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Dentistry at the Speed of Thought by Eugene Antenucci, DDS, FAGD, DICOI

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In 1999 Bill Gates wrote a prophetic book titled “Business @ The Speed of Thought: Using a Digital Nervous System,” where he stated in the very first chapter: “I have a simple but strong belief. The most meaningful way to differentiate your company from your competition, the best way to put distance between you and the crowd, is to do an outstanding job with information. How you gather, manage and use information will determine whether you win or lose.”1 The relentless onward march of advanced digital technology in dentistry is a fact of life in managing a dental practice, and it is undeniably true that how we “gather, manage and use information will determine whether you win or lose.”1

Our world in 2014 has undergone profound changes since Bill Gates wrote those words in 1999, and the world of dentistry has hardly been spared the effects of revolutionary change. It can be argued that in 1999 the major concerns for dental practitioners were dental anatomy and physiology, materials science and perfecting dental operative techniques. It was challenging enough to master the techniques of achieving the perfect margin while simultaneously learning to become physicians of the oral cavity as well as being small business owners. Today, however, dentistry has undergone a rapid revolution as it incorporates technology at a dizzying pace. Not only are the 2014 dentists clinicians of the oral cavity, master technicians, materials scientists and business people, they are also finding themselves in the position of needing to understand and impliment advanced aspects of computer engineering and a vast array of available digital technologies.

The Digital Impression vs. Traditional Impression Techniques

At the heart of restorative dentistry is the successful restoration of damaged tooth structure, and this can only be accomplished in the case of full- and partial-coverage restorations and bridges with an accurate rendering of the margins of the intended restorations (by taking an “impression” of the tooth or teeth in question). The “impression” is the means of capturing and relaying the vital information required for creating indirect restorations—inlays, onlays, crowns, veneers, implant abutments and bridges. As dentists know, this most critical step in the process of delivering a well-fitting, functional, aesthetic and long-lasting restoration is highly dependent on proper technique. Traditional dental impressions involve a variety of elastomeric impression materials (polyvinyl siloxanes, polyethers and hybrids), which are used because of their ability to accurately reproduce detail while being dimensionally stable. Ease of use and patient comfort is not a part of this equation. Trays are required to deliver the material. The tray delivery of impression materials, regardless of the type of impression material, may abrade patient tissues, pose difficulty in conforming to anatomy, cause many patients to gag, is often unpleasant tasting, have variable reactions with saliva and blood, and require time, usually in excess of three minutes to become dimensionally stable. Impression materials are expensive, as are trays. In addition, materials are needed for counter-impressions and bite registration. Infection control protocols must be followed throughout the process. Physical impressions must also be poured. When performed inoffice, the doctor has the ability to control quality by assuring that proper water to powder ratios have been adhered to in pouring the models to avoid inaccuracies, and by viewing the model and marking the margins for the lab. If model creation is delegated to an outside lab, as is often the case, control is no longer in the hands of the office, and the critical step of viewing the model for accuracy and marking margins is out of the practitioner’s control. Additionally, traditional impression techniques require extra chairtime on future dates, particularly when the majority of these restorations are fabricated by traditional outsourced laboratory methods, requiring days to weeks for fabrication, time spent relaying instructions and reviewing instructions with a technician, the need to catalog and organize lab work for lab delivery, return and office storage until the patient’s final delivery appointment.

Digital impressions change the traditional methods and workflow completely, directly relating to more control over results, with improvements in patient comfort and convenience, quality of restorative results and savings in time and money. When an impression is captured digitally, impression materials and trays are not required. Models do not need to be poured. The treating doctor immediately assesses the virtual model and marks the margins. The time necessary to take and assemble a digital impression, counter model and articulation is a fraction of the time needed with conventional techniques. Patient comfort is greatly improved — they do not experience material textures or unpleasant tastes and gagging is not a concern. Restorative control is placed in the hands of the treating practitioner. Infection control protocols are significantly streamlined and improved. Accuracy is inherent in the digital impression, and not dependent on factors such as material distortion, improper model handling, improper model pouring techniques, inaccurate trimming and margination of dyes by an outsourced technician who did not create the preparation.

Digital impressioning is not a magical dental technique. It is simply the replacement of traditional materials with a scanner or camera that can be used intraorally or extraorally to accurately capture and replicate the intended tooth shape and position. Traditional means of tooth preparation, tissue retraction and isolation from oral fluids are used. Clinicians taking digital impressions do not need to alter their preparation, isolation or retraction techniques. After digital impressions are acquired, the virtual models are assembled and the clinician fully evaluates the models.

A feature of this technology is that models and preparations are viewed at significantly enhanced magnification, and inadequacies become fully evident. If there are inadequacies, they are acknowledged immediately, and the areas of the impression required are simply retaken with minimal loss of time and without added patient discomfort. Once the digital impressions are accepted, the margins are marked, again under magnification much higher than available under conventional circumstances with models. The articulated models with margins clearly marked under the direct supervision of the treating practitioner become immediately available for the clinician to directly fabricate a restoration with chairside systems (adding further to patient convenience and comfort by avoiding temporization and a second office visit) or can be digitally relayed to an outsourced laboratory for fabrication, usually with greatly diminished turnaround time.

My personal experience with digital impressioning goes back to 1996 when I first incorporated a chairside digital impressioning and fabrication system. In 1996 the technique was by no means easy or friendly. Since that time, the process has matured to the point where it is now significantly and unarguably superior. Currently I am working with Planmeca PlanScan, powered by E4D Technologies (Fig. 1). PlanScan is the only intra-oral scanner that uses blue laser technology. Its smaller wavelength (450nm) is more reflective, resulting in sharper images. Its ability to capture fine details allows it to highlight hard and soft tissues of varied translucencies, and dental restorations, models and impressions for more clinically precise prosthetics. The camera provides consistent performance and reliability, and is simple to use. No reflective powdering is required, and fogging will never occur when acquiring images. Unlike some other systems clinically being used, the PlanScan wand with removable tips and an effective infection control protocol allows for a high level of disinfection prior to each patient use. Scanning is rapid, with video-rate scanning and plug-and-play connectivity, it captures and processes data nearly as quickly as the operator’s hand moves, allowing for rapid acquisition of quadrant and fullmouth scans.

Once an image is acquired, Planmeca’s Romexis PlanCAD design software utilizes the convenience, portability and power of an advanced laptop for the restoration’s design. The software is extremely intuitive, simple to learn and easy to use in designing and creating a full range of restorations of superior restorative materials chairside using the PlanMill 40 milling unit, including crowns, inlays, onlays, bridges and veneers. PlanCAD allows for seamless connectivity with a large number of dental laboratories and has an open architecture, meaning its .STL files are not restricted when exporting. Milling systems universally read .STL files, and the open architecture places no restrictions on which systems can read these files. No encryption is added to these files on export, which companies often do to maintain complete control (including financial) over the use of their systems.

The CAD software is used to mark the restoration margins, select the anatomic morphology of the restorations to be created, define the orientation or path of draw of the restorations, create optimal height of contours, conform anatomy to the adjacent and opposing dentition, create optimal proximal and occlusal contacts, select the material the restoration will be made from, and send the virtual design wirelessly for milling.

The entire process is completed for a single unit within two hours, depending on the type of material used and whether that particular material requires processing time for crystallization, staining and glazing in an oven. Total doctor time required is between 30 and 45 minutes regardless of the type of restoration selected.

Case Presentation

A patient presented to my office on emergency with pain in an anterior tooth resulting from extensive caries. This male patient, 43 years of age has not seen a dentist for more than five years. He presents with several missing teeth and with evident areas of decay (Fig. 2). He acknowledges the need for dental care, swears that he will pursue care as soon as his emergency is resolved, but his chief complaint is his upper right canine, which is visibly decayed and has acute pulpal symptoms. He is a man with little time or patience for dentistry, but has an immediate need for treatment due to his acute pain and also the fact that this anterior tooth decay is also affecting his appearance.

The caries was so extensive that limited coronal tooth structure was left remaining following caries removal (Fig. 3). Endodontic treatment was performed within 45 minutes, and composite was placed over the access while he was asked to wait an hour until my schedule allowed me to complete the restorative part of his treatment.

In addition to a post and core buildup, crown lengthening was necessary. Adequate attached gingival tissue was present in order to allow for a soft-tissue gingivectomy. A diode laser was used at a power setting of 1.6W in continuous pulse mode for 40 seconds total time in order to expose adequate root surface and provide a 2mm ferrule. In addition, the laser provided separation between the tooth structure and tissue, along with very little bleeding (Fig. 4). A #1 Flexipost was placed after going to depth with the #1 Reamer. The tooth was etched, adhesive was applied and the post was cemented with syringable DenMat core paste, which was also used as the buildup material. The tooth was prepared with a shoulder, the finish line placed slightly subgingivally on the facial. Traxodent Hemodent paste was used for hemostasis in the areas abraded during final preparation, and the area was compressed for four minutes by having the patient bite down on a medium-sized Comprecap.

After fully rinsing and drying the area, the tooth was ready for an optical impression using the PlanScan Intra-oral Scanner. The wand was fitted with a removable tip that had been sterilized according to manufacturer’s recommendations. The optical impression of the preparation and adjacent teeth took less than a minute. The technique I used involved beginning on the preparation (Fig. 5), moving distally to capture the occlusal surface of #5, then moving back over #6, and angling the wand to capture interproximal areas as it passed mesially to #7 and #8. The wand was then angled to capture the buccal surfaces including gingival tissues and then moved distally until #5 was captured on the facial. The palatal surface was then captured by moving the wand on the palatal mesially until #7 was captured. The camera allows for tactile sense of position since the camera is designed to touch the teeth as it scans. The screen displays color gradations in areas that are captured with the colors depicting which areas may require additional scanning (Fig. 6). Once the image was captured, the model was made with the click of the mouse. The model was evaluated for accuracy and accepted.

This process was repeated for the opposing arch, and then again for an impression of the arches in occlusion. When the three sets of optical impressions were accepted, the case was virtually articulated automatically by the software and the design process could begin.

The design itself began with evaluating and setting the orientation of the model—analogous to setting a physical model in plaster on an articulator with the proper horizontal and vertical planes present. The preparation was then enlarged on the screen and the margin was drawn with a very powerful yet simple-to-learn-and-use set of tools. Once the margin was drawn, another mouse click created the design and fit the crown proposal on the margins and in place on the model.

A series of design tools allowed for a systematic approach to refining the crown proposal, adjusting contours, adjusting occlusion and adjusting contacts. This all took place with the patient watching from his chair in the operatory. The entire design process took four minutes, and the restoration was sent to the PlanMill 40 for milling.

An e.Max block was selected. E.Max blocks are monolithic lithium disilicate material, a material with extremely high flexural strength, excellent biocompatibility and wear compatibility with opposing tooth structure. The aesthetics are beautiful, and clinical results are well documented. The blocks are violet, with inherent designated shades, and require a cycle in a porcelain oven for crystallization. I selected shade A2 and would characterize the cervical with A3 at the time of crystallization. Milling time was approximately 13 minutes. The sprue was removed (Fig. 7 & 8), the crown was steam-cleaned and dried, then fitted in the mouth in its pre-crystallized state. Contacts and occlusion were adjusted. This process took another five minutes, after which e.Max stain and glaze materials were applied to the crown (Fig. 9), and it was placed in the oven for approximately 16 minutes, during which the crown was crystallized and stains and glazes are set. When the oven cycle was completed, the crown was allowed to cool for five minutes. Once cooled, IPS etching gel (Ivoclar Vivadent) was applied for 20 seconds and thoroughly rinsed and washed from the internal surface of the crown, followed by air-drying. Ivoclar Monobond Plus was applied for 60 seconds in order to mediate the adhesive bond with the luting composite. This entire process took less than 30 minutes, and was conducted by my chairside assistant while I was treating another patient.

The tooth was cleansed with chlorhexidine and dried, then etched with orthophosphoric acid for 10 seconds, washed and dried. MultiLink by Ivoclar was selected as the luting resin cement. Primer A and B was mixed, applied with a brush to the tooth and air-dried. MultiLink Transparent (Ivoclar Vivadent) shade was applied to the internal surface of the restoration. The restoration was seated in place, and when the gel set began, floss was passed through the contacts to assure that they were clear of resin before the cement fully set (Fig. 10). When the cement had fully set, the cement was fully removed from facial and palatal surfaces, contacts and occlusion were verified, and the case was completed. Final cementation and finishing took less than 10 minutes.

My busy patient was extremely pleased with the result, but more so was pleased with the fact that in a single visit he was done with dentistry for the time being, and with a root canal, direct post and crown on his anterior tooth. He was gracious enough to return to the office at 8 p.m., three days post-op, for a final photo (Fig. 11).

In 1999 Bill Gates spoke of business at the speed of thought. Today we are able to provide our patients with dentistry at the speed of thought. Techniques and processes have matured and advanced to the point that they can provide same-day results predictably, in an extremely cost-effective fashion, with great acceptance by our patients. Digital impressioning techniques are no longer difficult and laborious to learn. New devices available to dentists offer enhanced ease of use with decreased and intuitive learning curves. The benefits of digital impressioning are numerous, requiring serious consideration from all dentists who provide restorative dental services to their patients. Digital impressioning is simply the best means for dentists to gather the information needed to restore the form, function and beauty of our patients’ teeth.

References
  1. Gates, William H. III; Business @ The Speed of Thought: Using a Digital Nervous System, 1999; Warner Books, Inc.; p 4.)
  Author's Bio
Dr. Eugene Antenucci’s expertise is in the clinical integration and utilization of advanced dental technologies. He has assisted many dentists make sound decisions in working with and profiting from technology in practice. As an international lecturer, his programs have provided hundreds of attendees with concrete and usable information on the practical applications of technologies such as digital impressioning, intra- and extra-oral imaging, digital radiography, dental lasers, cone-beam CBCT imaging, office automation, as well as the incorporation of social media and the internet in dental marketing in order to increase a practice’s visibility and flow of new patients.

Eugene maintains a full-time restorative, implant and cosmetic private practice in Huntington, New York.
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