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Simple method of fabricating an impression coping to reproduce peri-implant gingiva on the master cast
Simple method of fabricating an impression coping to reproduce peri-implant gingiva on the master cast Mariano A. Polack, DDS, MSa Germantown, Md. This article describes a simple technique in which a custom impression coping is fabricated with flowable composite and used to reproduce peri-implant soft tissues on the master cast. This procedure is designed to generate an accurate reproduction of the gingival contours surrounding the implant, thus contributing to a final restoration with favorable esthetics. (J Prosthet Dent 2002;88: 221-3.)
T
he restoration of implants in the anterior maxilla can be a complex task (Fig. 1). The importance of developing proper soft tissue contours has been reported as a challenge and a key factor in achieving adequate esthetics.1,2 One method of contour development is to mold and contour the peri-implant soft tissues with a provisional restoration.3 Various methods have been suggested for the fabrication of a custom impression coping for reproduction of the peri-implant soft tissues. These techniques usually involve some type of autopolymerizing acrylic resin that is added to the impression post.3,4 Another method for reproduction of the gingival form surrounding an implant involves seating the provisional restoration used to shape the gingiva after the implant has been exposed into the soft tissue master cast.5 After the soft tissue material has been removed from the cast, an elastomeric material is injected around the provisional restoration and must be trimmed to replicate the soft tissues. This technique may not be particularly precise, because the final contours of the gingival reproduction on the master cast depend on the accuracy of the trimming performed by the operator. To benefit from any technique, an accurate reproduction of the gingival tissues surrounding the implant is needed on the master cast. However, when the provisional restoration is removed and the impression coping is connected to the implant to make the final impression, the soft tissue may collapse into the space above the implant.6 In addition, most standard round cylindrical impression copings do not support the modified gingiva properly, preventing its adequate reproduction in the master cast.4 This problem could translate into an unesthetic final restoration with less-than-ideal surrounding soft tissues. This article describes a technique in which an impression coping is customized with a flowable composite and used to reproduce peri-implant soft tissues accurately
a
Private practice.
AUGUST 2002
Fig. 1. Congenitally missing right lateral incisor.
on the master cast, thereby contributing to a final restoration with favorable esthetics.
TECHNIQUE 1. The provisional restoration should contour the gingiva to the desired shape. This process may take several weeks. Once it has been achieved, remove the provisional restoration. A space between the implant and the gingiva will be evident (peri-implant crevicular space) (Fig. 2, A). 2. For retention purposes, use a carbide bur to make 2 or 3 notches on the side of a standard impression coping (Spline; Sulzer Dental Inc, Carlsbad, Calif.). Immediately connect the coping to the implant. 3. Without delay, fill the peri-implant crevicular space with flowable composite (Permaflo; Ultradent, South Jordan, Utah) to the height of the peri-implant tissue crest, and light-polymerize it (Visilux II, output intensity ⱖ 450 mW/cm2; 3M Dental Products, St. Paul, Minn.). Add more flowable composite, extending it onto the post to enhance mechanical retention to the existing composite, and light-polymerize (Fig. 2, B). The composite will remain attached to the impression coping and support the soft tissues adequately. THE JOURNAL OF PROSTHETIC DENTISTRY 221
THE JOURNAL OF PROSTHETIC DENTISTRY
POLACK
Fig. 2. A, Peri-implant crevicular space exposed after removal of provisional restoration. B, Impression post with flowable composite filling peri-implant crevicular space and extending onto post to gain mechanical retention.
Fig. 3. A, Soft tissue master cast. B, Cemented metal-ceramic implant restoration. Note interdental papilla filling interproximal space, overall gingival contours, and esthetics.
4. Make a closed-tray7 final impression with an elastomeric material (Express; 3M Dental Products). Make an interocclusal record with the material of choice. 5. Unscrew the now-customized impression coping, and immediately replace the provisional restoration. 6. Connect an implant analog (Spline; Sulzer Dental Inc) to the custom impression coping, and seat it firmly in the impression. 7. Fabricate a soft tissue master cast. 8. Unscrew and remove the custom impression coping. The cast will accurately reproduce the gingival tissues surrounding the implant (Fig. 3, A). 9. Mount the cast in the articulator of choice. Select the abutment, and fabricate the final restoration of choice (Fig. 3, B).
SUMMARY A technique for reproducing, on the master cast, the anatomically healed tissue surrounding a provi222
sional implant restoration has been presented. The use of flowable composite instead of acrylic resin has several advantages: the former is easier to place because of its syringe delivery system, and it is less time consuming because it can be polymerized immediately (acrylic resin may require the bead-brush technique8 or additional polymerization time). The described technique prevents distortion of the gingival form when the final impression is made and permits accurate reproduction, allowing for predictable esthetics in the final restoration.
REFERENCES 1. Chee WW, Cho GC, Ha S. Replicating soft tissue contours on working casts for implant restorations. J Prosthodont 1997;6:218-20. 2. Jovanovic SA, Paul SJ, Nishimura RD. Anterior implant-supported reconstructions: a surgical challenge. Pract Periodontics Aesthet Dent 1999;11: 551-8; quiz 560. 3. Donitza A. Prosthetic procedures for optimal aesthetics in single-tooth implant restorations: a case report. Pract Periodontics Aesthet Dent 2000; 12:347-52; quiz 354.
VOLUME 88 NUMBER 2
POLACK
THE JOURNAL OF PROSTHETIC DENTISTRY
4. Hinds KF. Custom impression coping for an exact registration of the healed tissue in the esthetic implant restoration. Int J Periodontics Restorative Dent 1997;17:584-91. 5. Breeding LC, Dixon DL. Transfer of gingival contours to a master cast. J Prosthet Dent 1996;75:341-3. 6. Biggs WF, Litvak AL Jr. Immediate provisional restorations to aid in gingival healing and optimal contours for implant patients. J Prosthet Dent 2001; 86:177-80. 7. Spector MR, Donovan TE, Nicholls JI. An evaluation of impression techniques for osseointegrated implants. J Prosthet Dent 1990;63:444-7. 8. Esquivel JF, Welsch BB. Simplifying the bead-brush technique. Gen Dent 1999;47:607.
Noteworthy Abstracts of the Current Literature
Reprint requests to: DR MARIANO A. POLACK 15303 GABLE RIDGE CT, APT A ROCKVILLE, MD 20850 FAX: (240)631-8076 E-MAIL: [email protected] Copyright © 2002 by The Editorial Council of The Journal of Prosthetic Dentistry. 0022-3913/2002/$35.00 ⫹ 0 10/1/127895 doi:10.1067/mpr.2002.127895
Shock absorbability and hardness of commercially available denture teeth. Kawano F, Ohguri T, Ichikawa T, Mizuno I, Hasegawa A. Int J Prosthodont 2002;15:243-7.
Purpose. This study analyzed the impact resistance and energy absorption (shock absorbability) of several commercially available denture teeth. The relationship between impact resistance and hardness of the teeth was also evaluated. Material and methods. Seven mandibular right first molars were obtained from 1 type of acrylic resin denture tooth (BioAce Resin Teeth, Shofu), 1 type of porcelain tooth (Livdent FB20, GC), and 7 different types of composite teeth (Surpass, GC; Duradent, GC; SR-Postaris, Ivoclar; SROrthosit, Ivoclar; Efucera-P, Yamahachi; Duracross, Nissin; and Edentula Posterio, Shofu). A heat-polymerized acrylic denture base resin (Acron, GC) was used to form the base for the 63 tooth specimens. Following base polymerization, the completed specimens were stored in distilled water for 37°C for 50 hours. Impact testing was completed on each specimen by releasing a 10-mm diameter steel ball weighing 5.5 g from 50 mm above each of the specimens. As the ball fell to the central fossae of the artificial teeth, a personal computer was used to record the complete acceleration responses. The impact values were then computed for the specimens. Vickers hardness measurements were completed following the impact tests. A 1-way analysis of variance and a Scheffe compromise post hoc test were used to analyze the gathered data. Further, the relationship between values and Vickers hardness was ascertained using the Pearson correlation coefficient. Results. Within the limitations of this study a significant difference occurred in the impact values of the teeth tested (␣⫽.05). The porcelain teeth exhibited the significantly highest impact values of all the teeth. The acrylic resin teeth exhibited the lowest impact values, however, the values of the acrylic resin teeth were statistically similar to 4 of the composite teeth (Surpass, Duracross, Duradent, and SR-Orthosit). Efucera-P demonstrated the highest impact value among the composite teeth. The hardness of the porcelain teeth was approximately 53 times greater than that of the acrylic resin teeth. The composite teeth showed intermediate hardness values between the acrylic resin teeth and the porcelain teeth. Finally, a significant correlation existed between the impact values and the hardness of the teeth tested. Conclusions. This in vitro study demonstrated that the 7 types of composite denture teeth showed tested better hardness properties when compared to 1 of acrylic resin tooth type. Along with the improved hardness properties, these composite teeth also maintained the greater shock absorbability inherent in teeth fabricated from acrylic resin. 14 References.—DL Dixon
AUGUST 2002
223
T
he restoration of implants in the anterior maxilla can be a complex task (Fig. 1). The importance of developing proper soft tissue contours has been reported as a challenge and a key factor in achieving adequate esthetics.1,2 One method of contour development is to mold and contour the peri-implant soft tissues with a provisional restoration.3 Various methods have been suggested for the fabrication of a custom impression coping for reproduction of the peri-implant soft tissues. These techniques usually involve some type of autopolymerizing acrylic resin that is added to the impression post.3,4 Another method for reproduction of the gingival form surrounding an implant involves seating the provisional restoration used to shape the gingiva after the implant has been exposed into the soft tissue master cast.5 After the soft tissue material has been removed from the cast, an elastomeric material is injected around the provisional restoration and must be trimmed to replicate the soft tissues. This technique may not be particularly precise, because the final contours of the gingival reproduction on the master cast depend on the accuracy of the trimming performed by the operator. To benefit from any technique, an accurate reproduction of the gingival tissues surrounding the implant is needed on the master cast. However, when the provisional restoration is removed and the impression coping is connected to the implant to make the final impression, the soft tissue may collapse into the space above the implant.6 In addition, most standard round cylindrical impression copings do not support the modified gingiva properly, preventing its adequate reproduction in the master cast.4 This problem could translate into an unesthetic final restoration with less-than-ideal surrounding soft tissues. This article describes a technique in which an impression coping is customized with a flowable composite and used to reproduce peri-implant soft tissues accurately
a
Private practice.
AUGUST 2002
Fig. 1. Congenitally missing right lateral incisor.
on the master cast, thereby contributing to a final restoration with favorable esthetics.
TECHNIQUE 1. The provisional restoration should contour the gingiva to the desired shape. This process may take several weeks. Once it has been achieved, remove the provisional restoration. A space between the implant and the gingiva will be evident (peri-implant crevicular space) (Fig. 2, A). 2. For retention purposes, use a carbide bur to make 2 or 3 notches on the side of a standard impression coping (Spline; Sulzer Dental Inc, Carlsbad, Calif.). Immediately connect the coping to the implant. 3. Without delay, fill the peri-implant crevicular space with flowable composite (Permaflo; Ultradent, South Jordan, Utah) to the height of the peri-implant tissue crest, and light-polymerize it (Visilux II, output intensity ⱖ 450 mW/cm2; 3M Dental Products, St. Paul, Minn.). Add more flowable composite, extending it onto the post to enhance mechanical retention to the existing composite, and light-polymerize (Fig. 2, B). The composite will remain attached to the impression coping and support the soft tissues adequately. THE JOURNAL OF PROSTHETIC DENTISTRY 221
THE JOURNAL OF PROSTHETIC DENTISTRY
POLACK
Fig. 2. A, Peri-implant crevicular space exposed after removal of provisional restoration. B, Impression post with flowable composite filling peri-implant crevicular space and extending onto post to gain mechanical retention.
Fig. 3. A, Soft tissue master cast. B, Cemented metal-ceramic implant restoration. Note interdental papilla filling interproximal space, overall gingival contours, and esthetics.
4. Make a closed-tray7 final impression with an elastomeric material (Express; 3M Dental Products). Make an interocclusal record with the material of choice. 5. Unscrew the now-customized impression coping, and immediately replace the provisional restoration. 6. Connect an implant analog (Spline; Sulzer Dental Inc) to the custom impression coping, and seat it firmly in the impression. 7. Fabricate a soft tissue master cast. 8. Unscrew and remove the custom impression coping. The cast will accurately reproduce the gingival tissues surrounding the implant (Fig. 3, A). 9. Mount the cast in the articulator of choice. Select the abutment, and fabricate the final restoration of choice (Fig. 3, B).
SUMMARY A technique for reproducing, on the master cast, the anatomically healed tissue surrounding a provi222
sional implant restoration has been presented. The use of flowable composite instead of acrylic resin has several advantages: the former is easier to place because of its syringe delivery system, and it is less time consuming because it can be polymerized immediately (acrylic resin may require the bead-brush technique8 or additional polymerization time). The described technique prevents distortion of the gingival form when the final impression is made and permits accurate reproduction, allowing for predictable esthetics in the final restoration.
REFERENCES 1. Chee WW, Cho GC, Ha S. Replicating soft tissue contours on working casts for implant restorations. J Prosthodont 1997;6:218-20. 2. Jovanovic SA, Paul SJ, Nishimura RD. Anterior implant-supported reconstructions: a surgical challenge. Pract Periodontics Aesthet Dent 1999;11: 551-8; quiz 560. 3. Donitza A. Prosthetic procedures for optimal aesthetics in single-tooth implant restorations: a case report. Pract Periodontics Aesthet Dent 2000; 12:347-52; quiz 354.
VOLUME 88 NUMBER 2
POLACK
THE JOURNAL OF PROSTHETIC DENTISTRY
4. Hinds KF. Custom impression coping for an exact registration of the healed tissue in the esthetic implant restoration. Int J Periodontics Restorative Dent 1997;17:584-91. 5. Breeding LC, Dixon DL. Transfer of gingival contours to a master cast. J Prosthet Dent 1996;75:341-3. 6. Biggs WF, Litvak AL Jr. Immediate provisional restorations to aid in gingival healing and optimal contours for implant patients. J Prosthet Dent 2001; 86:177-80. 7. Spector MR, Donovan TE, Nicholls JI. An evaluation of impression techniques for osseointegrated implants. J Prosthet Dent 1990;63:444-7. 8. Esquivel JF, Welsch BB. Simplifying the bead-brush technique. Gen Dent 1999;47:607.
Noteworthy Abstracts of the Current Literature
Reprint requests to: DR MARIANO A. POLACK 15303 GABLE RIDGE CT, APT A ROCKVILLE, MD 20850 FAX: (240)631-8076 E-MAIL: [email protected] Copyright © 2002 by The Editorial Council of The Journal of Prosthetic Dentistry. 0022-3913/2002/$35.00 ⫹ 0 10/1/127895 doi:10.1067/mpr.2002.127895
Shock absorbability and hardness of commercially available denture teeth. Kawano F, Ohguri T, Ichikawa T, Mizuno I, Hasegawa A. Int J Prosthodont 2002;15:243-7.
Purpose. This study analyzed the impact resistance and energy absorption (shock absorbability) of several commercially available denture teeth. The relationship between impact resistance and hardness of the teeth was also evaluated. Material and methods. Seven mandibular right first molars were obtained from 1 type of acrylic resin denture tooth (BioAce Resin Teeth, Shofu), 1 type of porcelain tooth (Livdent FB20, GC), and 7 different types of composite teeth (Surpass, GC; Duradent, GC; SR-Postaris, Ivoclar; SROrthosit, Ivoclar; Efucera-P, Yamahachi; Duracross, Nissin; and Edentula Posterio, Shofu). A heat-polymerized acrylic denture base resin (Acron, GC) was used to form the base for the 63 tooth specimens. Following base polymerization, the completed specimens were stored in distilled water for 37°C for 50 hours. Impact testing was completed on each specimen by releasing a 10-mm diameter steel ball weighing 5.5 g from 50 mm above each of the specimens. As the ball fell to the central fossae of the artificial teeth, a personal computer was used to record the complete acceleration responses. The impact values were then computed for the specimens. Vickers hardness measurements were completed following the impact tests. A 1-way analysis of variance and a Scheffe compromise post hoc test were used to analyze the gathered data. Further, the relationship between values and Vickers hardness was ascertained using the Pearson correlation coefficient. Results. Within the limitations of this study a significant difference occurred in the impact values of the teeth tested (␣⫽.05). The porcelain teeth exhibited the significantly highest impact values of all the teeth. The acrylic resin teeth exhibited the lowest impact values, however, the values of the acrylic resin teeth were statistically similar to 4 of the composite teeth (Surpass, Duracross, Duradent, and SR-Orthosit). Efucera-P demonstrated the highest impact value among the composite teeth. The hardness of the porcelain teeth was approximately 53 times greater than that of the acrylic resin teeth. The composite teeth showed intermediate hardness values between the acrylic resin teeth and the porcelain teeth. Finally, a significant correlation existed between the impact values and the hardness of the teeth tested. Conclusions. This in vitro study demonstrated that the 7 types of composite denture teeth showed tested better hardness properties when compared to 1 of acrylic resin tooth type. Along with the improved hardness properties, these composite teeth also maintained the greater shock absorbability inherent in teeth fabricated from acrylic resin. 14 References.—DL Dixon
AUGUST 2002
223