We have all experienced that tug on our competence – am I doing enough to keep up with the ever-changing cutting-edge techniques and materials? Digital solutions to dental focused problems have grown into a continuously expanding presence in the literature, in our continuing dental education content, and certainly in our lives.
Some questions include: Where does digital dentistry excel? What are the thoughts from the dental laboratories? How do we take the information available and apply it to our practices?
Where does digital dentistry excel in 2020?
- Single tooth implant restorations
- Restorations made for prepared natural teeth
- Complex restorations for edentulous arches and smaller segments of missing teeth
- Complete removable denture prostheses
- Maxillofacial prosthodontics
A single tooth restoration supported by a dental implant fixture is perfectly suited for the CAD/CAM world of digital dentistry where the tolerances can be dialed in to create a precision fit. Restorations made for natural teeth require attention to the detail of preparation design, digital image capture, and material handling to create outstanding results.
Once the restorations increase in complexity, the tendency is to lean toward the known world of single tooth implant restorations or to focus on material properties and key handling features.
As the prosthesis of choice becomes larger as in complete removable denture or maxillofacial prostheses, the digital image capture becomes an increasingly important part of the process in terms of the accuracy and precision of the process.
Survey of dental laboratories
The National Association of Dental Laboratories published the results of their survey of dental laboratory technicians taken during the summer of 2019. Three of the survey questions are included to provide insight.
While dental professionals have options in terms of incorporating CAD/CAM digital dentistry, the impact could be measured through dental laboratories with the volume of procedures required to evaluate benefit over a broader scope of procedures.
This 2019 survey conducted by the National Association of Dental Laboratories showed:
- Digital solutions are integrated into lab workflows.
- The dental laboratory industry includes a printed product to facilitate end results.
Figure 3 would likely not be of surprise other than the last category where not one of those surveyed responses expect digital based manufacturing to decrease in the next 3-5 years. What this means is that we have made it past the early adoption phase in the dental laboratory realm in 2020 and digital solutions are now part of the day-to-day thought process.
Figure 4 looks at where dental laboratory industry has changed to include a printed product to facilitate the end result. It is interesting to see a divide of sorts between the models and surgical guides and the products below the line intended to serve as a restoration or prosthetic device designed for use in a patient's mouth.
These survey results indicate where digital technology would create the most influence looking forward. Certainly, available materials and techniques capture our attention and imagination in terms of what is possible and where are the limitations and barriers at present.
The 23% responding to “Global Economics & Market Adjustments” category couldn't have known what was to happen in the spring of 2020 with the impact of the COVID-19 outbreak, where if the survey were to be taken now, the percentage would undoubtedly be higher.
At present, it is possible to capture an intraoral image or make an image of a traditional model and send that information to any location on the globe as a digital file. The design work can be completed, evaluated, the final product can be refined and returned to an office for milling or printing. This provides a level of control in terms of who is permitted and what they need to do in order to have contact with the final restoration prior to evaluation and insertion clinically.
The majority of the impact of legislation and regulation in its current form is felt by the dental laboratories where 18% noted this will have an influence in every-day operations. In short, anything made in a dental office under the direction of a dentist for the treatment of their patients does not fall under the FDA's guidelines.
Once dental related products are made, sold and delivered to other offices the FDA has laid out specific rules and regulations specific to how the end-product is made. For example, hand-crafted medical devices do not fall under a classification within the FDA and are therefore under much less scrutiny.
The FDA recommends strict adherence to manufacturing practices for Class I devices that include x-ray positioners, facebows, dental floss, orthodontic brackets, and dental burs. Class II devices include denture teeth, sleep appliances, gold alloy, dental implant abutments and milled crowns for which the FDA mandates labelling requirements, performance evaluations and post-market surveillance.
Regarding a milled crown, the CAD software must be validated through the FDA, and the pre-milled block of material is tested, identified with a label and once cleared for market use is continuously evaluated over time. This is a simple process as the milling material and the resulting material of the milled crown remain the same, the CAM component simply removes the excess material.
Printing a dental device through additive manufacturing falls under a different set of regulations. The materials used in printing changes as it moves from a liquid form to a solid form and the FDA finds it to be important that the change is controlled and validated. The FDA regulates the materials, the design software as well as the printer to make sure the final result is a predictable material that can be made on a consistent basis.
How can digital dentistry visibly help the patients in our practice today?
The July/August 2019 issue of Harvard Business Review includes an article titled “Digital Doesn't Have to be Disruptive,” which provides a few thoughts on prioritizing implementation of new technology to existing protocols in a myth versus reality context.
Myth 1: Digital is about technology versus the reality of digital is about serving our patient's needs.
The shipping company Maersk provided an example where they prioritized tracking and identifying the location of a shipment anywhere around the globe in an effort to facilitate communication with their clients that were reliant on the timing of the delivery. Prioritizing communication in the office sets the tone for expectations and allows our patients to make plans accordingly. Clearly identifying the next steps for treatment needs so the team can answer questions in person, over the phone, or through electronic means is a simple and effective method to serve our patient's needs without delay.
Myth 2: Digital will replace the physical versus the reality of needing a combination of both digital as well as physical.
The Nest thermostat is an example of the digital replacing the physical. Imagine the opportunity where a digital thermostat could help identify inefficiencies in the heating, ventilation and air conditioning unit (HVAC) and could signal for a technician to identify and take preventative measures as opposed to reacting to broken components.
Tele-dentistry has taken a spotlight with the events of the spring of 2020 and will likely continue to be a component of our approach involving digital dentistry. In Figure 5, take a look at the information available in a simple iPhone photo sent in and how that helps us to prepare for the appointment.
While the fractured front tooth is the immediate concern, it is clear that the patient has severely worn the functional surfaces of the posterior teeth of the overdenture prosthesis. Now we are prepared and ready to take action appropriate for this patient.
Myth 3: Digital is about overhauling versus the reality of incremental bridging of existing systems.
While there is certainly a large boost of energy involved with implementing new technology, there is also a large amount of risk associated with a complete overhaul. Imagine if Marriott simply decided to immediately stop all its existing protocols and systems developed and refined over decades in favor of a VRBO or Airbnb approach.
There are many examples of incremental bridging applied to our practices. CDOCS.com provides a solution to a specific set of patients in our practices, and additive printing technology increases opportunity for another group of patients. Analog approaches or at minimum analog steps in a digital workflow continue to rely on the knowledge, skill and judgement that we have acquired over time and practice.
The goal with new techniques and materials available is to identify how this cutting-edge technology can improve the way we practice and the outcomes that we deliver to our patients.
Douglas G. Benting, D.D.S., M.S., F.A.C.P. is a member of Spear Resident Faculty.