How technology is changing the implant workflow

It’s not news that dentistry is undergoing a huge change thanks to technology. CAD/CAM restorations are becoming the norm, making patient care simpler and faster than ever before and facilitating a more streamlined flow between dentists and labs. More labs and practices are investing in 3D printers, and as soon as a suitable material for printing long-term restorations is available, one can only imagine the effects. But as one dental laboratory manager said, no dental workflow has changed as much as implant-based restorations.

Today, technology is enabling more general dentists to get into implant dentistry. With the right tools, dentists can do the case virtually before ever touching the patient. That helps them see the final outcome as well as any obstacles they may face along the way. Rather than calling an audible, they can plan accordingly. Any dentist who’s interested can design and print surgical guides in the office, though it’s just as easy to have the lab do it if that’s preferred.

Once the patient is healed and ready for the restoration, dentists already know that the final restoration will be in the right position. In fact, before they start, they’ve already ensured that it’s safe, esthetic and in perfect occlusion, thanks to digital treatment planning software and surgical guides.

And that’s a good thing because dental implantology has plenty of room to grow in this country.  

“The penetration of implants is still pretty low,” says Paresh Patel, DDS. “I would say that implants in the United States are still at around five or six percent penetration, so there’s a whole set of the population out there who don’t have implants but could benefit from implants.”

The cost of implants is likely a major barrier for many people, but Dr. Patel says another reason implant penetration isn’t as high as it could be is not as many dentists offer the procedure.

“We need to get more dentists educated about implants, so they can provide that kind of service for their patients,” he says. “If we can teach dentists to not just extract teeth, but to preserve the site, we can incorporate all these other fancy things like CBCT and surgical guides to ensure that we have the confidence to place the implant where we think it needs to go.”

The good news is that implants could soon take up a larger piece of the dental pie. Thanks to a fully digital workflow, it’s easier than ever for dentists to offer implants in their practices.

“User interfaces for digital technology are increasingly intuitive and we are aiming for more automation at various steps in the treatment flow,” says Dr. Pascal Kunz, vice president of product management for digital dentistry at Nobel Biocare.

The old way

To compare the new to the old, let’s first review the old. Traditionally, implant cases started by taking an analog impression before sending it to the lab, where laboratory technicians would insert an impression post and fabricate an abutment and crown. The lab technicians would often be concerned with correcting the results of dentists who forgot to take prosthetic requirements into consideration during implant planning. As a result, the tools available to lab techs were designed for redressing mistakes rather than preventing them. Back in the operatory on surgery day, the dentist would carefully drill a pilot hole by hand, being careful not to drill too deep on accident.

Times have changed. “Most of the work that used to be done manually can now be done through advanced technological planning and ordering software, or outsourced if desired,” says Priya Menon, director of marketing, North America, at Dentsply Sirona Implants. “In place of the analog process of taking an impression, intraoral scanning provides accurate information about the patients’ dentition and soft tissue.”

Part of that advanced technological planning consists of digital impressions, design software and surgical guides. And that takes the stress off both sides: Lab techs are no longer correcting mistakes after they happen, and dentists know that the surgical guide will keep their drill exactly where it needs to be from X, Y and Z. From start to finish, the digital workflow takes the stress away from implant planning and placement.

“When we first started doing CAD/CAM dentistry, it was really just to scan a tooth or scan a model for Invisalign or something like that,” Dr. Patel says. “But now I think just about every implant system has a scanning flag or a scan body that we can put into the implant. It’s going to be a more accurate way to transmit that information to the laboratory, like the timing of the implant and the location of the implant in relation to the adjacent teeth as well as the soft-tissue profile.”  

Erinne Kennedy, DMD, MPH, didn’t place implants until her residency, where she learned how to place implants traditionally using periapical radiographs and a custom stent.

“After doing it the traditional way, I learned the value of digital dentistry and digital implant placement, especially digitally guided surgery,” she says. “I’ve learned about how innovation can make it not only seamless but predictable. It was a good experience to have done it that way and then to see what technology could offer.”

Creating a digital workflow

Dr. Patel has a fully digital implant workflow in his office. His cases begin by taking a scan of the patient’s mouth with an intraoral scanner. For these, he chooses to use either his 3Shape TRIOS or his iTero Element.

“It’s not that one is better than the other; it’s just different ways of getting something digital into the virtual world,” he says. “If you don’t have an intraoral scanner, it’s difficult to start with a digital model of the patient’s mouth.”

It’s difficult, but not impossible. The workaround for this of course is to take an alginate impression and either scan that or send it to the lab to scan and turn into a digital file, which can then be merged into a DICOM file from a CBCT scan.  

“Now, we can drop in virtual teeth in our implant software, whether that’s Blue Sky Plan or Implant Studio from 3Shape,” he says. “That allows you to virtually do a diagnostic wax-up. We can even put that into a digital articulator, so we can see how the virtual tooth that I planned is going to mesh with the opposing arch. We’re not caught up in just where it aligns mesiodistally and faciolingually but functionally. Is this in the correct spot? Is the occlusion going to be on the long axis of the implant?”

“Owners of intraoral scanners can now export .stl or .ply files containing tissue information, in color, into NobelClinician,” Dr. Kunz says. “This can then be used with the software’s SmartFusion feature, which fuses CBCT scans with digital impressions, and a new functionality we call SmartSetup - a fully automated tooth setup completing the partially edentulous imported digital arch with a tooth setup proposal.”

Dr. Kunz says that prosthetic-driven treatment planning can begin at the patient’s first visit thanks to this software.

“This immediately helps to classify the complexity of the treatment by supporting assessment of bone and soft tissue at prosthetically important positions as well as the need for augmentation. It also fosters broader collaboration within referral teams,” he says.  

Dr. Kunz concludes that this combination is designed to significantly improve the quality of the initial assessment. Dr. Patel is also assessing a need for augmentation from the start. Using his software, he can detect if there’s enough bone volume to fully encase an implant. If not, he can evaluate how much hard or soft tissue he’ll need to add before the procedure.

“All of these answers can be done before we take the first cut to the patient,” he says. “It certainly makes the patient aware of what we need to do to ensure long-term success because the patient can look at a digital version of what their mouth looks like. And it’s easy to explain to a patient a lack of bone or lack of tissue, or that everything looks appropriate and we don’t have to do anything prior to placing the implant.”

From there, he says that it has become “predictable, efficient, precise and affordable” to create a surgical guide, since many dentists already have printing and milling machines in their practices. Regardless, he asserts that it’s still efficient to send the DICOM file to the lab, which can print and send a surgical guide within a matter of days. The result is a “reproducible event,” in that dentists know they are going to place the implant exactly where they planned it.

“That changes everything. Before, even as precise as a surgeon can be, sometimes things go on a different trajectory. What we thought was going to be a screw-retained crown now doesn’t become a screw-retained crown and we have to enlist the help of a custom abutment and a cement-over crown, and that may or may not be what you wanted to do,” he explains.

“To me, having that final piece - which is either the doctor printing the guide with the advent of 3D printers or sending it to the laboratory to be fabricated - is a huge game changer. It gives you one more step of confidence that what you planned virtually is what you’re actually going to deliver in reality.” 

Imaging, diagnostics and treatment planning

Cone beam CT scans are another tool that provide dentists with the appropriate insight on their cases. Using the results of CBCT scans, dentists can conduct thorough implant planning and know when the case should be referred to a specialist.

“Right from the get-go we can plan a surgery that we want to do and a surgery that makes sense for my skill set, or we can just step back and refer out for some additional grafting, bone expansion or soft-tissue grafting,” Dr. Patel says.

If the case does make sense for the dentist to do, then he or she performs the surgery virtually first.

“We combine intraoral scanning of the patient’s mouth with the DICOM file of the CT scan to allow us to virtually drop in a crown, articulator and implant we’re thinking about,” Dr. Patel says.  

That allows Dr. Patel to know the deficiencies ahead of time. If a patient needs a sinus graft, for instance, the CT planning software will tell him exactly how much bone to add to ensure the secure placement of the desired implant.

“Having these things together changes the amount of time that you put in,” he explains. “You’re doing all the legwork before you actually make a cut on the patient, whereas before you had an idea, but not a complete idea. You were in a 2D world versus a 3D world.”

Planning in the 2D world and performing in a 3D world meant accepting the possibility of changing the plan mid-surgery. Now, Dr. Kunz says, you know what you’re going to do before you do it - and that should never be underestimated.

“Great treatment results are rarely a coincidence,” he says. “Excellent esthetic outcomes have to follow a plan.”

And now that a lot of software is cloud-based, it’s easier than ever for the whole treatment team to be on the same page.

Patient education

Imaging technology has probably had the biggest impact on case acceptance. Because patients can understand what they’re looking at, they feel more comfortable with the skills of the dentist. They can see for themselves that the dentist has a solid understanding of their personal physiology and feel more secure in the decision they’ve made, whether that includes a treatment plan or not. For patients who aren’t suitable candidates for the procedure, they can see why for themselves and not feel inclined to find a dentist who will do the surgery and put themselves at risk for implant failure.

“Importantly, improved visualization of esthetic goals will also evolve patient communication,” Dr. Kunz says. “The possibility to present images of the situation, treatment plan and planned outcome at the first appointment will create the ‘aha’ moments that bring the proposed solution to life for the patient. This is valuable, as it enables a more educated consent to treatment.”  

“For me, those images really help to sell the case,” Dr. Patel adds. “It’s hard for patients to understand, but when we convert it into almost a three-dimensional skeletal view and can overlay their optical scan on top, it’s very easy for the patient to understand. Once they understand, they can accept the treatment a little easier.”  

Dental techs more involved

The digital process, in any scenario, always facilitates better communication. Add in amazing imaging capabilities and you can transport someone miles away into your operatory with the click of a button. Because of that, dental technicians have more input from the start - and that’s a great thing.

“The maturity of visual tools will offer additional insight to the dental technician and change ways of working - delivering a blurry image and a paper prescription could soon be a thing of the past,” Dr. Kunz says.

Dental technicians can review the treatment plan and digital design and create a depth-limiting surgical guide. The result includes a well-planned case done with guided surgery, during which the drill bit goes exactly where the dentist and technician planned from angle to depth. The custom abutment is then milled from e.max or zirconia.

“The role of the technician is important in so many dental procedures but particularly in implant treatment,” Dr. Kunz explains. “To achieve a truly esthetic, long-lasting outcome with implant treatment, you have to plan the surgery with the prosthetics in mind. Who better to help you with that than the person who will create the prosthesis?

“Our collaborative workflow will allow the dental technician to get involved right from the start of the treatment process so that the restorative solution is taken into consideration already at the implant planning stage.”

Surgical guides

Dentists can also create guided surgery pieces independently without ever having touched the patient. The software will show a rendering of what their chosen implant would look like, which dentists can move around on the screen and impose on the 3D impression. They can tip the implant in all three planes and know exactly where they want the implant to be.

Because surgical guides are such a critical component in this digital workflow, in-office 3D printers are an important tool for many dentists. Within hours, they can print a surgical guide to make sure that the placement is accurate and that they have the trajectory they want.

Dr. Patel believes that 3D printing gives confidence to general dentists who, though surgically oriented and skilled with extractions or other surgeries, may not yet be comfortable doing implants alone. Because of 3D-printed surgical guides, they can now take on cases they would otherwise avoid, knowing that the guide will keep them on track with what they’ve planned. And it’s something that can be incorporated into any office that isn’t too expensive.

“It creates a more efficient process that can decrease patient chair time and improve overall treatment time, leading to higher patient acceptance and satisfaction,” Menon says.

“I think 3D printing is fantastic,” Dr. Kennedy adds. “Right now, we use 3D printing and milling to develop the custom guides for implant placement. I think it would be fantastic if everyone was not only digitally planning the implant in their office but they were printing guides on site, too.”

Dr. Kennedy also asserts that using technology and guided surgery improves dentists’ confidence.

“You know that the tool that you’re using is precise, and you know that where you place the implant is exactly where you want it to go,” she says. “When I was in residency and wasn’t doing digitally guided surgery, there were moments where I did not feel confident. Having a tool that allows you to have confidence throughout the entire procedure is priceless.”  

Changing perspective

Dr. Patel says CT technology and reliable tissue grafting has had a major impact on the perspective doctors have in implant cases.

“When I first started [doing implant dentistry] in 2008, it was more like, ‘This is where the bone is and this is where the implant should go,” he says. “Now, we try to envision where the tooth or crown actually needs to go and consider if we need to augment the soft tissue to allow the implant to be in a more favorable position. With CT technology and reliable hard- and soft-tissue grafting, we can change our philosophy to be more about where to put the tooth for form and function. We can now change the tissue to allow for placing the supporting structure, which is the implant, correctly.”

This philosophy change is due in part to CBCT scanners being more affordable and available than ever before, Dr. Patel says.

“I would think that anyone who was getting into implant dentistry now would start off by looking at adding a cone beam to their office. The price point has come down and they also understand that not knowing the volume of bone, it’s hard to implement a restoratively driven approach,” he says.

The second part of this scenario, tissue grafting, has become more reliable thanks in part to biologics such as bone, tissue and collagen.

“The biologics have become more affordable, predictable and available,” Dr. Patel says. “When I first started, bottled bone wasn’t available as much as it is now. Now, you can easily find someone who’s selling some version of bone grafting, hard tissue grafting or collagen membrane - all of the things you need to do to create the correct recipient site before you place the implant. The availability of biologics and predictability of procedures has skyrocketed. Now, we really look at where to put the implant in relation to the restorative component, which is the crown.”  

The digital revolution

“When I was still working as a clinician, there was no doubt that a digital revolution in dentistry would need to come,” Dr. Kunz says. “The question was when it would truly arrive and what the pace of change would be. Today, we are living in the middle of something I would describe as an evolution and transition period.”

Dr. Kunz says that further enhancements to the digital implant treatment workflow will continue to focus on providing greater ease of use and simplifying processes.

“We are constantly evaluating ways in which we can reduce or combine steps in the treatment and restorative workflows to reduce time-to-teeth. We are looking specifically at how we can further help dental professionals meet patient demand for immediate solutions,” he says.

And, Dr. Kunz adds, as more systems become open, it will be even easier for “clinicians and labs to integrate new solutions alongside equipment they already own.”

As Dr. Patel mentioned, cost is a prohibiting factor for many people. But for edentulous patients, it’s not necessarily about which treatment plan they choose, whether it’s dentures or implants. The digital process is making huge changes in both workflows, improving the overall ease of use, treatment time, functionality and esthetics. The end result, in both cases, is happier patients with a full set of beautiful, fully functional teeth.