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Technique for fabricating a cement-retained single-unit implant-supported provisional restoration in the esthetic zone
Technique for fabricating a cement-retained single-unit implant-supported provisional restoration in the esthetic zone Mario R. Ganddini, DDS,a Ross H. Tallents, DDS,b Carlo Ercoli, DDS,c and Rafael Ganddini, DDSd University of Rochester Eastman Dental Center, Rochester, NY The fabrication of provisional restorations is an important stage in implant treatment. In the esthetic zone, the potential for error without the use of provisional restorations in the selection of the abutments, framework design, appropriate vertical dimension of occlusion, occlusal profile, and the esthetic interpretation may be significant. Provisional restorations are indicated in esthetic zones, for the contouring of the gingiva, to achieve an acceptable emergence profile, to have custom-guided tissue healing, and to induce appropriate soft-tissue topography. This article describes the fabrication of a provisional restoration for a single-unit implant-supported crown. (J Prosthet Dent 2005;94:296-8.)
P
rovisional restorations for implant-supported restorations aid the restorative dentist in achieving an esthetic result. One of the important functions of provisional restorations is the healing and molding of the soft tissues. The provisional restoration is a guide and is critical to the definitive prosthetic design.1 The achievement of an esthetic implant-supported restoration may be a challenge to the restorative dentist due to the circular shape and small diameter of the implant when compared to the root of a natural tooth. A problem inevitably occurs with respect to constructing an artificial crown and abutment system that will imitate the natural tooth crown form when emerging from the gingival tissues with narrow margins to fit the implant head.2 A recent report discussed the evaluation of dimensions and characteristics of the cementoenamel junction (CEJ) of maxillary anterior teeth and compared them to current implant designs.3 The authors indicated that there are significant discrepancies between the flat, symmetric shoulder of the implant and the contours of the CEJ. Soft-tissue contour adjacent to single-unit implant-supported restorations may be restored faster with the use of a provisional restoration than with a healing abutment alone.4 Several techniques have been proposed to duplicate the gingival contour of an esthetic restoration.5 Attard and Barzilay6 used a technique with an interim restoration as an abutment for the definitive impression. Hinds7 described the fabrication of a custom impression coping for the replication of the healed tissue around the implant. Bain and Weisgold8 inserted autopolymerizing acrylic resin directly into the sulcus during impression a
Graduate student, Prosthodontics, University of Rochester Eastman Dental Center, Rochester, NY. b Professor, Department of Dentistry, Division of Orthodontics and Prosthodontics, Program Director Orofacial Pain, University of Rochester Eastman Dental Center, Rochester, NY. c Assistant Professor, Program Director, Division of Prosthodontics, University of Rochester Eastman Dental Center, Rochester, NY. d Private practice, Prosthodontics, Guatemala City, Guatemala.
296 THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 1. A, Implant carrier in place. B, Sprue attached to access opening of implant carrier.
making. Neale and Chee9 and Chee and Donovan10 advise performing gingivoplasty procedures to recontour the tissues before making provisional restorations. This article describes a simple, nonsurgical, cost-effective technique for the fabrication of a single-unit implantsupported provisional restoration, using the implant carrier—an implant component originally designed to transport the implant from the sterilized package to VOLUME 94 NUMBER 3
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THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 3. Autopolymerizing resin sealing crown margin.
Fig. 2. A, Master cast with implant carrier, facial view. B, Implant carrier prepared for restoration. C, Polycarbonate crown fit in place.
the implant site11—as an impression coping and provisional abutment.
TECHNIQUE 1. Remove the healing abutment (Zimmer Dental, Carlsbad, Calif) and screw the implant carrier (Zimmer Dental) on the implant. Make a radiograph to verify that the implant carrier is securely in place (Fig. 1, A). SEPTEMBER 2005
Fig. 4. A, Provisional restoration in mouth at time of insertion. B, Provisional restoration after 6 weeks of healing.
2. Place a sprue (Hollow Plastic Sprue; Handler Dental Lab Aids, Westfield, NJ) in the implant carrier screw-access opening for an open tray impression technique (Fig. 1, B). 3. Make an impression of the maxillary arch using vinyl polysiloxane (Dimension; 3M ESPE, St Paul, Minn), with the sprue protruding through the tray. 297
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4. Attach the appropriate implant analog (Zimmer Dental) to the implant carrier. 5. Make a soft-tissue moulage using a vinyl polysiloxane material (Gingitech; Ivoclar Vivadent, Schaan, Lichtenstein). 6. Pour the impression using a Type IV dental stone (ResinRock; Whip Mix, Louisville, Ky). 7. Remove the cast from the impression (Fig. 2, A). 8. Prepare the implant carrier as needed to ensure adequate occlusal and axial clearance for a cementretained crown (Fig. 2, B). 9. Adapt a polycarbonate crown (3M ESPE) to the prepared implant carrier (Fig. 2, C). 10. Add autopolymerizing acrylic resin (Jet Tooth Shade Acrylic; Lang Dental, Wheeling, Ill) to the polycarbonate crown and place it on the prepared implant carrier. 11. Remove the crown from the abutment once the resin is polymerized. 12. Remove the abutment and add autopolymerizing acrylic resin (Jet Tooth Shade Acrylic; Lang Dental) to the crown to achieve a properly sealed margin. Recontour the provisional crown to establish an optimal emergence profile for the definitive restoration (Fig. 3). 13. Insert the abutment and the crown and allow the peri-implant soft tissue to heal for 6 weeks; then reevaluate to determine if any alterations to the provisional restoration are required. Fabricate the definitive restoration (Fig. 4).
DISCUSSION Several advantages have been purportedly related to the placement of fixed provisional restorations after second stage surgery: (1) improved tissue contours related to emergence profile, (2) development of an interdental or interimplant papillae, (3) potential avoidance of a third surgical procedure, and (4) customization during the healing process to form an esthetically contoured prosthesis.12 The technique described in this article differs from previously described techniques in that it reduces gingival trauma by eliminating the use of acrylic resin intraorally and minimizing surgical procedures. Chair time is minimized because most of the procedures are performed in the laboratory. Also, cost reduction occurs because a single component, the implant carrier, which is provided bundled with the implant, is used both as the impression coping and the provisional abutment. However, it is important to note that the implant carrier is not provided universally by all implant systems. This
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technique is contraindicated in the presence of axial misalignment of the implant that will require the use of an angulated or custom abutment.
SUMMARY An alternative for the fabrication of a cement-retained single-unit implant-supported provisional restoration has been described. The procedure requires minimal chair time and is cost effective, as fewer components are used during the treatment. REFERENCES 1. Moscovitch MS, Saba S. The use of a provisional restoration in implant dentistry: a clinical report. Int J Oral Maxillofac Implants 1996;11:395-9. 2. Sadan A, Blatz M, Salinas TJ, Block MS. Single-implant restorations: a contemporary approach for achieving a predictable outcome. J Oral Maxillofac Surg 2004;62:73-81. 3. Gallucci GO, Belser UC, Bernard JP, Magne P. Modeling and characterization of the CEJ for optimization of esthetic implant design. Int J Periodont Restorative Dent 2004;24:19-29. 4. Jemt T. Restoring the gingival contour by means of provisional resin crowns after single-implant treatment. Int J Periodontics Restorative Dent 1999;19:20-9. 5. Macintosh DCT, Sutherland M. Method for developing an optimal emergence profile using heat-polymerized provisional restorations for single-tooth implant-supported restorations. J Prosthet Dent 2004;91: 289-92. 6. Attard N, Barzilay I. A modified impression technique for accurate registration of peri-implant soft tissues. J Can Dent Assoc 2003;69:80-3. 7. 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. 8. Bain CA, Weisgold AS. Customizes emergence profile in the implant crown—a new technique. Compend Contin Educ Dent 1997;18:41-5. 9. Neale D, Chee W. Development of implant soft-tissue emergence profile: a technique. J Prosthet Dent 1994;71:364-8. 10. Chee WW, Donovan T. Use of provisional restorations to enhance softtissue contours for implant restorations. Compendium Contin Educ Dent 1998;19:481-6, 488-9. 11. Ganddini MR, Schejtman N, Ercoli C, Graser GN. Prosthodontic application for implant carriers. J Prosthet Dent 2004;92:399-402. 12. Biggs WF. Placement of a custom implant provisional restoration at the second-stage surgery for improved gingival management: a clinical report. J Prosthet Dent 1996;75:231-3. Reprint requests to: DR CARLO ERCOLI DIVISION OF PROSTHODONTICS UNIVERSITY OF ROCHESTER EASTMAN DENTAL CENTER 625 ELMWOOD AVENUE ROCHESTER, NY 14620 FAX: 585-244 8772 E-MAIL: [email protected] 0022-3913/$30.00 Copyright Ó 2005 by The Editorial Council of The Journal of Prosthetic Dentistry.
doi:10.1016/j.prosdent.2005.06.010
VOLUME 94 NUMBER 3
P
rovisional restorations for implant-supported restorations aid the restorative dentist in achieving an esthetic result. One of the important functions of provisional restorations is the healing and molding of the soft tissues. The provisional restoration is a guide and is critical to the definitive prosthetic design.1 The achievement of an esthetic implant-supported restoration may be a challenge to the restorative dentist due to the circular shape and small diameter of the implant when compared to the root of a natural tooth. A problem inevitably occurs with respect to constructing an artificial crown and abutment system that will imitate the natural tooth crown form when emerging from the gingival tissues with narrow margins to fit the implant head.2 A recent report discussed the evaluation of dimensions and characteristics of the cementoenamel junction (CEJ) of maxillary anterior teeth and compared them to current implant designs.3 The authors indicated that there are significant discrepancies between the flat, symmetric shoulder of the implant and the contours of the CEJ. Soft-tissue contour adjacent to single-unit implant-supported restorations may be restored faster with the use of a provisional restoration than with a healing abutment alone.4 Several techniques have been proposed to duplicate the gingival contour of an esthetic restoration.5 Attard and Barzilay6 used a technique with an interim restoration as an abutment for the definitive impression. Hinds7 described the fabrication of a custom impression coping for the replication of the healed tissue around the implant. Bain and Weisgold8 inserted autopolymerizing acrylic resin directly into the sulcus during impression a
Graduate student, Prosthodontics, University of Rochester Eastman Dental Center, Rochester, NY. b Professor, Department of Dentistry, Division of Orthodontics and Prosthodontics, Program Director Orofacial Pain, University of Rochester Eastman Dental Center, Rochester, NY. c Assistant Professor, Program Director, Division of Prosthodontics, University of Rochester Eastman Dental Center, Rochester, NY. d Private practice, Prosthodontics, Guatemala City, Guatemala.
296 THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 1. A, Implant carrier in place. B, Sprue attached to access opening of implant carrier.
making. Neale and Chee9 and Chee and Donovan10 advise performing gingivoplasty procedures to recontour the tissues before making provisional restorations. This article describes a simple, nonsurgical, cost-effective technique for the fabrication of a single-unit implantsupported provisional restoration, using the implant carrier—an implant component originally designed to transport the implant from the sterilized package to VOLUME 94 NUMBER 3
GANDDINI ET AL
THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 3. Autopolymerizing resin sealing crown margin.
Fig. 2. A, Master cast with implant carrier, facial view. B, Implant carrier prepared for restoration. C, Polycarbonate crown fit in place.
the implant site11—as an impression coping and provisional abutment.
TECHNIQUE 1. Remove the healing abutment (Zimmer Dental, Carlsbad, Calif) and screw the implant carrier (Zimmer Dental) on the implant. Make a radiograph to verify that the implant carrier is securely in place (Fig. 1, A). SEPTEMBER 2005
Fig. 4. A, Provisional restoration in mouth at time of insertion. B, Provisional restoration after 6 weeks of healing.
2. Place a sprue (Hollow Plastic Sprue; Handler Dental Lab Aids, Westfield, NJ) in the implant carrier screw-access opening for an open tray impression technique (Fig. 1, B). 3. Make an impression of the maxillary arch using vinyl polysiloxane (Dimension; 3M ESPE, St Paul, Minn), with the sprue protruding through the tray. 297
THE JOURNAL OF PROSTHETIC DENTISTRY
4. Attach the appropriate implant analog (Zimmer Dental) to the implant carrier. 5. Make a soft-tissue moulage using a vinyl polysiloxane material (Gingitech; Ivoclar Vivadent, Schaan, Lichtenstein). 6. Pour the impression using a Type IV dental stone (ResinRock; Whip Mix, Louisville, Ky). 7. Remove the cast from the impression (Fig. 2, A). 8. Prepare the implant carrier as needed to ensure adequate occlusal and axial clearance for a cementretained crown (Fig. 2, B). 9. Adapt a polycarbonate crown (3M ESPE) to the prepared implant carrier (Fig. 2, C). 10. Add autopolymerizing acrylic resin (Jet Tooth Shade Acrylic; Lang Dental, Wheeling, Ill) to the polycarbonate crown and place it on the prepared implant carrier. 11. Remove the crown from the abutment once the resin is polymerized. 12. Remove the abutment and add autopolymerizing acrylic resin (Jet Tooth Shade Acrylic; Lang Dental) to the crown to achieve a properly sealed margin. Recontour the provisional crown to establish an optimal emergence profile for the definitive restoration (Fig. 3). 13. Insert the abutment and the crown and allow the peri-implant soft tissue to heal for 6 weeks; then reevaluate to determine if any alterations to the provisional restoration are required. Fabricate the definitive restoration (Fig. 4).
DISCUSSION Several advantages have been purportedly related to the placement of fixed provisional restorations after second stage surgery: (1) improved tissue contours related to emergence profile, (2) development of an interdental or interimplant papillae, (3) potential avoidance of a third surgical procedure, and (4) customization during the healing process to form an esthetically contoured prosthesis.12 The technique described in this article differs from previously described techniques in that it reduces gingival trauma by eliminating the use of acrylic resin intraorally and minimizing surgical procedures. Chair time is minimized because most of the procedures are performed in the laboratory. Also, cost reduction occurs because a single component, the implant carrier, which is provided bundled with the implant, is used both as the impression coping and the provisional abutment. However, it is important to note that the implant carrier is not provided universally by all implant systems. This
298
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technique is contraindicated in the presence of axial misalignment of the implant that will require the use of an angulated or custom abutment.
SUMMARY An alternative for the fabrication of a cement-retained single-unit implant-supported provisional restoration has been described. The procedure requires minimal chair time and is cost effective, as fewer components are used during the treatment. REFERENCES 1. Moscovitch MS, Saba S. The use of a provisional restoration in implant dentistry: a clinical report. Int J Oral Maxillofac Implants 1996;11:395-9. 2. Sadan A, Blatz M, Salinas TJ, Block MS. Single-implant restorations: a contemporary approach for achieving a predictable outcome. J Oral Maxillofac Surg 2004;62:73-81. 3. Gallucci GO, Belser UC, Bernard JP, Magne P. Modeling and characterization of the CEJ for optimization of esthetic implant design. Int J Periodont Restorative Dent 2004;24:19-29. 4. Jemt T. Restoring the gingival contour by means of provisional resin crowns after single-implant treatment. Int J Periodontics Restorative Dent 1999;19:20-9. 5. Macintosh DCT, Sutherland M. Method for developing an optimal emergence profile using heat-polymerized provisional restorations for single-tooth implant-supported restorations. J Prosthet Dent 2004;91: 289-92. 6. Attard N, Barzilay I. A modified impression technique for accurate registration of peri-implant soft tissues. J Can Dent Assoc 2003;69:80-3. 7. 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. 8. Bain CA, Weisgold AS. Customizes emergence profile in the implant crown—a new technique. Compend Contin Educ Dent 1997;18:41-5. 9. Neale D, Chee W. Development of implant soft-tissue emergence profile: a technique. J Prosthet Dent 1994;71:364-8. 10. Chee WW, Donovan T. Use of provisional restorations to enhance softtissue contours for implant restorations. Compendium Contin Educ Dent 1998;19:481-6, 488-9. 11. Ganddini MR, Schejtman N, Ercoli C, Graser GN. Prosthodontic application for implant carriers. J Prosthet Dent 2004;92:399-402. 12. Biggs WF. Placement of a custom implant provisional restoration at the second-stage surgery for improved gingival management: a clinical report. J Prosthet Dent 1996;75:231-3. Reprint requests to: DR CARLO ERCOLI DIVISION OF PROSTHODONTICS UNIVERSITY OF ROCHESTER EASTMAN DENTAL CENTER 625 ELMWOOD AVENUE ROCHESTER, NY 14620 FAX: 585-244 8772 E-MAIL: [email protected] 0022-3913/$30.00 Copyright Ó 2005 by The Editorial Council of The Journal of Prosthetic Dentistry.
doi:10.1016/j.prosdent.2005.06.010
VOLUME 94 NUMBER 3