A review of surveys conducted by DLP and our sister clinical publication, Dental Products Report, indicates that patients have been asking their doctors more about implants, clinicians have been prescribing them more as a restorative option, and labs have experienced substantial growth in their implant business as a result (see “Implants: Who Wants ‘Em” on page 20).

Patient interest in implants has been piqued by direct-to-patient marketing—by dental practitioners and implant component manufacturers—focusing on such benefits as decreased bone resorption in tooth-replacement restorative cases; less-invasive surgeries; increased retention and stability in denture cases; and immediate-loading procedures and mini implant designs that have opened implant treatment to more patients. As a result, more GPs are prescribing implant treatment, then either performing the surgery themselves (in increasing percentages) or referring to a specialist. Word of mouth also factors in, with patients expounding to friends and family about the simplified implant treatment and clinicians networking with peers about personal practice growth through implant services. Although the labor-intensive implant procedures are more costly than traditional restorative or prosthodontic care—and frequently require out-of-pocket payment by patients—those patients with disposable income or savings who can afford the higher-end treatment options favor the benefits of implant treatment.

While many restorative procedures routinely are performed by the dentist—direct cavity filling or basic chairside CAD/CAM-produced crowns—implant usage necessitates laboratory involvement. And new procedural modalities are stretching the overall influence the dental technologist has in the planning and fabrication of implants. Today, labs are involved in the many traditional hands-on steps that make up implant restorations, from fabricating the temporary restoration up through the final PFM or metal-free restoration.

“The dental laboratory is the driving force in guided implant dentistry because it’s prosthetically driven,” said Daniel R. Llop, CDT, the President and CEO of nSequence, an implant-focused education and outsource partner. “People don’t buy implants, they buy teeth. At nSequence, prosthetic-driven guided therapy will assure the needed elements of final restorative success and deliver the best prosthetic choice and esthetic outcome for the patient.”

Eli Ganon, an expert and consultant in dental technology added, “More labs are shifting from traditional crown and bridge to offer high-end implant planning. They will plan the case from A to Z for the doctor and provide the doctor with actual case planning, treatment planning, design, and the final crown or bridge.”

Full-spectrum integration can be a technological quagmire, however, as end-to-end unification of the digital components used by dental labs and practices in implant treatment often involves software and hardware systems that may be unable to transfer data from one component to the next and back again.

“Today, there is no one that has a complete virtual environment design software that is totally integrated,” said Ping Fu, CEO of Geomagic Inc., a leading developer of 3D software for various dental applications such as implant planning and CAD/CAM.

She added that Geomagic is applying its research and development ingenuity to create workflow solutions that will pull together disparate digital pieces into a cohesive, seamless whole. Similar to how Apple’s iTunes platform works with data from music, video, and podcast files, the application will allow the user (clinician or technician) to work with such data as DICOM files from a CBVCT unit or STL files from a digital scanner and connect them with other applications.

“We’re looking at the whole workflow,” she said. “Who needs to talk to whom, and who needs to share what data. And then put a framework around it where the software never changes when new tools, reference models, and file formats are added.”

For techno-wary lab owners who want to expand their menu of high-end implant services but are cautious about adopting unproven hardware and software, companies such as the Canadian firm BioCad bundle just the necessary components to ease into the process (see “Rooted in the future” BioCad highlight on page 24). Like several CAD/CAM outsource business models, BioCad involves the lab technologist in a number of different levels, depending on the individual strategy.

Reno-based nSequence sees itself as a “total solution for guided implant surgery,” said founder Llop, including education, treatment planning, and R&D (see “Rooted in the future” nSequence highlight on page 28) as well as 3D digital radiography technology.

Right from the start, the lab’s participation in the next-generation of implant treatment begins. The absolute precision of CBVCT scanning requires a marking appliance to help identify oral tissue position in the 3D radiograph image. Working with a model, the lab fabricates a thermoplastic guide with radiopaque material imbedded inside that helps with orientation of the digital image.

However, as digital impressions advance and gain acceptance over standard bite impressions, poured models used to make these radiographic guides will give way to models CAD/CAM milled or 3D printed using stereolithographic technology. Even these milled or printed models may not last long in practical use as technology continuously moves on.

“Eventually, the radiographic guide will disappear once you can completely do your virtual planning in digital space,” Fu predicted.

From the highly accurate CBVCT 3D image, the implant surgical site can be planned out with unprecedented accuracy, taking into account jawbone height, width, density, and other factors. The precise drill site, depth, and angulation can be determined, and a surgical guide stent then can be fabricated via sterolithography to assist the clinician during surgery. Fabrication of these surgical guides is available for the clinician directly from such companies as Nobel Biocare (NobelGuide) and Materialise Dental (SimPlant) in differing business models. Alternatively, other 3D software planning manufacturers (Keystone, iDent, Implant Logic, Biomet 3i, IMTEC DigiGuide MDI) involve the laboratory in the process.

Labs investing in the proper training, software, and equipment will have the opportunity to offer the specialized appliances to their clients or as an outsource service to other labs.

“There’s no reason the lab couldn’t do it,” Fu said. “In fact, it’s better. Labs can be trained to do radiographic work very quickly because they have the fundamental knowledge of the final dental prosthesis.”

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