Implant Tribune UK No. 1, 2015

Dental implantology: Evolution or the road to ruin? / Managing patients with risk factors / Peri-implantitis: Is it a crisis? / Making implantology affordable

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IMPLANT TRIBUNE
The World’s Implantology Newspaper · United Kingdom Edition
www.dental-tribune.co.uk

Published in London

Vol. 9, No. 3

Dental implantology: Evolution
or the road to ruin?
By Aws Alani, UK
Teeth are highly evolved structures
that have developed progressively
over millions of years in attempts to
protect themselves from caries and
periodontal diseases. Over the years,
many advances have been made that
can treat these various diseases predictably. Various strategies have been
developed to prevent or slow down
these problems given adequate patient compliance and appropriate
personal and professional maintenance.
Despite these very significant improvements, there are still instances
when patients are advised that one
or other tooth has to be extracted.
It is the obvious sadness, heartache
or despair that patients are caused by
this bad news that has driven, caring

clinicians to find ways to replace
teeth with various devices, including
dentures, bridges and implant-retained prostheses.
P.-I. Brånemark, now sadly deceased, famously quipped: “No one
should have to die with their teeth
in a glass of water beside their bed.”
His original inspiration coupled
with determination, intuition, passion and an ability to surround
himself with a great team of individuals with differing skills made
osseointegration much more predictable. Brånemark’s landmark
studies changed prosthetic dentistry
dramatically, but a careful look at
the design of these protocols and the
implants themselves reveal that they
were hugely different to the patient
selection protocols and the types of
implants being placed today.

Furthermore, the restorations supported on them were made of the established materials then and obeyed
traditional mechanical laws. In terms
of biological cleanability, the metal,
polished “high water” abutment design
allowed for optimal interproximal
cleaning, while the implant surface itself was also relatively smooth in comparison with the rougher surfaces we
often see today. Market saturation,

cost, profit and market share in many
technology-driven markets often pursue innovation of some sort of change
to help gain greater market share or
profit. The over-commercialisation of
dentistry generally creates a constant
turnover of supposedly new and better
products, where the common notion
of “if it ain’t broke don’t try to fix it” is
lost on many directors of marketing or
increasingly profit-driven CEOs.

Why and where?
Where this technological change
has taken implantology and what
the real reasons are that this was and
is happening need to be examined.
Increasingly, the shadow of periimplantitis looms likes a spectre
over the provision of implants. Unlike caries or periodontal disease,
there is very little consensus or reAD

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[2] => Untitled

IMPLANT NEWS

Implant Tribune United Kingdom Edition | 3/2015

Ethical, moral
and legal issues

search that can provide a predictable
cure for what now is now a new breed
of disease. Peri-implantitis is relentless once established within fine
threads of the implant, and the bone
resorption and soft-tissue problems
that follow can result in spectacular
problems. Part of the key issue probably lies in the surface exposed to
the susceptible patient’s oral environment, as most microbiologists
will allege. The bacterial content and
make-up of the biofilm is a reflection of the surface on which it resides. Implant surfaces have become
progressively rougher in order to
hasten the early osseointegration
processes and to try to provide patients with their restoration quicker
in an ever more competitive financial environment.
However, speed is not always helpful. Experience shows that some
things are better achieved gradually.
Once exposed to the environment
of a susceptible patient, the macrotopography of the threads provides
an ideal ecological niche for bacterial
proliferation. Further nano-level
features make the implant surface

These problems become much
more worrying when viewed from
ethical, valid consent and medicolegal perspectives. This is particularly
so when patients are convinced to
undergo elective extractions of teeth
that often seem reasonably intact or
treatable with conventional proven
treatment strategies.

a veritable inflammation super
highway for the pathogenic organisms. Predictably enough, the microorganisms found on the rough
surface are usually the common
pathogenic ones, but also some
species are found that have previously never been discovered in the
oral cavity.

Patient selection issues
We need to consider the types of
patients whom we are now accepting for implant provision. At King’s
College Hospital, the criteria for statesponsored implant provision largely
involve patients with hypodontia
and those who have suffered trauma.

Usually both cohorts are likely to
present with well-maintained, minimally restored dentition or with scope
for oral health improvement prior
to consideration for any restoration,
let alone an implant. Unfortunately,
we are unable to provide this treatment for smokers.
This is in stark contrast to the patients
who may be provided with implants
in general and specialist practice, such
as patients who are likely to have lost
teeth as a result of plaque-associated
diseases. Indeed, it could be considered
a paradox by many interested observers that some clinicians are providing
patientswithimplant-retainedrestorations when they have shown that they
are highly prone to plaque-associated
disease via tooth loss and have not
demonstrated any real capacity for
changing that. Patients who smoke,
those with a history of periodontitis
and those with poor oral hygiene are
well known to be at a very significantly
higher risk of peri-implantitis.

The Dental Tribune International
C.E. Magazines
www.dental-tribune.com

Biological versus
mechanical problems

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If we are being frank, the pathogenic
bacteria-induced diseases are not the
only long-term problem that we are
now seeing. The reported frequency of
mechanical complications has risen
over the years, but the reported problems are probably only the tip of the
iceberg, as many complications have
not and will not be reported for a
variety of understandable reasons.
Over time, the components of implants have shown notable weaknesses. Screw loosening, fractured
screws, loose abutments and the cracking of ceramic can be laborious and expensive to manage. One aspect, which
may be lost on some, is that since they
lack a periodontal ligament dental implants cannot and will never be able to
acclimatise to changing occlusal and
non-axial forces. These are very likely to
create stresses within the masticatory
system, thereby resulting in breakages.
These forces are compounded greatly
if patients exhibit parafunction on
a daily basis and that is sometimes an
unknown risk factor until it is too late.
The more implants that are placed, usuallythefewerteetharepresent,resulting
in a net reduction in physiological feedback and thereby creating an increased
chance of failure of some type.

It appears that there is a worrying
drift towards aggressive treatment
with extractions in order to provide
a supposed full-mouth rehabilitation
with multiple implants. The increasingly dubious practice of sacrificing
teeth for the sake of implants appears
to many concerned clinicians to be
quite irrational. As ethical oral health
practitioners, deliberately removing
saveable teeth for prosthetic replacement using implants as support appears to be consciously flying in the
face of increasingly apparent evidence of various complications with
implants and many would consider
that approach to be foolish. How
many “implantologists” doing that to
others would genuinely have it done
to themselves or done to some close
family member?

Planned obsolescence
A state-of-the-art implant today is
likely to be obsolete tomorrow. Electively removing teeth is irreversible
and replacing teeth with implantretained devices means that patients
are trapped in the era of the implantology in which these were placed and
restored, that means issues of machining, surface blasting, roughness,
platform switching, design and attempts at bone augmentation by
cow, coral or Californian substances.
The list goes on and on and will probably continue to expand with what
many might consider human experimentation without licence.
Now comes the time for implant
manufacturers to take stock of their
many “market-driven” mistakes, including fast initial integration with
the roughest possible surfaces. Instead
they need now to produce proven
(i.e. not speculative) designs to better
prevent these well-known problems
of infection and breakage.
A wiser, pragmatic approach appears to be to concentrate everyone’s
efforts on saving teeth and thereby eke
out their usefulness for the patient’s
lifetime. Recently, the legendary Prof.
Jan Lindhe, interviewed in the British
Dental Journal, summarised the state
of play as follows: “There is an overuse
of implants in the world and an underuse of teeth as targets for treatment.”

Aws Alani is
a Consultant in
Restorative Dentistry at Kings
College Hospital
in London, UK,
and a lead clinician for the
management of
congenital abnormalities. He can be contacted at
awsalani@hotmail.com.

[3] => Untitled

IMPLANT NEWS

Implant Tribune United Kingdom Edition | 3/2015

Managing patients with risk factors
values to help guide treatment decisions and as a communication tool
with our referring dentists.”

By DTI
GILLINGHAM, UK/GOTHENBURG, Sweden:
Requests for shorter treatment times
along with an increasing number of
patients with risk factors place greater
demands on dentists and technology.
Correctly assessing osseointegration
and implant stability and is key in
successful implant treatment. Using
traditional methods such as torque
and percussion tests are not suitable
for monitoring osseointegration, it
requires a more advanced diagnostic
tool.
Gain insight from these esteemed
periodontists on what they do to objectively and noninvasively identify
which implants are ready to load and
which ones need additional healing
time.

Dr Paul Rosen, Clinical Professor of
Periodontology & Oral Implantology
Temple University Kornberg School
of Dentistry in Philadelphia, USA,
also explains below why Osstell is
important in his practice.

Dr Pamela K. McClain

Dr Rachel Schallhorn

Drs Pamela K. McClain and Rachel
Schallhorn, both Diplomates of the
American Board of Periodontology,
have been using Osstell and the ISQ
scale (Booth 43d) for a number of years
now to measure primary implant
stability and osseointegration.

plant stability,” they say. “At the time
of placement if the ISQ is too low (depending on the location—anything
below 45) we will remove the fixture,
possibly graft and then wait another
3–6 months before trying to place
another fixture. We try to take the
measurement on the buccal/lingual,
and mesial/distal aspects and record
the highest and lowest values.”

is stable if the number was high to
begin with—over 65) we will release
the patient for restorative treatment.
It gives us and the patient a more
objective way to assess the implant
stability. If it’s not ready at that time
we continue to recheck every six

“We are currently using Osstell
when we place all implants to establish a baseline measurement of im-

McClain and Schallhorn add: “We
typically recheck the ISQ value at three
months. If the ISQ has improved (or

“THE REVU”
launched by
Straumann

By DTI
CRAWLEY, UK: To facilitate online
communication within the implant
industry, Straumann has recently
launched a new digital hub for dental
professionals in the UK and Ireland.
With a look of a stylish digital magazine, the THE REVU platform will feature news and clinical cases, among
other content covering everything
from the dentistry industry and marketing to business and education.
According to Straumann, THE REVU
is taking an original approach to blogging and video blogging (vlogging),
delivering the perfect combination of
branded and non-branded editorial
and video content. The platform will
launch with interactive questions and

Dr Paul Rosen

weeks until the ISQ has improved or
indicates stability.”
“Since we began using this device in
2009, our decision making process
has become more simple and objective. We will continue to use the Osstell

“Osstell use is critical for my implant practice. Every year, this device
more than pays for itself as there
are always several patients who heal
slowly or who have implants placed
with extremely low insertion torque.
This confounds my ability to predict
when healing has been adequate to
proceed to the restorative phase.
Osstell provides me with quantitative information necessary to make
informed decisions. No longer am
I the villain who slows up patient
care, but it is objective data about the
patient’s healing that becomes the
determining factor.”
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answers, scientific
reviews and an inside look into one
clinician’s journey
into implants. It will
tell a different story
every day by bringing new and informative content
to the fore in a clear
and simple manner, Straumann’s
Head of Marketing
and Business Development in the UK
and Ireland, Justin Annett, said.
“The launch of THE REVU is a fantastic opportunity to transform the
way we communicate online. Our
aim is to build an online community
that embraces not just our company
values, but all dental professionals
connected with implant dentistry
too,” he commented at the launch.
“Taking the leap into digital is
courageous, but one which we feel
continues to keep us at the forefront
of both our and our customers’ marketing activities.”
Dental professionals can access
the site via their computer, laptop or
mobile device at www.therevu.co.uk.

www.fdi2015bangkok.org
www.fdiworldental.org

[4] => Untitled

TRENDS & APPLICATIONS

Implant Tribune United Kingdom Edition | 3/2015

Peri-implantitis: Is it a crisis?
By Dr Michael R. Norton, UK
this condition is often asymptomatic to the patient and as such
is typically only diagnosed at
routine recall. Hence there is a
need to recognise that when implant treatment is completed the
patient should remain on annual
reviews for at least the first five
years, and thereafter once every
two years.
On presentation with mucositis
a combination of mechanical
debridement and sub-mucosal decontamination and antimicrobial
therapy are indicated. The treatment should be repeated three
times within a two week period, socalled Triple Therapy (Norton M).

In the US over 500,000 implants are
placed each year, whilst in the UK
that figure was around 140,000 for
2010. The prevalence of peri-implantitis has been reported to be up to
29 per cent 1 most notably in patients
whose implants are placed within
a partial dentition. This yields a
potentially vast number of implants,
possibly as many as 185,000 in the
US and UK alone that might succumb to some form of peri-implant
disease on an annual basis.
The bacteria found within periimplant lesions are similar to
those found in deeper periodontal
pockets,2, 3 and cross infection by
periodontopathogens as a primary
aetiology has been implicated as
a possible pathway. However the
wide variety of implant designs,
surfaces etc. make the treatment
of peri-implantitis much less predictable and subject to much
greater variability than periodontal disease, where natural teeth
present a known anatomy and well
defined surface structure.
In 2008 a systematic review4
of the literature regarding periimplantitis using PubMed and the
Cochrane library revealed little
consensus on the treatment of this
troublesome condition. One study
reported on the efficacy of submucosal debridement using ultrasonics or carbon fibre curettes5,
while two others compared the
effect of an Er:YAG laser against
that of mechanical debridement
and 2 % chlorhexidine as a combined therapy.6, 7
The first found similar results
between laser and combined therapies, while the second concluded
that the laser effect was limited to
a six month period. A further study
compared combinations of oral
hygiene instruction, mechanical
debridement and topical minocycline with a similar regime which
substituted 0.1% chlorhexidine as the
antimicrobial.8 The former seemed
to confer some benefit while the
latter showed limited or no clinical
improvements. Finally, a study comparing two bone regeneration proce-

dures reported clinically significant
improvements mediated by both.9
Nonetheless a multitude of
other studies have also been published reporting on the efficacy
of tetracycline10, CO2 laser11, and
photocatalytic decontamination
amongst others in the treatment of
peri-implantitis.12 Such a plethora
of therapies makes it difficult for

yet this has been a consistently
cited risk factor in many other
studies. Indeed in a study published
in the Swedish Dental Journal in
2010, the percentage of implants
with peri-implantitis was significantly increased for smokers compared to non-smokers (p = 0.04).14
Other factors that have been
implicated include excess cement,

the clinician to choose a regimen
that is both within the reach of the
average clinician and has some
documented reliability.

Risk factors
There have been a number of risk
factors cited for peri-implantitis.
Recently, in a study published in the
Journal of Clinical Periodontology,
a clear association was demonstrated through multi-level statistical analysis between risk of periimplantitis and location, specifically the maxilla, while overt periimplantitis was shown to be highly
correlated to patients with a predisposing history of periodontitis,
and being male.13 Surprisingly in
this particular study no correlation
was demonstrated with smoking,

poor oral hygiene, and prosthesis
design which are of course interrelated with some prostheses
making effective oral hygiene untenable, while others present deep
margins that make removal of excess cement almost impossible.

Warning signals
Peri-implantitis rarely presents
unannounced unless of course
the patient fails to be placed on a
regular recall programme or fails
to attend for regular review. Early
signs are often apparent in the
form of peri-implant mucositis.
This condition is characterised
by mucosal oedema, rubor and
bleeding on probing (BOP). By
definition it is not associated with
purulence or bone loss. However

The protocol is as follows:
1. Mechanical scaling of implant
surface with titanium or carbon
fibre curettes.
2. Sub-mucosal irrigation with 5–10 ml
chlorhexidine (0.2 %) per site, at
the deepest level of the pocket on
all sides of the implant.
3. Application of Minocycline Gel
2 % (Dentomycin, Henry Schein
Ltd) at the deepest level of the
pocket on all sides of the implant.

However once peri-implant mucositis has taken hold it is unfortunate that it is often exacerbated
by the design of implants today.
The presence of a rough surface,
taken to the top of an implant, and
the application of microthreads
or grooves have been proposed as
potential confounding factors for
the advance of the lesion due to
biofilm formation and bacterial
contamination of the surface which
leads to bone loss and further surface exposure. With advancing
bone loss it often results in colonisation of the deeper pockets with
well known periodontopathogens
and infection ensues. This then is
peri-implantitis.
Peri-implantitis is characterised
by the presence of vertical or crater-

like bone defects and spontaneous
purulence and bleeding on palpation (Figs. 1 & 2). It is typically
associated with deep peri-implant
pocketing > 5mm.
This condition is undoubtedly
of increasing concern due to some
principle factors, such as the almost exclusive use of roughened
implant surfaces, the treatment
of partially dentate patients with
a history of periodontal disease,
the placement of implants with
inadequate bone volume resulting
in facial dehiscences, as well as the
use of cement retained prostheses.
Implants with a micro-roughened surface texture have presented excellent long-term data
and until recently there has been
very little published in the literature demonstrating a susceptibility of these surfaces to this condition. However recent work by
Albouy et al 15, 16 has received widespread attention with concern for
the evidence that suggests some
modern micro-textured surfaces
may be completely resistant to
decontamination.16
Ultimately, if left unchecked and
untreated, it may become impossible to arrest the condition, leading
to wholesale failure of the case
(Figs. 3 & 4). Such failures impose a
tremendous strain and burden on
the clinician (let alone the patient),
destroying the confidence of a patient who has endured significant
expense and trauma and occasionally results in a breakdown of communication between both parties
that all too often sadly results in a
legal claim of negligence. Such claims
can be hard to defend for patients
where no warnings and/or supportive periodontal/peri-implant
therapy have been undertaken.
Treatment typically requires
surgical access to excise any fibrous capsule and for direct access
to the implant for surface decontamination. The author’s preference
until now has been to use chlorhexidine and tetracycline solution
for this purpose while others have
reported the use of citric acid and
hydrogen peroxide amongst others.17 The use of lasers has also been
extensively reported.6, 7, 18–20 However in a recent systematic review a
meta-analysis could only be done
for Er:YAG laser as the literature on
all other laser types was weak or
heterogenous.21
The author has recently completed the acquisition and treatment
of 20 patients in an efficacy study
using Er:YAG water laser (Morita,
AdvErl Evo) and it is hoped that
publication of the results will be
forthcoming. Indeed promising
data has already been published to
date using this same machine.22, 23
Nonetheless this methodology
remains outside the reach of most
general practitioners and has yet to
be proven predictably effective. As
such most attention therefore remains focused on physical debridement via surgical intervention and
topical antimicrobial therapies.

[5] => Untitled

TRENDS & APPLICATIONS

21

Implant Tribune United Kingdom Edition | 3/2015

Open flap debridement, defect decontamination, and repair as well as
pocket elimination have all become
the mainstay of those treating this
condition.
So is there a crisis? The problem is
that there is no clear consensus on
the prevalence of the disease since
this will vary according to the cut off
values for the clinical parameters
measured24 and to date there appears
to have been little consensus of these
cut off values. As such estimates of
incidence of the disease appear to
vary from 28 to 56 per cent of subjects
and 12 to 43 per cent of implant sites.25
Furthermore there is an ongoing
controversy about the initiating
process of peri-implant disease since
it is potentially considered a primary
infection of periodontopathic origin
by some26 while others hold that it is
a secondary opportunistic infection
subsequent to bone loss caused by
other etiological factors27 such as
a provoked foreign body reaction or
iatrogenic dehiscence of the bone,
exogenous irritants such as dental
cement, bone loss through occlusal
overload etc. If the latter is true then
controlling the disease is theoretically made more simple by controlling the conditions for the implant,
such as ensuring adequate buccal
bone thickness, avoiding or controlling more carefully the use of dental
cement, and paying closer attention
to the occlusion.
In an effort to gauge the rate of
mucositis and peri-implantitis requiring surgical intervention, the
author audited his patient pool in the
year 2014. Out of a total of 191 patient
reviews constituting 795 implants
only 15 patients (7.9 per cent) required triple therapy at 20 implants
(2.5 per cent) for mucositis while
10 patients (5.2 per cent) required
surgical decontamination at 10 implants (1.3 per cent).
As can be seen this is well below
the figures proposed in the article
by Zitzmann & Berglundh (2005).25
This may of course reflect a more
liberal approach to cut off values
for parameters such as pocket depth
and bleeding on probing as proposed
Klinge in 2012.
Nonetheless after over 20 years
running a practice dedicated to implant dentistry the author’s own
audited failure rates indicate that
less than 1 per cent of implants present as late failures, owing to periimplantitis or fixture fracture as a
result of bone loss. This would corroborate the findings by Jemt et al
in which a cohort of patients already
diagnosed with peri-implant bone
loss showed a slow rate of additional
progressive bone loss over a 9-year
follow-up with an implant failure
rate of 3 per cent.28
In all likelihood it is the author’s
view that peri-implantitis is only a
crisis if we allow bad implant dentistry to persist where there is a lack
of control of the initiating factors as
described above, and that it is more
rather than less likely that it is the
result of a secondary opportunistic
infection rather than a direct suscep-

“...there is no clear consensus on the
prevalence of the disease...”
tibility to primary infection of periodontopathic origin. However, there
will clearly be some patients with
a high genetic susceptibility with
other predisposing factors such as
the presence of untreated periodon-

tal disease, smoking and diabetes
who may well succumb as a result of
primary infection.
Furthermore there remains a clear
need to better define the different

types of peri-implant disease and to
establish a consensus as to the cut off
values for the different parameters
used to evaluate the disease so that
future figures for incidence and
prevalence are comparable.

Editorial note: A complete list of reference
is available from the publisher.

Dr Michael R.
Norton runs a
practice dedicated to implant &
reconstructive dentistry in London
in the UK. He
can be contacted at drnorton@
nortonimplants.com
AD

[6] => Untitled

TRENDS & APPLICATIONS

Implant Tribune United Kingdom Edition | 3/2015

Making implantology affordable
Controlling costs and increasing access to dental implant treatment
By Dr Tuss Tambra, UK
All CE/FDA-marked systems meet the same standard whether affordable
or prestige brands.

Implant dentistry is an elective restorative treatment solution with a surgical component for dentally fit patients.
If properly executed, it is one
of the most successful and
clinically researched treatment modalities in dentistry.
Unfortunately, patients who
are not disease-free are being
treated with dental implants
and, as a result, the litigation
rate has risen sharply.
A success rate of 98 per
cent is almost universally
claimed when promoting
implant dentistry to patients. So, if implant dentistry is 98 per cent successful,
then why are more cases
failing and why is litigation
increasing? Lack of proper
training, poor treatment
planning and poor execution (surgical and restorative)
are undoubtedly the main
culprits. If a clinician has the 1a
appropriate surgical and
restorative training in dental implantology, does the brand of dental implant
used make a clinically significant difference to the success rate? Does paying more for the implant and restorative components really produce better
results? Why is price an issue?
Price should generally not prevent access to high-quality, wellresearched and effective dental treatment. However, the current pricing
structure in implantology means that
a huge proportion of patients do not
have the disposable income to cover
the costs of such treatment. The McGill
study demonstrated the numerous
benefits (functional, clinical, psychological and general health) for edentulous patients in whom dental implants were used to stabilise complete
dentures. The improvements in chewing efficiency, general health resulting
from an improved diet and general
well-being (more social interaction
owing to a lack of fear of teeth falling
out) shows the significant impact dental implants make in society as a whole.
How can this situation be changed
to allow more potential patients to
access dental implant treatment? First,
clinicians could significantly reduce
fees charged to patients. This can only
happen if the component and laboratory costs are reduced, with the dentist
passing the savings on to the patient.
Another option is that dental implant
companies reduce the prices of both
implants and restorative components. According to the industry, however, prices across the industry are
already competitive and companies
need to cover their business costs.
Is there an alternative to the above?
Clinicians cannot reduce charges
without assistance from the dental
implant companies and all dental
implant companies are private busi-

nesses with shareholders who want
to produce products (implants) that
benefit society and see some return
on their investment in terms of profit
generation.

Economic drivers
Market forces must come to bear
in dentistry. In the current global
economic climate, ignoring the financial implications of the decisions we
make is no longer an option. Patients
expect high-quality, safe and affordable treatment. For this to happen,
clinicians need to source products at
a reasonable price point, passing on
these savings directly to the patient,
reducing overheads and treatment
charges and, therefore, increasing access to treatment. Some of the prestige implant companies have already
felt the impact of the loss of market
share and have either bought out
competitors, created joint ventures or
incorporated competing products
into their product lines.
Do smaller implant providers offer
potential benefits? One is certainly

their ability to respond more quickly
to increased patient
expectations of treatment. The rapid expansion of digital
dentistry, CAD/CAM
technology and intra-oral scanning
is resulting in smaller companies
being able to provide clinicians with
a total, open-source guided surgery
and restorative solution. With larger
companies, the ability to change direction is much more difficult and
time-consuming; turning an oil tanker
takes more time than a dinghy.

Key points of
consideration
when reviewing a
new implant system
Globally, all medical and dental
products undergo strict vetting procedures to ensure patient safety,
including product durability testing,
animal studies, human trials and
testing at universities. They are then
required to obtain a CE mark, FDA
approval or some other approval to
allow the products to be used in clinical dentistry. In short, once a product
has a CE/FDA mark, it meets all the
necessary testing and patient safety
requirements to be used on humans.

The next step is to assess all clinically relevant
criteria. Since there are
more than 1,300 dental
implant systems available, clinicians needs to
assess all available clinical and scientific data
and test the validity of
various claims made by
dental implant companies. If checking for certification/approval is the
first step for a clinician,
then the second should
be establishing how future proof the new implant is. In the early days of implantology, dozens of companies started
trading and most of them closed in
a relatively short period. For early
adopters of those systems, the risk
was not being able to restore or
maintain such systems, as parts
were no longer available. Therefore,
as a general dentist, one should verify
the length of time for which the
system has been on the market, who
the parent company is and what the
connection interface is (is it a clone
system of a well-known implant that
is no longer in patent?). In simple
terms, if the company ceases to trade,
can I still source components and
maintain my patients?

Implant-speciﬁc
considerations
A significant proportion of connection options (internal hex, external
hex, Morse taper and conical connections) are no longer in patent. The
clinical research on these has already
been done and their success rates have
been well documented in a multitude
of studies. As a result, most affordable
implant systems are adopting these
non-patented connections rather
than developing their own, meaning
that prosthetic components are
cross-compatible with other similar
systems.

A clone connection implant can
thus be restored with a high-end
restorative component provided by
another implant company or using
patent-free connections by opensource milling centres that can provide these components for significantly lower costs. One caveat with
open-source milling is to check the
quality of the milling provided in
order to avoid the complications
that arise from poorly fitting restorations.
Systems like the ICX now provide
non-precious metal blanks with premilled implant connection interfaces
and ceramic blanks bonded to adhesive base components. It is a premade
titanium implant connection that is
bonded to the all-ceramic block. It is
the milling of the implant connection
interface that is the most vital part of
the process, so if an open-source centre can obtain a pre-milled connection
blank, then its work is much reduced
and the dentist can be rest assured
of a high-quality component with an
accurate fit. The benefit of adhesive
bases in all-ceramic work is the improved strength of the connection
and reduced fracture rates compared
with all-ceramic abutments.
Is using one of the clone connections listed above an issue? All these
connections function with excellent
long-term, clinically documented
results. The key factor for success is
the closeness of fit between the internal/external implant connection
and the mating surface of the abutment, also called the micro-gap. This
produces a stable, rigid connection
with no abutment movement under
loading. A stable implant–abutment
interface combined with platform
switching is the key to bone preservation around the neck of the implant
and avoiding screw loosening.
How can one most easily compare
multiple connection platforms in a
simple and easy to understand way
without needing a degree in mechanical engineering? Engineer Holger
Zipprich from Goethe University
Frankfurt’s dental school in Germany
has produced real-time videos of

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TRENDS & APPLICATIONS

Implant Tribune United Kingdom Edition | 3/2015

several implant–abutment interface
responses to loading that are available
on YouTube. Once the videos have
been viewed, a rational decision as to
which connections are more stable
(rigid) under loading can be reached
and this information then applied to
selecting an implant system.
Does the system offer a wide range
of prosthetic, CAD/CAM and guided
surgery solutions for dental implant
treatment? Once a dental implant
system has gained some degree of
market penetration (or traction) and
has documented evidence to support
its clinical effectiveness, it is worthwhile taking an unbiased view of the
system. Hopefully, most glitches would
have been identified and corrected by
the early adopters, thus reducing the
risks for the more cautious clinicians.
A personal recommendation is
to focus on the restorative aspects
first (restoratively driven treatment).
Questions to be asked include whether
the system has a broad range of components for the various treatment
needs in implant dentistry, CAD/CAMbased treatment solutions and a
guided surgery solution for the surgical placement of dental implants.
If you are impressed by what you see,
then place a few implants and monitor them closely. If the treatment
outcomes are successful and you have
a positive impression of the system,
then there is no reason that
you should not add a costeffective solution to your
dental implant portfolio.
What impact does the
macro-geometry (implant
shape) and micro-geometry (surface treatment)
have in relation to longterm success? The surface
treatments applied to various implant systems are
designed to improve the
degree of osseointegration
and bone–implant contact.
This is extremely important for the long-term preservation
of bone around a dental implant.
However, is the surface treatment
that important when looking at immediate loading situations? In those
situations, it is the primary stability
of the dental implant, combined with
the closeness of fit to reduce micromovement of frameworks, that is
the key factor in determining longterm success. Any beneficial effects
of a surface treatment will occur postosseointegration and several months
after loading. So, are the macro-geometry of the implant and the physical
stability of the abutment connection
more important than the surface
treatment for long-term success or
vice versa?
Again, it depends on what the clinician is planning to do, immediate
loading or conventional delayed
protocols. Very little independent research has looked into the accuracy of
the claims made by implant systems,
and even less work has been done directly comparing the various implant
designs to evaluate different systems.
One group that has attempted such
an analysis is the Cochrane Collaboration and its reports are presented later
in the article.

Primary stability is
mainly governed by the
Image No 2009_01444
implant thread design
and this directly affects
the insertion torque.
The implant–abutment
connection stability is
equally important. If this
was not the case, then
Image No 2009_01445
an implant inserted with
a low insertion torque
Position of the
and poor component fit
Measuring ranges
would be subject to prosthetic movement under
3a
occlusal loading with
loss of primary stability and implant
abutments, bars and frameworks for
the abutment? In Orale Implantologie
failure long before osseointegration
restoration with both ICX and other
in 2007, Berlin dentist Dr Stefan Wolf
would have occurred.
dental implants in addition to preSchermer examined the micro-gap
made components. Titanium, zircobetween the abutment and the deIf one is following conventional
nia and non-precious restorative
ntal implant connection interface of
delayed loading protocols, then the
components for ICX and other brands
several systems and showed that ICX
surface treatment, as well as the
are available and are supplied with the
implant–abutment micro-gap was
macro-geometry and connection
final prosthetic screw included. With
the smallest of all of those examined
stability, will affect long-term success.
some systems, the final screw is not
(Figs. 3a & b).
Do the larger prestige dental implant
included and must be purchased sepbrands provide dental implants with
arately. ICX also has a bespoke CBCT
Closeness of fit is directly related
the most ideal thread designs, best priguided surgery solution called Magelto movement of the abutment when
mary stability, and highest tolerances
lan that is also multi-implant system
under load. The fatigue test figures in
of fit of abutments and frameworks,
based. The dentist can either purchase
conjunction with the smallest microor do the various surface treatments
the software or upload the DICOM
gap figures show the ICX implant has
have a clinically significant improvefile to the parent company server and
a well-designed and rigid connection
ment in long-term success when comthe company will carry out the design
interface that is platform switched. The
pared with a so-called budget brand?
process and fabricate the guide once
macro-geometry of the implant with
Again, no real cross-comparison rethe design has been approved by the
self-tapping apical threads provides
search exists. The surface roughness
dentist. Magellan can also be used to
high insertion torques with excellent
of the dental implant is also of vital
produce guided surgery drill guides
primary stability. These are key comimportance, as research has found
for various dental implant systems,
ponents in preserving crestal bone
increased peri-implantitis associated
but at a fraction of the cost.
around an implant. In terms of surface
treatment, the ICX implant
has an etched and blasted
micro-roughened surface
(Ra of 1–3 μm) with a pure
titanium dioxide surface
with no additives.
The implant was previously described as having
a hydrophilic surface. However, this claim was successfully challenged by
Straumann and is no longer
used to describe the implant.
The surface is currently being updated.
with macro-roughened surfaces.
Smooth or machined surfaces clinically show reduced levels of osseointegration, so the current thinking
seems to be that micro-roughened
surfaces provide the optimum surface for osseointegration.

An affordable
implant solution
The low-cost system that will be used
here for comparison is the ICX system
manufactured by medentis medical in
Germany. On the market for several
years and well known in Europe, it has
recently arrived in the UK as part of
the company’s global expansion. All
of its research has been conducted and
validated by several prestigious institutions, adding weight to the product,
including the Fraunhofer Institute,
which conducted durability testing, as
well as universities in Cologne, Aachen
and Mainz, which also contributed
with clinical research. The Robert
Mathys Institute in Bettlach in Switzerland performed research on the microgap (tolerances of fit of abutments).
The ICX system has a well-developed
CAD/CAM workflow for fabricating

When considering an implant solution, a look at the total system costs involved with both surgical and restorative components can reduce the overall cost to the patient. The table shows
a price comparison of the ICX system
against multiple implant systems, both
prestige brands and cost-effective
systems based on 2013 costs in the UK.
In terms of cost and product content,
the ICX implant seems to provide a costeffective implant solution for patients.
How does the implant fare when
tested in the laboratory against the
prestige systems? The Fraunhofer
Institute conducted durability (ISO
14801) tests (Figs. 1a & b)on several implant systems, including Straumann
Bone Level implants. These tests
showed that the ICX implant was
more fatigue resistant than all of the
implants tested (Figs. 2a & b). Thus,
the implant has a durable, fatigueresistant connection interface.

The implant–
abutment interface
How stable is the connection when
viewed in terms of closeness of fit or the
micro-gap between the implant and

As a prosthodontist working in private practice most of what is outlined
above is how I personally approach
new implant systems. There is very
little clinical research comparing
the various dental implant systems
directly to one another and a significant proportion of studies published
cannot be directly cross-compared, as
there is no standard clinical method
for doing so. All of the variations in
implant geometry, surface treatment
and restorative solution in addition to
the operator variables (the surgeons
involved, their individual skill sets
and the correlation of the statistics)
all make such direct comparisons
between implant systems a potential
minefield.

has contributors in over 120 countries. Starting in 2003 with follow-up
reports conducted in 2005 and 2007,
the group published its latest evaluation last year.1 The full report can still
be accessed online, as can the previous
versions. It has led to intense online
debate by various dental implant
companies and clinicians largely because of its conclusions, which are
reproduced here directly from the
summary of the report: “Based on
the results of the included RCTs
(randomised controlled trials), we
found no evidence showing that
any particular type of dental implant
had superior long-term success. There
was limited evidence showing that
implants with relatively smooth
(turned) surfaces were less prone to
lose bone due to chronic infection
(peri-implantitis) than implants with
much rougher surfaces (titaniumplasma-sprayed). These findings were
based on several RCTs, often at high risk
of bias, with few participants and relatively short follow-up periods.”
In summary, use of a cost-effective
dental implant system (in the author’s
opinion) is justified in terms of economic savings to the patient and increasing the reach of dental implant
treatment to the wider public. It is
reasonable once the system has been
cleared for use in general dentistry
(CE mark, FDA approval) and should
be considered a viable clinical option
once the dentist has reviewed the
available clinical data (conventional
and guided surgery solutions) and
restorative treatment (conventional
and CAD/CAM-based) options. He or
she will then come to an informed decision, at which point he or she should
place and review a small number of
implants in varying clinical situations
and monitor the results.
Conflict of interests: Dr Tuss Tambra has
not received any payments or other inducements of any kind from any company
mentioned in the article.

Reference
1. Esposito, M., Ardebili, Y. & Worthington, H.V.,
“Interventions for Replacing Missing Teeth:
Different Types of Dental Implants”,
Cochrane Database of Systematic Reviews,
7 Article CD003815 (22 Jul 2014). accessed
9 Jul 2015.

Dr Tuss Tambra
is a registered
specialist prosthodontist from
Stafford in the
UK. He can be
contacted at
d r. t a m b r a @
hotmail.co.uk.

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[cover] => Implant Tribune UK No. 1, 2015

[toc] => Array ( [0] => Array ( [title] => Dental implantology: Evolution or the road to ruin? [page] => 01 ) [1] => Array ( [title] => Managing patients with risk factors [page] => 03 ) [2] => Array ( [title] => Peri-implantitis: Is it a crisis? [page] => 04 ) [3] => Array ( [title] => Making implantology affordable [page] => 06 ) ) [toc_html] =>

Table of contents

[toc_titles] =>

Dental implantology: Evolution or the road to ruin? / Managing patients with risk factors / Peri-implantitis: Is it a crisis? / Making implantology affordable

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