Whether we like it or not we are embracing the digital era in our brave new world. Many dental practices are now becoming paper free – a digital innovation – and even using iPads to record patient details and medical histories. We are continually surprised by the rising age of the technologically savvy patient – particularly those of a certain generation that perhaps we assume would be less “digital” than the perceived iPhone generation.

This change in patient demographic and attitude towards technology is filtering through to us in the Dental profession.

The “nuts and bolts” of implant dentistry tends to lend itself more readily to the digital revolution of Dentistry in the UK and now Globally. Many practitioners opposed to or reluctant to embrace it are actually being influenced by it from shifting workflows in Dental laboratories even where more traditional clinical practices are followed chairside. Quite often wet impressions are poured, and stone models are scanned to produce digital STL files for laboratories to process during crown and bridge unit manufacturing.

As an Implant clinician you do not have to invest in a CT scanner or chairside intraoral scanner – there are ways that other centres and laboratories can provide these services – however having these tools at your disposal greatly increases your efficiency and you are not relying on external services for your patients.

So How do we begin the Implant Digital Workflow?

Treatment Planning

“If you fail to plan – then you plan to fail” – Benjamin Franklin

dental wings intraoral scanner
Dental Wings Intra-Oral Scanner

Successful implant treatment begins with thorough case assessment and planning of the proposed restoration. this is important for all cases not just what we deem the complex ones – even the most experienced implant placer can miss a potential treatment planning hazard especially during a busy day.

Accurate study model casts are an essential part of this – however we can now use intraoral scans preoperatively to begin the digital workflow. We take a scan rather than impressions to form digital models. Our laboratory can then use these to create digital wax ups of proposed treatment outcomes

Printed Models

We are routinely used to 2Dimensional x-ray imaging techniques within dentistry but with the availability and access to Cone Beam CT scanning devices now we are able to assess bone quantity and quality of proposed implant surgical sites.

With ever reducing doses of 3D imaging and improving accuracy we are able to use CT scans combined with clever software packages such as Codiagnostix to plan safe and accurate implant placement and restoration. We are able to preoperatively plan precise implant placement with safe surgical margins away from important anatomical structures such as the inferior alveolar nerve or maxillary sinus. From this we are then able to design and either mill or print a surgical guide to use for precise implant placement.

Surgical Treatment Phase

Even with assisted surgery or guided surgery there are sometimes certain restrictions that prevent us from achieving the most ideal implant placement – such as this case shown where posterior access in the second molar region is reduced so achieving the perfect parallel is extremely difficult.

2D X-ray
3D X-ray

 

 

 

 

 

 

There are fully guided systems available which allow for absolutely precise implant placement, but these are fraught with complexities and should be reserved for experienced placers. The accuracy of surgical guides should not be used to make up for a lack of surgical competency. There are many factors to be considered when using surgical guides – such as:

  • Is the guide tooth supported, soft tissue or bone supported – tooth supported allows the greatest degrees of accuracy
  • If tooth supported –
    • are there windows in the guide which demonstrate full seating of the guide
    • are the teeth mobile which support exact positioning of the guide – any mobility adds a degree of inaccuracy
    • is the guide made from a direct intraoral scan or a scan of a study model – if scanning a study model is this an accurate stone model representation – otherwise risk poor seating and inaccuracy of the guide
  • if soft tissue supported –
    • mobility completely negates any accuracy of the guide, so it should only be used for a pilot drill and then adopt a more conventional surgical protocol
  • if bone supported –
    • likely to have a very large surgical flap raised
    • it’s very difficult to get accurate full seating of a bone supported guide in the precise planned position and relies upon external fixation

Prosthetic Reconstruction

Once the implants are placed in situ and fully integrated we then have a choice with conventional wet impression techniques versus digital intraoral scanning devices. For the majority of cases intra-oral scanning is extremely predictable and reliable – more so than conventional techniques – with milled (and lately printed) models having excellent properties and fewer accumulation of processing errors – however deeply placed implants relative to adjacent teeth with deep contact points are very difficult to scan and pick up.

Straumann tissue level implants offer a very straightforward restorative platform to scan from.

With greater numbers of implants and fewer teeth to act as reference points – intraoral scanning becomes less reliable – particularly across the arch – so we need to have caution and be aware of its limitations. We have used composite flow stuck to the soft tissues to increase reference points for our scanners which increases their ability to stitch images more accurately together. With this in mind we cannot assume the scan is accurate and any framework fabricated would be non-passive – so we must use other methods to verify the scans accuracy – we have found locking temporary abutments within a composite framework intraorally the easiest and most reproducible way to do this. It then allows us to design and mill a truly passive framework by Createch and temporary acrylic bridge.

Review

There are many opportunities to opt in and out of using technology when considering the digital implant workflow. For anyone considering capital investment the most important question they should ask themselves is how will or can this improve the outcomes I provide to my patients and then determine if that warrants the expenditure. Too often we are subjected to sales pitches of the next biggest thing by company sales reps and gadgets and gizmos end up by the way side.

Acknowledgments


Andy Morton and Ian Murch – my fantastic lab technicians at Borough Crown and Bridge that I work closely with.

Dr Ross Cutts BDS (Lond) Dip Imp Dent RCS (Eng)

Practice Principal, Cirencester Dental Practice

Ross graduated from Guy’s Hospital, London in 2000. He is a dentist with Special Interests in Implant Dentistry and Advanced Restorative Procedures. He has placed over 2,000 implants in the last 10 years.

He is a Fellow of the International Team for Implantology (ITI) – and is a Study Club Director and clinical mentor for this Worldwide Organisation. He regularly holds implant courses and lectures nationwide on a variety of topics at different levels, however he has a particular interest in Aesthetic Implant Dentistry, Digital Dentistry and complex Bone Grafting procedures.

Interested in learning more – why not attend our Guided Surgery Course taking place this November, 2018 click here for details.

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