by By Laura Thill
Advances in technology and digital workflow have led to easier implant procedures – both for doctors and patients.
As implant technology becomes increasingly more precise, doctors are encountering fewer complications and patients require fewer re-dos. That means fewer return visits and less chair time – a win-win for both doctor and patient.
“Implants have been greatly improved in the years I’ve been practicing,” says Dr. Brent Mortenson, oral surgeon, Oral Facial Surgery Group, a Mortenson dental partner in Louisville, Kentucky. Newer titanium alloys and the way implants are now prepared have made it easier for doctors to perform the procedure, he points out. “Better implant abutment connections and platform switch design have led to a decrease in peri-implantitis.” Perhaps the most significant advance, however, has been the use of CT-guided implants and 3D imaging, enabling implants to be placed more precisely in the patient’s bone, he notes. Whereas two-dimensional imaging often fails to reveal when there is an insufficient amount of bone for the implant, with 3D imaging “I often can drill through the gingiva and place the implant to depth with very limited tissue exposure, which means faster healing and decreased pain,” he says. Indeed, patients are much happier when their implant is done right the first time, he adds.
“Digital workflow has greatly enhanced dental implant therapy,” says Dr. Mark Nation, a prosthodontist at Advanced Dental Solutions, a Mortenson dental partner in Louisville, Kentucky. “With the use of digital optical scanners, together with cone beam computed tomography, we can quickly treat implant cases, design and produce surgical guides, and create abutments and restorations. The improvement of implant alloys, drill designs and implant surface treatments have greatly enhanced initial implant stability and integration rates, leading to improvements in the size of implants and better predictability in immediate extraction and implant placement scenarios. Smaller-diameter and shorter implant fixtures have proven to be very effective. These smaller dental implants can be utilized in situations where, in the past, the practitioner would have had to perform extensive bone grafting procedures to allow for traditionally sized dental implants.
“Digital workflow in dental implant treatment allows the practitioner to deliver quicker, more precise implant placement through surgical guides and faster fabrication of the restoration,” Nation continues. “Smaller, narrower dental implants reduce the need for costly bone grafting procedures.” This means fewer appointments and less expense for both doctors and patients, he points out.
Common challenges
All that said, even the experts face challenges when it comes to implants. “One of the biggest problems I see in implant dentistry is the lack of proper diagnosis and treatment planning to facilitate the appropriate placement of implants, along with the proper restorative space to fabricate the prescribed prosthesis,” says Nation.
Indeed, a better understanding of restorative designs can decrease the risk of fracture overloading, notes Mortenson. “A Morse tapered connection provides a more stable connection than a butt joint connection and reduces the risk of infection. Additionally, placing an implant at the right height and position helps reduce the risk of complications, he points out. Damage to surrounding nerves, blood vessels and teeth can be caused by improper planning, he explains, adding that a more accurate assessment can be made using CT scanning.
Many patients lack sufficient bone structure, making the implant procedure that much more challenging, according to Mortenson. Such cases require significant bone grafting. Whereas an implant in ample, healthy bone will be successful 95 percent of the time, an implant into grafted material is associated with a lower success rate, he points out. “I’ve encountered problems when an immediate load implant case has been sent to a dentist who does not understand he or she must place a crown that is not in occlusion.” In such cases, it’s common for patients to return to his office with a failing implant due to the traumatic occlusion that the implant was not healthy enough to sustain, he says.
Finally, specialists can get frustrated when they place an implant, and a dentist less versed in restorative technique follows up with a restoration, according to Mortenson. “Many postoperative complications associated with restorations are largely due to a poor restorative design and limited knowledge of restorative issues – particularly occlusion, which is quite different with regard to an implant than a standard tooth,” he explains.
The good news is that advances in implant technology have been associated with a lower risk of complications. “Titanium alloys have led to a decrease in fractures traditionally associated with dental implants,” Nation says. “Also, peri-implantitis, which traditionally has occurred when cement is placed too close to the implant fixture abutment connection, can be avoided by using custom or patient-specific abutments to place cement margins closer to tissue margins and clean away the cement appropriately.”
Successful implants largely depend on how well implant surgeons understand the characteristics of the implant system used at their practice, says Nation. “They must understand and teach whomever they work with the importance of cleaning and servicing the implant restoration and oral environment,” he explains. “Most importantly, implant surgeons must carefully consider the esthetic desires of their patients. They must have an esthetic and oral diagnosis, and they must realize any existing challenges of the patient’s anatomy. They must understand the restorative needs to enable fabrication of an esthetic, functional and serviceable prosthesis.” This applies to all restorations, from single implant to full-arch implant restorations, he adds.
“Most challenges can be remedied through good communication with the dental team,” says Nation. “A restorative practitioner, a surgical practitioner and laboratory must work out the implant case together. When more eyes are on a case at the beginning, fewer problems will be encountered in the end.”
Communication and support
One of the best resources for dentists is the support of other dentists. “No single practitioner, no matter what his or her field of dentistry, can meet the needs of every single patient,” says Nation. In a large dental practice, dentists can share their knowledge and insights with one another, he points out. At a large dental practice, there are always other practitioners to rely on, consult with and ultimately provide patients with a comprehensive treatment plan.
“The best treatment involves adequate consultation and communication,” says Mortenson. “Care should be initiated with a letter stating the desired treatment, followed by face-to-face or telephone conversations to ensure everyone is on the same page. Financial planning should be reviewed with the patient. This is something the patient must understand prior to beginning care to prevent surprises later on. Oral Facial Surgery Group is one of the few organizations I’m aware of that has oral surgeons, prosthodontists and general dentists who can easily interact, see one another’s charts and discuss treatment.”
“Because dental implant treatment is a restorative procedure with a surgical component, there has to be a vision for the final restoration established prior to treatment,” says Nation. “Whoever is responsible for restoring the case must properly diagnose and prescribe the appropriate restoration for the patient. This individual is wise to consult with the laboratory technician early in the process to help with the details of the intended procedures and ensure the proper materials and appointment times are used. Once this is established, the surgeon must have an understanding of the intended prosthesis and be able to plan for appropriate implant placement to accommodate it. This may require bone reduction, bone grafting, soft tissue grafting or a combination of each.
The laboratory can help with design to ensure cleansability as long as the appropriate type of restoration is selected, Nation continues. “The restorative doctor and surgeon must educate the patient on homecare, maintenance and possible re-care. If there is communication and a common understanding across the dental team of what is needed to treat the dental implant patient, there will be a high probability that the case will be successful.”
When can general dentists step in?
Advances in technology have made it easier for general dentists to complete more implant procedures. While this can be a convenience for patients, general practitioners must not take on more than they are comfortable with, warn experts. “As long as dentists have the appropriate training and feel comfortable, they can do any and all surgical components of implant dentistry,” says Dr. Brent Mortenson, oral surgeon, Oral Facial Surgery Group, a Mortenson dental partner in Louisville, Kentucky. “With that, I would recommend that average general dentists limit themselves to very straightforward cases, with adequate bone and no need for significant bone grafting.” With reasonable training, however, in time they can add procedures, he says.
It’s important that general dentists fully assess the patient’s dental and medical history, determine the complexity of the case and understand patient expectations, before agreeing to perform the implant, says Dr. Mark Nation, a prosthodontist at Advanced Dental Solutions, a Mortenson dental partner in Louisville, Kentucky. “They must be confident that potential complications are well within their abilities,” he says. Surgical placement is only one part of a dental implant procedure, and single-tooth implant restorations typically are much more straight-forward than full-arch dental implant restorations.” That said, dentists must have the knowledge to understand the dental restoration that is appropriate for their patients, be able to select the appropriate restorative materials, and understand how these materials will perform in the patient’s oral environment, he adds.
“Specialists are necessary when the complexity of the case – medically or dentally – is beyond the general dentist’s experience, training and/or comfort level,” Nation continues. “Many times, implant cases require considerable grafting of hard and soft tissues to allow for proper implant placement and restoration. Full arch dental implant restorations require comprehensive diagnostics and treatment planning. These procedures are time consuming and quite technical, and many general dental practices do not have the practice flow or fee schedule to accommodate them.
“General dental practitioners must assess the impact of more complex, time intensive procedures, such as complex implant diagnostics, surgery, grafting or multistep implant restorative procedures, and consider how they might negatively impact their revenues, especially if there are complications,” Nation says. “Specialty practices are designed for specific procedures, and the office flow is not affected as it would be in a successful and busy general dental practice.”
Endosteal vs. subperiosteal implants
Both endosteal and subperiosteal implants have a history of success in dental implant, according to Dr. Mark Nation, a prosthodontist at Advanced Dental Solutions, a Mortenson dental partner in Louisville, KY. Subperiosteal implants are comprised of a large metal framework, which is custom fabricated to intimately fit a patient’s jawbone. They are placed on the alveolar bone, below the gum tissue, and usually have trans-gingival struts, which pass through the gingiva to connect to the intended prosthesis. Subperiosteal implants are known to achieve some level of integration and have proven to be effective in some cases.
Endosteal implants are placed directly in the bone and have a connection, which allows for direct attachment to the implant fixture at bone level or tissue level, depending on the implant design. Endosteal implants are prefabricated and the patient’s bone is drilled to accommodate the implant.
When should they be used?
Subperiosteal implants can be utilized in cases of minimal bone, and the bone is inadequate for endosteal implants. If bone height is deficient, a subperiosteal implant can be used since it resides on – not in – the bone. For patients unable to have bone grafts, a subperiosteal implant may be an alternative.
Endosteal implants are the most common form of dental implants today and are appropriate to use when the patient’s bone is adequate to house the endosteal implant without impacting non-osseous structures, such as nerves. The patient must have the minimum bone required: Eight or more millimeters in height and at least six millimeters in circumference.
Endosteal implant procedures generally are less complicated than subperiosteal implant procedures, according to Dr. Brent Mortenson, oral surgeon, Oral Facial Surgery Group, a Mortenson dental partner in Louisville, Kentucky. “Subperiosteal implants generally develop some degree of peri-implantitis and require routine maintenance to help keep them healthy over time,” he says. Also, placing – as well as removing – them often involves a more invasive surgery, he notes.
In contrast, there are a variety of restorative procedures that can be completed with endosteal implants, Mortenson says. “The complication rates are much lower using this style of implant and the longevity of the restoration is much higher.”
