Inside Dental Technology
September 2012, Volume 3, Issue 8
Published by AEGIS Communications
Digitally Planning Implant Treatment
Changing the way laboratories interact with patients, clients, and clinicians
There is no question that the field of dentistry is now widely digitized. Developments in 3D imaging technology over the course of the last decade,1 combined with the gradual phasing-out of traditional techniques, like radiographs and impressions, have led to dentists using digital tools to plan treatment. Shifting to a digital workflow offers laboratory technicians, as well as their clinician clients, distinct advantages in treatment planning, working collaboratively, and creating a better outcome for patients undergoing dental treatment.
The planning of dental implants in particular has been moving into the digital arena, with numerous benefits for everyone involved. Laboratories, clinicians, specialists, and implant manufacturers all have to work together closely to create a successful case, and newer methods using a digital workflow have improved communication and allowed everyone to contribute to the case easily and equally.
For the laboratory technician, digital implant planning strays from the traditional methods involving waxing and molds. While laboratory technologists are not performing the same tasks they were previously, they are still an absolutely integral part of the treatment planning. There are several levels to successfully planning, preparing, and executing dental implants using a digital workflow, and clinicians rely heavily on laboratory technicians to not only craft the final implant prosthesis, but to also provide guidance while planning the procedure.
Digital implant planning has brought the clinician and the laboratory technician together into an intimate, collaborative environment, and it is important that both parties recognize that with this new workflow, cooperation is key to a successful case. According to many industry experts, digital implant planning is poised to quickly become the standard of care in the industry, and laboratory technicians and clinicians need to work as a team to adapt to the new technology and stay on the forefront of the most cutting-edge technology.
Digital Imaging: An Overview
Cone-beam computed technology (CBCT) lays the groundwork for digital implant planning. It is perhaps the best method at this time for viewing and understanding three-dimensional anatomy, which is imperative to planning any surgical intraoral procedure.2 CBCT is extremely accurate, and the images captured with this technology paint a detailed picture of the hard tissue structures of the patient’s mouth. The images are detailed enough to show the clinician and laboratory technician the location of “anatomical landmarks like the mandibular canal, maxillary sinus, adjacent roots, and aveolar cortical plates and undercuts.”2 This is because CBCT imaging allows for 3D visualization of the patient’s mouth from any plane.1 With these extensive and extremely detailed 3D scans, the clinician, the surgeon, and the laboratory technician can begin planning the case before the patient is even in the dental chair.
In digital implant planning, images that clinicians capture with CBCT scans are not only viewed on a computer screen, they are also uploaded to digital implant planning software. Some CBCT scanners come pre-loaded with implant planning software, but Jorge Pages, marketing manager for Straumann CARES® Guided Surgery software, recommends that dental professionals purchase implant-planning software from an implant company that has its own CAD program. “The software that comes pre-loaded on CBCT machines is often less sophisticated than the specialized software that the clinicians and lab techs can purchase on their own,” explains Pages. Implant-planning software typically includes treatment-planning options, as well as the ability to make surgical templates. These treatment plans and template designs can then be shared with the entire dental team, putting everyone on the same page.
Creating Better Implants with Better Information
Among dental professionals, it is almost universally agreed that planning implants digitally is more accurate, comprehensive, and safe than planning implants without the aid of computer imaging. This is because the 3D view afforded to dental professionals from the CBCT scans allows everyone to be aware of the patient’s anatomy, as well as prosthetic positions of the teeth to be replaced, without having to open the patient up. Mark Jackson, RDT and owner of Precision Ceramics, says that in the past implant planning was done with traditional 2D x-rays or panoramic x-rays, and that these implant cases could not be planned with the same amount of accuracy that they are today. “One of the biggest issues with panoramic x-rays is that there is distortion as the gantry swings around the patient’s head, and this distortion can be pretty severe depending on patient position and the type of machine being used.” Distortion caused the radiographs to be inaccurate, and as a result the clinicians and laboratory technicians planning the case were not entirely sure of the patient’s anatomy, and were liable to make mistakes. “A lot of work done with traditional radiographs involved guesswork, because the clinicians and technicians were never completely sure how distorted the images were,” continues Jackson.
Conversely, planning implants digitally using 3D images offers the clinician and laboratory technician a much more accurate and comprehensive approach. Images taken from CBCT scans have very little distortion, and everything in the image is basically as it is in the patient’s jaw. Bradley Bockhorst, DMD director of clinical technologies at Glidewell Laboratories, says that because 3D imaging allows for a much more thorough evaluation of the patient’s anatomy it significantly improves the quality of care for the patient. “You can identify critical anatomy, such as the mandibular canal and adjacent roots, as well as evaluate the health of the sinuses,” he says.
These digital files also provide such accurate data when planning implant cases that there is much less opportunity for error. As a laboratory owner, Jackson believes that this increased accuracy is extremely good for the laboratories. “I can unequivocally say that labs always prefer to work on properly planned implant cases. The implant is always in the best location, it’s always the right diameter, it’s always at the right angle, and it’s very easy to restore. To work on a well-planned case is very satisfying and does not take a lot of time,” explains Jackson. Laboratories often spend a lot of time trying to correct compromised cases, and Jackson believes that as more and more clinicians and laboratories start planning their implant cases digitally, less time will be spent trying to correct mistakes. It is also worth noting that when laboratories do not have to correct problems, they are able to better focus on creating better restorations, instead of adjusting their work to accommodate a problem case.
Knowing exactly where the patient’s nerves and roots are located prior to opening up any tissue also allows the surgeons and clinicians to plan their implant cases in a much faster time frame. The laboratory can begin designing and making the final restorations after the first implant consultation, and have it finished before the implant surgery has taken place.
Opening Up Lines of Communication
Perhaps the most important advantage of digital implant planning is the increased communication between all of the team members involved in the case. All digital implant planning software requires that the clinician, the surgeon, the manufacturers, and the laboratory share the same files and work on a platform that everyone can access. Cliff Gratz, a Nobel Biocare implant representative for the Philadelphia, Pennsylvania area, says that digital implant planning drives everyone to clearly communicate with each other prior to surgery, eliminating potential misunderstandings. Communication issues affect everyone in the implant-planning process, and Gratz describes “The biggest hurdle I have encountered as an implant rep in my eight years in the business is a lack of communication between the restorative dentist, the surgeon, the lab, and myself. Using digital implant-planning software puts all four of us on the same page. It’s absolutely tremendous.”
Mark Jackson also believes that the way digital implant planning opens up the lines of communication makes a significant difference in how implants are planned and placed. “It used to be that everyone on the dental team was making decisions independently of each other, and that led to lots of problems, namely, restorations that were far from the ideal. However, by getting the laboratory technician, who’s going to make the prosthesis, involved with the surgeon who is placing the implant and the clinician who will be delivering the restoration, digital implant planning has created a much smoother case management system,” says Jackson.
Jackson also explains that improved communication allows the laboratory technicians to guide the surgeons and restorative dentists toward placing the implant in the best restorative position possible. “Very rarely do problems occur when everyone is communicating freely,” says Jackson. “This is because the implant case is planned so thoroughly, and thoroughly planned cases end with beautiful restorations.” Jackson describes that when a case is planned thoroughly by all parties, it takes less time all around. “It takes less time to create the restoration; it takes less time for the surgeon; and it takes less time to deliver the restoration. The person who benefits the most from this is the patient,” he explains.
Daniel Llop, CDT and founder of nSequence Laboratory, believes that digital implant planning is important to laboratories because it helps to cement the laboratory’s place as a fellow dental professional. “Dental labs are not third party vendors, they are dental professionals just like surgeons and general practitioners,” says Llop.
Llop asserts that laboratory technicians shoulder some of the responsibility for providing patients the best possible end result to their implant procedures, and that they should be proud of the great work that they do. “The dental lab technician is responsible for the teeth that will be put in the final restoration for the rest of that patient’s life. We should be deeply invested in making sure that restoration is the best that it can possibly be,” he says.
The biggest benefactor, however, of the open lines of communication afforded by digital implant planning is the patient. When everyone is working together on the same platform, with extremely accurate 3D images of the patient’s anatomy, the entire process moves more quickly and with fewer issues. The patient spends less time in the chair and has a better end result. In addition, as more dental professionals adopt digital implant-planning platforms, costs will be driven down, with more patients going the implant route as they can better afford it. As means of communication improve, the field is poised to expand.
A Unique Opportunity for Growth
While digital implant planning offers a plethora of benefits, according to Daniel Llop, the dental laboratory has a lot of work to do in terms of integrating the new software and technology. “In general, laboratories need a little help moving their processes to incorporate the latest technology. It’s an attainable goal, and once it’s done, the labs will see a lot of success and growth.” Llop says that the dental laboratory of the future looks a lot different, as the laboratory technologists will be less involved in creating base restorations, and more involved in final assembly and artisan work. “It gives them an opportunity to create the best, most realistic restorations possible, without having to worry about the creation of the framework,” he adds.
Digital implant planning also motivates the laboratory to start employing a different kind of laboratory technician. Llop says that the future of the laboratory could lie in hiring people with a background in software and technology to manage the digital planning side of things, while traditional laboratory technicians concentrate on creating the final restorations. “It is much easier and productive to teach an IT specialist or an engineer dental technology than it is to teach a dental technician computer science or engineering. Laboratory owners now have a whole realm of people they can hire that can be excited to be a part of the expanding digitalization of dentistry,” elaborates Llop.
Overcoming Obstacles to Integration
Incorporating digital implant planning technology into a dental laboratory is not something that happens overnight, and there can be a number of obstacles that prevent laboratories from jumping on the digital bandwagon. Many consider the technology itself, the scanning and milling hardware, as well as the implant-planning software, to be cost prohibitive. It is true that the technology is expensive, but for many laboratories the new revenue being brought in, and the new partnerships that these laboratories form with clinicians and surgeons quickly cover the upfront costs. In addition, as the technology becomes more widespread, it will become more streamlined, also driving down costs. Glidewell’s Bradley Bockhorst says, “As the technology becomes more streamlined and accessible, it will naturally become more affordable.” Bockhorst also mentions that as more companies enter the digital implant-planning market, the level of competition increases, causing the quality of the technology to improve. “This competition has helped raise the bar in digital implant planning; the programs and procedures becoming more streamlined and affordable and companies are introducing innovative and effective new digital tools.”
Some dental laboratories, like Mark Jackson’s Precision Ceramics, have installed their own CT scanner, and provide a service for their clients by scanning patients in-house. “Installing a CT scanner has made Precision Ceramics much more of a dental implant resource. Having the capability to perform our own scans has allowed us to join a massive network of general practitioners and dental surgeons, and we are now benefiting from all the referrals we have received through that network,” he says. Jackson recognizes that installing a CT scanner incurs massive upfront costs to the laboratory, not only for the technology itself, but also for the education, licensing, insurance, and even the room where the machinery is kept. “We have an entire room encased in lead. Lead glass, lead doors, lead doorknobs, lead hinges, even the electrical boxes in the walls are lead,” Jackson describes. The software associated with the CT scanner is also costly, as it is very sophisticated. “The investment in your IT infrastructure is enormous if you’re looking to join the CT scanning side of the dental laboratory business,” explains Jackson. “However, there is a lot less competition, and you get a lot of business because of your CT capabilities alone.”
Affording the advanced technology is not the only barrier to integrating digital implant planning into a dental laboratory. It is also important for dental laboratories to recognize that they will not immediately be able to plan difficult implant cases the moment they integrate the technology. There is a learning curve, as with most technologies, and experts agree that the best way for a laboratory to start digital implant planning is slowly. Starting with simple, one implant restorations and then slowly taking on more and more difficult cases is the best way to ensure that the laboratory not only builds its reputation in the digital implant-planning field, but also has the knowledge to help treatment plan complicated cases.
Another aspect of integrating digital implant planning laboratories should consider is marketing. Straumann’s Jorge Pages says that it is not enough to buy and learn the new technology, laboratories must have an implementation plan, “Labs should really take the time before buying a system to do some research and talk to local dental surgeons. That way they have a ready client base for when the system is operational and they are ready to take on cases.” Pages adds that having a “buy it and they will come” mentality could ultimately hurt the lab’s business plan in the long term.
Digital Implant Planning—A Standard of Care
Laboratory owners, clinicians, and dental implant manufacturers all agree that digital implant planning will soon become a standard of care in the industry. A combination of the technology’s accuracy, as well as its ability to streamline the planning and placing of implants, makes it an extremely useful tool for dental professionals, whether it is the clinician, the surgeon, or the dental laboratory.
Mark Jackson believes that as implants move more into the realm of the general practitioners, the need for digital implant planning will become more apparent. “The more clinicians there are placing implants, the more likely that there will be mistakes made by these clinicians. Many of those mistakes do not have to happen if the clinician is using digital implant-planning software,” says Jackson. The digital implant-planning process is so intensive, forcing the dental team to consider all aspects of the patient’s anatomy and planning the case from beginning to end prior to the first surgery, that the margin for error is much smaller, and there are more people involved in the case to find and correct problems before they occur. Jackson says that dental laboratories should stay ahead of the dental industry, and be prepared to incorporate this technology before it becomes the standard of care.
Eventually, clinicians and dental laboratories will be able to overcome the costs of implementing a digital implant-planning system, and all implants will be planned with the assistance of 3D CT scans and comprehensive implant technology. It is simply easier for the dental professionals involved, and provides the best possible outcome for the patients.
Improving Already Excellent Work
The dental laboratory has been a partner to the clinician and the oral surgeon since dentists began placing oral implants. Advancements in technology, like digital implant planning, help the laboratory to become even more involved with other dental professionals, growing their presence in the industry and making themselves more accessible to new business. Laboratories already create stellar restorations for implant cases, and play a pivotal role in perfecting the procedure to ensure that patients receive effective, esthetic implants that will last them for the rest of their lives. Digital implant planning allows them to expand their role further into the planning stage, preventing problems and more effectively creating restorations that look natural and blend with the patient’s natural teeth.
nSequence’s Daniel Llop says, “Dental technicians know what they’re doing. They are great at what they do. Digital implant planning gives clinicians and surgeons the opportunity to get a glimpse at the technician’s level of expertise and provide technicians with the information they need to keep doing what they’re doing, and doing it well.”
1. Howerton WB, Mora MA. Advancements in Digital Imaging: What is New and on the Horizon? JADA. 2008;139(suppl):20S-24S.
2. Almog DM, Nawrocki M. Virtual dental implant planning: the next step. Dental Tribune. April 3, 2010.
The Hazards of Placing Implants
While everyone in the dental industry agrees that implants are quickly gaining in popularity and are becoming easier and easier to place in patients, no one can deny that there are serious risks involved in the procedure. There are a number of important nerves in the jaw, and improper placement of a dental implant can paralyze the patient’s tongue, lips, or even whole areas of the face. Mark Jackson, RDT and owner of Precision Ceramics, says, “Patients who suffer mishaps during implant placement often cannot taste food, they cannot kiss their loved ones, and they cannot even talk correctly. It is imperative that everyone on the dental team go into an implant case with as much information as possible to prevent these kinds of mistakes.” The possible serious complications inherent in implant placement is one of the reasons that digital implant placement has become so popular, and why the industry is moving toward adopting it as the standard of care. Three-dimensional CT scans show all of the anatomy of the jaw as they exist in the patient, without any distortion. When the dental team knows where all the nerves are in the patient, the likelihood of severing one by accident
practically disappears. It is important that laboratories and clinicians alike begin to use the most advanced technology available to them, not just because it makes their work easier, but because it makes the procedures much safer for the patient.
Guided Implant Surgery
For many dental laboratories and clinicians, digital implant planning goes hand-in-hand with guided implant surgery. Guided implant surgery involves the use of a physical guide, which is placed in the mouth of the patient and directs the surgeon’s drill. With the guide, there is no guesswork. The surgeon knows exactly where to drill, and there should be no risk of hitting critical anatomy in the process.
Guided implant surgery involves the laboratory in a whole other aspect of digital implant planning. While some manufacturers create implant surgery guides in conjunction with their digital implant-planning software, many others transfer the responsibility of making the implant guides to the laboratory. Manufacturing implant surgery guides creates another source of revenue for the laboratory, and introduces laboratory technicians to technology that they may not have encountered. Adding implant surgery guides to a laboratory’s offerings can open doors and increase business, allowing the laboratory to make new contacts in the industry and forge closer relationships with their clinicians and surgeons.
However, there is a certain level of risk involved with manufacturing surgery guides. The guides need to be 100% accurate, and if the guide is off in any way, there can be far-reaching consequences. Surgeons will drill according to the guide, and if the guide is inaccurate in any way, the surgeon will drill in the wrong place. The manufacture of surgical guides requires acute attention to detail, and laboratories should not take that task lightly. Even if the clinician using the surgical guide makes a mistake, such as not placing the guide properly in the patient’s mouth, the laboratory that created the guide would still be liable for any problems. Mark Jackson suggests that any laboratory considering entering the guided-surgery market should first consult with their insurance company and give themselves extra coverage in the event that something goes awry.
How Can the Dental Laboratory Best Partner with Clinicians?
Laboratories are not the only dental team members adopting digital implant-planning technologies and procedures, and oftentimes are better prepared to use this technology than their oral surgeons and clinicians partners.
Gary Henkel, DDS, is a general practitioner who has worked closely with several dental laboratories for most of his career, and he believes that the laboratory is already leaps and bounds ahead of the clinician when using CAD/CAM technology and computer software. “A lot of clinicians are just not comfortable with the new technology. It’s not something they’ve ever used before and they need a lot of guidance,” says Henkel. Clinicians can be so uncomfortable with the digital implant-planning software that they send their digital implant-planning data to a specialized company that will plan the implant for them, so the clinician does not have to use the software. Henkel believes that clinicians using companies like these are ill advised, as the person planning the implant case has never met the patient and never will. However, Henkel also thinks that clinicians who do not know the technology should use their questions as an opportunity to bond with their laboratory technicians. “Most clinicians are aware that laboratories are well ahead of them in regards to computer design, and a shared desire between the two to use this technology will allow the lab to cement their relationship with the clinician, while the clinician learns how to use the software,” Henkel says.
Laboratories who make the effort to partner and educate their clinician clients need to have more instrumentation and equipment on board, so that they can share their files electronically. This commitment to partnership may also require the laboratory to take a few technicians off the bench, give them special training, and dedicate them to specifically working with digital designs. Many large laboratories already have a staff of technicians who specialize in working with clinicians to digitally plan implants.
Henkel also says that one of the biggest benefits he has encountered with digital implant planning is that increased communication with the laboratory has made his implant work better. “Being able to interact with good, highly-skilled lab technicians who are really experienced in the implant world helps me because they can rein me in when I propose something that won’t work,” says Henkel, who describes that oftentimes a laboratory technician is the one who makes him aware of any issues in his implant planning. “The technician will suggest that the implant should be a little more upright, or that the restoration should be shifted a little bit to make sure it is not in an abrasive area. A good technician is absolutely invaluable to me as a practitioner.” Henkel makes a point that many clinicians are unaware of potential problems that an implant design can cause the laboratory, and being able to discuss the implants with the laboratory technician ahead of him makes the entire process run more smoothly.