Developments in Digital Implant Workflows
A discussion with Henriette Lerner, DMD, PhD
Henriette Lerner, DMD, PhD, is a past president of the Digital Dentistry Society and the founder and director of the HL Dentclinic and Academy in Baden-Baden, Germany. As a specialist in oral surgery who focuses on implantology, she has contributed to the field of digital dentistry through education, research, publications, and product development.
Inside Dentistry (ID): Why is robotic surgery such an important next step in the evolution from guided to dynamic surgery?
Henriette Lerner, DMD, PhD (HL): Dynamic navigation offers advantages when compared with static navigation, particularly regarding the freedom of immediate planning and surgery without the need to fabricate a surgical guide. Nonetheless, dynamic navigation has a steeper learning curve in the precision and handling. The real gain in accuracy of dynamic navigation is realized through robot-assisted surgery, which further enhances the precision of implant placement. Robot-assisted surgery leverages all of the advantages of dynamic navigation, including the freedom of immediate planning and surgery, continuous monitoring of the surgical process that allows for real-time adjustments, and the ability to visualize the implant placement virtually in real-time to ensure that it is positioned correctly within the bone structure for optimal stability and functionality. However, robot-assisted surgery also offers the advantage of providing dynamic guidance to the surgeon, displaying real-time data and visuals that assist in aligning the implant precisely according to the preplanned position. In addition, if there are deviations from the planned trajectory or position during surgery, the real-time feedback feature alerts the surgeon, enabling immediate corrections to ensure accurate placement. The feedback loop between the robotic system and the surgeon permits instant adjustments, ensuring that any discrepancies in implant placement are addressed promptly to maintain precision, which enhances the overall accuracy, reduces the margin of error, and improves the success rate of procedures.
ID: What other current or future developments are important in terms of improving the digital workflow for full-arch rehabilitations?
HL: The highest target of the digital workflow is the accuracy. Artificial intelligence (AI), including machine learning and all of its branches, is tremendously increasing the accuracy of all of the individual technologies in the digital workflow as well as the digital acquisition of patient data (eg, intraoral scanning, cone-beam computed tomography, etc). Various technologies and systems have already solved many of the challenges associated with scanning in full-arch cases. There are scanning technologies in development that, based on other new optical technologies, are about to overcome the challenges of scanning the preparation margins and soft tissues, even in the presence of blood or saliva.
Another development is in how traditional 2D photography is being augmented by the use of face scanners that provide a 3D visualization of patients' faces, which is extremely useful in the creation of more personalized and accurate smile designs. As a next step, the ability to scan the face "in motion," which is on the way, will further improve our ability to visualize patients' future smiles by realistically mimicking their expressions and the exposure of their teeth. The accuracy of the superimposition of all digital data in the creation of the "virtual patient" has increased due to advances in segmentation technology involving the use of convolutional neural networks, which are a branch of machine learning. The digital registration of jaw movements will permit the creation of a virtual patient in motion or the so-called "digital twin."
Beyond this, the accuracy of implant planning is of primary importance. Esthetically guided implant planning is still a time-consuming step in the digital workflow. Ideally, implant planning will become fully automated, respecting the criteria for stability, function, and esthetics. The first steps in that direction have already been taken. There are applications that are already able to automatically plan single implants with the push of a button.
The fabrication of provisional and final restorations using CAD/CAM is another step in the digital workflow of full-arch rehabilitations that is undergoing important developments. Here, many improvements have been made lately, especially in the use of 3D printing technology with regard to speed, price, stability, and of course, accuracy.
ID: What potential does bioprinting have in implant dentistry?
HL: Once mature, the field of bioprinting has the potential to significantly change the science and protocols of bone and soft-tissue grafting. The use of bioprinting technology could offer the possibility of customized graft design and fabrication, patient specific composition, and increased grafting precision during surgery. Through the fabrication of complex, multilayered grafts, bioprinting is enabling the integration of different cell typologies to enhance biologic mimicry. The key to the integration of biomaterials regarding improving the potential of the bone is of course the vascularization; that's why vascularized grafts would be the next step. The ongoing research holds a lot of promise for near-future successes in tissue engineering and regenerative dentistry.
ID: In what way will artificial intelligence be the most impactful for implant dentistry?
HL: As I mentioned before, AI and all of its branches have the potential to positively impact every step of the digital workflow in implant dentistry, so I wouldn't necessarily emphasize any one aspect. In the clinical steps, the primary contribution of AI is to improve accuracy, so that may be seen as its highest achievement. Relatedly, AI is enabling improvements in implant education through the use of virtual reality in simulations and the use of augmented reality and mixed reality for surgical assistance. The roles of AI in achieving more accurate diagnoses through clinical decision-making support as well as in patient management are also decisive.
ID: What types of technology can help improve implant education, and why is that so important?
HL: To further expand on what I said, virtual reality technologies are being applied for hands-on trainings and surgical simulations, augmented reality is making communication easier and creating 3D holograms of technologies and patients, and mixed reality is enabling the interaction with the 3D worlds of virtual reality and augmented reality.
ID: Are there any other developments that you hope to see in the future for any aspects of implant dentistry?
HL: Considering that the dentistry of the future (and the future is today) will not only be digital but also integrative, I look forward to the development of any tools that will enable us to increase the level of oral health in symbiosis with systemic health regarding prevention, early diagnosis, minimally invasive procedures, faster healing, and last but not least, increasing the longevity of our patients' dentition and lives.
