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too far, way too quickly: “Teeth in a
day.” “Teeth in a minute.” “Teeth in an
hour.” As soon as I saw that I thought:
“You’ve got to be kidding me. You’re
going to do the final bridge in one
day? That’s a joke.” You’re not going
to be happy with that, not routinely.
You might have a case or two that
work, but not on a regular basis. Not
for everybody, not even for advanced
clinicians. You’re going to suffer problems.
And sure enough, I was right.
Then they backed off to only temporaries
in a day, not the final bridge.
But why? They had to. They were
getting killed, even by some of their
own great researchers who were doing
their prototype work. Why? They
were only getting a 90 percent success
rate in some of these cases. Drs.
Osamu Komiyama and Peter Moy
— great clinicians — were only getting
an 89 to 90 percent survival rate
of these implants, even though they
would normally get 95 to 97 percent.
Part of the problem is the full-arch
case. The full-arch case is the most
difficult, yet that’s where you need
guided surgery the most. And this is
the problem. For the single tooth, I
have all my guides right there — the
adjacent teeth, the opposing dentition
— and I can see where I need to go.
For an advanced clinician, it’s not as
critical. No matter how good you are,
though, when you have all the markers
gone, and you have an edentulous
ridge, you have to ask yourself where
you place it buccal-lingually. Where do
you place it mesiodistally so it doesn’t
come out in an embrasure space?
That’s where I need more information.
So that’s where you’re going to
see guided surgery being used, in the
more difficult cases.
What’s the problem, then? Well, first
you do the proper setup. You know
where the teeth are going to be —
proper bite, proper position. So you
duplicate the denture and make a
radiographic guide with markers on
it. You send the patient to the radiologist,
or you do it in your office.
Whoever does it better be seating the
mock-up denture with the markers on
it in the proper place because if it’s
0.1 mm or 0.2 mm off in the wrong
position mesiodistally, it’s not hooking
onto anything. It just depends on
how the patient is biting. So they get
a CAT scan by a radiologist. But the
radiologist isn’t a dentist, so they put it
in and ask, “Does it feel OK?” And the
patient says: “Well, I guess so. I think
it’s fine. How does it look?” The radiologist
says, “Just hold still.” And they
take a picture. But even if it’s 2 mm
forward, or 2 mm slipped back, the
position of the markers to the ridge is
completely wrong — and you’ve spent
all this time on it. Then you go to your
computer, you’re marking the position
where you want the teeth based on
where that radiographic template was
during the X-ray, and all your markers
are off. So then the surgical template
that you’re going to make now includes
holes for drilling in a place
that you told them was correct, but it
isn’t correct. It’s off because the radiographic
template was put in the wrong
spot. If the radiographic template is
fine, then it’s very accurate, and you’ve
got plenty of bone and plenty of
attached gingiva. But if that’s off, it’s
a nightmare, and that’s when it really
becomes a problem.
So temporaries in an hour, fine. But
not final bridges in an hour. There are
too many variables, too many things
that you might want to change and
modify. Temporaries in an hour are
fine. That’s immediate loading with a
fancy version of the immediate loading
we discussed before. I have no
problem with that, and I recommend
it. But be careful.
When we do these fully edentulous
cases where we’re worried about this
— and other people do this, too — before
we put the radiographic template
in, we’ll put mini implants in: a couple
of implants in the ridge, at least two,
one on each side. Then we reline the
denture that’s going to be used, or the
duplicate denture, so it’s in the right
spot — with just a doughy mix over
the top with something to lock into it.
So now when it goes in, it can only go
in one spot.
DC: It’s indexed.
DT: It’s indexed. We add fixed index
material, so the radiographic template
and then the surgical template get
hooked onto it.
DC: As long as it’s not too stable.
DT: Right [laughing]. So now, we’ll
sometimes save even one tooth in
the treatment plan if the person’s not
edentulous. Sometimes we’ll just save
one or two teeth, just to stabilize the
guide, even though the teeth are going
to come out after the implants are in.
And we do that to help stabilize the
radiographic template, and that stabilizes
the surgical template.
DC: So it leads to a more accurate result.
DT: Absolutely. All the time.
DC: Do you see technology changing the
role of dental labs in restoring implant
cases?
DT: Obviously there are different ways
to come into the digital world. For example,
almost all of your crowns now
at Glidewell are digital. You’re not the
old technician sitting there with wax,
knowing how to use the wax, and
which type of wax —
DC: We don’t have any of those.
DT: Well, if you think about that, you’re
certainly one of the largest labs in the
country, if not the world — you’re all
digitized. I think this is great. What it
has done is that even if someone gives
the lab an old type of impression, not
one that’s scanned, the general dentist
or even a prosthodontist can enter the
digital world right away just by sending
you a model. Everything is digitized after
that. So, I think it’s just going to be
faster and more direct. It can be done
via e-mail and then your electronic waxup,
so to speak, is transferred back. I
think there’s no question that this is the
way it will all go in the future.
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