Decisions regarding to restorative and cosmetic dental procedures are not to be taken lightly. There are long term implications with regard to health, functionality, finance and aesthetic. This is probably most true when the choices relate to dental implants. It’s imperative to get as much up to date information as possible when considering your implant options.
Patients coming in for implant consultations have been known to raise concerns about having heard that ceramic dental implants are more susceptible to fracture. While this concern is essentially unfounded today, it does have some basis in fact.
Much of the data and research for ceramic dental implants has come out of Europe, where use of zirconia dental implants has a far more extensive and varied history. Commercial use of zirconia implant materials in Europe began in 1987. While zirconia immediately proved its worth as an implant material from the perspectives of osseointegration with the jaw bone and biocompatibility with gum tissue, it did in fact experience much higher rates of failure due to fracture.
The newer, stronger generation of zirconia dental implants have now been in use across Europe for nearly 20 years, and almost 10 years in the U.S. Patient enthusiasm along with endorsement from renowned experts such as Dr. Noumbissi have led to a continuous increase in zirconia use as a dental implant material, and this trend seems sure to continue into the foreseeable future.
It is typically found in rock and sand deposits, from which it is mined and refined. The few byproducts and waste materials that are produced during the refining process are naturally common in typical beach sand. As such, disposal is generally cheap and easy with virtually no environmental impact.
Although zirconium is not as prevalent in mainstream vernacular as its cousin, titanium, its many virtues as a manufacturing material has caused its use to become rather widespread over the last 90 years.
The applications don’t stop there. Zirconium derived materials are used in a variety of spacecraft. The stable electron configuration is yet another reason widely used as a refractory for purposes of metallurgy.
Zirconium is also used in the positron emission tomography imaging process. Commonly known as PET scanning, this technology is at the cutting edge of cancer diagnosis and treatment today. This is not zirconium dioxide’s first application in the medical field, however.
As mentioned, zirconium is exceptionally inert to both organic and inorganic compounds. This makes it an especially biocompatible element. In fact, trace amounts or zirconium can be found in all biological systems. For decades now, zirconia ceramics have been used as surgical prosthetics. This is especially true in the field of dental implants, where ceramic zirconia tooth implants are now widely regarded as the highest available standard of care.
The abundant availability of zirconium, along with its environmental and biological inertness, indicate that its use in modern products and technology is not likely to wane anytime in the foreseeable future. In fact, the unique physical and chemical properties of zirconia combine with mechanical durability to suggest that we have only begun to scratch the surface of technological applications for this benevolent element.
Those ancient implants were made of sea shell. From a medical standpoint, that material was as effective as any other implant material human beings could come up with, until the first titanium dental implants were placed in patients during the 1960s. At that point titanium had already been used in various other surgical implant procedures due to its propensity to integrate with bone structure.
While titanium implants had unprecedentedly high success rates, it does have some less than ideal attributes as a dental implant material. One is the manner in which titanium decays, as it results in titanium oxide particles being dispersed into the soft tissue, the bone, and the blood stream. People have varying levels of sensitivity to titanium in their body. Titanium oxide contamination in the body can cause myriad health complications, but some people’s sensitivity to the metal is so acute that it causes their body to reject the implant itself. Additionally, people with especially visible implants often find that the grey titanium post can be seen through their tooth colored crown.
The tooth colored ceramic immediately proved a better cosmetic option for front teeth replacement. Soon the material was being used to create durable, tooth colored crowns that were attached to existing tooth structure. It was quickly discovered that, unlike titanium, zirconia facilitated the growth of soft tissue as well as bone. Zirconia implants are also less susceptible to corrosion, and the material is commonly used in spaceship construction due to its resistance to fracture and heat damage.
While zirconia quickly proved in various clinical trials to have multiple short term advantages over titanium as an implant material, some American skeptics have pointed to a lack of long term data regarding the success rate of ceramic dental implants. While zirconia implants have only had FDA approval since 2007, the ceramic material has been used to make dental implants in Europe since 1987. Just as technology and methods have evolved with metal implants and indeed the field of dentistry at large, many adaptations have been implemented to the concept of ceramic implants that have significantly improved the standard of care. Even without adjusting for these improvements, however, there is more than enough long term data from Europe to attest to the long-term viability of zirconia dental implants, even by conservative standards.
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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.
We 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 planning, bone 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.
It seems more and more people are becoming aware of and concerned with the myriad chemicals, compounds, and materials that are going into their bodies. It’s a legitimate concern indeed, as new substances seem to be finding their way into our food, medicine and overall environment at an increasingly rapid rate. With all of these new molecules popping up for us to check out, it can be easy to take for granted that the materials we’ve already been using for generations are inherently safe. As we’ve seen in the cases of mercury, lead and asbestos, that is certainly not always the case; toxic materials can sleep through the cracks of public awareness and remain in use for very long periods of time.
Thankfully, there are no doctors to my knowledge that are placing asbestos dental implants. There are different materials being used in the dental implant industry today, however, and it is extremely prudent to be aware of the potential risks involved with any material that is being permanently inserted into your body.
As with many biological prosthetics, titanium has been the primary material of choice for dental implants placed around the world for many years. It was seen as an ideal choice due to its light weight and durability. It is relatively less difficult to integrate with the body than a lot of other metals, and under normal environmental circumstances it was believed to be practically impervious to corrosion.