Clinicians share stories of their early days working with implant cases and what’s changed since, and where they think the future of implants may be going.
Advances in implant dentistry have made this treatment more predictable and the process more pleasant for patients, which means more of them are seeking it. For dentists, it is easier than ever to get started with implant dentistry. Adding the service allows you to provide patients with another treatment option and it is a great revenue booster.
We recently spoke with dentists involved in placing and restoring implants about the benefits of offering this treatment and the advances they have seen. There have been many changes, all designed to make procedures more streamlined, outcomes more familiar, and implant dentistry more accessible
John Flucke, DDS
About 10 years ago, John Flucke, DDS, decided it was time to start offering implants in his practice. Patients who needed implants often were disappointed upon realizing they would have to go to another office for the procedure—some would even opt for Dr Flucke to place a bridge rather than put their trust in another team. Patients have a strong connection to his practice, and he saw an opportunity to offer another service they needed.
Dr Flucke was just about to begin taking an implant placement course when he interviewed a young doctor to join his practice—a doctor who had placed about 200 implants during her residency. She was hired and took the lead on placing implants, with Dr Flucke involved with every other aspect, from planning to restoration.
“People develop a trust with their primary dental caregivers and don’t want to go to other places for treatment unless they really have to,” Dr Flucke says. “And most things we were sending out were kind of the bread-and-butter cases—they weren’t complicated. We’ve had a great response and have actually done more implant restorations since we started offering implants here, because more of our patients are going forward with the treatment.”
Over the years, Dr Flucke has seen implant dentistry evolve from a challenging procedure to one that digital technologies have made easier and more predictable.
Today’s workflow is software driven, he says. After taking a 3D scan, dentists can plan the entire procedure in the software, simply by dragging and dropping a digital version of the exact implant they will place into the 3D volume. The software also takes measurements to indicate how much bone is available, which is critical information before the procedure. Once ready, dentists can send the digital file to a lab to create a surgical guide, or they can mill or 3D-print it themselves.
“It used to be [that] the really nerve-racking part of the procedure was the placement,” Dr Flucke says. “Nowadays, the real skill is the software piece of it; the surgical part isn’t difficult at all because everything has already been worked out ahead of time in the software. When you’re done, you have a real-life copy of the digital image and treatment planning you completed on the screen.”
Jennifer Sanders, DMD
Even though Jennifer Sanders, DMD, learned how to place implants after dental school, she has chosen only to restore them in her practice. She would love to add implants to her list of services in the future, and may one day encourage her associates to get the required training and start taking on surgery cases.
Through her research and work restoring implants, Dr Sanders has learned a lot about the different systems—particularly what she likes and what she does not. “The more mature and established I become, the pickier I am about what system I want to work with,” she says. “I’m not afraid to tell my oral surgeon, ‘I don’t like that system, could you use this one instead?’”
The number of implant systems available continues to grow, she says, with each brand offering various styles and parts along with corresponding drivers and wrenches. Smaller companies are starting to emerge, offering cost-effective solutions that make it easier for dentists to offer implant dentistry.
Digital technologies like intraoral scanners and CBCT units have streamlined the entire process, Dr Sanders says. With these advances, placement has become more straightforward and familiar.
One of the biggest trends she has noticed in recent years is the move to a holistic approach, she says. For example, she is getting more requests from patients for ceramic implants because they do not like the idea of putting metal into their body or have discovered they are reactive to titanium. The larger implant companies are starting to offer reliable ceramic options, a trend Dr Sanders expects will continue.
“[Patients] are becoming more aware of the [biological] reactivity,” she says. “It’s not just the shape of the implant or the coating, but also digging more into how a person’s body reacts to it.”
Todd Snyder, DDS, FAACD
As a dentist who started restoring implants about 20 years ago, Todd Snyder, DDS, FAACD, has seen numerous improvements that have led to enhanced predictability and better outcomes for implant patients.
The first is the healing aspect. Traditional stock healing caps cannot, for the most part, create anatomical tissue shapes, he says. Achieving tissue emergence that looks realistic requires the ability to create a custom healing abutment, which is now an option. “This allows the tissue to contour and heal so when it’s time to take an impression to fabricate the final restoration, the tissue has already healed and matured to the shape you want,” Dr Snyder says. “You also have an impression analog that’s custom and basically maintains the same shape of the tissue. You can pick that up in the impression and send it to the lab, so they don’t have to guess where to put it; it’s already been done. You get a better impression and a better final product.”
The impression parts come together easier now, Dr Snyder says, reducing the time it takes to get an accurate impression. For example, you now have scannable abutments that make the process faster. “The impression component has gotten quicker and easier,” he says, “whether you’re working with a custom, open, or closed tray.”
The restorative aspect is also more streamlined, he says. In the past, implants typically featured external connections. Now, most of them are internal, providing advantages including better seating and durability. New drivers also make it possible to gain access to areas where angled screw channels could not go before, another advancement.
“The restorative aspect has gotten significantly better and easier,” Dr Snyder says. “We used to have to do a lot of cemented crowns onto implants. The ability for the lab to do more screw-retained implants makes the process easier and the implants more durable.”
Jeff Rohde, DDS
When Jeff Rohde, DDS, began learning how to place implants about 13 years ago, it was during what he describes as the “era of just trying to get the implant in where there is bone.” He was restoring implants then, so this philosophy often made that task difficult. He found he was getting implants back with angulations that were so off, he knew they would eventually fail. He decided that if he was going to work with implants, he wanted the treatment planning to be prosthetically driven, and that he wanted to do the placing and the restoring.
“It was partially a need for that and partially a diversification,” Dr Rohde says. “I felt like if I really knew the process and really understood osteointegration and how to evaluate [whether] someone has good tissue and good bone, then I would be better as a clinician. I knew it would give me a better big-picture understanding of what clinical possibilities could meet my patients’ needs.”
The implant systems have evolved, with different types of screws and surface treatments among the advances. The biggest change, however, is how easy the process has become. To put in a regular platform on an average-sized implant, for example, only takes 3 drills. Guided surgery protocols also have improved, reducing surgery time to less than 10 minutes.
“We 3D-print a surgical guide in our office, so by the time I get to the implant I already know exactly where it’s going to go,” Dr Rohde says. “There’s no guesswork anymore.”
Navigation systems are available now, allowing dentists to place implants freehand, guided by GPS rather than a surgical guide, he says. That workflow, once laborious and expensive, is becoming more accessible.
Adding implant placement has brought many benefits to Dr Rohde’s practice, allowing him to keep more cases in-house to boost revenue and to alleviate anxiety by offering patients a service they need in an office they know and trust. It also gives him peace of mind to know that when patients return to the office for placement, their treatment has already been planned based on the final tooth.
“The restorative side is a piece of cake now,” he says. “If I can do a digital scan for the final impressions, the crowns just fall right into place and they look great. So, the restorative process is simplified by the fact that we have control every step of the way.”
Joel Rosenlicht, DMD
In the 42 years since Joel Rosenlicht, DMD, an oral and maxillofacial surgeon, began placing implants, he has witnessed tremendous advances in the technology and a huge growth in the treatment’s popularity. With immediately loaded implants now back in favor, things have come full circle.
The first implant he is familiar with, he says, was placed in 1937. The orthopedic bone screw was immediately loaded and lasted for years. Many of the immediately loaded implants placed afterward failed, however, because there was no true understanding of the biology or physiology needed to achieve good bone integration. That has changed. “Because of those failures and the recognition in the late ’70s and early ’80s that titanium was an ideal material because of its compatibility with bone and because you could assure a greater degree of success and integration, there became a strong trend to placing implants in a 2-stage procedure,” says Dr Rosenlicht, a clinical adviser for implant company Ditron Dental. “Now that we really understand the factors that contribute to the success of dental implants, we’re able to go back and place those implants immediately and restore them immediately, as long as we don’t violate any principles [and] contribute to failure.”
New technologies, including surgical guides, virtual navigation, and robotic navigation, have made placement easier and success more achievable, Dr Rosenlicht says. The implants are manufactured with different surface treatments so they can achieve much higher stability in bone. Clinicians now can determine bone density in advance, so they know how to properly prepare the bone, meaning the implant achieves maximum stability. Predictable osteointegration is possible, and that is leading to better outcomes.
Another important advancement in implant dentistry is the recognition that implants, like teeth, can develop periodontal issues. Minimizing peri-implantitis has become a paramount concern, Dr Rosenlicht says, with new implant designs addressing the issue. Platform switching and maximizing bone contact are among the adjustments companies like Ditron are making.
“Having an implant that has very high tolerances and minimal microgaps to maintain an intimate stability with the implant are key factors in minimizing peri-implantitis,” he says. “Some of these newer designed implants with aggressive threads and surface textures that allow for better integration of bone into the implant surface [and] surface platform switching, and these very well adapted components of the implants are all part of the new evolution of implant design.”
Dr Rosenlicht says room remains for growth. As the products continue to improve, so will the success rate. More dentists will be comfortable offering implant dentistry, broadening access to the treatment. Patients who opt for implants will have a better overall experience.
“[Patients] are starting to look at implant dentistry as a mainstream type of treatment,” he says, “and are more likely to choose it over traditional, costly, time-consuming, and sometimes unpredictable restorative dentistry.”