Digital Treatment Planning
Marty Jablow, DMD
Digital treatment planning continues to evolve through better imaging modalities. Two-dimensional radiography is a good screening tool for many procedures. Three-dimensional imaging allows us to diagnose and treatment plan in ways we were not able to before. This enhanced digital treatment planning continues to evolve in dentistry. We have seen cone-beam computed tomography (CBCT) go from the realm of assisting oral surgeons to safely remove third molars to providing better treatment outcomes for managing sleep apnea, orthodontics, and implants. Digital impressions of the dental arches can be merged with CBCT data to allow better visualization of the effects of restorative treatment. It no longer puts the implant where there is bone but works backwards from the proper placement of the crown in the arch and towards the optimal location of the implant.
In the United States, it has been estimated that general dentists only place about 25% to 30% of implants compared to the rest of the world where the number approaches 90%.1 Through the use of digital treatment planning, both the planning and surgical placement can be done with a high degree of confidence, thus opening the door to more general dentists placing their own implants. There are many high-quality surgical guide software systems available to general dentists that range from free to a few thousand dollars. These systems support the fabrication of surgical guides, giving the dentist more confidence in the proper placement and outcomes of implant surgery and restorations.
The goal of all restorative dentistry is to obtain optimal esthetics while restoring form and function. The same holds true for implant restorative dentistry. In order to achieve this, the visualization of the final restorative reconstruction is necessary prior to the start of treatment. This visualization drives the restorative treatment planning.2 Once the goal of treatment is established, a sequence for treatment is developed, and the treatment plan is worked backwards, leading to a better understanding of the case and hopefully a reduction in complications.3
Digital treatment planning enhances the diagnostics of implantology by assisting the dentist alone or partnered with a trained laboratory technician to account for anatomical limitations and restorative goals. The crown can be digitally placed and the surgery planned for the most precise plan. Intraoral scans, either from a scanned model from a CBCT or an intraoral digital scanner, combined with CBCT data of the patient’s anatomy, produce a very accurate digital model. After treatment planning is complete, a surgical guide is printed via stereolithography (SLA). This guide provides highly accurate bridging of the digital model to the patient.4
Integration in Practice
Marty Jablow, DMD
With the increase in digital treatment planning among general practitioners, it may seem daunting to take the next step to increase your digital presence. However, integrating this technology doesn’t have to be a difficult task and the overall goal of making your practice run more efficiently and keeping patients happy is worth it in the long term.
Hardware
The first thing you will need to begin using digital treatment planning is a CBCT. You can purchase a CBCT unit or refer the patient to someone who has one. In many cases, if you are using an implant surgeon they may already have a CBCT machine. There are also mobile CBCT services in many major metropolitan areas that will come to your office or your patient’s home or office. Make sure you specify that you want the standard DICOM image from whoever provides the CBCT. Many systems are closed architecture (SIMPLANT®, Dentsply Sirona, www.dentsplyimplants.com; Sirona CEREC, Dentsply Sirona, www.sirona.com) and you need a specific viewer to look at the images. In most cases, unless you have invested in that specific software, this will be a read-only file and cannot be used to do a complete digital diagnosis. If you have these closed system files, many dental labs have the ability to convert the files for you. It may be necessary to fabricate a guide for the patient prior to scanning, as reference points may be needed, especially if the patient is edentulous. The easiest way is with Suremark’s Scaneez™ stick n’ scan™ cone beam denture markers (www.suremark.com). These radiopaque markers are easily applied to a patient’s denture and are available either in small dots or tooth sized for easier implant planning.
Once you have the CBCT image file you will also need to acquire a 3D model of the patient if you plan on performing a guided surgery. This can be done with an impression or model scanned by a CBCT (such as the CS 9300, Carestream Dental, www.carestreamdental.com) or an intraoral scanner like the TRIOS® (3Shape, www.3shape.com), iTero Element™ (Align Technology, Inc., www.aligntech.com), the True Definition Scanner (3M, www.3m.com), and the CS 3500 (Carestream, www.carestreamdental.com). Make sure you can generate a standard STL file for the model.
The DICOM image from the CBCT and model image STL are then merged, giving you a soft-tissue and a hard-tissue rendering of the patient.
Software
Now you can start planning for your implant placement. The software may have been provided with the purchase of your CBCT or you can purchase the software for your office. Examples of this planning software are Dentsply Sirona’s SIMPLANT, SICAT (www.sicat.com), Anatomage Dental’s Invivo5 (www.anatomage.com), or Dental Wings’ coDiagnostiX™ (www.dentalwings.com). Blue Sky Bio offers a treatment planning software available as a free download for Windows or Mac users called Blue Sky Plan (www.blueskyplan.com).
Treatment Planning
If you are comfortable planning the implant yourself, then use the software of your choice. Start by determining the precise placement of the prosthetics in the arch and work your way down to the implant placement. If there is not enough volume of bone for an implant in the area, consider bone grafting and getting the best possible osseous foundation for your implant. Do not compromise your implant and prosthetics if there is insufficient bone. When the final digital treatment plan is developed, the files can be transferred to a dental lab for fabrication of the surgical guide. If you have access to a medical grade 3D printer, you can print your own surgical guide.
If this process seems difficult to you, there are third-party companies that can assist in the planning and fabrication of the surgical guides. These companies may be affiliated more with one specific system or equipped to provide assistance with a variety of implant systems. Cad-Ray has a strong grasp of Dentsply Sirona’s CEREC and Galileos systems, allowing complete planning of a prosthetics solution to be done within your practice. Consultants at Implant Concierge (www.implantconcierge.com) will walk you through every step of the process, from uploading the files to helping you finalize the treatment plan, telling you what materials you need from implant to grafting, along with producing a flat-priced surgical guide and temporaries. Digi3Dworks (www.digi3dworks.com) produces low-cost surgical guides from the Blue Sky BSP software starting at $35. Blue Sky Bio has their own free software with lots of online tutorials and webinars to help you through your guided implant cases. Blue Sky does have their own line of implants but their software allows the use of a variety of implant manufacturers.
Conclusion
The ability to digitally treatment plan and execute a guided implant surgery has never been easier. From novice to seasoned implant professionals, the costs and complexity of digital treatment planning has been reduced, allowing more general dentists to confidently place their own implants or better plan prosthetics with their implant specialists. While it is an initial adjustment from paying for the system and software to learning how to best integrate it, the long-term benefits of digital treatment planning will ultimately yield more successful cases.
References
1. Malcmacher L. Why don’t general dentists place more implants? Dentistry Today website. http://www.dentistrytoday.com/viewpoint/9651-why-dont-general-dentists-place-more-implants. Accessed June 13, 2016.
2. Garber DA, Belser UC. Restoration-driven implant placement with restoration-generated site development. Compend Contin Educ Dent. 1995;16(8):796-804.
3. Bahat O, Handelsman M. Presurgical treatment planning and surgical guidelines for dental implants. In: Wilson TG, Kornman KS, Newman MG, eds. Advances in Periodontics. Chicago, IL: Quintessence; 1992:323-340.
4. Turbush SK, Turkyilmaz I. Accuracy of three different types of stereolithographic surgical guide in implant placement: an in vitro study. J Prosthet Dent. 2012;108(3):181-188.
About the Author
Marty Jablow, DMD
America’s Dental Technology Coach
Manalapan, New Jersey
