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 Table of Contents  
REVIEW ARTICLE
Year : 2018  |  Volume : 4  |  Issue : 2  |  Page : 35-41

Role of digital technology in prosthodontics: A step toward improving dental care


1 Department of Prosthodontics, Center for Dental Education and Research, All India Institute of Medical Sciences, New Delhi, India
2 Department of Dental, Bhagwan Mahavir Hospital, New Delhi, India

Date of Web Publication25-Apr-2019

Correspondence Address:
Dr. Chanchal Gupta
Department of Prosthodontics, Center for Dental Education and Research, All India Institute of Medical Sciences, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijohr.ijohr_19_18

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  Abstract 


Advancements in dental technology enable patients to receive modern solutions of conventional dental problems. Prosthodontists can incorporate digital technology into their practices to improve their workflow efficiency and ease of collaboration with laboratories. In this article, digital technologies that are available for prosthetic dentistry such as digital radiography, electronic prescriptions, computerized case presentations, virtual articulator and facebow, computer-aided design/computer-aided manufacturing restorations, digital impressions, and shade selection are described along with emphasis on advantages and limitations of digital technology.

Keywords: Computer-aided design/computer-aided manufacturing, digital dentistry, digital technology


How to cite this article:
Gupta C, Mittal A. Role of digital technology in prosthodontics: A step toward improving dental care. Indian J Oral Health Res 2018;4:35-41

How to cite this URL:
Gupta C, Mittal A. Role of digital technology in prosthodontics: A step toward improving dental care. Indian J Oral Health Res [serial online] 2018 [cited 2019 May 19];4:35-41. Available from: http://www.ijohr.org/text.asp?2018/4/2/35/257148




  Introduction Top


Although conventional techniques in dental care have worked excellently for decades, for a simpler, faster, more accurate, and more efficient workflow, there is a large potential in digital dentistry.[1]

Digital dentistry refers to the use of dental technologies or devices that incorporates digital or computer-controlled components to carry out dental procedures rather than using mechanical or electrical tools.[2]

There are many areas of digital dentistry available, and many more are being researched. Some of them are as follows:

  1. Digital radiography
  2. Intraoral imaging/optical impressioning
  3. Computer-aided design/computer-aided manufacturing (CAD/CAM)
  4. Shade matching
  5. Digital smile designing
  6. Virtual articulators and digital facebows
  7. Laser
  8. Occlusion and temporomandibular joint (TMJ) analysis and diagnosis
  9. Photography – extraoral and intraoral
  10. Practice and patient record management – including digital patient education.



  Digital Radiography Top


The era of the digitalization in dental radiography came in 1987 with the first digital radiography system called radiovisiography (RVG), launched by Dr. Francis Mouyen. A physicist and engineer Paul Suni created the charge-coupled device (CCD) image sensor technology that made the RVG digital radiography system a reality.[3]

Digital radiography offers immediate viewing of images which is highly desirable for patient education and implant procedures.

The advantages are as follows:

  • Lower radiation (when following the ALARA principle)
  • Significant time reduction
  • Ease of storage and organization (omits the use and maintenance of chemicals and dark rooms)
  • Image enhancements for easier reading and diagnosis, comparison, and subsequent viewing.


The limitations are as follows:

  • Software-related barriers need to be overcome for use of computers in dental radiography
  • High cost also does not encourage many of the practitioners
  • Difficulty in cross-infection control because most digital sensors and (Photo stimulable phosphor) PSP plates cannot be sterilized and therefore require protective plastic barriers.


Radiovisiography

RVG is a multicomponent system which enables an operator to capture colored images from a patient mouth via an intraoral camera and transfer of this image to a computer. The images on the computer can be zoomed, rotated, cut, or edited or further manipulated enhancement, contrast stretching, and reversing.[4]

The newer versions of intraoral cameras are (i) very light in weight (<50 g), (ii) the illumination for image capture not a fiber-optic which is affected by aging, but it became light emitting diodes which give adequate white illumination to comply with darkness inside the mouth, and (iii) radiation exposure is reduced with RVG.[4]

Cone-beam computed tomography

G. N. Hounsfield, in 1972, introduced computerized transverse axial scanning which leads to introduction of computed tomography (CT). Arai et al. in Japan and Mozzo et al. in Italy introduced the cone-beam CT (CBCT) for the oral and maxillofacial applications which offered three-dimensional (3D) exploration and more accurate imaging compared to 2D imaging.[5],[6] Compared to CT, CBCT has lower radiation dose, higher resolution, less artifacts, less expensive, and smaller with different detection systems. Due to its advantage over CT, CBCT gains popularity in the field of dentistry too soon.[7]

In CBCT, radiation source consists of a conventional low-radiation X-ray tube, and the resultant beam is projected onto a flat panel detector (FPD) or a CCD with an image intensifier. The FPD has a high spatial resolution. CBCT produces more focused beam and less radiation scatter compared with the conventional fan-shaped CT devices. This cause increases in X-ray utilization and reduction in X-ray tube capacity required for volumetric scanning. Tube and detector do one rotation (180° or 360°) around the selected region and the resulting primary data are converted into slice data. These reconstructed slice data can be viewed in user-defined planes. The CT volume consists of 3D construction of image elements which 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.[8],[9]

There has been a gradual evolution to five generations of the system.[10]

  1. First-generation scanners consisted of a single radiation source and a single detector and information was obtained slice by slice
  2. The second generation was introduced as an improvement and multiple detectors were incorporated within the plane of the scan
  3. The third generation was made possible by the advancement in detector and data acquisition technology
  4. Fourth generation includes a moving radiation source and a fixed detector ring. Angle of the radiation source should to be taken into account. More scattered radiation was seen in this system
  5. Fifth-generation scanners were developed to reduce “motion” or “scatter” artifacts.



  Optical Impression Top


Many oral scanner systems are currently available in market today. Two of these systems (CEREC AC and E4D Dentist) not only offer the option of in-office design and milling but also allow design and milling by dental technicians. Two other systems (iTero and Lava Chairside Oral Scanner [C.O.S.]) produce digital impressions that require design and milling at a dental laboratory or milling center [Table 1].[11] All of these systems can produce models from their digital files.[12],[13]
Table 1: Digital impression systems

Click here to view


For making digital impression, after the completion of tooth preparation tissues are retracted to visualize the tooth margins, then tooth is dried and readied for scanning. Some scanning systems require the use of an oxide powder on the tooth to remove optical highlights from the surface of the preparation and to enhance the scan quality. Scanners use either a series of static images or a stream of video images to capture the geometry of the tooth preparation.[14],[15]

The advantages of digital impression are as follows:

  • Provide improved precision and consistency
  • Allow a clinician to visualize the preparation on a computer display from many perspectives
  • Allow the clinician to design the restoration on a computer while visualizing the opposing dentition
  • Provide a clean and streamlined impression method without the complexity of the many materials required for conventional impressions with an elastomeric material
  • Offer instant display and feedback for making corrections immediately
  • Reduce the environmental impact of disposing the materials required for conventional impressions.



  Computer-Aided Design/Computer-Aided Manufacturing Top


CAD/CAM was introduced in dentistry during the 1980s. CEREC (Sirona) and Procera (Nobel Biocare) were the first CAD/CAM devices.[16]

CEREC was originally introduced strictly as a chairside technique, for one-visit procedure for fixed restorations, especially for inlays and onlays. When creating a chairside CAD/CAM filling, the dentist makes a digital picture of the prepared tooth with a small intraoral camera. This digital image contains 3D information about the tooth size and morphology, defect to be restored, about adjacent teeth anatomy and relation with tooth. According to this digital image, the dentist designs the adequate restoration directly on a computer screen using CAD/CAM software.[17]

The advantages of chairside CAD/CAM technique are one-visit fixed restorative procedure, less chances for error compared to traditional technique, aids in preparation visualization, no need of impression making, no need of temporary restoration, reduced potential for tooth sensitization, no laboratory costs as no model or die pouring required, and projects as a state-of-the-art image.

Disadvantages of chairside CAD/CAM technique are soft tissue management more critical than with traditional technique, depending on the material and patient, customization may be required, high learning curve, and higher production required to cover capital investment.

Procera was introduced as a nonchairside CAD/CAM device. Models send to a Procera laboratory, where, after scanning of model, metal copings milled and sent back to the dental laboratory for application of ceramics on the copings. Esthetic inlays, onlays, veneers, copings, substructures, full-coverage crowns, partial and complete dentures, surgical stent for implant placement, and maxillofacial prosthesis all can be fabricated using current techniques.[18],[19]

The advantages of chairside laboratory-integrated technique are accuracy, less chances of error compared to conventional technique, opportunity to subcontract CAD/CAM to avoid capital costs, focus on artistic ceramics, scanned image transferred directly from the office to the laboratory, reduced chairside time, and team approach. Only disadvantage of this technique over chairside CAD/CAM technique is two visits are required for delivering of prosthesis.

All true CAD/CAM systems exhibit three computer-linked functional components although the degree of sophistication may differ.[20]

  1. A means of data acquisition – equivalent to traditional impression-making
  2. Restoration design
  3. Restorative production.


CAD was initially based on “subtractive method,” but the recent processes involve “additive” approaches such as rapid prototyping and selective laser sintering technologies or a combination of additive and subtractive CAM.[21],[22]

The available advanced CAD/CAM systems can be divided into the following three groups based on their production methods.[23]

  • In office system: Where a dentist digitally scans the prepared tooth, creates restorations chairside, and then seats it within a single appointment
  • In laboratory system: Where laboratories could scan models made from physical impressions and use CAD/CAM to produce restorations
  • Centralized production: Where a dentist captures chairside digital impressions and then send data via the internet to the laboratory.



  Shade Matching Top


Visual shade matching is now being overrun with automatic shade selection devices such as colorimeters, spectrophotometers, and digital imaging devices which give more consistent shade and a near-life effect with color mapping of tooth selected. Digital imaging and shade matching decrease the interoperator and intraoperator variability and also ease the communication with the laboratory.[24]

Colorimeters measure the tristimulus values, filtering light in the red, green, and blue areas of the visual color spectrum. Since colorimeters do not register total visual light spectral reflectance, they can be less accurate than spectrophotometers. The ShadeVison® (X-Rite, Grandville, MI, USA) and ShadeEye NCC® (Shofu, Menlo Park, CA, USA) are two of these colorimeters.[25] Shade vision system can send the shade information to the dental laboratory via e-mail, disk, or printout.

Spectrophotometers measures and records the amount of visible radiant energy reflected or transmitted by an object one wavelength at a time for each value, chroma, and hue present in the entire visible spectrum. They can be the most accurate instrument for color matching in dentistry.[25],[26] There are several very high-quality and reliable clinical spectrophotometers available, e.g. the VITA EasyShade Compact® (Vita North America, Yorba Linda, CA, USA) and CrystalEye® (Olympus America, Center Valley, PA, USA). VITA Easyshade Compact is the device that meets the greatest number of requirements for choosing the shades in clinical settings. The device can be used to determine an overall tooth shade, the shade of each third of the tooth – cervical, middle and incisal, as well as to confirm the shade of the restoration.

Digital cameras and imaging systems are latest automated shade selection devices. Digital cameras are based on the RGB color model in which the camera obtains red, green, and blue data that are used to produce the color image. In this additive color, red, green, and blue light are added together to generate a broad arrangement of colors. Digital cameras provide a basic approach to electronic shade selection and require a degree of shade selection with the human observer.[24],[27] The use of commercially available digital cameras in the dental practice can be very advantageous to the clinician due to cost-benefit, ease of use, and availability of digital cameras.


  Digital Smile Designing Top


The digital smile design is a multiuse tool that can assist the restorative team throughout treatment, improving the dental team's understanding of the esthetic issues and increasing patient acceptance of the final result. The placement of references lines and other shapes over extra- and intra-oral digital photographs widens the dental team's diagnostic vision and helps to evaluate the limitations, risk factors, and esthetic principles of a given case. These critical data will lead to improved results in all phases of treatment.[28],[29]

Various software available such as Smile Designer Pro, Visagismile, Digital Smile Design, Planmeca Romexis® Smile Design, 3Shape Smile Design, Photoshop CS6 (Adobe Systems Incorporated), Keynote (Apple Inc.), Smile Designer Pro (Tasty Tech Ltd), Aesthetic Digital Smile Design (ADSD-Dr. Valerio Bini), Cerec SW 4.2 (Sirona Dental Systems Inc.), Planmeca Romexis Smile Design (Planmeca RomexisÒ), VisagiSMile (Web Motion LTD), and DSD App by Coachman (DSDAppLLC).

Photoshop CS6 and Keynote were not created specifically for DSD but have been used by dentists and dental professionals as DSD programs.

The DSD protocol offers advantages in the following areas – esthetic diagnosis, communication, feedback, patient management, and education.


  Virtual Articulators and Digital Facebows Top


The virtual facebow is developed to provide an alternative to the conventional facebow for the mounting of casts to an articulator.[30] The virtual facebow implements several design features:

  • To prevent and minimize errors
  • To provide accurate mounting and reinforce the anatomical considerations associated with articulators
  • To provide effective, efficient, and accessible digital companion to dental implant diagnosis and treatment planning.


For transferring digital facebow to virtual articulator, first, a virtual cast is made with either extraoral (ATOS I v. 2; GOM mbH, Braunschweig, Germany) or intraoral dental scanners (Lava COS; 3M ESPE, St Paul, Minn). Then, three reference points are attached on patient's head, two are on TMJs and third one is on infraorbital point and Scanned with optical scanner (ATOS I v. 2; GOM mbH) to obtain the relationship between fixed part of head. After that, three most prominent cusps of upper jaws determine by pushing the articulating paper on the metal facebow fork to upper jaw. Pointer's tip locates on a prominent point and pointer is scanned. Repeat this 2 times more for three cusps and transfer the six positions of pointer (3 intraoral, 2 TMJ, and 1 infraorbital) into scanner's software (GOM professional software) using reverse engineering software (RapidformCAD, v2006; INUS Technology, Inc., Seoul, Korea).[30],[31]

This image is transferred to virtual articulator software which indicates the position of the upper jaw between virtual articulator and virtual cast. By taking three surfaces (left, right, and frontal) of the patient's jaw in centric relationship, mandibular virtual cast locate in correct position.

The purpose of virtual articulator is to simulate jaw motion for contributing to design the virtual crown and other prosthetics.[31],[32],[33] Dental technician can reduce the error of design and make a good prosthesis for patient with simulation of Centric Relation (CR), protrusion, and laterotrusion. Two types of virtual articulator are available on the basis of method of simulation of jaw motion.

Mathematically simulated articulator

It acts like conventional articulator because this type of articulator needs the information taken from the conventional articulator or jaw motion analyzer (Bennet angle, condylar angle, protusion, retrusion, and laterotrusion). With this information, articulator automatically simulates the motion of lower jaw like a mechanical articulator.

Completely adjustable articulators (motion analyzer)

It was designed in Greifswald University of Germany by Kordass and Gaertner. It records/reproduces exact movement paths of the mandible using an electronic jaw registration system called jaw motion analyzer (JMA). If the JMA tool is not available, different jaw motions can be defined via parameters as used with the mechanical articulators (Protar 7, KaVo).


  Laser Top


The laser is an acronym, which stands for “light amplification by stimulated emission of radiation.”[34] The advantages of laser are painless and bloodless clean surgical field, less anxious to patient, no or minimal need of anesthesia, less postoperative discomfort and swelling, faster healing, and reduced risk of infection.[35]

Various hard and soft tissue lasers used in dentistry such as (i) The Er: YAG laser possesses the potential of replacing the drill, (ii) The CO2 laser can be used to perform gingivectomy and to remove small tumors, (iii) argon laser is used in minor surgery, (iv) Nd: YAG is used in endodontics, oral surgery and for tissue retraction, (v) the diode laser is effective for oral surgery, endodontic treatment and to correct esthetics by soft-tissue manipulation.[36],[37],[38] The current trend is small, portable, cordless, low-cost diode lasers, such as the NV1 (Discus/Philips) and iLase (Biolase).

The role of laser in various field of prosthodontics such as in removable prosthodontics laser use in vestibuloplasty, frenectomy, contouring of irregular ridge anatomy, removal of tori and hyperplastic or redundant soft tissue, reduction of hard or soft tissue tuberosity. In fixed prosthodontics, laser is useful for crown lengthening procedure, soft tissue management around abutments, formation of ovate pontic sites, tooth preparation for veneers and full coverage crowns and bridges, removal of the carious lesion and faulty composite restorations before placement of final restorations. In implantology, laser is used for second-stage uncovering and peri-implantitis.[39],[40],[41],[42]

The use of lasers in the maxillofacial prosthetics is mainly for the initial workup of 3D acquisitions of optical data of the extraoral defects. Laser technology has proved to be particularly useful for planning the shape and position of the prostheses.[43] Lasers can totally eliminate the need for conventional impression techniques and associated disadvantages such as discomfort to patients and deformation of the soft tissue. Lasers also overcome the drawbacks of 3D CT and magnetic resonance imaging reconstruction as the patient is not exposed to considerable radiation and any stress.

Lasers have been used for fabrication of prosthesis using CAD-CAM, Direct Laser Metal Sintering (DLMS), rapid prototyping, etc. Deposition of Hydroxy apatite (HA) thin films on titanium implants pulsed laser deposition has proven to be a promising method to produce pure, crystalline, and adherent HA coatings which show no dissolution in a simulated body fluid.[44],[45] The use of lasers for surface treatment of titanium castings for ceramic bonding has shown improved bond strength when compared to acid etching techniques which are commonly used.[46] Lasers can also be used for welding of titanium components of the prostheses.

Disadvantages of lasers are that lasers cannot be used to fill cavities located between teeth, around old fillings, traditional drills may still be needed to shape and polish the fillings, lasers do not eliminate the need for anesthesia, and more expensive than drilling. Some hazards also associated with lasers are ocular injury, tissue damage, respiratory hazard, fire and explosion, and electrical shock.[35]


  Occlusion and Temporomandibular Joint Analysis and Diagnosis Top


Digital occlusion makes the daily dental practice of occlusion simpler and more predictable for the dentist. Using the T-Scan allows any dentist to effectively target truly problematic occlusal contacts, effective diagnostic, and treatment planning.[47]

T-Scan was introduced in 1988 by Dr. William Maness as an automated computerized sensor for analysis of the dental occlusion.[48],[49] It aimed to register the patient occlusion on a thin patented 60 μ thickness disposable sensor to record instantaneously the patient bite in terms of location, timing, and force of every tooth in contact. This record is transferred to a computing system which can make an actual simulation of the patient occlusion on a monitor, assuming the different situations possible during centric, eccentric, and functional movements. This provides both qualitative and quantitative assessment of occlusion. It not only presented a valuable method for clinical evaluation and understanding of the occlusal problems but also an important tool for teaching purposes.

The advantages of T-Scan are simple operation, dynamic viewing of occlusion, timed analysis of force during various positions of teeth contact, and possibility of permanent documentation and monitoring of the occlusal condition after carrying on the various treatment protocols.

There have been many improvements in the system (up to fourth generation) now allowing use of a 100 μ thin sensor and software to analyze and display the timing and force of the patients bite in 2D and 3D graphics. Jaw tracking devices (K6 Diagnostics) would be helpful in studying jaw movements and hence occlusion which may be a micro-trauma for temporomandibular disorder.[50]

An electromyographic device named BITE STRIPTM can record muscle activity for 6 h which provides useful information in nocturnal bruxism.[51] All these techniques mainly revolve around the aim of studying stomatognathic system, as accurately and precisely possible.


  Dental Photography Top


It is an aid for patient education and aesthetic treatment planning. Photographic records are easier to store and can be viewed at various angulations and easily measured. Regular photographic records, at all dental visits, could be great help to examine the age changes such as occlusal vertical dimension, tooth color, and facial changes. This can redefine practice of prosthodontist with their ability of visual communication and medico-legal documentation for contemporary practice.[52]

Use of digital photographs has also been explored in areas of maxillofacial restoration to replicate the iris for fabricating a custom ocular prosthesis for an ophthalmic patient and restoring other maxillofacial defects such as mandibulectomy.[53],[54] Software such as Adobe Photoshop and Coral Draw allow potential for the digital subtraction photography, which improves detection of caries, periapical lesions, bone changes, and periapical healing following an endodontic treatment as early as 2 months.[55]


  Practice And Patient Record Management – Including Digital Patient Education Top


Practice and patient record management

Implementation of computers into each operatory and throughout the practice is the first and most frequent adoption of digital dentistry.[56] Current and highly effective systems include Eaglesoft (Patterson), Dentrix (Schein), PracticeWorks (Carestream Dental), and Web-based software such as Curve Dental are using worldwide by the dentist for better management for their practice.

Digital patient education

Digital patient education is need of today's dentistry. It includes technologies and methods of communication which are already available in other industries, such as voice-activated audio films, touch-screen computer, and live educational videos. Digitalization in patient education helps in rapid recall of photos and educational components, 3D video presentation with and without monitors or tablets, and live consultation and patient education.[57]

Many software available in dentistry for effective patient education, including CAESY (Patterson), Guru (Schein), DDS GP for iPad (Kick Your Apps), and Consult-PRO Chairside (Consult-PRO). Drawing sketches of teeth on paper to educate patients is a thing of the past nowadays.

Importance and advantages of digital dentistry

Digitalization in dentistry makes dentistry easier, faster, better, and – most important – enjoyable (for dentist and patients both).[58] To be considered a clear advantage, the area of digital dentistry must include three things:

  1. Improved efficiency – both cost and time
  2. Improved accuracy in comparison to earlier methods
  3. A high level of predictability of outcomes.


Challenges in digital dentistry

Digital dentistry brings many challenges for dentists and dental technicians as well as society. Cost is the major limitation of most areas of digital dentistry because a higher capital investment generally needed to adopt new technology.[7] Other limitations are as follows.

Large digital gap between dentists and dental technicians

Technicians are steps ahead of the dentists in terms of digitalization. Many of them have had a full digital workflow for years; receiving digital impressions, designing the models in computer software, and sending the digital information to milling machines that create the prosthetic restorations. On the other hand, many of the dentists are still using conventional techniques, taking molded impressions of their patients' teeth, and physically transporting the impressions to the dental labs.[58]

High digital skills and precision for the use of intraoral scanners

Nowadays, dental professionals started the use of intraoral scanners for simplifying workflow, but it requires high digital skills and precision. It is crucial to get a perfect digital file by intraoral scanner to hand over to the dental laboratory. Conventional impression allows dentists to make minor mistakes as they can be fixed by the dental technician, but a digital impression does not allow for any mistakes at all.

As dentist's precision on the intraoral scanning technique improved, they also gain a better understanding of the complete process of digital dentistry and helps too close the gap between dentists and technicians.

Maintaining a balance between simplicity, speed, and reliability

Digitalization demands speed with simplicity and reliability. As technology develops rapidly, the manufacturing companies also grow too fast to provide speed and simplicity. Along with this, they need to stabilize their hardware and software so that the digital techniques also maintain their reliability. So, it is a responsibility of manufacturing companies to make sure about quality of their products and help dental professionals to simplify the workflow.


  Conclusion Top


Digitalization is one of the most important parts of modern dentistry. If digitalization is implemented in clinical dentistry with proper knowledge, then it can increase the joy of practicing dentistry and better care for patients.

To achieve a fully digitalized workflow in dental care, prosthodontist should start using the digital techniques to the same large extent as the technicians. They should keep knowledge of all ongoing advancement in dentistry and use judicially in their practice to meet today's patient's needs and improve their own workflow.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Abstract
Introduction
Digital Radiography
Optical Impression
Shade Matching
Digital Smile De...
Virtual Articula...
Laser
Occlusion and Te...
Dental Photography
Practice And Pat...
Conclusion
Computer-Aided D...
References
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