Technology Can Make Implant Placement More Seamless
As part of the July AGD Impact cover story, Ross Isbell, DMD, MBA, AGD Impact Testing the Tools columnist who practices in Gadsden, Alabama, discusses how some of the latest technology can aid in implant planning and placement.
AGD Impact: What are the benefits of implant surgical guides?
Isbell: Implant surgical guides — when used correctly — can be incredible aids for prosthetically driven implant placement. Coupled with a process for designing the final crown before moving into the surgery phase, a guide can be a simple device for placing an implant into a tooth-bounded edentulous area with the goal of a single crown or as part of a complicated device used to plan all-on-X locations that give ideal anterior-posterior spread and angulation for a large prosthesis. When placing a guide for a tooth-bounded area, it can be as simple as snapping the guide in place and using it as an aid to ensure angulation is ideal and that negative complications with surrounding anatomy such as nerves will not be a problem. In some systems, you can design and mill the final or temporary implant crown as part of the process to design and print or mill the guide. In an all-on-X situation, there are typically no remaining teeth, so anchorage of the guide must be completed using anchor pins at preplanned locations. However, they are not foolproof, and there is some room for error. With both of these situations, you still must follow standard precautions for tracking the process of your surgery — even though surgical guides can be incredibly accurate, if the guide is placed incorrectly by even 1 degree, there can be significant change in the final implant location.
How can general dentists implement a guide system?
You will need the patient to have a cone-beam computed tomography scan completed and have a digitized impression. This is most easily done with an intraoral scan, but there are many labs that will accept an analog impression and scan it for you. So, even if you don’t have technology in your office, you can still have guides made. You will, however, need to purchase and familiarize yourself with your implant system’s guided kit. These may include different keys and drills that your lab will need to plan for in the fabrication process and that you will need to understand for the surgery to be truly accurate.
How does a 3D navigation system help with implant planning and placement?
I have demo’d, but not used, a 3D navigation system called X-NAV. The results that I get from my oral surgeon using these types of devices are really excellent, though. The feedback I have received from the surgeon about this surgical process is that it gives the confidence of guided surgery and precision in placement location while allowing for the freehanded adjustment feel during the procedure. As I said about standard guides, it is still critical to follow normal procedures for radiography and location confirmation.
Is it worth the investment?
I place the majority of my implants freehanded, but I am also placing most of these into abundant bone and know that my placement location will be within an acceptable tolerance range for restoration. If there is any question of whether there is enough bone, I will either change into a guided process or refer to a specialist for ridge augmentation or sinus lifting. For peace of mind and a greater guarantee of prosthetic fabrication ease, then yes, I think guides to aid placement can be worthwhile, though they definitely are not required.
What lasers work best with implants?
If the question is regarding the uncovering of implants, then I would argue that it doesn’t truly matter, though some lasers are gentler on tissue than others. Personally, I use a diode for uncovering instead of scalpels in order to reduce bleeding and eliminate the need for suture removal. CO2 lasers have a similar coagulation style and effect as diode lasers. Nd:YAG and Er,Cr:YSGG lasers have been shown to be effective with peri-implantitis management and for helping with tissue regeneration processes, but they are significantly more expensive. So, whether you need a laser, and which one you need, really depends on what your treatment goals are.
How are new materials (e.g., ceramics) making implants better?
In regard to restoration, new materials are allowing for better temporization and tissue-healing customization than ever before and are giving us better opportunities to make margins disappear. So many patients are unhappy with the “dark line” at the bottom of their porcelain-fused-tometal crowns on normal teeth, and this is often a cosmetic issue with implants, as well, if they are not placed at an appropriate depth. With appropriate planning of implant location subgingivally, newer ceramics are changing the custom abutment game so that anodized titanium is not always a requirement for angulation correction and can allow for great soft tissue contours. In considering the new types of surface treatments that implant bodies are receiving, the implants we are using now are so much more bioactively helpful in creating a stable osseointegration from an early healing time.
What imaging/impression-making technologies are optimal for implant planning?
Every implant system has a scan body that allows your particular scanning system to capture and send information to the lab for fabrication. There are also scan body systems that work specifically with your scanner and mill type that can convert a variety of implant systems into what you need for in-office fabrication. I personally use Biohorizons implants with a Truabutment scan system for most of my fabrications to be completed in-office. However, if I want to send it to my regular lab, I need to use the Biohorizons-specific scan body or take a polyvinyl siloxane impression. The most important thing is having a good relationship with your lab and making sure you capture all the information it needs.
What other new technologies are you keeping your eye on or would like to try out?
I have not yet advanced my studies to the point where I am designing guided bone and tissue growth for site preparation prior to implant placement, but there are some awesome software programs out there that are making that a reality, too. Some new scan post systems attach directly into the healing abutment and present an interesting change to the workflow, but the stability and accuracy seem imperfect at this point.
Ross Isbell, DMD, MBA, currently practices in Gadsden, Alabama, with his father, Gordon Isbell, DMD, MAGD. He attended the University of Alabama at Birmingham (UAB) School of Dentistry and completed a general practice residency at UAB Hospital. To comment on this article, email impact@agd.org.
AGD Impact: What are the benefits of implant surgical guides?
Isbell: Implant surgical guides — when used correctly — can be incredible aids for prosthetically driven implant placement. Coupled with a process for designing the final crown before moving into the surgery phase, a guide can be a simple device for placing an implant into a tooth-bounded edentulous area with the goal of a single crown or as part of a complicated device used to plan all-on-X locations that give ideal anterior-posterior spread and angulation for a large prosthesis. When placing a guide for a tooth-bounded area, it can be as simple as snapping the guide in place and using it as an aid to ensure angulation is ideal and that negative complications with surrounding anatomy such as nerves will not be a problem. In some systems, you can design and mill the final or temporary implant crown as part of the process to design and print or mill the guide. In an all-on-X situation, there are typically no remaining teeth, so anchorage of the guide must be completed using anchor pins at preplanned locations. However, they are not foolproof, and there is some room for error. With both of these situations, you still must follow standard precautions for tracking the process of your surgery — even though surgical guides can be incredibly accurate, if the guide is placed incorrectly by even 1 degree, there can be significant change in the final implant location.
How can general dentists implement a guide system?
You will need the patient to have a cone-beam computed tomography scan completed and have a digitized impression. This is most easily done with an intraoral scan, but there are many labs that will accept an analog impression and scan it for you. So, even if you don’t have technology in your office, you can still have guides made. You will, however, need to purchase and familiarize yourself with your implant system’s guided kit. These may include different keys and drills that your lab will need to plan for in the fabrication process and that you will need to understand for the surgery to be truly accurate.
How does a 3D navigation system help with implant planning and placement?
I have demo’d, but not used, a 3D navigation system called X-NAV. The results that I get from my oral surgeon using these types of devices are really excellent, though. The feedback I have received from the surgeon about this surgical process is that it gives the confidence of guided surgery and precision in placement location while allowing for the freehanded adjustment feel during the procedure. As I said about standard guides, it is still critical to follow normal procedures for radiography and location confirmation.
Is it worth the investment?
I place the majority of my implants freehanded, but I am also placing most of these into abundant bone and know that my placement location will be within an acceptable tolerance range for restoration. If there is any question of whether there is enough bone, I will either change into a guided process or refer to a specialist for ridge augmentation or sinus lifting. For peace of mind and a greater guarantee of prosthetic fabrication ease, then yes, I think guides to aid placement can be worthwhile, though they definitely are not required.
What lasers work best with implants?
If the question is regarding the uncovering of implants, then I would argue that it doesn’t truly matter, though some lasers are gentler on tissue than others. Personally, I use a diode for uncovering instead of scalpels in order to reduce bleeding and eliminate the need for suture removal. CO2 lasers have a similar coagulation style and effect as diode lasers. Nd:YAG and Er,Cr:YSGG lasers have been shown to be effective with peri-implantitis management and for helping with tissue regeneration processes, but they are significantly more expensive. So, whether you need a laser, and which one you need, really depends on what your treatment goals are.
How are new materials (e.g., ceramics) making implants better?
In regard to restoration, new materials are allowing for better temporization and tissue-healing customization than ever before and are giving us better opportunities to make margins disappear. So many patients are unhappy with the “dark line” at the bottom of their porcelain-fused-tometal crowns on normal teeth, and this is often a cosmetic issue with implants, as well, if they are not placed at an appropriate depth. With appropriate planning of implant location subgingivally, newer ceramics are changing the custom abutment game so that anodized titanium is not always a requirement for angulation correction and can allow for great soft tissue contours. In considering the new types of surface treatments that implant bodies are receiving, the implants we are using now are so much more bioactively helpful in creating a stable osseointegration from an early healing time.
What imaging/impression-making technologies are optimal for implant planning?
Every implant system has a scan body that allows your particular scanning system to capture and send information to the lab for fabrication. There are also scan body systems that work specifically with your scanner and mill type that can convert a variety of implant systems into what you need for in-office fabrication. I personally use Biohorizons implants with a Truabutment scan system for most of my fabrications to be completed in-office. However, if I want to send it to my regular lab, I need to use the Biohorizons-specific scan body or take a polyvinyl siloxane impression. The most important thing is having a good relationship with your lab and making sure you capture all the information it needs.
What other new technologies are you keeping your eye on or would like to try out?
I have not yet advanced my studies to the point where I am designing guided bone and tissue growth for site preparation prior to implant placement, but there are some awesome software programs out there that are making that a reality, too. Some new scan post systems attach directly into the healing abutment and present an interesting change to the workflow, but the stability and accuracy seem imperfect at this point.
Ross Isbell, DMD, MBA, currently practices in Gadsden, Alabama, with his father, Gordon Isbell, DMD, MAGD. He attended the University of Alabama at Birmingham (UAB) School of Dentistry and completed a general practice residency at UAB Hospital. To comment on this article, email impact@agd.org.