Does the developing software for guided surgery increase the probability of GPs placing their own implants?

Jay B. Reznick, DMD, MD maintains a private practice in Tarzana, California, specializing in oral and maxillofacial surgery. He is a member of multiple dental associations and is board-certified by the American Board of Oral and Maxillofacial Surgery.

Ara Nazarian, DDS, DICOI maintains a private practice in Troy, Michigan, with an emphasis on comprehensive and restorative care. He is a diplomate in the International Congress of Oral Implantologists. He is also the director of the Reconstructive Dentistry Institute.

Dr. Francis Serio: Let me start out with the old adage, “Just because you can, does not mean you should.” There is no question that guided surgery has been a major advance in the treatment planning and placement of implants for implant-supported restorations. These advances may tempt those without proper training and experience to think that the accurate placement of implants is now automatic. Unfortunately, there is nothing “simple” about these procedures.

Among the numerous possible errors to consider when using guided surgery are mouth-opening limitations, surgical guide preparation, length of metal sleeve, and precise stent location and fixation. Dr. Moon and his team of researchers studied these possible errors and recently published their error findings, which included a difference of 3.84° + 1.49° in angulation, the mean distance differences between planned and placed implants was 0.45 mm + 0.48 mm horizontally and 0.63 mm + 0.51 mm vertically at the implant neck. So in other words, even under controlled conditions there is some chance for error. This may not make a difference to the seasoned operator but could spell the difference between success and failure for the neophyte who thinks that stents are foolproof. It may also be problematic when the volume of bone is limited in any dimension. In addition, the increase in the number of remaining teeth and distal tooth support increase stent accuracy with bone or mucosa supported stents being the least accurate.

One additional consideration is the beginning of the swing of the pendulum back to increased focus on the maintenance of the natural dentition; the January 2016 issue of the Journal of Dental Research bears this out with three articles by Drs. Giannoble, Tarnow, and Derks that invite discussion on how to manage the rise of peri-implantitis, and whether perhaps salvaging compromised teeth with the rise of this complication is a more ideal approach in some cases.

So, do I think that more GPs will be doing implants with guided surgery? Yes. Do I think that it is a good thing? Not necessarily.

Dr. Jay Reznick: The simple answer is that software and developments in guided surgery are definitely increasing the number of GPs who are doing implants. I think a couple of things are at play—general dentists, with economic pressures on them, are looking for newer procedures and procedures that they were previously referring out to be able to do them in their offices. At the same time they are looking at what they are getting back from their surgical specialists as far as the implants being placed, and feeling like these so called experts are not giving them the implant placement that they need in order to restore the case. Some may say, “I’m the one who has to restore this case. I think that I could probably do better at placing the implant because I know where it needs to be for the restoration.” Guided implant surgery gives them the tool to be able to do the treatment planning, the implant planning, based on the prosthetic plan. For example, cone-beam planning software shows the clinician exactly where it needs to go to be lined up correctly and positioned correctly for the final prosthesis. If you need to add bone or modify the bone, you know that ahead of time. The surgical guide that is then manufactured allows you to place that implant with an extreme amount of efficiency, accuracy, and consistency.

One of the things that I think is very important in this whole process is education because guided surgery is a tool to deliver accurate, efficient implant placement, but the rules of implantology that we all need to learn still apply. It shouldn’t be thought of as a replacement for proper training or a crutch to place an implant for somebody who shouldn’t really be placing implants. Getting back to the original question—does it increase the probably of GPs placing their own implants? I think in a sense it gives them the confidence to know that where they placed the implant is where they planned to go. I think it has given them the confidence to learn to do straight forward implant cases themselves and hopefully continue working with their surgical specialist for the more complicated cases.

Dr. Ara Nazarian: With the increasing development of CBCT software and the reduced costs of surgical guides, general dentists will inevitably embrace placing dental implants within their own practices. When combined with continuing education and experience, single tooth implant placement within one’s practice can eventually grow to multiple implant treatment with time. However, it is important to note that there will still be a need for specialists for more complex cases. Damaging a vital structure, invading the sinus, or hitting an adjacent tooth has always been the greatest fear when placing dental implants. These fears are legitimate and do have consequences. More importantly, no dental provider wants to harm his or her patient.

With 3D CBCT imaging becoming more ergonomic and affordable, more and more GPs will enter the arena of implant dentistry. Some clinicians may choose to fabricate their own printed surgical guides and others may decide to use a third party that focuses on guided surgery solutions. Also, we see an increasing number of dental labs offering these services, so the transition to doing guided surgery is becoming more available.

Most patients feel comfortable and have good rapport with their general dentist, so it is logical for them to want everything from the provider they know and trust. In fact, a vast majority of the implants we place come from within our hygiene department or patient referrals. Additionally, we get new patients that find us from the Internet that decided to come in for the consult because they read that I can provide both the surgical and restorative components of dental implant treatment with the added technology in my practice. During the consultation, we utilize 3D virtual treatment plans followed by guide fabrication to efficiently and effectively deliver implant treatment. Not only does this shorten the actual surgery appointment, but it also increases patient confidence in the practice.

With the cost of CBCT and surgical guides becoming more economical as well as education and training more readily available from a variety of different teaching institutions, there is no reason not to start implementing implant placement and restoration within your general practice.