Oral implantology specialist shares expertise on bone growth concept

What factors contribute to the success of implant treatments?
First of all, we have to take a patient centric approach and have moved away from adopting a universal treatment protocol. We believe everything should be micro customised for each patient who seeks treatment with us. It is essential to have a full grasp of why each patient has lost their natural teeth in the first place, as well as the reasons that now motivate them to consider implant therapy treatment. Teeth are supposed to last a lifetime but for these people, failure in dentistry and/or oral care have made this inconceivable. We know that implant patients are often in their 50’s and we also need to factor in possible issues relating to cardiovascular disease or diabetes which need to be kept under control. It is also important to carry out a full assessment of patients’ oral care behaviour, ascertain whether they understand how embracing new oral habits will favourably impact on the success of these implants, and whether they are ready to do so when they start the implant treatment process.

Once we move past the diagnosis process, the next step is to decide which implant to choose and which techniques to use, as you assess patient’s individual needs. At this point, you need to look at the kind of bone you are working with, which will determine what dental implant will be suitable for the placement in terms of width, height, and overall dimension.

In the lower jaw, I would be looking for an implant that is sturdy and not too big to be able to sustain the tooth; In the maxilla or sinus however, a decision has to be taken about whether the implant can be stabilised and if the sinus lift can be carried out at the same time, or if the implant should be placed six months down the line once the required bone level is achieved.

When it comes to what patients want, we often get asked to come up with a fast and effective solution.  Provided the first time implant patient understands the risks involved, we can undertake the full treatment all at once. However, when patients have experienced previous implant failures, we recommend a 2-step approach that takes longer, building the bone first and placing the implant in a second phase.

We are lucky to work with German company bredent, which offers three types of implants (blueSKY, copaSKY and SKY Classic) that are ideally suited to tackle every situation with which we are faced. Having the opportunity to consider three different approaches really provides us with optimum chances for successful osseointegration and treatment outcome for our patients. We don’t have to stick with only one type of implant or one size, we can switch things around.

blueSKY is perfect for flush placement with the bone and its use in the augmented ridge which creates optimal conditions to maintain a high level of bone height after the implant placement. blueSKY, with its enhanced primary stability, offers the ideal option for immediate restoration including platform switch.

The implant design of bredent’s copaSKY allows for atraumatic insertion in the hard bone and provides high primary stability due to compression in the soft bone. This makes it suitable for all bone qualities and allows for immediate restorations.

SKY Classic is designed in a way to ensure that its relatively long, refined section of 0.5 mm of only etched surface offers optimal preconditions for the attachment of connective tissue and epithelium. Therefore, the SKY classic implant is placed supracrestally. It can be used for all standard indications but is particularly suitable for uneven alveolar ridges thanks to its special neck design. The 8 mm length can also be used as a short tissue-level implant.

What are the benefits of a back taper?
The microstructured back taper from bredent is a bevel in the shoulder (crestal) area which is present on most of the manufacturer’s implants, and which provides additional space for bone and soft tissue growth. With the back taper, the bone naturally tries to close any gap, you achieve good tissue growth which will ‘lock in’ the rest of the implant. It really helps when you place the implant subcrestally as you release tension from the cortical bone. We need to keep this prospect in mind, especially when we need immediate loading and insertion torque supported only by the bone inside the cortical.

The back taper really helps below the cortical bone, as you can obtain good connections. If you use the one-abutment one-time concept as you place an implant for a bridge, you can immediately place the multi-unit and never touch them again. This way, you avoid contaminants inside your connection and prevent inflammation and bone resorption.

When performing implant treatments there is that worry that something will go wrong during placement which is why it is so important to have an in-depth conversation with the patient prior to surgery. The fact of the matter is that implants are very prone to food remnant attachment, bacterial contamination and plaque build-up which will subsequently lead to peri-implantitis.  It is also difficult to re-clean implants.  In the last seven years my approach has been to place the implant deeper, using multi units to come up outside the bone with space 2mm higher, so keeping biofilm, food remnants and bacterial contamination away. The patient cannot really do anything wrong that way.

With bredent implants, it is much easier to see the back taper as it is more pronounced. I think that everyone has recognised the importance of platform switching. Now we can also combine this with back taper implants so that we not only get good bone stability but also space for bone growth. This is especially true with copaSKY, where the back taper has a micro structured surface, and we really appreciate that added value.

What implants do you use most?
Currently, I would say copaSKY implant but I used a lot of blueSKY in the past. We also recently conducted a clinical study* reviewing the implant treatments we performed five years ago and bone growth was noted around the 4.5 blueSKY we placed. This was an observation based on 500 implants.

What is the benefit of micro-structuring of the surface?
The benefit of micro-structuring on the back taper is that you get better growth on that surface. However, there is a risk with a micro-structure if you don’t place it subcrestally, you might experience bone loss. It is therefore important to think ahead and have a clear idea of where your bone will be after the healing phase.

With immediate loading cases and immediate placement of implants after extraction, you really need to think it through. copaSKY gives you the benefit of the micro-structured surface whilst blueSKY doesn’t, but the latter has the advantage of helping you if the healing does not go to plan.

Over the years I have seen a lot of companies introduce this concept in a variety of ways, however I find the bredent back taper ideal as it is larger. As far as future development goes, I am not sure if it is possible to add more value with more novel implant designs. However, there is a need to become much more efficient in ways which make implant therapy more accessible to patients. This is even more pertinent as we have an ageing population and more patients losing their teeth.

Have you seen cases of bone formation as a result of using implant systems?
When we place bredent implants subcrestally, we get bone growth. When the placement is carried out crestally, it is sometimes unfortunate that we can experience bone loss. In my view there is a big difference in design of the Ti Base. So when we place single crowns, we exclusively use copaSKY as we feel we achieve much better results.

What are platform switching, zero bone loss, and bone growth concepts?
With platform switching, we need the abutment platform to be smaller than the neck of the implant. The space is required for tissue growth and vascularisation.

As for the zero-bone-loss concept, it is something to which we all aspire. It also involves the soft tissue so we have to keep in mind its quality and width. This sometimes means we have to carry out some form of bone graft, tissue graft or place the implant deeper if the tissue height is 1 or 2 mm. In order to achieve zero-bone loss, it is not realistic to use standard protocols for every patient; we need to be aware of what’s going on with the tissues in the specific area where we plan to place the implant. It is achievable so long as you keep that in mind and you ensure you have good tissues at the site of the proposed implant.

Bone growth can be discerned around six months after treatment. Once we observe the mechanical stimuli to improve the bone around the implants and get positive remodelling of the bone, we feel a lot happier about the outcome of the treatment.

What are the conditions necessary for bone growth concept?
I wish I had a simple answer to give you, but it is more complicated than that. We need to factor in the type of implants, bone grafts, restorations, the height and quality of the tissue, the general health of patient, you name it. Of course if you are dealing with a heavy smoker, there is no way the tissue graft would survive the integration process, so it is really a case by case situation.

I think that the implant design is important and accounts for one third of the overall process. Also, the subcrestal implant placement has a significant role, and combined with the micro structured surface of the back taper, which naturally stimulates the bone growth, helps us achieve good connection and increase the chances of success. Every treatment needs to be customised using a number of techniques which we can draw on to achieve optimal results for the benefit of the patient.

I feel reassured using bredent’s implants as the company has a strong history of developing novel concepts and systems to achieve successful treatments. This gives me a lot of confidence that I will achieve positive outcomes for my patients by achieving bone growth whilst avoiding complications.

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