Complexity = Collaboration

The revival of the removable prosthetic market in the past half decade is being driven by a convergence of economic, demographic, and technological factors. The forces of the tremendous advancements in materials, automated production technologies, and expanded treatment options combined with more-demanding dental patients and a surge in the general population of those who are 65 years or older have come together in a backdrop where demand and supply struggle to stay in balance. In addition, dentists continue to retire from practice at a faster rate than they are graduating from dental school¹ and the new graduates coming into practice have limited knowledge of removable prosthetics as dental-school curriculums continue to diminish their clinical exposure to this segment of dentistry. In the meantime, the shrinking number of technicians who are knowledgeable about removable prosthetics is challenging the laboratory industry in meeting the aging population’s needs for the next 30 years.

Edentulism remains a problem. Approximately 35 million Americans do not have any teeth, and another 178 million are missing at least one tooth.² Twenty-five percent of adults older than age 60 have lost all their teeth.² With life expectancy in the US projected to increase from 78.2 years to 82.6 years for the average adult by 20503 and the baby boomer population estimated to comprise 22% or more of the general population by the year 2020, the need for restoring patients who are partially or fully edentulous looks promising. These facts have caught the attention of not only dentists, but also laboratories whose specialties did not include full and partial denture products.

Multiple factors are now forcing a shift. The slower-than-expected economic recovery, the promise of more expensive complex implant-supported cases, and patient demographics have dentistry’s stakeholders restructuring their businesses to include removable prosthetics services and products in order to capture market share.

Increased patient demand for implant-borne treatment options that promise a better quality of life by improving the fit, function, and esthetics of conventional removable options has rejuvenated the removable prosthetic market. Promoted on TV by commercial entities such as ClearChoice or via consumer campaigns conducted by large manufacturers such as Nobel Biocare for its All-on-4® concept, the use of implant-supported and implant-retained removable prosthetics have become a new standard of care desired by existing and new patients seeking to replace missing dentition.

However, the complex biological and biomechanical aspects of removable prosthetics requires clinical and technical expertise, making this a stumbling block for many clinicians who have graduated from dental school in the last 20 years. “We now have two generations of dental graduates practicing in the US who have minimal experience in removable prosthetics and need guidance through the process,” says Robert Kreyer Jr, CDT, partner of Custom Prosthetics Inc. and Implant Prosthetics Education Center in Cupertino, California. “In addition, the removable segment of the industry has changed rapidly in terms of its complexity with the introduction of implant-retained and supported prosthetics.” Understanding occlusion, implant placement, occlusal forces, and implant esthetics are all core competencies that come into play. That is why Kreyer believes that a collaborative dentist–technician relationship is so critical to the successful outcome of any removable case. With the expanded treatment options and the new choices in advanced materials and processing techniques, the complete implant prosthetics team must work together to meet the patient’s expectations in terms of function, fit, and esthetics.

This is especially true when cases involve the use of digital technologies to create precision-milled implant bars, laser-sintered partial denture frameworks, and even CAD/CAM-produced full dentures. “The digital aspect of removable prosthetics has opened up the lines of communication between the practice and laboratory because the laboratories are more in control of the core knowledge and have become specialists in the technologies and the biomechanics of these products,” Kreyer says. “Whether it is recommending the use of certain denture base materials, teeth, and prosthetic approaches to the case, the technician has become a vital prosthetics partner in helping to case-plan these complex treatment protocols.” Facilitating the dentist’s understanding of the various manufacturer protocols, the restorative space needed for each of these treatment options, tissue management, different approaches surgeons have for bone reduction, and surgical techniques all play into an implant prosthetics team approach to case management.

Such a unified tactic also has benefitted all stakeholders, including the patient, in managing the costs associated with complex implant-borne treatment. Rather than the surgeon, general dentist, and laboratory each submitting their bills at the end of treatment, Kreyer and his implant prosthetics team discuss the payments associated with the case and the margins everyone needs so they can provide the patient with a solid estimate before treatment. This financial and collaborative approach may help offset the impact of commercial implant centers by allowing more general dentists to offer these services to patients. “This affords the general dentist the ability to retain a patient whose trust and comfort level has been fostered over years of treatment instead of losing that patient to an alternative provider who the patient doesn’t know,” Kreyer says. “It is a successful approach that we have adopted to help our surgeons and general dentists mimic and compete with the package plans that the large commercial implant centers offer patients.”

The introduction of digital processes into the production of removable prosthetics in the past 5 years has offered the implant prosthetics dental team unprecedented accuracy in the delivery of implant bar-supported and metal-based partial restorative solutions. CAM-milled implant bars and 3D laser-sintered/melted partial frameworks from CAD files eliminate the unpredictability and inherent inaccuracies of conventional analog processes. Innovations involving CAM-milled full-arch denture bases also hold promise for the future. “Digital dentures will have a huge impact on this industry,” Kreyer predicts. “Companies are looking at this market because they see the increased need as our population base continues to increase, individuals live longer, and the demands for a more precise and esthetic restorative solutions than that of their parents and grandparents continues to grow.” Still in its infancy, CAM-produced conventional full dentures have clinical protocol issues and variables that need to be addressed in order for clinicians to deliver the information necessary to digitize the processes accurately. However, Kreyer warns that dental laboratory technicians need to be involved in the collaborative planning and design process as well as the final finishing procedures to ensure successful outcomes.

“There are myriad digital tools surgeons, dentists, and technicians can use today to facilitate the communication of case and patient data,” Kreyer says. “The gold standard has been digital photographs, But now, by using iPhones, iPads, and Internet resources, we can video patients as they speak or at try-in to determine flaws in the design, or bring the technician into the operatory to speak face-to-face with the surgeon or dentist while the patient is in the chair using powerful Internet software such as FaceTime to view any problems and resolve the situation immediately.” Manufacturers also have proprietary software communication portals to connect their dentists, surgeons, and technicians for collaborative thinking on implant planning, placement, and restorative design for complex cases.

“This allows all implant prosthetic team members to virtually plan and implement a treatment plan together and see and agree on case outcome before the patient comes in for that first surgical appointment,” Kreyer says. “Being able to transform an edentulous patient to a patient who can walk out the door with a complete arch of implant-supported complete provisionals in 5 hours takes an incredible amount of collaboration and upfront planning and execution. That’s why the dental industry is witnessing such demand for and success with these types of cases.” High expectations from socially active older patients who expect to retain the normal functionality and the natural esthetics of their youth, he says, are driving the market.