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Volume 3 Issue 9 September 2020
Titanium Bases in Implant Dentistry: A Comprehensive Narrative Review
Luis Gabriel Ladino*, Angy Sanabria and Michael Cruz
Postgradaute Program of Prosthodontics, Insititución Universitaria Colegios de Colombia UNICOC, Colombia
*Corresponding Author: Luis Gabriel Ladino, Postgradaute Program of Prosthodontics, Insititución Universitaria Colegios de Colombia
UNICOC, Colombia.
Research Article
Received: July 24, 2020; Published: August 20, 2020
SCIENTIFIC ARCHIVES OF DENTAL SCIENCES (ISSN: 2642-1623)
Abstract
Abbreviations
Keywords: Dental Implants; Implant Abutment; Titanium Base, Implant Dentistry, Review
Different materials have been used to develop abutments including titanium, that has shown excellent mechanical properties,
however, in some cases aesthetics may be compromised. The titanium bases were developed to improve upon the disadvantages
previously mentioned. The purpose of this narrative review was to describe the different kinds of titanium bases and their
management in implant dentistry restorations. This review was done by performing a search up to May 2020 in the following
databases: PubMed, Embase, Google Scholar and LILACS and a total of 454 articles were found. After reading the abstract and title
and full text, seventeen articles (n = 17) were included in the review. The reviewed literature assessed the use of titanium bases
regarding its surface topography and their luting protocol, also whether does not interfere with the health of the tissues surrounding
the implant, mechanical and aesthetic properties. Titanium bases are a predictable alternative in screw-retained or cement-retained
Cr-Co: Chrome-Cobalt; CAD/CAM: Computer Aided Design/Com-
puter Aided Manufacture; 10-MDP: 10-Methacryloyloxydecil Dihy-
drogen Phosphate
Introduction
Dental implants have become a predictable solution to replace
missing teeth, its success rates have been reported to be 97% at
prosthodontics is the abutment, which is the intermediate struc-
ture between the implant and the crown, it allows the retention of
the restoration and provides support [3].
Currently, various materials are available regarding abutments:
titanium, chrome-cobalt (Cr-Co), zirconia, and gold [4]. Titanium
and Cr-Co abutments have high resistance, however, they can cause
a grey shadow in the mucosa surrounding the implant, which can
-
ments were developed, which offer a better color match to natural
teeth because they have better light transmission [5,6], nonethe-
less, it can wear or fracture because of the implant platform [7-10].
The titanium bases appear as an alternative to avoid the possi-
ble fracture of the connection in zirconia abutments. Because of its
metal composition, the titanium bases provide optimal resistance,
allowing adequate stability and biocompatibility with adjacent soft
tissues [11,12]. These abutments are fabricated with a type V tita-
nium alloy. Some implant manufacturers offer an anodized coating
on their abutments, also, they offer two different designs, smooth
-
ing is of vital importance to the success of the restoration [13,14].
The titanium bases were designed because it was compatible
with CAD/CAM technology; it allows faster working times, and ac-
Citation: Luis Gabriel Ladino., et al. “Titanium Bases in Implant Dentistry: A Comprehensive Narrative Review". 3.9
(2020): 51-59.
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ceptable adaptation, creating the hybrid concept in abutments, in
which it can use a screw-retained or cement-retained system, that
could be indicated in the following clinical situations: (1) well-po-
sitioned implants ready for crown placement and (2) in tilted im-
plants, the position can be corrected with modifying the abutment
with burs and luting the customized coping followed by the crown,
in which case it’s not viable to recover [15].
The main advantage to titanium bases is that you can recover
the abutment and the crown, just like with the customized abut-
ments or any screw-retained system, because of it being cemented
extra orally it allows to remove any cement excess, thus avoiding
The central theme of the published articles related to abut-
ments is the mechanical behavior of them, including the connec-
tion and the type of restoration; however, the titanium bases re-
main understudied in the literature, this is likely associated to the
fact that this has been used for a short time in clinical situations.
Purpose of the Study
The purpose of this narrative review was to describe the dif-
ferent kinds of titanium bases and their management in implant
dentistry.
Materials and Methods
An electronic search was carried out until May 2020 in Data-
bases: PubMed, Embase, Google Scholar and LILACS, using the key-
word “Titanium Bases”. Two reviewers selected all the titles and
abstracts obtained for possible inclusion. Full-text articles were
retrieved based on abstract selection; any disagreement provided
by the article information was resolved through discussion with a
third reviewer.
Results and Discussion
17 articles were selected, including 4 in vitro studies that evalu-
ated the biomechanical behavior of titanium bases with different
designs of restorations; 3 articles used monolithic ceramic crowns,
zirconia crowns, and zirconia cores with feldspathic ceramic coat-
ing; besides, one article evaluated transmucosal abutments at-
tached to titanium bases. 6 in vitro articles evaluated different pro-
tocols for luting, mechanical surface treatment (sandblasting with
aluminum oxide particles and tribochemical treatment), using self-
curing cement, and dual polymerization cement. 3 in vitro articles
evaluated the retention strength of ceramics to different abutments
among which they studied lithium disilicate, zirconia, and hybrid
ceramics cemented to a titanium base and prefabricated zirconia
and titanium abutments. One in vitro study evaluated different
margin designs (posterior conical, chamfer, and shoulder); a sin-
gle in vivo prospective randomized cohort study with a 12-month
follow-up where the behavior of titanium bases and titanium abut-
ments with peri-implant tissues was evaluated.
Mechanical behavior of titanium bases with different
restorations
Esthetic restorative CAD/CAM materials can generally be di-
vided into two main categories: ceramic and composite materials
[18]. Comparing both categories, composite restorations are stron-
allow easy occlusal adjustment [19]. In contrast, ceramic restora-
tions have better biocompatibility, superior aesthetics, greater
wear resistance and greater color stability [20]
Tribs., et al. [21], evaluated the stress distribution of cemented
ceramic crowns to titanium bases with different restorative tech-
niques, using 75 titanium bases with cone morse connection, di-
for 60 seconds and it is cemented to the titanium base and being
restored with a ceramic monolithic crown; second, monolithic ce-
ramic directly cemented to the titanium base which silane was ap-
plied to it for 60 seconds and monolithic crown cemented to the
titanium base with the access conduit which was conditioned with
sealed with composite resin. The analysis showed a high preva-
-
tion, this area is critical since it is close to the fulcrum point of the
crown and also because it has the thinner ceramic volume.
About fracture resistance, the esthetic restorative material of
choice is zirconia since it has been shown to have great mechanical
properties and that crowns can be manufactured in a monolithic
or layered way, and is, in turn, can be cemented on titanium either
for use in the posterior or anterior sector; but this type of resto-
Citation: Luis Gabriel Ladino., et al. “Titanium Bases in Implant Dentistry: A Comprehensive Narrative Review". 3.9
(2020): 51-59.
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ration generates unknowns on which have better mechanical be-
havior, therefore Elshiyab., et al. [22], carried out a study where
they evaluated 40 titanium bases; restoring 20 titanium bases
and 20 with layered crowns with zirconia copings using the IPS
e-max ceramic system (Ivoclar Vivadent) in the shape of a lower
50% survival rate within two years clinically simulated, compared
-
-
to massive fractures with lower masticatory loads, when multiple
implants are connected with a screwed restoration, there is a need
for the use of a transmucosal abutment to correct the differences
in positions of the implants and create a passive insertion pathway.
McGlumphy., et al. [23]; introduced the term “combined implant
crown” which was made up of a torqued titanium base on a trans-
mucosal abutment and is attached to the implant, although this
type of restorations is widely used in dentistry there is not enough
evidence-based data to investigate the mechanical failure of this
type of restorations. Heller., et al. [24], conducted a study using 36
straight transmucosal abutments restored by 18 with monolithic
zirconia crowns cemented to titanium bases, then torqued to the
transmucosal abutments and the other 18 placing the crown di-
rectly to the transmucosal abutment, reporting that the crowns
screwed to straight transmucosal abutments presented static max-
imum load resistance values of 872 Ncm; and at dynamic load, they
presented deformation, fracture of the transmucosal abutment,
the crowns cemented to titanium bases and then torqued to the
straight transmucosal abutment. presented values at static load,
of 718 Ncm. At the dynamic load, transmucosal abutment failures
and adhesive failures occurred. Therefore, both types of restora-
tions are viable treatments that do not represent a statistically sig-
et al. [25], evaluated 40 implants with a cone morse con-
nection, where half of the ceramic restorations were adhesively ce-
mented to conventional titanium bases, which were sandblasted
with 50 µm aluminum oxide particles, at a pressure of 2.5 bar for
10 seconds. At a distance of 10 mm, a pretreatment agent for tita-
nium conditioning (Alloy Primer - Kuraray) was applied and ce-
mented with Panavia 2.0 (Kuraray); the other half of the crowns
used an experimental titanium base with notches in the ceramic
restoration, all the samples were thermocycled and were restored
with a zirconia crown. For the notched group, the vertical mismatch
before aging was greater than after aging. 100% of the cemented
group restorations failed in the screw, and 100% of the notched
element simulation showed that both modalities presented a simi-
lar stress distribution on the external surface of the crown and the
threads of the implant.
An important factor to consider at the time of restoration is the
diameter of the implant platform, in a study by Zenthöfer., et al.
[26], where they compared the retention force of cemented zirco-
nia abutments to titanium bases on two different platform diam-
eters (4.8 and 6.5 mm), reporting that the greater disunity forces
are associated with a wider platform diameter.
A prosthetic treatment option when multiple teeth are lost is an
in the study by Kolbeck., et al. [27], evaluating the behavior of an
implant-tooth supported restoration supported with a zirconia
abutment cemented on a titanium base and a titanium abutment
compared to a tooth-supported prosthesis, found that the best dis-
-
Biological behavior of titanium bases
Bacterial microleakage between the different types of support-
ed implant prosthesis retention can affect peri-implant bone loss;
-
cording to the cementation technique adopted [28]. Excess cement
generates a biological complication that can act as a mechanical
irritant and bacteria deposit. Marginal peri-implant bone loss and
cement [29]. The titanium bases allow an extraoral control of the
cementation line, thus avoiding biological complications and giv-
ing greater long-term stability of the treatment. Pamato., et al. [30],
carried out a prospective randomized clinical study in 23 patients
where they placed 55 implants, divided into 2 groups, the control
group: cemented abutment (24 implants) and the study group: ti-
tanium base (28 implants). Clinical (probing bleeding and probing
depth) and radiographic (mesial, distal bone levels, and crown/im-
Citation: Luis Gabriel Ladino., et al. “Titanium Bases in Implant Dentistry: A Comprehensive Narrative Review". 3.9
(2020): 51-59.
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plant ratio) evaluations were performed at the time the implants
were loaded, at 6 months and 12 months. Bleeding at probing was
loss is associated with the antagonist and the place where the im-
plants were placed, the titanium bases did not interfere with the
health of the peri-implant tissues. In contrast, there is a study by
Asgeirsson., et al. [31], where they evaluated in 24 patients the
clinical, technical and aesthetic parameters of the zirconia abut-
ments with feldspar coating cemented on titanium bases, report-
was found in terms of technical and aesthetic results, but about
probing were evident.
Regarding peri-implant bone loss, there are studies by Linkevi-
cius., et al. [32] and Erhan., et al. [33], who found in radiographic
and tomographic parameters, the presence of less bone loss in
thick soft tissues and immediately loaded personalized abutments
compared to soft tissues and delayed-loaded abutments.
Luting protocol
Implant-supported and tooth-supported restorations can be
that in their content are largely made of a vitreous matrix that is
responsible for providing aesthetics, and 2) acid-resistant ceram-
ics that are formed in a large amount of crystalline phase to im-
between ceramic and titanium bases, such as the composition of
treatment, and adhesion mechanisms (chemical, mechanical, or
both). Therefore, it is important to select the ideal surface treat-
success of the restoration [35].
Among some studies, where they evaluate the effect of different
surface treatments, the research by Kemarly., et al. [36], where they
evaluated 90 titanium bases which were divided into three groups
of thirty each. Thirty of the titanium bases received no surface
treatment. Thirty were sandblasted with 50 um aluminum oxide
particles at 2.0 bar pressure and the remaining 30 titanium bases
were treated with tribochemical treatment at 2.0 bar pressure for
15 seconds. In each of the three groups of 30 titanium bases, 10
were conditioned with a universal primer on the bonding surface
for 60 seconds and dried, 10 were treated with a treatment agent to
condition the metal for 60 seconds and the remaining 10 received
for any of the three chemical treatments; Regarding mechanical
treatments, sandblasting with aluminum oxide particles was statis-
the surface treatment to be performed on the titanium base is the
topography it presents, since in a study by Celin Arce., et al. [13];
they evaluated 60 titanium bases that had 15 150-micron deep
grooves on the surface, which were subjected to different surface
treatments: adhesive containing the 10-MDP molecule, 15 titanium
bases were sandblasted with 50-micron aluminum oxide particles
for 20 seconds, 15 titanium bases were sandblasted with 50-micron
aluminum oxide particles for 20 seconds, and an adhesive contain-
ing the 10-MDP molecule was applied to the zirconia crowns and
15 titanium bases did not receive any surface treatment. Sandblast-
ing with 50-micron aluminum oxide particles is contraindicated in
this type of titanium bases since they seal the microgrooves affect-
ing the topography and decreasing the adhesion force, in terms
of surface treatment with an adhesive that contains the 10-MDP
molecule, demonstrated the highest values of adhesion. In another
study by Linkevicius., et al. [37], where they evaluated another type
of topography of the titanium bases, which presented a Laser Lock
surface treatment, comparing the retention force of two cementa-
tion protocols, one in which the titanium bases were sandblasted
with oxide particles 50-micron aluminum and another where no
surface treatment was made; reporting that the alumina particles
that remain on the surface of the titanium bases weaken the bond
strength between the titanium and the ceramic, recommending the
cementation of this type of titanium bases without any treatment
prior to cementation.
Another important factor during cementing is the type of ce-
ment; the investigations of Wiedenmann., et al. [38] and Gehrke.,
et al. [39], evaluated the behavior of zirconia abutments cemented
to titanium bases with different bonding agents: Multilink Hybrid
Abutment- Monobond Plus (Ivoclar Vivadent), Panavia F2.0 and V5
-
ly); which reported the highest values of adhesion in the Multilink
Hybrid Abutment-Monobond Plus bonding agent. In addition, in
the study by Freifrau., et al. [40] the use of another ceramic material
for the abutment is reported, such as lithium disilicate cemented to
titanium bases; they made a comparison of bond strength between
Citation: Luis Gabriel Ladino., et al. “Titanium Bases in Implant Dentistry: A Comprehensive Narrative Review". 3.9
(2020): 51-59.
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these two ceramic materials using different resin cement, Multil-
ink Hybrid Abutment- Monobond Plus (Ivoclar Vivadent), Panavia
Relyx Ceramic Primer (3M ESPE); reporting greater bond strength
for the Multilink Hybrid Abutment- Monobond Plus for two ceram-
ic materials. In addition, to these studies, the one by Güngör., et al.
[41], where they study a different bonding agent such as Zirconite
(DJM), which is a dual-polymer self-adhesive universal resin ce-
ment specially designed for zirconia cementing, being compared
to Multilink Hybrid Abutment (Ivoclar Vivadent) Panavia F2.0
-
tioning agent, Zirconite presented the highest values of adhesion
followed by Multilink Hybrid Abutment.
When evaluating the success of restorations, it will not only be
affected by the bond strength but also, aesthetic factors such as the
maintenance of the restoration’s color will be taken into account,
cement but also for the choice of its color. In the study by Liu., et
al. [42], which evaluated the color stability of the restorations
with different cement: Variolink Esthetic, Translucent glue, Zinc
oxide temporary cement, Multilink Hybrid Abutment HO 0, Relyx
Unicem A2, Panavia V5 clear, Panavia V5 A2, Panavia V5 White,
Panavia V5 opaque; these cement were used in unsanblasted ti-
tanium bases; Multilink Hybrid Abutment HO 0, Relyx A2, Unicem
A2, Panavia V5 clear, Panavia V5 A2, Panavia V5 White, Panavia V5
opaque, they were used in sandblasted titanium bases, represent-
ing a clinical situation of a left upper lateral incisor, the evaluation
was performed using the spectrophotometer. The effect of sand-
blasting on the color result depended on the type of cement used;
for unsandblasted titanium abutments, the results were favorable
for Multilink Hybrid Abutment HO 0 cement (Ivoclar Vivadent),
followed by Panavia V5 A2 (Kuraray) and Panavia V5 Opaque (Ku-
raray). When the titanium abutments were sandblasted, the resin
cement Multilink Hybrid Abutment HO 0 (Ivoclar Vivadent), was
the only cement that presented a value below the detection of the
human eye.
Ceramic resistance fracture
To provide restorations compatible with titanium bases, the
abutment material, that abutment design and the crown mate-
rial were evaluated, thus generating aesthetic and reliable com-
ponents, in the study carried out by Bankoglu., et al. [43], evalu-
ated 5 abutment/crown systems on titanium bases, among their
research groups are: monolithic lithium disilicate crown cemented
to the titanium base, monolithic lithium disilicate crown cemented
to a lithium disilicate abutment and it is cemented in the titanium
base, monolithic lithium disilicate crown cemented to a zirconia
abutment and this is cemented in the titanium base; crown with
zirconia cap and feldspar coating cemented in the titanium base
and monolithic disilicate crown of lithium cemented on a prefab-
ricated zirconia abutment, half of the groups were thermocycled
then brought to failure by means of the universal instron machine
and the other half was only brought to failure, among their results
are that the group monolithic lithium disilicate crown cemented to
a zirconia abutment and this cemented on the titanium base pre-
sented the highest values of resistance to the fracture in both the
groups with and without thermocycling, while the group of lithium
disilicate monolithic crown cemented to a lithium disilicate abut-
ment and this one cemented to titanium base presented the low-
est values reported in the study. In the study by Nouh., et al. [44]
evaluated the fracture resistance and failure mode of monolithic
zirconia crowns cemented on titanium bases, zirconia crowns ce-
mented on zirconia abutments and these on titanium bases and
monolithic lithium disilicate crown cemented on titanium bases,
and lithium disilicate crowns cemented on lithium disilicate abut-
ments and these on titanium bases; all groups were subjected to
thermocycling; where the fracture resistance was higher in zirco-
nia crowns cemented on zirconia abutments, and these cemented
on titanium bases. In another study seeking to evaluate equally
different ceramic systems both in the abutment and in the resto-
et al. [45] evaluated the stress
distribution of different groups that were distributed according to
the material of the crown and the abutment. The same crown ma-
strength of the restoration compared to a lithium disilicate hybrid
abutment, demonstrating that the stress generated on these abut-
-
rial is placed underneath.
Kyaw., et al
load on the transformation of the phase of the zirconia abutments,
-
tion of the monoclinic phase obtained from the aging techniques.
To determine the bending moments and failure modes of zirconia
abutments bonded to titanium bases Pitta., et al. [47], conducted
Citation: Luis Gabriel Ladino., et al. “Titanium Bases in Implant Dentistry: A Comprehensive Narrative Review". 3.9
(2020): 51-59.
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a study with fully ceramic monolithic crowns after aging; among
their ceramic materials they evaluated lithium disilicate monolith-
ic crowns, hybrid ceramic monolithic crowns, zirconia monolithic
crowns and lithium disilicate monolithic crowns on a titanium
abutment, this being the control group. They found that the group
of monolithic crowns of zirconia cemented on a titanium base pre-
-
by Gierthmuehlen., et al. [48], where they evaluated the clinical
behavior of 28 patients restored with lithium disilicate monolithic
crowns cemented on titanium bases; they evaluated marginal ad-
aptation, surface roughness, color stability and anatomical shape.
At the end of one year, the occlusal surface was rough, which was
limited to the contact points or functional areas and was mainly
related to the wear of the material and, as regards the other param-
eters evaluated, they remained stable during the follow-up time.
Margin design
The interface between the titanium base and the zirconia abut-
ment has become a concern because the edge margin of the zirconia
abutment is in the subgingival portion of the implant, the adhesion
between the abutment and the titanium base component is very
important since if a separation is made in this area, it can generate
peri-implant diseases; Mieda., et al. [49], conducted a study using a
chewing simulator to compare three types of zirconia margins on a
titanium base: posterior taper, shoulder, and chamfer to determine
the best margin shape for safe clinical application. Among their re-
sults they found that the zirconia margin with a posterior conical
shape transferred the tension to the interior of the implant, on the
contrary, the chamfer margin releases stress outside the implant;
the shoulder and posterior conical groups did not present frac-
tures in the margin of the zirconia coping. Only the chamfer groups
shoulder margin group had marked separation on both sides. Ac-
cordingly, the authors reported that the posterior taper margin
prevents deformation and damage, generating greater long-term
stability with high longevity for adhesive performance between
the zirconia coping and the titanium bases.
The behavior of sterilization in titanium bases
The sterilization process of the titanium bases provides a bac-
teria-free surface generating greater epithelial adhesion, reducing
the chances of the presence of any peri-implant disease. However,
the effect of sterilization at the abutment/implant interface is un-
known when using chemical or dual-cure cement, therefore the
studies by Pils., et al. [50] and Fadanelli., et al. [51], evaluated the
possible effects of an autoclave sterilization process on the tensile
strength of zirconia abutments cemented on titanium bases com-
pared when this process was not performed, there was no statisti-
were subjected to sterilization presented higher retention values.
Conclusion
This review mainly focused on the general information about
the use of titanium bases in prosthetic implant dentistry to give
dentists a basic knowledge about their possible applications in
implant-supported restorations. Currently, their application is in-
creasing in recent years in prosthodontics because of their ben-
peri-implant diseases and improve the esthetics. As a conclusion
titanium bases are a predictable alternative in screw-retained or
-
thetics in the anterior region could be high.
C
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