Digitally-Driven Dentistry: Using Advancements in Science and Technology to Deliver Restorative Excellence

This is a summary of the webinar, hosted by Henry Schein Dental with featured speaker, Sundeep Rawal. You may watch the webinar here.

As dental practices transition from an analog to a digital world, technologies are enabling doctors to provide care in ways they never thought possible. “We can deliver restorative outcomes that are easier, faster, cost less money, and really translate into affordability for our patients,” says internationally recognized dentistry expert Dr. Sundeep Rawal. “Using cone beam computed tomography and intraoral scanning acquisition enhances our restorative workflows.”

Doctors can now perform intraoral scanning with a CBCT and get more utility out of that information than merely replacing an alginate or a PVS material. As Dr. Rawal explained in a recent webinar, cone beam computerized tomography (CBCT) is more than just a 3-D radiograph. The data acquired from CBCT can be used for more than just conventional radiography. It can be imported into a software application to help with design and planning scenarios, creating definitive restorations, planning provisionalization, or designing the smile.

With this data, doctors can diagnose a treatment plan, and then ultimately, go into manufacturing all throughout that digital workflow and get predictable outcomes. They can see exactly where the tooth position is with respect to bone, and then plan accordingly. “That is more than just taking a three-dimensional radiograph and measuring 10 millimeters of length and eight millimeters of width,” says Dr. Rawal. “This is using the data to the fullest to being able to plan and then execute on that plan based off of a prosthetically-driven design.”

Advantages of Intraoral Scanning (IOS)

IOS offers significant advantages, including:

• Eliminating the need for a physical master cast

• Easier transfer of information

• Ability for the doctor to gain instant feedback

“Instead of shipping physical impressions that take several days, we’re transferring data,” says Dr. Rawal. “That saves time over analog impressioning. And certainly patients prefer digital scanning compared to having intraoral material-based impressions. Data shows that we can get much more accuracy when it comes to the fabrication of restorations when the impression is taken through an intraoral scan. If you look at the digital crowns that are made through optical impressioning, they get better marginal fits and less discrepancy between the crown and the margin of the restoration.”

“What’s shocking to me is that we have had CBCT and intraoral scanning technologies in dentistry for decades, yet if you look at the penetration in the marketplace, you'll see that we're only at about 15% for intraoral scanning and maybe a little bit more for CBCT utilization,” said Dr. Rawal. “It's also in many respects exciting because the potential room for growth and the potential room for change and how we treat our patients is extraordinary. We're at the brink of a sea change in dentistry, where in five years or so, all of us will be treating our patients in ways that are much different and much more in line with where we are with modern technology today.”

CBCT for Guided Surgery

Taking dentistry one step further, doctors are using CBCT to not just acquire data but to use the data through a guided protocol. “The science shows that when we place implants through guided protocol, we statistically get better results than if we free-hand it,” says Dr. Rawal. “If we take CBCT information and most importantly, we use that CBCT information not just to measure a length and a width, but to diagnose the accurate position of the implant planned in software and then execute on the plan by going guided, we're able to place the implant within a quarter of a millimeter of vertical depth within a couple of degrees of angulation.”

One such case using guided surgery involved the replacement of a traumatically-injured maxillary single central incisor with a dental implant. A young man’s tooth was damaged during a basketball game, and went to see Dr. Rawal for treatment. “We didn’t opt to place an immediate implant because we weren’t sure of the exact nature of the trauma,” he said. “We decided to extract and graft, to create the ideal maximum amount of volume of the hard and soft tissue to utilize.”

Rawal digitized the intraoral scan, digitized the bone with a CBCT scan, and then merged the two in software before deciding on the ideal place for the dental implant. “We didn’t stop by saying we can place a 4.3 x 13 mm long implant in,” he said. “We executed on the plan by creating a guide. That allowed the implants to go in in the right spot. We let it integrate, we went through our site development. We went through provisionalization, and then ultimately, we end up with this result. We got this result because the head of the implant was placed in an appropriate position to allow me the running room to create the emergence profile to support tissues appropriately.”

Creating a Single Scan

By merging CBCT and IOS data, the doctor can identify not just the volumetric area of the bone to work with but the bodily position and angulation. “This is very powerful because it allows us the ability to create predictable outcomes for our patients,” said Dr. Rawal. “This gives us a surface scan that’s very accurate of the hard and soft tissues, enabling us to make sophisticated decisions about where implants should be. Then we can take this into design software to plan and fabricate a provisional. Now we're combining clinical visits. We can do things like creating a screw-retained provisional prosthesis ahead of time that we'll be able to deliver at the time of surgery. Combining workflows in this way creates greater efficiencies in our treatments.”

The process of placing implants in this way is fairly straightforward:

• The doctor digitizes information from the intraoral scanner to create a smile design.

• He creates a motivational mock-up so he can show the patient exactly how it will look.

• The patient approves the mock-up, and the doctor designs based off the mock-up.

• Based on knowing that the implant will go in predictably, the doctor also has the flexibility to incorporate advanced restorative options, such as angulated screw channel technology, knowing we can place the implant in the most ideal situation.

“We know that we're going to be able to deliver the aesthetics we want, with the function we want, have total retrievability, and use innovative restorative protocols —all because we used intraoral scanning technology and CBCT,” said Dr. Rawal.

These workflow efficiencies can also be applied to full-arch implant therapy or full-arch natural tooth restorations. “Full-arch implant therapy used to be the hardest, most cumbersome, time-consuming, lengthy procedures we did in dentistry. And it was the most expensive,” said Dr. Rawal. “Most patients couldn't afford to do it, but all that changed in the last decade because we're utilizing these technologies along with CAD/CAM and milling of titanium and zirconia to be able to deliver predictable full-arch outcomes that are affordable. Today, they’ve become the easiest dentistry that I can do in my practice.”

In one case, a patient presented with a terminal dentition. Two teeth were so mobile that making a physical impression would likely have displaced the teeth. Instead, Dr. Rawal scanned the patient’s mouth, digitized the information, and merged it with CBCT data to plan the case. This gave him the ability to clearly see where the patient’s existing restorations were. “We could clearly a very accurate soft tissue profile for the emergence, and could put scan bodies on and know exactly the most accurate position of the head of those implants,” Rawal explains.

Having the information in one scan gave Rawal the flexibility to create a screw-retained provisional ahead of time. He then created a tooth-only prosthesis with abutments and pontics. On the day of surgery, he was able to extract the damaged tooth, place the implant very accurately, and then provisionalize the patient all in one day.

“This has now become a very routine procedure that we are able to perform in our practice,” says Rawal. “Then post-osseointegration, we have the ability to take this information and do amazing things because now we can actually scan where the provisional prosthesis is, in the lower arch, I can scan the provisional prosthesis in the upper arch and I can then do more with the data because I can take things like the bite. Once I have the bite, I'm able to then do things like articulate at the right vertical with the right centric and then I can even cut away the provisional and then scan the soft tissue. I can put scan bodies on so I can get a fairly accurate representation of where my implants are. I can capture all of this data, give it to my lab, and now we're able to go and predictably fabricate the definitive restorations. I can go from data acquisition or final impression to delivery in two visits.”

By using the entire digital workflow, we know and trust that we’re going to get a good restorative outcome – and gain efficiencies for our practice and our patients. Since there's less chair time and less expense, I can make it more affordable. And this means more patients say yes to therapy.”