The use of digital dentistry is on the increase as costs to acquire digital technology have gone down dramatically and allowed for more practitioners to integrate digital equipment with reduced investment. One of the most significant benefits of digital technology in dentistry is the ability to streamline processes that can be cumbersome via the analog way. In digital dentistry, it is important to understand the advantages and disadvantages of each device or system available.
Key points
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The use of digital dentistry is on the increase as costs to acquire digital technology have gone down dramatically and allowed for more practitioners to integrate digital equipment with reduced investment.
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One of the most significant benefits of digital technology in dentistry is the ability to streamline processes that can be cumbersome via the analog way.
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In digital dentistry, it is important to understand the advantages and disadvantages of each device or system available.
Introduction
When we look around, it is amazing yet eerie to see how surrounded we are by technology. The word technology comes from 2 Greek words, translated into techne and logos . Techne means art, skill, craft, or the way, manner, or means by which a thing is gained. Logos means word, the utterance by which inward thought is expressed, a saying, or an expression. Literally, then, technology means words or discourse about the way things are gained. In today’s more relevant definition of technology, it can be broken down into 4 working subsets: technology, an object, knowledge, and last, a process. For the purposes of this article, the authors expand on all of these subsets for digital dentistry. Digital dentistry and its implementation into practice is more than just the piece of equipment. It is important to understand more than how to use the device, the nuances of the technology, the processes involved, and how the technology fits into your existing practice system.
As with anything new to an existing system, there are pros and cons of modifying a single process within the current work flow; digital applications are just additional tools in your toolbox, like a hammer and a screwdriver.
In digital dentistry, it is important to understand the advantages and disadvantages of each device or system available. From a well-rounded understanding, you will be able to see how and if it fits within your practice. Just like any other instrument, digital technology also has its limitations; in some situations digital technology works very well, whereas in other circumstances, digital technology may be contraindicated, similarly to using a screwdriver instead of a hammer. Herein, the authors discuss digital technology in dentistry, its advantages, shortcomings, and it potential to elevate how to practice contemporary dentistry with a vision to the future.
The use of digital dentistry is on the increase as costs to acquire digital technology (digital radiology, for example) have decreased dramatically and allowed for more practitioners to integrate digital equipment with reduced investment. For the purposes of this article, the authors focus on the acquisition of patient data by exploring digital intraoral scanners and digital radiography and they touch briefly on digital photography. They also look at the applications one can have with the digital data, and their potential outputs-associated 3-dimensional (3D) printing and milled restorations.
One of the most significant benefits of digital technology in dentistry is the ability to streamline processes that can be cumbersome via the analog way. The biggest incentive about creating more efficiency in a dental practice is the ability to provide consistent high-quality dentistry while decreasing costs for the patient. In any business, the net operating income, namely, the amount of money left over after expenses, is something that cannot be ignored, and therefore, reducing the chair time needed per procedure will bring about more revenue generated on a daily basis, and digital dentistry can speed up certain processes, allowing for a more efficiently run practice. In the authors’ practice, for example, new patient data acquisition time was reduced dramatically with the use of digital technology, especially when considering the time needed for preliminary physical impressions, to pour up the models, to mount the case as well as to store the cases.
In the authors’ practice, the new patient record includes a full set of photographs, intraoral scan, and a full-mouth radiograph set. A scan will allow the practitioner to evaluate the dentition and discuss with the patient immediately on a 3D model versus having to wait to pour up a case, mount on an articulator, and then bring the patient back to discuss the findings. Because data are stored digitally, the practitioner can reference the acquired data at any time, thus enabling the practitioner to go back into these digital files to reexamine the patient to ensure nothing was overlooked.
Another advantage of digital dentistry is how the practice can expand their boundaries when assembling the dental team. In an esthetic dental practice, having an exceptionally capable ceramist in the team and using digital technology enable the practitioner to work remotely and send patients’ cases to practically any ceramist throughout the globe. In addition, with the quality of digital photography and its accuracy at capturing color, shade match can be done remotely as well. With the use of calibrated gray cards and polarized lens photography, accurate color information can be transmitted to the ceramist; this can eliminate the need for a custom shade appointment that would have normally had to be done in person by the ceramist.
Another noteworthy advantage of transitioning and embracing digital capabilities is demonstrating to existing as well as new patients how updated your approach is. Not only do patients appreciate seeing that their caregiver is up-to-date but also many admire clinicians who are leaders in technology, and they become your biggest advocates. By the same token, as patients become increasingly aware of advances in dentistry, if you do not have the updated technology in your office, they may question your professional abilities. One great example is with the significant advertising being done by those clear aligner therapy startups, such as Smile Direct Club, and how their stores feature intraoral scanners. As more and more of the public are aware of these scanning technologies, the more they expect it to be the norm.
Drawbacks of digital technology in dentistry?
Startup Costs
The costs are still relatively high when considering acquiring digital dental equipment. Many of the systems operate on a subscription-based licensing platform. For example, some Digital Smile Design Apps require a yearly subscription. Likewise, some intraoral scanners have a monthly or annual fee, and cloud-based data storage for backups often comes with a fee. Training is usually provided by the equipment distributor, but any advanced instructional use of technology is not. Because of the limited resources provided by many digital companies, the learning curve can be quite steep initially.
Lack of Standardized Work Flows
It is the authors’ experience that digital dentistry currently lacks well-defined universal work flows that can be seamlessly integrated into any practice. Interoperability is an issue, and different data acquisition devices from different companies will export different file types. Although the universally accepted digital scan file is stereolithography (STL), some of the scanners will prefer to export in their own native scan files, such as a polygon file format (PLY) or in the case of 3shape, it will export as a Digital Imaging and Communications in Medicine format (DCM), which will need to be converted to STL.
Limited Access to Digital Partners
One of the biggest challenges of digital is finding other members of the dental team that use digital technology, because many of the higher-end small-scale laboratories are still not fully digital because of the lack of digital case submission volume. The cost for the small laboratories to acquire printing technology in-house and digital design software may not be economically feasible if most of their current client list is not digital.
Intraoral Scanners and Scanning
The following are some of the current popular scanners. In the graph, the pros and cons of each system are displayed. Speed and cost can vary, and there is no consistent correlation between those mentioned above and output quality. Some require additional equipment to operate them (like a laptop for 3Shape). Although some scanners may be more accurate, the size of the intraoral camera may be an obstacle for some circumstances, like capturing distobuccal cusp of maxillary second molars or a limited size oral cavity (ie, pediatric dentists and orthodontists). A learning curve and adjustment for scanning, and scanning sequence and digital workflow present other challenges when integrating digital impressions. Also, determining deep marginal finish lines of prepared teeth can be exceedingly more challenging and require an additional skill set to be learned.
The Digital Dentistry as part of the restorative process can be broken down into 3 step: Data-acquisition, design, and manufacturing. In this section, the different options and systems for digital impressions are discussed. Although there are several different digital impression systems on the market today, there are only 3 categories these systems can be categorized into: (1) scan only (stand alone); (2) scan, design, and output to a third-party mill; and (3) all-in-one ecosystem.
Stand-alone systems
There are several stand-alone systems on the market today; however, the following 5 would be considered the most relevant scanners. They include Cerec Primescan, Carestream CS, iMedit 500, iTero, and Trios. Each of these scanners makes a very high-quality digital impression, and all have specific features and benefits designed to enhance the user experience.
It is important to note that although each of these scanners will make an impression in color, that this color image is not always transferred to the laboratory for fabrication. In order to achieve the highest-quality restorative outcome, it is extremely important to understand the technology and software that your laboratory is using to process your digital impressions. For example, although itero, Carestream, Cerec, and Medit all make digital impressions in color, the STL that is provided to the laboratory for fabrication is a black and gray scale image, making it more challenging and most times impossible to mark the margin, especially with veneer and equigingival preparations.
Scan, design, and output to a third-party mill
The next category of products is used for scanning the patient, but also has the ability to add chair-side design software. Although purchased separately, Trios by 3Shape allows seamless integration, and with additional modules can be purchased directly from 3Shape and added to the Chairside Dental Desktop software. These modules include Implant Studio, Smile Design, Restorative Design, Ortho Simulator, Caries Detection, and the CAM software required to output design to an in-house mill. Other intraoral scanners can also be integrated as part of chair-side systems, but unlike 3Shape, use a second party design software called exocad ChairsideCAD.
All-in-One ecosystem
The systems available in this category are Planmeca Emerald and Sirona Cerec. These systems allow a dentist and team to make a digital impression of a patient in their office, use the internal design software to design a restoration for the patient, and mill that restoration using an integrated in-office mill. These systems have proven to be very successful for some users but require a very specific workflow to be clinically successful. Both systems are simple in their setup: included is an intraoral scanner with built-in design software and a mill with built in CAM software,“call it plug and play.” The challenge lies in the processing of the material and patient timing. The 2 most commonly used materials in dentistry are Emax and zirconia, and both require postprocessing and sintering times that range from 45 minutes to 10 hours. A true benefit can be seen using this technology to mill composite and polymethyl methacrylate for inlays/onlays and also temporaries. In addition, both the Planmeca Emerald and Sirona Cerec are also available as a stand-alone system, whereby digital impressions can be made and sent to the laboratory for fabrication.
When investing in technology, it is important to consider one’s potential future use. If the goal is to eventually have the ability to be self-sufficient and produce most restorations in-office, it is important to consider the workflow and available options for each specific scanner system when planning a purchase. The integration and workflow are not as seamless as many manufacturers promote, and each system has their own nuances.
Just like the system setup for the dental operatory, the dental laboratory has a variety of different hardware and software that can be used to design and fabricate indirect fixed restorations, digital dentures, implant planning, surgical guides, and restorations, as well as other dental devices. Nowadays, most if not all dental prosthetics can be fabricated using CAD/CAM technology.
Although all systems are open and produce an STL file, the file format is in gray scale and does not demonstrate colors and therefore cannot differentiate between tooth and tissue colors. It is the responsibility of the scanner manufacturer to produce a color-ready file or alternatively a file that can export the finish-line position ready to be used by the laboratory for margin evaluation and restoration design. The inability to view the file in color may create a real challenge for the restorative dentist when evaluating a digital impression for finish-line reproducibility.
Regardless of the scanner’s ability to import and export into laboratory software in color, they all work well to make digital impressions for crown and bridge, implants workflow, dental appliances, smile design, and treatment planning. The key with all of the systems still boils down to the quality of dentistry. None of the scanners have the ability to see through tissue, and therefore, it is essential that tissue be retracted properly from the margin, as well as preventing fluids from hindering a qualifying impression. Equally important, the digital impression must be evaluated on screen before being sent to the laboratory for fabrication ( Fig. 1 ).
