Hong and Oh Maxillofacial Plastic and Reconstructive Surgery (2017) Maxillofacial Plastic and

39:33 DOI 10.1186/s40902-017-0132-2

Reconstructive Surgery

REVIEW Open Access

Recent advances in dental implants

Do Gia Khang Hong and Ji-hyeon Oh*

Abstract
Dental implants are a common treatment for the loss of teeth. This paper summarizes current knowledge on implant
surfaces, immediate loading versus conventional loading, short implants, sinus lifting, and custom implants using
three-dimensional printing. Most of the implant surface modifications showed good osseointegration results.
Regarding biomolecular coatings, which have been recently developed and studied, good results were observed in
animal experiments. Immediate loading had similar clinical outcomes compared to conventional loading and can be
used as a successful treatment because it has the advantage of reducing treatment times and providing early
function and aesthetics. Short implants showed similar clinical outcomes compared to standard implants. A variety of
sinus augmentation techniques, grafting materials, and alternative techniques, such as tilted implants, zygomatic
implants, and short implants, can be used. With the development of new technologies in three-dimension and
computer-aided design/computer-aided manufacturing (CAD/CAM) customized implants can be used as an
alternative to conventional implant designs. However, there are limitations due to the lack of long-term studies or
clinical studies. A long-term clinical trial and a more predictive study are needed.
Keywords: Dental implants, Osseointegration, Immediate dental implant loading, Sinus floor
augmentation, Computer-aided design

Background osseointegration [4]. The surface roughness of implants has

The most common cause of teeth loss is periodontitis, and been increased by various methods such as machining,
other causes include dental caries, trauma, develop-mental plasma spray coating, grit blasting, acid etching, sandblasted
defects, and genetic disorders [1]. The use of dental and acid etching (SLA), anodizing, and biomimetic coating
implants to rehabilitate the loss of teeth has in-creased in [3–6]. The key factor in implant osseointegration is surface
the last 30 years [2]. Before dental implants, dentures and roughness, which shows increased osteoblast activity at 1 to
bridges were used, but dental implants have become a 100 μm of the surface roughness compared to a smooth sur-
very popular solution due to the high success rate and face [6]. It is believed that rough surfaces have better
predictability of the procedure, as well as its relatively osseointegration than smooth surfaces, but the results of the
few complications [1, 3]. research have been diverse and it is not clear that multiple
Many studies related to dental implants have been treatments provide better predictive results [7].
published and some are in progress. In this paper, current The machined implant surface is the first-generation im-
knowledge of dental implants is summarized in each plant surface design with a turned surface implant [4, 7].
section (implant surface, immediate loading versus Plasma spray coating generally forms a thick layer of depos-
conventional loading, short implant, sinus lifting, and ition such as hydroxyapatite (HA) and titanium by spraying a
custom implant using three-dimensional printing). material dissolved in heat on the surface of the implant
[5]. Grit-blasting is a process of spraying particles onto the
Review surface of the implant using ceramic material or silica. Sand,
Implant surface HA, alumina or titanium dioxide (TiO2) particles are used
Modification of the implant surface has been studied and and acid etching is performed to remove the remaining
applied to improve biological surface properties favoring blasting particles [5]. Acid-etching is the rough-
ening of the titanium implant surfaces using strong acids
* Correspondence: [email protected] such as hydrofluoric acid (HF), nitric acid (HNO 3), and
Department of Oral and MaxilloFacial Surgery, Dental Hospital, sulfuric acid (H2SO4) or combinations of these acids [5].
Gangneung-Wonju National University, Gangneung-si, Gangwon-
do, Korea, Republic of

© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution
4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution,
and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source,
provide a link to the Creative Commons license, and indicate if changes were made.
Hong and Oh Maxillofacial Plastic and Reconstructive Surgery (2017) 39:33 Page 2 of 10

SLA is acid etching after sandblasting with 250–500 μm In animal studies, modifications of the implant surface
large grit particles [7]. Anodizing is the dielectric break- by biomolecular coating seemed to enhance osseointegra-
down of the TiO2 layer by applying an increased voltage tion by promoting peri-implant bone formation in the
to generate a micro-arc. This process forms a porous layer early stages of healing, and it seemed to improve histo-
on the titanium surface [8]. morphometric analysis and biomechanical testing results
In the short-term, the survival rate of SLA, HA coat- [4]. In animal studies, biological coating did not have a
ing, and oxidized surface modifications was reported to statistically significant effect on peri-implant bone growth,
be 100%, but the survival rate tended to be slightly lower but statistically significant effects were observed with inor-
in the long-term [9–11]. The long-term survival rate of ganic and extracellular matrix component coatings [2].
each surface modification is shown in Table 1. In SLA, Furthermore, such modifications of the implant surface do
the survival rate at 10 years follow-up was 98.8 ~ 99.7% not always provide beneficial effects on osseointegra-tion
[12, 13] and in titanium plasma sprayed (TPS), the sur- [4]. Long-term clinical studies are needed.
vival rate at 20 years follow-up was 89.5% [14]. With
anodizing, the survival rate at 8 ~ 12 years follow-up was Immediate loading versus conventional (delayed) loading
96.5 ~ 100% [15–17]. With HA coating, although the According to many previous studies, many researchers
survival rate at 10 years follow-up in 2007 was as low as believed that after implantation in the jaw for a future
82.0% [18], there was also report of 98.5 and 93.2% in prosthesis, titanium implants should be left submerged to
published papers in 2000, respectively, which was similar undergo a healing process before they are capable of
to uncoated titanium implants [19]. func-tional loading. This healing process, which is called
There are various surface modifications as mentioned osseoin-tegration, could be completely achieved in a
above. It is said that any surface modification provides a period from 3 to 6 months [23]. The reason for the
good surface for osseointegration when the surface rough- delayed loading was to avoid micro-movement on the
ness is 0.44 ~ 8.68 μm [5]. It is said that acid etching and implant, which could interfere with the healing process. If
coating are the most preferred for making good roughness this situation occurs, connective tissue can develop at the
of the implant surface [7]. There is a study that suggested interface between the implant surface and the bone. The
HA is superior to sandblasting, SLA, TPS, and/or ma- result would be failure of the implant due to not being
chined surfaces in bone-implant contact ratio [20]. On the able to resist the mastica-tory forces [24].
other hand, there is a study that suggested a bone-to- Following the progressive development of technologies and the
implant contact of a blasted-etched and covered with HA wide spread of implantation in dentistry, more recent re-search has
group was better than a blasted group, acid-etched group, focused on the mechanism of bone healing. It has provided a better
and blasted and acid-etched group; however, there were understanding of osseointegration [25]. It was suggested that it
no significant differences [21]. would be possible to reduce the period between implantation and the
Recently, research on implant surface modifications placement of a prosthesis [26].
using inorganic materials (HA, calcium phosphate, bis- Over the past 20 years, a number of studies and trials
phosphonate, etc.), growth factors (bone morphogenetic have reported similar results with trans-mucosal implants
protein, platelet-derived growth factor, transforming compared with submerged implants. As a result, it is not
growth factor beta, fibroblast growth factor, vascular necessary to submerge the implants under the mucosa
endothelial growth factor, etc.), peptides, and extracellu- during the healing period, which eventually introduced
lar matrix components (collagen, chondroitin sulfate, the immediate loading protocol [27, 28].
vitronectin, hyaluronic acid, etc.) has been underway as This protocol was initially developed for the treatment
part of bioactive surface modification [2, 4, 22]. of edentulous patients, and its main purpose was to restore

Table 1 The survival rates by modifications of the implant surface

Author/year Modification material of implant surface Follow up Survival rate
Buser D, et al./2012 [12] Sandblasted and acid-etched (SLA) 10 years 98.8%
van Velzen FJ, et al./2015 [13] Sandblasted and acid-etched (SLA) 10 years 99.7%
Chappuis V, et al./2013 [14] Titanium plasma sprayed (TPS) 20 years 89.5%
Degidi M, et al./2012 [15] Anodized 10 years 96.5%
Mozzati M, et al./2015 [16] Oxidized 9–12 years 97.1%
Pozzi A, et al./2014 [17] Oxidized 8–10 years 100%
Binahmed A, et al./2007 [18] Hydroxyapatite (HA) 10 years 82.0%
Lee JJ, et al./2000 [19] Hydroxyapatite (HA) 4–8 years 93.2–98.5%
Hong and Oh Maxillofacial Plastic and Reconstructive Surgery (2017) 39:33 Page 3 of 10

immediate function and aesthetics, which are usually the 6 months), it was reported that the same change of 1.2
main concerns of patients [29]. Numerous recent studies mm in marginal bone over 5 years in both groups was
that focused on this concept have shown excellent results observed [39]. Also an insignificant difference in mean
because the primary outcome was survival of the implant. MBL between the two treatment modalities in both late
A study showed an implant survival rate of 91.7% for im- and immediate inter-antral implantation in the nonaug-
mediately loaded implants at the 2 years of follow-up mented edentulous maxilla was reported [32].
[30]. A 100% survival rate was reported in 11 edentulous Patient-related outcomes were frequently chosen as a
pa-tients treated with immediate full-arch implants [31]. secondary outcome in many publications related to imme-
In studies that compared the immediately loaded im- diate loading versus conventional loading. In a previously
plants with conventionally loaded implants, the results mentioned systematic review, most patients preferred im-
showed high survival rates in both groups. The first part mediate loading rather than the conventional loading de-
of a study about late inter-antral implantation in the pending on general and aesthetic satisfaction as well as on
nonaugmented edentulous maxilla reported survival rates postoperative outcomes, such as pain, edema or the need for
of 98.3% in the immediate loaded implants group and medications [34]. Other different findings were found.
96.7% in the conventional group at a mean observa-tion Patients in the immediate loading group reported higher
period of 4.7 years [32]. The results in the second part of satisfaction than the conventional loading group. How-ever,
the study, in cases of immediate inter-antral im- at the end of a 1 year observation period, functional
plantation, also showed similar findings. They were 97.6 differences between the two groups had disappeared. Post-
and 96.6% for a mean observation period of 3.9 years operative pain was the only significant difference, with a
[33]. A systematic review reported a survival rate of lower value in the immediate loading groups after the third
98.2% in the immediate loading versus 99.6% in the con- day [40]. A study, however, showed that immediate loading
ventional loading when reviewing 29 randomized-control evoked more postoperative pain on the first day and more
studies [34]. swelling on the third day rather compared to the delayed
However, when considering the rate of failure between loading. The study compared immediate and delayed loading
immediate loading and conventional loading in edentu- of single implants to support mandibular overdentures, thus
lous patients, there were publications that showed a suggesting that the number of implants could affect the
higher risk of failure in treatment with an immediate decision about whether immediate loading or conventional
loading protocol. Another article of meta-analysis showed loading should be considered [41].
that immediate loading indicated a slightly higher implant Based on the current evidence pool, it could be sug-
failure rate than conventional loading gested that immediate loading can be used as a success-
[35]. A similar finding was also reported, but with a ful treatment modality. It reduces treatment times,
more significant difference [34]. provides early function and aesthetics, preserves the al-
Marginal bone loss (MBL) is also considering as a pri- veolar bone as well as prevents unwanted migration of an
mary outcome when comparing immediate loading and adjacent tooth in the case of missing a single tooth.
conventional loading. Progressive MBL was demon- However, to achieve the desired treatment outcome, some
strated as one of the measurements for evaluation of im- factors must be taken into consideration when im-mediate
plant failure [36]. There were many recent publications loading is chosen as a treatment procedure (ad-equate
that focused on the comparison of MBL in both im- primary stability, patient compliance, and the number of
plantation of single-tooth cases and edentulous cases. implants).
A minimal MBL with no mobility and peri-implant
radiolucency in both treatment modalities were reported Short implant
when evaluated clinically and radiographically in 20 pa- In an atrophic alveolar ridge, there are many anatomical
tients with the need for fixed implant-supported pros- limitations (maxillary sinus, nasal floor, nasopalatine
thesis for missing mandibular first molars over a period of canal, inferior alveolar canal) that make placement of a
72 months [37]. Another study on implantation for single- standard implant difficult [42]. To overcome these limi-
tooth cases also showed similar findings. There were no tations and vertical bone deficits, additional surgical pro-
significant differences in bone loss between the cedures, such as guided bone regeneration, block bone
immediate implant loading and conventional implant grafting, maxillary sinus lift, distraction osteogenesis, and
loading groups at 1 year follow-up after implantation of a nerve repositioning, are performed to place a stand-ard
single tooth in the anterior maxilla [38]. implant [42, 43]. However, the procedure is sensitive,
This trend could also be found in many studies that fo- challenging, costly, and time-consuming and increases
cused on edentulous cases. When immediate loading four surgical morbidity and causes many complications such
implants with a pre-existing denture converted to a fixed as sinusitis, infection, hemorrhage, nerve injury, and gait
dental prosthesis compared with conventional loading (3– disturbance [42, 44, 45].
Hong and Oh Maxillofacial Plastic and Reconstructive Surgery (2017) 39:33 Page 4 of 10

Short implants are considered to be simpler and more was also a statistically significant higher incidence of
effective by reducing the likelihood of such complica- com-plications in the group with a standard implant with
tions, patient discomfort, procedure costs, and proced-ure a bone graft [60, 64]. In addition, there was also
times in rehabilitation of the atrophic alveolar ridge [42, statistically significant higher marginal bone loss in the
46–49]. The term of a short dental implant is sub-jective, group with a standard implant with a bone graft [63, 64].
and there is no clear criteria for the length of a short Recent studies have indicated that single-crown im-
dental implant [43, 46, 47]. Some articles defined 10 mm plants in the posterior region can be considered as a
or less as the criterion of a short dental implant [47, 50], predictable treatment option [51, 65, 66]. However, the
and some defined less than 10 mm as a short dental implant placement on type IV bone or with the length of 8
implant [46, 51]. Some defined the short implant as 8 mm mm or less should be used with caution, because of the
or less [43, 52, 53]. Implant companies have re-cently higher risk of failure compared to the standard im-plant
offered short implants of less than 8 mm [47]. In this [65, 66].
paper, a short dental implant was defined as less than 8 In conclusion, the use of a short implant of less than 8
mm, which is similar to other papers [48, 54–56]. mm had similar clinical outcomes compared with a
The list of the papers reviewed and the results are shown in standard implant, but long-term follow-up data for more
Table 2. The papers were published within the last 5 years than 5 years is needed.
(from 2013 to 2017) and included dental implants that were
less than 8 mm. The period of follow-up ranged from 1 to 5 Sinus lifting
years. The length of the dental implant varied from 4 to 6.6 Sinus augmentation technique
mm, and a comparison with long or standard dental im-plants Sinus augmentation, in other words, sinus lifting was first
also varied with and without bone grafts. In this paper, described as a surgical technique for creating a bone
failure was defined as implant loss. window in the vestibular wall of the sinus. After that, the
The clinical outcome of short implants in these various sinus epithelium was gently raised to create a space for
criteria is controversial. The lower survival rate of 86.7% bone grafting. Bone harvesting was performed in the iliac
for 6-mm short implants after 5 years was reported [57]. crest area and then placed in the prepared space. The
On the other hand, the survival rate of 100% for 6-mm healing period took about 6 months before implant-ation
short implants after 3 years [54] and the survival rate of [67]. The use of autogenous bone, allograft and alloplast
97.6% for 4-mm short implants after 1 year were reported material for bone grafting during sinus aug-mentation was
[58]. The survival rate of 95.2% for 6-mm short implants suggested. In addition, the one-stage ap-proach was
after 5 years [59], and the survival rate of 100% for 6-mm demonstrated, in which sinus augmentation and
short implants after 1 year were reported [60]. The sur- implantation are performed in one surgery while the two-
vival rate of 97.1% for 5-mm short implants after 1 year stage approach had the implantation taking place after
[61], and the survival rate of 97.2% for 6-mm short im- several months of sinus augmentation [68]. The
plants after 1 year were reported [62]. abovementioned technique has been known as sinus lift-
In studies comparing standard implants without a bone ing with the lateral window and is still widely used in
graft and short implants, the survival rate ranged from modern implant dentistry due to its reliable efficiency.
86.7 to 97.6% [57–59]. In studies comparing standard im- Osteotome sinus floor elevation was a less invasive
plants with a bone graft and short implants, the survival one-stage technique. In this technique, the sinus epithe-
rate ranged from 91.7 to 100% [54, 60, 61, 63, 64]. There lium was accessed via a crestal approach. The tip of the
Table 2 The survival rate of standard and short implants
Author/year Length standard implants Length short implants Diameter Follow up Survival rate Survival rate
and number of implants and number of implants (Ø mm) standard implants short implants
Pohl V, et al./2017 [54] 11, 13, 15 mm 68 6 mm 61 4 mm 3 years 100% 100%
Rossi F, et al./2016 [57] 10 mm 30 6 mm 30 4.1 mm 5 years 96.7% 86.7%
Felice P, et al./2016 [58] ≥ 8.5 mm 116 4 mm 124 4 mm 1 year 98.28% 97.58%
Romeo E, et al./2014 [59] 10 mm 19 6 mm 21 4 mm 5 years 100% 95.24%
Pistilli R, et al./2013 [60] ≥ 10 mm 91 6 mm 80 4 mm 1 year 96.7% 100%
Pistilli R, et al./2013 [61] ≥ 10 mm 69 5 mm 68 5 mm 1 year 98.55% 97.1%
Gulje F, et al./2013 [62] 11 mm 101 6 mm 107 4 mm 1 year 99.01% 97.2%
Esposito M, et al./2014 [63] ≥ 10 mm 68 5 mm 60 Standard : 4 and 3 years 97.06% 91.67%
6 mm Short : 6 mm
Felice P, et al./2014 [64] ≥ 9.6 mm 61 6.6 mm 60 4 mm 5 years 95.08% 91.67%
Hong and Oh Maxillofacial Plastic and Reconstructive Surgery (2017) 39:33 Page 5 of 10

osteotomes, with increasing diameter, push a mass of a limited volume. Extra-oral donor sites could provide a
bone to a required level that beyond the original sinus significant volume of grafting material, but there is an
floor, eventually elevating the sinus epithelium. The im- increase in surgical complexity, morbidity, and scarring
plants were then inserted without drilling after sinus [73]. Therefore, bone substitutes have been developed to
augmentation, followed by bone grafting if necessary. further increase the option for choosing grafting materials.
However, it was suggested that a minimum of 6-mm al-
veolar bone height was needed for primary stability [69]. Allografts consist of ‘same species’ tissue, which is har-
One of the most common complications of sinus aug- vested from cadaveric bone and undergoes various pro-
mentation was perforation of the sinus epithelium, which cedures to reduce antigenicity. Xenografts consist of
could be a result of sinusitis, excessive bleeding and different species tissue. The organic components are re-
delayed healing. Many modified techniques and sur-gical moved to create a mineral scaffold containing residual
instruments were introduced to avoid complica-tions of collagen. Alloplasts are synthetic bone substitutes. There
sinus augmentation. A crestal approach using a non- are many types, which are classified by porosity. These
traumatic drill to decrease the risk of tearing the sinus graft materials could be manufactured as bone particles or
membrane was suggested. In retrospective study, long large blocks can be mixed with autogenous bone [45].
implants (13 mm and 15 mm) were inserted in 265 cases. Following the introduction of many types of grafting
For bone grafting, many options were available. The bone material, a controversy arose focusing on the question of
can be harvested from the osteotomy site, or a bone which material should be chosen as the best solution for
substitute can be used. In the case of experienced grafting augmentation and the related procedures.
surgeons, implants could be inserted without grafting, and The osseointegration of micro-implants was compared
the tip of the implants could act as a support for the sinus when performing sinus augmentation with the use of one
membrane. Similar to crestal approach technique, a of the three types of grafting materials: autogenous bone,
primary stability is achieved if a minimum of 3 mm of bovine hydroxyapatite (BH), or mixture of BH with au-
alveolar bone height is available [70]. togenous bone. The results of clinical and histological
In addition, there were good results with the use of ab- evaluations concluded that there were no statistically sig-
sorbable collagen membranes in perforated sinus for sinus nificant differences between any of the grafting materials;
elevation and implant placement [71]. In other technique however, it was suggested that adding autogenous bone
for treatment of the posterior edentulous maxilla, im- might accelerate the healing time [74]. This similar trend
plants were first placed in the ulna. After 6 weeks, bone was also demonstrated. A randomized controlled trial
blocks containing implants were harvested and trans- (RCT) was conducted to compare the effectiveness be-
planted into the sinus area protruding 3 to 4 mm. Im- tween pure bovine bone matrix grafts with pure autogen-
plants were then left to heal for 6 weeks. To compare the ous grafts. The final results also suggested that using
efficiency of this treatment modality, patients treated with bovine bone matrix grafts or autogenous grafts yielded no
particulate bone grafts (an autogenous bone graft from the differences in terms of the implant or prosthetic failure,
symphysis, tibia, or iliac crest) acted as controls. Grafts complications, discomfort, and bone level; however, there
were allowed to heal for 6 months before implantation in was an increase in operating times for autogenous bone
the control group. There were no differences between the grafts. The reason could be it required a longer time for
two groups in terms of implant stability. There was a sig- the bone harvesting procedure [75].
nificant increase in implant stability at 6 and 12 months in With the advancement in genetic and molecular re-
both groups. An ulna implant block, in combination with search, numerous studies have been conducted in the past
sinus grafting, could be an effective solution for decade to establish a better understanding of the ef-
increasing the vertical bone height, especially in severe ficiency, safety, and mechanism characteristics of recom-
cases of bone atrophy [72]. binant human bone morphogenetic protein-2 (rhBMP-2),
which is an osteoinductive protein that is essential for
Grafting materials bone growth and regeneration. Some of the growth
In terms of grafting materials, the autogenous graft is factors, platelet-rich plasma (PRP) and other molecules,
considered to be the most predictable and reliable source were found [76]. Many types of research were conducted
of grafting for the replacement of deficient bones. The to determine the effectiveness of using grafting material
characteristics of the autogenous bone graft are that they with the addition of rhBMP-2 in sinus augmentation for
are osteoconductive, osteoinductive, and osteogenic, and enhancing osseointegration.
hardly any other grafting materials from other sources A study aimed to determine whether the use of PRP could
have the same capabilities. Intra-oral donor sites are have a positive effect on osseointegration of autogen-ous
convenient to harvest and share the same biological and bone grafts used for sinus augmentation. Both maxil-lary
molecular structures with the recipient site but yield sinuses in five edentulous patients were augmented
Hong and Oh Maxillofacial Plastic and Reconstructive Surgery (2017) 39:33 Page 6 of 10

with an autogenous bone graft. PRP was only added to one The use of a short implant (4 to 8 mm long) was also an
grafting site. Micro-radiographical and histomorphological interesting and straight forward alternate treatment
examination revealed no significant difference between the modality for sinus augmentation followed by longer im-
PRP and non-PRP sides, suggesting that PRP has no useful plant placement. In a recent systematic review, there was
characteristic in promoting healing of autogenous bone further clarification of this concept. Eight RCTs from an
grafting [77]. In animal study, the bovine bone graft with initial search count of 851 titles were selected, and data
PRP had less new bone formation and bone healing process extraction was performed. Both long-term follow-up (16–
than xenograft alone [78]. On the other hand, there was a 18 months) and short-term follow-up (8– 9 months) study
study to confirm the effect of using PRP when using the bo- showed no significant differences when comparing
vine bone as the grafting material in a RCT. Patients under- implant survival rates. Most common com-plications were
went sinus augmentation with bovine bone graft alone or membrane perforations, and they were almost three times
bovine bone graft with PRP. Additionally, a split-mouth higher for longer implants in the aug-mented sinus
study was conducted, which performed histological evalu- compared to shorter implants. Morbidity, surgical time,
ation. Analysis of the results revealed that grafting sites and cost-effectiveness also showed more favorable data in
treated with PRP showed better bone remodeling, suggest- the shorter implant group [83].
ing the possibility of an increase in the new volume of bone Sinus augmentation is the most common indication as-
when PRP is used with bovine bone grafting [79]. sociated with implant placement in patients with severe
edentulous maxilla. With the advancement of implant
Alternative techniques dentistry, there have been introductions of new techniques
Despite the reliability and efficiency of various sinus and grafting materials, which were aimed to improve the
augmentation techniques, there is still a high rate of treatment outcomes of sinus augmentation. Several new
complications and complexity for such procedures. With concepts, such as the use of an angulated implant, zygo-
the advances in technology and improvements in design matic implant, or short implant, could provide another
and manufacture of implants, some alternative concepts option for implantation in the posterior maxilla without
suggested implantation without sinus augmentation could the need for sinus augmentation, thus making treatment
be possible. time shorter and reducing the rate of complications and
The use of a tilted (angulated) implant in the posterior the complexity of the treatment procedure.
maxilla was suggested to avoid sinus augmentation. In
this study, an evaluation was made to compare the effi- Custom implant using three-dimensional printing
ciency between tilted and axial implants with no sinus Custom implant using three-dimensional printing (3DP)
grafting. After 5 years of follow-up, the implant success was first used in the fields of rapid tooling and rapid
rate was 95.2% (survival: rate 100%) for the tilted im- prototyping. Initially, specifically single, personalized ob-
plants and 91.3% (survival rate 96.5%) for the axial im- jects were manufactured by 3DP in restorative dentistry.
plants. The average marginal bone loss was 1.21 mm for By combining oral scanning with a CAD/CAM design
the tilted implants and 0.92 mm for the axial ones [80]. and using 3DP, dental labs can produce dental pros-theses
The concept of using tilt implant was further en-hanced. (crowns, bridges) and plaster/stone models more rapidly
Trans-sinus tilted implants, with the implant body inside and with excellent precision than most tradition
the sinus, were utilized in the All-on-4 con-cept for procedures performed by lab technicians [84].
complete edentulous maxilla patients (Fig. 1). A survival With the advancement of implant dentistry, there was
rate of 96.4% was achieved at the implant level. The an increase in utilizing CAD/CAM as a supportive means
survival rate of prostheses was 100%. Sinusitis oc-curred to maximize the results of implant treatment. Customized
in two patients (2.9%). The high survival rate and low implant abutments have been successfully produced using
complication rate suggest that trans-sinus implants could CAD/CAM for difficult cases when standard abutments
be an alternative solution to avoid sinus augmen-tation may not provide a suitable option for a future prosthesis.
[81]. Thus, to combine with customized abutments, customized
Zygomatic implants offer another option treatment coping was also manufactured for such cases to provide a
modality to sinus augmentation. Almost similar to trans- more accurate impression [85].
sinus tilted implants, zygomatic implants are long im- In addition to the usage of 3DP and CAD/CAM in the
plants that pass through the sinus or laterally to the sinus making of prosthesis-related components, some have
[82]. The difference was the anchorage position. While presented concepts of utilizing this advanced technology
the tip of a trans-sinus tilted implant is positioned in the in the planning phase of implantation. The use of cone
bone between the anterior sinus wall and the nasal cortical beam computed tomography (CBCT) combined with
bone [81], a zygomatic implant will anchor itself into the CAD/CAM was suggested to produce a surgical guide for
zygomatic process for stability. implant placement (Fig. 2). In this scenario, mini-
Hong and Oh Maxillofacial Plastic and Reconstructive Surgery (2017) 39:33 Page 7 of 10

Fig. 1 The all-on-4 concept for complete edentulism. It is a concept that rehabilitates the complete edentulism using four implants. The
anterior implants are placed vertically and the posterior implants are tilted to avoid anatomical structures such as the maxillary sinus

implants were used as reference points. A software cre- There was an experiment to clinically and histologi-
ated the three-dimensional simulation and allowed the cally evaluate the customized implant placed in an
clinician to plan an ideal implant placement, virtually in- already extracted socket in monkeys. After the extraction
tegrating the future prosthetic for a complete rehabilita- of the single-root teeth (upper central and lateral inci-
tion treatment. A digital file of the surgical template was sors), fabrication of the customized implant was per-
exported, and fabrication of surgical guide was per- formed with a CAD/CAM system after the root was
formed by 3DP [86]. There was a study showing favor- machine copied to a titanium analog. The implants were
able results in the accuracy evaluation of computer- then inserted into the respective sockets. Histological
guided implant surgery [87]. findings showed an average mineralized bone-to-implant
3DP and CAD/CAM has involved itself in almost contact of 41.2 ± 20.6%, suggesting that osseointegration
every aspect of implant dentistry, from the planning could occur after the placement of titanium implants
phase to finalizing the prosthesis. The only component created by a laser-copy machine [89].
left is the implant itself, which is still commonly manu- With a more sophisticated study design, the effective-
factured by traditional methods. One of the new possible ness of customized zirconia implants with two different
theories with 3DP technology is to produce a custom- surface modifications was compared in 18 patients. The
ized implant with the analog that mimics the root of the customized implants were fabricated after the extraction
missing tooth, as an alternative to the traditional implant of the corresponding teeth. The implant surface then
design (threaded, straight, or tapered). With similar di- underwent the sandblasting process. However, in group
mensions to the original root, the customized implant 1 (n = 12), implants were modified with additional
could provide better matching with the root socket [88]. macro retention while the implants for the other group
Recently, many types of research have further explained (n = 6) were not. No complications occurred during the
that this theory have been conducted on cadaver models, healing period. All implants without additional macro
animal models, or in clinical trials. retention were lost within 2 months. In the other group,
the overall survival rate was 92%. As a result, it could be
confirmed that customized zirconia implants, with spe-
cific modifications, could achieve primary stability and
osseointegration [90].
However, it should be noted that two of the previous
studies used a concept of fabricating the customized im-
plant based on the three-dimensional (3D) data of an
already extracted tooth. Thus, it could be indicated that,
in the cases of a patient requiring implant replacement
for a single-tooth, the tooth has to be extracted as the
first surgery, and only then could implantation be per-
formed later in another surgery. It would seem more ef-
ficient to have the customized implant ready before
tooth extraction, allowing immediate implantation and
Fig. 2 The surgical guide for implant placement. CBCT and CAD/ omitting the need for a second surgery. A question arose
CAM are used to produce a surgical guide for implant placement about whether a pre-extracted tooth or a post-extracted
Hong and Oh Maxillofacial Plastic and Reconstructive Surgery (2017) 39:33 Page 8 of 10

tooth could provide more accurate 3D data as a basic Acknowledgements

model for the fabrication of a customized implant. Not applicable.
There was a study that compared the accuracy of a Funding
customized implant created by 3DP and a fused depos- This research was conducted with the support of the Cooperative Research
ition modeling technique (FDM) based on the pre- Program for Agriculture Science and Technology Development (Project no.
PJ01121404), Rural Development Administration, Republic of Korea.
extraction CBCT data of the tooth (in vivo) with the real
original tooth after extraction (in vitro) from orthodontic Authors’ contributions
patients. The 3D deviations between the in vivo teeth, in All authors wrote the manuscript. Both authors read and approved
the final manuscript.
vitro teeth, and the 3DP customized implant were com-
pared using studio software. According to the results, an Ethics approval and consent to
independent t test showed that no statistically significant participate Not applicable.
difference was observed between the in vitro teeth and in Consent for publication
vivo teeth in terms of average deviation. It could be Not applicable.
concluded that with the combination of 3DP and FDM,
Competing interests
CBCT data of a pre-extracted tooth could be used for The authors declare that they have no competing interests.
fabricating the corresponding customized implants with
high precision as an alternative to 3D data of the post- Publisher’s Note
extraction tooth [91]. Springer Nature remains neutral with regard to jurisdictional
A study with a similar design and method was also claims in published maps and institutional affiliations.
conducted, with data collected from a human cadaver. Received: 15 August 2017 Accepted: 25 September 2017
After comparisons, the results showed that the greatest
differences between the customized implant and the op-
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