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The Complete Digital Workflow in Interdisciplinary Dentistry

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The Complete Digital Workflow in Interdisciplinary Dentistry pyri Co gh CLINICAL RESEARCH Not for Publicationt b y Q u i N n o t t r f e o The complete digital workflow in ssence interdisciplinary dentistry Christian Coachman, DDS, CDT Private Practice, Sao Paulo, Brazil Adjunct Professor, Department of Preventive and Restorative Sciences, University of Pennsylvania School of Dental Medicine, Philadelphia, Pennsylvania, USA Newton Sesma, DDS, MS, PhD Assistant Professor, Department of Prosthodontics, School of Dentistry, University of Sao Paulo, Sao Paulo, Brazil Markus B. Blatz, Prof Dr med dent Professor of Restorative Dentistry, Chairman, Department of Preventive and Restorative Sciences, and Assistant Dean for Digital Innovation and Professional Development, University of Pennsylvania School of Dental Medicine, Philadelphia, Pennsylvania, USA Correspondence to: Prof M. B. Blatz Robert Schattner Center, University of Pennsylvania, School of Dental Medicine, 240 S. 40th Street, Philadelphia, PA 19104, USA; Tel: +1 215 573 3959, Fax: +1 215 898 9981; Email: [email protected] 2 | The International Journal of Esthetic Dentistry | Volume 16 | Number 1 | Spring 2021 pyri Co gh COACHNotMA forN PublicationET ALt b y Q u i N n o t t r f e o Abstract integrating these systems into a feasible, realistic,ssenc e and practical workflow. Creating a simple complete New digital tools facilitating data acquisition, team digital workflow is key to taking advantage of these communication, computer-assisted diagnostics, and digital opportunities and offering their benefits to all treatment planning as well as the design and fabrica- patients. Making digital workflows the routine rather tion of restorations, guides, stents and devices in gen- than the exception is fundamentally important in or- eral have fundamentally altered key clinical and lab- der to grow a dental practice in this new environment. oratory steps. The number of new technologies and This article presents a new complete digital workflow the amount of new equipment used today to acquire that changes and improves the process of treating a patient data, the software to manipulate this data, and comprehensive case from diagnostics to execution the machines to manufacture devices from it drasti- and maintenance. cally increases all the time, as do the challenges of (Int J Esthet Dent 2021;16:2–17) The International Journal of Esthetic Dentistry | Volume 16 | Number 1 | Spring 2021 | 3 pyri Co gh CLINICAL RESEARCH Not for Publicationt b y Q u i N n o t t r f e o ssence 6. Digital Quality Control 1. Patient Digitalization (Rescanning, Overlapping, and Monitoring) (Documenting 2D, 3D, Movement, Graphics, CLINIC & and Notes) PLANNING CENTER CLINIC New Patient New Patient or Maintenance Retreatrnent 5. Guided Dentistry (Manufacturing Devices and LAB & Restorations, Guided Clinical CLINIC Procedures) 2. Cloud Data Management CLOUD (Storing, Organizing, Accessing, Sharing, and Team Communicating) Acceptance Case 4. Patient 3D Presentation 3. 3D Treatment Simulations & Collective CLINIC (Visual Communication and Storytelling Intelligence for Patient Engagement, Education, and PLANNING (Facially Driven Designs and Interdisciplinary CENTER Motivation) Simulations for Diagnosis, the ­­ Decision-making Process, and Planning) Fig 1 The six steps of the new complete digital workflow. Introduction analyses and models into the smile assess- ment and design.3-5 The purpose of this article is to present the Intra- and extraoral optical scanners en- concepts involved in the six key steps that able the 3D evaluation of all oral and facial comprise a complete digital dental concept structures, as does digital radiography such and workflow (Fig 1). as CBCT, while specific computer programs In the dental laboratory, CAD/CAM sys- and software tools facilitate the digital plan- tems that include optical or mechanical ning and visualization of anticipated esthet- scans of a cast, digital restoration design ic outcomes to accurately plan and execute software, and a CAM system – either in the multidisciplinary treatment.6 laboratory or at a centralized milling center Digital smile analysis and design was first – have become standard over the last few described in the early 2000s,7-9 leading to decades.2 There are still significant oppor- the development of several computer pro- tunities to further establish and integrate grams for esthetic analyis.6 In 2008, the first digital tools in the dental practice and in in- fully facially guided digital smile design pro- terdisciplinary treatment. For example, digi- tocol was developed.10 Merging facial, ex- tal smile design tools and software have un- traoral, and intraoral photographs with 3D dergone a significant evolution and are now digital models facilitated the application of a far more advanced than traditional esthetic completely digital workflow to evaluate es- evaluation and treatment guidelines, which thetic parameters and treatment plan smiles are typically based on 2D measurements. in 3D.11 Since then, digital technologies in One key aspect is the ability to include 3D dentistry have progressed in a way that few 4 | The International Journal of Esthetic Dentistry | Volume 16 | Number 1 | Spring 2021 pyri Co gh COACHNotMA forN PublicationET ALt b y Q u i N people could have predicted. These tech- n o t t r f e o nologies enable the establishment of truly ssence esthetic outcomes through algorithm librar- ies of natural teeth and smiles, which are superior to hand-built wax-ups and setups because they do not depend on individual skills and subjective interpretation.12 All the various digital tools, however, are limited or even useless unless they are inte- grated into a complete and comprehensive digital concept and workflow. This article describes a new and complete digital work- flow that can be applied in the dental prac- tice, and discusses the impact of this work- flow on interdisciplinary dental treatment. Our goals were to identify and demonstrate current trends, share our visions for the fu- ture, and create an understanding of these visions, even though some of the digital tools may not as yet be perfect. Despite some current limitations, which should be Fig 2 Patient Digitalization with a 3D face scan integrated with the CBCT scan, resolved sooner or later, digital workflows STL files, virtual articulator as well as face and jaw movements. already provide excellent, more predictable, and reproducible outcomes compared with analog techniques. knowledge and understanding of facial and dental esthetics that overly relied on written The six steps of the new complete information, combined with the inaccura- digital workflow cies and distortions of analog procedures such as impression making, facebow trans- Step 1: Patient Digitalization fer, interocclusal records, and analog artic- ulators. In contrast, Patient Digitization can In the new complete digital workflow, tradi- greatly improve visualization, evaluation, tional and analog patient documentation is and diagnosis. In addition, these steps can replaced by Patient Digitalization (Fig 2). The be carried out on the computer even with- integration of a 3D face scan with the CBCT out the patient being present, saving valu- scan, STL files, virtual articulator as well as able chair time. Adding a full-skull CBCT face and jaw movements allow for a signifi- scan during the first appointment allows cantly more accurate analysis and visualiza- for a thorough evaluation of structures and tion of all orofacial issues as well as function- possible pathologies, including TMJ, airway, al, structural, and esthetic aspects, including and facial analyses, that cannot be detect- the temporomandibular joint (TMJ), airway, ed otherwise. Instead of proposing a CBCT and other anatomical structures.13 scan only when an issue is suspected, or In the past, clinicians relied almost ex- only performing a sectional CBCT examina- clusively on their subjective and some- tion, routine use of full-skull CBCT imaging times incorrect clinical evaluation and judg- may have a significant impact on patients’ ment. This process was hindered by limited well-being, since individual anatomical The International Journal of Esthetic Dentistry | Volume 16 | Number 1 | Spring 2021 | 5 pyri Co gh CLINICAL RESEARCH Not for Publicationt b y Q u i N features and possible pathologies of the scanner, etc) may pose some challengesn o t t r f e o maxillofacial complex that cannot be de- when assembling the digitalized patientssen ce tected otherwise can be evaluated and iden- and possibly lead to distortions. However, tified, possibly at an early stage. While radi- the merging and overlapping of such files ation exposure for a full-skull CBCT scan is becoming significantly simpler, especially is greater than for a sectional one, overall with the application of artificial intelligence exposure with current CBCT machines has (AI) tools. Technologies to increase preci- been significantly reduced compared with sion and accuracy in the digital workflow earlier models and traditional computed to- are constantly improving and may already mography machines.14 supersede analog steps, eg, taking into ac- With the Patient Digitization tools avail- count interocclusal records, facebow reg- able today: istration and transfer, and the mounting of ■ Intraoral scanners (IOSs) eliminate the need models in an articulator. for intraoral photographs and impressions. ■ Face scans eliminate the need for extra- Step 2: Cloud Dentistry oral photographs and provide a 3D image. ■ Virtual articulators, overlapped with face Another
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