Interview: “Consumers Are Pushing Dentists Toward Metal-Free Implantology”

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A great deal of progress has been made in terms of materials, techniques and design of dental implants since the beginnings of modern implantology over 50 years ago. While titanium and titanium alloys have always been in use, the search for metal-free implantable materials began in the late 1960s and early 1970s, and during the last decade, zirconia has emerged as the most reliable implantable bioceramic. The International Academy of Ceramic Implantology (IAOCI) is an organization entirely dedicated to ceramic and metal-free alternatives to metal implants. It was founded in 2011 by Dr. Sammy Noumbissi, with whom Dental Tribune Online had the opportunity to speak about the mission and vision of the IAOCI, as well as the state of ceramic implantology today.

Dental Tribune Online: Dr. Noumbissi, could you please provide some background information on the development of ceramic implants?

Dr. Sammy Noumbissi: The use of dental implants to replace teeth has increased very rapidly in the last 15 or more years. With this increase in dental implant procedures, the number of manufacturers has increased too. Also, we have witnessed the introduction of various alloys of titanium over time.

Now, just like with any pharmaceutical or medical product, the increase in demand and changes in production methods come with problems and challenges. Although initially anecdotal, reports of titanium and titanium alloy intolerance have increased and are increasingly being investigated and demonstrated in the scientific dental literature. Based on the body of research available today, this intolerance of implant alloys can in great part be attributed to the release of metal ions in the host bone and surrounding tissue as a result of the breakdown and corrosion of metal alloys in the presence of body fluids and the oral environment in particular. Such facts have been established and widely recognized in orthopedics.

In the late 1960s, pioneers in ceramic implantology and notably Professor Sami Sandhaus began the search for modern non-metal implantable ceramic materials. However, many of the early ceramic implants were monocrystalline in their structure and could not survive the demands of the oral environment. Then came the use of polycrystals and in the early 2000s Yttria-stabilized zirconia bioceramic emerged as the material of choice for metal-free intrabony implantation in dental implantology.

How did you become involved in research on ceramic dental implants?
My interest in ceramic implants came about in two ways. First, on a personal level, when I discovered that the metal fillings and implant I had in my own mouth were determined to be the source of some of the health problems I had experienced. Second, on a professional level, where a few of the patients to whom I had provided metal implants returned for check-ups or more implants, and upon reviewing their medical and dental history, it was also determined that the implants were at least in part responsible for the health problems they were experiencing. I then began to actively look for alternatives and at the scientific literature, including case reports in both medical orthopedics and dental implantology. It was clear that bioceramics in the last two decades had established themselves in both medicine and implant dentistry as the most bio-inert implantable material available. In 2011, two colleagues and I decided to create the IAOCI.

What is the primary aim of the IAOCI?
Associations and academies exist around various types of trades and industries. The common purpose of such groups is to organize and create a supportive environment for those involved in the respective area. The IAOCI was created with the same spirit, not only to organize metal-free implantology but also to provide the profession as a whole with quality and high-level continuing implant education on bioceramics as implantable materials. The IAOCI is also a resource for the public seeking practitioners who have experience with ceramic implants.

In your opinion, what are the dangers of metal implants?
Metal and most particularly titanium implants have been very successful. Their use has grown exponentially and with that manufacturers have multiplied, as well as manufacturing protocols. As a result, we have observed a steady increase in the alloy elements mixed with titanium during the manufacturing process. The problems begin when the metal implant highly alloyed or not, once placed is subjected to functional stresses, galvanism, body fluids and the harsh oral environment. The combination of mechanical, chemical and electrical events induces cracks and pitting of the metal, as well as breach in the oxide layer, and the implant undergoes corrosion attack. The corrosion attack, which is essentially an oxidation process, leads to the release of metal ions that studies have shown to be found in the surrounding bone, lymphatics, spleen, liver and in some cases crossing the blood–brain barrier.

What alternatives to metal dental implants are currently available on the market?
Today, the well-researched and proven alternative material to metal for dental implants is zirconium dioxide, also known as zirconia. This is also a well-proven fact in medical orthopedics. Zirconia is the crystal phase of zirconium and as such it is not a metal. There are different manufacturing protocols for zirconia for dental implantation and they all lead to a variety of polycrystal bioceramics, such as zirconia-toughened alumina, hot isostatic-pressed zirconia and Yttria-stabilized zirconia. The common and most important properties of these bioceramics are inertness in the bone and oral environment, structural stability, absence of electrical activity, extremely low plaque retention and superior aesthetics.

Is the success rate of metal-free implants comparable with that of titanium implants?
In the early days, there were challenges. The materials were monocrystalline with very highly polished and glassy surfaces, which made the early implants prone to fracture, poor attachment of bone-forming cells and low bone–implant contact. The manufacturing protocols, design, surface modification techniques and technologies of zirconia implants have evolved to a point where bone integration is ensured and comparable results are obtained.

Are ceramic alternatives the future of dental implantology?
Every industry projection one sees about implants signals good news for the future. Implants are now and will continue to be widely accepted by patients and the profession. Both groups agree that this is state-of-the-art treatment. However, owing to technology, the public is much more informed about health issues and therapies. We are in a similar situation today to that of Invisalign braces a few years back, in that consumers are pushing dentists toward metal-free implantology for the most part. In five years’ time, I believe that the number of ceramic implants being placed will double.

Bio-inert materials are the future of any type of implantable device. I believe bioceramics have taken hold and will be around for a long time because there has been a strong shift toward providing health care with the minimum risk and invasiveness over the last few years, as well as in a way that is more integrated, natural and biological. Furthermore, manufacturers have rapidly evolved and adapted the material and implant designs to clinical needs and demands. We now have a wide variety of implant designs, surface microstructures, components and prosthetic connections, making ceramic implants applicable to an extensive range of tooth replacement situations.

Dentists may have concerns about the reliability of ceramic implants. How does your organization address this?
Even within specialties, there is a need for organized groups because in today’s world research and application of discoveries are moving at lightning speed compared with 20 years ago. Therefore, once one has an environment in which much of the time and energy is spent tracking, learning and sharing innovative techniques and materials, members have a forum where they can obtain the information, training and skills to deliver the best of care to their patients in an evidence-based and organized manner.

As a matter of fact, our membership has doubled in the last two years and when prospective or new members are asked why they want to join or joined the academy, the most common response is that they are seeking a forum where they can obtain structured information and training.

Another frequent reason is that dentists have had patients challenge or inform them on the use and occasionally the existence of ceramic implants. Through technology and the ease of access to information, the public obtains information faster than we busy clinicians.

The IAOCI will be hosting its Fifth Annual Winter Congress in Montego Bay, Jamaica. What can people expect from the event?

The theme in 2016 will be the last decade in ceramic implantology. We will have 14 speakers from seven different countries who will share their experiences with a variety of ceramic implant systems over the last ten years. One of our guest speakers has over 15 years of documented experience with zirconia implants. We will also have workshops on different implant systems, ceramic regenerative products and revolutionary soft-tissue- and hard-tissue-enhancing protocols proven to optimize implant integration and long-term stability.

Researching Your Dental Implant Decision

Researching Your Dental Implant Decision

Researching Your Dental Implant Decision | Sammy Noumbissi DDSWe live in an age when people have the luxury of being able to research virtually any potential purchase before make it.  In many ways, “buyer beware” has been replaced by “buyer be well read.”  If you want to, you can spend 5 hours gathering information to aid in your next shoe purchase.  You can see the view from your seat before buying a ticket to a basketball game. If you’re shopping for a new body part, that research tends to take on a whole new level of significance.  This is more or less the situation when one considers getting a dental implant.  Though many people don’t think of it this way, each of our teeth is an individual body part with specific purpose and functionality.  Like many other systems in our bodies, the mouth functions most optimally when each of the individual components are in healthy, working condition. Dental implants are different from many other body prosthetics, however.  For one thing, they are nearly identical from a functional standpoint to the original body part (whether they are visibly identical to the original tooth depends largely on your choice of implant).  Unlike many other body prosthetics, implants are not designed to be removed, refit, or replaced.  They also differ from procedures like joint replacements in that much of the hardware being installed can be visible to the patient as well as others. Because so many different factors go into making a good dental implant decision, and due to the somewhat permanent nature of the procedure, researching the various available options is an essential part of the process for any prospective dental implant patient.  When exploring one’s tooth replacement options, there are three primary areas of focus to be concerned with. Are Dental Implants the Right Option for Your Particular Situation? Obviously the first step is to determine whether you are a good candidate for an implant to begin with.  As we’ve just discussed, there are many things to consider about dental implants.  Generally speaking, an implant is the best, longest lasting option for replacing a missing tooth.  They can also be an excellent alternative to extensive root canal treatment, which is prone to almost inevitable failure.  Implants tend to be stronger, more functional, and more hygienic than bridges and partials. It’s important to ensure that you as the patient have sufficiently healthy gum and bone tissue to support and espouse the implant.  Ultimately this is something that your doctor will need to advise you on; more on that in a moment.  Thankfully, modern advancements in bone reconstruction and guided bone regeneration have significantly improved the standard of implant care and widened the field of potential implant candidates.  With regard to gum tissue, some materials are more conducive to the maintenance of healthy gingiva. What are the Best Implant Materials to Use? While there are myriad options available when it comes to dental implant material, they basically all fall into one of two categories:  metal implants and ceramic implants.  Metal and alloys were the only option for the first decade or so following the advent of the modern dental implant before ceramic implants began to slowly make their way on to the scene.  While titanium is still the most commonly used implant material, titanium implants do carry a higher risk of a plethora of complications.  Metal free implants made from zirconia have been used with increasing frequency over the last two decades, and are now widely considered to be the highest standard in dental implant care.  This is due primarily to zirconia’s higher rate of biocompatibility in addition to its being an aesthetically superior material. Choosing the Right Doctor for You Carefully choosing your doctor is the most crucial aspect of making this decision.  This is of course because the right doctor will be paramount in helping you to make informed decisions on all of the other pertinent factors.  Many general practice family dentists offer dental implants as part of their wide range of offered services.  As we have discussed here, however, dental implant surgery and treatment entails an exceptionally high number of critical variables; the management of which requires extensive expertise. Finding a doctor whose primary area of focus is implantology will give you the best chance of receiving the best advice and treatment with regard to issues of material choice, implant planningbone augmentation, and more. Dr. Sammy Noumbissi is one of the country’s foremost experts on pre and post op dental implant care.  His office, located in Silver Spring, Maryland, employs the latest techniques and most advanced technology in order to ensure that all of his patients receive the highest standard of care possible.  Contact the office today to schedule a free consultation.

Drs. Noumbissi & Luettmann Zirconia Implantology Workshop At The 36th Annual Asia Pacific Dental Congress: APDC 2014 Dubai, UAE

Dear Colleagues, Friends and Patients,

On Monday June 16, 2014, Drs. Sammy Noumbissi and Ralf Luettmann of Hamburg Germany conducted a full day Workshop in Advanced Implantology at the 36th Annual APDC meeting. There was a combination of lectures and hands on where all 12 attendees were able to perform placement of Zirconia dental implants in artificial jaw models. This program was the first of its kind at the APDC and in the Middle-East.

Loma Linda University Graduate Implant Program Alumni Symposium. June 9, 2014

Zirconia Implantology Lecture At Loma Linda University’s Graduate Program In Implant Dentistry

A great professor and mentor Dr. Alejandro Kleinman is retiring from Loma Linda University’s Graduate Program in Implant Dentistry. Prof. Kleinman was instrumental in Dr. Noumbissi’s decision and selection to attend the program in 1999. In his honor the Robert A. James Society of Implant Dentistry is hosting an Implant Dentistry Alumni Symposium that will take place at Loma Linda University in the Randall’s Visitor Center on Monday June 9, 2014.  Dr. Noumbissi was invited and accepted to speak at this event along with other graduates of the program.

Zirconia Implantology In The United Arab Emirates

Functional, safe and aesthetic replacement of dentition has long been a challenge for dentistry. The lectures objectives were to provide the delegates  and specialty residents with a high-level and comprehensive overview of the fastest growing addition to dental implantology; Metal free zirconia dental implants.  Zirconia has been, and continues to be, widely used in restorative dentistry.
Today, manufacturing processes have been developed making high performing, quality all-zirconia implants for use in single unit, multi-unit and edentulous treatment plans.  Zirconia is an inert bioceramic which has excellent biomechanical properties, does not conduct heat, retains no plaque and unlike titanium it is not susceptible to galvanic activity or corrosion in the oral environment.

Dr. Noumbissi was invited to be a keynote speaker at the 2nd International Conference and Exhibition on Dental and Oral health. This conference was held at the Crown Plaza Hotel Dubai in the United Arab Emirates from April 21 to 23, 2014. The theme of Dr. Noumbissi presentation was “All Ceramic Implantology with Zirconia Dental Implants: Rationale and Clinical outcomes”.  On April 22, 2014 Dr. Noumbissi introduced ceramic implants to the Dubai School of Dental Medicine. In attendance were thirty residents and faculty from the oral surgery, periodontics, prosthodontics and endodontics specialty departments. The topic presented was “Zirconia Dental Implants: A Viable Alternative to Titanium Implants”