Dental implants have become an increasingly popular tooth-replacement solution over the past few years. Patients are generally more educated on good oral hygiene practices and have better oral health than ever before. Unfortunately, tooth loss is still quite prevalent among adult patients. Patients have a longer life expectancy and the desire to remain active well into their senior years.
There is a growing need for tooth-replacement solutions for our rapidly growing older populations. It is estimated that a few million patients in the United States have received at least one dental implant. This figure is growing at an exponential rate. The demand for dental implants is growing by the day. Patients are becoming more educated on implants, which also have an astonishing success rate with very few complications.
The technology and advancement of dental implants has also rapidly grown. There are new techniques and materials which make the treatment even more impressive. 3D printing and CAD CAM technology are expected to make significant improvements to implants in the coming years. There are numerous factors which should be considered when evaluating the various types of implant systems.
The procedure used to place dental implants has evolved significantly in order to meet the needs of the patients. There is ongoing research which determines how even the most minor changes to the implant can increase the success of the treatment.
More than a hundred different companies produce the various implant components, however, there are only a few major dental implant companies which have global respect and recognition. The top implant companies are Straumann, Zimmer Biomet, Nobel BioCare, MIS, BioHorizon, and Dentsply.
There are quite a few generic implant companies which often provide implant components at a discount. However, cheaper is not always better, especially for something which is used in the body. Patients are better educated than ever regarding dental implant technology. There is also more awareness regarding the top dental implant manufacturers. Some patients may even have a preference on who manufactures their implant components. Dentists who provide implants should also be well-educated regarding the implant manufacturers.
It is also important for the dental laboratory to be familiar with the implant manufacturers. The lab technicians have specific training and tools required for the specific components. It can be advantageous for a practice to use dental implant components from the top manufacturing companies. As the world becomes more global, it is increasingly important for patients to have confidence that they have high quality implant components.
The top implant companies make significant investments in research and development. Selecting products from these companies gives providers confidence that their patients are receiving top quality components that will last. During the initial placement of the implant, a biological response is triggered which results in an exchange of information between the cells and biomaterials. This process is called osseointegration where the implant actually fuses to the jawbone.
It can be overwhelming to decide on which implant system to use and invest in. It is important to review the manufacturers to gain an understanding of the quality of products which are offered. Most dental implant companies want to be a one-stop shop for producing all necessary components of the implant. Practices who accept complex implant cases are often unable to use a single system for accommodating the needs of all patients. In many cases, the provider will need to consider two or more brands to meet the needs of their patients. It is often advantageous for practitioners to deal with a smaller number of manufacturers as it allows the provider to have a better understanding of the dental implant system.
Following the decision about which implant system to use, patients will also need to choose between cement-retained abutments or screw-retained implants. Another decision is between custom abutments instead versus stock abutments. In most cases, a custom abutment is preferred as it can achieve better esthetic results.
Most dentists typically prefer titanium implants; however, zirconia is gaining in popularity. There are also different types of crowns which can be used with a custom abutment.
Cementable Abutments and Screw-Retained Implants
There are various factors which should be considered when choosing between cement-retained implant crowns or screw-retained implant crowns. Important factors include things such as retrievability, maintaining the peri-implant tissues, ease in use, suitability for angled implants, and the cost for treatment.
Retrievability
In some cases, it may be necessary to remove an implant crown temporarily. Certain cements are available on the market which are specifically made for implant restorations that make it easy to retrieve the implant crown. The dentist may also opt to use a temporary cement to secure the implant crowns in place. While this can be a good solution, it does mean that the crown will be less retentive, creating challenges. A screw-retained implant crown, in comparison, is much more predictable in cases where the crown must be retrieved. This is especially important when more abutments are needed. A multi-unit restoration which is permanently cemented in place will be much more challenging to remove with predictable results.
Maintenance of Peri-Implant Tissues
When the crown is cemented into place, there is a risk that excess cement could be extruded into the sulcus. Unless the cement is fully removed, this can cause damage to the peri-implant tissues. Subgingival cement which is present around an implant can increase the risk of peri-implant mucositis and peri-implantitis, causing implant failure. Fortunately, there are techniques for successfully removing subgingival cement during the placement of an implant crown. However, patients are still at risk for the dentist to overlook some of the cement. A screw-retained crown does not have this risk and is easily removed for cleaning or maintenance.
Usability
It can be more challenging to insert a screw-retained implant crown than a cement-retained crown. This is especially true when fitting multiple unit restorations. With a cement-retained restoration which contains multiple abutments, the procedure for fitting the restoration is very similar to the placement of a routine bridge. When placing a screw retained restoration, in comparison, there are a number of extra steps which are necessary. This ensures the framework has a passive fit and also eliminates stress being placed on the implant.
Angled Implants
It is not possible to place screw holes in the incisal or facial contours of implant crowns, for esthetic reasons. When the implant angle is not perfect, the dental professional must use an angled, screw-retained abutment. This unfortunately results in an increased cost. It is easier to rely on a cement-retained crown with a custom or stock angled abutment.
Stock and Custom Abutments
The dental professional will need to decide between using a stock implant abutment versus a custom implant abutment for each implant case. It is important to be educated on the features of each solution to ensure it is the best solution for the patient.
Stock abutments are pre-set, standard sizes. They can be used for bone and tissue level implants. Companies that specialize in manufacturing dental implant components have designed stock abutments to be user-friendly. This makes it possible to easily obtain impressions. Stock abutments are commonly used for cement-retained restorations and are typically more affordable. Patients can selected between an angled or straight abutment. Stock abutments are also best used for tissue level implants which are not within the esthetic zone of the mouth.
A challenge with stock abutments is that they are a standardized size. This means the tissue will conform to the shape of the abutment. These types of abutments are not ideal when placing an implant within the esthetic zone. This is because it is more difficult for a ceramist to create the correct emergence profile, provide vital tissue support, and achieve the desired results. When using a stock abutment, the final margin placement of the crown cannot be controlled, as it is determined by the implant depth and abutment height. Dentists often spend additional time making alterations after placement to achieve the correct profile and fit.
A custom abutment can be used in cases of both bone and tissue level implants. These types of abutments can be waxed or milled into the precise shape as it relates to the crest of the tissue. Various types of custom abutments can be created from titanium or zirconia. They can also be fabricated from zirconia with a titanium base. When the dentist is placing a custom abutment, they will use delivery jigs which aid in achieving the desired results. Custom abutments are more accurate and precise. While custom abutments cost more, they are able to achieve more predictable esthetics and far better tissue management. This type of abutment is suitable for cemented and screw retained crowns. Custom abutments are more efficient than stock abutments which can result in a more cost-effective treatment option due to lower lab fees and fewer clinical resources needed to achieve a good fit.
Titanium Implants
In most cases, a dental implant is made from titanium. This material biocompatible and integrates with the bone without issues. Bone grows on the surface of titanium implant, securing it in place and making it immovable. Titanium alloy implants have an incredibly high success rate of 95% or higher. Pure titanium was originally used to fabricate implant components, but it was too soft. As a result, implant companies developed an alloy which is capable of offering superior strength, while maintaining the exceptional biocompatible capabilities. There have not been any reports of an allergic reaction to titanium, however, some patients may be allergic or have sensitivity to other types of metals used in the alloy. Close to 5% of patients have a sensitivity to nickel, which should be discussed with the dental professional prior to the implant placement.
Zirconium Implants
As the result of sensitivities and allergies associated with titanium alloy, some implant companies began developing metal-free implants which use zirconium. While this type of material is considered to be a ceramic, it contains trace amounts hafnium and yttrium metals. Zirconia is incredibly strong and has osseointegration properties similar to titanium.