Hello and a very warm welcome to episode 021 of Elmar’s Tooth Talk: The missing link to total health. I am Dr Elmar Jung.
As always, before we start let me tell you what’s in it for you in this episode:
We talk about:
– WHAT is an implant
– The history of implants
– Who was the father of dental implants
– WHAT types of implants are available
– WHAT materials are used for implants
– WHAT advantages and disadvantages do they have
– WHY some people should not have an implant
How important teeth are for life, for our well-being and for our social position is often only noticed when they are missing or begin to fall out.
So today we’re talking about a method to replace missing teeth. A method that has been gaining in importance in dental care since the 1980s and has become an integral part of many dental practices for some even their only offer for their clients.
It has become a billion-dollar business. We talk about implants.
What is an implant?
The word implant comes from Latin and means planting in.
An implant is an artificial material implanted in the body. A distinction can be made between medical, plastic and functional implants.
Medical implants include cardiac pacemakers, joint replacements such as artificial hips or vascular prostheses. Plastic implants are best known as breast implants while functional implants are used, for example, to monitor animals and are associated with the implantation of RFID (radio frequency identification) chips.
When I talk about implants here today, I always refer to dental implants.
A dental implant is an artificial tooth root that is inserted into the jawbone. A crown, denture, bridge, the so-called supra-structure, is then placed onto the implant.
Before going into more detail about the individual materials, the advantages and disadvantages as well as health considerations, let’s briefly take a look at the history of dental implants.
History of the implants
The replacement of missing teeth with a wide variety of materials goes back well into ancient Roman times. Skulls show that teeth carved out of quartz, ivory or wood were used as early as 2-3000 years ago. Human or animal teeth were also used, and the foreign teeth were connected to one’s own with gold bands.
Obviously, a treatment only the very rich could afford.
The earliest evidence of implantology is the archaeological find around 600 AD in the Central American high culture of the Mayas of a mandibular fragment.
The first implants to be inserted into the jawbone were the attempts by Magiolis at the beginning of the 19th century. Magiolis created artificial bone compartments and inserted tubes made of gold onto which he attached a pin tooth.
Attempts with implants have been made using a variety of materials and techniques. However, the expected success was almost always missing.
The first breakthrough came in 1939 with the cobalt-chrome-molybdenum screw developed by the American Alvin Strock, which was designed similar to a wood screw. The first successful implant metal called Viallium, had been developed a year earlier by Charles Venable, an orthopedic surgeon.
From then on it went very quickly and newer concepts were developed. Needle implants came on the market in 1962, improved screw implants in 1965 and plate implants in 1968.
The father of modern implantology
The Swedish anatomy professor Per-Ingvar Branemark is considered the father of modern dental implantology.
Branemark came to his discovery in the 1960s rather accidentally when he found in animal experiments that the titanium implanted in the bone grew together with the bone.
In 1966, Branemark coined the term bone “osseointegration”, which means bone integration or bone anchoring.
It was not until 1982 that Branemark and his titanium implants were scientifically recognized. Until then, the Swedish dental profession refused to recognize him because he was not a dentist and his method was not new, but expensive, painful and dangerous.
In 1965, Branemark treated his first dental patient, the Swedish taxi driver Gösta Larsson, who was born with a jaw deformity, with four titanium implants. These four implants were then used to hold the dentures so that Larsson could eat and speak properly for the first time in his life. Larsson died in 2006 and thus had his implants in the bone for 40 years without any local complications.
In addition to Branemark, the Swiss Prof. Sami Sandhaus, and the German Prof. Willi Schulte from Tübingen, the town I studied dentistry, were the early pioneers of ceramic implants.
Other implantologists from the very beginning were dentists such as Münch, Ledermann, Mutschelknauss, or Brinkmann.
Today it is mainly dentists who have their own practice who have made a name for themselves with the development of their own implant systems. As an example, I would like to name two colleagues whose systems have become very successful and known far beyond their own practice.
Dr. Axel Kirsch from Stuttgart with his IMZ implants made of titanium, which has been on the market as the Camlog implant system since 1995 and which has a kind of shock absorber as a special feature that simulates the mobility of the periodontal fibres, which is the structure on which the natural tooth is suspended in his tooth socket, so to speak. And
Dr. Ulrich Volz from Konstanz, now Kreuzlingen in Switzerland with the first 100% metal free dental implant System, the Z-System. In 2018 Volz joined forces in a strategic partnership with the Straumann Group, the global leader of dental implants.
Three are more than 100 different implant systems available at present.
Most of the systems used today work on the screw principle, which means that the implant is screwed into the bone instead of being knocked in or just being pushed into it.
The new WIN! ® PEEK implant system takes a different approach here. It is not screwed in, but rather inserted into the bone like a dowel.
What material should you choose?
There are basically three materials available in implantology.
Titanium, from which the first implants were made and it is still the most widely used material today.
Zirconium oxide is particularly impressive because of its improved biological compatibility and its white colour, but until a few years ago it had to struggle with susceptibility to breakage. According to Dr Volz and colleagues using only ceramic implants, this disadvantage has now been conquered.
The new kid on the block in dental implantology is PEEK, a high-performance plastic that has long been used in orthopedic and in surgical instruments and endoscopes, but has not yet received much attention in dental implantology.
The main advantages of PEEK are its better mechanical properties and its biocompatibility. PEEK is more elastic than titanium or zirconium oxide, similarly elastic as bone.
Normally the implant takes on a large part of the mechanical load and thus relieves the bone, which can lead to bone loss, as the bone needs mechanical load to regenerate and maintain its strength.
The increased elasticity of PEEK is advantageous here, as it relieves the bone less of the mechanical stress
PEEK can also be injection moulded, which reduces manufacturing costs.
Many implant systems work with surface processing by etching, sandblasting or plasma coating in order to enlarge the surface and thus ensure a better hold
One-piece or multi-piece implants
Implant systems can also be differentiated according to whether they function in one or two parts.
Some colleagues who work in implantology believe that the two-part implant systems are increasingly more accepted in the market. This is mainly because with one-piece dental implants the implant head protrudes from the gums and thus stress can often not be prevented before the implant is properly healed, which in turn can reduce the chances of success.
With the advent of computer tomography in dentistry, the jawbone conditions can be measured precisely. In this way, the position of the implant can be precisely planned before the operation and implemented with the help of so-called drilling templates, which are individually manufactured.
When are implants used?
The areas of application for implants are very diverse. Implants are most often used to replace individual teeth. They can also be used as bridge anchors or for anchoring partial or full dentures.
What about the longevity of implants?
The longevity of implants is very much dependent on the quality of the surrounding bone, oral hygiene, diet, a possibly existing chronic underlying disease and of course the skill of the dentist placing the implant.
Excellent oral hygiene must be practiced to prevent bacteria from reaching the implant through the gums and thus leading to the dreaded peri-implantitis, an inflammation around the implant.
If you believe the statistics, which obviously come from the manufacturer themselves, the success rate of implants is very high. According to these statistics about 85-90% of implants are still working well after 5 years.
The question, of course, is what is the definition of success? We will come to that later.
Immediate implant placing after tooth extraction or delayed implant placement
When it comes to implant planning, a distinction is made between immediate and delayed implants placing
With the immediate implant, an implant is placed immediately after the removal of an extracted tooth, while with the delayed implant placing the bone has the chance to heal for about six months before the implant is placed.
Proponents of immediate implant placement argue that the immediate implant is the best course of action because it is the best way to preserve bone. This plays a crucial role, especially in the front region of the upper jaw, since the bone walls towards the lip are naturally very thin here, which basically applies to the entire upper jaw.
The lower jawbone surrender has a much more robust structure.
The challenge is, if a tooth had to be extracted, there must be a reason for this. Either the tooth was dead, root canal treated or in such a state that restoration was just not possible. Now when it comes to tooth removal it is important to clean the jawbone socket where the tooth was sitting to remove as good as possible all infection from this area.
Unfortunately, it is difficult to know or to see what is going on around the tooth if one hasn’t got the proper equipment. With the CaviTAU ultrasound scan, according to Dr Hans Lechner, the inventor and developer of the CavITAU, one can evaluate if the jawbone around the tooth that requires extraction is of good bone density. Lechner claims that if the CAviTAU does show dense bone an immediate implant is possible if however it shows reduced bone density delayed implant placing is recommended.
Immediate or delayed implant loading?
Normally the dentist waits four to six months after placing an implant before fitting a crown or other suitable prosthesis over it.
However, there is a trend to immediately loading the implant straight after placing. An as always there are pro’s and con’s to each option.
Delayed implant loading
This works in two steps. First the gum is flapped for the implant to be inserted into the bone then the flap is sutured back into its position and the implant is left to heal for about six month. After this time the site is opened, and the implant uncovered. The gum heals and shortly after impressions are taken to restore the missing tooth.
Dentists often opt for delayed loading if they have to use bone grafts to enhance the jawbone.
Immediate implant loading
This works in one step. After placing the implant, it is loaded either immediately or within 48 hours of the insertion.
The advantage is you can chew faster with your new tooth and your visits to the dentist are reduced. Supposedly there is less gum loss and it is assumed that an initial primary stability will be achieved and over time a secondary stability sets in with the osseo-integration of the implant into the bone.
Immediate loading requires excellent oral hygiene, a harmonious bite without any parafunction and good dense jawbone.
What are the advantages of implants over other restoration options?
In my opinion, the greatest advantage is that no neighbouring teeth have to be touched, as is the case with a bridge.
This is particularly advantageous when the neighbouring teeth do not yet have any restoration at all.
Implants can give dentures a better hold and thus reduce the pressure of the prosthesis on the gum.
It is claimed that the implantation leads to a reduction or even stop of bone loss in the edentulous jaw area which appears to be the case with PEEK.
Further advantages are better chewing power, improved speaking capability and more appealing aesthetics compared to a denture.
What are the disadvantages or possible risks of implant restoration?
Like all surgical interventions implant placement poses some considerable risk and needs to be carefully planned.
For example, nerves can be injured. This is a risk that should not be underestimated, especially with implantation in the lower jaw.
In the upper jaw, there is a risk that the maxillary sinus will be opened.
Implants grow firmly into the bone. As a result, the chewing pressure is not cushioned by the fibre apparatus, as is the case with natural teeth, which can lead to stress or overloading of the temporomandibular joint and also to bone loss.
Then there is the financial implications. Implants have their price which obviously varies greatly depending on the dentist you chose.
If your oral hygiene is not optimal, you want to improve this first before embarking on the implant route. Otherwise you are faced with unpleasant infection of implantitis.
And of course there is a risk of the implant getting mobile and thus losing the implant due to incorrect or overloading.
Smoking and underlying chronic diseases such as diabetes can increase the risk of failure
There are three factors that are often neglected
1. In the case of multi-part implant systems, the risk of infection arises from the design of the implants alone, since these are not sealed units and so bacteria can penetrate these material-related gaps.
Normally, a constant flow of fluid around the tooth neck prevents bacteria from penetrating between the gum and the tooth root. Quasi a natural defense mechanism. No implant has such a protective function.
2. Implants are often used in previously damaged bones, which among other things can result in the existing infection or bacterial toxins spreading further in the body.
3. If implants and their crowns or bridges are made of different metals, it inevitably occurs – that is Faraday’s law – corrosion and thus metal particles get into the body.
When should an implant be avoided?
General medical concerns are the main focus here.
It is recommended to avoid an implant in the case of severe obesity, medication with psychotropic drugs, immunosuppressants or long-term antibiotics. Blood diseases, osteoporosis or radiation can also be contraindications.
Alright, that was a first overview on implants a topic relatively undisputed in conventional dentistry and looked at with caution if you dig a little bit deeper.
In next week’s episode we talk about patient’s experience with implants and the impact this had on their health.
This is Elmar’s Tooth Talk – The Missing Link To Total Health.
Until next time