Trends in dentistry: What is currently happening in implantology?

Franziska Beier, Dental Tribune International

Tue. 9. April 2019

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Dentistry is developing quickly and even more so the field of implantology. To update dentists, Dental Tribune International asked four implantology organisations for their points of view on the major developments in implantology in the last two years, as well as which products and procedures guarantee reliable treatment, and their opinion on the increase of discount implants on the market. The representatives generally agreed that digitalisation has had and is having a major impact on dentistry. They highlighted the importance of continuing education for specialities. Even though discount implants are in high demand, the experts recommended that these should be handled with particular care, as they are usually not as well researched and documented as higher-priced models, increasing the risk of postoperative complications.

Dr Abid Faqir, President of the Association of Dental Implantology, UK:

I would say that the most important development in dental implantology over the past couple of years has been the introduction of digital dentistry. By utilising the digital workflow, we are able to optimise the placement of dental implants and restorations. We have seen a huge increase in the adoption of digital technologies in the UK over the last two years.

In dental implantology and other fields, continuing education is key for successful dental treatments. Practitioners need a broad understanding of dentistry, and it is essential to remain up to date with all the latest information in the field to continue providing evidence-based treatment. Mentorship from experienced individuals is just as important. Being a part of bodies like the Association of Dental Implantology provides the opportunity to network, call upon the experience of others and continually make use of carefully designed educational events.

With regard to the predicted increase in lower-priced dental implants seen around the world, I believe there is a similar trend in the UK. As dental implants are available through general dentistry, treatment can be price-sensitive for many of our patients and therefore lower-cost options are in demand. The Association of Dental Implantology has regular meetings with manufacturers and suppliers selling dental implants and related products in order to remain abreast of the latest offerings. There is definitely a place in the market for lower-priced dental implants, as long as they are well researched and documented so that there is no compromise in quality or safety.

Dr Rolf Vollmer, vice-president of the Deutsche Gesellschaft für Zahnärztliche Implantologie [German Association of Dental Implantology], Germany:

First of all, it should be noted that in the surgical field certainly no major advances can be expected, since virtually all implant systems can achieve osseointegration if the surgeon has the appropriate knowledge and skills. What has undergone a positive development is digital technology. Today, not only can guiding templates and mucosa-supported templates be produced at a reasonable price, but it is also possible to print jaw models cost-effectively on the basis of DICOM data from a CBCT device. Thus, for implant insertion, a corresponding drilling template can be manufactured that has a very high accuracy of fit. Bone-supported drilling templates represent a major step forward, since a significantly higher accuracy and only slight angular deviations can be observed. Afterwards, while avoiding additional radiation exposure of the patient, it is possible to check the surgical result by means of appropriate scan bodies and with the aid of suitable scanners. Precise diagnostics and the availability of a 3-D printed model in advance make it easy to identify bone volume and anatomy, as well as any potential difficulties. This means greater certainty for the implantologist before the planning phase. The direct implementation of the DICOM or STL files requires only a CBCT scan before planning and it is no longer necessary to produce radiographic templates with corresponding reference points. Overall, this also means a much lower patient radiation dose. According to a recent review published in the International Journal of Oral and Maxillofacial Implants that analysed 2,244 placed implants, the accuracy of bone-supported templates showed an average horizontal deviation of 1.4 mm at the implant tip. The axial deviation averaged 3.98°. As reported by this study, the navigated procedure is superior to a classic freehand implantation with regard to deviation. In an in vitro study, the authors found axial deviations of 7.63° in freehand implantation. Despite all these advantages, it should be considered that the requirements for the surgeon, even with navigated implantation, are still quite demanding. The same applies to flapless implant placement, which also requires significant surgical experience.

Ceramic implants have once more become quite popular in recent years. The market share is currently at 1.72 per cent. However, one should not forget that they were already on the market more than 40 years ago. I have witnessed this phase personally and regard the development still quite critical for the following reasons. Ceramic implants require a larger diameter than titanium implants, for instance. With the latter, you can still achieve good results with a diameter of 3 mm. Furthermore, as in the past 40 years, some of the ceramic implants are still one-stage systems. This causes an issue in temporary care and handling, since corresponding forces acting on the implants cannot be avoided because they cannot heal covered. Now, there are also two-stage implant systems with carbon or PEEK fixtures available. What is critical is that, to the best of my knowledge, these special fixtures have not yet undergone sufficient testing. In addition, screw-retained superstructures or bar constructions on titanium implants are not possible in this form. Only telescopic crowns are feasible, but must be cemented. It should also be noted that ceramic implants are screwed in at a significantly lower torque compared with titanium implants, such that immediate loading must also be considered critically. In my view, these implants remain, at least for the time being, reserved for a certain client base, those who suffer from titanium intolerance and those with special bone situations that allow placement of implants with a larger diameter.

Performing implant surgeries requires special training. This is possible in the form of curricula offered by scientific societies, including the German Association of Dental Implantology, in which anatomy and complications are taught and discussed in detail. Furthermore, standard techniques, such as bone splitting and sinus lift, but also simple implant cases with sufficient bone volume are taught in phantom courses. The German Association of Dental Implantology was one of the pioneers in this field and has been offering training opportunities for almost 20 years. Personally, I have to say that, especially in the last few years, the trend has been moving away from conventional restoration with a crown or bridge to implant prostheses. Of course, patients should always be informed about alternatives. However, I have to say that patients decide—if financially possible—in favour of implant treatment. Especially in the atrophic mandible—where there are practically no alternatives to implantation—patients should always be informed of the possibility of prosthesis retention on implants.

Regarding the market share of discount implants, it should primarily be noted that the production from the raw material can be done quite inexpensively. Different coatings have reached high quality standards. However, the next step includes quality management. A company visit to a Europe-based business, for example, offers the opportunity to experience how quality management is done. Personally, I have great doubts as to whether this procedure is ensured for discount implants. In May 2020, a new EU regulation is expected to come into force establishing substantial requirements of manufacturers. Thus, it will be impossible for medical devices to be launched without extensive clinical trials. However, the basic system of private testing will remain. It is also claimed that implants, just like medicines, should be approved by the state. In my opinion, this will sort the wheat from the chaff. It is doubtful whether all companies will be able to keep up with these new regulations or whether they will disappear from the market. In this context, it should also be noted that the batch number of an implant is lasered into the bottom of the screw opening. This allows one to determine whether it is an original implant or a copy. In special cases, it has been possible to use the batch numbers to identify human remains.

Dr Ady Palti, co-chairman of the International Congress of Oral Implantologists, US:

The most important development since the last IDS has been the implementation of digital dentistry in the daily practice. Implant dentistry can be achieved today from A to Z based on digital concepts. We can plan the necessary bone augmentation prior to the surgery, plan the perfect implant position based on the prosthetic planning and produce a surgical guide and if necessary, a prosthetic reconstruction, all digitally printed and then milled in the dental practice.

Every implant practitioner should implement a 3-D analysis of bone and soft tissue prior to deciding on a plan for implant-supported treatment.

There is no doubt that prices are a major factor influencing patients and dentists in their final decision-making about implant-supported cases. Value products will increase the possibility of dentists and patients deciding on implant restoration, creating new markets.

The International Congress of Oral Implantologists is the largest education platform in implantology worldwide. We continue to deliver basic and advanced implant education in over 100 countries in the world, and we will continue to develop the skills and knowledge for our members and their patients globally.

Dr Charlotte Stilwell, member of the board of the International Team for Implantology, Switzerland:

The most significant developments in the past few years have focused on concrete initiatives to provide structured educational programmes that start dental practitioners off and then support them along their educational journey in implant dentistry. The ITI Curriculum was introduced to set a global standard for such initiatives. It offers a structured curriculum and high standard of learning that starts at a very basic level of implant dentistry and then successively builds on this to get practitioners started on treatments of straightforward indications before gradually moving forward to more advanced patient cases.

It is the key to equipping general dental practitioners with the core knowledge to enable routine assessment and monitoring and equally importantly basic treatment support for implants and their prostheses.

The ITI Curriculum is also an education pathway leading to international certification at three levels that are applicable to general dental practitioners. The delivery of the didactic and clinical educational formats offers flexibility through a blend of part-time classroom courses, hands-on training, mentored patient treatment and comprehensive, dedicated online ITI Curriculum learning material from the ITI Academy.

The rapid, industry-driven introduction of products and techniques has provided a welcome increase in treatment options and workflows to the benefit of both practitioner and patient. However, the advent of numerous less rigorously researched or documented and discount implant brands represents a not inconsiderable danger that has brought along with it a corresponding increase in implant-related complications.

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