From digital and computerized applications to medical and material breakthroughs, implant therapy has never been more predictable and accessible
The core concept of replacing a missing tooth with an implant has remained basically unchanged since its inception. Truly, Brånemark’s first implants differed little in approach from the Mayans’ prostheses made of seashell fragments in the 7th century. Today’s implants remain variations on a cylinder meant to simulate a tooth root.
Experimentation with implant manufacturing, materials, shape, and size has been continuous, evidenced by the flurry of introductions of advanced implant products by today’s manufacturers.
Many would argue that the more impactful changes in implant therapy are the ancillary technologies that enhance diagnosis and process in general. X-rays, which revolutionized implantology, have been replaced by 3-dimensional CBCT scans. In fact, 3D imaging is now the standard of care for implant dentistry, according to Ara Nazarian, DDS, DICOI.
“In my mind, the most significant development has been the use of 3D imaging for diagnosis and treatment planning. To name just a few benefits, CBCT scans enable us to precisely assess bone quality, determine the orientation of the implant to accommodate planned restorations, and virtually eliminate the risk of complications like nerve damage and sinus penetration by taking the guesswork out of implant size selection,” Dr. Nazarian said.
Another advancement in implantology is bone grafting. “From innovative delivery modes to advanced chemistry and manufacturing, available systems for regenerating bone have made treatment a possibility for individuals who previously could not have supported an implant restoration,” according to Dr. Nazarian.
From bone grafting to surgical guides, the tools available to ensure implant success promise to evolve and expand in the years ahead.
Implants
Evidenced by the frequent introductions of updated, revamped, and even new implant systems, the global research and development into better systems is robust and continuous. “Among the major companies, platform switching and aggressive threading are the most significant newer trends in implant design,” noted Dr. Perry Jones, who places many implants at his comprehensive general practice in Richmond, VA, and educates students and colleagues on all aspects of implant dentistry. Improvements in implants themselves and other components like abutments are primarily aimed at enabling immediate loading, promoting complete osseointegration, simplifying the restorative process, and, of course, preventing implant failure. Here is a sampling of both new and time-tested systems.
Intended specifically for use in restrictive spaces, Hiossen’s ETIII Ø3.2 implant and mini-fixture have Hiossen’s proprietary SA (sand-blasted and acid-etched) surface for optimal roughness and morphology. It provides a hermetic seal to minimize micro-movement and reduce saliva and bacteria percolation.
Offering integrated platform switching, Zimmer Biomet's T3 implants medialize the implant/abutment junction (IAJ) inward to create a biologic width between connective tissue and the IAJ, helping to maintain bone levels. A short version is available for cases where bone height is compromised.
Nobel Biocare’s NobelSpeedy implants can be immediately loaded because they provide high primary stability in soft bone. Offering a short drilling protocol for reduced chair time, the system is appropriate for fixed full-arch cases and is preferred for the All-on-4 treatment concept.
Offered in straight and 20° angled styles, Saturno narrow-diameter implants from Zest Dental Solutions feature 1-piece construction with a pivoting O-ball connection for maximum resiliency and a minimal profile. Aggressive threading provides good primary stability and they are self-tapping for ease of insertion.
The beveled collar of the Tapered Plus implants has BioHorizons’ Laser-Lok surface, a series of precision engineered cell-size microchannels. This laser-machined surface treatment promotes bone and soft-tissue attachment and increases soft-tissue volume to allow platform switching.
The metal-free zirconia Straumann PURE Ceramic Implant Monotype is ivory colored for optimal esthetics and soft-tissue management. Its ZLA-treated surface resists plaque formation and promotes osseointegration. It is offered in 4.1-mm and 3.3-mm diameters for clinical flexibility.
Offered in 5-mm and 6-mm lengths, Bicon’s SHORT Implants incorporate a 1.5° locking taper for an effective bacterial seal, a sloping shoulder to distribute occlusal stresses and preserve crestal bone, and a plateau design to eliminate the need for splinting and to promote callus bone formation. The design offers the ability to place an implant in edentulous sites where there is minimal bone height, avoiding the costs and morbidity of bone-grafting procedures.
The only narrow-body implant with a screw-retained prosthetic system, ANEW from Dentatus can be placed in interdental spaces as narrow as 3.5 mm. Texturized threading increases surface area for enhanced osseointegration and a low profile accommodates divergent angles. 
The Astra Tech Implant System EV from Dentsply Sirona includes straight, conical, sloped, short, narrow, and wide designs using only 1 surgical tray. A proprietary interface provides 1-position-only placement for ATLANTIS patient-specific CAD/CAM abutments. Round and triangular options are available to support soft-tissue sculpturing needs.
The straight neck of SEVEN from MIS Implants, combined with the compatible final drill, promotes crestal bone preservation. Micro-rings on the neck enhance bone-to-implant contact at the crestal zone, minimizing resorption.
Using a simplified surgical protocol with length-specific drills, Hahn Tapered Implants from Glidewell feature a pronounced thread pattern with self-tapping grooves to facilitate swift, efficient delivery. Coronal microthreads and a machined collar with built-in platform switching preserves crestal tissue.
The Ritter Spiral Implant from Ritter Dental is used with an intuitive surgical kit that streamlines site preparation and shortens osteotomy time. The surface is grit-blasted and acid-etched with macro and micro particles for optimal bone contact and stability.
From Henry Schein, the CAMLOG Implant System facilitates stable and dependable restorations. The heart of the system is the Tube-in-Tube connection between implant and abutment. Its precision and special geometric principle with 3 cams ensure almost perfect force and torque distribution.
A universal internal hex connection makes the Engage implant from OCO Biomedical compatible with multiple implant systems’ abutments and drivers. Engage implants also feature built-in platform shifting designed to improve soft-tissue growth and positioning for more natural-looking esthetics.
Implants: By the Numbers
- • 36 million-plus Americans do not have any teeth
- • 120 million people in the U.S. are missing at least one tooth
- • 23 million in the geriatric population are completely edentulous and about 12 million are edentulous in one arch
- • 90% of peope with edentulism have dentures
- • 2.3 million implant-supported crowns are made annually
- • 15 million people in the U.S. have crown and bridge replacements for missing teeth
- • 500,000 people in the U.S. receive implants each year
- • 98% is the success rate of dental implants, based on scientific literature
Bone Regeneration/Grafting
Material options have grown in the area of bone grafting, with a new generation of synthetic materials along with better processing of natural grafts. However, the greatest evolution is that bone grafting has become standard of care, according to Madison, WI, practitioner Dr. Kaveh Ghaboussi. “In my practice, we have the socket grafting conversation with all potential implant patients,” Dr. Ghaboussi said. “The prevalence of socket grafting has contributed significantly to skyrocketing implant success rates.”
Here’s a look at select bone-grafting materials with a variety of attributes for all clinical needs.
Sunstar’s GUIDOR easy-graft CLASSIC alloplastic bone-grafting material is syringed directly into the defect and hardens into a stable and porous scaffold in about 1 minute. The 100% synthetic material is fully resorbable and is supplied for unit-dose delivery.
Supplied in sponge form in various sizes, CopiOs bone void filler from Zimmer Biomet comprises calcium phosphate within lyophilized Type I bovine collagen. When in contact with viable bone at the defect site, the sponges act as an osteoconductive resorbable scaffold for the growth of new bone.
SynthoGraft pure phase beta tricalcium phosphate from Bicon comes in 2 particle sizes: 50 to 500 μm and 500 to 1,000 μm. It exhibits fast vascularization and subsequent resorption when mixed with the patient’s blood.
Derived from red marine algae similar to natural-bone hydrosyapatite, Dentsply Sirona’s Frios Algipore provides volume stability with its optimal resorption kinetics. Offering simplified applications, it creates a stable form during the entire bone formation phase.
Hiossen’s A-Graft is a deproteinized bovine bone (DBB) material with a porous structure similar to human bone. It allows the patient’s natural bone-building factors to flow through the graft, enhancing osteoconduction and biocompatibility.
The spherical beads comprising Bioplant from Kerr Restoratives promote blood retention and provide essential scaffolding for effective bone growth. The synthetic material minimizes migration from the surgical site and repels oral pathogens to reduce the risk of infection.
A sterile, gradually resorbable bone substitute, Septodont’s R.T.R. Syringe releases calcium and phosphate ions that help promote new bone formation. The material is an osteoconductive micro- and macroporous structure that fosters dense new bone growth and helps renew bone integrity within 3-6 months.
Nobel Biocare’s creos xenogain family comprises a deproteinized bovine bone material matrix with preserved micro- and macrostructures along with a formulation that also includes 10% porcine collagen Type 1. The nonsintered materials offer easy handling and are offered sterile in a vial, syringe, or ready-to-mix bowl.
CBCT
Cone beam imaging has moved quickly from a valuable stand-alone diagnostic tool to an invaluable component of a broadening digital workflow for implant treatment planning. Merging CBCT scans with data from intraoral scanning has introduced previously unimaginable capabilities for pinpointing implant positioning and fabricating items such as surgical guides and temporary restorations. Today’s systems are more affordable, safe, comfortable, and user-friendly than previous generations. Here’s a look at the market leaders.
The i-CAT FLX V-Series from KaVo Kerr offers 3 maximum fields of view (V8, V10, and V17), each with the option to scale or collimate scan height to capture only the area of interest. The system also provides enhanced low-dose 3D imaging options, a traditional 2D panoramic, Tx STUDIO planning software, and a seamless upgrade to larger view when treatment offerings grow.
Providing accurate 360° gantry rotation, PreXion3D Excelsior CBCT Scanner delivers exceptionally clear images with its 0.3-mm focal point and 0.08 to 0.2-mm voxel size. It offers 4 fields of view and accommodates standing patients and those in wheelchairs. The PreXion software integrates into practice networks without any specialized hardware, and the PreXion3D Viewer can be installed on any Windows PC on the network, allowing scans to be viewed from any computer.
Patient positioning and FOV adjustments with the Planmeca Viso are done directly from the control panel with integrated cameras and a live video view. The proprietary CALM algorithm for patient movement correction minimizes retakes, and the imaging arm design maximizes patient space and reduces acquisition time. Planmeca Viso offers 3x3 cm to 30x30 cm FOV with limitless options in between.
To enhance implant procedures, X-Mind TRIUM from ACTEON allows instant volume measurement and bone-density assessment with the click of a button. Combined with ACTEON’s Imaging Suite software, the system offers intuitive mouse navigation and advanced functionalities.
Featuring intelligent automation and first-time-right imaging technology, Carestream Dental’s CS 9600 provides reliable patient positioning, reproducible results, and high-quality images. Three versions, with 10-, 12-, and 14-mm fields of view, can be upgraded to a larger FOV without replacing the unit. Low-dose programs deliver 3D images at a significantly lower dose than 2D panoramic imaging.
Dentsply Sirona’s GALILEOS ComfortPLUS allows digital impressions to be merged with CBCT data using GALILEOS Implant (implantology), SICAT Function (TMJ), and SICAT Air (airway management) treatment planning software. The swiveling and tilting EasyPad control simplifies operation with intuitive buttons and symbols. The unit ensures maximum certainty during implantation procedures through the use of integrated surgical guides with guaranteed accuracy.
The OP 3D Pro from KaVo Kerr offers 5 volume sizes, with a choice of 3 image resolutions for each. The optional cephalometric function can be right- or left-handed for optimal performance and ease of use. Automatic Dose Control provides the optimal dose based on patient-specific anatomy for 2D and 3D, and low-dose technology offers quality images at a very low dose.
Intraoral Scanners
Similar to the other digital technologies featured here, digital impressioning continues to expand into general practices, not only for implant planning but to replace conventional material-based techniques for basic restorative dentistry. As part of the implant workflow, digital scanning is critical for helping create surgical guides. “The intraoral scanner captures accurate surface morphology, which is necessary but not available from the CBCT scan alone,” noted Dr. Jones. “The scans, when merged with CBCT data, allow us to create real-deal surgical guides with depth-limiting stops and are planned for all dimensions in space. We can be completely accurate with our implant placement.”
A long way from the first-generation versions that relied on powdering, were relatively slow, and could not reproduce natural colors and shades, the scanners described here show advances in speed, accuracy, ease of use, and patient comfort.
With its speed and powderless system, the Medit i500 allows for a smoother scanning experience, shortening turnaround times and increasing office productivity. The Medit i500 uses an open CAD/CAM system, allowing clinicians to export STL files out of Medit LINK and share with preferred labs or easily transfer files and track progress throughout the workflow.
Planmeca Emerald uses a multicolor laser-based system that delivers realistic colors and allows dentists to easily distinguish between hard and soft tissue. With an active antifog feature at the tip, the lightweight scanner offers plug-and-play operation for ease of use at multiple workstations. Designed for increased patient safety, autoclavable seamless scanner tips prevent cross-infection while encouraging continuous scanning.
Carestream Dental’s CS 3600 has 3 autoclavable interchangeable tips: the normal tip for general scanning; the side-oriented tip with a lower height for buccal, occlusal, and posterior regions; and a posterior tip for children and adults with smaller mouths. Green arrows guide the way, and live-scanning warnings provide feedback in real time, indicating areas of the scan that lack detail and require additional scanning to optimize clinical outcome.
Dentsply Sirona’s CEREC Omnicam features a rounded camera handpiece that simplifies rotation and enhances comfort for the patient and user. Its Shade Detection feature provides objective assistance for proper shade selection. The system is designed for ease of use, as the feedback function and detailed instructions let you know what you need to do at all times.
Designed to operate solely on a tablet, the 3M Mobile True Definition Scanner is easily moved between operatories. Using 3D-in-motion video technology, the affordable system captures accurate, detailed visuals of anatomy and enhances patient education.
Recently enhanced with 3Shape AI technology, the 3Shape TRIOS Wireless includes 3 long-lasting rechargeable batteries that are easily exchanged for uninterrupted scanning. Users can navigate between scan pages on the monitor during scanning without touching the keyboard or mouse.
TRIOS supports the widest range of treatment workflows, delivering open STL and DCM files.
Aadva IOS from GC America is a cart-based system with a 19-inch touchscreen monitor, a rotating cradle with an antifog function, and a flexible arm. Its simple, intuitive operation is geared for users new to the digital workflow. The Aadva Intraoral Scanner features a small, lightweight, ergonomic handpiece that increases patient comfort.
Suitable for multilocation practices, Align Technology’s iTero Element Flex is a wand-only system that transforms compatible laptop computers into a portable scanning workstation. Meanwhile, the iTero Element 2 is equipped with next-generation computing power that enables 2x faster start-ups and 25% faster scan processing time, as compared to the iTero Element.
3D Printers
A relatively early adopter, Dr. Jones has been using a high-end 3D printer in his practice for about 5 years. “We use 3D printing for fabricating 3 main items: models (completely replacing poured stone models), surgical guides (completely replacing milled guides), and provisional (when we need them).”
Dr. Ghaboussi also 3D prints provisionals in certain cases. “In fact, for some patients with cost concerns, I can fabricate 3D-printed provisional for long-term use,” said Dr. Ghaboussi. “I, of course, let the patient know that they’re not as strong or durable as other options, but I’ve seen them last for years, and they’re a fraction of the cost of lab-fabricated restorations.”
That said, a 3D-printed material suitable for permanent prosthetics still does not exist, but may be a reality in the next few years. To be ready for this new wave of restoration fabrication, check out these systems, developed specifically for dental applications.
Formlabs’ Form 2 employs stereolithography technology and accommodates 17 complementary materials specifically developed for the unit. It automatically recognizes the resin, configures settings, and monitors inventory via a dashboard.
Based on DLP (digital light processing technology) for rapid horizontal printing (models in 2 hours and surgical guides in 45 minutes), Planmeca Creo accommodates 6 models or 25 surgical guides simultaneously. It is compatible with different design software with an open interface for STL imports.
Integrating SprintRay’s RayOne UV DLP projector, which is well-calibrated and durable, MoonRay delivers the correct light wavelength consistently across the platform for optimal resin-curing control and dimensional stability
VOCO’s SolFlex 170 combines maximum building speed, process reliability, and high vat volume to allow overnight production. It is based on patented FlexVat technology that speeds printing to save time while minimizing support structures, conserving material.
The Asiga PICO2 from Whip Mix has an onboard PC to store multiple builds and flexible supports to avoid collisions. Other features include a remote log-in capability and a build time estimator to help schedule workflow.
Implants: Now a More Viable Option
“We are seeing a trend in the United States,” observed Dr. Ghaboussi. “In the past, you were much more likely to find patients with dental implants in the rest of the developed world than here. In 2018, that’s no longer true. Implant dentistry is on a steep upward trajectory in the U.S., with more and more general dentists surgically placing implants—in turn, making implants a viable option for more and more patients, which is great!
“This trend is definitively and directly attributable to the digital technologies available to us today, and I know we can look forward to even more innovation that will further simplify implant dentistry and make it THE solution for missing teeth.”
Doctor's Favorites
Andrew Spector, DMD, practices at Gentle Dentistry in Haworth, NJ, lectures frequently, and has taught surgical and prosthetic implantology as Clinical Associate Professor at NYU School of Dentistry. A fellow of the International Congress of Oral Implantology and certified in the Hybridge Dental Implant technique for full-arch treatment, Dr. Spector is no stranger to complex and challenging implant cases. Here, he describes a few of the tools he uses for predictable, simple, and successful implant therapy.
I've been placing and restoring implants for more than a quarter century and using MIS Implants almost exclusively for the last 8 years. The MIS product line offers me an amazing amount of flexibility, whether it be conical connection, internal hex, and other configurations. Their newest V3 has an innovative triangular head and provides a reservoir for blood clotting—reducing bone pressure at the crest and maximizing bone thickness at the crest. Additionally, the MGUIDE guided surgery system is simple and effective.
For bone grafting, I have tried many materials over the years. Today, I use a variety of materials, including 4BONE BCH from MIS. A combination of mineralized bone and biphasic calcium sulfate, it eliminates the need for a membrane in many cases.
Like everyone else, I depend on 3D imaging for implant treatment, and I own Dentsply Sirona’s ORTHOPHOS. I originally chose this unit because of its seamless integration with CEREC, which I have used for more than 20 years. But more recently, we’ve integrated sleep medicine and airway analysis services into the practice, and with a 14-second scan, I get all the information I need for implant planning and airway treatment.
The CBCT technology goes hand in hand with the scans I capture with my CEREC Omnicam from Dentsply Sirona. Again, originally used mainly for restorative cases as part of the CAD/CAM protocol, its scans can be blended directly into the CBCT scan so we have the option of machining a surgical guide in the office. Additionally, I can mill a temporary for the implant site.
One other instrument that’s really streamlined the implant process is my Solea laser from Convergent Dental. It’s been invaluable for second-stage surgery because I don’t need anesthesia in most cases. It uncovers the implant with little or no blood, and healing is much faster than with traditional methods.
Pick Your Plan
Even though insurance coverage for implants is slowly but surely becoming more commonplace, the average reimbursement rate remains at about 50% of actual fees. Thus, implant treatment remains one of the most expensive services offered in the practice. As a practitioner, you naturally want to be able to provide state-of-the-art implant dentistry for your patients; however, offering financing could be the factor that convinces patients to pursue treatment.
Setting up an in-house payment plan can be time-consuming and labor-intensive for the front-office staff. To minimize time spent on billing and collections, many practices use an outside service to establish and administer financing options for patients. Here are a few solutions that have a successful track record offering a wide range of dental-specific options:
Care Credit offers promotional financing for patients to pay installments over time for deductibles, co-pays, and treatment not covered by insurance, with the practice getting paid in 2 business days. Resources for the practice include online training, marketing materials, and a dedicated provider website. Additionally, CareCredit now integrates into Dentrix and Easy Dental practice management software solutions offered to dental professionals by Henry Schein One.
With Lending Club Patient Solutions, there is no upfront payment, prepayment penalty, or payment due for 3-7 weeks. In addition to fixed-rate plans (up to $50,000), Lending Club offers 2 revolving-line credit plans: promotional no-interest and promotional rate plans (up to $32,000). Patients see all amounts, monthly payments, and interest rates for which they prequalify. The monthly payment is $102 for a $5,000 case with a 7.99% APR fixed-rate plan over 60 months, and the monthly payment is $181 for a $10,000 case with an 8.99% APR fixed-rate plan over 72 months, with the APR based on the applicant’s credit.
Dental Implants Continuing Education Resources
When it comes to implant education, there are many options for those looking for training or to elevate their craft. In addition to the courses taught by manufacturers and universities, here are a few other training opportunities to check out:
- American Academy of Implant Dentistry: The AAID’s MaxiCourses provide the 300+ hours of CE hours necessary to fulfill the CE requirement of the Associate Fellow Member process of the AAID, positioning participants to become proficient in all aspects of implant dentistry. Courses include lectures from experts as well as hands-on participation.
- International Congress of Oral Implantologists: The ICOI directs members to select university-based and private courses that it reviews to ensure they are scientifically based, free of commercial conflict of interest, and meet a high-quality educational standard.
- Atlantic Dental Implant Seminars: Seminars are given in association with the American Academy of Implant Prosthodontics and the Linkow Implant Institute. Training is offered for everyone from beginners to experienced clinicians looking to employ surgical and prosthodontic implant procedures.
- Dental Learning: Dental Learning allows dental professionals to stay updated with the latest advances in treatment protocols, products, and the services available to them. Numerous online CE courses are available on topics such as "Building an Implant Practice" and "Dental Implants: What, Where and Why."