize,29–32 a risk
that rises with the number of implants involved in the
restoration (Fig 2). Clinical factors affecting the like-
lihood of nonremoval of all subgingival residue may
affect the final result of cemented restorations, which
is obviously not an issue with screw-retained restora-
tions (Table 1).
Passive Fit
Passive fit is desirable to minimize the stress be-
tween implants and prosthetic components.33 The
absence of passivity may entail mechanical (ie, screw
loosening, microcracks in the porcelain, or compo-
nent fracture34–37 ) and biologic risks.38 One of the
biologic considerations that must be borne in mind
is that bone can tolerate minor fit discrepancies.39,40
As a result, present knowledge suggests that while
framework misfit increases the stress on peri-implant
bone, bone loss should not be attributed to this de-
velopment. Mechanical complications, such as screw
loosening and porcelain chipping, appear to be more
closely related to factors other than nonpassive fit and
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Gómez-Polo et al
would be unaffected by some reasonable degree of
misalignment.41 Some authors have reported that bet-
ter passive fit can be attained with cementation than
with screw retention.42,43
Fracture Strength
Like the other factors discussed, fracture strength is
largely determined by the design characteristics of
cemented and screw-retained prostheses. The exis-
tence of an access hole in screw-retained prostheses
detracts from strength. Although that property may
affect the other prosthesis components that contrib-
ute to fracture strength (ie, implant, screw, abutment,
framework, and veneer material), the most frequent
flaw, and therefore the one that merits the most atten-
tion, is porcelain fracture or chipping.
Occlusal Area
The drawback to screw retention in the context of oc-
clusal area is that, particularly in posterior teeth, the
access hole translates into an occlusal area loss of
around 3 mm in diameter42 in occlusal tables, esti-
mated to be about 4.5 to 5.5 mm in premolars and 5
to 6 mm in molars.42 Such tables would not be perfo-
rated in cemented prostheses.
Retrievability
This is one of the main arguments used by the ad-
vocates of screw-retained as opposed to cemented
prostheses.5–13 Although several techniques have
been described to make cemented FDPs easier to re-
move, retrieval is always simpler with screw-retained
prostheses. This is an advantage if a technical or
biologic complication arises that requires prosthesis
removal. Moreover, the advantages of this approach
grow with the number of implants, for when prob-
lems arise with a cemented prosthesis, its retrieval
(ie, perforation of the crown at the exact spot without
damaging the abutment screw and unscrewing) is
more complex with each additional implant, as is the
likelihood of damaging or even having to replace the
restoration.
Volume 31, Number 1, 2018 45
Factors in Using Cemented or Screw-Retained Fixed Implant-Supported Prostheses

Table 1   Factors Affecting the Choice of Screw Retention or Cementation in Fixed Implant Prostheses
Determining
factors Screw retention Cementation Application
Esthetics Palatal Corrigible Vestibular Anterior Always Incorrigible angle =
emergence emergence emergence cementation
(up to 25 to
30 degrees)
Up to 88% acceptance Posterior Up to 100% acceptance Secondary concern
Retention 4 mm minimum space Occlusal N/A if < 6 mm Occlusal space <
space 6 mm = screw retention
Biologic risk Low Gingival Try to avoid if margin not visible Margin not visible =
margin screw retention
Low Excess Single Partial FDP: Full arch Cement removal crucial
cement crown Risk rises with
no. of implants
Conditioning Single
factors Single crowns Partial FDPs Full arches crowns Partial FDPs Full arches
Passive fit Easy to Medium High Better Easy to Easy to achieve Medium –Better in cementation
achieve difficulty difficulty with more achieve to high –More important in
implants difficulty long frameworks
–Guidance to be based
Consider better fits afforded by ‘new’ technologies on complications
Fracture Lower strength (but higher than max Chipping Higher strength –Higher strength in
strength mastication load) cemented prostheses
No differences, low frequency Other types No differences, low frequency –Guidance based on
of fracture complications

Occlusal area Screw emergence Mastication No screw emergence –No studies show
effectiveness differences in mastication
effectiveness
Complications Medium Low to medium Mechanical Low Low to medium –Higher frequency in
frequency frequency frequency frequency screw retention (especially
in screw loosening and
chipping in SC)
Associated Fewer complications Biologic Associated Medium to high Higher –Higher in cemented FDPs
with screw with excess frequency frequency and full arches
loosening cement
(fistula, (bone loss)
inflammation)
Retrievability Easy retrievability Span length Difficult, Difficult, Difficult, –Importance dependent on
destructive, destructive, destructive, frequency of complications
costly costly costly –Easier with screw retention
(the more implants, the
more differences)
Green shading = clinical situations in which the option is recommended (ie, complications are less likely or can be readily addressed).
Light orange shading = clinical situations in which the option may entail a medium risk of complications or treatment measures of medium difficulty.
Pink shading = clinical situations in which the option is the least recommended because it may entail a greater likelihood of complications or risk of
complications difficult to treat. Gray shading = clinical situations in which the factor seems to have a minor effect on the outcome or where scant support
for such effect is found in the literature. FDP = fixed dental prosthesis; N/A = not applicable.

Complications is significantly higher in cemented than in screw-

Two types of complications may be defined: biologic
and mechanical.
Biologic Complications. Of all the biologic com-
plications that may arise in implant-supported pros-
theses, the two for which the greatest differences
between screw and cement retention are identified
are the presence of fistulas or suppuration and peri-
implant bone loss. Some reviews that draw no dis-
tinction between SC, FPD, and full-arch restorations
report that the incidence of fistulas or suppuration
retained prostheses (1.65 vs 0.22, respectively, out of
100 implants a year).44
Most reviews confirm that the scientific evidence
available on peri-implant bone loss is insufficient and
in need of further research,45 even though it is one
of the most thoroughly studied biologic complica-
tions. While some reviews (which do not differenti-
ate between SCs, FPDs, and full-arch restorations)
conclude that bone loss is greater in screw-retained
prostheses, they stress the scant clinical significance
of the differences identified.46 The papers that do

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Fig 3  Computer-aided design with angulated screw access hole
and special screw, designed to be screwed at a non-axial angle.
distinguish prosthesis types report a higher percent-
age of implants with peri-implant bone loss of over
2 mm in cemented than in screw-retained FPDs and
full-arch restorations.14
In other words, while minor differences are ob-
served between cementation and screw retention in
SCs, a higher incidence of > 2 mm bone loss after
5 years is found in cemented than in screw-retained
FPDs (6.5% vs 2.5%) and full-arch restorations (34.7%
vs 11.4%). No differences in implant survival rates
were found between screw-retained and cemented
SCs and FPDs, in contrast to rates for full-arch res-
torations, for which the 5-year estimated implant sur-
vival is 98.4% with screw-retained and 94.2% with
cemented prostheses.14
Mechanical Complications. Reviews compar-
ing the two retention mechanisms that do not take
prosthesis type into consideration find a higher rate of
mechanical complications in screw-retained than in
cemented restorations.46 No differences are reported
between the two approaches in terms of abutment,
framework, screw, or implant fracture, although por-
celain fracture appears to be more frequent in screw-
retained than in cemented prostheses (3.56 vs 1.02,
respectively, out of 100 implants a year). Literature
reviews likewise identify differences in other compli-
cations, such as loss of retention (5.44 vs 0.61 out of
100 implants a year for cementation vs screw reten-
tion, respectively) and abutment loosening (2.31 vs
0.62, respectively).44 When prostheses are classified
by type, the differences in chipping rate are greater in
longer-span restorations, with statistically significant
differences found for full-arch restorations (67.4%
screw retained vs 23.9% cemented). Porcelain chip-
ping is also greater in screw-retained than in cement-
ed SCs (9.6% vs 2.9%) and FPDs (24.9% vs 12.3%),
although in this case evidence for statistical signifi-
cance is lacking.14
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Gómez-Polo et al
Another mechanical complication for which differ-
ences in the two approaches are reported is screw
loosening, which has a higher rate of occurrence in
screw retention than in cementation. The difference
found for SCs in this regard is significant (21.2% vs
3.9%, respectively).14
Discussion
Determining and conditioning factors are shown in
Table 1.
Determining Factors
Esthetic Outcome. The importance of this factor de-
pends on the location of the restoration and the im-
plant angle.
Anterior. In this case, the implant angle determines
three possible scenarios:
1. Favorable emergence (palatal location): The
objections to screw-retained prostheses based
on esthetic conditions appear to be unfounded,5
for clinician and patient acceptance levels are
comparable for the two approaches,47 as are the
scores for various esthetic parameters, including
the white esthetic score (WES),48,49 pink esthetic
score (PES),50,51 and Implant Crown Aesthetic
Index (ICAI).52
2. Corrigible angle: There are a number of
alternatives in place to angle the access hole
relative to the implant to position it on the
palatal face, including angulated and dynamic
abutments,53 the use of computer-aided design/
computer-aided manufacture (CAD/CAM)
techniques to angle the screw channel in
conjunction with screws designed to be set at
nonaxial angles (Fig 3),54,55 and transverse screw
Volume 31, Number 1, 2018 47
Factors in Using Cemented or Screw-Retained Fixed Implant-Supported Prostheses
abutments. In cases of a corrigible angle of up to
28 degrees, esthetic considerations are secondary
because emergence is on an esthetically
insensitive side of the tooth.
3. Incorrigible angle: Screw retention with an
incorrigible angle would entail the presence of
a screw access opening on the labial side of the
anterior teeth, which is esthetically unacceptable
today. Such clinical situations determine the use
of cementation. Screw retention would only be
possible with a palatal-lingual (cross-pin) setting.
Posterior. Although the access hole in screw-
retained prostheses detracts from restoration es-
thetics, this factor is of less importance for posterior
restorations and plays a secondary role, particularly in
the maxillary teeth. In patients with high esthetic de-
mands, however, it may pose a problem. Techniques
are available to plug the access hole with material that
matches the rest of the restoration, along with polytet-
rafluorethylene to insulate and protect the screw
should the need arise to access it.56 In prostheses
with metal frameworks where the dark color is more
difficult to conceal, adding an opaque resin-based re-
storative57 or a plug of injectable ceramic or a layer
of opaque ceramic material58 on the inner side of the
access channel appears to improve implant esthetics
drastically,59 with acceptance rates of nearly 90%.60
However, none of these approaches yield results as
acceptable as those attained with cementation. This
is less of a problem in ceramic abutments, given the
lighter color of the walls of the screw access hole. In
posterior positions, esthetic outcome would be a con-
ditioning rather than a determining factor.
Retention. This factor is directly related to the oc-
clusal space in cemented restorations. Given that the
framework and its esthetic layering are together no
less than 2 mm thick, several authors contend that
an occlusal space of at least 6 mm is needed for ce-
mented restorations8,61,62 to ensure that there is room
for the 4-mm abutments required for satisfactory re-
tention. Screw retention is the better option when the
occlusal space is smaller, as the abutment would not
be high enough with a cemented prosthesis to ensure
proper retention, giving rise to recurrent prosthesis
decementation (Table 1).
Biologic Risk. Several studies show that excess
cement is a risk factor that may be associated with an
increase in bacteria and subsequent inflammation in
peri-implant tissue.63,64 Some papers report that most
restorations (approximately 81%) with excess cement
develop signs of peri-implant disease, which may not
appear until 10 years after prosthesis placement.65
This flow of cement into the peri-implant sulcus66–69
can be reduced by extraoral cementation techniques,
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such as pre-cementing on a replica or analog of the
abutment outside the patient’s mouth and removing
any excess to subsequently cement the permanent
abutment in the patient’s mouth. However, the dif-
ficulty in applying such a technique grows with the
number of implants supporting the prosthesis.
An additional risk posed by cementation is that the
prosthesis may be scratched during cement removal,
particularly when resin cements are involved. Metallic
instruments or stainless steel explorers make deeper
scratches, although plastic scalers do not obviate the
problem altogether.29 The outcome is greater accumu-
lation of subgingival plaque70 that is difficult to remove
and may compromise peri-implant soft tissue health.71
One of the factors with the heaviest impact on the
failure to eliminate all excess cement is the location
of the cementation margin,30,72 which should be su-
pra- or equigingival and noncircular; ie, mimicking
the shape of the gingival margin.73,74 If subgingival, it
should not penetrate the gingiva by more than 1 mm.
The general consensus seems to be that the deeper
the margin, the greater the amount of subgingival ce-
ment that may be left behind.30,72 That being the case,
the clinician can only be reasonably sure that all the
excess cement is fully removed in clinical situations in
which the margins are supra- or equigingival.
Other factors may affect biologic risk; eg, the depth
of the undercut in the tooth to be replaced,75 as depth
hinders the elimination of cement residue. General peri-
odontal condition is another factor, given that remnants
of cement are more likely to induce peri-implantitis in
patients with a history of periodontitis than in those with
no such history.76 Consequently, when margins can-
not be equi- or supragingivally positioned, prostheses
should be screw retained, particularly when the under-
cut is deep75 and periodontitis is an issue.76
Considerations of Prosthesis Type. The presence of
subgingival cement residue has been shown to con-
stitute a biologic risk and to favor the development
of peri-implantitis, but deploying the utmost care69 in
positioning the margin equi- or supragingivally and
applying techniques to reduce cement remnant extru-
sion may lower that risk. Such measures are especially
effective in SCs, as the clinician needs to remove ce-
ment residue from only one abutment-crown junction.
Even then, however, remnants of cement extruded into
subgingival areas deeper than 4 mm are very difficult
to remove, a problem that can logically be avoided by
retaining the prosthesis using screws.
Biologic risk is higher with FPDs and full-arch res-
torations than with SCs, and the rule on locating ce-
mentation margins supra- or equigingivally is more
critical in these restorations, as the probability of leav-
ing residual subgingival cement is higher. Moreover,
the likelihood of excess subgingival cement is greater

with a higher number of implants, as there are more
sites from which it must be removed. Screw retention
is therefore more suitable in partial long-span and
full-arch FDPs.77
Conditioning Factors
When none of these determinant clinical situations
are present, the choice is less clear, and conditioning
factors (passive fit, fracture strength, occlusal area,
complications, and retrievability) must be assessed.
As most studies contend, decision-making in such
cases may owe more to personal preference than to
scientific evidence.5–13,46 That notwithstanding, when
all these factors and the many complications reported
in the literature are taken into consideration, one sys-
tem may be found to be more advantageous than the
other in certain common clinical situations.
The weight to be attributed to each of the many
conditioning factors is difficult to determine and near-
ly impossible to quantify numerically. Nonetheless, the
biologic and mechanical complications of the various
types of prostheses described in scientific papers may
provide insight into the impact of these factors on the
method ultimately deployed.
Passive Fit. Passive fit is regarded as desirable in
implant-supported prostheses. The implications for
misalignment of the final restoration differ depend-
ing on whether it is cemented or screw retained: in
a cemented framework, the misalignment remains
unaltered or may even widen in the final restoration
after cementing, and in screw-retained prostheses,
the misfit narrows, resulting in less passivity.78 Hence,
passivity of fit is greater in cemented than in screw-
retained frameworks,79,80 and the difference between
the two presumably grows with the number of teeth
to be replaced and the implants involved (full arch >
long span; FPD > short span; FPD > SC). Given recent
progress in impression techniques and framework
manufacture, the accuracy of fit is improving, conse-
quently lowering the difference in passivity between
the two approaches to retention. Some authors con-
tend that fit is not always more passive in cemented
frameworks81 and the fit attained depends more on
prosthesis manufacturing procedures than on the
retention mechanism.82 Moreover, misalignment con-
tained within reasonable bounds appears to be toler-
ated well biologically and mechanically. The inference
would be that, providing the framework is satisfacto-
rily prepared, passive fit should not be a major factor
in opting for one retention procedure over the other.
Considerations of Prosthesis Type. Structural pas-
sivity problems are less severe with SC prostheses;
however, differences may appear in the microscopic
fit between the abutment and the implant. Here, the
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Gómez-Polo et al
type of implant connection83 and the procedure used
to manufacture the framework84 are key consider-
ations. One of the factors that may contribute to com-
plications, such as screw loosening85 (which is more
common in screw-retained restorations), is the higher
frequency of crowns screwed directly to the implant
than in cemented prostheses, in which abutments oth-
er than the milled prefabricated units supplied by com-
mercial implant manufacturers are seldom used. As
some studies84 suggest that manufacturing restora-
tions with machined connections narrows the implant-
abutment gap, it may also reduce the difference in the
frequency of complications between screw-retained
and cemented restorations. Partial long-span FDPs
and full-arch restorations are most liable to misalign-
ments and hence to differences in passive fit between
cemented and screw-retained restorations, with dif-
ferent implications for biologic (ie, bone loss) and me-
chanical (ie, chipping, screw loosening) risks.
In light of ongoing technological advances in
framework manufacture, which will reduce the dif-
ference in passivity between screwing and milling,
passive fit may logically acquire greater importance
in restorations with three or more implants. The dif-
ference in the passive fit between the two retention
procedures should in any event be judged in terms
of the complications reported in the studies reviewed
here. As noted earlier, however, these complications
can be attributed to many factors, which would have
to be balanced against others more favorable to screw
retention based on the frequency of complications.
Fracture Strength. Several in vitro studies and fi-
nite element analyses of SCs87 and FPDs88 show that
fracture strength is lower in screw-retained than in
cemented prostheses, and the literature contains no
information on strength in full-arch restorations. Some
reviews based on clinical findings show no differ-
ences in abutment, framework, implant, or retention
screw fracture strength between the two retention
systems,44 but differences are observed in porcelain
chipping, which is more frequent in screw-retained
restorations.14 This may be attributed to the interrup-
tion in material integrity induced by the access hole,
leaving the porcelain with no structural support and
compromising its strength. In vitro studies, at least
for SCs, appear to conclusively prove that porcelain
fracture strength values are higher in cemented pros-
theses.89,90 Nonetheless, the strength values for both
cemented and screw-retained prostheses are higher
than the loads generated in the oral cavity during
mastication.
Occlusal Area. Some authors42 have regarded
this as a very important factor due to the amount of
occlusal area accounted for by the access hole in
screw-retained prostheses. However, while access
Volume 31, Number 1, 2018 49
Factors in Using Cemented or Screw-Retained Fixed Implant-Supported Prostheses
channels are 3 mm in diameter, the effect on occlu-
sion is minimized15 by subsequently plugging the hole
with insulation and a restorative material, which may
form part of the occlusal surface and occlude with the
antagonist tooth.72 For that reason, and in light of the
absence of studies comparing mastication effective-
ness between cemented and screw-retained prosthe-
ses, the scientific evidence available supports neither
over the other.
Retrievability. The literature describes a host of
techniques to compensate for this drawback in ce-
mentation, ranging from the use of temporary ce-
ments20 to registering the approximate point on the
layering ceramic where the prosthesis would have to
be perforated in the event of retrieval. Such mark-
ings may consist of a lighter color porcelain stain on
the occlusal face,91,92 a perforated vacuum-formed
template showing the position of the access holes or
screws to be set over the prosthesis if necessary,93
digitally processed semi-transparent occlusal photo-
graphs of the casts (one of the abutment only and the
other with the crown in place) to be overlaid to lo-
cate the screw position,94–96 or the use of CAD/CAM
technologies to pre-scan the models.97 As all these
techniques call for perforating the cemented prosthe-
sis to access the screw, they convert cemented into
cemented-screwed prostheses,98,99 forfeiting some of
the advantages of the former. Moreover, the methods
are difficult, destructive, and costly,73 and may dete-
riorate the prosthesis or even require its replacement
if the hole appears in an esthetically sensitive area or
if a significant portion of the restoration is destroyed
in the process.
Another factor to be borne in mind in this respect
is the high incidence of complications in implant-sup-
ported prostheses14: only 66% of implant-supported
FDPs are complication free.100 This is a clear indica-
tion of the importance of prosthesis retrievability,
which grows with the number of implants,8,73 given
the difficulty involved in their removal.
Considerations of Prosthesis Type. In cemented SCs,
retrieval may not be particularly complex if the abut-
ment screw hole is accessibly located; ie, if it is palatal
in anterior and occlusal in posterior restorations. The
differences between the two types of restorations are
most narrow in this type of prosthesis, particularly if
any of the several techniques for locating the screw
are deployed.91–97
The implications of this factor are indisputably
greater in long-span FPDs and full-arch restorations
than in crowns or short-span prostheses. Prosthesis
removal becomes more difficult, destructive, and
costly as more implants are involved, given the higher
likelihood of not finding some of the screws or of ves-
tibular emergence.
50 The International Journal of Prosthodontics
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Complications. Biologic complications are more
frequent with cemented prostheses, presumably
due to the presence of excess subgingival cement.
The impact of excess cement seems to increase
with prosthesis type (full arch > partial FDP > SC),
probably due to the number of supporting implants.
In light of the foregoing, this factor appears to bear
greater weight than others, such as the passive fit of
the framework. While insufficient passivity could the-
oretically induce stress and subsequent peri-implant
bone loss, these effects pale against the greater bio-
logic complications found in cemented than in screw-
retained restorations.
As a rule, then, the mechanical complications more
common in screw-retained than in cemented resto-
rations include screw loosening in SCs and porcelain
chipping in all types of reconstructions. Retention loss
and abutment loosening are the mechanical compli-
cations found more often in cemented prostheses.
Considerations of Prosthesis Type. Although screw
loosening induces a higher rate of complications in
screw-retained than in cemented SCs, the latter are
assumed to pose higher biologic risk.101 As no sig-
nificant differences have been observed between the
two in terms of bone loss of over 2 mm, however, bio-
logic risk appears to be low if the cementation margin
is equigingival or no deeper than 1 mm subgingival
or if techniques to reduce the excess cement, such
as extraoral simulation with an analog, are deployed.
Given that in crowns the cement needs to be removed
around a single implant, the clinician has sufficient
time during setting for that operation, although the
risk of bone loss might be expected to be higher in
wider teeth with a larger undercut, such as molars.76
Chipping and screw loosening would also be ex-
pected to be less frequent in cemented crowns. As
SCs exhibit the lowest rate of porcelain chipping,
and restorations inserted with both procedures can
bear higher loads than generated during mastication,
this factor may be regarded as less significant than
in longer prostheses, particularly in anterior regions.
Screw loosening, in turn, is clearly the most frequent
complication, especially in posterior crowns.102 Many
factors affect the likelihood of loosening, including
torque-controlled drivers that afford more predict-
able pre-load and clamping forces, the type of implant
connection, and the manner in which the abutment is
manufactured. This complication is found much more
often in screw-retained crowns.
If no determining factors are present when pre-
paring an SC restoration, the clinician must decide
between using screws and assuming the greater like-
lihood of mechanical complications (ie, screw loosen-
ing), which are readily corrected given screw-retained
crown retrievability, or cementing and assuming some

biologic risk of bone loss (which can be reduced if the
implant is not deeply subgingival, the location of the
cementation margin is correctly designed, and intra-
oral placement follows preliminary extraoral cement
elimination) and poorer retrievability (although this is
less critical than for FPDs and full-arch restorations)
in the less likely event of complications.
FPDs exhibit a significantly higher percentage of
implants with peri-implant bone loss of over 2 mm
than the other two types of restorations. This may be
attributed to the need to remove cement from more
places, along with the presence of pontics, which
hinder access to the cement. Screw loosening is the
mechanical complication most frequently found in
this type of restoration, with a higher percentage in
screw-retained than in cemented FPDs, although the
difference between them is narrower than in SCs.
The ratio of screwed to cemented FPDs is higher
than in crowns, ranging from 70:30 to 84:16. The in-
ference would appear to be that given the minimal
differences in technical complications, the concerns
revolve primarily around the biologic complications
stemming from the difficulty involved in eliminat-
ing cement. That difficulty grows with the number of
implants, as does prosthesis retrievability (of greater
consequence in prostheses with a higher number of
implants), which may explain why the data appear to
show a greater preference for screw retention in lon-
ger-span prostheses.14,44,77
The differences in biologic complications are also
more readily visible in full-arch restorations than in
shorter prostheses, with higher survival rates in screw-
retained restorations (98.4% vs 94.2%). The percentage
of cemented restorations with bone loss of over 2 mm
is higher than that recorded for screw-retained resto-
rations (34.7% vs 11.4%, respectively).14 Therefore, the
likelihood of peri-implant bone resorption due to less
passive fit in screw-retained restorations is clearly of
less concern than the higher biologic risks induced by
excess cement in cemented restorations.
The rate of mechanical complications is fairly
similar in the two types of reconstructions (54.1% vs
62.9% for screw retained and cemented, respective-
ly). For porcelain chipping, the most frequent of these
complications, some studies show that the incidence
is higher in screw-retained restorations,103 while oth-
ers report no such difference. However, most reviews
report studies with very small samples of cemented
full-arch restorations, which is a consideration that
should not be overlooked. Even assuming that me-
chanical complications are slightly higher in screw-
retained restorations, the retrievability inherent in this
approach would afford quicker and simpler solutions
than would be possible in cemented restorations sup-
ported by a large number of implants.
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NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Gómez-Polo et al
The lower biologic risk, the similarity in terms of me-
chanical complications, and the enormous difference
in retrievability appear to render screw retention a
more suitable option than cementation in full-arch res-
torations.14,44,77 Based on the information on full-arch
restorations contained in recent reviews, the percent-
age of cemented reconstructions is significantly low-
er14 than the percentage of screw-retained prostheses
(with the latter accounting for 92% to 99%),44 denoting
a greater preference among clinicians for the latter.
In light of the variability in the findings published
to date, the introduction of new prosthetic develop-
ments in framework manufacture and layering materi-
als, and the rising awareness of the consequences of
excess subgingival cement and the widespread use of
techniques to avoid it, more unequivocal conclusions
can only be drawn if further well-designed RCTs are
conducted.
Conclusions
The conclusions that may be drawn from the fore­
going discussion are as follows:
•• Neither alternative is clearly better than the other
for all clinical situations.
•• Determining factors in certain clinical situations
render one of the two more recommendable. For
esthetic reasons, cementation is more suitable
when the implant angle cannot be corrected
to conceal the screw access channel. Screw
retention is the better option when the occlusal
space is smaller than 6 mm or margins cannot be
positioned in a supra- or equigingival (ie, visible)
location.
•• In the absence of determining factors, the decision
of which option is more appropriate in a given
situation should be based on conditioning factors,
which carry different weights depending on
prosthesis type.
•• In SCs, determining factors are not always present.
In such cases, neither alternative is clearly the
better choice. Mechanical complications (ie,
screw loosening and chipping) are more frequent
but also more readily solved in screw-retained
restorations, and less frequent but more difficult to
remedy in cemented restorations.
•• In the absence of determining factors, general
guidelines for FPDs are difficult to establish, al-
though there is a tendency to use screw retention
in longer FPDs with more implants given that no
differences are identified in mechanical compli-
cations, retrievability is higher in screw-retained
prostheses, and biologic complications are more
apt to appear in cemented FPDs.
Volume 31, Number 1, 2018 51
Factors in Using Cemented or Screw-Retained Fixed Implant-Supported Prostheses
•• A clear tendency to use screw retention in
full-arch restorations is detected, for although
mechanical complications, particularly chipping
(which can be readily remedied due to the
retrievability of screw-retained prostheses), may
be slightly more common, this approach entails
a lower risk of biologic complications (which are
more difficult to solve and can lead to implant
failure) stemming from the nonremoval of all traces
of excess cement.
Acknowledgments
The authors declare that there are no conflicts of interest in the
present study.
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