Making it your own

The global dental implant market is currently worth $3.2 billion and expected to be worth an additional billion dollars in the next 5 years, with 31 percent of the revenue in North America, according to a report¹ recently released by market research firm Markets and Markets (marketsandmarkets.com).

The report cites the functional and esthetic efficacy of implants, along with growing patient awareness and the continuing growth of CAD/CAM in the implant arena as key factors spurring the growth. And while the expected additional revenues will be spread throughout the dental industry, many laboratories and dental manufacturers are lining up behind CAD/CAM as a way to capture as much of that growing revenue as possible.

Keeping up with the growth

As the owner of Precision Craft Dental Laboratory in Smithfield, R.I., Richard Napolitano, CDT, has seen the growth of the implant market for the past 30 years, and said in just the last 10 years he’s seen his implant business jump by about 30 percent. It’s a trend he expects to continue due to both the factors cited in the M & M report and the fact that recent dental school grads are receiving more training in implants than previous generations of dental students, leading to an influx of clinicians interested in providing implants.

But whatever the cause of the growth in the implant marketplace, Napolitano believes the efficiencies of CAD/CAM production will be the key to Precision Craft capturing its share of that new business.

At his lab, the CAD/CAM solution comes by working in partnership with BIOMET 3i and the company’s CAD software and third-party collaborations. Using the technology has allowed him to offer implant restorations with custom-designed abutments at about two-thirds of the cost of using more traditional fabrication techniques for the same restoration. Additionally, he can offer zirconia copings and frameworks for both implant abutment and natural tooth restorations with the 3i incise CAD software with Renishaw Scanner.

“We’re finding that there’s a decrease in price and time. That’s really sparking the interest in a lot of dentists,” he said. “Everything’s being driven down by these CAM designs. You still have control over the design, but you’re not spending the man hours or the money on the materials that will inflate the price.”

These same efficiencies are being embraced by many parts of the industry, with a variety of companies continuing to expand and refine their CAD/CAM offerings and how their systems work with products from other companies.

For Straumann USA this means bringing all of the company’s digital offerings under the new CARES® (Computer Aided REstorative Solutions) brand, which includes new software, a new scanner, a partnership with Cadent for accepting intraoral scan data from its iTero system and expanded uses of the system including lab-fabricated stents for guided surgery procedures. Straumann USA CEO Martin Dymek said the expanding technologies will help make implants an even more common dental option because they lead to better patient outcomes.

“Technology continues to enhance the predictability and expand the range that implants can be used in,” he said. “In many cases, we’re actually looking at a far more precise, more accurate restoration, which certainly saves time for the patient.”

This expansion of CAD/CAM in the implant realm is also something being embraced by 3M ESPE, where the company continues to expand the capabilities of its selectively open Lava™ Network with abutment design and milling capabilities. Lava Design System Brand Manager Roger Dawson, CDT, said he expects to see only more and more use of digital production techniques, and he believes the bulk of the dental lab industry will take advantage of the technology as it continues to prove itself in the marketplace.

“The technician, I think, is always looking for ways to get better, always looking for ways to be on top, and always looking for ways that they can streamline their processes,” he said.

“The problem we’ve got in laboratories is that we always look at everything that comes along with a little bit of a squinted eye. We love to try new technologies that work, but we’ve been burned by a lot of technologies that didn’t work. We always look at it with a little bit of doubt because we’re concerned that it could be a failure. And we don’t have time for failures.”

Greater control, better results

But while Dawson said he respects the level of skepticism many in the industry bring to new products and new techniques, CAD/CAM and digital workflows should no longer be viewed as something new, but rather as something standard. By adopting the digital workflow, technicians can realize a range of efficiencies in costs and labor, but doing so involves trusting the new techniques and being ready to work in a different way.

Dawson said a major advantage in the latest generation of Lava Design Software is the capability to scan an interface from virtually any implant system and design a custom abutment that can be milled out of Lava Zirconia to fit that implant.

When combined with the company’s Lava DVS (Digital Veneering System), which creates a zirconia coping with a glass ceramic outer layer from the same digital design, Dawson said the system is capable of creating a complete implant solution while skipping a number of labor-intensive steps from more traditional workflows.

“With a virtual design in our system, now I don’t have to wax up, I don’t have to do anything other than scan the interface and then virtually design an abutment top,” he said. “Now it is possible to create an abutment, a coping and DVS top without even having a model. The reports I get from my technicians is they feel it makes them more efficient, and it gives them more design ability and design control.”

Control is the operative word for Napolitano and his lab. Part of the decision to implement the 3i incise system was the ability to bring zirconia production in-house via the Renishaw Dental Milling Machine. Thus far, the results have been impressive to him and the clinicians he works with as they’re seeing improved frictional retention and marginal adaptation from the in-house-produced zirconia copings.

“Predictability is very important to us as far as consistency in the products. If I have variable fits or variable margins, I’m going to be in trouble with my doctors,” he said. “We’re finding our clinicians are accepting it whole-heartedly. They’re seeing a major difference in the fit of our copings.”

Precision Craft COO Ryan Napolitano attributes the improved fit from the 3i incise system to a handful of factors including the ability to set a customized cement gap during the digital design and software options for designing copings for use with implant abutments, which tend to have a parallelism not found in crown preps for non-implant cases. These design efficiencies are bolstered by the milling fabrication that takes advantage of both computer-guided precision and the inherent strength of creating restorations from a monolithic block of material.

“The technicians are very excited over this, because they’re able to apply what they’re trained for without the casting and manufacturing inaccuracies that we’ve had in the past. With the CAD/CAM designed structures, there’s the predictability and consistency,” he said. “It’s in the labs’ best interest to try to utilize CAD/CAM to automate as many processes as they can, and thereby get a consistent result at a more cost-effective price.”

Individualizing abutments

In the world of implants, this really comes into play with the growing options for creating patient-specific abutments that take advantage of the patient’s individual anatomy at the implant site to enhance the esthetics of the final restoration.

Richard Napolitano said he’s experienced an increase in requests for custom abutments for his implant cases, but he also tries to push dentists to go in that direction because of the benefits custom abutments offer to the lab, the dentist and especially the patient.

“We’re finding that the results of custom abutments allow us to do a more esthetic and functional case for a considerably cheaper price,” he said.

Ryan Napolitano said he believes that just like the steady move toward increased CAD/CAM use, the industry also  will shift to the point where milled custom abutments are the norm for implant cases because they offer better results for the patient and lower costs for labs that do not need to stock as many materials or supplies because of the more efficient digital workflow.

Astra Tech’s Atlantis (astratechdental.us), Nobel Biocare’s NobelProcera (nobelbiocare.com) and BIOMET 3i’s Encode® custom abutment services have made CAD/CAM-produced abutments available to labs with all levels of digital integration. The model of smaller labs working with outsource partners and milling centers for part or all of the digital workflow certainly seems like it will be a viable option for smaller labs looking to add CAD/CAM services to their product offerings.

While Dawson said he doesn’t believe stock abutments will completely disappear, he believes the enhanced esthetics and improved function that can be realized through the use of custom abutments will drive the increase in demand for them from dentists. Having local control of design and production, such as that offered through 3M ESPE’s Lava Network, offers dental labs a huge advantage when providing dentists with custom abutments for their implant cases, he added.

“With what we’ve got now, the technician has to send nothing out and has complete control of design and doesn’t have to change abutment construction when it gets back to them,” Dawson said. “They have complete control of when they get their abutments back and when they can create their crowns and their full contour tops.”

Dymek and Straumann also are strong believers in the benefits of custom abutments and the CARES system provides a workflow for efficient design and fabrication. That workflow puts the lab technician’s focus on the digital design process with Straumann serving as a partner for the fabrication.

When cases begin from an iTero intraoral scan, they allow the lab technician to begin the design the instant the data file is received. And with the final production handled by Straumann’s industrial scale milling center, that technician can move on to working on another case while that process is underway.

“We’ve engineered this from start to finish. This is an entire seamless connectivity within one workflow. This has all been designed to work well together,” Dymek said. “We feel the best way to ensure a robust restoration as well as for maximum accuracy is a ­central milling model where industrial strength mills and processes can be utilized.”

New connections

But while centralized, industrial-scale milling is Straumann’s model for implant parts and abutments, Dymek said the CARES system sets up local labs for closer connections to their dentist partners by giving labs the capability of designing and fabricating surgical stents for use in Straumann’s guided surgery workflow.

This brings the lab into the case from the very beginning of the treatment planning, but Dymek said if labs are not engaged at that point of the case, the CARES system provides a new access point by allowing surgeons with iTero units to send intraoral scans of the implant site immediately after surgery, giving the technician a chance to get a jumpstart on designing the restoration. This is designed to improve communication between everyone involved with the case and maximizes use of digital patient information.

“Once the [physical] impression is sent to the lab, the surgeon has no way of evaluating the quality of the impression. Whereas once we have that digitized the opportunity exists for the surgeon, the restoring dentist and the lab have the ability to look at that data together,” Dymek said. “This creates a unique digital relationship between a surgeon and a laboratory, which is certainly not a relationship that exists with great frequency today. They certainly can streamline the ordering and treatment planning of that site, by being engaged at the time of surgery.”

Being engaged with an implant case prior to surgery is often a major benefit to everyone, Ryan Napolitano said while noting that sometimes it can be a challenge to convince dentists of these benefits. Still, a skilled technician working on a case-whether digitally or via more traditional techniques-prior to surgery is able to apply his or her knowledge of dental mechanics and skill at anatomical design to help the case have the best chance for exceptional function and esthetics.

Grasping efficiencies

In all aspects of the implant cases, Ryan Napolitano said Precision Craft is benefiting from adopting the BIOMET 3i Encode® and 3i incise CAD/CAM system. Bringing more of the production processes in-house has proved to bring in not only a greater degree of control but also a decrease in production time and a reduction of costs per unit to the lab. This has allowed them to provide dentists with higher-quality work in less time and at a lower price.

“We like the fact that we can control the flow of work much more accurately,” he said. “You’re turning out a quality product faster, and it’s able to be delivered in a shorter period of time.”

Dawson also strongly believes there is no turning back from the digital technology making ever-deeper inroads in the dental lab industry. It is a competitive business, and anything that makes a lab more efficient needs to be considered, especially if it simultaneously improves quality.

With 35 years of experience as a ceramist in his background, Dawson said he understands the way lab technicians and owners approach new developments and next big things cautiously. However, he believes the jury is no longer out on CAD/CAM technologies, and when it comes to complex implant cases CAD/CAM offers immense benefits to lab owners and technicians as well as efficiencies and improvements that can help them stay ahead.

“As a lab owner I want my work to look better than the guy’s down the street with the same amount of effort or less. I want it to look better without having to work harder to get it. That gets me more work,” Dawson said. “I don’t have to hide my head in the sand. What I need to do is grab a hold of this technology and ride with it.” 

Editors note: Richard and Ryan Napolitano are paid consultants for BIOMET 3i.

References

1. “MarketsandMarkets: Global Dental Implants Market worth US$4.2 Billion by 2015” http://www.marketsandmarkets.com/PressReleases/Dental-Implants.asp. Accessed Oct. 5, 2010.