Entering the Digital Universe
Implementing appropriate technology for personalized protocols
Sefira Fialkoff
The implementation of digital technology has had a revolutionary effect on all aspects of dentistry, especially for implant-related procedures. When compared with analog planning using conventional impressions, digital workflows often result in reduced working time, improved accuracy, and greater patient satisfaction.
However, deciding when and how to incorporate digital technology into a practice's workflows is not a one-size-fits-all process. Understanding the advantages and limitations of the various technologies available, as well as the practice's particular needs and resources, is critical in deciding how best to incorporate digital technology into a dental practice. As the development of technology continues to advance at a rapid pace, so does the rate of adoption, and the profession is moving into a future in which artificial intelligence and other advanced digital technologies will likely dominate.
Today's Digital Workflows
When it comes to digital technology, the key to unlocking a wide range of digital protocols is the adoption of an intraoral scanner. Although the type of system utilized and the operator's experience and comfort level may impact both quality and efficiency, generally, intraoral scanning is faster than conventional impression making techniques regardless of the nature of the restoration and the size of the scanned area.1 Other important advantages of using an intraoral scanner include the ability to rescan missed areas and to previsualize areas, which allows feedback in real time. "Incorporating an intraoral scanner into your practice is a no-brainer," says Paresh Shah, DMD, MS, a private practitioner in Winnipeg, Manitoba. "The learning curve is shallow and fast. My entire team scans, and most of them have learned how to do it within an hour."
Despite this, intraoral scanning is far from ubiquitous. At the American Dental Association's 2021 annual meeting, none of the three main speakers on digital dentistry were scanning in the mouth. Some dentists digitally scan for some techniques but prefer to make conventional impressions for others. For some techniques, dentists combine conventional impression making and intraoral scanning.2 "I use the intraoral scanner for all restorative impressions, including preoperative impressions and bites, provisional impressions, and postoperative impressions," says Jason Olitsky, DMD, an accredited member of the American Academy of Cosmetic Dentistry who maintains a private practice in Ponte Vedra Beach, Florida. "I do not use the scanner for impressions for minimal or no-prep veneers; it can be challenging to mark margins, especially in proximal areas where the contact was not broken."
Deciding whether or not to incorporate digital technology in a practice is a personal choice that depends on not only the cost of the technology but also the types of procedures being performed. In addition, the frequency at which a practice performs certain procedures is an important factor in deciding which digital tools are most appropriate. New technology needs to be appropriately implemented into protocols in order to realize its efficiencies and other benefits. "My advice to dentists is to determine both current and future needs in their practices," says Nicolas Rohde, PhD, chief strategy officer at vhf Inc. "And because it is difficult for most dentists to determine future needs, it is important to stay flexible and invest in an open system rather than a closed one. An open system gives the user the freedom to choose from a myriad of different material and equipment options from different manufacturers."
The conventional fabrication of implant-supported reconstructions can be a challenging process requiring a variety of complex manual manufacturing steps, materials, and equipment as well as the skills and expertise of a restorative dentist and dental technician. Although dentists still require the foundational education, digital protocols have improved efficiency and accuracy. "When it comes to in-office design, you need software, and that's when the decision becomes a matter of personal preference," explains Shah. "How much time do you want to spend designing, and what is that time worth monetarily?" Many clinicians implement digital protocols in which they acquire intraoral scan and cone-beam computed tomography (CBCT) data but then outsource the design work to a laboratory. This can provide the benefits of digital technology while reducing the learning curve and time involved.
As a technology that has been around for more than 30 years, 3D printing has applications in dentistry ranging from prosthodontics, oral and maxillofacial surgery, and oral implantology to orthodontics, endodontics, and periodontics.3 In-office 3D printers can quickly produce high-quality solid models, removable die models, and implant analog models with crisp margins and contacts as well as a variety of other products, including surgical guides, clear aligners, splints, provisional restorations, and dentures. However, 3D printing can also be costly and time-consuming, especially regarding the postprocessing steps. "We have a 3D printer, but outsource our milling," says Olitsky. "This gives us the ability to be more hands-on in designing for the patient and allows us to reduce overhead for a select number of our cases. We use the 3D printer to print models to assist us in finishing ceramic restorations as well as to print long-term temporaries and transitional overlays for cases in which we need to alter the patient's vertical dimension of occlusion in stages."
With the widespread use of in-office digital technology, guided implant surgery has advanced to become nearly routine for implant placement. CBCT is used along with intraoral scanners, advanced software, and 3D printers to streamline the planning of implant positions and the fabrication of surgical guides while decreasing patient chair time.4,5 Dental laboratories and manufacturers have also become fully capable of fabricating guides specific to the wide range of implant systems available, so a full suite of in-office technology that includes a 3D printer is not a prerequisite.
Ultimately, when evaluating the costs and other factors involved in the adoption of digital dentistry, the effect on patient care should be the top priority. "Doctors need to take a critical look at the available technology," explains Shah. "You have to consider not only the cost but also the overall value to the practice. Will it help you to improve patient care? Will it also improve the practice's workflow?"
Limitations and Solutions
There are many potential limitations to the implementation of digital workflows in dentistry today, including the initial expense of the technology; the learning curve associated with its use; the ongoing investment for required materials, upgrades, and maintenance; and the staff and resources necessary. "Dental schools and manufacturers play important roles in addressing these issues," explains Shashikant Singhal, BDS, MS, director of education and professional services at Ivoclar Vivadent, Inc. "Schools help students develop a basic understanding of digital technology so that when they graduate, they can explore what's in the market and how best to utilize it. At the same time, manufacturers provide product-specific education about technologies and workflow possibilities while continuing to develop new technologies that are increasingly user-friendly and ideally more economical."
While modern tools such as intraoral scanners, CBCT machines, and 3D printers are paving the way for the future of dentistry, these technologies are also developing at an almost breakneck speed. Adopting technology requires careful evaluation of the merits of each individual product in order to determine how it will fit into the larger picture of a practice's workflow. There are many strategies and options for combining different technologies to create personalized workflows.
In clinical applications, intraoral scanning and CBCT will continue to be better integrated with 3D printing technologies, which, in turn, will further promote the development of digital protocols, not only simplifying and streamlining the traditional modeling and production process but also making the products more accurate, lowering the labor cost, and enabling the fabrication of new products, such as custom 3D printed implants using direct metal laser sintering.6,7 "I had a vision for how our practice would incorporate digital technology before purchasing the equipment," says Olitsky. "I knew exactly what I wanted to do with a design program and a 3D printer as we developed into an office with its own dental laboratory."
Carefully planning what you intend to do with new technology is critical to the success of implementation, as is evaluating your current resources and local market. "My number one recommendation for practices is to identify what they'd like to achieve with a technology and what resources they have to utilize that technology," says Singhal. "If most of your practice involves delivering crowns, you want to identify a digital workflow that will optimize that process. That may mean that milling them in-house is better than outsourcing, but if you don't have anyone in your practice who can use that milling machine for you, then the technology is of no use."
For those who wish to pursue milling, Rohde notes that all vhf machines and software applications are designed in a way that allows users with different experience levels to work with them. "For example, our same-day dentistry mill, the Z4, is plug-and-play and extremely easy to operate; however, for the slightly more advanced user, it supports most indications with almost every block material, and it even mills screw-retained crowns and titanium abutments," he says. "Not every user would want to mill abutments from the beginning, but everyone loves to have the option to do so as they advance."
A lack of patient demand to drive the utilization of a new technology can render it useless as well. Therefore, understanding the needs and preferences of your patient base is critical to the decision-making process. "I worked to create customer demand among my patients before even purchasing the equipment," notes Olitsky.
Although limitations such as the upfront investment costs, learning curves, and resources required to digitalize a practice's workflow have impacted technology's rate of market penetration, education presents another barrier. "The younger generation of dentists adopts technology much more quickly," explains Singhal. "Manufacturers donate products to schools, but if you've already graduated, you'll need to continue your education elsewhere. Beyond formal programs, there are mentors all over social media who can help you learn what's available and how to use it."
Progress and the Future
Presently, there is still a balance between analog and digital workflows in the profession, but the transition toward digitalization is happening very quickly as the continued advancement of digital technology facilitates even greater accuracy and efficiency. The development of new technologies, as well as new materials to support them, will play an important role in the future of digital dentistry. "We went from casting metals, to pressing glass ceramics, to milling glass ceramics, and now, we're milling metals and zirconia too," says Singhal. "We can see that the future of 3D printing will emphasize improvements in the manufacturing processes of prostheses as well as better data capture and the development of new products and materials for printing."
The ease with which one can transfer and store files and manipulate the data to treatment plan and design is already remarkable, but further efficiency is likely on the horizon. "The future of digital technology will involve increasing the efficiency of the workflows while making the software more intuitive for the users," suggests Olitsky. "Digital workflows enable better communication between dentists, patients, and laboratory technicians and open the door for dentists to become more hands-on in the design and laboratory fabrication components of cosmetic cases." By further improving communication and collaboration, digital technology can provide even smoother workflows and lower patient costs in the future.8
In addition to the need for resources, patient demand, and education, other factors, such as the COVID-19 pandemic, have affected the uptake of digital technology in dentistry as well. According to Inside Dentistry survey data, in 2019, 53% of responding dentists reported that they spent more than 10% of their yearly practice budget on new technology. That number jumped to 56% in 2020 before falling to 47% in 2021.9
As exemplified by the proliferation of teledentistry during the COVID-19 pandemic, digital technology can also help remove barriers to patient care.10 Teledentistry facilitates the real-time and store-and-forward exchange of clinical information and images. Remote consultations can be used to evaluate and triage patients presenting with new issues, to facilitate follow-up after treatment, and to provide education regarding preventive care for oral health promotion, but it is an adjunct rather than a replacement for routine in-person dental care. "I don't see a situation in the next 5 to 10 years in which patients are scanning their own mouths remotely," says Singhal. "We are seeing an expansion into remote dentistry with teeth whitening and direct-to-consumer orthodontics, but from a dental professional standpoint, it's still a gray area. Patients don't know what they don't know."
There are many ways in which the adoption of digital technology and workflows can benefit practices and their patients, but the technology must be conscientiously selected and correctly implemented to realize these benefits. When practices carefully assess what they are willing and able to invest regarding money, training, staff, and other resources and establish that sufficient patient demand exists to realize a return on investment, they can select the most appropriate technology and protocols to suit their individual circumstances and visions for the future. Each practice's transition into digital dentistry should happen to a degree and at a speed that is appropriate for the practice. With the speed with which digital technologies and protocols are advancing, it's prudent for practices to make considering them a priority; however, practices should only implement a technology if doing so will allow them to advance the number one priority: the delivery of the best possible patient care.
References
1. Siqueira R, Galli M, Chen Z, et al. Intraoral scanning reduces procedure time and improves patient comfort in fixed prosthodontics and implant dentistry: a systematic review. Clin Oral Investig. 2021;25(12):6517-6531.
2. Hong SJ, Lee H, Paek J, et al. Combining conventional impressions and intraoral scans: a technique for the treatment of complete denture patients with flabby tissue. J Prosthodont. 2019;28(5):592-595.
3. Tian Y, Chen C, Xu X, et al. A review of 3D printing in dentistry: technologies, affecting factors, and applications. Scanning. 2021;2021:9950131.
4. Carter JB, Stone JD, Clark RS, Mercer JE. Applications of cone-beam computed tomography in oral and maxillofacial surgery: an overview of published indications and clinical usage in United States academic centers and oral and maxillofacial surgery practices. J Oral Maxillofac Surg. 2016;74(4):668-679.
5. Chen P, Nikoyan L. Guided implant surgery: a technique whose time has come. Dent Clin North Am. 2021;65(1):67-80.
6. Anssari Moin D, Derksen W, Waars H, et al. Computer-assisted template-guided custom-designed 3D-printed implant placement with custom-designed 3D-printed surgical tooling: an in-vitro proof of a novel concept. Clin Oral Implants Res. 2017;28(5):582-585.
7. Li L, Lee J, Amara HB, et al. Comparison of 3D-printed dental implants with threaded implants for osseointegration: an experimental pilot study. Materials (Basel). 2020;13(21):4815.
8. Lin L, Fang Y, Liao Y, et al. 3D printing and digital processing techniques in dentistry: a review of literature. Adv Eng Mater. 2019;21(6):1801013.
9. Mazda J. Trends in dentistry 2021: making sense of unusual times. Inside Dentistry. 2021;17(12):12-16.
10. Fricton J, Chen H. Using teledentistry to improve access to dental care for the underserved. Dent Clin North Am. 2009;53(3):537-548.
COMING IN JULY
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