influence of crown height space in cases of …

J of IMAB. 2020 Apr-Jun;26(2) https://www.journal-imab-bg.org 3107

Original article

INFLUENCE OF CROWN HEIGHT SPACE INCASES OF DETACHMENT OF THE IMPLANTSUPPORTED FIXED PARTIAL DENTURES: RET-ROSPECTIVE CLINICAL STUDY.

Dimitar Kirov1, Biser Stoichkov2

1) Department of Prosthetic Dentistry, Faculty of Dental Medicine, MedicalUniversity, Sofia, Bulgaria.2) Department of Oral and Maxillofacial Surgery, Faculty of Dental Medi-cine, Medical University, Sofia, Bulgaria.

Journal of IMAB - Annual Proceeding (Scientific Papers). 2020 Apr-Jun;26(2)Journal of IMABISSN: 1312-773Xhttps://www.journal-imab-bg.org

SUMMARY:Aim of the study: The purpose of the current study

was to determine the influence of the crown height spaceon the loss of retention in different types of implant-sup-ported Fixed Partial Dentures (FPD).

Material and Methods: 116 patients being partiallyedentulous regarding maxilla and mandibula have been fol-lowed retrospectively and restored by means of fixed pros-theses on 261 implants. The study covered a five-year fol-low-up. The following indicators have been traced: implan-tation area, type of prosthetic restorations (single crowns,splinted crowns, bridge implant - implant, bridge implant- natural tooth), the height of restorative space and detach-ment of prosthetic restorations.

Results: The detachment of the prosthesis was foundin 5.7% of all cases. This was most frequently seen in themandibular molar area (73.33%) when single crown resto-rations were used. The incidence of loss of retention in-creased when the crown height space was less than 8.0 mm.The conducted tests showed that these indicators affectwith statistical significance.

Conclusion: The results of the current study give usgrounds for assuming that the reduced crown height space,the places of implantation and the type of restorations areimportant prerequisites for the occurrence of prosthetic res-torations detachment.

Keywords: crown height space, detachment of FPD,dental implant complications, implant supported FPD

INTRODUCTIONRetaining of the fixed implant-supported restora-

tions is accomplished in several ways – by means of adhe-sion (cementing), screwing or by a combination of both [1].Their advantages and disadvantages, as well as their influ-ence on the frequency of mechanical and biological com-plications [2, 3], have been widely discussed in the scien-tific literature.

Mechanical complications in fixed implant-sup-ported prostheses can be difficult to correct, particularly

when they are permanently cemented. Loss of retention be-tween the abutment and prosthetic restoration is one of themost common complications associated with the long-termfunction of fixed implant restorations.

The results of the detachment researches of fixed im-plant prostheses are heterogeneous and show a frequencyof such complication from 2.0 to 12.5% within the first fiveyears. The risk of loss of retention after the fifth year in-creases to 23.72% [4-8].

For the construction of the fixed implant supportedrestorations having high aesthetic and functional charac-teristics, the height of the restorative space is supposed tobe within an optimal range. It has been found out that themost favourable height for making fixed implant restora-tions is between 8 and 12 mm [9, 10]. This has an influ-ence on the stability of such restorations for the years tocome. The loss of adhesive retention is most often estab-lished when the height of prosthetic restoration is less than6 mm [11, 12]. In such cases, the shorter abutment cannotprovide adequate retention of prosthetic restorations [13].

On the other hand, the type of restoration has a sig-nificant impact on the onset of detachment in fixed implantsupported restorations. Data from the studies of ClellandN et al. and of Pellizzer EP et al. shows that the incidenceof mechanical complications is lower in making dentureswith splinted crowns compared to those with single crownsunder similar other conditions [14, 15].

According to other authors, the use of splintedcrowns leads to a reduced incidence of failed implant treat-ment [16].

The biomechanical impact analyses in the study ofbridges of the implant - natural tooth type are contradic-tory. The occurrence of mechanical complications is moreoften described, and the detachment of the fixed prosthe-sis turns out to be most frequent among them [17-20].

The aim of this study was to determine the influenceof the crown height space on the loss of retention in dif-ferent types of implant-supported Fixed Partial Dentures(FPD).

https://doi.org/10.5272/jimab.2020262.3107

3108 https://www.journal-imab-bg.org J of IMAB. 2020 Apr-Jun;26(2)

MATERIAL AND METHODSIn the present study, 116 patients being partially

edentulous regarding upper and lower jaws - 63 women and55 men were followed retrospectively. The treatment wasperformed with fixed restorations on 261 implant supports.Two-stage late implantation was used following open sur-gical procedures (Fig 1-1 and Fig 1-2).

Fig. 1-1. Subcrestal implant placement by flap sur-gery with a minimum elevation of the soft tissues.

Fig. 2-1. Second surgical stage: Dental implant un-covering by forming a mucoperiosteal flap and removingthe cover screw. Six months after implantation.

Fig. 1-2. Closure of the surgical wound.

The age of the study group is from 15 to 78 years.The dental implants were exposed after four months of im-plantation in the lower jaw and after six months in the up-per jaw (Fig 2-1 and Fig 2-2).

Fig. 2-2. Second surgical stage: placement of heal-ing abutment and tissue suturing. The time required forhealing and shaping gingival tissues is between 2 and 3weeks.

The following indicators have been traced out:• Implantation area;• Type of fixed restorations: single crowns, splinted

crowns, bridge implant - implant, bridge implant - naturaltooth;

• Crown height space;• Decementation of FDPAll implants have been performed after a preliminary

occlusal analysis, including examination of the occlusalscheme, teeth eruption, crown height space as well as in-ter-tooth and maxillomandibular relations. Reporting theavailable volume bone was determined by CT scans madein a central occlusion. The following equipment was ap-plied - Planmeka Promax 3D (Planmeca Oy, Asentajankatu6, FIN-00880 Helsinki, Finland). The crown height spacewas measured at the selected implant sites on the paraxialslices. The open-source software ImageJ 1.52i (National In-stitutes of Health, Bethesda, Maryland, USA) was used. Thedistance from the crestal bone of the alveolar ridge to thefunctional tubercles of the antagonist’s teeth was reported(Fig 3).


Fig. 3. Measurement of the crown height space byCBCT. The pre-selected implant sites are marked at the left,in the middle and right - vertical cuts in the implantationplaces. The distance is reported from the level of alveolarridge to the functional tubercles of teeth antagonists.

– Type of prosthetic restoration. Single crowns weremade in 112 (42.9%) implants, splinted crowns in 51(19.5%), bridge “implant – implant” in 62 (23.8%) - andbridge “implant - natural tooth” in 36 (13.8%). Their re-tention was accomplished by cementation in all 261 cases.

– Crown height space. The data are summarized inseveral groups according to those accepted in scientific lit-erature (22): insufficient restorative space - less than 6 mm,minimum - from 6 to 8 mm, optimally - from 8 to 12 mm,large - from 12 to 15 mm as well as cases with a height ofmore than 15 mm. The minimum reading value is 5.37 mm,the maximum is 18 mm and means – 10.786 at a standarddeviation 2.987. The frequency of the analyzed cases hasbeen presented in Table 1.

Table 1. Distribution of the detachment of fixed par-tial dentures regarding their type and crown height space(CHS). The incidence of this complication is highest whenthe height is less than 6 mm. The total number of suchcases was 18, and in 1/3 of these cases, we found detach-ment after the functional loading of dental implants withinthe first year.

Table 1. Crown Height Space distribution

Cronw height space Frequency Percent(mm) (cases)

less than 6 mm 18 6,90%

from 6.0 to 8.0 mm 21 8,00%

from 8.0 to 12.0 mm 153 58,60%

from12.0 to 15.0 mm 29 11,10%

more than 15.0 mm 40 15,30%

Total 261 100,00%

– Prosthesis detachment. This complication wasfound out in 5.7% of all follow-up cases. Figure 4 pointsout the distribution of cases with and without detachmentdepending on crown height space.

Regarding implant sites, data show that the mostcommon adhesive bond loss of retention has been observedin the lower molar area (73.33% of all cases). Kruskal-Wallis test is usually used to check whether there are dif-ferences between groups. Statistically significant differ-ences were ascertained depending on the site of implantsperformed and the detachment of prosthetic restoration -γ2 (5) = 11.110, p = 0.049.

The influence of the FPD type, at the onset of suchcomplication, was followed by Kruskal-Wallis test. The datashow that there are statistically significant differences be-tween various types of prosthetic restorations - γ2(4) = 8.147,p = 0.004. The most common detachment was found to bein single crowns - 12 cases, followed by splinted crowns - 2,prosthesis in bridges of “implant - natural tooth” type - onecase and never in bridges of the “implant – implant” type.

The influence of the crown height space on the lossof retention of the prosthetic restorations has been studied

All restorations have been fixed with polymerpolyacryl-urethane cement - (Dentotemp, Itena, 153, Vic-tor Hugo Ave, 75116, Paris, France).

Postoperative checkups were performed respectivelyin the 1st, 3rd and 6th months, then once a year. An evalu-ation of the prosthesis restorations condition was carriedout: cracks traces, porcelain fractures, detachment and pres-ence of micro mobility. In cases of prosthetic restorationsdetachment, they were re-cemented with glass ionomer ce-ment - Ketac Cem Plus (3M ESPE AG, ESPE Platz, 82229Seefeld,) Germany (21).

The results statistical processing is consistent withthe nature of the data and the nature of the phenomena be-ing traced. Most of the indicators have no normal distribu-tion, which necessitated the use of nonparametric methodsof analysis. Descriptive methods of categorical and quan-titative variables (mean, median, mode, standard deviation,minimum and maximum), cross tabulations, as well as hy-pothesis testing methods have been applied (Kolmogorov-Smirnov, Mann-Whitney and Kruskal-Wallis). Data process-ing was done with IBM SPSS Statistic 20 (Armonk, NY,10504-1722, USA).

RESULTSThe results are based on data recorded by clinical

examinations and software measurements. It is assumed fora zero hypothesis (H0), that the crown height space doesnot affect the detachment of the adhesive retention betweenthe implant platform and fixed prosthetic restorations.

In order to gain clear processing and results in in-terpretation, we combined the data in relation to the im-plantation areas into six groups: maxillary molars, maxil-lary premolars, anterior maxillary teeth, mandibular ante-rior teeth, mandibular premolars and mandibular molars.Theimplants distribution according to the place of implanta-tion is as follows: maxillary molars -32 (12.3%), maxillarypremolars - 48 (18.4%), maxillary anterior teeth - 35(13.4%), mandibular anterior teeth - 20 (7.7%), mandibu-lar premolars - 29 (11.1%) and mandibular molars - 97(37.2%).


by Mann-Whitney test. The data revealed statistically sig-nificant differences between different groups: with detach-ment (mean rank 134.68) and those without (mean rank70.70), U = 940.500, p <.0001. In Table 2, it is presentedtheir distribution depending on the crown height space and

Table 2. Crown Height Space vs. FPD Type vs. Detachment of the FPD Crosstabulation (Count)

FPD Type

Detachment of Single Splinted Bridge Bridge Total

the FPD crown crowns Implant - Implant -

Implant Natural tooth

Not Detached Crown Height Space less than 6 mm 6 3 2 1 12

from 6.0 to 8.0 mm 9 6 1 1 17

from 8.0 to 12.0 mm 64 31 31 25 151

from12.0 to 15.0 mm 7 6 8 6 27

more than 15.0 mm 14 3 20 2 39

Total 100 49 62 35 246

Detached Crown Height Space less than 6 mm 5 1 0 0 6

from 6.0 to 8.0 mm 3 1 0 0 4

from 8.0 to 12.0 mm 2 0 0 0 2

from12.0 to 15.0 mm 1 0 0 1 2

more than 15.0 mm 1 0 0 0 1

Total 12 2 0 1 15

Total Crown Height Space less than 6 mm 11 4 2 1 18

from 6.0 to 8.0 mm 12 7 1 1 21

from 8.0 to 12.0 mm 66 31 31 25 153

from12.0 to 15.0 mm 8 6 8 7 29

more than 15.0 mm 15 3 20 2 40

Total 112 51 62 36 261

The data in Table 2 show that the incidence of thedetachment of the FDP increases while the crown heightspace decreases.

In the cases of detached restorations and replacementof cement with such higher retention resistance, we re-corded a new detachment in only three cases, after a pe-riod of 8 to 12 months. All of them were with single crownrestorations and limited restorative space - below 6.0 mm.The definitive resolution to the arisen complication hasbeen reached by making new screw-retained crowns.

DISCUSSIONThe data from the conducted analyses give us rea-

son to assume that the crown height space has a direct in-fluence on the detachment occurrence of the implant sup-ported FDP. On such grounds, we may reject the zero hy-potheses (Ho) and accept the alternative one.

The results of this study show that increased inci-dence of the detachment of implant-supported fixed par-tial dentures has been observed in crown height space be-low 8.0 mm (Fig 4).

type of implant supported restorations.The data in Table 2 show an increased rate of de-

cementation of implant-supported FPD when the height ofthe restorative space is minimal. This complication usuallyoccurs when single crown restorations are used.


Fig. 4. Distribution of cases versus the crownheight space. In the group with the loss of retention, thedistance from the alveolar crest to the tubercles of theteeth antagonists is less than 8.0 mm in 66.66% of thepatients studied.

restorations with splinted crowns has been reported in con-ditions of reduced crown height space. Such data are con-sistent with the published data from the studies of ClellandN et al. [14] as well as Pellizzer EP et al. [28] showing thatthe incidence of biomechanical complications is lower insplinted crown prostheses compared to prosthetic restorationswith similar single crowns under analogous other conditions.In this study, it may be assumed that the splinted crownsfavour the distribution of functional stress by reducing stressin the area of the crest module and abutment, which is sup-ported by the results of similar research [29].

The analysis of short and long-term studies showedfewer failures in adhesive retention of the fixed implant sup-ported restorations compared to screw retained [1]. However,in case of a new loss of retention under conditions of re-duced crown height space - less than 6 mm, making a newscrew retained prosthesis restoration turns out to be a goodalternative.

Surface treatment of abutments by creating retentiongrooves or increasing the contact surface of abutment bymeans of sandblasting creates conditions to improve the re-tention of the prosthetic restoration [30]. These methods aremost effective when applied with a simultaneous increaseof the abutment height and the use of reinforced cement [31].

CONCLUSIONAlthough the data in the present study are limited,

the results suggest that the reduced crown height space is aprerequisite for detachment of the implant supported FPDs.In such situations, the possibilities of subcrestal position-ing of the implant platform and the use of abutments withminimal gingival height should be considered at the plan-ning stage of prosthetic restoration. With this approach, thereis a possibility of achieving improved retention due to theincreased height of the implant abutment. If subcrestal im-plantation is impossible and the crown height space is be-low 6.0 mm, an alternative approach is to use a screw-re-tained FPDs.

AcknowledgementsWe would like to thank Assoc. Prof. Milena

Stoycheva, Medical University - Sofia, Faculty of PublicHealth, for statistical data processing.

These data are similar to those depicted in other stud-ies tracking the influence of this factor in cases of impairedretention of FPDs [23, 24]. The studies of Abbo B. et al. in-dicate that decreasing the abutment height by 1 mm signifi-cantly reduces the retention of the prosthetic restoration [25].This tendency is most pronounced when the crown heightspace is below 6 mm and combined with the use of singlecrowns. Our data are in agreement with the research carriedout by Rödiger et al. [26] where the influence of the abut-ment height and inclination over the detachment of the pros-thetic restoration is monitored. The published data revealthat these two variables directly impacted long-term reten-tion, regardless of the type of cement used - temporary orpermanent [26].

On the other hand, the use of abutments with a largerdiameter can significantly improve the retention of fixed res-torations at a reduced height [27]. This approach cannot al-ways be applied in clinical practice due to the anatomicalconstraints in the implantation area with respect to the avail-able width, length and natural alveolar bone inclination.

A significantly lower incidence of the detachment of

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Corresponding author contact information:Dimitar Kirov, assistant Professor, DDS, PhDDepartment of Prosthetic Dentistry, Faculty of Dental Medicine, MedicalUniversity - Sofia,1, St. Georgi Sofyiski Str., 1431 Sofia, Bulgaria.e-mail: [email protected]

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Please cite this article as: Kirov D, Stoichkov B. Influence of crown height space in cases of detachment of the implantsupported fixed partial dentures: Retrospective clinical study. J of IMAB. 2020 Apr-Jun;26(2):3107-3113. DOI: https://doi.org/10.5272/jimab.2020262.3107

Received: 25/06/2019; Published online: 30/04/2020

influence of crown height space in cases of …

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