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6 Inter-implant Papilla Preservation: Replacing a Tooth Adjacent to an Implant

6 Inter-implant Papilla Preservation: Replacing a Tooth Adjacent to an Implant

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9  Papilla Management and Development Using Provisional Prosthesis

Fig. 9.19 (a) Pre-op

clinical with failing #10.

Note implant had been

placed at #9 1 year

previously. (b) Pre-op

image of failing #10





J. Y. K. Kan and K. Rungcharassaeng

Fig. 9.20  Occlusal view

after proximal root shield


flap reflection. The crown portion of the remaining mesial tooth structure was

then sectioned horizontally leaving the root with a cervical extension ~1  mm

coronal to the mesial marginal bone. The mesial root fragment was prepared

creating a 1.5–2 mm uniformly thick C-shaped root fragment spanning from the

mesiobuccal to the mesiolingual line angles. After the mesial portion of the tooth

socket was debrided and detoxified, sequential implant osteotomy was performed

to achieve the proper three-dimensional implant (NobelActive, Nobel Biocare)

position in relationship to the mesial root fragment, which might result in contacts between the implant and the mesial root fragment (Figs. 9.21a–c). A histologic study of buccal root fragment retention (socket-shield technique) in

conjunction with immediate implant placement has shown that there were connective tissues (a junctional epithelium and the formation of new cementum)

interposed between the coronal root fragment and implant, while the more apical

portion of the root fragment, which was in direct contact with the tips of the

implant threads, was covered by a cellular type of cementum (Hurzeler 2010).

These findings seem to suggest the presence of normal peri-implant soft tissue

and an intimate contact between the implant and root fragment (Hurzeler 2010).

Bone graft materials (Bio-­Oss, Osteohealth, Shirley, NY and Puros, Zimmer

Dental, Carlsbad, CA) were placed into the gaps between the implant and the

bony socket as well as the mesial root fragment. A provisional shell was then

relined onto a zirconia abutment and adjusted to clear all centric and eccentric

functional contacts.

9  Papilla Management and Development Using Provisional Prosthesis





Fig. 9.21 (a) Immediate implant placement. (b) Occlusal view after implant placed by the proximal root shield. (c) Clinical facial view after proximal root shield and immediate implant placement and provisionalization

Appropriate antibiotics and analgesics were prescribed. The patient was

instructed not to brush the surgical site but to rinse gently with 0.12% chlorhexidine

gluconate (Peridex, Procter & Gamble) and be on a soft diet for 2 weeks. The patient

was advised against functioning activities to the implant site for the duration of the

implant healing phase (6 months).

The final implant impression was made 6 months after the surgery. The definitive

all-ceramic crown (Procera, Nobel Biocare) with a customized zirconia abutment

(Procera, Nobel Biocare) was fabricated and cemented. Clinical and radiographic at

3.5 years showed satisfactory aesthetic results with well-maintained inter-implant

papilla between #9 and #10 (Fig. 9.22a, b).

The benefits of proximal socket-shield (PSS) procedure with IIPP in maintaining

both the bone level and the dentogingival supracrestal fibers have been reported in

the literature [47]. Nevertheless, this is a technique-sensitive procedure with limited

long-term evidence. Therefore, proper case selection and execution as well as close

monitoring in larger-scale studies are needed to substantiate the validity of the



Fig. 9.22 (a) Facial clinical

view of 4 year follow-up.

(b) Radiographic of 4 year


J. Y. K. Kan and K. Rungcharassaeng




While a well-executed IIPP as well as its adjunctive procedures (alternate IIPP

and PSS) of anterior maxillary single implants has been shown to be a predictable treatment modality in maintaining facial and proximal peri-implant tissues,

its success depends primarily on careful patient selection, accurate diagnosis,

9  Papilla Management and Development Using Provisional Prosthesis


and proper planning. Nonetheless, these are highly technique-sensitive procedures that demand a complete comprehension to deliver a harmonious and functional restoration in the aesthetic zone.


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9  Papilla Management and Development Using Provisional Prosthesis


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Part IV

Design, Fabrication and Delivery of the

Definitive Implant Prosthesis

Enhanced Implant Impression

Techniques to Maximize Accuracy


Panos Papaspyridakos and Todd R. Schoenbaum


Purpose: The purpose of this chapter was to review the scientific literature on

implant impression techniques for partially edentulous patients and to propose

evidence-based clinical guidelines for implant treatment in the aesthetic zone.

Materials and Methods: Comprehensive review of available literature was

conducted in a systematic approach and descriptively analyzed, where


Results: Based on the available scientific evidence on implant impressions in

the aesthetic zone, the customized impression coping technique is recommended

for either single implant or multiple implant scenario. Open-tray or closed-tray

technique can be successfully used for single implant scenario. The splinted

open-tray impression technique is more accurate than non-splinted one and is

recommended for multiple implant scenario. Pouring of the impression should

be done in low expansion stone with or without soft tissue moulage. Digital

implant impressions are gaining popularity and are scientifically validated with a

streamlined workflow for single implant scenario.

Conclusion: Aesthetically pleasing implant restorations can be successfully

fabricated with the appropriately selected impression technique, depending on

the implant scenario.

P. Papaspyridakos (*)

Division of Postgraduate Prosthodontics, Tufts University School of Dental Medicine,

Boston, MA, USA

T. R. Schoenbaum

Division of Constitutive and Regenerative Sciences, University of California,

Los Angeles, CA, USA

© Springer International Publishing AG, part of Springer Nature 2019

Todd R. Schoenbaum (ed.), Implants in the Aesthetic Zone,




P. Papaspyridakos and T. R. Schoenbaum

10.1 Introduction

Oral rehabilitation of partially edentulous patients with micro-textured dental

implants is currently a routine procedure, and clinical studies have proven the longitudinal effectiveness of this treatment modality [1]. Due to the fact that dental

implants are functionally ankylosed with direct contact to the bone, they lack the

inherent mobility of the periodontal ligament, and misfit cannot be tolerated at the

implant-abutment interface [2]. The reason is that misfit at the implant-abutment

junction of implant fixed dental prostheses (IFDPs) may lead to mechanical strains

in the prosthesis and to the transmission of stresses to the alveolar bone and supporting implants after the tightening of all prosthetic screws [2, 3]. Screw loosening and/

or fracture, implant fractures, and prosthetic components strain and fracture have

been related with prosthesis misfit [4–6].

The clinical fit of an IFDP at the implant-abutment junction is directly dependent

on the accuracy of impression technique and cast fabrication [2, 6, 7]. Hence, an

accurate implant impression is necessary in order to generate an accurate definitive

cast, which is the foundation for the fabrication of an accurately fitting prosthesis.

There are several clinical and laboratory variables that affect the accuracy of an

implant cast, namely, impression techniques, impression material and die stone

properties, pouring techniques, machining tolerance of prosthetic components,

implant angulation, and/or depth [8].

10.2 Impression Materials

An accurate impression is incumbent for fabrication of implant prostheses and represents the essential first step. In regard to implant prosthodontics, the impression

material must provide adequate rigidity to prevent rotation of the impression coping

during the impression taking or implant analog fastening and cast fabrication. The

superior mechanical properties of polyether and addition polyvinyl siloxane (PVS)

make them the material of choice for implant impressions [9]. In regard to which

impression material is better, a systematic review assessed the scientific evidence

from ten in vitro studies that compared the accuracy of impression techniques with

polyether, PVS, and various other impression materials [8]. The authors reported

that the accuracy of implant impressions is not affected by the impression material

(polyether and addition PVS) for partially edentulous [8]. Polyether or PVS can be

both used for final implant impressions without any difference in the outcomes.

10.3 Impression Techniques

10.3.1 Splinted Versus Non-splinted Impression Techniques

Various implant impression techniques have been used to generate a definitive cast

that will ensure the accurate clinical fit of IFDPs. The necessity for rigidly splinting

10  Enhanced Implant Impression Techniques to Maximize Accuracy


the impression copings has been advocated in several studies, while others have

shown no difference.

A systematic review assessed the available evidence for implant impressions in

partially edentulous patients, based on 13 in vitro studies comparing the accuracy of

splinted vs non-splinted impression techniques [10–23].

Eight in vitro studies reported that the splinted technique was more accurate than

the non-splinted technique, three in vitro studies reported that there was no difference, and two in vitro studies reported that the non-splinted was more accurate [8].

Thus, the preponderance of evidence shows that the splinted impression technique was more accurate than the non-splinted conventional impression techniques

for partially edentulous patients [8]. Hence, the splinted technique should be the

first treatment approach of choice for partially edentulous patients when two or

more implants are present.

Regarding the splinting materials used, most of the studies used polymethyl

methacrylate (PMMA) autopolymerizing acrylic resin as the splinting material of

choice, coupled with dental floss or metal bars. Prefabricated PMMA resin bars,

composite resin bars, and visible light-curing acrylic resins were used for splinting

as well. An in vitro study showed that the total polymerization shrinkage of Duralay

acrylic resin at 1  day was 7.9% and that 80% of the shrinkage occurred within

17 min of mixing at room temperature [24]. That is the reason why sectioning of the

acrylic resin splint has been advocated in many studies followed by reconnection

with minimal amount of resin to compensate for the polymerization shrinkage.

Moreover, the use of new splinting materials like composite resin or visible light

polymerizing acrylic resin resulted in better results [8].

Depending on the degree of angulation and implant connection design configuration, variables, such as impression technique (rigid splint vs no splint) and impression material (more rigid vs more elastic), will influence impression accuracy [25].

The removal of rigidly splinted internal connection impression copings may be

challenging when the angulation of the implants is extreme (more than 30°). In

addition to that, the impression coping design may have an effect on impression

accuracy with angulated implants. Some implant designs feature connection types

and impression copings with long engaging internal components that do not allow

for impression of angulated implants with the traditional engaging copings splinted

together. Non-engaging copings can be used alternatively for these implant systems

when angulated implants are present and splinting is performed. The number and

anteroposterior spread of implants will likely have an additional effect on the ease

of removal of the implant impression. Removal of an impression of multiple

implants requires flexure of the impression material, whether using the closed- or

open-tray impression copings.

10.3.2 Open-Tray Versus Closed-Tray Impression Techniques

The open-tray (pickup or direct) and the closed-tray techniques (transfer or indirect)

are the two primary options for taking an implant-level impression.

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6 Inter-implant Papilla Preservation: Replacing a Tooth Adjacent to an Implant

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