DENTAL TECHNIQUE
Clinical assessment of fractured implant abutment screws: The Bernese silicone replica technique Kensuke Igarashi, DDS, PhDa and Kelvin I. Afrashtehfar, DDS, MScb With implant dentistry increasABSTRACT ingly associated with satisfactory Fractured implant abutment screws can be retrieved with repair or rescue devices. However, long-term clinical and patientwhether the screw was completely retrieved or the inner implant body was damaged may be 1,2 centered outcomes, implant uncertain. A silicone replica technique was recently implemented in Bern and may be the most complications have also incpredictable method available at the moment for clinically assessing the internal implant body. This reased.3-5 Mechanical complitechnique is straightforward and precise and may help dentists determine the internal implant condition when managing a fractured screw. (J Prosthet Dent 2017;-:---) cations include a 3.9% incidence of fractured implant abutments elastomeric impression material such as polyvinyl screws and a 6.7% incidence of loosened implant abutsiloxane18 or vinylsiloxanether.19 ments screws,4 with loosening often being the precursor to 6 a fractured screw. Consequently, completely retrieving TECHNIQUE the fractured abutment screws without damaging the implant is a clinical challenge.7-12 Using a dental excavator13 or ultrasonic scaler14 may be the most straight1. After retrieving the fractured abutment screw with forward methods; however, they may not always be the repair device (RSS; Straumann AG), rinse successful, and a repair or rescue device for the retrieval of thoroughly with 10 mL of saline from a disposable fractured implant abutment screws may be necessary.15 syringe (Omnifix; B. Braun Medical Inc) with a Although these devices may remove the fractured screws stainless steel 25-gauge irrigating needle (ProRinse; by drilling and hand tapping into the implant body, the Dentsply Sirona). condition of the internal implant body may be impossible 2. Air-dry the inner implant fixture using a 3-way syto observe clearly, even with magnification. Moreover, the ringe and clean with a microbrush (Microbrush; presence of fragments of the fractured screw in the depth Microbrush Intl). of the implant screw hole may prevent seating of the new 3. Insert the intraoral tip of an impression cartridge abutment and may not be perceived by the clinician. (Identium Light; Kettenbach GmbH & Co KG) as Prosthesis misfit may cause a new mechanical complicadeeply as possible inside the implant body tion16 in addition to periimplant soft tissue damage and (Fig. 1). marginal bone loss.17 A reliable method of evaluating the 4. Inject the light-body impression material until it internal implant condition is needed. extrudes from the implant shoulder. As the tip is This article describes the Bernese silicone replica withdrawn, keep injecting material until excess technique developed for a precise assessment of the inmaterial is approximately 5 mm coronally from the ternal implant condition. This dental technique uses an shoulder of the implant (Figs. 2, 3).
Materials provided by the Department of Reconstructive Dentistry & Gerodontology, School of Dental Medicine, University of Bern, Bern, Switzerland. a Postdoctoral Fellow, Department of Reconstructive Dentistry & Gerodontology, School of Dental Medicine, University of Bern, Bern, Switzerland; and Assistant Professor, Department of Life Science Dentistry, The Nippon Dental University, Niigata, Japan. b Fellow, Advanced Studies in Oral Implantology, Department of Reconstructive Dentistry & Gerodontology, School of Dental Medicine, University of Bern, Bern, Switzerland.
THE JOURNAL OF PROSTHETIC DENTISTRY
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Figure 1. Intraoral tip for light-body silicone Figure 2. Extrusion of excess impression material. inserted in implant.
Figure 4. Interproximal wooden wedge inserted.
5. Insert an interproximal wooden wedge (Polydentia SA) held in cotton pliers (Tweezers College LiquidSteel; Carl Martin GmbH) as deeply as possible into the middle of the impression in 1 motion to avoid introducing air bubbles (Fig. 4). 6. Allow the impression material to polymerize and remove the internal implant negative pattern by carefully turning the external excess in a counterclockwise direction (Fig. 5). 7. Compare the removed pattern (left) with a control silicone pattern (right) (Fig. 6). The control silicone pattern should be prepared beforehand from an undamaged dental implant. DISCUSSION This dental technique describes the steps needed to assess the internal implant condition after using a repair device (Supplementary Video). The authors are unaware of previous reports on the internal implant condition after retrieving a fractured abutment screw. Knowing the
THE JOURNAL OF PROSTHETIC DENTISTRY
-
Issue
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Figure 3. Extruded excess impression material.
Figure 5. Impression pattern removal.
internal implant state as precisely as possible is essential to determining whether the dental implant can be salvaged for a future prosthesis. This straightforward method can clinically assess the condition of an internal implant. Additionally, the Bernese silicone replica technique is safe and inexpensive. Few techniques are available for evaluating the complete removal of a fractured abutment screw after using a repair device. For example, there are workshops in which participants are instructed to assess the success of retrieving a fractured abutment screw by inserting an impression post. If the impression post is completely inserted, then the screw removal procedure is considered successful. Our group, however, has shown that this test is unreliable because the apical portion of the impression screw does not reach the bottom of the implant screw hole. Therefore, a consistent method of determining complete removal of the fractured abutment screw is needed. Impression making has been associated with 2 clinical reports of fractured screw removal,20,21 but the purpose was finding a Igarashi and Afrashtehfar
-
2017
3
6. 7. 8. 9. 10.
11. 12. 13.
Figure 6. Internal implant condition comparison. Removed fractured screw (left) and control (right) negative patterns.
prosthetic solution, not to assess the internal implant condition. This technique may not be suitable for all clinical scenarios. For example, when silicone is subjected to more than the recommended 25 C storage temperature, the material sets faster, and the silicone pattern may distort.22 In another scenario, when internal implant screw threads have been severely damaged, the silicone pattern may engage undercuts and be torn on removal.23 Moreover, a pattern of an undamaged implant from the same manufacturer may not always be available, for example, if no undamaged implant is stored and if the patient has only 1 implant of that type.
14. 15. 16. 17. 18.
19.
20.
21.
SUMMARY This technique assesses the internal implant condition after fractured abutment screw retrieval with a repair device and a silicone impression. This method can be considered straightforward and precise. REFERENCES 1. Grey EB, Harcourt D, O’Sullivan D, Buchanan H, Kilpatrick NM. A qualitative study of patients’ motivations and expectations for dental implants. Br Dent J 2013;214:E1. 2. Ghanem H, Afrashtehfar KI, Abi-Nader S, Tamim F. Impact of a “TED-Style” presentation on potential patients’ willingness to accept dental implant therapy: A one-group, pre-test post-test study. J Adv Prosthodont 2015;7: 437-45. 3. Goodacre CJ, Kan JY, Rungcharassaeng K. Clinical complications of osseointegrated implants. J Prosthet Dent 1999;81:537-52. 4. Kreissl ME, Gerds T, Muche R, Heydecke G, Strub JR. Technical complications of implant-supported fixed partial dentures in partially edentulous cases after an average observation period of 5 years. Clin Oral Implants Res 2007;18:720-6. 5. Jung RE, Pjetursson BE, Glauser R, Zembic A, Zwahlen M, Lang NP. A systematic review of the 5-year survival and complication rates of
Igarashi and Afrashtehfar
22.
23.
implant-supported single crowns. Clin Oral Implants Res 2008;19: 119-30. Schwarz MS. Mechanical complications of dental implants. Clin Oral Implants Res 2000;11(Suppl 1):156-8. Williamson RT, Robinson FG. Retrieval technique for fractured implant screws. J Prosthet Dent 2001;86:549-50. Shah K, Lee DJ. An alternative approach for the management of fractured implant abutment screws on a mandibular implant-retained overdenture: A clinical report. J Prosthet Dent 2016;115:402-5. Nergiz I, Schmage P, Shahin R. Removal of a fractured implant abutment screw: A clinical report. J Prosthet Dent 2004;91:513-7. Johnston GR, Jamjoom FZ, Lee DJ. A technique for the removal of a wedged implant abutment fragment or debonded titanium base. J Prosthet Dent 20 May 2017. doi: 10.1016/j.prosdent.2017.02.018. [Epub ahead of print.] Imam AY, Moshaverinia A, Chee WW, McGlumphy EA. A technique for retrieving fractured implant screws. J Prosthet Dent 2014;111:81-3. Maalhagh-Fard A, Jacobs LC. Retrieval of a stripped abutment screw: A clinical report. J Prosthet Dent 2010;104:212-5. Satwalekar P, Chander KS, Reddy BA, Sandeep N, Sandeep N, Satwalekar T. A Simple and cost effective method used for removal of a fractured implant abutment screw: A case report. J Int Oral Health 2013;5: 120-3. Patel RD, Kan JY, Jonsson LB, Rungcharassaeng K. The use of a dental surgical microscope to aid retrieval of a fractured implant abutment screw: A clinical report. J Prosthodont 2010;19:630-3. Luterbacher S, Fourmousis I, Lang NP, Braegger U. Fractured prosthetic abutments in osseointegrated implants: A technical complication to cope with. Clin Oral Implants Res 2000;11:163-70. Kourtis S, Damanaki M, Kaitatzidou S, Kaitatzidou A, Roussou V. Loosening of the fixing screw in single implant crowns: Predisposing factors, prevention and treatment options. J Esthet Restor Dent 2017;29:233-46. Chen CJ, Papaspyridakos P, Guze K, Singh M, Weber HP, Gallucci GO. Effect of misfit of cement-retained implant single crowns on crestal bone changes. Int J Prosthodont 2013;26:135-7. Hoods-Moonsammy VJ, Owen P, Howes DG. A comparison of the accuracy of polyether, polyvinyl siloxane, and plaster impressions for long-span implant-supported prostheses. Int J Prosthodont 2014;27: 433-8. Enkling N, Bayer S, Jöhren P, Mericske-Stern R. Vinylsiloxanether: A new impression material. Clinical study of implant impressions with vinylsiloxanether versus polyether materials. Clin Implant Dent Relat Res 2012;14: 144-51. Pow EH, Wat PY. A technique for salvaging an implant-supported crown with a fractured abutment screw. J Prosthet Dent 2006;95: 169-70. Canpolat C, Ozkurt-Kayahan Z, Kazazoglu E. Management of a fractured implant abutment screw: A clinical report. J Prosthodont 2014;23: 402-5. Purk JH, Willes MG, Tira DE, Eick JD, Hung SH. The effects of different storage conditions on polyether and polyvinylsiloxane impressions. J Am Dent Assoc 1998;129:1014-21. Hansson O, Eklund J. Impressions for prosthodontic restorations reproducing narrow spaces and severe undercuts. Acta Odontol Scand 1988;46: 199-206.
Corresponding author: Dr Kelvin Ian Afrashtehfar Department of Reconstructive Dentistry & Gerodontology School of Dental Medicine, Faculty of Medicine University of Bern Rm C305, Freiburgstrasse 7 3010 Berne SWITZERLAND Email: [email protected] Acknowledgments The authors thank the scientific illustrator, Ms Bernadette Rawyler, Department of Multimedia and Computer Science for her assistance in the elaboration of the video. K.I. thanks The Nippon Dental University School of Life Dentistry at Niigata for supporting the postdoctoral education. K.I.A. thanks the International Team of Implantology (ITI; Basel, Switzerland) for the educational support. Copyright © 2017 by the Editorial Council for The Journal of Prosthetic Dentistry.
THE JOURNAL OF PROSTHETIC DENTISTRY
Clinical assessment of fractured implant abutment screws: The Bernese silicone replica technique Kensuke Igarashi, DDS, PhDa and Kelvin I. Afrashtehfar, DDS, MScb With implant dentistry increasABSTRACT ingly associated with satisfactory Fractured implant abutment screws can be retrieved with repair or rescue devices. However, long-term clinical and patientwhether the screw was completely retrieved or the inner implant body was damaged may be 1,2 centered outcomes, implant uncertain. A silicone replica technique was recently implemented in Bern and may be the most complications have also incpredictable method available at the moment for clinically assessing the internal implant body. This reased.3-5 Mechanical complitechnique is straightforward and precise and may help dentists determine the internal implant condition when managing a fractured screw. (J Prosthet Dent 2017;-:---) cations include a 3.9% incidence of fractured implant abutments elastomeric impression material such as polyvinyl screws and a 6.7% incidence of loosened implant abutsiloxane18 or vinylsiloxanether.19 ments screws,4 with loosening often being the precursor to 6 a fractured screw. Consequently, completely retrieving TECHNIQUE the fractured abutment screws without damaging the implant is a clinical challenge.7-12 Using a dental excavator13 or ultrasonic scaler14 may be the most straight1. After retrieving the fractured abutment screw with forward methods; however, they may not always be the repair device (RSS; Straumann AG), rinse successful, and a repair or rescue device for the retrieval of thoroughly with 10 mL of saline from a disposable fractured implant abutment screws may be necessary.15 syringe (Omnifix; B. Braun Medical Inc) with a Although these devices may remove the fractured screws stainless steel 25-gauge irrigating needle (ProRinse; by drilling and hand tapping into the implant body, the Dentsply Sirona). condition of the internal implant body may be impossible 2. Air-dry the inner implant fixture using a 3-way syto observe clearly, even with magnification. Moreover, the ringe and clean with a microbrush (Microbrush; presence of fragments of the fractured screw in the depth Microbrush Intl). of the implant screw hole may prevent seating of the new 3. Insert the intraoral tip of an impression cartridge abutment and may not be perceived by the clinician. (Identium Light; Kettenbach GmbH & Co KG) as Prosthesis misfit may cause a new mechanical complicadeeply as possible inside the implant body tion16 in addition to periimplant soft tissue damage and (Fig. 1). marginal bone loss.17 A reliable method of evaluating the 4. Inject the light-body impression material until it internal implant condition is needed. extrudes from the implant shoulder. As the tip is This article describes the Bernese silicone replica withdrawn, keep injecting material until excess technique developed for a precise assessment of the inmaterial is approximately 5 mm coronally from the ternal implant condition. This dental technique uses an shoulder of the implant (Figs. 2, 3).
Materials provided by the Department of Reconstructive Dentistry & Gerodontology, School of Dental Medicine, University of Bern, Bern, Switzerland. a Postdoctoral Fellow, Department of Reconstructive Dentistry & Gerodontology, School of Dental Medicine, University of Bern, Bern, Switzerland; and Assistant Professor, Department of Life Science Dentistry, The Nippon Dental University, Niigata, Japan. b Fellow, Advanced Studies in Oral Implantology, Department of Reconstructive Dentistry & Gerodontology, School of Dental Medicine, University of Bern, Bern, Switzerland.
THE JOURNAL OF PROSTHETIC DENTISTRY
1
2
Volume
Figure 1. Intraoral tip for light-body silicone Figure 2. Extrusion of excess impression material. inserted in implant.
Figure 4. Interproximal wooden wedge inserted.
5. Insert an interproximal wooden wedge (Polydentia SA) held in cotton pliers (Tweezers College LiquidSteel; Carl Martin GmbH) as deeply as possible into the middle of the impression in 1 motion to avoid introducing air bubbles (Fig. 4). 6. Allow the impression material to polymerize and remove the internal implant negative pattern by carefully turning the external excess in a counterclockwise direction (Fig. 5). 7. Compare the removed pattern (left) with a control silicone pattern (right) (Fig. 6). The control silicone pattern should be prepared beforehand from an undamaged dental implant. DISCUSSION This dental technique describes the steps needed to assess the internal implant condition after using a repair device (Supplementary Video). The authors are unaware of previous reports on the internal implant condition after retrieving a fractured abutment screw. Knowing the
THE JOURNAL OF PROSTHETIC DENTISTRY
-
Issue
-
Figure 3. Extruded excess impression material.
Figure 5. Impression pattern removal.
internal implant state as precisely as possible is essential to determining whether the dental implant can be salvaged for a future prosthesis. This straightforward method can clinically assess the condition of an internal implant. Additionally, the Bernese silicone replica technique is safe and inexpensive. Few techniques are available for evaluating the complete removal of a fractured abutment screw after using a repair device. For example, there are workshops in which participants are instructed to assess the success of retrieving a fractured abutment screw by inserting an impression post. If the impression post is completely inserted, then the screw removal procedure is considered successful. Our group, however, has shown that this test is unreliable because the apical portion of the impression screw does not reach the bottom of the implant screw hole. Therefore, a consistent method of determining complete removal of the fractured abutment screw is needed. Impression making has been associated with 2 clinical reports of fractured screw removal,20,21 but the purpose was finding a Igarashi and Afrashtehfar
-
2017
3
6. 7. 8. 9. 10.
11. 12. 13.
Figure 6. Internal implant condition comparison. Removed fractured screw (left) and control (right) negative patterns.
prosthetic solution, not to assess the internal implant condition. This technique may not be suitable for all clinical scenarios. For example, when silicone is subjected to more than the recommended 25 C storage temperature, the material sets faster, and the silicone pattern may distort.22 In another scenario, when internal implant screw threads have been severely damaged, the silicone pattern may engage undercuts and be torn on removal.23 Moreover, a pattern of an undamaged implant from the same manufacturer may not always be available, for example, if no undamaged implant is stored and if the patient has only 1 implant of that type.
14. 15. 16. 17. 18.
19.
20.
21.
SUMMARY This technique assesses the internal implant condition after fractured abutment screw retrieval with a repair device and a silicone impression. This method can be considered straightforward and precise. REFERENCES 1. Grey EB, Harcourt D, O’Sullivan D, Buchanan H, Kilpatrick NM. A qualitative study of patients’ motivations and expectations for dental implants. Br Dent J 2013;214:E1. 2. Ghanem H, Afrashtehfar KI, Abi-Nader S, Tamim F. Impact of a “TED-Style” presentation on potential patients’ willingness to accept dental implant therapy: A one-group, pre-test post-test study. J Adv Prosthodont 2015;7: 437-45. 3. Goodacre CJ, Kan JY, Rungcharassaeng K. Clinical complications of osseointegrated implants. J Prosthet Dent 1999;81:537-52. 4. Kreissl ME, Gerds T, Muche R, Heydecke G, Strub JR. Technical complications of implant-supported fixed partial dentures in partially edentulous cases after an average observation period of 5 years. Clin Oral Implants Res 2007;18:720-6. 5. Jung RE, Pjetursson BE, Glauser R, Zembic A, Zwahlen M, Lang NP. A systematic review of the 5-year survival and complication rates of
Igarashi and Afrashtehfar
22.
23.
implant-supported single crowns. Clin Oral Implants Res 2008;19: 119-30. Schwarz MS. Mechanical complications of dental implants. Clin Oral Implants Res 2000;11(Suppl 1):156-8. Williamson RT, Robinson FG. Retrieval technique for fractured implant screws. J Prosthet Dent 2001;86:549-50. Shah K, Lee DJ. An alternative approach for the management of fractured implant abutment screws on a mandibular implant-retained overdenture: A clinical report. J Prosthet Dent 2016;115:402-5. Nergiz I, Schmage P, Shahin R. Removal of a fractured implant abutment screw: A clinical report. J Prosthet Dent 2004;91:513-7. Johnston GR, Jamjoom FZ, Lee DJ. A technique for the removal of a wedged implant abutment fragment or debonded titanium base. J Prosthet Dent 20 May 2017. doi: 10.1016/j.prosdent.2017.02.018. [Epub ahead of print.] Imam AY, Moshaverinia A, Chee WW, McGlumphy EA. A technique for retrieving fractured implant screws. J Prosthet Dent 2014;111:81-3. Maalhagh-Fard A, Jacobs LC. Retrieval of a stripped abutment screw: A clinical report. J Prosthet Dent 2010;104:212-5. Satwalekar P, Chander KS, Reddy BA, Sandeep N, Sandeep N, Satwalekar T. A Simple and cost effective method used for removal of a fractured implant abutment screw: A case report. J Int Oral Health 2013;5: 120-3. Patel RD, Kan JY, Jonsson LB, Rungcharassaeng K. The use of a dental surgical microscope to aid retrieval of a fractured implant abutment screw: A clinical report. J Prosthodont 2010;19:630-3. Luterbacher S, Fourmousis I, Lang NP, Braegger U. Fractured prosthetic abutments in osseointegrated implants: A technical complication to cope with. Clin Oral Implants Res 2000;11:163-70. Kourtis S, Damanaki M, Kaitatzidou S, Kaitatzidou A, Roussou V. Loosening of the fixing screw in single implant crowns: Predisposing factors, prevention and treatment options. J Esthet Restor Dent 2017;29:233-46. Chen CJ, Papaspyridakos P, Guze K, Singh M, Weber HP, Gallucci GO. Effect of misfit of cement-retained implant single crowns on crestal bone changes. Int J Prosthodont 2013;26:135-7. Hoods-Moonsammy VJ, Owen P, Howes DG. A comparison of the accuracy of polyether, polyvinyl siloxane, and plaster impressions for long-span implant-supported prostheses. Int J Prosthodont 2014;27: 433-8. Enkling N, Bayer S, Jöhren P, Mericske-Stern R. Vinylsiloxanether: A new impression material. Clinical study of implant impressions with vinylsiloxanether versus polyether materials. Clin Implant Dent Relat Res 2012;14: 144-51. Pow EH, Wat PY. A technique for salvaging an implant-supported crown with a fractured abutment screw. J Prosthet Dent 2006;95: 169-70. Canpolat C, Ozkurt-Kayahan Z, Kazazoglu E. Management of a fractured implant abutment screw: A clinical report. J Prosthodont 2014;23: 402-5. Purk JH, Willes MG, Tira DE, Eick JD, Hung SH. The effects of different storage conditions on polyether and polyvinylsiloxane impressions. J Am Dent Assoc 1998;129:1014-21. Hansson O, Eklund J. Impressions for prosthodontic restorations reproducing narrow spaces and severe undercuts. Acta Odontol Scand 1988;46: 199-206.
Corresponding author: Dr Kelvin Ian Afrashtehfar Department of Reconstructive Dentistry & Gerodontology School of Dental Medicine, Faculty of Medicine University of Bern Rm C305, Freiburgstrasse 7 3010 Berne SWITZERLAND Email: [email protected] Acknowledgments The authors thank the scientific illustrator, Ms Bernadette Rawyler, Department of Multimedia and Computer Science for her assistance in the elaboration of the video. K.I. thanks The Nippon Dental University School of Life Dentistry at Niigata for supporting the postdoctoral education. K.I.A. thanks the International Team of Implantology (ITI; Basel, Switzerland) for the educational support. Copyright © 2017 by the Editorial Council for The Journal of Prosthetic Dentistry.
THE JOURNAL OF PROSTHETIC DENTISTRY
