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Solving Common Problems with Science: Implant Abutment Screw Loosening

Video highlights

Common reasons for screw loosening
Understand how screws work
Considerations regarding facial change and development
Correct usage of torque limiting tools
Practical tips and habits to avoid screw loosening

The most common prosthetic issue with single tooth implants is the loosening of the screw. In his lecture, Dr. Chandur Wadhwani looks at screws, how they work, and the science behind them. He will provide tips and habits to ensure your prosthetics are more effective.

It is well known that the screw, or screw loosening is the most common prosthetic problem with single implant restorations. What is particularly interesting is that not only does a large percentage of screws become loose, but it also occurs over time. So, when does this happen, and what are the consequences besides the known biological and mechanical issues? With the loosening of a screw, one can experience anything from mucositis to a screw fracture, from an abutment fracture to an implant fracture – all resulting in costs for the patient and the treating clinician.

Dr. Wadhwani shares seven habits that will help to understand how screws work, how to use screws optimally, identify risk factors, and how to address them.

1. Habit: Seek to understand – how do screw joints work?

The first thing to understand about screws is that as we tighten a screw, we impart a force directly onto the screw. This is a rotational force that is called torque. It is known that a vast amount of this torque is actually absorbed purely by friction, friction in different parts of the joint. The friction starts when the screw thread is entered into the internal aspect of the implant and then goes all the way through to the head and any connecting component within this device. By the time the screw is seated, most of the imparted energy has been absorbed. And with the right amount of force applied, the resulting elasticity or stretch of the screw will actually optimize the screw joint. Looking at where the ultimate tensile strength is, it is also the point where the screw has the highest risk of fracture. The goal is to achieve an axial stretch within the screw, reaching about 75%, from 66 to 75% of the ultimate tensile strength within that screw. It is known that if you under-tighten a screw, you don't stress it enough. If you over-tighten a screw and bring it to the point of limit where it will start to rupture, it will permanently deform. But this weakness within a screw appears not so much when you stretch it but when it's subjected to sideways movement. And, in dentistry, we have cyclic movements – the movement of the jaws. With this lateral flexure, take care not over tighten the screw. Because if you tighten to the point where the stretch is almost optimum and then you have sideways movement, you will diminish what's known as the preload or the stretch within the screw, and the screw will become permanently deformed. This demonstrates the importance of keeping the torque to that prescribed by the manufacturer. Problems may occur, even with the correct torque applied, when a large cantilever is present or in cases with bruxism. Lateral forces will destroy the screw. We should stay within the limits of the torque to not overstretch or understretch the screw and understand that the vast majority of the torque that we use is purely absorbed as friction. Only about 10% of the applied torque value goes to preload.

2. Habit: Put first things first – torque wrench issues

How can you achieve optimum torque, and which torque-limiting devices or machines should be used? Various devices are available, but they typically fall into two categories: mechanical and electronic. It is well known from research and industry testing those electronic devices are not always accurate or precise, while manual ones can be highly precise and accurate. Therefore, this lecture will focus on manual devices.

Manual devices are divided into two groups: beam wrench and toggle devices. A toggle or friction device consists of mechanics within the actual torque limiting device, usually, a spring and a ball bearing. Although both beam wrench and toggle devices can be precise and accurate, a spring and a ball bearing toggle device has two consequences that the beam wrench does not have. The first consequence, toggle devices are susceptible to contamination, affecting the way the spring works. This is because the toggle device is used directly in the mouth, and moisture from the mouth can get into the mechanism. If the device is not cleaned and oiled properly, the resulting contamination gets baked on during autoclaving, hardens, and ultimately affects the spring. This can cause over-torque up to 400% higher than a clean, non-contaminated device. Therefore, it is crucial to maintain these devices properly.

The other consequence of having a spring and ball bearing within the device is that they suffer from inertia, causing a time lag between the spring activating and a new rotation of the torque wrench. This inertia means the torque wrench must be used slowly to achieve the optimum torque. Experiments have shown that the optimum torque can be achieved by using this device over 4 seconds. If used more quickly, it will under-torque. There are in fact two ways to use this torque wrench to optimize the torque value. First, take it up to about 80% of its desired torque and then slow down the last 20%. Second, do it slowly over 4 seconds, which is the preferred method.

When comparing the toggle device to the beam wrench, the beam wrench has no working parts whatsoever and is, therefore, easier to maintain. Furthermore, it has no speed limitation because there is no inertia. The beam wrench can be used as fast or slow as desired, and the delivered torque will be accurate.

So, we know speed and maintenance are factors. We also know that the automotive industry uses torque wrenches very similar to those we use, but ours are on a micro-scale. So, are we both equally accurate and precise in using these devices? The person who changes your tires is mandated to calibrate and check their torque wrench daily or weekly. However, when we surveyed 400 dentists, we discovered that only 6% knew what we were talking about or ever calibrated their torque wrenches. This finding underscores the need to understand how screws work and how to optimize torque because inaccurate tools can lead to imprecise results. Such inaccuracies could translate into screws loosening sooner than expected or more issues with screws breaking down. As per ISO 6789, which governs us and our industry, we should calibrate our torque wrenches at least once a year, except when exposed to extreme temperatures or damage. An autoclave is considered an extreme temperature environment. Thus, checking your torque wrench frequently is crucial, especially if you have the toggle type. The toggle type is an excellent device, but it requires regular maintenance. You need to use it for at least four seconds to achieve accuracy and precision, and check it regularly.

3. Habit: Begin with the end in mind – occlusal changes

Why do I mention that screw loosening can occur over a period of years? This is an intriguing phenomenon that I have encountered in one of my cases, a 70-year-old male patient. When I took photographs of the restoration in 2012, the occlusion appeared to be perfect with regular incisal edges. However, when the patient returned for a regular check five years later, there was a noticeable difference in the incisal height.

So we investigate the clinical situation. We know that human faces continue to grow and develop throughout their lives, which can impact the position of an implant in relation to the natural dentition over time. We also know there is an age when people experience a growth spurt that can further affect the position of the implant. Furthermore, facial growth can be predicted based on the pattern of the face. In a study of a group of adolescents and mature adults by Bernard, he measures the change in the position of implants relative to natural teeth over a period of four years on average -- he finds the change is similar in both groups. The resulting change in occlusion can alter the mechanics of the implant crown, increase the lateral forces on the screw, which is the weakness of the screw, and lead to screw loosening.

The facial form can somewhat predict these changes to occlusion over time. If we have a brachiocephalic face type, characterized by a short wide face, it tends to grow sideways. Over time, the implants may look like they were placed more palatally because the face and dentition have grown. If we compare it to the dolichocephalic face type or long face, growth is towards the anterior. The impact is more profound in these patients because the lateral incisors start to look much shorter. Be aware of the facial form with your patient to be accurate, follow the occlusion, and adjust it accordingly to prevent screw loosening.

Another feature of facial growth and development is mesial drift. The teeth move anteriorly over time due to wear and again due to dental alveolar growth. This means we get open contacts, which, when recorded, occur in about 50% of cases. Once again, this results in a difference in occlusion, which will again impact the way the screw works. So we can anticipate some screws that will loosen even if we do everything optimally. Be aware that the occlusion will change. So how can you help that occlusion and help slow down that change? Well, we can do what orthodontists do. We can provide a retainer to help limit tooth movement and help protect our restoration and the screw within.

4. Habit: Think win/win – Preventing bad outcomes

It is also important to inform the patient and explain what might occur. Tell them about normal facial growth and that monitoring is needed to prevent these complications. The best habit is to inform your patients so they know what to anticipate. I give my patients a form at the very beginning of their restoration explaining what will change and monitoring, not only from a restorative point of view with the occlusal changes but also from a disease perspective.

5. Habit: Sharpen WHAT you see – parallax effect

When we surveyed over 400 dentists, many dentists didn't understand where to place the beam according to the marker. The marker beam's width represents a certain torque, about four Newton centimeters in the example of the Nobel Biocare mechanical torque limiting device. This translates to an error of up to four Newton centimeters if the beam is placed incorrectly. So, where should the beam be placed? When reading the Newton centimeters, the beam marker should be in the center of the beam. Furthermore, beam markers all suffer from parallax; their position appears different when viewed from different angles. It can only be read correctly by looking at it from exactly 90 degrees. Otherwise, the parallax effect means that you don't necessarily see the right marking on the beam length, and depending on the angle of view, you'll either under-torque or over-torque. We have to understand the tools that we are using.

6. Habit: Synergy – Component precision

Synergy means that your componentry must fit. If your components fit and interlock well, the screw has a minimum amount of work to do. The friction effect will change the preload value if they do not fit. So you must use components that fit and are compatible with each other. As we know from the literature, the vast majority of third-party components are at risk for failure in fit. To ensure compatible components, it is recommended to use only components delivered by the original manufacturer, not by a third party. Using the right components and applying the correct force optimizes seating. If you can use the original componentry, outcomes are improved, with less screw loosening effects, such as fracture, and higher predictability.

7. Habit: Be Proactive – Optimum tightening technique

Different opinions and methods may be presented when you ask how I should tighten the screw on this implant componentry. Realistically, if we are scientists, there should only be one way that we tighten a screw depending on the material we use. The different surface affects the screws because most of the energy goes and is absorbed as friction during tightening. Surface effects on the screw can reduce this friction. One of them is you could use gold. Some screws have a gold layer of 23 karat gold on them. And what they do is when you tighten them up, it reduces the friction, increasing the preload. Surfaces and surface coatings contribute to the preload and stability of the screw joint system.

These are my seven tips to contribute to our understanding of how the screw works and how to optimize your approach to screw tightening to limit the number one problem with single-tooth implant restorations.

References

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[12] Wadhwani CPK, O'Brien R, Rosen PS, Chung KH. Testing and calibrating the mechanical-type toggle torque wrenches used in implant dentistry: A dental technique. J Prosthet Dent. 2020 Mar;123(3):403-407. doi: 10.1016/j.prosdent.2019.04.021. Epub 2019 Aug 2. PMID: 31383530.

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[17] Nilsson A, Johansson LÅ, Stenport VF, Wennerberg A, Ekfeldt A. Infraposition of anterior maxillary implant-supported single-tooth restorations in adolescent and adult patients-A prospective follow-up study up to 6 years. Clin Implant Dent Relat Res. 2019 Oct;21(5):953-959. doi: 10.1111/cid.12818. Epub 2019 Aug 5. PMID: 31381250.

[18] Wadhwani CPK, O'Brien R, Rosen PS, Chung KH. Effect of viewing angles on measurement errors when using an implant cantilever beam torque-limiting device. J Prosthet Dent. 2022 Jan 4:S0022-3913(21)00656-9. doi: 10.1016/j.prosdent.2021.11.022. Epub ahead of print. PMID: 34996611.

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[21] Karl M, Irastorza-Landa A. In Vitro Characterization of Original and Nonoriginal Implant Abutments. Int J Oral Maxillofac Implants. 2018 Nov/Dec;33(6):1229-1239. doi: 10.11607/jomi.6921. PMID: 30427953.

[22] Hsu KW, Shen YF, Wei PC. Compatible CAD-CAM titanium abutments for posterior single-implant tooth replacement: A retrospective case series. J Prosthet Dent. 2017 Mar;117(3):363-366. doi: 10.1016/j.prosdent.2016.07.023. Epub 2016 Oct 17. PMID: 27765397.

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Clinical topics

Prosthetic rehabilitation Implant prosthetics

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Anonymous

02.04.2023 | 12:28

What is if the abutment-diameter is bigger than the previous gingiva-former?? Then proper gingiva-forming is even more mportant?

I experience often that i can screwca crown a lot deeper when waiting these 10minutes ... Maybe thats my insufficient gingiva-forming in advance then?

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I experience often that i can screwca crown a lot deeper when waiting these 10minutes ... Maybe thats my insufficient gingiva-forming in advance then?

Emil Svoboda

06.04.2023 | 03:41

It can be very difficult to verify that you have optimized the fit of the implant-abutment connection clinically. Being able to screw the abutment-crown complex deeper is a sign that it is not down all the way. However, even if the abutment-crown complex does not appear to go down further, this is not a verification that the fit is optimized. The contacts with adjacent teeth may be preventing it from seating properly, and/or the bone or gingival may be preventing its seating. With multiple teeth prosthetics where the abutments are already embedded in the prosthesis, the abutment connectors are often aligned in non-optimal 3-D positions that prevent them from seating. This is often the case with multiple unit prosthetics installed by the screw-in technique. Certainly the simplest clinical condition is when abutments are installed without the prosthesis attached ... and indeed ... if the abutment does not slip right into place ... the dentist should be prepared to expose the implant top, remove any tissue impediments and verify the seating of the abutment visually. This would be the best we can do to mitigate the negative effects of the implant-abutment misfit. Of course ... also pay close attention to all the important information provided by Dr. Wadwhani.

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Emil Svoboda

02.04.2023 | 17:24

Why do you assume that an optimized fit of components when it is difficult to achieve clinically?

Besides the problem of non-optimal parts there are the root causes of misfits that must be mentioned. Prosthesis Dimensional Error contributes to the misalignment of parts when the connectors embedded in the prosthesis have smaller tolerances for error than the prosthesis. Incongruent Paths of Insertion when the paths of insertion determined by adjacent teeth is incongruent with those determined by the implant and abutment-crown complex. Resistance to Displacement by adjacent hard and soft tissues that can prevent the abutment from seating into the implant. What do you think?

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Chandur Wadhwani

02.04.2023 | 19:24

You are correct abutment positioning and resistance from both hard and soft tissue will affect the way an abutment will seat into or onto the implant fixture. it is imperative that the clinician understand path of insertion and gingival tissue resistance and displacement effect. If the periimplantitis tissues are too tight then the abutment and abutment restoration complex may not seat fully. this places extra stress on the screw and leads to premature failure. path of insertion is also critical- (even though teeth have been shown to move laterally by upto 150 microns from studies on tooth wedging) the guiding path can prevent seating of the abutment. this should always be critically accessed both clinically and during the laboratory procedures with accommodations being made where necessary! thank you for your great questions!

Emil Svoboda

03.04.2023 | 22:29

I believe that understanding the root causes of mechanical misfit connections is key to reducing treatment complications … like screw loosening and implant breakage .. related to fixed prosthetics. Misfit connections are less stable than optimized connections and are also a known risk factor for peri-implantitis. Knowledge about the mechanisms by which dentists cause them does not appear to be common. I have published a concise explanation of their root causes “Slides 38-43 in my presentation “Making Fixed Prosthesis Installation Safer … “ under articles at www.ReverseMargin.com” I look forward to your comments. :-)

Emil Svoboda

16.04.2023 | 22:03

Dear Dr. Wadhwani, Thank you for your answers. You mentioned Path of Insertion. Indeed, even for a single tooth there are multiple Paths of Insertion to consider. There is the path of insertion determined by the adjacent teeth and other tissues, the path of insertion determined by the implant and its screw channel, and the path of insertion determined by the abutment connector and its abutment screw. The problems is, to get an optimized implant-abutment fit with the current screw-in system (where the abutment has been incorporated into the crown on a dental model) it would be nearly impossible to align all these paths of insertion within the tolerance of their connecting parts ... if those tolerances were plus/minus 5 microns - 1/20 the diameter of a hair. It would be difficult to adjust contacts at that tolerance with a rotary instrument while holding the crown complex in one's hand. If the mesial and distal contact were slightly off ... that would likely result in a misfit as it would not allow the abutment to seat optimally. This certainly could lead to all the problems you mention including peri-implant disease. Now with multiple units, well I can say that is really impossible as it is not even possible to align implants within such a narrow tolerance and the model error would even make the other paths of insertion even more difficult to align. This is a BIG problem. The only solution I see is for the manufacturers to make the fit of connectors sloppier (ie larger tolerances). However larger tolerances would be expected to behave more like misfit joints, as they would leave more space for pathogens to breed and be looser than parts with tighter tolerances. Why don't the implant manufacturers publish the tolerances of their parts to help dentists choose what is best for their patients? Why don't they reveal this common problem of misfit parts to dentists that is related to the screw-in system that they promote? Without that information ... how can clinicians use their ingenuity begin to address the implant-abutment and abutment-prosthetic connector misfit problem and its consequences? I look forward to your comments.

Emil Svoboda

16.04.2023 | 22:22

Dr. Wadhwani, Regarding the comment that natural teeth can move150 microns laterally. I assume you mean that adjacent teeth can move 150 microns to compensate for expected Prosthesis Dimensional Error and Incongruent Paths of Insertion. While it is possible for some teeth, especially those that have lost some support I am not sure we can depend on adjacent teeth to properly compensate for the above problems and Resistance to Displacement by adjacent tissues. I know that gingiva can be very difficult to displace when it is thinner and up against bone or adjacent hard tissues. I know that implant retained adjacent crowns are very difficult to displace and teeth that are contacting other teeth are difficult to displace. Indeed I would say that it is usually not that easy to predict whether we have successfully displaced adjacent teeth and other tissue and adjusted contacts sufficiently to ensure an optimized fit of the implant-abutment junction when installing the crown or bridge onto teeth or dental implants. Indeed, I do believe that the dentists' best chance to optimize the implant-abutment connection is when there is no tooth attached to the abutment. The attached tooth adds to the complexity by needing contact adjustment and it obscures the dentist's vision. Also if the abutment is free to align itself with the implant, it has the the best chance to do so optimally. This problem is of course multiplied with multiple units. What do you think?