DENTAL TECHNIQUE

Cemented implant restoration: A technique for minimizing

adverse biologic consequences
Guillermo Galván, DDS,a John C Kois, DMD, MSD,b Yada Chaiyabutr, DDS, MSD, DSc,c and
Dean Kois, DMD, MSD, PLLCd

Many articles have been writ- ABSTRACT

ten in support of both screw-
The purpose of this technique was to eliminate excess cement from the implant restoration by
retained and cement-retained using a 2-step cementation process. A custom acrylic resin abutment, a duplicate of the titanium
fixed implant crown restora- abutment, is fabricated before the restoration is cemented. At cementation, cement is placed inside
tions and the advantages and the restoration, which is placed onto the acrylic resin abutment outside the mouth. The majority of
disadvantages of each.1,2 The the excess cement from inside the restoration is expressed onto the acrylic resin abutment. The
advantages of screw-retained restoration is then placed on the titanium abutment inside the mouth. The result is a minimum
restorations2,3 include no ce- amount of excess cement expressed intraorally. This technique minimizes the adverse biological
ment complications and ease consequences of leaving excess cement beneath implant-supported restorations. (J Prosthet Dent
2015;-:---)
of removal in patients whose
definitive restoration requires repair such. Disadvan- cementation.8,9 Managing cement volume is challenging
2,3
tages include the management of the screw hole, es- because there needs to be enough cement to hold the crown
thetics, and more difficult home care. Cement-retained to the abutment, but not so much that an excess becomes
restorations have the advantage of more ideal esthetics difficult to control and risks damage to the periimplant tis-
and easier home care in that they more closely mimic sue if insufficiently removed. Steps to decrease the volume
natural teeth; however, the location of the margin of the of cement in the crown have been described.10 Sometimes
cemented restoration is critical and can produce chal- the precise design of the abutment and restoration allows
lenges. If the cervical margin is deeply buried beneath the use of less cement to maintain the same retention.
the free gingival margin, the removal of excess cement The problem is that even when the inside of the
can be difficult and less predictable,4 and may affect tis- restoration is only one-third filled with cement, excess
sue health.5 If the margin is established at or near the free cement is still often expressed at the margins, which
gingival margin, the underlying abutment may be complicates cleanup, especially in restorations with deep
exposed, compromising esthetics, and can ultimately lead subgingival margins.11,12 An indirect technique with a
6,7
to implant failure. Naturally, proper margin location trial acrylic resin abutment has been described.13
of the restoration-abutment interface is helpful and Although some implant systems already have plastic
beneficial.8 stock abutments available for this technique, they are
Other favorable factors include the use of water-soluble standard stock abutments that do not match the shape of
cement, which can be debrided with an explorer probe and the custom abutment, and managing cement is still a
titanium curette, and radiographic verification after problem.

Presented at the American Academy of Restorative Dentistry Annual Meeting, Chicago, Ill, February 2013.
a
Clinical Instructor, Kois Center, Seattle, Wash.; and Private practice, Valladolid, Spain.
b
Founder and Director, Kois Center, Seattle, Wash.; Affiliate Professor, Department of Restorative Dentistry, School of Dentistry, University of Washington,
Seattle, Wash.; and Private practice, Seattle, Wash.
c
Research Director, Kois Center, Seattle, Wash.; and Affiliate Instructor, Department of Restorative Dentistry, School of Dentistry, University of Washington,
Seattle, Wash.
d
Faculty and Scientific Advisor, Kois Center, Seattle, Wash.; and Private practice, Seattle, Wash.

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Figure 1. Custom implant abutment. Figure 2. Obtain replica from direct impression of abutment. Polymeri-
zation shrinkage creates acrylic resin abutment with smaller volume than
titanium abutment.
Techniques for fabricating custom trial abutments14-16
have used occlusal registration material to fabricate a
copy of the custom abutment. In this technique, the
restoration is filled with polyvinyl siloxane (PVS) to
obtain a precise replica of the abutment. Subsequently, a
2-step, indirect cement procedure is used for the defini-
tive restoration with the PVS trial abutment.12 This
technique has some inherent shortcomings: If the PVS
trial abutment is narrow at the incisal edge, this may
break off inside the restoration, or the PVS trial abutment
may provide insufficient cement space.
The technique described benefits both stock and
custom abutments. Trial acrylic resin abutments
customized to match the shape of the definitive custom
abutment and the inside of the crown make this tech-
nique more predictable. Unlike the PVS trial abutment,
an acrylic trial abutment has less volume than the
definitive titanium abutment restoration that it is
mimicking. In other words, it is not an exact duplicate,
but a slightly smaller version. Therefore, when the indi-
rect 2-step cementation technique is used with an acrylic
resin abutment, a thin layer of cement uniformly fills the
inside of the restoration. The result is cementation of the Figure 3. Acrylic resin replica of titanium abutment.
restoration with a similar level of retention as a 1-step
direct technique, but with a minimum of excess cement.
the titanium abutment from the PVS. Fill the void
TECHNIQUE left by the abutment in the PVS impression with
fluid Pattern Resin (GC America) and place a warm
1. Fabricate the acrylic resin trial abutment after dowel pin into the acrylic resin to accelerate the
receiving the definitive custom titanium abutment setting of the resin. Remove the acrylic resin abut-
and definitive restoration from the laboratory ment from the dappen dish once the acrylic resin
(Fig. 1). Remove the titanium abutment from the hardens and remove the excess flash. The acrylic
replica. Attach the cervical portion of the titanium resin trial abutment has almost the same volume as
abutment to a thin wax bar and hang it vertically the titanium abutment (Fig. 3).
into a rubber dappen dish. Fill the dappen dish with 2. Apply a thin layer of petroleum jelly (Vaseline;
light-body PVS to cover the titanium abutment Johnson & Johnson) to the subgingival portion of
(Fig. 2). Once the impression material sets, remove the titanium abutment before placing the titanium

THE JOURNAL OF PROSTHETIC DENTISTRY Galván et al

- 2015
Figure 4. A, Fill definitive restoration with luting agent and seat it firmly
onto acrylic resin trial abutment. B, Excess cement will squeeze out
beyond margins of restoration onto acrylic trial abutment. C, Immedi-
ately afterward, remove trial abutment from restoration, spreading even,
thin layer of cement inside restoration. Seat restoration promptly intra-
orally onto titanium abutment.
Galván et al
3
Figure 5. Minimum cement excess around margins of restoration.
abutment in the mouth. Connect the implant
abutment to the implant and tighten it to the
appropriate level. Retighten the screw after 10 mi-
nutes to the definitive torque level.17 Close the
screw access opening with Teflon tape.
3. Fill the definitive restoration with the desired luting
agent and seat it firmly onto the acrylic resin trial
abutment. Excess cement will squeeze out beyond
the margins of the restoration onto the acrylic resin
trial abutment. Immediately afterward, remove the
trial abutment from the restoration. Note a thin
layer of cement evenly spread inside the restoration.
Promptly seat the definitive restoration intraorally
onto the titanium abutment (Fig. 4) expressing a
minimum amount of cement excess around the
margins of the restoration (Fig. 5).
SUMMARY
This article presents a straightforward technique for
creating a customized acrylic resin duplicate implant
abutment in the dental office. It is cost effective and not
time consuming. It can be used with any implant-
cemented restoration and is especially useful when an
implant crown has a deep subgingival margin. Excess
cement is decreased while maintaining the retention of the
restoration.
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Corresponding author:
Dr Guillermo Galván
Acera Recoletos N-12 1st Fl A
Clinica Galvan Lobo Sl B47619382
Valladolid 47004
SPAIN
Email: Guillermo@galvanlobo.com
Acknowledgments
The author thanks Jose Antonio Noya and Carlos Noya, dental laboratory tech-
nicians who helped make the specimens, and Dr Nancy Hartrick who helped edit
the manuscript.
Copyright © 2015 by the Editorial Council for The Journal of Prosthetic Dentistry.

THE JOURNAL OF PROSTHETIC DENTISTRY Galván et al