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Digital Impressions
Dental professionals are continually assessing the application of innovative technology for their practices. Digital impression systems are one such technology, as they offer an alternative to conventional impression-taking that is accurate and efficient, and met with significant patient acceptance. Digital impressions are based on the broader workflow of computer-aided design/computer-aided manufacturing (CAD/CAM). By the year 2050, it is predicted that 50% of dental services will involve CAD/CAM technology.1
The Process Today
The CAD/CAM workflow involves three distinct processes. The first process is to use a scanner or camera to record the intraoral condition. The camera transmits the recorded data to a computer software program. The second process involves manipulating the data file to create the desired volume model of the final restoration or prosthesis. The third process fabricates the restoration from the computer design. The most common fabrication process today uses subtractive milling, in which a set of milling diamonds cut away excess material from a premanufactured block of restorative material, leaving the restoration.
Digital impression systems focus on the first process in the CAD/CAM workflow. They are designed to efficiently and accurately record the patient’s teeth and soft tissues to a computer data file. The systems include an intraoral camera or scanner connected to a computer. The computer has a software program to manage the administrative information for the case, such as patient information, and allows for evaluation of the scanned data in a 3-dimensional virtual model. The software program also includes an online laboratory prescription form for ordering restorations from the laboratory. The computer electronically transmits the data file over the Internet to the laboratory for processing. Once the laboratory downloads the data file, it can use it to process models as well as import it to a CAD/CAM program to fabricate the desired restoration.
Getting More Mobile, Accessible, and Versatile
Digital impression systems are mobile units that have a computer in the base of the unit with the camera and monitor on top for easy access and visibility for clinical use. They are self-contained units in which the manufacturer ensures consistent compatibility of the computer, software, and camera. A more recent development is the introduction of modular systems. These systems rely on a “plug and play” type of camera that can be easily moved between multiple computers in the office. Most current digital impression systems utilize a video-type camera to record intraoral structures.
Digital impression systems create large files such as stereolithography (.stl) files. Where and how these data files may be used is one characteristic that sets different systems apart. Some manufacturers restrict the import of their digital files to specific computer programs. This is referred to as “closed architecture,” and it essentially limits the uses of the files as determined by the manufacturer. As digital impression systems have continued to evolve, however, manufacturers have allowed for more widespread import of .stl files in a greater array of software programs, significantly increasing the clinical applications. This is called “open architecture.” Dental laboratories are especially interested in open architecture use of .stl files to limit the number of CAD/CAM programs and devices they need to process restorations from a variety of digital systems. Open architecture systems will likely be a key trend in the future.
Digital impressions are becoming more versatile with expanding clinical applications. Once intraoral data have been recorded with the camera, an .stl file can be used to fabricate any number of laboratory-processed restorations and prostheses. The accuracy of the data file does not degrade with use or over time. The most common uses for digital impressions are fabrication of crowns, onlays, veneers, and fixed partial dentures. However, intraoral scanning abutments have been introduced for implant applications. The encode abutment or scan body is screwed to the implant and a fixture-level digital impression is scanned. The recorded .stl file can be used to fabricate custom abutments as well as resin models for complete CAD/CAM fabrication of the abutment and restoration from a single digital impression. A particular benefit of this process is that it can be done at the time of surgery without contamination of the surgical site.
Dental Lasers
Lasers emit a precise beam of light that causes a temperature rise in the target tissue, causing a range of effects from hemostasis to cellular vaporization.2-5 In 1989, the first laser specifically designed for dentistry was cleared by the FDA and subsequently sold in the United States. Although advertised as being able to treat almost every aspect of dental disease, the reality was that this laser would perform only soft tissue surgical procedures.
Present Indications
In the present day, estimates are that between 15% and 20% of dentists worldwide own some model of laser. There are approximately 30 indications for their use, including soft tissue surgery, adjunctive treatment of periodontal disease, treatment of aphthous ulcers and herpetic lesions, coagulation, removal of carious lesions and tooth preparation, debridement of calculus, osseous surgery, and endodontic applications.6 Not every laser can perform all of the above listed procedures; however, they can be used for soft tissue applications. Only the erbium family of lasers performs well on tooth and bone. All laser devices have general similarities in terms of delivery systems (optical fiber or articulated arm) and controls. Each manufacturer has specific features that can make the operation of the device easier. The surgical result is not dependent on any of those items.
The two disadvantages to the current offering of instruments are the relatively high cost and the requirement for training. This instruction can vary with each manufacturer, but the clinician should insist on completion of rigorous hands-on simulation exercises to gain an adequate understanding of laser-tissue interaction for the various procedures that he/she intends to perform.
Practice Management SoftwaRE
During the past 25 years, practice management software has revolutionized dental practice operations in the areas of scheduling, accounting, patient communication, and data management. According to the Levin Group Data Center™, more than 90% of dental practices now have some form of practice management software.
Staying Ahead of the Curve
Although practices have made significant gains in efficiency, technology also presents challenges. Practice software must be regularly upgraded or replaced in a similar timeframe. If not, inefficiency begins to take over processes and protocols, reducing staff productivity and effectiveness.
To put their practices in the best position for success, dental professionals must provide their teams effective tools for successfully performing their duties. In today’s digital offices, updated practice management software is a requirement. Before purchasing practice management software, dental teams must ask these five questions:
What features are we looking for?
Today’s practice management software provides a wealth of functionalities, from appointment scheduling, perio charting, and visual imaging to patient recall, electronic insurance claim submissions, and patient billing. As more and more offices consider going paperless, almost every administrative function can be migrated to a digital realm.
Is the software easy to use and how is the support?
Most practice management software has been designed to be user friendly. But practices should “test-drive” any software before purchasing. In addition, dental teams need to know how the software will be supported once it is purchased. Does the company provide in-office or web-based training? Does it have sales representatives who regularly visit the office or is support only available by phone? Does it have a proven track record when it comes to customer satisfaction? In addition, practices should examine what type of warranty the company provides.
Can it be integrated with other technologies?
When selecting software, dentists should make sure it integrates with other technologies in the office. Although this is a chief concern of many dentists, it often occurs too late—after a purchase has been made. Having also advised numerous dental companies over the years, I can say that when new technologies do not integrate with the practice management software, they fail in the marketplace. This question needs to be asked before—not after—purchasing software.
Can it easily provide the data we need?
Without accurate practice data, good decision-making is undermined. Software that could deliver essential practice data at the press of a button would be an invaluable tool. For example, according to Levin Group Data Center, the national average of the number of new patients declined 5.1% for practices in 2012. This means that practices need to be much more effective at retaining current patients. Software that can run reports on overdue and inactive patients, enabling the practice to get them back on the schedule, would be highly valuable.
What is the cost and will it provide an adequate ROI?
A return on investment is vital because it contributes to the practice’s financial stability. Dental practices operate with significant overhead. Therefore, each new technology purchase should be able to provide a timely return on investment (ROI). Most software systems are similarly priced, but that does not mean they provide a similar value. In addition to the initial price, there can be hidden costs, such as yearly upgrades that may be necessary but expensive.
References
1.Silwadi M. CAD/CAM & Digital Dentistry International Conference website. www.cappmea.com/cadcam8. Accessed June 6, 2013.
2.Knappe V, Frank F, Rohde E. Principles of lasers and biophotonic effects. Photomed Laser Surg. 2004;22(5):411-417.
3.Springer TA,Welch AJ. Temperature control during laser tissue welding. Appl Opt. 1993;32(4):517-525.
4.McKenzie AL. Physics of thermal processes in laser-tissue interaction. Phys Med Biol. 1990;35(9):1175-1209.
5.Rechmann P, Goldin DS, Hennig T. Er:YAG lasers in dentistry: an overview. In:Featherstone JDB, Rechmann P, Fried DS, eds. Lasers in Dentistry IV. Bellingham, WA: SPIE Press; 2006:2-13.
6.501(k) Clearances. U.S. Food and Drug Administration Web site. www.fda.gov/medicaldevices/productsandmedicalprocedures/deviceapprovalsandclearances/510kclearances/default.htm. Updated June, 18, 2009. Accessed May 15, 2013.
About the Authors
Dennis J. Fasbinder, DDS
Clinical Professor of Dentistry and Director
Advanced Education in General Dentistry Program
The University of Michigan School of Dentistry
Donald J. Coluzzi, DDS
Clinical Professor
University of California San Francisco School of Dentistry
Roger P. Levin, DDS
Chairman and Chief Executive Officer
Levin Group, Inc.
