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IMPRESSIONS IN IMPLANT DENTISTRY – A REVIEW

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Review – report

INTERNATIONAL JOURNAL OF RESEARCH IN DENTISTRY

IMPRESSIONS IN IMPLANT DENTISTRY – A REVIEW.

Dr Sumathi K*1 Dr Sneha S Mantri , Dr Suryakant C Deogade
Hitkarini Dental College & Hospital, Jabalpur.

Received: 7 Feb 2015; Revised: 5 Mar. 2015; Accepted: 2 Apr 2015; Available online: 5 May 2015

ABSTRACT
Dental implants have provided an alternative treatment option after the popularity of the concept of osseointegration. There
are numerous options available to the implantologist in relation to different impression techniques and materials available for
impression making. Implant impression accuracy is one area of ongoing research and development to improve the success of
the implant prosthesis. The various impression techniques and parameters affecting the accuracy of implant impression is
reviewed in this article
Key words
Direct technique, indirect technique, Snap fit, Mira tray, G-Cuff TM, digital impression

INTRODUCTION

Modern implantology has lit up the lives of million individuals across the world. The objective of impression
making in implant dentistry is to relate the coronal portion of the implant to other structures of oral cavity.
Achieving passive adaptation is one of the most important biomechanical purposes in prosthetic treatment based
on implant.1,2,3 Misfiting of the prosthesis may lead to mechanical and biological complications, mechanical
complication includes loosening , bending or fracture of implant or prosthetic components and biological
complication may affect the osseointegration by loading above the physiologic tolerance level. Recording the
three dimensional orientation of the implant as in the oral cavity is the critical aspect than reproducing the
surface detail in impression making.4 This article outlines the various impression techniques in implant
dentistry.

Precautions before impression making

A radiograph is made to confirm the level of seating of impression coping/abutment to the implant fixture.
Using vinyl glove instead of latex glove which retards the setting of the poly vinyl siloxane impression
material.2

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Implant impression are classified as

Implant impression

Conventional Digital

Chair side Laboratory Centralized

Production production production

At the time of surgical After the fixture placement

placement of fixture

Bone indexing

WithTray With Jig Based on level of impression Based on coping

Implant level Abutment level

Transfer Pick-up Splinting

Conventional method to record the implant position includes either at the time of surgical placement of fixture
or after osseointegration is achieved.

Implant Indexing

Implant Indexing is a method in which impression is made at the time of surgical placement. This allows for the
preparation of an abutment and provisional crown placement for one stage procedure or the provisional crown is
inserted instead of healing abutment at the time of exposure in two stage implant procedure. It is of two types:
tray technique and jig technique.5

Tray technique

The pick- up coping is recommended to minimize the amount of force loaded onto the newly placed implant
using a traditional tray.

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Jig technique

Prior to surgery a jig is fabricated to avoid using the impression material while the surgical flap is opened. An
acrylic splint including 3-4 adjacent teeth should be fabricated on a diagnostic cast. Space is created in the jig
for the future impression coping. After surgical placement of implant fixture, place the pick- up coping. A cold
sterilized jig is positioned in the mouth. Relate the coping to the jig using liquid acrylic or Triad gel. Make sure
that the coping screw rotates freely and the undercut is not blocked. The acrylic or gel can be cured now.
Release the coping screw and free the splint with the abutment in it. Release space in the stone cast to
accommodate the implant analog. Position the jig and attached analog. Pour the stone and remove the jig once
the stone is set. The implant is indexed onto the model.

Transfer or Indirect technique

The copings are connected to the implants, and an impression is made and separated from the mouth, leaving
the copings intraorally. The copings are removed and connected to the implant analogs, and then the coping-
analog assemblies are reinserted in the impression before fabricating the definitive cast. A tapered coping
facilitates the use of a closed tray or indirect technique.3,4,6,7,8

Pick-up or Direct technique

In Pick up impression technique, impression coping is removed from the mouth together with the set
impression. A conventional alginate impression is made and rigid custom tray is fabricated with a window cut
through over the implant region to gain access to the retaining screw to allow release of the screw prior to
removal of the impression coping — impression assembly, the analogues are attached to the impression copings
while they are embedded in the impression tray. After removing the healing abutment, the selected impression
coping is fitted and the tray is tried in. A square coping is required for open tray to allow the coronal ends of the
impression coping screw to be exposed and the technique is therefore the direct technique.3,4,6,7,8

Snap-fit (press fit) plastic impression coping

This technique does not require an open tray, but instead uses a closed tray. The press-fit impression coping is
connected to the implant by pressing instead of screwing and the plastic impression copings are picked up in the
impression.

Advantages

1. Helps to overcome the movement of impression coping inside the impression material
2. Time saving

3. used in both the open and closed tray implant impression techniques

4. more comfortable for both the clinician and the patient

The snap-fit technique may be a reliable impression making technique but regarding accuracy of this technique
none of the study is available for investigation.9

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Splint Technique

The underlying principle of splinting was to connect all the impression copings together using a rigid material
to prevent individual coping movement during the impression making. 10 Assif et al and Naconey et al showed
that splinting technique was significantly more accurate than unsplinting technique.11,12 Other studies showed
that splinting may provide stabilization of transfer coping against torque from analogue tightening and reduce
rotational freedom within resilient impression material. The materials used to splint copings are auto
polymerizing acrylic resin, dual polymerizing acrylic resin and impression plaster.13

Even though auto polymerizing acrylic has been reported to be the material of choice, it has some
disadvantages like distortion of splint materials , fracture of connection between splint material and impression
copings 14, bulk shrinkage caused by long splinting might cause considerable distortion.15 Light cured acrylic
resin is less accurate as compared to auto polymerizing acrylic resin and impression plaster. Assif et al has
stated that the reason for this could be shrinkage during polymerization of the light cured acrylic resin creates
stresses at the impression coping / acrylic resin interface. The intensity and direction of the light source may
have a negative influence on the adaptation of the resin to the coping.16

The advantages of impression plaster includes rapid setting, quite accurate ,rigid, easy to manipulate, less time
consuming ,economical and exothermic reaction is negligible.17 Disadvantages of impression plaster is that it
can be used only in completely edentulous patients in whom there are no anatomic limits like undercuts.16

Implant-level technique

Implant level impression involves placing an implant analog that mimics the implant on the stone model. It is
designed to transfer the soft tissue profile as well as the implant's position and hex orientation. This can be done
by using both open and closed tray.

Abutment level technique

Abutment level impression involves placing an abutment analog that mimics the abutment.

Recent advance in impression tray

The Mira tray developed by Hager is the recent advance to overcome the difficulties in an open tray
technique.18 The tray comes with unique design and available in three sizes. The transparent foil in the occlusal
surface helps in identifying the head of the pins intra orally. The loaded impression tray is inserted and pressed
apically; the pins pierce the film and capture the impression more easily. Once the material is set, the pins are
rotated counter clock wise to remove the tray intra orally. This tray can be used in all situations whether the
arch is partially or completely edentulous.

Gingival retraction

The aim of gingival retraction is to allow the impression material to create space for the impression material in
order to provide sufficient thickness of impression material to withstand the tearing force while retrieving the
impression.19 Bennani discussed various gingival retraction methods in teeth and implant and concluded that

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there is no existing device or method to retract gingiva that can be used for direct impression of the implant
abutment.20

The support provided by the peri- implant fiber is not the same as the peridental structure; therefore it may not
be able to prevent the collapse of retracted tissues as compared to peridental tissues. Hence it is difficult to
make accurate impression in implant dentistry.21
To overcome this a Canadian company, Stomatotech, came up with a simple idea to retract the gingival tissue
using a disposable plastic collar The main purpose of the G-CuffTM system is to support the soft tissue that
surrounds the dental implant abutments allowing the impression means (conventional or digital) to access to the
surface of the abutment. It is inserted on the apical end of the abutment before the abutment is engaged to the
implant.22 Following the abutment’s engagement to the implant, the plastic collar is found between the apical
part of the abutment and the gingival soft tissue. Shortly after the removal of the impression from the mouth, the
plastic collar is pulled out and removed permanently. The plastic collar creates a perfect gingival retraction with
a valve factor preventing the liquids from contaminating the area of the finish line of the abutment.
Benefits of G-CuffTM
1. simple, more reliable, economical
2. compatible with most of the existing dental implant brands
3 .impression can be made with either “open tray” or “close tray”
4. Due to the significant shortening of the lab procedure the risk of impression distortion is dramatically
lowered.
5. Eliminates the need of the materials such as: Impression Copings, Implant Analogs, Temporary Abutments
and Custom Impression Trays.

Factors determining the accuracy of impression

1. Number of implants

Impression making of multiple implants are complicated than single implant. The positional errors in restorative
stage are less likely to affect the passive fit in single implant. Daoydi MF et al found that a positional error in
the restorative stage is unlikely to affect the passive fit with the implant. But rotational or dimensional
discrepancy in the impression is likely to affect the appearance, contact points and occlusal requirements.23

2. Position of implants

The amount of distortion is limited in parallel abutments. In case of non parallel abutments, the direct transfer
method provides the accurate working cast when compared to the indirect method.24

3. Impression material

The appropriate selection of impression material and tray bring the accuracy of the cast. The choice of material
varies according to the complexity of work, impression technique, tray, implant system and prosthetic
components to be used. 25 Elastomeric impression material seems to be logical, since they prevent impression

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displacement due to the rigidity. They are stable in diameters, resistant in deformation, have low strain when
under pressure, and they also have high initial shear strength. The unpleasant smell and polymerization
reactions of poly sulfide make it difficult to use. Condensation silicones are dimensionally less stable. Mostly
poly ether and addition cured silicones are used. The amount of expansion of polyether makes the transfer loose
and mobile in impression. Therefore not suitable for techniques using impression transfer.21 Polyether and
addition silicone are preferred in presence of undercuts and multiple implants. A study by S Reddy et al
concluded that polyvinyl or polyether impression materials have similar dimensional accuracy for transfer
procedures in parallel or angled implants.26

4. Type of Impression Tray

Selection of a tray is an effective factor on accuracy of impression. Impression trays can be either custom made
or stock trays. Generally custom made trays are preferred since it permits a uniform thickness of impression
material.27 It has been determined that applying special hard trays is better than polycarbonate trays because
rigid stainless steel trays limits the distortion of the impression.28 Masri et al concluded in his study that plastic
stock trays can increase the possibility of deformation due to lack of rigidity. 29Carotte et al found that metal
and rigid plastic trays gave greater accuracy than flexible trays. Though the study was directed to conventional
fixed partial dentures, the principle of implant dentistry remains the same.27
5. Design of the coping

Shortened length connection screw eases the removal of the coping from the implant in open tray technique.
Roberto Sorrentino et al stated that shortened connection length compensated the higher removal stress in
angulated implants.30 The coping length extended inside the impression material plays an important role in
retention and resistance against displacement.31New modifications like acrylic resin transfer caps, gold
machined castable abutments have been introduced to improve the accuracy of impression.

6. Splinting transfer coping

Inaccuracies in the impression during clinical and lab phase may occur due to the movement of the copings in
multiple implants. To obtain maximum accuracy, splinting of transfer copings plays an important role in case of
multiple implants.

7. Surface treatment of coping

To enhance the accuracy, the coping can be treated with air-borne particle abrasion and impression adhesive.32
But a study conducted by Vigolo P, FonziF disprove this.33

Digital impression technique

Dental restorations produced with computer assistance have become more in recent years.34 The current trend
in digital technology is to achieve a total digital workflow from implant planning to definitive restoration.

Benefits of the digital impression for implant rehabilitation

1 .eliminates tray selection

2. eliminates dispensing and setting of impression material

3. disinfection and shipping of impression to the laboratory not required

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4. patient comfort and education

5. virtual assessment for implant prosthetic space, depth of restorative interface, emergence profile
configuration before proceeding with lab steps.35,36

6. digital scanning data base can be stored in computer hard drives which are not subjected to physical damage.
7. more efficient, more predictable

8.allows additional re-scans without repeating entirely the impression technique and save chair time for
patients.37,38

9. Other application of CAD/CAM is to produce implant abutments and frame work from metal or ceramic
materials.

10. Digital impression allows for day-of-surgery impressions and indexing for creating custom abutments to
place the final restoration earlier in the healing period after implant integration.

The three main components required for the CAD/CAM are the (1) the digital scanner to which transforms the
geometry into the digital data which can be processed by the computer (2) software that processes the data (3) a
production technology that transforms the data set into the desired product.

There are three different concepts in CAD/CAM production in dentistry.

1. Chair Side production

All the components are available at the chair side and thus dental restoration fabrication takes place without a
laboratory procedure. The intra oral digital scanner registers the clinical situation and offers the patient
indirectly fabricated restoration in a single visit. Cerec system (Sirona) offers this facility. Variety of materials
can be processed from glass-ceramic to high performance oxide ceramic, since Cerec system functions with
water cooling.

2. Laboratory production

The first step is similar to the traditional FPD impression. The dentist sends the impression to the laboratory and
the master cast is scanned to obtain the 3-dimensional data. The CAD process data will be sent to a special
milling devices and that produces the real geometry in the dental laboratory.

3. Centralized production

In this, the prosthesis is fabricated in a milling centre. The satellite scanner in the laboratory is connected with a
production centre via the internet. Data collected in the laboratory are sent to the production centre for the
fabrication of prosthesis with a CAD/CAM device. The benefit of this system is only small investment needed
for the CAD system and high quality production obtained from the centre.

Conclusion

Designing and making prosthesis in implant dentistry needs time and attention to obtain adaption, accuracy and
efficiency of the prosthesis. Various techniques had been introduced to get accurate impression. There is no
evidence supporting that one impression technique or material is better than the other. Impression forms the

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back bone for the success of the prosthesis therefore appropriate technique has to be selected for greater
accuracy. Digital impressions have made the dental practitioners to say no to impression copings and laboratory
procedures related to it. The computerized engineering technology provides high precision fit, durability,
simpler fabrication protocol and minimal human intervention. The development in CAD/CAM technology will
most likely lead to an exponential growth in implant dentistry.

Table :1 Comparison of Indirect and Direct impression technique

Indirect technique Direct technique

Tray No tray preparation Window should be created at the

preparation implant region of the tray

Type of the Round/conical coping used Square coping are preferred

coping used

Interarch space Used in patients with limited mouth More space needed for the instrument
opening placed in implant to unscrew the implant
abutment connection

Precision of Chances of distortion because of the re- 1. Less distortion because coping
impression insertion of coping back in impression remains in the impression.
before fabrication of master cast 2. Splinted copings add more
precision.

Splinting Not possible Possible

multiple coping

Gaggers Used for gaggers May induce gagging

Angulated Easy to make Difficult to make

implants

Deeply placed Not Indicated Indicated

implants

Advantage Easy to perform Reduce the effect of implant angulations

and deformation of impression material
upon recovery from mouth

Disadvantage Possibility of rotational movement of Need to fabricate custom tray

coping when securing implant analog
resulting in inaccuracies

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Table:2 Difference in Implant and Abutment level impression techniques

Implant level Abutment level

Coping location
Abutment selection and
preparation
Abutment modification
Requires sub gingival Supra gingival margins, hence
placement of copings easier
On a model in the laboratory Can be done in the mouth
Not needed May be needed in the mouth

Custom Abutment Available Not available

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