Virtual Collaboration

Accompanying the request is a close-up image of a patient’s badly chipped maxillary central incisor as well as previously taken digital images of the patient’s smile and digital color scans of his undamaged anterior teeth. The patient’s close-up image of damaged tooth No. 9 had been taken with a smart toothbrush plugged into his smartphone and uploaded to analytic software that indicated the tooth had a possible vertical hairline fracture. The image and preliminary analysis had been transmitted by the patient along with a request for an appointment the next day to Dr. Scott, one of your restorative surgeons. He strongly suspects the fracture runs up through the root, which means the tooth will need to be extracted and an implant placed. You tap your scheduling software icon to check your availability and send confirmation of the consultation to Dr. Scott.

Early the next morning the data from Dr. Scott’s office streams in on the large holographic computer screen in front of you. First come a series of CBCT scan-captures of the patient’s anatomical features including sinus locations, nerves, and blood vessels, followed by an ultrasonic scan of the soft tissue landmarks. Then real-time 3D full facial scans of the patient in repose and smiling as well as a video of the patient speaking. Jaw tracking software that records protrusive and excursive movements of the patient’s mandible come next, and, finally, a digital impression scan with detailed color analysis of the adjacent teeth.

You study the scans, rotating them on your virtual touch screen. You know Dr. Scott is expecting recommendations on what type of implant should be used in this situation, implant placement advice for the best esthetic results, what materials you would recommend for the implant, provisional, and final restoration, and a smile design proposal that will help secure patient acceptance of the treatment plan.

Securing patient buy-in on the treatment plan is a critical step. You download the scans into your design software and quickly merge the 3D face scan, jaw-tracking analysis, and impression scan, and virtually articulate the teeth on screen. The patient has a diastema between teeth Nos. 8 and 9, so you decide on presenting two smile design solutions: one for restoring only tooth No. 9, and another proposing an implant for No. 9 and minimally invasive veneers on teeth Nos. 7, 8, and 10 to close the diastema and bring the lateral incisors into alignment. You select tooth shapes for the implant and veneers from your extensive tooth library and tweak to improve the shape and contours. Your designs morph onto the facial scan smile and patient video for a virtual try-in. The patient will be able to view himself in augmented reality smiling and speaking with both proposed solutions. You upload the smile designs to the shared holographic computer screen in front of you and await Dr. Scott and the patient to appear on screen.

“Good morning, Mr. Roberts,” says Dr. Scott. “Thank you for the two restorative proposals. The patient decided the implant/veneer approach is the direction he wants to go. What are your recommendations for implant type and material?”

You had already considered all the available implant options for this case and knew that chairtime efficiency and outcome success were all important. “Good morning, Dr. Scott. My recommendation would be Natural Dental Implants’ 3D printed zirconia implant root with integral abutment infused with the patient’s stem cells to ensure and speed up the osseointegration process. I can design the implant now and transmit the files to your 3D printer while you prep the patient. A snap-on provisional design will be uploaded to your milling machine and ready for seating after the implant is placed. The final crown and veneers will be delivered to your office by Friday, ready for insertion after the implant has completely osseointegrated.”

You smile as the restorative surgeon gives his go ahead and you immediately begin isolating tooth No. 9 from the CBCT scan to design and transmit the data to Dr. Scott’s in-practice printer. Once transmitted, the design of the provisional is executed and data transmitted to the chairside mill. You open your business management billing software to record the charge for the hour of clinical technical consultation, two half-hour smile designs, a half-hour for implant design, and a half-hour for provisional design. “It was a profitable morning,” you think to yourself. You enter the case into your case management software and upload the approved smile design along with the data sent from the practice for your team to finalize for delivery Friday.

This scenario sounds like science fiction today, but in tomorrow’s digital ecosystem, this new level of connectivity and intelligence will create greater relevance and value to the dental experience by bringing dental professionals and patients together in a seamlessly networked platform where digitally captured data turns information into action and action into machine-driven processes. By utilizing the power of the Internet of Everything, patients, dentists, and technicians interact and connect to an integrated communication platform that empowers collaboration among all stakeholders in the decision-making process from diagnostic evaluation and treatment options to treatment planning and the production of the final prosthetic.

Today, that seamless networked flow of information and digital files is still in its evolutionary infancy. However, the industry is already experiencing an explosion of new digital-age communication pathways for transmitting information. From communicating via the simple text message to the complexity of virtually sharing digitally captured CBCT, impression, and patient face scans transmitted over secure networks, connectivity between patient and clinician and clinician and the laboratory is not only impacting the speed and flexibility of dental services but is also changing the traditional roles of dental professional stakeholders and remodeling the structure of their businesses.

“The digital world is allowing the walls between the specialties to come down,” says Lee Culp, CEO, of Sculpture Studios in Cary, North Carolina. “In the past, each stakeholder had a specific role to play independent of the other. But in our new digital realm, those walls are fading and the successful outcome of a case is shifting to an equally shared responsibility.”

That shift to a shared responsibility is elevating the laboratory as a respected partner equally invested in the final outcome. “The ability to communicate in a digital world is allowing us to have much more influence and input on cases,” says Luke Caruso III, President and COO of Ottawa Dental Laboratory. “There is a growing level of respect in the relationships we have with our clients as a vested team member.”

The digital ecosystem is also impacting the business structure of the industry as laboratory owners harness the power of digital tools to create and deliver services that focus on the customer and end user experience.

Working in a virtual environment has become commonplace for a majority of laboratories. Whether scanning impressions, models or receiving digital impression data, converting the physical to digital has become a necessity for producing the final prosthetic. What has been missing is the ability of technicians to see the patient or easily interact virtually on the case with the clinician. But that all may be changing with the introduction of new digital tools powered by smart phone technology, new software modules, dental apps, and connected networked platforms that laboratories can use to instantly transmit images to alert clients of potential problems with the case, present technically workable smile designs even while the patient is still in the chair, or collaborate with team members in real time on complex cases. All this information can easily be shared with clients to use as an education or case acceptance tool with their patients.

“Most development in digital tools has concentrated on the ability of the dentist and laboratory to communicate,” says Rune Fisker, Vice President Product Strategy 3Shape. “But now we need tools that facilitate dentist-to-patient communication. We know from market data, for example, that case acceptance for anterior cases can be increased 85% by showing the patient a good preview of the final case outcome.”

For laboratories eager to provide these types of services, the barrier has always been receiving images of the patient. But the ubiquity of smart phone technology and "click-and-send" ease of use offers dentists a familiar digital device that can instantly provide laboratory partners with the information they need to marry 2D images of the patient with either a 3D impression scan or a scan of the physical impression or model and design a realistic proposal of the final outcome. Designs can be uploaded to manufacturers’ proprietary secure web interface networks such as Dentsply Sirona Connect, 3Shape Communicate, and Planmeca Romexis or now transmitted and viewed on mobile devices via newly introduced smile design apps.

“The 2D smile design concept is well established, and all major CAD/CAM vendors provide the means for laboratories to transfer 2D images,” says Larry Bodony, President exocad America. “Until now it's been challenging for technicians to use 2D smile data in the 3D context of restorative design. Now, technicians can manipulate tooth libraries in the context of a truly digital smile design, creating optimal function and esthetics.” Now, new 2D smile design software allows all this to be accomplished in a few minutes, and the 2D proposal is then used to guide the 3D restorative design. By the end of this year both 3Shape and exocad will have released their respective smile design software modules with the full complement of features including designing the smile using extensive 3D tooth libraries, the ability to manipulate the 2D and 3D anatomy images simultaneously. The resulting proposal can be shared in one step.

What may be the forerunner of future developments in the virtual smile design concept is an augmented reality software concept introduced by Kapanu AG, an Ivoclar Vivadent company, at the IDS 2017 exhibition. Its immersive and dynamic Augmented Reality Engine may reach what Lee Coursey, Managing Partner, Russelville Dental Lab, Russellville, KY, calls the “ultimate goal” when trying to design an esthetic outcome for the patient. “We still need a way to see the lips of the patient in motion when smiling and in repose to achieve the best solution for that patient.” The augmented reality that Kapanu presented does just that. It allows patients to see real-time natural motion video of themselves speaking and smiling as the new smile design proposal morphs into view in full 3D color (Figure 1). “Our software allows users to superimpose their dental designs onto recordings of the patient in natural motion,” says Roland Mörzinger, CEO and co-founder. “This virtual try-in allows patients to see their new smile before they consent to the treatment. In addition, visualization of the treatment goal facilitates communication not only with the patient but also between the dental professionals.”

For more complex implant-driven or removable cases, the smile design becomes the starting point rather than the end point for communicating all the details required for successful case outcome. “In the future, the implant surgeon, dentist, and laboratory technologist will be working together in a completely virtual environment with a 3D patient,” says Fisker. It’s the environment that Culp works in every day, and has structured his laboratory to specialize in this type of complex dentistry.

Face scans of the patient will be merged with a CBCT scan, jaw motion scans, and impression or model scans to allow positioning the maxilla in the plane of occlusion. Then that data will be used to virtually place the implants to achieve the restorative smile design. A select but growing number of companies such as Planmeca, Dentsply Sirona, and 3Shape have incorporated face scanning in their CBCT scan technology; others such as Zirkonzahn and pritidenta offer a standalone unit with DOF Dental soon releasing their portable tablet solution.

Both 3Shape and Zirkonzahn plan to release jaw motion analyzing and tracking software to their respective laboratory-centric implant planning software solutions. “Our jaw analyzer sensor will track jaw movement and translate that digitally into the software,” says Nick Glickman, Marketing & Education Zirkonzahn. “That will enable the team to track and customize lower jaw movement in the virtual articulator to understand fully how the restorative design will react in the mouth.” That data is then imported into implant planning software so the team can virtually plan where those implants should be placed in order to achieve the planned end result. All the other components of the implant protocol—surgical guide, provisional restorations, and final restorations—can be created based on the planned implant coordinates.

“Patients don’t buy implants; they buy the end result,” says Caruso, whose team uses open-architecture DWOS CoDiagnostix software for planning guided surgery implant cases. “So we can now better control the case and create a virtual diagnostic wax-up and smile design to help guide implant placement and then fabricate a highly esthetic restorative solution based off that diagnostic plan.” The surgeon, restorative dentist, and laboratory meet virtually through GoToMeeting, with each team member simultaneously viewing the case and making needed changes in three dimensions. Open-architecture software also allows Caruso to freely export the implant proposals to communicate with clients who may be using different software platforms or 3D viewers or even transmit the final proposal using the CoDiagnostix application.

“Laboratories have the opportunity to now offer an entire range of services for their clients that were never available before,” says Culp. “And the ability to work as a team is elevating the level of respect for and responsibilities of our profession.”

These new digitally driven mass communication pathways are the building blocks for a digital ecosystem that will continue to enhance the level of input dental laboratories have on influencing the final case outcome and will better position the patient at the center of the dental experience. Used to their fullest, new technologies will help move the role of the dental technician from the back seat to the driver’s seat of the case and will offer clients the opportunity to shift the focus of the patient conversation away from selling a restorative solution to selling the end result of the treatment plan. A more collaborative environment opens the door of opportunity for laboratories to market themselves as advocates for creating better dentistry.

Until now the workflow for creating digital dentures depended on a front-end analog impression- and record-taking process. The holy grail for those invested in the digital denture concept has been to discover a digitally driven intraoral capture solution to fully digitize the workflow from beginning to end. Dr. Charles Goodacre, DDS, MSD, Distinguished Professor at the Restorative Dentistry School of Dentistry, Loma Linda University, committed himself to solving this complex problem. Along with his son, Brian Goodacre, DDS, assistant professor for the Dental Education Services School of Dentistry, Loma Linda University, the two have discovered and clinically tested a process that results in usable digital files that can be integrated into the digital design and production workflow process.

“The literature suggested that using digital intraoral technology to capture the edentulous arch was not a workable solution, so we were skeptical when we began our study,” says the senior Goodacre. “We first tried coating the mucosa with pressure-indicating pastes and also tried intraoral scan spray to orient the scan, but in the end we found these methods unnecessary.” They discovered they could successfully scan the fixed tissue of the edentulous maxilla in about 2 minutes and create a usable digital file (Figure 2 through Figure 4). Digitally capturing the mandible, on the other hand, proved more difficult. The nearly 5-minute scan of the edentulous mandible was only able to capture the center of the ridge and a portion of the periphery but not the lateral extensions. However, they were able to capture enough of the mandible border to send the digital scans of both arches to Avadent for milling Wagner Try-In denture bases complete with milled teeth. “The mandibular try-in had enough of the anatomy that we could stabilize it and use it to make a reline impression,” said Brian. “So even though the process at this point is not fully digital in the mandible, most dentists would agree it is much easier to make a reline impression than a conventional complete arch impression.”

The Goodacres believe that the limited testing they have completed on this concept to date is viable enough to announce their findings at this October’s International Digital Denture Symposium in Baltimore. “We plan on continuing our experimentation with this concept,” says Brian. “Our hope is that others will also begin work to refine the process and ultimately find a way to successfully digitally capture the entire mandibular arch.”