Accuracy of The Implant Impression Obtained From Different Impression Materials and Techniques: Review

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J Clin Exp Dent. 2011;3(2):e106-11.

Journal section: Clinical and Experimental Dentistry


Publication Types: Review

Accuracy of the implant impression techniques.

doi:10.4317/jced.3.e106

Accuracy of the implant impression obtained from different impression


materials and techniques: review
D.R. Prithviraj 1, Malesh L. Pujari 2, Pooja Garg 2 , D.P. Shruthi3
MDS Professor and Head, Dept. of Prosthodontics. Govt. Dental College and Research Institute, Bangalore. Victoria Hospital
Campus, fort, Bangalore.
2
Post Graduate Student, Dept. of Prosthodontics. Govt. Dental College and Research Institute, Bangalore. Victoria Hospital
Campus, fort, Bangalore.
3
BDS. Dental College and Research Institute, Bangalore. Victoria Hospital Campus, fort, Bangalore.
1

Correspondence:
Dept. of Prosthodontics.
Govt. Dental College and Research Institute, Bangalore.
Victoria Hospital Campus, fort, Bangalore.
560002
[email protected]

Received: 30/04/2010
Accepted: 06/12/2010

Prithviraj DR , Pujari ML, Garg P , Shruthi DP. Accuracy of the implant


impression obtained from different impression materials and techniques:
review. J Clin Exp Dent. 2011;3(2):e106-11.
http://www.medicinaoral.com/odo/volumenes/v3i2/jcedv3i2p106.pdf
Article Number: 50294
http://www.medicinaoral.com/odo/indice.htm
Medicina Oral S. L. C.I.F. B 96689336 - eISSN: 1989-5488
eMail: [email protected]

Abstract

With the predictable integration of implants, the emphasis is shifted towards precise prosthesis. Reproducing the
intraoral relationship of implants through impression procedures is the first step in achieving an accurate, passively
fitting prosthesis. The critical aspect is to record the three dimensional orientation of the implant as it is present
intraorally, other than reproducing fine surface detail for successful implant prosthodontic treatment. The development of impression techniques to accurately record implant position has become more complicated and challenging. During the prosthetic phase of implant therapy there are numerous options available to the implantologist in
relation to different impression techniques and materials available for impression making. It is critical to ensure that
implant prosthesis interface have passive fit and original position of the implant maintained in the master cast.
There is no evidence supporting that one impression technique or material is better than the other. In the present
article the various parameters affecting the accuracy of implant impression along with impression material and
technique pertaining to different clinical situations is reviewed.
Key words: dental implants, impression techniques, snap fit technique, open tray technique, closed tray technique.

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J Clin Exp Dent. 2011;3(2):e106-11.

Introduction

Osseointegrated dental implants have been proven successful in the treatment of edentulism (1). Mainly, osseointegrated implants were used for rehabilitation of
edentulous patients with the principle objective of replacing conventional complete dentures with an implantsupported prosthesis. Other applications of implants in
dentistry include partially edentulous, single-tooth, and
implant overdenture treatments (2). In implant prosthodontics, a successful result can be achieved only
when passively fitting prostheses are fabricated (3). Reproducing the intraoral relationship of implants through
impression procedures is the first step in achieving an
accurate, passively fitting prosthesis. The critical aspect
is to record the 3-dimensional orientation of the implant
as it is present intraorally, other than reproducing fine
surface detail for successful implant prosthodontics
treatment (4-6).
Although there is some evidence that prosthesis misfit
may not affect osseointegration, there is evidence that
prosthesis misfit is likely to increase the incidence of
mechanical component loosening or fracture. The causes of component failure and loosening are multifactorial, but it must be assumed that prosthesis misfit plays
an important role in complications such as occlusal and
abutment screw loosening and fracture in implant restorations (7-10). Because of these, prosthesis misfit is to
be minimized.
An electronic search was performed from MEDLINE
databases with the key words accuracy of implant impression techniques. To be included, the study had to
investigate the accuracy of implant impressions techniques and materials and be published in an English peerreviewed journal. In addition, hand search of related articles were performed to enrich the results for the time
period from January 1983 to June 2009.
At present, various implant impression techniques, such
as splint, pickup, and transfer techniques and different
impression materials, like polyether, vinyl polysiloxane
(VPS), and polysulfide have been introduced and investigated for accuracy. Other factor related to the accuracy
of the implant impression, including the angulation or
depth of implants has also been studied. However, the
results are not always consistent, and various studies reported greater accuracy with different impression techniques as well as impression materials. The purposes of
the present review are to investigate the:
1) Accuracy of reported implant impression techniques.
2) Accuracy of various implant impression materials.
3) Factors affecting the implant impression accuracy.
One of the most important factors for the success of
implant prosthesis is the accuracy of the impression
procedure, in order to obtain the original position of
the implants during the processing of the master cast
and to allow the passivity of the framework casting to
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Accuracy of the implant impression techniques.

its supporting abutments without interference between


the prosthesisimplant connections. The development
of impression techniques to accurately record implant
position has become more complicated and challenging.
Several impression techniques have been suggested to
obtain a master cast that will ensure the passive fit of
prosthesis on implants (11).

Impression Techniques

Splint Technique Versus Nonsplint Technique


The splint technique for an implant impression was introduced along with the development of a metal-acrylic
resin implant fixed complete denture for an edentulous
jaw. The underlying principle was to connect all the impression copings together using a rigid material to prevent individual coping movement during the impression
making procedure. From the studies examining implant
impression accuracy, splinting has been an important
subject of investigation.
Among the impression making methods presented in the
literature, the splinted technique has gained popularity
and has proven to be the most accurate (12,13). Even
though there was no consistent result for higher accuracy with any one technique as opposed to the other, splint
or nonsplint, more number of studies has reported increased accurate implant impressions with the splint technique than with the nonsplint technique. Some authors
suggested possible problems with the splint technique,
such as distortion of the splint materials (14) and fracture of the connection between the splint material and
the impression copings (15). Kim et al. (16) investigated
the accuracy of the implant impression over multiple laboratory procedures and found that the nonsplint technique was more accurate during the impression-making
procedure, while the splint technique was more accurate
during the cast fabrication procedure (Table 1).
Acrylic resin is the material used quite often for splinting, thus, minimizing the shrinkage of the acrylic resin is the most important factor to ensure an accurate
impression using the splint technique. Some authors
sectioned the splint material connection, leaving a thin
space between, then rejoining with a minimal amount
of the same material to minimize the shrinkage or they
connected all of the impression copings with splint material, and then waited for complete polymerization of
the material (17-20).
The splinting technique using light cured acrylic resin
was significantly less accurate than by using autopolymerizing resin or by impression plaster. This may be
caused by the incomplete polymerization of the light cured acrylic resin; another reason may be that the shrinkage during polymerization of the light cured acrylic resin
creates stresses at the impression coping / acrylic resin
interface. There is also significant importance to the intensity and direction of the light source that might have

J Clin Exp Dent. 2011;3(2):e106-11.

Author
( Year)
Barrett
et al. (4)
(1993)
Assif et al.
(12)
(1992)

Implant Splint
number material
6
DF+AAR

Splint method

Impression
accuracy
No difference

PE

Splint

PE

Splint

PE

Non splint

PE

No difference

PE

Splint

Splint, section, then


rejoin before
Impression

PE

No difference

PE, VPS,
plysulfide,
condensation
silicone
VPS

Splint

No difference

VPS

Splint

Splint 10 min before


impression

AAR

Assif et
al. (13)
(1996)

AAR

Polymerize on
individual copings,
then join 15 min
before impression
Splint

Inturregui
et al. (17)
(1993)

Impression
plaster

Splint copings to
custom tray
Splint and wait for
10 minutes

Hsu et al.
(18)
(1993)

DF+AAR

Splint, section, then


rejoin 15 min before
impression
Splint 20 min before
impression

Stainless steel
wire+AAR

Splint 20 min before


impression

AAR

Polymerize on
individual copings,
then join 20 min
before impression
Splint 30 min before
impression

Naconecy 5
et al. (19)
(2004)
Del Acqua 4
et al. (20)
(2008)

Steel
pin+AAR

Assuncao
et al. (29)
(2004)

AAR

Splint

Herbst et
al. (35)
(2000)
Cabral et
al. (38)
2007)

DF+AAR

Splint 20 min before


impression

DF+AAR

Splint 3 min before


impression

AAR

Accuracy of the implant impression techniques.

Impression
material
VPS

AAR

Splint 17 min,
section, then rejoin
before impression

AAR: autopolymerizing acrylic resin; DF: dental floss


VPS: vinyl polysiloxane; PE: polyether
Table 1. Studies comparing accuracy of splint and nonsplint impression techniques

a negative influence on the adaptation of the light cured


acrylic resin to the coping. Impression plaster sets rapidly, is quite accurate and rigid, and does not bend or
distort, it is also easy to manipulate, less expensive. The
exothermic reaction is negligible (21).
It was interesting that more studies advocating the splint

technique were found within recent literature. Five out


of 7 studies recommending the splint technique were published after 2003, as opposed to 2 older studies which
appeared before 1996. Modifications in splinting techniques and its manipulation may result in minimizing the
distortion.
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Transfer Technique Versus Pick-Up Technique

Traditionally, there are 2 different implant impression


techniques for transferring the impression copings from
the implant to the impression. The transfer technique
uses tapered copings and a closed tray to make an impression. The copings are connected to the implants, and
an impression is made and removed from the mouth, leaving the copings intraorally. Subsequently the copings
are removed and connected to the implant analogs, and
then the coping-analog assemblies are inserted in the impression before pouring the definitive cast. The clinical
situations which indicate the use of the closed tray technique are when the patient has limited interarch space,
tendency to gag, or if it is too difficult to access an implant in the posterior region of the mouth (22).
Conversely, the pick-up impression uses square copings
and an open tray (a tray with an opening), allowing the
coronal ends of the impression coping screw to be exposed. Before separating the implants, the copings screws
are unscrewed to be removed along with the impression.
The implant analogs in the impression are connected to
the copings to fabricate the definitive cast. Disadvantages of this technique is that there may be some rotational movement of the impression coping when securing
the implant analog, and blind attachment of the implant
analog to the impression coping may result in a misfit of
components (23). Fourteen studies have compared the
accuracy of pick-up and transfer impression techniques,
twelve studies reported that the accuracy did not differ
and 2 studies showed more accurate impressions with
the transfer technique. However, the results of 1 of the 2
studies were questionable because the experimental design was not clinically relevant and favored the transfer
(24) technique and it was the only study that advocated
the transfer technique when 3 or fewer implants were
placed (25).
Daoudi et al. (26) compared the closed tray technique
at the implant level with the open tray technique at the
abutment level for single tooth implants and found the
open tray technique to be superior and more predictable.
The closed tray technique had discrepancies in axial rotation and inclination of the analogs. Several authors have
reported the superiority of the open tray technique. Carr
(27) compared the open and closed tray techniques with
a 5 implant mandibular cast where the interabutment divergence angles were all less than 15 degrees. The open
tray technique was found to be superior as it provided
the most accurate working cast. Carr (27) indicated that
the inaccuracy of the closed tray technique may arise
from nonparallel implants and the apparent deformation
of a stiff impression material such as polyether. In a subsequent paper evaluating a 2 implant situation, 1 parallel to the long axis of the teeth and the other with a 15
degree lingual inclination, Carr (27) reported that both
techniques provided comparable results.
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Accuracy of the implant impression techniques.

Daoudi et al. (26) investigated repositioning of the copings after making the transfer impression by 3 different
groups of people: senior dentists, postgraduate dental
students, and dental technicians. The copings never returned to the original position and this was believed to
be the primary source of error in the transfer impression
technique. This error could be multiplied when the impression is made in situations of multiple implant placements. It was found that for situations in which there
were 4 or more implants, more studies showed more accurate impressions with the pick-up technique than the
transfer technique.
Some implant manufacturers have developed a snap-fit
(press fit) plastic impression coping. This technique is
not a pick-up impression because it does not require an
open tray, but instead uses a closed tray. It is not a transfer impression, either, because the plastic impression
copings are picked up in the impression. The press-fit
impression coping is easier to manipulate, time saving,
and more comfortable for both the clinician and patient
because the coping is connected to the implant by pressing instead of screwing. The press-fit coping design
allows removal of the coping with the impression and
has the advantage of both the open- and closed-tray implant impression techniques. Thus, the press-fit impression coping helps to overcome movement of impression
copings inside the impression material. The snap-fit technique may be a reliable impression making technique
(28) but regarding accuracy of this technique none of
the study is available for investigation.

Impression Materials

Various impression materials were tested; polyether and


VPS were used most frequently. There were 11 studies
comparing the accuracy of polyether and VPS, and 10
studies reported that the accuracy did not differ (4,25,29).
Lee et al. (30) reported that putty and light-body combination VPS impression material was more accurate than
medium-body polyether impression material, when the
implant was placed deep subgingivally. Wenz et al. (31)
investigated different mixing methods of the impression
materials. According to the study, the 2-step VPS method involves making the first impression using putty
only, to create space inside of the impression. Subsequently, the impression is filled with light-body impression material, and then the second impression is made.
The 1-step method uses both putty and light-body VPS
simultaneously. Results indicated that the 2-step VPS
impression was significantly less accurate than the 1-step putty and light-body VPS combination impression,
the medium-body VPS monophase impression, and the
medium-body polyether monophase impression.
Although polyether has been suggested as the material
of choice for implant impression procedures, the use of a
more elastic impression material, for example a vinyl

J Clin Exp Dent. 2011;3(2):e106-11.

polysiloxane material, may hypothetically reduce the


permanent deformation of impression material determined by the stress between the material and impression
copings created when an impression with the copings is
removed from internal connection implants (32).
Wee et al. (5) studied the torque resistance of impression
materials and reported that polyether material showed
the greatest torque values, which may be favorable for
the manipulation of a pick-up impression. Other materials, such as condensation silicone, polysulfide, reversible hydrocolloid, irreversible hydrocolloid, and plaster
did not show improved accuracy compared to either polyether or VPS.
With proper material selection and manipulation, accurate impressions can be obtained for fabrication of tooth
implant supported restorations. Most of the impression
materials available today provide superb accuracy if
they are manipulated correctly. Although VPS materials
are likely to be more accurate than other materials, differences in accuracy (assuming correct manipulation) are
likely not clinically significant.

Factors Affecting the Implant Impression Accuracy

Coping Modification
Liou et al. (22) found that the impression copings with
different designs showed a different level of impression
accuracy. To increase accuracy, the coping was extended or treated with airborne-particle abrasion and impression adhesive (33-35). However, the same surface
treatment did not increase the accuracy in another study
(32). Acrylic resin transfer caps and Gold machined castable abutments have been introduced to achieve better
accuracy (36,37). Lee et al. (30) found that adding a
4-mm piece of the impression coping as an extension on
the original impression coping compensated for the inaccuracy of subgingival placement of the implant. These
modifications may lead manufacturers to develop new
impression coping designs to enhance the accuracy of
the impression.
Vigolo et al. (37) evaluated in vitro the accuracy of definitive casts obtained from transfer impressions using
square copings for the replacement of one tooth. In the
first group, nonmodified square impression copings
were used; in the second group square impression copings previously airborne-particle abraded and coated
with manufacturer-recommended impression adhesive
were used. It was observed that displacement abutment
positions in the specimens were significantly smaller in
casts obtained from modified transfers than nonmodified
transfers.

Angulation

Two studies reported less accurate impressions with


angulated implants than with straight implants using

Accuracy of the implant impression techniques.

an experimental cast with 4 or 5 implants (29, 38). On


the other hand, 2 other studies that used 2 or 3 implants
reported no angulation effect on the accuracy of impressions (24, 39). When multiple implants are placed with
different angles, the distortion of the impression material on removal may increase. Also, this effect may be
heightened by an increasing number of implants. To determine the relation between the angulation effect and
the numbers of the implant, more studies are required.
Other studies (30, 40) examined the effects of various
factors on the accuracy of implant impressions, such as
different connection levels (implant level and abutment
level), different impression trays, implant depth, and
time delay for stone pouring. The studies (30, 40) were
too few to draw any conclusions. Further studies, including clinical trials, are required to provide more evidence about the factors that affect the implant impression
accuracy.

Conclusions

A review of studies of accuracy of implant impression


techniques revealed that more studies reported greater
accuracy of implant impressions with the splint technique than with the nonsplint technique. For situations
in which there were 3 or fewer implants, most studies
showed no difference between the pick-up and transfer
techniques, whereas for situations in which there were 4
or more implants, more studies showed more accurate
impressions with the pick-up technique (open tray) than
the transfer technique (closed tray). Polyether and VPS
were the recommended materials for the implant impressions. Results indicated that the 2-step VPS impression
was significantly less accurate than the 1-step putty and
light-body VPS combination impression, the mediumbody VPS monophase impression, and the medium-body polyether monophase impression.

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