A Simplified Technique for Implant-Abutment Level Impression After Soft Tissue Adaptation Around Provisional Restoration

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University of Kentucky UKnowledge Oral Health Practice Faculty Publications Oral Health Practice 5-24-2016 A Simplified Technique for Implant-Abutment Level Impression After Soft Tissue Adaptation

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1 University of Kentucky UKnowledge Oral Health Practice Faculty Publications Oral Health Practice A Simplified Technique for Implant-Abutment Level Impression After Soft Tissue Adaptation Around Provisional Restoration Ahmad Kutkut University of Kentucky, ahmad.kutkut@uky.edu Osama Abu-Hammad Taibah University, Saudi Arabia Robert Q. Frazer University of Kentucky, rfrazer@uky.edu Click here to let us know how access to this document benefits you. Follow this and additional works at: Part of the Dentistry Commons Repository Citation Kutkut, Ahmad; Abu-Hammad, Osama; and Frazer, Robert Q., "A Simplified Technique for Implant-Abutment Level Impression After Soft Tissue Adaptation Around Provisional Restoration" (2016). Oral Health Practice Faculty Publications This Article is brought to you for free and open access by the Oral Health Practice at UKnowledge. It has been accepted for inclusion in Oral Health Practice Faculty Publications by an authorized administrator of UKnowledge. For more information, please contact UKnowledge@lsv.uky.edu.

2 A Simplified Technique for Implant-Abutment Level Impression After Soft Tissue Adaptation Around Provisional Restoration Notes/Citation Information Published in Dentistry Journal, v. 4, issue 2, 14, p by the authors; licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC-BY) license ( Digital Object Identifier (DOI) This article is available at UKnowledge:

dentistry journal Article A Simplified Technique for Implant-Abutment Level Impression after Soft Tissue Adaptation around Provisional Restoration Ahmad Kutkut 1, *, Osama Abu-Hammad 2 and Robert

D646, Lexington, KY 40536, USA 2 Faculty of Dentistry, Taibah University, Almadena Almunawara, Saudi Arabia; deoaah@gmail.

3 dentistry journal Article A Simplified Technique for Implant-Abutment Level Impression after Soft Tissue Adaptation around Provisional Restoration Ahmad Kutkut 1, *, Osama Abu-Hammad 2 and Robert Frazer 3 1 Division of Prosthodontics, Department of Oral health Practice, College of Dentistry, University of Kentucky, 800 Rose St. D646, Lexington, KY 40536, USA 2 Faculty of Dentistry, Taibah University, Almadena Almunawara, Saudi Arabia; deoaah@gmail.com 3 Division of Prosthodontics, Department of Oral health Practice, College of Dentistry, University of Kentucky, Lexington, KY, 40536, USA; rfrazer@uky.edu * Correspondence: ahmad.kutkut@uky.edu or aokutkut@gmail.com; Tel.: Academic Editor: Bernhard Pommer Received: 20 January 2016; Accepted: 4 May 2016; Published: 24 May 2016 Abstract: Impression techniques for implant restorations can be implant level or abutment level impressions with open tray or closed tray techniques. Conventional implant-abutment level impression techniques are predictable for maximizing esthetic outcomes. Restoration of the implant traditionally requires the use of the metal or plastic impression copings, analogs, and laboratory components. Simplifying the dental implant restoration by reducing armamentarium through incorporating conventional techniques used daily for crowns and bridges will allow more general dentists to restore implants in their practices. The demonstrated technique is useful when modifications to implant abutments are required to correct the angulation of malpositioned implants. This technique utilizes conventional crown and bridge impression techniques. As an added benefit, it reduces costs by utilizing techniques used daily for crowns and bridges. The aim of this report is to describe a simplified conventional impression technique for custom abutments and modified prefabricated solid abutments for definitive restorations. Keywords: implant; abutment; impression; coping; analog; crown and bridge 1. Introduction Dental implants and implant restorations are preferable alternatives to conventional dentures and bridgeworks. New digital technology and enhanced biomaterials are simplifying the restoration of implants and making the chair side dental treatment quicker for patients [1]. The dental technology market is overwhelming and is experiencing unprecedented growth; sales of dental implants, abutments, and computer guided surgery are expected to exceed $1.54 billion by 2018 [2]. The implant component that serves to support and retain the prosthesis is referred to as the abutment. The abutment can be prefabricated or custom made. Custom abutments can be machined (milled) or cast to serve in those circumstances where prefabricated components are not feasible. Impression techniques for implant restorations can be implant level or abutment level, open tray or closed tray, and may use metal or plastic impression copings. Metal impression copings are more accurate than plastic copings [3]. The impression coping shape has more impact on impression inaccuracy than does the impression technique [4]. Peri-implant tissue remodeling is a continuous process occurring after surgical implant placement and through the restoration process. It has been documented in the literature that a biological width forms around the platform of implants at the time of restoration [5,6]. A bone loss of mm occurs at the implant-abutment junction due to the presence of a micro-gap at the implant-abutment connection. Dent. J. 2016, 4, 14; doi: /dj

Dent. J. 2016, 4, 14 2 of 8 abutment connection. This contaminates the implant platform and initiates inflammatory reactions and consequent bone resorption.

4 Dent. J. 2016, 4, 14 2 of 8 abutment connection. This contaminates the implant platform and initiates inflammatory reactions and consequent bone resorption. Contamination is suggested to happen when the healing abutment Dent. J. 2016, 4, 14 2 of 8 is removed during placement of the impression coping and during definitive abutment placement. As a consequence of bone loss, 1 mm of soft tissue recession can generally be expected during the first This year. contaminates Most of this the implant loss occurs platform within andthe initiates first three inflammatory months reactions following and abutment consequent connection bone surgery. resorption. Eighty Contamination percent of the isrecession suggestedwas to happen on the buccal when the side healing [5,6]. It abutment is recommended is removed to wait during three months placement for the of tissue the impression to stabilize coping before and either during selecting definitive a final abutment abutment placement. or making As a consequence final impression. of As bone a general loss, 1rule, mm of one soft can tissue anticipate recession approximately can generally1 bemm expected of recession during from the first the year. time Most of abutment of this connection loss occurs surgery within the [5,6]. first three months following abutment connection surgery. Eighty percent of the recession Kutkut was el al. on [7] the reported buccal side a [5,6]. technique It is recommended for reconstructing to wait three the implant months for emergence the tissue profile to stabilize using before either selecting a final abutment or making a final impression. As a general rule, one can titanium and zirconia custom implant abutments. To ensure an esthetic restoration, a provisional anticipate approximately 1 mm of recession from the time of abutment connection surgery [5,6]. restoration should be fabricated on the definitive abutment to allow peri implant soft tissue stability. Kutkut el al. [7] reported a technique for reconstructing the implant emergence profile using Final modifications of the finish line on the definitive abutment and abutment level impression titanium and zirconia custom implant abutments. To ensure an esthetic restoration, a provisional should be made after peri implant soft tissue stability is achieved [7]. restoration should be fabricated on the definitive abutment to allow peri-implant soft tissue stability. The aim of this report is to describe a simplified conventional impression technique for custom Final modifications of the finish line on the definitive abutment and abutment level impression should abutments be made after and modified peri-implant prefabricated soft tissue stability solid abutments is achieved for [7]. definitive restorations. It is useful when modifications The aim of to this prefabricated report is to describe implant a simplified abutment conventional are needed impression to correct technique the angulation for custom of malpositioned abutments and implant modified [8,9]. prefabricated solid abutments for definitive restorations. It is useful when modifications to prefabricated implant abutment are needed to correct the angulation of malpositioned 2. Impression implant [8,9]. Technique In conventional dental implant therapy, patients are asked to return for implant restoration after 2. Impression Technique two or three months of healing following the surgical implant placement. In most cases, patients return In with conventional the healing dental abutment implant in therapy, place (Figure patients 1). are After asked administrating to return for implant appropriate restoration topical after and local twoanesthesia, or three months the healing of healing abutment following is removed the surgical and implant the impression placement. coping In most is screwed cases, patients into the implant return (Figure with the 2). healing The abutment impression in place is made (Figure with 1). a After polyvinyl administrating siloxane appropriate material (PVS; topical 3M and ESPE, localst. Paul, anesthesia, MN, USA) the healing using open abutment tray or is closed removed tray and impression the impression techniques coping (Figures is screwed 3 and into 4) the [10,11]. implant The (Figure 2). The impression is made with a polyvinyl siloxane material (PVS; 3M ESPE, St. Paul, MN, impression is poured after the connection of the implant analogue in order to produce the working USA) using open tray or closed tray impression techniques (Figures 3 and 4) [10,11]. The impression cast. In the laboratory, a prefabricated titanium abutment is modified or a titanium custom abutment is poured after the connection of the implant analogue in order to produce the working cast. In the is used for posterior implants whereas zirconia custom abutment is used for anterior implants [7]. laboratory, a prefabricated titanium abutment is modified or a titanium custom abutment is used for The custom abutment is milled in the laboratory with an appropriate emergence profile (Figures 5 posterior implants whereas zirconia custom abutment is used for anterior implants [7]. The custom and 6) [7,12 15]. abutment is milled in the laboratory with an appropriate emergence profile (Figures 5 and 6) [7,12 15]. Figure Figure Healing Healing abutmentin in place after three months of of surgical implant implant placement. placement.

5 Dent. J. 2016, 4, 14 of Dent. J. 2016, 4, 14 3 of 8 Figure 2. Implant level impression coping in place. Figure 3. Implant replica connected into impression coping incorporated in PVS (polyvinyl siloxane) closed tray impression technique. Figure 4. Implant replica connected into impression coping incorporated in PVS open tray impression technique due to malposition implant placement.

6 Dent. J. 2016, 4, 14 4 of 8 Dent. J. 2016, 4, 14 4 of 8 Figure 5. Zirconia custom abutment in place for anterior implant restoration with anatomic emergence profile. Figure 6. Titanium custom abutment in place for posterior implant restoration with anatomic emergence profile. Approximately two weeks after the implant level impression, the definitive abutment is screwed into the implant and evaluated for for the the finish finish line line position. It should It should be be approximately 1 mm 1 mm below below the gingival the gingival margin margin [5,6]. [5,6]. Any needed Any needed modifications modifications are marked are marked intraorally intraorally and the abutment and the abutment is modified is extraorally. modified extraorally. The modified The definitive modified abutment definitive is abutment polished and is polished torqued and to 35 torqued Ncm. Screw to 35 access Ncm. should Screw be access filled should with Fermit be filled with (Patterson Fermit Dental, (Patterson St. Paul, Dental, MN, USA). St. Paul, The MN, provisional USA). The crown provisional relined crown with tooth is relined colored with acrylic tooth resin colored over acrylic the new resin definitive over the abutment new definitive and cemented abutment with and temporary cemented cement with (Figure temporary 7). cement All provisional (Figure 7). crowns All provisional are placed crowns in function are placed with in full function contact with in centric full contact occlusion in centric [7]. After occlusion one [7]. to three After months one to of three provisionalization, months of provisionalization, patients return patients for the definitive return for abutment the definitive level impression. abutment level The impression. provisional The crown provisional removed crown and any is removed remaining and cement any remaining is cleaned cement off the is definitive cleaned abutment. off the definitive After administration abutment. After of administration an appropriate of topical an appropriate and local topical anesthesia, and a local single anesthesia, retraction a cord single (00 retraction 11 ) is packed cord around (00 ) is the packed abutment around to the retract abutment just the to peri-abutment retract just the soft peri abutment tissue (Figure soft 8) tissue [16]. After (Figure approximately 8) [16]. After five approximately minutes, the five retraction minutes, cord the is retraction removed and cord light is removed body polyvinyl and light siloxane body impression polyvinyl siloxane material impression is injected material around the is injected finish line around of the the implant finish line abutment. of the implant Heavy body abutment. PVS impression Heavy body material PVS impression is placed material in the tray is placed and an in impression the tray and is an made impression using a closed is made tray using impression a closed technique. tray impression After technique. complete polymerization After complete of polymerization the impression of material, the impression the impression material, is the retrieved impression and evaluated is retrieved using and evaluated the same criteria using the as same for conventional criteria as for crown conventional and bridge crown impressions and bridge (Figure impressions 9) [17]. The (Figure provisional 9) [17]. The crown provisional cemented crown back is cemented with temporary back with cement temporary and cement excess and cement excess is cement removed. is The removed. shade The is selected, shade is selected, and an interocclusal and an interocclusal record, facebow, record, facebow, and an and impression an impression of the opposing of the opposing teeth are teeth made are made and sent and to sent the to laboratory the laboratory for conventional for conventional crown crown and and bridge bridge fabrication (Figure (Figure 10) 10) [17]. [17].

7 Dent. 14 Dent. J. J. 2016, 2016, 4, 4, of of 8 Figure 7. Figure 7. Provisional crown Provisional restoration crown restoration for for anterior anterior implant. implant. Figure Figure Abutment Abutment level level impression impression as as conventional conventional crown crown and and bridge bridge impression impression technique. technique. Figure 9. Conventional crown and bridge impression technique for implant abutment. The all ceramic or metal ceramic restorations are evaluated and the contacts and occlusion are adjusted as needed then cemented on the definitive abutments with permanent cement (Figures 11 and 12). Occlusion is evaluated with an 8-µm foil (Shim stock Occlusion Foil, Patterson Dental, St. Paul, MN, USA) to achieve resistance to withdrawal only under maximal intercuspation [7,18]. All prosthetic restorations should utilize the manufacturer s recommended components and protocol.

8 Dent. J. 2016, 4, 14 6 of 8 Dent. J. 2016, 4, 14 6 of 8 Dent. J. 2016, 4, 14 6 of 8 Figure 10. Conventional die for implant abutment supported crown fabrication. Figure 10. Conventional die for implant abutment supported crown fabrication. The all ceramic or metal ceramic restorations are evaluated and the contacts and occlusion are adjusted The as all needed ceramic then or metal cemented ceramic on the restorations definitive are abutments evaluated with and the permanent contacts cement and occlusion (Figures are 11 and adjusted 12). Occlusion as needed is then evaluated cemented with on an the 8 μm definitive foil (Shim abutments stock Occlusion with permanent Foil, Patterson cement (Figures Dental, 11 St. Paul, and MN, 12). Occlusion USA) to achieve is evaluated resistance with an to withdrawal 8 μm foil (Shim only stock under Occlusion maximal Foil, intercuspation Patterson Dental, [7,18]. St. All Figure 10. Conventional die for implant abutment supported crown fabrication. prosthetic Paul, MN, restorations USA) to achieve should resistance utilize the to manufacturer s withdrawal only recommended under maximal components intercuspation and [7,18]. protocol. All prosthetic restorations should utilize the manufacturer s recommended components and protocol. The all ceramic or metal ceramic restorations are evaluated and the contacts and occlusion are adjusted as needed then cemented on the definitive abutments with permanent cement (Figures 11 and 12). Occlusion is evaluated with an 8 μm foil (Shim stock Occlusion Foil, Patterson Dental, St. Paul, MN, USA) to achieve resistance to withdrawal only under maximal intercuspation [7,18]. All prosthetic restorations should utilize the manufacturer s recommended components and protocol. Figure Figure Anterior definitive crown cemented over definitive implant abutment. Figure 11. Anterior definitive crown cemented over definitive implant abutment. Figure Posterior definitive crown cemented over definitive implant abutment. Figure 12. Posterior definitive crown cemented over definitive implant abutment. 3. Discussion Employing conventional crown and bridge impression techniques for accurate implant-abutment level impressions may be required when further modifications need to be applied to prefabricated or customized implant abutments [8,9]. It has been reported that the accuracy of the implant-abutment Figure 12. Posterior definitive crown cemented over definitive implant abutment.

9 Dent. J. 2016, 4, 14 7 of 8 level impression is higher when the pick-up technique is used as opposed to conventional crown and bridge impression techniques [11,12]. Polyether and vinyl polysiloxane (VPS) have been recommended materials for the accurate implant-abutment level impressions [3,4,11]. The use of the conventional retraction cord technique or injectable materials to provide gingival retraction around implant abutments have been identified to be effective to expose finish lines and are suitable for conventional impression making methods [16]. There is a strong suggestion in literature that soft tissue around implant abutment connections can be sculpted through provisional restoration contours to optimize the esthetic outcomes [7,13]. Also, gold, titanium, and zirconia abutment materials exhibit excellent biological responses [13 15]. The complexity of restoring dental implants may require more armamentarium. Simplifying the restorative portion of implant supported restoration treatment through incorporating conventional crown and bridge impression techniques may allow more practitioners to restore dental implants in their practices. When this technique is utilized, special components (i.e., impression caps, positioning cylinders) or laboratory parts (i.e., multiple implant analogs) may not be required thereby reducing the costs and complexity of implant restorations and allowing the procedure to become more easily incorporated into any dental office. 4. Conclusions Peri-implant soft tissue stability around provisional restoration insures optimum esthetic outcomes. Employing well-known familiar impression techniques allow for the recording of optimum finish line positions after the appropriate adaptation of soft tissue around provisional implant restorations. This variation to the use of prefabricated impression copings allows the production of predictable restorations that are esthetically acceptable to the patient. Author Contributions: All clinical cases for this technique and manuscript write up were performed by first author. Co-authors helped in revising and proof read the manuscript. Conflicts of Interest: The authors declaim no conflict of interest. References 1. American College of Prosthodontics Messenger. Available online: (accessed on May 2012). 2. Millennium Research Group. Annual Industry Report US Markets for Dental Implants: Executive Summary. Impl. Dent. 2003, 12, Fernandez, M.A.; Paez de Mendoza, C.Y.; Platt, J.A.; Levon, J.A.; Hovijitra, S.T.; Nimmo, A. A comparative study of the accuracy between plastic and metal impression transfer copings for implant restorations. J. Prosthodontics 2013, 22, [CrossRef] [PubMed] 4. Rashidan, N.; Alikhasi, M.; Samadizadeh, S.; Beyabanaki, E.; Kharazifard, M.J. Accuracy of implant impressions with different impression coping types and shapes. Clin. Implant Dent. Relat. Res. 2012, 14, [CrossRef] [PubMed] 5. Small, P.N.; Tarnow, D.P. Gingival recession around implants: A 1-year longitudinal prospective study. Int. J. Oral Maxillofac. Implants. 2000, 15, [PubMed] 6. Grunder, U. Stability of the mucosal topography around single-tooth implants and adjacent teeth: 1-year results. Int. J. Periodontics Restor. Dent. 2000, 20, Kutkut, A.; Abu-Hammad, O.; Mitchell, R. Esthetic considerations for reconstructing implant emergence profile using titanium and zirconia custom implant abutments: Fifty case series report. J. Oral Implantol. 2013, 41, [CrossRef] [PubMed] 8. Schneider, A.L.; Kurtzman, G.M. Simplifying single-stage solid abutments: Techniques for impressioning and temporization. Dent. Today. 2004, 23, [PubMed]

Dent. J. 2016, 4, 14 8 of 8 9. Charters, R.T. Restoration of a modified solid abutment of the ITI dental implant system: One of the most unique systems in implant dentistry. J. Dent. Technol.

10 Dent. J. 2016, 4, 14 8 of 8 9. Charters, R.T. Restoration of a modified solid abutment of the ITI dental implant system: One of the most unique systems in implant dentistry. J. Dent. Technol. 2001, 18, [PubMed] 10. Chee, W.; Jivraj, S. Impression techniques for implant dentistry. Br. Dent. J. 2006, 201, [CrossRef] [PubMed] 11. Lee, H.; So, J.S.; Hochstedler, J.L.; Ercoli, C. The accuracy of implant impressions: A systematic review. J. Prosthet. Dent. 2008, 100, [CrossRef] 12. Azer, S.S. A simplified technique for creating a customized gingival emergence profile for implant-supported crowns. J. Prosthodontics 2010, 19, [CrossRef] [PubMed] 13. Lewis, M.B.; Klineberg, I. Prosthodontic considerations designed to optimize outcomes for single-tooth implants. A review of the literature. Aust. Dent. J. 2011, 56, [CrossRef] [PubMed] 14. Bertolini, M.D.; Kempen, J.; Lourenço, E.J.; Tells Dde, M. The use of CAD/CAM technology to fabricate a custom ceramic implant abutment: A clinical report. J. Prosthet. Dent. 2014, 111, [CrossRef] [PubMed] 15. Wu, T.; Liao, W.; Dai, N.; Tang, C. Design of a custom angled abutment for dental implants using computer-aided design and nonlinear finite element analysis. J. Biomech. 2010, 43, [CrossRef] [PubMed] 16. Bennani, V.; Schwass, D.; Chandler, N. Gingival retraction techniques for implants versus teeth: Current status. J. Am. Dent. Assoc. 2008, 139, [CrossRef] [PubMed] 17. Del Acqua, M.A.; Arioli-Filho, J.N.; Compagnoni, M.A.; Mollo Fde, A., Jr. Accuracy of impression and pouring techniques for an implant-supported prosthesis. Int. J. Oral Maxillofac. Implants 2008, 23, [PubMed] 18. McArdle, B.F.; Clarizio, L.F. An alternative method for restoring single-tooth implants. J. Am. Dent. Assoc. 2001, 132, [CrossRef] [PubMed] 2016 by the authors; licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC-BY) license (

Tooth preparation for posterior fi xed partial denture (FPD) Tooth preparation for anterior fi xed partial denture (FPD)

CHAPTER 17 Tooth preparation for posterior fi xed partial denture (FPD) 1 Defi nition and feature of FPD 2 Actual sequence of tooth preparation for posterior FPD Verify abutment teeth Occlusal guide groove