How Digital Technology Improves Accuracy, Reproducibility of Implant Dentistry

Overview

Using digital treatment planning and workflows has been demonstrated to

make dentistry faster, easier, more flexible, and more efficient from diagnosis

through restoration in terms of time, cost, and patient experience. Over the

years, digital technologies have become more intuitive, user-friendly, and

easier to integrate with existing technologies of choice as well as with new and

emerging technologies. As a result, technological advancements have enhanced

practitioners’ overall experience in addition to their return on investment.

Numerous studies and anecdotal reports support the theory that using digital

technology can help clinicians accomplish surgical and prosthetic rehabilitation

with higher accuracy and reproducibility. (Tordiglione L; Salomao GV; Franchina

A.) Specialists and general dentists can expect today’s technologies – including

intraoral scanning, 3D imaging, CAD/CAM, 3D printing, and precision treatment

planning software – to make many procedures more efficient, predictable, and

less costly and invasive. [Tallarico M. Computerization and digital workflow in

medicine: focus on digital dentistry. Materials 2020(13):2172.]

In this e-book, Riley Clark, D.M.D., an implant-only general dentist and educator

discusses his experience with using Carestream Dental’s digital technologies in

hundreds of implant cases, along with the new DIOnavi implant system protocol

combined with 3Shape software, which he and the DIOnavi dental lab use to

communicate and fabricate restorations.

How Digital Technology Improves Accuracy, Reproducibility of Implant Dentistry

Plus, exploring Carestream’s versatile digital solutions

Continual advances with digital technologies used in dentistry enable dentists

to capture high-quality data, envision and plan treatments ranging from singletooth

restoration to full-arch and full-mouth rehabilitation, and provide patients

with a variety of fixed and removable options that mimic both the esthetics and

mechanics of natural teeth.

What has been coined the “digital workflow” has progressed from its earliest

days of merely referring to electronic patient records and supply ordering to

making it possible to virtually plan complex cases in advance of treatment,

to communicate and modify plans with patients, and to fabricate custom

replacement teeth that are natural looking, esthetic, and potentially functional for

a lifetime. The results can be life changing for their patients.

Riley Clark, D.M.D., who practices in Heber City, Utah, and is the clinical

instructor of the WhiteCap Institute, thinks that while the diagnostic and

treatment planning phases of his full-arch and full-mouth cases are enhanced

by using digital technology, the most significant impact is now on the restorative

phase. “I think the fact I’m doing this 100% with technology, not using a single

tray-type impression, is really unique,” he says. “The patients and I love the

way we do the work-up of the case and the treatment planning.” Until he began

working with digital technologies, Dr. Clark says he never had a truly streamlined

workflow that worked in a linear fashion where all the steps complemented each

other. “There was a lot of redundancy in the treatment steps, each of which

were important, but they didn’t actually provide a linear path toward our final

restoration. But that’s all you could do for a long time.”

Dr. Clark describes how much his workflow within the digital technology

framework has changed over recent years. First, he adapted digital X-rays, then

digital scanning. Next, using cone-beam computed tomography (CBCT) for

diagnostics and later for surgical treatment planning became routine. Then, he

was introduced to an implant system protocol that plans cases from the surgical

approach through final restoration employing the original data he captures

from his Carestream CS 3600 and CS 9600 devices. This data, combined

with 3Shape software, is used to determine the appropriate implant, implant

placement, and supporting bridge design for full-arch rehabilitation based on his

original diagnostic information.

“Today, we can start with digital from a diagnostic standpoint and then use that

digital work-up all the way through the treatment plan. It is so refreshing to work

with an efficiency that benefits the doctors, the patients, and the lab,” Dr. Clark

says. “Everyone wins, and I can to do cases in a fraction of the time with fewer

appointments.”

For Dr. Clark, the process of streamlining his procedures started when he began

following a particular protocol DIOnavi was developing in December 2020,

although he has been using the company’s implants for two years. DIOnavi is

also creating workflow solutions with its systems. The DIOnavi EcoDigital Implant

Platform involves a “partner practice relationship” with clinicians to support

practitioners through the entire implant-placement process. “Implant dentistry is

a technology discipline now,” Dr. Clark says.

The role of Carestream’s technologies

The protocol Dr. Clark follows can be used with whatever technology clinicians

choose to use because of the open file format platforms offered by Carestream

and 3Shape. “I think Carestream is one of the few companies that do a really

good job of capturing the data better,” he adds. “The Carestream software is

user-friendly, extremely accurate, and very fast. It doesn’t make you jump through

a lot of hoops to export and share the files. That’s what matters most to me.”

Essentially, he uses the CS 3600 intraoral scanner and CS 9600 CBCT for the

first steps of diagnostic information gathering and treatment work-up. With the

resulting DICOM and STL data he can create a thoughtful restorative plan. “We

use 3Shape software to design the entire case from the ground up,” Dr. Clark

says.

An advantage the Carestream software offers is that the raw data in the STL file

is always saved. If Dr. Clark discovers he has missed something after dismissing

a patient, he can always refer back to the STL file. “You’re not starting over from

zero again,” he explains. “That’s a huge time-saving feature. And, unfortunately,

we do have to use it from time to time.”

“The CS 9600 is just a beautiful machine,” Dr. Clark continues. “It wows patients

with its technology—from its touch screen to the camera.” Clinically, the image

quality is sharp and reliable, and the software is intuitive and straightforward, Dr.

Clark adds.

Another useful feature of the CS 9600, Dr. Clark notes, is the metal artifact

reduction (MAR) settings. “This really helps when scanning patients who are

heavily restored,” Dr. Clark explains. “Patients getting this type of full-mouth

implantology have already been through a lot of dentistry like root canals,

crowns, and bridges. 

The artifact reduction enables the lab to visualize everything

properly as they’re merging the data and doing the diagnostic work-up.”

Dr. Clark and his father, P.K. Clark, practice together and are fortunate to have

the facility to house their own dentals lab, including an onsite DIOnavi lab. The

data from the Carestream hardware is merged with the 3Shape software by

the DIOnavi lab technician who then can print the surgical guide and format

the surgical and restorative plans. “Carestream is the tool to get the files so

3Shape can do what it needs to do,” Dr. Clark says. “Coming down the pipeline

is DIOnavi’s new ecosystem software where the entire process is controlled by

DIOnavi hardware and software.”

The plans for every treatment and restorative phase are available to Dr. Clark

for evaluation and approval via a website page that both parties can access.

Dr. Clark assesses the proposed work-up and either confirms the plan and

associated components or requests modifications. A video conference call often

follows, so the planners can screen share and discuss next steps. Dr. Clark

and his lab team members also can interact in person whenever necessary to

facilitate good communication.

The new role of the temporary

Another difference in Dr. Clark’s new digital protocol is that the initial work-up

becomes the foundational reference point for future steps in the rehabilitation

process. And the temporaries themselves not only function as a beautiful interim

solution for the patient, but as the key to success. “If you fast forward the case—

let’s say the surgery’s done, the implants are in, multiunit abutments are placed,

and a chairside fixed provisional has been fabricated—what’s really exciting is

at that point is we use our CS 3600 to scan those temporaries both inside and

outside of the mouth. That data is used as our entire workflow map to design the

final restoration. We use the temporaries to capture the bite registration, tooth

contours, and soft-tissue contours.

“Basically, from scanning the fixed temporary, we know the multiunit abutment

position, the patient’s vertical dimension of occlusion (VDO), the smile line,

and the tooth contour,” he continues. “This enables us to talk to the lab with

reference to what they already have, what they have already designed and the

patient already has in their mouth.”

This is what Dr. Clark means by “the linear process.”

“The plans that we made in the initial phases of treatment are now helping us

jumpstart the restorative workflow,” he explains. “This has made the process

faster, go more smoothly, and eliminates redundancy. All of the files go straight

to the lab, and they merge them and work it all up for the final prosthesis,” Dr.

Clark continues.

“And that’s what’s so cool about this system,” Dr. Clark says. “All of those

moving parts are now just one thing—this patient’s temporary. We just scan

it and capture all of the data from one source.” He describes how he had to

capture that data five or six different ways following his old analog workflows and

that by the time he tried to metaphorically line it all up, he was no longer actually

using everything in proper relationship to each other. “That creates a slower

workflow and outcome for the patient as we struggle to build things exactly how

we want them. Now we’re always progressing forward, never taking steps back.”

After two to five months of healing with the temporary in place, the patient

returns and the temporary is scanned again. If necessary, the lab can do a

redesign or just make any minor changes the patient or Dr. Clark might want

in the final restoration. Communication about the likes and dislikes of the

temporaries is paramount to the success of the case.

“I like the patients to visualize the final,” he says. “If the patient doesn’t like the

contour or shape of a couple of teeth, I can make those minor changes in the

final restoration. But if we need to make big changes, I will make those in the

temporary and give it back to the patient to make sure they love it before we

proceed.”

Dr. Clark notes that the DIOnavi company does not charge him for additional

temporaries. In his mind, this enables clinicians to better accommodate patient’s

needs and desires. “Sometimes, in certain cases, I might consider skipping a

step to avoid using the lab again and incurring more costs for the patient and

myself. But with this workflow, I just can scan it, get a new temporary, and make

sure the patient has experienced the exact final product before I actually have it

made.”

Dr. Clark notes that most patients do not object to being in temporaries for

a few weeks or even months because they are such great looking and good

functioning temporaries. “If you need to change the VDO, or change some bite

stuff, you want to give it time to see how the muscles and the jaw are feeling with

that new anatomical position. I want patients to get used to it and make sure

they love it.”

Compared to his previous protocol, if the patient didn’t love it, restoring a

temporary the old-fashioned way would require removing it, taking another

impression of the implants, and using a bite block to reestablish the bite. “You

try to take good impressions of the temporary teeth in place, and then the lab

has to merge four or five different data sets to understand the whole picture. It

just creates unneeded confusion,” Dr. Clark says.

Today, he never actually takes an impression of the implants—it’s all done using

the temporary. In his opinion, using digital instead of analog impressions also

avoids ending up with a new prosthetic provisional that has new problems

“because they’re making a new provisional from scratch. They aren’t referencing

the old data; they’re starting new. I always wished I could just translate all that

preoperative work we did, and there’s a lot of it, to continually move forward. This

workflow allows us to do that. We don’t have to start all over from the beginning.”

What about patient selection?

As in any surgical treatment scenario, the clinician needs to make sure there

is adequate bone volume and quantity, enough restorative space, and decide

whether the treatment plan of full-arch or full-mouth implants is the best course

of action. “There are a lot of different variables,” Dr. Clark says. “The technology

and the digital files really help us analyze all of that data to make sure we’re

doing the right thing.”

Technology helps make predictable outcomes

The technology also makes placing implants more predictable, he explains.

“It ensures that we have a thoughtful treatment plan and a very thoughtful

restorative plan.” Digital technology empowers the clinician to simplify each

step and confirm each process for a complicated procedure like full-mouth

implantology even before starting the surgery.

Dr. Clark points out that the materials he uses for restoring full arches are not

necessarily new, but processes are. Polymethylmethacrylate (PMMA) works

well for long-term temporaries but can be 3D printed now. Final restorations

are fabricated with zirconia instead of porcelain fused to metal, with either pink

porcelain or pink composite resin used for the hybridization of the soft tissues.

It’s all about building experience

Dr. Clark has seen a lot of advances in implant protocol in relatively few years.

“I’m a young dentist but I feel like I’ve had two or three careers worth of this

experience. I mainly do complex full-mouth or full-arch implant cases every day,

all day.

“Plus, I’ve worked closely with our in-house dental lab and got to see how the

lab phase of cases has evolved, which helped me better understand what I was

doing clinically and how it affects the lab phase,” he continues.

Dr. Clark always thought that if he could leverage technology to improve what

he learned in dental school, he could provide a great service to his patients.

“I wanted to embrace a more predictable workflow to augment my own

professional development,” he explains. “I’ve taken that in steps that have

translated into our digital full-arch restorative workflow. I use technology to

make me as good as possible. I’m passionate about giving each patient the best

solutions and options.”

Looking to the future

Digital intraoral scanning, digital X-ray and CBCT technologies, and digital

planning software are able to collect more precise data, provide more accurate

restorations, and perform highly accurate surgery, and increasingly complex

treatments. The added benefit of these technological advances are enabling

clinicians to increase efficiency and lower overhead. Dentists and patients can

use these interactive technologies to communicate with each other better and

make more informed decisions together about proposed treatments. These

advancements have also benefited patients in terms of convenience, reduced

chair time, and cost.

“Technology is always evolving. It is so exciting for dentists as a profession

and for our patients that we are continually improving,” Dr. Clark says. “We are

finding the most optimal ways of serving our patients, and that helps me be

fulfilled as a dentist.”

About the Clinician

Riley Clark received his D.M.D. degree in 2014 from Case Western Reserve

University in Cleveland, Ohio, and attended advanced training in IV sedation

at Duquesne University in Pittsburgh, Pennsylvania. He practices implant-only

dentistry in Heber City, Utah. He is the main lecturer at the WhiteCap Institute, a

dental implant training center founded by his father, P.K. Clark.

Dr. Riley Clark has performed thousands of implant surgeries and advanced

bone grafting procedures. Hundreds of doctors have attended his courses to

learn the latest techniques, protocols, and workflows for implant surgery and

restoration. Dr. Clark also lectures nationally on implant dentistry for various

dental companies and dental societies.

The DIOnavi FullArch implant system

The DIOnavi FullArch system was developed to be used for every stage of a case, including:

-implant treatment planning and design

-fabricating surgical guides

-choosing implants, abutments, cylinders

-creating virtual models

-designing partial and full dentures

According to the DIOnavi website, following their protocol enables clinicians to move from

treatment planning to surgery faster, provide safer treatment, deliver predictable outcomes,

improve patient comfort, reduce chair time, decrease clinician stress, and improve the bottom

line of the practice.

DIOnavi’s centralized planning and designing center relies on unique algorithms combined

with individual patient data to customize a proposed treatment plan that is developed

and compared with a database of thousands of cases to verify best practices and level

of accuracy. This information is also used to design the surgical guide and temporary

crown or multi-tooth prosthesis. Digital scans and other patient data are used to determine

personalized treatment and to ensure implants are precisely placed to provide comfort,

promote healing, and ensure long-term reliability. This data also can be used by clinicians to

make temporaries in the office and place them immediately.

Additionally, according to the website, DIOnavi EcoDigital implant procedures may be

considered when conventional implants and implant surgery techniques have been ruled out

in some cases due to age or health conditions such as high blood pressure, diabetes, or heart

disease.