E27:Podcast: Bret Royal of Implant Concierge on benefits of implant surgery

Hello and welcome to Ascent Dental Radio. A program dedicated to the balance between the clinical aspect of health care and the business of health care. And now here is your host, Dr. Kevin Coughlin.

Kevin: This is Dr. Kevin Coughlin. Thank you for listening to Ascent Radio. My podcast is Ascent-Dental-Solutions. My name is Dr. Kevin Coughlin, a practicing dentist since 1983. I want to give congratulations to Doug Foresta, Standout and Be Heard. Doug has been helping me produce this podcast for the last several months and he can be reached at dougforesta@gmail.com.

Today, we have what I consider one of the leaders in the industry, Mr. Bret Royal, Founder and CEO of Implant Concierge. If you haven’t heard about it, you will hear about it in the near future. Bret is here to talk about the advantages of Implant Concierge, which I’ve learned firsthand.

He established seven businesses all related to the implementation and utilization of cone beam technology and guided implant surgical services into the dental market. As CEO of Implant Concierge, LLC, he’s built one of the largest CAD/CAM guided manufacturers in the world while focusing on service, simplicity and affordability.

With no further ado, I’d like to introduce to you Mr. Bret Royal, CEO of Implant Concierge. Bret, thank you so much for taking your valuable time to speak to us and the dentists all across the world about the advantages of guided implant surgery. Give me a little bit of a background about why you started your company and how your company is doing right now.

Bret: You bet. First of all, Dr. Coughlin, thank you so much for having me on Ascent Radio and on your podcast. It’s truly an honor. I really am excited to be here. My company was founded originally as a dental imaging center along with myself and 42 other dentists in San Antonio. And it was right when cone beam CT was coming out, it was pretty new and expenses of buying a cone beam CT unit, obviously, was not a smart economical decision at the time.

So myself and a few other dentists here in San Antonio went in as partners and opened a really nice state of the art dental imagining center focused on treatment planning and dental implants. Because of my network of surgeons across Texas, we went from one imaging center to ten relatively quickly in about three and a half years.

From the very beginning, the cone beam CT was fascinating, but what really got me excited because of my dental implant background was taking the cone beam CT images and creating a virtual surgery and presenting that to the doctor and as well to the patient to help improve the case acceptance and also just the quality and predictability of dental implant surgery. Over the years as the business grew and the services were becoming more and more popular, we really needed a way to take our business from local region dental imaging centers where we were provided really robust services to more of a national platform, even a global platform. That’s how Implant Concierge was created, is how can we take what we currently do but provide it to many more dentists across the United States and not just where we’re located.

Implant Concierge was founded on things that we had already been doing, but putting it online and making it much more simplified and taking all the time away from the doctor to free up the doctor from having to buy software and spend a ton of time sitting there working with DICOM files, merging, segmenting and also doing all the thresholding, and just simplifying the process and building a communication tool that will allow doctors to work together to make the process very multi-disciplinary and also very simple.

That’s my background and it’s been an amazing growth over the past ten years. Implant Concierge is averaging about 3.8 new dentists per day since October 2014. So it’s been a wild ride, but it really matters because I think the services are what many dentists need as they embark upon providing implants for their patients.

Kevin: I can just digress a little bit that I placed my first implant in 1983. At that time, I scheduled almost three hours to place that singe tooth implant. Over the next 34 years, I’ve put in literally thousands of dental implants. And only until the last five to seven years that I realized that — because this podcast goes out everywhere to non-clinical people, to clinical people, to the public in general, you may not realize this, but when we first started placing implants, we would drill a hole into the bone and check for the quality and quantity of bone. If it feels dense, if it felt strong, that was a good indication that the implant would be successful. Those pioneering days, I’m happy to say, are gone by the wayside.

Today, with cone beam technology and your company sophistication of software and guided surgery, we can now basically do the surgery virtually before we ever start the treatment on Mr. or Mrs. Smith. The cone beam allows us to check for quality and quantity of bone, height and width of bone. Why don’t you take a couple of minutes and explain to our audience some of the advantages and sophistications of using the virtual treatment plan before the actual treatment plan?

Bret: You bet. Many, many dentists go into a case with a lot of concerns about the anatomy and the amount of bone. As you said, the cone beam CT was powerful and fine giving us the bone quality and quantity upfront so at least now we know. But on top of that, now we can go ahead and we can place the implant. It allows us to avoid challenging outcome of situations, whether it’d be the sinus or the nerve, we can also place the implant in the ideal restorative position.

And really this is the key, I think, for many dentists whether you’re a specialist or you’re a general dentist placing the implants, you want to be able to plan and place the implant in the ideal restorative position so that at the end of the outcome you have a tooth. You don’t have a crown on top of an implant.

Using the software, we can place the implant in the ideal position. We’re using the crown-down philosophy, using that restorative crown as our guidelines and then maximizing the bone to the implant position and size, the length and the width. The software allows us to do that. Taking the diagnostic cast or the patient’s digital dental model and merging it also gives us the soft tissue and so many other parameters to consider while we’re placing the implants.

Once we have that virtual surgery completed, now we can take it to the next step and take the virtual surgery and utilize that to design a 3D surgical guide that utilizing CAD/CAM and 3D printers we can now print a medical grade surgical guide that can be used that takes our virtual plan and then it turns it into reality into a surgery.

Kevin: I know that we have a wide variety of listeners with a diverse degree of experience. Basically, if you walk us through, from my perspective, we have tooth-supported surgical guides and bone-supported surgical guides. In simple lay terms, some people have no teeth and we’re replacing all of their missing teeth with dental implants and other people have a wide variety of teeth still present and we’re replacing just a single tooth.

Can you explain the process, the procedures and how Implant Concierge works through the completely edentulous patient, the patient has no teeth at all, so that our listeners get a firm idea of the power of Implant Concierge and the tremendous success rate by following the correct process and procedures?

Bret: You bet. And I think if you go to our website, we have these protocols listed out to review and look at a step one through five process. But ultimately, the dentist would simply start the case at Implant Concierge and let us know which teeth are missing. In this situation, all teeth would be missing. And also on another chart, they let us know where they ideally would like to place the implants.

Once that’s completed, the Implant Concierge is going to get the dentist the exact specifications and rules, the workflow, so to speak, as far as exactly how to do it.

The number one step on a fully edentulous patient or someone with no teeth is to have a well-fitting hard reline denture. Once we have that denture, we can go ahead and use they call them X-ray markers, but it’s really a one millimeter lead ball that’s on a sticker and they’re actually for mammograms.

So we go ahead and we take six of these X-ray markers and just stick them randomly to the patient’s denture. At that point, utilizing the doctor’s cone beam CT scanner, we’ll go ahead and scan the denture with these X-ray markers on them and then we’ll very carefully take the denture and position it near the patient’s mouth. While the patient is wearing it, they’re also given a CBCT scan. Essentially, the patient was scanned one time with the cone beam CT unit and the denture was exposed twice.

Once those two scans were taken, it’s generate a file called DICOM. That’s what cone beam CT generates, is a DICOM files. Both those data sets or DICOM files are uploaded directed into Implant Concierge’s HIPAA compliant communication portal. So they’ll go and upload us the files. Once we have those, it’s a matter of utilizing software to match them back together and then using a tool called Thresholding, we can literally threshold the difference and create the soft tissue model.

From there, once we have that soft tissue model, we can pretty much do anything we would like to do. And we utilize the denture, the soft tissue model and the bone to meet with the dentist to finalize the final positioning during that virtual implant planning or VIP session.

It really is magical how simple it has become over the years. This used to be a very time consuming and also a very expensive process for a fully edentulous patient. Now, a fully edentulous patient is one of our easiest cases that we can do, believe it or not.

It’s come a long way in a matter of two, three years, saving that patient weeks of waiting for the diagnostic tools and treatment planning to be completed as well as a ton of costs that can now be minimized from not having to create really expensive scanning appliances. So this dual scan protocol, using the X-ray markers along with the patient’s denture is just a wonderful advancement for the patient and for the dentist.

Once that meeting is done, Dr. Coughlin, at that point we go ahead and we build a surgical guide that matches the intaglio surface or the denture so it fits just like the patient’s denture did. And then at that point, the dentist can go ahead and do a very efficient surgery.

Kevin: Just for our listeners out there, these little millimeter microdots or mammillary dots for radiopacities, you can order these through your local surgical supply house or I believe Implant Concierge can also order these radiopaque dots also. Another quick for individuals are make sure when Bret explained to you, you’re better off taking the denture with the diagnostic radiopaque dots and scan that first, then put it in the mouth rather than vice versa.

Because once that prosthesis is put in the mouth, sometimes the saliva and moisture can loosen up those radiopacities and you like to keep them in the same place. Am I correct on that, Bret?

Bret: Yeah, that’s a great tip. So step number one definitely would be to scan the denture out of mouth first with the markers and then carefully put it into the mouth. As far as the purchasing location, if you just type in “one millimeter X-ray markers” you’ll have a whole plethora of medical supply companies. Or if you buy from Implant Concierge, we have created a little package where you get a box of 110 of these markers for $40, that includes shipping, as well as the protocol sheet as well as a little sponge because you want to position the denture on top of a sponge or a form on top of your CBCT scanner.

So it’s almost like a little scanning kit for your dental assistants to follow along very precisely. It’s a little bit technique sensitive when it comes to taking the cone beam CT X-ray so having these protocol sheets right there for the dental assistants who will be taking the X-ray is very helpful to avoid any issues or poor scan quality.

Kevin: Bret, can you talk a little bit now about the patient who’s dentate, someone who has a multiple number of teeth but may need one, two, three or four additional teeth replaced and the sequence on that?

Bret: You bet, Dr. Coughlin. Providing a surgical guide for a patient who currently has teeth or what we consider a partially dentate patient is also extremely simple. The workload depends upon the technology that the dentist currently owns. Once again, you start the case at Implant Concierge and then follow the protocols.

The first thing that we’ll need is to take a cone beam CT scan of the patient. What’s nice about this is that no scanning appliance is necessary or a radiopaque template or a special bite guide. Nothing is really required. All we want is a simple separation using cotton rolls of the upper and lower maxilla and mandible teeth.

Once you have a simple separation, sometimes people will even use a bite stick and lay it across the occlusion table just to create a little bit of a separation. At that point, once you have the separation of the teeth, go ahead and take a CBCT scan so there now we have our DICOM.

You directly upload that into Implant Concierge and then if the dentist does not own a digital impression technology, then they’ll go ahead and take an alginate impression and then pull up a really nice accurate diagnostic cast and then ship us the diagnostic cast. Once we receive the diagnostic cast, we’re going to go ahead and digitize it using an optical scanner and create a digital file of that diagnostic cast. And then we turn that digital file into what we call a .stl (dot STL).  

If the dentist owns an intraoral scanning unit or a digital impression unit, that’s wonderful because the dentist can take a quick impression of the arch of interest and upload the STL file directly into Implant Concierge and within minutes, Implant Concierge will have the DICOM of the CBCT as well as the digital impression.

And then we’re off the races of merging and planning the case for the dentist. It’s either a cone beam CT plus a diagnostic cast, or if you have a digital impression, take a digital impression and upload that directly to Implant Concierge. So the workflow for partial is very simple.

Kevin: I know all of this information is on your exquisite website. But if the patient is partially edentulous and has a good fitting partial or removable partial prosthesis, do you want that partial in there when you do the cone beam or would you prefer that that be out of the mouth?

Bret: That is a great question and a lot of dentists they make the mistake. You do not want to have the partial in the mouth when taking a cone beam CT scan. The reason makes a lot of sense; cone beam CT scan does not like metal and most partials have some type of metal framework built within or the clasp.

So those clasps create all kinds of scatter or what people call noise on the cone beam CT. When you scan a patient, make sure everything is removed from the mouth. However, that RPD or the Removable Partial Denture, is so valuable for us for planning.

So whenever you send in your diagnostic cast, if the patient has an RPD, go ahead and take a second impression, what we call a pick-up impression of the patient wearing their RPD and send that in also. So now we have two diagnostic casts; one of the patient with their missing teeth and then one of the patient wearing their actual RPD. Because that gives us the actual reality or the actual positions of the restorative teeth and where you’d like to have them.

Once we know where the restorative teeth are at and we know the bone, we can do an amazing treatment planning that’s extremely accurate, once again, using that crown-down philosophy. So the RPD is a very useful tool.

Kevin: Am I correct if the patient doesn’t have a removable prosthesis if you’d advocate a diagnostic wax-up? So you’d send the impressions or I should say the pod accurate models of the edentulous area and then you would do a diagnostic wax-up so that we’re helping you where we want the occlusal plane, the path of insertion, the emergence profile, et cetera. Am I correct on that?

Bret: That is correct. This becomes a situation where you kind of have to make decisions. If we’re only missing one or two teeth, my team, they’re very well trained, they’re all dental assistants and also lab technicians, we know where teeth belong so we can virtually place a tooth in the right position to give us that crown-down philosophy.

However, if you’re missing a long span of bridge of teeth, maybe like say three plus teeth in a row, may four teeth in a row, then it’s really powerful if the dentist would send us I want the teeth to be in this exact position. So a lot of dentists what they’ll do is they’ll go ahead and do a quick wax-up in their lab or have their lab create a wax-up and send us that diagnostic cast with the wax-up on it as well.

If the dentist does not want to do a traditional wax-up, that’s not a problem. We have some very powerful software where you can send us the diagnostic cast as well as the upper and the lower end by registration and what we’ll do is we will virtually merge those files together and we’ll do a virtual articulation and then we’ll create a virtual wax-up that’s going to be extremely accurate, just like your lab would do on the bench with the articulator.

It is actually a huge advantage if the dentist does send us a wax-up because that way, we can make sure we use the crown-down philosophy. Having the doctor’s wax-up is always going to be superior versus someone else’s because you guys know exactly where you want that tooth.

Kevin: Mr. Royal, I cannot explain as our listeners know listening to me for several months now doing this podcast, I only endorse companies that I believe, like and trust in. My association with your company what has just been to me over the top is the care, the service and the ability to want to train us to provide a better care and better service for our patients.

Bret, can you tell us your website and how the doctors listening can get in touch with you to ask additional questions or order from your to get started with Implant Concierge?

Bret: You bet, Dr. Coughlin. I just want to say once again, thanks for having me. I also want to say my whole vision, my whole goal is to make guided surgery because I think it’s so powerful and so wonderful and as simple and affordable as possible. That’s what  I think we’re based upon.

I think we’re one of the few companies that actually provide this level of service and support. So I’d love to give you my contact information so that way your listeners if they want true service and a guided surgical company, I hope they give us a call. We can help them out to provide that predictable solution that they’re looking for as well as the confidence.

Our number is 866-977-2228 and the website address is www.implantconcierge.com. The easiest way is to call us, someone will jump on your computer with you, give you all the protocols and we’ll even review your cone beam CT scans before you upload them to make sure that they’re of great quality and scan correctly. Whatever we can do to help out, we’d love to be there for you.

Kevin: Mr. Royal, thank you very much and I know your company is going to go nothing but straight up, the service, the care, the expertise over the top. I know how busy you are. I can’t thank you enough for taking the time.

You’ve been listening to Ascent Radio. Again, a shout out to Stand Out and Be Head by Mr. Doug Foresta who’s producing this podcast. A special thanks to him. That’s dougforesta@gmail.com if you’re interested in podcast and the power that it can provide for education and knowledge.

My name is Dr. Kevin Coughlin and you can contact me at www.ascent-dental-solutions.com, with a focus on education, training, development and knowledge. Thanks again for listening and I look forward to talking to you in the near future.