W W W. C D E W O R L D. C O M
PEER-REVIEWED
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JUNE 2018 V5 N114
eBook
Continuing Dental Education
D I G I TA L D E N T I S T R Y
Digital & Analog:
Dentistry in a Hybrid World
Lee Ann Brady, DMD
SUPPORTED BY AN UNRESTRICTED GRANT FROM KULZER • Published by Dental Learning Systems, LLC © 2018
CE
eBook
Continuing Dental Education
Digital & Analog:
Dentistry in a
Hybrid World
About the Author
Lee Ann Brady, DMD
Director of Education,
Clinical Mastery Series;
Private Practice,
Glendale, Arizona
DISCLOSURE: Dr. Brady received an honorarium for the webinar presentation on which
this content is based.
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PEERREVIEWED
2 CDE CREDITS
New Technology for Proactive
Patient Care
Lee Ann Brady, DMD
ABSTRACT
Within a practice, balancing digital
dentistry concepts with pre-digital
“analog” dentistry is an evolving
challenge. Although many dental
offices are attempting to become 100%
digital, they are more likely achieving
only 90% while they continue to rely at
times on traditional analog techniques.
Fortunately, excellent systems have
been designed to navigate the ground
between analog and digital, giving
clinicians the time to decide when
and where to incorporate more digital
technology.
LEARNING OBJECTIVES
• review capturing digital lab records
and systems to optimize an analog/
digital partnership
• discuss the implementation of digital
impression making systems
• describe the workflow for digital lab
fabrication
W
ithin a practice, balancing digital dentistry concepts with
pre-digital “analog” dentistry is an evolving challenge.
Although many dental offices are attempting to become
100% digital, they are more likely achieving only 90% while they
continue to rely at times on traditional analog techniques. The primary question is: Between the two extremes—completely digital
or analog—where is the practice, and where does the dental team
want it to be? Would it be advantageous to integrate more digital
systems? Are there areas where analog remains the better option,
even within the changing dental landscape? To truly gauge the
opportunities and make informed decisions, practitioners must take
into account technical, efficiency, and cost-effectiveness factors.
The multi-level relationships between digital and analog need to
be assessed for the best fit for the practice.
To start, five questions about the current practice can help determine
where it stands, and where a change might be worthwhile:
• Is the current system working?
• Would a change in technology significantly improve clinical results?
• If a change resulted in comparable clinical results, would the
technology be more patient-friendly, giving more people access to
care? Would it be more comfortable, efficient, or cost effective?
If indicated, a shift to more digital dentistry may be worth implementing, despite other challenges. Ironically, the tipping point—if
there is one—for many practices may not come from the chair, but
from the bench.
LABORATORIES TAKE THE LEAD
In their interactions with the dental laboratory, clinicians are
already taking advantage of digital dentistry, even if it is not
central to their office. Much laboratory work is now accomplished
using digital workflow, CAD/CAM, and other relevant technologies. Even when using an analog fabrication technique for the
restoration, the laboratory often still relies on a digital workflow,
and even smaller, one-person laboratories are outsourcing work
to milling centers.
VOLUME 5 • NUMBER 114
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3
Consider the process of fabricating a restoration.
Clinicians’ experience with milling restorations is
typically with in-office milling units using very
small blocks or with the aforementioned 3-D printers. However, at the laboratory, milling or printing
takes place on a much larger scale and the process is vastly automated via digital scans, design
software, and centralized production systems that
permit a high volume of coincident processing.1-2
This milling technology has achieved demonstrable
accuracy from both a manufacturing and a clinical perspective, ultimately benefiting the lab, the
practice, and the patient.3-6
Thus, most dentists today live and work in a
hybrid world: often the laboratory is digital, while
the practice is analog or in transition, necessitating
additional steps in the workflow. The more dental
laboratories rely on digital data, the more important
it is for dental practices to examine how diagnostic
information is captured and communicated to the
laboratories, whether through analog or digital
technology—or a combination.
CAPTURING AND COMMUNICATING RECORDS
One of the first ways that dentistry entered the
digital world was by moving away from traditional radiography. Although film and developing materials still exist, the majority of practices
have made the transition to digital sensors and
monitors.7 A clinician’s choices for entry into
digital imaging have expanded significantly.
A first-level digital integration that can be easily
implemented, without intense technical experience,
is digital photography, using an intraoral camera
to capture images from many perspectives (tooth,
smile, face). Previously, with film photography,
if a photograph were missed or if the exposure
were wrong, the patient was gone before a clinician realized the images would need to be retaken.
Digital photography provides immediate results in
real-time. The opportunity to gain instant feedback
and continually adjust is invaluable to a productive
workflow and superior results.8-10
4
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Another advantage with digital images is more
efficient storage and organization. Images can
even be transmitted and saved over Bluetooth
or Wi-Fi, which removes the need for a camera
card to transfer images. This integration provides
a streamlined system.8-10
The downside is mastering different camera
hardware and designing a storage system that
works with the practice software, retrieval systems,
and storage needs to be maintained and backed
up and secured.10 Another issue is the the need to
secure transmission of sensitive medical information in and out of the practice. Secure communication is necessary to remain HIPAA-compliant
and maintain patient confidentiality.11 Transferring
digital data raises concerns that transferring analog
data does not, especially when a clinician needs to
transfer analog and digital data together.
Digital records are especially valuable when
used to collaborate with a laboratory. The clinician
can send images of preparations to the technician
while the patient is still in the chair, even before
impressions have been taken, to solicit feedback.
The technician can provide input on the need for
more taper or how accurate the margin appears. In
addition, the images provide a humanizing element
for the laboratory, showing the patient’s face, eyes,
hair color, smile, and lips, which provides a better
sense of how to shape the esthetics.
As shown by the integration of digital photography, even small decisions can have significant
impact on a dental practice. A simple choice,
such as switching to a digital SLR camera for
more sophisticated photographs, leads to using
the device for videography as a dynamic piece
of the treatment puzzle. As esthetic dentists
transition from static photography to videography, the laboratory technician will be able to
hear patients talk and see them move, gaining
a better understanding of dynamic lip mobility.
This level of laboratory communication advances collaboration and allows the dentist the
JUNE 2018
freedom to work with laboratories unhindered
by geographic location.
NEXT-LEVEL INTEGRATION: CBCT, DIGITAL
IMPRESSIONS
Adding cone-beam computed tomography
(CBCT) into the practice enables a more advanced level of digital imagery. In addition,
incorporating digital jaw tracking is moving
dentistry closer to full replacement of the articulator. Clinicians will likely come to rely on
a virtual articulator that combines records such
as facial photography and videography with
CBCT, intraoral full-arch upper/lower scanning, and digitized jaw tracking.12 Together,
these tools create a 4D representation of the
patient, revealing how the mandibular and maxillary teeth work together in real time.
CBCT is a classic example of the complex,
evolving decisions required before acquiring and
implementing advanced digital tools. When this
technology first came became available, it was
viewed primarily as an adjunct to implant dentistry.13 However, CBCT has now moved from the
realm of implantology to broader applications. The
technology can be used to diagnose at the level
of the temporomandibular joints or to assess airways.7,14,15 In addition, it can be a valuable tool for
orthodontics or endodontics, which demonstrates
how it has moved from a niche application to a
routine, general practice technology.14-16 After assessing their technology needs, some clinicians are
choosing to replace digital panographic systems
by investing in CBCT, taking advantage of a more
advanced capacity to serve patients.
Similarly, digital impression systems’ use in the
dental practice has shifted from its earlier purpose.
Initially packaged with in-office milling, digital impression systems have now been separated to allow
for different purchasing choices to fit the practice.
Introducing a digital scanning or impression system
into the office can be a less complicated decision
than incorporating in-office milling.
VOLUME 5 • NUMBER 114
The options for digital scanning have advanced
from the ability to scan only a quadrant to an entire
arch of teeth quickly, as well as from only scanning bite records to scanning how the teeth are
in maximum intercuspation. The computer can
articulate the upper and digital models together.
Furthermore, scanners have become smaller while
moving to different file formats.17-19
Digital impression systems are growing in popularity: it is becoming more mainstream for practices
to incorporate some form of digital scanning. Also
of note is the ability to 3D print surgical guides
in-house and integrate this with CBCT, which is
invaluable for dentists who place implants.13,19 They
can design the implant placement, create the guide,
and send it directly to a 3D printer in their office.
Other 3D printing options that are becoming more
popular are occlusal appliances and nightguards,
along with printing metal such as full-coverage
gold restorations.20
WORKING A HYBRID SYSTEM
Hybrid systems raise the question of compatibility and open architecture software.21
Clinicians must question if a piece of technology will integrate with systems already in use.
Will the data gathered from the new technology
integrate smoothly with current dental software
and patient charts? Will the system run on the
practice’s existing network, or will it require
separate computers, networking and/or storage devices? Beyond the practice, will the file
formats work for the laboratory?
An example of extra steps need to adjust for
incompatibility is working with physical articulators. Years ago, because they weren’t interchangeable, if a clinician mounted a patient’s model on an
articulator, the entire articulator had to be shipped
to and from the laboratory because they couldn’t
take the models off one instrument and place them
on another and achieve accurate results. This situation improved when the instruments became more
compatible and interchangeable across the board.
CDEWORLD.COM
5
Technicians could then see the same mounting that
clinicians did. For incompatible digital systems,
converting data back and forth adds extra steps
to the process.
1
Fig 1. An analog impression, which can be digitally scanned either
by the office or the lab for incorporation into a digital workflow.
2
Fig 2. Using CAD CAM software to prepare a margin.
3
Fig 3. Digitally design can replace physical models and wax-ups for
a restoration.
6
CDEWORLD.COM
One common situation when analog is still used
in the office (and digital in the laboratory) is when a
clinician takes a physical impression to send to the
laboratory, which then needs to digitize the data.
The technician transfers analog to digital data by
either physically scanning the impression or pouring the model from the impression and scanning
it (Figure 1). For this dual analog/digital process,
clinicians can use impression materials that improve the laboratory’s ability to scan impressions.
Materials that build upon VPS impression material afford greater accuracy when an impression is
digitized, leading to more accurate digital data.22,23
Clinicians can contact their laboratory and ask if
impressions are being digitized or scanned, and
choose their impression material accordingly, to facilitate the most accurate-fitting final restoration. If
the laboratory is scanning the physical impression,
the technician may need to spray the impression
with a contrast material.22
Digital data allows the laboratory to facilitate
a design process integrated with either a milling
or printing machine. For example, if the case is a
crown and bridge, the technician works with software, tracing the margins of the preparation (Figure
2). The laboratory can also create digital wax-ups
and models for restorations (Figure 3). The laboratory could also reverse the process, creating models
from digital data. For example, if a clinician uses an
intraoral scanner, the laboratory is receiving pure
digital data with no physical impression. However,
if the technician sees a reason to create a physical
model, the process will have to move from digital
to analog. The three modalities for this are: 1) a
milled model, by carving the model from a plastic
or PMMA material; 2) stereolithography, an older
technology in which a vat of resin is cured in very
precise layers to build a model up; or 3) the most
state-of-the-art modality, 3D printing.24
THE DIGITAL HIGHWAY
Digital data has become the preferred workflow between practices and laboratories. One
advantage is the ease of sending data through
JUNE 2018
file sharing, which eliminates the need for boxing and shipping, along with the concerns of
lost shipments or extreme temperatures ruining bite records and impressions. The built-in
feedback system is also extremely beneficial
in helping dentists evaluate and improve their
work. When they look at preparations on a
computer screen, they will either notice what
could be improved.
There are two ways to transfer digital data to
the laboratory: 1) intraoral scanning or a digital
impression system; or 2) a box scanner in the practice. Including a box scanner in the practice is an
efficient way for clinicians to interface between
analog and digital systems. Once a physical impression has been taken, it can be scanned, digitizing
the data for the laboratory. A clinician can take that
impression and start making the provisional, the
scan does not have to be completed immediately.
This creates a workflow where in between patients,
a clinical assistant can take an impression and proceed to set up a patient’s case, then complete the
scan and send it to a specific laboratory along with
the prescription. One of the greatest advantages is
being able to review the digital model as a means
of gathering feedback. From an economic perspective, a box scanner may also be more feasible for a
dental practice than an intraoral scanner.
There are aspects of taking a physical impression
that are technique sensitive, and similar concerns
for digital impression systems. Dentists may use
intraoral scanners most often for their single-tooth
dentistry, but for more advanced dentistry such as
larger veneer cases or an entire quadrant, they may
prefer to switch back to analog. Other dentists use
a digital scanner for full crowns, but not for partial
coverage. There is a learning curve associated with
digital dentistry, and clinicians must feel comfortable with their skills.
How does a clinician decide between all the
different intraoral scanners and digital impression
systems on the market? A dependable first step is
to physically interact with the technology and get
VOLUME 5 • NUMBER 114
a feel for the equipment. From this, clinicians can
determine if the system will fit in the operatories
or if they like the shape and weight of a handpiece.
Other considerations are the the sensitivity of the
camera, commitment to open architecture, and
hardware and software interface. Is the user interface intuitive, friendly, and relatively simple to
understand? In addition, although clinicians are
often the ones buying the technology, they may not
actually operate it. Consideration should be placed
on whether assistants can “test drive” the system
and decide if it is intuitive.
MAKING THE MOVE
Now more than ever, the practice of dentistry is
a hybrid of digital and analog along a wide spectrum of combinations. All of the many systems
and technologies that have been discussed so far
are not in fact “the future of dentistry”—they
are already in use, although not completely entrenched. In the meantime, before new technology
becomes more widely used, dentists will continue
to practice with a foot in both worlds. Fortunately,
excellent systems have been designed to navigate
the ground between analog and digital, giving
clinicians the time to decide when and where to
incorporate more digital technology.
For example, with the ability to integrate analog
data from an articulator into a digital articulator,
clinicians have the power to evaluate how the soft
tissue relates to the skeletal, and how that relates to
the teeth, while visualizing all the functional and
parafunctional interactions (Figure 4). As a result,
clinicians can now design restorations to fit within
the soft tissue, from a functional perspective.
As practitioners continue to assess their technology requirements, laboratories continue to be a
valuable resource. Understanding their protocols
and becoming part of the laboratory’s digital workflow can increase cost effectiveness, efficiency, and
quality of care in a dental practice. On the whole,
clinicians have many options for expanding the
amount of dentistry done with a laboratory in a
CDEWORLD.COM
7
4
Fig 4. A digital articulator can be utilized to visualize functional and
parafunctional interactions.
digital space or streamlining their own in-office
systems, and these options continue to advance.
Finally, an additional, important benefit of digital
innovation is that it continues to engage practitioners, as they have increasing opportunities to learn
different techniques for their practice and patient
care, while gaining new insight into their workflow
and expanding their perspectives on the frontiers
of oral health.
REFERENCES
1. Battersby J. CAD/CAM – the end for dental labs or a new beginning? Dentistry IQ. May 6, 2014. Available at: https://www.
dentistryiq.com/articles/2014/05/cad-cam-the-end-for-dental-labsor-a-new-beginning.html. Accessed June 18, 2018.
2. Beuer F, Schweiger J, Edelhoff D. Digital dentistry: an overview
of recent developments for CAD/CAM generated restorations. Br
Dent J. 2008;204:504-511.
3. Sailer I, Feher A, Filser F, Gauckler L J et al. Five year clinical
results of zirconia frameworks for posterior fixed partial dentures.
Int J Prosthodont. 2007; 20: 383–388.
4. Tinschert J, Natt G, Mautsch W, Spiekermann H, Anusavice K J.
Marginal fit of alumina- and zirconia-based fixed partial dentures
produced by a CAD/CAM system. Oper Dent. 2001; 26: 367–374.
5. Vult von Steyern P, Carlson P, Nilner K. All-ceramic fixed partial
dentures designed according to the DC-Zirkon technique. A 2-year
clinical study. J Oral Rehabil. 2005; 32: 180–187.
6. Luthardt R G, Holzhuter M, Sandkuhl O et al. Reliability and
properties of ground Y-TZP-zirconia ceramics. J Dent Res. 2002;
81: 487–491.
7. Farman AG. Digital radiography in dental practice. Inside
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Dentistry. 2016;12(11):26-27.
8. Desai V, Bumb D. Digital Dental Photography: A Contemporary
Revolution. Int J Clin Pediatr Dent. 2013;6(3):193-196.
9. Mladenovic D, Mladenovic L, Mladenovic S. Importance of
digital dental photography in the practice of dentistry. Sci J Faculty
Med in Niš. 2010;27(2):75–79.
10. Terry DA, Snow SR, McLaren EA. Contemporary dental
photography: selection and application. Compend Contin Educ
Dent. 2008;29(8):432–436.
11. Laskin B. Obtaining, storing, and transmitting patient files.
Inside Dentistry. 2016;12(7):92-93.
12. Koralakunte PR, Aljanakh M. The role of virtual articulators in prosthetic and restorative dentistry. J Clin Diagn Res.
2014;8(7):ZE25-ZE28.
13. Surapaneni H, Yalamanchili PS, Yalavarthy RS, Reshmarani
AP. Role of computed tomography imaging in dental implantology:
an overview. J Oral Maxil Radiol. 2013;1(2):43-47.
14. Serota K. Cone beam computed tomography: how safe is CBCT
for your patients. Dental Economics. 2011;101(1). Available at:
https://www.dentaleconomics.com/articles/print/volume-101/
issue-1/features/cone-beam-computed-tomography-how-safe-iscbct-for-your-paitents.html. Accessed June 17, 2018.
15. Buchanan A, Cohen R, Looney S, et al. Cone-beam CT analysis of patients with obstructive sleep apnea compared to normal
controls. Imaging Sci Dent. 2016;46(1):9-16.
16. Tally T. AAE/AAOMR recommendations for the use of CBCT
in endodontics. Inside Dentistry. 2017;13(9):40-47.
17. Ehrlich T. The next level of digital impressions. Inside Dentistry.
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18. Antenucci E. Dental impressions: maturity of imaging technologies driving shift from physical to digital. Compendium.
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19. Gallucci GO, Lee SJ. Digital vs conventional implant
impressions. Efficiency outcomes. Clin Oral Implant Res.
2013;24(1):111-115.
20. Dawood A, Marti Marti B, Sauret-Jackson V, Darwood A. 3D
printing in dentistry. Br Dent J. 2016;219:521-529.
21. Poss S. Digital versus traditional impressions: an objective
discussion. Compendium. 2014;35(6):384-385.
22. Brown C. Making a new impression. Inside Dental Technology.
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23. Perakis N, Belser UC, Magne P. Final impressions: a review
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Periodont Restor Dent. 2004;24(2):
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in-lab. J Dent Technol. 2018;35(1):36-42.
JUNE 2018
CDE
Quiz
TO TAKE THE QUIZ, VISIT
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2 CDE Credits
10. Macedo RG, Robinson JP, Verhaagen B, Walmsley AD,
Versluis M, Cooper PR, and van der Sluis LM. A novel methodology providing new insights into the ultrasonic removal
of a biofilm-mimicking hydrogel from lateral morphological
Lee AnnofBrady,
DMD
features
the root
canal. Int Endod J. 2014; 47: 1040–1051.
Digital & Analog: Dentistry in a Hybrid World
11. Vandrangi
P, Basrani
B.decisions
Multisonicimpact:
ultracleaning in molars
1.
Digital versus
analog
withA.the
GentleWave
system.
Oral
Health.
2015;May:72-86.
only the patient..
B. only the dentist.
C. how insurance is billed for a particular case.
D. multiple stages in dental treatment.
6. Secure communication is necessary to:
A. make sure the data is not corrupted.
B. remain HIPAA-compliant.
C. demonstrate evidence of concern for the patients.
D. comply with local law enforcement guidelines.
2. At the laboratory, milling is from a:
A. small block of material.
B. puck, or large circular piece of material.
C. translucent material.
D. hypoallergenic material.
7. As esthetic dentists transition from static photography
to videography, the laboratory technician will be able to:
A. provide nearly perfect shade matching.
B. determine what type of restoration will be required.
C. hear patients talk and see them move.
D. make restorations that require less removal of tooth structure.
3. Clinicians communicate information to the
laboratories via what type of technology?
A. analog
B. digital
C. combination of analog and digital
D. all of the above
4. Digital photography provides:
A. photographs with a perfect depth of field regarding focus.
B. perfect exposure times for an image.
C. immediate results in real-time.
D. the patient with a hard copy of a picture to take home
5. A potential downside to digital photography is
mastering different camera hardware and designing a
storage system that works with the:
A. practice software.
B. retrieval systems.
C. storage needs to be maintained and backed up and secured.
D. all of the above
This article provides 2 hours of CE credit from Dental Learning Systems, LLC. To participate in the CE lesson for
a fee of $0, please log on to http://cdeworld.com. Course is valid from 4/1/18 to 4/30/21. Participants must attain a
score of 70% on each quiz to receive credit. Participants will receive an annual report documenting their accumulated credits, and are urged to contact their own state registry boards for special CE requirements.
TO TAKE THE QUIZ, VISIT
CDEWORLD.COM/EBOOKS/CE/114
VOLUME 5 • NUMBER 114
8. When CBCT technology first came became available, it
was viewed primarily as an adjunct to:
A. implant dentistry.
B. simple extractions.
C. orthodontic therapy.
D. endodontic procedures.
9. If the laboratory is scanning the physical impression,
the technician may need to:
A. use polarized light while scanning the impression.
B. use ultraviolet light while scanning the impression.
C. spray the impression with a contrast material.
D. ask for a second impression as a backup.
10. If the technician sees a reason to create a physical
model, the process will have to move from digital to
analog using which of the flowing modalities:
A. a milled model, by carving the model from a plastic or
PMMA material.
B. stereolithography, an older technology in which a vat of
resin is cured in very precise layers to build a model up.
C. 3D printing.
D. all of the above
Dental Learning Systems, LLC, is an ADA CERP Recognized
Provider. ADA CERP is a service of the American Dental
Association to assist dental professionals in identifying quality
providers of continuing dental education. ADA CERP does
not approve or endorse individual courses or instructors, nor
does it imply acceptance of credit hours by boards of dentistry.
Concerns or complaints about a CE provider may be directed
to the provider or to ADA CERP at ADA.org/CERP
Approval does not imply acceptance by
a state or provisional board of dentistry
or AGD endorsement. The current term
of approval extends from 1/1/2017 to
12/31/2022. Provider #: 209722.
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