What digital dentistry means for implants

It’s an exciting time in dentistry: The abundance of technologies and software available to professionals in the industry drastically improves the workflow for clinicians and manufacturers, both individually and as partners in the process.

The digital workflow is becoming more visible every day in practices and laboratories across the country, and technicians are grateful. It’s the lab side that’s been a proponent of the digital workflow from the beginning, investing in and practicing with CAD/CAM years before their dental partners, and it’s that experience that makes them a valuable partner in the digital implant workflow.  

“The technologies have improved significantly in the last five years,” says Jason Atwood, DT, CDT, senior digital solutions adviser at Core3dcentres NA. “The biggest advantage is that we’re able to offer more every day.”

Atwood, who used to work as a technician in the implant department at Aurum Ceramic, is now responsible for educating dental technicians on new products and technologies and integrating those systems into the digital workflow. He believes that up-and-coming technologies expand possibilities without making sacrifices on quality.

“The consistency and repeatability are really where the biggest gains have been,” he says.

“I think the software has gotten much better in enabling better designs,” says Mark Ferguson, general manager of Vulcan Custom Dental in Birmingham, Alabama. “On top of that, the manufacturing has also gotten better. You’re getting more accurate parts out of what you’re designing.”

Ferguson believes that certain technologies such as 3D printing have disrupted the workflow between dentists and labs.

“It has enabled a more digital workflow,” he says. “For dentists and labs that want to be in that environment, there’s easier communication through 3D PDFs, STL viewers and things like that. It’s as easy as sending an email when you have some of the software in place.”

It’s the ease of communication that provides a huge leap forward in what, for many technicians and dentists, is increasingly becoming a vital part of their business: implant cases.

“In many ways, implant abutments are the easiest cases to do digitally because you get the most benefit from a more streamlined workflow like through split file design for instance,” Ferguson says.

Split file designing offers the lab tech to design a custom abutment and crown simultaneously. This feature of the digital workflow improves accuracy, as there is no need to spray the abutment with CAD spray before taking a scan, eliminating the guesswork behind what qualifies as a “light dusting.” It also optimizes the workflow.

“It saves a lot of time in the lab because you’re not sending a case out to buy a custom abutment, getting it back and then basically starting the case all over again to make a crown,” Ferguson says. “With split-file design, you design it all at the same time and then either send it to different manufacturers or different machines in-house. You’re not waiting for parts to stack on top of each other.”

“With the growth in intraoral scanning, we’ve seen an increase in the digital workflow in regards to implants,” Atwood says. “A doctor is able to use an intraoral scanner to scan a scan flag inside the patient’s mouth and then send that file digitally to any milling center without having to ship anything. Some of these intraoral scanner solutions like iTero, Carestream or TRIOS allow for a digital workflow. You can extract an STL from any of these systems and mill it on just about any machine out there. It has really opened up a lot of possibilities. At Core3d, we receive cases from most of the major intraoral scanners; we’re able to take scans from any of those machines and mill a custom abutment from it.”

“Scanners have now gotten accurate enough to be able to do more advanced cases from an intraoral scan,” Ferguson says. “The intraoral scanners are able to do accurate full-arch restorations, which enables a more complete digital record of the case and results in a better restoration for the patient, making a positive impact on their health in the long run.”

“The role of improved visualization should not be underestimated,” says Dr. Pascal Kunz, vice president of product management for digital dentistry at Nobel Biocare. “Great treatment results are rarely a coincidence. Excellent esthetic outcomes have to follow a plan.”

Dr. Kunz says that cloud-based software will make it easier for both clinicians and technicians to visualize the treatment goal from the beginning no matter where they’re located.

“This collaborative process will be more streamlined than ever before, supported by technology such as the SmartSetup function in the NobelClinician software,” he says. “This automatically creates a digital wax-up for the teeth identified as missing on the diagnostic scans, supporting an appropriate prosthetic-driven treatment plan.”
While Ferguson doesn’t believe that STL files are the “most accurate,” he does argue that it helps to have a standard format - one that can be created on different scanners to be used on different design software.

“The open STL file enables the lab to keep their comfort level in the design software, while if the doctor is able to produce an STL file from their scanner, that certainly gives everyone with an open system the option to use what’s best for them in their practice or lab,” Ferguson says. “That enables you to keep everything best in class.
“One of the great things has been the ability to create different types of models for implants from intraoral scans. Five years ago, you might have been able to design the abutment, but you didn’t have a great workflow there.”

Growing pains

Of course, the digital boom comes with its own challenges.

“There are a lot of smaller implant companies out there that don’t have a digital solution yet,” Atwood says. “We often get calls from labs asking if we can do certain implants, but we don’t have a digital library for a few of the smaller implant companies that are out there.”

While more players are entering the digital manufacturing realm, laboratories can struggle to keep up. “It seems like we’re always trying to grow that library to meet the demand,” he says. “That’s our biggest challenge. We get questions about certain abutments not being available, but we’re constantly growing that library.”

Atwood works with 3Shape, which has a library for most of the major manufacturers, he says. But for those smaller companies that don’t have a digital solution that includes their settings and parameters for milling their abutments, dentists may be left with limited options.

“If one of those manufacturers falls outside the library of what’s available, then there is no digital solution for them,” Atwood says. “So a patient might end up stuck with an implant in their mouth because they want a custom screw-retained zirconia restoration, but they can’t get it because that particular implant isn’t available in the digital library from these manufacturers.”

While manufacturers and labs continue to work out the kinks, the solution is to switch to an analog workflow.

For Ferguson, the biggest challenge deals with scan bodies, or scan flags. With digital impressions, a scan body takes the place of impression coping.

“That scan body is connected to an implant library that gives the CAD/CAM system the implant positioning,” Ferguson says. “Whether scanning in a box lab scanner or with an intraoral scanner, the way any of our digital workflows work is by scanning with a scan body so that the software can detect the positioning of the implant in relation to the rest of the arch.”

Ferguson says that the biggest challenge his laboratory faces is that dentists often don’t understand how scan bodies function in the manufacturing process.

“What often happens is that doctors buy a scan body and use it, but they don’t understand that that scan body might lock a lab into getting the case manufactured from a particular milling center,” he says. “The doctor may not even let the lab know where they got the scan body from, so sometimes it takes some time for the lab to figure it out.”

Communication

Both Ferguson and Atwood agree that one of the major benefits of clinicians going digital is the increase in communication between the dental practice and lab.

“Labs have been using digital technology for a bit longer, so as the clinicians go digital, they’re starting to rely more on their lab to help them get through that learning curve,” Ferguson says. “With digital, the communication is easier. You can have STL viewers on your smartphone. Technology helps both sides visualize everything and keeps everyone on the same page, working as a team.”

“Digital communication is going to be beneficial,” Atwood says. “Previously, the dentist would just write down instructions on a piece of paper like a prescription. The dentist would send it to the lab, and if the lab had questions, they might call the practice.”

With new visual tools, that will all change.

“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.

Being able to communicate online has opened up more lines of communication, Atwood adds.

“We use a lot of screenshots of designs that we send to doctors for approval,” Atwood says. “We do live, online planning sessions for implants with 3Shape software like Implant Studio, where the lab gets involved with the planning and placement of implants, not just the final restoration.”

What does that look like, exactly?

“Using implant planning as an example: The doctor will request a lab to assist with placing the implant,” Atwood explains. “With Implant Studio, the doctor sends in an intraoral scan of the patient’s mouth along with a CBCT scan of the patient’s bone. The lab then uses that software to virtually plan and place the location of the implants. They do an online consultation with the doctor. The doctor is able to have input and control where these implants are placed in the bone - how deep, what angle and what rotation.”

Because the lab is involved from the beginning, they can take into account the final restoration of the tooth.

“They can place a virtual crown in the mouth, overlaid on top of the intraoral scan, so that they have an idea of where the final crown will be as they’re placing the implant,” Atwood says. “After it heals, they can use the same scans and the same software to fabricate the final restoration with predictability and involvement right from the beginning, instead of just receiving an impression of a case and being asked to do a final restoration. They can take into account where to place the screw hole (if they want a screw-retained restoration) or at what angle they want to put these abutments to try and get the correct placement in the mouth.”

With more involvement from both sides throughout the process, there will be less need to “make it work,” as lab techs often hear. Instead, dentist and technician will work as partners in the process, sharing, viewing, designing and virtually placing abutment and crown on screen. With custom surgical guides, the dentist can ensure a safer, more accurate procedure and the patient can reap the benefits of quality care.

“In my opinion, the best outcome for the patient always happens through communication, particularly in an implant case,” Ferguson says. “The more complex the case gets, the more communication that’s needed.”

The question no one wants to ask

What about those tech-savvy dentists who look forward to incorporating more chairside milling and 3D printing? Will chairside soon be able to take the place of the local dental lab? Can implant dentistry be done without labs?

“I feel like if a dental practice wants to be ‘that’ practice, you literally can do everything now,” says David Rice, DDS. “Between your ability to mill a [restoration] or a surgical guide or our ability to hook into 3D printers, we can make almost every appliance. A dental practice today and in the future is going to be a full-service provider from the clinical end to the laboratory end, or at least have the potential to do that.”

While there is the potential to do that, many on the laboratory side believe it will be more about incorporating the technician as a professional into the clinical workflow, not eliminating the role altogether.

“I think the domestic laboratory market will continue to grow as the clinical side grows,” says Bennett Napier, executive director of the National Association of Dental Laboratories.

“I know that there are a lot of products and companies out there that are selling chairside solutions for doctors, and there is a place for it, especially because patients are often drawn to chairside restorations,” Atwood says. “But I don’t think it will ever totally replace the dental lab.”

The benefits don’t outweigh the time required to rely fully on in-office manufacturing, he adds. “If the dentist is taking a lot of time to do lab work, that’s fewer patients that he can see. He’d have to hire staff to handle the increased workflow.

Ferguson agrees. “I don’t think it’s the most time-efficient way for a dental practice to function,” he says. “Getting more patients in the chair would be far more profitable than trying to cut down on their lab bill. The tools are out there for doctors to do a lot of work within their own practices, but I don’t think they want to take on everything.”  

“Technology should facilitate this relationship, not replace it,” Dr. Kunz says. “[Dental technicians] should feel very much involved in the treatment process. While options exist for other dental professionals to work on the prosthesis, we still believe that a trained dental technician is best placed to develop high-quality prosthetics. And, when we consider that the implant and the restoration work as one system in the mouth, this is crucial for high-quality treatment outcomes. And above all, it’s in the best interests of the patient.”

The ideal workflow in dentistry relies on a team of people with different skills, he says, in which every professional is doing what they’re best at. Instead of operating their own lab chairside, dentists are more likely to hire more in-house lab technicians. In that case, the technician would gain more access to the patient, which would be a step in the right direction. Instead of taking attention away from patient care by giving it to manufacturing, a dentist and technician can provide better care, without sacrificing time to devote to the skills they have honed over the years.

“There is always going to be a segment of the dentist population that will want to stop using a lab, but a doctor doesn’t go to dental school to become a lab technician, they go to learn the skills for working with patients,” Ferguson says.

“While technologies come and go, the human qualities of a skilled, local dental technician remain invaluable,” Dr. Kunz says.

As laboratories can help escort dentists into the digital workflow, so can milling centers assist labs who have been slower to adapt.

“Most labs have access to a large milling center that can provide any kind of a digital solution,” Atwood says. “If you have a dentist who’s been using his local lab for years and has a good relationship with them and he has a patient that wants to do a custom titanium abutment but his local lab doesn’t have the capability, then they can outsource that to a milling center like Core3d who can provide them with a custom milled titanium abutment.” The dentist gets the same care and attention that he expects from his partner lab while still moving forward in digital dentistry.

“We had a lab recently who has a long-standing relationship with a dentist who just got an intraoral scanner and wants to try going digital, but the lab he’s been using for the last 15 years has no digital capability whatsoever,” Atwood says. “He still wants to do work for [the dentist], but has no way to handle these intraoral scans, so he has them sent to us. We fabricate printed models and other things that he may need like analogs for implants, then we forward it to the lab, where they finish the case for him."

Emerging tech

It’s no surprise that the most exciting things on the manufacturing side are developments to what’s already available in digital design and manufacturing.

On the design side, it’s about model-less restorations.

“The biggest buzz right now is model-less restorations,” Atwood says. “In the case of an implant, a dentist will take an intraoral scan of a patient’s mouth with a scan flag, send the request to the lab for a custom screw-retained zirconia crown, and the lab sends that on to us at the milling center. We mill it out for them from the digital file, send them the crown, and they finish it and send it on to the dentist without ever having made a model. It just goes directly into the mouth and the whole thing was made from a scan that was taken on a virtual model and never fitted on any kind of stone. No impression was ever taken. I think there’s a lot of focus and energy and research going into that right now.”

Though designing a crown without ever having to make a model seems easier, it’s not necessarily a more comfortable process, according to Ferguson.

“With advancements on the scanner side, I think most people prefer to have a model,” Ferguson says. “I think people are tending more to adjust models to fit crowns that are made digitally as opposed to creating the crown and model separately. There’s been a bit of a shift toward trusting the crown more. You can look at contacts in occlusion on your model, but in terms of fit you’re going to look at the crown.”

Instead, he is more excited about changes in manufacturing.

“I think the advancements in 3D printing are really exciting right now,” Ferguson says. “It’s not only about higher accuracy and lower cost, but new materials and where the leading edge of people will take it, like with hybrid manufacturing - a combination of 3D printing and milling.

“We’ll be moving toward getting the highest accuracy and the best use of each technology. Each particular type of manufacturing has its advantages over other types. When you can start to use an interdisciplinary manufacturing approach, I think we’re going to see some really cool things. Between that and 3D printing in general, the biggest thing coming down the pipe with 3D printing is new materials.”

As for how to respond to emerging tech, it’s all about making proper assessments of the available tools to see what would work the best in your workflow.

“Dental technicians should not immediately jump on all new technologies, but assess what are the right tools to help them achieve their goals,” Dr. Kunz says. “They should not feel like they are working in a ‘digital’ way, just in the most efficient way for the best possible results.”