The Digital Advantage

CAD/CAM systems are making inroads into everyday dentistry, being used for assessment, diagnosis, treatment planning, implementation, evaluation and communication. That all adds up to a strong advantage — for patients, clinicians and account executives.

Although digital imaging is not a new technology, its use for making dental impressions has been refined over the years. Advanced technology in the form of computer-aided design and computer-aided manufacturing (CAD/CAM) was introduced to the dental profession in 1987.1 These technologies can be divided into two categories: digital impressioning and dental restoration CAD/CAM systems.

Sales professionals have an opportunity to inform dental providers about how using CAD/CAM technology can improve patient care and efficiency in the office. Learning how to utilize new technologies broadens dental and dental hygiene practitioners’ skill sets, strengthens job marketability, expands roles in comprehensive care delivery, and provides opportunities to improve patient comfort and en­hance preventive patient education.2 Implementing advanced technology in clinical practice is essential to continually raise the level of care provided and fuel the evolution of workforce models.1,3

Improvements in hardware, software and milling units — as well as restorative materials — have increased the use of digital dentistry.1 Implementing digital impression technology can increase case acceptance by providing on-screen images that can be discussed in treatment presentations. The ability to magnify scanned dentition can also aid diagnoses and help ensure more accurate impressions, which, together with the accuracy of CAD/CAM fabrication, can contribute to better-fitting restorations and more predictable outcomes. Francois Duret, DDS, DSO, PhD, MS, MD-PhD, first imagined the concept of a dental CAD system in 1971. By 1985, the first three-dimensional (3D) intraoral digital imaging system became commercially available, and the resulting images were successfully used to create an inlay milled from a ceramic block.4 It is estimated that 16% to 18% of dentists in the U.S. employ CAD/CAM technology in their offices, with approximately 12,000 dental milling devices in use.5 Technological advances in CAD/CAM will contribute to its adoption in modern practice,6 and the investment firm William Blair projects that global dental CAD/CAM sales will rise to 9,100 units per year in 2017.1

0517-Table
 

Most dentists and dental hygiene professionals believe new technology helps advance dentistry and quality of care for patients.7 Table 1 lists some advantages and disadvantages of digital impression and chairside CAD/CAM systems. Data acquired during digital impression scanning are sent to dental laboratories for fabrication of restorations. Or, if properly equipped, the dental team can use chairside CAD/CAM systems to design and mill restorations in-office. This allows indirect restorations to be prescribed and placed in a single visit.

Milling machines use a subtractive process via rotary cutters to remove portions of solid blocks of ceramic or composite resin to fabricate the restoration. Because digital technology is associated with improved efficiency and profitability,8 dental labs have enthusiastically embraced it — investing in systems that are capable of fabricating crowns, inlays, onlays, veneers, multiunit fixed bridges and im­plant abutments. Even dentists who do not directly use CAD/CAM technology in their offices still benefit from this technology by way of digitally created restorations designed and fabricated by dental laboratory vendors. For the most part, labs are scanning conventional impressions or dies and designing restorations via digital technology for their clients.9

While not the subject of this article, additional advances in CAD/CAM dentistry include 3D printing. Unlike a milling process, 3D printing is an additive process in which successive layers of material are used to create physical models. Currently, 3D printing is limited to polymers and does not include ceramics.10 Examples of 3D printing include crown and bridge models, orthodontic models, bite appliances and surgical guides for implants.


POINT OF SALE | SPEED AND EFFICIENCY

  • Digital impressions facilitate visualization of precise detail, allowing immediate corrections.
  • In practices equipped with in-office CAD/CAM systems, patients can enjoy same-day dentistry, which eliminates the need for provisional, or temporary, restorations.
  • Digital impressions may be more comfortable for patients because they sidestep the need for trays and conventional impression material.
  • Scanner or intraoral camera images can be used to visually demonstrate oral health issues, which later will provide a foundation for the diagnosis and treatment plan.
  • The speed and convenience of digital imaging enhance clinical efficiency.

The Longevity And Success Of CAD/CAM Restorations Have Supported Adoption Of This Technology

Sales professionals have an opportunity to inform dental providers about how using CAD/CAM technology can improve patient care and efficiency in the office. Learning how to utilize new technologies broadens dental and dental hygiene practitioners’ skill sets, strengthens job marketability, expands roles in comprehensive care delivery, and provides opportunities to improve patient comfort and enhance preventive patient education.2 Implementing advanced technology in clinical practice is essential to continually raise the level of care provided and fuel the evolution of workforce models.1,3

Improvements in hardware, software and milling units — as well as restorative materials — have increased the use of digital dentistry.1 Implementing digital impression technology can increase case acceptance by providing on-screen images that can be discussed in treatment presentations. The ability to magnify scanned dentition can also aid diagnoses and help ensure more accurate impressions, which, together with the accuracy of CAD/CAM fabrication, can contribute to better-fitting restorations and more predictable outcomes. Francois Duret, DDS, DSO, PhD, MS, MD-PhD, first imagined the concept of a dental CAD system in 1971. By 1985, the first threedimensional (3D) intraoral digital imaging system became commercially available, and the resulting images were successfully used to create an inlay milled from a ceramic block.4 It is estimated that 16% to 18% of dentists in the U.S. employ CAD/CAM technology in their offices, with approximately 12,000 dental milling devices in use.5 Technological advances in CAD/CAM will contribute to its adoption in modern practice,6 and the investment firm William Blair projects that global dental CAD/CAM sales will rise to 9,100 units per year in 2017.1

Most dentists and dental hygiene professionals believe new technology helps advance dentistry and quality of care for patients.7 Table 1 lists some advantages and disadvantages of digital impression and chairside CAD/CAM systems. Data acquired during digital impression scanning are sent to dental laboratories for fabrication of restorations. Or, if properly equipped, the dental team can use chairside CAD/CAM systems to design and mill restorations in office. This allows indirect restorations to be prescribed and placed in a single visit.

Milling machines use a subtractive process via rotary cutters to remove portions of solid blocks of ceramic or composite resin to fabricate the restoration. Because digital technology is associated with improved efficiency and profitability,8 dental labs have enthusiastically embraced it — investing in systems that are capable of fabricating crowns, inlays, onlays, veneers, multiunit fixed bridges and implant abutments. Even dentists who do not directly use CAD/CAM technology in their offices still benefit from this technology by way of digitally created restorations designed and fabricated by dental laboratory vendors. For the most part, labs are scanning conventional impressions or dies and designing restorations via digital technology for their clients. 9

While not the subject of this article, additional advances in CAD/CAM dentistry include 3D printing. Unlike a milling process, 3D printing is an additive process in which successive layers of material are used to create physical models. Currently, 3D printing is limited to polymers and does not include ceramics.10 Examples of 3D printing include crown and bridge models, orthodontic models, bite appliances and surgical guides for implants.


Lexicon

  • Abutment: The connection between a prosthesis and an implant.
  • Amalgam: An alloy of mercury, silver and sometimes other metals used to create silver fillings.
  • Biocompatible: A synthetic or natural material used to replace part of a living system or to function in contact with living tissue.
  • CAD/CAM: Computer-aided design and computer-aided manufacturing is technology used to design and manufacture indirect restorations.
  • Calculus: Hardened plaque, also referred to as tartar.
  • Marginal integrity: The seal or interface between the final, cemented restoration and the prepared tooth.

CAD/CAM Technology In Action

Digital technology — CAD/CAM in particular — has many applications in dentistry and dental hygiene that enhance patient outcomes and clinical efficiency.11 The longevity and success of CAD/CAM restorations, especially with the advent of stronger ceramic materials, have supported adoption of this technology. Digital scanning, design and manufacturing have been addressed in educational curricula for dental and dental hygiene students, who must have the knowledge to make evidence-based decisions about new technology.1,12 The results of a recent survey distributed to U.S. dental school academic deans found that technology incorporated into curricula closely mimics technology in private dental practices. In addition, technologies chosen by dental schools were adopted due to acceptance and use in private practice.12

Research demonstrates that digital scans are comparable to conventional impression methods.13 In practices equipped with in-office CAD/CAM systems, advantages to the patient include one-appointment, or same-day, dentistry that eliminates the need for provisional restorations. Digital impressions may also be more comfortable for a patient because they sidestep the need for trays and conventional impression material, such as polyvinyl siloxane. Whether the restoration is fabricated by a lab or with in-office milling, the patient benefits from the availability of biocompatible and highly esthetic ceramic materials that allow long lasting, minimally invasive restorations.

Digital impressions offer clinicians the benefits of magnification and facilitate visualization of precise detail that allows for immediate corrections. Scanned impressions also eliminate common shortfalls of traditional impression techniques, including material shrinkage, pulls and bubbles, and expansion of die stone. In addition, there are no cumbersome physical models to store or disinfect. Digital impressions can be saved electronically and permanently, without consuming physical laboratory or office space. System costs aside, imaging and retakes are quick, easy, and less costly compared to traditional impressions.

Marginal integrity is another example of why CAD/CAM technology has been widely accepted, as this and internal fit of fixed prostheses rank among the most crucial criteria in determining clinical success. Poor marginal integrity can cause plaque accumulation, leading to periodontal breakdown, recurrent decay and, ultimately, failure of the restoration.14 Opinions vary regarding acceptable margin gap for crowns. In general, margin gaps of 100 micrometers or less are clinically acceptable.14 A study evaluating two CAD/CAM systems found that both produced superior margin fit values, and that margin adaption for both systems was within the acceptable range.14 Additionally, a systematic review by Boitelle at al15 evaluated the fit, precision and accuracy of CAD/CAM restorations. The findings indicate it is possible to create a milled restoration having a teeth/prosthesis gap less than 80 micrometers. The review also shows these systems improve the average prosthesis’ adaptation compared to conventional manufacturing methods.

Enhancing Patient Care

Implementing digital technology, including the use of intraoral cameras and digital impression scanners, can enhance the dental and dental hygiene process of care.16,17 During the examination, the clinician gathers subjective and objective information related to the patient’s oral health status. The use of these imaging technologies can aid in the detection and diagnosis of dental disease by providing a magnified, high-resolution image that can be shared digitally between clinicians, or during referrals.

A scanner or intraoral camera allows the clinician to document patient hard tissue data and digitally record clinical findings (Figure 1). Images can be used to visually demonstrate oral health issues that later will provide a foundation for the diagnosis and treatment plan. For example, some systems record high-definition, color video images that can be used not only for digital impressions, but also for 3D imaging. Nonstatic imaging is fast, clear and easy.

 

 

FIGURE 1. Digital scan of a maxillary arch. COURTESY IRA T. BLOOM, DDS

FIGURE 1. Digital scan of a maxillary arch.
COURTESY IRA T. BLOOM, DDS

 

FIGURE 2. Digital scan of an anterior bitewing. COURTESY IRA T. BLOOM, DDS

FIGURE 2. Digital scan of an anterior bitewing.
COURTESY IRA T. BLOOM, DDS

 

Patients can be shown images of fractured teeth, deteriorating restorations, calculus and gingival inflammation. The patient-centered care plan is assisted by precise imaging and the opportunity for enhanced patient education. Treatment plans can be tailored to the patient’s priorities, goals, interventions, and expected outcomes. Digital acquisition units using 3D imaging enable clinicians to show patients oral health conditions in a much more effective and dramatic way than simple verbalization of dental findings (Figure 2). Communicating the long-term benefits of restoration longevity, esthetic quality, and increased patient comfort achieved with various restorative technologies encourages informed, decision making by the patient. In practices that offer amalgam, composite and milled restorations, it is important for all team members to be capable of discussing the advantages and options for each type. Knowledgeable clinicians, for example, can describe how CAD/CAM restorations can help retain maximum tooth structure, and why that’s important to the strength of the tooth. In practices equipped with in-office CAD/CAM fabrication capability, advantages include one-visit restorations, — eliminating the need for provisionals — a highly custom fit, and an esthetically pleasing outcome.

In addition, oral health slideshows depicting before-and-after digital images of restorative procedures and periodontal therapy demonstrate potential positive outcomes of proposed treatment. This technology allows clinicians to take patients on a tour of their mouths while providing scenarios and options for optimal care. As a result, it enables a more personalized approach to help patients better understand their oral conditions and guide them toward greater responsibility for their oral health.

Time Saver

Clinicians can use these digital technologies to image planned restorative treatment, answer patient questions, reinforce comprehensive care plans, and discuss maintenance and treatment options for the patient’s individual conditions. The speed and convenience of digital imaging enhances clinical efficiency, as the entire process takes minutes. For example, having preoperative images or impression scans from the dental hygiene visit could save the dentist time during the restorative phase of the treatment plan, at which point the dentition can easily be reimaged before the dentist preps the tooth (Figure 3).

 

 

FIGURE 3. Digital scan of a crown preparation. COURTESY IRA T. BLOOM, DDS

FIGURE 3. Digital scan of a crown preparation.
COURTESY IRA T. BLOOM, DDS

 

Another example would be a dental hygienist or assistant who images a full arch for the purpose of night guard fabrication. In this scenario both the patient and dentist benefit from reduced time and appointment commitment needed for fabrication, fitting and delivery of the appliance. Additionally, the patient is already involved in the decision-making process and ongoing maintenance discussions, thus promoting a vested interest in treatment outcomes and success.

Most practice management professionals would agree that cross-training the dental team in the use of digital imaging/impressions and CAD/CAM technology is invaluable to improved efficiency and cohesive care. Clinicians who are knowledgeable about digital imaging and restorative design and delivery will add value to the practice. Oral health professionals can apply these technologies for educational and diagnostic purposes, while simultaneously increasing case acceptance and enhancing productivity during the restorative phase of treatment. Ultimately, the dental team’s ability to image, design and mill restorations may increase practice productivity.

Dental health care delivery exists in a digital world that is continually evolving as technology — and the innovative transformation of patient care — advances. For this reason, sales reps play a key role in informing customers how implementing cutting-edge technologies, such as digital imaging and CAD/CAM restorations, can enhance the dental health care experience in their practice.

 

Featured Photo Courtesy of ALENGO/ISTOCK/ THINKSTOCK

References

  1. Reifeis PE, Kirkup ML, Willis LH, Browning WD. Introducing CAD/CAM into a predoctoral dental curriculum: a case study. J Dent Educ. 2014;78:1432–1441.
  2. Gadbury-Amyot CC. Technology is a critical game changer to the practice of dental hygiene. J Evid Based Dent Prac. 2014;14(Suppl):240–245.
  3. Rhea M, Bettles C. Dental Hygiene at the Crossroads of Change: Environmental Scan 2011–2021. Available at: adha.org/resources-docs/7117_ADHA_Environmental_Scan.pdf. Accessed March 15, 2017.
  4. Hodd JA. CAD/CAM dentistry for today’s on-the-go military. US Army Med Dept J. 2011:26–37.
  5. Christensen GJ, Child PL Jr. Fixed prosthodontics: Time to change the status quo? Dent Today. 2011;30:66–73.
  6. Poticny DJ, Klim J. CAD/CAM in-office technology: innovations after 25 years for predictable, esthetic outcomes. J Am Dent Assoc. 2010;141(Suppl 2):5S–9S.
  7. Levin RP. Purchasing new technologies. J Am Dent Assoc. 2010;141:461–462.
  8. Hack GD, Bloom IT, Patzelt SB. Digital impressions. In: Masri R, Driscoll C, eds. Clinical Applications of Digital Dental Technology. Danvers, Mass: John Wiley & Sons, Inc; 2015:27–28,39.
  9. Masri R, Driscoll C, eds. Clinical Applications of Digital Dental Technology. Danvers, Mass: John Wiley & Sons, Inc; 2015.
  10. Alghazzawi TF. Advancements in CAD/CAM technology: options for practical implementation. J Prosthodont Res. 2016;60:72–84.
  11. Kumar S, Reynolds R, Williams NJ. The information revolution. Dimensions of Dental Hygiene. 2013;11(6):52–55.
  12. Brownstein SA, Murad A, Hunt RJ. Implementation of new technologies in U.S. dental school curricula. J Dent Educ. 2015;79:259–264.
  13. Ender A, Mehl A. Full arch scans: conventional versus digital impressions — an in-vitro study. Int J Comput Dent. 2011;14:11–21.
  14. Hamza TA, Ezzat HA, El-Hossary MM, Katamish HA, Shokry TE, Rosenstiel SF. Accuracy of ceramic restorations made with two CAD/CAM systems. J Prosthet Dent. 2013;109:83–87.
  15. Boitelle P, Mawussi B, Tapie L, Fromentin O. A systematic review of CAD/CAM fit restoration evaluations. J Oral Rehabil. 2014;41:853–874.
  16. Wilkens E, Mueller-Joseph L, Wyche C, Homenko D. The professional clinician. In: Wyche CJ, ed. Clinical Practice of the Dental Hygienist. 11th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2012.
  17. Standards for clinical dental hygiene practice. Available at: adha.org/resources-docs/2016-Revised-Standards-for-Clinical-Dental-Hygiene-Practice.pdf. Accessed March 15, 2017.

 

From MENTOR. May 2017;8(5):32-37.

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