- Email: [email protected]
A technique to eliminate subgingival cement adhesion to implant abutments by using polytetrafluoroethylene tape
A technique to eliminate subgingival cement adhesion to implant abutments by using polytetrafluoroethylene tape Timothy A. Hess, DDS School of Dentistry, University of Washington, Seattle, Wash Residual excess cement adhered subgingivally to an implant abutment has the potential to cause periimplant mucositis or periimplant disease. This article describes a procedure in which polytetrafluoroethylene (PTFE) tape is used to protect dental cements from adhering to the implant abutment. This technique ensures complete removal of cement from the implant abutment after seating of the crown. (J Prosthet Dent 2014;-:---)
Cement is increasingly being implicated as a cause of periimplant mucositis and periimplant disease.1-4 Subgingival cement is difficult to detect and remove with an instrument as a result of the circumferential orientation of tissue fibers around the implantabutment-crown complex.5 Unfortunately, most dental cements lack adequate radiopacity to be detected with conventional radiography, and innovative detection techniques are not yet commercially available.6-8 Custom abutments with equigingival margins have the potential to reduce but may not eliminate residual subgingival cement in the periimplant sulcus.9,10 Metal or zirconia custom abutments are often unesthetic if equigingival or supragingival.11,12 Esthetics may be improved by selecting an implant crown with an esthetic adhesive margin (ICEAM).13 However, on placement, cement has the potential to migrate from the abutment to the surface of the implant and below the osseous crest.14-17 The use of gingival displacement cord to protect periimplant tissues from residual excess cement is inappropriate. The cord increases the potential space of the periimplant sulcus, thereby increasing the flow of cement apically and possible entrapment of the fibrous cord.18,19 A technique of stretching polytetrafluoroethylene (PTFE) tape,
commonly known as Teflon tape, plumber’s tape, or tetrafluoroethylene (TFE) threaded seal tape (Oatey Co), around the abutment before seating will protect the adhesion or bonding of cement to the subgingival aspect of the abutment whether it is metal, porcelain, or zirconia. PTFE tape will not enlarge the periimplant sulcus because it is less than 50 mm thick when stretched. Before intraoral use, strips of PTFE tape are sterilized by placing them in sterilization pouches in a cassette autoclave (Statim5000; SciCan) set to a 17.5-minute wrapped cycle. This article describes a procedure in which PTFE tape is used to protect dental cements from adhering to the implant abutment.
TECHNIQUE 1. Fabricate the implant crown (IPS e.max; Ivoclar Vivadent Inc) with an ICEAM abutment (IPS InLine Press on Metal Ceramic; Ivoclar Vivadent Inc; Lodestar Gold; Ivoclar Vivadent Inc) and (RC Engaging Gold Abutment; Straumann) such that the buccal, mesial, and distal margins are equigingival and the lingual margin supragingival. Remove the implant crown with an ICEAM abutment from the cast and attach it to a laboratory analog (RC Implant Analog; Straumann) (Fig. 1), thereby ensuring no PTFE tape will be trapped between the abutment and the implant when seating.
1 ICEAM abutment with laboratory analog.
Presented at the American Academy of Restorative Dentistry 83rd Annual Meeting, Chicago, Ill, February 2013. Affiliate Instructor, Department of Restorative Dentistry.
Hess
2
Volume
-
Issue
2 PTFE tape stretched around ICEAM with twist on buccal.
3 ICEAM seated with no PTFE over abutment margins.
4 Crown seated.
5 Removal of excess cement.
2. Apply a light coating of petroleum jelly (Vaseline; Unilever) to the porcelain on the ICEAM. 3. Stretch PTFE tape from the lingual to the buccal and twist the ends together. Etch the gingival margin of the ICEAM with 5% hydrofluoric acid (Ceramic etching gel; Ivoclar Vivadent Inc) and apply silane (Silane Primer; Kerr) to the porcelain margin (Fig. 2). 4. Place ICEAM and tighten to the manufacturer’s recommendation. Verify that no PTFE tape is above the gingival margin (Fig. 3). If PTFE tape is above the gingival margin, use a packing instrument (CP1; G. Hartzell & Son) to slide it off the abutment margin into the periimplant sulcus. Stretch and retwist the PTFE ends to minimize the thickness on the facial surface and reduce potential enlargement of periimplant sulcus; the twisted region of PTFE tape can be routinely thinned to a thickness ranging from 0.4 to 0.7 mm.
Compress the twisted region of the PTFE tape in the facial sulcus to further reduce its thickness and gingival displacement with minimal enlargement of the periimplant sulcus occurring in a controlled, accessible location. Condense a small piece of sterile PTFE tape over the screw head to protect it from cement intrusion. Do not close off the screw-access channel of the abutment with any other material. 5. Verify seating of the ICEAM abutment and crown with a bitewing radiograph. Adjust the occlusion. Etch the crown with 5% hydrofluoric acid (Ceramic etching gel; Ivoclar Vivadent Inc) and silanate (Silane Primer; Kerr) on the intaglio surface. 6. Apply resin adhesive (Optibond XTR Adhesive; Kerr) to the intaglio surface of the crown and margin of the ICEAM. Load a small amount of resin cement (NX3 Nexus Dual Cure-Yellow; Kerr) to the margin of the crown. Seat
The Journal of Prosthetic Dentistry
-
the crown buccal to lingual or lingual to buccal (Fig. 4). 7. Wait until the gel state of the resin cement or initial polymerization. Remove excess cement, apply glycerin (Glycerin; McKesson), and light polymerize all surfaces (Fig. 5). 8. Untwist the PTFE tape, and lift mesial and distal ends incisally (Fig. 6). 9. Gently pull on 1 end of the PTFE tape toward the buccal (Fig. 7). 10. If necessary, polish the margin with a composite resin polishing point (Enhance; Dentsply Intl) to finish the restoration (Fig 8).
DISCUSSION The use of gingival displacement cord to impede the flow of subgingival cement is generally unsuccessful. Unfortunately, displacement cord can enlarge the sulcus and allow increased flow of subgingival cement similar to
Hess
-
2014
3 custom gold, titanium, and zirconia abutments, but margins should be supragingival whenever possible.9,10 A limitation of this technique is the potential for the cement to also adhere to the periimplant tissues, not just the abutment.9 Clinicians must select abutment designs and techniques to reduce the total amount of cement introduced into the crown-abutment complex, thereby minimizing the potential for excess cement being forced into and remaining in the periimplant sulcus.14-17 The direction of placement, whether buccal to lingual or lingual to buccal, is at the discretion of the clinician. Buccal to lingual has the advantage of the cement being expressed preferentially from the most supragingival margin. Lingual to buccal has the advantage of the clinician being able to observe the path of the cement and subjectively assess whether cement is being expressed into periimplant sulcus. Typically it is easier to access the buccal periimplant sulcus than the mesial, distal, or lingual.
6 PTFE untwisted.
SUMMARY
7 Removal of PTFE tape.
This article describes a simple technique with PTFE tape to eliminate residual excess cement from the implant abutment. Elimination of this cement from the abutment will help avoid periimplant disease that can lead to loss of integration of the implant.
REFERENCES
8 Definitive restoration. when it is used to displace tissue for impression making.19 PTFE tape is less than 50 mm when stretched and will not enlarge the sulcus. Dental cements can become trapped in the fibers of displacement cord, and often verification of complete removal from the perimplant sulcus is impossible. PTFE tape’s surface, in contrast, will not
Hess
become entrapped by the cement and can easily be teased from the periimplant sulcus. Care still must be taken with design of the ICEAM, and in nonesthetic areas, the margins should be kept supragingival.9,10 This stretched PTFE tape technique may be used with other abutment designs, including stock or
1. WilsonTGJr.Thepositiverelationshipbetween excesscementandperi-implantdisease:aprospectiveclinicalendoscopicstudy.JPeriodontol 2009;80:1388-92. 2. Quirynen M, De Soete M, Van Steenberghe D. Infectious risks for oral implants: a review of the literature. Clin Oral Implants Res 2002;13:1-19. 3. Gapski R, Neugeboren N, Pomeranz AZ, Reissner MW. Endosseous implant failure influenced by crown cementation: a clinical case report. Int J Oral Maxillofac Implants 2008;23:943-6. 4. Linkevicius T, Puisys A, Vindasiute E, Linkeviciene L, Apse P. Does residual cement around implant-supported restorations cause peri-implant disease? A retrospective case analysis. Clin Oral Implants Res 2012 Aug 8. (Epub ahead of print).
4
Volume 5. Agar JR, Cameron SM, Hughbanks JC, Parker MH. Cement removal from restorations luted to titanium abutments with simulated subgingival margins. J Prosthet Dent 1997;78:43-7. 6. Wadhwani C, Hess T, Faber T, Pineyro A, Chen CS. A descriptive study of the radiographic density of implant restorative cements. J Prosthet Dent 2010;103: 295-302. 7. Liu KZ, Xiang XM, Man A, Sowa MG, Cholakis A, Ghiabi E, et al. In vivo determination of multiple indices of periodontal inflammation by optical spectroscopy. J Periodontal Res 2009; 44:117-24. 8. Pette GA, Ganeles J, Norkin FJ. Radiographic appearance of commonly used cements in implant dentistry. Int J Periodontics Restorative Dent 2013; 33:61-8. 9. Linkevicius T, Vindasiute E, Puisys A, Linkeviciene L, Maslova N, Puriene A. The influence of the cementation margin position on the amount of undetected cement. A prospective clinical study. Clin Oral Implants Res 2013; 24:71-6. 10. Linkevicius T, Vindasiute E, Puisys A, Peciuliene V. The influence of margin location on the amount of undetected cement excess after delivery of cement-retained implant restorations. Clin Oral Implants Res 2011;22:1379-84.
11. Ishikawa-Nagai S, Da Silva JD, Weber HP, Park SE. Optical phenomenon of peri-implant soft tissue. Part II. Preferred implant neck color to improve soft tissue esthetics. Clin Oral Implants Res 2007;18:575-80. 12. Park SE, Da Silva JD, Weber HP, IshikawaNagai S. Optical phenomenon of peri-implant soft tissue. Part I. Spectrophotometric assessment of natural tooth gingiva and peri-implant mucosa. Clin Oral Implants Res 2007;18:569-74. 13. Wadhwani CPK, Piñeyro A, Akimoto KEN. An introduction to the implant crown with an esthetic adhesive margin (ICEAM). J Esthet Restor Dent 2012;24:246-54. 14. Tarica DY, Alvarado VM, Truong ST. Survey of United States dental schools on cementation protocols for implant crown restorations. J Prosthet Dent 2010;103:68-79. 15. Wadhwani C, Pineyro A. Technique for controlling the cement for an implant crown. J Prosthet Dent 2009;102:57-8. 16. Wadhwani C, Pineyro A, Hess T, Zhang H, Chung KH. Effect of implant abutment modification on the extrusion of excess cement at the crown-abutment margin for cement-retained implant restorations. Int J Oral Maxillofac Implants 2011;26:1241-6. 17. Wadhwani C, Hess T, Pineyro A, Opler R, Chung KH. Cement application techniques in luting implant-supported crowns: a quantitative and qualitative survey. Int J Oral Maxillofac Implants 2012; 27:859-64.
The Journal of Prosthetic Dentistry
-
Issue
-
18. Al-Ani A, Bennani V, Chandler NP, Lyons KM, Thomson WM. New Zealand dentists’ use of gingival retraction techniques for fixed prosthodontics and implants. N Z Dent J 2010;106:92-6. 19. Bennani V, Schwass D, Chandler N. Gingival retraction techniques for implants versus teeth: current status. J Am Dent Assoc 2008;139:1354-63. Corresponding author: Dr Timothy A. Hess 1268 E Main Street Auburn, WA 98002 E-mail: [email protected] Acknowledgments The author thanks Chandur Wadhwani, BDS, MSD, and Jurijs Avots, RDT, for their support. Copyright ª 2014 by the Editorial Council for The Journal of Prosthetic Dentistry.
Hess
Cement is increasingly being implicated as a cause of periimplant mucositis and periimplant disease.1-4 Subgingival cement is difficult to detect and remove with an instrument as a result of the circumferential orientation of tissue fibers around the implantabutment-crown complex.5 Unfortunately, most dental cements lack adequate radiopacity to be detected with conventional radiography, and innovative detection techniques are not yet commercially available.6-8 Custom abutments with equigingival margins have the potential to reduce but may not eliminate residual subgingival cement in the periimplant sulcus.9,10 Metal or zirconia custom abutments are often unesthetic if equigingival or supragingival.11,12 Esthetics may be improved by selecting an implant crown with an esthetic adhesive margin (ICEAM).13 However, on placement, cement has the potential to migrate from the abutment to the surface of the implant and below the osseous crest.14-17 The use of gingival displacement cord to protect periimplant tissues from residual excess cement is inappropriate. The cord increases the potential space of the periimplant sulcus, thereby increasing the flow of cement apically and possible entrapment of the fibrous cord.18,19 A technique of stretching polytetrafluoroethylene (PTFE) tape,
commonly known as Teflon tape, plumber’s tape, or tetrafluoroethylene (TFE) threaded seal tape (Oatey Co), around the abutment before seating will protect the adhesion or bonding of cement to the subgingival aspect of the abutment whether it is metal, porcelain, or zirconia. PTFE tape will not enlarge the periimplant sulcus because it is less than 50 mm thick when stretched. Before intraoral use, strips of PTFE tape are sterilized by placing them in sterilization pouches in a cassette autoclave (Statim5000; SciCan) set to a 17.5-minute wrapped cycle. This article describes a procedure in which PTFE tape is used to protect dental cements from adhering to the implant abutment.
TECHNIQUE 1. Fabricate the implant crown (IPS e.max; Ivoclar Vivadent Inc) with an ICEAM abutment (IPS InLine Press on Metal Ceramic; Ivoclar Vivadent Inc; Lodestar Gold; Ivoclar Vivadent Inc) and (RC Engaging Gold Abutment; Straumann) such that the buccal, mesial, and distal margins are equigingival and the lingual margin supragingival. Remove the implant crown with an ICEAM abutment from the cast and attach it to a laboratory analog (RC Implant Analog; Straumann) (Fig. 1), thereby ensuring no PTFE tape will be trapped between the abutment and the implant when seating.
1 ICEAM abutment with laboratory analog.
Presented at the American Academy of Restorative Dentistry 83rd Annual Meeting, Chicago, Ill, February 2013. Affiliate Instructor, Department of Restorative Dentistry.
Hess
2
Volume
-
Issue
2 PTFE tape stretched around ICEAM with twist on buccal.
3 ICEAM seated with no PTFE over abutment margins.
4 Crown seated.
5 Removal of excess cement.
2. Apply a light coating of petroleum jelly (Vaseline; Unilever) to the porcelain on the ICEAM. 3. Stretch PTFE tape from the lingual to the buccal and twist the ends together. Etch the gingival margin of the ICEAM with 5% hydrofluoric acid (Ceramic etching gel; Ivoclar Vivadent Inc) and apply silane (Silane Primer; Kerr) to the porcelain margin (Fig. 2). 4. Place ICEAM and tighten to the manufacturer’s recommendation. Verify that no PTFE tape is above the gingival margin (Fig. 3). If PTFE tape is above the gingival margin, use a packing instrument (CP1; G. Hartzell & Son) to slide it off the abutment margin into the periimplant sulcus. Stretch and retwist the PTFE ends to minimize the thickness on the facial surface and reduce potential enlargement of periimplant sulcus; the twisted region of PTFE tape can be routinely thinned to a thickness ranging from 0.4 to 0.7 mm.
Compress the twisted region of the PTFE tape in the facial sulcus to further reduce its thickness and gingival displacement with minimal enlargement of the periimplant sulcus occurring in a controlled, accessible location. Condense a small piece of sterile PTFE tape over the screw head to protect it from cement intrusion. Do not close off the screw-access channel of the abutment with any other material. 5. Verify seating of the ICEAM abutment and crown with a bitewing radiograph. Adjust the occlusion. Etch the crown with 5% hydrofluoric acid (Ceramic etching gel; Ivoclar Vivadent Inc) and silanate (Silane Primer; Kerr) on the intaglio surface. 6. Apply resin adhesive (Optibond XTR Adhesive; Kerr) to the intaglio surface of the crown and margin of the ICEAM. Load a small amount of resin cement (NX3 Nexus Dual Cure-Yellow; Kerr) to the margin of the crown. Seat
The Journal of Prosthetic Dentistry
-
the crown buccal to lingual or lingual to buccal (Fig. 4). 7. Wait until the gel state of the resin cement or initial polymerization. Remove excess cement, apply glycerin (Glycerin; McKesson), and light polymerize all surfaces (Fig. 5). 8. Untwist the PTFE tape, and lift mesial and distal ends incisally (Fig. 6). 9. Gently pull on 1 end of the PTFE tape toward the buccal (Fig. 7). 10. If necessary, polish the margin with a composite resin polishing point (Enhance; Dentsply Intl) to finish the restoration (Fig 8).
DISCUSSION The use of gingival displacement cord to impede the flow of subgingival cement is generally unsuccessful. Unfortunately, displacement cord can enlarge the sulcus and allow increased flow of subgingival cement similar to
Hess
-
2014
3 custom gold, titanium, and zirconia abutments, but margins should be supragingival whenever possible.9,10 A limitation of this technique is the potential for the cement to also adhere to the periimplant tissues, not just the abutment.9 Clinicians must select abutment designs and techniques to reduce the total amount of cement introduced into the crown-abutment complex, thereby minimizing the potential for excess cement being forced into and remaining in the periimplant sulcus.14-17 The direction of placement, whether buccal to lingual or lingual to buccal, is at the discretion of the clinician. Buccal to lingual has the advantage of the cement being expressed preferentially from the most supragingival margin. Lingual to buccal has the advantage of the clinician being able to observe the path of the cement and subjectively assess whether cement is being expressed into periimplant sulcus. Typically it is easier to access the buccal periimplant sulcus than the mesial, distal, or lingual.
6 PTFE untwisted.
SUMMARY
7 Removal of PTFE tape.
This article describes a simple technique with PTFE tape to eliminate residual excess cement from the implant abutment. Elimination of this cement from the abutment will help avoid periimplant disease that can lead to loss of integration of the implant.
REFERENCES
8 Definitive restoration. when it is used to displace tissue for impression making.19 PTFE tape is less than 50 mm when stretched and will not enlarge the sulcus. Dental cements can become trapped in the fibers of displacement cord, and often verification of complete removal from the perimplant sulcus is impossible. PTFE tape’s surface, in contrast, will not
Hess
become entrapped by the cement and can easily be teased from the periimplant sulcus. Care still must be taken with design of the ICEAM, and in nonesthetic areas, the margins should be kept supragingival.9,10 This stretched PTFE tape technique may be used with other abutment designs, including stock or
1. WilsonTGJr.Thepositiverelationshipbetween excesscementandperi-implantdisease:aprospectiveclinicalendoscopicstudy.JPeriodontol 2009;80:1388-92. 2. Quirynen M, De Soete M, Van Steenberghe D. Infectious risks for oral implants: a review of the literature. Clin Oral Implants Res 2002;13:1-19. 3. Gapski R, Neugeboren N, Pomeranz AZ, Reissner MW. Endosseous implant failure influenced by crown cementation: a clinical case report. Int J Oral Maxillofac Implants 2008;23:943-6. 4. Linkevicius T, Puisys A, Vindasiute E, Linkeviciene L, Apse P. Does residual cement around implant-supported restorations cause peri-implant disease? A retrospective case analysis. Clin Oral Implants Res 2012 Aug 8. (Epub ahead of print).
4
Volume 5. Agar JR, Cameron SM, Hughbanks JC, Parker MH. Cement removal from restorations luted to titanium abutments with simulated subgingival margins. J Prosthet Dent 1997;78:43-7. 6. Wadhwani C, Hess T, Faber T, Pineyro A, Chen CS. A descriptive study of the radiographic density of implant restorative cements. J Prosthet Dent 2010;103: 295-302. 7. Liu KZ, Xiang XM, Man A, Sowa MG, Cholakis A, Ghiabi E, et al. In vivo determination of multiple indices of periodontal inflammation by optical spectroscopy. J Periodontal Res 2009; 44:117-24. 8. Pette GA, Ganeles J, Norkin FJ. Radiographic appearance of commonly used cements in implant dentistry. Int J Periodontics Restorative Dent 2013; 33:61-8. 9. Linkevicius T, Vindasiute E, Puisys A, Linkeviciene L, Maslova N, Puriene A. The influence of the cementation margin position on the amount of undetected cement. A prospective clinical study. Clin Oral Implants Res 2013; 24:71-6. 10. Linkevicius T, Vindasiute E, Puisys A, Peciuliene V. The influence of margin location on the amount of undetected cement excess after delivery of cement-retained implant restorations. Clin Oral Implants Res 2011;22:1379-84.
11. Ishikawa-Nagai S, Da Silva JD, Weber HP, Park SE. Optical phenomenon of peri-implant soft tissue. Part II. Preferred implant neck color to improve soft tissue esthetics. Clin Oral Implants Res 2007;18:575-80. 12. Park SE, Da Silva JD, Weber HP, IshikawaNagai S. Optical phenomenon of peri-implant soft tissue. Part I. Spectrophotometric assessment of natural tooth gingiva and peri-implant mucosa. Clin Oral Implants Res 2007;18:569-74. 13. Wadhwani CPK, Piñeyro A, Akimoto KEN. An introduction to the implant crown with an esthetic adhesive margin (ICEAM). J Esthet Restor Dent 2012;24:246-54. 14. Tarica DY, Alvarado VM, Truong ST. Survey of United States dental schools on cementation protocols for implant crown restorations. J Prosthet Dent 2010;103:68-79. 15. Wadhwani C, Pineyro A. Technique for controlling the cement for an implant crown. J Prosthet Dent 2009;102:57-8. 16. Wadhwani C, Pineyro A, Hess T, Zhang H, Chung KH. Effect of implant abutment modification on the extrusion of excess cement at the crown-abutment margin for cement-retained implant restorations. Int J Oral Maxillofac Implants 2011;26:1241-6. 17. Wadhwani C, Hess T, Pineyro A, Opler R, Chung KH. Cement application techniques in luting implant-supported crowns: a quantitative and qualitative survey. Int J Oral Maxillofac Implants 2012; 27:859-64.
The Journal of Prosthetic Dentistry
-
Issue
-
18. Al-Ani A, Bennani V, Chandler NP, Lyons KM, Thomson WM. New Zealand dentists’ use of gingival retraction techniques for fixed prosthodontics and implants. N Z Dent J 2010;106:92-6. 19. Bennani V, Schwass D, Chandler N. Gingival retraction techniques for implants versus teeth: current status. J Am Dent Assoc 2008;139:1354-63. Corresponding author: Dr Timothy A. Hess 1268 E Main Street Auburn, WA 98002 E-mail: [email protected] Acknowledgments The author thanks Chandur Wadhwani, BDS, MSD, and Jurijs Avots, RDT, for their support. Copyright ª 2014 by the Editorial Council for The Journal of Prosthetic Dentistry.
Hess