Latest / Straumann® ProTalk / Clinical edition: The real purpose of guided surgery with Dr. Nikos Mattheos (video version)

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Clinical edition: The real purpose of guided surgery with Dr. Nikos Mattheos (video version) · Straumann® ProTalk

0:00
Accuracy for the sake of accuracy is meaningless.
0:03
You should not see the guide as something that makes you able to do
0:08
something that you couldn't do otherwise.
0:10
And there is this one kid on the block that we hear a lot that is robotics.
0:14
How far are we from this being a true reality?
0:16
I think that this is already happening to a great extent, so that
0:20
there is more than 100,000 implants being placed by robots today.
0:25
But this trust is on us, not on the machine.
0:29
If you're wondering how far digital dentistry can really lead us, from static
0:34
guided surgery, dynamic navigation, or even robotics or artificial intelligence,
0:39
then this episode is for you.
0:55
Today, I'm joined by Nikos Mattheos directly from Thailand.
0:58
He's one of the most knowledgeable and influential voices in digital dentistry.
1:03
Nikos, what a pleasure to have you with us.
1:06
Thank you.
1:06
Thank you very much, Christian.
1:08
The pleasure is all mine, and thank you for the opportunity
1:10
to be here and share some of my thoughts with you and the audience.
1:15
Oh, I've been waiting for so long to have you here, so I'm gonna pick
1:18
your brain as much as possible.
1:21
That'll be mutual, for sure.
1:23
I like to start with first things first.
1:25
We hear the buzzword guided surgery, and let's assume I'm a dental student
1:31
coming fresh out of dental school and I hear left and right guided surgery.
1:36
What is exactly we're talking about?
1:38
Thank you.
1:39
I think there is a lot of buzz, you're right.
1:41
And some time ago when we started to start to define a little bit what
1:45
we're talking about, we realized it's not really about surgery.
1:48
The whole thing computer-assisted implant surgery might be misleading because in
1:52
reality, this is about a link in the chain that leads you to better outcomes.
1:59
It's the way we practice implant dentistry today, starting with a digital
2:03
treatment plan and then executing it to perfection to an optimal clinical outcome.
2:09
And this is one part of this execution.
2:12
Okay.
2:13
Now, so we're breaking down.
2:16
There will be prosthetically driven implant planning, and then there will be
2:20
the surgery itself, and that's exactly this one segment we're talking about.
2:24
Exactly.
2:24
And if you focus on the technology and you isolate it from the
2:28
big picture, it makes no sense.
2:30
Accuracy for the sake of accuracy is meaningless.
2:34
The only purpose of accuracy is to serve a properly designed digital treatment plan.
2:40
If you have it, then accuracy is essential to transfer it and to get
2:44
to the clinical outcome you want.
2:46
But without this context, accuracy makes no real sense, and this is
2:49
why guided surgery only makes sense as part of a workflow, not as a
2:54
standalone individual technology.
2:56
Got it.
2:58
And we also hear different nuances, right?
3:01
We have static guided surgery with the surgical templates.
3:06
We also have dynamic navigation.
3:08
We see also talking about robotics.
3:11
What are the differences between them?
3:13
And can we already talk about advantages or not yet?
3:16
I think these are all serving the same purpose.
3:19
The service is towards the treatment plan.
3:22
Execute with precision the plan that you have already done.
3:26
But of course, they come from different starting points.
3:29
the static is established technology.
3:31
It has 20 years of, background of evolution.
3:34
It has come to the point that is reliable, that is delivering,
3:38
but it has stagnated as well.
3:40
Dynamic is a totally new point of view, a different technology
3:44
trying to bring some different advantages and different approaches.
3:47
And robotic is, is the latest trend which we see overall in surgery, not
3:52
just in implant surgery, but implant surgery is maybe spearheading this trend.
3:56
We will see this spreading and spilling off to many other directions in dentistry.
4:01
I see.
4:02
I had this other day a conversation with, with Chmielewski, right?
4:07
Maya and Kris, and also in a different situation with Sonia
4:11
Lazy, a periodontist from Canada.
4:13
You see from different complete regions, different expertise.
4:18
One is perio, one is surgeon and restorative, yet both came with a, with
4:23
one topic that caught my attention.
4:25
They say, "There are moments that our hands are not so well connected to our
4:30
brain, and I like to count on digital technology and guided surgery to ensure
4:35
that from point A to point B, I'm there."
4:39
So both said, unless I cannot fit a guide to my patient, depending on
4:46
tooth position, mouth opening, I will always do my surgeries regardless
4:51
of my skill set, I can brag myself of being a good clinician, yet- I
4:57
would like to rely on guided surgery.
4:59
Is that how you see it as well?
5:01
I will see this point as a starting point.
5:03
Yes, the guide will add efficiency to what you do.
5:06
You can really trust on the guide to deliver the precision without you
5:10
having to be every single second.
5:12
And to be honest, the precision that you get from a guide, it, it exceeds
5:16
the, the precision you can get as a human surgeon, as an operator.
5:21
For me, however, it comes a little bit farther.
5:23
It empowers you to deliver care at a higher level.
5:27
So it is not only that I can put the implant predictively where I was planning
5:31
to do it, it's because of what comes next.
5:34
It-- Because maybe because I have a prefabricated prosthesis that I can
5:38
now put immediately on the spot, then I can minimize the amount of time
5:42
that the patient will spend without a tooth or without a function there.
5:46
Maybe it's because I can go flapless, so I can minimize the invasiveness.
5:51
So for me, I think these technologies, with the increased accuracy, they empower
5:55
you to deliver a treatment plan, but also an outcome that you couldn't do if
6:01
you didn't have this level of accuracy.
6:03
Potentially reducing morbidity.
6:05
Yeah, also.
6:06
And think about- You said flapless ... immediate provisionals that would
6:09
require chairside another hour with a patient on a fresh extraction wound,
6:14
for example, putting in and out acrylic.
6:16
And now you can minimize this time by having this already prefabricated.
6:21
So I think this is where this guided surgery gives you the added value
6:24
and the true benefit to the patient.
6:26
The patient will have less time on the chair, shorter treatments, more
6:30
predictable outcomes, and faster clinical outcomes in that direction.
6:35
I like how you contextualized this just now because, for example,
6:39
as you said, the acrylic, right?
6:41
Immediate temporization with the tooth shell that you have to do a
6:44
pickup and then add composite and then start trimming and polishing in ways
6:49
that two factors may be on a table.
6:51
First, the shape, you really have to be careful, manually right there.
6:57
And second, the roughness in which we can prefabricate smooth surfaces, in terms
7:04
of the provisional crown with the right emergence profile matching that shape.
7:10
it's only advantage today versus what we have seen in analogic workflow, isn't it?
7:15
Absolutely.
7:15
Absolutely.
7:16
It makes things faster, more predictable, streamlined, and
7:20
it, works in a much safer way.
7:23
You don't have to be a super specialist.
7:25
we could do immediates with immediate provisional 25 years ago, but it was
7:29
an extremely sensitive technique.
7:32
It was a very highly selected patient and a very skilled surgeon
7:36
with a very skilled prosthodontist.
7:37
Today, you can democratize or, globalize this technique because you can make
7:42
it available to more people than ever by having a reasonably well-trained
7:46
clinician and the digital technologies to deliver it to very high standards.
7:52
Nico, we just mentioned about some colleagues that they say I won't
7:56
treat any patient that is not guided unless conditions don't allow, right?
8:01
However, we see on the other hand, a few colleagues that are quite skeptical still.
8:06
They like to do things their own way, freehand.
8:11
Why do we still see a bit of a skepticism?
8:14
Is it related to cost?
8:16
Is it the learning curve?
8:18
W- what is the roadblock that we still see left and right conversation
8:22
about adopting or not adopting?
8:25
Absolutely.
8:26
I think there are different roadblocks, different choking points
8:29
in these different technologies.
8:30
Fully understand the challenges.
8:33
One thing that I would like also to make very clear, I think you should not see
8:37
guided surgery as a compensation for lack of expertise or lack of competence.
8:43
You should not see the guide as something that makes you able to
8:48
do something that you couldn't do otherwise, because then really this is
8:51
where we come into tricky situations.
8:54
our approach is always to make sure you have the competence to
8:58
do everything that you need to do freehand, and then you advance with
9:02
the surgical guides for efficiency.
9:04
Because you see, the l- the surgical guides have no learning value.
9:08
This is also an interesting observation we had.
9:11
There is a learning curve, and the learning curve is not an
9:13
expression, it's an actual equation.
9:16
On the horizontal axis, we have, the amount of time you spent to learn a
9:21
task, and on the vertical you have, the amount of competence you acquire.
9:26
Yeah.
9:26
So how much time do you need to perfect the skill?
9:30
The surgical guides, they can be quite fast.
9:34
You can learn this quite fast, but there is no educational value.
9:38
It will not make you a better surgeon.
9:40
If you start by placing implants with guides, you will not become
9:44
better in placing implants freehand.
9:46
Navigation is different.
9:48
Navigation is a freehand procedure where you have a real-time feedback essentially.
9:54
So we have observed that it takes much longer for someone to perfect the
9:59
navigation skills, but at the same time they're improving as s- freehand surgeons.
10:05
So there is an educational value in navigation, and you can use it
10:09
to train people to increase their surgical competencies, which is not
10:12
the case with the surgical guides.
10:14
I see.
10:15
So we use the navigation to train people.
10:17
We use the surgical guides to increase efficiency once
10:21
they have acquired the skills.
10:23
I like this, and it makes me remind of a conversation I had with Hermann
10:29
Gallucci where he said, the, it's not by accident that it's called
10:33
navigated surgery," similar as in a car.
10:37
You still sometimes know your way from point A to point B, yet you punch in
10:43
the address because you will feel more secure that you're going in the right
10:48
trajectory Is that, how you see it?
10:51
Yes, absolutely.
10:52
You, always develop your own strategies.
10:54
And I can see how people grow into this technology because in the beginning,
10:58
they always start focusing on the patient, and once they get stressed,
11:02
they fall back to what they knew before, focusing on the patient.
11:05
Once their comfort grows, they rely more and more on the navigation
11:09
until in the end they actually can be very comfortable to work on a
11:12
screen while operating on a patient.
11:15
Yeah, I see.
11:16
It's a very difficult spatial skill.
11:17
It's a totally different brain function.
11:20
As dentists, we never learn to work like that.
11:23
It's very unnatural for a dentist to have his fingers here, his eyes there,
11:28
and the brain reconciling the two.
11:31
And today with the goggles that we have, the glasses that we can a- at least look
11:35
in the same direction, this seems to,
11:38
overcome, right?
11:38
Ergonomically, at least it does, yes.
11:40
But as a cognitive task, it's still the same.
11:42
You actually have to reconcile two different realities.
11:45
Yeah.
11:45
One reality in your fingertips, another reality in the two-dimensional
11:49
screen you have in front of you, even if it's in the AR glasses.
11:53
And this is a little bit like gaming.
11:55
And this is why gamers have documentedly better, performance,
12:02
in these initial surgical tasks.
12:04
There is even meta-analysis about this.
12:07
Pa- surgeons with history of gaming, they perform much better in the
12:12
initial stages of the surgery.
12:14
So the
12:14
new generation of dentists, they will become better g- guiders.
12:18
Yes.
12:18
I think that we're coming to a paradigm shift.
12:21
We are going to have screen time being patient time.
12:24
Much of the actual treatment now will take place in the screen, either
12:29
before or during the intervention.
12:31
I see.
12:33
And now we covered the what, we covered the, why.
12:38
Now there's the how, right?
12:39
The Niko Materos philosophy.
12:41
There's a situation.
12:43
How do you evaluate, assuming you did the planning, prosthetically
12:48
driven, and it comes to that section, that is the surgery.
12:52
How do you decide left or right if you're going with the static
12:55
guide, if you're going navigated?
12:57
How do you move forward?
12:59
I think I have developed my own preference by now.
13:02
I, prefer the navigation over the statical guides.
13:05
This is my personal pathway because I feel that I have much more advantages.
13:11
the guides are limiting you.
13:13
The guides deprive you of your- control of what you're doing.
13:18
If you think about it, we are doing a surgery without being
13:21
able to see the, osteotomy we're conducting and without being able
13:25
to fully feel the drilling as well.
13:27
So I do feel that the navigation gives you the freedom of your own
13:33
surgery as you had been taught to.
13:36
At the same time, it's something that, allows you also to
13:40
operate in any condition.
13:41
You, Doesn't matter how wide is the mouth opening, which position in
13:45
the mouth, how long are the drills.
13:47
So I prefer the navigation as, opposed to static.
13:51
But of course, it has its own disadvantages, and I think one
13:54
of the biggest barriers for people is the business model.
13:57
It has a very high initial cost in the majority of cases, and then
14:02
you still have to pay on the go.
14:03
Most of these navigation devices impose some sort of a cost per
14:08
case on top of what you have paid.
14:10
So it is something that many dentists, especially if they don't have these
14:15
complex workflows or the flow of patients, might seen as a barrier.
14:19
It has a learning curve.
14:20
You have to learn, and you have to get support while you're learning.
14:23
It's not something that you buy and you put plug and play and you're perfect.
14:28
And, I think it is a technology that has many applications, but there is
14:33
no device which fulfills everything.
14:36
with navigation technology, the optical tracking, you can do photogrammetry.
14:41
You can do jaw motion tracking.
14:43
You can do endodontics.
14:45
You can do a lot of applications, even cutting, preparing crowns.
14:49
But there is no single device to do that.
14:51
Yeah.
14:51
And I don't want to have three devices to do three different
14:54
things with the same technology.
14:56
So I think as the technology matures, the business models become more competitive.
15:01
I think we will see these barriers falling.
15:03
I think we can agree that regardless of which direction, which you just stated
15:09
pretty much now you developed a preference towards one versus another, any guided
15:15
surgery is better than no guided at all.
15:17
Absolutely.
15:18
And the best thing is when you put the guided surgery into a workflow
15:21
for a better clinical outcome.
15:23
It's not precision for the sake of precision.
15:26
It's precision for the sake of shorter treatments, faster clinical outcomes,
15:31
less invasive treatments, and so on.
15:33
So we have to always challenge ourselves, what is the outcome
15:37
that we're looking for?
15:38
How can we improve the outcome and then get the technology backwards thinking?
15:43
Exactly.
15:44
Even anatomically speaking, we have tons of reasons.
15:47
We have sometimes converging roots that you wanna be precise.
15:50
You have concave labial walls that you really don't wanna fenestrate.
15:55
the number of reasons are all over the place.
15:57
We have inferior alveolar nerve that you- Of course ... don't wanna touch
16:00
at all, and you wanna be precisely per- The, list is endless on the reasons-
16:05
Yes ... why guided surgery is far more beneficial than completely freehand.
16:09
Absolutely.
16:12
Nikos, I have to shift gears, and we discussed about this one.
16:16
I like this quote called, "It's not what we think."
16:20
We have the right to think, of course, but evidence is there for a reason,
16:24
and that's why we say it's not what we think, it's what we know, evidence-based.
16:28
And I was curious to pick your brain.
16:30
If there is one article, one piece of evidence that to you was like this
16:36
aha moment that you thought, this one thing is something I should share with
16:41
the dental community because it made me think differently or opened my eyes
16:45
to something that I had never paid attention to," can you highlight one?
16:50
quite a few, but you are right.
16:52
we have had a lot of, experience with research in this navigation and static.
16:57
for 25 years now, guided surgery is something that is really being researched.
17:02
Some time ago, we, tried to, make a cluster analysis of the accuracy from
17:08
all the different clinical trials.
17:09
So we started looking to clinical trials from the very beginning until now about
17:14
static and dynamic and robotic, and check the accuracies and everything.
17:18
And you might be surprised.
17:20
we looked into more than 300 clinical trials, and almost 95% of
17:27
these trials had only one primary outcome, which was accuracy.
17:31
Oh.
17:31
That's all.
17:33
Millimeters of deviation, degrees in the angle deviation, that
17:36
was pretty much the only outcome of the majority of the studies.
17:40
So over-focusing on accuracy, and then the question was, what's the point of this?
17:45
So what is the difference between 0.7 millimeters deviation and 1.2?
17:51
Would it really make a difference for the patient, for you, for your workflow?
17:55
So that was the real question emerging, and then I came across one study
17:59
that was the oldest of all probably.
18:02
I- The
18:02
what of
18:03
all?
18:03
The oldest of all.
18:04
The oldest.
18:05
Yes, because I was looking to the origins.
18:07
Who was the first one to publish a study with something that
18:11
had to do with guided surgery?
18:13
And I came up with a paper of Brånemark.
18:16
Brånemark published a very primitive version of static surgery around 2000.
18:23
It was called Novum back then.
18:25
The implant, right?
18:27
Exactly, And it was a very, let's say an ancestor of the static surgery because
18:33
he had a horseshoe metal frame that fits on the mandible- One size fits all
18:38
exactly, with three holes, and he will drill through these three holes, and that
18:42
was the ancestor of the static surgery.
18:46
Now, what was interesting in this paper, there was not a single mention
18:50
of the word accuracy Why did he did it?
18:54
He do it, he didn't do it for the sake of accuracy.
18:56
The only reason he did it was because he wanted to load immediately, and he want
19:01
to have a framework prefabricated so that he can put it on top and load immediately.
19:06
So the purpose of this static guide was the clinical benefit of immediate loading.
19:13
Accuracy was not part of the picture.
19:15
So I think along the way we became over-focused on the technology.
19:19
We start competing on millimeters and fractions of millimeters, and we lost
19:23
the focus on the clinical outcome.
19:25
So I think this was a little bit a moment where it forced me to
19:28
realize, yes, there is no point in pursuing millimeters anymore.
19:33
You cannot get it to zero, and even if you get it to zero, it doesn't matter.
19:37
The point is, show me the real benefit.
19:40
Design a study which can show why the benefit of the patient is what
19:44
it is, why these technologies make sense for our patients, why does it
19:50
make it better for our treatments?
19:51
And I think this is where we now start to swift in this direction.
19:55
That's really good to know because indeed we see a lot of, if you
19:59
search PubMed, you'll be flooded with articles about accuracy, right?
20:04
Yes,
20:04
exactly.
20:04
And accuracy as an end, no, what for?
20:08
It's a means to an end.
20:09
What is that end?
20:10
Absolutely.
20:10
Absolutely.
20:10
Yeah.
20:10
So we need to see the end now.
20:12
I think this is the maturity that we have reached, that now we need
20:16
to, make a good case to everyone to show that there is an end.
20:20
It's not just about millimeters and angles.
20:22
It, there is actually a true tangible benefit for the patient, for the
20:26
workflow, for the institution as well, for the clinic that
20:29
actually, facilitates this workflow.
20:34
I like this very much.
20:35
I will shift gears to one topic that I know is very close to your heart,
20:38
artificial intelligence, right?
20:40
And,
20:43
we see already the presence of artificial intelligence is helping us
20:47
to do virtual extractions, identifying noble structures like nerves, so it's
20:53
already present in real radiologic analysis, treatment planning.
20:59
Is that it?
21:01
Where is artificial intelligence going to?
21:04
Let, me rephrase.
21:05
What is the role today of artificial intelligence that we
21:08
can say it's already a part of the present, and where is it going to?
21:12
Because the way I see from what I just described, it's
21:17
still all pre-therapy, right?
21:20
It's helping us to better diagnosis, to a better directioning.
21:25
Is AI also present throughout the surgery that it can help us shift something
21:31
in real time, or we're not there yet?
21:34
Yes.
21:35
that's the goal.
21:36
That's something really both exciting and scary as well.
21:39
You're right.
21:40
We're in the pre-therapeutical point, and to be honest, I think it's only
21:44
the beginning of the pre-therapeutical.
21:46
It's still very little elementary diagnostics.
21:49
For me, the big change will be when the AI will be able to do the digital
21:54
treatment plan, to do the system design.
21:57
Because essentially now part of the success is moved from
22:02
the procedure to the plan.
22:04
In the past, you were asking about a good surgeon, a good prosthodontist.
22:08
Now we have moved much of this complexity into the digital design.
22:13
So if you have a good design, then it can be executed very well with
22:16
the technology we have, even if the prosthodontist is not a master or
22:20
the surgeon is not like a wizard.
22:23
So this is where the chances are now that we make mistakes is
22:27
in the planning, in the design.
22:29
And most of the dentists have a natural resistance to spend time on the screen
22:34
because they feel that their time is better spent on the patient, and
22:38
that's what we've been trained for.
22:39
That's what we charge.
22:40
Yeah.
22:41
Many people do not really feel they can charge a digital treatment
22:45
plan, but it becomes a crucial point of the whole workflow.
22:48
So now I think with many dentists not willing to spend much time on
22:53
the screen, they start to outsource.
22:55
Who to?
22:56
To the dental technician most commonly, who might or might not be having
23:00
the skills to plan biologically on the evidence level we have.
23:05
There are some third-party services.
23:07
I see advertisements from websites where people, clinicians, they
23:11
undertake treatment planning.
23:13
Straumann is doing this, of course.
23:15
You have, so many in the box solutions.
23:17
Just send us- Smile in a box ... Yeah, exactly.
23:19
So this becomes now a business, and I think this is where the AI would
23:22
really have a very meaningful role to take over the digital treatment plan.
23:27
And there are many, products right now in the process, in the making.
23:31
So many of, solutions are being developed.
23:35
What I see as a risk is that the way they develop the solutions, they're using
23:39
historical cases to train generative AI to plan ahead, which for me is like you're
23:45
driving looking through the rearview mirror because we have so much evidence
23:50
about designs and how important they are.
23:53
So I don't want to throw this out of the window and have an AI
23:57
planning on the basis of 20,000 cases that were planned 10 years ago.
24:01
So I do think that we are in the process where we have to very carefully think
24:05
how to introduce an AI that can treatment plan based on the evidence that we have
24:11
and the individuals of the patient.
24:13
I think it's possible, but it takes a bit more different approach strategically.
24:19
Niko, I saw a presentation of yours that It kept me, kept my brain,
24:25
rattling for a few days after.
24:28
And when you say the direction where we're going, very likely in the future, dentists
24:33
will pretty much be validating treatment plans done artificial intelligence-based.
24:38
Is that really still how you see it?
24:40
I see the, I see it coming.
24:42
I think you can see prototypes already that actually do that.
24:46
The problem is that the treatment plan that comes from the AI is
24:49
not really the treatment plan I would have done with what I know.
24:53
So it takes more than just validating.
24:55
I have to really...
24:56
But once we introduce what we know to the, AI, then we will really get there.
25:03
And this is what we do as a mistake.
25:05
We are developing AI, which is deciding on the basis of what we have fed with
25:11
large number of cases from the past.
25:14
While in reality, we have to use the principles of biological design that
25:18
came through research and then supplement it with the ability to individualize.
25:23
And I think when this happens, we will have really very good solutions.
25:27
digital treatment plan, implant prosthesis, implant, prosthesis
25:32
and supracrestal complex is a system that is quite algorithmic.
25:36
And I think we can introduce the, framework of a sound design, which then
25:43
AI can populate to the individual patient.
25:46
I see.
25:47
Y- Do you also see this impacting the way we educate in dental school?
25:54
For example,
25:58
I see already a trend toward a few universities to be 100% the
26:02
prosthodontist, prosthodontics department, the restorative department,
26:07
be already fully digital, for example.
26:09
Not even talk about Godiva- Yes ... or certain impression materials
26:13
that we already know clinicians will come out of dental school.
26:17
They won't face that reality anymore.
26:19
We are already one step ahead.
26:21
So the precious time they spend in dental school, let's shift towards
26:25
what they were g- going to use.
26:29
This is already very extreme, right?
26:31
to discard quite some fundamentals.
26:33
Yes.
26:33
And w- if we're talking about AI present, how, h- how is the
26:37
future of education in this
26:38
one?
26:38
Yes.
26:39
You-- we are guilty as charged.
26:40
You got me there.
26:41
I actually personally, bullied our residents.
26:45
Whoever walks in the corridor with a stone model will have a severe punishment.
26:49
we use nothing of these conventional impressions or diagnostics anymore.
26:54
It's all digital.
26:56
But there is a risk I see there with the AI, and it's a true scary risk.
27:00
You know what is the risk?
27:01
Let's suppose that AI now gets to the point that it can treatment plan.
27:05
Yeah.
27:06
And it can-- you can upload your cone beam CT and the STL file, and then it
27:11
segments, and it gives you a prediction of a full arch restoration, where the
27:15
implant will be, how the abutments will look like, how the teeth will like.
27:19
Because I think we're not far from this point.
27:21
Now, when this happens, for me, that I have spent, let's say, 30 years planning
27:26
cases, it will be an added efficiency and something that will make my work faster.
27:31
But for someone who just graduates, that might be a disaster because how will
27:37
you teach to these people the treatment planning, which is one of the most crucial
27:41
skills and might take years to develop the comfort to, to plan these cases.
27:46
Yeah.
27:46
So once you can click the button and they will get the prediction, how
27:50
can I actually teach this to them?
27:52
How would they validate-
27:53
Exactly ... if they don't even know what they're validating?
27:55
How will they grow the competence to that level?
27:56
So- Yeah ... what do I have to do?
27:58
Shall I have, to say that, "Oh, you are not allowed to use AI for
28:01
planning until you reach this level"?
28:03
It's a difficult thing, but once it's available.
28:07
I think this is a challenge.
28:09
this is with the AI already seen in the language models.
28:13
There are some studies, one was from A- MIT, which, observed how the cognitive
28:19
decline comes when- Yeah ... they're using language model to write essays.
28:24
Then after several sequences, they lose the ability themselves
28:27
to write to that level.
28:29
Yeah.
28:29
So for people who have the skills, it will be added efficiency.
28:33
For people who don't have it yet-
28:35
Yeah
28:36
... this is the challenge.
28:37
How do we get them there?
28:40
Not to only push
28:41
buttons- Without pushing the buttons only ... but to also know
28:43
why they're pushing the button.
28:43
Yes, exactly.
28:44
and being able to also, yes, criticize and understand and so on.
28:48
Niko, I would like to, to shift a little bit, the direction of our
28:56
conversation on the following topic.
28:58
We discussed AI helping us predict, plan, analyze risks
29:05
with artificial intelligence.
29:06
Then we get one step there ahead.
29:09
We have a, nice privilege to choose dynamic or static navigation.
29:14
And there's this one kid on the block that we hear a lot, that is robotics.
29:19
H- how are we going that direction?
29:21
I see China is quite advanced exploring this technology Is this the direction
29:26
implant dentistry should be looking at?
29:28
Is, How far are we from this being a true reality?
29:32
I think that this is already happening to a great extent.
29:35
by now, the two major machines that are out there for some time, they
29:41
have surpassed 100,000 implants.
29:43
So there, there is more than 100,000 implants being placed by
29:46
robots today i-in China and US.
29:49
And, I don't see it as a direction for implant dentistry, it is an
29:54
overall direction for surgery.
29:56
Robotics will become more and more prevalent in surgery, especially when
30:01
they can solve significant problems.
30:03
Now, in implant dentistry, there is a lot of research and development,
30:08
but it has not come yet to the point that it can really solve a clinical
30:12
problem, a real clinical problem.
30:14
But it is maturing.
30:16
It's technology that is maturing very fast.
30:18
It's introduced with, a lot of new parameters all the time.
30:23
So I do see that in the future, a robot will be part of our clinic, and it will
30:27
be able to do many things that we will actually do not want to spend time on.
30:33
And, placing implants might be one of them, but there could be
30:36
also many different directions.
30:38
I think this promise of precision and automation from a pre-programmed
30:44
plan is, something that is really difficult to resist.
30:47
The whole, medical surgical field is moving in this direction.
30:53
It will be quite a paradigm shift, especially in implantology, right?
30:58
we were just talking about, dynamic navigation is freehand.
31:03
You have control.
31:04
You feel the-- where you're going.
31:05
You feel the drilling.
31:07
And then literally a ro-robotic, you're Outs- You're outsourced
31:12
to- No ... the procedure now.
31:15
there are many stages in between, Usually people, when they think about
31:18
robotics, they think about the task autonomy, that, you're sitting in
31:22
a chair program, and then the arm is going and placing the implant.
31:25
It'll come back later.
31:26
There is also-- Yes, exactly.
31:27
There is in-between stages.
31:29
There is the collaborative approach to the robot, which is, still a very, valid
31:34
direction, which means you're having, in a sense, a navigation, but the handpiece
31:40
is limiting your movement to only the trajectory that you have programmed.
31:45
So you are holding the handpiece, and you are drilling, but you can only move
31:49
along the axis of the perfect position.
31:51
Robotic.
31:52
And this is robotic.
31:52
This is the collaborative robotic.
31:54
It's not like the task autonomous.
31:56
So the handpiece will not move by itself.
31:58
You will have to hold it and lightly touch it, but it's your
32:03
hand that is putting it in and out.
32:05
But the robot is limiting your trajectory of movement only to the programmed one.
32:11
But we don't strap patients to the chair, right?
32:13
We d- How does that work together?
32:16
they're very fast.
32:17
They're way too fast.
32:18
they can respond to the movement of the patient.
32:21
They're very fast.
32:22
I think that this is not really a problem that I have seen happening.
32:25
And, interestingly, what, we had some honest question some time ago was,
32:32
because we don't strap the patients, they're all volunteers, and they all
32:36
really volunteer to be operated by a robot, one might think, "Why do they do
32:41
that?" Because they still have to pay.
32:43
It's not that we give them the free treatment, and they have the
32:46
option to have it with a robot or to have it with a surgeon, but they
32:50
still want to have it with a robot.
32:52
So some time ago, I really wanted to approach this more systematically a-
32:56
and try to investigate their motivation.
32:58
So we have assigned a PhD student who is interviewing all the robotic
33:02
patients before and after, trying to find out what makes them volunteer.
33:06
Are they science fiction freaks?
33:08
are they curious?
33:09
Whatever.
33:10
Can you guess what is the major motivation that is emerging?
33:14
Oh.
33:16
it's paradox, but the reason that they get operated by the robot is
33:20
because they trust the dentist who recommended to them this technology.
33:25
Oh, I see.
33:26
It's very interesting.
33:27
So in a sense, the real asset that we have is this trust from the patient.
33:32
So if your patient trusts you, and you tell the patient, "This device works well,
33:37
it's precise, it's good, you can have the surgery with a robot," then they will
33:42
go and have the surgery with a robot.
33:44
But this trust is on us, not on the machine, at least not yet.
33:50
And I'm very happy to see you saying that the professional made the recommendation
33:56
for such a procedure because countless times I've had conversation about
34:01
guided surgery with colleagues that are especially more experienced and
34:05
say, "Oh, no, I'm too experienced.
34:07
I know what I'm doing." Fine by me.
34:11
It was just a simple question.
34:13
But in to get to a stage where they would recommend the robotic,
34:17
it not implying that they are less of a surgeon, for example.
34:22
Yes, exactly.
34:23
True.
34:24
that's a true sign of professionalism.
34:27
Yes, I think this is the next level, and you can-- you're even more,
34:32
skilled because you're handling a very different level of complexity-
34:36
when you're operating a robot, and in order to take the risk also to
34:40
put your whole scientific weight behind this recommendation, for sure.
34:45
Do you see this could also be very well applied for, sites
34:48
that can imply higher risk?
34:50
For example, remote anchorage, zygomatic.
34:52
Absolutely.
34:53
I would think that this will be the first areas where the robots will
34:56
reach, cost-effectiveness because right now this is the major barrier.
35:00
They're not efficient.
35:01
They're not cost-effective.
35:03
placing an implant with a robot is far more expensive and far
35:07
more time-consuming on average.
35:09
so you pay for this 0.5 millimeters of accuracy by thousands of magnitude.
35:15
But the complexity is what will make it more efficient.
35:19
So if you look at zygomatic, for example, there is already some cadaver
35:23
studies that are upcoming, will be soon published, which they actually show
35:27
that with the robot you could be faster and more precise than with a single
35:33
intervention with a human operator.
35:35
So I think that the complexity will start, and then eventually it
35:39
will spill over to lower levels of complexity as the technology matures.
35:43
Not only faster, but consequently safer.
35:46
Yeah, of course.
35:47
the quality- Yeah ... standard is the same for sure.
35:50
The precision is higher, but also speed in these kind of major
35:54
operations is important- Yeah
35:55
because the patient is really under general anesthesia very often.
35:58
It's much more invasive.
36:00
You also want to keep things as streamlined as possible.
36:05
Niko, you've been exploring, as you mentioned, for more than two decades
36:09
digital technologies, guided surgeries, and, this universe of digital.
36:15
And- There is this one point that I say experience taught me this.
36:21
The knowledge base and the tools that you have, you acquired over the years, but
36:26
can you remember of one situation that you can go back 20 years and you say,
36:31
"Oof, I wish I could revisit that case because this was something that today
36:36
I would have done differently maybe."
36:38
Can you remember of one?
36:40
I think there will be quite a lot.
36:42
You see- Almost every technology and every level of technological
36:48
innovation has exactly this moment, that you really try something, you
36:52
get burned a couple of times, you back a little bit, and then it gradually
36:56
comes to the level that it delivers.
36:58
I think that we all have experienced this, especially when
37:01
you try to be on the forefront.
37:03
Of course, you always do your risk assessment, but, very often you, you
37:06
have to repeat procedures, very often you have to really cancel procedures
37:10
because things didn't come out the way that you- Yeah ... have expected.
37:15
And sometimes we get overexcited with technology.
37:17
Yeah.
37:18
That you were happy that it was Nikos that was there and not the robot.
37:22
Yes, exactly.
37:23
There is this, one bridge too far, when you go one step too much and
37:29
you say, "Oh, it was so nice, but I walked a little bit too far. I have
37:33
to step back for a couple of steps."
37:36
And in between all the learnings that you have, that you just mentioned quite a few
37:40
situations, is there any one tip or trick or, that you would advise young clinicians
37:49
that are starting in digital, in, guided whichever segment- they're going?
37:55
Let's assume static, Yes ... guided surgery.
37:58
That is today what's predominantly is being used, right?
38:02
Dynamic navigation is coming in, however, still getting there.
38:07
Yes.
38:08
today the present is static, guided surgery.
38:12
Is there any tip or trick regardless of, In which part?
38:17
Is it data acquisition?
38:18
Is it segmentation?
38:19
Is printing?
38:20
Is there anything that you say, "This is something I tell all
38:24
my students watch out for"?
38:26
it's a lot of things.
38:27
I think one of the thing that we sometimes misunderstand with, guided
38:32
surgery, especially the static, is that you're planning on a computer without
38:36
having the patient in front of you.
38:39
Usually, you see the cone beam CT, you see the STL, but you don't know
38:43
how much his, mouth is opening.
38:46
You don't know really how long he can stay with the mouth open, very open.
38:51
Very often we do an ideal treatment plan with a beautiful looking guide
38:56
in the digital plan, but when you try to put it in the mouth, the
38:59
patient struggles to have it in.
39:01
When you try to put the guide and your fingers, you realize it was too small.
39:05
You had to make it shorter.
39:06
So sometimes I realize that we miss the connection between the real
39:11
patient and the digital avatar because we don't have all the information.
39:15
So very often you plan your guide on an ideal environment, but in
39:20
reality the patient has limitations, so we might really have to reconcile
39:24
these two, and this is where experience makes the big difference.
39:28
Not to do your planning 100% on a screen, right?
39:33
Yes.
39:34
This is- You have to have the patient's, parameters as well.
39:37
We see it, for example, when we do sinus elevation, lateral window.
39:41
Now we place implants, and we do the lateral window with the same guide.
39:46
You can design the window and put it on your guide and have the
39:49
implants and the lateral window.
39:51
But then when you put the window too high, because on the cone beam
39:55
CT looks beautiful position, but on the patient you have to lift all
39:58
the way to the nose to get there.
40:00
So sometimes these are all the things that y- you see the disconnect between
40:04
the digital plan, which is only partial information, and the real patient with a
40:09
thick chin or with a small mouth or with a low level of tolerance to mouth opening.
40:15
So all these things sometimes we miss.
40:20
Oh, if it was just that simple, right?
40:23
It was... Yes.
40:25
Nikolaos, I would like to know from you, looking ahead, this is
40:29
a very philosophical question.
40:32
in regards to all this digitalities, is this just something that we keep dentists
40:37
as we are, and this only comes towards us?
40:41
Or there is something that we should start equipping ourselves
40:46
better in terms of skill?
40:47
How much can we step up or should step up in order to walk hand-in-hand
40:53
with the technology as well?
40:54
Is this improving?
40:56
Is this changing the role of the dentist in the future?
41:00
H- how do you see this whole evolution, not only hardware
41:03
and software, but human skill?
41:05
Absolutely.
41:05
I, am sometimes puzzled myself.
41:08
I think this is the time Where there is the biggest disparity between what we are
41:13
trained for and what we're practicing at.
41:16
So if you look at the education and the university and, the
41:20
forefront of clinical practice right now, there is a big mismatch.
41:25
And I think this is because it's moving much faster than our
41:29
education is catching up with.
41:31
So most of us are not prepared, and then it falls upon us to, to find the
41:35
level of comfort where we want to, grow.
41:37
So I think eventually we will have to grow to a direction where we
41:41
have multiple tools, and we have the skills to select the right tools
41:46
for the workflow that we're using.
41:49
I think this is the future important parameter.
41:52
Look at the workflow, look at the clinical outcome, and then select the tools.
41:56
Because if you start by first gathering the tools- Yeah ... you will get lost.
42:00
I think we're getting into an ocean of devices and software.
42:04
We do not have the standards yet.
42:06
All these devices do not talk to each other in the best way.
42:10
So you might really get yourself burned out if you start from the wrong end.
42:15
Just go gradually to clinical outcomes, move to workflows, and then
42:19
select very selectively the gadgets.
42:22
I see.
42:23
I like this a lot.
42:24
just as we said, there might be a preference for one or another,
42:28
as long as you master that one.
42:30
Yeah.
42:31
The ideal is to achieve the clinical outcomes that are benchmarked
42:36
by the profession right now.
42:37
This is how patients should be treated.
42:40
That's what you need to achieve.
42:41
Then work backwards to get the workflow that works for you,
42:45
that you're comfortable in.
42:47
And, maybe you have to also be a little bit, agnostic to all the sirens, because
42:51
there is bombardment of technologies, and it's very difficult to know how
42:57
they deliver until you try them.
42:59
I see.
42:59
This is also one new thing.
43:00
It's not about a new knife with a new shape or a new
43:04
instrument- with a new surface.
43:06
It's a software which has 1,000 different parameters.
43:09
Yeah.
43:09
And it takes a lot of time to learn it, so you don't even
43:12
know if you can invest the time-
43:14
Yes
43:15
... by the time you realize.
43:16
So I think we have to become very, selective.
43:19
And everything you choose doesn't work on its own.
43:22
It's interconnected with other software- Exactly ... with other hardware, with you.
43:27
Yes.
43:27
Exactly.
43:27
Yes, true.
43:29
Nikos, sadly, as captain mentions, "Cabin crew prepare for landing,"
43:35
sadly, we start our descent.
43:38
I can only thank you very much.
43:40
I've been waiting for this opportunity to sit down with
43:43
you and have this conversation.
43:44
I'm honored to have you with us.
43:47
And to all of our colleagues out there that would be interested to learn more
43:51
about your research, your education opportunities, where they can find you?
43:56
Thank you very much for the opportunity.
43:58
And, I'm always available online.
44:02
Actually, my own ideas lab is my website.
44:05
I have a, website, mattheos.net, my name.
44:09
I have always had it from the very beginning.
44:11
It's my own creation, and I maintain it myself.
44:14
So it's, nothing about, products or services.
44:17
It's mainly about ideas.
44:19
I put my ideas there first.
44:22
I get a lot of feedback, and then I work them around, and then I develop
44:26
things, in different directions.
44:29
So that's how I really get inspiration from friends and colleagues.
44:33
That's absolutely amazing, and they can also find the education offerings there?
44:37
yes, of course.
44:38
ITI, Thailand...
44:38
also, absolutely.
44:39
All the links will follow from there, yes.
44:43
Cool.
44:43
Thank you.
44:43
Thank
44:43
you very much.
44:44
Very much for this.
44:45
I very much appreciate.
44:45
Thank you.
44:47
And to all of you out there, if this content was helpful to
44:50
you, make sure you give it a you comment, and share to a friend.
44:54
sharing is caring.
44:56
Don't forget that.
44:57
Until the next episode, stay digital.
44:59
Ciao.