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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]

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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)

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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

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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

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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 great benefit of the complete dig- photographs or scans, eliminate the need ital workflow is the onceptc of Cloud Den- for analog facebows and articulators. tistry. Since the patient is digitalized and all documentation is available as digital files, The required digital files for complete Pa- the information can be immediately stored tient Digitalization are: in the cloud with specifically designed soft- ■ 2D digital files ware and in formats that are compliant with ● Static images local patient information privacy laws. • Photographs (extra- and intraoral) One major challenge for developing in- • Radiographs terdisciplinary treatment plans for every pa- • Panoramic radiographs tient is the lack of time to brainstorm and ● Dynamic images discuss treatment options with other ex- • Videos (technical, phonetics, and perts before making key decisions. In today’s personality) world, talking to experts and team mem- ■ 3D digital files bers on the phone or scheduling in-person ● Face scans (at rest and while smiling) meetings is often not practical, feasible or fi- ● Intraoral scans (maxilla, mandible, nancially sensible. Consequently, and since and interocclusal records) creating a customized treatment plan for ● CBCT scans every patient in such manner is extremely ■ Movements time consuming, many dentists find them- ● Facial movements selves developing comprehensive treat- ● Intraoral mandibular movements ment plans on their own and without the ■ Texts/graphics valuable input of other experts. However, ● Medical history/questionnaires developing a treatment plan based on only ● Dental charts one opinion and without specialists’ partici- ● Periodontal charts pation may, especially in complex cases, be ● Occlusal charts very limiting, and may not fully address all of the patient’s conditions and needs. Inter- Various digital file formats from the differ- disciplinary treatment planning requires a ent digital tools (CBCT machine, IOS, face decision-making process based on a team

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Fig 3 Traditional in-person treatment planning meetings are replaced by a digital Asynchronous Communication system that allows team communica- tion from different places and at different times.

approach. Even when specialists and team The advantages of consolidating all pa- members are working in the same building, tient data in the cloud are: conflicting schedules may prevent in-per- ■ Overcome the greatest challenge to in- son meetings and direct communication. terdisciplinary treatment planning, which In addition, even simple consultations on a is the inability to discuss a patient case specific patient situation can be difficult to as a team due to time and location manage within a reasonable timeframe. constraints. The solution to these challenges is a sys- ■ Improve quality of evaluations, diagno- tem that allows for so-called Asynchronous ses, and treatment plans through inter- Communication (Fig 3), ie, interacting with action and collaboration of team mem- several people who are neither in the same bers and top specialists from any place place nor available at the same time. This in the world. concept is derived from social media, where ■ Eliminate the need for in-person meetings. users can send a message to several people ■ Accelerate information flow and improve who can interact and comment whenever it collaboration with specialists, dental lab- is convenient for them to do so. It allows for oratories, 3D planning and imaging cen- information transfer and exchange, so team ters, and others. members can actively participate even when ■ Allow patients to participate and stay in- their schedules or locations do not coincide formed about the process to the extent in time or space. In this sense, it follows the determined by the provider. collective intelligence (CI) concept, which is shared or group intelligence that derives Implementation of the Asynchronous from the collaboration, collective efforts, Communication concept is only possible and competition of many individuals. The through Patient Digitalization and Cloud first dental software that attempted to pro- Dentistry. It is key that all patient information vide a platform for Asynchronous Commu- is available online (in the cloud), and that all nication was the DSDApp (by Coachman). team members are connected and inter- The software platform Smile Cloud (ADN3D acting through a common communication Biotech SRL) offers a similar solution. channel (Fig 4).

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t t r f GENERATING SAVING & ORGANIZING PROCESSING es o e DATA DATA DATA senc

Analog and Digital Systems Protected Cloud Platform Sharing, Accessing, and Interacting

Dentist 1

Dentist 2

Dentist 3

Staff

Planning center Aligner company

Laboratory

etc

Digital allows more and deeper Digital allows better Digital allows asynchronous information from the patient management of information communication and collective a intelligence systematically

Fig 4a and b The digitalized EFFICIENT & EFFECTIVE COMMUNICATION patient information is Collaborating from Different Places and Different Time Zones available online (cloud) with all team members connected Planning Center and interacting through the Asynchronous Communication Laboratory system, creating Cloud more efficient and effective communi- cation and making better use of the Other Services collective intelli- Dentist 1 gence. Dentist 2

b Digital allows better decision making as a team for every single patient

Step 3: Virtual Treatment Simulation will facilitate the formulation of alternative treatment plans. The interdisciplinary communication and The next step in the complete digital collaboration of all connected specialists workflow is to test drive the various al- and participants (Asynchronous Commu- ternatives and possibilities with 3D simu- nication) starts after the patient is com- lations. The idea is to ‘make mistakes on pletely digitalized and the uploaded in- the computer to reduce the mistakes in formation is readily available in the cloud. the mouth.’ It is similar to an airplane pilot The exchange of ideas and suggestions who will simulate numerous flights before

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flying a real plane with actual people on originally developed to assist with these as- n o

t t r f e o board. pects; they only allowed clinicians to take ssence As the team of specialists suggests treat- advantage of these digital tools after ma- ment options, a 3D software expert team jor treatment decisions had already been (Planning Center) will translate these ideas made. into simulations to visualize prospective Facially driven and interdisciplinarily in- outcomes and their impact. It is critical not tegrated software platforms are the keys to draw conclusions too quickly or make for modern digital dentistry. The new com- decisions based only on clinical examina- plete digital workflow provides the dentist tions and conventional documentation, with the opportunity to translate all treat- but to allow the 3D simulations to improve ment options proposed by the team into the understanding of the impact of possi- 3D simulations, either through the dental ble treatment options and procedures. A office acquiring all the necessary technol- software system that allows for all types of ogy and training staff members to man- simulations on the same platform and at age these technologies or, in a more real- the same time is necessary to enable this. istic scenario, by dentists outsourcing the It should use the face as a starting point to workup to a Planning Center that translates make it facially driven and interdisciplinari- proposed treatment plans and procedures ly connected. This may seem obvious, but into simulations, allowing any dentist to until recently, dental and smile design soft- take advantage of this technology without ware systems were not facially driven and worrying about financial investments and did not allow for simultaneous interdisci- learning curves. These simulations connect plinary simulations. Software programs of- the clinical treatment planning team with fered by various manufacturers, specialties, the Planning Center through the cloud, and service providers, eg, Invisalign (Align which is only possible if all patients are dig- Technology), Cerec (Dentsply Sirona), Dol- italized. Consequently, the connection of phin (Patterson Dental), and NobelClinician all three initial steps of the modern digital (Nobel Biocar­ e), were not connected or workflow are: Patient Digitalization › Cloud compatible. Since the specialties were not Dentistry/Asynchronous Communication › connected, the impact of one procedure Virtual Treatment Simulation/Planning Cen- on another could not be evaluated, and in- ter Outsourcing. terdisciplinary digital simulations were not Today, any treatment plan can be sim- possible. Moreover, most of the original ulated, which provides a very powerful un- dental software programs concentrated derstanding of the impact of the planned on teeth. They did not use the face as the procedure from an interdisciplinary per- starting point, so can be considered neither spective. From simple to complex, from facially driven nor interdisciplinary. Com- single procedure to combined procedures, mon dental software programs focused the facially driven smile design (Figs 5 and only on the treatment execution of den- 6) shows a restorative plan, which deter- tistry and not on the planning. However, mines and guides an orthodontic simu- the most powerful part of digital dentistry lation that not only moves the crowns of is that it can assist clinicians with the most teeth but also demonstrates root move- difficult aspects of dentistry: diagnosis, de- ment and its impact on the surrounding cision making, risk assessment, design, and bone. treatment planning. Unfortunately, none There are two key timeframes when us- of the common software programs were ing 3D software in dentistry:

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a b

c d

Fig 5a to d Initially, dental software did not use the face as the starting point. It was typically fragmented and did not have interdisciplinary connectedness. It was therefore unable to provide combined simulations and comprehensive treatment planning.

a b c

d e

Fig 6 Example of a case planned using interdisciplinary facially driven software, where the starting point is the ideal initial functional and esthetic smile design (a). Then, the orthodontic simulation (b), implant planning (c), periodontic analysis (d), and restorative design (e) are all planned based on the initial smile design and simulated together to allow for the evaluation of the impact of one procedure on another.

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t t r f e o COMPLETE DIGITAL CLINICAL SOLUTIONS ssence

PATIENT OFFICE PATIENT DENTAL BRAINSTORM PATIENT ACQUISITION MANAGEMENT DOCUMENTATION TREATMENT SIMULATIONS PRESENTATION Digital marketing Digital management Digital photos Digital team Digital presentation Digital CRM software Digital videos communication software Digital customer Digital charts Digital face scans Digital cloud sharing Digital screens support Digital reports Digital intraoral scans Digital imaging center Digital network Digital messenging Digital CBCT scans Digital planning center Digital smile simulations Digital radiographs Digital laboratory Digital chairside NEW PATIENT Digital perio charts Digital facial analysis printing Digital medical Digital smile design CASE ACCEPTANCE history Digital treatment Digital jaw movement simulations Digital bite analysis Digital diagnostics

PRE CASE ACCEPTANCE DIAGNOSIS/DESIGN/PLANNING/SELLING STRATEGIES

DIGITAL DEVICES GUIDED DENTISTRY MAINTENANCE MONITORING PRODUCTION PERFORMANCE Digital recall management Digital 3D ortho software Digital guides Digital diagnostics Digital 3D perio software Digital intraoral scans Digital photos Digital 3D restorative software Digital quality control Digital videos Digital 3D orthognathic Digital face scans software Digital intraoral scans Digital printing technology Digital radiographs Digital milling technology Digital perio chart PATIENT LOYAL

CASE ACCEPTANCE Digital shipping tracking Digital jaw movement Digital bite analysis

POST CASE ACCEPTANCE EXECUTION/TECHNICAL STRATEGIES

Fig 7 Key steps in the complete digital clinic that involve technology. Blue sections indicate steps that require 3D software.

1. Before case acceptance: for diagnostics, For the first key timeframe (before case ac- interdisciplinary treatment planning, and ceptance), facially driven and interdisciplin- patient presentations. arily integrated software is required. In the 2. After case acceptance: to design and past, 3D technology was only geared to- fabricate specific guides, devices, align- ward the second key timeframe (after case ers, and restorations to perform guided acceptance). The face was not needed, clinical procedures (Fig 7). since facial analysis and smile design were

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embrace an idea. It is very importantn that o

t t r f e o the treatment plan presenter understandsssen ce how to use visual communication strategies to engage the patient, create awareness, and ultimately receive case acceptance. All treatment simulations performed before and used to define the treatment plan will now become extremely powerful to edu- cate the patient (Fig 8). Presenting treatment plans and antici­ pated procedures to the patient can be out- lined in four steps that form part of a journey and which should be executed in a specific sequence (Fig 9):

Fig 8 Patient treatment plan presentation should take place in a sophisticated presentation room with all technologies readily available for improved communi- 1. The Emotional Journey cation, education, and motivation. This first step includes the smile design pro- cess and motivational mock-up. Technology is used to engage the patient emotionally by creating the vision of a possible future smile that can have a significant impact on the patient’s life. This will ‘deprogram’ the mind- set of patients regarding dentistry, which is already determined. Similarly, interdisciplin- usually extremely negative, and will ‘rewire’ ary integration was missing, since diagnosis, them with a positive and exciting vision of planning, and treatment selection had al- how dentistry can change their lives for the ready been completed beforehand. How- better by regaining or improving an attrac- ever, these now obsolete concepts did not tive and confident smile. The Emotional recognize some of the greatest advantages Journey is implemented through virtual and most powerful features of 3D technol- smile simulations, a real motivational mock- ogies with respect to diagnostics and treat- up experience (with 3D design software and ment planning. printing technology) as well as visual pre- sentation skills and technologies such as Step 4: Digital Patient Presentation ‘before’ and ‘after’ images, scans, personal and Case Acceptance device apps, technologies, and others. The Emotional Journey as a first step is The next step of the workflow is the presen- not only related to esthetic cases. Emotion- tation of the treatment plan to the patient. al communication strategies are about gain- After all ideas have been simulated and ing the patient’s trust and empathy, creating Asynchronous Communication has allowed a rapport or link, and starting a relationship. the team to evaluate them and define an Patient cases that involve esthetics should ideal treatment plan, the next critical step is also involve an emotional link between the to get the patient involved. Technology can patient and the possible future smile. Ba- play a key role in educating and motivating sic psychology principles demonstrate that the patient. Visual communication is the for any type of relationship, one first needs best way to communicate and make people to gain ‘emotional credits’ with the other

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t t r f e o ssence The EMOTIONAL Journey

The PROBLEMS Journey Clinical exam

Face – Airway Functional Journey

Treatment Plan Journey The SOLUTIONS Journey 3D virtual treatment simulation

The FINANCIAL Journey $

Fig 9 The four journeys of the treatment plan presentation.

person before engaging in more rational as- experiencing and understanding the prob- pects to ultimately increase the value of any lems at hand and the possible consequenc- technical explanations. It is, therefore, rec- es that may occur if they are not resolved. ommended to first create an emotional link Since dentists already understand the prob- with the patient and later discuss technical- lems and the solutions, a very common ities, problems, solutions as well as financial mistake that many of them make is to tend and personal implications. to quickly move to explaining the solutions without properly clarifying the concerns. 2. The Problems Journey The Problems Journey is best performed Digital technologies are applied to take the with digital tools that provide visual infor- patient on a profound journey to demon- mation and explanations. Among the most strate all the clinical findings and areas of powerful tools at this point are IOSs with true concern as well as the impact of not treating colors, combined with other digital images these issues. The clinician must understand generated by cameras, mobile phones, pan- the importance of the Problems Journey oramic and other radiographic images, 3D and the reasons for explaining the issues be- CBCT scans, facial scans, videos, and oth- fore explaining the solutions. It is difficult for ers. New scanning technologies, eg, near a patient to value a solution before visually infrared and ultrasound, have tremendous

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added value since they can detect, docu- technologies to increase quality, efficiency,n o

t t r f e o ment, and track certain pathologies such and predictability. These two conceptsss goen ce as caries and, besides the ensuing clinical hand in hand and are illustrated in Figures benefits, can provide meaningful assistance 10 to 12. with patient education. Digital dentistry is extremely helpful in overcoming one of the greatest limitations 3. The Solutions Journey of restorative dentistry: the discrepancies In this step, all treatment simulations are between the initial plans and the final out- presented to the patient. After the emotion- comes. In the past, the differences between al connection has been made and a clear an initial diagnostic wax-up and the final understanding of the problems has been treatment result were usually tremendous. reached, the patient is able to give value In addition, they unfortunately represented to the suggested solutions. The images the rule and not the exception. Analog pro- generated by the 3D treatment simulation tocols have failed to address these limita- software (Asynchronous Communication) tions. It can be expected that, in the future, are now used to engage the patient with freehand intraoral procedures will no lon- the solutions toward a full understanding of ger be performed, and all procedures will the reason and benefit of each treatment use some kind of digitally designed guide procedure. or device. This is the concept of Guided Dentistry. In addition, all procedures must 4. The Financial Journey be evaluated before moving on to the next Once the solutions are fully understood, the step by comparing the initial simulation patient is ready to consider and appreciate with the achieved result. By superimposing the costs involved. For an effective patient scans of the initial and the actual situation, presentation, it is important to understand discrepancies can be detected and correc- that, in addition to a high-quality treatment tive measures carried out, where neces- plan and its presentation, a suitable environ- sary. This is the concept of Digital Quality ment is necessary in which the presentation Control. can take place (see Fig 8). It is therefore criti- cal to have a very sophisticated presentation Future outlook room with all the technologies easily acces- sible to avoid losing momentum when telling A number of digital tools such as digital ra- the beautiful story of the patient’s journey. diographs assist in the Digital Quality Con- trol process. There are already programs One of the key goals of the previous steps in available that apply AI and machine learning the completely digital workflow is to create (ML) tools to read radiographs and detect perceived value, which will eventually lead certain pathologies and aberrations such to case acceptance. as caries and marginal gaps. In the future, these tools will become automated and ap- Steps 5 and 6: Guided Dentistry and plied on a large scale to alert the clinician Digital Quality Control and the team to any quality related issues and concerns during follow-up visits, es- After case acceptance, two final concepts of pecially when they trigger adjustments or Guided Dentistry and Digital Quality Control remakes. In fact, AI and ML will most likely will help the team to deliver the treatment be applied to automate almost all the steps in the best possible manner using digital of the complete digital workflow, from

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t t r f e o ssence GUIDED DENTISTRY VIRTUAL

REAL

Fig 10 Guided dentistry overview. The treatment plan is developed based on the initial design (the final goal). All dental devices and guides are fabricated to minimize discrepancies between the plan and the final outcome.

Treatment Script & the Digital Laboratory

0. Emergencies 1. Implant 2. Aligner 3. Crown lengthening 4. Bite deprogrammer 5. Transitional table tops & palatal veneers 6. Guided preps & provisionals 7. Final restorations 8. Night guard

Fig 11 a facially driven smile design and treatment plan is translated into a 3D project. The project guides the development of a treatment ‘script’ that details the exact sequencing and timing of the procedures to be performed. Each procedure is guided by a dental device to preserve the precision of the initial ideal treatment plan as approved by the dentist and the patient.

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a b

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e f

g h

i j

Fig 12 Each procedure is guided by a dental device to preserve the precision of the initial ideal treatment plan as approved by the dentist and the patient. The situation is scanned after final healing and overlapped with the initial simulation for quality control analyses. (a) Preoperative situation. (b) Facially driven 3D smile design. (c) Transparency of the ideal design overlapped with the preoperative situation, visually showing the discrepancies that include the need for crown lengthening. (d) Design of a double crown-lengthening guide respecting the new ideal gingival margin and biologic width. (e) Guided soft tissue removal. (f) Guided bone removal. (g) The ideal design should be the reference for 3D quality control. (h) The scan after healing to overlap with the ideal design and for quality control of the surgical result as well as to show a possible need for refinement or approval of the outcome. (i) Intraoral situation after crown lengthening (j) Definitive ceramic restorations.

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diagnostics and treatment planning to mate- patient information, a facially driven smile n o

t t r f e o rial selection and follow-up.12 Critical errors design and treatment plan is translated into ssence that are based on human error or subjective a 3D project. This project guides the cre- opinions can consequently be minimized or ation of a treatment ‘script’ with the exact even avoided. Current concepts related to sequencing and timing of the procedures ‘intuitive ML’ make these visions of automa- to be performed. Accordingly, guides and tion even more likely. devices are fabricated to reduce the dis- crepancies between the plan, as approved Summary by the dentist and the patient, and the ulti- mate outcome. The final outcome and the The new complete digital workflow com- situation during follow-up visits are scanned prises six key steps, from digitalized patient and overlapped with the initial simulation information and cloud-based interdisciplin- for quality control purposes. Adjustments or ary treatment planning to digital simulation, retreatment can be carried out according- case acceptance, guided treatment, and dig- ly. Figure 7 summarizes key elements of the ital quality control. Based on the digitalized complete digital dental practice.

References

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