A Look at What’s on the Dental Implant Horizon

A Look at What’s on the Dental Implant Horizon. Image courtesy of edwardolive/stock.adobe.com.

Fifteen years ago, you wouldn’t find many general dentists placing implants. Specialists handled the bulk of these cases as most GPs just didn’t have the training or skill level required. That has shifted in recent years, with more general dentists now comfortable keeping cases in house—largely thanks to the technological advancements that have streamlined treatment planning and placement.

These advancements, along with more access to education, have made both restoring and placing implants much easier than in the past, allowing the treatment to become mainstream.

There’s also more demand. Today, patients have a better understanding of the benefits implants provide over other restorative options, and more are seeking them out. And, of course, patients are more likely to accept treatment if they know they can have the work completed by a dental team they already trust, rather than going to a specialist they’ve never met before, expanding access to more people who need this treatment.

“Implants have become so much more accessible for patients,” says Neil Park, DMD, vice president of clinical affairs for Glidewell. “Word has gotten out that if you’re missing a front tooth, you don’t have to have the teeth on either side cut down to make a bridge. You have a 1-tooth problem; let it remain a 1-tooth problem rather than turning it into a 3-tooth problem.”

More clinicians are surgically placing dental implants, Jim Janakievski, DDS, of 35Newtons^®️ says, and they are also often completing the treatment in a shorter amount of time. Implant companies have focused on making this treatment more routine, with advancements in implant design that have allowed for more predictable immediate implant placement and immediate installation of a provisional prosthesis.

Adjustments to implant designs and surface treatments also have improved predictability, while digitizing the process has taken the stress out of placement. Dentists no longer have to guess where the implant will go; they know before they start the procedure.

As the technologies, techniques and systems continue to evolve, the process will become more streamlined and outcomes even more predictable, creating a huge opportunity for GPs to offer a new, revenue-boosting service in their practice.

“We have broadened the horizon on who can place implants, and now we have the majority of implants being placed by general dentists,” says Ole Jensen, DDS, MS, Ditron founder and chairman of the board. “They’ve progressed into the area of full arch treatment and couldn’t have done it without using technologies like guided surgery.”

The Digital Workflow

Digital technology has changed how implants are placed. Intraoral scanners and CBCT units make it easy to acquire images and upload them into treatment planning software for diagnostics and to create a surgical guide, either in-house or through a third-party service. Most dentists are using a lab or digital planning company to create these guides, says Stefan Holst, vice president of product and strategy for Nobel Biocare, at least for now, making the digital service aspect an important piece of implant dentistry.

Stackable guides are now a possibility as well, Dr Park says. Often, after extraction, the bone must be shaped, leveled, and reduced. Dentists can create a bone reduction guide and then create another guide that stacks on top to show where to place the implant, making surgery more predictable and faster. Implant surgeries once three hours long now typically take one.

“When you have all that digital data and know where the implant will be placed, you can make the provisional ahead of time,” Dr Park says. “Patients are going to be happy they can walk out of surgery with teeth, making them more likely to accept treatment.”

The goal with all these advancements is to capture digital technology for every stage of the workflow, from treatment planning to placement to creating the prosthetic, says Alon Mozes, CEO and co-founder of Neocis. There’s an opportunity to provide these solutions in one ecosystem, which is what he plans to offer via Yomi, a computerized navigational system for dental implant surgery, in the future. For now, the robotic system has been approved to guide dentists through implant surgery.

Dentists can load CBCT and intraoral scans into the Yomi software to create a treatment plan, Mozes says. Yomi then physically works with dentists during placement to ensure they drill according to that plan. It’s important to note the robotic arm doesn’t perform the drilling, but rather “forces dentists to color inside the lines,” Mozes says, based on the plan created in the software. The plan also can be changed during the procedure if needed, adding flexibility.

“Surgery is the riskiest part of the workflow,” Mozes says. “By introducing robotic surgery, you avoid hitting nerves, sinuses, and anatomical structures and ensure you place the implant exactly where you want it. This enables more flapless procedures, so you don’t have to make a big incision and fold the gums back to expose the bone, which is painful for the patient.”

A process called photogrammetry is also starting to gain steam, Dr Jensen says, particularity for taking impressions after multiple implants have been placed. It has been leveraged in industrial processes for years, recording relationships to mechanical parts using thousands of photographs taken at different angles. It’s not used widely in dentistry just yet, but he expects it to be in the future.

“This is the perfect technique to see the relationship between multiple dental implants in the arch,” he says, noting anyone on the dental team can take the photographs. “It’s on the scale of about 3 times more accurate than a traditional dental impression.”

Intraoral scans have helped improve impression accuracy for single units, he says, but that accuracy decreases when there are multiple. Photogrammetry doesn’t give the soft tissue morphology, however, so it’s important to take a small wash impression and merge the images digitally.

Technologies will continue to evolve, further streamlining the process and enhancing implant predictability in the future.

Shortening Treatment Time

Immediately placing and loading implants is also a trend, Holst says, as there’s now a much better understanding of the biology and what it takes to make it possible. This significantly cuts treatment time and makes the procedure more efficient, according to Indraneel Kanaglekar, Senior Vice president and President, Global Dental, for ZimVie, a company that offers a variety of end-to-end tooth replacement solutions that include implants, biomaterials and digital workflow solutions. Patients can receive the implant and a temporary restoration on the same day, supporting preservation of soft tissue architecture which results in fewer visits overall.

While immediate loading is the direction the industry is going, there are a whole checklist of things that need to happen for that or any type of implant case to be successful. Achieving initial stability, of course, is one, as is factoring in the patient’s health, and compliancy, says Scott McNally, MegaGen vice president of sales, East. Achieving initial stability, of course, is one, as is factoring in the patient’s health, and compliancy.

Every patient is different and taking a more holistic approach to treatment is another trend in implant dentistry. The end goal is to deliver an implant that functions for 20 to 30 years, and to do so as minimally invasively as possible.

Advances in Implant Systems and Components

Changes, such as improved surface technology and macrogeometry, have been made to the implants themselves over the years with the goal to consistently achieve immediate/primary and secondary/long-term stability. Doing so helps improve longevity and lowers the risk of problems, such as infection and bone loss, that can lead to failures.

Tapered implants with more aggressive threads are providing that primary stability, Dr Park says.

“Every study you read, the first thing that’s mentioned is primary stability. Through the patented thread design of the AnyRidge implant, you can attain that ideal stability. Better surface technology such as the X-Peed surface is key,” says Joel Gonzales, vice president of sales, West, for MegaGen America, noting that’s a focus at the company. “We can’t control the patient’s physiology, but we’ve done everything we can to stack the cards in our favor to make sure there’s safe and better osteointegration. If you have primary stability everything else falls into place, and the thread design is what definitely provides it.”

There’s also now more focus directed on long-term maintenance, Holst says, to avoid complications down the road. Clinicians are recognizing that screw-retained implants are more predictable than cemented restorations, for example. Soft tissue is becoming more relevant as clinicians now understand it’s not just the implant but the whole system that determines long-term success.

One area manufacturers are addressing is the implant’s fit to the abutment, Dr Jensen says. If the fit isn’t just right, bacteria carrying fluid and titanium particles can move in and out of the gap—leading to bone loss and, for some patients, peri-implantitis. Attachments like Ditron’s internal hex allow for that precision fit with a sub-micron gap, keeping bacteria, fluids, and particles out. Making the top of the implant narrower also helps, as it moves the gap where bacteria can flow further away from bone, Dr Jensen says. Through this platform bone switch, there is bone at the crest of the implant rather than titanium, and that leads to healthier bone and fewer complications.

Custom abutments make a huge difference. Changing the mindset to use custom implants can also help in the long term with over-engineered molar implants.his ensures a precise fit for the crown, minimizing the micro-leakage in the abutment interface, which leads to problems by not using OEM parts, Gonzales says.

People come in different shapes and sizes, so it’s important to develop different core sizes to match different widths of ridges to have ideal long-term biologic factors such as ridge width and thick, soft tissues. With the wide cores, we now have custom implants as well, something MegaGen offers with the AnyRidge implant line.

Today, more clinicians understand the benefits of a retrievable implant restoration design, says Dr Alexander Shor of 35Newtons. With advancements in implant component design, clinicians can now have a restoration fabricated with an angulated screw channel, making it simpler to accomplish retrievability where implant angulation often complicated this type of design. Progress with other materials such as 35Newtons’ screw channel barrier FirstPlug^®️, now allow for an efficient technique for sealing the implant screw channel.

FirstPlug is a patented medical grade polytetrafluoroethylene (PTFE) material that is engineered to be placed into the implant screw channel. The design has been optimized for efficiency and patient safety. It is a replacement for off the shelf products like cotton pellets (which harbor bacteria), gutta-percha and silicone (which are difficult to handle), and plumber’s tape (which is an industrial product).The material properties allow for ideal compaction and support for the overlying resin-based material.

Connections between the implant abutment and the restoration also have become much stronger, Dr Park says, another advancement improving predictability.

Better Techniques, Better Outcomes

Over the years, drilling protocols have become more streamlined, Dr Park says, and dentists are now using fewer drills during placement.

There are also advancements being made to the drills themselves. For example, many of the drilling systems heat up the bone, causing damage, Dr Jensen says, an area Ditron has addressed. Another issue is drills are often sterilized and reused. This leads to degradation of the drills and the chance small contaminates can be left behind. Disposable drills may be the answer and are becoming available.

“In the beginning, we told dentists to use a certain drilling protocol regardless of how the patient presented to you,” Dr Park says. “Now, based on the density of the bone, there could be alterations to the protocol. Osteotomes are also being used instead of drills, which can create the implant site without taking bone away. Osteotomes compress and compact the bone instead.”

More dentists are also using bone substitutes, either animal or human derived, to ensure there’s sufficient bone and to improve esthetic outcomes, Kanaglekar says.

“More than half of implant sites need some type of hard or soft tissue grafting procedure before they’re ready to accept an implant,” Dr Park says, noting Glidewell has streamlined the choices, making it easier for dentists to keep these products on hand. “We now have very straightforward material choices for hard and soft tissue grafting.”

Along with treating patients more holistically, dentists are looking for more minimally invasive techniques, says Emelie Gonzales, president of MINEC America (MegaGen International Network of Education and Clinical Research). Partial extraction therapies (PET), which include the socket shield technique, the root submergence technique, as well as pontic shield, are all procedures that protect the bone. When used correctly, they create what Gonzales describes as “the best natural bone graft.”

There are now systems that offer a different approach to how an implant site is prepared, Holst says. Nobel Biocare has created an implant with a biologically driven site preparation protocol. The new tool shapes the bone at very low speed and without water irrigation, minimizing trauma and maintaining cell viability in the implant recipient site. This enables faster healing, better initial stability, and a more predictable result.

Having sufficient bone is critical to longevity. These advancements focus on that area and will only continue to improve in the coming years.

Looking Ahead

As patient demand continues to grow, Dr Jensen predicts just about every dentist will offer implants in the near future, even specialists like orthodontists. The number of implants placed can easily double in the coming years, especially as a growing number of dentists move to a digital workflow, representing a huge opportunity.

The procedure will continue to become simpler, faster and cheaper, Kanaglekar says, with technologies like digital imaging, guided surgery, CAD/CAM technologies to produce patient-specific solutions. There also will be an increased use of biomaterials to ensure patients have sufficient bone and that and that tissue is formed in a way that leads to esthetic outcomes.

Advancements in technology will allow dentists to routinely manufacture provisional and permanent restorations in their own office, so less fabrication work will be outsourced to dental labs and other third parties, Dr Shor says.This is possible today, with single unit restorations and surgical guides. With increasing ease, accuracy, and materials, this will be a natural transition.

Immediate loading will become more common as implants are developed specifically for this purpose and as digital planning becomes even more robust, Dr Janakievski says. The entire procedure will become easier, as clinicians will have access to simplified software solutions and clinical instrumentation along with the support and education they need to make it all possible.

“The digital processes are just going to get better and better,” Dr Park says. “So many times, when people do a full arch they’ll convert an existing denture or a pre-made provisional denture, and that’s a messy, time-consuming process. Now, we can mill ahead of time and create a nice fitting provisional that’s’ easy to deliver, greatly reducing treatment time. In the future, that provisional is going to be printed, and dentists will have the ability to do that right in their offices. It’s really all about the digital technology.”