ipecicl reorintfrom

THEINTERNATIONAL
JOURNAL
OF

PERIODP?NTICS
RESTdRATIVE
DENTISTRY

Copyright
@ 1997 by Quintessence
PublCo, Inc

97
The Internotiono Journol of Periodontics& RestorotiveDentisirv
 585

CuslomlmpressionCopingfor on
ExoctRegistrolion of the Heoled
Tissuein lhe Estheticlmplonl
Restorotion

ru
@.i
KennefhF.Hindg DDS- lmplont dentistryhos evolved
f r o m B r d n e m o r k ' se o r l y w o r k
with the totollyedentulousorch
to portiollyedentulousesthetic
restorotions.l The old stondord
of just ochieving osseointegro-
tion, function,ond longevityof
lf is well known thaf guided soff lissuehealing wifh o provisionolresforofionis t h e i m o l o n t r e s t o r o t i o ni s n o
essentiolto obtoin opfimol onteriorestheficsin fhe implonf prosthesis.Whof longer stote-of-the-ort. The new
isnot well known ishow to tronsfero record of beoutiful onotomicolly
stondord of core requiresthot
heoled tissuefo fhe loborotory,Withthe odvent of emergence profile heol-
the implont prosthesis olso be
ing obufmenfs and correspondingimpressioncopings,fhere hosbeen o
esthetic,2.3
dromotic improvemenfover fhe oil@nd 4.0-mmdiomefer design.Thisis o
greot improvement,however it stilldoes nof occurotely tronsfero record of Thisnew esthetic stondord
onotomicolly heoled tissue,which isoften friongulorlyshoped, fo the lobo- in implont dentistryploces on
ratory,becouse fhe impressioncoping iso round cylinder,This orficle i n c r e o s e dc h o l l e n g eo n t h e
exploinshow fo fobricofe o "cusfom impressioncoping" thof is on exocf dentol teom ond the comoo-
record of onotomicolly heoled tissuefor occurote duplicofion.Thistech- niesmonufocturingthe compo-
nique issignificontbecouse it ollowson even closerreplicotionof the nents used.Potientsore more
.l997;
noturoldentifion.(lntJ PeriodontRestDent I 7:585-591.) estheticollydemonding todoy
o n d r e o u i r er e s t o r o t i o n tsh o t
replicotethe noturoldentition.
T h e o n l y w o y t o s o t i s f yt h e
d e m o n d so f t h e p o t i e n t i s b y
proper plonningbefore the
s t o r t o f t r e o t m e n t . 2 . 4E o c h
phose (presurgeryond of stoge
I o n d s t o g e 2 s u r g e r y )i s o n
-Privote Proctice, Loguno Niguel,Colifornio.
opportunityfor tissuemonipulo-
tion in the processof ochieving
Reprintrequests:Dr KennethF.Hinds,25500Roncho Niguel Rood, oerfection in the finol esthetic
Suite 260, Loguno Niguel,Coliforoio 92656. restorotion. The dentol implont

Volume17.Number6. 1997
586
teom must toke odvontoge of
eoch step to furiher refine the
h e o l i n g t i s s u et o p r o p e r o n o -
tomic shope, contours,ond
heolth. The hondling of the tis-
sue of stoge 2 surgery is probo-
bly the most criticol phose in
the processof restorotion.
"Custom-guided" tissue
heolin92 with o provisionol
restorotion is the most pre-
dictoble woy to ochieve not-
u r o l .o n o t o m i c o l l y s h o p e d t i s -
sue ond optimol esthetics.
M o n y c l i n i c i o n st o d o y p r e f e r
thot on implont regisirotionor
index be token of stoge 1 sur-
gery.5-8Thisollows the implont
teom io immediotely ploce on
onotomicolly contoured provi-
s i o n o l r e s t o r o i i o no i s t o g e 2
surgeryond to stort to guide
t h e s o f t t i s s u et o h e o l i n o n
ideol, noturol morphology thot
replicotesthe tooth form,2
After complete heoling hos
been obtoined (usuolly ot 6 to
B weeks) the best woy to trons-
fer o record of beoutifully
heoled tissueto the loborotory
for exoct duplicotion in the
finol restorotion must be deter-
mined,
In the post only 4-mm-diom-
eier round impressioncopings
were ovoiloble to tronsfertrion-
gulor-shoped tissue (in the
onterior of the mouih) thot wos
5 to 7 mm. The loborotory wos
t h e n f o r c e r - lt o r r r r e s sh o w t o
v \Jv'
expond the 4-mm opening to o
f u l l - s i z eo n o t o m i c o l l y s h o p e d
restorotion.The result wos often
u n s o t i s f o c t o r y .o n d o f t e n o
The Internotionol Journol of Periodontics& RestorotiveDentistry
ridge lop prosthesis, which is not
on occepioble esthetic restoro-
tion ond is incompotible with
periodontol heolth.5'e' Io
With the odvent of the
E m e r g e n c e P r o fi l e S y s t e m
( l m p l o n t l n n o v o t i o n s )h e o l i n g
o b u t m e n t s / c o p s 5 . 0 ,6 . 0 ,o n d
7,5 mm in diometer ond corre-
s p o n d i n g i m p r e s s i o nc o p i n g s
there hos been o dromotic
improvement over the originol
4 . 0 - m m - d i o m e t e rd e s i g n .T h i s
system works well in exponding
the tissueduring sioge 2 heol-
inn to tho nrnner dimenSiOn
ond in tronsferringthot size to
the loborotory with the corre-
sponding impression cop-
ing.5,o,l1,l2 However,the system
stilldoes not occurotely tronsfer
the onotomicolly heoled tissue,
becouse the impressioncoping
is o round cylinder ond the tis-
sue is often triongulor-shoped
(in the onteriorof the mouth) or
ovol-shoped (in the posteriorof
t h e m o u t h ) . T h i ss y s t e m i s t h e
best ovoiloble to dote ond
works well in oll situotions,
except in ihe esthetic resioro-
t i o n w h e n o p r o v i s i o n o lh o s
been used to custom guide the
ticcr ra hanlinn
Jonsen'stechnique of mok-
ing two provisionol restorotions
ond using one of them os o
p i c k - u p i m p r e s s i o nc o p i n g w i l l
tronsferthe heoling tissuevery
occurotely.sThe only disodvon-
toge with this technique is thot
the clinicion must fobricote two
p r o v i s i o n o l r e s t o r o t i o n so n d
moke them exoctly identicol.

The solutionto obtoining on
exoct impressionof the heoled
tissueond hoving the obility to
tronsfer this to the loborotory is
to customize the pick-up-type
impressioncoping. The present
report detoils o new procedure
thot provides o ropid method
for this tronsfer process thot
yieldsoptimol estheiic results,
Method ond moteriols
Two poiients requiring esthetic
restorotions were selected to
demonstrote this new tech-
nique Both potients presented
with stondord externol hexogo-
nol implontsthot hod heoled
for 8 weeks ofter stoge 2 expo-
sure ond thot were reody for
f i n o l i m p r e s s i o n sG
. uided soft
tissueheoling with o provisionol
restorotionwos used to shope
t h e t i s s u et o i d e o l o n o t o m i c
form ond heolth
Clinical fechnique
An onterior tooth ond o poste-
rior tooth were chosen to dem-
onstrote the effectiveness of
this method, The onterior tooth
h o d o t r i o n g u l o r - s h o p e dr o o t
form, whereos the posterior
tooth hod on ovol-shoped root
form. Previousimpressiontech-
niques ore odequote for poste-
riorteeth with minimoltissue
depth (l to 2 mm). However,for
587
onterior teeth in which the tis- A 4- or S-mm pick-up-type
sue depth is greoter thon 2 impression coping wos ot-
mm, the resultsmoy not be os toched to the Regisilmold ond
occurote ond ultimotely not os coupled to engoge the hexo-
e s t h e t i c .T h i sn e w t e c h n i q u e gon of the implont onolog (Fig
moy be used in oll situotions(oll 3b), Porcelite Duol Cure com-
implonts)in the mouth in which p o s i t e r e s i n ( K e r r )w o s m i x e d
there ore 2 or more millimeters ond injected oround the cop-
of tissuedepth ond in which on ing (Figs4o ond 4b). After 3 to 4
occurote tronsfer record of ihe minutesthe composite resinwos
heoled onotomic tissue is fr rllrr nr rrarl nnr{ fl'ra n anina
vvF/rr rv
desired. could be removed.lf necessorv,
ihe set con be occeleroted
with o stondord curing light.This
Fabricotion of o newly creoted "custom impres-
cusfom impressioncoping sion coping" wos closely exom-
ined ond polishedto produce o
The potient's provisionolrestor- smooth surfoce.
otion wos removed from the
implont, ond the loborotory
onolog wos oiioched (Figs 1o
ond I b). Regisilbite registrotion
poste (Dentsply)wos then mixed
ond used to fill o plostic circulor
confoiner 23 mm deep, The pro-
visionolrestorotion,with its ono-
log ottoched, wos ploced into
the Regisiluntil it hit bottom (Figs
2o ond 2b). One of the odvon-
t o g e s o f R e g i s i li s t h o t i t s e t s
q u i c k l y , i n I t o 2 m i n u t e s .T h e
provisionolrestorotionwos un-
screwed from the Regisilmold
ond repositionedin the potient's
mouth. Thisprevented tissuecol-
lopse over the the implont ond
olterotion of its shope. As o result
o f t h i s m o n i p u l o t i o n ,o n e x o c t
registrotionof the tissueportion
of the provisionol restorotion,
wiih the onolog in the mold, wos
obtoined (Fig3o),
'l997
Volume 17,Number 6,
5BB

Fig Io (lefI) Remavol of fhe idecslly

snplnt lrar'l orovicionol re\tOrAlton.

F9 lb (right) Affachmenf of an
implctnt onalag fo the provisionctl
resforation,

Fig 2o (lefI) Plastic cylinder is fillecl23

mm deep with Regisil.

Fig 2b (right) Plocemenf of fhe provi-

sionol resfarotton wifh fhe onolag
affoched rnfo fhe confotner of Regisil.

Fig 3o (left) Repilcctfion of fhe ttssue

partion of the pravsianal restorattontn
fhe Regisilmold.

ffi Fig 3b (right) Alfctchment of S-mm-

d ic:meter pick-up-fy pe rm p ressi
coping.
on

Fig 4o (tefl) lnJectonof fhe Porcctite

Duol Cure composile restntnto lhe
Regisilmold.

Fig 4b (rignI) Top vtew of the cured

custom impresstoncoping within the
mold.

The InternotionolJournol of Periodontics& RestorotiveDentistrv

 589

Fig 5a (left) Custom impression coping

Fig 5b (right) Comporison of the new

cusfom impression coping with o sfon-
dord impression coping ond fhe tissue
portion of fhe provisionol resforation,

Fig 6a (lefi) Clinicctl oftochment of

fhe cusfom impression coping.

Frg 6b (right) Clinicctl incisol view of

fhe custom impressioncoping.

Fig 7o (left) Custom impression cop-

ing retained in the impression moferiol
wifh on implonf onolog offoched.

Fig 7b (rignI) Finol onotomic flssue

cost showing the occurole transfer
record of fhe healed tissue.

Resulls from the implont ond reploced removed.As o result,the custom

F i g u r e s5 o o n d 5 b s h o w o n
exoct replico of the tissue por-
tion of the provisionolrestoro-
tion. All of these procedures
were performed in 5 to 6 min-
utes while the poiient wos in
the choir.
Finolimpression
The potient's provisionolrestoro-
tion, which hod prevented col-
lopse of the tissue,wos removed
with the custom impressioncop-
ing (Figs6o ond 6b).The custom
impressioncoping wos screwed
down to its proper position,ond
o periopicol rodiogroph wos
token to verify fit. A siondord
p i c k - u p i m p r e s s i o nw o s t o k e n
with o firm moteriol (such os
p o l y e i h e r o r p o l y v i n y l )o n d o
modified plostic troy with on
occess hole of the site of the
impressioncoping. The custom
impression coping wos un-
screwed through the occess
h o l e o n d t h e i m p r e s s i o nw o s
impressioncoping in Fig 7o wos
i n c l u d e d i n t h e i m p r e s s i o nA, n
implont onolog wos then ot-
toched, ond gingivol simulotion
moteriol wos injected oround
the portion of the custom im-
pressioncoping thoi projected
out of the impression.
The impressionwos poured
in die stone to moke the finol
tissuecost for the loborotory.As
o result,the loborotory hod on
exoct replico of the potient's
heoled onotomicolly shoped
tissue (Fig 7b), The implont

.l997
Volume I 7, Number 6,
590

Fig 8o Multiple-loyered image showing the custom abul Fig 8b Final restorotion:The implant is placed in an idectl
menf transitioning through the tissue, position.

Figs 9o ond 9b Clinicol views showing fhe custom impression Fig 9c Finol restorotion: The implant is ploced in o nonideol
coping. position.

restorotion could then be fobri- r i g h t l o t e r o l i n c i s o r ,A f t e r e x - Figure 9c shows the resulis

r:cterj nr:r:rrrntelv to fii the
v v v v , v , v ,
h e o l e d t i s s u eo n d o b t o i n o n
improved esthetic result.
Ficrrres8rr crnclBb show the
resultsof this new technique in
on ideol situotion,in which ihe
implont wos ploced properly in
o normol shoped ridge.This45-
yeor-old mole presented wiih o
froctured root ond mesiol de-
fect to the opex of his moxillory
)
troction,guided tissueregener- of thisnew technique in o situo-
otion with o membrone, ond tion in which the implont wos
proper heoling, the implont ploced in o nonideol position.
wos ploced ond restored with This2l -yeor-old mole presented
o custom obutment ond o with o loose Morylond fixed
cementoble porceloin pros- n r r r t i r r l r ^ l c n tr r e t q r e s t o r e o
t h e s i s .T h e o n o t o m i c c u s t o m c o n g e n i t o l l y m i s s i n gm o x i l l o r y
obutment in Fig Bo replicotes right firstpremolor.The implont
the noturol root form in this wos ploced too for to the buc-
esthetic restorotion. col ond too close to ihe odjo-
cent tooth. As o result,it ongled

The InternotionolJournol of Periodontics& RestorotiveDentistry


d i s t o l l yt o w o r d t h e m o x i l l o r y
right second premolor,ond
mode stondord pick-up-type
impressiontechniques difficult.
The finol impressionwos token
with o custom impressioncop-
ing os illustrotedin Figs9o ond
9b. The implont wos restored by
moking o 1S-degreeongle cor-
rection wiih o custom obut-
ment ond o cementoble por-
celoin prosthesis.
Discussion
T h i so r t i c l e h o s d e m o n s t r o t e d
the effectiveness of o new
meihod for tronsferringheoled
clinicol tissueto the loborotory
v i c o c u s i o m i m p r e s s i o nc o p -
ing. Thisis o significontfinding,
becouse it not only is o very
occurofe tronsfer method, but
it hos olso been shown to work
in situotionswith ideol implont
plocement ond those with
severe ongle problems. lt is
onticipoted ihot this method
will hove universolopplicotion
in implont dentistry,
Another odvonioge of this
new technique is thot it only
r e q u i r e so p p r o x i m o t e l y 5 t o 6
minutesto octuolly fobricote
this custom impressioncoping.
T h u s .i n j u s t o f e w m i n u t e s o n
occurote coping con be mode
thot will ultimotelysove the clin-
icion choir time when the per-
monent restorotionis delivered,
Since the loborotory will hove o
very occurote model of the
h e o l e d o n o i o m i c t i s s u e .t h e
591
p e r m o n e n t r e s t o r o t i o nw i l l f i i 3. RifkinRG. Developing o proper se-
quence for implont-supported resto-
m o r e p r e c i s e l y ,r e q u i r e l e s s
rotions.Int J Dent Symp 1995;3:40-43,
c h o i r - s i d em o d i f i c o t i o n , o n d
4. Sheppord WK,Ducor JP London RM,
hove o much improved, consis- P l o n n i n gf o r i m p l o n t p l o c e m e n l .
tent esthetic result, Colif Dent AssocJ 1995;23(3):l4-18,
5, Jonsen CE, Guided soft tissueheol-
i n g i n i m p l o n t d e n t i s t r yC
. olif Dent
Assoc J 1995:23(3).57 -64.
Conclusion
6, Hochwold DA. Surgicoltemplote
i m p r e s s i o nd u r i n g s t o g e 1 s u r g e r y
With the new esthetic stondord
for fobricotion of o provisionol
in implont dentistry,it is impor- reslorotion to be ploced ot stoge 2
,l991:66
tont thot new techniques ond s u r g e r y .J P r o s t h e i D e n t
(6):796-798.
methods be developed to
meet increosingdemonds. This 7, ReiserG, DornbushJR,Cohen R. Ini-
tioting restorotive procedures ot first
orticle hos introduced o new
stoge surgery with o positionol
technique to oid the clinicion index: A cose study,Int J Periodont
toword meeting this new chol- RestDent 199212,279-293,
lenge The fobricotion of o cus- 8. PrestipinoV Ingber A, lmplont fixture
t o m i m p r e s s i o nc o p i n g h o s position registroiionot the time of
f i x t u r e p l o c e m e n f s u r g e r y ,P r o c t
been shown to be on occurofe
Periodontics Aesthet Denl 1992;4
ond efficient method to trons- (9):23-27.
fer o record of the heoled 9, LozzoroRJ,Monoging the soft tissue
onotomic tissueto the loboro- morgin:The key to implont oesthet-
tory. Thiswill ollow ihe loboro- ics,Proct PeriodonticsAesthet Dent
19 9 3 ; 5 ( 5 ) -: 7
1,
tory technicion to fobricote o 'l0.
L o z z o r o R J ,C r i t e r i o f o r i m p l o n t
restorotionthot fits precisely
s e l e c t i o n : S u r g i c o lo n d p r o s t h e t i c
with proper contour, function, c o n s i d e r o t i o n sP , roct Periodonlics
ond esthetics, Aesthet Dent 1994:6(9):55-62,
I l. Soodoun AP Singletooth implont
restorotion:Surgicol monogemeni
for oesthetic results.Int J Dent Symp
Acknowledgmenls
I 995;3(l):30-35,
The outhor would liketo thonk Dr 12. Soodoun AP SullivonDY KrischekM,
Goll MC. Singletooth implont mon-
C h o r l e sR i b o k f o r h i s e n c o u r o g e m e n t
nrrement fnr srrr:r-esg,Proct Perio-
ond criticol reoding of this monuscript,
doniics Aesthet Dent 1994;6(3)',
73-80.
References
L Hobo S,lchido E,Gorcio LT,Osseointe-
grotion ond Occlusol Rehobilitotion.
Chicogo: Quintessence, l99l :7-l l.
2, Touoti B, Custom-guidediissueheol-
ing for improved oesthetics in
implont-supporied restorotions.Int J
Deni Symp I 995;3:36-39.
Volume 17.Number 6. I997