Controlling costs and increasing access to dental implant treatment

A success rate of 98% is almost universally claimed when promoting implant dentistry to patients. So, if implant dentistry is 98% successful, then why are more cases failing and why is litigation increasing? Lack of proper training, poor treatment planning and poor execution (surgical and restorative) are undoubtedly the main culprits. If a clinician has the appropriate surgical and restorative training in dental implantology, does the brand of dental implant used make a clinically significant difference to the success rate? Does paying more for the implant and restorative components really produce better results? Why is price an issue?

Price should generally not prevent access to high-quality, well-researched and effective dental treatment. However, the current pricing structure in implantology means that a huge proportion of patients do not have the disposable income to cover the costs of such treatment. The McGill study demonstrated the numerous benefits (functional, clinical, psychological and general health) for edentulous patients in whom dental implants were used to stabilise complete dentures. The improvements in chewing efficiency, general health resulting from an improved diet and general well-being (more social interaction owing to a lack of fear of teeth falling out) shows the significant impact dental implants make in society as a whole.

How can this situation be changed to allow more potential patients to access dental implant treatment? First, clinicians could significantly reduce fees charged to patients. This can only happen if the component and laboratory costs are reduced, with the dentist passing the savings on to the patient. Another option is that dental implant companies reduce the prices of both implants and restorative components. According to the industry, however, prices across the industry are already competitive and companies need to cover their business costs.

Is there an alternative to the above? Clinicians cannot reduce charges without assistance from the dental implant companies and all dental implant companies are private businesses with shareholders who want to produce products (implants) that benefit society and see some return on their investment in terms of profit generation.

Economic drivers
Market forces must come to bear in dentistry. In the current global economic climate, ignoring the financial implications of the decisions we make is no longer an option. Patients expect high-quality, safe and affordable treatment. For this to happen, clinicians need to source products at a reasonable price point, passing on these savings directly to the patient, reducing overheads and treatment charges and, therefore, increasing access to treatment. Some of the prestige implant companies have already felt the impact of the loss of market share and have either bought out competitors, created joint ventures or incorporated competing products into their product lines.

Do smaller implant providers offer potential benefits? One is certainly their ability to respond more quickly to increased patient expectations of treatment. The rapid expansion of digital dentistry, CAD/CAM technology and intra-oral scanning is resulting in smaller companies being able to provide clinicians with a total, open-source guided surgery and restorative solution. With larger companies, the ability to change direction is much more difficult and time-consuming; turning an oil tanker takes more time than a dinghy.

Key points of consideration when reviewing a new implant system
Globally, all medical and dental products undergo strict vetting procedures to ensure patient safety, including product durability testing, animal studies, human trials and testing at universities. They are then required to obtain a CE mark, FDA approval or some other approval to allow the products to be used in clinical dentistry. In short, once a product has a CE/FDA mark, it meets all the necessary testing and patient safety requirements to be used on humans. All CE/FDA-marked systems meet the same standard whether affordable or prestige brands.

The next step is to assess all clinically relevant criteria. Since there are more than 1,300 dental implant systems available, clinicians needs to assess all available clinical and scientific data and test the validity of various claims made by dental implant companies. If checking for certification/approval is the first step for a clinician, then the second should be establishing how future proof the new implant is. In the early days of implantology, dozens of companies started trading and most of them closed in a relatively short period. For early adopters of those systems, the risk was not being able to restore or maintain such systems, as parts were no longer available. Therefore, as a general dentist, one should verify the length of time for which the system has been on the market, who the parent company is and what the connection interface is (is it a clone system of a well-known implant that is no longer in patent?). In simple terms, if the company ceases to trade, can I still source components and maintain my patients?

Implant-specific considerations
A significant proportion of connection options (internal hex, external hex, Morse taper and conical connections) are no longer in patent. The clinical research on these has already been done and their success rates have been well documented in a multitude of studies. As a result, most affordable implant systems are adopting these non-patented connections rather than developing their own, meaning that prosthetic components are cross-compatible with other similar systems.

A clone connection implant can thus be restored with a high-end restorative component provided by another implant company or using patent-free connections by open-source milling centres that can provide these components for significantly lower costs. One caveat with open-source milling is to check the quality of the milling provided in order to avoid the complications that arise from poorly fitting restorations.

Systems like the ICX now provide non-precious metal blanks with pre-milled implant connection interfaces and ceramic blanks bonded to adhesive base components. It is a premade titanium implant connection that is bonded to the all-ceramic block. It is the milling of the implant connection interface that is the most vital part of the process, so if an open-source centre can obtain a pre-milled connection blank, then its work is much reduced and the dentist can be rest assured of a high-quality component with an accurate fit. The benefit of adhesive bases in all-ceramic work is the improved strength of the connection and reduced fracture rates compared with all-ceramic abutments.

Is using one of the clone connections listed above an issue? All these connections function with excellent long-term, clinically documented results. The key factor for success is the closeness of fit between the internal/external implant connection and the mating surface of the abutment, also called the micro-gap. This produces a stable, rigid connection with no abutment movement under loading. A stable implant–abutment interface combined with platform switching is the key to bone preservation around the neck of the implant and avoiding screw loosening.

How can one most easily compare multiple connection platforms in a simple and easy to understand way without needing a degree in mechanical engineering? Engineer Holger Zipprich from Goethe University Frankfurt’s dental school in Germany has produced real-time videos of several implant–abutment interface responses to loading that are available on YouTube. Once the videos have been viewed, a rational decision as to which connections are more stable (rigid) under loading can be reached and this information then applied to selecting an implant system.

Does the system offer a wide range of prosthetic, CAD/CAM and guided surgery solutions for dental implant treatment? Once a dental implant system has gained some degree of market penetration (or traction) and has documented evidence to support its clinical effectiveness, it is worthwhile taking an unbiased view of the system. Hopefully, most glitches would have been identified and corrected by the early adopters, thus reducing the risks for the more cautious clinicians.

A personal recommendation is to focus on the restorative aspects first (restoratively driven treatment). Questions to be asked include whether the system has a broad range of components for the various treatment needs in implant dentistry, CAD/CAM-based treatment solutions and a guided surgery solution for the surgical placement of dental implants. If you are impressed by what you see, then place a few implants and monitor them closely. If the treatment outcomes are successful and you have a positive impression of the system, then there is no reason that you should not add a cost-effective solution to your dental implant portfolio.

What impact does the macro-geometry (implant shape) and micro-geometry (surface treatment) have in relation to long-term success? The surface treatments applied to various implant systems are designed to improve the degree of osseointegration and bone–implant contact. This is extremely important for the long-term preservation of bone around a dental implant. However, is the surface treatment that important when looking at immediate loading situations? In those situations, it is the primary stability of the dental implant, combined with the closeness of fit to reduce micro-movement of frameworks, that is the key factor in determining long-term success. Any beneficial effects of a surface treatment will occur post-osseointegration and several months after loading. So, are the macro-geometry of the implant and the physical stability of the abutment connection more important than the surface treatment for long-term success or vice versa?

Again, it depends on what the clinician is planning to do, immediate loading or conventional delayed protocols. Very little independent research has looked into the accuracy of the claims made by implant systems, and even less work has been done directly comparing the various implant designs to evaluate different systems. One group that has attempted such an analysis is the Cochrane Collaboration and its reports are presented later in the article.

Primary stability is mainly governed by the implant thread design and this directly affects the insertion torque. The implant–abutment connection stability is equally important. If this was not the case, then an implant inserted with a low insertion torque and poor component fit would be subject to prosthetic movement under occlusal loading with loss of primary stability and implant failure long before osseointegration would have occurred.

If one is following conventional delayed loading protocols, then the surface treatment, as well as the macro-geometry and connection stability, will affect long-term success. Do the larger prestige dental implant brands provide dental implants with the most ideal thread designs, best primary stability, and highest tolerances of fit of abutments and frameworks, or do the various surface treatments have a clinically significant improvement in long-term success when compared with a so-called budget brand? Again, no real cross-comparison research exists. The surface roughness of the dental implant is also of vital importance, as research has found increased peri-implantitis associated with macro-roughened surfaces. Smooth or machined surfaces clinically show reduced levels of osseointegration, so the current thinking seems to be that micro-roughened surfaces provide the optimum surface for osseointegration.

An affordable implant solution
The low-cost system that will be used here for comparison is the ICX system manufactured by medentis medical in Germany. On the market for several years and well known in Europe, it has recently arrived in the UK as part of the company’s global expansion. All of its research has been conducted and validated by several prestigious institutions, adding weight to the product, including the Fraunhofer Institute, which conducted durability testing, as well as universities in Cologne, Aachen and Mainz, which also contributed with clinical research. The Robert Mathys Institute in Bettlach in Switzerland performed research on the micro-gap (tolerances of fit of abutments).

The ICX system has a well-developed CAD/CAM workflow for fabricating abutments, bars and frameworks for restoration with both ICX and other dental implants in addition to premade components. Titanium, zirconia and non-precious restorative components for ICX and other brands are available and are supplied with the final prosthetic screw included. With some systems, the final screw is not included and must be purchased separately. ICX also has a bespoke CBCT guided surgery solution called Magellan that is also multi-implant system based. The dentist can either purchase the software or upload the DICOM file to the parent company server and the company will carry out the design process and fabricate the guide once the design has been approved by the dentist. Magellan can also be used to produce guided surgery drill guides for various dental implant systems, but at a fraction of the cost.

When considering an implant solution, a look at the total system costs involved with both surgical and restorative components can reduce the overall cost to the patient. Table 1 shows a price comparison of the ICX system against multiple implant systems, both prestige brands and cost-effective systems based on 2013 costs in the UK. In terms of cost and product content, the ICX implant seems to provide a cost-effective implant solution for patients.

How does the implant fare when tested in the laboratory against the prestige systems? The Fraunhofer Institute conducted durability (ISO 14801) tests (Figs. 1a & b) on several implant systems, including Straumann Bone Level implants. These tests showed that the ICX implant was more fatigue resistant than all of the implants tested (Figs. 2a & b). Thus, the implant has a durable, fatigue-resistant connection interface.

The implant–abutment interface
How stable is the connection when viewed in terms of closeness of fit or the micro-gap between the implant and the abutment? In Orale Implantologie in 2007, Berlin dentist Dr Stefan Wolf Schermer examined the micro-gap between the abutment and the dental implant connection interface of several systems and showed that ICX implant–abutment micro-gap was the smallest of all of those examined (Figs. 3a & b).

Closeness of fit is directly related to movement of the abutment when under load. The fatigue test figures in conjunction with the smallest micro-gap figures show the ICX implant has a well-designed and rigid connection interface that is platform switched. The macro-geometry of the implant with self-tapping apical threads provides high insertion torques with excellent primary stability. These are key components in preserving crestal bone around an implant. In terms of surface treatment, the ICX implant has an etched and blasted micro-roughened surface (Ra of 1–3 µm) with a pure titanium dioxide surface with no additives. The implant was previously described as having a hydrophilic surface. However, this claim was successfully challenged by Straumann and is no longer used to describe the implant. The surface is currently being updated.

As a prosthodontist working in private practice most of what is outlined above is how I personally approach new implant systems. There is very little clinical research comparing the various dental implant systems directly to one another and a significant proportion of studies published cannot be directly cross-compared, as there is no standard clinical method for doing so. All of the variations in implant geometry, surface treatment and restorative solution in addition to the operator variables (the surgeons involved, their individual skill sets and the correlation of the statistics) all make such direct comparisons between implant systems a potential minefield.

Are there any independent reviews of published articles that might be a source of further information? Possibly the Cochrane report, which is an ongoing study. The Cochrane Collaboration is a global, independent network of researchers, professionals, patients, carers, and people interested in health who gather and summarise the best evidence from research to help you make informed choices about treatment. It does not accept commercial or conflicted funding and has contributors in over 120 countries. Starting in 2003 with follow-up reports conducted in 2005 and 2007, the group published its latest evaluation last year.[1] The full report can still be accessed online, as can the previous versions. It has led to intense online debate by various dental implant companies and clinicians largely because of its conclusions, which are reproduced here directly from the summary of the report: “Based on the results of the included RCTs [randomised controlled trials], we found no evidence showing that any particular type of dental implant had superior long-term success. There was limited evidence showing that implants with relatively smooth (turned) surfaces were less prone to lose bone due to chronic infection (peri-implantitis) than implants with much rougher surfaces (titanium-plasma-sprayed). These findings were based on several RCTs, often at high risk of bias, with few participants and relatively short follow-up periods.”

In summary, use of a cost-effective dental implant system (in the author’s opinion) is justified in terms of economic savings to the patient and increasing the reach of dental implant treatment to the wider public. It is reasonable once the system has been cleared for use in general dentistry (CE mark, FDA approval) and should be considered a viable clinical option once the dentist has reviewed the available clinical data (conventional and guided surgery solutions) and restorative treatment (conventional and CAD/CAM-based) options. He or she will then come to an informed decision, at which point he or she should place and review a small number of implants in varying clinical situations and monitor the results.

Editorial note: A list of references is available from the publisher.

Conflict of interests: Dr Tuss Tambra has not received any payments or other inducements of any kind from any company mentioned in the article.