Inside Dental Technology
October 2011, Volume 2, Issue 9
Published by AEGIS Communications
Implant Dentistry’s New Frontiers
Digital innovation outpaces adoption but promises extraordinary possibilities.
By Pam Johnson
The clinical and technical landscape of implant dentistry is evolving rapidly as the industry speeds up advances that will further simplify patient procedures, shorten treatment processes, and integrate digital technologies as well as develop new materials that will ensure higher predictability, greater accuracy, and more natural esthetics. Many dental professionals consider implants as the next promising frontier and financial boom for dentistry with sustainable patient demographics that stretch over the next two decades and beyond. Dental market researchers project a slow but steady return to robust market growth once the shaky global economy stabilizes and consumer confidence is buoyed. By 2015 the market for dental implants and final abutments is estimated to grow from over $700 million in 2008 to $1.5 billion by 2015.1
The largest aging patient population is the ultimate factor driving optimism toward a long-term market growth potential for implant dentistry in North America. Most Baby Boomers have reaped the benefits of good nutrition and lifelong dental care, helping to break the generations-old pattern of mid-life complete edentulism. But as old restorations fail and chronic diseases becomes inevitable, saving compromised natural dentition may not always be possible. Better educated about the restorative options available from modern dentistry and with access to a world of information just a mouse-click away, these patients are demanding dental solutions for missing teeth that will preserve their quality of life, youthfulness, and natural esthetics into very old age.
“In 2010 there were 100 million Americans missing one or more teeth and 36 million were completely edentulous in one or both arches,” comments Louis Rose, DDS, DMD, a Philadelphia, Pennsylvania, periodontist and co-editor-in-chief of Compendium of Continuing Education in Dentistry. “And in January 2011 the first members of the nearly 80 million Baby Boomers born between 1946 and 1964 turned 65. This is a patient base very concerned about retaining their oral health and appearance.” And for those in this population demographic who have already lost all teeth in one or both arches and are restored with conventional dentures, implant-retained prosthetics promises restored function and eliminates the stigma of traditional removable prosthetics.
However, Rose points out, the current economic climate has momentarily tempered the enthusiasm that these statistics and the potential that the Baby Boomer patient base poses for implant dentistry. Coupled with the elective nature of the procedure, the current economy is forcing patients to prioritize spending behaviors and moving implant-centered companies to look for ways to lower the cost of treatment in order to increase patient acceptance as well as streamline, speed up, and add precision to diagnostic, treatment planning, and restorative production procedures.
To that end, powerful digital technologies such as diagnostic cone-beam computed tomography (CBCT) scanning have trickled down from other industries to dentistry. They have been reconfigured and adapted by major manufacturers for use in the practice to take the guesswork out of the diagnostic phase and to tie into digital treatment-planning software for team collaboration and automated production of surgical guides for precision implant placement as well as customized abutment solutions for restoring the implant site.
“Digital impression scanning has also now been brought into the equation,” says Lars Hansson, CDT, FICOI, who heads up Bay View Dental Laboratory’s implant department. “The clinician can now scan the Biomet 3i Encode healing cap or Straumann ITI scan jig using Align Technology’s Cadent iTero or 3M ESPE’s Lava C.O.S. impression scanners and then send that data for third-party abutment design and milling and automated production of the model. Soon intraoral scan capability will allow clinicians to scan the implant interface and send that STL data to the laboratory where we will have complete control over the abutment and restorative design and production.”
However, as quickly as technology is moving forward and dental laboratories are adopting its use, the same cannot be said for the clinical side of dentistry. To date, technological innovation has outpaced adoption in the practice. Further hamstringing the entire digital solution is that not all the clinical technologies can be integrated into the laboratory CAD/CAM processes, log-jamming CAD/CAM production-oriented laboratories with cases that need analog processing and manual handling or third-party involvement. Slow adoption of digital tools chairside, the void of a standardized operating platform for integrated communication and laboratory production processes as well as the disconnect in educating clinicians and dental students on how to use these tools may continue to retard adoption of digitally driven implant dentistry.
“There is a lot of technology that has to come together to make our lives more predictable and accurate and in the long run more economical,” says Scott Ganz, DMD, who maintains a maxillofacial prosthodontics and implant dentistry practice in Fort Lee, New Jersey and who has been involved in the evolution of this technology for more than 25 years. “Where we, as an industry, are missing the boat is in helping clinicians understand how to use and integrate these digital tools to make their lives easier. If that were done, then general dentistry could be placing and treatment planning many more implants.”
The integration and communication gap that exists within the manufacturing community is also mirrored within the structure of dentistry. Much like the myriad independent implant-centered companies that each have slightly different protocols and visions, the structure of dentistry is populated with independent specialties—from the oral surgeon and general dentist to the laboratory technician—that often operate independently of one another, not completely understanding what the other needs in order to provide the best restorative care for the patient.
“Implant dentistry must be a team effort in order to get the right prosthetic look and the right prosthetic result,” says Hansson. “But that is not the real world.” Many times communication between the surgeon and the general dentist doesn’t happen right away, he continues, and the only time the protocol does work correctly is when the technician is allowed to relate the expected results prior to the surgical procedure.
Ganz agrees. “The goal of the outcome should be the tooth, not the implant,” he says. “No patient enters into the procedure to get an implant. They want a replacement tooth that looks and functions naturally to fill that empty space.” And that is where he believes the implant industry has become slow to respond to advances in technology. “We now have all these sophisticated tools to diagnose implant receptor sites, create templates to guide accurate implant placement based on the position if the “virtual” tooth sitting on a “virtual realistic abutment,” he complains. “It would be nice if we could have open platforms so that the iTero could communicate with an iCat or an E4D with other CBCT machines so that we can do what we want to do.” Not until the powerful software, which is being used today by laboratories to design the tooth, adjust contacts, and tweak occlusal design, is ported into an open and standardized digital implant platform where the diagnosis and planning are taking place will all members of the team be working on the same page and toward a common goal—the tooth.
When implant cases are treatment planned from the bottom up rather than the top down, laboratories often find themselves having to make compromises. “As technicians we want to be able to ensure that the implant is positioned correctly so that we can deliver the restoration that has been promised,” says Hansson. “But in reality, most laboratories are getting the case after treatment planning and placement and doing what I call a post-pretreatment plan, which is forcing us to be implant magicians instead of implant technicians.” And that, he says, is when compromise happens. If the porcelain fractures off a compromised restoration, the laboratory will most likely get the blame.
Robert Levine, DDS and director of the Pennsylvania Center for Dental Implants and Periodontics agrees that proper 3-d implant position is the most important aspect of any implant case. “Surgically it’s not about osseointegration any more; it’s about implant position,” he explains. “If we don’t have good implant position, then we shouldn’t be placing the implant. Either ridge reconstruction and/or orthodontics prior to placement may need to be considered.” The best way to determine good position Levine says is through use of an anatomically correct (radiographic-when appropriate) surgical guide template and CBCT scan to determine exact bone and space availability and then by obeying the laws of implant placement, which calls for 2 mm of space from the implant to the adjacent teeth (in single tooth application), 3-4mm apical to the mid-buccal of the anatomic surgical guide template (based on tissue level or bone level implant to be used respectively) and then choosing the proper width/length implant depending on which tooth is being replaced. Having these concepts in mind enables the whole team to deliver an esthetic restoration with good emergence profile.
But the ability to treatment plan using digital planning software is where Ganz says there is another missing element in the process. “If surgeons and general dentists do not know how to interpret and use the data from a CBCT scan, then you can order the most wonderful surgical template in the world, but the implant will be going in the wrong place,” says Ganz.
Educating general dentists on how to treatment plan implant cases rather than surgically place them is an area that Rose believes implant companies should continue to concentrate their efforts. “Nearly 75% of general dentists today are not even treatment planning implant cases,” he says. “If they could be trained how to treatment plan these cases, then they could be in the driver’s seat to achieve the outcome they, the laboratory, and patient want. Once the case is planned, they can then send the patient to the periodontal or oral surgeon for implant placement.”
But Ganz argues that most GPs and even specialists do not want to take the time to sit in front of a computer and play around with the data to come up with a treatment plan that is foolproof. That’s why he says third-party companies such as 3DDX Dental (www.3ddx.com), Conescan.com, 360 Imaging (www.360imaging.com), and laboratories like nSequence (www.nsquence.com), Glidewell Laboratories (www.glidewelldental.com), Precision Ceramic Dental Laboratory (www.pcdl-usa.com) and ROE Dental Laboratory (www.dentalimplantplanning.com) have evolved and moved in to fill the gap to coordinate between the CBCT scan data and the treatment plan. The DICOM data (Digital Imaging and Communication in Medicine) is sent to them via the Internet and they have a board-certified radiologist read the radiograph. The data is then analyzed and converted into a meaningful format that can be understood by the general dentist. It is a business model that Ganz believes is the most viable for digitally driven implant dentistry to work properly and ensure the involvement of the laboratory. “The clinician only needs a computer to view the treatment plan and then remotely plan the case with the surgeon and laboratory and coordinate the surgical template and instructions to the laboratory for creating the restoration. The clinician however, is ultimately responsible for the final plan that is based on much more information than by non-digital means.”
Involvement in digital implant planning is an area that Ganz believes not only opens the door of opportunity for laboratories and brings them a new digital frontier tool set but also is a necessary protocol to avoid costly remakes and even more serious problems. “After all, if the tooth is the goal, who then fabricates the tooth? The dental laboratory technician.”
Expanding Role for Laboratories
Although the digitally driven implant process from treatment planning and automated production of the surgical guide to CAM-manufactured restorative solutions is still a niche business segment for a majority of laboratories, there are those who believe that sophisticated and complex “engineered restorations” are the future of the industry. “As I look at the future of this industry, I believe a majority of the single-unit crowns and three-unit bridges currently fabricated by dental technicians will move out of the laboratories and into the dental practice or overseas,” says Mark Jackson, RDT, co-owner of Precision Ceramics Dental Laboratory in California. “Fabricating mass quantities of single units is just not where the money is going to be as we move forward. What that leaves for dental laboratories is the bigger, more complicated cases that will involve the use of some significantly advanced technologies to structurally design and restore them.” That’s why Jackson has invested more than $1 million dollars to restructure and reposition his business to be a resource for CBCT scanning, implant imaging and planning, surgical guide fabrication, and anatomical modeling.
Jackson and the other progressive few who have ventured into this larger digital arena are finding themselves taking on leadership roles as consultants to their clients on everything from engineering the treatment-planning process and recommending which implant system is best for a particular case, to walking clients through the CBCT scanning process.
“I think the clinical community in general has recognized that dental technologists by the nature of our business have a greater opportunity to handle a larger number of implant cases than they do,” says Ira Dickerman, owner of Dickerman Dental Prosthetics in Massachusetts. “And the younger dentists, even though tech savvy, have received little to no instruction on dental technology processes and procedures. Consequently, they are finding that they need much more support on these types of cases from their laboratory. And working together in a digital world makes it much easier to communicate and confer on a case.”
Because of the complex nature of implant dentistry, laboratories need to invest the time and money to become educated on the clinical aspects of the field in order to act as a consultative partner to their customers, Hansson says, and then keep abreast of the explosion of new technologies, implant systems, and treatment protocols. Much like the role laboratories play on the crown-and-bridge side with advising clients on best practices for impression techniques and cement or bonding protocols, this segment of dentistry affords laboratories the same leadership opportunities.
“But in order to provide these types of services, technicians have to understand the complexities of the clinical aspects of implant dentistry,” advises Hansson, who has been involved with the Academy of Osseointegration (www.osseo.org) for the past 13 years and is vice chair of the allied staff, heading up the laboratory technician education program for the organization. “We have to take clinical courses to understand how to implement our technology in the oral environment, how to design an emergence profile, and understand the different implant systems and bone grafting on the same level as the surgeons in order to build a proper abutment and choose the correct restorative material for the case.”
It is a laboratory’s blend of restorative knowledge and clinical understanding that David Little, DDS, finds invaluable for treatment planning guided-implant cases. His San Antonio, Texas-based practice involves the laboratory in the treatment-planning process from the beginning and views this protocol as a positive trend. “This technology allows the surgeon, restorative dentist, and laboratory to plan the case from the restoration backwards so we know exactly where we are going and what our goal is,” he says. “If we do that, then when the implants are placed, the entire case will be in harmony. It keeps the entire team on the same page.” He begins every case with a diagnostic wax-up to ensure that the end result for the entire team is the vision for the case. The CBCT scan data is sent to iMagDent (www.imagdent.com), a CBCT imaging service with locations in four major states, for conversion and data interpretation by a board-certified radiologist. iMagDent then imports the data into Simplant (www.materialise.com) software for online treatment planning with the surgeon and laboratory and manufacture of the surgical guide by select laboratory partners. iMagDent has, like other scan conversion centers and surgical guide providers, established partnerships with implant and medical-imaging companies such as Nobel Biocare (www.NobelBiocare.com), Biomet 3i (www.biomet3i.com), and Anatomage (www.anatomage.com) for providing image-guided surgical solutions.
Not only does involvement in this realm of dentistry require laboratories to acquire clinical knowledge, but it also means licensing or purchasing the preferred implant treatment software used by their clients and learning each of the treatment-planning and manufacturing protocols. With the exception of BlueSky Bio (www.blueskybio.com) treatment-planning software, which is free to download from the company website, all other software programs involve varying costs and differing protocols that must be learned. “There is definitely a learning curve associated with using any of these software programs and working with clients on the treatment-planning aspect,” says Dickerman, who owns both the NobelGuide and Straumann Guided Surgery (SGS) systems. “But the more often you do it, the faster you learn it.”
For BJ Kowalski, president of ROE Dental Laboratory in Cleveland, Ohio, becoming involved with CBCT based virtual implant planning has also expanded to include assisting practices with CT-based scanning procedures, surgical guide protocols, and acting as a treatment planning consultant. This has helped his business forge new partnerships with surgeons and periodontists. “We have become a leading resource for them and often earn referral to their colleagues for the restorative work ,” says Kowalski, who projects a 20% growth rate for his implant department this year. “That also puts us in a very good position to get the restorative work when it comes time.”
For Jackson the 2-year process to get his new CBCT scanning center to meet budget projections has paid off. And now it is the busiest department in his laboratory. “We scanned seven or eight patients yesterday and I billed out a total of $6,000+,” he says. “When you can bill out six figures for a single room with one piece of machinery and one technician in a single day, that is a good investment. And keep in mind, I still have the restorative aspects of those cases to complete and bill out.”
Both Kowalski (www.dentalimplantplanning.com) and Jackson (www.precisionsurgicalguides.com) have built websites exclusively for clients to upload DICOM CBCT scan data and where diagnostic case planning can be analyzed, digital implant-planning software options can be selected, live online case planning can be facilitated, surgical guides made, solutions for immediate provisionalization decided, and the final restoration ordered. “We wanted a separate landing page or website dedicated to virtual implant planning,” says Kowalski. “We pre-plan the case using the software and implants of their choice and then schedule an online meeting to review and modify the planned case with the surgeon or clinician.”Jackson is looking at the borderless opportunities digital dentistry offers, preparing his business for a global community of surgeons, specialists, and restorative dentists who need a wide range of services identified through CBCT scans from radiographic reports and implant solutions to TMJ diagnostics and airway analysis for snore guards. “We provide that client with 24-hour turnaround,” says Jackson. “They can archive all their big volume DICOM data on our cloud-based server free for one year and access that data from any computer regardless of location.”
But digitally driven implant dentistry is not relegated to large laboratories with deep pockets. Small businesses too are tapping into digital implant technology without investing the thousands or hundreds of thousands of dollars in equipment and software by outsourcing the digital treatment planning to service bureaus such as Jackson’s Precision Ceramics Dental Laboratory or nSequence and accessing custom implant abutment and milled-bar manufacturing from companies such as Atlantis (acquired by Dentsply Prosthetics), Compartis (www.partisusa.com), Biomet 3i, Straumann, Preat Corp. (www.preat.com), or other outsource partners.
“Laboratories of all sizes are moving very quickly into the realm of CAD/CAM technology and have the ability to be players in the realm of digital dentistry,” says Ganz. “That to me is key because laboratories are the critical link between the clinician and the restoration that goes in the mouth.”
It is also the key for laboratory owners positioning their businesses for the future. As the industry moves ever closer to integrating all of the digital technologies and refining the art and science of implant dentistry, Hansson believes that all the multifaceted aspects that go into restoring an edentulous site will become ever more critical. “How and where the implant is placed and implant angulation will correlate to abutment design and occlusion, to what restorative material is chosen, how the coping is designed, and how the porcelain is built,” he says. “And so the margin for error will become exponentially narrower and narrower.”
1. iData Research U.S. Markets for Dental Implants and Final Abutments, November 6, 2009. Available at: www.idataresearch.net/idata/articleUpload/27427c11544c0c1202158b5878ec658f_1244737183_dental_implant_market.pdf.
2. Dentists balk at referring implant patients to endodonists. Nancy A. Melville, DrBicuspid.com. August 22, 2011.