Who benefits more from computer-guided implantology – the beginner, who gains additional safety, or the experienced practitioner, who becomes even more precise as a result? The second episode of the trilogy on computer-guided implantology in the podcast Queens & Sons of Dentistry pursues this question. The answer given by the guest, an experienced oral surgeon and lecturer, is a differentiated one – and culminates in a clear staged plan for getting started.
Two methods, two stress profiles
The starting point of the consideration is an observation from everyday treatment: with the freehand technique everything runs stress-free until the problem arises – for instance when it turns out that the implant is not correctly positioned and has to be drilled anew so that it fits. The stress then arises in the middle of the procedure. With navigation it is precisely the other way round: the stress lies at the beginning, when everything has to be in place – the system calibrated, everything adjusted, the updates installed. Afterwards the practitioner is relaxed, because he knows exactly what has to be done. These are, according to the surgeon, two completely different moments of stress with a different influence on the operation.
Why the first implant should not be dynamically navigated
From this stress profile the guest derives a clear recommendation: for a beginner who is already tense before the procedure in any case, full dynamic navigation with its elaborate registration prior to the operation is currently not the right thing. Placing the first implant straight away with systems such as Falcon or Navident he considers to be too much of a good thing. For getting started he recommends statically guided implantology with a surgical guide instead: the practitioner is guided through the sleeve and has a more relaxed procedure. Dynamic navigation primarily benefits the professional who already brings a certain routine with him and is confident on the surgical side.
The foundation: basic surgical experience
The guest is unequivocal on the question of the fundamentals. The host refers to conversations with numerous dentists who advise having extracted a thousand teeth before the first implant, in order to get to know the jaw and its properties. The surgeon concurs: it is not merely a matter of placing an implant and turning in a screw. The practitioner needs a feel for the tissues – mucosa, cortical bone, periosteum, musculature, fatty tissue and the course of the nerve. For him there is no better school than the removal of third molars: anyone who has struggled and sweated over wisdom tooth removals, apicoectomies and extractions is subsequently able to work in a guided manner and to feel comfortable doing so. For what happens if the guide breaks because it was incorrectly designed, if the navigation system loses the signal, or if, during the tooth removal preceding the implant placement, the root fractures? A plan B is then needed, an emergency plan – and a great deal of experience in order to bring the procedure safely to a conclusion. The host compares this with the newly qualified driver who gets straight into a sports car: if the car breaks down, there is no basis whatsoever for helping oneself.
Step by step: master the planning first
Asked which tips he would give his former self for the start, the surgeon answers without hesitation: proceed step by step. The first important building block is the planning software – his favourite is coDiagnostiX, a program that initially seems somewhat unwieldy but is in fact very complete and with which a great deal can be planned. Anyone who familiarises themselves with it automatically immerses themselves in the fundamentals: what is an STL data set, what is a DICOM data set, and how do the two come together in the program? This work could certainly be delegated – at the beginning, however, the guest expressly advises against it. Not acquiring everything at once and not taking on too much is the watchword.
Outlook: navigation as the coming standard
To sceptical colleagues who rule out computer-guided working for themselves, the surgeon responds with a clear forecast: navigation and robotics will become the new standard and will replace the freehand technique. The greatest obstacle is the preparation at the beginning – yet a good surgeon has to prepare his case in any event; nowadays it is also not justifiable from a legal point of view to approach a case unprepared. He sees the future in systems that recognise the patient's teeth directly without markers, so that the case can be started without additional effort. In orthopaedics, operating theatres with cameras are already a reality: instruments and trays are automatically recognised as they are brought in, without anything having to be recorded manually for the logistics. It is precisely in this direction, in his conviction, that implantology is developing as well.