The Jameson Files: Implant utilization in treatment planningFeaturing Dr. Jerry Soderstrom

by Dr. John Jameson

The implementation of implant utilization in treatment planning is expanding in dentistry today. Some dentists, like Dr. Jerry Soderstrom, have begun to limit their practices to mainly implant placement. Dr. John H. Jameson spoke with Dr. Soderstrom on the topic of implant utilization in treatment planning. Some technological advancements enable a predictable type of treatment offered in treatment plan regimens.

Dr. Jameson: Dr. Soderstrom, why should dentists offer implant treatment to their patients?

Dr. Soderstrom: It is conservative dentistry and is about the only way to solve the result of tooth extraction, which is an irreversible process of bone atrophy. The sooner the implant is placed after tooth loss, the less bone atrophy a patient will undergo. Bone atrophy can be slowed with a bone-grafting procedure. However, unless the grafts are loaded with implants, the irreversible process of bone atrophy continues. For dentists, implants have become more predictable to restore than natural teeth because implants are immune to problems with decay and periodontal disease. There is no periodontal ligament with a dental implant. Implants can be prone to medical problems that may underlie the patient’s physiology, mechanical overloading, bacterial contamination, or a combination of etiologies.

Dr. Jameson: Predictability and results. Since you’ve had a chance to use a multiplicity of systems in your numerous years of experience, which type of implant system do you currently use and what are the advantages of that system?

Dr. Soderstrom: The primary system I use is a root form implant system called quantum bio engineering. Unlike some root form systems, quantum bio engineering distributes peak stresses into the tissues rather than into the bone. It also distributes mechanical stress all around the implant on the top side of each thread near the body of the implant instead of concentrating mechanical stress on the outside and underside of the first thread. It is not to say that root form implants are the only implants placed at my office. The next most common type of implant is the subperiosteal implant. You might ask why I use this implant when it has a history of failure. The subperiosteal implant actually has an equal success rate when properly applied and used in the correct application. We also use plate form implants or blade implants for certain applications. The key to which basic type of implant you use - whether root form, plate form, or subperiosteal - is based upon the diagnosis of the patient. The primary factors are the quantity, quality, and trajectory of available bone.

Dr. Jameson: So, as you look at your treatment planning format, you use a multiplicity of tools to approach each case specifically based on the needs of the individual patients?

Dr. Soderstrom: Right. I have used about 20 different root form implant systems, about seven different plate form implant systems, and two types of subperiosteal implant systems. Direct bone impressions were initially used. For approximately the last 15 years, I have primarily used CT scan-generated anatomical models for the subperiosteal implants. In reality, the subperiosteal implants placed using a CT scan technique are custom-cast, endosteal implants as they integrate to the bone. What I am looking for with all the implants I place - no matter whether the implant is a root form, plate form, or subperiosteal - is a bone-integrated implant that not only supports teeth, but more importantly, maintains available bone.

Dr. Jameson: What is available in the way of CT scanning technology? In what way has scanning technology (CT scanning, reformatting softwares, and three-dimensional printers) changed the way you practice dentistry today?

Dr. Soderstrom: This technology has allowed me to get a better handle on what I am working with in terms of available bone height, width, density, and exact location of anatomical structures, such as the inferior alveolar neurovascular bundle and the maxillary sinuses. It also may be used to capture the relationship between the arches. In other words, where is the bone in the maxilla compared to where it is in the mandible? We can see where the available bone is compared to where the tooth position needs to be esthetically and phonetically for the patient. When I first started using CT scanning, it was to construct anatomical models to eliminate a difficult bone impression surgery for the subperiosteal implant patient. In the early 1990s, Implant Master 101 became available. This was the precursor to Simplant, which became available in the mid-1990s. Reformatting software keeps the axial plane of the CT scan and changes the sagittal and horizontal planes to a panoramic curve and a 90-degree slice or cross-sectional paraxial oblique view of the arch. The width and trajectory of bone is easily assessed. Implants can be placed into the reformatted electronic data. When this is combined with solid models available with rapid prototyping from stereolithography and three-dimensional printing, we enter into a realm where the virtual treatment plan can be transferred to the patient.

Dr. Jameson: Universally, for the implant dentists - particularly for the general practitioner who is placing implants or trying to restore implants and has actually done the initial diagnostic workup on his or her patients - there seems to be a tremendous service that was needed to help them achieve this predictable end result. So, you developed a company called Implant Imaging Corporation to help these implant dentists. For the dentist who is looking at implants, but may feel insecure in some of their diagnoses or treatment planning capabilities, what services do you offer to a dentist placing implants today?

Dr. Soderstrom: That is extremely complimentary to say that I developed Implant Imaging Corporation due to such purposes. But, to tell you the truth, I found a need to have a CT scanner in my office and to have software for the purpose of reformatting the CT scans. I also felt a need to be able to develop anatomical models with the centric occlusion and vertical dimension of the proposed restoration captured. The only way I could afford the full-body CT scanner, master reformatting software, and a three-dimensional printer was to offer those services to other dentists to help offset the expense of the technology. I have found there are a lot more dentists interested in treatment planning implants in three dimensions. New advances in cone-beam technology have brought scanners with this technology to the market specifically for dentistry, such as NewTom 9000 and I-Cat. Implant Imaging Corporation has successfully constructed solid models and reformatted this type of data in Simplant. Specifically, the services that Implant Imaging Corporation provides are:

1) To construct solid models from CT scans and cone beam scans using sterolithography and three-dimensional printing

2) To reformat Dicom data from CT scans and cone beam scans in Simplant

3) To construct SurgiGuides from CT scan and cone beam scan treatment plans

4) Treatment planning services using solid models and reformatted scans

5) Brokering used CT scanners and training staff how to take dental CT scans and manage data

The dentist need only send us a CT scan on an optic disc or CD or a cone beam scan on a CD. If the data has already been reformatted in Simplant, this also can be used for a solid model.

The reason I wanted a CT scanner in my office was so I could offer these services to my patients on a day-to-day basis. We found that it was an excellent way to market treatment to the patients. Case acceptance increased dramatically. If the patient goes to the expense of getting a CT scan, then they are very interested in implants and it is more likely they will follow through with treatment than if they do not get a CT scan. When the patient sits with the implant dentist and watches the doctor place implants in virtual images, hold models of the patient’s bone in the dentist’s hands, and then sees how precise surgical guides can transfer this plan to the mouth, the patient gains the confidence to allow the dentist to help him or her. The benefit becomes obvious to the patient when, right before his or her eyes, the result of tooth loss and edentulous atrophy is visualized. When solid models that capture the bite and the vertical dimension of occlusion are available to the dentist, it is easier to see how the effects of edentulous bone loss complicate occlusal schemes with implant-supported restorations. The longer the teeth have been missing, the more the maxilla contracts and the mandible expands, and the more Class III crossbite the occlusal relationship becomes. This relationship has changed the opposite of the esthetic needs of the patient. Diagnosis of available bone is critical to meeting the functional and esthetic needs of the implant placement, and the CT scan simplifies this complicated scenario of edentulous bone loss.

Advantages of three-dimensional dental implant treatment planning are:

• Decreased risk to the patient
• Decreased medical-legal exposure to the implant dentist
• Increased predictability of treatment, especially immediate loads
• Increased communication between implant surgeon and restoring dentist
• Increased communication with the dental laboratory
• Increased communication with the patient
• Time savings
• Allowing a novice to advance to more complicated cases
• A marketing advantage for presenting treatment to the patient and in gaining case acceptance
Greater profitability

The disadvantages are:

• Cost
• Availability of scans
• Increased radiation exposure

As scanners become more available for dental applications, and as cone beam technology becomes more refined, all of these disadvantages will be overcome.

Dr. Jameson: For doctors who want to try to achieve this kind of educational level or better understand what diagnostic and treatment planning tools are available, what continuing education and/or credentials are important for an implant dentist? What is needed to be a masterful implant dentist?

Dr. Soderstrom: I started with courses through the American Academy of Implant Dentistry (AAID). I am, by the way, a general dentist. I graduated from Northwestern University in 1979. I joined the AAID as a general member and began ascending what is an organized ladder of credentials through the AAID. The entry level credential in the AAID at this time is an associate fellow. This is available for both restorative and surgical implant dentists. It requires documentation of three implant cases, several hundred hours of continuing education, and a written examination. The next level of membership in the AAID is fellow. The next level of credentialing I went through was to become a diplomate of the American Board of Oral Implantology/Implant Dentistry. This is a testing organization and is open to dentists who are not members of the AAID. The AAID is the parent organization of the ABOI/ID, but it is completely separate from the AAID and is not a political organization. I am currently vice president of the ABOI/ID. There are several routes to qualify to take the ABOI/ID exam, a combination of written and oral case examinations. A thorough and comprehensive knowledge of dental implants is necessary to be successful at either the ABOI/ID diplomate exam or the AAID fellowship exam. The AAID associate fellowship exam is at a level of competence.

There are many continuing education courses currently available on implants. I would encourage the dentist interested in implants to take as many of them as possible and not to rely on implant manufacturers as the sole source of information. The AAID has several venues for the maxi course on implants. This would be a good place to start to gain a background on dental implants as a science and to become a masterful implant dentist.

Jerry Soderstrom, DDS, a practicing dentist, is president of the Dental Implant Group (formerly Soderstrom Implant Dentistry) in Rapid City, Sioux Falls, and Brookings, S.D.; president of Implant Imaging Corporation, also in Rapid City; and director of education and development for Quantum Bio Engineering Ltd. in Plantation, Fla.