by 
By Thomas Hirsch, DDS, the owner of a Malibu, California-based dental practice and founder of Isolite Systems, currently Zyris
Newer technology has made implants simpler and more accurate.
Dental implants date back to 2500 BC, when the ancient Egyptians tried to stabilize teeth with gold ligature wire. Today, researchers are exploring ways to grow a new tooth in a human adult – something that could take root, so to speak, in the next 10 years or so.
Recently, a Tufts University team constructed a cellular matrix that allows successful implantation of a tooth bud into a pig’s jaw. Under their design, early adult-stage teeth develop within five months. Researchers project that humans won’t profit from these developments for another ten years. The exciting progress hints at options once believed to be impossible.
For now, dental implants are the closest alternative to growing new teeth. Research has brought major benefits to implant technology as well.
A higher standard of care
It was debated several years back that if dentists had a CT scanner in their office, they would be held to a higher standard of care. And, in fact, they were.
“Medical professionals who are liable for non-diagnosis of any abnormality on the CBCT scan include the dentist who orders the CBCT scan and likely any other professional who uses the CBCT for diagnosis or treatment planning. Dentists must possess the requisite standard of care when diagnosing and treating patients. This standard is normally stated as the level of knowledge, skill and care of a reasonable dentist. To meet this standard when using CBCT, dentists should use CBCT’s full capabilities to obtain maximum diagnostic accuracy. The standard of care must be met whether or not the dentist received specialized training on CBCT imaging because dentists are required to stay current in the areas in which they actively practice by enrolling in continuing education courses. There is even argument that dentists who use CBCT should be held to the higher standard of a board-certified oral and maxillofacial radiologist.” 1
So how do dentists integrate a CBCT into their treatment planning and execution of dental implant procedures? Plan, plan, plan. It’s actually quite simple. First, patients should be medically evaluated before any implant surgery is scheduled. Patients either must have enough bone to support the implant, or be good candidates for surgery to build up the bone where the implant will be placed. Chronic illnesses, such as diabetes or leukemia, may interfere with healing after surgery. Patients that have taken bisphosphonates can have osteonecrosis of the surgical site. Using tobacco can also slow healing.
Another great advance, although it’s no longer considered new, is CADCAM technology. CADCAM, combined with CBCT technology, allows dentists to virtually plan the final result. So, the next step in this journey is to take physical or digital impressions of the patient’s maxillary and mandibular arches. Once the arches are scanned and the vital structures are identified (in this example, that includes the adjacent teeth and the mandibular nerve, as well as the mental foramen) a virtual final restoration can be designed.
With the proper size and shape of the final virtual restoration, the implant of choice can be positioned.
It’s vitally important to determine the path of insertion of the implant relative to the occlusal surface of the crown, lest the screw access hole exits out of the buccal or lingual! Now it’s clear where the implant should be placed, but how does the dentist ensure it gets there? Neophytes in implant placement would do well to take beginning and advanced surgical dental implant courses. But even the best laid plans can fall short when using steady hands to place implants in the genesis, which is why the surgical guide has become so important. Dentists can construct and print their own guide, mill it and have their laboratory fabricate one, or they can work with a third party. Whether the procedure involves a single implant or multiple implants, the surgical guide ensures it runs smoother, with fewer complications.
The surgery
Now comes the fun part: the surgery. For this, dentists must trust in their planning and clinical abilities, since they cannot actually see under the patient’s bone, and proceed as follows:
- Review patient’s medical history.
- Review treatment, options, risks, complications, alternatives and fees.
- Verify surgical guide fit.
- Treat in accordance to surgical protocol.
- Lay a flap or go flapless (tissue punch).
- Place the implant.
- Place the cover screw or healing abutment.
- Close the surgical site.
At my dental office, the surgical time to place a simple implant, a healing abutment and to close the surgical site can be a short as 10 minutes. Much depends on the implant method selected. In the end, when the implant is placed with a high degree of precision and accuracy, it makes the final crown restoration a simple one.
Thanks to directly visible surgical conditions, implantation is not only safer, it’s also minimally invasive. What’s more, dentists can save time during patient consultations since their patients understand the 3D visualization more easily.
Maximum efficiency
All of this great CADCAM and CBCT technology has allowed me to design my operatories for maximum efficiency. We have placed treatment centers in all of our rooms. Our chairs are integrated with surgical motors built into the dental unit, and there is a pump for sterile saline. We always have a surgical handpiece ready to go. It has become very convenient to remove a cover screw, healing cap, abutment or implant crown. Sure, this has involved an investment in technology, but the returns have been fantastic. My front desk assistant has been crossed-trained to determine how long the procedures will take and to schedule a shorter amount of time to accommodate them.
My hygienist can recommend treatment with a great deal of confidence, knowing that guided dental implant procedures are much easier for the patient and entire team, and my dental assistant essentially has an extra pair of hands during surgery. And as for me: dental surgery has become more like a hobby than work. I do it for the love of it.
References
1 Stuart J. Oberman, Esq. Dental Tribune U.S. Edition, Vol. 6 No. 18, December 2011.
