International Journal of Dental and Health Sciences Volume 01,Issue 02 Review Article

DIGITIZATION IN Mohit Singh1, Mansha Mohan2, Shivangi Choudhary 3,Rohit mittal4

1,2,3 & 4. Post Graduate, Department of Prosthodontics & Implantology, D J College of Dental Sciences & Research, Modinagar, Uttar Pradesh, India.

ABSTRACT:

The technology is now available to run a practice almost paper free. It is theoretically possible to store clinical notes, photographs, and radiographs; and study models on disc, and refer or consult online. In recent years, it has developed significantly into the major dental branch, currently used by the increasing number of dentists and dental technicians worldwide. Digitalization has become a part and parcel of contemporary prosthodontics with the probability of most of the procedures being based on the digital techniques in the near future. X rays or photographs, making impressions, recording jaw movements or fabricating prosthesis, educating and training new dentists or patient motivation for practice build up; all has become digital. CAD-CAM was first patented in followed by various other technologies like CT, CBCT. It has revolutionized not just the ceramic technology, but has also been used for the CAD-CAM implant surgeries, maxillofacial prosthesis and diagnostic splints. Key words: Prosthodontics, Digitization, CAD/CAM Technology, CBCT, Optical Impression.

INTRODUCTION: preserving oral health and provides next to natural aesthetics with an enhanced Dentistry can be dated back to eighteenth approach, reduced treatment time, century, when impressions meant use of minimized error potential and better waxes and plaster of Paris; and the dental quality assurance.[1] equipment consisted of hand driven and later water driven motors. From then, Digitalization has become a part and there has been a long journey to achieve parcel of contemporary prosthodontics contemporary paraphernalia. Along with with the probability of most of the limited materials and equipment there procedures being based on the digital were selective treatment options, but techniques in the near future.1 Digitalized with the passing years and endless growth dentistry enables efficient, fast and in research, emerged a gamut of options precise and error free production of fixed in dentistry. The contemporary dental prosthodontics appliances. Early 1980s practice has endless options for also paved a way for computer aided

*Corresponding Author Address: Dr. Mohit Singh, Department of Prosthodontics & Implantology, D J College of Dental

Sciences & Research, Modinagar, Uttar Pradesh, India.E-mail: [email protected]

Singh M. et al., Int J Dent Health Sci 2014; 1(2): 208-219 design/computer aided manufacturing everyday activities. Some activities have (CAD-CAM) technology.[2] become redundant and fade out, while new activities appear and take their place. There is endless scope of digitalization and technology in prosthodontics– let it The dentistry is also a field which is be in the clinical and lab procedures like increasingly experiencing the impact of use of CAD-CAM technology, stereo digitalization. Digitalization will impact all lithography, rapid prototyping, use of aspects of dentistry; even alter the flow of virtual articulators and digital face bows, traditional treatment processes. digital radiographs, or in the field of Workflow between the different parties training education and research by the involved (dentists, surgeons and dental use of virtual patient program, dental laboratories) can be affected drastically. software, optoelectronic recording of jaw The claim that dental workflows will motion, retention testing device, audio change because of digitalization is widely visual aids the list will remain endless.[1,2] accepted. Renowned dental surgeons and implantologists, such as Professor Daniel The future of digital imaging could include Wismeijer of the Academic Center for the testing and upgrade of x-ray Dentistry Amsterdam, acknowledge the equipment and software on-line. Research impact of digitalization on the dental is also continuing into the development of profession. Prof. Wismeijer describes credit card size ‘smart card’, which could digital dentistry as follows: “The patient carry a patient’s medical and dental notes will remain analogue and the in-mouth along with their radiographic images. It is piece (bridge, crowns, etc.) he or she important that advances in technology are receives is analogue. Everything in accepted and the benefits that they between will become digital.” He produce utilized in order that clinical continues: “with the support of digital practice and patient care continue to dentistry, the whole world (practices, labs, improve.[3] etc.) can be involved in optimizing the [4] Various Digitalization Techniques used in value chain”. Prosthodontics: Straumann Digital Solutions: Over the past years the use of digital In the beginning of 2010 Straumann technologies has had a great impact on launched a new array of integrated many fields, from communication to computer-based technologies under the education. This digital revolution started name of ‘Straumann Digital Solutions’. in the latter half of the 20th century by These technologies can be categorized converting analog objects/signals into into three competencies: computer digital bits and bytes. Over time such guided surgery, intra-oral scanning, and technological advances have changed, and CAD/CAM prosthetics.[5] still do change, how people and businesses carry out their normal

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Singh M. et al., Int J Dent Health Sci 2014; 1(2): 208-219 Straumann’s vision of Digital Solutions is prosthetic inlays, crows, onlays and that “the patient and the restoration will bridges are designed with the help of remain analogue and everything in computer (CAD) and then milled on between will become digital”. computerized machines (CAM). Impression models are scanned using 3D Computer guided surgery: scanners, or directly scanned by the intra- The computer guided surgery product oral scanning. The dental technicians that Straumann offers consist of three model the tooth restoration on a main components: coDiagnostiX planning computer. The data are then sent to software, gonyX surgical template centralized production centers, which production tool, and the Guided Surgery produce the prosthetic in a range of Kit and Implants. The process for guided biocompatible, durable and esthetic surgery starts off with a master model of materials, including high-performance the teeth impression that represents the ceramics. CADCAM’s solutions extend patient current situation. This is the basis from single tooth inlays right up to 14-unit [6] for the production of the scan and surgical full-arch restorations. template. From this master model a scan- CAD/CAM was introduced in prosthesis is made to represent a dentistry in the year of 1971. The use of provisional teeth set-up.[5] CAD/CAM technology in dentistry is Intra-oral scanning: increasing, both in the dental laboratory and general practice settings, to fabricate Straumann is the exclusive distributor in all-ceramic inlays, onlays, crowns, and Europe of the Cadent’s iTero intra-oral veneers. Only one CAD/CAM system is scanning system4. This technology of currently available for in-office chair side intra-oral scanning enables the dentist to use, CEREC® 3D by Sirona Dental Systems. create 3D images of the patient’s teeth There exists a misconception that the using a digital scanner from inside the CAD/CAM process is complicated and mouth. The intra-oral scanner is time consuming. However, this CAD/CAM developed to replace the conventional system is simple to operate, versatile, and process of impression taking in the dental precise. All-ceramic restorations can be practice and model casting in the dental designed and milled chair side, traditional laboratory. The 3D images can then be impressions and temporaries are imported into CAD software to be used eliminated, and the patient leaves the [5] restorative procedures. appointment in about an hour with a final restoration in place.[4] CAD/CAM Technology: Definition: CAD/CAM Systems: Computer Straumann provides a vast portfolio of Aided Designing/Computer Aided CAD/CAM products: scanners, modeling Machining systems that can produce software, a full range of prosthetics and durable materials. Modern dental

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Singh M. et al., Int J Dent Health Sci 2014; 1(2): 208-219 dental prosthesis with help of robots or 7. Designing the maxillo facial prosthesis computers. [9,10]

The first report on CAD/CAM, published in Clinical steps in the fabrication of 1973, made it clear that the optical CAD/CAM : impression technique, or dental A. Crown Preparation CAD/CAM, encompasses all methods of analysis including diagnosis and B. Optical Impression.[7] treatment, working in space, and developing means of measurement that A. ALL CERAMIC CROWN PREPARATION: are preferably optical.[6] The functional cusps should be reduced General Principles of CAD/CAM: All true 2.0 mm, nonfunctional cusps should be CAD/CAM systems exhibit there reduced 1.5 mm, and the central fissure computer-linked functional components, area should be reduced at least 1.5 mm to although the degree of sophtication may ensure adequate strength to the crown. In differ. addition, axial reduction of the tooth should be a minimum of 1.2 mm. - A means of data acquisition The facial and lingual walls of the crown - Restoration design. preparation should be done in two planes to avoid thin areas in the milled - Restorative production. restoration. Rounded shoulder or chamfer The first stage requires digital data to be margins, at least 1.0 mm thick, ensure a collected from the patient's mouth this is strong edge of material to prevent equivalent to traditional impression fracture of the restoration. A sloped taking.[7] shoulder (90°-120°) ensures a strong edge of material while providing a good Uses of CAD/CAM in prosthodontics are transition of translucency and shade as follows: between the tooth and crown at the 1. Inlays and onlays margin area. Thin areas at the margins, such as light chamfers or bevels, are 2. Crowns and bridges predisposed to fracture and are not recommended.[6] 3. Fabrication of post and cores

4. Complete denture fabrication

5. Removable Partial Denture Prosthesis Fabrication

6. Designing the placement of the

Implant8

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Singh M. et al., Int J Dent Health Sci 2014; 1(2): 208-219 B. OPTICAL IMPRESSION problem. A moving radiation source and a fixed detector ring  POWDERING were introduced. This meant that  ACQUIRING SINGLE OPTICAL modifications to the angle of the IMPRESSION radiation source had to be taken into account and more scattered  ACQUIRING MULTIPLE OPTICAL radiation was seen. IMPRESSION POWDERING:  Finally the fifth (sometimes known

Background Information on Powdering: as the sixth) generation scanners were the introduction to reduced To make an optical impression it is “motion” or “scatter” artifacts.[12] necessary to powder (or opaque) the tooth surface to be imaged because of CBCTs for dental, oral, and maxillofacial two reasons: The surface of the tooth surgery and orthodontic indications were must be covered with a non reflective designed to counter some of the coating to make it easier for the infrared limitations of the conventional CT [7] camera to see the details. scanning devices.[13]

CONE BEAM COMPUTED TOMOGRAPHY

CT technology was developed by Sir Godfrey Hounsfield in 1967 and there has been a gradual evolution to five generations of the system.

 First generation scanners consisted of a single radiation source and a (I CAT CBCT) single detector and information The radiation source consists of a was obtained slice by slice. conventional low-radiation X-ray tube and  The second generation was the resultant beam is projected onto a flat introduced as an improvement and panel detector (FPD) or a charge-coupled multiple detectors were device (CCD) with an image intensifier. incorporated within the plane of The FPD was shown to have a high spatial the scan. resolution. The cone beam produces a more focused beam and much less  The third generation was made radiation scatter compared with the possible by the advancement in conventional fanshaped CT devices. This detector and data acquisition significantly increases the X-ray utilization technology. and reduces the X-ray tube capacity [13,14]  The fourth generation was required for volumetric scanning. developed to counter this

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Singh M. et al., Int J Dent Health Sci 2014; 1(2): 208-219 CBCT Data - There is less artifacts caused by metallic structures but because of - The tube and the detector perform lower dose there is more noise one rotation (180 or 360°) around and detailed information about the selected region. soft tissues is lost. - The resulting primary data are - CBCT is less expensive and converted into slice data. smaller.13

- The reconstructed slice data can be viewed in user-defined planes.

The CT volume consists of a 3D array of image elements, called voxels. Each voxel is characterized with a height, width, and depth. Since the voxel sizes are known from the acquisition, correct measurements can be performed on the images.[12]

CBCT as compared with conventional CT

The following is a summary of the CBCT Image Production additions and modifications of CBCT as compared with conventional CT, which Machine make CBCT a more appealing alternative: CBCT Acquisition Systems: There are various classifications of devices but CBCT - Radiation dose is lower. This is devices may be divided to fit into four mainly because of the lower subcategories based on the need of the effective tube current used for the clinician: and one field of view of the scan CBCT: while the voltage of the (FOV). source is approximately the same (90–120 kV), the current is roughly - Dentoalveolar (FOV less than 8 cm) between 1 and 8 mA for the CBCT - Maxillo-mandibular (FOV between while e.g., for the multislice CT the 8 and 15 cm) current is around 80 mA but can also be as high as 200 mA. - Skeletal (FOV between 15 and 21 cm) - Detection systems are different (FPD or CCD with image intensifier. - Head and neck (FOV above 21 cm)[8] - The resolution is higher; this is mainly due to lesser isotropic voxel size.

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Singh M. et al., Int J Dent Health Sci 2014; 1(2): 208-219 Uses of CBCT Technology: The T-Scan II lets you to measure the relative force of each individual contact in 1. Diagnosis. two different views: 2. Clinical application. The 2D Contour view looks most similar to 3. Clinical evaluation of treatment articulation paper markings on a patient's outcomes.[5] teeth.

Clinical Applications of the CBCT: In the 3D View, the force levels are shown by both color and column height. The 3D CBCT provides information for 3D models view also makes it easier to visualize and made by rapid prototyping. The obtained understand occlusal relationships during 3D models can serve as a matrix that excursive movements. enables precise planning of operations such as for mini-implant positions in T-Scan can measure force over time, it is anatomically complex sites.[18] CBCT is also an indispensable tool for appraising the a tool for the evaluation of surgical and sequential relationships of a from MIP or orthodontic treatment.[6] There have not CR position into a lateral excursion. been a lot of papers published but they In addition to looking at the different are increasing in their number as the CBCT views of maximum intercuspal forces in a is becoming more readily available.[12] static mode, you can also use the T-Scan OCCLUSAL RECORDING SYSTEM -THE T- to assess the dynamic aspects of an entire SCAN II: functional movement. After recording a T- Scan occlusal movie you can store the "The Future Force in Occlusal Diagnostics" data in your computer and retrieve it as needed. T-Scan's vivid, full-color graphics The T-Scan is the most accurate system can be transferred into other documents available to measure occlusal forces and for patient records or insurance quantify how well balanced a patient's reports.[19,20] occlusion is the novices can use the T- Scan to more quickly develop their skills. The occlusal forces that are applied to With the T-Scan, you can take the implant prosthesis can be a potentially guesswork out of the articulation destructive factor in shortening the paperwork. With the T-Scan, evaluating potential longevity of any implant these forces is as simple as having a prosthesis. Both material failures and patient bite down on our ultra-thin sensor implant de osseointegration have been (above) and having the computer analyze attributed to excessive occlusal loading to [19] and display the data. dental implants.[19]

Choose from 2D or 3D Views: Poorly directed and non-uniform occlusal loading will torque prosthesis and apply

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Singh M. et al., Int J Dent Health Sci 2014; 1(2): 208-219 stresses that may ultimately result in excessive forces on the occlusal materials prosthetic failures. while inducing shear stress in the supporting bone. To definitively attain this goal, it is necessary to employ computerized 6. By analyzing implant prosthesis lateral occlusal analysis, which affords the excursive function with the T-Scan II, operator a precise way to assess the force precise illustration of interference and time factors that are contained within location, and how long (in time; fractions the tooth contact points present on of seconds) the involved teeth are implant prosthesis.[19] maintaining contact.

Perceptions lessened in Implant Patients: 7. Segmental implant loading with a time delay in combination cases of implants Prior to the development of the T-Scan II, and natural teeth.[20] the common implant prosthesis occlusal adjustment technique was to employ COMPUTERIZED JAW RELATION articulating paper markings alone, with RECORDING SYSTEM force and time interpretation based upon Dental Software extends and enhances patient confirmation of occlusal “feel”. the capabilities and provides many Through a dental prosthesis without options for data analysis and neurological feedback to the Central presentation.[21] Nervous System. This makes subjective patient perceptions as a guide to occlusal  Overlying curves on the screen for force balance a very inaccurate way to progressive treatment monitoring assess the quality of the occlusal forces and a variety of evaluation that are present on implant prosthesis. possibilities; zoom for diagnostically relevant parts of the The areas of implant prosthodontics curve. where the T-Scan II can greatly raise the level of occlusal precision are:  Dynamic motion (Replay) - both right and left recordings can be 1.Balancing and centering the occlusal viewed at the same time, in real forces on a full arch complete implant time or slow motion. supported fixed prosthesis.  Many options for case 2. Removal of lateral interferences. presentations - three-dimensional 3. Establishing delayed implant loading. movement of the hinge axis and time curves. 4. Centering the occlusal forces on a full arch.  More detailed calculations of the condylar data - can be repeated 5. Removal of lateral interferences in for various articulators. excursive function that will place

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Singh M. et al., Int J Dent Health Sci 2014; 1(2): 208-219  Increased communication with lab 1. Ambiguity of shade taking has been - data can be transmitted online to reduced. the technician Gamma Dental 2. Less time is required for color Software works on IBM compatible reconstruction PC's, no special hardware required. Allows creation of 3. Even in difficult cases for shade taking patient databases, stores it is easier to select the proper additional documents like text files porcelain powders. and pictures. 4. Gives a clean and safe image to COMPUTERIZED REMOVABLE PARTIAL patients in terms of infection control DENTURE DESIGN -STELLIGRAPHE and promotes the reliability of dentists. Stelligraphe is a powerful and simple professional tool. Few clicks of mouse to Database means the accumulated data indicate the teeth absent to pose the with which we can classify, sort, update, crowns and the bridges). The last click to search, or print out the needed validate and Stelligraphe realize information. Data in other data files can [22] instantaneously: also be linked as a relational database.[23]

Stelligraphe: Software patented by Doctor DIGITAL IMPRESSIONING Gaillard and Jourda and carried out by Jacques Orliac and Philippe Beaugrand. Much of the credit for the boom in the demand for digital dental impressioning Stelligraphe – Characteristics systems lies with the dental laboratories. Many dental technicians, to assure that Vast panoply of tools to work out the the prospects for their future within the prosthesis: dental industry remain viable; have  Extraction of teeth embraced digitization of impressioning devices, coping and framework design  Crowns, bridges technology, and milling machines capable  Establishment of hooks, brackets, of producing superior restorations. In supports. many cases, savvy laboratories are convincing their customer dentists to join The recently introduced Total Porcelain the digital revolution.[24] System combines the dental colorimeter, Shade Eye System (SES) and Vintage Halo There are two classifications of digital [24] Porcelain based on the new color concept dental-impressioning devices: of natural teeth – dental colour space.[22]  CAD/CAM devices Clinical Evaluation of the Colorimeter  Dedicated intraoral digital scanners

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Singh M. et al., Int J Dent Health Sci 2014; 1(2): 208-219 The Finite Element Method is an approximate numerical method of stress CONCLUSION: analysis, used in solving complex The contemporary dental practice has structural problems by dividing the endless options for preserving oral health complex structures into simpler and and provides next to natural aesthetics smaller segments. The technical with an enhanced approach, reduced improvement in computers and finite treatment time, minimized error potential element software has improved the and better quality assurance. These accuracy and speed of this analysis. It reasons rightly explain present day reveals stress and strain throughout the dentistry being called golden age of entire structure in response to specific dentistry. load.[25] Digitization started to influence dental Advantages: The FE method has some fraternity with the form of audio visual distinct advantages over other methods of aids in both teaching and patient stress analysis: education. Digitization has become part 1. The technique is non-invasive. and parcel of contemporary prosthodontics with the probability of

2. The tooth, alveolar bone, the most of the procedures being based on periodontal ligament can be digital techniques in near future. Let us simulated and when the material think of X-rays or photographs, making properties of these structures are impressions, recording jaw movements or assigned, it is the nearest that one fabricating prosthesis, educating and can possibly get in simulating the training new dentists or patient oral environment in-vitro. motivation for practice build up, all has 3. The actual stress experienced at become digital. Today a practicing dentist any point can be measured. needs to be equipped with the latest fast changing technology so as to pose a 4. The actual displacement of the great challenge. tooth can be visualised graphically. The literature regarding recent techniques 5. Reproducibility does not affect helps us assimilate latest trends for physical properties of the involved benefit of patient and expansion of and the study can be profession as a whole. The transition from repeated any number of times. old to new occurs with the basic aim of making patient’s life better. 6. The FEM has a potential for accurate modeling of a real object of complicated shape and different material properties.[25]

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Singh M. et al., Int J Dent Health Sci 2014; 1(2): 208-219 REFERENCES:

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