{"id":6039,"date":"2023-05-02T11:58:08","date_gmt":"2023-05-02T09:58:08","guid":{"rendered":"https:\/\/blog.avinent.com\/?p=3417"},"modified":"2024-11-13T12:50:39","modified_gmt":"2024-11-13T11:50:39","slug":"fractured-screws-implant-prosthesis","status":"publish","type":"post","link":"https:\/\/avinent.com\/en\/blog\/fractured-screws-implant-prosthesis\/","title":{"rendered":"Fractured screws in Implant-supported prosthesis. Diagnosis and extraction techniques."},"content":{"rendered":"\n\t\t\t\t\n

One of the most frequent complications of implant-supported prostheses, and which causes most visits to the surgery, is the loosening of the component that is screwed to the implant (1,2). Although, on most occasions it is simple to resolve (re-screw it to the torque recommended by the manufacturer), if this situation remains over time, the instability of the implant\/attachment (or implant prosthesis, in this case of prostheses screwed to the implant head) and the unfavourable distribution of forces could end up causing the joining screw or screwed attachment (3) to fracture.<\/p>\n\n\n\n

Diagnosis of fracture of a screw:<\/strong><\/h2>\n\n\n\n

Although\nthe clinic should warn the patient that mobility of an implant-supported\nprosthesis needs treatment and they should go to the surgery, it is often not\nuntil the prosthesis has completely de-inserted that the patient decides to\nrequest dental care and the fracture of the screw is detected (4). At this\ntime, a part of the thread of the fractured screw or attachment is found in the\nde-inserted portion, but a fragment will remain inside the implant.<\/p>\n\n\n\n

Detection\nof the fracture of the screw or screwed element can be simple by visual\ninspection of connection of the implant and the de-inserted part of the\nassembly, but often requires verification by tactile sensation with an\ninstrument (e.g. exploratory probe) or the viewing of the fragment in a\nperiapical x-ray. If there is an intact screw of the same system, it is also possible\nto compare with the fragment of extracted screw to determine if it is complete\nor not, or try to screw it to the implant body to check if there is any\nobstacle preventing it from being completely screwed on (4,5).<\/p>\n\n\n\n

\"Radiographic
Figure 1: Radiographic images of implants with screw fragments in their interior. Images taken from Imam et al. 2014, and Leblebicio\u011flu Kurtulu\u015f et al. 2018 (6,7).<\/figcaption><\/figure><\/div>\n\n\n\n

If\nthe situation of loosening or de-insertion of the prosthesis has remained over\ntime, the overgrowth of gingival tissue may hinder diagnosis. In this
\ncase, to re-expose the implant platform and make\nexploration easier, the method of choice will be the use of diode laser to\neliminate the excess tissue, since the use of an electric scalpel could transmit\nexcessive heat to the implant and the underlying bone, and the conventional\nscalpel could scratch the implant\u2019s outer surface, favouring its later\ncolonisation by microorganisms (5).\n\n\n\n<\/p>\n\n\n\n

\"Overgrowth
Figure 2: Overgrowth of gingival tissue on the implant platform. Imagen taken from
Mizumoto et al. 2018 (5).<\/figcaption><\/figure><\/div>\n\n\n\n

Extraction techniques of fractured screw thread or attachment fragments:<\/strong><\/h2>\n\n\n\n

Once\nthe presence of a fragment has been verified inside the implant, the main\nobjective is to remove it to be able to screw in a new element. To do this, it\nneeds to be rotated in the opposite direction to the screwing so that it slides\nalong the internal thread of the implant to the exterior. That process is, on\noccasions, very quick and simple and, on others, requires more complex\ntechniques, a greater consultation time or the case may even arise where it is\nnot possible to successfully perform it, maintaining the integrity of the\nimplant thread. In this last case, it would be necessary to explant the implant\nand replace it, or look for prosthodontic alternatives that do not require the\nuse of the damaged implant (8,9).<\/p>\n\n\n\n

Despite\nit being possible to find a large variety of cases of fractures with different\nfragment extraction techniques and some in vitro studies testing certain extraction\nmethods in the literature, at today\u2019s date there is no system or protocol\navailable to act in the event of this complication.<\/p>\n\n\n\n

According to Mizumoto et al. (5), we can classify the different available techniques in accordance with the difficulty and risk they entail for integrity of the implant and prosthesis. Using said classification, some of the techniques described in the literature are detailed below:<\/p>\n\n\n\n

a)     Low risk techniques\ufeff<\/strong><\/h3>\n\n\n\n

<\/strong>This category includes the most conservative methods performed with typically used instruments available in any dentist\u2019s surgery.
Using a fine, small and rigid instrument (exploratory or endodontic probe, curette) the tip is positioned on the coronal surface of the screw fragment and an anticlockwise movement is performed (4,5,8,10). Special care should be taken with very fine or flexible instruments such as, for example, endodontic files, that could fracture (11).<\/p>\n\n\n\n

\"Extraction
Figure 3: Extraction of screw fragment with exploratory probe, clinical image taken from Mizumoto et al., 2018 (5)<\/figcaption><\/figure><\/div>\n\n\n\n

If these methods are not effective and the fragment moves from its place, vibration by the use of ultrasound may loosen it (5,7,10,12,13). It should be performed with a fine tip, a high power and applying a gentle rotation in anticlockwise direction on the occlusal surface of the screw to try to avoid vibration from inserting the screw deeper in the implant thread. It is recommendable to use abundant irrigation in order to not transmit high temperatures to the implant and surrounding bone (12,14).<\/p>\n\n\n\n

\"Low
Figure 4: Low risk techniques: with exploratory probe (A) and with ultrasound (B) in vitro. Image taken from Agust\u00edn-Panadero et al., 2020 (15).<\/figcaption><\/figure>\n\n\n\n

There are cases where despite the fragment having loosened, it is not simple to completely remove it from the implant thread: residues and deformations of the screw threads and of the implant may hinder the full sliding of the fragment to the exterior (7). In these cases, it is possible to use tweezers (13,16), needle-holders (3), cottons swabs (17), adhesive micro-applicators for restorations (16) to perform the complete extraction of the fragment.
\nDespite the fact that these techniques are considered low risk for the implant, special precautions should be taken in the use of the instruments, with the aim of avoiding damage, scratching or fracturing the internal threads of the implant (5).<\/p>\n\n\n\n

  • \"\"
    Figure 5: Removal of the fragment with cotton swab. Image taken from Barbosa et al., 2014 (17).<\/figcaption><\/figure><\/li>
  • \"\"
    Figure 5: Removal of the fragment with cotton swab. Image taken from Barbosa et al., 2014 (17).<\/figcaption><\/figure><\/li>
  • \"\"
    Figure 6: True Grip\u00ae adhesive micro-applicators (A). Removal of the screw fragment with adhesive micro-applicator for restorations (B), Image taken from Chen and Cho, 2018 (16).<\/figcaption><\/figure><\/li><\/ul>\n\n\n\n


    b) Moderate risk techniques:\ufeff<\/strong> <\/h3>\n\n\n\n

    This group includes the methods that require some modification to the screw fragment.
    In the cases that the anchoring of the conservative instruments is not possible, a groove or notch that allows locking the instrument and exerting the rotation force may be of practical use (10,18\u201320). A transversal groove can be made to try to extract with fragment with the aid of a flat screwdriver, if there is one in the clinic, or this could even be made with the stem of a bur for straight handpiece, metal cutting discs and self-hardening acrylic handle (21).
    If it was not possible to rotate the fragment manually, the use of the rotary instruments may be of use. It is performed by resting a bur, drill or trephine (the active part of which may be modified to make anchoring easier) on the fragment and actuating the rotary instrument in anticlockwise direction and at low speed (around 600 rpm) (5,19,20,22,23). Or instead, it is possible to combine both techniques: first make the groove in the fragment and then apply the rotary instrument so that the rotation exerted is more effective (19,20,22\u201324).
    Some companies offer broken screw extraction kits, combining a series of instruments especially designed for this purpose: Fragment Fork\u00ae (Astra Tech\u00ae; Dentsply Sirona), Rescue Kit Straumann\u00ae (Institut Straumann AG\u00ae), Rescue Instrument Nobel Biocare\u00ae (Nobel Biocare\u00ae), and Certain-Screw Removal Kit (Biomet 3i\u00ae), which are compatible with their own make of implants. Others such as Broken Screw Extraction Kit from Rhein 83\u00ae are universal and can be used with most market platforms. These kits include bur guides which adapt to the implant platform that minimise the damage caused by the burs to the implant\u2019s internal thread.
    Next, the components and systems of use of one of the most widely used kits, Broken Screw Extraction Kit from Rhein 83\u00ae, is detailed:
    This kit is formed by a centring guide compatible with most market platforms, a \u201cgrip bur\u201d, a \u201cspecial bur\u201d and a manual bur-holder device.<\/p>\n\n\n\n

    \"Components
    Figure 7: Components of Broken Screw Extraction Kit from Rhein 83\u00ae. Top left, the manual bur-holder device: bottom left, the centring guide, in the centre the \u201cgrip bur\u201d and to the right the \u201cspecial bur.\u201d Image taken from https:\/\/www.rhein83.com\/<\/figcaption><\/figure>\n\n\n\n

    In first place, the manufacturer recommends starting with the \u201cgrip bur\u201d manually applied. To do this we will place the centring guide on the implant platform and place in it the \u201cgrip bur\u201d with the manual device. The active part of the \u201cgrip bur\u201d is designed to facilitate gearing in the possible irregularities of the screw surface, hence manually applying an anticlockwise rotation it will be attempted to slide the screw towards the exterior. When all the notches of the bur stem are outside the centring guide, the screw will have been completely removed.<\/p>\n\n\n\n

    • \"\"
      Figure 8: Extraction sequence with \u201cgrip bur\u201d. From left to right: \u201cgrip bur\u201d in the centring guide, \u201cgrip bur\u201d anchored with the fragment, notches of the bur on the centring guide indicating the complete extraction, removal of the fragment with tweezers. Image taken from https:\/\/www.rhein83.com\/. <\/figcaption><\/figure><\/li>
    • \"\"
      Figure 8: Extraction sequence with \u201cgrip bur\u201d. From left to right: \u201cgrip bur\u201d in the centring guide, \u201cgrip bur\u201d anchored with the fragment, notches of the bur on the centring guide indicating the complete extraction, removal of the fragment with tweezers. Image taken from https:\/\/www.rhein83.com\/.<\/figcaption><\/figure><\/li><\/ul>\n\n\n\n

      If the fragment remains blocked inside the implant, the next step is to attempt extraction with the \u201cspecial bur\u201d The centring guide shall also be used, and in the case, a counter angle of implantology shall also be used with anticlockwise rotation and maximum torque, applying constant pressure to prepare the fragment surface. The residues will be cleaned by applying water, air and suction in the internal implant chamber. Next, the \u201cspecial bur\u201d will be applied in anti-clockwise direction at a rate of between 500 and 600 rpm, using abundant irrigation for 3 seconds. In this way we can achieve either extraction or complete destruction of the screw.<\/p>\n\n\n\n

      • \"\"
        Figure 9: Extraction sequence with \u201cspecial bur\u201d. From left to right: \u201cspecial bur\u201d in the centring guide, \u201cspecial bur\u201d anchored on the fragment, notches of the bur on the centring guide indicating the complete extraction, complete extraction of the fragment. Image taken from https:\/\/www.rhein83.com\/.<\/figcaption><\/figure><\/li>
      • \"\"
        Figure 9: Extraction sequence with \u201cspecial bur\u201d. From left to right: \u201cspecial bur\u201d in the centring guide, \u201cspecial bur\u201d anchored on the fragment, notches of the bur on the centring guide indicating the complete extraction, complete extraction of the fragment. Image taken from https:\/\/www.rhein83.com\/.<\/figcaption><\/figure><\/li><\/ul>\n\n\n\n


        c) High risk techniques:<\/strong>
        <\/h3>\n\n\n\n

        The high-risk techniques are those that involve modification now not only of the screw, but also of the actual implant to be able to be used again for a new prosthesis.
        They are divided into two groups: techniques that look to repair the implant thread to again enable the screwing of components and those that require complete elimination of the thread (5).
        When the aforementioned methods for extracting screws have the unpleasant consequence of deformation of the implant\u2019s internal thread, the contouring or reworking with manual or rotary instruments is an option that may simply resolve this problem (6,8,9,15,22,25\u201328).<\/p>\n\n\n\n

        \"Manual
        Figure 10: Manual reworking of threads, clinical image taken from Mizumoto et al., 2018 (5).<\/figcaption><\/figure><\/div>\n\n\n\n

        Another technique consists of using these profilers when the fragment is still stuck inside the thread, paradoxically pushing it towards the inside of the implant, but making the thread more favourable for the later sliding of the screw in anticlockwise direction with any of the aforementioned instruments (6).
        If the implant thread cannot be repaired with these methods, it is possible to not screw components in it and move on to a somewhat more aggressive technique: drill the internal thread of the implant completely, with diamond burs and abundant irrigation until it is completely smoothed, to later make a post & core using the conventional technique (29, 30).
        If all the techniques fail, we should consider not using the problem implant despite being biologically healthy, leaving it buried in the mucosa and seeking another prosthodontic solution (5) or planning the explantation and placing of a new implant (8).<\/p>\n\n\n\n

        Bearing in mind this classification and the extraction methods described, even if there is no protocol or consensus in this regard, it seems sensible to start by the most conservative techniques and progressively increase the risk if the desired result is not obtained. The use of screw extraction kits can simplify the procedure, with specially designed instruments for a quick and effective extraction. The knowledge of these techniques by the clinic is highly convenient to avoid, insofar as is possible the need for surgical techniques that increase the biological and financial cost for the patient.<\/p>\n\n\n\n

        Article based on G\u00f3mez Prieto E, from R\u00edo Highsmith J. An\u00e1lisis in vitro de la influencia de la deformaci\u00f3n y reparaci\u00f3n de la rosca interna del implante en el mantenimiento la precarga. Estudio piloto [Trabajo Fin de M\u00e1ster]. (In vitro analysis of the influence of the deformation and repair of the internal screw of the implant in maintaining the preload.Pilot Study [Master\u2019s Dissertation]). Madrid; Complutense University of Madrid; 2022<\/em><\/p>\n\n\n\n

        • \"\"
          Figure 1: Radiographic images of implants with screw fragments in their interior. Images taken from Imam et al. 2014, and Leblebicio\u011flu Kurtulu\u015f et al. 2018 (6,7).<\/figcaption><\/figure><\/li>
        • \"\"
          Figure 2: Overgrowth of gingival tissue on the implant platform. Imagen taken from
          Mizumoto et al. 2018 (5).<\/figcaption><\/figure><\/li>
        • \"\"
          Figure 3: Extraction of screw fragment with exploratory probe, clinical image taken from Mizumoto et al., 2018 (5)<\/figcaption><\/figure><\/li>
        • \"\"
          Figure 4: Low risk techniques: with exploratory probe (A) and with ultrasound (B) in vitro. Image taken from Agust\u00edn-Panadero et al., 2020 (15).<\/figcaption><\/figure><\/li>
        • \"\"
          Figure 5: Removal of the fragment with cotton swab. Image taken from Barbosa et al., 2014 (17).<\/figcaption><\/figure><\/li>
        • \"\"
          Figure 5: Removal of the fragment with cotton swab. Image taken from Barbosa et al., 2014 (17).<\/figcaption><\/figure><\/li>
        • \"\"
          Figure 6: True Grip\u00ae adhesive micro-applicators (A). Removal of the screw fragment with adhesive micro-applicator for restorations (B), Image taken from Chen and Cho, 2018 (16).<\/figcaption><\/figure><\/li>
        • \"\"
          Figure 7: Components of Broken Screw Extraction Kit from Rhein 83\u00ae. Top left, the manual bur-holder device: bottom left, the centring guide, in the centre the \u201cgrip bur\u201d and to the right the \u201cspecial bur.\u201d Image taken from https:\/\/www.rhein83.com\/<\/figcaption><\/figure><\/li>
        • \"\"
          Figure 8: Extraction sequence with \u201cgrip bur\u201d. From left to right: \u201cgrip bur\u201d in the centring guide, \u201cgrip bur\u201d anchored with the fragment, notches of the bur on the centring guide indicating the complete extraction, removal of the fragment with tweezers. Image taken from https:\/\/www.rhein83.com\/.<\/figcaption><\/figure><\/li>
        • \"\"
          Figure 9: Extraction sequence with \u201cspecial bur\u201d. From left to right: \u201cspecial bur\u201d in the centring guide, \u201cspecial bur\u201d anchored on the fragment, notches of the bur on the centring guide indicating the complete extraction, complete extraction of the fragment. Image taken from https:\/\/www.rhein83.com\/.<\/figcaption><\/figure><\/li>
        • \"\"
          Figure 9: Extraction sequence with \u201cspecial bur\u201d. From left to right: \u201cspecial bur\u201d in the centring guide, \u201cspecial bur\u201d anchored on the fragment, notches of the bur on the centring guide indicating the complete extraction, complete extraction of the fragment. Image taken from https:\/\/www.rhein83.com\/.<\/figcaption><\/figure><\/li>
        • \"\"
          Figure 10: Manual reworking of threads, clinical image taken from Mizumoto et al., 2018 (5).<\/figcaption><\/figure><\/li><\/ul>\n\n\n\n

          Bibliography<\/strong><\/p>\n\n\n\n

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          26. <\/strong>Joda T, Br\u00e4gger U. Management of a complication with a fractured zirconia implant abutment in the esthetic zone. Int J Oral Maxillofac Implants. febrero de 2015;30(1):e21-23.
          27. <\/strong>Lee JH, Park JH, Park CJ, Cho LR. Technique to retrieve implant abutment fragments. J Prosthet Dent. octubre de 2015;114(4):486-9.
          28. <\/strong>Imam AY, Yilmaz B, Ozcelik TB, McGlumphy E. Salvaging an Angled Implant Abutment with Damaged Internal Threads: A Clinical Report. J Prosthet Dent. mayo de 2013;109(5):287-90.
          29. <\/strong>Shah K, Lee DJ. An alternative approach for the management of fractured implant abutment screws on a mandibular implant-retained overdenture: A clinical report. J Prosthet Dent. abril de 2016;115(4):402-5.
          30. <\/strong>Canpolat C, Ozkurt-Kayahan Z, Kazazoglu E. Management of a Fractured Implant Abutment Screw: A Clinical Report. J Prosthodont. julio de 2014;23(5):402-5. <\/p>\n\t\t","protected":false},"excerpt":{"rendered":"

          \t\t\t\tOne of the most frequent complications of implant-supported prostheses, and the one that generates more office visits, is the loosening of the component that is screwed to the implant.
          \nthe loosening of the component that is screwed to the implant is the loosening of the component that is screwed to the implant.
          \nimplant.\t\t\t\t<\/p>\n","protected":false},"author":2,"featured_media":3406,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"inline_featured_image":false,"footnotes":""},"categories":[32],"tags":[],"profesional_medics":[],"segment":[170],"class_list":["post-6039","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-tips","segments-implantes"],"acf":[],"yoast_head":"\nFractured screws in implant-supported prostheses - Extraction | Avinent<\/title>\n<meta name=\"description\" content=\"One of the most frequent complications of implant-supported prostheses are fractured screws, we tell you about the different extraction techniques.\" \/>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Fractured screws in implant-supported prostheses - Extraction | Avinent\" \/>\n<meta property=\"og:description\" content=\"One of the most frequent complications of implant-supported prostheses are fractured screws, we tell you about the different extraction techniques.\" \/>\n<meta property=\"og:url\" content=\"https:\/\/avinent.wwwarcelona.net\/en\/blog\/fractured-screws-implant-prosthesis\/\" \/>\n<meta property=\"og:site_name\" content=\"Avinent\" \/>\n<meta property=\"article:published_time\" content=\"2023-05-02T09:58:08+00:00\" \/>\n<meta property=\"article:modified_time\" content=\"2024-11-13T11:50:39+00:00\" \/>\n<meta property=\"og:image\" content=\"https:\/\/avinent.wwwarcelona.net\/wp-content\/uploads\/2023\/04\/5-5.jpg\" \/>\n\t<meta property=\"og:image:width\" content=\"800\" \/>\n\t<meta property=\"og:image:height\" content=\"400\" \/>\n\t<meta property=\"og:image:type\" content=\"image\/jpeg\" \/>\n<meta name=\"author\" content=\"wwwarcelona\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<meta name=\"twitter:label1\" content=\"Written by\" \/>\n\t<meta name=\"twitter:data1\" content=\"wwwarcelona\" \/>\n\t<meta name=\"twitter:label2\" content=\"Est. reading time\" \/>\n\t<meta name=\"twitter:data2\" content=\"21 minutes\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\/\/schema.org\",\"@graph\":[{\"@type\":\"Article\",\"@id\":\"https:\/\/avinent.wwwarcelona.net\/en\/blog\/fractured-screws-implant-prosthesis\/#article\",\"isPartOf\":{\"@id\":\"https:\/\/avinent.wwwarcelona.net\/en\/blog\/fractured-screws-implant-prosthesis\/\"},\"author\":{\"name\":\"wwwarcelona\",\"@id\":\"https:\/\/avinent.com\/#\/schema\/person\/36b86133d985ef99a16d3a953381b494\"},\"headline\":\"Fractured screws in Implant-supported prosthesis. 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