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Step-by-Step Implant Cementation

Guidance and Alternate Technique

One cause of local tissue inflammation associated with dental implants that has recently come to light is dental cement. Cements, while often used in the attachment of the coronal restoration to the implant fixture, have been directly linked with peri-implant diseases and have been blamed for bone loss and implant failure (Figures 1 and 2).1-3 One aspect of the disease process that is especially concerning is the time between restoring the implant and the disease process—on average three years pass before dentists discover a problem, with a range of four months to beyond nine years (Figures 3 and 4).4

Dental students and dentists alike should be aware of the differences between implants and teeth. Because their peri-implant biology is not the same, the appropriate cementation techniques, suitable cement selections, and even the procedures for the clean-up of excess cement are different. The authors recognize that a comprehensive review of the attachment apparatus and cement properties is beyond the scope of this discussion5; the article will briefly highlight these issues and offer solutions to overcome the attendant problems.6

 

Peri-Implant Biology

Many clinicians consider implants to be similar to teeth, but they differ in many important ways.7-9 A weak adhesion exists between soft tissue connective tissues and implant surfaces, for example, whereas teeth have a more robustly developed attachment system.  This is related in part to the role of the connective tissue, which adheres rather than attaches to the surfaces of a dental implant.10 The clinician should be aware of the fact that the weaker soft tissue adhesion seen with implants is more susceptible to complications caused by excess cement and the hydrostatic force of cement being pushed into the tissues during crown placement.

 

Cementation Techniques

Clinicians often do not understand that only a very limited amount of cement is needed to fix a restoration to an implant abutment (Figure 5). A recent survey of over 400 dentists showed that many dentists placed in excess of 20 times more cement into the crown than was required.11 This overload of cement means that 95% are extruded out at the restorative margin, which is frequently found subgingivally, making cement removal virtually impossible.

 

Solution

The solution is to limit the amount of cement that is placed in the crown. For comparative purposes, it may be helpful to equate the amount of cement needed to everyday, well-known subjects.  For example, “The space provided for cement on the inside of the crown is the same thickness as a layer of nail polish.” This layer is often about 50 micrometers thick, which is about the thickness of a human hair. A technique has been developed using a spacer and some fast-setting dental impression material to make a chair-side copy abutment (CCA) that can be used to coat the inside of the crown with close to the 50 um needed.6  

 

Chairside Technique

The crown is painted internally with a water-soluble lubricant. This allows polytetrafluoroethylene (PTFE) plumbers tape, which is 50 um thick, to be adapted to the inside of the crown using a dry brush (Figures 6 and 7). The adaptation is completed by the operator, who gently pushes the abutment into the crown and then carefully removes it. The inside of the crown is inspected to confirm that the PTFE is well formed (Figure 8).

The CCA is then fabricated. Using a fast-setting impression or bite registration material, the inside of the crown is filled and even overfilled until a “handle” is produced (Figure 9). (Hint: A fine-tip nozzle is ideal for use in this process.)  The CCA is removed, as is the PTFE, and the inside of the crown is cleaned (important!) to remove the lubricating agent (Figure 10).  This produces the CCA, which is 50 um smaller than the inside of the crown.  At this stage, the CCA is inspected and compared to the actual abutment so the author is assured of the proper orientation (Figure 11).

The CCA is now ready for use. The abutment is placed in the patient’s mouth, checked for proper seating, and its screw is torqued to the appropriate Ncm value. The crown is now ready to be cemented. The crown can be loaded with any amount of cement desired—the CCA will subsequently be pushed into the crown, and the excess cement will be extruded chairside and easily removed (Figures 12 and 13). This is done extraorally.

 

Advantages of the CCA

The use of inappropriate or excessive amounts of cement in the placement of implant restorations can result in clinical complications. A fast, inexpensive, simple technique, the aforementioned CCA approach limits excess cement to an absolute minimum, and makes cleanup quicker and easier. The CCA can be used for custom, stock and even multiple abutments (Figures 14 and 15). The CCA is an improvement over use of the actual abutment, or laboratory abutments which, in the authors’ experience, do not provide quite enough cement space to assure suitable amounts of cement for problem-free crown retention. The CCA produces the ideal amount.

 

*Private practice, Bellevue, WA.

 

Related Reading:

  1. Pauletto N, Lahiffe BJ, Walton JM. Complications associated with excess cement around crowns on osseointegrated implants: A clinical report. Int J Oral Maxillofac Impl 1999;14:865-868.
  2. Gapski R, Neugeboren N, Pomeranz AZ, et al. Endosseous implant failure influenced by crown cementation: A clinical case report. Int J Oral Maxillofac Impl 2008;23:943-946.
  3. Callan DP, Cobb CM. Excess cement and peri-implant disease. J Implant & Advanced Clinical Dentistry 2009;1:61-68.
  4. Wilson T. The positive relationship between excess cement and peri-implant disease. J Periodontol 2009;80:13 88-92.
  5. Wadhwani CPK, Piñeyro A. Implant cementation: Clinical problems and solutions. Dent Today No. 145.
  6. Wadhwani C, Piñeyro A. Technique for controlling the cement for an implant crown. J Prosthet Dent 2009;102: 57-58.
  7. Terranova VP, Goldman HM, Listgarten MA. The periodontal attachment apparatus: Structure, function, and chemistry. In: Genco RJ, Goldman HM, Cohen DW. Contemporary Periodontics. St. Louis, MO: Mosby, 1990.
  8. Berglundh T, Lindhe J. Dimension of the periimplant mucosa. Biological width revisited. J Clin Periodontol 1996;23:971-973.
  9. Abrahamsoon I, Berglundh T, Wennstrom J, et al. The peri-implant hard and soft tissues at different implant systems. A comparative study in the dog. Clin Oral Implants Res 1996;7:212-219.
  10. Elian N, Jalbout Z, Cho S-C, et al. Dental implants: The biology of aesthetic integration. In: Tarnow DP, Chu SJ, Kim JJ. Aesthetic Restorative Dentistry: Principles and Practice. Mahwah, NJ: Montage Media Corporation, 2008.
  11. Wadhwani C, Hess T, Pineyro A, et al. Cement application techniques in luting implant-supported crowns: A quantitative and qualitative survey. Int J Oral Maxillofac Impl 2012;27(4):859-864.
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