RESEARCH AND EDUCATION

Comparison of excess cement around implant crown margins

by using 3 extraoral cementation techniques
Avish J. Jagathpal, BDS, PDD, MChD,a Zunaid I. Vally, BDS, MChD,b Leanne M. Sykes, BDS, MChD,c and
Jonathan du Toit, BDSd

Fixed implant-supported ABSTRACT

prostheses can be either
Statement of problem. Extrusion of excess cement into the subgingival area around implant-
screw- or cement-retained. supported crowns is associated with detrimental inflammatory response, but controlling this
Both have reported long-term excess material remains a challenge.
success rates, with advantages
Purpose. The purpose of this in vitro study was to perform a comparative analysis of 3 extraoral
and disadvantages.1 The ad-
cementation techniques to reduce excess extruded cementation material around implant-
vantages of cementation over supported crowns.
screw retention are improved
esthetics, simplicity of use, Material and methods. Forty-four internal connection implant replicas were embedded in acrylic
resin to form the experimental model. Cementable abutments were tightened onto the implants.
easier restoration fabrication,
Zirconia crowns were luted to each of the cementable abutments by using 1 of 4 techniques:
potential for angulation control, pattern resin analog that was 3D-printed, fast-setting polyvinyl siloxane analog, and
correction, improved passivity putty index analog. Extruded excess cement was collected at each luted crown and weighed.
of fit, reduced costs and
Results. The mean residual weight of excess cement found in the pattern resin analog technique
chairside time, and easier ac- group was the least (0.087 mg), followed by the polyvinyl siloxane analog technique group (1.678
2 ,3
cess to posterior sites. mg). The putty index analog technique group reported the least reduction of excess extruded
Cement retention may be cement (7.621 mg). All techniques produced substantially less extruded cement than the control
indicated in the esthetic zone (85.166 mg). In a 1-way analysis of variance, statistically significant differences (P<.001) were
where implants may have to found among all the test techniques. Pairwise comparisons also found that all 3 test techniques
be angled because of the re- were statistically different from each other.
3 ,4
sidual ridge anatomy. Conclusions. The pattern resin (3D-printed) analog technique produces the least amount of
Cementation onto implant extruded excess cement at an implant-supported crown, limiting detrimental impact on
abutments eliminates the peri-implant tissue health. (J Prosthet Dent 2020;-:---)
screw access channel, provides
optimal esthetics, prevents screw loosening, reduces cost, Radiographs made after cementation do not diagnose
and strengthens the crown without affecting occlusal excess cement on the buccal or lingual surfaces.7,12 In
4 ,5 addition, not all luting agents are sufficiently
load distribution.
The greatest shortcoming of cement retention is the radiopaque.7
inability to fully prevent cement extruding into the peri- When seating the implant-supported crown, hydraulic
implant tissues or completely remove it.6 The retained pressure builds up, forcing cement in the direction of least
cement leads to peri-implant complications.4,7-11 resistance, typically toward the gingival sulcus.9 In natural

Supported by Southern Implants (PTY) LTD, Centurion, South Africa.

a
Consultant, Department of Prosthodontics, School of Dentistry, University of Pretoria, Pretoria, South Africa.
b
Professor, Department of Odontology, School of Dentistry, University of Pretoria, Pretoria, South Africa.
c
Professor, Department of Prosthodontics, School of Dentistry, University of Pretoria, Pretoria, South Africa.
d
Graduate student, Department of Periodontology, School of Dentistry, University of Pretoria, Pretoria, South Africa.

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2 Volume - Issue -

et al3 study that reported that excess cement for the putty
Clinical Implications index copy abutment technique had a mean ±standard
This study reports on various extraoral deviation mass of 0.007 ±0.001 g. A sample size of 11
crowns per treatment group provided a 90% power to
precementation techniques to reduce the amount
detect a mass change of 20%, that is 0.0015 g. Testing
of excess cement that may be extruded into the
was 2-sided with a=.05.
peri-implant tissues. The data confirm that extraoral
Forty-four experimental models were created by
cementation analogs substantially reduce the
embedding internal-connection implant replicas
amount of this extruded material.
(Ø4×8 mm, LA-DC4; Southern Implants (Pty) Ltd) in
acrylic resin blocks with a modulus of elasticity of
approximately 3 GPa, similar to bone. Identical cement-
teeth, attachment of the dentogingival complex may, in
able implant abutments (TCA-DC4; Southern Implants
part, resist this.4 In the absence of a resilient attachment to
(Pty) Ltd) were screwed onto the implant replica in each
the implant abutment, cement may be extruded deep
specimen and tightened to 35 Ncm as recommended by
below the gingiva. Attempts to remove excess may damage
the manufacturer. The screw channels were closed with
the implant, abutment, or prosthesis. Both retained cement
polytetrafluoroethylene (PTFE) tape. Each implant abut-
and damaged surfaces may promote plaque accumula-
ment had a tissue contour that ensured all specimens
tion.13 Furthermore, debris created from the debrided
were seated in the same orientation. An intraoral scanner
surfaces may incite an adverse tissue reaction14, resulting in
(Cerec Omnicam; Dentsply Sirona) was used to scan
peri-implant inflammation, soft tissue swelling, bleeding
each abutment. Identical crowns were designed with the
on probing, exudation, or even total implant failure.13
system software and were milled by using a 5-axis milling
Residual excess cement15,16 has been associated with
machine (Cerec MCX5 inLab milling machine; Dentsply
peri-implantitis in between 60% and 81% of patients.
Sirona). The crowns (N=44) were milled from zirconia
Therefore, cementation procedures must avoid extrusion of
disks (Incoris f0.516 mm zirconium; Dentsply Sirona) and
excess cement or aid in the complete removal of cement
sintered in a high-temperature furnace (inFire HTC
remnants. The extraoral cementation (practice abutment,
speed; Dentsply Sirona) with a 50-mm cement space.
copy abutment, or trial abutment) technique minimizes the
For standardization, all test and control crowns were
excess cement by first placing the cement-loaded crown
milled from the same design on the same milling ma-
onto a laboratory- or chairside-fabricated analog to displace
chine (Cerec MCX5 inLab milling machine; Dentsply
the excess cement before insertion intraorally.15,17-19 In
Sirona). As the choice of cement is typically based on
theory, this technique results in the crown then containing
clinician experience rather than on scientific data,20 dual-
an optimum volume of cement with only minimal excess
polymerizing resin cement (RelyX U200 Clicker; 3M
and has been found to be effective.3,18 Wadhwani et al4
ESPE) was used for all specimens because of its uniform
recommended the chairside use of fast setting dental
viscosity and consistent mixing ratio. To standardize the
impression material or occlusal registration material to
volume of cement used per test, 1 full click was extruded
create a copy abutment for extraoral cementation. Chaudry
from the clicker system. The total volume of mixed
et al3 and Chee et al18 reported significantly reduced
cement was applied to each crown. Excess was removed
amounts of cement when comparing a putty index analog
at the cervical margin during the testing to maintain the
(PIA) with standard cementation techniques. Similarly,
same volume of cement within each crown at the start of
Frisch et al17 reported on a technique of inserting a
the test. All cementation procedures were performed by 1
laboratory-fabricated pattern resin analog (PRA) into the
operator (A.J.). After all cementation tests, the final
crown to extrude excess cement.
implant-abutment-crown complex consisted of an acrylic
Which of these techniques yield the lowest amount of
resineembedded internal connection implant replica, a
excess cement and provide the best clinical outcome are
screwed-down transmucosal cementable abutment, and
unclear. Therefore, the purpose of this in vitro study was
a cemented CAD-CAM crown. All test specimens were
to determine which of the 3 cementation techniques
clamped for 10 minutes with 80 N by using calibrated
yielded the lowest amount of excess luting material
laboratory clamps, as described by Chee et al3 (Fig. 1).
during the trial seating of cement-retained implant
Pilot testing revealed that in spite of the cement being
crowns. The null hypothesis was that no difference
dual-polymerized, the material had not completely
would be found in the amount of excess cement extruded
polymerized after 10 minutes. Thus, all specimens were
from the crowns among the different techniques.
light polymerized circumferentially for 20 seconds (400 to
490 nm wavelength) after the 10 minutes allowed for
MATERIAL AND METHODS
maximal cement flow. The control specimens were
Three extraoral cementation techniques (ECTs) were designated group C, PRA group, fast-polymerizing
investigated. The sample size was based on the Chee polyvinyl siloxane analog (PVA) as group, and PIA as

THE JOURNAL OF PROSTHETIC DENTISTRY Jagathpal et al

- 2020
Figure 1. Extrusion of excess cement under calibrated load of 80 N. Note
cement excess extruded from crown-abutment interface.
group. In all groups, the crowns were filled to the mar-
gins with cement and seated onto implant-abutment
assemblies with finger pressure, after which a calibrated
load of 80 N was delivered to each assembly.
For the PVA group, a film of petroleum jelly was applied
to the intaglio surface of all test crowns with a microbrush,
and PTFE tape was adapted to the intaglio surface of the
crowns with another microbrush. The petroleum jelly
ensured the tape adhered inside the crowns, as described
for this technique.4 The tape also acted as a spacer for the
cement layer (Fig. 2A). The implant abutments were then
inserted to fully adapt the tape inside the crowns (Fig. 2B).
These were removed, and fast-polymerizing polyvinyl
siloxane (Jet Bite; Coltène) was injected into the PTFE-lined
crown (Fig. 2C), forming chairside abutment replicas
(Fig. 2D). Once polymerized, a mark was drawn on the
abutment to record the buccal surface, ensuring correct
repositioning. All contents were removed, and the crown
thoroughly cleaned with dry cotton pellets. The crowns
were filled with cement and seated, the excess cement was
removed, and the crowns were transferred for cementation
to the experimental models.
To standardize a PRA for the PRA group (Fig. 3A),
resin abutment analogs were printed with a 3D printer
(Form 2; Formlabs Inc) in lieu of a hand-mixed material.
A single TCA-DC4 abutment was scanned by using a
dental CAD-CAM software program (Exocad; exocad
GmbH) and was designed with 50 mm additional die-
spacer by using design software (Microsoft 3D builder;
Microsoft Corp). This was done to accommodate the
polymerization shrinkage of the pattern resin, reported to
be up to 7.9%.21,22 The cumulative cement gap was 100
mm, which was within clinically acceptable limits ac-
cording to McLean and von Fraunhofer.23 The crowns
were similarly filled and seated onto the copy abutment
as seen in Figure 3B. The excess cement was removed,
and the crown was transferred for cementation in the
same manner as described previously.
Jagathpal et al
3
For the PIA group, a soft polyvinyl siloxane putty
(Express XT; 3M ESPE) was adapted to the intaglio sur-
face of the crowns to be cemented (Fig. 4A). Once
polymerized, the putty was removed, and the intaglio
walls of the crown cleaned with dry cotton pellets. The
putty index was modified with a surgical blade (No.15;
Swann Morton) according to the protocol of Chaudry
et al18 (Fig. 4B). The crowns were similarly filled with
cement and seated (Fig. 4C).
Thereafter, each cemented specimen was manually
scaled circumferentially in a sealed microenvironment
with a universal scaler (Ash instruments; Dentsply
Sirona) across the circumference of the abutment-crown
interface to remove the excesses extruded material.
Polymerized, extruded cement was collected and
weighed (Microbalance scale; Mettler Toledo) in a
controlled draught and dust-free environment to elimi-
nate loss or contamination of the specimens. The scale
had a specified accuracy of ±0.001mg. The tare weight
was determined by placing a clean disposable collection
dish on the scale and resetting the weight to zero. The
weights recorded experimentally represented the amount
of excess cement extruded into the peri-implant space.
RESULTS
A total of 44 retrieved specimens were collected and
weighed (n=11). The amount of experimental extruded
peri-implant cement is reported in Table 1. The 3 ECTs
tested performed substantially better than the control
(standard cementation) (Fig. 5) (P<.001). Pairwise, all 3
test techniques are different from one another (P<.05).
The mean residual weight of the PRA technique group
was the least (0.087 mg), followed by the PVA technique
group (1.678 mg). The PIA technique group reported the
greatest amount of excess extruded material among the 3
ECTs (7.621 mg). All were substantially lower than the
control (85.166 mg) (P<.05).
DISCUSSION
Statistically significant differences were found between
the different techniques; therefore, the null hypothesis
was rejected. The risks posed to peri-implant tissues by
undetected residual cement have been well docu-
mented,4,7-11 and reducing the volume of excess material
extruded reduces these risks.3,4,17,19 Different cementa-
tion techniques that might reduce extrusion excess have
been evaluated.3,13 Most studies have focused on testing
various versions of ECT procedures compared with
alternate cementation procedures and have reported
seemingly similar results. However, the authors are un-
aware of studies that compared these ECT procedures
with each other.
When selecting a luting agent for use with implant
restorations, clinicians need to consider the need for
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Figure 2. A, Adaptation of PTFE tape to internal surface of zirconia crown in PVA group by using microbrush. B, Adaptation of PTFE tape to crown
intaglio surface with implant abutment. C, Fast-setting polyvinyl siloxane injected into PTFE-lined crown. D, Removal of occlusal registration analog and
PTFE lining from crown. PTFE, polytetrafluoroethylene; PVA, polyvinyl siloxane analog.

Figure 3. A, 3-D printed resin analog to simulate pattern resin abutment for PRA group. B, Extrusion of excess cement by using resin analogs in PRA
group. PRA, pattern resin analog.

prosthesis retrievability, the ease of prosthesis removal,
and the long-term maintenance of the crown-abutment
interface.5 Interim cements have been used to enable
retrievability of the restoration, but these cements have
low tensile strength, are water soluble, and have
unpredictable performance.13 Resin-based definitive ce-
ments have high tensile strengths and provide signifi-
cantly high uniaxial resistance forces. Santosa et al5
reported that 3M RelyX had a consistent viscosity and
weight when used in a trial abutment cementation

THE JOURNAL OF PROSTHETIC DENTISTRY Jagathpal et al

- 2020 5

Table 1. Raw data of weights (in milligrams) of extruded cement

retrieved from each of specimens of groups C, PRA, PVA, and PIA
respectively
Pattern Resin Polyvinyl
(3D Printed) Siloxane Putty Index
Test Control (C) Analog (PRA) Analog (PVA) Analog (PIA)
Test 1 95.780 0.068 1.757 5.944
Test 2 99.453 0.110 1.465 10.670
Test 3 64.395 0.075 1.760 9.165
Test 4 69.500 0.265 1.917 6.950
Test 5 93.987 0.037 1.862 4.080
Test 6 85.413 0.041 2.444 8.870
Test 7 94.870 0.139 0.855 7.138
Test 8 71.174 0.072 2.329 9.307
Test 9 90.026 0.027 0.959 7.280
Test 10 99.352 0.029 1.694 5.879
Test 11 72.872 0.098 1.415 8.546

100 85.166

90
80
Mean Weight (mg)

70
60
50
40
30
20
7.621
10 1.678
0.087
0
C PRA PVA PIA
Technique
Figure 5. Mean weight of luting agent retrieved from each group. Error
bar represents standard deviation. C, control; PIA, putty index analog;
PRA, pattern resin analog; PVA, polyvinyl siloxane analog.

disclose how cement excesses were retrieved or quanti-

Figure 4. A, Polyvinyl siloxane putty adapted to internal surface of crown
in PIA group. Groove scribed into putty to enable orientation of buccal
surface. B, Modification of putty index with size 15 surgical blade to
required dimensions. C, Insertion of putty index to extrude excess
cement in PIA group. PIA, putty index analog.
technique. They further reported that the use of the trial
abutment technique by using RelyX cement did not
produce a significant difference when compared with
conventional cementation.5 For these reasons, it was
chosen as the cement for the present study.
A lack of evidence exists regarding the precise
determination of cement excess. Some studies fail to
fied3; others reported that cement excess was determined
by the difference in weight of the entire implant-
abutment assembly before and after cementation.5,13
These studies considered the amount of cement be-
tween the crown and abutment as negligible. These
values were therefore omitted from their calculations.
Furthermore, it was not specified how the initial quantity
of loaded material was determined to ensure that a
minimally required amount was used, nor did they
specify how the volumes were standardized among
specimens.
In the present study, the mean residual weight of
extruded cement was greatest in the control group
(85.166 mg), followed by the PIA technique group (7.621
mg), then the PVA technique group (1.678 mg), with the

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6 Volume
3D printed PRA technique group producing the least
postcementation residual cement (0.087 mg). The cement
in the control group was consistent with the findings of
Santosa et al.5
The mean yield from the PIA group (7.6 mg ±1.9 mg)
is consistent with the findings of Chee et al,3 who re-
ported a mean excess of 7 mg ±1 mg by using the same
procedural protocol. They found the PIA technique to be
superior to the 3 other techniques, namely, cement
applied to internal margins only, apical half only, and
axial walls only.3 The PVA group provided the second
least amount of excess cement extruded in the luting
process (mean weight 1.678 mg). The technique was
technically difficult to perform consistently, delivering a
range of excess cement from 0.855 mg to 2.444 mg. In the
specimen preparation of the PVA group, of 11 specimens,
removal and replacement of the PTFE tape was necessary
11 times in spite of the petroleum jelly adhesion. A
greater cement space would form when layers of PTFE
could overlap during re-adaptation, introducing dis-
crepancies and inaccuracies in the lining. The authors
consider that the PVA technique is too unreliable, time
consuming, and technique sensitive. Moreover, petro-
leum jelly application is of concern because incomplete
removal may contaminate the cementation and reduce
retention.20
The best technique, which resulted in the greatest
reduction in excess cement, was the 3D-printed PRA.
Close adaptation of the abutment margin coupled with
the uniform cement layer likely resulted in results supe-
rior to those of the other tests performed. The mean
weight of the PRA test (0.087 mg) was almost 20× lower
than the next best trial abutment (PVA) (1.678 mg),
almost 90× times lower than the PIA (7.621 mg), and
nearly 1000× times lower than the control (85.166 mg).
The inability to achieve a satisfactory circumferential
marginal seal from the PVA and PIA techniques may
have been because of the lack of complete adaptation,
resulting in a greater volume of cement being retained. In
contrast, the PRA technique mirrored the actual implant
abutment, allowing better marginal adaptation of abut-
ment to crown, with more uniform and predictable
extrusion patterns. It is further hypothesized that the
adhesion of the resin cement to the PRA abutment on
removal resulted in more cement remaining on the
analog and less within the crown versus the PVA and
PIA abutments which reported poor adhesion of cement
to the abutments on removal.
Limitations of the present study included that the
laboratory analog was printed with a 50-mm cement
space. The printed analog was therefore 50 mm smaller
than the actual implant abutment to accommodate
polymerization shrinkage of the pattern resin as has been
described.20,21 When inserted into a crown milled with a
THE JOURNAL OF PROSTHETIC DENTISTRY
- Issue -
50-mm cement space, the total cement spacer equals 100
mm, which remains within the clinically acceptable
range23; however, this may vary depending on the
fabrication method and materials used.21,22 Furthermore,
the quality of the PVA abutment also depends on the
type of pattern resin or 3D printing resin used, as
different materials have differing rates of shrinkage. This
could also affect the amount of cement retained and
therefore extruded.
Cementable protocols in implantology may be a more
cost-effective option. However, when custom abutments
are required in addition to duplicating laboratory-
fabricated analogs, the cost will increase.
CONCLUSIONS
Based on the findings of this in vitro study, the following
conclusion was drawn:
1. When cementing implant-supported crowns, first
reducing excess cement extraorally with a pattern-
resin or laboratory-fabricated duplicate analog best
reduced the amount of cement extruded into the
peri-implant tissues.
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Corresponding author:
Dr Avish J. Jagathpal
Department of Prosthodontics
University of Pretoria
Prinshof 349-jr
Pretoria 0840
SOUTH AFRICA
Email: avish.jagathpal@up.ac.za, doc@capitalpros.co.za
Acknowledgments
The authors thank Southern Implants (PTY) LTD for their support in terms of
implant components and Dura Art Dental Laboratory for their 3D printing
support.
Copyright © 2020 by the Editorial Council for The Journal of Prosthetic Dentistry.
https://doi.org/10.1016/j.prosdent.2020.04.016
THE JOURNAL OF PROSTHETIC DENTISTRY