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The Drill on Implants
Exploring implant dentistry's most controversial and confusing issues
Inside Dental Technology set out to identify and cover the hottest topics in the growing arena of implant dentistry. We started by asking eight experts from the Editorial Advisory Boards of IDT and Compendium of Continuing Education in Dentistry to suggest key areas of concern, controversy, or confusion surrounding specific aspects of implant dentistry. We then surveyed 21 members of IDT's board who specialize in implants to narrow down the suggested topics to three.
The results were clear: Our experts want to read more about the cement- vs. screw-retained options, the value of CT guided surgery, and the question of full-arch fixed restorations vs. removables.
CT Guided Surgery: Is It Worth the Time and Money?
The cost is high, but some say the benefits are even more significant
By Jason Mazda
Two statements are true of most new industrial technologies: They can improve the quality and/or efficiency of an existing workflow, and there will be a cost associated with their implementation and integration. The question usually revolves around whether the benefits outweigh the costs.
This question has yet to be conclusively answered in regard to the widespread use of CT guided surgery for dental implant placement. While there appears to be a consensus that CT guided surgery is the optimal treatment option for certain indications, disagreement persists as to whether the process is always worth the time and money that it requires.
CT guided surgery involves the use of a CBCT scan to digitally plan the location of implant placements, and surgical guides to facilitate accurate placement during surgery. This level of planning also can allow for collaborative input from the laboratory before the surgery, and even fabrication of the restoration prior to the implant placement. Implant dentistry is cited as one of the major factors in the forecasted 10% CAGR globally for CBCT units from 2013 to 2021.1
“This is the future,” says Christian Coachman, CDT, DDS, Owner of Digital Smile Design in Sao Paulo, Brazil, and an international lecturer on the subject of guided surgery. “The technology is available to improve the quality of restorations, so it should be utilized.”
Beyond esthetics, computer-generated guides can be more crucial depending on the severity of potential implant placement errors. Barry Levin, DMD, the Implants Section Editor for Compendium of Continuing Education in Dentistry, says he uses CT guided surgery at his Jenkintown, Pennsylvania practice to avoid catastrophic injury when placing implants in close proximity to vital anatomic structures such as the maxillary sinus or inferior alveolar canal. The process is also useful, Levin says, in situations when a significant amount of bone augmentation has been performed and the clinician has all of the hard- and soft-tissue dimensions necessary and does not need to raise a flap.
However, Levin says those cases only account for approximately 5% of his work. The rest of the time, he says, CT guided surgery is a luxury that he does not recommend to patients. Factoring in the CBCT scan, designing the guide, and production expenses, the average additional cost of using a surgical guide for an implant surgery is approximately $1,000, Levin says, though some others put that number slightly lower.
“I think it is overused,” he says. “An experienced, formally trained periodontist or oral surgeon should not need a guide in most cases. Conversely, someone who needs a guide to feel comfortable should not be performing the surgery.
“General dentists are placing implants with the use of guides, but they really should not perform surgery unless they are prepared to change course and use conventional methods to manage complications that may arise.”
Lee Culp, CDT, CEO of Sculpture Studios in Cary, North Carolina, says the CBCT scan and the computer-generated surgical guide should be considered separately. While a skilled surgeon might not need a guide in many cases, Culp says, a CBCT scan and pre-surgery laboratory planning should be part of every implant surgery.
“The laboratory traditionally has joined the treatment team in the latter stages of cases, and often we have to perform heroics to make the restorations work,” Culp says. “Even then, restorations often do not match patient expectations as much as they could have if the clinician, laboratory, and patient had discussed the case in the planning stages using a CBCT scan.”
Even if a less-than-ideal placement is unavoidable, a CBCT scan allows the patient to be forewarned about issues involving esthetics, emergence profile, occlusion, and more.
Coachman’s philosophy is that a smile should be designed from the outside inward, starting with the whole face. Optimal esthetics cannot be achieved, he says, when the technician starts the case with pre-placed implants.
“The more you plan digitally outside the mouth, the less the surgeon needs to change inside the mouth,” Coachman says.
While the cost of CT guided surgery may seem prohibitive at the time, Coachman and Culp both assert that the long-term benefits of a more successful outcome should be considered. If a less-than-ideal placement results in more appointments and procedures several years later, the initial savings from not using CT guided surgery may seem paltry.
“Long-term predictability is most important,” Culp says.
Developments in the technology will shape the future of this debate. For example, cost, which is at the center of the discussion, should become less of a prohibitive factor.
“I expect a lowering in prices of the equipment involved in the diagnostic process,” Culp says. “Also, as more competition emerges and new technologies allow more laboratories to fabricate guides in-house, we will see costs drop significantly over the next few years.”
Coachman says while intraoral scanners are not yet accurate enough to perform fully guided surgery for multiple units, he expects that to change.
“We will see improved precision on several elements: intraoral scanning, overlapping STLs and CBCTs, design software, 3D printing, and more,” Coachman says. “Every little piece will be improved to the point at which we can design final screw-retained bridges in advance and finish the case in one appointment.”
Levin says if the cost is appropriate and the accuracy sufficient, CT guided surgery could be acceptable on a widespread basis.
“This technology is wonderful as an auxiliary tool to the human element of diagnosis and treatment planning,” Levin says. “It can make treatment easier for patients and more successful for everybody.”
The developments could be a boon for laboratories, allowing more of them to offer the type of comprehensive implant services that Culp’s offers, working with clinicians from the start of cases.
“More laboratories will create inclusive packages with the diagnosis, treatment planning, guide, creation of the abutment, and final restoration — an A-to-Z service,” Culp says. “That makes the case very predictable the entire way.”
1. Wise Guy Reports. Global Dental CBCT Industry Report 2016. https://wiseguyreports.com/reports/global-dental-cbct-industry-report-2016. Published January 22, 2016. Accessed February 5, 2016.