How the digital revolution is making an impact on implant treatment

November 10, 2017

Advances in dental software and digital materials are leading to a more collaborative workflow.

It’s no secret that digital technologies are taking the dental and lab worlds by storm. The digital transition has led to more efficient workflows, easily accessible patient information and intuitive user interfaces, among other benefits.

Digital Esthetics recently sat down with Dr. Pascal Kunz, vice president of product management digital dentistry at Nobel Biocare, to discuss the digital workflow and its impact on implant treatment.

1. Tell us a little bit about yourself. What’s your role at Nobel Biocare?

Kunz: I am a trained medical doctor and dentist and have worked in both professions clinically. In dentistry, I was treating patients on a daily basis for six years until I was asked to join Nobel Biocare. Listening to our customers on a daily basis and benefiting from understanding their unmet needs is central to everything we do here, so it really helps that I have been in their shoes. Innovating for the benefit of the patient and helping the profession to improve through the benefits of modern technology is what drives me. We are now working very closely with colleagues from other companies in the Danaher Dental Platform to streamline our offerings and connect technologies for the next generation of workflows and equipment.

2. From your perspective, how far into the digital transition has dentistry gone and how much more is there to go?

Kunz: When I was still working as a clinician, there was no doubt that a digital revolution in dentistry would need to come. The question was when would it truly arrive and what the pace of change would be. Today, we are living in the middle of something I would describe as an evolution and transition period. Dentistry is complex in many ways and other industries with fewer regulatory requirements can potentially move faster.

Patient data is more routinely stored, accessed and shared in digital form, and the industry needs to ensure that patient data is handled correctly, respectfully and securely. This is a responsibility that we take extremely seriously at Nobel Biocare. While technology changes, one thing does not - the need for a clear focus on the patient. In addition, user interfaces for digital technology are increasingly intuitive, and we are aiming for more automation at various steps in the treatment flow.

There are many dental professionals who, understandably, are wary of new ways of working and prefer to continue using the processes they were originally trained in. The number of early adopters in dentistry remains relatively small, but those who embrace emerging technologies stand to benefit. Technology should help us to become even better, not force us to leave our traditional education and skills untapped. I think overall the industry leaders have realized that digital dentistry has arrived and are beginning to embrace the change that is happening.

3. Nobel Biocare has recently updated its collaborative workflow. What led you to do this?

Kunz: The changes you refer to allow 3D surface scan information into our NobelClinician software workflows. This means that owners of intraoral scanners can now export STL or PLY files containing tissue information, in color, into NobelClinician. This can then be used with the software’s SmartFusion feature, which fuses CBCT scans with digital impressions, and a new functionality we call SmartSetup, a fully automated tooth setup completing the partially edentulous imported digital arch with a tooth setup proposal. This can be immediately used for prosthetic-driven treatment planning in NobelClinician already at the first patient visit. This immediately helps to classify the complexity of the treatment by supporting assessment of bone and soft tissue at prosthetically important positions and the need for augmentation. It also fosters broader collaboration within referral teams.

At Nobel Biocare, we have long appreciated the benefits of bringing skilled dental technicians into the treatment process at the earliest possible stage. The role of the technician is important in so many dental procedures, but particularly in implant treatment. To achieve a truly esthetic, long-lasting outcome with implant treatment, you have to plan the surgery with the prosthetics in mind. Who better to help you with that than the person who will create the prosthesis?

Our collaborative workflow will allow the dental technician to get involved right from the start of the treatment process so that the restorative solution is taken into consideration already at the implant planning stage.
As a wealth of research shows, Nobel Biocare implants with the proven TiUnite implant surface and specially developed drill protocols are engineered, tested and cleared to enable immediate loading protocols, probably like no other system. The possibility to provide an esthetic, screw-retained provisional helps the clinician to take full advantage of this and meet his or her patient’s desire to leave the dental office with a smile he or she can be proud of.

With our workflow, the treatment team has everything they need to get to the desired outcome as efficiently as possible. What’s more, the provisional then also serves as a useful blueprint when the technician is creating the final restoration.

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4. How do you think software and hardware have improved in the last five years?

Kunz: In traditional workflows, clinicians and labs were quite disconnected. The lab technician was far too often confronted with implant positions that did not adequately take prosthetic requirements into consideration. The lab tools available were largely aimed at ‘bailing out’ such less-than-ideal implant placement instead of preventing mistakes on the clinician’s side in the first place. The latest digital solutions have evolved to become more adaptable, offering greater involvement of the dental technician before decisions on final implant positions are made. The needs of every patient are unique, and today’s workflows are becoming as varied as their needs.

Developments in IT hardware have played an important role too of course, from graphics cards that allow faster, higher quality visualization to networks and equipment for greater connectivity. The NobelClinician software, for example, has evolved to become a scalable solution for the entire practice. Patient information need no longer be accessed from only one clinician’s computer, but instead can be used swiftly and securely from any room in the dental office.

5. Where do you see dental software and hardware going in the next five years?

Kunz: A modular approach will likely be increasingly important. By this I mean a ‘plug and play’ experience with digitizing and treatment devices that not only serve a standalone purpose and work straight out of the box, but that can also be quickly and seamlessly integrated into workflows alongside equipment from other manufacturers.
Further automation and pre-processing of various tasks that are still cumbersome today will become increasingly important. Automation and artificial intelligence will help dental professionals to work in a more structured way and avoid doing the same things twice. As such, I foresee intuitive technology that learns from the user and adapts accordingly will be increasingly in demand. Provided it’s clinically relevant, automation can drive real efficiency gains for dental professionals and patients. But of course, we still believe that skilled humans are a vital part of this setup.

6. How have recent advances in digital materials improved what dental technicians and dentists can do?

Kunz: In terms of materials, the latest line of NobelProcera restorations in full-contour high-translucency multilayered zirconia combine strength with excellent esthetics. The role of digital tools is to help technicians make the most of such materials, not least at the design stage.

For example, the DTX Studio software allows the user to take advantage of the angulated screw channel option for the latest NobelProcera implant-based restorations. This makes it possible to position the screw access hole so that is not located on the facial or incisal edge or in occlusion, while also improving retrievability.

Digital and more traditional methods can also be combined to help achieve the desired esthetic result. With partial cutback tools in the software, the technician can adapt the design of the restoration for the addition of ceramic layering.

7. How has the implant world adapted and changed to the digital workflow?

Kunz: We have certainly seen a very strong uptake of Nobel Biocare digital solutions for dental implant treatment. We are seeing significantly more software installations and more cases planned digitally. The option for guided pilot drilling only has also proved popular, with clinicians understanding the importance of achieving the desired position, depth and angulation of the first drill, but then appreciating the flexibility of a freehand approach.

The importance of fully understanding the clinical situation, including prosthetic requirements, prior to treatment is greatly valued by clinicians. That’s why we are developing solutions like the DTX Studio software to effectively and accurately combine diagnostic information from various sources, with particularly strong connections to devices from KaVo Kerr, which is also part of the Danaher Dental Platform.

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8. Where do you see dental implants improving in the next decade because of technology?

Kunz: From a digital dentistry perspective, further enhancing implant treatment will continue to be about providing greater ease of use and the simplification of processes. We are constantly evaluating ways in which we can reduce or combine steps in the treatment and restorative workflows to reduce time-to-teeth. Again, as Nobel Biocare implants with the TiUnite surface are proven to support immediate loading protocols, we are looking specifically at how we can further help dental professionals meet patient demand for immediate solutions.

Though not a digital topic specifically, potentially the biggest improvement in treatment outcomes lies in dental professionals better understanding the value of using components that are engineered to work together. Restorative components that are not ‘authentic’ or ‘original’ may be lower in price, but even small deviations in fit, not noticeable to the naked eye, can cause serious problems, including implant failure.

9. What other areas of technology does Nobel Biocare see coming that will change dentistry?

Kunz: The role of improved visualization should not be underestimated. Excellent esthetic outcomes have to follow a plan. The good news is that cloud-based software will make it easier than ever before for the whole treatment team, both clinical teams and technicians, to visualize the goal right at the beginning of treatment, even if they are based in different locations.

This collaborative process will be more streamlined than ever before, supported by technology such as the SmartSetup function in the NobelClinician software. This automatically creates a digital wax-up for the teeth identified as missing on the diagnostic scans, supporting an appropriate prosthetic-driven treatment plan.
Importantly, improved visualization of esthetic goals will also evolve patient communication. The possibility to present images of the situation, treatment plan and planned outcome at the first appointment will create the ‘aha’ moments that bring the proposed solution to life for the patient. This is valuable, as it enables a more educated consent to treatment.

10. Is there anything you would like to add?

Kunz: While technologies come and go, the human qualities of a skilled, local dental technician remain invaluable. As I see it, the best way for a laboratory to fend off competition from remote providers is to take greater advantage of the personal service they are able to offer. It’s this that can truly form the basis for long-lasting partnerships. Technology should facilitate this relationship - not replace it.

Dental technicians should not immediately jump on all new technologies either, but assess what are the right tools to help them achieve their goals. At Nobel Biocare that’s our philosophy - we are developing solutions that complement the unique craftsmanship that skilled technicians can offer. They should not feel like they are working in ‘digital’ way, just in the most efficient way for the best possible results. While options exist for other dental professionals to work on the prosthesis, we still believe that a trained dental technician is best placed to develop high-quality prosthetics. When we consider that the implant and the restoration work as one system in the mouth, this is crucial for high-quality treatment outcomes. And above all, it’s in the best interests of the patient.