Laboratory owners expand services through technology to position themselves strategically as indispensable partners in end-to-end implant planning.
By Richard Palmer

Ask anyone in dentistry today, and they are likely to express that while dental implant treatment has been around for nearly 30 years, it is on the verge of becoming the standard for restorative care involving edentulism in any degree. Add into this mix a consumer patient base savvy to the benefits afforded by implants through mass-market and targeted marketing, and dental professionals are seeing t he potential to grow their businesses along the entire treatment spectrum-from planning to placement to final restoration-through an expanded menu of services to accommodate this trend.

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.”

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.”

Extra Services
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.

Implant Outsource
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.

Digital Integration
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

References
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%

Cone beam technology provides scans within seconds.

Dentists, ear-nose-and-throat (ENT) physicians, and pulmonologists (respiratory physicians) all work within very precise areas of the mouth, sinuses, and/or throat to treat their patients. For this reason, three-dimensional CT scans can be very beneficial in enabling them to provide the most accurate diagnosis and treatment planning for their patients.

In 2008, 3D Mobile Scan was founded to service dentists and phsicians with conenient, mbile CT service delivered to their doors. Now available throughout Volusia County and beyond, head and neck CT scans, complete within seconds using low-radiation imaging, are quickly and comfortably accomplished and offer unlimited 3D views and reports.

“This service enables practitioners to get significantly more precise images of their patients with out a major equipment investment,” says Celeste DeLoache, operator of 3D Mobile Scan in Volusia. “Using our CT scan service can help practices avoid unnecessary delays and reduce risk management by having the scans performed at their offices for immediate viewing.”

In the dental arena, this newer technology is useful for many different procedures, including implants, oral surgery, orthodontics, extractions, impactions, periodontics, bone grafting, and TMJ, points out Celeste: “It is also helpful for ENTs in diagnosing and treating the sinuses and for pulmonologists wanting three-dimensional images of the airways for diagnosis, treatment, and treatment evaluation for sleep apnea.”

“We use three-dimensional CT scans because I wanted the improved treatment and diagnosis accuracy, planning, and quality for our patients and practice that these scans can provide, ” says Dr. Lester. “The benefits of cone beam technology, which is what 3D Mobile Scan uses, are well documented.”

According to Dr. Lester, one example of using cone beam technology to improve patient satisfaction is for tooth extraction: “CT scans are useful for removing wisdom teeth because there are certain nerves that run through the jaws that are very close to the area where we do the surgery. It is critical that we know precisely where they are because, working in such a tight area, we don not have much room for error. We want to get as close to those nerves as possible without touching them. The CT scan provides a very exacting, three-dimensional image so we can tell exactly where the path is.

The 3D Mobile Scan cone beam priduce very low radiation, says Celeste: “The exposure to the patient is approximately three to five percent of a typical hospital CAT scan, yet the data that it privides is in many ways better.”

“There is also software available to use with the CT scanner so that we can create digital models of our patients’ teeth,” notes Dr. Lester. “Patients no longer have to sit through the uncomfortable process ofhaving messy, time-consuming molds taken.”

For patients needing braces, the scans can be very useful for overly comparisons to measure improvement. Or, for a person having a chin advancement or jaw surgery, three-dimensional scans can be used to give both the prospective surgical candidate and the physician a preview of how the patient will look following the procedure.”

“Cone beam three-dimensional technology is the twenty-first century advancement for diagnosis and treatment planing in dentistry,” observes Celeste.

For more information about 3D Mobile Scan, please phone 888-662-7226.

“NewTom Day is a unique event”, said Donald Rabinovitch, President of AFP Imaging, “enabling users and technological leaders alike to share their thoughts and experiences on CBCT development and expansion.” “AFP Imaging and QR are proud to host this event each year as we expand on the use and standardization of CBCT use in the dental and medical arena. This educational meeting has proven to be beneficial in the advancement of CBCT knowledge and application.”

The NewTom CBCT family of imaging products includes the NewTom 3G (horizontal unit), NewTom VG (vertical unit), and the mobile NewTom VG Flex 3D imaging systems. The three-dimensional images that CBCT generates allows for far more accurate diagnosis, treatment planning, monitoring, and analyses of outcomes than was possible with conventional two-dimensional images. The NewTom family of products interface with a large number of third-party software packages contributing to their relevance in a variety of dental and medical arenas. QR is a wholly owned subsidiary of AFP Imaging and the industry leader in dental cephalometric 3D imaging technology. QR manufactures the NewTom family of CBCT cephalometric imaging products.

NewTom VG features Safe Beam^TM technology, which automatically adjusts the radiation dosage according to the patient’s age and size. Because it utilizes intermittent bursts of radiation only milliseconds in duration during image acquisition and not the constant radiation stream typical of some other CBCT imaging products, patients’ exposure to radiation is in most cases significantly less than that of competing systems.

“The 25% reduction in scan time is one of many features on the horizon for NewTom CBCT scanners”, said Roberto Molteni, Executive Vice President of Technology at AFP Imaging Corporation. “The great success of NewTom in the marketplace, coupled with supportive customer feedback has given AFP Imaging the tools to develop new and beneficial improvements for both patients and practitioners’ alike.”

Not limited to new installations, the reduced scan time can be applied to all existing NewTom VG installations with a simple software upgrade. The NewTom Cone Beam Computed Tomography (CBCT) family of imaging products includes the NewTom 3G and VG three-dimensional imaging systems. Whether you are an orthodontist, a maxillo-facial surgeon, a periodontist, an oral surgeon, an implantologist, or an ENT physician, three-dimensional CBCT scanning is an invaluable tool.

NewTom VG Cone Beam CT Scanner CBCT Imaging by AFP Imaging

(Elmsford, NY) - AFP Imaging Corporation (OTCBB: AFPC.OB) announced today that its Dent-X division has introduced the NewTom^TM VG (Vertical Generation) Cone Beam Computed Tomography Scanner as part of the educational seminar, “Into the Third Dimension: The Present Future of Dental Care,” at the American Dental Association (ADA) Annual Session in San Francisco’s Moscone Center September 27 - 30, 2007. The Company’s cone beam x-ray scanner (CBCT) provides high resolution 3-D dental images using lower radiation levels than others in the industry. The NewTomTM VG also offers flexible seating options to allow patients to either stand, sit or even remain in a wheelchair while being scanned. NewTomâ„¢ software constructs unsurpassed three-dimensional, virtual radiographs for diagnostic evaluation. The product sets the gold standard for current and the next generation of 3-D dental, imaging equipment. The primary clinical applications for the unit are implants, orthodontics and oral surgery where CBCT is not recognized as the standard of care.

The NewTom VG incorporates Safe Beam^TM Technology. This insures the lowest possible dose of radiation by automatically evaluating the actual volume of the patient’s oral structures and then adjusting the x-ray technique accordingly. In addition, our CBCT is capable of capturing, in a single x-ray scan, large anatomical volumes with its nine-inch field of view (FOV) by incorporating a state-of-the-art, large-area flat panel x-ray image detector (200 mm x 250 mm) with high-spatial resolution and wide-signal dynamics. Only one scan is necessary to capture the entire maxillofacial volume, including the dental arches and the Temporo-Mandibular joints that connect the upper and lower jaws. Equally important, it delivers exceptional 3-D image quality through the use of high speed computers and proprietary software. The NewTom VG, reflects a sleek, slender Italian design and takes up 60 percent less space than a comparable horizontal system. It is an ideal scanning unit for in-office use, especially when operatory space is limited. Yet, unlike other vertical units, it can easily accommodate large-sized patients through its open architecture and an ergonomically designed rotating radiographic assembly. The VG model incorporates a special x-ray tube source allowing for the full exploitation and maximization of the spatial resolution performance of the large, flat-panel x-ray detector.

Powerful, user friendly software provides advanced features that are designed to simplify the radiographic scan and the reconstruction of images. The VG software is based upon years of prior experience and development. These images are critical in 3-D dental evaluations and treatment planning for the precision location of implants using antero-posterior, latero-lateral and transversal slices. The NewTom VG also comes equipped with the advanced application, Dolphin^TM software. The VG encompasses many advanced clinical reporting aids for the private practitioner.

AFP Imaging also supplies the NewTom 3G scanner that provides a horizontal support table to accommodate the special needs of elderly, infirm, small children or trauma patients. These units are commonly placed in hospital or imaging center environments. AFP is the only Cone Beam Computed Tomographic manufacturer to currently provide both vertical and horizontal configurations using the same advanced software. Both products are manufactured by Quantitative Radiology, srl (QR), Verona, Italy, a wholly owned subsidiary of AFP Imaging, and the first company to develop CBCT dental technology, ten years ago.

Donald Rabinovitch, President of AFP Imaging, says, “The NewTom VG is truly a breakthrough product. We’ve been able to replicate the excellence of the superior CBCT images associated with our original model, the NewTom 3G, in a vertical unit that’s better suited to individual medical offices. The system is expected to accelerate the adoption of CBCT imaging in the dental field. The dental profession increasingly recognizes the value of three-dimensional imaging over historic analog x-ray films and even two-dimensional digital radiographs. The NewTom VG as well as the NewTom 3G provides exceptional, accurate images to facilitate patient evaluations and treatment planning. We believe that three-dimensional radiographs have now become the standard of care in dentistry, particularly for treatment planning for implants, orthodontics and oral surgery.”

About AFP Imaging

AFP Imaging (OTCBB: AFPC.OB) is a diagnostic imaging supplier whose products are distributed worldwide with clinical applications for dental, medical and veterinary professionals. The company’s quality assurance program is ISO 9001 certified, an international standard. AFP’s digital imaging technologies and product lines are providing the gateway for future internal and externals growth. Through its global distribution network, the company has produced branded products installed in approximately 100,000 dental and medical facilities. Each site serves as a reference point for future user upgrades of equipment. The company’s products are distributed under various trademarked brand names that include AFP, DENT-X, NEWTOM and EVA. For additional corporate information please visit www.afpimaging.com, www.dent-x.com and www.newtomdental.com.

The remarks contained in this press release and presented elsewhere by management from time to time contain forward-looking statements, which involve risks and uncertainties, including statements regarding the Company’s plans, objectives, expectations and intentions. The Company’s actual results may differ significantly from the results discussed in this press release or in other forward-looking statements presented by management. Among the factors that could cause actual results to differ materially include the failure of revenue on new products to develop as estimated, regulatory delays, loss of existing customers, the Company’s inability to meet increasing demand for its new products, general downward trends in the Company’s industry and other risk factors as described in the Company’s filings with the Securities and Exchange Commission. The Company expressly disclaims any obligation or undertaking to release publicly any updates or revisions to any such statements to reflect any change in the Company’s expectation or any change in events, conditions or circumstances on which such statement is based.