Software, Skill, and Intelligence
Creating custom implant abutments and bars still requires extensive dental intelligence
Custom abutments and milled implant bars allow dental teams to restore cases regardless of where the implant sites are placed. Custom abutments allow us to adjust for angulation, build proper support, and create more esthetic margins. This yields a more predictable and successful outcome. Milled implants bars can be designed to compensate for screw access holes that are not ideal to ensure proper support into the appliance. For example, if implants have been placed near the vestibule on the labial aspect of a maxilla with severely angulated access holes, then the bar can be brought back over the ridge to support the occlusal plane of the prosthesis and the mastication forces of the patient. The access holes can be covered with the flange of the appliance. Custom abutments and milled implant bars can help solve all of these problems, therefore extending the viability and success of these implant-supported prostheses.
Latest developments: The newest software modules are allowing technicians to do more with the design aspect of implant bars than ever before. In one recent case, we were able to scan the under-side of a Locator® attachment, custom design an abutment to fit it, and incorporate that into a digital design to fix a very deep and angulated implant site that otherwise would have been unusable.
Ultimately, every time you design a bar, it should follow the esthetic and functional needs of the prosthesis. The talent of the designer remains critical in creating innovative custom pieces, but the software is providing more effective tools.
Additionally, the solutions available now through various attachment systems make it possible to compensate for extreme divergence angulation issues. Restoring a case when everything is aligned perfectly is easy, but often divergence and depth issues create challenges, and we now have numerous solutions.
Working with a milling partner: Perhaps the two most critical considerations when selecting a milling partner are turnaround times and communication. Ensuring that your milling partner is proficient with the brands you are utilizing and that they are FDA 510K compliant is also important; sometimes it is best to utilize milling services from the implant manufacturers themselves.
Regardless, the laboratory should be responsible for quality control on all designs. The skill to make the proper changes and adapt them if necessary is crucial. This requires an overall knowledge of prosthetic principles with regard to the fundamentals of restoring implants and all modalities. The key is communication and implementation on what the team needs regarding case planning for the implant bars or abutments. Milled implant bars, in particular, can be expensive, so the exact criteria must be evident for a successful case. You need to be able to communicate proven prosthetic principles and trust that the milled implant bar follows successful design protocol for proper function and patient acceptance.
Ensure the best outcomes: The most important factor, especially with more complex cases, is acquiring all the information needed and building the diagnostic aspect. Always start with the desired end result in mind and work backward. Envision how the prosthetic will look and function. Be aware of the inter-occlusal space. This includes providing lip support and also which materials are indicated to achieve successful functional and esthetic outcomes. This must be provided to whomever is designing and milling the abutments and bars. Sometimes, it may be necessary to fabricate multiple setups and try-ins to determine what will be ideal.
Another key factor is following the correct protocol. Do not take shortcuts. The planning procedure takes the most time, and it requires expertise. Training and education are important for all team members. The clinician's comfort level on these cases can sometimes be very low, and they often want to take shortcuts. Avoiding shortcuts and educating when necessary is required; following all steps correctly creates a successful, predictable case.
Key Takeaway: Know your materials and know your inter-occlusal space.
Each implant component requires a different amount of vertical space. Occlusion is so important in evaluating all of the components for esthetics and function. If you know your materials and space, you can do all kinds of innovative things with custom abutments and milled implant bars.
About the Author
Craig Moore is the Director of Full Arch Technical Services with DSG Implant Experience Center.