Ti-Bases and the Lab's Role

"More often, cases can be restored with stock componentry with great success without the need for custom abutments," Galvis adds. "Even with the shift of all-on-X (AOX) full-arch implants going Ti-baseless, there will always be a place for the Ti-base."

Kevin Westrich, Jr., Vice President of D3 Solutions & Functional Esthetics Dental Lab, notes that a Ti-base is a predictable way to have a great implant connection with a lot of workability. Labs can offer a variety of Ti-base options, including multiple height selections for optimal retention and angled screw channels for improved accessibility. "We have a lot more flexibility to make the restorations doctors want," Westrich says. "It is substantial what we can achieve and how we can help reduce the amount of bone loss when cementation is addressed. It is much better today than it was in the past, especially close to the fixture level."

Addressing Possible Challenges

Pinhas Adar, MDT, CDT, of Adar Dental Network, shares his approach to overcoming challenges in implant restorations, particularly with the use of titanium cylinders to achieve a better fit and more predictable outcomes compared to zirconia-based solutions. "In the majority of my cases, I recommend using titanium cylinders as an insert," Adar says. "The fit of the titanium on top of the implant is much better than with zirconia connected straight to the titanium."

"The titanium cylinder gives me an option because if something is off, then it will be between the titanium cylinder and zirconia, which you can adjust with the fit checker and then adjust the zirconia," Adar says.

Adar says his office will typically adjust inside the zirconia, because sometimes the zirconia sintering does not come out well, the machine is not calibrated, or the milling tool breaks. "Also, it could be due to distortion in digital scanning and matching files and other digital problems," he says, adding that titanium cylinders work best when they are long enough.

For large zygomatic cases where the arches are very large, a split-files approach can be used with a metal bar on the first part and zirconia on top, says Adar. "Either you're unable to mill because the zirconia block is not big enough for zirconia milling or because the machines are unable to mill accurately," he says.

Adar notes that he has found unpredictable results with milling machines, after testing several types, and stresses the importance of finding the right machines for your lab. "There's nothing you can adjust. Either it fits or it doesn't," he says. "You have to have the right machines and special tools." He adds that many manufacturers suggest not to mill zirconia direct to a multi-unit interface because the zirconia shrinks and sometimes distorts during the transformative stage in the sintering oven, and then no adjustments can be made.

"Interfacing straight to multi-units with DESS, Rosen, or other types of screws is a good solution during surgery," he adds. "You don't need cylinders. Printed temporaries are very accurate because there is no shrinkage because it is additive technology. There is no milling necessary. It saves time; it saves money." We still need accurate models in our lab, Adar notes, to ensure verification and a good fit.

Benefits of Shifting to the Lab

Westrich highlights the increasing trend of dental laboratories handling the bonding of Ti-bases instead of clinics. He explains, "while many offices have been doing this for some time, the offices see the time/cost savings when labs handle this. When the proper procedures for bonding are followed, the results are better and there's less of a chance of debonding."

Any procedure done intraorally that can be done in a laboratory would highly benefit from being done out of the mouth, Galvis notes. "My laboratory does hundreds of AOX arches a month. During conversions, we perform all the connecting to implant components out of the mouth," he adds. "Lab procedures ensure uncontaminated processes free of saliva and blood and a prosthetic that is cured in a pressurized clean environment. These lab procedures have resulted in our temporary arches lasting the entire healing processes with minimal reports or breakages."

Adar notes that some labs cement internally without using models. "They insert it in with cement in their hand," he says. "Sometimes they put it on the model. They don't even screw it. They just put it on and think it's going to fit."

"We always cement one side first and support the other side-the very back ones and the middle," Adar says. "We have the adjusted occlusal plaster jig as well. We always use a verified model."

Adar's lab utilizes an easy bar technique. "We train our doctors to capture either during or after surgery," he says. "We make sure the model is accurate and that's where we cement it on. It's always screwed in on the model. Some laboratories tell the doctors to cement in the mouth, which is painful because there is also moisture control. It's better to do it in the lab."

Easy bars are pre-made bars a dentist can connect with titanium cylinders in the mouth with something that does not shrink. It becomes like the metal bar, is less expensive, and anyone can do it, according to Adar. Some dentists even use easy bars to capture for models, he says.

"They have steps to make sure their titanium cylinders are down," he explains. "First verify, then take the x-ray. Select the easy bars, connect them well, then after it sets, take it out, check with your fingers. Nothing moves."

"A lab's goal should not be faster turnaround times or reducing costs-it should be reducing chair time for the doctor because that is where the time is most valuable," Galvis notes. "We spend more time on the lab side researching, going to the white papers and making sure we're educating ourselves on how to bond the best."

"Even though all this technology is pretty turnkey, being on top of maintenance helps with efficiency or reliability," says Westrich. "Like keeping mills clean, running calibrations often, and understanding mill strategies for producing full-arch restorations. Lastly, keeping printers calibrated and in the right temperature settings." All these little things can help reduce the possibility of having to do remakes.

"If it fits and cements well on the model, you think everything's perfect," Westrich adds. "If the calibration isn't done with the mills, if you're not following protocols for proper bonding with the bases, or even if your 3D printers are off, you're going to have issues."

"We use photogrammetry instead of impressions. It's a very accurate process," Adar says. "We do everything digitally through those files so the temporaries will be accurate."

"The way you process the photogrammetry files matching the digital files is very crucial; human error can be a problem," he adds.

Understanding the Materials

According to Galvis, there are many great materials on the market now. "Some cements show great results in terms of bond strength," he says. "Others offer different colors to ensure the grey of the Ti-base does not change the shade of the restoration post-cementation."

"The entire process and fabrication needs to be harmonious," Galvis says. "This must be developed internally within the lab workflows. Too much cement gap leads to debonding. A tight crown results in grinding and introduction of micro fractures. Cementing procedures are extremely particular. Missing the smallest step or contamination in the process will result in a debond. This is why cementing outside of the mouth is the best decision when possible."

Westrich also says that establishing good maintenance protocols is critical. "If we let things slip here, we're all working for free in a way," he says. "There are going to be things that are not correct with the models moving forward from the print.  If we are working on a faulty model from the beginning, it will cost us a remake."

Galvis emphasizes that cleanliness is key with "proper application of bonding agents and following manufacturer instructions to a tee. I often find complaints from operators of these materials saying that some do not work, but speak to someone else and they say they never saw a stronger bond. It's all about human error. Protocol must be followed correctly."

Educating oneself with the material being used is optimal and best practice, Westrich says. "It's also the understanding that each manufacturer is different, from the Ti-bases to the cements you're using and the zirconias; it's important to make sure that all your curing processes meet the manufacturer's guidelines of use for those particular products."

The quality of digital files is crucial, Adar says. "It's important to have reference points and make sure that the files are clear, because if you cannot see it, we cannot see it."

Galvis notes that labs do not like hearing about debonding, although it happens. "There are a lot of factors, but the main one is human error in the proper procedures," he adds.

Adar cautioned to check and double check information. "We make sure the doctors follow the protocol and we have the accurate model the way we train them to do," he says. "I don't want to redo it, because the re-do costs money."

"The future may be more restorations becoming Ti-baseless if the research shows it is practical and successful," Galvis says. "In order to do this, mills need better strategies and/or maybe 3D printing. I see Ti-baseless being successful for full-arch workflows while I see single crowns and bridges Ti-bases being around for a while longer."

"For hybrid situations, we're definitely seeing more AOX going straight to the multi-unit with a screw seat," Westrich says. "It is taking out a variable of titanium and cementation in some instances to help ensure the fit. You can still have some issues if the Ti-base is not bonded well or seated properly. That is when we see debonding down the road."

"I don't see the laboratory getting out of the business of helping with the bonding process for doctors on single units or bridges," Westrich adds. "As long as everyone is giving the best information up front (scans or impressions), it will help the laboratories produce an accurate product. I see Ti-bases as a good thing because it does help make restorations much easier to correct for angulation with all the new screw-retained products, and it allows for easy access for the maintenance, hygiene, and care of the patient."

Adar notes a strong future for this approach, especially for people who are edentulous. "As the older population grows, this is going to grow as well," he says. "The solution may be the same, but materials may change. Maybe there will be more printers that produce better materials for restoration instead of milled zirconia."

"We could have more additive technology, which is going to solve lots of the accuracy and milling process problems," Adar says. "If everything is calibrated, it shouldn't be a problem. If the materials get better, maybe it will lead to less expensive processes."

Implants are the future of dentistry and will always require the touch of a technician, Galvis notes. "Clinicians will need to rely on a technician's expertise. Given that there are so many parts and componentry, it is a technician's responsibility to provide clinicians with material and componentry options so the clinician can decide on best treatment options for the patient. It is a necessity to forge good relationships between labs and clinicians to produce the best possible restorations for the patient."

Conclusion

As implant dentistry continues to evolve, Ti-bases remain a cornerstone for creating reliable, long-lasting restorations. From the shift toward greater laboratory involvement in the bonding process to advancements in materials and digital technologies, it is clear that collaboration between dental labs and clinicians is more important than ever. With careful attention to detail, proper protocols, and ongoing education, dental laboratories can enhance the accuracy, efficiency, and overall success of Ti-base restorations. Looking ahead, the future of Ti-bases in both single crowns and full-arch cases appears strong, with continued innovation likely to improve both materials and processes, ensuring the highest standard of care for patients.