My face felt like a bag of wet cement because of the novocaine. Somewhere above, a faint, tinny sound of muzak seeped into the space. My face was covered in a blue surgical drape, and the dentist’s headlamp’s tiny white spot moved across it before focusing on my mouth. I overheard Dr. Mohamed Ali and his aide hunched over a laptop nearby exchanging some numbers that sounded like precise coordinates. The robot then started to get closer, and I could tell that it was almost ready to start its cautious descent through my gums and into my jawbone. Dr. Ali merely said, “Guided,” and the drilling started.
In San Francisco, Dr. Mohamed Ali was the first dentist to use a robot named Yomi to replace lost teeth. My lost tooth from a botched root canal two years prior would finally be secured by a titanium implant that he and Yomi placed in my jaw. Yomi aims to improve the precision and predictability of implantation surgery for dental professionals. The robotic arm “guides” the dentist to the precise location and angle of the drill bit after the system’s software creates a thorough spatial understanding of the patient’s mouth. After years of development and testing, Yomi was put through clinical trials by the 15-year-old healthtech startup Neocis to demonstrate its efficacy and safety.
Dr. Ali claims that the robot facilitates the treatment for the patients, many of whom are unfamiliar with robot-assisted surgery in general or Yomi in particular. “They seek a solution because they have broken teeth,” he explains. “But they feel much more at ease and confident when they realize that the surgery will be very minimally invasive and that the recovery period will be brief.”
HOW IT FUNCTIONS
In San Francisco, Dr. Ali’s practice is located on the nineteenth floor of an ancient, elaborate high-rise close to Union Square. It appears to be a typical dentist office at first glance. However, as soon as you see all of the computer screens (mostly used to display dental images), you can tell that this is a tech-forward office. As soon as you see the robot in the treatment rooms, your initial opinion is validated. Yomi is essentially a white medical trolley with an enormous monitor mounted on top of it. Its arm, which extends from a silver ball (the shoulder), bends at another silver ball (the elbow), and freely bends at a different joint (the wrist) at the drill mechanism, is its single humanoid trait.
The robotic arm and 3D imaging software are tightly integrated in the Yomi system. A CT scan of the patient’s skull, including the mouth and jawbone, is performed before the implant process starts. Yomi receives the CT scan and presents a highly detailed three-dimensional image. The dentist and Yomi use that picture to create a visual plan that shows the precise placement, depth, and angle of the implant.
Now that Yomi had a spatial map of my mouth, its software would need to align that representation with my actual mouth’s anatomy in order to navigate through the process. That is, even if my head moved slightly, it had to know precisely where the end of the arm was in reference to my jaw. The robot’s software uses an additional little piece of hardware known as the “link,” which fastens to the lower teeth on the side opposite the implant site, to help it orient itself to that location. The Yomi software can synchronize the 3D image with the patient’s actual mouth and the drill piece’s location based on the position of the “link.” All components of the system view the same object, thus even if the patient’s head moves slightly, they can still cooperate to finish the plan.
For me, the precision of this plan was especially crucial because my jaw bone, which formerly supported my lost tooth (number 14), had somewhat atrophy. Because No. 14 was close to my back teeth, Dr. Ali would be drilling into the jawbone just below the floor of my sinus cavity, and it was hardly thick enough to support the implant. In order for the implant to anchor, it had to be inserted far enough into my jawbone without interfering with my sinuses.
Luckily, Yomi is really good at that level of accuracy. Using the imaging software on the robot, Dr. Ali creates a plan for precisely the exact angle and depth of titanium implant insertion into the mandible. [Image: Sullivan Mark]
The Yomi arm is able to move freely until it approaches the patient’s lips. After that, it enters “guided” mode, providing the dentist with information on how to maneuver the drill in respect to the patient’s mouth. When the drill advances toward the precise drilling location indicated by the plan, it moves readily; when it progresses away from the precise position, it offers resistance. It guides the dentist in the direction of the proper drilling angle. Occasionally, the robot provides more than just opposition. The drill would not have continued in that way if Dr. Ali had moved it too close to my nasal cavities.
At tooth 14, I felt my jaw tensing up as the implant was being placed. The implant needed to be inserted with some torque. While it wasn’t easy, it wasn’t excruciating either. While many of Dr. Ali’s patients opt to be sedated during the process, I decided to remain awake in order to record the findings. It was all over in about half an hour. When I heard Dr. Ali remark the implant was positioned precisely and had never touched my sinus wall, I was still a little queasy from the novacaine. After the novocaine wore off that night, I experienced some jaw pain, but nothing that two Tylenols couldn’t fix.
NEOCIS
Yomi has been introduced to the dentistry business by Neocis, a Miami-based organization that has been collaborating with surgeons nationwide, including Dr. Ali, for the past few years. Alon Mozes and Juan Salcedo, who were engineers at MAKO Surgical and created a revolutionary robotic system for orthopedic surgery, launched Neocis in 2008. The two men came to the conclusion that robotics may greatly benefit dentistry, particularly highly sensitive, intrusive operations like implant placement. The following year, they established Neocis and began developing what would eventually become the Yomi system.
In 2012, Fred Moll, a medical robotics entrepreneur, led a $1.07 million Series A financing for the startup. After completing clinical trials, the robot was approved by the Food and Drug Administration in 2016 to be used in dental surgery, making it the first robotic system of its kind. In 2017, Neocis launched the Yomi robot, which now costs about $200,000 plus extra monthly maintenance and upkeep fees. Nearly 200 of these robots have been installed in the United States. According to Mozes, Yomis have implanted 40,000 devices to date. Over the course of 14 years, investors such as Norwest Venture Partners, NVIDIA’s NVentures, and Peter Thiel’s Mithril fund have contributed a total of $179 million to Neocis.
According to Mozes, Yomi can offer a platform that dental offices may integrate with all the workflows and systems required to complete an implant, from 3D imaging to crown placement. According to him, “[Yomi] is the only robotic system in the industry where we can address the surgical phase.” “It really gives us the chance to grow that into a platform that covers the whole implant workflow.”
One example is the practice of Dr. Ali, which currently provides CT scans, planning and diagnosis, and a surgical robot. A separate office area, one floor below the offices, is occupied by technicians who create unique crowns for each implant patient using a specialized computer-aided design (CAD) technology. The new crowns are milled using a robust 3D printer that is connected to the CAD system. The titanium implant itself is now made by a Swiss business by the name of Straumann, and it is the only component that Dr. Ali does not make herself. In the future, Ali says, “I want to buy a 3D printer so I can print my own implants, but that’s a very big project and requires FDA clearance.”
According to Mozes, since all of those systems are integrated onto a single platform, artificial intelligence (AI) may be able to automate more steps in the procedure, perhaps reducing the time between the initial consultation and crown implantation.
A RECENT HISTORY IN DENTISTRY
Mozes and Salcedo stand atop an ever-expanding wave. AI and robotics are currently used to assist in a wide range of medical procedures. While they don’t actually practice medicine, robots that assist doctors can have a significant impact. Any surgeon, no matter how skilled or experienced, can execute a surgery exactly the same way every time with a robot. Research has demonstrated that the expertise and training of the human caregiver has a startling impact on the treatment outcomes. Robots could be able to reduce such variance and increase the predictability of results.
According to Ali, “a dentist with limited experience in implant dentistry could still complete 75–80% of dental implant cases beautifully and successfully.” “There are situations where doing gum and bone grafting will call for additional training or surgical expertise.”
Artificial intelligence and robots have applications in both high-risk and low-risk medical procedures, such as dental implants and vein treatment around the heart. Robot-assisted dentistry is now being taught in dental colleges around the United States. Yomi systems have already been purchased by a number of prestigious dental schools, including the universities of Tennessee, West Virginia, NYU, and Boston University.
NOW ME AT NUMBER 14
I saw Dr. Ali once more after a 12-week break. It took some time for my jawbone to develop and mend around the implant. He removed the little flaps of gum tissue from my mouth and looked over the implant when I saw him again. He fastened an abutment, a metal component, into the implant’s top. The abutment, which resembles a metal post protruding from the gum line, holds the crown—my new tooth—in place. My teeth were photographed by a technician so that the new crown would match.
A few weeks later, Dr. Ali carefully considered the new crown’s placement in respect to the other teeth and how it might affect my bite. To cut a long tale short, it felt and looked perfect. I came to the realization that I had forgotten that I was recovering something significant that I had misplaced because I had become so absorbed in the robot and the process. The older of my parents was born during a dental era when it was normal practice to simply extract all teeth and replace them with dentures. I find that gruesome and archaic now. Dr. Ali stated to me as I was leaving the office, “I’m here for you.” “Savor the feeling of your teeth.”
I grinned and ran my tongue over my new No. 14 while riding the train home.