Virtual Setups Using Intra Oral Scanners for Same Day Consultation

IOScan_exampleBy John White DDS, MSD, ABO

Having been in orthodontic practice for 35 years, I’ve seen a lot of changes in all aspects of orthodontic care.  Most changes have been totally under our control and are merely choices. Whether you choose to use self-ligating appliances or not impacts your mechanics but not really your ability to produce an excellent result. Most cases do not require a CBCT to adequately diagnosis or treatment plan to achieve that same excellent result. Robotic orthodontics, also known as pre-bent appliances, have benefits and drawbacks, but once again are unnecessary for creating that “perfect smile”. Most of us have never done more than dabble in lingual appliances; without any loss to our practice. And while clear aligner therapy has probably the greatest (potential) impact on the traditional delivery of orthodontic care, there are plenty of very successful orthodontic practices that presently don’t use it at all or only on a limited basis.

That being said, competition in the market place has changed significantly, from the outside. We can’t rely on the “gold plated” referrals from our GP colleagues like we once did. Second opinions are becoming the norm. We have one chance to develop a relationship while we present our treatment “design”.  We deal less with patients and more often with consumers.  Where we used to do exam / records / consultation on separate visits, the sequence has evolved for many of us into a single visit. We used to show our beautifully finished cases with plaster models and photos, or cut and pasted smiles from the AAO smile library and so forth. Today’s consumers want more.

The advent of CAD/CAM treatment planning and design software is changing all that.  We now have the ability (and even possibly the responsibility) to do virtual treatment planning, trying out options and alternatives with accuracy and predictability. The ability to customize everything about treatment from the beginning goes beyond the capability to modify and adapt the otherwise generic prescriptions and archforms of the past to match the particular patient’s needs.

Tens of thousands of patients have seen their clear aligner predictions or pre-bent setups. This is changing the exam and consultation process. Patients are becoming aware that we can show them what their teeth will look like post treatment. An interactive approach to smile design and occlusion function is not only possible but a significant advance in marketing and patient appreciation of what goes into their treatment plan beyond just straight teeth.

For purists, one of the leaders in CBCT scanners is currently beta testing 3D integration of IO scans with CBCT imaging and computerized jaw tracking.

There are stand-alone software that permits visualization and treatment planning of IO scanned data, and some IO scanners come bundled with similar software.  Some scanners are not only able to directly scan to aligner companies, but also come bundled with “Treatment Simulator” software.

While I am invested primarily in a single technology, I routinely use several of these and am doing trial runs of others. The learning curve is not terribly steep for any of these. And they all work.

The logistics of same day exams with IO scan and treatment simulation becomes the biggest hurdle.  We do an office tour ending with a CBCT (with face scan) and photos, if the IO scanner is available and the patient has time, we do an IO scan. This combination takes 30-40 minutes (as opposed to 20-25 without IO scan). While we review CC and get acquainted, everything is loaded.  The treatment simulation is run in the background (the 3 treatment algorithm choices are preselected).

After we have reviewed my diagnosis we look at the treatment simulation and start moving teeth to reflect my recommendations and patient wishes.  This not only increases patient engagement but shows that I am intimately involved in the treatment design, not just letting the computer treatment plan for me. It helps explain tooth size discrepancies and why IPR may be necessary (even on extraction cases). We can measure expansion and torque requirements and cuspid inclination. And it is especially useful for pre-restorative setups; visualizing spacing and vertical setup, bonding undersize laterals, etc.. Multiple treatment scenarios can be done to help illustrate trade-offs in compromise cases.

Not only is there improved communication with and education of the patient/parent, but a unique understanding of the case above and beyond the “Old Days” where I fondled a set of soaped and polished study models or CR mounted models.

Finally, we can re-establish our reputation with consumers as the experts in orthodontics by using and properly explaining to them the benefits of this technology.

8 thoughts on “Virtual Setups Using Intra Oral Scanners for Same Day Consultation

  1. I am totally agree with first visit one shot.
    First visit around one hour in my office routinely
    1 clinical examination
    2 10 Photos : 5 portraits + 5 intra-buccal
    3 lateral+face Xrays + panoramic
    4 clearing teeth if necessary
    5 Intra Oral scan with Itero
    6 Invisalign Outcome Simulator
    7 Full CBCT + 3D face with Planmeca 3D Promax Mid + Proface
    8 several simulations with teeth bone and face in few minutes
    9 Fees and financial plans
    In one hour the patient had all the information for his orthodontic treatment
    That’all !
    And we can start treatment immediately !

  2. I hope your not taking a CBCT on everyone. The misuse of technology doesn’t instill confidence in our speciality. Manufactured “demand” continues to subordinate the orthodontist. Who in the AAO sanctioned this “Techtalk”?

    • As clinicians, we should all be aware of radiation exposure levels to our patients regardless of whether it is 2D/3D imaging. In our practice, we do take CBCT scans on all of our patients but only after a thorough clinical exam and only if we deem it necessary for radiographic imaging. We also have our patients/parents sign an informed consent form prior to taking any CBCT scan so that they understand the risks and benefits and the purpose of the CBCT scan.

      Dr John Ludlow and his team of researchers were kind enough to demonstrate in a research project which was published in the AJO in November/December of 2013 that the iCAT FLX low dose CBCT scanner provides lower radiation exposure levels than 2D digital and film radiography at the Quick Scan Plus settings and comparable or only slightly higher radiation exposure levels at the Quickscan settings. As clinicians who are using these CBCT scanners in clinical practice everyday, we are trained to understand the different types of settings so that we are following the ALARA principles.

      Computer tomography is a technology which completely revolutionized the face of radiology in medicine and in fact, Drs. Cormack and Hounsfield won the Nobel Prize in medicine for their invention in 1978. CT is a tool for all of us to use as clinicians for the benefits of our patients for far superior diagnostic imaging which leads to superior treatment planning and patient care. I personally feel very fortunate that today we now have this technology available for treating our patients in dentistry. However, I do completely respect your concerns with protecting our patients from excessive radiation exposure levels and as a result it is our responsibility to make certain that we use it wisely!!!

        • Hi Todd,

          I would be more than happy to disclose my commercial relationship with iCAT. I have been an owner of the iCAT for almost 10 years now. Over the past 2 years we have swapped out our iCAT Classic and iCAT Next Gen for 2 iCAT FLXs. The reason for our doing so and having to spend a significant amount of money to upgrade is because my 2 partners and myself believe firmly that 3D imaging has become the standard of care in our practices and has made us better clinicians. In addition, the fact that the iCAT FLX set at the appropriate settings gives us the advantage of 3D imaging with lower radiation exposure levels than a digital ceph and pan. How awesome is that?

          I do sit on the Clinical Advisory Board of Imaging Sciences along with several other well known and respected clinicians across the U.S. This is an unpaid position and the responsibilities include an annual meeting every summer for an intense two day brain storming session to collaboratively discuss how to make both the hardware and software applications of the iCAT better for both us, the clinicians, but most importantly for our patients. I choose to do this because i have always had a strong interest in learning about new technologies and this opportunity allows me to stay up to dat and become involved with future developments with CBCT which I think is a pretty cool opportunity.

          I do lecture for Imaging Sciences a few times per year. I do get paid an honorarium for my services which I feel is very fair as it takes me a great deal of time to put together new presentations with new cases And pays for my time for travel away from my family and out of the practice. I would like to clearly point out that I have no financial interest in a Imaging Sciences. Although I wish I did way back prior to their acquisition by Danaher.

          Todd, I am a firm believer in technology and how it can improve our lives. We do need to learn how to use all technologies wisely, correctly, and safely for our patients. Please let me know if you have any additional questions.

          Most Humbly,

          Ed

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