Effect of crown seating methods on the remnant cement in the subgingival region of a cement-retained implant crown | Scientific Reports

Oct 16, 2024

Scientific Reports volume 14, Article number: 24249 (2024) Cite this article

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This study aimed to investigate the effects of crown seating speed, crown seating force, quantity of cement used, and type of implant cement on the amount of remnant cement in the subgingival region (RCS) after cementation. Cement-retained implant crowns were cemented to titanium abutments using the following methods: four types of implant cement (TBN: TEMP BOND NE, NR: NEXUS RMGI, ME: MAXCEM ELITE, and U200: RELYX U200), three quantities of cement (0.02 ml, 0.04 ml, and 0.06 ml), three crown seating speeds (5 mm/s, 10 mm/s, and 15 mm/s), and two crown seating forces (25 N, 50 N). The surface area and length of the RCS were measured using a 3D intraoral scanner. The total RCS weight was measured using an analytical balance. The RCS increased significantly as the seating speed increased, the seating force increased, and the quantity of cement increased (p < 0.05). The RCS values were the highest for TBN, followed by U200, NR, and ME (p < 0.05). The lower seating speed, smaller quantity of cement used, and smaller seating force applied in cement-retained implant restorations minimized the RCS in cement-retained prostheses. The type of cement is a factor that determines the aspects of the RCS.

Implant prostheses are categorized as cement- or screw-retained prostheses1. Compared with screw-retained prostheses, cement-retained implant prostheses do not have screw access, which is advantageous because they allow a more stable occlusal surface and better aesthetics2. In addition, the cement layer between the implant abutment and restoration makes it easier to obtain passive seating with cement retention while compensating for nonpassive stresses caused by small errors generated during machining, acting as a buffer, and improving occlusal stresses1,3. However, the greatest drawback of cement-retained prostheses is that residual cement remains under the gingiva4,5, which may cause peri-implant disease and even implant loss6,7,8,9,10,11. As shown in a previous clinical study, in the majority of patients (81%), excessive dental cement under the gingiva was closely related to peri-implant disease symptoms5. Cement-retained prostheses are more difficult to retrieve than screw-retained prostheses, and, therefore, technical and eventually biological complications can be treated more difficult3. Most likely, the cement-retained prostheses will be destroyed by separation1.

Clinical considerations to prevent the movement of excessive cement into the gingiva, particularly when an implant prosthesis is cemented, are important because of its anatomical features12. In a natural tooth, there is a connective tissue surrounding the root that connects it to the alveolar bone, which is called the periodontal ligament12,13. The implant has no periodontal ligaments between the bone and the implant, and the fibres are arranged in parallel, which cannot provide a physical barrier to bacterial invasion and limits the progression of periodontal disease12. Therefore, unlike natural teeth, implants are more vulnerable to infiltration by external substances or bacteria14,15. In addition, it is clinically difficult to determine whether cement remains in the subgingival region5. Even when radiographic examinations are used, it is difficult to discriminate between remnant cement pieces16. Fragments that were 2 mm or thicker could be discovered for glass ionomers and resin cements in radiographic images, but the remnant cement in the subgingival region (RCS) of implant prostheses is generally extremely thin17. Therefore, complete removal of RCS of the implant prosthesis is clinically difficult5. Especially in cases where the implant crown margin is positioned deeper in the gingiva, the RCS is more difficult to remove16.

To reduce excessive cement residing in the gingiva, clinicians must consider clinical procedures for cementing the implant crown on the abutment18. Cement selection is important for preventing RCS; cements that are highly radio-opaque17,19, easy to remove20, and biocompatible21 are recommended. One study described similar amounts of undetected cement remnants being discovered around the esthetic margins of zirconia crown copings regardless of cement type (RMGI cement and methacrylate cement)22. Other research showed the main effects for the independent variables cement type (zinc oxide phosphate cement, glass ionomer cement, and zinc oxide noneugenol cement) showed statistically significant differences20. Additionally, cement viscosity is another factor affecting RCS; for example, cement with lower viscosity tends to spread more readily to subgingival areas than does cement with higher viscosity23. Determining the quantity of cement used for seating the implant crown is a critical factor affecting the RCS6,7. It is obvious that for the crown and abutment to completely seat, any cement that has been placed inside them in excess of the cement lute space must be extruded24. Therefore, the more cement applied, the more cement is deemed to spread into the peri-implant sulcus6,23. Seating speed and strength are additional factors that can affect the RCS because they change the viscosity of cements25 and significantly affect the amount of cement that extrudes26.

The purpose of this in vitro study was to evaluate the effects of crown seating speed, seating force, quantity of cement, and type of cement on remnant cement in the subgingival regions of cement-retained implant crowns. The null hypothesis was that there would be no difference between the RCS extruded with different types of cement, quantities of cement, crown seating speed, or crown seating force.

Preparation of specimens. Figure 1 shows the details of the specimens used in this study. The experimental models included the mandibular second premolar, first molar, and second molar, with the first molar restored using an implant. The base and adjacent tooth were composed of photopolymer acrylate type resin (MAZIC D MODEL 2.0, VERICOM CO., Republic of Korea) designed with dental systems (3SHAPE, Copenhagen, Denmark) and printed with Hunter DLP 3D printer (FLASHFORGE 3D TECHNOLOGY CO., Zhejiang, China). Customized zirconia crowns (LAVA PLUS, 3 M ESPE, Deutschland GmbH, Germany) were designed with Dental systems (3SHAPE, Copenhagen, Denmark) and fabricated with P53 milling machine (UP3D, Shenzhen, China). Customized titanium abutments were designed with Dental systems (3SHAPE, Copenhagen, Denmark) and fabricated with CNC milling machine (RABBIT BIO, Daegu, Korea). The base of the model was designed with dimensions of 40 mm length, 10 mm width, and 15 mm height (Fig. 1a). The abutment parameters were a height of 5 mm, diameter of 6 mm, and neck taper angle of 65°. All abutments were constructed at an 8° convergence angle (Fig. 1b). The angle between the long axis of the abutment and the bottom of the model was 90° (Fig. 1c). A disc shape with a height of 3 mm was given to the top of the crown to ensure that the force from the universal machine was applied in a stable, consistent direction and force (Fig. 1a). The upper surface of the disc was designed to be parallel to its base. The angle of the long axis of the abutment and the disc-shaped structure ensured that the crown-seating force could be applied axially and appropriately to cement the zirconia crown on the CAD-CAM abutment (Fig. 1c). The margin of the crown was located at the level of the surrounding free gingiva. The cement space of the zirconia crown was set to 35 μm, and the volume of the cement space was calculated via CAD.

Preparation of the experiment. (a) CAD-CAM model design. (b) Customized titanium abutment design. (c) The printed model with an analog, abutment, printed resin gingiva, and crown. The angle between the long axis of the abutment and the bottom of the model was 90°, and the top surface of the cylinder and the bottom surface of the model are parallel. (d) Procedure for artificial gingiva fabrication. The resin gingiva was changed to polyvinyl-siloxane (PVS) through the mock-up process with an impression material. (e) The disc structure helped the specimens were applied exact and consistent force from the universal machine. (f) The abutment crown assembly was easily removed from the model releasing the screw in the bottom after cementation.

Preparation of artificial gingiva. The location of the crown margin and the shape of the tissue around the implant were designed using CAD and resin gingiva (MAZIC D MODEL 2.0, VERICOM CO., Republic of Korea) was printed with Hunter DLP 3D printer (FLASHFORGE 3D TECHNOLOGY CO., Zhejiang, China). The resin gingiva was changed to polyvinyl siloxane (PVS) through a mock-up process using an impression material (Fig. 1d). The original shape of the resin gingiva was transferred to the impression material (I-SIL PREMIUM PUTTY; SPIDENT, Republic of Korea). The impression body was divided into the buccal and lingual sides. Half of the mould made with the impression material was firmly positioned on the specimen, the low-viscosity PVS material (GI MASK, COLTENE, Switzerland) was injected, and the remaining half of the mould was firmly set. After 9 min, the mold was removed to obtain the artificial gingiva.

The selection of a sample size of 10 was based on a power analysis conducted in a reference using similar materials and methods27, which determined a sample size of 10 using Minitab software at α = 0.05. Each group consisted of 10 specimens. A constant quantity of cement was mixed according to the manufacturer’s protocol and injected using a 1-ml disposable syringe. The crown was gently positioned on the abutment. In the seating speed group, a universal testing machine was used to apply a constant speed to seat the crown onto the abutment for 6 min until hardening occurred. In the seating force group, a constant load was applied vertically using an accurate weight (25 N or 50 N) to the crown for 6 min until hardening. All samples were maintained at room temperature for 24 h before the RCS measurements were performed. Excess cement was removed after the manufacturer-recommended setting time. A dental explorer was used with 10 strokes each for the mesiobuccal, buccal, distobuccal, mesiolingual, lingual, and distolingual aspects.

Crown seating. Four types of cement were used, with three different quantities and five seating conditions (three seating speeds and two seating forces), resulting in a total of 60 experimental groups. The four cement materials used were zinc oxide noneugenol cement (TBN; TEMP BOND NE, KERR CORP, Orange Calif, USA), resin-modified glass ionomer luting cement (NR; NEXUS RMGI, KERR CORP, Orange Calif, USA), and methacrylate cement (ME; MAXCEM ELITE, KERR CORP, Orange Calif, USA; and U200; RELYX U200, 3 M ESPE, Deutschland GmbH, Germany) (Table 1). The quantity of cement was 0.02 ml, 0.04 ml, and 0.06 ml depending on the size of the cement space, which was 5, 10, and 15 times the volume of the cement space, respectively. The crown seating conditions were set at speeds of 5 mm/s, 10 mm/s, and 15 mm/s or forces of 25 N and 50 N using a universal testing machine (SHIMADZU CORP., Kyoto, Japan) (Fig. 1e).

RCS measurement. The abutment crown assembly was removed from the model after the crown was sutured. There is a hole drilled downward on the specimen, enabling the assembly to be pushed out without interfering with the adhesive bond between the crown and abutment post-setting (Fig. 1f). A 3D intraoral scanner (MEDIT i700; MEDIT CORP., Seoul, Korea) was used to obtain digital RCS images. To ensure the reliability and validity of measurements, the researcher has been trained in the proper use of the scanner and understands calibration procedures. During scanning, researchers kept the scanner’s lenses and mirrors clean and free from debris. Intra-oral scanners have been calibrated through the “Calibration Wizard” software and checked for quality control before scanning. Digital images were stored in Stl format and analysed using the collaboration platform software Medit Link (MEDIT CORP, Seoul, Korea). The areas of the entire abutment surface (Fig. 2a) and the surface occupied by the RCS (Fig. 2b) were defined and recorded using Medit Link (MEDIT CORP, Seoul, Korea). The longest length of the RCS, defined as the RCS length, was measured vertically from the gingival edge of the abutment to the deepest point of the RCS on the abutment (Fig. 2c). The RCS surface percentage was calculated using the following formula (1):

Intraoral scan images. (a) Area of the entire abutment subgingival surface. (b) The area occupied by the RCS. (c) RCS length. RCS: remnant cement in subgingival regions.

The RSC weight was evaluated using an analytical balance (OHAUS CORP., Parsippany, USA). The abutment-crown assembly, from which the supragingivally positioned cement was removed, was weighed. The abutment-crown assembly was weighed again after the removal of the RCS with a dental explorer and alcohol sponge. The RCS weight was calculated using the following formula (2):

Statistical analysis. The data were analysed using descriptive statistical methods (mean ± standard deviation (SD)) and then compared between the groups. The Shapiro‒Wilk test was used to assess the normality of the data. Based on the results of assessing the normality of the data with the Shapiro-Wilk test, parametric or non-parametric statistical analysis methods were selected for the statistical analysis. Statistically significant differences between the “Implant cement type”/ “Quantity of cement”/ “Seating speed” groups in the mean RCS values were investigated with the Kruskal–Wallis test. Statistically significant differences between the “Seating force” groups in the mean RCS values were investigated with the Wilcoxon rank sum test. A 3-way analysis of variance (ANOVA) was conducted to assess the significance of the RCS between each experimental group according to the different types of implant cement, quantities of cement, crown seating speed, and crown seating force.

Kruskal–Wallis. Tables 2 and 3, and 4 show the analysis results of the effects of cement type, cement amount, seating speed, and seating force on the RCS values. TBN cement obtained the highest RCS values, and ME cement obtained the lowest values, followed by U200 and NR cement, respectively (p < 0.05). The quantities of cement impacting the RCS values range from high to low: 0.06 ml, 0.04 ml, and 0.02 ml, with statistical significance (p < 0.05). As the seating speed increased, there was a statistically significant increase in the RCS values (p < 0.05). For seating force, the RCS values of the 50 N group are significantly higher than the 25 N group (p < 0.05).

3-way ANOVA. Figs. 3, 4 and 5 show the results of RCS values in each cement group assessed according to the type of cement, crown seating speed, and quantity of cement used. The lowest values were obtained in the groups with 5 mm/s, 0.02 ml of cement, and ME implant cement, whereas the highest values were obtained in the groups with 15 mm/s, 0.06 ml of cement, and TBN implant cement (p < 0.05). The 3-way ANOVA showed that there was a significant interaction between the type of implant cement, quantity of cement, and crown seating speed (p < 0.05). Figures 6, 7 and 8 show the results of values assessed according to the type of cement, crown seating force, and quantity of cement used. The lowest values were obtained in the groups with 25 N, 0.02 ml of cement, and ME implant cement, whereas the highest values were obtained in the groups with 50 N, 0.06 ml of cement, and TBN implant cement (p < 0.05). The 3-way ANOVA showed a significant interaction between the type of implant cement, quantity of cement, and crown seating force (p < 0.05).

3-way ANOVA results for the RCS surface area (%) according to the type of implant cement, quantity of cement, and crown seating speed. RCS: remnant cement in subgingival regions. TBN: TEMP BOND NE, NR: NEXUS RMGI, ME: MAXCEM ELITE, and U200: RELYX U200. Superscripts A−C represent significant differences (p < 0.05) in crown seating speed, quantity of cement, and type of cement.

3-way ANOVA results for RCS length (mm) according to the type of implant cement, quantity of cement, and crown seating speed. RCS: remnant cement in subgingival regions. TBN: TEMP BOND NE, NR: NEXUS RMGI, ME: MAXCEM ELITE, and U200: RELYX U200. Superscripts A−C represent significant differences (p < 0.05) in crown seating speed, quantity of cement, and type of cement.

3-way ANOVA results of RCS weight (mg) according to the type of implant cement, quantity of cement, and crown seating speed. RCS: remnant cement in subgingival regions. TBN: TEMP BOND NE, NR: NEXUS RMGI, ME: MAXCEM ELITE, and U200: RELYX U200. Superscripts A−C represent significant differences (p < 0.05) in crown seating speed, quantity of cement, and type of cement.

3-way ANOVA results of RCS surface area (%) according to the type of implant cement, quantity of cement, and crown seating force. RCS: remnant cement in subgingival regions. TBN: TEMP BOND NE, NR: NEXUS RMGI, ME: MAXCEM ELITE, and U200: RELYX U200. Superscripts A−B represent significant differences (p < 0.05) in crown seating speed, quantity of cement, and type of cement.

3-way ANOVA results for RCS length (mm) according to the type of implant cement, quantity of cement, and crown seating force. RCS: remnant cement in subgingival regions. TBN: TEMP BOND NE, NR: NEXUS RMGI, ME: MAXCEM ELITE, and U200: RELYX U200. Superscripts A−B represent significant differences (p < 0.05) in crown seating speed, quantity of cement, and type of cement.

3-way ANOVA results of RCS weight (mg) according to the type of implant cement, quantity of cement, and crown seating force. RCS: remnant cement in subgingival regions. TBN: TEMP BOND NE, NR: NEXUS RMGI, ME: MAXCEM ELITE, and U200: RELYX U200. Superscripts A−B represent significant differences (p < 0.05) in crown seating speed, quantity of cement, and type of cement.

Although cement-retained implant prostheses have several advantages, residual cement under the gingiva often causes critically unfavourable results, including peri-implant disease and implant loss. In this study, the effect of crown seating conditions on remnant cement in the subgingival region was evaluated to determine the best method of implant crown seating for preventing subgingival cement remnants. The results showed that the RCS surface area, length, and weight significantly increased with increasing crown seating speed, crown seating force, and quantity of cement. ME had the lowest values, whereas TBN had the highest RCS value, RCS length, and RCS weight. Therefore, the null hypothesis was rejected.

The results of this experiment showed that regardless of the type of implant cement, crown seating force, crown seating speed applied, or quantity of cement used had a significant effect on the RCS. Previous studies have shown similar results in that the application of less cement causes less RCS, and various methods have been suggested to reduce the amount of cement required for implant restoration18,27. Otherwise, for natural teeth, a sufficient amount of cement is recommended because less cement in a fixed prosthesis causes voids in the cement space, which may cause hypersensitivity and secondary caries28. However, as hypersensitivity and secondary caries do not occur in implants, the use of less cement to prevent RCS can be recommended without worries about complications in natural teeth. In addition, determining the amount of cement is more accurate and convenient when using a CAD-CAM system. Applying less cement may be difficult because the appropriate amount of cement is determined by the cement space of the restoration, which is difficult to measure. However, compared with conventional fabrication for dental restorations, a more reliable calculation of cement space is possible in CAD-CAM, and clinicians can determine the appropriate amount of cement.

Owing to the inherent correlation between velocity and force in the software of the universal machine used in this study, the independent adjustment of these parameters is unfeasible. Therefore, the experiment was repeatedly conducted using speed and force as separate variables. The results showed that setting the crown at a faster speed or stronger force increased the RCS surface area, length, and weight. The shear-thinning properties of cement generate an excessively rapid flow when the crown is quickly seated26. Therefore, the increased speed of the crown seat causes more cement to spill under the gingiva. A previous study that evaluated the effect of crown seating speed on natural teeth also showed that seating at a speed greater than 14 mm/s leads to air entrapment and incomplete sealing of the crown margin26. Moreover, crown seating with sufficient and firm force is usually recommended for the restoration of natural teeth because crown seating with strong force improves the marginal seal of crowns during cementation29. Based on the results of this study and previous studies, to minimize RCS and ensure complete implant crown seating, it is ideal to use gentle and controlled force during the initial crown placement while applying a firmer force toward the end of the seating process.

In addition to the prerequisite of dental cement for natural tooth-fixed prostheses, cement for implant-fixed prostheses should be considered to prevent peri-implantitis20. Cement with high radiopacity helps detect RCS28, and cement that is easy to remove minimizes instances where excess cement is trapped in the abutment20. In addition, good biocompatibility and antibacterial characteristics help minimize the negative impact of excess cement21. Importantly, less invasion into the gingiva is an important characteristic of implant cement. In this study, four types of dental cement were evaluated using RCS values. The RCS values of the ME implant cement were the lowest, whereas the RCS values of TBN were the highest. The characteristics of dental cement, including viscosity, flowability, and particle size, may cause different RCS values between cements. Previous studies have shown that the lower the viscosity is, the more cement intrudes apically into the subgingival region23,25,30. The rheological properties of viscosity depend on the filler content31,32. An increased proportion of smaller particles33, lower porosity, and void size34 was observed with an increase in the viscosity of the unset cement. There is a linear correlation between film thickness and flowability rate for cement materials35, and more flowable cements are assumed to spread more easily to the gingival region of the abutment, causing more RCS. For a more exact evaluation of the relationship between RCS and the characteristics of cement, further studies with more various cements will be necessary. Under the experimental limitations of this study, the results regarding the differences in RCS values between cements suggest that cements known for good flowability, such as TBN, are preferable for crowns with supragingival margins, indicating that using minimal amounts is desirable to prevent RCS.

In this study, it was possible to derive more reliable results using CAD-CAM. The long axis of the abutment was designed to be perpendicular to the base of the specimen and the top of the crown. The relationship between the gingival level and the crown margin was consistently set with less error. Most importantly, the amount of cement can be controlled based on the volume of the cement space, which is a critical factor for RCS. The use of an intraoral scanner enabled accurate measurement of the RCS area by reproducing the abutment surface in 3D. Despite the advantages of being a reliable study, this study has several limitations, as it is an in vitro study. Temperature and moisture, which affect the polymerization of dental cement, differ between the specimen and the mouth of the patient. In addition, the spreading aspects of RCS in the artificial gingiva may differ in the gingiva of patients. Therefore, further clinical studies are needed to verify the results of the present study. In this study, the mandibular first molar was used as the research model. The abutment of this tooth shows a relatively symmetrical shape in the mesio-distal and bucco-lingual directions, which is different from the abutments of anterior teeth. This difference in shape may also cause variations in the occurrence patterns of RCS. Therefore, it seems necessary to conduct experiments similar to this study on a wider variety of tooth shapes. Due to the lack of data on the seating speed and force used by clinicians during cementation, the parameters were set arbitrarily in this study. To apply these values clinically, it is necessary to conduct future studies to determine the typical seating speed and force used by clinicians and establish guidelines based on this information.

Based on the findings of this in vitro study, the following conclusions were drawn.

When cementing an implant crown, appropriately determining the type and amount of cement, as well as the seating speed and force, is important to minimize RCS.

A lower crown seating speed, smaller quantity of cement used, and smaller crown seating force applied in cement-retained implant restorations reduce the RCS.

Cements with high flowability can cause more RCS.

The datasets used and/or analysed during the current study are available from the corresponding author upon reasonable request.

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This work was supported by the National Research Foundation of Korea (NRF) grant funded by the Korea government (MSIT) (RS-2024-00453437).

Fanghui Ji and Ji Suk Shim contributed equally to this work.

Korea University Graduate School, Medicine, Seoul, Republic of Korea

Fanghui Ji & Jae Jun Ryu

Department of Dentistry, Korea University Guro Hospital, Seoul, Republic of Korea

Ji Suk Shim & Jeongyol Lee

Department of Dentistry, Korea University Anam Hospital, Seoul, Republic of Korea

Hwiseong Oh

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J.S.S. conceived the experiment; F.H.J. and O.H.S. conducted the experiments; J.Y.L., J.J.R., and F.H.J. analyzed the results; and F.H.J. and O.H.S. wrote the manuscript. O.H.S. was responsible for management and coordination responsibility for the research activity planning and execution. All the authors reviewed the manuscript.

Correspondence to Hwiseong Oh or Jae Jun Ryu.

The authors declare no competing interests.

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Ji, F., Shim, J.S., Lee, J. et al. Effect of crown seating methods on the remnant cement in the subgingival region of a cement-retained implant crown. Sci Rep 14, 24249 (2024). https://doi.org/10.1038/s41598-024-73806-w

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Received: 07 February 2024

Accepted: 20 September 2024

Published: 16 October 2024

DOI: https://doi.org/10.1038/s41598-024-73806-w

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