Inside Dental Technology
March 2014, Volume 5, Issue 3
Published by AEGIS Communications
Full Speed Ahead
Rapid innovations in implant dentistry drive new opportunities for the laboratory industry
Worth an estimated $6.4 billion in 2013, and expected to reach a value of over $9 billion by 20181, the market for implants and prosthetics in the United States remains one of the fastest growing segments in the dental industry. This area continues to innovate and evolve, resulting in a growing profit center of opportunities for both clinicians and dental laboratory owners who wish to expand their businesses and offer a more complete patient care model.
According to Jon Suzuki, DDS, PhD, MBA, president of the International Congress of Oral Implantologists (ICOI) and Professor and Chairman of Periodontics and Implant Dentistry at Temple University in Philadelphia, PA, it is the patient’s desire for implant treatment driving this growth. “Across the board, implant treatment is primarily patient-driven. Patients want to replace their missing teeth, but they do not want to deal with either a fixed prosthetic or removable appliance,” he explains. Currently, there are more than 35 million people in the US who have no teeth, and an additional 178 million individuals who are missing at least one tooth.3 These numbers are projected to increase as baby boomers begin to lose 60+-year-old dentition, with the number of partially edentulous patients expected to surge to over 200 million in the next 15 years.3 With an economy in slow recovery mode and patient demand as the driver behind implant dentistry, the next few decades are expected to bring a new wave of patients looking for permanent, functional, and esthetic solutions to tooth loss.
For clinicians and laboratory owners, these statistics hold the promise for potential business growth opportunities.
General dentists are also showing their interest in responding to the increased demand. Today, roughly 20% of general dentists are placing implants for their patients—a percentage that is projected to increase as technology improves and further removes the “guesswork” involved in the surgical placement procedure. In the meantime, the vast majority of dentists are well versed and involved on the restorative side of implant-related cases.
The potential to capture more revenue stream has not only won the attention of general dentists and laboratory owners, but also that of researchers, manufacturers, and educators. The resulting advances in research and development of implant-related solutions have led to the creation of new materials, software, and technology. With so many “new frontiers” emerging, dental laboratory owners must stay abreast of new innovations coming down the pipeline and position their businesses to serve customers looking to become more deeply involved in providing patients with implant treatment.
Improved Placement Capabilities
The ultimate success of any implant case is dependent on one factor—the quality of bone in the patient’s jaw. However, evaluating this quality was, until recent years, typically in the hands of a specialist and limited by 2D visualization technologies and physical assessments that could only be made once bone was exposed. Frank J. Tuminelli, DMD, FACP, a Dental Implant and Prosthodontic Specialist with practices in Great Neck and Woodbury, NY, and current president-elect of the American College of Prosthodontists, explains that these technological limitations often resulted in minimal correlation between where an implant was placed and where the replacement tooth ought to be to achieve optimal esthetics and function. “The practice was to simply put the implants in the best possible bone,” he says. Afterwards, the patient would be given time to heal, then the restorative dentist would take impressions to send to the laboratory. In the end, it became the laboratory’s responsibility to problem-solve and fabricate a prosthesis that would overcome any issues related to the implant’s placement. Today, by using the latest technologies, implant dentistry is less dictated by bone quality than by the final esthetic and functional outcome. “Today, the entire implant process is restoratively driven. The dental team can engineer what we want in terms of the end result and plan backwards to where the implant must be placed to achieve that goal,” says Tuminelli. “We’re planning from the top down rather than from the bottom up.”
Presently, sophisticated digital technologies and advanced bone grafting procedures have provided dental team members with the opportunity to not only view and evaluate bone quality in virtual 3D, but to also pre-plan bone treatment, implant placement, and optimal restorative treatment in a virtual environment. This gives the surgical and restorative team the ability to solve issues of function and esthetics prior to the patient undergoing any surgical procedures.
Regenerative bone grafting procedures are mostly used when the case involves a specialist, like a periodontist or an oral and maxillofacial surgeon. Jon Suzuki notes that these specialists have a wealth of options available to them, from using demineralized and freeze-dried bone allografts from tissue banks, to xenografts of bovine and equine sources, to alloplastic and synthetic bone graft materials. With these grafting options, implants are now a possibility for patients whose jawbones would never have been suitable for supporting implants. Suzuki suggests that dental technicians increase their awareness of the different regeneration principles used in bone grafting procedures. “If a dental technician notices that a crown-to-root ratio is not going to be suitable, then they will be in a position to partner with the periodontist or oral surgeon to improve the ratio through bone regeneration,” he says.
The incorporation of cone beam computed tomography (CBCT) into dental implant planning provides the dental team with more knowledge of the patient’s oral landscape. Lenny Marotta, CDT, MDT, PhD, owner of Marotta Dental Studio in Farmingdale, NY, says this approach to implant dentistry ensures that there are no surprises throughout the case. “The breadth of the information available from a CT scan is excellent,” says Marotta. “The dental team is able to see all of the different components before even beginning to work in the patient’s mouth. They know how much room they have, where the occlusion will be, and how the implant needs to be placed to ensure optimum function and esthetics.”
Working together as a team for many years, Marotta and Tuminelli have been using CBCT when planning multiple-unit implant cases for more than 5 years, and more recently have begun using the technology for planning complex maxillofacial cases. CBCT scan data allows Marotta and Tuminelli to create and 3D print a physical model of the patient’s dental situation to get a clear picture of where the nerves, blood vessels, and sinus are positioned, as well as the quality of the bone structure. From there, they can precisely measure, create and adjust surgical guides, and otherwise plan out each critical aspect of the implant procedure in the real and virtual worlds. “Planning cases with CBCT is a very predictable approach to implant dentistry,” explains Tuminelli. “I wouldn’t say it is essential to every implant case, but for patients where placement is near the sinus cavity, or near vascular or nerve supplies, or even in the esthetic zone such as a central incisor, it can be indispensible. It’s a very useful tool when you need to make sure an implant will go exactly where you need it to.”
Implant Planning Software
After scanning, the CBCT data can be imported into implant planning software. From there, the specialist, restorative dentist, and technician may plan the case in tandem, all accessing the case information from their respective computers. Frank Tuminelli asserts that a team approach is imperative when planning complex implant cases. “Technicians look at implant dentistry from a very different perspective than we clinicians do. They know what they can deliver in a final prosthesis based on the data presented in implant planning software, and they are conscious of the advantages presented in using one technique over another,” he says.
Currently, most software modules offer users an option for facilitating a virtual conversation among team members. Some offer a free version or a viewer so that users may more easily share case plans with other members of the dental team.5 Other programs have expanded to include mobile applications (apps) for use with tablet devices to encourage collaborative case planning. “Clinicians and dental technicians are looking for more digital processes to simplify their everyday workflow. Apps represent a significant step in that direction, and they are valuable because they allow everyone to be involved in the process and enhance the way in which they can collaborate,” explains Jennifer Nelson, Associate Product Manager, SIMPLANT®, DENTSPLY Implants North America. “It helps to ensure accuracy and offers another way for everyone on the dental team to communicate effectively.”
The ability to merge CBCT data with intraoral or model surface scans, as well as face capture data through an Internet-based network or interchange and import that information into implant planning software, provides the team with a complete virtual patient for diagnostic, implant placement, and restorative planning prior to surgery. “It’s a total solution that provides enormous value not only for the implant team but also for the patient,” says Kim Solomon, Director of Regenerative Solutions and Digital Dentistry at Nobel Biocare.
As implant-planning software becomes easier for the entire dental team to use, it is likely that more and more laboratory owners will incorporate the service into their businesses. This is the mindset of Chris Bormes, President of the PREAT Corporation. He explains, “In the near future, technicians will be creating just as many restorations with a keyboard and a mouse as with traditional dental technology tools.” Bormes adds that this widespread use of digital technology is taking restorations designed with implant planning software to the next level in terms of esthetic artistry. “Digital dentistry has finally reached a point where it can support the craftsmanship of dental technicians. The work being done digitally these days is impressive not only from a technical standpoint but from the level of esthetics that is being achieved,” he says.
Expanded Digital Efficiencies
Digital solutions at all levels provide the dental team with the tools they need for more efficient and customized patient care. BJ Kowalski, President of ROE Dental Laboratory in Garfield Heights, OH, says that the incorporation of digital technologies into the dental workflow in implant dentistry is not only making the procedures more affordable for the patient, but it also has provided the implant team with a superior product. “These new methods allow us to increase the speed and precision with which care can be delivered. There are fewer delays in treatment time and case delivery because now multiple components of the case can be fabricated concurrently,” he says.
Digital dentistry has also elevated the role of the dental laboratory, allowing participation in the early stages of implant planning. Lenny Marotta explains that by using these digital tools the team is prepared for the entire procedure before it even begins. “All of the decisions regarding the case and all of the pieces are fabricated and ready to go prior to ever having the patient in the chair,” he says.
Technological advances are a major factor in the industry’s ability to move further toward top-down implant planning and shaping the future of the implant industry. Digital intraoral scanning is at the forefront of this movement. Although still in its infancy in terms of adoption, the market value for intraoral impression scanners is projected to increase from $28 million in 2012 to nearly $70 million by 2019.4 In the meantime, the ability of laboratories to merge surface scans of traditional models is offering the dental team expanded data points for diagnosis, treatment planning, and achieving an optimal functional and esthetic restorative outcome. Jobe Dubbs, NobelProcera Product Manager at Nobel Biocare, says that integrating surface model scanning with other data—such as CBCT scans—as part of the overall virutal implant planning process streamlines the way information is exchanged in a dental environment. “Making case information readily available virtually and instantaneously is the best way to treat a patient. It offers both the laboratory and the clinician enormous value,” he says. Dubbs also explains that as the capture of data accelerates, so does the treatment planning process, offering a more streamlined experience for the patient. “Further integration of digital platforms will make every step of the implant planning process faster and more predictable.”
Even for laboratories not wholly invested in scan, design or milling technologies, involvement in the digital restorative side of implant dentistry is possible through manufacturer-driven production centers. According to Jorge Pages, Laboratory Marketing Manager at Straumann USA, laboratories that want to offer products such as patient-specific abutments will often turn to a production center to create the restorations design via an online web platform or a more traditionally-based model or wax-up abutment. Pages explains that in response to this trend of milling implant-related restorations via production centers, some manufacturers have begun accepting software files from other CAD scan systems, allowing dental laboratories to own a single system, yet still have access to restorative platforms across various manufacturers “In addition to those owning a Dental Wings CAD system, this year Straumann is opening its restorative platform of customized milled products to owners of 3Shape technology,” says Pages. “This means those laboratories with a Dental Wings or 3Shape Scanners can provide original Straumann restorations without investment or training in a new system. This greatly expands the laboratory’s product offerings and provides another revenue stream from dentists that request original manufacturer components.”
With the “new frontiers” in implant dentistry expanding exponentially, laboratory owners may struggle with staying ahead of emerging trends and learning about new technologies. There are, however, a number of resources available to them—if they know where to look. Lenny Marotta suggests that laboratory owners attend as many association-sponsored dental and dental technology shows as possible. “You just have to go and educate yourself. Go take the classes offered at association shows, even if those courses are only targeted at dentists. You will learn things that will make you indispensable to your clients,” says Marotta. Manufacturers may also offer independent educational opportunities for dental technicians looking to raise their implant IQ. Kim Solomon suggests that manufacturer implant representatives in particular can also provide a wealth of free information for laboratory technicians. “There is a lot of information out there, but finding it requires that technicians take the initiative, think outside of the box, and investigate their options,” he explains.
With extensive knowledge of emerging innovations, laboratories may position themselves to be a critical resource for their clients on all implant-related matters. “Dentists need dental technicians more than ever before. A technician who knows implant dentistry inside and out, who can take the lead on implant cases, is very valuable to his or her clients,” explains Chris Bormes. As such, laboratory owners looking to capitalize on the growing implant dentistry market can benefit from not only ensuring that their laboratories offer the latest technologies available, but also that their staff is knowledgeable and engaged in the ever-evolving implant field.
Even though there may be a need for some dental laboratories to “play catch up,” BJ Kowalski sees the continuing evolution of implant dentistry as a positive step for the entire industry. “Not only are patient treatment times becoming shorter, the final product is becoming increasingly customized, offering superior function and esthetics for each individual case.” Kowalski also believes that while researching and adopting any new technology may initially be expensive, with time adoption will bring down costs. “Premium technology comes to the market with a premium price. It also brings treatment planning efficiencies, which will eventually drive prices down. Implantology will become faster, better, and cheaper, making it more accessible to patients and increasing business opportunities for dentists and laboratories.”
1. Dental Implants & Prosthetics Market Current Trends, Opportunities & Global Forecasts to 2018. Markets and Markets. Updated October 2013. Accessed January 24, 2014. http://www.marketsandmarkets.com/Market-Reports/dental-implants-prosthetics-market-695.html.
2. Dental Implants. WebMD®. Updated 2014. Accessed January 24, 2014. http://www.webmd.com/oral-health/guide/dental-implants.
3. Facts & Figures: Tooth Loss. GoToAPro. Accessed January 27, 2014. http://www.gotoapro.org/news/facts--figures/.
4. iData Report, 2013.
5. Kowalski, B. Implant Planning Software. Inside Dental Technology. 2014;5(3):58-61.
Taking the Long View
While implant solutions are becoming easier to execute for both the clinician and the patient, some experts say that the treatment of edentulous patients will eventually involve a complete lack of foreign prosthetics. Instead, biological engineers will be able to “grow” a new tooth for a patient. Frank Tuminelli, DMD explains, “We can now grow dentin and enamel in a laboratory, and sometime in the future, we should be able to grow teeth. The question then becomes, when do we start re-introducing teeth rather than implanting prosthetics made from foreign materials?” He then adds, “Implant dentistry is not necessarily the apex of restoring someone’s mouth. It’s where we are now, but I don’t think it’s the end of our restorative story.”
Hari Prasad, BS, CMDt, MS, Assistant Director of the Hard Tissue Research Laboratory and Senior Research Scientist at the University of Minnesota, is currently working on answering Tuminelli’s question. Prasad’s research is focused on bone growth, bone regeneration, stem cells and periodontal regeneration. “Right now, we are investigating the effects of scraping cementum from a patient and combining it with a bone grafts and growth factor to grow new cementum that will be able attach to periodontal ligaments,” he explains. “The addition of the growth factor plays a vital role in the final result. The use of growth and differentiation factors, such as recombinant human platelet-derived growth factor, bone marrow aspirate, and recombinant human BMP (rhBMP)-2, results in fast and vital bone formation in such applications as extraction socket defects, vertical bone growth in the posterior mandible, sinus augmentation, and horizontal ridge augmentation. This is because the grafts cannot perform the way they are supposed to without the aid of growth factor.” Native mesenchymal stem cells and osteoprogenitor cells are playing very important role in periodontal defects as well as bone regeneration. Prasad mentions that beyond simple regeneration, many researchers are also working with dental stem cells to grow new teeth to replace ones that are lost. While the research is now in early stages, Prasad believes that 20 or 30 years into the future, no one will be losing teeth, as science will allow them to better maintain their own, original dentition.