Why Has Dentistry Resisted the Widespread Adoption of Computer-Assisted Implant Surgery?

-  Dr. Orentlicher

Any new, innovative unfamiliar treatment workflow, material, software, instrumentation, or equipment requires effort to master. Most advancements "tweak" or improve the efficiency or outcome of an existing technique or procedure. Rarely is an innovation introduced in dentistry that comprehensively "disrupts" the way things have been done traditionally. However, it seems that in the past decade or so these disruptors have manifested more frequently. Examples include cone-beam computed tomography (CBCT), digital orthodontic aligners, intraoral scanning, and digital planning and milling of provisional and definitive restorations, just to name some. More than 15 years ago, when CT guided implant surgery was introduced, it was a complete unknown to the dental implant community. This technology represented a very different way of planning and placing a dental implant, demanding that clinicians acquire new knowledge and skills. It became a complete disruptor of the norm, restoratively and surgically.

So here in 2020, why isn't computer-assisted implant surgery more predominant? The answer may simply boil down to time, money, and fear.

Time. It takes additional time for the doctor to make impressions (digital or conventional) and work-up the planned restoration position(s) with a diagnostic wax-up or digital image of the planned implant prosthetics. If indicated, time is also required to fabricate a radiographic template for the patient to wear while having a CT/CBCT scan, order or take said scan, import the CT/CBCT data into software, plan the case "virtually," order or mill the surgical guide, and learn the techniques and equipment needed to place implants through a surgical guide. Training courses typically are necessary.

Money. The patient incurs added costs for the laboratory work to fabricate the radiographic scan prosthesis (if necessary), the CT/CBCT scan, and the fabrication of the surgical guide. For the doctor, it means additional costs for training and learning new technologies, possibly upgrading computer hardware, and purchasing new software programs and armamentaria/equipment.

Fear. Fear of the unknown can be very real. The doctor will have to learn new, unfamiliar technologies and techniques that can have complicated multiple-step workflows that may be difficult to integrate into practice. Doctors may fear that they will "lose the case" if additional costs are presented to the patient and added onto an already expensive treatment plan. Doctors may feel that since they have been successfully treatment planning and placing implants one way (non-"virtually") for many years, why do it another way?

Patients' biggest fears and questions usually relate to pain, swelling, and recuperation time. Many guided surgery software products have embedded tools that can help clinicians educate patients about "virtual" technologies in a visual manner during consultation. Showing patients the software, describing the benefits of the potentially minimally invasive flapless techniques inherent in the treatment, and discussing the possibility of placing immediate provisional restorations often allays patients' concerns.

My practice integrated CT guided dental implant surgery, using static guides, more than 20 years ago. After much trial and error and learning, I have consistently seen excellence in implant placement and surgical and restorative outcomes with these technologies. Whether using static guides, navigation, or robotic surgery, these are all "guided" techniques. Yes, a steep learning curve is involved, and sustained success requires clinicians to expend time and money and overcome their apprehensions. But when the day comes when I need a dental implant, I definitely want it placed guided.

Guided surgery for dental implant planning and placement has evolved to encompass other types of surgical intervention, including static and dynamic navigation. Many of the objections, difficulties, and barriers of the past have been largely overcome, while others still exist and some new challenges have materialized. The foundation of computer-assisted implant workflows and surgery is the ability to obtain proper records and integrate those records into a plan that can be executed based on patient need and the clinical scenario.

All planning must incorporate 3-dimensional (3D) data representing the patient's individual anatomy. The need for CT became evident in the early 1980s. Barriers to its use were limited availability, cost, and potential radiation exposure. At the time, chest x-ray-sized film needed to be visualized on large light boxes. In the early 1990s computer software applications became available to interact with CT scan data sets to allow visualization on a computer screen. The development of in-office CBCT helped to mitigate those initial barriers. CBCT brought 3D imaging and improved software capabilities within the reach of many clinicians.

The next issue facing clinicians was the learning curve associated with reading 3D scans to diagnose and treatment plan. While oral and maxillofacial surgeons were familiar with reading CT scans due to their in-hospital training, dental schools lagged behind, leaving third parties to aid in this educational process.

There are three categories of guided implant surgery: diagnostic-freehand, template-assisted, and full-template guidance (Ganz-Rinaldi Classification). In diagnostic-freehand, the clinician has a CBCT scan and uses either the embedded software or a third-party software to assess anatomy, potential implant site(s), and measurements. This information is then applied to place implants in a freehand surgical manner. Template-assisted provides for a physical static guide or a virtual template used with dynamic navigation to aid during osteotomy preparation followed by freehand implant placement. Full-template guidance requires the use of an implant-specific surgical drill kit, which provides depth and angulation control, and an implant-specific carrier to deliver the implant throughthe template. Control of the rotational position of the implant-abutment connection is also possible with this approach.

The planning steps for a single-tooth, multiple-unit, or complete-arch restoration are essentially the same when considering that the ultimate goal is the tooth. The clinician needs to understand how to assess patient anatomy using software applications in order to proceed with each case. Inherent problems with any guided surgical approach lie first in the clinician's ability to obtain accurate records. A restoratively driven treatment plan must be designed and planned to attain the desired outcome. Digitizing the oral environment, whether through intraoral scanning or impression/study cast scanning with a desktop scanner, is necessary and may require coordination with a dental laboratory.

There are several reasons for clinician resistance to guided implant surgery. It is easy to examine a 2D periapical x-ray and believe that an implant can be placed freehand based on historical surgical and restorative training acquired in dental school. It also takes time to collect the required information, do the planning, and learn to use the software applications. Excellent communication with the dental laboratory or service provider is essential. The added cost for surgical template fabrication, dynamic navigation equipment, and instrumentation is also a factor. Fortunately, there is now a universal language to better accommodate the digital workflow. With continued system improvements, more clinicians will no doubt increasingly implement accurate and consistent protocols to enhance treatment outcomes by using these technologies.

In my observation over 24 years of practice, the adoption of technology typically goes through three stages: (1) skepticism (theoretical state); (2) acceptance as truth but largely deemed unnecessary and is marginalized (metaphysical state); (3) finally, acceptance as truth and considered transformational (positivistic state). Often, the earliest and harshest critics come to embrace the technology and may even claim to be experts in its use.

Generally speaking, with anything new, first there is knowledge, then persuasion, which leads to decision making (a critical juncture where one either adopts or rejects the idea), implementation, and, lastly, confirmation. Concomitantly, there are innovators, early adopters, early majority users, late majority users, and laggards.

With regard to computer-guided implant surgery, although the literature clearly shows improved accuracy over freehand surgery, in reality its market penetration has much room for improvement. On a global scale, the surface has been barely scratched. Further, let's consider a parallel problem in dentistry that is facing these same struggles in the early adoption phase-the utilization of CBCT imaging technology and tooth movement planning/simulation software for orthodontia. At a time when aligner therapy is growing exponentially and do-it-yourself orthodontic business solutions are gaining market share, one might think that holding orthodontic therapy to a higher standard through orthodontic specialists would permeate the profession, but it doesn't. Why is the standard of care for moving teeth in 2020 still a 2D radiographic image? Dental crowns move nicely on a computer screen using digital intraoral scanning technology, but what about the actual roots of the teeth and, more importantly, the dentoalveolar bone complex? How does this outcome relate to optimal coupling of teeth in a fully seated condylar position? What happens to the periodontal foundation when tooth movement is undertaken? Certainly no one would accept a diagnosis of hypertension from a physician if only the systolic blood pressure reading was measured, from which antihypertensive medication was prescribed. So why are dentists developing treatment plans with only half of the pertinent information?

In reality, without the use of CBCT digital imaging and communications in medicine (DICOM) data and orthodontic tooth movement simulation technology, clinicians cannot fully understand the impact of such tooth movements on the periodontium and dentoalveolar bone complex and are, at best, making educated guesses.

For many clinicians who are running a business in a private practice setting, the use of technology can be cost prohibitive. This is, in turn, helping drive the formation of dental service organizations (DSOs) and group practices where multiple doctors can benefit from the same technology and reduce the cost per doctor. Additionally, it takes time for an operator to become proficient using the technology, and until proficiency is gained, value will not be realized. Many users may be likely to retreat to their old, comfortable ways.

Digital technology can be an exciting part of patient care in dentistry. However, dental providers must resist "digital intoxication" and remain steadfast by using technology with a biologic compass and periodontal conscience. An interdisciplinary, team approach with transparency and collaboration is crucial.

Dr. Orentlicher periodically receives speaking honoraria from Nobel Biocare.

Gary Orentlicher, DMD
Section Chief, Division of Oral and Maxillofacial Surgery, White Plains Hospital, White Plains, New York; Section Editor,
Oral and Maxillofacial Surgery,Compendium; Private Practice specializing in Oral, Maxillofacial, and Implant Surgery,
Scarsdale, New York

Scott D. Ganz, DMD
Adjunct Assistant Professor, Department of Restorative Dentistry, Rutgers School of
Dental Medicine, Newark, New Jersey; Private Practice, specializing in Maxillofacial Prosthetics and Implant Dentistry,
Fort Lee, New Jersey

George A. Mandelaris, DDS, MS
Adjunct Clinical Assistant Professor, University of Illinois, College of Dentistry, Department of Graduate Periodontics, Chicago, Illinois; Private Practice specializing in Periodontics and Dental Implant Surgery, Chicago, Illinois