Exclusive Survey: Expected outcomes

Talk with implant specialists, implant manufacturers and dental labs with a focus on implant restorations and one word seems to pop up in every conversation. Get them talking about developments and advancements in the world of implants and it won’t be long before they excitedly bring up the word “predictable.”

That’s because a confluence of developments in implant technologies, techniques and materials is making every aspect of implant treatments more reliable, cost effective and efficient. This means the functional and esthetic outcomes implants make possible never have been more accessible to both clinicians and patients.

“We want our implant and the crown it supports to look like the tooth was never lost. That’s an exciting area that we’re just getting better and better at,” said DPR Clinical 360º Implant Team Lead Dr. Brien Harvey, who practices in Tucson, Ariz., and has more than 20 years of experience placing dental implants.

While he can recall times 15 years back when he’d send a patient out for a bridge rather than placing an anterior implant, today Dr. Harvey is confident in implants as the treatment of choice for missing single or multiple teeth in any area of the mouth.

“I don’t think there’s any question that implants are predictably successful and give us the results we’re looking for,” he said.

What patients want

The days of implants being a surprising option to patients are long gone, said Dr. Robert Miller, who practices at The Center for Advanced Aesthetic & Implant Dentistry in Delray Beach, Fla., and has 25 years of implant experience. Now, patients expect implants as the solution to missing teeth and dentists need to be prepared to meet those expectations.

“There’s no reason to have to prepare otherwise healthy teeth to simply replace a tooth,” he said. “Not everyone will have the confidence to do both the surgical and restorative aspects of implant dentistry. But if implant dentistry truly has become the standard of care, all dentists must be involved in some capacity.”

That seems to be the direction the industry is headed, with 52% of our October Implant Survey respondents saying their practice does not place implants, but 73% saying they’ve attended an implant-related CE course in the last year. For the clinicians not yet involved in placing implants, restoring implants or both, Dr. Miller said now is a great time to add those services to a practice (see “Getting started”) because the development of 3D imaging and treatment planning technologies, milled custom abutments, improved implant designs, and advanced knowledge of hard- and soft-tissue biology are making implant success something clinicians and patients can rely on.

“There’s not one particular instrument or modality, it’s the confluence of all these technologies,” Dr. Miller said. “Each one of those is important, but together they are a game changer.”

Starting at the end

In fact, Dr. Harvey said the development of implant technologies has changed the entire way implant cases are approached. Instead of focusing on the surgery first to successfully place the implant with planning for how to restore the site being left for later, the three-dimensional images from cone beam computer tomography (CBCT) systems and advanced treatment planning software allow clinicians to design the functional and esthetic outcomes and then plan a surgical procedure to place the implant where it will best support that restoration.

Dr. Jay Reznick, who practices at the Southern California Center for Oral and Facial Surgery in Tarzana, Calif., said this development has led to a complete shift in the approach to implant cases. Before the availability of CBCT imaging, surgeons had few options but to flap open the gum and place the implant where the bone looked good. Now, with the guesswork eliminated, the final outcome can be visualized before surgery begins.

“It’s a complete paradigm shift from a surgically directed implant placement to a prosthetically driven implant placement,” he said. “We’re starting with the final result and working backwards from there.”

Starting with a focus on the finish line should be a confidence builder for both doctors and patients, said Dr. Kent Knoerschild, who currently serves as Co-Director of the Comprehensive Dental Implant Center at the University of Illinois at Chicago and is Director of its Advanced Prosthodontics specialty program. In his roles as clinician and educator, Dr. Knoerschild believes strongly in the benefits of designing the case virtually prior to beginning treatment.

Working in 3D

Working digitally makes the actual surgery and the final restoration’s functional and esthetic outcome far more predictable, he said, especially when software such as the Astra Tech’s Facilitate™ treatment planning software (astratech.us) is used to plan the complete implant case from surgery to final prosthetic result. He has used this planning software since its first-generation Simplant was released in the 1990s.

“Quite often you hear people talk about this being surgical planning software, but this is really comprehensive patient treatment planning software,” he said. “We’re looking at it from a diagnostic perspective, and we’re looking at it from a provisional and definitive restoration treatment planning perspective as well. Implant position and angulation is an integral part of that final prosthetic design. For an implant team, it’s a robust and effective communication platform for restoring clinicians and surgeons to make the best treatment decisions for their patients. Because it’s useful with many implant systems, it can be helpful for every clinician.”

Having the extra planning information prior to surgery not only leads to more predictable outcomes, but also helps clinicians streamline the inventory of materials needed for implant cases. Because clinicians can know exactly what to expect during surgery, Dr. Miller said it is now possible to order implant parts, bone graft materials and other supplies on an as-needed basis.

“The instruments that we use give us more information than we’ve ever had before. The thoughtful clinician will use that information to more preplan the case than necessarily to execute it,” he said. “In the early years, we always kept an inventory of implants and parts because we were never really sure what the ridge and anatomy would look like. Today we are able to digitalize a ridge, digitalize the occlusion and then make the appropriate choices. There’s no question that having the presurgical information will reduce the amount of inventory you need, and also helps you select implant types.”

Finding the right fit

Using CBCT scans prior to implant placement offers numerous advantages in terms of locating critical anatomical features and cutting down on surgical surprises, but both Dr. Miller and Dr. Harvey said they do not use the scans for every single implant they place. Dr. Miller said there are some straightforward cases where the scans are not necessary, and experience helps him spot those cases.

The technological advantages offered by CBCT still can’t replace solid communication between a restoring dentist and the surgeon placing the implants as early as possible in a case. While Dr. Harvey said he uses CBCT scans quite often and having a 3D model of the ridge morphology in relationship to the emergence profile for the crown “can make all the difference in having a predictable esthetic result,” being involved in a case early is just as critical, especially when the case starts with a failing tooth that is still in place because that provides the best chance to achieve an outcome that replaces or improves upon what a patient had before.

The true value of CBCT scans really comes into play during complex implant cases that involve placing multiple implants, working around existing implants or placing implants that must work together as the foundation for an overdenture bar. Dr. Harvey said in those cases, digital treatment planning can help create a plan that will require the least amount of tissue management, and this usually leads to better results.

Dr. Knoerschild said digital treatment planning technologies have made a range of new implant treatments available to clinicians, and thus made predictable implant solutions available to a wider range of patients. By planning a case digitally, the design of milled bars and other needed components can be determined and started prior to surgery. With Facilitate digital plans and surgical guides, partial or complete arch provisional restorations can be fabricated prior to surgery using patient casts or stereolithic models. Milled abutments also can be fabricated. This is effective use of clinical time, and patients appreciate the treatment result.

“We can predict how a specific design for a final full-arch, fixed complete denture restoration with a CAD/CAM substructure can be achieved, and we can predict the same patient’s outcome using titanium or zirconia abutments with full-coverage restoration materials,” he said. “The software is really restoration planning software. In fact, all the measurements that one can make within the software world directly translate into the actual work later on.”

Digital throughout

Keeping the digital workflow streamlined and efficient while producing precise and predictable real-world results is the concept behind Straumann USA’s new CARES (Computer Aided REstorative Solutions) digital solutions system (straumann.us). Straumann USA CEO Martin Dymek said the system, which includes a new CAD/CAM scanner for labs, guided surgery software and local template fabrication, updated CAD software, and a partnership with Cadent for incorporating digital impressions from that company’s iTero system (cadentinc.com), offers seamless digital connectivity throughout an implant case that can improve communication between everyone involved, leading to improved outcomes and additional implant case acceptance.

The process can start with a CBCT scan, and that data is directly imported into the coDiagnostiX software, which is used to plan implant and abutment placement and create a virtual treatment plan. One distinguishing, time-saving factor with Straumann’s guided surgery platform is that the surgical stent is fabricated at a local dental lab rather than at a centralized location, helping to further enhance the relationship between the surgeon and the laboratory. The stent is used by the surgeon to precisely place the implants, and if the surgeon has access to an iTero, the lab can get right back to work on the case.

“The surgeon can then scan that implant site and then send that digital information to the laboratory, where the laboratory can begin to develop and design the restorative components literally at the time of surgery,” Dymek said. “This creates a unique digital relationship between a surgeon and a laboratory, which is certainly not a relationship that exists with great frequency today.”

By keeping everything as digital as possible throughout the case, Straumann’s CARES system aims to improve case planning and collaboration and increase efficiency and predictability. With the surgeon, restoring dentist and lab technician all able to work together based on the same digital information, Dymek said the system can lead to greater accuracy in design and production, especially for the complex, multi-implant cases where that level of precision is critical to a successful outcome. By offering a ‘root to tooth’ solution, from initial digital case planning through bone regeneration and implant placement, to CAD/CAM abutment and the final crown, CARES makes Straumann a one-stop shop for the treatment team.

“In many cases, we’re actually looking at a far more precise, more accurate restoration which certainly saves time for the patient,” he said.

Taking the next step

While Straumann’s system makes use of both CBCT scans and digital impressions, for now those two sets of data are used separately during different parts of the case. But Sirona (sirona.com) has taken a different approach by directly integrating the data from intraoral scans captured by the company’s CEREC CAD/CAM system and the 3D CBCT scans from its GALILEOS cone beam system.

Dr. Reznick was among the beta testers working with this new combined system and to this point has handled more implant cases with the CEREC Meets GALILEOS system than any other clinician in the world, covering everything from single-tooth replacements to multi-tooth restorations and even solutions for fully edentulous patients.

The all-digital workflow allows him to design the final CAD/CAM restoration prior to planning the implant surgery that will ideally support the desired functional and esthetic outcome. While the technology has made his treatments more predictable and provided impressive outcomes, Dr. Reznick said the system provides other benefits such as eliminating an entire case planning appointment because he usually has all of the scan data he needs up front.

“At the very first consultation we are treatment planning the implant and scheduling the surgery,” he said. “It’s eliminated an entire visit for the patient, which from a chairtime standpoint, that’s another 30 minutes I can be doing something else that’s productive.”

While adding new technology can increase the costs of procedures, Dr. Reznick said he finds this is offset by the fact that patients are impressed with the technology and his case acceptance rate is now close to 95%, whereas prior to using this combined system it was closer to 80%.

“Patients really appreciate being able to see exactly what I’m thinking of when I’m planning. When you can actually show it to them, it makes a lot more sense,” he said. “Yes it does increase the cost slightly, but it’s actually had just the opposite effect. When patients see us using these techniques, they’re actually more likely to go ahead with treatment.”

He’s also found the system to be a great way to improve his communication with doctors referring implant cases to him as a surgeon. If he only will be performing the implant placement and the restoring doctor has a CEREC unit, both clinicians are able to work off the same data with the restoring doctor designing the prosthesis and then sending Dr. Reznick the files so he can plan the optimal surgical placement for the implants.

Guided into place

For cases planned with the CEREC Meets GALILEOS system or the Straumann coDiagnostiX software, the implant surgeries are guided procedures, with a patient-specific stent designed within the software to ensure the implants are precisely placed in the locations planned in the digital model. Dr. Reznick said he now uses a guided surgical procedure for almost every implant he places because the increased accuracy is the best way to deliver optimal results for his patients.

“Pretty much the consensus is that 15-20% of the implants that are placed are aberrantly positioned in some way,” he said. “Once I started doing guided surgery, my implant placement was perfect every single time, but I also had the benefit of the 3D imaging for every case so I know if there will be anatomical issues.”

Having the surgery planned out ahead of time makes the actual surgical procedures a smoother process, and this idea seems to be catching on with 68% of survey respondents saying surgical guides should be used when placing implants (see “Implants pop quiz” p. 42). Both Dr. Reznick and Dr. Harvey lauded the efficiency that can be achieved through guided implant placements because the guides ensure the implants are correctly angled and seated to the planned depth. For complex, multi-implant cases, the guides can cut surgical time in half, Dr. Reznick said, adding that guided single implant placements can be completed in as little as 5 minutes.

“It’s literally boom, boom, boom, and you’re done,” he said. “With guided surgery, everything is very well planned out, everything is very well controlled. Your success rate is much higher. It’s easier for the restoring dentist to restore the case because everything is where it’s supposed to be. And for the surgeon, it allows you to be more productive during your day.”

The improved accuracy provided by guided surgery is difficult for him to ignore, but Dr. Harvey said it is still important to double-check everything during surgery. Even when working with a custom guide, he still takes interoperative radiographs to make sure even the guided placements are going as planned in the digital model.

“The surgical guides and the CBCTs are maximizing the predictability, but it doesn’t change the importance of precise surgical techniques and monitoring the process interoperatively,” he said.

This is a point Dr. Knoerschild stresses to his advanced prosthodontics students when they are learning implant techniques. He encourages the use of guided surgical techniques, especially in more complex situations. Guided surgery will improve control in accurate placement and surgical efficiency, but he believes they also need a solid foundation in more traditional surgical and prosthetic techniques as well.

Just like with CBCT scans, Dr. Knoerschild said the true value of guided surgery really comes into play during complex cases where multiple implants are being placed at the same time. In those cases achieving the planned angulations, depths and spacing of the implants is critical to achieving a successful outcome and the guides can make a huge difference.

“I think if you’re looking for great predictability for a large number of patients this is a very effective way to go to make sure the implants are placed correctly,” he said. “The more complex the prosthesis design and the greater desire that one wants alignment of the implants a specific way, the stronger the indication for doing it guided. Digital planning guides implant placement and therefore guides restoration.”

Above the implant

Enhanced imaging and case planning technologies are certainly making implant placement more accurate and reliable, but technological developments are also making it easier to achieve the desired functional and esthetic results when the healed implants are restored with an abutment and crown. When it comes to preserving attachment levels and tissue management, Dr. Harvey said it is helpful to begin treatment planning before a tooth is extracted.

Dr. Ethan Pansick, who is in private practice in prosthodontics in Delray Beach, Fla., said developments in custom abutment fabrication can lead to improved esthetic outcomes, and more importantly, improved tissue management. Because implants are round but teeth are not, Dr. Pansick routinely uses custom Atlantis abutments from Astra Tech, which he said leads to better outcomes because, “you’re going to get a molar abutment that looks like a molar or a central incisor abutment that looks like a central incisor.”

He prefers the Atlantis abutments because of the versatility available in material choices and the ease of taking the same fixture level impression, opposing impression and bite registration when prescribing them that he would take when planning to use a stock abutment. However, the biggest advantage in using the custom abutments is his ability to have input on critical design aspects such as setting the margins where they will provide optimal esthetics and optimal ability to clean up cement when crowns are attached.

“In today’s implant arena, one of the biggest modes of failure that we have is that the soft tissue is getting inflamed due to cement left at the margin,” he said. “When the cement cleanup line is much closer to the gingival margin you can get all that cement out much more readily and much more easily than with a stock abutment situation.”

Another advantage of working with custom abutments, Dr. Pansick pointed out, is the ability to reangulate with them so that new implants can work with previously placed implants, and patients with complex anatomical situations can now be good candidates for implant success.

Custom abutments also are great tools for providing outstanding esthetic results, and Dr. Miller said abutment design becomes critical when implants are being placed in the esthetic zone.

Those cases are the ideal situation for using 3M ESPE’s (3mespe.com) custom abutments made with individually colored Lava™ Zirconia, said Roger Dawson, CDT, 3M ESPE Senior Technical Services Specialist. This allows the abutment and Lava coping to be shaded to match each other. Because the lab uses one scan to create and design the abutment and coping, both zirconia pieces can be designed and finished together.

The porcelain work also can be digitally designed using the same scan with the Lava™ Digital Veneering System. The dentist simply provides an implant level impression to the lab, with the lab providing the implant level abutment link for scanning purposes. Because the Lava™ Scan ST Design System is able to scan the abutment link directly, without a scan locator, a wide variety of implants can be restored using abutments made from Lava zirconia.

“The abutment is cemented to a titanium abutment interface,” Dawson said. “This provides a strong metal-to-metal connection between the screw and abutment. Because the screw does not torque directly into the zirconia material, dentists can follow the standard recommendations for torque pressures on the screw and abutment.”

Implants enhanced

With all the attention that is often focused on the computer-driven technologies helping to improve implant placement and restoration design, it can be easy to overlook the numerous advancements to the design of the implants themselves. However, Dr. Harvey said increased implant success and predictability is directly related to the ways implant manufacturers have improved their designs and fabrication processes.

“In my opinion, some of the greatest advances have come from development of the conical interface internal attachments to minimize microleakage,” he said. “It’s amazing to me how the advances in the implant designs over the last 15-20 years have resulted in predictable, maintained tissue health. That’s been huge for me as a periodontist. Now the expectation is that patients will come back with maintained tissue health.”

While stressing that implant choice is especially critical to successful outcomes in the esthetic zone, Dr. Harvey said state-of-the art implant designs are making implants suitable for a greater number of patients, and many of the micro-textured implant surfaces work extremely well. Still, clinicians need to pay attention to the ongoing research into the ways new implant designs can optimize bone healing.

Straumann was looking to expand the cases where implants could be used with the design of the proprietary alloy used in its narrow-diameter Roxolid implants, Dymek said. Those implants were an important advancement for the company because they allow implants to be used in situations where less bone is available for the implant placement. Coupled with the coDiagnostiX planning software, treatment teams working with Straumann can tell right away the amount and quality of bone they have to work with and make the right implant platform selection for a patient’s clinical situation.

“These developments in technology, which Straumann is very committed to, are helping to deliver more predictable implant care to a wider range of patients,” Dymek said.

Dr. Miller said smaller-diameter implants definitely have their place in the modern implant practice, and they are a tool that can expand implant treatment to new patient groups. But while there is a very wide range of implants available for a wide range of patients, it is important for clinicians to understand the advantages of one type of implant over another so they can make the correct choice about what type of implants they will use.

At his practice, Dr. Miller performs a larger number of cases where tooth extraction is followed by an immediate implant placement. For those cases, he prefers to use implants from Intra-Lock International (intra-lock.com) that feature the Ossean® surface treatment that promotes a compressed healing time. Developments such as this are greatly reducing the timeline that patients receiving implants face.

“I can place and restore an implant in two months,” he said. “We no longer have to wait four to six months or longer for a case to be loaded.”

Tomorrow’s implants

Today’s cutting-edge implant technologies allow clinicians to provide patients with amazing results in a greater number of clinical situations, but even more amazing advancements are seen on the horizon. With 3D imaging, computer design and CAD/CAM technology continuing to be developed for more implant uses, a greater number of steps in this process could be handled in office.

Dr. Reznick said he looks forward to being able to fabricate his own surgical guides and abutments, along with full-contour milled restorations on his chairside CEREC system, which would allow for same- or next-day implant treatments.

“I think once you start using this technology and appreciating it, it’s really hard to go back to doing it the old-fashioned way. The technology is readily available, and it’s very reliable. I don’t see a reason why doctors would hesitate to get into this technology for their patients,” he said.

Drs. Harvey and Knoerschild expressed similar thoughts on how advanced implant technologies are making successful outcomes more predictable now and will lead to even more reliable and rapid results for patients. However, just as Dr. Knoerschild wants to make sure his residents learn the fundamentals of implant techniques along with the ins and outs of technological developments, Drs. Harvey and Miller both stressed that clinical skills and knowledge will always be the most important factors in achieving implant excellence.

“The clinicians will always be the most important in this discipline, no matter how many layers of technology you wrap around them,” Dr. Miller said. 

About this survey

The October 2010 Implants Survey was sent via e-mail to general practitioners in the United States. The link was promoted on the DPR Facebook page, where we currently have 5,794 fans. The survey was completed by 307 people.