Before the patient is in the dentist’s chair, Dr. Ryaz Ansari and his surgical assistant discuss the angle, depth and positioning of the dental implant they’re about to place. Using a robotic device called the “Yomi,” the surgical assistant moves the virtual dental implant with a mouse, as Ansari looks at the computer screen, which displays a 3D image of the patient’s jaw. Observing the digital dental implant’s position in the jaw on the screen, Ansari, an oral and maxillofacial surgeon who practices at JawFixers in West Hartford and Manchester, says, “I want it a little more inwards. That’s good. If you can just rotate this up. … Let’s bring that line to the middle. Excellent. Beautiful.”
When placing a titanium dental implant, the oral surgeon has to think about placing it deep enough and at the right angle without it touching the nerves or the sinuses, which are millimeters away. Before calling the waiting patient in, Ansari and the assistant double-check each measurement again.
“Once this is all planned out, then I deliver this to the patient. The robot’s going to replicate exactly what I’m telling it to do,” Ansari says. “It’s going to tell me that I’m going according to this plan. Sometimes you open up the surgical site and you’re like, ‘I want to change it a little bit.’ Robotic guidance allows you to change on the fly as well, whereas [with] a static guide that we get printed, we can’t change that. It doesn’t allow us that flexibility during surgery. This scan is giving us 95 percent of the information. No matter how much we image, all the information we collect ahead of time, the real test is when we open the gum and we see inside what the bone looks like.”
During the surgery, which lasts about 15 minutes, the Yomi occasionally pings, signaling the plan is being followed. The robotic arm, designed like a human arm but with a drill instead of a finger, guides the human arm. If Ansari moves the robotic arm a hair off from the plan, he would feel resistance and hear an auditory alarm, he says.
Robot-assisted surgery is just one way that technological advances are changing dental care. Digital scanning, 3D printers, laser technology and other tools are also popping up in more dentists’ offices. All this tech means dentists are able to diagnose, treat and perform restorative and cosmetic procedures with never-before-seen precision, and patients receive care that is increasingly effective, efficient and comfortable. Some dental procedures are being sped up, while the number of dental visits for restorations such as crowns, inlays, veneers and bridges is being reduced. Regardless of dental insurance coverage, patient costs remain virtually unchanged, dentists say. Fewer visits mean fewer shots of local anesthetic, and the digital scan capabilities eliminate the need for patients to put their teeth in that goopy impression material.
The Yomi is the first FDA-approved dental robotic tool, and Ansari says he’s the first oral surgeon in Connecticut to use the device. One of 10 oral surgeons nationwide selected to test it and provide feedback to the engineers who designed it, he’s been working with it for about two years, he says. (One other Connecticut dental practice recently began using the Yomi system: Connecticut Center for Oral, Facial, and Implant Surgery in West Hartford.)
Today, the gold standard for replacing a tooth is with an implant, which is a titanium fixture that goes into the jawbone and replaces the root of a tooth, he says. An oral surgeon works with the portion of the mouth under the gums and a restorative dentist works on the teeth.
What’s the advantage to the patient of using the robotic device? Accuracy, precision and time, Ansari says. When drilling a hole into a jaw to place an implant, surgeons strive to prevent injury to the nerves, sinus or other teeth. “Freehand, even after 30 or 40 years of experience, you can still be slightly off,” he says.
Prior to adopting this method, Ansari would take a dental impression, send it to the lab and wait for a surgical guide to come back. With the Yomi, he’s able to look at the dental scan that shows the 3D image, plan and perform the surgery on the same day.
All this tech means dentists are able to diagnose, treat and perform restorative and cosmetic procedures with never-before-seen precision, and patients receive care that is increasingly effective, efficient and comfortable.
The surgery is considered minimally invasive, as sometimes no incision to the gum is needed; if an incision is required, it’s smaller, Ansari says, causing less pain afterward, along with a faster recovery. With coronavirus concerns, the oral surgeon can look at the screen while moving the robotic arm, allowing further distance between patient and provider than with the conventional method. The procedure itself is faster, which reduces the time patients are in close proximity to providers.
Once someone gets an implant, they see a general dentist or prosthodontist to get a crown made and inserted. A computer-aided design and computer-aided manufacturing (CAD/CAM) system was introduced to dentistry in the mid-1980s. Technological advances, including 3D imaging capabilities that allow dentists to optically scan the teeth, have changed the patient experience. With this technology, patients can get their permanent restorations, such as crowns, in one 2-hour visit rather than two visits. Their dentist can make the tooth in the office with the CAD/CAM system rather than sending the work out to a lab. And dentists say the chairside technology allows them to make a more realistic-looking tooth that matches the color of the other teeth.
“The patients really appreciate the fact that they don’t have to leave the office with temporary restorations,” says Dr. Jennifer You, owner of Levy Dental Group in New Haven. “They don’t have to take off multiple days from work. They can have their crowns on in a day.”
For the past nine years, prosthodontist Dr. Damon Jenkins has used a CAD/CAM system to provide patients with crowns, bridges, veneers and tooth repairs and restorations. “People are coming to you, usually because they’re in pain. They’re having a problem,” says Jenkins, who has upgraded the systems at his Coventry practice over the years, including the use of 3D printing and a dental cone beam computer tomography (CT) scanner, which produces a three-dimensional image of teeth, soft tissues, nerve pathways, and bone in a single scan. “The digital system has made it a little bit easier to get from point A to point B, to deliver something that’s functional, that’s beautiful to them that they enjoy having in their mouth.”
The traditional method for getting a crown involves two office visits. In the first visit, the patient gives a dental impression by biting down on top and bottom trays of dental goop for 4-5 minutes; the dentist applies a temporary crown on top of a prepared tooth and sends the request for the permanent crown out to a lab, which outsources it overseas, says Dr. Peter Drpeteg, of Perimenis Family Dental Practice in Stamford. The patient returns about two weeks later for another shot of anesthesia and the final crown.
The digital system gives the dentist 450 teeth designs to choose from, and, with 3D imaging, dentists can see what the new tooth will look like, Jenkins says. This ensures the bite is lined up correctly, producing a better-quality result, he says.
Dentists also say it helps them do a better job aesthetically. Teeth are not one color from the gum to the tip and contain many shades within a single tooth, You says. One of the most difficult restorations to do well is replacing a single front tooth, because if the dentist doesn’t match it to the adjacent teeth, it will stand out.
With the CAD/CAM system, the machine 3D prints the tooth or crown from a piece of porcelain/ceramic, removing material from the block similar to how an artist would carve a sculpture out of stone. Rather than writing down the shade and hoping the lab gets it right, Drpeteg says he has “a whole closetful of different shades and translucencies” in his office. When working on front teeth, Drpeteg says, he’ll sometimes make the restoration in two or three shades so the patient can see the options in their mouth and choose. “I give them a mirror. They then have ownership of it,” he says. “They’re in the room as I’m doing the design.”
The system can also be used for other purposes. If someone has extensive decay, dentists can 3D-print partial or full dentures that can be placed in the mouth and only removed by the dentist once every six months to check for bacteria. (The creation of full or partial dentures would be done with the help of an oral surgeon to strategically place four to six implants.)
“People are coming to you, usually because they’re in pain. The digital system has made it a little bit easier . . . to deliver something that’s functional [and] beautiful to them.”
The CAD/CAM system can be used to help improve people’s smiles by adding to teeth that have been worn down by grinding or by building up teeth with excessive spacing, Jenkins says.
Some dentists are using the system for cosmetic improvements, such as what dentists call “aligner therapy,” also known as “clear braces,” an alternative to traditional metal braces. Dentists can design a digital version of the new smile and show patients what the new smile will look like in their face, Jenkins says. Patients can suggest modifications before treatment begins.
While there are several aligner brands on the market, such as Invisalign, ClearCorrect and SureSmile, Drpeteg says, “I did not do aligners until I could use a digital scan to send the cases to the aligner companies.” Aligners use a series of thin plastic trays to direct the teeth into a more ideal position. Patient compliance with wearing the trays determines success, he adds. “While I feel a dentist-supervised treatment is the only way to do this safely,” Drpeteg says, “there are direct-to-patient companies that are around.”
Another technological advance is the use of lasers, which deliver energy in the form of light, and don’t have the drill squeal that so many people dislike. Lasers can be used to remove tooth decay and prepare the surrounding enamel for a filling if the tooth does not already have a filling. Lasers also can remove a small piece of tissue for a biopsy to check for cancer and to remove lesions in the mouth. Some people have excessive gum tissue that’s overgrown on the tooth, and Jenkins says he can use a laser to recontour the soft tissue.
Lasers can help disinfect infected periodontal pockets, or gaps between teeth and gum tissue. More powerful soft-tissue lasers help grow bone around teeth with periodontal pockets, Drpeteg says. “This can remove the need for a patient to undergo periodontal surgeries, which require incising the patient’s gums,” he says.
Lasers can also be used for treatment of bone and tooth structure, Drpeteg says. While some dentists use lasers’ heat to speed up teeth whitening, Drpeteg says he thinks the benefit is minimal compared to the professional bleaching products available.
Among lasers’ limitations: they can’t be used to fill cavities between teeth, on a tooth with an existing filling or to fill large cavities that are being prepared for a crown. They also can’t be used to remove silver fillings or defective crowns, and traditional drills may still be needed to finish the work of installing a new filling. And local anesthesia is still needed during laser use.
While there are lasers at different wavelengths promoted as a drill replacement, Drpeteg says, “as of yet I have not been moved enough to bring this technology into my office to treat my patients.”
Does insurance cover treatments using CAD/CAM and the Yomi robotic device?
Yes, if the treatment is for oral health reasons. The cost is the same to the patient whether it’s performed the analog way or with technological advances. Most insurance does not cover cosmetic dental treatment.
What if the patient doesn’t have dental insurance?
Dentists charge the same fee for analog and tech-enhanced treatments. While dentists have to pay for the equipment, they save expenses by not having to outsource to a lab or clean a patient area twice because of two separate visits.
What about pain?
With the Yomi, Dr. Ryaz Ansari says, sometimes the oral surgeon does not need to make an incision to the gum. If one is required, it’s smaller than with the analog method. Either way, he says, there is less pain after surgery and a faster recovery. With the CAD/CAM-assisted method, a local anesthetic is still required.
Chew on the costs
Here’s a general cost guide for common dental procedures, according to animated-teeth.com. Prices can vary based on factors such as procedure complexity, where the dentist is located, and the experience level of the dentist.
In-office teeth whitening:$390 to $920
Whitening kits from dentist: $100 to $400
Over-the-counter whitening: $20 to $100
Crown: $700 to $1,600 per crown
Bonding: $480 to $810 per tooth
Veneers: $735 to $1,390 per tooth
Invisalign: $3,000 to $5,000
Implants: $1,650 to $2,400 per implant