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SYSTEMATIC REVIEW
Incidence of peri-implant disease associated with cement- and
screw-retained implant-supported prostheses: A systematic
review and meta-analysis
Isabella Neme Ribeiro dos Reis, DDS, PhD,
a
Gisele Lie Fukuoka, DDS,
b
Bruna Egumi Nagay, MS, DDS,
c
Claudio Mendes Pannuti, DDS, MS, PhD,
d
Rubens Spin-Neto, DDS, PhD,
e
and
Emily Vivianne Freitas da Silva, DDS, PhD
f
Implant-supported fixed dental
prostheses are a highly effective
option for oral rehabilitation,
with excellent survival and suc-
cess rates.
1–7
They can be ce-
mented on abutments or
screwed onto the implant or
onto an abutment, and both
types can be used in prostheses
supported by single or multiple
implants.
8,9
However, the choice
between cement- or screw-re-
tention is a crucial step in pros-
thesis design, as it can impact
the occurrence of technical and
biological complications in the
short and long term.
10
Screw-retained restorations
provide advantages that include
predictable retrievability, no
need for cementation, and ease
of removal when needed, in-
cluding during maintenance
Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
No conflict of interest.
a
Postgraduate student, Department of Stomatology, Division of Periodontics, School of Dentistry, University of São Paulo (USP), São Paulo, Brazil.
b
Postgraduate student, Department of Prosthodontics, School of Dentistry, University of São Paulo (USP), São Paulo, Brazil.
c
Postgraduate student, Department of Prosthodontics and Periodontology, Piracicaba Dental School, University of Campinas (UNICAMP), Piracicaba, Brazil.
d
Associate Professor, Department of Stomatology, Division of Periodontics, School of Dentistry, University of São Paulo (USP), São Paulo, Brazil.
e
Associate Professor, Department of Dentistry and Oral Health, Section for Oral Radiology, School of Dentistry, Aarhus University, Aarhus, Denmark.
f
Professor, Department of Prosthodontics, School of Dentistry, University of São Paulo (USP), São Paulo, Brazil.
ABSTRACT
Statement of problem. Implant-supported fixed dental prostheses can be cement- or
screw-retained on the implant or abutment, with advantages and disadvantages for each method.
Cemented prostheses have been associated with peri-implant disease because cement remnants
act as a reservoir for bacteria and hinder biofilm control. However, contrasting evidence has been
presented regarding this association based on studies with varying designs, and a systematic
review and meta-analysis is required.
Purpose. The purpose of this systematic review and meta-analysis was to answer the focused
question: In patients who received implant-supported prostheses, is the incidence of peri-implant
diseases higher in cemented implant-supported prostheses than in screw-retained ones?
Material and methods. The search was conducted using the National Library of Medicine
(MEDLINE-PubMed), SCOPUS, EMBASE, and ISI Web of Science databases. Randomized clinical trials
(RCTs) that assessed the incidence of peri-implant disease in cement- and screw-retained prostheses
were included. Two authors independently screened the titles and abstracts, and analyzed the full texts,
extracted data, and assessed the risk of bias. The findings were summarized using meta-analyses with
random effects, and the level of certainty of the evidence was determined using the grading of
recommendations, assessments, development, and evaluations (GRADE) approach.
Results. The search yielded 4455 articles that met the inclusion criteria based on the title and/or
abstract selection. A total of 6 RCTs were included for analysis. The meta-analysis revealed no significant
difference between cement- and screw-retained prostheses for the risk of peri-implant mucositis (RR:
1.36, 95% CI: 0.42–4.38, P=.61). Similarly, no significant difference was observed between cement- and
screw-retained prostheses for the incidence of peri-implantitis (RR: 1.00, 95% CI: 0.23–4.31, P=1.00).
Conclusions. Moderate certainty evidence suggests that cement- and screw-retained prostheses
present a similar risk for peri-implant mucositis and peri-implantitis. (J Prosthet Dent xxxx;xxx:xxx-xxx)
THE JOURNAL OF PROSTHETIC DENTISTRY 1
appointments or to facilitate treatment of the implants and/
or peri-implant tissues.
10
However screw retention requires
at least 4 mm of interocclusal space, may increase costs, and
can affect esthetics at the screw access channel.
10,11
In
comparison, cement-retained restorations can compensate
for improperly positioned implants and help achieve a
passive fit through the space for the cement layer.
10,12,13
However, removing cemented prostheses can be challen-
ging or even impossible without damaging the prosthesis.
8
Excess cement can also pose a problem, as it has been
linked to biological complications such as peri-implant
diseases.
14,15
Cement remnants could create bacterial re-
servoirs, impede biofilm control, and contribute to peri-
implant disease development.
14–19
Peri-implant mucositis has been characterized by
bleeding upon gentle probing,
20–22
while peri-im-
plantitis involves inflammation, bleeding, suppuration
on probing, and progressive loss of supporting
bone.
22–28
Because of their high prevalence
29
and chal-
lenging treatment, especially for patients with peri-im-
plantitis, identifying the factors that lead to a higher risk
of peri-implant disease is essential for prevention and
proper management.
30–37
Different individual and en-
vironmental factors have been studied, including the
role of excess cement in disease development.
Biological complications have been reported for both
cement- and screw-retained prostheses. A systematic re-
view
8
showed higher rates of soft tissue complications with
screw-retained prostheses, while cemented prostheses had
more frequent bone loss over 2 mm and implant failures in
complete arch prostheses. Another systematic review
38
in-
dicated a tendency for greater bone loss in cement-retained
prostheses, but the difference was not statistically sig-
nificant. Yet another review
39
reported no significant dif-
ferences in implant failures and bone loss over 2 mm
between the groups but observed a higher incidence of
fistulae and suppuration in cement-retained prostheses.
Two systematic reviews
8,39
allowed only indirect compar-
isons of the prosthesis retaining method, while another
review
38
analyzed only 2 studies that analyzed both ce-
ment- and screw-retained prostheses. More recent reviews
analyzed peri-implant mucosa inflammation in both
screw-
40
and cement-retained
41
prostheses, but the limited
number of prostheses hindered meaningful comparisons.
Moreover, these previous reviews included studies with
different designs and were not limited to randomized clin-
ical trials (RCTs).
Robust data are still needed to support the differ-
ences in the incidence of peri-implant diseases between
cement- and screw-retained prostheses. Therefore, this
systematic review aimed to compare cement- and
screw-retained prostheses as regards the incidence of
peri-implant mucositis and peri-implantitis by using
RCTs that compared both retention types. The null hy-
pothesis was that no association would be found be-
tween prosthesis retention type and the incidence of
peri-implant disease.
MATERIAL AND METHODS
This systematic review was registered at the
International Prospective Register of Systematic Reviews
(PROSPERO) database (CRD42022379444) and was
conducted in accordance with the Preferred Reporting
Items for Systematic Reviews and Meta-Analyses
(PRISMA) 2020 guidelines.
42
The focused question was:
Is the incidence of peri-implant diseases higher in ce-
mented implant-supported prostheses than in screw-
retained prostheses? The population, intervention,
comparison, outcome, and study type (PICOS) elements
were patients who received implant-supported pros-
theses (P), cemented prostheses (I), screw-retained
prostheses (C), incidence of peri-implant mucositis and
peri-implantitis (O), and RCTs (S).
The inclusion criteria were RCTs, original articles
published in any language, and participants aged 18
years or older. Studies that did not categorize peri-im-
plant diseases, lacked an analysis of peri-implant disease
incidence, failed to provide data on the number of ce-
ment- and screw-retained prostheses, published articles
related to the same study but with shorter follow-up,
and failed to compare both types of retention were
excluded.
The MEDLINE/PubMed, Embase, Scopus, and Web
of Science databases were searched up to January 2023.
The literature search was adapted for each database
(Supplemental Table 1, available online). Additionally,
the nonpeer-reviewed literature was searched via
OpenGrey (http://www.opengrey.eu) and Grey Litera-
ture Report (http://www.greylit.org), and the reference
lists of the included studies were searched to identify
further potentially relevant studies.
Two reviewers (G.L.F., B.E.N.) conducted the study
selection independently after removing duplicates.
Initial screening involved titles and abstracts, resulting in
a Cohen kappa agreement of 0.86. Subsequently, full
texts of selected studies were retrieved and assessed by
Clinical Implications
Cement- and screw-retained implant-supported
prostheses presented similar risks for the incidence
of peri-implant diseases. These results have clinical
implications for clinicians and patients when
choosing between cement- and screw-retained
prostheses. The decision should be based on
factors that include clinician preference, technical
considerations, retrievability, and esthetics.
2 Volume xxx Issue xx
THE JOURNAL OF PROSTHETIC DENTISTRY Reis et al
the same reviewers, with a kappa agreement of 0.90.
Disagreements were resolved through discussion and
consensus. If consensus could not be reached, a third
reviewer (I.N.R.R.) was consulted for arbitration. The
same reviewers independently extracted the data from
the included studies. Where data were missing, the
authors were contacted to provide the information.
Two independent reviewers (G.L.F., B.E.N.) assessed the
quality of the included studies using the Cochrane Risk of
Bias Tool for RCTs (RoB 2). A software program (Review
Manager v. 5.4, The Cochrane Collaboration) was used for
data analysis, specifically examining the incidence of peri-
implant mucositis and peri-implantitis in cement- and
screw-retained crowns. Prostheses were categorized as ce-
mented or screw retained. Random-effects meta-analyses
were conducted to calculate pooled risk ratios (RR) with
95% confidence intervals (CIs) for dichotomous outcomes.
Subgroups were analyzed in studies using different cement
types to assess significant differences in pooled effect esti-
mates. Statistical heterogeneity was evaluated by using the
Cochrane Q test and I². Sensitivity analysis involved ex-
cluding 1 study at a time to assess its impact on the overall
evidence.
The certainty of the evidence was determined for each
outcome by using the Grading of Recommendations
Assessment, Development and Evaluation (GRADE) ap-
proach and the GRADEpro Guideline Development Tool
(McMaster University and Evidence Prime) as very low, low,
moderate, or high.
RESULTS
The study flowchart is shown in Figure 1. A total of 5693
articles were identified. After duplicate removal, 4455
remained title and abstract screening, 22 articles were
assessed in full text and 6 were considered eligible in
view of the inclusion criteria.
The characteristics of the articles are outlined in
Tables 1 to 3. Six RCTs were included and encompassed
255 participants and 279 implants. The publication dates
of the articles ranged from 2002 to 2012. The studies
were carried out in Spain,
24
Italy,
16
Switzerland,
3,17
Denmark,
4
and Germany.
21
Four studies were con-
ducted solely in university settings,
3,4,21,24
and 2 were
performed in both university and private practice.
16,17
The follow-up period ranged from 2
21
to 10 years.
4
In all
studies, the corresponding authors were contacted via
email for clarification of missing data. Two authors
3,4
provided further information and data to enable the
meta-analysis. For prosthesis cementation, 1 used a
methacrylate-based cement,
24
3 used resin ce-
ments,
3,17,21
1 used zinc phosphate cement,
4
and 1 used
glass ionomer cement.
16
Regarding quality assessment, RoB 2 raised concerns
for all RCTs (Fig. 2A).
3,4,16,17,21,24
The outcome (D4)
assessment indicated that only Schropp et al
4
clearly
reported the blinding of assessors. Concerns were also
noted for randomization (D1), assignment to interven-
tion (D2.1), and selection of reported results (D5). While
Total
(n=5693)
Records identied
through PubMed
(n=1790)
Records identied
through Scopus
(n=715)
Records identied
through Embase
(n=1863)
Records identied
through Web of Science
(n=1325)
Duplicates
(n=1238)
Records
screened
(n=4455)
Records excluded based
on the title/abstract
(n=4435)
Kappa=0.86
Kappa=0.90
Hand searched
articles
(n=1)
Full read
records
(n=22)
Studies included
(n=6)
Reasons for the exclusion of 16 papers:
- 4 did not classify peri-implant diseases.
- 5 did not report the incidence of peri-implant disease on cement- and screw-retained prostheses.
- 2 no incidence of peri-implant diseases.
- 2 did not provide information regarding the number of cemented and screw-retained prostheses
included in the analysis.
- 2 were non-RCTs.
- 1 article was excluded because two articles were from the same study (3- and 5-year follow-up);
therefore, we selected only the one with the longer follow-up (5-years) (Krauss et al., 2022).
IdenticationScreeningEligibilityIncluded
Figure 1. Flowchart of selection process of included studies. RCT, randomized controlled trial.
Month xxxx 3
Reis et al THE JOURNAL OF PROSTHETIC DENTISTRY
most studies employed random assignment using an
online software program or a spreadsheet, 3 stu-
dies
4,17,24
did not provide sufficient information on al-
location concealment. Furthermore, 4 studies
3,4,16,17
raised concerns for D2.1 because of unclear information
on co-interventions and their balance between groups
and for D5 because of discrepancies in reporting all
assessed time points. However, domains related to in-
tervention adherence (D2.2) and missing outcome data
(D3) were classified as low risk for all RCTs since no
unexplained group exchanges or data were available for
all or nearly all participants.
Four studies
3,4,16,21
were included in the analysis of the
incidence of peri-implant mucositis. The analysis did not
reveal a significant difference between cement- and screw-
retained prostheses for the risk of peri-implant mucositis
(RR: 1.36, 95% CI: 0.42–4.38, P=.61), with moderate het-
erogeneity I²=61% (Fig. 3A). The analyzed studies used
different cement types, including resin, zinc phosphate, and
glass ionomer cements, and no significant difference was
Table 1.Data of participants of included studies
Author (year) Study Design
Time of Follow-up
(years)
Participants
N
Mean Age
(years) Sex (female/male)
Agustín-Panadero
et al, 2019
RCT 3 75 included and
68 at 3-year follow-up
42.7 49/26 included
Amorfini et al, 2018 RCT 10 40 included and
30 at 10-year follow-up
47.95 Only data of 7- and 9-year follow-
up were reported:
19/13
Kraus et al, 2022 RCT 5 44 included and
41 at 5-year follow-up
52.8 Not reported
Schropp et al, 2013 RCT 10 63 included and
53 at 10-year follow
46 35/28 included
31/22 at 10-year follow-up
Wolfart et al, 2021 RCT 2 41 included and at 1- and
2-year follow-up
47 24/17 included and at 1- and
2-year follow-up
Zembic et al, 2012 RCT 5.6 22 included and
18 at 5.6-year follow-up
41.3 14/8 included
10/8 at 5.6-year follow-up
N, number; RCT, randomized clinical trial.
Table 2.Data of implants and prostheses characteristics of included studies
Author
(year)
Implants Prosthesis
N System
Area
(Posterior,
Anterior
or Both)
N of
Cement-
retained
N of
Screw-
retained
Extension
(Single,
Partial or
Complete-
Arch)
Abutment
Material Prostheses Material Cement Type
Loading
(Delayed or
Immediate)
Agustín-
Panadero
et al, 2019
68 at 3-year
follow-up
Internal
hexagonal,
conical
geometry
(Vega
Klockner)
Posterior 43 25 Single Titanium
grade IV
Metal-ceramic crowns milled
from Co-Cr (Archimedes,
Klockner S.A.) coated with
feldspathic ceramic (IPS
D-Sign, Ivoclar AG)
Provisional
cement (Premier
Implant Cement)
Not reported
Amorfini
et al, 2018
30 at 10-year
follow-up
Regular
neck,
tissue level
(Institut
Straumann
AG)
Anterior 15 15 Single Zirconia S: ceramic veneer fused
directly on the zirconia
abutment; C: porcelain-fused-
to-zirconia crown cemented
on custom zirconia abutment
Glass ionomer
cement (RelyX
Luting TM)
Delayed (3
months)
Kraus
et al, 2022
41 at 5-year
follow-up
Two-piece
(OsseoSpee-
d, Astra Tech
Implant
System
Dentsply
Sirona
Implants)
Both 19 22 Single Zirconia S: abutments directly
veneered (Creation ZI-F,
Creation Willi Geller
International GmbH);
C: veneered lithium disilicate
crowns (e.max, e.max Ceram,
Ivoclar AG)
Resin cement
(Panavia 21)
Delayed
Schropp
et al, 2013
53 at 10-year
follow-up
Parallel-
walled
(Osseotite,
Biomet 3i)
Both 51 2 Single STA or custom
(gold alloy)
Metal-ceramic crown Zinc phosphate
cement (Dentsply)
or Temporary
cement
(TempBond)
Early (10 days):
22
Delayed (3
months): 22
Late (1.5
years): 19
Wolfart
et al, 2021
56 at 1-year
follow-up
Screw-line
(Promote
Plus, Camlog
Biotechnolo-
gies)
Posterior 28 28 Single Standard
titanium
(Camlog
Esthomic
Abutment
straight)
Monolithic lithium-disilicate Multilink implant
(Ivoclar AG)
Delayed (3
months
mandible; 6
months maxilla)
Zembic
et al, 2012
31 at
5.6 year
follow-up
Regular
platform,
external
hexagon
(Brånemark
RP, Nobel
Biocare AB)
Both 29 2 Single Zirconia or
Titanium
C/S: ceramic crowns (alumina,
zirconia);
C: 1 metal-ceramic crown
Resin cement
(Panavia 21 TC)
and
RelyX Unicem) or
Glass ionomer
cement
(Ketac Cem)
Delayed (4–6
months)
C, cement-retained prosthesis; N, number; S, screw-retained prosthesis.
4 Volume xxx Issue xx
THE JOURNAL OF PROSTHETIC DENTISTRY Reis et al
found among these subgroups. The certainty of the evi-
dence was moderate (Table 4).
Four studies
3,4,17,24
were included in the analysis of
the incidence of peri-implantitis. The incidence of peri-
implantitis was not significantly different between ce-
ment- and screw-retained reconstructions (RR: 1.00,
95% CI: 0.23–4.31, P=1.00), with no heterogeneity
I²=0% (Figure 3B). This analysis included studies that
used various cement types, including methacrylate-
based cement, resin cements, and zinc phosphate ce-
ment. However, no significant difference was found
between the subgroups based on different cement types.
The certainty of evidence was moderate (Table 4).
DISCUSSION
To the best of our knowledge, this is the first systematic
review of clinical trials with meta-analysis investigating
the risk of peri-implant diseases considering the type of
prosthesis retention. The null hypothesis of no differ-
ence in the incidence of peri-implant disease between
Table 3.Overview of included studies in relation to peri-implant mucositis and peri-implantitis and outcomes
Author (year)
Definition of Peri-
implant Mucositis
Definition of
Peri-implantitis
N of
Smokers
N of Patients
with History of
Periodontitis
N of Patients with
Bone/ Connective
Tissue Grafting
Implant Survival
(Cement- or
Screw-retained)
Prostheses Success
(Cement- or Screw-
retained)
Agustín-Panadero
et al, 2019
Not reported Not reported Not
reported
Not reported No C: 100%
S: 100%
C: 90.9%
S: 76%
Amorfini et al, 2018 Not reported Not reported Not
reported
Not reported Yes, but number for
bone and connective
tissue grafting not
reported
Total: 94% Total: 85%
Kraus et al, 2022 BOP at > 50% Bone loss
< 2 mm
BOP at > 50% Bone
loss ≥2 mm
Yes, 14
smokers
Yes, 3 patients Not reported C: 90.0%
S: 100%
C: 79.4%
S: 82.6%
Schropp et al, 2013 Bone loss ≤1 mm
PD < 5 mm
BOP and/or suppuration
Bone loss > 1 mm
PD ≥5 mm
BOP and/or
suppuration
Yes, 16
smokers
Yes, but the
number of
patients was
not reported
Yes, but number for
bone grafting not
reported
Total: 95.3% Not reported
Wolfart et al, 2021 BOP
“Inflammatory
cell infiltrate is limited
to the soft tissue”
(Lindhe and Meyle,
2008)
BOP
“Inflammatory
cell infiltrate extends to
the adjacent bone bed”
(Lindhe and Meyle,
2008)
Not
reported
Yes, but
number of
participants not
reported
Yes, but number for
bone grafting not
reported
Success:
C: 82.1%
S: 85.8%
C: 88.1%
S: 75.6%
Zembic et al, 2012 Not reported Not reported Yes, 3
smokers
Yes, 4
participants
Yes, 5 participants
received connective
tissue grafting
Total: 89.45% 90.3%
BOP, bleeding on probing; C, cemented. N, number; S, screw-retained.
Amorni et al, 2018
Agustin-Panadero et
al, 2019
Kraus et al, 2022
Schropp et al, 2013
Wolfart et al, 2021
Zembic et al, 2012
Study D1 D2.1 D2.2 D3 D4 D5 OVERALL
? ? ? ?
???
? ? ? ?
????
? ? ?
?
? ?
?
++
+ +
+ ? –
++ +
+++
+ ++
+ + + +
+++
Low risk Some concerns High risk
Figure 2. Risk of bias assessment of included studies. D1, Randomization; D2.1, Assignment of intervention; D2.2, Adhering to intervention; D3,
Missing outcome data; D4, Measurement of the outcome; D5, Selection of the reported result.
Month xxxx 5
Reis et al THE JOURNAL OF PROSTHETIC DENTISTRY
cement- and screw-retained prostheses was not re-
jected. The meta-analysis results suggest no significant
difference in the risk of peri-implant mucositis between
cement- and screw-retained prostheses, with moderate
certainty of evidence supporting the findings. Similarly,
no significant difference was found in the incidence of
peri-implantitis between screw- and cement-retained
reconstructions, and the absence of heterogeneity
among the studies (I²=0%) indicated consistent results.
A moderate certainty of evidence further supports the
validity of these findings.
The present results were consistent with those of
Wittneben et al,
39
who reported that screw-retained
reconstructions had a lower incidence of fistulae or
suppuration. However, they also reported no significant
difference between the groups regarding the prevalence
of peri-implant mucositis and peri-implantitis.
15
In
contrast, Sailer et al
8
reported that while screw-retained
reconstructions had more technical problems, such
as loosening of the abutment or prosthesis screws and
chipping of the veneering ceramic, cemented re-
constructions had more serious biological complications,
Figure 3. Meta-analysis for comparison between cement- and screw-retained prostheses. A, Incidence of peri-implant mucositis. B, Incidence of peri-
implantitis. CI, confidence interval; Chi², chi-squared test; df, degrees of freedom; I², percentage of total variation across studies due to heterogeneity;
M-H, Mantel-Haenszel; RR, risk ratio; Tau², between-study variance estimate; Z, statistical test of significance of overall effect.
6 Volume xxx Issue xx
THE JOURNAL OF PROSTHETIC DENTISTRY Reis et al
such as bone loss > 2 mm or loss of the implant. How-
ever, Sailer et al
8
included observational studies but no
RCTs that directly compared cement- and screw-re-
tained fixed prostheses, which may explain the differ-
ences in findings compared with those of the present
study.
A systematic review
14
on excess cement and
peri-implant disease reported a higher prevalence of
peri-implant disease with excess cement, especially in
immediate loading or post-second-stage surgery ce-
mentation and in studies involving fixed dental
prostheses. However, the review did not compare ce-
ment- and screw-retained prostheses, and the included
studies had diverse designs, including case series and
reports. Some of these studies reported prostheses with
excess cement without signs of inflammation. The au-
thors suggested that the biofilm potentially adhering to
the rough surface in conjunction with restricted access to
the cementation margin was critical for developing
peri-implant disease.
14
Other factors related to the im-
plant-supported prosthesis have been reported to affect
cement removal. For example, cement removal can be
challenging when the prosthesis margin is greater than
1–1.5 mm submucosally.
5,18
Additionally, prosthesis
design can impact cement removal, with greater un-
dercuts resulting in more undetected cement after
cleaning.
12
Moreover, a concave emergence profile can
impede the removal of cement remnants more than
convex abutments, resulting in greater amounts and
deeper residual cement.
9
However, these factors were
not explored in the studies included in the present re-
view, and caution should be exercised in interpreting the
results.
The type of cement used is also a relevant factor. A
recent clinical study
13
reported that the type of cement
used can influence the ease of cement removal. Resin
cement was found to be the most difficult to remove,
followed by glass ionomer cement. In contrast, zinc
oxide noneugenol cement produced minor residual ce-
ment because of its low strength and adhesiveness.
13
Potential inflammatory complications related to the use
of methacrylate-based cements were highlighted in a
clinical study.
43
Additionally, the results from an in vitro
study suggested that different cement types may have
varying effects on peri-implant soft tissue reactions.
19
While the subgroup analysis in the present study did not
identify significant differences in the incidence of peri-
implant mucositis and peri-implantitis among different
cement types, caution should be taken in interpreting
these results because of the limited number of studies
included in each subgroup analysis. Therefore, selecting
an ideal cement for implant-supported prostheses may
depend on professional preferences and the clinical si-
tuation.
Nevertheless, efforts to remove cement adequately
require careful attention to minimize the risk of re-
sidual cement. While other factors may be involved in
the development of peri-implant disease, in addition
to the cementation type or presence of residual ce-
ment, it is plausible that cement may act as a biofilm
retainer, hinder patient hygiene, and/or trigger a for-
eign body reaction, as demonstrated in a histological
study.
33
Strengths of the current systematic review included
that only RCTs, which present a high level of scientific
rigor and minimize potential biases, were analyzed, al-
lowing for more reliable conclusions. Moreover, all in-
cluded studies followed the participants from implant
placement, so no peri-implant disease was present at
the beginning of the study. The inclusion of studies that
evaluated both cement- and screw-retained prostheses
is another strength, and the authors are unaware of a
previous meta-analysis to directly compare cement- and
screw-retained prostheses for the incidence of peri-
Table 4.Summary of certainty of evidence using GRADE approach
Certainty Assessment № of Patients Effect
Certainty
№ of
Studies
Study
Design
Risk
of Bias Inconsistency Indirectness Imprecision
Other
Considerations
Cemented
Protheses
Screw-
retained
Prostheses
Relative
(95% CI)
Absolute
(95% CI)
Incidence of peri-implant mucositis
4 randomized
clinical
trials
a
not
serious
b
not serious
c
not serious
d
serious
e
none 46/113
(40.7%)
7/67
(10.4%)
RR 1.36
(0.42–4.38)
38 more
per 1.000
(from 61
fewer to
353 more)
⨁⨁⨁◯
Moderate
Incidence of peri-implantitis
4 randomized
clinical
trials
a
not
serious
b
not serious
c
not serious
d
serious
e
none 7/142
(4.9%)
0/51
(0.0%)
RR 1.00
(0.23–4.31)
0 fewer
per 1.000
(from 0
fewer to 0
fewer)
⨁⨁⨁◯
Moderate
CI, confidence interval; GRADE, Grading of Recommendations, Assessment, Development, and Evaluations; N, number; RR, risk ratio.
a
Only randomized clinical trials included in this analysis.
b
Risk of bias ranges only from low to some concerns in the RoB 2 domains of the assessed studies.
c
P value for heterogeneity not significant with overlap in confidence intervals.
d
Evaluation of indirectness based on PICO question. Performed direct comparisons of interventions, populations, and outcomes.
e
Total number of participants in this comparison less than Optimal Information Size (300).
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Reis et al THE JOURNAL OF PROSTHETIC DENTISTRY
implant mucositis and peri-implantitis. Further, all stu-
dies included in the review had a minimum follow-up
period of 2 years, with some studies having follow-up
periods of up to 10 years. Including studies with longer
follow-up periods provides a more accurate evaluation of
the incidence and progression of peri-implant diseases
over time.
Limitations of this review included that, although
statistical heterogeneity was not significant or was
moderate in the meta-analyses, the different definitions
of peri-implant diseases may have influenced the in-
direct comparison between cement- and screw-retained
prostheses and should be considered. Definitions of
peri-implant mucositis and peri-implantitis varied
among studies, and, in some articles, the diagnostic
parameters were not reported. The definition of peri-
implant diseases remains controversial in implant den-
tistry, and the prevalence of peri-implantitis has been
reported to be highly variable, even with clinical case
definitions.
26
Reporting the diagnostic criteria for peri-
implant disease definition in future studies, such as
those defined in the 2017 World Workshop, can improve
the quality of evidence and enhance its applicability in
clinical decision-making.
20,22,23
Moreover, some varia-
tion was observed in radiography standardization across
studies, which may have impacted the interpretation of
bone level changes.
27
The modest sample size and the
less diverse nature of the included studies could narrow
the scope of the conclusions. Furthermore, 2 RCTs in-
cluded in the analysis did not primarily compare ce-
ment- and screw-retained prostheses in terms of peri-
implant disease incidence,
4,17
and there was an im-
balance in the number of cement- and screw-retained
prostheses. However, a sensitivity analysis excluding
these studies resulted in nonsignificant pooled results
between the groups for both peri-implant mucositis
(P=.37) and peri-implantitis (P=.30). Additionally, as the
included studies had varying follow-up periods and
limited information was available on the incidence of
peri-implant diseases at specific time intervals, evalu-
ating the incidence of peri-implant diseases at specific
time points was not feasible. Furthermore, the lack of
information on potential confounding factors prevented
sensitivity analysis. Therefore, caution is advised when
interpreting the review's results because of the varia-
bility of clinical procedures, including implant loading
time, implant system, and co-interventions (such as
bone augmentation), which may affect peri-implant
outcomes.
7,28,37
Moreover, peri-implant mucositis has
been associated with neglecting supportive implant
therapy
20,25
and radiation therapy,
20,35
and peri-im-
plantitis has been associated with a history of period-
ontitis,
6,23
inadequate maintenance care,
23
smoking,
32
and uncontrolled diabetes.
36
The impact of these factors
on the overall review result could not be assessed be-
cause of insufficient reporting.
Overall, the findings suggest that both cement- and
screw-retained reconstructions have a similar risk of peri-
implant disease, an important consideration for clinicians
and patients when treatment planning. The results suggest
that the choice between cement- and screw-retained
prostheses should be based on an individual evaluation,
taking into account factors such as clinician preference,
technical considerations, retrievability, and esthetics, as ce-
ment-retained prostheses were not associated with a higher
risk of peri-implant disease. Future studies should explore
cementation techniques, materials, and operator experience
and training to better understand their impact on the in-
cidence of peri-implant disease.
CONCLUSIONS
Based on the findings of this systematic review and
meta-analysis, the following conclusions were drawn:
1. Moderate certainty evidence suggests an equal risk
for peri-implant mucositis and peri-implantitis
with cement- and screw-retained prostheses.
2. The choice of prosthesis retention method should
be guided by additional clinical contexts and pa-
tient-specific factors.
APPENDIX A. SUPPORTING INFORMATION
Supplementary data associated with this article can be
found in the online version at doi:10.1016/j.prosdent.
2023.08.030.
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Corresponding author:
Dr Isabella Neme Ribeiro dos Reis
Department of Stomatology
School of Dentistry
University of São Paulo (USP)
Avenida Professor Lineu Prestes, 2227
São Paulo, SP 05508-000
BRAZIL
Email: bellaneme@yahoo.com.br
Copyright © 2023 by the Editorial Council of The Journal of Prosthetic Dentistry.
All rights reserved.
https://doi.org/10.1016/j.prosdent.2023.08.030
Month xxxx 9
Reis et al THE JOURNAL OF PROSTHETIC DENTISTRY
