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The Democratization of Dental Implants for General Dentistry by Howard Katz, DDS

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Introduction

This article will describe other options on how to make guided dental implant surgery an affordable and do-able option in certain implant cases using existing equipment and regular dental X-rays. This will reduce the exposure of the dental personnel and patients to radiation from CT scanners in the dental office, and the financial risk of buying expensive technologies that might seldom be used.

Alternative technologies to CT scans offer dentists and patients an affordable treatment planning option with less brain radiation for many guided dental implant surgery cases. These technologies will reduce risk and costs preventing general dentists from doing implants, and make procedures safer for patients. This will satisfy the huge pent-up demand in the dentist and patient population.

The Problem

Technological improvements have made implants the best option for replacing lost teeth, and a better treatment option than many other dental procedures for compromised teeth. Implants will become the treatment of choice as patients figure out they are much more reliable and the better return on investment than multiple procedures to restore severely compromised teeth. This will impact the profitability of general dental offices that do not provide implants to their patients.

In the U.S., general dentistry faces strong competition from implant centers and corporate dental offices that offer integrated cone beams, oral surgeons, implant specialists, prosthodontists and in-house labs for complete treatment and restorations. These onestop shops have large TV and radio advertising budgets that will lure many patients away from smaller practices that currently have to make multiple referrals to complete an implant case. General dentistry has to find ways to incorporate implants into the menu of treatments they offer, as well as retaining and attracting new patients to expand the implant side of their businesses.

There are technical cost and liability barriers that prevent the average dentist from planning and placing implants. The liability issues relate to damaging vital structures like nerves and nasal sinuses while creating the osteotomy (hole in the bone) or by malpositioning the implants. These barriers are largely overcome with guided surgery or drilling through metal sleeves in pre-fabricated templates targeted specifically at ideal sites for an implant in the patients' jawbones. Dentists believe that these guides are best made by dental laboratories using 3D X-ray data from CT scans. The guides provide and restrict the dentist to the specific site, the ideal angle and the exact depth for the osteotomy drills. This makes osteotomies safer and more accurate for the implants.

Ideally, CT scans should only be used in situations where there is limited amount of bone or there is the potential for sensitive anatomical structures in close proximity to an intended implant site. However, CTs are being used even when they are not absolutely necessary. The CT's popularity has been fuelled in part by misinformation about its necessity, safety and efficacy. Unnecessary CT scans should be avoided wherever possible because the use of ionizing radiation in diagnostic imaging include cancer, burns and other injuries.1,5,6,7,9,10,13 Repeated low doses have a cumulative effect over time.1,2,3,4 Currently dentists can order CT scans at any frequency, with no knowledge of when the patient was last irradiated or how much radiation the patient might have received. Dental offices with CT scans are also seven times more likely to prescribe a CT scan as compared to those offices that do not have a CT scanning machine. In addition, dental personnel may retake numerous CT scans if they are not satisfied with the accuracy and quality of the imagery.

Standards of care should be practical, safe and should not create barriers to access any dental care. This is not always the case with CT scans. The laboratory-made surgical guides made with CT scans have other disadvantages. These include:
  • CT scans are typically too expensive for the average patients and might increase the price of an implant procedure above affordability.
  • There is a poor ROI for a small dental practice. Most small practices do not do enough cases to justify the costs of having a CT scanning device, the software and training staff to use it. This encourages overuse after the investment is made.
  • The scanning devices might require additional office space specially built out to be accommodated and that restrict radiation.
  • Each CT scan may soon require registration and documentation with the state.
  • The slow process to fabricate a guide might be inconvenient to certain patients and dental offices.
  • Certain parts of the country do not have convenient or close access to dental offices or radiology clinics with CT scans.
  • Translating the simulated plan to the patient at the time of surgery might be difficult or inaccurate.
  • Historically one in 10 guides made with CT scans are inaccurate. This makes simulated virtual implant placement sometimes unreliable and not absolutely trustworthy.14
  • The dentist does not always have the option to select the best site to position the implant for ideal function, aesthetics and easy restoration.

Just because a technology is new and costs more does not guarantee better treatment outcomes. There is a need for alternative diagnostic and treatment planning options for guided implant surgery.

The Solution

The ideal implant guide fabrication system for the dental office should be affordable and not place the practice under significant financial burden, especially when implant cases are few and far between. The diagnostic X-rays should not harm patients in any way. All sensitive anatomical structures - like nasal sinuses, nerves and perforations out the side of the bone - should be easily and intentionally avoided. The system should enable the dentist or dental assistant to fabricate an accurate, stable guide in a few minutes for both open sockets and previously healed sites. The accuracy of the guide should also be easily verifiable.

The system should be versatile to accommodate a large range of implant drill diameters.

The completed surgical guide should rest against the remaining teeth or be supported by gum tissue. The material used to fabricate the guide should be rigid and stable to prevent distortion like warping or shrinkage. These cause the drill to become inaccurate or that will prevent the stent from seating. The sleeves in the guides that the drill passes through should be made of hardened metal to prevent shavings going into the bone while the osteotomy is being prepared. These sleeves should be compatible with a variety of reduction inserts so that they can accommodate a range of different drill diameters. The drills and the reduction sleeves should fit snugly through the implant guide sleeves.

There are few systems that offer all of the desired features. Safegide, a California-based company, offers technology that works with a regular dental X-ray machine to make incredibly accurate implant drilling templates. Its technology comprises of a range of plastic inserts and metal sleeves that can be used to measure the available bone, and then preset the ideal drill angles and depth for the implants. The kit comes with a single tool used to center multiple drill diameter sizes through a common-sized metal drill guide sleeve.

There is usually some bone loss after healing. The Safegide System also includes a verification system that enables the dentist to check the accuracy of the guide as well as the available bone height before any drills are used. X-rays are taken of pre-sized guide points that have been pushed through metal sleeves above the intended implant site.

A range of different shaped radio-opaque inserts and daisy elastics are available. These are used to pick up socket location and directions, and to measure bone height. Daisy elastics center the posts in the socket (Fig. 1). Each insert has four sections (Fig. 2). These four sections are:
  • A measuring guidepost calibrated in 3mm increments used as a reference to calculate bone height. The post is always reduced in length shorter than the socket. A daisy or doughnut elastic centers the reference post in a socket.
  • A platform to stop the metal sleeve sliding onto the post.
  • A sleeve guide to hold and aim the metal sleeve bore in exact direction of the desired osteotomy. The selection of sleeve guide orientation may be determined either by direction vision, peri-apical X-rays or a CT scan. A metal sleeve that fits snug, but not too tight, is on the sleeve guide section of the insert that does not go into the socket. This metal sleeve is bonded on to a premade splint.
  • The handle with directional indicia. These show lingual or facial orientation on an X-ray.


Daisy elastics are fitted onto the reference post end of the insert to center the posts in the sockets (Fig. 3). An angled insert with a metal sleeve and daisy elastic are used to angle the implant drill into the lingual wall of the socket (Fig. 4). Inserts are selected based on directing the implant drills into the ideal locations in available bone (Fig. 5). The insert with the metal sleeve attached is inserted into the molar palatal root socket through the space in the pre-made jig (Fig. 6). The metal sleeve on the insert is bonded onto the pre-made jig (Fig. 7). The metal sleeve aims the drill in the desired direction through the lingual wall (Fig. 8). Verification points are used to verify on X-ray the intended direction of the osteotomy drills and to recalculate bone height after socket healing (Fig. 9). A parallel guide insert is used to fabricate a drill guide for use in a lower molar socket.

Guides made with the kit do not replace or improve the outcome of implant surgery guides made with data from a CT scan. The system should not be used without experience in implant placement and is more effective with a CT scan. The advantage of the system is that surgical guides may be assembled in minutes in the dental office compared with weeks in outside dental labs. The shortcoming of the system is that it ideally should not be used without a CT scan in sites where there is less than 2mm of bone surrounding the intended implant site, or where there is the potential for an anatomical accident.

Innovations in dental implantology will continue to make implants safer, easier and with more predictable outcomes for the general dentist. Dental offices that do not embrace providing implant procedures might struggle to remain profitable. CT scans will always be an essential part of implantology but are not always necessary.

References
  1. Amis, Jr. ES, et al: American College of Radiology white paper on radiation dose in medicine. Journal of the American College of Radiology, 2007;4:272-284
  2. Holmberg O, et al: Current issues and actions in radiation protection of patients. European Journal of Radiology, 2010, doi:10.1016/j.efrad.2010.06.033
  3. Smith-Bindman R, et al: Radiation dose associated with common computed tomography examinations and the associated lifetime attributable risk of cancer. Archives of Internal Medicine, 2009;169(22):2078-2086
  4. ECRI Institute: CT radiation dose, Health Devices, April 2010;110-125
  5. Koenig TR, et al: Radiation injury to the skin caused by fluoroscopic procedures: lessons on radiation management. Annual Meeting of the Radiological Society of America, 2000, http://www.uth.tmc.edu/radiology/ exhibits/koenig_wagner/index.html (accessed Nov. 15, 2010)
  6. Koenig TR, et al: Skin injuries from fluoroscopically guided procedures. American Journal of Roentgenology, 2001;177:3-11, http://www.ajronline.org/cgi/content/full/177/1/3 (accessed Nov. 15, 2010)
  7. U.S. Food and Drug Administration, White Paper: Initiative to reduce unnecessary radiation exposure for medical imaging, February 16, 2010, http://www.fda.gov/Radiation-EmittingProducts/RadiationSafety/ RadiationDoseReduction/ucm199904.htm (accessed November 9, 2010)
  8. National Council on Radiation Protection and Measurements: Ionizing radiation exposure of the population of the United States (2009). NCRP Report No. 160, Bethesda, Md., 142-146
  9. Berrington de Gonzales A, et al: Projected cancer risks from computed tomographic scans performed in the United States in 2007. Archives of Internal Medicine, 2009;169:2071-2077
  10. Radiological Society of North America: Exposure to ionizing radiation and estimate of secondary cancers in the era of high speed CT scanning. Presentation to 96th Scientific Assembly and Annual Meeting, December 1, 2010, http://rsna2010.rsna.org/program/event_display.cfm?em_id=9004767 (accessed February 28, 2011)
  11. Firestine, K: CT dose reduction in pediatric patients. Radiology Management, March/April 2011
  12. Diagnostic ionizing radiation and pregnancy. Is there a concern? Pennsylvania Patient Safety Advisory, March 2008;5(1):3-15
  13. FDA unveils initiative to reduce unnecessary radiation exposure from medical imaging. FDA news release, February 9, 2010, http://www.fda.gov/newsevents/newsroom/pressannouncements/ucm200085.htm?sms_ ss=email (accessed Nov. 15, 2010)
  14. Sonick, Michael, ”A Comparison of the Accuracy of Periapical, Panoramic, and Computed Tomographic Radiographs in Locating the Mandibular Canal.“ JOMI, 1994:9:455-460.
Author's Bio
Dr. Howard Katz is a general and cosmetic dentist. He is the president, founder and lead instructor for Dentox, the teaching body that brought Botox and dermal fillers into dentistry. Dr. Katz is also the inventor of Oraverse dental anesthetic reversal agent, the Safegide implant guidance systems, the uses of sugar alcohols (xylitol and sorbitol) in dental products and Fulcrum electronic exodontia devices. He can be reached at hkatz4@hotmail.com and at www.safegide.com.
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