Ti based implant crowns

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Labslip

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I do a ton of lithium disilicate and maybe that's where my angst is with ti-bases.
I assume the lithium disilicate is being pressed rather than milled. If so, the narrow chimney of a ti base can be difficult to invest without bubbles (at least in my hands). A custom abutment would be preferred. Bubbles aren't a concern when milling out of zirconia. My personal preference is a ti base.
 
Jack_the_dentureman

Jack_the_dentureman

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I assume the lithium disilicate is being pressed rather than milled. If so, the narrow chimney of a ti base can be difficult to invest without bubbles (at least in my hands). A custom abutment would be preferred. Bubbles aren't a concern when milling out of zirconia. My personal preference is a ti base.
I will continue the off topic.
! to fill small holes, pass a wire of appropriate thickness through them. after flooding, slowly pull out the wire that will pull up the vest material
 
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Labslip

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to fill small holes, pass a wire of appropriate thickness through them. after flooding, slowly pull out the wire that will pull up the vest material
Great technique, or you can mill it out of zirconia and not worry about the bubbles or the technique.
 
rkm rdt

rkm rdt

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Ti bases are great when you want to undercut the other guy on price.
 
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Labslip

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Original manufacturer ti bases retail in our lab in the neighborhood of $200. We use original manufacturer parts on all cases unless our customers specifically request otherwise.
 
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Labslip

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Having said that, there are, of course, tons of lower cost ti base options if that's your jam. Significantly lower cost.
 
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drguzman

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I hate ti-bases, the cheap [email protected] way of doing implants in my opinion (no support, no retention, no emergence, etc...). I haven't done a ti-base in 10 years and do about 600 implants/year. Educate your Docs, custom titanium abutments are what should go on implants.
I agree with you that a custom abutment is a superior way of restoring an implant. Personally, it is the only way I do it.

There is a great article from Heitz-Mayfield et al, "Clin Oral Impl Res 2020,31:397-403" called Implant Disease Risk Assessment IDRA- a tool for preventing peri-implant disease. I've gone over it with our hygienists (Perio office),and it enables them to quickly assess how things could go south for a patient. It has a graph that looks like a spider web, and many categories that put a patient at risk of peri-implantitis. One of those categories is RM-Bone, which is Restorative Margin to Bone distance. When it is less than 1.5mm, they are at high risk/red area, when it is more than 1.5mm they are in the moderate or yellow area, and when the restorative margin is at tissue level they are in the green or no risk zone.

In the references there is a great peri-implantitis study from sweden (paid by the swedish government, giving the researchers true freedom of science, and no pressure of any implant company) Derks 2016, Journal of Dental Research, "Effectiveness of Implant Therapy Analyzed in a Swedish Population", It followed 588 patients, over a 9 year period.

From page 47 "Patients with periodontitis and with 4 or more implants, as well as implants of certain brands and prosthetic therapy performed by general practitioners, exhibited higher Odds Ratio for moderate/severe peri-implantitis. Similarly higher Odds Ratios were identified for implants installed in the mandible and with crown restoration margins positioned at 1.5mm or closer from the crestal bone at baseline. "

Warning: Personal Opinion below..

From my limited experience and in my opinion, there is a better biological environment when tissue is in contact with sterile/clean titanium, than when there is any kind of ceramics close to bone/connective tissue.

I frequently see, when removing healing abutments (which please tell your doctors to only use a new healing abutment) small spots of bleeding, which come from ripping off the hemidesmosomal attachment from the tissues to the clean titanium surface(no odors noted),suggesting a better barrier from the oral environments than that seen when removing a crown on a ti-base (odors frequently noted).

If you think of the "cement gap" setting you are all using, as tight as it might be, 20microns is plenty for bacteria to colonize. There will be some microscopically rough cement at that crown/abutment interface. Wouldn't it be nicer to have that 3-4mm away from bone? just food for thought.

Some general practitioners might dismiss an article that shows if a general dentist is delivering the case the risk of peri-implantitis is higher, but I hope you will all find a nicer way of presenting the idea to your doctors than hitting them straight with data & science. :)

-Luis Guzman. Prosthodontist/Board Certified Periodontist/Amateur digital technician ;)
 
Davor RDT

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I agree with you that a custom abutment is a superior way of restoring an implant. Personally, it is the only way I do it.

There is a great article from Heitz-Mayfield et al, "Clin Oral Impl Res 2020,31:397-403" called Implant Disease Risk Assessment IDRA- a tool for preventing peri-implant disease. I've gone over it with our hygienists (Perio office),and it enables them to quickly assess how things could go south for a patient. It has a graph that looks like a spider web, and many categories that put a patient at risk of peri-implantitis. One of those categories is RM-Bone, which is Restorative Margin to Bone distance. When it is less than 1.5mm, they are at high risk/red area, when it is more than 1.5mm they are in the moderate or yellow area, and when the restorative margin is at tissue level they are in the green or no risk zone.

In the references there is a great peri-implantitis study from sweden (paid by the swedish government, giving the researchers true freedom of science, and no pressure of any implant company) Derks 2016, Journal of Dental Research, "Effectiveness of Implant Therapy Analyzed in a Swedish Population", It followed 588 patients, over a 9 year period.

From page 47 "Patients with periodontitis and with 4 or more implants, as well as implants of certain brands and prosthetic therapy performed by general practitioners, exhibited higher Odds Ratio for moderate/severe peri-implantitis. Similarly higher Odds Ratios were identified for implants installed in the mandible and with crown restoration margins positioned at 1.5mm or closer from the crestal bone at baseline. "

Warning: Personal Opinion below..

From my limited experience and in my opinion, there is a better biological environment when tissue is in contact with sterile/clean titanium, than when there is any kind of ceramics close to bone/connective tissue.

I frequently see, when removing healing abutments (which please tell your doctors to only use a new healing abutment) small spots of bleeding, which come from ripping off the hemidesmosomal attachment from the tissues to the clean titanium surface(no odors noted),suggesting a better barrier from the oral environments than that seen when removing a crown on a ti-base (odors frequently noted).

If you think of the "cement gap" setting you are all using, as tight as it might be, 20microns is plenty for bacteria to colonize. There will be some microscopically rough cement at that crown/abutment interface. Wouldn't it be nicer to have that 3-4mm away from bone? just food for thought.

Some general practitioners might dismiss an article that shows if a general dentist is delivering the case the risk of peri-implantitis is higher, but I hope you will all find a nicer way of presenting the idea to your doctors than hitting them straight with data & science. :)

-Luis Guzman. Prosthodontist/Board Certified Periodontist/Amateur digital technician ;)
Thank you !
 
Jack_the_dentureman

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I agree with you that a custom abutment is a superior way of restoring an implant. Personally, it is the only way I do it.

There is a great article from Heitz-Mayfield et al, "Clin Oral Impl Res 2020,31:397-403" called Implant Disease Risk Assessment IDRA- a tool for preventing peri-implant disease. I've gone over it with our hygienists (Perio office),and it enables them to quickly assess how things could go south for a patient. It has a graph that looks like a spider web, and many categories that put a patient at risk of peri-implantitis. One of those categories is RM-Bone, which is Restorative Margin to Bone distance. When it is less than 1.5mm, they are at high risk/red area, when it is more than 1.5mm they are in the moderate or yellow area, and when the restorative margin is at tissue level they are in the green or no risk zone.

In the references there is a great peri-implantitis study from sweden (paid by the swedish government, giving the researchers true freedom of science, and no pressure of any implant company) Derks 2016, Journal of Dental Research, "Effectiveness of Implant Therapy Analyzed in a Swedish Population", It followed 588 patients, over a 9 year period.

From page 47 "Patients with periodontitis and with 4 or more implants, as well as implants of certain brands and prosthetic therapy performed by general practitioners, exhibited higher Odds Ratio for moderate/severe peri-implantitis. Similarly higher Odds Ratios were identified for implants installed in the mandible and with crown restoration margins positioned at 1.5mm or closer from the crestal bone at baseline. "

Warning: Personal Opinion below..

From my limited experience and in my opinion, there is a better biological environment when tissue is in contact with sterile/clean titanium, than when there is any kind of ceramics close to bone/connective tissue.

I frequently see, when removing healing abutments (which please tell your doctors to only use a new healing abutment) small spots of bleeding, which come from ripping off the hemidesmosomal attachment from the tissues to the clean titanium surface(no odors noted),suggesting a better barrier from the oral environments than that seen when removing a crown on a ti-base (odors frequently noted).

If you think of the "cement gap" setting you are all using, as tight as it might be, 20microns is plenty for bacteria to colonize. There will be some microscopically rough cement at that crown/abutment interface. Wouldn't it be nicer to have that 3-4mm away from bone? just food for thought.

Some general practitioners might dismiss an article that shows if a general dentist is delivering the case the risk of peri-implantitis is higher, but I hope you will all find a nicer way of presenting the idea to your doctors than hitting them straight with data & science. :)

-Luis Guzman. Prosthodontist/Board Certified Periodontist/Amateur digital technician

#@ ARTICLE @#
I think you mean that with this spider web
It is still a generalization and a misunderstanding if stating that ti-base is and will be the cause peri-implantitis

These articles aren't even about custom abutments or ti-base.
which I haven't found any clinical tests to prove that ti-base has the problems these articles and studies address. There are some clinical studies showing that Ti-base does not cause problems.



Again - I don't say which is better, because it depends on the clinical situation.
 
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drguzman

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Yes, these articles are not on Ti Base Vs Custom Abutment, they are more on Peri-implantitis, which by the time it happens, it is not on the lab. Now how many young clinicians ask you all, "what do you think?". You have the opportunity to further educate a lot of clinicians and improve patient's lives.

Having that margin at tissue level statistically makes a difference for the health of the implant (at least according to Derks).

Restorative Margin to Bone distance (made an illustration but it's too tricky to just drop the image)

Now there are many height of Ti Bases, so 1.5mm of taller would protect more the bone levels, with the drawback of complicating the chance of having a restoration that emerges in a Non-Pumpkin shape (think of a 4.8mm implant going to a 10-12mm Molar, in just 2-3mm of height. If the Ti Base is 2mm in height you know have 1mm to go from 4.8mm to 12mm (the Pumpkin restoration).

Second Illustration

There is advantages and disadvantages the different treatments, and plenty of literature to support both.

<Opinion below>

On a Ti Base:
  • there is definitely less risk of cement being a problem (assuming it's done right, at the lab, cemented, cleaned, polished, steamed etc),compared to clinically cementing intra orally. This point cannot be emphasized enough as excess cement is in the race for the biggest implant killer factor (up there with heavy smoking and uncontrolled diabetes). Now it is not always possible to do a Ti Base, for example, the path of insertion, and the path of the implant do not allow the seating of the restoration (which for a single restoration, it is not crossing anyone's mind to use a non engaging ti base).
  • The restoration is less expensive to make, but requires more clinical precision (no cement to provide passivity, so seating the restoration might require more skill at adjusting contacts. Less experienced clinician might loose the proximal contact, and now what would happen to the cement if you have to add porcelain to a contact?
  • If there is gingival recession, there is reduced risk of metal ever showing. Also, reduced chance the average clinician will notice things are migrating south
On a Custom Abutment:
  • There is less risk of having cement compromise the implant in comparison with a stock abutment (which i hope your docs are not using),but more risk of having excess cement compared to a Ti Base.
  • The restoration is more expensive
  • You could detect early changes/recession if the lingual margins are at gingival level.
  • It is easier to probe the restoration when compared to a Pumpkin type emergence.
  • The emergence is fully customizable, which close to the platform having a narrower emergence provides more space for connective tissue thickening (which would minimize risks of gingiva looking gray)
On the Scary side, thinking of screw retained restorations on multiple implants, the less precise the impression/cast, the more likely there will be misfit clinically, and your restoration will be under stress and break earlier, making you look bad, or making you wonder if there is anything wrong with your processes at the lab... did you fire the restoration too many times? was it the material? is there something wrong with your sintering? or is it the clinician impression? is the clinician grinding and inducing cracks? If your prosthesis survives, some implants will fail, and you might get ask to discount a second restoration or worse. I'm just thinking scenarios here since I don't have a lab people send stuff to, but I do talk to technicians in my area who educate dentists in the area more than I do because they have worked for years together and have a longer relationship, etc. I am sure you all might be familiar with doctors' egos, and those egos might not trust younger doctors even if they are specialists.

Just food for thought :)


 
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