Fit of implant frameworks: an in vitro comparison between two fabrication techniques

Toshiyuki Takahashi, DDS, PhD,a and Johan Gunne, DDS, PhDb Tokyo Dental College, Chiba, Japan; Faculty of Medicine and Odontology, Ume University, Ume, Sweden. Statement of problem. It has been suggested that a precise t between the implant and the framework cylinder is necessary to ensure a satisfactory long-term clinical outcome. Purpose. The purpose of this study was to compare the precision of t between implant abutments and framework cylinders in frameworks fabricated by the Procera system and those fabricated from cast gold-alloy. Material and methods. A total of 19 frameworks, 14 made with the Procera system (type 1) and 5 made of a cast gold-alloy (type 2), were fabricated. A total of 95 implants, 70 type 1 and 25 type 2 frameworks, were evaluated. Three replicas of the space between the implant abutments and the framework cylinders of the master cast were made for each test specimen. The replicas were cut with a scalpel in 2 axial directions: buccal-lingual and right-left. For the purpose of measurement, a microscope with a precision of 0.5 m was used at original magnication 30. The Student t test was used to determine whether there were signicant differences between the framework designs. Results. The buccal-lingual measurements for the type 1 and type 2 frameworks showed mean values of 28.1 m (SD 9.8) and 42.0 m (SD 1.8) on the buccal side, respectively, and 25.6 m (SD 11.2) and 51.6 m (SD 10.9) on the lingual side, respectively. For the right-left view, the mean measurements were 26.6 m (SD 8.4) and 49.2 m (SD 11.4) on the right side, respectively, and 27.4 m (SD 8.5) and 44.4 m (SD 6.5) on the left side, respectively. The total mean value for type 1 frameworks was 26.9 m (SD 9.3); that for type 2 frameworks was 46.8 m (SD 8.8). Conclusion. Within the limitations of this experiment, it was demonstrated that the t of frameworks made with the Procera system was signicantly better than that of the frameworks made with cast gold-alloy (P .01). (J Prosthet Dent 2003;89:256-60.)

CLINICAL IMPLICATIONS
This study suggests that the t of implant frameworks fabricated by the Procera system were signicantly better than that of frameworks made with cast gold-alloy.

t has been suggested that a precise t between the implant and the framework cylinder is necessary to ensure a satisfactory long-term clinical outcome. Poor t of frameworks connected to implants has been shown to cause a deformation of the surrounding bone1 and an increase in technical problems.2 Fit of implant-supported prostheses, correlation to distortion of the surrounding bone, change of marginal bone level around the implants, and technical problems have recently been addressed in several reports.1-12 However, in most of the reports that deal with the preSupported by the Department of Odontology/Faculty of Medicine and Odontology, Ume University and Ume Dental Laboratory, Ume, Sweden. a Assistant Professor, Department of Crown and Bridge Prosthodontics, Tokyo Dental College. Guest researcher, Department of Odontology/Prosthetic Dentistry, Faculty of Medicine and Odontology, Ume University. b Professor, Department of Odontology/Prosthetic Dentistry, Faculty of Medicine and Odontology, Ume University. 256 THE JOURNAL OF PROSTHETIC DENTISTRY

cise t, the framework was fabricated from cast goldalloy. Implant prosthesis frameworks in cast materials, such as gold-alloy, involve a certain risk for built-in tension and stress caused by the wax-up and casting procedures. Recently, frameworks have been milled from pure titanium and, according to the manufacturer, have been considered to have a high degree of t. It has been reported that Procera machined framework (All-inOne) ts better to the implant abutment than the goldalloy casting framework.11 The purpose of this study was to compare the precision of t between implant abutments and framework cylinders in frameworks fabricated by the Procera system and those fabricated from cast gold-alloy.

MATERIAL AND METHODS

All superstructures were fabricated in the same laboratory but were not fabricated by the same technician. The 19 frameworks had 2 different shapes. Seventeen
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Fig. 1. Film thickness was recorded as distance between edge of abutment and edge of cylinder.

Table I. Number of frameworks and implants (within parentheses) in type 1 and type 2
Type Maxilla Mandible Total

1 2 Total

6 (29) 3 (13) 9 (42)

8 (41) 2 (12) 10 (53)

14 (70) 5 (25) 19 (95)

were completely edentulous (cross arch xed dentures), and 2 were partially edentulous. A total of 19 frameworks, 14 made with the Procera system (Nobel Biocare, Gothenburg, Sweden) (type 1) and 5 made of a cast gold-alloy (Type 2) were fabricated. A total of 95 implants, 70 type 1 and 25 type 2 frameworks, were evaluated (Table I). The Procera system is a new CAD-CAM technology developed to fabricate the framework for implant-supported prostheses that originates from a technique to make titanium crowns.13-17 After the fabrication of the frameworks at the laboratory, 3 replicas of the space between the implant abutments and the framework cylinders of the master cast were made for each test specimen. A light-body A-silicon impression material (Provil Novo green; Heraeus Kulzer, Hanau, Germany) was applied, with the help of a syringe, on and around the implant abutment of the master cast. The framework was then placed onto the implant abutments of the master cast and maximal 4-nger pressure (about 8 to 10 kg18) was applied on the
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occlusal surfaces of the framework. After the setting of the impression material, the framework and the impression material were removed from the master cast, resulting in a thin lm of light-body material representing the discrepancy between the framework cylinder and the implant abutment. In most situations, a thin lm of impression material resulted on the inside of the cylinder and the part of the cylinder opposing the abutment. For purposes of stabilization a medium-body material (Provil Novo yellow; Heraeus Kulzer) was injected into the cylinder and around the impression material surface, jointing with the light-body lm to form one piece (Fig. 1). With this procedure it was possible to remove and handle the intermediate replica of light-body material. The replica adhering to the medium-body material was cut with a scalpel in 2 axial directions, buccal-lingual side and right-left side (Fig. 2). In this manner the replica was divided into 4 pieces. For purpose of measurement, a microscope (Wild Leitz Co, Wetzlar, Germany) with a precision of 0.5 m was used at original magnication 30. Measurements of the thickness of the lm were performed at 4 points between the abutment and the cylinder, totaling 4 measurements for each implant abutment. The thickness of the lm was recorded as the shortest distance from the cylinder to the abutment at the four points (Fig. 1). Ninety-ve implants, 3 replicas of each
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Fig. 2. Four measurement points for each abutment. Lc, Line to connect each centric point of implant abutments; L1-L5 cross Lc at right angles through each centric point of implant abutments.

Table II. Precision of t (mean and standard deviation [SD] in micrometers) between implant abutment and cylinder of superstructure for All-in-One frameworks (type 1)
Framework Buccal Lingual Right Left Mean SD No of Implant

1 2 3 4 5 6* 7 8 9 10* 11* 12* 13* 14* Mean SD

*Upper jaw case.

49.0 48.2 26.7 26.7 29.0 34.3 22.5 25.5 19.3 22.8 31.3 19.6 20.6 18.5 28.1 9.8

34.8 44.3 27.3 21.6 24.2 51.5 21.9 18.2 15.7 17.9 30.6 14.4 16.4 20.1 25.6 11.2

37.5 43.9 30.9 24.2 29.0 37.5 22.3 21.6 19.7 20.3 30.3 17.7 19.6 17.8 26.6 8.4

39.6 45.5 34.4 25.8 26.5 37.0 22.7 24.3 18.4 22.2 27.8 20.6 17.6 20.6 27.4 8.5

40.2 45.5 29.8 24.6 27.2 40.1 22.4 22.4 18.3 20.8 30.0 18.1 18.6 19.3 All-Mean 26.9 All-SD 9.3

6.2 1.9 3.6 2.2 2.3 7.7 0.3 3.2 1.8 2.2 1.5 2.7 1.9 1.3

4 6 5 5 5 2 6 5 5 6 4 5 6 6 Total 70

implant, with lm thickness measured at 4 points on each specimen, give a total of 1140 measurements. In most positions there was a thin lm of impression material, but occasionally there was no material between the abutment and cylinder. No material was measured as zero thickness. Students unpaired t test was used to determine whether there was a signicant difference of the lm thickness between the 2 types of frameworks.

RESULTS
The measurements of the 2 types of frameworks are given in Tables II and III. For type 1, the analyses showed that the mean values were 28.1 m (SD 9.8) on
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the buccal side, 25.6 m (SD 11.2) on the lingual side, 26.6 m (SD 8.4) on the right side, and 27.4 m (SD 8.5) on the left side. The total mean was 26.9 m (SD 9.3) (Table II). For type 2, the analyses showed that the mean values were 42.0 m (SD 1.8) on the buccal side, 51.6 m (SD 10.9) on the lingual side, 49.2 m (SD 11.4) on the right side, and 44.4 m (SD 6.5) on the left side. The total mean was 46.8 m (SD 8.8) (Table III). For any measurement points (buccal, lingual, right, and left), the t of type 1 was statistically signicantly better (Students unpaired t test, P .01) than type 2. For all of type 1, the mean values of the lm thickness at the 4 measurement points were less than 30 m.
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Table III. Precision of t (mean and standard deviation [SD] in micrometers) between implant abutment and cylinder of superstructure for gold-alloy casting frameworks (type 2)
Framework Buccal Lingual Right Left Mean SD No. of implant

1 2* 3 4* 5* Mean SD
*Upper jaw case

42.4 44.2 42.4 39.3 41.6 42.0 1.8

42.0 39.1 64.6 53.0 59.3 51.6 10.9

45.4 40.8 68.9 48.3 42.6 49.2 11.4

45.4 40.6 55.0 42.8 38.1 44.4 6.5

43.8 1.9 41.2 2.2 57.7 11.8 45.9 6.0 45.4 9.5 All-Mean 46.8 All-SD 8.8

5 5 7 3 5 Total 25

DISCUSSION
The Procera system (CAD-CAM technology), which originated from Andersson,13 was developed14-17 and modied for fabrication of frameworks for implant-supported restorations. The All-in-One is a framework milled from a pure titanium block. The reason for the development of the All-in-One was to create a framework with high biocompatibility, low cost, and a t precision to the abutment through industrial production with the latest CAD-CAM technology. In the clinic, the dentist follows the same routine procedures as for the fabrication of other types of frameworks. After the nal check of design and tooth arrangement, the dental technician fabricates a resin pattern of the desired framework. The pattern is scanned for computerized handling of the implant positions, abutment replicas, and framework design. The framework is milled from the computer data. The accurate position of the implants and the relation to each other is possible without use of welded joints. After the framework has been milled, it is carefully measured in a stereomicroscope to check the t against the cast. It has been reported that the gap distance between the gold-alloy casting framework and the implant abutment was 42 to 74 m,5 and for Procera-machined and laser-welded frameworks it was less than 25 m.11 Osseointegrated implants present a signicantly different mobility compared with the natural teeth supported with periodontal ligaments.19 Therefore minor distortion of frameworks could invoke a risk of inducing stress from frameworks connected to osseointegrated implants. Natural teeth have the ability to adjust to the mist because of the mobility of the periodontal ligament. The difference in mobility between implants and natural teeth means that the precision of t of the framework is more important when xed prostheses are connected to implants than to natural teeth. Several methods for evaluating the implant framework t have been recommended, such as alternate nger pressure, direct vision and tactile sensation, radiographs, one-screw test, screw resistance test (half a turn), and disclosing media.12 To quantify the mist, a comMARCH 2003

puterized coordinate measuring machine,3 a 3-dimensional photogrammetric technique,4,5 and laser videography11 were described. However, most of these methods need expensive equipment and an advanced technique. In this experiment, a disclosing medium was used to measure the gap distance between the implant abutments and the framework cylinders (All-in-One and gold-alloy casting) of the master cast. The method is characterized by simplicity and low cost. For all specimens, the type 1 framework differed from the type 2 framework (Table I). Because most of the frameworks were fabricated with the Procera system, at the time of this study it was not possible to nd more than 5 treatments with the type 2 framework. However, the standard deviations were very low for both groups, and data analysis found both a clinically and a statistically signicant difference between the 2 groups. As a result, the total means were 26.9 m (SD 9.3) for type 1 frameworks and 46.8 m (SD 8.8) for type 2 frameworks. For type 1 frameworks, this is in agreement with the data of Riedy et al.11 The mean value of type 2 frameworks was lower than reported by Jemt and Lie.5 This increase of the precision of t could be explained by an improved technique at the dental laboratory derived from a long experience with the casting method. It is suggested that the framework with a good precision of t will decrease the stress to the implant components and the surrounding bone, thus avoiding deformation of the bone and an increase in technical problems.

CONCLUSION
Within the limitations of this study, it was demonstrated that the t of implant frameworks fabricated by the Procera system (All-in-One) were signicantly better than that of frameworks made with cast gold-alloy. For any measurement points (buccal, lingual, right, and left), the t of the All-in-One frameworks was statistically better than the framework made with cast goldalloy. For the All-in-One frameworks, all mean values of the thickness of the lm at the 4 measurements points (buccal, lingual, right, and left) were less than 30 m. Students unpaired t test showed a signicant difference
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(P .01) between the frameworks made with Procera system and the frameworks made with cast gold-alloy.
REFERENCES
1. Jemt T, Lekholm U. Measurements of bone and frame-work deformations induced by mist of implant superstructures: A pilot study in rabbits. Clin Oral Implants Res 1998;9:272-80. 2. Kallus T, Bessing C. Loose gold screws frequently occur in full-arch xed prostheses supported by osseointegrated implants after 5 years. Int J Oral Maxillofac Implants 1994;9:169-78. 3. Tan KB, Rubenstein JE, Nicholls JI, Yuodelis RA. Three-dimensional analysis of the casting accuracy of one-piece, osseointegrated implant-retained prostheses. Int J Prosthodont 1993;6:346-63. 4. Lie A, Jemt T. Photogrammetric measurements of implant positions. Description of a technique to determine the t between implants and superstructures. Clin Oral Implants Res 1994;5:30-6. 5. Jemt T, Lie A. Accuracy of implant-supported prostheses in the edentulous jaw: Analysis of precision of t between cast gold-alloy frameworks and master casts by means of a three-dimensional photogrammetric technique. Clin Oral Implants Res 1995;6:172-80. 6. Jemt T. Three-dimensional distortion of gold-alloy casting and welded titanium frameworks: measurements of the precision of t between completed implant prostheses and the master casts in routine edentulous situations. J Oral Rehabil 1995;22:557-64. 7. Jemt T, Book K. Prosthesis mist and marginal bone loss in edentulous implant patients. Int J Oral Maxillofac Implants 1996;11:620-5. 8. Lindquist LW, Carlsson GE, Jemt T. A prospective 15-year follow-up study of mandibular xed prostheses supported by osseointegrated implants: clinical results and marginal bone loss. Clin Oral Implants Res 1996;7: 329-36. 9. Jemt T, Rubenstein JE, Carlsson L, Lang BR. Measuring t at the implant prosthodontic interface. J Prosthet Dent 1996;75:314-25. 10. Jemt T. In vivo measurements of precision of t involving implant-supported prostheses in the edentulous jaw. Int J Oral Maxillofac Implants 1996;11:151-8. 11. Riedy SJ, Lang BR, Lang BE. Fit of implant frameworks fabricated by different techniques. J Prosthet Dent 1997;78:596-604.

12. Kan JYK, Rungcharassaeng K, Bohsali K, Goodacre CJ, Lang BR. Clinical methods for evaluating implant framework t. J Prosthet Dent 1999;81:713. 13. Andersson M, Bergman B, Bessing C, Ericson G, Lundquist P, Nilson H.. Clinical results with titanium crowns fabricated with machine duplication and spark erosion. Acta Odontol Scand 1989;47:279-86. 14. Bergman B, Bessing C, Ericson G, Lundquist P, Nilson H, Andersson M. A 2-year follow-up study of titanium crowns. Acta Odontol Scand 1990;48: 113-7. 15. Karlsson S. The t of Procera titanium crowns: an in vitro and clinical study. Acta Odontol Scand 1993;51:129-34. 16. Persson M, Andersson M, Bergman B. The accuracy of a high-precision digitizer for CAD/CAM of crowns. J Prosthet Dent 1995;74:223-9. 17. Andersson M, Carlsson L, Persson M, Bergman B. Accuracy of machine milling and spark erosion with a CAD/CAM system. J Prosthet Dent 1996;76:187-93. 18. Satoh K. Experimental study on the inuence of various dental luting cements on the elevation of crown during cementation. Shikwa Gakuho 1989;89:1317-37. [Japanese] 19. Sekine H, Komiyama Y, Hotta H, Yoshida K. Mobility characteristics and tactile sensitivity of osseointegrated xture-supporting system. In: van Steenberghe U, editor. Tissue integration in oral and maxillofacial reconstructions. New York: Elsevier Science; 1987. p. 326-32. Reprint requests to: DR TOSHIYUKI TAKAHASHI DEPARTMENT OF CROWN AND BRIDGE PROSTHODONTICS TOKYO DENTAL COLLEGE 1-2-2, MASAGO, MIHAMA-KU CHIBA 261-8502 JAPAN E-MAIL: totakaha@tdc.ac.jp Copyright 2003 by The Editorial Council of The Journal of Prosthetic Dentistry. 0022-3913/2003/$35.00 0 doi:10.1067/mpr.2003.40

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