Terri Lively

Grinding It Out: The Best Material for Bruxers. Image: © RFBSIP - stock.adobe.com


You delivered beautiful dentistry to your patient, but now it’s gone. What happened to it? Bruxism.

Here are what materials our research says you should use for patients who will grind their teeth all over your beautiful work.

Bruxism can happen during sleeping and waking hours. However, some research suggests that daytime bruxism is easier to manage because the patient knows they are doing it. Bruxism that happens while sleeping might be harder to identify and manage because many people don’t realize they grind their teeth while they sleep.

The Cleveland Clinic asserts that bruxism is a common sleep disorder, affecting approximately 10% of adults and 15% of children.

the International Journal of Environmental Research and Public Health 

 The Sleep Foundation suggests slightly lower numbers for the adult population at 8% but a 50% rate for children.

Whatever the incidence rate of bruxism, it’s reasonable to assume some of these people sit in your dental chair. Research published in 2022 in 

 suggests the following when you identify patients who grind their teeth and have damaged their dentition

Practicality is of the essence in treatment planning and the complexities of damaged tissue reconstruction.

Dentists can choose a conformative or reconstructive approach depending on the patient’s grinding style. In other words, the reconstruction should work with the patients’ patterns, not against them.

Tissue preservation is paramount, so directly placed bonded composite materials are an excellent option. The materials are biocompatible, easy to fix, and inexpensive, and they absorb the stress of the patient’s bruxism.

The failure rate is high when the restoration is a complex fixed prosthetic or an implant-supported bridge. Use occlusal splints in these cases. Furthermore, reconstructive options with retrievability and removable features are the most effective prosthetics.

Like any restorative case involving a crown, choosing the right materials for the job is essential to facilitate the best possible outcome. But which is best is a matter of perspective, the bruxism’s severity, the restoration’s location, and the patient’s preference.

For example, clinicians usually restore lost enamel in the anterior, adding material to fix short and flattened teeth. In contrast, posterior repairs usually fix chips, breaks, and fractures.

 Additionally, the esthetic concerns in each area of the mouth differ, which can also affect what you choose.

One suitable option for materials is gold, particularly in the posterior. The most robust material for a crown, gold can be an excellent choice for patients who grind their teeth. It withstands the force of bruxism even better than other materials and is less prone to breaking. It wears similarly to enamel and is easy on the opposing.

Speaker and educator Jeffrey Lineberry, DDS, AAACD, owner of the Carolina Center for Comprehensive Dentistry in Mooresville, North Carolina, says that if the patient is willing to, he suggests gold when bruxism is an issue.

However, gold isn’t immune to the effects of bruxism; patients can destroy that too. Dr Lineberry says that while zirconia, porcelain, and lithium disilicate restorations break, patients usually wear a hole through the gold restoration.

That said, Dr Lineberry says that many patients do not like the idea of gold. Therefore, in cases where gold is the best option for their restorative case, clinicians should explain the benefit of it.

“My simple way of saying it to patients is, ‘Well, I can tell that you don’t enjoy coming to the dentist frequently. If I could put material in there that is not going to fracture and will be the longest-lasting material, would you be interested in doing that?’” Dr Lineberry says. “That’s different than saying ‘I want to put gold in your teeth.’”

Part of the problem is that when some people hear gold, they think it will be too expensive. Dr Lineberry says that when you present it to patients as an investment in staying out of the chair as often, it can help them overcome their anxiety about cost.

However, he also says that before you launch into a new treatment plan, it is essential to consider why the restoration broke or wore down in the first place. Is it a premature contact? Is the damage to the cuspal because of wearing down the front teeth, and now the back teeth are dragging? If you fix the problem but not the cause, you aren’t fixing anything.

“It is essential to look at the big picture,” he says.

However, the best presentation might not overcome the patient’s objection to gold. Another great option when it comes to materials to choose from is zirconia. DDS Lab suggests that zirconia crowns, particularly those made of solid zirconia, are the best option for posterior crowns and bridges.

 also suggests that monolithic zirconia crowns with 1.0-mm thickness had high fracture resistance and low-stress values when subjected to 800 N of loading.

There are a few reasons zirconia works. First, its strength and monolithic nature mean solid zirconia is an excellent choice for patients with clenching or grinding problems. Also, zirconia requires less tooth preparation, so clinicians do not have to remove as much tissue.

In a continuing education course, experts at Dentalcare.com agree that solid zirconia is an excellent option for restoring teeth in the posterior for patients with bruxism because of its substantial strength and the material’s natural translucency. Also, it causes minimal wear on the opposing. However, they suggest layered zirconia for the anterior over the monolithic type because it is still strong but has improved esthetics due to its increased translucency and opalescence.

Another option in the anterior is porcelain fused to metal. It is another esthetic material that is durable and long-lasting. However, it can cause more wear on opposing teeth than zirconia.

Dr Lineberry also likes bonded lithium disilicate in these cases and sometimes monolithic zirconia for single units on back molars. He reaches for these materials when he has a good idea of what the patient is doing with their bruxism and can explain to patients what can happen if they grind on it. Setting proper expectations is critical, Dr Lineberry says.

“I tell patients if they can destroy what Mother Nature put there, they can destroy whatever is man-made,” Dr Lineberry says. “Bottom line, when you have a patient who can clench and grind hard enough to where they fracture a virgin tooth down the middle, that takes an immense amount of force to do that.”

Moreover, Dr Lineberry says it’s not a one-time issue but a cyclical force. If a person is biting and squeezing a thousand times a day or more, that’s a lot different from a person who chews only on a restoration.

“The other critical thing regarding indirect restorations is ensuring you have adequate retention and resistance, but also clearance,” Dr Lineberry says. “The material will not perform ideally if it’s too thin. You want to ensure all those things are right because when we see these numbers on how strong certain porcelain or zirconia is, it’s based on specific parameters. If you have less than that parameter, you will get less than that performance.”

Complications with dental implants are often related to bruxers. Per a 2018 study published in 

, the “excessive occlusal overload” that bruxism results in is the leading cause of implant failure. These failures include implant fracture, screw loosening, screw fracturing, and porcelain fracture.

Assessment of Survival Rate of Dental Implants in Patients With Bruxism: A 5-Year Retrospective Study” found that out of 640 implants, a total of 275 had complications, including 145 screw-type and 130 cemented-type implants. There were 45 complications in single crowns, 125 in partials, and 105 complete prostheses. The failure rate was nearly 42.9%. Between the sexes, the survival rates were relatively similar on a year-by-year comparison and had a 70% rate of survival after 5 years.

the International Journal of Biomaterials

 suggests that night guards are essential to protect the prostheses in these cases. Also, night guards for the maxillary teeth can help clinicians see what’s happening in the occlusal scheme when patients grind their teeth at night. This information can help design the implant case to prevent overloading on the implant in the bone from lateral stresses. Moreover, an acrylic resin night guard can prevent these stresses by distributing the force differently in the mouth.

For example, if the appliance keeps the occlusal contacts in centric occlusion, it can prevent fractures. Also, the colored acrylic resin can show the wear inflicted by bruxism. If it is not worn through, the researchers suggest, the patient’s teeth grinding isn’t generating excessive force on the prosthesis.

The design of the night guard protects the implants, too. By hollowing out the night guard at the implant sites in the mandible, no force is transmitted to the prosthesis. By relieving the occluding surface of the night guard for implant sites in the mandible, the occlusal force from bruxing isn’t transferred to the implants. Additionally, putting soft material around the crowns relieves the stress and decreases the impact of teeth grinding on the crown.

In addition to using a night guard, the Foundation for Oral Rehabilitation recommends finding another way to treat the case that doesn’t involve implants or attempting to address the reasons behind bruxism before placing implants. It also makes suggestions for treatment considerations as follows

determining the distribution and number of implants needed to adjust to the specific biomechanical and clinical requirements of the individual case;

choosing a solid connection, particularly internal or conical; and

changing and reinforcing the prosthetic’s superstructure or design to withstand bruxism force, like splinting through bars, using a removable-only restoration, using flat occlusion, using shortened or no extensions, and being careful with full-ceramic construction.

Dr Lineberry agrees that implants and bruxism have problems. He thinks paying particular attention to occlusion is essential in these cases. Implant occlusion differs from standard occlusion because the implants don’t have the periodontal ligament present, so the teeth compress, and the implants don’t. So, getting that implant-adjusted occlusion right is essential. Also, he designs stress breakers in the restoration.

“Some people may want to make them as strong as possible, but if something is going to fail, I would much rather it be the restoration and not the implant,” Dr Lineberry says. “The implant is more challenging to replace than [to] put another crown on it or to recement.”

So, What Implant Materials Hold Up Best to Bruxism?

The 2012 information on selecting the material for dental implants that can withstand the forces of bruxism was not definitive. Instead, the researchers say that clinicians at the time preferred metal to porcelain to protect the implants, especially for second molars in the maxilla. However, more research was needed at the time to support this preference.

Ten years later, the research is still unclear about what materials to use for implants subjected to bruxism. 

 suggests a few materials that might help diminish the effects of bruxism on the prosthesis. However, it also says successful management has a “poor evidence base.” Moreover, clinicians can try to reconstruct severely damaged dentition, but there are several caveats about how and each requires a lot of maintenance.

 Cleveland Clinic. Updated May 7, 2021. Accessed August 3, 2023. my.clevelandclinic.org/health/diseases/10955-teeth-grinding-bruxism

Osses-Anguita ÁE, Sánchez-Sánchez T, Soto-Goñi XA, et al. Awake and sleep bruxism prevalence and their associated psychological factors in first-year university students: a pre-mid-post COVID-19 pandemic comparison. 

. 2023;20(3):2452. doi:10.3390/ijerph20032452

Suni E, Truong K. Bruxism: teeth grinding at night. SleepFoundation.org. Updated August 8, 2023. Accessed August 31, 2023. https://www.sleepfoundation.org/bruxism

Thayer MLT, Ali R. The dental demolition derby: bruxism and its impact - part 3: repair and reconstruction. 

. 2022;232(11):775–782. doi:10.1038/s41415-022-4293-8

James L. Bruxism: the grind of the matter, restorations.

. Updated February 10, 2023. Accessed July 28, 2023. https://www.dentalcare.com/en-us/ce-courses/ce485/restorations

Abreu, M. PFM vs zirconia: which material is better? DDS Lab. April 23, 2018. Accessed July 27, 2023. https://blog.ddslab.com/pfm-vs-zirconia-which-material-is-better

Lan TH, Pan CY, Liu PH, Chou MMC. Fracture resistance of monolithic zirconia crowns in implant prostheses in patients with bruxism. 

. 2019;12(10):1623. doi:10.3390/ma12101623

Chitumalla R, Halini Kumari KV, Mohapatra A, Parihar AS, Anand KS, Katragadda P. Assessment of survival rate of dental implants in patients with bruxism: a 5-year retrospective study. 

. 2018;9(Suppl 2):S278-S282. doi:10.4103/ccd.ccd_258_18

Komiyama O, Lobbezoo F, De Laat A, et al. Clinical management of implant prostheses in patients with bruxism. 

. 2012;2012:369063. doi:10.1155/2012/369063

Parafunction. Foundation for Oral Rehabilitation. Accessed August 1, 2023. https://www.for.org/en/treat/treatment-guidelines/edentulous/patient-assessment/risk-assessment-special-high-risk-categories/parafunction

Articles

Here are what materials our research says you should use for patients who will grind their teeth all over your beautiful work. 

Grinding It Out: The Best Material for Bruxers

Follow Up Expectations Management With Visuals | Image Credit: © Тарас Нагирняк / stock.adobe.com

It would be nice if patients took their clinician’s word for it every time regarding diagnosis and treatment planning. Luckily, technology can help you show them while you tell them what’s going on with their oral health, which can help improve patient engagement and adherence.

The Agency for Healthcare Research and Quality says that health care is most effective when patients are knowledgeable about their conditions and what choices are available to them. This understanding makes them actively engaged in their care.

Plus, they don’t always take the clinician’s word for it. Brandon Thorpe, DMD, a private-practice dentist at Spring Dental of Lumio Dental in Tulsa, Oklahoma, says there’s been a clear shift in patient education preferences.

“Today, patients want to see the problem related to the recommended treatment plan, and they want confirmation and validation from technology,” Dr Thorpe says.

Managing patient expectations is an essential part of patient education. The Foundation for Oral Rehabilitation (FOR) suggests discussing patients’ oral health goals for a specific treatment. These patient goals should drive the patient education conversation.

These conversations might also reveal the patient’s overarching goals for oral health. For example, some patients may want to invest only in treatments that alleviate pain, while others may want to maintain or improve esthetics.

FOR offers the following areas to discuss with patients regarding their goals for an upcoming restorative treatment plan and delivery:

Evaluating patient expectations in 4 areas: comfort, esthetics, function, and quality of life. 

Determine the primary problem, whether they care about what looks best, whether they need to improve their speech or mastication, and whether their self-esteem is affected by the current state of their oral health.

Discovering how far patients want to go with it. 

For example, do they want full-mouth rehabilitation or wish to concentrate only on the esthetic zone? Is surgery on or off the table?

Determine their professional or personal obligations.

 These areas might drive their decision-making and affect how they approach the provisional phases of treatment.

Then, once these factors have been discussed, the clinician should address the following areas in patient education to ensure the best possible outcome with regard to the patient’s expectations:

What is possible with the proposed treatment and, perhaps more importantly, what isn’t

The treatment times and timelines, as well as the expected recall appointments

What it will cost, and what insurance might cover or reimburse

The patient’s role in long-term success regarding adherence, time, and effort, and, perhaps more importantly, what happens if they do not take that role seriously

The behavioral adaptations required during and after treatment, including smoking cessation, special diets, and pain management

The risks to the patient that are associated with the treatment

Follow Up Expectations Management With Visuals

John Flucke, DDS, chief dental and technology editor for 

, says humans are visual creatures. Dr Flucke, who has a bachelor’s degree in psychology, says one of the fascinating things he learned as an undergraduate was that about 87% of what human beings perceive about their environment comes from what they see.

“There’s the adage, ‘I hear, I forget. I see, I remember,’ ” Dr Flucke says. “That comes into play with this. We saw that in dentistry with the advent of digital x-rays.”

He remembers showing patients their dental x-rays through the view box, showing them the decay, and watching them nod in agreement. However, once he showed them digital x-rays of the decay on the monitor, he was astounded by the difference in patient reaction. He jokes that it was obvious that they were lying before when viewing the old x-rays; their new response was so much more engaged with the image of their teeth and gums.

“When you can show it to people on a monitor, it changes things,” Dr Flucke says.

International speaker and mentor Ankur Gupta, DDS, says patients know more about health and dentistry than ever before, which is both a good and bad thing. The problem with being more knowledgeable is that a great degree of skepticism can occur. However, he says clinicians can consistently circumvent suspicion by using high-level photography.

In the past, the problem was that high-level photography came with high costs, both in time and money. Dr Gupta says that when he opened his Ohio practice in 2004, the TV was $2000, the intraoral camera was another $1200, and the SLR cameras were $1000 each. So, high-level photography already cost over $4000.

The higher costs also came in productivity. Since the earlier cameras were not as intuitive as today’s, Dr Gupta was the only one who took the photos, which was inefficient. The actual dollars and the lost productivity due to inefficiency made demonstrating to patients what he saw in their mouths cost prohibitive. Those barriers to entry have gone away, he says.

“Now, you get a TV for $99 on Amazon and mount it in your operatory. Every single operatory can have a TV. You can get an intraoral camera for $300, and an extraoral camera that is so incredibly easy to use and autofocus that anybody, including the least tech-savvy person in your office, can still grab it, point it, and take some nice photos,” Dr Gupta says.

He appreciates how the imagery changes the conversation. Every patient can see what the clinician sees, such as an open or failing margin or teeth that are tipped.

“For me, nothing has ever been as valuable as allowing patients to look at their oral situation closely with a screen in front of them,” he says.

The Oclean X Pro Digital Smart Sonic Toothbrush uses a gyroscope sensor to track 8 areas in real-time brushing behaviors and identify any missed areas to improve user oral health. | Image Credit: © Oclean

However, patient education is not just for treatment plans and restorative cases. Patient education is also a critical component of preventive care.

Dental hygiene educator and international speaker Katrina Sanders, RDH, BSDH, M.Ed, RF, says dentistry used to have a one-size-fits-all approach to preventive care back in the 1950s. Everyone used the same toothbrush, paste, and floss.

The many options available today make it harder to choose what’s best. Sanders says hygienists should help patients sort through all the information and products available to create a customized care plan.

For example, patients who have experienced bone loss might have more significant embrasures to clean. Therefore, the hygienist should recommend a specialized tool to address their needs. The same concept applies to patients who lack dexterity or have implants or implant-supported dentures. They need different tools, such as electronic toothbrush heads or water flossers, wooden wedges, or picks, to adapt to the restorations’ surrounding areas.

A Sneak Peek at Where Patient Education May Be Headed

As digital technology continues to evolve, the future of patient education has begun to take shape. Our trio of experts—John Flucke, DDS, Ankur Gupta, DDS, and Katrina Sanders, RDH, BSDH, M.Ed, RF—share more thoughts on how this shift involves digital technology that can help with diagnosis, interpretation, and presentation.

Dr Flucke predicts a future where AI provides treatment planning, but also shows patients just what their smile will look like after the treatment. These applications will also play a role in orthodontic simulations. Not only will this system show patients what they can expect from the treatment, but it can also increase the predictability of the case because the workflow is digital.

“You can print those models that are perfect, and then you can tell the person, ‘This is what we’re going to use to build all of this,’” Dr Flucke says. “So, this isn’t kind of what you’re going to look like; this is exactly what you are going to look like.’”

Looking ahead, Sanders thinks the future of patient education on the preventive side is using salivary diagnostic tests in the dental operatory. Gathering the practical data revealed the test is common practice in medical and even veterinary spaces but not in dentistry. Sanders sees that changing for preventive care, putting salivary diagnostics as a standard part of the dental appointment, alongside x-rays and observations by periodontal probing and the naked eye.

Moreover, having salivary diagnostics alongside the other assessments subject to clinical subjectivity might help clarify the best path forward for the patient’s oral health and identify critical signs of other systemic diseases.

“Salivary diagnostics will start predominating as the assessment tool of choice to get practical, objective data about the concentration of bacteria I see in the patient’s mouth. That gives me a lot of information,” Sanders says, adding that it will also help her choose an oral hygiene modality change that will benefit the patient. “Whatever modalities you prescribe, you can institute the salivary diagnostics on the back end to see if that modality has succeeded. We’re able to evaluate the success of our treatment fully.”

Sanders says the American Academy of Periodontology includes salivary biomarkers and C-reactive protein loads to evaluate patient disease progression on the grading forms. Sanders also acknowledges that some practices already employ salivary diagnostics in their patient care protocols. She thinks these forward-thinking practices are elevating preventive care by screening for diseases and hopes that more dental practices will follow the same protocol sooner rather than later.

Moreover, she says, widespread adoption of salivary diagnostics can help identify bacteria that link to other systemic diseases, which enhances the patient-centric experience customized to individual patient needs.

“Now, we can curate that conversation even more and say, ‘Mr. Jones, you have high levels of Fusobacterium nucleatum, and we now know that this bacterium is implicated in colorectal cancer. Do you have a family history of colorectal cancer? When was the last time that you had a colonoscopy?’ ” Sanders says. “It creates a more personalized conversation that meets not only the patient’s oral health care needs but also their systemic health care needs.”

â Editorial Advisory Board, thinks the future of patient education is leveraging social media to showcase one’s practice. Patients will research dental experiences through social media before they call and make an appointment. He says that dentists who will be well positioned are already embracing it and have a social media presence. 

The content doesn’t have to be elaborate, he says. Explaining what a crown or cavity looks like when drilling on it are examples of what a clinician could include. Right or wrong, Dr Gupta, says these presentations could be how patients differentiate a dentist who knows what they are doing from a dentist who doesn’t.

“That’s not fair, and it’s not accurate, but that type of perception will be more rampant,” Dr Gupta. “If you’re going to explain what a cavity is to your patient in the chair, you might as well explain it to your phone so you can post it on your social media.”

She thinks these changes are great for patient care. However, it can also be a lot for patients and oral health care providers.

“The range of what oral hygiene care products looked like in the 1950s to what we would consider to be an oral hygiene care product today has very much expanded in an exciting way,” Sanders says. “But it can also be overwhelming.”

Dr Flucke thinks that the next big moment in patient education will happen via artificial intelligence (AI). In his office he uses Pearl’s Second Opinion, an AI tool that analyzes x-rays. The color-coded areas of the x-ray are where the AI has identified various oral health conditions.

“When you can show somebody an x-ray, that’s one thing,” Dr Flucke says. “But then, when you can show them an x-ray and say, ‘this is the x-ray, and here’s what Second Opinion thinks, and these pink areas show up,’ or whatever color for the type of problem you are wanting to educate on, people can readily see that.”

An aid from AI: Artificial intelligence technology such as Pearl’s Second Opinion can help clinicians communicate clearly with patients.

AI provides 2 things in this scenario, he says. First, it makes it easier for the patient to see. Second, it gives more information, so patients understand there is a problem. Too often, patients equate no pain to no problem in their oral health; however, that isn’t always the case.

“As I’ve said for a couple of decades now, better-informed patients make better decisions,” Dr Flucke says.

“Simplicity is critical in this process,” Dr Thorpe agrees. “Technology like VideaHealth’s dental AI software, digital photography, and intraoral scanning is helping our team provide greater transparency for patients and uncomplicated visualizations of areas of concern. With dental AI, it is like having a secondary expert opinion alongside you during patient interactions, which helps boost patient trust.”

Assessments involving intraoral scanning and case presentation with VideaAI are concise and easy ways to help patients understand what is happening inside their mouths, Dr Thorpe says. All of this adds up to an improved patient experience that brings more trust to the relationship because clinicians are helping patients better understand the “why” behind their treatment recommendations.

“Dental AI allows patients to co-diagnose in a way, as they are more engaged in the process, asking, ‘What is the red box/yellow circle?’” he explains. “All of this leads to increased treatment acceptance and, ultimately, better patient outcomes.”

Also, 3D imaging makes a significant impact on patient education. Dr Flucke thinks that the ability to show patients on a screen the oral condition from every angle adds to their information. Also, using a time-lapse feature for a series of scans over a period can demonstrate to patients what’s happening in their mouths. This feature is excellent for educating the skeptics, Dr Flucke says. It shows patients in an objective way the wear and tear that occurs in the oral cavity over time.

“I love the expression, ‘I don’t fix the blame; I fix the problem,’” Dr Flucke says. “Sometimes people feel judged. But I tell them that ‘This is a judgment-free zone. I’m going to tell you what I see, what I think you need, and we’ll go from there.’”

Technology Helps Change the Conversation, Too

Regarding preventive care, Sanders thinks smart toothbrushes from the manufacturers help the clinician get more involved in the patient’s success with their home care. The data collected from patient brushing reside in the app, allowing hygienists to observe some details. For example, the data include how long and how often patients are brushing, how efficient and effective they are, and how much pressure they use with the brush.

“It has been terrific,” Sanders says. “The technologies that help educate the patient on how they are delivering self-care as a way of helping to maintain the level of work that we do in the operatory also really gives us a leg up in understanding how to support the unique challenges each patient may have in their home care.”

For example, when discussing self-care, the data in the app open up the dialog between clinician and patient and put the conversation back in the patient’s hands. The data also empower patients to take control of their oral health and help clinicians educate them on how their actions affect their oral health.

“Most patients know you should be brushing and flossing your teeth and gums, and yet data points remind us that that is not enough to move most patients to deliver the self-care they need,” Sanders says. “So now these technologies help the patient understand. If they come in for that 6-month hygiene visit and things don’t look good, we can look back at the things that they’ve been doing over the past 6 months and ask them, ‘Has that been serving your oral health, or has that been influencing the level of disease that I see today?’ ”

Patient education happens outside the dental chair, too. Dr Gupta employs the help of a subscription platform called Channel D. Through an app, Channel D produces funny and entertaining videos about dental issues and oral health that play in the waiting room. The content covers topics like explaining implants, what a cavity is, and why patients grind their teeth at night. In addition, the Channel D team can add Dr Gupta’s social media videos and incorporate photos of him and the team into the graphics.

“They superimpose my picture on the animated doctor. It looks like I produced them, but I didn’t,” he explains. “These videos are done in a way that they’re very highly entertaining and they prompt a lot of patient engagement.”

Dr Thorpe sees the future of patient education taking shape now and says it involves digital technology that can help with diagnosis, interpretation, and presentation.

“It will be a system that uses a mix of intraoral photographs/full arch scanning/x-rays plus AI to efficiently interpret and consolidate findings into a concise and easy-to-read visual representation for the patient,” Dr Thorpe says.

Dr Flucke also sees a future where AI provides treatment planning. Moreover, it can show people what their smile will look like after the treatment.

He also sees similar applications for orthodontic simulations. Not only will this show patients what they can expect from the treatment, but it can also increase the predictability of the case because the workflow is digital. The same data for the simulation will be what the dentist uses to build the case. As dentistry moves forward, treatment planning can demonstrate exact results instead of the clinician’s best guess.

1. Patient education and engagement. Agency for Healthcare Research and Quality. Reviewed May 2023. Accessed July 28, 2023. 

https://www.ahrq.gov/health-literacy/patient-education/index.html

2. Patient demand. Foundation for Oral Rehabilitation. Accessed July 26, 2023. 

https://www.for.org/en/treat/treatment-guidelines/edentulous/patient-assessment/patient-demand?active_tid=342

Here’s a look at why patient education is essential, what technology can help, and where the future of patient education is going.

One hundred fifty million—that is the number of persons in the United States who have lost at least 1 tooth, according to the American Academy of Implant Dentistry (AAID). However, clinicians place only 2.5 million dental implants annually.

That means many individuals are missing teeth. How many of them are your patients?

Adult tooth loss is clearly a fact, at least in the United States. However, implant dentistry is not necessarily the treatment modality these clinicians and patients are choosing today.

However, that could be changing. Some analysts predict growth of the global dental implants market to $9.5 billion by 2032,

 whereas others anticipate steady growth in the United States alone to an estimated $2.2 billion by 2029.

 According to the AAID, the driving factors behind the growth include an aging population, a desire to keep one’s teeth, and growing awareness of the advances in diagnostic and restorative techniques for dental implants.

So, what advances are piquing these patients’ interest in dental implants?

Implant Planning and Placement: Automation Will Streamline, Workflow

Alon Mozes, CEO and cofounder at Neocis, Inc, says new planning and image diagnostics technologies are an exciting area for today’s implant dentistry. Implant planning is becoming more sophisticated, with more tools at dentists’ disposal. Automation, he says, will support dentists to the point where even those with limited experience placing implants will have more support from software regarding imaging diagnostics and planning for implant placement that takes advantage of bone density in the area.

“The software will be able to highlight if they’re risking damage to any critical anatomy, like the alveolar nerve or sinuses,” Mozes explains. For example, the software for Neocis’ robotic platform The Yomi Robot colorizes the implant’s surface based on the Hounsfield units in the CT scan. He says the system will indicate whether the dentist is planning in excellent or poor bone and will flash red if they are planning too close to the nerve or risking perforation of the sinus. “That makes it much easier for them to think about planning the implant,” Mozes says.

However, planning is only part of the workflow. Implant dentistry is about restoring teeth. To allow more collaboration and communication, Neocis is also developing sophisticated prosthetic planning, allowing dentists to plant the implants and the restorations in 1 central software ecosystem, Mozes explains.

“That enables dentists to plan the complete end-to-end workflow,” Mozes says. “You can restore the patient’s teeth and get the surgical result you want.”

There are different perspectives on the workflow. Some clinicians care most about getting the implant into the excellent bone. However, Mozes says clinicians on the restorative side want to ensure that the emergence axis is precise for easy, functional, and esthetic crown placement. If you place the implant in the bone but the placement is not precise, it can create problems. “When you get to the restorative side where you have to have custom abutments in a much longer restorative process to get the result you’re looking for,” Mozes says, “you can get some very upset restorative dentists, whereas the surgeon may be perfectly content.”

In addition to facilitating collaboration, these enhancements to implant planning also streamline it. Additional support will be available to dentists to outsource their planning and design to Neocis.

“We’ll have support through multiple avenues, whether that’s through the software itself and automated suggestions powered by artificial intelligence or through a planning service we provide as a company to assist the dentists,” he says. “Then it’s very easy to loop in all those stakeholders, the restorative dentist, the oral surgeon or periodontist, and a lab. All of them need to collaborate along this patient journey forthe best result.”

In addition, the robotic platform makes the lab’s job easier. Surgical guides are not necessary. The plan is in the software, and the robot helps the clinician execute it flawlessly. Instead, the focus is on the prosthetic because the robot covers the drilling and placement. Sometimes, the dental practice can use the file to create the prosthetic in-house. “So, that planning software becomes very instrumental in giving the dentists more control over the entire end-to-end workflow,” Mozes says.

The Yomi robotic platform is comprehensive because it allows you to merge your imaging requirements automatically, like a DICOM CT scan and an STL file from the intraoral scanner. Then, the dentist can review the bony anatomy, surface, and soft tissue and precisely plan the implant location and prosthetics preoperatively. However, the platform continues to support the clinician because the robot arm will physically guide the surgeon interactively to ensure they follow the plan exactly, with haptics and visual displays during implant placement.

“The dentist is always in control of the drill, but as they get close to the surgical site [the platform] will kick in if the clinician diverges from the plan and help them adjust. It will show them on the screen in real time as it adjusts and how they’re improving,” Mozes said. “Most importantly, physically, it’s going to feel like it’s easy to move the angle in the right direction, and it’s going to feel very stiff and resistive when they try to move [in] the wrong direction. It doesn’t move by itself. It makes sure you drill exactly where you intended.”

An additional benefit is that with the robot’s guidance, successive drilling will be in the same spot. Performing freehand surgery, Mozes says, can result in an oval-shaped drill hole by minute changes in the angle. Therefore, the implant will have a snug fit because the drill has more precision coming from drilling at the same angle repeatedly. “Implant stability has a lot to do with the life of the implant and the success of how well that integrates,” he adds.

Mozes anticipates automation handling more of the implant planning steps soon. From nerve planning to sinus outlining and even some restorative steps, like sizing and shaping the crown properly, the dentist can have a streamlined process without too much work. Further out, he sees machine learning algorithms, leveraging thousands of cases Neocis has worked on, automating the planning. “At some point,” Mozes says, “you’ll be able just to push a button and say, ‘Tell me where’s the best implant location for this patient,’ or, ‘What is the best restorative solution for this patient?’ and the software will be able to drop in the implant, put a crown on it, and give it to the dentist for a thumbs-up.”

Dental Abutments: Pulsed Electromagnetic Field Provides Novel Treatment for Peri-Implantitis, Faster Osseointegration, and Tighter Soft Tissue Seal

The osseointegration process and healing time are essential considerations in any implant case. Some of today’s implant designs try to address and improve the outcomes in both areas.

Benny Barak, MBA, ADV, CEO of Magdent—founded by Shlomo Barak, DMD, an oral and maxillofacial surgeon, and Moshe Neuman, DMD, a periodontist with an MSc in bone biology—says the hottest topic in implants is understanding how different companies can create a better, tighter seal between the healing abutments and soft tissue to reduce risk of peri-implantitis. The Magdent-MED (miniaturized electromagnetic device) produces a pulsed electromagnetic field (PEMF) proven to accelerate the natural healing process around the dental implant. Barak says Magdent’s PEMF technology could reduce inflammation and change the bacterial biofilm around implants. “With these 2 factors, we were able to create a faster integration and a better and tighter seal between the implants and our healing abutments,” Barak explains.

The FDA cleared PEMF for the use of stimulating bone growthin 1979 and it has been used since then for multiple procedures in orthopedics. Magdent is the first company to use this novel technology in dentistry. The product is undergoing FDA clearance for the US market.

The MED is made of titanium alloy and fits standard healing abutments into the implant. Clinicians need to activate MED before placement in a 5-second procedure; the MED’s battery then generates the PEMF for up to 30 days after activation.

The MED will be compatible with up to 85% of implant brands, with various models available today including most of the internal hex models of Nobel Biocare, Zimmer-Biomet Tapered Screw-Vent, BioHorizons, Camlog, Astra Tech, MIS, Implant Direct, Hiossen, and AlphaBio, among others. A single-use hex driver comes with the MED to seat it and thread it into the implant with only finger pressure.

Doctors working with the MED found that the gingiva was thicker and more keratinized than the soft tissue surrounding other implant sites. However, there are hard tissue benefits as well, as the MED stimulates osseogenesis and osseointegration, Barak explains. A new study Magdent recently published reveals that using the PEMF technology unique to MED allowed clinicians to grow bone for patients with peri-implantitis, which he describes as a game changer.

“We discovered that the MED helps to accelerate bone formation in peri-implantitis cases. With these improvements, the bone held the implant in its location, and they were able to save those implants for those patients,” Barak says, adding that this is also seen in a follow-up study being conducted in Brazil with Jamil Shibli, DDS, PhD, MSc, of Guarulhos University, that is on track to produce the same result.

Other research published by Magdent implies that even patients with poor bone quality—such as those with diabetes, cancer, or osteoporosis, or even heavy smokers—become better candidates for a successful implant placement. The MED’s abutment technology improves success in these cases normally prone to failure.

In addition, the Magdent MED solution is affordable, especially compared with other market options, according to Barak. Some companies with products that reduce bacteria around the implant charge thousands for their solution; Barak says this focuses on only 1 of several aspects the MED addresses. However, with Magdent’s MED, each clinic acquires 1 activator and then MED products for their patients, at an estimated cost of $100 to $120 per MED.

Looking ahead, Barak sees an aging population with a higher emphasis on maintaining oral hygiene, and an increased need for a solution helping high-risk patients, the number of whom has increased due to post–COVID-19 condition. Also, Barak says multiple resources report a growing global competitive annual growth rate for the dental implant industry. The combination of the growing emphasis on oral health and the introduction of more technology will make implants the standard of care. Barak anticipates that Magdent’s patented ability to treat peri-implantitis will only help grow this trend. Magdent MED has had interest from multiple companies across the European market due to Magdent’s CE mark clearance; the MED is expected to soon be available in the US market.

Moreover, the MED is showing excellent results in tripling acceleration of osseointegration and increasing bone quality around the implant. Barak says that in a study Magdent has published that used rabbits, the PEMF technology increased bone-to-implant contact by 48% and bone volume density by 62%.

“These 2 figures, along with the other outcomes that we saw in the study,” Barak says, “really give a dentist the ability to feel more comfortable when they place implants for these patients [who] suffer from poor bone quality because they know that our technology grows stronger bones for their patients while in the recovery stage.”

Balancing Thread Aggression to Aid Immediacy and Control

Indraneel Kanaglekar, senior vice president and global dental president at life sciences firm ZimVie, says that when it comes to implant design, a few trends drive where things are going. First, companies are focused on bone-level implants, not tissue level. In most cases, implants these days are subcrestal, which is driving more innovation in bone-level implants, Kanaglekar says.

The second trend in implant design development is driving toward immediate placement and restoration, which leads to designing aggressive threads that provide instant stability, allowing the clinician to confidently complete the restorationright after placement. However, one of the problems with aggressive threading is that the implant placement can be hard to control, leading to loss of precision, or in some cases bigger complications. This is mainly if the clinician is not precise enough to keep the placement from deviating, Kanaglekar says. Therefore, development is focused on obtaining precision of placement with primary stability.

“The implant design is moving towards being fully tapered with more aggressive threads while still giving sufficient control to the clinician and striking the right balance between control and aggressiveness to provide immediate solutions,” he says. “With our implants, the T3 PRO and TSX, we worked on that balance where you get the right amount of placement torque and bone-to-implant contact ratio, giving confidence to the clinicians of primary stability while ensuring excellent control.”

In addition to striking a balance between aggression and precision of the design, the engineering team at ZimVie also had to ensure the new implants were compatible with the existing instrumentation and surgical set.

“It was about measuring 2 things: the bone-to-implant contact, which gives primary stability, as well as the torque level when you place the implant,” Kanaglekar says. “We ensured that we achieved that while not going overboard regarding how much the threads protrude from the implant body.”

A third trend in implant design is optimizing the roughness of the surface to enhance osseointegration. Kanaglekar says this effort is significant in the coronal portion of the implant to mitigate the risk of peri-implantitis complications that can create bone loss. ZimVie’s new implants have an acid-etched surface on the top, which is rough enough where it is going to allow bone growth but not excessively rough that it causes infection issues. ZimVie’s acid-etching technology creates a surface roughness that is not hospitable to bacteria, creating peaks and valleys that they cannot reside in, Kanaglekar explains.

“Some companies leave the collar completely polished to minimize the chances of bacteria adhering to it, but that also decreases the chance of initial bone growth after you place the implant because it’s so smooth. So, we believe that getting the balance right is important, and we believe that acid-etching surface technology is an optimum surface roughness that allows the best solution,” Kanaglekar says.

ZimVie is addressing implant design in other ways. The new implants handle various indications with differing sizes and lengths. Also, ZimVie is expanding its portfolio with continuous enhancements to digital workflow, ensuring that the implant procedure is simple and efficient in terms of the total time it takes, uses fewer physical materials, and produces more long-term implants.

“It’s a holistic approach,” Kanaglekar says. “You can’t focus just on software. We start with the intraoral scanner’s integration with the software. Then, it’s going to software that can help dentists plan the surgery and design the guide. After the surgery, our proprietary Encode® technology makes the impression procedure very simple. Then we focus on our patient-specific solutions and how to make it as easy and intuitive as possible.”

Looking forward with implant design, he says the goal would be to make the procedure as simple and patient specific as possible. For now, there are far more crowns and bridges than implants today.

“We ultimately want to come to a point where no matter which dentist you go to, they are going to recommend an implant if you have a missing tooth,” Kanaglekar says. “The advancement of technology and improvement in clinical outcomes should eventually lead to implants being the only solution for a missing tooth.”

Patient-Specific Implants Replace Implant Systems

Iris Wedeking, MBA, CEO and cofounder at iDENTICAL™, says implant design is taking digital dentistry to the next level by challenging the idea that the surgery needs a drill. iDENTICAL’s patented technology creates a personalized, 3D-printed titanium implant modeled from the patient’s tooth. The dentist extracts the natural tooth, scans it, and then sends the scan to iDENTICAL. iDENTICAL then uses its patented design features to create a personalized dental implant the dentist inserts into the patient’s native socket site, no drilling required.

Wedeking says there are numerous benefits to this fully digital workflow. First, because the implant is manufactured based on the patient-specific design, it fits in the socket without drilling. Also, the workflow skips the 3- to 6-month healing time because no bone grafting is required. This makes implant dentistry more accessible; you can place these implants with minimal training because no drilling is required. Placing the implant requires a specially designed inserter, after which the clinician gently taps it into place.

Per Wedeking, the 3D-printed titanium implants are anatomically shaped and have precise features to maximize primary stability and promote faster osseointegration. The porous lattice structure on the apical portion is designed so that the bone grows into and onto the lattice structure.

Wedeking says her husband, a clinician placing implants for 20 years, invented the original iDENTICAL implant design based on the advancements he observed in 3D imaging, digital design, and manufacturing technologies. From CBCT imaging, CAD/CAM, 3D printing, and others, he saw an opportunity to create a less invasive procedure with improved patient outcomes by using 3D imaging to design a patient-specific implant.

“Moving toward patient-specific devices is already happening in other body parts. For example, 3D-printed, patient-specific spinal implants have been around for quite some time,” Wedeking says. “Dentistry is finally catching up.”

Here is a look at key areas where companies have focused their research, from implant planning automation and implant surface technology design to what is next for abutments, and even how some companies seek to reshape the implant workflow entirely.