ipecicl reor int f rom

THE I NTERNATIONAL JOURNALOF

PERIODP?NTICSRESTdRATIVE

DENTISTRY

Copyright @ 1997 by Quintessence Publ Co, Inc

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ru@.iKennefh F. Hindg DDS-

Cuslom lmpression Coping for onExoct Registrolion of the HeoledTissue in lhe Esthetic lmplonlRestorotion

lf is well known thaf guided soff lissue healing wifh o provisionol resforofion isessentiol to obtoin opfimol onterior esthefics in fhe implonf prosthesis.Whofis not well known is how to tronsfer o record of beoutiful onotomicollyheoled tissue fo fhe loborotory,With the odvent of emergence profile heol-ing obufmenfs and corresponding impression copings, fhere hos been odromotic improvemenf over fhe oil@nd 4.0-mm diomefer design.This is ogreot improvement, however it still does nof occurotely tronsfer o record ofonotomicolly heoled tissue, which is often friongulorly shoped, fo the lobo-ratory, becouse fhe impression coping is o round cylinder,This orficleexploins how fo fobricofe o "cusfom impression coping" thof is on exocfrecord of onotomicolly heoled tissue for occurote duplicofion.This tech-nique is significont becouse it ollows on even closer replicotion of thenoturol dentifion. (lnt J Periodont Rest Dent .l997; I 7:585-591 .)

-Privote Proctice, Loguno Niguel, Colifornio.

Reprint requests: Dr Kenneth F. Hinds,25500 Roncho Niguel Rood,Suite 260, Loguno Niguel, Coliforoio 92656.

lmplont dentistry hos evolvedfrom Brdnemork 's eor ly workwith the totolly edentulous orchto portiolly edentulous estheticrestorotions.l The old stondordof just ochieving osseointegro-tion, function, ond longevity ofthe imo lon t res to ro t i on i s nolonger stote-of-the-ort. The newstondord of core requires thotthe implont prosthesis olso beesthetic,2.3

This new esthetic stondordin implont dentistry ploces oninc reosed cho l l enge on t hedentol teom ond the comoo-nies monufocturing the compo-nents used. Potients ore moreestheticol ly demonding todoyond reoui re restorot ions thotreplicote the noturol dentition.The on l y woy to so t i s f y t hedemonds of the pot ient is byp rope r p lonn ing be fo re thes to r t o f t r eo tmen t .2 .4 Eochphose (presurgery ond of stogeI ond s toge 2 su rge ry ) i s onopportunity for tissue monipulo-tion in the process of ochievingoerfection in the finol estheticrestorotion. The dentol implont

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teom must toke odvontoge ofeoch step to furiher refine theheo l ing t i ssue to p roper ono-t o m i c s h o p e , c o n t o u r s , o n dheolth. The hondl ing of the t is-sue of stoge 2 surgery is probo-

b ly the most c r i t i co l phose inthe process of restorotion.

" C u s t o m - g u i d e d " t i s s u eh e o l i n 9 2 w i t h o p r o v i s i o n o l

r e s t o r o t i o n i s t h e m o s t p r e -

dictoble woy to ochieve not-u ro l . onotomico l l y shoped t i s -s u e o n d o p t i m o l e s t h e t i c s .M o n y c l i n i c i o n s t o d o y p r e f e r

thot on implont regisirot ion orindex be token of stoge 1 sur-gery.5-8 This ol lows the implontteom io immediotely ploce ononotomicol ly contoured provi-

s i o n o l r e s t o r o i i o n o i s t o g e 2surgery ond to s to r t to gu idet h e s o f t t i s s u e t o h e o l i n o nideol, noturol morphology thotreplicotes the tooth form,2

After complete heoling hosbeen obtoined (usuolly ot 6 toB weeks) the best woy to trons-f e r o r e c o r d o f b e o u t i f u l l yheoled tissue to the loborotoryf o r e x o c t d u p l i c o t i o n i n t h efinol restorotion must be deter-mined,

In the post only 4-mm-diom-eier round impression copingswere ovoiloble to tronsfer trion-g u l o r - s h o p e d t i s s u e ( i n t h eonterior of the mouih) thot wos5 to 7 mm. The loborotory wosthen fo rcer - l to r r r ress how tov \ J v '

expond the 4-mm opening to ofu l l -s ize onotomico l l y shopedrestorotion. The result wos oftenu n s o t i s f o c t o r y . o n d o f t e n o

ridge lop prosthesis, which is noton occepioble esthetic restoro-t ion ond is incompot ib le w i thperiodontol heolth.5'e' I o

W i t h t h e o d v e n t o f t h eE m e r g e n c e P r o f i l e S y s t e m( lmp lon t lnnovot ions) heo l ingobutments /cops 5 .0 , 6 .0 , ond7,5 mm in diometer ond corre-s p o n d i n g i m p r e s s i o n c o p i n g st h e r e h o s b e e n o d r o m o t i cimprovement over the or iginol4 . 0 - m m - d i o m e t e r d e s i g n . T h i ssystem works well in expondingthe t issue during sioge 2 heol-i n n t o t h o n r n n e r d i m e n S i O nond in tronsferr ing thot s ize tothe loborotory with the corre-s p o n d i n g i m p r e s s i o n c o p -ing.5,o, l1, l2 However, the systemstill does not occurotely tronsferthe onotomicol ly heoled t issue,becouse the impression copingis o round cyl inder ond the t is-sue is often tr iongulor-shoped(in the onter ior of the mouth) orovol-shoped (in the posterior ofthe mouth) . Th is sys tem is theb e s t o v o i l o b l e t o d o t e o n dw o r k s w e l l i n o l l s i t u o t i o n s ,except in ihe esthetic resioro-t i o n w h e n o p r o v i s i o n o l h o sbeen used to custom guide thet i c c r r a h a n l i n n

Jonsen's technique of mok-ing two provisionol restorotionso n d u s i n g o n e o f t h e m o s op ick-up impress ion cop ing w i l lt ronsfer the heol ing t issue veryoccurotely.s The only disodvon-toge with this technique is thotthe clinicion must fobricote twop r o v i s i o n o l r e s t o r o t i o n s o n dmoke them exoct ly ident icol .

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The solution to obtoining onexoct impression of the heoledtissue ond hoving the obility totronsfer this to the loborotory isto customize the pick-up-type

impression coping. The presentreport detoils o new procedurethot provides o ropid methodfor th is t rons fer p rocess tho tyields optimol estheiic results,

Method ond moteriols

Two poiients requiring estheticrestorot ions were selected tod e m o n s t r o t e t h i s n e w t e c h -nique Both potients presented

with stondord externol hexogo-no l imp lon ts tho t hod heo ledfor 8 weeks ofter stoge 2 expo-sure ond tho t were reody fo rf ino l impress ions . Gu ided so f tt issue heol ing with o provisionol

restorot ion wos used to shopet h e t i s s u e t o i d e o l o n o t o m i cform ond heolth

Clinical fechnique

An onterior tooth ond o poste-

rior tooth were chosen to dem-onstrote the effect iveness ofthis method, The onter ior toothhod o t r iongu lor -shoped roo tf o r m , w h e r e o s t h e p o s t e r i o r

tooth hod on ovol-shoped rootform. Previous impression tech-niques ore odequote for poste-

r i o r t e e t h w i t h m i n i m o l t i s s u edepth (l to 2 mm). However, for

onter ior teeth in which the t is-s u e d e p t h i s g r e o t e r t h o n 2mm, the results moy not be osoccurote ond ultimotely not ose s t h e t i c . T h i s n e w t e c h n i q u emoy be used in oll situotions (oll

implonts) in the mouth in whichthere ore 2 or more mi l l imetersof t issue depth ond in which onoccurote tronsfer record of iheh e o l e d o n o t o m i c t i s s u e i sdesired.

Fabricotion of ocusfom impression coping

The potient's provisionol restor-o t ion wos removed f rom thei m p l o n t , o n d t h e l o b o r o t o r yonolog wos oi ioched (Figs 1oond I b). Regisil bite registrotionposte (Dentsply) wos then mixedond used to fil l o plostic circulorconfoiner 23 mm deep, The pro-

visionol restorotion, with its ono-log ottoched, wos ploced intothe Regisil until it hit bottom (Figs

2o ond 2b). One of the odvon-toges o f Reg is i l i s tho t i t se tsqu ick ly , in I to 2 minu tes . Theprovisionol restorot ion wos un-screwed from the Regisi l moldond repositioned in the potient's

mouth. This prevented tissue col-lopse over the the implont ondolterotion of its shope. As o resulto f th is mon ipu lo t ion , on exoc tregistrotion of the tissue portion

of the provisionol restorot ion,wiih the onolog in the mold, wosobtoined (Fig 3o),

A 4- or S-mm pick-up-type

i m p r e s s i o n c o p i n g w o s o t -toched to the Regisil mold ondcoupled to engoge the hexo-gon of the implont onolog (Fig

3b), Porcel i te Duol Cure com-pos i te res in (Ker r ) wos mixedond injected oround the cop-ing (Figs 4o ond 4b). After 3 to 4minutes the composite resin wosf r r l l r r n r r r a r l n n r { f l ' r a n a n i n a

v v F / r r r v

could be removed.lf necessorv,i h e s e t c o n b e o c c e l e r o t e dwith o stondord curing light. Thisnewly creoted "custom impres-sion coping" wos closely exom-ined ond polished to produce osmooth surfoce.

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Fig Io (lefI) Remavol of fhe idecsllysnplnt lrar' l orovicionol re\tOrAlton.

F9 lb (r ight) Affachmenf of animplctnt onalag fo the provisionctlresforation,

Fig 2o (lefI) Plastic cylinder is fillecl 23mm deep with Regisil.

Fig 2b (right) Plocemenf of fhe provi-sionol resfarotton wifh fhe onolagaffoched rnfo fhe confotner of Regisil.

Fig 3o (left) Repilcctfion of fhe ttssuepartion of the pravsianal restoratton tnfhe Regisil mold.

Fig 3b (right) Alfctchment of S-mm-d i c: meter pick-up-fy pe r m p ressi o ncoping.

Fig 4o (tef l) lnJecton of fhe Porccti teDuol Cure composile restn tnto lheRegisil mold.

Fig 4b (rignI) Top vtew of the curedcustom impresston coping within themold.

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Fig 5a (left) Custom impression coping

Fig 5b (right) Comporison of the newcusfom impression coping with o sfon-dord impression coping ond fhe tissueportion of fhe provisionol resforation,

Fig 6a (lefi) Clinicctl oftochment offhe cusfom impression coping.

Frg 6b (right) Clinicctl incisol view offhe custom impression coping.

Fig 7o (left) Custom impression cop-ing retained in the impression moferiolwifh on implonf onolog offoched.

Fig 7b (rignI) Finol onotomic flssuecost showing the occurole transferrecord of fhe healed tissue.

Resulls

F i g u r e s 5 o o n d 5 b s h o w o nexoct replico of the tissue por-

t ion of the provisionol restoro-t i o n . A l l o f t h e s e p r o c e d u r e s

were performed in 5 to 6 min-u tes wh i le the po i ien t wos inthe choir .

Finolimpression

The potient's provisionol restoro-tion, which hod prevented col-lopse of the tissue, wos removed

from the implont ond replocedwith the custom impression cop-ing (Figs 6o ond 6b). The customimpression coping wos screweddown to its proper position, ondo p e r i o p i c o l r o d i o g r o p h w o stoken to ver i fy f i t . A siondordp ick-up impress ion wos tokenwi th o f i rm moter io l (such ospo lye iher o r po lyv iny l ) ond omodi f ied p los t i c t roy w i th onoccess hole of the si te of theimpression coping. The customi m p r e s s i o n c o p i n g w o s u n -screwed th rough the occessh o l e o n d t h e i m p r e s s i o n w o s

removed. As o result, the customimpression coping in Fig 7o wosinc luded in the impress ion , Ani m p l o n t o n o l o g w o s t h e n o t -toched, ond gingivol s imulot ionmoter iol wos injected oroundthe port ion of the custom im-pression coping thoi projected

out of the impression.The impression wos poured

in die stone to moke the f inoltissue cost for the loborotory. Aso result, the loborotory hod onexoct repl ico of the pot ient 's

heo led onotomico l l y shopedt i s s u e ( F i g 7 b ) , T h e i m p l o n t

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Fig 8o Multiple-loyered image showing the custom abulmenf transitioning through the tissue,

Figs 9o ond 9b Clinicol views showing fhe custom impressioncoping.

restorotion could then be fobri-r : c t e r j n r : r : r r r n t e l v t o f i i t h ev v v v , v , v , )

h e o l e d t i s s u e o n d o b t o i n o nimproved esthetic result.

Ficrrres 8rr crncl Bb show theresults of this new technique inon ideol s i tuot ion, in which iheimplont wos ploced properly ino normol shoped r idge. This 45-yeor-old mole presented wiih ofroctured root ond mesiol de-fect to the opex of his moxi l lory

r igh t lo te ro l inc isor , A f te r ex-troct ion, guided t issue regener-o t ion w i th o membrone, ondp r o p e r h e o l i n g , t h e i m p l o n twos ploced ond restored witho c u s t o m o b u t m e n t o n d oc e m e n t o b l e p o r c e l o i n p r o s -

t h e s i s . T h e o n o t o m i c c u s t o mobutment in Fig Bo repl icotest h e n o t u r o l r o o t f o r m i n t h i sesthetic restorotion.

Fig 8b Final restorotion:The implant is placed in an idectlposition.

Fig 9c Finol restorotion: The implant is ploced in o nonideolposition.

Figure 9c shows the resul isof this new technique in o si tuo-t ion in wh ich the imp lon t wosploced in o nonideol posi t ion.

This 2l -yeor-old mole presented

w i t h o l o o s e M o r y l o n d f i x e dnr r r t i r r l r ^ lcn t r r re tq res to re ocongen i to l l y miss ing mox i l lo ryr ight f i rst premolor. The implontwos ploced too for to the buc-col ond too close to ihe odjo-cent tooth. As o result, it ongled

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d i s t o l l y t o w o r d t h e m o x i l l o r yr i g h t s e c o n d p r e m o l o r , o n dmode s tondord p ick -up- type

impression techniques di f f icul t .The f inol impression wos tokenwith o custom impression cop-ing os illustroted in Figs 9o ond9b. The implont wos restored bymoking o 1S-degree ongle cor-r e c t i o n w i i h o c u s t o m o b u t -ment ond o cementob le por -

celoin prosthesis.

Discussion

This o r t i c le hos demonst ro tedt h e e f f e c t i v e n e s s o f o n e wmeihod for tronsferring heoledcl inicol t issue to the loborotoryv ic o cus iom impress ion cop-ing. This is o signi f icont f inding,becouse i t no t on ly i s o veryoccurofe tronsfer method, butit hos olso been shown to workin si tuot ions with ideol implontp l o c e m e n t o n d t h o s e w i t hs e v e r e o n g l e p r o b l e m s . l t i son t ic ipo ted iho t th is methodwil l hove universol oppl icot ionin implont dentistry,

Another odvonioge of thisnew techn ique is tho t i t on lyrequ i res opprox imote ly 5 to 6minutes to oc tuo l l y fobr ico tethis custom impression coping.Thus . in jus t o few minutes onoccurote coping con be modethot will ultimotely sove the clin-ic ion choir t ime when the per-

monent restorotion is delivered,Since the loborotory will hove ov e r y o c c u r o t e m o d e l o f t h eh e o l e d o n o i o m i c t i s s u e . t h e

permonent res to ro t ion w i l l f i im o r e p r e c i s e l y , r e q u i r e l e s sc h o i r - s i d e m o d i f i c o t i o n , o n dhove o much improved, consis-tent esthetic result,

Conclusion

With the new esthetic stondordin implont dent istry, i t is impor-tont thot new techniques ondm e t h o d s b e d e v e l o p e d t omeet increosing demonds. Thisor t i c le hos in t roduced o newtechn ique to o id the c l in ic iontoword meeting this new chol-lenge The fobricotion of o cus-t o m i m p r e s s i o n c o p i n g h o sbeen shown to be on occurofeond eff ic ient method to trons-f e r o r e c o r d o f t h e h e o l e donotomic t issue to the loboro-tory. This wi l l o l low ihe loboro-tory technicion to fobr icote ores toro t ion tho t f i t s p rec ise ly

with proper contour, funct ion,ond esthetics,

Acknowledgmenls

T h e o u t h o r w o u l d l i k e t o t h o n k D rChor les R ibok fo r h is encourogementond cri t icol reoding of this monuscript,

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2, Touoti B, Custom-guided i issue heol-i n g f o r i m p r o v e d o e s t h e t i c s i nimplont-supporied restorotions. Int JDeni Symp I 995;3:36-39.

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4. Sheppord WK, Ducor JP London RM,P l o n n i n g f o r i m p l o n t p l o c e m e n l .

Coli f Dent Assoc J 1995;23(3): l4-18,

5, Jonsen CE, Guided soft t issue heol-ing in imp lon t dent is t ry . Co l i f DentAssoc J 1 995:23(3).57 -64.

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reslorotion to be ploced ot stoge 2surgery . J Pros the i Dent

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index: A cose study, Int J PeriodontRest Dent 19921 2,279-293,

8. Prestipino V Ingber A, lmplont f ixtureposit ion registroi ion ot the t ime off i x tu re p locemenf surgery , Proc tPeriodontics Aesthet Denl 1992;4(9):23-27.

9, Lozzoro RJ, Monoging the soft tissuemorgin: The key to implont oesthet-ics, Proct Periodontics Aesthet Dent1 993;5(5) :1 -7 ,

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cons idero t ions , Proc t Per iodon l icsAesthet Dent 1 994:6(9):55-62,

I l . Soodoun AP S ing le too th imp lon trestorotion: Surgicol monogemenifor oesthetic results. Int J Dent SympI 995;3(l ) :30-35,

12. Soodoun AP Sull ivon DY Krischek M,Goll MC. Single tooth implont mon-nrrement fnr sr rr:r-esg, Proct Perio-d o n i i c s A e s t h e t D e n t 1 9 9 4 ; 6 ( 3 ) ' ,73-80.

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