The inter.

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Custom Impression Coping for an Exact Registration of the Healed Tissue in the Esthetic Implant Restoration

impiant denfisfry has evolved from Brnemark's eorly work with the totolly edentulous arch to portiolly edentulous esthetic restorations.' The old standord of jusf aohieying osseointegration, function, ond longevity of if is welt icnawn fhat guided soft fissue heaiing with a provisional restoration is the implonf restoration is no essenfiai fo obfain optimai anterior esthetics in the implant prosfhesis. What longer stote-of-the-art. The new is nof weil known is how to transfer a record of beautifui anatomicaliy stondard of care requires that heaied fissue fo the laboratory With the advent ot emergence profiie heaithe implant prosthesis olso be ing abutments and corresponding impression copings, there has been a esfhetic.^-^
Kenneth F Hinds. DDS' dramatic improvement over the originai 4.0-mm diameter design. This is a great improvement hawever if sfiil daes not accurately transfer a record af onatamicatly heaied tissue, which is often triangularly shaped, to fhe iaboratory. because the impression coping is a round cylinder. This artioie expiains how to fabricate a "custom impression coping" fhaf is an exact record of anatomicaliy heated fissue for accurate dupilcation. This technique is significanf becouse it aiiows an even oioser replicatian of fhe naturai dentitian. (Int J Periadonf Rest Denf 1997; 17:585-591.)

'Private Practice, Laguno Niguel. California. Reprinf requests: Dr Kenneth F Hinds, 25500 lanoho Niguel Road, . Suite 20, Laguna Niguel, California 92056.

This new esthetic standard in impionf dentistry piaces an increased ohailenge on the dentai team and the componies manufocturing the components used. Patients are more estheticoily demonding today ond require restorations that replicate the natural dentition. The only way to satisfy the demonds of the patient is by proper planning before the stort of freatmenf.^" Each phose (presurgery and at stage 1 ond stoge 2 surgery) is on opportunity tor tissue monipulation in the process of achieving perfeofion in the finai esfhefio restoration. The denfai impiont

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team must tai<e advantage of each step fo further refine fhe healing tissue to proper anatomic shape, contours, and heaith. The handiing ot the tissue at stage 2 surgery is probabiy the mosf critical phase in the prooess of resforation. "Custom-guided" fissue heaiing^ with a provisionai restoration is the mosf predictable way to aohieve natural, anatomically shaped tissue and optimai esthetics, iVlany clinicians today prefer that an implant registration or index be taken at stage 1 surgery.^-^ This allows the impiant team to immediately place an onatomically contoured provisional restoration at stage 2 surgery and to start fo guide the soft tissue to heai in an ideai, natural morphology that replicates the tooth form.^ Affer compiefe heaiing has been obfained (usuaiiy at to 8 weeks) the besf way to 1ransfer a record of beautifuliy heaied tissue to the laboratory for exact dupiication in fhe finai restoration must be determined. in the past only 4-mm-diameter round impression copings were avaiiabie fo transfer triangular-shaped tissue (in the anterior of the mouth) that was 5 to 7 mm. The iaborafory was then forced to guess how to expand the 4-mm opening to a full-size anatomically shaped restoration. The result was often unsatisfactory, and offen a

ridge iap prosthesis, which is nof an ooceptabie esthetic resforation and is incompatible with periodontai heaith,^''-'^ With the advent of the Emergence Profiie System (Implant Innovations) heaiing abutments/caps 5.0, 6.0, and 7,5 mm in diameter and corresponding impression copings fhere has been a dramafio improvement over the original 4.0-mm-diameter design. This system works weil in expanding fhe tissue during stage 2 healing to the proper dimension and in transferring that size to the laboratory with the corresponding impression copng,5,9,n,i2 However, the system still does not accurately transfer fhe anatomically healed tissue, because the impression coping is a round cylinder and fhe tissue is often triangular-shaped (in the anterior of the mouth) or oval-shaped (in the posterior of fhe mouth). This system is the best available to date and wori<s weii in ali situations, except in the esthetic restoration when a provisionai has been used to custom guide the fissue healing. Jansen's technique of mai<ing two provisional restorations and using one of them as a pici<-up impression coping wiii fransfer the healing fissue very accurately.^ The oniy disadvantage with this technique is that the ciinician must fabricate two provisional restorations and make them exactly identicai.

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The solution to obtaining an exact impression of the heaied tissue and having the abiiity to transfer this to the laborotory is to customize the pick-up-type impression ooping. The present report details a new procedure that provides a ropid method for this tronsfer process that yields optimal esthetic results.

anferior teeth in which fhe tissue depth is greater than 2 mm, the resuits moy not be as accurote and ultimateiy not as esthefio. This new fechnique may be used in aii situofions (oil implants) in the mouth in which there are 2 or more millimefers of tissue depth and in whioh an occurate transter record of the healed anatomic tissue is desired.

Method and malerials

Two patients requiring esthetic restorations were seiected to demonstrate this new technique. Both patients presented with standard externol hexagonal impiants that had healed for 8 weeks after stage 2 exposure and that were ready for final impressions. Guided soff tissue heoling wifh a provisional restoration was used to shope the tissue to ideal anatomic form and health. Fabrication of a custom impression coping The patient's provisional restoration was removed from the impiant, and the loboratory anaiog was ottached (Figs l a and lb). Regisil bite registration paste (Dentsply) was then mixed and used to fill a plastic circuior container 23 mm deep. The provisional restorotion, with its onolog attached, wos placed into the Regisii untii it hit bottom (Figs 2a and 2b). One of the advanfoges of Regisil is fhaf if sets quickiy. in 1 to 2 minufes. The provisional resforation was unscrewed trom the Regisil moid and reposifioned in the patienf's mouth. This prevented tissue ooliapse over the the implant and alteration ot its shape. As a result of this manipuiation, an exact registration of the tissue portion of the provisionai restoration, with the onalog in the mold, wos obtained (Fig 3a).

A 4- or 5-mm pick-up-type impression coping was attached to the Regisii moid and coupled fc engage the hexagon of the implant analog (Fig 3b). Poroelite Dual Cure composite resin (Kerr) was mixed and injeoted around the coping (Figs 4a and 4b). Affer 3 to 4 minutes the composite resin wos fuliy cured ond the coping couid be removed, if necessary, the set can be accelerated with a standard curing iight. This newly created "custom impression coping" was ciosely examined ond poiished to produce o smooth surfooe.

Ciinical technique An anterior toofh and a posterior foofh were chosen fo demonstrate the effecfiveness of this mefhod. The anterior toofh had a trianguior-shaped root form, whereas the posterior tooth hod on ovai-shaped root torm. Previous impression techniques ore adequate tor posterior teeth with minimal tissue depth (1 to 2 mm). However, for

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Fig la(ieft) Removal at the ideaiiy contoured provisional restoration. Fig f> (right) Aftachment of an impiant onaiog to the provisional restoration.

Fig 2a (ieft) Plastic cylinder is fiited 23 mm deep with Regisii. Fig 2b (right) Piacement of the provisionai restoration with the anaiog qftqched into the container of Regisii.

Fig 3a (ieft) Replication of the tissue portion of the provisionqi restorqfion in the Regisii maid Fig 3b (right) Attachment of 5-mmdiameter pick-up-type impression coping.

Fig a (ieft) Injection of the Parceiite Dual Cure camposite resin into the Regisii maid. Fig 4b (right) Top view of fhe cured custom impression coping within the moid.

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Fig Sa (ieff)

Oustom impression coping.

Fig Sb (right) Comparison of the new custom impression coping with a stondord impression coping qnd the tissue portion of the provisionai restoration.

Fig 6a (left) Oiinicai ottachment the custom impression coping.

of

Fig 6b (righf) Ciinicai incisai view of fhe custom impression coping.

Fig 7a (ieft) Oustom impression coping retained in the impression materiai with an implant analog ottoched Fig 7b (right) finai anatomic tissue cast showing the accurate transfer record of the heated tissue.

Results Figures 5a and 5b show an exact repiica of fhe tissue porfion of fhe provisional resforafion. All of these procedures were performed in 5 fo 6 minutes while fhe patienf was in the chair.

Final impression The potient's provisionai restoration, which had prevented coliapse of fhe tissue, was removed

from the impianf and repiaced with the custom impression coping (Figs a and 6b), The custom impression coping was screwed down to its proper position, and a periapicai radiograph was taken fo verify fit, A standard pick-up impression was fai<en wifh a firm maferiai (such as poiyether or polyvinyl) and a modified piasfic fray with an access hole at fhe sife of the impression coping. The cusfom impression coping wos unscrewed fhrough fhe access hole and fhe impression was

removed. As a resuit, the cusfom impression coping in Fig 7a was included in fhe impression. An impianf anaiog was fhen attached, and gingivai simulafion material wos injected around the portion of the cusfom impression coping fhat projeofed ouf of the impression. The impression was poured in die stone fo mai<e the finai tissue cast for the iaborotory As a resuif, fhe iaboratory had an exact replica of the pafienfs healed anafomicaily shaped fissue (Fig 7b). The impiant

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Fig Sa Multiple-layered image showing the custom abufment transitioning through the tissue.

Fig 8b final restoration' The impiant is piaced in on ideai position.

figs 9a and 9b coping.

Olinicai views showing the custom Impression

Fig 9c Final restoration: The impiont is placed in a nonideal pasitian.

restoration could then be fabric a t e d accurately to fit fhe healed tissue and obfain an improved esthetic result. Figures 8a ahd 8b show the resuifs of fhis new technique in an ideal situation, in whioh the impiont wos pioced properly in a normoi shoped ridge. This 45year-old male presented with a fractured roof and mesiai detect to the opex of his moxiilary

righf ioferoi incisor. After extraotion, guided tissue regeneration with a membrone, and proper healing, the impiant was piaoed and restored with a custom abutment and a cementoble porcelain prosthesis. The anatomio custom abutment in Fig 8a replicates the naturai root form in this esthetic restorotion.

Figure 9c shows the resuits of this new technique in a situation in which the impiant was placed in a nonideal position. This 21-year-old male presented with a ioose Maryiand fixed portial denfure fo restore a congenitaily missing maxillary right firsf premoior. The implant wos placed too far to the buccal and too ciose fo fhe adjacent tooth. As o result, it angled

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distaily toward the maxillary right second premolar, and made standard pick-up-type impression techniques difficult. The finai impression was taken with a custom impression coping as illustrated in Figs 9a and 9b. The impiant was restored by making a 15-degree angle correction with a custom abutment and a cemenfable porcelain prosfhesis.

permanent restoration will fit more precisely, require less chair-side modification, and have a much improved, consistent esthetic result.

3. fiifi<in IG Deveioping o proper sequence for implant-supported restorotions. Inf J Dent Symp l'?95:3:'10-43. A. Sheppoid WK, Ducor JP London RM Planning far impiont piocement. Calif Dent Assoo J 1995:23(3):14-t8, 5. Jonsen CE. Guided soff tissue healing in implont dentistry. Colif Dent Assoc J 1995:23C3):57-d. 6, Hochwald DA. Surgicai tempiote impressian during stage 1 surgery for f o b r i c a t i o n of a provisionol restoration to be pioced at stoge 2 surgery J Prosthet Dent 1991,6 (6): 796-798 7 Reiser G, Dombush Jl, Cohen R, Initiating restorative procedures at first stage surgery with a positional inde: A case study, int J Periodont Rest Dent 1992.12:279-293. 8. Prestipinc V Ingber A. Implant fixfure position registration at the time of fixture p i o c e m e n t surgery. Pract Periadontics Aesthet Dent !992:4 C9):23-27. 9, Lozzora RJ, Manoging the soft tissue margin: The key to impionf aesthetics, Proct Periadantics Aesthet Dent 1993:5CS).l-7. 10. Lazzaro RJ. Criteria for implont seiectian: Surgicoi and prosthetio considerations. Proot Periadontics Aesthef Dent 1994:C9):55-2. 11. Saadoun AP Singie tooth implant restoroticn: Surgicai manogement for aesthetic resuits. Int J Dent Symp 1995:3(1 ).30-35. 12. Saadoun Afi Sullivan DY Krisohek M, Gaii MC. Singie tooth implant monagement for success. Pract Periodontics Aesthet Dent 1994:6(3): 73-80,

Conciusion With the new esthetic standord in implant dentistry, it is important that new techniques and methods be developed to meet increasing demands. This articie hos introduced a new teohnique to aid the oiinician toward meeting this new challenge. The fabrication of a custom impression coping has been shown fo be an accurote and efficient mefhod to fransfer a record of the healed anatomic tissue to the laboratory. This wiii aliow the ioboratory technician to fabricate a restoration that fifs preciseiy wifh proper contour, function, and esthetios.

Discussion This articie has demonstrated fhe effectiveness of o new method for transferring heaied ciinicai tissue fo the laboratory via a custom impression coping. This is a significanf finding, because it not only is a very occurate transfer mefhod, but it has aiso been shown to work in situations with ideal impiant plaoement and fhose with severe angle problems, it is anticipated fhat this method will have universal applicotion in implant dentistry. Another advantage of this new technique is fhat it only requires approximately 5 fo minutes to aofuaiiy fabricate this custom impression coping. Thus, in just a few minutes an accurafe coping can be made thaf wifi ulfimateiy save the clinician chair time when the permanent restoration is delivered. Since the laboratory will have a very accurate modei of the heaied anatomic fissue, the

Acknowledgments
Ttie outhor would iike to ttiani< Dr Chories Ribok for his enoouragement ond criticol reoding of this monuscript.

Reterences
t. iHobo S, ichido E, Goroio LT. Osseointegration ond Ooolusoi Rehobiiitotion. Chicago'Quintessence, 1W1:7-11. 2. Touoti B. Custom-guided tissue healing for i m o r o v e d aesttiefics in impiant-supported restorotions. Int J Dent Symp 1995:3:36-39.

Volume 17, Number 6,1997