ORIGINAL CONTRIBUTIONS
ARTICLE 2
The quality of fixed prosthodontic
impressions
An assessment of crown and bridge impressions received
at commercial laboratories
Clayton T. Rau, DDS, MS; Vilhelm G. Olafsson, DDS, MS;
Alex J. Delgado, DDS, MS; André V. Ritter, DDS, MS, MBA;
Terry E. Donovan, DDS
T
he transfer of accurate records to the dental
laboratory is an important part of prosthesis
fabrication in fixed prosthodontics. Obtaining
an optimal gingival displacement and an ideal
impression for a fixed dental prosthesis is still 1 of the
most challenging procedures in dentistry.1,2 Although
many steps must be taken to fabricate an indirect
restoration during which an error can occur, the tech-
nician can be expected to produce a quality restoration
only if the impression is of adequate quality. All den-
tists must possess the ability to identify and analyze the
quality of impressions because this ultimately will
determine success of the restoration.3
Accurate transfer of records requires a general un-
derstanding of soft- and hard-tissue anatomy, especially
in the area of the cervical finish line. Practitioners also
need to understand how to select and manipulate
gingival displacement and impression materials.3-8
Results from numerous studies demonstrate improve-
ments in handling and accuracy of modern impression
materials.6,9 However, despite these improvements, the
quality of impressions sent to laboratories for fabrica-
tion of indirect restorations apparently has remained
inadequate.3,8,10-13
Relationships between dentists and laboratories tend
to be less than ideal and often are relatively short
This article has an accompanying online continuing education activity
available at: http://jada.ada.org/ce/home.
Published by Elsevier Inc. on behalf of the American Dental
Association.
654 JADA 148(9) http://jada.ada.org September 2017
ABSTRACT
Background. The authors evaluated and quantified
clinically detectable errors commonly seen in impressions
sent to commercial laboratories and determined possible
relationships between finish line errors and other factors
involved.
Methods. The authors visited 3 large and 1 small com-
mercial dental laboratories over a 12-month period. Three
calibrated examiners evaluated the impressions. The exam-
iners evaluated all impressions for errors by using
2.5
magnification loupes under ambient room lighting without
the aid of additional illumination.
Results. The authors evaluated 1,157 impressions; 86% of
the examined impressions had at least 1 detectable error, and
55% of the noted errors were critical errors pertaining to the
finish line. The largest single error categories evaluated were
tissue over the finish line (49.09%), lack of unprepared stops
in dual-arch impressions (25.63%), pressure of the tray on
the soft tissue (25.06%), and void at the finish line (24.38%).
The factors blood on the impression (odds ratio, 2.31;
P < .001) and tray type (odds ratio, 1.68; P < .001) were
associated significantly with finish line errors.
Conclusions. Marginal discrepancies made up the largest
category of error noted in impressions evaluated. The au-
thors noted an increase in errors at the finish line with dual-
arch impression techniques and in the presence of blood.
Practical Implications. Dentists have ethical, moral, and
legal obligations bestowed on them by the profession and
need to evaluate critically the work they send to laboratories.
The authors strongly recommend an improvement in tech-
nique and reviewing of all impressions and working casts.
Key Words. Laboratories; dental; impression material;
restorative dentistry; fixed prosthetics.
JADA 2017:148(9):654-660
http://dx.doi.org/10.1016/j.adaj.2017.04.038
 ORIGINAL CONTRIBUTIONS

term.14 Results of a survey of 4 TABLE 1

commercial dental labora- Unacceptable criteria descriptions and frequencies.
tories in 1997 showed that
36% of the 290 impressions CRITERION DESCRIPTION OF ERROR FREQUENCY,
8 NO. (%)
evaluated had visible defects.
Finish Line, Void or Bubble Any detectable void on the cervical finish line of a 282 (24.38)
Two years later, results of preparation
another study showed the Finish Line, Lack of Wash Cervical finish line recorded in heavy body or putty material 60 (5.19)
quality of 50% of impressions Material with no wash above or below the finish line; monophase
and dies to be unsatisfactory excluded from error
or unusable.15 In 2005, results Tray, Inadequate Retention Impression material pulling away from tray or not engaging 30 (2.60)
of Material tray retention features
of an evaluation of 193 im-
Tray, Pressure of Tray on Vertical tray flanges exposed by displacement of 290 (25.06)
pressions from 11 laboratories Soft Tissue impression material; any occurrence within 2 teeth of
showed 89% of all impres- preparations or on the preparations
sions to have at least 1 Tray, Show Through of Horizontal tray areas exposed by displacement of 201 (17.38)
appreciable error.3 This raises Occlusal or Incisal Edges impression material; any occurrence within 2 teeth of
preparations or on the preparations
a question: If impression
Material, Inadequate Lack of complete fusion between body and wash materials 121 (10.46)
materials are improving Fusion of Viscosity
constantly, why are impres- Material, Void on Voids not located on the finish line greater than 1 154 (13.32)
sions actually getting worse? Preparation millimeter
Although differences exist Gingival Displacement, Lack of flash beyond the cervical finish line, detected by 568 (49.09)
between materials, all require Tissue Over Finish Line change of reflection or visible horizontal bur marks on the
preparation for ill-defined margins
optimum technique in soft-
Gingival Displacement, Blood, coagulant, or any foreign materials around the 176 (15.22)
tissue displacement, proper Blood on Impression cervical finish line
placement of the material Dual Arch, Lack of No thinning of impression material over occlusal contacts; 61 (8.50)
around the preparation, and Maximum Intercuspal detected by holding impression against light source
correct use of available Position*
2 Dual Arch, Unprepared Lack of unprepared teeth anterior and posterior to the 256 (25.63)
impression trays. One of the Stops† preparations
major causes of unacceptable
Dual Arch, Canine Lack of registering the complete maxillary and mandibular 135 (13.51)
impressions is poor gingival Recorded† canine teeth
3,8,13
displacement. Another of * Data for lack of capture of maximum intercuspal position is for dual-arch trays only (n ¼ 718).
the major causes of unaccept- † Data for an error in recording the canine and unprepared teeth anterior or posterior to the abutments
include both sectional dual-arch trays and single-arch trays because the same principles apply to both
able indirect restorations is from a laboratory standpoint (n ¼ 999).
lack of understanding of the
principles of impression mak-
ing and understanding of what constitutes an acceptable partial dentures, and implant abutments. We evaluated
impression.7 Proper manipulation of the impression ma- impressions immediately after a standard disinfection
terial is arguably more important in determining the final protocol but before any other processing had been
accuracy of the impression than any characteristic of the completed. When multiple abutments were impressed,
material itself.6,9,16 On the basis of personal communica- we scored a defect on any abutment as a defect for the
tion with laboratory owners, many technicians claim they entire impression. If impressions had been poured with
are noticing a decrease in the quality of work they have stone before being evaluated, we excluded them from the
been receiving over the years. The purpose of this study study population. We made no attempts to identify the
was to evaluate clinically detectable errors commonly seen dental offices from which the impressions originated;
in impressions for fixed prosthodontic restorations sent therefore, our study qualified for exemption from the
to commercial laboratories, determine their frequency, Institutional Review Board of the University of North
and determine possible relationships between finish line Carolina at Chapel Hill (exemption 14-2040).
errors and other examined factors. Three examiners (C.T.R., V.G.O., A.J.D.) were cali-
brated by inspecting 10 impressions rejected from the
METHODS University of North Carolina Dental School student
Over a 12-month period from October 2013 through clinics as being unacceptable for fixed dental prosthesis
October 2014, we visited 3 large commercial dental lab- fabrication. After initial evaluation, the examiners
oratories and 1 small dental laboratory8 known to receive discussed errors they noted and established criteria
fixed prosthodontic impressions. We evaluated all im- (Table 1). We did not analyze the calibration statistically
pressions for conventional fixed dental prostheses because each listed error was objectively identifiable
received at these facilities on the days visited. We and agreed on by all examiners.3,8 All impressions were
excluded impressions for veneers, resin-bonded fixed evaluated by 1 of 3 calibrated examiners according to

JADA 148(9) http://jada.ada.org September 2017 655

 ORIGINAL CONTRIBUTIONS

C.T.R.
Impression Materials on Fixed Prosthodontics
V.G.O.
Lab #______
A.J.D.

Type of tray used:

Metal stock Plastic stock Custom Plastic dual arch Metal dual arch

Size of tray used:

Anterior quadrant Posterior quadrant Full arch

Errors in the finish line:

Voids or bubbles Lack of wash material

Errors in the tray or material:

Inadequate retention Pressure of tray on soft tissue Inadequate fusion of viscosity

Lack of polymerization Void on the preparation Show through of occlusal or incisal edges

Cotton roll attached

Errors with gingival displacement or hemostasis:

Retraction cord attached Tissue over finish line Blood on impression

Errors in dual arch technique

Lack of MIP Unprepared stops present Canine recorded

Restoration requested

PFM Full cast gold Zirconia based Lithium disilicate Other

Die requested for trimming

Figure 1. Impression evaluation form. MIP: Maximum intercuspal position. PFM: Porcelain fused to metal.

an impression evaluation form (Figure 1) for errors by
using
2.5 magnification loupes under ambient room
lighting without the aid of additional illumination.
For each impression examined, we noted type of tray
used, sectional or full-arch tray, type of prosthesis ordered,
errors involving the abutment finish line, errors in tray or
material use, errors with soft-tissue management, and errors
in dual-arch impression technique. We made no attempts to
identify the cause of noted errors in each impression eval-
uated. Figures 2 through 4 depict examples of unacceptable
errors. We defined critical errors as any factor affecting the
finish line, specifically tissue over the finish line and finish
line voids or bubbles. We made no attempts to evaluate the
casts fabricated, restorations fabricated, or complaints
or remakes with specific regard to these impressions.
Statistical analysis. The purpose of the statistical
analysis was to describe the frequencies of each factor
evaluated and assess whether a critical error of the finish
line was associated with any of the factors evaluated. We
performed a c2 test of independence to examine the
relationship between each evaluated factor and critical
error occurrence. We combined some data because low
values in certain variables prevented further data analysis
(for example, plastic and metal dual-arch trays combined
into 1 dual-arch category). We repeated the c2 test for
the newly established variable groups. We further sub-
jected items that showed significance in the c2analysis to
a multiple logistic regression analysis. We then calculated
odds ratios for all pairwise comparisons within each
significant variable.

656 JADA 148(9) http://jada.ada.org September 2017

 ORIGINAL CONTRIBUTIONS

TABLE 2
Frequency of restorations requested.
RESTORATION REQUESTED FREQUENCY, NO. (%)
Porcelain Fused to Metal 398 (34.40)
Zirconia Based 448 (38.72)
Lithium Disilicate 185 (15.99)
Full-Cast Gold 73 (6.31)
Other 12 (1.04)
Not Stated 4 (0.35)
Die Requested for Trimming 37 (3.20)
Total 1,157

Figure 2. Representative impression showing finish line voids. TABLE 3

Frequency of type of impression tray
used.
TRAY TYPE FREQUENCY, NO. (%)*
Custom 2 (0.18)
Metal Dual Arch 185 (15.99)
Metal Single Arch 10 (0.86)
None 1 (0.01)
Plastic Dual Arch 535 (46.24)
Plastic Single Arch 424 (36.64)
Total 1,157
* Percentages do not total 100 because of rounding.

noted were tissue over the finish line (49.09%), lack of

Figure 3. Representative impression showing pressure of the tray on
the soft tissue adjacent to the abutment tooth, as well as on the abut-
ment tooth.
Figure 4. Representative impression showing failure of recording the
finish line because of inadequate gingival displacement methods.
RESULTS
We evaluated 1,157 impressions. Table 1 shows the fre-
quencies of errors. Overall, an error was noted in 86% of
the examined impressions. The most common errors
unprepared stops in dual-arch impressions (25.63%),
pressure of the tray on the soft tissue (25.06%), finish line
void or bubble (24.38%), and showing through of occlusal
or incisal edges (17.38%). When we combined voids at the
preparation finish line and tissue over the finish line to
establish a critical error rate, the resultant error rate was
55%. We did not report data for cotton rolls and
retraction cord because the laboratory personnel
removed these items from the impression before cast
fabrication. We noted only 1 incidence of lack of poly-
merization (not listed in Table 1).
Table 2 shows the frequency of prostheses ordered.
The 2 predominant prostheses types requested were
zirconia oxide–based restorations (38.72%) and
porcelain-fused-to-metal restorations (34.39%). Zirconia
oxide–based restorations included monolithic zirconia
and porcelain fused to zirconia. Only 3.2% of practi-
tioners requested their dies be returned for the practi-
tioner to trim and mark finish lines.
Table 3 shows data for the type of impression trays
used to make the impression. A large portion of the
impression trays used were plastic (82.88%), and the
dual-arch impression technique was the most commonly
used method among practitioners (62.23%).
The c2 analysis yielded significant (P < .05) differences
in finish line error for preparation void, occlusal show

JADA 148(9) http://jada.ada.org September 2017 657

 ORIGINAL CONTRIBUTIONS
through, blood on the impression, prosthesis requested,
sectional or full-arch tray, and tray type. The multiple
logistic regression test was statistically significant (P <
.001), and each of the following factors was statistically
significant: blood, tray type, and type of restoration
requested.
Considering the comparison of the tray types, the
likelihood of a critical error versus a noncritical error for
dual-arch trays was approximately 1.68 times (95% con-
fidence interval [CI], 1.32 to 2.13) more likely than that for
single-arch trays. Considering the factor of blood, the
likelihood of a critical error versus no critical error for
blood present was approximately 2.31 times (95% CI, 1.67
to 3.18) more likely than that for blood absent. In the case
of the restorations ordered, we observed significant odds
ratio estimates only for the comparison of die and
porcelain-fused-to-metal restorations and of die and
zirconia-based restorations. The likelihood of critical
error versus no critical error for die requested was
approximately 0.38 times (95% CI, 0.18 to 0.77) less likely
than for porcelain-fused-to-metal restorations, whereas
the likelihood of a critical error versus no critical error
for die requested was approximately 0.37 times (95% CI,
0.18 to 0.76) less likely than for zirconia-based
restoration.
DISCUSSION
The ability of the dentist to self-evaluate the quality of
recorded impressions is a demanding yet essential step
for the clinical success of restorations. Numerous factors
must be considered when making a definitive impres-
sion, and each of these must be considered separately to
obtain an acceptable result accurately. In this study, we
aimed to evaluate the quality and association of errors
observed in impressions sent to 4 commercial labora-
tories in North Carolina and South Carolina in the
United States for conventional fixed dental prostheses.
This study’s results showed that 86% of impressions
sent to the participating dental laboratories had at least 1
detectable error. These findings are in agreement with
those of previous studies.3,8,13,15,17 However, they are in
contrast to the findings of a study by Beier and col-
leagues1 in which 3% of impressions were unacceptable.
In the latter study, “experienced dental clinicians”
recorded impressions with proper gingival displacement
and moisture control. This careful attention to detail
might be the reason for the low failure rate but may not
be a representation of private practices.3,8,13,15,17 In our
study, the cervical finish line area had at least 1 detectable
error in 55% of the impressions evaluated, a finding
consistent with those of other studies.3,8,13,15,17 Accurate
impressions of the finish lines can be expected only with
proper gingival displacement, finish line placement, fin-
ish line design, and moisture control.
Fifteen percent of impressions were visibly soiled with
blood, providing a source of potentially infectious
658 JADA 148(9) http://jada.ada.org September 2017
material. The presence of blood on the impression was
associated with an increase in the probability of an error
on the cervical finish line (odds ratio, 2.31; P < .001).
Investigators repeatedly have found that moisture affects
the accuracy of all elastomeric impression materials.18-21
The practitioner should place a retraction cord to
minimize trauma to the gingiva during preparation,
and optimal tissue health should be obtained before
attempting any preparation or impression proce-
dure.4,5,22-26 Sorensen and colleagues24 described a
method of using 0.12% chlorhexidine gluconate rinse to
optimize tissue health before fixed prosthodontic pro-
cedures that many other authorities also recommend.
Inadequate gingival displacement and isolation likely
are responsible for the poor record of cervical finish lines.
In addition, other factors, including sulcular width,
duration the retraction cord was left in the sulcus, and
nonwetting of the retraction cord before removal, pro-
duced poor recording of cervical finish lines. Laufer and
colleagues27,28 demonstrated that a sulcular width of less
than 0.2 millimeters resulted in an increased incidence of
voids along the finish line and greater probability of
distortion. Finger and colleagues29 also showed that,
irrespective of the type of material, a 0.2-mm sulcus is
fully reproduced, and the combination of light body
wash materials with higher viscosity tray material pro-
duced more accurate sulcus reproduction than did
monophase impression techniques. Some advocate that if
a sulcus width of 0.2 mm is required, then the clinician
should aim to open the crevice at least 0.3 to 0.4 mm.7 To
obtain the critical sulcular width of 0.2 mm that will
remain present for up to 20 seconds after cord removal,
Baharav and colleagues30 found that the retraction cord
needs to be left in place for a minimum of 4 minutes.
Numerous authors recommend thoroughly wetting
the retraction cord before removal from the sulcus.4,22,31
When the cord is not wetted properly before removal, it
will result in traumatic damage to the gingival epithelium
and induce hemorrhage, negating most of the effects of
the hemostatic treatment.31
Plastic stock trays (82.8%) were the most widely used
impression trays, which is an increase from findings in
previous reports.3,8,13,17 The widespread use of these trays
may be related to their low cost or lack of dentist
knowledge about their shortcomings and limitations.3
Trays should be as rigid as possible to resist deformation
from pressure both during the impression-making pro-
cess and after removal from the mouth. Many clinicians
choose materials of higher viscosity under the assump-
tion that they will compensate for the added volume
needed when using stock plastic trays and that these
more rigid materials will resist distortion. This is an
incorrect assumption; study results have shown that
more rigid polyvinyl siloxane materials actually result in
an increase in flexure of the trays and marginal opening
of restorations.17,32 If impression materials of higher
 ORIGINAL CONTRIBUTIONS
viscosity induce marked distortion in impressions, then
contact with the soft and hard tissues certainly results in
increased tray flexure.33 This observation was found in
25.2% of impressions evaluated in this study.
Dual-arch impression trays accounted for 62.2% of
impressions received at the commercial laboratories.
These are designed to obtain simultaneously an
impression of the prepared teeth, the opposing dentition,
and the intercuspal relationship while using less material
than do traditional full-arch impressions.34 The dual-
arch impression technique is faster, is more comfortable,
uses less material, and is preferred by 80% of patients.34
They are, however, not without limitations for use. The
indications and requirements for their accurate use are a
maximum of 2 prepared teeth; unprepared stops both
anterior and posterior to the preparations; stable,
reproducible intercuspal position; the ability of the pa-
tient to close into maximum intercuspal position with
the tray in place; existing anterior guidance; the canine
being recorded in the impression; the tray not impinging
on any teeth or soft tissue; and the provider being
familiar with the procedures being performed.6,7,35-37
When used correctly, the dual-arch technique can pro-
vide clinically acceptable restorations, with a cost and
time saving to the dental practitioner.34,38-45 Our data
show that more than one-third of dual-arch impressions
violated at least 1 of these limitations, and we noted a
significant correlation between finish line errors and the
use of dual-arch trays.
Practitioners who requested their master casts be
returned for die trimming and finish line marking had
substantially better impressions than did providers who
requested the laboratory perform all procedures. This
is perhaps because these practitioners must see the
result of their impressions and take the additional steps
needed to ensure quality of work.
The amount of erroneous impressions sent to labo-
ratories in this study is alarming, with approximately
one-half of them having errors pertaining to the finish
line. This finding highlights the importance of operators
self-assessing their work before sending it to the
laboratory, even in cases in which steps in the
impression sequence have been delegated to auxiliary
staff members. On the basis of the data presented here,
soft-tissue management and proper gingival displace-
ment methods would be timely topics to address in
continuing education. Even with intraoral scanners
becoming increasingly popular, proper soft-tissue
management and gingival displacement are no less
critical in obtaining an accurate scan. Future studies on
the accuracy of digital scans sent to laboratories might
be of value.
We made no attempt to evaluate the quality of dies or
restorations made from the impressions evaluated. All
laboratories in this study verified that they contact
dentists and ask how they wish to proceed in the event a
faulty impression is received. Many times, the dentist will
ask the laboratory to proceed with processing the
restoration and will estimate the finish lines as best they
can. Anecdotally, the laboratory remake rate is between
3% and 4% (personal communication with laboratories
involved in this study) compared with the 86% of im-
pressions containing errors.
CONCLUSIONS
Within the limitations of this study, finish line discrep-
ancies made up the largest category of error noted in
impressions (49.09%), and the selection of simplified
impression techniques, such as dual-arch impression
trays, appears to increase the risk of producing critical
errors. Dentists have ethical, moral, and legal obligations
bestowed on them by the profession and need to evaluate
critically the work they send to laboratories. We strongly
recommend an improvement in technique and reviewing
of all impressions and working casts. n
Dr. Rau is the general dentistry department head, Lieutenant Commander,
United States Navy Dental Corps, 2nd Dental Battalion, PSC BOX 20130,
Camp Lejeune, NC 28542-0125, e-mail clayton.t.rau.mil@mail.mil. Address
correspondence to Dr Rau.
Dr. Olafsson is an assistant professor, Department of Operative Dentistry,
Faculty of Odontology, University of Iceland, Reykjavík, Iceland; and an
adjunct assistant professor, Department of Operative Dentistry, School of
Dentistry, University of North Carolina at Chapel Hill, Chapel Hill, NC.
Dr. Delgado is a clinical assistant professor and the interim director,
Division of Operative Dentistry, Department of Restorative Dental Science,
College of Dentistry, University of Florida, Gainesville, FL.
Dr. Ritter is a professor and the chair, Department of Operative Dentistry,
School of Dentistry, University of North Carolina at Chapel Hill, Chapel
Hill, NC.
Dr. Donovan is a professor and the director, Biomaterials, Department of
Operative Dentistry, School of Dentistry, University of North Carolina at
Chapel Hill, Chapel Hill, NC.
Disclosure. None of the authors reported any disclosures.
ORCID Number. Vilhelm Olafsson: http://orcid.org/0000-0002-9372-8003.
The authors thank the dental laboratories that made this study possible.
Because of conflict of interest with their clients, these laboratories would like
to remain anonymous.
The views expressed in this presentation are those of the authors and do
not necessarily reflect the official policy or position of the US Department of
the Navy, US Department of Defense, or the US government.
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