The advent of CAD/CAM technology and other significant advances continue to boost confidence in implant restorations among dental professionals.
"Implants are no longer 'smoke and mirror' technology. They've proven themselves and, for the last five years or so, many technicians and dentists consider them to be the standard of care for qualified patients," says Chris Morris, owner of ADL Dental Laboratory, Louisville, Kentucky.
Once skeptical of the complexity and long-term viability of implants, restorative dentists have become more comfortable prescribing implants as the first choice in tooth replacement and view them, in most cases, as the best method of preserving bone and tissue. "Restorative doctors now look at implants as an essential part of their armamentarium; it's an everyday part of their practices," says Dr. Mark Cherewka, the on-staff dentist at Thayer Dental Laboratory, Mechanicsburg, Pennsylvania.
In fact, some restorative doctors - albeit a minority at this point - have gotten so comfortable with implant therapy that they're placing some implants themselves. Thanks to implant companies' comprehensive educational offerings, these dentists are being encouraged to retain the surgical procedures in their own practices, especially when placing the more straight-forward cases, such as single implants and those in the lower anterior jaw. "This allows dentists to keep all of the fees in-house - they get paid for doing the surgery and for restoring the case," says Steven Pigliacelli, vice president, Marotta Dental Studio, Farmingdale, New York. "Also, since they're doing all the work, some dentists reduce their fees to the patient."
Implants Meet CAD/CAM
CAD/CAM technology has brought the same precision to implants as it has to all-ceramic restorations. "CAD/CAM is impacting every phase of implant fabrication from case planning through the final restoration. It is here to stay," says Colin Gibb, CDT, owner, Red Mountain Dental Arts, Mesa, Arizona.
CAD/CAM has had the greatest impact for laboratories in the fabrication of custom-milled zirconia and titanium abutments, which are offered on an outsourcing basis from manufacturers including 3i, Atlantis Components, Nobel Biocare and U-Best. Eliminating the labor-intensive process of waxing, casting and finishing custom abutments, this process enables the technician to design the abutment on a computer and then have the abutment milled at a centralized manufacturing facility. "We do 90% of our abutments this way," says Greg Thayer, owner of Thayer Dental Laboratory. "It's just a much more accurate process, especially in cases where the implants aren't parallel. It's a beautiful thing when you open the box and have perfectly placed abutments."
Laboratory owners also extol the virtues of milled titanium bars. "Because the bars are milled from solid titanium, we have no more worries about the variables caused by casting or welding," says Jeff Stronk, co-owner of Treasure Dental Laboratory, Salt Lake City, Utah. "And since titanium weighs considerably less than the precious metals previously used, there's greater patient comfort."
CAD/CAM technology is also the basis of a few diagnostic systems that are enhancing the accuracy of implant placement itself. Although CT scans have been used for some time in treatment planning, these new systems - including Nobel Biocare's NobelGuide and Materialise's SimPlant - allow the scans to be integrated into diagnostic software. The CT scans are converted to a 3D image to precisely analyze bone density and availability; to more accurately see nerve bundles, mental foramina and other critical points of interest; and virtually plan the case.
The information from the image is then used to produce a surgical template so the doctor knows exactly where the implant is to be placed, resulting in less traumatic surgery. "Instead of flapping the ridge and looking to see what the bone is like, we're able to completely plan the surgery on the computer screen and adapt it to get the desired results," says Morris. "It's putting the cart behind the horse instead of before it."
A number of other advancements are also working to increase confidence and implant acceptance, including:
Immediate-loading implants. These one-stage implants - in which the provisional restoration is attached immediately after surgery - are becoming more prevalent because patients can receive permanent restorations in as little as four to six weeks. "The time-savings is the real benefit to immediate loading. People want results in a New York Minute, especially here on the east coast, and can get their permanent restorations without waiting 16 weeks," says Larry Borman, co-owner of Tetra Dynamics, Inc., West Babylon, New York.
Internal connection designs (including internal hex, tapers and lobes). While external hex designs were once the most common, the internal configurations have gained popularity because they typically offer stronger abutment connections and fewer problems with screw loosening. "Internal connection designs are easier for dentists to restore because they are less technique-sensitive and more user-friendly," says Thayer.
Emphasis on tissue and bone preservation. Among developments in this area are implant surface coatings and designs that aim to enhance osseointegration and maintain soft tissue. Though in the past the most common implant surfaces were machined titanium or hydroxyapatite coatings, many implant companies are now reporting even better results with alternatives, such as titanium coatings or plasma sprays, acid etching or microthreads.
A newer concept with the aim of maintaining soft tissue and bone is platform switching, which means using a prosthetic component that has a smaller diameter than the implant collar, rather than a component and implant with the same diameter. This creates a shoulder between the implant and the abutment, which has shown to enhance tissue and reduce crestal bone loss.
"Tissue management is a hot topic in implantology right now," says Gibb. "Generally, all implants on the market integrate into the bone, but a key concern is how to maintain bone and tissue levels and how the tissue responds to the surface design of the coronal portion of the implant."
The myriad technological advancements are certainly raising the bar: as implants become easier and more predictable from the laboratory, clinical and surgical perspectives, there are greater expectations for the final result. "In the past, the restorative dentist was always happy with an implant as long as it osseointegrated," says Borman. "But now it also has to function well, fit well and look great."
Patients are on board, too
As with cosmetic restorations, consumer demand for implants is being fueled by makeover shows as well as direct-to-the-public marketing, such as Nobel Biocare's recent 'NobelSmile' television commercial (click here for the article). Like the pharmaceutical companies that market drugs directly to the patient, many laboratory owners say this type of consumer-targeted promotion will grow in our industry and increase the likelihood of patients asking about implants as a restorative option.