Critical Appraisal of Implant Impression Accuracies: A Systematic Review
Critical Appraisal of Implant Impression Accuracies: A Systematic Review
Critical Appraisal of Implant Impression Accuracies: A Systematic Review
a
Assistant Professor, Department of Prosthodontics, Yonsei University Dental Hospital, College of Dentistry, Yonsei University, Seoul, Korea.
b
Captain, The Armed Forces Medical School; and Former graduate student, College of Dentistry, Yonsei University, Seoul, Korea.
c
Professor and Chairman, Department of Prosthodontics, Gangnam Severance Dental Hospital, College of Dentistry, Yonsei University, Seoul, Korea.
placement situations, but no consistent results had been review were searched for eligible studies. In case of any
reported.16 disagreement regarding inclusion, a consensus was
Recently, an optical impression technique that uses reached by discussion. Finally, a selection was made
scannable healing abutments instead of impression based on the inclusion/exclusion criteria applied to the
copings was introduced into clinical implant dentistry.17 full text articles.
Digital impression techniques seem to have several ad- The criteria for study inclusion were studies with at
vantages, including patient comfort, removal of possible least 3 implants for meaningful analysis, laboratory
errors associated with elastic materials, and increased studies, and studies comparing different impression
cost effectiveness.18 However, few studies have assessed techniques. The criteria for study exclusion were clinical
these techniques.19,20 or technical reports, only abstracts published in journals
Different measurement devices, including profile or conference proceedings, studies comparing die mate-
projectors,21,22 micrometers,23-25 coordinate measuring rials or systems, studies with insufficient information,
machines,26,27 strain gauges,28,29 and digital superimpo- review articles, and full text articles in languages other
sition30 have been used to evaluate the accuracy of than English.
implant impression techniques. However, even when the A data extraction sheet was used by the reviewers to
same devices have been used, these have been applied extract the relevant data from the included articles. In-
differently in different studies. To date, most implant formation on several parameters was recorded including
impression studies have just reported on the type of authors, year of publication, implant system, implant-
impression technique that produces the most accurate abutment connection type (external, internal, hexagon,
results. The benefits and drawbacks of each method have conical), number of implants, impression level (implant
not been evaluated. level or abutment level), impression technique, and
The purpose of the current systematic review was to assessment method. Disagreements regarding data
evaluate and compare the results of implant impression extraction were resolved by discussion.
studies based on the assessment methods used. The References from the selected studies were also
distribution of the assessment methods and the charac- screened to identify pertinent literature. The initial data
teristics of each measurement method were also search generated 389 articles. Based on the initial
analyzed to evaluate the advantages and disadvantages screening of the titles and abstracts, 88 studies were
of each assessment. selected for full text evaluation. A total of 33 studies were
omitted based on the exclusion criteria, and the
MATERIAL AND METHODS remaining 55 articles were selected for assessment. One
article was included after additional assessment of the
A MEDLINE/PubMed search was performed for labora-
articles and their references. In total, 56 articles were
tory studies published in dental journals from January 1,
selected for the analyses (Fig. 1, Table 1). Articles that
1990, to February 28, 2013. The search was limited to
were not included in this study after full text reading are
English language publications.
listed in Table 2. For a detailed list of excluded studies,
The following Medical Subject Headings (MeSH[*] )
see Supplemental Table 1 (available online).
or free text(†) words were used for the electronic search:
(dental implants* OR dental abutments* OR oral im-
RESULTS
plants† OR endosseous implants† OR dental prosthesis,
implant supported* OR implant restoration†) AND The 56 selected studies were classified into 4 main groups
(dental impression technique* OR dental impression based on the assessment methods used. These measured
materials* OR dental models* OR master casts† OR the extent of linear distortion of the implant (or abut-
definitive casts† OR final impression† OR digital ment) head positions (n = 37), angular distortion of the
impression† OR digital scanning†) AND (dimensional implant (or abutment) long axis (n=17), gap distances
measurement accuracy* OR three dimension† OR between the cylinders of a master framework and of
distortion† OR displacement† OR fit†). replicas in test models (n=10), and the amount of strain
All obtained titles and abstracts were screened inde- produced in a master framework (n=4).
pendently by 2 reviewers (J.H.K. and S.K.). If the abstract Among the 4 assessment methods, investigators
was not available, or if the title and the abstract did not preferred to assess the accuracy of the measurement of
provide sufficient information regarding the inclusion linear distortion of implant impressions. More than 50%
criteria, a full text article was acquired for screening. On of studies (n=37) compared the amount of linear distor-
the basis of the chosen abstracts, full text articles were tion to evaluate the accuracy of implant impression
selected for independent assessment by the reviewers. In techniques.6,7,10,13,15,17,19,21,23,26,27 Of these 37 studies, 17
addition, references of the selected publications and of were included in a previous systematic review,16 and 20
previously published reviews relevant to the present were published after the review.
impressions.6,8,14,21,23,24,26-28,30,31,37,41-43,45,46,50,52,59,62,63 In
Total studies identified from the previous review,16 4 studies reported that the splinted
electronic search (n = 389)
impression technique was more accurate,8,21,24,28 and only
1 study reported that the nonsplinted impression was
Studies excluded after more accurate.46 Eleven further studies were included in
reading
of titles and/or the present systematic review, 7 of which reported a
abstracts (n = 301) preference for a splinted technique over a nonsplinted
technique.6,14,30,50,52,59,62 No study reported that non-
Studies identified for screening splinted techniques resulted in more accurate impressions.
full text evaluation in the
initial phase (n = 88)
The next common study designs were comparisons of
direct versus indirect impression techniques and different
Studies excluded
impression materials. Seventeen studies compared the
after full text reading impression accuracy achieved with direct and indirect
based on exclusion techniques.6,8,13,23,24,30,34,37,41,43,45,46,51,53,57,61,63 In the
criteria (n = 33)
previous review,16 4 studies reported that the direct
impression technique was more accurate.24,34,45,46 Five
Studies included in the studies reported no dimensional difference between the
second phase of evaluation (n = 55)
techniques, and only 1 study43 reported that the indirect
impression technique was more accurate. Since the re-
Studies added view, 6 further studies have reported that the direct
by reviewing
the references impression technique is more accurate,6,13,23,41,61,63 and 3
of 55 studies (n = 1) have reported no difference in accuracy between the
techniques.30,51,53 No study has reported that the indirect
impression technique is more accurate.
Studies included in the final review
(n = 56) Sixteen studies compared the accuracy of polyether
and polyvinyl siloxane.7,8,10,32,38,41-43,45,47,49,55,56,68 Nine
Figure 1. Search strategy and history. studies were published before the previous review, none
of which reported any significant difference between the
2 materials. Since then, however, 2 studies have reported
Seventeen studies compared the amount of angular a preference for polyvinyl siloxane over polyether,41,49
distortions.7,8,26,27,46-51,53-58 Sixteen studies measured the and 1 study has reported a preference for polyether.7 A
amount of angular change of the implant or abutment recent study reported that polyether was more accurate
long axis, and 1 study measured the amount of implant than polyvinyl siloxane in the parallel location of im-
head rotation around the long axis.55 Eight studies were plants and that polyvinyl siloxane was more accurate
included in the previous review,16 and the other 9 studies than polyether in the nonparallel location of implants.32
were published after the review. Five studies investigated the effect of implant paral-
Ten studies measured the gap distance between the lelism on impression accuracy.8,13,51,57,58 Before the pre-
cylinders in the master framework, which was fabricated vious review, 1 study advocated the parallelism of
to fit as passively as possible on the master model, and implants,8 and another study57 reported no difference in
the implant (abutment) head in test models.14,24,59-66 accuracy based on the parallelism or nonparallelism of
One study was published before the previous system- implants. Since the review, 2 studies have advocated
atic review,16 and 9 studies were published between 2008 parallel implants,51,58 but another study has reported no
and February 2013. difference in accuracy between parallel and nonparallel
Four studies compared the amount of strain produced implants.13
in the master framework.28,29,67,68 Strain gauges were One study compared the accuracy of definitive casts
attached to the master framework, which was passively fabricated by conventional or digital impression tech-
fitted when possible on the master model. All the studies niques.17 The study concluded that conventional non-
were reported before the previous systematic review,16 splinted pick-up produced more accurate definitive casts
and no study published since met the inclusion criteria than digital impression. Kwon et al54 compared the
for the present systematic review; therefore, recent re- accuracy of implant impression with or without im-
searchers seemed to have little preference with regard to pression copings and concluded that implant impression
the use of the master framework with strain gauges to without copings was less accurate than direct impression
assess the accuracy of implant impression techniques. technique.
Twenty-two studies compared the effects of splinting Among 56 studies included in this review, more than
or different splinting materials on the accuracy of implant 80% compared the accuracy of implant impressions using
EXT, external type implant/abutment connection; INT, internal type implant/abutment connection; AAR, autopolymerizing acrylic resin; LCR, light-polymerizing composite resin; CS, condensation
type silicone; AS, addition type silicone; IP, impression plaster; PE, polyether; LD, linear distortion; AD, angular distortion; GAP, gap distance between master framework and replicas in exper-
imental models; STRAIN, amount of strain introduced in master framework.
*Six implants were placed in master model but divided into 2 groups (n=3).
†
Eight implants were placed in master model but divided into 2 groups (n=4) for comparison.
nonsplinting versus splinting with different splinting vice versa, determining which impression technique is
techniques, direct versus indirect techniques, and more accurate is difficult. Therefore, many studies have
impression materials. Less than 20% of studies compared also assessed the total amount of 3-dimensional
the accuracy of parallel versus nonparallel implants or displacement (Dr) to determine which impression tech-
between implant/abutment connection types (external or nique is more accurate. The second method determines
internal). the degree of accuracy by measuring the linear distance
(in a single plane) between 2 centroids of implant or
abutment heads. Even though this method cannot detect
DISCUSSION
the translational rotation of the implant body or long
The current systematic review analyzed relevant studies axis, it is still considered a simple and intuitive means of
of the accuracy of implant impression techniques. This assessing the accuracy of different impression techniques.
review not only summarized the results of the included The third method is a modified version of the second and
studies, but also classified the studies according to the is a very simple method of determining the interimplant
assessment methods used to understand the benefits and distance; practically, however, it is difficult to locate cal-
limitations of each study. ipers at the same positions of implants. This method has
The amount of linear distortion was the most not been reported since the previous systematic review.16
frequently used method of evaluating the accuracy of The fourth method was used by only 1 research group,50
implant impressions. The studies included in this sys- who measured the closest distance between implant long
tematic review used one of 4 different evaluation axes to compare impression techniques. This method
methods to measure the amount of linear distortion: the cannot detect translational or axial rotation of implants,
amount of 3-dimensional displacement of the centroids and the implant position (especially the head position)
of implant or abutment heads (Dx, Dy, Dz), the change in can be displaced without changing the closest distance
linear distance (Dr, Dr2 = Dx2 + Dy2 + Dz2) between the between the interimplant long axes. Therefore, the re-
centroids of implant or abutment heads, the distance searchers also measured changes in the angles between
between 2 reference points (the outer surfaces between the implant axes and combined the results with the
the implant heads), and the closest distance between the closest distance between them.
long axes of implants. Angular distortion can be classified into 2 categories:
Displacement of the implant or abutment head po- rotation of the implant head around the implant long axis
sition is the most important factor for evaluating the and translational rotation of the implant long axis to a
accuracy of an implant impression, thus evaluating the specific reference axis or plane. The XY, YZ, and ZX
amount of displacement of each implant or abutment planes were frequently chosen as the reference plane,
centroid in X, Y, and Z axes appears to be the most logical with the amount of angular change described as dqXY,
assessment method to measure the amount of linear dqYZ, and dqZX, respectively. When a specific implant or
distortion. However, this method has an inherent limi- replica was chosen as a reference axis, the angles be-
tation. When an impression technique results in greater tween the reference axis and the long axes of the im-
displacement in the X-axis direction (Dx) but less plants were measured, and the difference in value
displacement in another axis (Dy or Dz) than the other between the measurements made before and after the
impression technique used in the same investigation or impression procedure was regarded as the angular
Table 2. Articles that were not included in the study after full text distal prosthetic screw of the master framework, a slight
reading angular displacement of a distal implant or abutment head
Reason for Exclusion Year can produce an exaggerated opposite side gap. Further-
Less than 3 implants more, identifying which specific implant or abutment
Carr et al 1992
replica was displaced the most was difficult.
Inturregui et al 1993
Implant/abutment connection types are simply clas-
Bartlett et al 2002
sified as external or internal connections. Of the 20 in-
Burns et al 2003
Bambini et al 2005
vestigations published since the previous review,16 14
Cabral et al 2007
studies6,7,13,19,26,30,32,33,40,42,49,50,52,53 used internal con-
Assuncao et al 2008 nection implants, reflecting the popularity of internal
Assuncao et al 2008 connections in contemporary implant dentistry. Sorren-
Assuncao et al 2008 tino et al32 evaluated the effect of implant alignments
Lee et al* 2008 (parallel versus nonparallel) and coping engagement
Wostmann et al 2008 lengths (1 mm versus 2 mm) in internal connection im-
Filho et al 2009 plants. They reported that more accurate casts were
Lee et al 2009 produced when the implants were parallel rather than
Assuncao et al 2010 nonparallel alignments and that short engagement
Alikhasi et al 2011 length produced more accurate results when the im-
Jang et al 2011 plants were not parallel. Mpikos et al51 reported that
Rutkunas et al 2012
neither impression technique nor implant parallelism
Tarib et al 2012
influenced the impression accuracy in external connec-
Howell et al 2013
tion implants, but the accuracy was significantly influ-
Not a laboratory study
Jemt et al 1999
enced by the implant parallelism in internal connection
Papaspyridakos et al 2012
implants. Most internal connection implants have longer
Lack of information or broader implant/abutment connections than external
Schmitt et al 1994 connection implants. The longer or broader connection
Not a comparison of impression techniques area can cause displacement of the impression copings
Lechner et al 1992 during the removal of the impression tray, exaggerating
Vigolo et al 1993 the amount of distortion in nonparallel implant align-
Wee et al 1998 ments. In addition to the longer or broader connection
Cranin et al 1998 area, there is a special consideration for internal
May et al 1999 connection implants. Greater vertical distortion (Dz)
Wee et al 2002 resulted in a more retentive coping design rather than a
Castilho et al 2007 coping design with less retentive form.53
Review article
However, the study ignored an important difference
Lee et al 2008
other than the retentive designs of impression copings.
Not a comparison between impression techniques
Internal connection is further divided into internal
Del Corso et al 2009
Stimmelmayr et al 2012
hexagon and internal conical connections,69 and a
Ono et al 2012
certain amount of axial displacement is inevitable in
*Five implants were placed in the master model but only 2 implants were used for each
internal conical connection implants during tightening
comparison. procedures.70,71 The less retentive copings were used
for internal hexagon connections, whereas the more
distortion. The majority of the angular distortion studies retentive copings were used for internal conical
used a coordinate measuring machine or similar equip- connection implants. Even if clinicians try to use the
ment to measure the rotations. same amount of tightening force during impression
Before the previous systematic review, only 1 study procedures, internal conical connections have a greater
had compared impression accuracy by measuring the gap chance of vertical displacement than internal hexagon
between the master framework and the implant (replica) or external hexagon connections. Unlike for external
head.24 Since then, 9 studies included in the present re- hexagon implants, the results of splinting copings in
view have measured the gap distance between the master internal connection implants were inconsistent. Vigolo
framework and the implant head,14,59-66 a measuring et al72 reported that more accurate results were ob-
technique apparently popular among investigators. tained with splinted rather than nonsplinted pick-up
However, 4 of the 9 studies were published by the same techniques, but Ongul et al52 reported no signifi-
research group.59,60,64,66 This assessment method has 1 cant difference between nonsplinted and splinted
major disadvantage. Because investigators tightened each pick-up techniques for 6 implants with buccal
angulations. The former study used internal hexagon 3. Sahin S, Cehreli MC. The significance of passive framework fit in implant
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J Dent Tech 2001;18:23-5.
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compared with a resin splinted pick-up impression Evaluation of the accuracy of solid implant casts. J Prosthodont 1998;7:161-9.
technique for an experimental model with 5 implants. 12. Wee AG, Cheng AC, Eskridge RN. Accuracy of 3 conceptually different die
systems used for implant casts. J Prosthet Dent 2002;87:23-9.
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Corresponding author:
53. Rashidan N, Alikhasi M, Samadizadeh S, Beyabanaki E, Kharazifard MJ.
Accuracy of implant impressions with different impression coping types and Dr Sunjai Kim
shapes. Clin Implant Dent Relat Res 2012;14:218-25. Gangnam Severance Dental Hospital
54. Kwon JH, Son YH, Han CH, Kim S. Accuracy of implant impressions without Eonju-ro 211, Gangnam-gu
impression copings: a three-dimensional analysis. J Prosthet Dent 2011;105: Seoul 135-270
367-73. KOREA
55. Liou AD, Nicholls JI, Yuodelis RA, Brudvik JS. Accuracy of replacing three Email: sunjai@yuhs.ac
tapered transfer impression copings in two elastomeric impression materials.
Int J Prosthodont 1993;6:377-83. Copyright © 2015 by the Editorial Council for The Journal of Prosthetic Dentistry.
APPENDIX
Supplemental Table 1. Articles that were not included in study after full text reading
Articles
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Burns J, Palmer R, Howe L, Wilson R. Accuracy of open tray implant impressions: an in vitro comparison of stock versus custom trays. J Prosthet Dent 2003;89:250-5.
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Stimmelmayr M, Guth JF, Erdelt K, Edelhoff D, Beuer F. Digital evaluation of the reproducibility of implant scanbody fitean in vitro study. Clin Oral Invest 2012;16:851-6.
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