A mobile CBCT scanning van can roll up straight to the dental office, providing convenience for the patient and the practice.
From the Beginning
There are many places along the implant treatment workflow where laboratories can position themselves as part of the implant team, focusing on one specific aspect of care such as designing and milling patient-specific CAD/CAM zirconia abutments. Or, they could broaden their attention all along this path and establish their business as specializing in implants. Most laboratory owners would agree that the sooner they can become involved in the total implant treatment plan, the better the outcome. Mark Jackson, RDT, Vice President and co-owner of Precision Ceramics Dental Laboratory (www.pcdl-usa.com), said involvement early on in implant treatment drives it in a new direction from the get-go, essentially flipping it into a “crown-down” perspective. “Today, our implant cases are prosthetically driven, whereas before, they were surgically driven,” he said. “Now, we can figure out where the prosthetics are going to be, and then build the implant surgery around the prosthetics.”
Jackson made the business decision recently to position his Montclair, California-based PCDL at the very start of implant treatment by incorporating a cone beam computed tomography (CBCT) digital radiography unit into his lab, one of just a handful of dental laboratories with the advanced 3D imaging equipment. Although there were a small number of dental imaging centers or CBCT-equipped dental practices in his general area, Jackson saw a number of distinct advantages to having the technology in-house.”I want to be involved with the planning forward” Jackson said. “If I can get into the doctor’s office with my scanning and planning services, I have the inside track to get to that prosthetic case.” PCDL is adjoined by a dental practice, which will be the exclusive client of the CBCT imaging services before expanding out additional practices in the area.
“It also gives us a great deal of credibility in terms of implant planning because we now go from scanning to planning to surgery and restoration successfully in house every day,” Jackson said.
Working up to the CBCT scan during the initial preplanning stages, Jackson makes a diagnostic waxup to help the implant team and the patient plan restorative goals, then he makes a radiographic template from the waxup that has radiopaque markers such as gutta-percha or barium sulfate intaglios to establish important landmarks used in the 3D CBCT image for positioning. The patient comes to the facility and is fitted with the guide to check for precision, then a board-certified oral and maxillofacial radiologist at PCDL captures the 3D data in DICOM (Digital Imaging and Communications in Medicine) format and imports the files into the appropriate implant planning software based on the initial treatment plan. At this point, the implant team works together to locate the ideal placement and angle for the implants.
In a growing number of cases, a surgical guide is fabricated using the CBCT data to help the surgeon or GP with exact implant placement and to reduce the risk of surgical errors. The guide can be manually fabricated by the laboratory or outsourced for CAD/CAM fabrication through services such as Nobel Biocare’s Nobel-Guide and Simplant’s SurgiGuide.
“As more GPs start placing implants, they are the ones who are really going to benefit from these surgical guides,” Jackson said, adding the guides are “prohibitively expensive for just a single tooth,” which is where most GPs begin implant placement.
Apart from the benefits to the clinician in minimizing risk factors in the surgical placement of implants, the surgical guide also affords advantages to laboratory technicians with implant knowledge, like Randy Rogers, CDT, owner of Rogers Dental Lab in Bossier City, La. Rogers has worked with implant treatment for nearly 20 years, often assisting and consulting with clients on implant placement. “Surgeons would call me chairside and ask, ‘If I put it at this angle, would you be able to restore it?’ If we can get them all to do guided surgery, then they won’t need a technician to come to the practice.”
The radiology technician captures the scan data, which is displayed instantly on the computer screen as a 3D image.
On the Road
As Jackson worked through the remodeling process involved with incorporating the CBCT scanning service into his lab, he encountered a number of complications that needed solved. He said the IMTEC Iluma scanner is so sensitive he needed to pour a concrete floor to hold the machine steady; then he needed glass to be removed to get the machine itself into the building; he had to install lead shielding in the walls and radiological glass around; provide monitoring badges for employee lab coats; and finally he had to build a lobby to greet patients because he had never had patients come to the lab. All of this dramatically added to his initial startup costs.Working around these problems, but not without complications of its own, is an emerging business model that involves a reasonably compact CBCT unit, a van, and a sense for travel.
While patients in urban areas often have better access to dental imaging centers like PCDL-more common medical imaging centers typically are not suited for dental imaging because of the higher levels of radiation and lower image resolution generated by medical- grade CT scanners-those in lesser-populated rural areas often would be required to travel long distances to a dental imaging center. Even patients in some urban areas need to go to a medical facility for a CBCT scan, a scenario at which both patients and dentists balk.
“There’s a lot of psychology involved,” said Celeste DeLoache, Owner of 3D Mobile Scan (www.3dmobilescan.com), which provides mobile scanning services to patients in north and central Florida. “Most of the dental scanning centers end up being in dentists’s offices. Patients don’t really like going to another office and meeting a new staff. Also, the referring dentist sometimes worries about sending patients to another dentist’s office.”
Dr. Eric Yabu is a practicing general dentist in Oakland, Calif., who has experienced his own implant business increase from a single case every other month to five or more a month. To provide optimal implant treatment, he wanted to incorporate CBCT imaging into treatment planning to help identify suitable bone and to avoid nerves and other underlying anatomy. However, “It’s hard for one office to afford a CT scanner,” Dr. Yabu said. “And, while sharing amongst several dentists makes it more accessible, it still limits that access to a single location.” His solution was to partner with three other dentists to bring CBCT imaging to dentists and their patients in the Greater San Francisco Bay Area through Mobile CT Imaging (www.mobilectimaging.com).
Rogers also saw the need for better patient access to CBCT centers and started up a3Dimage (www.a3dimage.com), covering northern Louisiana and eastern Texas. Like PCDL, Rogers’ lab now is on the ground floor of the implant treatment planning process and is a valuable asset to his referring dentists.
All three of these mobile businesses operate on the model of bringing care directly to the patient, and all use the same type of scanner, the NewTom VG from AFP Imaging (www.afpimaging.com), which DeLoache said “was the only company that would give us a warranty on a mobile unit.” While similar
in many respects, each of these scanning centers has its own individual niche: Jackson and Rogers bring a laboratory perspective to the operation, DeLoache emphasizes the “spalike” environment of her van, and Dr. Yabu has the experience of a clinician performing implant procedures.
In most cases, the dental practice helps the patient set up the appointment and often arranges several scan sessions in one day for efficiency, though occasionally the van may meet the patient at home or place of business. The actual appointment takes only a few minutes, with the scan capture done in less than a minute. Individual state requirements for patient contact may affect who can see the patient and what certification is required to operate the machine. Where Rogers operates, “Because of radiation levels, the CBCT machine is rated as a dental unit, not a medical unit, so you don’t need a radiology technician.” As such, he employs a dental assistant certified in dental radiology.
Both Jackson and DeLoache have dentists with specific radiology training operating the units, but Jackson acknowledges a concern with CBCT in a dental lab. “I don’t think a stand-alone dental lab could do it. We have a dental practice here,” he said. “I think they would have to get a licensed radiological technician. Unless you have a separate radiology license, you would have to be working under the direction of a dentist.”
To make the patients more at ease, and also for liability protection, the mobile operations often have a practice staff member escort the patient to the van during the scan session. Dr. Yabu said his van is equipped with a surveillance camera inside to protect the patient as well as the business.
For Further Assistance
Once the radiographic information is captured, the data is given to the dentist for implant treatment placement determination. However, clinicians involved with basic implant treatment may not be experienced in the new-generation 3D images provided by CBCT.
“This technolog y has been around for a little while, clinicians are familiar with it, and know the concept, but they can’t just sit down and use the software,” DeLoache said, adding that an auxiliary part of her business model involves assisting clinicians either in the office or through an online GoToMeeting conference. In addition, 3D Mobile Scan provides a radiology report with each case that is produced by an oral and maxillofacial radiologist at the University of Florida. The radiology report also helps protect the clinician against certain liability by pointing out any physical problems that would require referral to a physician for follow-up, DeLoache said.
The radiologist at PCDL directly provides the radiology report to the practice along with the scans, but also provides a variety of implant planning services, such as placement consultation and surgical guides. In addition, Jackson said PCDL can accept CBCT data from outside dental radiology centers and then run with the treatment process from there.
Rogers also saw the need to assist clinicians. “Most dentists are not trained to read or navigate through CTs,” he said. “It’s different than looking at a periapical or a panagraph x-ray.” To help them, he started RP&I Consultants to work with doctors and the patients to come up with a treatment plan by explaining the CT but not interpreting it. “I get involved with the doctors to understand the software, treatment plan cases, and order surgical guides. I guide them through the CT and help them place the implants where they need to be placed to restore whatever it is they want to restore, whether it’s related to fixed or removable appliances.”
Rogers said investing in the CBCT scanner has more than paid for itself in the year he has been in operation. Estimating an average of 50 patients per month, with 25 being the break-even point, he said, “I have not had to make any payments out of pocket yet. We’ve shot enough scans to pay for the financing since I bought it.”
Looking to ensure a suitable return on her investment, DeLoache said she wants to solicit the business to Ear-Nose-Throat medical specialists to look at sinuses in the CBCT scans as well as sleep medicine physicians for treating sleep disorders by measuring the airway and designing apnea appliances. “This is a new technology designed to help people,” she said.
Reno-based nSequence Center for Advanced Dentistry (www.nsequence.com) was founded specifically to assist dental laboratories and imaging centers extend their implant services to clients by handling most or all of the technical aspects involved with the computer-based treatment planning while keeping the lab or scan center in the treatment communication loop during preand post-scanning services.
“We have spent the past 10 years developing the expertise to help the implant team,” said President and CEO Daniel Llop, CDT. “The main focus of the dental implant lab should be restoring dental implants. For most, it would take quite a quantum leap for them to jump into something like what nSequence does. We are a CBCT scan center as well, and that has helped us understand and master the DICOM integration with CAD/CAM technology.”
As part of its nSoftt implant protocol, nSequence has developed methods, software protocols, and anatomically correct models and surgical guides as well as additional post-scan services for laboratories and practices as a total treatment package, or as Llop refers to the service: one call plans it all. “Literally, we can design and manufacture all aspects of a surgery/lab/restorative case,” he said. The nSequence RRD Radiographic Registration Device eliminates the need for custom-fabricated CBCT guides and works with post-scan planning software. The RRD eliminates an average of 10 days from the guided implant surgical and restorative process and lowers the cost substantially. Using the RRD, the DICOM data can be combined with information from an optical impression capture (e.g., Cadent’s iTero) to create a digital diagnostic waxup for the dental team to preview. At this point, the lab, the surgeon, and the restoring doctor can schedule the case into their specific work flow.
Once the case is approved, the abutment STL information can be sent to the lab for inliability house production or outsourcing to a CAD/CAM for custom abutments, or nSequence can order the abutment for the lab. On the other side, the implants can be ordered for the clinician. At this point, nSequence can
generate a 3D printed AccuDental model that is a physical representation of the CBCT 3D virtual representation, complete with bone, clear soft tissue, root nerve, sinus, and clinical crown, which helps with patient acceptance of the treatment plan and serves as a validation model for the surgical/restorative team. The AccuDental Validation model includes the planned osteotomies. Llop said it is not a surgical guide but serves as the basis to help create an accurate validated conventional surgical guide and consequent prosthetics.
In addition, Llop said nSequence is a Fast-Track Master Site for Simplant, which allows it to control the precise design of the CAD/CAM produced surgical guide that is then fabricated in Belgium. “We don’t manufacture the guides for Simplant, but we don’t have to send the dental casts to Belgium,” Llop said. This shortens turnaround time by nearly a week.
Llop said one aspect of the nSoftt protocol for labs that want to remain inside implant treatment but outside the surgical planning process is the conversion of DICOM data and optical scan data into open-architecture STL files that the lab can use to fabricate CAD/CAM implant abutments as well as crown and bridge substructures in-house.
Software developer Geomagic also is in the process of extending its Geomagic Piano open-architecture platform to allow users to bring together CBCT data and optical scan data. “By combining the strengths of each system, we can create a true ‘restorativeimaging’ process,” said Robert Kody, Geomagic
Managing Director of Dental. “Conebeam gives the clinician high-detail skeletal data needed for implant treatment planning, while the chair side digital impression systems can provide high-fidelity morphology of the dentition and gingiva. The correct combination of these data-sets enables a range of new options for treatment.”
He explains that DICOM data, while useful for implant planning, lacks critical information required for design or manufacturing purposes. To address this issue, Geomagic Piano can support input from multiple sources creating intelligent multipurpose models for CAD/CAM systems. “Creating surfaces from DICOM data-sets is one method of combining diagnostic data with digital impression information. The resulting ‘hybrid’ data-set, can improve implant placement and enhance restoration design, while dramatically decreasing treatment time for future implant patients.”
Whichever direction implant treatment heads from this point, it can be assured that it will take a digital pathway like most of the rest of dentistry. And like other digital pathways, laboratories can start the journey from the beginning and travel the entire length, or get on and off at any point to best suit their operations and that of their clients. lab
1. The July 2009 DLP Implant survey was mailed to a random sample of 1,000 lab owners/managers taken from the DLP circulation; 147 surveys were returned for a response rate of 14.7%