E. Zdanavičienė et al.

REVIEWS REVIEWS
SCIENTIFIC ARTICLES
Stomatologija. Baltic Dental and Maxillofacial Journal, 23: 35-40, 2021

One abutment one time vs. repeatable abutment

disconnections in implants, restored with cemented /
screw retained fixed partial dentures: Marginal bone
level changes. A systematic review and meta-analysis
Imantas Vatėnas1, Tomas Linkevičius2

SUMMARY

Purpose. The aim of this systematic review and meta-analysis is to evaluate the impact of
abutment disconnections / reconnections on peri-implant marginal bone loss changes in partially
edentulous patients.
Methods. Clinical studies were selected via electronic and hand searches in English language
journals until January 1, 2020. Only randomized clinical trials (RCGTs) and prospective controlled
clinical trials (CCTs) showing direct comparison between the definitive implant abutments and mul-
tiple abutment replacements in the same patient or different patient groups in the partially edentulous
patients were considered. The outcome measures were (1) the type of the abutment was used, (2)
the time the abutment was placed, (3) marginal bone loss changes, (4) biological complications,
(5) mechanical complications.
Results. After evaluation, 4 controlled clinical studies were included. Majority of the articles
reveled protective marginal bone loss preservation for the implants with FAP (final abutment place-
ment) at the time of implant placement compared with the implants with MAP (multiple abutment
placements) in connected dental implants, in partially edentulous patients. Meta-analysis of the four
studies with 280 implants reviled significantly greater bone loss in cases with multiple abutment
disconnections/reconnections. The weighted mean difference in marginal bone loss was 0.4 mm
(95% confidence interval, 0.16-0.63 mm), showing bone preservation in the FAP group.
Conclusion. Within the limitations of this meta-analysis, multiple abutments disconnections
significantly affected marginal bone loss changes in partially edentulous patients. The finding sug-
gests to overview current prosthetic and surgical treatment planning protocols to prevent greater
marginal bone loss.

Keywords: marginal bone loss, final abutment, definitive abutment, abutment level, one abut-
ment one time, final abutment placement, multiple abutment placement, fixed partial dentures.

INTRODUCTION

Disconnection of healing or prosthetic abutments (1). Canullo et al. suggested on that "one abutment –
has always been a controversial topic in implant one time" concept – when you place the prosthetic
dentistry. abutment once and leave it till the delivery of the final
Becker et al. reported that disruption of the peri- restoration, might be a possible additional strategy
implant mucosal seal affected marginal bone loses, to further minimize peri-implant crestal bone resorp-
when abutments were disconnected and reconnected tion. He reported 0.2 mm greater MBL (marginal
twice from implants with internal conical connection bone loss) in the provisional abutment group in 3
years period compared with the definitive abutment
1
Šiaulių implantologijos klinika, Šiauliai, Lithuania group (11).
2
Institute of Odontology, Faculty of Medicine, Vilnius University, The presence of misfit between the framework
Vilnius, Lithuania
and the implant, although inevitable during the pros-
Address correspondence to Tomas Linkevičius, Institute of thetic procedures, could generate uneven stresses
Odontology, Faculty of Medicine, Vilnius University, Zalgirio str.
115/117, LT- 08217, Vilnius, Lithuania. and strains, which may be relevant to complications
E-mail address: [email protected] such as: screw fracture, framework fracture, implant

Stomatologija, Baltic Dental and Maxillofacial Journal, 2021, Vol. 23, No. 2 35
I. Vatėnas T. Linkevičius REVIEWS

fracture, marginal bone loss (MBL) and implant loss MATERIALS AND METHODS
(2). In contrast to abutment level (AL) setup, the ac-
curacy of implant level (IL) framework seems to be Search strategy
negatively affected by implant disparallelism, when Focused question
using systems with internal connections (3). However The main research question- do the multiple im-
compared with cemented restorations, screw- retained plant abutment disconnections have statistically signifi-
fixed partial dentures (FPD) have shown a lower cant difference compared with definitive placed implant
incidence of biologic complications and an easier abutment on marginal bone loss changes in partially
retrievability (4). This abutment level setup would edentulous patients, treated with cemented and screw
protect the dental implant from overload and counter retained restorations. Secondary outcome would be
balance potential misfit between framework and the evaluation of biological complications and mechanical
implants (5). complications overviewed if they are reported.
A 1 year prospective clinical study done by Search strategy
Gotheberg et al., used dental implants with external A MEDLINE search (PubMed) was performed
hexagonal connection (6). They observed greater to find articles published in the English language
marginal bone resorption on the IL than AL setup up to and including January 2020. The follow-
in screw retained restorations. Based on the current ing combinations of search terms used: "Dental
literature, the IL setup has an unclear clinical recom- implants"{Mesh} AND "final abutment" AND
mendations and the choice between AL and IL setup "definitive abutment" AND "abutment level" AND
is datable (7). "one abutment one time" AND "marginal bone loss"
Degidi et al. reported no statistically significant AND "clinical study" AND "clinical trial". Fur-
difference between the one abutment one time group thermore, the manual search included all full-text
and control group regarding the measurement of articles and other related reviews selected from the
vertical bone healing in subcrestally (2 mm) placed electronic search in the following journals: Clinical
postextractive tapered single dental implants, which Implant Dentistry and Related Research, Clinical
were restored immediately (10). Although Grandi et Oral Implants Research, European Journal of Oral
al. showed opposite results – after 12 months period Implants, Implant Dentistry, International Journal of
implants in the DA group lost an average of 0.11 mm Periodontics and Restorative Dentistry, Journal of
(SD: 0.06) peri-implant bone, implants in PA group Oral and Maxillofacial Surgery, Journal of Clinical
about 0.58 mm periimplant bone (SD: 0.11), statis- Periodontology, Journal of Periodontal Research,
tically significant difference in bone level change Journal of Periodontology and European Journal
between the groups (mean difference: 0.48 mm, Cl of Oral Implantology. The electronic research was
95% 0.04; 0.55, P<0.0001) (12). In both studies dental complemented by manual searching in the bibliog-
implants were placed immediately and restored with raphies of the most recent systematic reviews and
immediate cemented temporary restorations without all references of the included publications.
occlusive contact. Duda et al. revealed that two delayed
placed dental implants showed less MBL (average Inclusion criteria
0.82 mm in 1 year) compared with single immediately The criteria for the study inclusion were as fol-
placed and loaded dental implants (average 1.32 mm lows:
in 1 year) (13). From these presented articles it is 1. Clinical studies with direct comparison
unclear- is one abutment one time protocol could be between definitive and / or provisional abut-
more beneficial for the MBL compared to the standard ments in partially edentulous patients where
treatment protocol according to the implant placement two or more dental implants were connected,
time, implant loading time. As well according to the in the same patient or comparing two differ-
prostheses fixation type, we missing articles with screw ent groups of the patients.
retained restorations for the one abutment one type 2. Studies with at least 10 patients.
treatment protocol. At last we cannot exclude the fact 3. Studies with a mean follow-up of at least
that gingiva type having a huge impact to the MBL 1 year.
and overall results of the treatment. 4. Studies reporting marginal bone level
The aim of this systematic review was to evaluate changes.
the impact of abutment disconnection/ reconnection Exclusion criteria
on peri-implant marginal bone loss changes in par- 1. Case series.
tially edentulous patients, treated with cemented and 2. Case reports.
screw retained restorations. 3. Animal studies.

36 Stomatologija, Baltic Dental and Maxillofacial Journal, 2021, Vol. 23, No. 2
REVIEWS I. Vatėnas T. Linkevičius

dental implants were connected (10-13). Four

controlled clinical studies were approved by
inclusion criteria, all studies reported marginal
bone loss changes as an outcome.
Three of the four included studies were
randomized controlled clinical studies (14, 16,
17), one – controlled clinical trial (18). Totally
280 dental implants evaluated, the average
age of the participants in the studies varies
between 49.9 to 58.9 years old. Post placement
follow up time varies from 12 months to 36
months. All 280 implants used in the studies
had a rough crestal collar, conical internal
connection (Table 1). Two studies evalu-
ated groups with 4 abutment disconnections/
reconnections (16, 18), 2 studies evaluated
3 abutment disconnections/ reconnections
before definitive abutment placement (14,
17). One study reported peri-implant mucosal
dimensional changes, patient satisfaction (14).
One study reported probing depths and bleed-
ing on probing (17). One study declared – no
significant statistical difference in terms of
measured vertical bone healing (18). Although
Fig. 1. Overview of the search strategy other three studies revealed – there were
statistically significant differences between
Data extraction the two groups for peri-implant bone loss changes
Two reviewers (IV and TL) extracted relevant (Table 2). Overall in all studies were guidelines that
data from the selected articles independently, using marginal bone loss preservation in the FAP group
a specially designed date extraction methodology. more predictable compared with the MAP group. The
Any disagreement was resolved through discussion, marginal bone loss changes ranged from 0.086 mm
leading to consensus. Meta- analysis was performed to 1.047 mm for MAP group and from 0.005 mm to
only if the study full fills all inclusion criteria. 0.846 mm for the FAP group.
Two studies reported mechanical complica-
RESULTS tions. In one study five patients from the definitive
abutment group and four patients from the repeated
The initial search revealed 441 article titles and disconnection group were affected by complications
abstracts (Fig. 1). After application of the inclusion (difference – 4%; CI 95%: -11%, 20%; P=0.725) (14).
criteria, 9 articles selected for the full text evaluation. In another study – one abutment loosening at MAP
Further evaluation led to the exclusion of the 5 stud- group and one chip-off fracture was reported in the
ies. One study was excluded because of inadequate FAP group, overall failure rate at 1Y was 2% (17).
6 months follow up period (9). Other 4 articles were
excluded because the marginal bone loss changes Statistical Analyses
were evaluated around single dental implants not A meta-analysis integrates the quantitative find-
in the partially edentulous patients where 2 or more ings from separate but similar studies and provides

Table 1. Main characteristics of included studies

Study Year Design Funding Implant No. Smokers Timing of Follow up Flap design
recon placement months
Degidi et al. 2011 CT NA Densply 4 Yes Delayed 36 Full thickness
Toia et al. 2018 RCT Densply Densply 3 Yes Delayed 12 Full thickness
Nader et al. 2016 RCT NA Zimer dental 4 Yes Delayed 12 Full thickness
Bresson et al. 2017 RTC Densply Densply 3 Yes Imediat 36 Flapless
NA – not available; RCT – randomized controlled trial; CT – controlled trial.

Stomatologija, Baltic Dental and Maxillofacial Journal, 2021, Vol. 23, No. 2 37
I. Vatėnas T. Linkevičius REVIEWS

a numerical estimate of the

overall effect of interest (15)
Petrie et al., 2003). Fixed ef-
fects model was used. Under
the fixed effects model, it is
assumed that all studies come
from a common population,
and that the effect size SMD
(Standardized Mean Dif-
ference) is not significantly
different among the differ-
ent trials (Table 3). This
assumption is tested by the
"Heterogeneity test" (Table
4). If this test yields a low P-
value (P<0.05), then the fixed
effects model maybe not
the best. For meta-analysis
of studies with a continu-
ous measure (comparison of
means between treated cases Fig. 2. Forest plot of the fixed and random effects meta– analysis of the marginal bone
and controls), MedCalc uses level outcome
the Hedges g statistic (in our
case "Q" as a formulation for Table 2. Outcome assessment of included studies
the standardized mean differ-
ence under the fixed effects Study MAP placed FAP placed MBL change ± SD MBL change ± SD
implants implants (mm) MAP (mm) FAP
model. The standarized mean Degidi et al. 24 24 0.15±0.28 0.07±0.27
difference Hedges g ("Q") is Toia et al. 58 61 0.086±0.313 0.005±0.222
the difference between the Bresson et al. 39 34 0.50±0.93 0.07±0.18
two means divided by the Nader et al. 20 20 1.047±0.395 0.846±0.454
pooled standard deviation, SD – standard deviation; MAP – multiple abutment placements; FAP – final abutment
with an adjustment for small placement; MBL – marginal gone loss.
sample bias.
The meta-analysis was Table 3. Meta-analysis continuous measure
performed, MBL (marginal
Variable for studies Study
bone loss) evaluated as the
1. MAP groups Variable for number of cases Treated_N
primary outcome. The differ- Variable for mean Treated_Mean
ences in marginal bone level Variable for SD Treated_SD
changes between two groups 2. FAP groups Variable for number of cases Controls_N
FAP and MAP was estimated Variable for mean Controls_Mean
Variable for SD Controls_SD
as the effect size measure.
Study MAP groups FAP groups Total SMD 95% CI
The authors used fixed and
Degidi et al. 24 24 48 0.286 -0.298 to 0.870
random effects model for
Toia et al. 58 61 119 0.298 -0.0674 to 0.663
the analysis (Table 3). Forest Bresson et al. 39 34 73 0.615 0.136 to 1.095
plots were formulated to re- Nader et al. 20 20 40 0.463 -0.187 to 1.113
port the weighted average of Total (fixed effects) 141 139 280 0.400 0.162 to 0.638
outcome and 95% confidence Total (random effects) 141 139 280 0.400 0.162 to 0.638
intervals (CIs) (Fig. 2). The a SD – standard deviation; MAP – multiple abutment placements; FAP – final abutment placement.
level was set at 0.5.
There were assessed four studies (14, 16-18) in Table 4. Test for heterogeneity
the meta – analysis (Table 3) Tests for heterogeneity
demonstrated slight heterogeneity ( DF=3, Q=1.3018, Q 1.3018
P=0.7287 (P>0.05)) (Table 4). The random and fixed DF 3
effects model was used for the analysis. Both models Signifi cance level P = 0.7287 (P >0.05)

38 Stomatologija, Baltic Dental and Maxillofacial Journal, 2021, Vol. 23, No. 2
REVIEWS I. Vatėnas T. Linkevičius

meta- analysis of four studies showed the same re- correlation between the development of peri-implant
sult – an increase mean (95%CI) marginal bone loss mucositis and plaque accumulation (21, 22). It may
of 0.4 mm (0.16-0.63 mm). lead to greater MBL changes.
More over Toia et al. showed the significant
DISCUSSION difference of MBL between the IL (implant level)
and AL (abutment level) groups (P=0.003). At 1
The results of current meta- analysis demonstrate year , MBL was 0.084±0.31 mm and 0.005±0.22
that multiple abutment disconnections/ reconnections mm in the IL and AL groups, respectively. The study
having an effect on marginal bone level changes reveals that final restorations- screw retained in both
around the dental implants in partially edentulous groups. The more concerning fact that in the study
patients (Table 3). different gingiva high definitive abutments were
From the experimental studies it seems that used, that probably means that patients had different
multiple (5 times) abutment disconnections and gingiva types. Thickness of peri – implant mucosa
reconnections may have an effect on the soft and has been reported as a significant factor determining
hard peri-implant tissue alterations (19). It was the apico – coronal dimensions of the peri – implant
unpredictable that we found only one article with mucosa (23, 24). Studies demonstrating that dental
screw retained final restorations in the AL groups in implants placed with an initially thicker peri – implant
partially edentulous patients (17). Other two studies soft tissue have les radiographic MBL in the short
did not exactly disclose the method of fixation final term (25). All in the meta – analysis involved articles
prostheses on the DA (14, 18). Because of that we as a final restoration material chosen metal ceramics,
now can make the statement that till now we do not these days zirconium would be more acceptable and
know exactly are the AL screw retained restorations is gingiva friendly material (26).
better than IL screw retained restorations in partially Despite differences in treatment protocols of
edentulous patients according to the MBL. the included studies such us: location of the implant
Degidi et al. declared no statistically significant platform according to the alveolar crest, flap reflec-
difference was evidenced between the one abutment tion type, using of artificial bone substitutes, timing
one time and control groups regarding the measure- of the implant placement, type of the fixation of the
ment of vertical bone healing (18). In this study im- final or temporary prostheses, material of the final
plants were placed at least 1 mm subcrestaly, stable restorations, gingiva type, studies demonstrated
conical connection and no soft tissue data could had protective effect on the marginal bone loss for FAP
an impact on the results of this study. Opposite results group. Reducing the number of disconnections/ re-
presented by Bressan et al. the mean MBL 3 years connections of the dental implant abutments may be
after loading was 0.07 (0.18) mm for the DA (defini- beneficial overviewing the treatment protocol.
tive abutment) group and 0.50 (0.93) mm for the RA Ensuring adequate soft tissue thickness might
(repeated abutment) changes group (difference – 0.43 be useful protecting the bone underneath and having
mm; Cl 95%: 0.13, 0.74; P=0.007) (14). The implants less MBL. Using soft tissue friendly material as zir-
in this study all so were placed subcrestaly for 1 mm, conium and screw retained final restorations, research
but immediate, flapless implant placement was ac- with more standardized treatment protocol could be
cepted as well bone augmentation during Immediate beneficial in the future.
implant placement, different implant diameters were
used, nevertheless the single and multiple implant CONCLUSION
placement cases up to three implants were accepted
in the groups. Similar results presented by Nader Within the limitations of this meta-analysis, mul-
et al. DA group 0.84±0.45 mm, PA group 1.0±0.39 tiple abutments disconnections significantly affected
mm in 1 year period. In this study one abutment one marginal bone loss changes in partially edentulous
time and standard protocol was used in the same site patients with cement / screw retained restorations.
for the same patient, implants were placed 0.5 mm Future researches using AL ( abutment level ) screw
subcrestaly, only delayed implant placement and retained restorations is necessity to understand is this
prosthetic protocols were used. Final restorations treatment can be more beneficial according to the
were cemented, conical connection implants used MBL in the partially edentulous patients.
(16). It has been demonstrated that placement of the
abutment margin submucosally increases the amount ACKNOWLEDGMENTS
of undetected cement (20). It may lead to submucosal
plaque accumulation. Clinical studies have shown a The authors declare no conflicts of interest.

Stomatologija, Baltic Dental and Maxillofacial Journal, 2021, Vol. 23, No. 2 39
I. Vatėnas T. Linkevičius REVIEWS

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Received: 06 06 2020
Accepted for publishing: 28 06 2021

40 Stomatologija, Baltic Dental and Maxillofacial Journal, 2021, Vol. 23, No. 2