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Table of Contents
ORIGINAL ARTICLE
Year : 2016  |  Volume : 6  |  Issue : 1  |  Page : 29-36

Accuracy of implant impressions using various impression techniques and impression materials


1 Department of Prosthodontics, GITAM Dental College and Hospital, Visakhapatnam, Andhra Pradesh, India
2 Department of Prosthodontics, D. J. College of Dental Sciences and Research, Ghaziabad, Uttar Pradesh, India

Date of Web Publication20-Sep-2016

Correspondence Address:
Y Ravi Shankar
Department of Prosthodontics, GITAM Dental College and Hospital, Visakhapatnam, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-6781.190384

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   Abstract 

Purpose: This in vitro study was to investigate the accuracy of two kinds of impression techniques (open and closed tray) with three impression materials (polyvinylsiloxane [PVS]/polyether [PE]/vinylsiloxanether [VSE]) on angulated implants.
Materials and Methods: The reference model was a stainless steel die with six analogs placed at 0°, 10°, and 20° toward the center axis. Custom acrylic trays were made on a stone model replica of the reference die. A total of sixty samples of twenty each were made under each type of impression material. Each group was divided into open and closed tray groups. Two types of splinting were carried out in the open tray: Group 1 - with floss and pattern resin and Group 2 - with a plastic rod (coffee stirrer) and resin. Impressions were poured with Type IV stone to obtain experimental casts and were evaluated for positional accuracy by coordinate measuring machine in three dimensions (X, Y, and Z). Differences in measurements were analyzed using analysis of variance and Tukey's test.
Results: The lowest mean deviation was found in casts made from open tray splinted with floss and resin. There was also a significant difference in the measurements of PVS, PE, and VSE.
Conclusion: VSE impression material yielded more accurate casts than those of PVS and PE. Splinting with floss and pattern resin was found to be more accurate than stirrer and resin.

Keywords: Closed tray, open tray, pattern resin, polyether, polyvinylsiloxane, vinylpolysiloxanether


How to cite this article:
Shankar Y R, Sahoo S, Krishna M H, Kumar P S, Kumar T S, Narula S. Accuracy of implant impressions using various impression techniques and impression materials. J Dent Implant 2016;6:29-36

How to cite this URL:
Shankar Y R, Sahoo S, Krishna M H, Kumar P S, Kumar T S, Narula S. Accuracy of implant impressions using various impression techniques and impression materials. J Dent Implant [serial online] 2016 [cited 2022 Jan 25];6:29-36. Available from: https://www.jdionline.org/text.asp?2016/6/1/29/190384


   Introduction Top


Dental implants are fixtures that serve as replacements for the root of a missing natural tooth. [1] Dental implant therapy has been widely used for the restoration of partially and fully edentulous patients. [2]

Endosteal implants distribute the physiologic loads onto the surrounding supporting tissues. Implant units, unlike natural teeth cushioned in their alveoli by periodontal fibers, are somewhat intolerant to movement in their adaptation to the demands of the metal-supporting structure. [3] In natural teeth, the periodontal ligament compensates for minor inaccuracies of positioning of the abutments. However, the integrated implants are not mobile; therefore, it is important to ensure an accurate relationship on the definitive cast. [4]

Since the accuracy of the impression affects the accuracy of the definitive cast, an accurate impression is essential to fabricate a prosthesis with a good fit. An inaccurate impression may result in prosthesis misfit which may lead to mechanical and/or biological complications. Even though obtaining absolute passive fit is practically impossible, minimizing the misfit to prevent possible complications is a generally accepted goal of prosthodontic implant procedures. [5]

Literature shows that the accuracy of the implant cast depends on many factors; the type of impression material, implant impression technique, the implant angulation, the die material accuracy, and the master cast. [6]

There are two main techniques for dental implants impression, the direct (open tray) and indirect (closed tray) impression technique. In the open tray technique, the impression coping is incorporated in the impression and is removed from the mouth, together with the set impression. In the closed tray technique, the impression coping is retained in the mouth when the set impression is removed.

To ensure maximum accuracy, some authors emphasized the importance of splinting impression copings together intraorally before making an impression and some authors sectioned the splint material connection, leaving a thin space between and then rejoining with a minimal amount of the same material to minimize polymerization shrinkage or waiting for complete polymerization of the material. However, inconsistent results have been obtained. [7],[8] Various materials such as acrylic resin, dental plaster, bite registration silicone, and polyether (PE) have been used as splinting materials with varying degrees of accuracy.

Angulation of dental implants is another factor affecting the accuracy of the master casts. Anatomic constraints sometimes make it necessary to surgically position implants at an angle that are not optimal for prosthetic restorations. [9]

Similarly, many researchers have evaluated the accuracy of implant impression materials; better results have been obtained with PE and polyvinylsiloxane (PVS) in comparison to condensation silicone, polysulfide, irreversible hydrocolloid, and plaster materials. [10] Similar data also exist in terms of splinting, angulation, or type of material with different studies favoring splinting or nonsplinting, angulated or nonangulated, or the different impression materials, respectively. Therefore, there is no data clearly favoring one type over the other. [11]

Most studies have compared only a few individual variables such as technique, material, splinting, or angulation in their studies with very few studies assessing all these variables together in one study. This is important as all these variables are interlinked and can affect each other. Vinylsiloxanether (VSE) is a recent addition to the class of implant impression materials. Not many studies are available in the literature comparing all the three impression materials - PVS, PE, and VSE.

Therefore, this study was designed to investigate the accuracy of master cast using two impression techniques, i.e. open and closed tray techniques and impression materials including PVS, PE, and VSE, and to evaluate the effect of splinting and nonsplinting methods and angulations of implants in them.


   Materials and methods Top


The reference model was a U-shaped stainless steel die framework (12 mm Χ 10 mm Χ 50 mm) simulating the edentulous mandible fabricated with the help of a bench lathe. Six holes were drilled to a depth of 10 mm and diameter of 4.3 mm with the help of three-dimensional (3D) computerized numerical control universal vertical milling machine (HSC Roders GMBH, Germany). The lab analogs (4.2 mm diameter) were positioned in different angulations [Figure 1]. Assigned as A, B, R, C, D, and E, the center analogs R and C were placed perpendicular to the framework. The analogs B and D were placed at an angle of 10° and the analogs A and E were positioned at 20° to the center axis with respect to center analogs. Six orientation marks were drilled, i.e. three labially and three lingually which were 2 mm wide and 1 mm deep for orientation of the tray while making the impressions [Figure 1].
Figure 1: Master die with implant analogs

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Sixty custom impression trays were made with autopolymerizing methacrylate resin (DPI self-cure resin); for this purpose, the six lab analogs with the impression copings (ADIN Dental Implant Systems Ltd., Afula, Israel) in the metal model were covered by three layers of wax sheet (Charminar Dental Products, Hyderabad, India) to allow a consistent thickness of impression material, and an irreversible hydrocolloid impression (Algitex, DPI, Mumbai) was made. The casts obtained were used for fabrication of custom trays. The three location marks helped to standardize tray positioning during impression making.

The impression trays for open tray technique had six windows to allow access for the copings screws unlike the closed tray technique impression trays [Figure 2] and [Figure 3].
Figure 2: Open tray

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Figure 3: Closed tray

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Impressions were made using three elastomeric impression materials.

  1. PVS (Dentsply, medium-bodied) which was mixed in a base and catalyst ratio of 1:1
  2. PE (3M ESPE, medium-bodied) in the ratio of 7:1
  3. Vinylpolysiloxanether (Identium, medium-bodied) in the ratio of 5:1.


The impressions for open tray technique were divided primarily into splinted group and the nonsplinted group. The splinted group was subdivided into two groups; (1) splinting with dental floss and pattern resin and (2) splinting with plastic rod. The open tray impression copings were tightly secured to the analogs with a torque wrench of 10N torque such that the flat end of the impression coping faced toward the labial side.

In subgroup 1, prior to splinting, a putty index was fabricated at a level just below the grooves of the rectangular part of the impression coping to act as a scaffold for the pattern resin to stay on. Dental floss was wounded in a criss-cross manner around all the copings to firmly secure them [Figure 4].
Figure 4: Putty index acting as scaffold

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Pattern resin (GC ASIA Dental PTE. Ltd., Singapore) was mixed and adapted to surround the copings and dental floss with paintbrush [Figure 5]. After complete polymerization, the pattern resin was sectioned in the center with the help of a diamond disc to create a gap of 0.2 mm between the sectioned parts. This was to compensate for the shrinkage of the resin. Later, the sectioned parts were rejoined with brush bead technique prior to making the impression.
Figure 5: Pattern resin around copings

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In subgroup 2, the stirrer was sectioned to fit into the space and was secured to copings with the help of pattern resin on either side in paintbrush/brush bead method [Figure 6].
Figure 6: Plastic rod and resin

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Tray adhesive was applied to the impression tray and left to dry for 15 min. The impression material (PVS/PE/VSE) was mixed according to the manufacturer's instructions to attain a uniform mix.

Impressions were made, and following the setting of the material, analogs were fixed to the copings and casts were poured with Type IV die stone (Pearlstone, Rajkot Asian Chemicals, Veravel, Gujarat). For the closed tray impressions, after setting, the impression was removed and the analog coping assembly was together inserted carefully into the impression by firmly pushing it into place until it was seated securely.

The experimental casts were measured in three axes with coordinate measuring machine (ZEISS CONTURA bridge-type CMM-Gottingen, Germany) [Figure 7]. The reference point taken for all the measurements was analog R which was perpendicular to the surface of the cast. The various distances from this point were designated as shown in [Figure 8],[Figure 9] and [Figure 10]. The distances in X axis were termed as XA, XB, XC, XD, and XE. The distances in Y axis were designated as YA, YB, YC, YD, and YE. Similarly, for Z axis, it was ZA, ZB, ZC, ZD, and ZE.
Figure 7: Coordinate measuring machine

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Figure 8: Measurements in X axis

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Figure 9: Measurements in Y axis

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Figure 10: Measurements in Z axis

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Statistical analysis was performed using (IBM, SPSS, US) Statistical Package for Social Sciences software version 19.0. Mean and standard deviation were calculated for all the experimental casts. Analysis of variance (ANOVA) test was used to analyze the significance while comparing different group variables, namely impression techniques and impression materials. Tukey's multiple comparison test was then used to compare each of the groups, while comparing different impression techniques, and the significance was estimated.


   Results Top


The mean and standard deviation of the differences in interim plant distances (IIDs) measured in the X, Y, and Z axes and the inter-implant angulations in the Z axis are shown in the [Table 1],[Table 2],[Table 3] and [Table 4].
Table 1: Comparison of impression materials in open tray technique (floss + acrylic splint/SA)

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Table 2: Comparison of impression materials in open tray technique (plastic rod + acrylic splint/SB)

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Table 3: Comparison of various impression materials in open tray technique (nonsplinted)

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The mean values of Dev X, Dev Y, Dev 3D, Dev angle, and Dev IID were lowest in VSE followed by PE and PVS while the Dev Z was lowest in VSE followed by PVS and maximum in PE. Using one-way ANOVA, test of significance was done, and it was seen that the mean deviations among PVS, PE, and VSE were significant in Dev X (P = 0.039) and Dev Y (P = 0.041) as shown in [Table 1]. This indicates that the VSE was better than PE followed by PVS in floss + acrylic splint technique.

The mean deviations among PVS, PE, and VSE were significant in Dev Y (P = 0.038) and Dev IID (P = 0.053) as shown in [Table 2]. This shows that the VSE was better than PE followed by PVS in plastic rod + acrylic splint technique.

[Table 3] shows that the mean deviations among PVS, PE, and VSE were significant in Dev X (P = 0.045), Dev Y (P = 0.031), Dev 3D (P = 0.049), and Dev IID (P = 0.038). This shows that the VSE was better than PE followed by PVS in open nonsplinted technique.

The mean values of Dev X, Dev Y, Dev Z, Dev 3D, and Dev IID were lowest in VSE followed by PE and PVS whereas Dev angle was greater in PE compared to PVS and VSE as shown in [Table 4]. This shows that the VSE was better than PE followed by PVS in closed tray technique.

Graph 1 shows that the mean deviations in PVS material were more in SB indicates splint type B (plastic rod + resin) technique compared to SA indicates splint type A (floss + resin) techniques in Dev X, Dev Y, Dev Z, and IID. In PE materials, similar findings were noted that mean deviations were less in SA compared to SB technique in Dev X, Dev Y, Dev Z, and IID. In VSE materials, mean deviations in Dev X and Dev Z were lower in SB technique compared to SA and mean deviations in Dev Y and IID were lower in SA technique.


   Discussion Top


In implant prosthodontics, a successful result can be carefully achieved only when passively fitting prostheses are fabricated. The application of undue torque to screws during attachment of the superstructure to the abutments can jeopardize the outcome. To eliminate discrepancies in fit, it is essential that work should be done on a master cast that reproduces, as accurately as possible, the position of the abutments in the patient's mouth. An important factor that influences the precision of fit is impression accuracy.

In this study, monophase technique was used as it is accomplished in a single-step procedure using materials with a medium viscosity to allow the material itself to record finer details while avoiding the slumping of the material in the tray, less time-consuming, and simple to perform. [12],[13]

Three elastomeric impression materials have been used - PVS, PE, and VSE. PE and PVS have frequently been used for in vitro studies on implant impressions. [14],[15],[16] Very few studies are available demonstrating the efficacy of VSE. [17],[18]

Literature showed the use of stainless steel, aluminum, brass, and acrylic resin model in various studies. [19],[20],[21] A stainless steel metal die in the form of a U-shaped framework was used because of its coefficient of thermal expansion which is equal to the impression copings and lab analogs made of stainless steel in addition to its properties such as strength, higher resistance to indentation, and less corrosion.

The lab analogs have been placed parallel as well as at various angulations, and the effect of these angulations has been studied. [10],[22],[23] In clinical situation, the submandibular fossa mandates implant placement with increasing angulation as it progresses distally. Therefore, in the second premolar region, angulation may be 10° to horizontal plane; in the first molar area, 10-15°; and in the second molar region, 20-25°. [24]

The die assessed all these variables including two parallel and four angulated implants which made it a better reference to measure accuracy and was similar to the one used in other studies. [4],[25]

The results obtained showed that open tray technique exhibited more accuracy compared to the closed tray technique in accordance with the earlier studies. [23],[26] The copings could not be consistently and accurately repositioned into the impression and this was believed to be the primary source of error in the transfer impression technique. Since the impression coping remains in the impression, the open tray technique reduces the effect of implant angulation, deforming the impression material upon recovery from mouth, and removes the concern of replacing the copings into the impression.

Splinting has been found to be more accurate than nonsplinted technique. [11],[27] Splinted technique was found to be superior to nonsplinted technique in PVS and PE but was not found to be superior to VSE. In multiple implants impression, the impression copings are aligned at different angles, and rotational movement of the copings is more pronounced. The underlying principle of splinting the impression copings is to connect them together using a rigid material to prevent individual coping movement during the impression making procedure. [5] Hence, unsplinted impression copings may show individual movement which contributes to its greatest inaccuracy among the three open tray techniques used in the study.

The efficacy of sectioning and rejoining of the resin technique has been established by earlier studies. [11],[21],[28] The completed splint was sectioned and rejoined as mentioned. The plastic rod secured with pattern resin was another splinting material used, and the use of this technique has not been described in any of the previous studies. The results showed greater accuracy with splinted floss and pattern acrylic resin. The greater deviation with stirrer and resin splint could be attributed to the relative flexibility of the plastic rod compared to the floss and pattern resin. However, the encouraging advantage of this splint is its ease of fabrication and less time consumption compared to floss and resin.

PVS has overcome the disadvantage of polymerization shrinkage over the condensation silicone as there is no byproduct release. [13] Some studies found PVS to be more accurate compared to PE. [29],[30] Others stated that PE should be the material of choice to achieve a more accurate orientation of the implant analogs in the laboratory master casts. This might be explained by the fact that this material is more rigid than regular body PVS, thus preventing movement of the impression copings inside the impression material. [14] Integrating the qualities of PE and PVS into a newer material VSE has demonstrated good mechanical and flow properties along with excellent wetting characteristics in the unset as well as set conditions.

One of the other reasons for improved accuracy of VSE is the enhancement of the hydrophilicity which may influence the accuracy of impressions and can result in improved flow and finer detail of impressions made on moist dentinal surfaces and in the area of the gingival sulcus. [17] The composition of this new material is intended to incorporate the natural hydrophilicity of conventional PE materials along with the desirable properties of additional polysilicone materials such as elastic recovery and tear resistance. Very few studies have been available in literature citing the accuracy of VSE. The results of the present study positively supplement the existing studies. [13],[18]

The deviations in angulation were found to be higher in nonsplinted technique as compared to splinted technique. On comparing the impression materials, it was seen that the deviations were more in PVS followed by PE and VSE.

If multiple implants are parallel to each other, there will be no horizontal shift in the transfer; if the implants are positioned angled, the rotational misfit leads to a horizontal discrepancy. An angulation of 20° and rotational freedom of 1.5° can result in a horizontal misfit up to 127 microns. [31]

It is reported that angular positional transfer deformation increases with an increase in an implant's buccal/lingual inclination with respect to horizontal crestal plane. As implant angulations increase, distortion in the experimental cast increases. This can be explained with increased material deformation upon impression removal. Especially in multiple implant cases, an increase in implant angulation increases the area of friction and the amount of stresses generated in an impression decreasing impression accuracy. [10]


   Conclusion Top


Within the limitations of the study, it can be concluded that

  1. The open tray technique was more accurate than the closed tray technique when multiple implants are considered
  2. The VSE material showed lesser deviation from the reference die compared to PE and PVS
  3. Splinting of the impression copings had a significant effect on the accuracy of the casts
  4. Among the splinting methods used in the present study, splinting with dental floss and acrylic was more reliable than splinting with plastic rod and acrylic
  5. The relation between the angulation and impression material can be established that as with increase in angulation, the amount of forces of deformation increases which require an impression material which can withstand these forces that affect the accuracy of master cast.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]


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