August 4, 2016
by Dr. Mark Nicolucci
I am honoured to have been selected as an editor for the implantology issue of Oral Health. My father, Blake Nicolucci, has had an extensive career full of accolades and I can only hope to achieve some of what he has accomplished. He has served both Oral Health and the profession as a whole with dignity and dedication. As I step into this role, it is amazing to see how implant dentistry has emerged. From a day when implants were thought of as a radical treatment alternative, they have now become an accepted standard of care, often thought of as the superior or ideal treatment option for damaged or lost teeth. And with this emergence, the field has expanded and advances in design, methodology and material continue to arise.
Digital dentistry has had one of the most profound impacts on dentistry and continues to do so. A major advancement in this field for implant placement has been CBCT scanning. Not only does this technology provide a vast increase in the understanding of the anatomy of the implant site, but the speed, ease and low radiation this can be provided at has drastically improved over traditional medical CT scans. Many proponents, in part due to the ease of scanning, have proposed that CBCT scans should be developed before any implant placement. While I feel that not all sites require 3D scanning, it would be hard to justify why a scan was not taken prior to implant placement in any site that may exhibit complications. This has created a dramatic shift in implant treatment planning, where today most cases will involve sliding through CT slices rather than assessing traditional two-dimensional radiography.
As radiological visualization has drastically improved, digital impression techniques have been advancing as well. Optical scanners can provide a digital image of the oral cavity with much improved accuracy allowing predictable fabrication of final restorations without try-in appointments. While certainly useful for all types of restorations, this technology is on the rise to capture the oral position of implants.
Perhaps even more interesting is the combination of CBCT technology and optical impressions. Using software to combine these data sets, accurate guides can be made so that pre-planned implant positions can be achieved clinically. While not 100% accurate, guides manufactured today usually will not deviate by more than 1 mm and are often within tenths of a millimeter to the planned implant position. The predictability, accuracy and speed have many potential benefits and the necessary precise preplanning of the implant position provides a more routine accuracy to placement, which can avoid complications.
Although guided implant surgery is an amazing advancement, navigated
implant surgery has also come to market. Much like with neurosurgery, navigated surgery allows real-time tracking of the position of the surgical device; in the case of implant dentistry, the drill. This has fantastic implications for training dentists to place implants, as deviations from a planned implant position can be seen in real-time, allowing the surgeon the accuracy of guided technology with the freedom to compensate for complications. This technology is now ready-to-use, and Dr. Bashutski has provided an excellent case report on its use in this edition.
Implant materials also continue to advance. Zirconia specifically, has not only provided new possibilities restoratively, but also offers an alternative to titanium implants. While the research is still growing, the data that exists shows good biocompatibility and survival and zirconia implants can be an excellent alternative for patients who are interested in metal-free treatment options.
The acceptable size of implants also continues to evolve. Traditionally it had been thought ideal to use large diameter implants with lengths greater than 10 mm. Today we have seen research suggesting that both narrower and shorter implants fare equally well. With a growing movement towards patient centered outcomes, or patient related outcome measures (PROM), there is growing support to be able to place smaller implants where before it was thought contra-indicated. Titanium alloy especially has allowed us to narrow our platforms while still providing the strength to resist oral forces. Mini-implants, or implants less than 3 mm in diameter, have also shown surprising success rates in the literature. Although they do not appear to achieve survival rates as high as traditional implants, some authors show success rates above 90%. Much like with narrow implants, mini-implants allow surgeons to place implants into bone that would otherwise require augmentation.
Fixed full-arch implant restorations have also come a long way. Originally thought of as insufficient, aggressive and prone to failure, new methodology has shown that not only can full-arch prostheses function on as few as four implants, but cross-arch stabilization allows these restorations to be loaded immediately and predictably when sufficient initial stability is achieved. This has dramatically improved our efficiency when offering fixed solutions to patients who are edentulous or have a terminable dentition.
While many advances have lessened the need for ridge augmentation, the need still persists, especially with more and more patients being interested in implant-supported restorations. Originally the block graft was thought of as the gold standard for ridge augmentation, but more recently guided bone regeneration has been found to be very predictable. Growth factors have also come to market, such as BMP and PDGF, and we can also use our patient’s own blood to produce materials rich in growth factors, such as PRP and PRF. Vertical augmentation, which had been thought of as unpredictable, is being further investigated. Dr. Istvan Urban has led this advance, presenting predictable approaches to achieve vertical augmentation even in compromised patient situations.
In summary, the advances in implant dentistry are coming as fast as the field is expanding. We can now plan our implant placements better, grow our bone more predictably, and place our implants with more accuracy and into more sites than ever before. Better, smarter, and faster are words that resonate with these advances, and the exciting thing is that the advances will likely continue to come. I wonder what the field of implant dentistry will look like in 20 years. If our past is any predictor, we have some exciting times ahead of us. OH
Dr. Mark Nicolucci is Oral Health’s editorial board member for implantology. He is a graduate of the University of Western Ontario and received his specialty certificate from Temple University in periodontology and oral implantology. He has a masters in oral biology and lectures regularly in the Toronto area. He maintains a full-time specialty practice in West Toronto.