Dec. 19, 2013
Implant placement and restoration has become quite predictable. The process has also been simplified during the past few years.

by Paul Feuerstein, DMD

Implant placement and restoration has become quite predictable. The process has also been simplified during the past few years. It has taken over some of our old standards of salvaging teeth such as hemisections, extensive subosseous crown lengthening (including endo, core, and crown) and other heroic procedures.

For years, we always looked at these heroic restorations at a recall visit with trepidation to be sure they were still intact. Also, in single-tooth bridge replacement, preparing virgin teeth often came with an explanation to the patient that shaping a "perfectly good" tooth gives a better result ... while the practitioner was often swallowing hard.

A simple discussion with a patient about the predictability, longevity, and -- in the latter situation -- more conservative treatment as well as the ultimate cost, seems to yield to the choice of implants. To me, an amazing fact is that in many other countries around the world, esthetics is secondary and the cost of implants is so affordable that prevention is being discussed less. After all, if you lose a tooth, it can be replaced. This fact has been reported by companies in the oral health-care business.

This means that more patients are looking for this procedure that was limited to oral surgeons at the outset, then periodontists and endodontists. Many general practitioners want to add this procedure to their repertoire. Long gone are the days of full-flap exposure of the ridge and a bit of guesswork as to the bone thickness and proper positioning and the proper angle of the implant.

The advent of cone beam and new software has taken the guesswork out of the equation, as well as having made the procedure predictable. The further integration with digital impression scans, as well as external "face scans," has given us amazing planning and implementation tools.

This also has improved with new advances in the CAD/CAM industry. Such terms as 3-D printing, stereolithography, and multi-axis milling have rolled into dentistry in the office and in the dental labs. Rapidly changing materials keep dentists on their toes.

However, there is a word of caution. Some articles and courses are presenting this surgery as nothing more complex than paint by numbers. You are asked to raise your right hand and say, "I believe" as you place a surgical guide in place and start rotating (slowly and with copious irrigation) the first bone drill through the tissue.

As it turns out, there are some studies that show minor discrepancies in the modeling and design. Although perhaps only 1% or 2% off that could make a big difference in perforating a buccal or lingual plate or impinging on the mandibular canal or sinus. You still have to be an expert on the anatomy and surgical consequences.

There are also some issues with X-ray scatter in the scans if the patient has multiple metal restorations. There are small radiopaque markers in the scan guides that can be distorted in these cases, and even with the best software, the guides could be slightly compromised.

The dentist may also have to put up a fair amount of capital to get this equipment in the office.

A cone beam system, intraoral scanner, software, and perhaps an in-office mill make this flow fantastically. The ROI can be shown to be quite high, provided you have the patient base to perform all of these procedures.

One company, Sirona, has all of the components integrated including the ability to create the surgical guide in-house. From the cases presented, a patient could literally come in for a consult and, in the same day, walk out with an implant, abutment, and crown (I am omitting discussions in this column about immediate load, etc.). This is quite a service, not to mention the productivity for the office bottom line.

E4D, Carestream, IOS3D, and a few new systems integrate with CBCT units and are working on similar workflows. The companies that do not currently mill in-office, such as iTero and True Definition, have these capabilities but currently export the information to a lab for the guides. As the components become more interoperable, this whole scenario will be common.

Once again, these are all just tools. You still have to depend on your basic skills and knowledge.

Paul Feuerstein, DMD, installed one of dentistry's first computers in 1978, teaching and writing about technology since then while practicing general dentistry in North Billerica, Mass. He maintains a website (, Facebook page (Paul-Feuerstein-DMD-Dental-Technology), is on Twitter (@drpaulf), and can be reached via email at [email protected].

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