Interim implant-supported restorations play an important role in achieving the desired esthetic outcome and long-term success of implant prostheses.
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The initial interim restoration is made from a conventional implant-level impression, which is then modified to sculpt the gingival contour. Additional material is added to mold the papillae and gingival margins and recreate the natural gingival architecture. An appropriate impression technique is essential for an accurate transfer of the peri-implant emergence profile to the definitive cast.3
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Two different techniques have been described to transfer the emergence profile from the patient's mouth to the definitive cast. The indirect technique
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uses a custom impression coping to copy the peri-implant emergence profile. A standard impression coping is modified by filling the space with autopolymerizing or light-polymerizing resin between the impression coping and the submarginal emergence profile as outlined by a silicone matrix. This technique can transfer the emergence profile from the patient's mouth to the definitive cast with high precision. However, the technique is time-consuming and only suitable for a single implant. For multiple implant restorations with pontic site development, this technique is complex, as the subgingival emergence profile of several implant abutments and the pontic area need to be replicated. The custom impression copings must be splinted to accurately transfer the position of the implants. A disadvantage of the indirect technique is that the peri-implant soft tissue will collapse during the fabrication of the indirect custom impression copings. When the interim restoration is delivered, the patient will feel discomfort as the tissue is displaced.Schoenbaum and Han
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described an efficient and accurate direct custom implant impression coping technique to transfer the emergence profile of an implant abutment and pontic site to the definitive cast. However, this technique is limited to restorations supported by 2 implants. A concern has been expressed that the heat generated by the flowable composite resin and its toxicity may damage the gingival tissue.11
The injectable silicone-based gingival mask technique was developed to transfer the peri-implant emergence profile and the gingival margin of the interim restoration to the definitive cast.12
Technique
- 1.Use an implant-level impression, splinting the impression copings, to fabricate a soft tissue cast (Fig. 1).
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Figure 1Soft tissue working cast made from original implant impression using splinted impression copings. Gingival contours represent shape of healing abutments. - 2.Direct the dental laboratory to fabricate an interim restoration replicating the soft tissue profile of the healing abutments (Fig. 2).
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Figure 2Interim restoration as fabricated by dental laboratory technician. - 3.Modify the emergence profile and pontic area of the interim restoration with flowable composite resin (Filtek; 3M ESPE) (Fig. 3).
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Figure 3Interim restoration as modified by treating dentist for ideal emergence profile and ovate pontic contour. - 4.Reappoint the patient after 6 weeks to allow tissue maturation (Fig. 4).
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Figure 4Tissue condition after 6-week maturation period. - 5.Make an intraoral impression of the maxilla using an irreversible hydrocolloid (Jeltrate; Dentsply Sirona) to record the interim restoration with the gingival margin and soft tissue profile.
- 6.Fabricate a vacuum-formed matrix from a clear, hard thermoplastic sheet (Pro-form 0.020 temp splint; Keystone Industries) to cover the gingival tissue and prepare a small hole in the gingival area (Fig. 5).
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Figure 5Vacuum-formed clear matrix with hole placed for injection of silicone-based gingival mask. - 7.Remove the interim restoration and replace it on the definitive cast without the original gingival mask (Figs. 6, 7).
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Figure 6Interim restoration removed. Note tissue sculpted to desired architecture.![Figure thumbnail gr7]()
Figure 7Interim restoration fastened to original definitive cast. - 8.Seat the vacuum-formed matrix over the interim restoration on the definitive cast (Fig. 8).
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Figure 8Vacuum-formed clear matrix placed on original definitive cast with interim restoration attached. - 9.Inject the gingival mask material (Muller; Omicron GmbH & Co KG) directly around the implant replicas and into the space under the pontics through the hole in the vacuum-formed matrix (Figure 9, Figure 10, Figure 11).
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Figure 9Silicone-based gingival mask material injected into space between definitive cast, clear vacuum-formed matrix, and interim restoration.![Figure thumbnail gr10]()
Figure 10Original definitive cast modified with gingival mask.![Figure thumbnail gr11]()
Figure 11Gingival mask–capturing emergence profile of abutments and contour of pontic sites, eliminating need for second impression. - 10.Alternatively, to ensure that there are no air bubbles in the critical areas, the gingival mask material may be injected directly around the abutments and under the pontics before seating the vacuum-formed matrix. Then seat the matrix and continue to inject through the hole in the matrix until excess flows out under the matrix.
Summary
The injectable gingival mask material can transfer the emergence profile of implant abutments and the pontic site to the definitive cast both accurately and precisely. It is a straightforward technique that saves chairside time and does not require an additional impression. The clinician can modify the emergence profile and mold the papillae to optimize the access for hygiene and esthetics; this is then accurately transferred to the definitive cast. This technique can be used in different clinical situations, including different implant angulations.
References
- Predictable peri-implant gingival aesthetics: surgical and prosthodontics rationales.Pract Proced Aesthet Dent. 2001; 13: 691-698
- The esthetic dental implant: letting the restoration be the guide.J Am Dent Assoc. 1995; 126: 319-325
- Platform switching: a new concept in implant dentistry for controlling postrestorative crestal bone levels.Int J Periodontics Restorative Dent. 2006; 26: 9-17
- Guidelines for implant abutment selection for partially edentulous patients.Compend Contin Educ Dent. 2010; 31: 14-20
- Replicating soft tissue contours on working casts for implant restorations.J Prosthodont. 1997; 6: 218-220
- Accurate transfer of peri-implant soft tissue emergence profile from the provisional crown to the final prosthesis using an emergence profile cast.J Esthet Restor Dent. 2007; 19: 306-314
- Impression techniques for implant dentistry.Br Dent J. 2006; 201: 429-432
- Indirect implant-supported fixed provisional restoration in the esthetic zone: fabrication technique and treatment workflow.J Esthet Restor Dent. 2008; 20: 82-95
- Immediate loading and customized restoration of a single implant in the maxillary esthetic zone: a clinical report.J Prosthet Dent. 2009; 102: 211-215
- Direct custom implant impression copings for the preservation of the pontic receptor site architecture.J Prosthet Dent. 2012; 107: 203-206
- Composite-induced toxicity in human gingival and pulp fibroblast cells.Acta Odontol Scand. 2014; 72: 304-311
- Technique for fabricating a custom gingival mask using a maxillary complete-arch implant-supported fixed interim prosthesis with an integrated verification cast.J Prosthet Dent. 2016; 115: 5-8
Article info
Publication history
Published online: May 29, 2019
Identification
Copyright
© 2018 by the Editorial Council for The Journal of Prosthetic Dentistry.
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