Digital dentistry and dental technology: The dental world in transition

A great deal of work is digital

Dentistry is already in the throes of the digital transformation. Many laboratories have already gone digital. Some dental practices have also begun to adopt digital processes. Entire workflows have been converted into digital process chains, covering each individual step – from intraoral scanning to designing and manufacturing restorative work. From experience, we know that technicians and clinicians generally work more productively if they use digital technologies. This, however, does not contradict the fact that certain elements, such as manual skills, experience, and human judgement – and therefore the humans who use these digital processes – will remain essential in the long run.

The most appropriate solution is tailored to the needs of the individual

Entry into the digital world should be preceded by careful analysis and reflection. Each new step and each new investment should be thoroughly evaluated. After all, everything comes with a price. You should carefully weigh up in advance whether the innovation you have in mind is cost-effective and future-proof. After all, you do not want to waste your money. In particular, you should ask yourself the following basic questions:

• In which direction do you want your laboratory or practice go in the long run?
• Are you ready to make the necessary investments to achieve this?
• Will the investments pay off after all?

There is no ‘one-fits-all’ answer to these questions. Each laboratory owner and dentist has to find their own answer to these questions, based on their individual situation, and then decide for themselves which way is right for them. The answers will depend on the structure and positioning of the dental laboratory or practice. Country-specific differences also come into play – for instance the costs of hiring specialist staff can vary considerably among countries.

Combining analogue and digital processes

Regardless of the conclusions drawn after evaluating their situation, laboratory owners and dentists should at least touch on the idea of including digital technologies and CAD/CAM in their procedures because these technologies are making ever more inroads into dentistry. By no means should this mean that an all-or-nothing decision should be taken. Sometimes, the best approach is to adopt a middle-road strategy, in which certain steps are digitized and others will remain analogue. Manual and digital methods can be easily combined with each other. In the dental laboratory, for instance, a restoration can be designed digitally and then manufactured conventionally using a press or casting method. Moreover, the change from manual or analogue to digital methods does not need to be implemented in one big swoop. Rather, the transition can be implemented gradually in small steps.

Opinions on the digitization in dental practices and laboratories differ widely. Discussions about the pros and cons can be very emotional at times.

Advantages of CAD and CAM in dentistry and dental technology

There is no gainsaying that digitization opens up countless new opportunities. Many processing steps can be performed faster and more efficiently with the help of digital technologies – or they become obsolete altogether. The risk for errors is considerably reduced. Digitally captured data remain permanently available, making it easy to reproduce dental work. What is more, digitized processes provide more accurate data and better possibilities for visualizing treatment options and can therefore enhance the communication between the dentist and technician and between the dentist and patient. Procedures can be standardized and the quality of the processed materials enhanced. Dentists can choose between manufacturing certain restorations in the office and commission others from a dental lab. Dental technicians can spend more time on the esthetic design of restorations, because they do not need to spend as much time on lengthy preparatory work and in some cases they do not need to do any preparatory work at all.

Enhanced choice of dental materials

Reliable long-term monitoring may help provide patients with better dental care than used to be possible in the past. In addition, users can choose from a broader spectrum of materials because additional materials, such as zirconium oxide and high-performance polymers, are suitable for CAD/CAM procedures. Equally important, digital methods allow for more subtle and precise processing methods, making it possible to perform even more minimally invasive procedures and preserve more natural tooth structure.

• the human factor will remain indispensable in the future. Experienced dentists and   technicians with manual skills and the ability to customize and evaluate dental work from an esthetic point of view will remain central to the success of dentistry in the future.
• digital processes are not a substitute, but a tool for people. Their purpose is to serve dental professionals – not to make them superfluous.

Consequently, the trick is to use conventional analogue steps in tandem with digital processes: the solution is to use both together rather than use only one or the other. In a nutshell, the strengths of both approaches can be harnessed by combining the advantages of digital processes – mainly reliability, reproducibility and consistency – with the advantages of analogue methods, such as esthetics and creativity.

Manual refinements will remain indispensable

Many users explicitly want to continue to have the opportunity to intervene manually and make refinements. They do not want to be hundred percent dependent on CAD/CAM technologies, or on computers and software programs. Being able to manually adjust and refine their creations will remain essential to many dental technicians in the future.

People how are using CAD and CAM benefit from many advantages in their day-to-day work. CAD/CAM technologies assist dental technicians in performing complex processing steps. They provide results with reproducible precision. Workflows are often optimized. The need for time-consuming manual tasks – such as waxing-up, spruing or articulating – may be eliminated. This will free up time and capacity to e.g. perfect the esthetic and functional properties of the restorative work being created. In addition, the error rate and therefore the need for reworking or redoing dental work is reduced because computer-assisted workflows reduce the number of manual steps involved in the manufacturing process and therefore decrease the risk for manual processing errors. In this way, digitization empowers not only dental technicians but also dentists to achieve beneficial results faster and more effectively.

Below are four practical examples to illustrate the effect that CAD/CAM technologies can have on optimizing the workflows in the dental practice or laboratory.

Example 1: CAD/CAM and the press method

Press and CAD/CAM techniques complement each other perfectly. With some experience, users can implement digital designs quickly and effortlessly. A wax pattern of the restoration can be milled quickly and accurately, using a wax disc that is suitable for the given press indication. A digital wax-up is especially advantageous in the case of bridge work, because deformation of the wax does no longer occur and inaccuracies of fit can therefore be avoided.

Ready-to-press wax trees can be produced fast and economically using special software add-ons. Several press objects can be joined in a single wax tree, significantly speeding up the spruing procedure. The sprues are automatically positioned on the press objects and aligned in line with the manufacturer’s specifications, enhancing the reliability and quality of the entire press process. Manual spruing and incorrectly placed sprues are a thing of the past.

Example 2: Efficient planning and monitoring

Many treatments do not lead to the desired success because they are not based on a suitable – or perhaps no – treatment plan. Enormous progress has been observed in this area, too, due to the possibilities offered by CAD/CAM technologies. This is a crucial because sound planning is like a common thread that guides the treatment team through the entire treatment and is particularly important in complex cases. The data collected by various digital means is collated during the planning process in order to make the best possible use of them. The planning process has become considerably more reliable compared to what it used to be ten years ago. As a result, the workflow has greatly improved. We will certainly see even more progress in this area in the future.

When monitoring the treatment progress, certain conditions, such as the pre-op situation, can be scanned and then, after a period of time, compared to a second scan which is superimposed on the initial scan. In this way, possible changes can be identified and problems detected early. The treatment team can use this data to decide which type of treatment is appropriate or necessary.

Example 3: Outsourcing

Digitization enables dental technicians to outsource complex restorative work, for example to external milling centres. Milling centres can also assist in dealing with bottleneck situations in the laboratory.

Example 4: Virtual articulation

Digital articulators save dental technicians the effort of having to articulate the models. The focus is again on the twofold goal of minimizing risks and freeing up capacities for other tasks.

The digital change is progressing at a tremendous pace. Increasing numbers of manufacturers offer products and product systems specifically designed for digital processing in the dental practice and laboratory. New materials tailored towards digital manufacturing methods are being launched on an ongoing basis. As a result, digital workflows can be used for an ever increasing field of applications. An example in case is Ivoclar Vivadent’s “Digital Denture” system that offers an end-to-end digital workflow to produce complete dentures.

End-to-end systems solutions are in demand

Ideally, users should be offered end-to-end systems solutions in which materials, devices and software programs are fully coordinated with each other. Systems solutions ensure a particularly high level of reliability. The risk of incorrect processing is significantly reduced if a coordinated system is employed and the procedures can be carried out at an increased speed. Another advantage lies in the manufacturer's warranties.

CEREC and inLab

For many users, CEREC and inLab from Dentsply Sirona have become synonymous with CAD/CAM processing. CEREC enables dentists to design, manufacture and incorporate individual ceramic restorations directly at chairside in the course of a single session using a computer-assisted, efficient and time-saving workflow. inLab is a system aimed at dental technicians.

In the meantime, various manufacturers have developed CAM materials, some of which are certified for use in conjunction with CEREC and inLab machines (for example IPS e.max).

CAD/CAM portfolio from Ivoclar Digital

While CEREC and inLab were the trailblazers in this field, later suppliers followed with their own devices and system solutions. Today, users can choose between various systems from different manufacturers. Recently, companies that initially focused on materials for digital processing have extended their portfolio to include processing technologies. They have begun to offer complete CAD/CAM systems. Ivoclar Vivadent is one of them. The Ivoclar Digital brand, created in 2017, provides dentists and dental technicians with a comprehensive CAD/CAM offering that includes scanners, software solutions, materials and milling machines. Specifically, Ivoclar Digital offers end-to-end digital workflows that provide optimized interfacing, enhanced convenience and increased productivity.

Apps for operating dental furnaces are also available. They enable users to communicate with their furnace through a WLAN connection. An example is the Programat app, which, among other things, features a verification function for digital image analysis. This feature enables users to check if their photographs meet all the requirements for digital image analysis. If the image is confirmed to be adequate, it can be sent to the furnace. Wireless image data transfer enables users to send their photographs directly from their smartphone to the Programat furnace. All they need is a Wi-Fi connection.

The communication between dentist and dental technician is an essential factor for a successful treatment outcome – and thus for the satisfaction of the patient. Digitized means of communication open up new opportunities for both the laboratory and practice to communicate even more effectively with each other. Dentists and technicians can collaborate even more closely and communicate with each other even more accurately - even across long distances. The reliable exchange of data and smooth communication across the globe in real time are no longer a headache thanks to digital technologies.

Including facial expression, speech and occlusion

The next stage is to utilize moving pictures to tap into the possibilities of three-dimensional imaging. This would allow an even more patient-specific approach to treatment planning and execution. Prior to initiating the treatment, the facial muscles, speech and occlusion of the patient are analysed to further fine-tune the treatment planning process to meet the specific needs of the patient.

Digitization presents new challenges and opportunities not only for dental laboratories but also for dental practices. ‘Chairside dentistry’ is a much discussed topic these days. Just what do we mean when we talk about ‘chairside dentistry’?

What does ‘chairside dentistry’ mean?

Ever more dentists have starting to invest in digital technologies. For instance, they purchase intraoral scanners that enable them to take digital impressions. They then send the resulting scan data to their dental laboratory, taking advantage of a quick and convenient process. Physical impressions are no longer required. Some dentists have even begun to manufacture single-tooth restorations in their own practice, using the scan data as a basis. Special milling machines are available for the chairside production of these restorations. Chairside technologies enable dentists to provide patients with restorative work in a single visit and to collaborate with dental laboratories in a more effective and straightforward manner. All parties involved – dentist, dental technician and patient – will save time.

Beginnings date back to the 1980s

Certain manufactures have been offering digital materials, milling machines and intraoral scanners since the 1980s. The CEREC system from Dentsply Sirona is seen as a pioneer in this field and today represents the epitome of in-practice CAD/CAM processing for many users. CEREC enables dentists to design, manufacture and place individual ceramic restorations directly at chairside in the course of a single session using a computer-assisted, efficient and time-saving workflow. This is especially true for single-tooth restorations. Large restorative work, however, is accomplished as usual in collaboration with dental laboratories.

CAD/CAM range continues to grow

Along with the ever expanding range of application possibilities, the offering of CAD/CAM materials, devices and processes continues to grow. This benefits both dental laboratories and practices. Various manufacturers have begun to offer not only materials but also milling and grinding machines and complete systems that offer interesting options for both laboratories and practices. A case in point is the portfolio of the Ivoclar Digital category brand presented by Ivoclar Vivadent on occasion of IDS 2017 in Cologne.

Regional differences

The topics of ‘digitization’ and ‘chairside dentistry’ have been gathering momentum in recent years. Looking around the leading dental trade show IDS and browsing through the trade media confirm the importance ascribed to these topics. However, there are still major regional differences in the prevalence of digital workflows. For instance, chairside dentistry is far more common in North America than in Central Europe. Overall, digitization has made greater inroads into dental laboratories than into dental practices.

• Scan files are not only more accurate than conventional impressions. They can be transmitted to the dental laboratory much more easily and faster. In general, digital technologies offer dentists manifold opportunities to enhance the collaboration with their dental technicians.
• What is more, scan data are permanently available and retrievable – and thus reusable.
• Dentists can manufacture restorations for single teeth immediately in a single session; the need for a temporary is removed, increasing the efficiency of the dental practice. In addition, a better bond to the tooth can be achieved because bonding forces are higher on freshly cut tooth structure.
• Similar to dental laboratories, dental practices can boost their image if they use digital technologies, as it gives them an air of being modern and forward-looking. In addition, CAD and CAM offers both dental practices and laboratories an opportunity to distinguish themselves from the competition. Many patients may find it fascinating to watch their restoration emerge in the milling or grinding machine. They can watch their crown being built in front of their eyes.

Conclusion: more precision, more reliability

Digital processes enable dentists – and dental laboratories – to provide restorative work with even more precision and reliability. The certainty that an accurate final result will be achieved is even higher with digital processes and with manual procedures. This makes the treatment even more effective – and more efficient for all parties involved.

Craze vs concern

Not least of all, high investment costs deter many dentists from switching to digital workflows in their practice – and similar concerns also affect laboratory owners. Experts recommend allaying fearful attitudes and approaching the issue with an open mind; the possibility of digitization should be considered without bias. And if the conclusions are drawn in favour of becoming digitized, the transition towards digitized workflows should be included in the practice or laboratory strategy. Many experts have no doubts that there is no way around digitization in dentistry. In their view, sorting out this topic is inevitable.

Decisions should be considered carefully

Many CAD/CAM dentists have already expressed their experience that their workflows have improved significantly after a relatively short period of time once they transited to digital workflows. In addition, they have also praised the quality of the work that the digitized processes have helped them to achieve. Nonetheless, the question of “Shall I risk it or leave it?” should be explored carefully. There are three questions that every dentist should ask themselves:

• In which direction do you want your practice go in the long run?
• Are you prepared to make the necessary investments to achieve this – or do you feel   the costs too high?
• Will the investments pay off after all?

Every dentist has to find their own answer to these questions. There is no one-fits-all recommendation for them.

Tip: Embark on consistent further education

Anyone who has decided to enter digital dentistry should get further information on the topic, for instance by participating in continuing education and training events. Today, a steadily growing range of training courses is available, geared especially towards the needs of dentists with an affinity for CAD/CAM. Some universities even have begun to offer dedicated degree courses, such as the Master’s Degree in Digital Dental Technology.

An online research can provide an initial overview of comparable courses offered in various countries.

Digitization opens up an abundance of new, previously unimagined possibilities. Digital workflows lead to fast results more efficiently and more predictably. They provide new methods that enable accurate planning and communication procedures. All over the world, users, specialists and researchers are busy developing new procedures that provide even better and more patient-centric solutions. Some of their ideas may look bizarre at first, or even outlandish. Disciplines which at first glance have little or nothing to do with dentistry are increasingly coming into play.

Computer games to exercise jaw functions

Virtual jaw measurements are a point in case. These measurements assist in making restorations even more patient-specific in order to improve the patient’s occlusion. Mathematicians and IT specialists are developing programs and even computer games for the detection and correction of TMJ disorders. These applications should help people suffering from TMJ disorders to train their jaw functions and ease their pain. Ever more data is being collected to achieve ever more accurate results. Scientists are increasingly focusing on processes taking place in the brain alongside the functions of the masticatory muscles.

Using digital games to improve oral hygiene

Another example of digital ‘gimmickry’ with a practical aim are ‘serious games’: computer games for children and young people with the intention to acquire better oral hygiene habits in a fun way.

Many recent digital innovations have already entered dentistry and dental technology. And many more are to follow. All over the world, researchers, inventors and manufacturers are testing new developments to see if they are suitable for use in dental applications. The focus is always on the goal of making treatment and manufacturing processes ever more efficient and optimizing the results further. An essential key to success is capturing data that are as patient specific and accurate as possible. This explains why many inventions that at first glance have little or nothing to do with dentistry are actually highly relevant for dentists and dental technicians. Let’s look at these three examples:

Example 1: Wearables

Wearables are small, portable Bluetooth-enabled micro devices. They are attached to the body. Once positioned on the body, they continuously capture and process user-generated data.

Example 2: Data glasses

Data glasses are small computers that sit on the bridge of the nose. They connect to the internet via sensors and cameras. Among other things, data glasses can incorporate virtual objects (3D holograms) into the user’s field of vision by means of projected light points. The user can interact with these projected objects.

Data glasses – such as the Microsoft HoloLens – mix virtual reality with the real world. People who use such glasses work more quickly and efficiently. All relevant information can be transferred to the screen of the data glasses in real time. Moreover, the risk of error is reduced as every single working step is performed under expert guidance.

Example 3: ShyTech – high-tech that does not want to be seen

ShyTech means high tech that stays ‘shyly’ in the background. ShyTech integrates into everyday life and everyday objects in such a way that it hardly attracts any attention. Complicated devices with switches, cables and buttons are replaced with appliances featuring intuitive user interfaces. Only the functions that are immediately required remain visible. In this way, surfaces become user interfaces that blend in with their surroundings out of sight. The functions of these technologies can be controlled using natural voice commands, gestures or thoughts. It is a seamless integration of intelligent technologies that interact with each other – and with the user. Technique and technology adapt to humans, not vice versa.

Our world is becoming increasingly digital. This opens up an abundance of new possibilities for dental professionals. Digital technologies empower them to optimize their workflows to work more efficiently and reliably. Furthermore, data that has been collected digitally remains retrievable in the long run, allowing restorative work to be reliably reproduced.

Digital tools for administration and marketing

Dental professionals can use digital tools to facilitate activities beyond their dental work. For example, practice and laboratory owners can use digital processes to optimize their administrative tasks. In addition, digital tools enable them to carry out marketing activities for their practice or laboratory more effectively and address their patients and customers in a more targeted and timely manner. A professional website is just as important as meaningful entries in relevant databases.

Digital dentistry is becoming increasingly important. Even dentists and dental technicians who have not yet looked into the digital future of dentistry will not be able to avoid the issue in the long term. Digital processes and technologies will significantly change dentistry, if not revolutionize it. For dentists and dental technicians, this offers many new options and advantages for shaping their future for success.

Finding the strategies that are a good fit for you

For this reason, practice and laboratory owners should sooner or later think about how they can make the best possible use of these new circumstances. Changing to digital dentistry is worthwhile a thought. As shown above, the transition to digital dentistry can be achieved in small steps. Digital processes can be easily combined with conventional manual methods. The key to success is often to use a smart and balanced mixture of both digital and analogue. One-fits-all recommendations cannot be given. Rather, dentist and dental technicians should consider individual strategies that suit their circumstances best – without one-sided euphoria or a blanket refusal attitude, but with a sound sense of judgement and pragmatism.