Planning Software For Implant Dentistry And Surgical Guides

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Anyone with experience using planning software for implant surgeries and guide fabrication? I am looking at 360dps planning software but am not up on comparison to other software or if I want to do guided surgeries.
Thanks,

Mark

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Mark,

Scott Ganz is the expert in software, and would give a good basis for comparison. He is a prosthodontist in New Jersey.

I personally use Nobel’s software even though I don’t use Nobel implants. I did when I bought the software. Nobel’s software is made only for Nobel implants so if you want to prepare completely through the surgical guide, you can’t unless you’re using a Nobel implant. That being said, I’m happy using the surgical guide for pilot holes and perhaps one additional diameter, then removing the guide and completing the remainder free handed.

If you are doing large cases or want to do large cases, the software, any software, is invaluable. It saves surgical time, and the accuracy, while not perfect, is quite good.

Mike Pikos has done some fantastic work using Simplant, and perhaps he can comment on the work that he has done.

The software is definitely a clinical enhancer, will help you plan cases around barriers such as sinuses and nerves. I couldn’t get along without it.

Lee

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I’ve used Simplant routinely, and I mean routinely, for the past 14 years. I simply can’t comprehend how anybody would even think of placing implants without 3D imaging and planning software. There, I’m now off my soapbox. I can speak highly of Simplant, but the reality is that I have absolutely no experience with any other planning software so I have no basis of comparison. For anybody getting involved with 3D imaging or even for those with experience who just want to learn more, I’d definitely recommend Mike Pikos’ course. He and his faculty member, Alvaro Ordonez, give a superb 2 1/2 days on the topic. But I guess I’m somewhat partial to the Pikos Implant Institute!

Lloyd

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Thanks Lee,

When using the guides, are you performing flapless surgery?
Are there issues in the posterior with limited vertical access?
Is there an added fee for the guide?
Thanks,

Mark

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Thanks Lloyd,

Same questions I emailed to Lee.

Mark

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Lots of advantages in using guides for lots of reasons. Biggest one is you don’t have to make significant decisions intraoperatively as you can sit at your desk and do a case virtually instead. Flap vs. flapless is a different story and depends on whether or not you have to do any site modification in conjunction with implant surgery. Tardieu and Rosenfeld published a good Quintessence book (2009) on guided surgery that is predominantly focused on Simplant. Personally, I prefer Anatomage for simplicity and quick learning curve as well as value. Also have Nobel Clinician (not my favorite right now) and co-Diagnostix which I have not really worked with yet. No idea how 360dps compares.

Overall, I feel that having guided surgery is an essential option for implant surgeons, particularly if you want to represent that you are a specialist. That said, it doesn’t need to be used for all cases, only selected ones.

Jeff

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Jeff,

Codiagnostix with the Goybx guide makes alot of sense. The scanning appliance becomes your surgical guide. Hopefully, we will have it at NYU soon to tryit. If not we may work a study through one of the laboratories next year.

Dominic

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Thanks Jeff.

Good article.

Mark

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Hi Mark,

The biggest consideration is the soft tissue, as you know. Therefore, on the upper, I will do a transmucosal preparation using the pilot drill. If I suspect that it will be going through mucosa, I’ll then remove the guide, flap, and move the palatal tissue buccally, and complete the implant prep. If the keratinized gingiva is adequate, then I’ll do the procedure flapless.

The guide’s cost is I believe about $700. And yes, I do charge additionally for the guide.

There are problems at times with limited access. In those cases, I can usually get a shorter drill in and at least start the osteotomy and get the correct angulation. I’ll then remove the guide and complete the preparation.

Lee

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Being that I’m 3 hours behind most of you, it seems like Lee and Jeff did a wonderful job answering the questions before I was even awake. With flapless vs. flap, it’s a pretty simple algorithm in my mind. First, is bone grafting needed? If yes, have to flap. If no, PERHAPS flapless. If no bone grafting needed, is there enough gingiva? (I’m not a fan of mucosal margins, especially around implants). If enough gingiva, flapless. If not enough, do as Lee said. Make incision way to the palatal/lingual and position the gingiva to the facial. I determine the need for bone grafting from the CT scan. I determine the amount/lack of gingiva intraoperatively.

Hope you all had a fantastic holiday weekend,

Lloyd

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Jeff,

I assume the surgeon determines the implant position and the software merely facilitates the fabrication of a surgical guide. Is that the case?
If so, what parameters do you use to determine implant position when dealing with grafted sites.

Chuck

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Chuck,

The chief advantage of using planning software is that it promotes collaborative planning. Implant position is “negotiated” between surgeon, restorative dentist and lab depending on needs of the case. Sometimes surgeon wins, sometimes restorative dentist wins, sometimes everyone compromises. The benefit of using planning software is that the conversation can occur before the surgical procedure with a maximum amount of information.

If the surgeon is worried about grafted bone, then he/she makes a point to insure that appropriate consideration is given to the graft which could mean different angulation, bigger size, etc.

Jeff

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Good info Lloyd.

But you are not 3 hrs behind, you are a week behind. The holiday was last weekend.

Mark

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Thanks again Lee.

The contact person for 360dps told me guides were as little as 150.00 for single tooth, then 100.00/additional tooth and with a quick turn around.

Mark

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Jeff,

That makes sense.

As part of your process, do you utilize a pre graft scan and a post graft scan to delineate between grafted and non grafted bone / or graft at the time of implant placement, thus knowing you have primary stabilization in non grafted bone.
How much do you rely on grafted bone to support your implant?

Chuck

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I’m still living in the moment. Some things are just too good to let go of!

Lloyd

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Has anyone had a patient express discomfort with the radiation of a CAT scan? In light of the report published recently linking dental radiographs with head tumors I am wondering if patients will start to express concern. I think most dental x-rays deliver negligible radiation, but a CAT is different.

Thoughts?

Jim

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I have had minimal concerns raised. I would be reluctant in the majority of cases to place an implant w/o one.

Mark

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I assume you mean CBCT rather than medical CT? Obviously a huge exposure difference.

Patients don’t like radiation, but they like surgical complications even less. If they are informed that a CBCT provides more complete information for planning and visualization of landmarks and vital structures, then they generally accept the tradeoff.

I bet you don’t watch a black and white tv and that you do carry a cell phone.

Jeff

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Jeffrey,

As always, points are well taken, this tradeoff is well documented in my office between pre CBCT and post CBCT, completeness and the WOW factor is the experience with the 3D visualization that sets you aside from the guy down the street.

Gail

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Dear Group,

1. ICOI just came out with Consensus Report on use of CBCT in implant dentistry. See Implant Dentistry, Vol 21, No 2, April 2012. For those doing significant implant dentistry, I highly suggest you read it. I concur with their consensus.

2. A malpractice case in St. Louis recently was settled against the implant placing dentist because of the lack of diagnostic radiographs for the exam and treatment planning as well as the execution of the treatment plan. All of the implants failed in a maxilla that was sinus grafted with the aid of a panorex. The patient subsequently went to a second provider that successfully treated the case with the aid of CBCT and appropriate treatment planning. I was the expert witness for the insurance company representing the dentist.
The standard of care as stated by me would have been to have taken a CBCT in this case as the second treating team did which was consistent with the ICOI guidelines. There will be other cases but I was personal involved in this one. We all can have a bad result–you can’t have bad diagnostics. Now that ICOI and soon the ADA are finally getting into the mix, I couldn’t be happier. I hope AO and JOMI comes out with same policies or endorses the ICOI statement. PS– I would be happy to be on the AO committee to come out the the AO consensus.

3. If you buy a CBCT it comes with more responsibility and more costs–get ready for it. Be professional and get trained.

4. You will have to have software and now how to use it. For me, it is NobelClinician, Anatomage Invivo, and ICAT Vision. I use all three plus digital photographs on every implant case with Powerpoint. My staff is trained and gets most everything set up and I finalize it. I use primarily soft tissue supported guides but have used bone supported as well. We use them on difficult single tooth cases, some partial, and most full edentulous cases. Go to DentalXP and you can see my take on this with All On Four cases. I will also be presenting in Florida for Nobel then end of the month in Boca and will be presenting on this at the Dental XP World conference in Las Vegas–thanks to Maurice and David.

5. If you agree with me-great–if you dont’ get ready because many of us who have been doing this for years have seen the consequences of not doing it–pain, suffering, and heartache both for the patient and the dentist who thought they knew enough with 2D.

6. As one of the leaders and a friend in this discussion said to me in a meeting at the AAP–“the era of surgical voyeurism is over”–I could not agree more. It was over for me 7 years ago when I got my ICAT in my office. But prior to that I was using medical CT and software. This is 2012 not 1979 when I graduating from dental school-this is where we should be for the patients, referrals, and the profession at large.

Have a nice day.

George

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Amen

Mark

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George,

I agree completely. Especially the importance of proper treatment planing. Information is power and with increased power comes increased responsibility.
Just having a cbct is enough. One one must know how to use the information.
I would be curious how many implant cases where aborted based on cbct analysis.

Chuck

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Rare to abort. Common to alter the treatment. Augment. sinus lift. angulation discussions etc.

Mark

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Correction
Just having a cbct IS NOT enough.

Chuck

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I am going to say this and really don’t care who disagrees. Wouldn’t be great if we put as much effort into keeping natural teeth as we do placing implants? But then again there would be far less implants placed. Oh my!

DANNY

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“With great power comes great responsibility, Peter.”

-Stan Lee

Just a little something to lighten up your Friday. Seems like we’re all starting to take ourselves perhaps a touch too seriously? Have a revivifying weekend, everybody!

Lloyd

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Danny,

Believe or not I still like saving teeth too!!! Love ya.

George

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I think you know that I know that you know that I know that George! It is simply impossible to name those that have an even keel in Periodontics today!
Have a great weekend George,

Danny

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Danny,

I agree, that fundamentally, our core mission is, “Periodontists Save Teeth” be it through the effective and deliberate treatment of ‘Periodontitis the Disease’, or through a biologically sound periodontally-restorative interphase. The (very) long-term literature clearly supports this notion.
For those of us who have been placing implants for decades, where we have the opportunity to monitor these patients long-term in our hygiene program, how much peri-mucositis and peri-implantitis are we ‘skipping over? The average quality of restorative care on our very carefully placed (CBCT driven) implants is frequently less than biologically adequate and/or unmaintainable by our staff and patients. It is of little wonder that there are now three text books, and numerous CE programs devoted to failing implant dentistry. I am concerned where this will all end! – So, I think (and I know) that our core mission is to save, salvable teeth. Please do not get me wrong, implants are fantastic, and have converted many dental cripples to function, when used at the correct time and correct place.
Just venting and giving my ‘tuppence’ worth!

Colin

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Danny,

We’ve worked together for a long time. I do a lot of implants as you know.

Our calling and our mission is appropriate treatment planning in the best interests of the patient. George has made a good statement about diagnostic excellence in dental implant treatment planning, and of course I support that.

The same originally held true and still holds true regarding periodontal treatment planning. Our mission is first to save the whole dentition, if it can be saved in the best interests of the patient. Obviously, we would not save teeth with gross infections that we cannot control. We are treatment planners first, and treaters second. And if our profession of periodontics is to remain a viable profession, we need to maintain that principle. There may come a time, and perhaps the time is here, that patients will directly seek the opinion of the periodontist first, before making any major treatment decision. With appropriate patient education, that is happening to some degree now, and I hope that will continue to happen. I personally believe that we should be asking our patients to refer others to us directly for the same diagnostic experience. That kind of internal marketing can work very well. But the only reason that a periodontal patient would refer a friend or family member to a periodontist directly is because of the thought, care, and integrity that makes that dental experience unique in that patient’s eyes.

The case that you show (assuming that the radiograph doesn’t show pathology that we can’t see in the clinical photo) would not fall within any credible periodontist’s guidelines for extraction. And while you may have spoken with a Diplomate, such status does not guarantee integrity nor a cogent thought process.

So rest assured, my friend, that it is my feeling that the vast majority of periodontists remain ethical and while there may be some disagreement in treatment planning large cases, and how to best save a tooth (or not save a tooth), I cannot believe that a significant number of our colleagues would choose to extract the tooth that you have shown. Most of us would have shaken our heads the same way that you did.

Lee

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