Cement Selection for Cement-Retained Implant-Supported

Prostheses: A Literature Review

Fatemeh Nematollahi, DDS, MS,1 Elaheh Beyabanaki, DDS, MS,2 & Marzieh Alikhasi, DDS, MS3,4
1
Department of Prosthodontics, Islamic Azad University, Dental Branch, Tehran, Iran
2
Department of Prosthodontics, Faculty of Dentistry, Shahid Beheshti University of Medical Sciences, Tehran, Iran
3
Dental Research Center, Dentistry Research Institute, Tehran University of Medical Sciences
4
Department of Prosthodontics, Faculty of Dentistry, Tehran University of Medical Sciences, Tehran, Iran

Keywords
Dental implant; dental cement;
cement-retained restoration.
Correspondence
Elaheh Beyabanaki, Dental Research Center,
Faculty of Dentistry, Tehran University of
Medical Sciences, North Amirabad St.,
Tehran, Iran.
E-mail: e.beyabanaki@gmail.com.
The authors deny any conflicts of interest.
Accepted April 16, 2015
Abstract
Cement-retained implant-supported prostheses are widely used for restoring miss-
ing teeth; however, they show some complications in comparison to screw-retained
restorations, such as difficulty in retrieving the restoration and biocompatibility of
cement. Therefore, the practitioner should consider several important aspects when
using this type of restoration. In this regard, one major concern is appropriate cement
selection, with considerations including cement biologic compatibility, methods for
limiting the excess cement, ease of removing the excess cement, radiographic view
of the cement, and also the possibility of future retrieval of the prosthesis. The aim
of this review article was to address most aspects related to this type of prosthesis in
terms of cementation.

doi: 10.1111/jopr.12361

One of the critical factors for success of implant-supported
restorations is the connection integrity of prosthetic superstruc-
ture to the implant.1 This integrity is provided by cement or
screw as two means of implant-prosthesis retention. There is
no definite superiority of either of these means of retention, and
choosing between them is mostly dependent on clinician pref-
erence regarding the clinical situation.2,3 Cement-retained pros-
theses present some advantages and disadvantages as compared
to screw-retained prostheses (Table 1).4-13 In general, according
to a systematic review comparing these two types of restora-
tions, the total rate of technical (including abutment-loosening
complications) and biological complications of cemented pros-
theses was greater.14 On the other hand, screw-retained pros-
theses showed a higher rate of ceramic fracture and chipping;
however, fracture of framework, screw, abutment, and implant
was the same for either prostheses. Also, neither the abutment
material choice nor cement choice affected the failure of ce-
mented restorations statistically.14 Nevertheless, some issues
regarding using cement for these restorations require consid-
eration. The aim of this literature review is to address con-
cerns related to retention and cementation of cement-retained
implant-supported restorations.
ment, and dental or implant-supported cement-retained restora-
tion. The titles and abstracts of the searches were checked for
relevance. If possible the full text of relevant articles was ob-
tained via manual or electronic search. Otherwise, the elec-
tronically available abstracts of the articles were gathered. The
inclusion criteria for articles were:
1. In vitro and in vivo studies
2. Studies on implant-supported fixed restorations (fixed
dental prostheses and single crowns)
3. Review articles containing relevant articles on cement-
retained implant-supported restorations
4. Studies on complication of reconstruction with minimum
follow-up of 3 years
5. Clinical reports regarding retention type/innovative
methods for minimizing excess cement.
The exclusion criteria were:
1. Finite element analysis studies
2. Studies with non-extractable data regarding cement-
retained restorations
3. Studies not written in English
4. Studies on tooth-implant connected prostheses.

Materials and methods Results

A comprehensive PubMed search was conducted from 1955 to The total number of articles obtained from the PubMed search
2014. The keywords for this search included dental implant, ce- was 549. Only 201 of these articles met the inclusion criteria for

Journal of Prosthodontics 0 (2015) 1–8 

C 2015 by the American College of Prosthodontists 1
Cement Selection for Cement-Retained Implant-Supported Prostheses
Table 1 Advantages and disadvantages of cement-retained implant-
supported restorations in comparison to screw-retained restorations
Advantage Disadvantage
Better esthetics4 Less reliable retention11
Lower clinical and laboratory technique Difficulty in retrieving11
sensitivity5 Adverse biological effects of
Easier access to posterior regions5 excess cement12
Lack of reliable stability in inadequate
inter-occlusal space situation13
Better passive fit5
First option for mis-aligned implants6
Stronger connection between implant
and prosthesis7
Optimal occlusal contacts8
Less stress concentration9
More economical10
this review. One hundred and eighty-four of these articles were
either in vitro or in vivo studies, 5 were review articles, and
12 were clinical reports. Final selection resulted in 86 articles
including 79 in vitro/in vivo studies, 3 review articles, and 4
clinical reports. There were no randomized clinical trials in this
field.
Discussion
Abutment and casting characteristics
for retention
In general, the main factors that affect the retention of
tooth/implant-supported restorations are abutment dimensions,
framework properties, and cement characteristics.15,16 Two
types of abutments that can be used with cement-retained
restorations for implants are: (1) solid abutment, and (2) two-
piece abutments with a screw access chamber within them.
Occasionally in situations with possible greater forces or re-
duced abutment/restoration interface, however, deliberately
modifing the surface characterstics of the abutment or the cast-
ing for further retention is necessary.
Sandblasting and use of airborne particles for abrasion of
castings and/or modifying the surface of the abutments can
improve retention of implant-supported restorations.17-19 Other
modifications of abutments such as creating circumferential
grooves,20 removing 3 mm (one-third) of the screw access
channel wall of the abutment, selective removal of the abut-
ment walls, and also preserving axial walls of the abutment
have been reported to enhance the total retention.13 Fur-
thermore, using abutments with greater platform diameter,13
more height, and also greater height-to-width ratio could
influence the retention positively.21,22 Another property that
should be taken into account is abutment taper. There is prob-
ably a linear relationship between retention level provided by
abutment and its taper; in other words, the retention would
decrease as the abutment taper increases (e.g., 4° to 8°).23
Therefore, abutments with more parallel heads require more
tensile force to remove the coping.24 As a result, all of these
2 Journal of Prosthodontics 0 (2015) 1–8 
Nematollahi et al
characteristics as well as cement type and interocclusal space
should be considered when selecting an appropriate cement.25
Retrieving cement-retained restorations
The main advantage of screw-retained restorations is their pre-
dictable retrievability, which saves both the restoration and
implant from risk of damage.5 However, several techniques
have been proposed to simplify the removal of cement-retained
restorations as well. One way is identifying the location of
the abutment screw access opening. Using an abutment screw
access guide (template),26 placement of a well-defined small
ceramic stain on the occlusal surface of the restoration,27 or
superimposition of two digital photographs made of the work-
ing cast with and without the restoration28 have been proposed
for easy removal of cemented restorations if required. Another
method is using computer-aided design and computer-aided
manufacturing (CAD/CAM) technology to record the position,
angulation, and orientation of the screw access opening through
scanning the working cast or the mouth.29
Several methods have been suggested to incorporate screw
access in the cemented restorations without endangering their
retention.30,31 One technique is accommodating a screw access
hole and screw in the cemented restoration to be used later if
necessary.30 The advantage of this technique over conventional
screwed restorations is improvement of esthetics and occlusion
due to a more ideal position of the screw access hole, regardless
of implant position.30 Another method is preparation of a cylin-
drical guide hole on the lingual surface of the abutment and an
access hole in the lingual aspect of the restoration. The integrity
of the cement would be broken by shear force developed upon
using a removing driver.31
Effects of residual cement on tissues
The main disadvantage of cement-retained restorations is the
excess cement, which can result in inflammation of peri-implant
tissues (peri-implantitis) due to bacterial colonization.32 Ex-
cess cement is responsible for more than 80% of peri-implant
disease.33 The severity of peri-implant tissue response to resid-
ual cement varies from bleeding, swelling, and exudation to
attachment loss and ultimately implant failure.32,34 According
to Wilson,33 4 months to almost 9 years can pass before peri-
implantitis becomes clinically evident. Early signs of tissue
reaction to the excess cement presents as swelling, bleeding,
and bone resorption that could appear from a few weeks to
few months after delivery of the restoration; however, peri-
implantitis in the form of tissue inflammation and bone loss
may develop many years after cementation.32,33 Occasionally
it is possible that despite the presence of cement remnants, no
tissue response would develop.33 The presence of a marginal
gap between the implant shoulder/abutment and suprastructure
could result in bacterial colonization, adding to the severity of
the inflammation.35
Some factors, such as cement viscosity, marginal position of
the restoration, and implant diameter,could also have an effect
on the formation of peri-implantitis.36,37 In this regard, low
viscosity cements, restorations with deep margins, and greater
implant diameter are more susceptible to excess cement,
bleeding on probing, suppuration, and peri-implant attachment
C 2015 by the American College of Prosthodontists
 Table 2 Comparative investigations on retentiveness of different cements

Investigator Evaluated cements Test Lowest retention Highest retention

Schneider24 (1987) Zinc phosphate, zinc silicophosphate, Tensile test in a universal test Polycarboxylate Glass-ionomer
glass-ionomer, polycarboxylate machine at a 0.5 cm/min
Nematollahi et al

crosshead speed using a 500

kg load cell
Clayton et al80 (1997) ZOE, glass-ionomer, hybrid glass-ionomer, Tensile test in a universal test ZOE, and after that Zinc phosphate
composite resin, zinc phosphate machine at a 5 mm/min glass-ionomer
crosshead speed
Squier et al81 (2001) Zinc phosphate, resin composite, glass Tensile test in a universal test Glass-ionomer and zinc Zinc phosphate and

Journal of Prosthodontics 0 (2015) 1–8 

ionomer, resin-reinforced glass ionomer,
eugenol-free zinc oxide
Mansour et al68 (2002) Eugenol-free zinc oxide (Temp Bond NE),
ZOE (IRM), zinc phosphate (Hy-Bond),
RMGI (ProtecCem), polycarboxylate
(Durelon), Panavia 21
Akca et al82 (2002) 3 temporary cements, polycarboxylate,
glass-ionomer, zinc phosphate
Maeyama et al83 (2005) Eugenol-free zinc oxide, zinc phosphate,
glass ionomer, resin-reinforced glass
ionomer, composite resin
machine at a 0.5 cm/min
crosshead speed using a 50 kg
load cell
Tensile test in a universal test
machine at a 0.5 mm/min
crosshead speed
Tensile test in a universal test
machine at a 0.5 mm/sec
crosshead speed with 1000 N
load
Tensile test in a universal test
machine at a 0.5 mm/min
crosshead speed
oxide-non-eugenol resin-reinforced glass-ionomer
Eugenol-free zinc oxide and Panavia 21
ZOE, and after that zinc
phosphate
Temporary cements Glass-ionomer and zinc
phosphate cements
Eugenol-free zinc oxide, and Composite resin
after that zinc phosphate

C 2015 by the American College of Prosthodontists

Pan and Lin84 (2005) Zinc phosphate cement, Advance, All-Bond
2, Panavia F, Durelon, Temp Bond,
ImProv
Wolfart al42 (2006) Eugenol-free zinc oxide (Freegenol), zinc
phosphate (Harvard), glass ionomer
(KetacCem), polycarboxylate (Durelon),
self-adhesive resin (RelyX Unicem)
Mehl et al85 (2008) Eugenol-free zinc oxide (Freegenol), zinc
phosphate (Harvard), glass ionomer
(KetacCem), polycarboxylate (Durelon),
self-adhesive resin (RelyX Unicem)
Sheets et al4 (2008) Zinc phosphate cement (Fosfato de Zinco),
RMGI (RelyX), ZOE, eugenol-free zinc
oxide (TempBond NE)
Wahl et al86 (2008) Zinc phosphate, resin composite, glass
ionomer, resin-reinforced glass ionomer,
eugenol-free zinc oxide
Garg et al87 (2013) Eugenol-free zinc oxide, resin-bonded, ZOE
cement, zinc phosphate, polycarboxylate,
glass-ionomer
Tensile test in a universal test Temp Bond, and after that All-Bond 2 and Panavia F
machine at a 0.125 cm/min zinc phosphate
crosshead speed
Tensile test in a universal test Eugenol-free zinc oxide, and Self-adhesive resin
machine at a 2 mm/min after that zinc phosphate
crosshead speed
Tensile test with an experimental Zinc oxide and self-adhesive Polycarboxylate
device resin
Tensile test in a universal test Eugenol-free zinc oxide Zinc phosphate
machine at a 0.5 mm/min
crosshead speed
Tensile test in a universal test Glass-ionomer and Zinc phosphate and
machine at a 0.5 mm/min eugenol-free zinc oxide resin-reinforced glass-ionomer
crosshead speed using a 200
kgf load cell
Tensile test in a universal test Eugenol-free zinc oxide Polycarboxylate
machine at a 0.5 mm/min
crosshead speed
Cement Selection for Cement-Retained Implant-Supported Prostheses

3
Cement Selection for Cement-Retained Implant-Supported Prostheses
loss.33,37 To facilitate removal of remaining cement in the
sulcus, the undercuts should also be reduced to a minimum.38
There are several methods for detecting cement residue
around the tooth and implants. These methods include
radiographs,39 dental endoscope,33 and flap retraction.32
While leaving excess cement in the peri-implant sulcus results
in adverse tissue reactions, attempting to remove the cement
remnants with metal instruments such as curettes and scalers
on titanium implant components could increase implant surface
roughness.40 This roughness may result in biofilm formation.41
However, according to Wilson,33 removal of residual cement
was followed by resolution of the clinical and endoscopic signs
of peri-implant disease in 76% of the cases.
Methods for limiting excess cement
There is no guideline for the appropriate amount of cement
needed for cementation of restorations. Using too little cement
could lead to leakage and inadequate retention, while using
too much could cause other problems, such as alteration in
occlusal position of the restoration (incomplete seating of the
restoration), possible harm to peri-implant tissues, and more
difficulty for clean-up of excess cement.32,34,37,40,42
The most popular way of applying cement is spreading the ce-
ment into the restoration in a uniform thin layer.43 The optimal
cement volume necessary for cementation has been estimated
to be 3% of the total crown volume, which fills an approxi-
mately 40 µm space.44 It also has been stated that filling the
cervical half of the crown instead of fully coating the interior
surface of the restoration is an effective way for reducing the
excess cement without jeopardizing the marginal seal and re-
tention of the restoration.42 On the other hand, placing cement
only in the occlusal half of the crown probably results in a gap
in the restoration margin.45
Several methods have been proposed for minimizing the
amount of cement in the restoration prior to cementation,42,45
during cementation,46 and after cementation.40 One method
for reducing the excess cement before cementation is seating
the restoration filled with cement on a practice abutment (ana-
log abutment) extraorally.45,47 This abutment could be a stock
analog or a customized analog made of poly(vinyl siloxane)
(PVS).47 After immediate wiping of excess cement, the restora-
tion would be placed in the mouth.45,47 Also, using custom-
designed abutments (such as castable abutments or CAD/CAM
abutments) with supragingival margins or slightly controlled
subgingival margins in esthetic zones (not deeper than 1 mm)
could reduce the excess cement pushed subgingivally.
Providing a venting hole on the occlusal or lingual aspect of
the restoration is another way to control cement volume during
cementation; however, more work is needed for creating the
hole and filling it after cementation.48 Using a silicone index as
a cementation index has also been suggested for this purpose.49
There are controversial opinions about filling the abutment
screw channel. It has been shown that partial filling of the
channel can improve the prosthesis retention.20 According to
Wadhwani et al50 the channel can act as a reservoir for excess
cement if left open and not sealed off prior to cementation. It
also has been proposed to create two vent holes on two oppos-
ing sides of the abutment 3 mm below the occlusal surface.51
4 Journal of Prosthodontics 0 (2015) 1–8 
Nematollahi et al
This method has the advantage of increased retentiveness of
the cement, and also decreases the excess cement extrusion as
compared to sealing off the abutment screw channel or leaving
it open.51
Nevertheless, different materials have been suggested for
filling the screw access channel of two-piece abutments in
cement-retained restorations. When the channel is filled with
PVS impression material (Elite H-D; Zhermack, Rovigo,
Italy) or polytetrafluoroethylene (PTFE) tape, known as Teflon
tape, removal of temporarily cemented restorations might be
easier.52 However, using composite resin (Filtek Z 250; 3M
ESPE, St. Paul, MN), light-cured temporary filling (Clip; Voco,
Cuxhaven, Germany), or temporary filling (Coltosol; Coltene
Whaledent, Altstätten, Switzerland) materials for filling the
channel may improve the retention of such restorations on
abutments with compromised retentive form.52
Stretching PTFE tape around the abutment before seating the
restoration has been proposed to prevent adhesion of excess ce-
ment to the gingival part of the abutment.53 Since the thickness
of stretched PTFE tape is less than 50 µm, there is no risk of in-
creasing the peri-implant sulcus space.53 On the contrary, since
gingival retraction cords could enlarge the peri-implant sulcus,
their use has not been advocated for this purpose.54 Otherwise,
cement might flow more apically and the fibrous cord might
entrap submucosally. This is because of weaker peri-implant
periodontal attachment than that of natural teeth.54
Radiographic appearance of various cements
Considering detrimental effects of excess cements on the tissues
(peri-implantitis), radiopacity of cements could serve as an im-
portant and easy way of detecting subgingival cement remnants.
The ideal radiopacity of cement would help distinguish it from
other surrounding materials and anatomical structures,55 which
is as radiopaque as possible.56 However, no minimum specific
radiographic standards have been assigned to the cements used
for implant prostheses.57 Factors that have an impact on the
radiopacity of cements include material composition, material
thickness, exposure settings, X-ray beam angulation, and eval-
uation methodology.57-60
According to Wadhwani et al61 and Pette et al,62 cements
containing zinc (non-eugenol zinc oxides and zinc phosphate
cement) are the most radiopaque cements; however, RelyX
Luting (glass ionomer) (3M ESPE) and RelyX Unicem (uni-
versal resin) (3M ESPE) are the least radiopaque cements. Also
resin-based implant specific cements (Improv; Alvelogro, Sno-
qualmie, WA; and Premier Implant Cement; Premier Dental,
Plymouth Meeting, MA) are not visible radiographically.61
Pette et al62 declared that in addition to zinc-containing ce-
ments (Fleck’s; Keystone Industries, Gibbstown, NJ; Durelon;
3M ESPE; Temp-Bond NE; Kerr, Orange, CA: Temrex; Tem-
rex Corp, Freeport, NY; and Temp-Bond Original; Kerr), resin
modified glass ionomers (GC Fuji Plus and GC Fuji IX; GC
America, Alsip IL) and composite cements (Multilink Automix
Transparent, Multilink Automix Opaque, Multilink Implant
Opaque, and Multilink Implant Transparent; Ivoclar Vivadent,
Schaan, Liechtenstein) were radiographically detectable at
thicknesses of 0.5 and 1 mm. On the other hand, resin-
based cements (Temp-Bond Clear, Temrex NE; Kerr) were
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Nematollahi et al
radiolucent; however, since the 0.5 mm thickness of cements
used in the in vitro studies is 5 to 10 times more than what is
clinically used, cements with alleged intermediate radiopacity
at 0.5 mm thickness might not be radiopaque clinically.62
Biological compatibility of different cements
The toxic effect of various cements could be different due to
their chemical composition and polymerization reaction.63-66
Resin cements can have detrimental effects on tissues due to
release of free monomers after polymerization.63 Also, their air-
inhibited non-polymerized superficial layer contains formalde-
hyde, which is a cell toxic agent.63 On the other hand, zinc
ions released from zinc-containing cements such as zinc ox-
ide eugenol (ZOE) (Temp-Bond) and zinc oxide non-eugenol
cements (Temp-Bond NE) show antibacterial effects.65,66
Furthermore, not all cements used for cementation of restora-
tions on natural teeth are suitable for implant prostheses.67,68
Durelon is a polycarboxylate cement that has a corroding effect
on titanium (Ti), according to the manufacturer’s instructions,
and is only recommended for Ti-free restorations on natural
teeth.67 There are also some concerns about 2-hydroxy ethyl
methacrylate which is released form resin-modified glass
ionomer (RMGI) cement upon polymerization.69 This material
has several toxic activities such as apoptosis, inflammation,
respiratory problems, allergy, and contact dermatitis.69
Permanent vs. temporary cementation
Several aspects should be considered when choosing between
permanent and temporary cements. Temporary cements show
some advantages, including easy removal of excess cement,
sufficient retention in normal situations, and easy retrieval of the
restoration without damage to abutment or implant.70,71 Based
on the alleged equivalent longevity of an implant prosthesis
compared to a conventional fixed prosthesis,72 retrievability of
the restoration would be an important factor in time of cement
selection. Moreover, due to intimate fit between implant and
prosthesis components, using weak cements has been justified
by many clinicians.73
ZOE cement (Temp-Bond NX) is a temporary cement that
has gained popularity due to easy manipulation, relatively low
cost, and fractional stress relaxation.74 Stress releasing may be
a good quality for cements used for implant prostheses, because
implants lack the cushioning effect of the periodontal ligament,
unlike natural teeth.74 However, temporary cements show some
disadvantages compared to permanent cements, such as more
solubility, lower strength, easier debonding of the restoration,
and radiolucent appearance in radiography.24 Washout of tem-
porary cements leads to a gap between restoration margin and
the restoration margin that would result in tissue damage at the
implant/tissue interface.24 A survey by Schwarz et al75 showed
that fracture incidence and retention loss of temporary cements
were greater than those of permanent cements; however, they
found no difference in the fracture resistance of fixed partial
dentures or abutments using either temporary or permanent
cements.
The main advantage of permanent cements over temporary
ones is their higher degree of retentiveness.24 Several fac-
tors such as resistance/retention form, height, distribution and
Journal of Prosthodontics 0 (2015) 1–8 
C 2015 by the American College of Prosthodontists
Cement Selection for Cement-Retained Implant-Supported Prostheses
number of abutments, framework fitness, and the arch receiving
the prosthesis (maxilla vs. mandible) can influence the amount
of needed retention derived from cement.76-79
The inconsistency in the literature about the retentiveness of
different cements may be the result of different cement layer
thicknesses, various mechanical tests performed in different
conditions, and also the type of abutment and its preparation.24
Table 2 shows comparative retentive levels of various cements
used in different investigations for cement-retained restora-
tions. Generally, according to most of the studies that com-
pared tensile strength of different temporary and permanent
cements, the order of cements from least to most retentive-
ness is zinc oxide (with or without eugenol), polycarboxy-
late, glass ionomer, RMGI, zinc phosphate, and resin adhesive
cements.4,25,40,68,80-87
In selection among permanent cements, simplicity of remov-
ing the excess cement and possible damage to Ti abutments
also should be considered.40 According to Agar et al40 the or-
der of cements from least to most difficult to clean up is zinc
phosphate, glass ionomer, and resin cements.
Conclusion
Based on the information obtained from peer-reviewed arti-
cles, different available cements show different retention quali-
ties for cement-retained implant-supported restorations. These
qualities might not necessarily be the same as for the cement-
retained restorations for teeth. Also, considering biologically
detrimental effects of some cements, knowledge about the most
appropriate cement for different situations, and also proper ma-
nipulation of cements is of great importance. Furthermore, ap-
plying one of the methods for limiting excess cement helps
prevent biological side effects of remnant cement, contributing
to a successful treatment. The two cements most frequently
used in studies concerning cement-retained prostheses are zinc
phosphate and ZOE cement. While zinc phosphate shows more
retention than temporary cements, and also provides simple re-
moval of excess cement due to a weaker adherence to metal in
comparison to other permanent cements, ZOE provides easier
retrievability; however, the issue of appropriate cement selec-
tion for cement-retained implant-supported prostheses would
be better addressed by conducting randomized controlled clin-
ical trials to support the findings of the laboratory studies
mentioned in this review.
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