—EE——————————— CASE REPORT Techniques to Control or Avoid Cement Around Implant-Retained Restorations Ds. Steven Present, OMD; and Robert A. Levine, Abstract: As implant dentistry has grown in popularity, many clinicians have attempted to simplify their protocols to more closely resemble conventional erown and bridge procedures. However, a thorough understanding of the biologic differences between natural teeth and dental implants, as well asthe types of cements employed, is essential to achieving both short- and long-term success, as these biologic dis- parities between teeth and implants can lead to residual cement around implant-retained restorations, thus contributing to peri-implant disease. Four techniques are described that either reduce the flow of the esthetics of implant-retained restorations, ‘plant restorative dentistry has become increasingly com plicated over the years, yet outcomes have improved sig nificantly. Despite successes, in an effort to simplify proto- ols clinicians have attempted to make implant restorative procedures more like conventional crown and brid torations. However, due to the biologic and prosthetic differences between teeth and dental implants, thisisill-advised, Because the round junctional epithelium and connective tissue attachment natural teeth insert perpendicularly, this tends to limit and com. partmentalize the flow of excess cement. Thisis in contrast tothe epithelium and connective tissue around dental implants, where the connective tissue runs parallel and does not Insert into the body of the implant. As a result, the low of cement is not restrited and easily migrates apically ‘Consequently, dentistry hass In the incidence of peri-mucositis and peri-im- plantitis. In many ofthese cases this isa result of not only thedificultyftryingto remove excess ‘cement from around implant-retained restora: tions, butalso oflinickansusingthe wrong types ‘ofeement.” ‘The advantages and disadvantages of serew retained versus cement-retained implant resto ave been discussed previously In this artiele, the authors describe various techniques rations’ Because the junctional epithelium and connective tissue attachment around natural teeth insert perpendicularly, this tends to limit and compartmentalize the flow of excess cement. ve cement or eliminate it altogether while maintaining proper occlusion without compromising flow of cement or eliminate it altogether, thereby reducing the incidence of peri-implant disease and helping to maintain a good long-term prognosis for implant-retained restorations, ‘Techniques to Eliminate or Control Flow of Cement Lingual Set-Serew ‘One method for eliminating cement around implant-retained res torations is to use serew retention. Occlusal serew access, however, can present problems with esthetics and make controlling the ceclusion dificult. In addition, there is an increased possibility of isk of porcelain chipping. By using a lingual set-serew the ‘concerns can be eliminated. The problems with lingual set-serews, however, are that they ult to manage and have a tendency to ability to provide ad- Toosen because of the ‘equate torque Acastable threaded insert hasbeen developed (Zest Anchors LLC, www:zestanchors.com) that utilizes the Straumann SCS" serew (Straumann, ‘wwestraumann.us), This system has worked ‘well for the authors, Since the serew is, than conventional lingual set-serew itis easy tohandle,and theclinicianisable to usea torque ‘wrench to deliver the proper amount of torque required by the manufacturer. However, due to its greaterst itcanonlybeused for molars and they have been utilizing to better contro! {he TT are premolars 492 COMPENDIUM dunez012A case involving this technique is depicted in Figure 1 through Figure 4 Serew-Retained with Ceramic Insert An effective means of improving esthetics while maintaining the occlusion isto use a laboratory-processed ceramic plug that is bonded into the screw access opening over Teflon’ tape (aka, plumbers or polytetrafluoroethylene [PTFE] tape, available from Various manufacturers), thereby protecting the top ofthe retaining screw? The plugeean be fabricated out of either a pressed ceramic suchas IPS e.max’ Press (Ivoelar Vivadent, wow. ivoclarvivadent. com) or a laboratory-processed composite such as Cristobal (DENTSPLY International, wwwdentsply.com). Use ofthis technique not only maintains the ocelusion, but also renders the access opening practically undetectable. Thus, it satis fies the esthetic demands ofthe patient, adequately maintains the occlusion, and meets the requirements of the clinician regarding cement elimination and retrievabilty Fig 1. Cast custom abutment Fig 2 Lingual view of crown in place with lingual Straumann SSCS screw. Fig 3. Buccal view fof restoration: Fig 4. Occlusal ‘View of restoration, Note how crew insert is flush withthe lingual wall He BE POS L restoration retention system Better by design 99.8% pure titanium Easy to customize to suit root canal NO drilling required Anatomical shape Anti-rotation vents Unique passive interlock for retention faster | safer | stronger more tooth preserving easier | 19 West 34th Street, Suite 916, New York NY10001 | Tel: 855 714 9250 Fax: 212 714 9252 | Email: flhol@verzon.net wawflhol.com Patented Worldwide alabe from your Dental Dealers 433Fig 5. Completed restoration with oceusal access hole on laboratory ‘medel. Fig 6. Restoration with ceramic insert. Fig 7. Restoration with wien the entire occlusal surface Fig’. Restoration in patents mouth roe to placement of coramic insert. Fig 9, Restoration with ceramic Insert bonded into place Fig 10, Raclograph of completed restoration. 434 COMPENDIUM June 2018 The case shown in Figure 5 through Figure 10 utilized a Cristobal-fabricated plug bonded in with Multilink Cement (Wvoclar Vivadent) Rubber Dam Technique Ifcement is to be used, its flow into the subgingival area must be limited. This can be accomplished with the use of a rubber da type implants, n. This technique, however, does not work with tissue-level To use this technique, required materials are: scissors, light oF ‘medium rubber dam, rubber dam puneh, and silicone lubri Ge, Masque™, Bosworth Co, warw bosworth.com, or equivalent) Beginby cuttinga small rectangu lar piece ofthe rubber dam, mak ingsure that it filsbut does not ‘overfill—the mesial-distal inter dental space,’Then, punch hole inthe rubber dam appropriately sized such that it will fit tightly over the abutment, and then place the abutment through the rubber dam (Figure 1). Next, apply’ a small amount of lubricant tothe transmucosal sec tion of the abutment. Inthiscase, the authors used Corsodyl'L0%e nithKline Consumer Healtheare, www sk com). Any excess that gets onto any part ofthe elinial crown, aspeet ofthe abutment mustbe cleaned oft ‘Then, seat the abutment. Rubber dam and torque the abutment Related Content: For more information, read Screw-Access Marking: A Technique to Simplify Retrieval of Cement-Retained Implant Prostheses at dentalaegiscomVgo/ccedane chlorhexidine gel (Glaxo Into place as recommended by the implant manufacturer (Figure 12) Applyalightcoatingof.cementand place the crown while gently holding the facial and lingu the gingival mucosa, Finally, clean off any excess cement (the dam portions ofthe rubber dam against will prevent the apical migration ofthe cement), and remove the dam Figure 13) Teflon (PTFE) Tape Technique With this next technique, after confirming the intraoral fit ofthe ‘crown and verifying the patient's occlusion, the followingsteps are recommended: Start by cutting a small piece of Telon tape (aka, plumbers or PTFE tape) and placing it inthe internal surface of the crown (Figure 14), Seat the erown with th ape onto, the abutment. This will adapt the tapeto the internal surface of the crown and will act as 2 50-micron spacer for the cement (Figure 15). Then, carefully separate t pe from the abut ment, beingeareful not to disturb the adaption ofthe tape from the internal surface ofthe crown (Pigure 16), Next, inject quick-setting vinylpolysiloxane (VPS) bite re istration material into the crown with the Teflon tape inside, completely filling the erown and creating a handle (Figure 17). Remove the bite registration impression and the Teflon tape from the crown. The result is that an abutment replica has thus, jer than the actual abut etlon ecrown/Teflon| been created that is 50 microns s ment (Figure 18).ized a fement ‘Then, place cement (itis strongly recommended not to use a resin-hased cement") into the erown—the authors recommend either zine oxide eugenol or zine phosphate—and seat the VPS replica nto the crown, Excesscement willbe extruded, Remove the replica clean any excess cement from the external surface of the ‘crown, and seat the erown int litle excess cement to remove (Figure 19 and Figure 20). orally There should then be very Discussion Asan increasing number of clinicians have been restoring dental implants, they have tried to simplify their protocols to more closely resemble conventional crown and bridge procedures. However, ‘without a thorough understanding ofthe biologic differences be- tween natural teeth and dental implants, as well as the types of ‘ements employed, this can lead to both short-and long-term prob- lems for patients In his landmark paper, Wilson demonstrated that the timeframe from the initial signs of peri-implant disease post-cementation can range from as short as 3 months tos long ‘489 years? The current authors have documented a case as little as6 weeks with signs of peri-mucostis* Therefore itis neces to monitor all implant cases and be on the alert for any signs of post-delivery peri-implant disease Foresthetic reasons, many clinicians like to place the margins oftheirrestorations greater than 2-mm subgingival. Linkevicius Fig. Abutment is placed through rubber dam. Fig 12 After abut- iments placed trough rubber dam ie torgued into place. Fig TS ‘ter excess cement is clesned off, the dam is removed, EA e You have v questions. OSAP has the answers. Dental safety is serious | « Business. That why we focus on protocols to keep your patients and talteam safe, Members Visit OSAP.org and join today. OSAPZ, Bocas Sat Mators 8 COMPENDIUM 435,tal and Agar etal have demonstrated that itis almost impossible R ions with sub- N ingival margins, especially when the margins are greater than 13 to remove excess cement around implant restor mm, and that extensive scratching on the abutment occursin the R attempts to remove the cement. Margins that were placed I-mm N supragingival or at the gingival margin had practically all the ‘cement removed. The vulnerability ofthe abutment to seratch I ing in the effort to remove excess cement can lead to increased plaque adherenceand possibly an increase in the susceptibility to peri-implant disease.” Ina prospective study by Linkevicius etl ! from visible margi t patients requiring single-tooth implant restorations, on ne location was emphasized. Additionally, the inability of s radiographic examination to reveal remnants ofeement was ls 3 pointed out ? Keith et al have demonstrated thatthe mean marginal dis F erepancy of serew-retained metal-ceramie crowns on implant abutments is sgnicanty smaller than that of cemented met n al-ceramic erowns and that poorly fitted restorations may have long-term adverse effects on the implant-restorative complex within the hard and soft tissues" Hebel etal have stated that be E cause the serew-access hole is directly over the implant, vertical Joadingand biomechanics may be compromised. However, with newer techniques, materials, and abutment-implant inte design, this no longer presents a problem. By implementing the techniques described herein, the authors believe that the po: tential adverse effects cements can present to implant-retained restorations can be reduced and possibly eliminated, However continuous teamwork and collaboration between the restorative dentist, implant surgeon, and dental laboratory technician incase planning and design is essential to ensuring the best possible outcomes for patients. Conclusion Inorder to ensure long-term stability and predictability and reduce the incidence of peri-implant disease related to im: plant-retained restorations, clinicians must have a thorough understanding of the biologic differences between restora tions on natural teeth and dental implants. In this article, the authors have described four techniques to either eliminate the need for cement or limit the flow of cement into the sub singival area, Lingual Set-Screw case Figure through Figure 4): Robert Levine F920 DDS (Philadelphia, PA, surgery; Steven Present, DMD (Nort Wales, PA), prosthetics: Newtech Dental Laboratory (Lansdale, PA) Fg Asmat peo of elon ae laced nthe tral suo ofthe laboratory work own Fig, Thee epson acs fhe cow" ard wil Serew- Retained with Ceramic Insert case (Figure 5 through cifom he obarvare Fig vos ore reosston mete. Fiure 10): Wendy Halpern, DMD (Plymouth Mecting, Pa othe crown wih te Telon tape side creathgarande, surgery; Steven Present, DMD, prosthetics; Newtech Dental trees hs been creed tat SSO microns smale™” | syortorylhoratony Work, Fig20, Crown seated on ose of exnaied coment Rubber Dam Technique case (Figure 11 through Figure 13);Thank you for taking our Ley ole MO are Mm =o (Cer et clu eee CE Enrollment Plan is a great way to save on CE credits! e ny Compendium