CBCT Imaging for your Practice: Is Now the Time?

By Dr. Kenneth R  Webb

As I walked the exhibit floor at the AAO Annual Session in San Diego this past April, I stopped and talked to several of the company reps displaying the latest generation of CBCT scanners. Competition is good – what struck me is how far this technology has come in such a short period of time. Effective dose, image quality, and versatility are three areas where the advances are most impressive. I have witnessed these advancements first hand in my practice where we have been using CBCT since 2012 and recently upgraded a satellite office from a 2D digital Pan / Ceph to an “Ultra Low Dose” current generation CBCT scanner. I’d like to share some of my thoughts about the 2D to 3D transition.

Effective Dose
I encourage anyone interested in CBCT technology to search for studies authored by Dr. John Ludlow and his team. Dosimetry data and image quality for many CBCT scanners (both older and current generations) have been researched in great detail. Comparative data for 2D dental radiographic imaging (both intra and extra oral) is also available. By replacing our 2D Digital Pan / Ceph with a current generation CBCT scanner we have reduced the effective dose of our diagnostic records imaging by approximately 60%. (Ludlow JB, Walker C. AJO-DO, 2013;144 (6): 802-817) This is accomplished with one, approximately 5 second, ultra-low dose CBCT scan compared to the two longer duration exposures (pan then ceph) required with 2D imaging. Certainly a win-win for our patients.

Versatility
What else can we use the 3D data for? Digital models: used to assess the inter-arch and intra-arch relationship as well as aiding the determination of arch length and arch width requirements and assessing arch symmetry. Modelling labs can produce articulated 3D study models from the CBCT data (DICOM) files.

STL files of the patient’s dentition and occlusion can be uploaded into whatever software you may be using in your office for 3D model storage and viewing. Additionally, these models can be used (with appropriate software) to produce treatment simulations by “moving” individual teeth or the arches as a whole. Imagine completing your diagnostic records with Intra / Extra Oral photos and one 5-second CBCT scan!

Viewing the Diagnostic Data
The software that comes with a CBCT scanner can easily produce the customary 2D diagnostic images that we are used to evaluating (panoramic, lateral and A-P ceph). In addition – you see everything! The data can be viewed in sagittal, axial or coronal sections (slices) or as a 3D “volume rendering” which can be rotated and sliced (“clipped”) at will. So why is this additional information gained from CBCT imaging important?

Pathology
You will see pathology in the 3D data that isn’t visible with standard 2D imaging. When pathology is visible in 2D, the 3D data can more accurately ascertain location, extent, and character of the area of concern. This is beneficial to our patients.

Developmental Anomalies
One of my first revelations when we began imaging in 3D was the prevalence and extent of “individual anatomic variation”. But how much is too much? We have made referrals to medical specialists for significant developmental anomalies in the cervical spine, nasal cavity and paranasal sinuses. Patients / parents are appreciative of the thoroughness of our diagnostic process that includes 3D imaging.

Asymmetries
They get their own paragraph! Your patient smiles at you and you notice a vertical asymmetry and occlusal plane “smile” cant. Is it caused by hemimandibular hyperplasia, condylar hyperplasia, a unilateral expansive lesion in the maxilla, a growth response to unilateral progressive condylar resorption (to name a few) or a growth response to a foreign object lodged in the nasal cavity? I’ve seen them all. Similar clinical presentations – different treatment plans.

TMJ
Condylar position in centric occlusion, condylar size and shape, glenoid fossa morphology, condylar osseous morphology, joint space, findings suggestive of degenerative joint disease – both active and stable. It is hard to argue that these are not important considerations in our diagnostic process.

Airway
The value of volumetric and cross-sectional analysis of the naso – pharyngeal airway and its relationship to orthodontic diagnosis and treatment planning has, and continues to be, studied in great detail. Is the growth and development of a patient who presents with narrow arches, an anterior open bite or anterior crossbite, tongue thrust and a strong mouth breathing pattern secondary to adenoid / tonsillar hyperplasia, a deviated nasal septum, environmental allergies or restrictive airway dimensions in general? Should your imaging modality include an assessment of these areas?

And there is more…
Orthognathic surgical treatment planning, TAD placement guidance, precise localization of ectopic and supernumary teeth, and assessment of treatment progress – including evaluation of root torque. All are possible or enhanced with 3D imaging. And by managing scan parameters (field of view, scan time and voxel size) at an effective dose equal to or less than 2D imaging modalities.

So, if you haven’t brought this technology into your practice – is now the time?

At the 2017 AAO Winter Conference in Ft. Lauderdale, Mr. Chris Bentson reported on a survey of recent (2016) U.S. Orthodontic Residency graduates: 88% responded that they had used CBCT imaging for diagnosis and treatment planning during their residencies including 21% that used it on all patients.

For the 2013 graduates, the responses were 76% and 9% for the same questions.

Based on these statistics, are we that far away from 3D imaging being included in the “standard of care” discussion? Embracing new technology is not easy but the value added for the practitioner and our patients is significant. The orthodontic educators who expertly taught my generation faced a similar situation during their careers with a then relatively new technology: panoramic radiographic imaging. My generation faced the challenges of transitioning from analog imaging (film) to digital.

Change is not easy. The transition from 2D to 3D imaging in your practice will require a financial and educational commitment. The whole staff will be a part of this paradigm shift. A positive – 3D imaging will be a differentiator for your practice. If you are seeking an associate, partner or complete transition, 3D imaging will make your practice more attractive to the next generation of orthodontists.

3D imaging will benefit you and your patients. Is now the time?

Is it Time to Say Goodbye to our DSLR Cameras?

By Dr. Anthony M. Puntillo, DDS, MSD

When I first graduated from my orthodontic residency, now more than 23 years ago, a standard set of initial records included plaster models, facial and intraoral photographs taken with film, developed, then trimmed and placed into mounts and panoramic and lateral cephalometric radiographs taken with film and developed in darkrooms. The digitization of our society has made the process of gathering and storing this important diagnostic information much more efficient for most orthodontists. In fact, more than four years ago (November 2012) I wrote a Tech Blog article on digital retainers and the impressionless orthodontic practice. Since then the use of intraoral scanners and 3D printing in our profession has grown exponentially. It is now not hard to imagine a day in the near future when impressions will disappear completely from the practice of dentistry.  As I near the end of my 8 year term on the CTECH committee, I can’t help but wonder what is next.   Where else can we use technology to eliminate inefficient processes from our practices?

The most obvious next step for me is the elimination of intraoral photographs. All of those intraoral scanners, now used by most orthodontists, take multiple photographs of our patients’ teeth to create the 3D digital images. Several of these scanners can capture images in true, or close to true color. It can’t be long before we come to the realization that digital images taken with a good intraoral scanner are a better alternative to the standard set of 5-7 intraoral 2D photos we have been taking for decades. The 3D digital image is not only a better diagnostic record of the patient’s current dental state, it also is more versatile in that it can also be used to create and fabricate appliances (i.e. clear aligners, indirect bonding setups, retainers, etc.). If a good intraoral scan can consistently be completed in less than 10 minutes, aren’t we wasting our time and that of our patients’ taking 2D photos. I concede that we are all very accustomed to diagnosing our patients with these 2D photographic images. However, it was not that long ago when most thought that multiple radiographic exposures were necessary on the majority of our patients.   Now most of our patients are diagnosed with a single, quick radiograph taken on a CBCT machine and from that single exposure we derive a much higher level of diagnostic information.

To be honest, I am not yet ready to mothball our cameras. For starters, I still think that facial 2D photos are necessary. I know that there are 3D cameras available that will someday eliminate the need for our extraoral series of facial photos. However, for whatever reason (I believe primarily cost) these have not yet caught on. So for now we will still be taking a series of three 2D digital photos of our patients’ faces. Additionally, 2D intraoral pictures still play a significant role in our new patient consultations. We have not yet found the best way to display and share the captured 3D dental images (STL files) to educate our patients. I anticipate that this last hurdle will be overcome in 2017 and when that happens our DSLRs are going to see much less action and our IOSs are going to play an even larger role in our new patient process.

2017 Winter Conference – Technology: Balancing Profit, Lifestyle & Patient Care

By Dr. Doug Depew

The 2017 AAO Winter Conference is quickly approaching. Our theme of this year’s meeting Technology: Balancing Profit, Lifestyle and Patient Care.  It promises to be a meeting filled with information for both newer and established practices to help make those tough decisions on what technology is important to use in our practices and when we may wish to invest in it.

The meeting will begin with keynote speaker Jack Shaw.   Mr. Shaw is a world- renowned technology futurist who will be discussing how cutting edge and disrupting technologies will change the way we do business and run our practices in the coming years.

IT guru Steve McEvoy will be answering some of those pesky questions we all have about computer hardware, effective and cost-efficient data backup, and security.   In the ever changing world of computers, what you hear at this meeting will certainly be different than what Mr. McEvoy would have talked about even a couple of years ago.

On Friday afternoon we’ll have a lively discussion by Drs. Greg Jorgensen and Neil Kravitz regarding building our practices through social media, websites, and Internet marketing. Their success in these areas has been paramount in growing their thriving practices.

Saturday morning will begin with Dr. Aaron Molen sharing his experience and thoughts on bringing emerging technology into our practices to help create more efficient and more comfortable patient care.

We’re excited to have Drs. Ed Lin and Christian Groth discussing how to integrate some of the latest technology hardware into our orthodontic practices. This includes workflows for using CBCT, Scanners and 3D Printing.

The conference will conclude with Chris Bentson and Charles Loretto with a discussion on how technology can affect the value and profitability in our practices. This should help answer the question about at what stage of practice a doctor might consider investing in advanced technology.

The location for the meeting is at the gorgeous Marriott Harbor Beach Resort and Spa in Ft. Lauderdale, Florida. The dates are February 10-11, 2017. The schedule is organized in a way to allow some time for afternoon recreation.

There will be plenty of time allotted for attendees to ask questions of the speakers to be sure all bases are covered.   To learn more and to register, visit https://www.aaoinfo.org/meetings/2017-winter-conference-technology-balancing-profit-lifestyle-patient-care

3D Digital Indirect Bonding…Why You Should Consider It for Your Practice

By Dr. Ed Lin

DrLin-Headshot-2Indirect bonding was first introduced to orthodontics over 20 years ago and has become an integral part of many orthodontic practices and orthodontic labs worldwide. The four reasons/advantages for its inception are: 1) Indirect bonding has been widely viewed as giving the orthodontist the ability to achieve more accurate bracket placement on a static model and not having to deal with the clinical challenges with direct bonding on a patient, 2) The doctor can perform the final check for bracket placement at his/her own leisure and not under a set clinical schedule, 3) To improve clinical efficiency with decreased doctor chair time at the full bonding appointment, and 4) Finally, for improved patient comfort due to decreased time which the patient is in cheek retractors.

Having utilized indirect bonding in our practices for over 17 years now, these four reasons/advantages are without a doubt why all four doctors in our practices utilize indirect bonding for all of our patients. However, there are some disadvantages that are also present with conventional indirect bonding such as: 1) Distortion of the impressions leading to inaccurate models/trays, 2) Distortion of the pour up of the impressions resulting in inaccurate models/trays, 3) Short clinical crowns are not ideal for conventional indirect bonding and need to be direct bonded especially in the mandibular arch, 4) Brackets can be bumped prior to curing on the model leading to incorrect bracket placement, and 5) Seating of the indirect bonding tray is technique sensitive and can lead to over seating or under seating of the trays resulting incorrect bracket placement.

With the advancements of technologies in dentistry with intraoral scanning, 3D digital virtual bracket placement software, and 3D printing, these technologies have now given us the capabilities in orthodontics to improve upon conventional indirect bonding with 3D digital indirect bonding. Currently, there are 4 companies that I am aware of in the US market that offer 3D digital indirect bonding: OrthoSelect’s Digital Indirect Bonding System (DIBS), Arcad Digital Indirect Bonding System, Great Lakes Orthodontics’ Exceed, and SureSmile’s Elemetrix 3D Printed Indirect Bonding System. All four of these companies have proprietary cloud based software for management of patient case submissions and all of them accept intraoral scans.

For Arcad and Great Lake Orthodontics, upon final approval of the virtual bracket positions in their proprietary software, they will 3D print the models with specific indexes for very precise and accurate bracket placement on the 3D printed models. Once the brackets are placed manually on the 3D printed indexed models, their labs will then create an indirect bonding tray through conventional lab techniques and are then ready to be utilized for indirect bonding for the patient. The advantages with both systems are that they are dealing with digital data with an intraoral scan so there are no issues with a poor impression. Also, with 3D printed models, there are no issues with a poor model with air bubbles or blebs on the model. As a result, the conventional indirect bonding trays are more accurate and precise.

For OrthoSelect’s DIBS and SureSmile’s Elemetrix indirect bonding systems, upon final approval of the virtual bracket positions in their proprietary software, both of these companies will 3D print the indirect bonding trays. The brackets are then manually placed into the 3D printed indirect bonding trays for both systems and are then ready to be placed on the patient. OrthoSelect’s DIBS and SureSmile’s Elemetrix systems have the same 2 advantages as Great Lakes and Arcad’s systems, as they are only dealing with digital data with an intraoral scan, so there are no issues with poor impressions or poor model pour ups. However, since only the indirect bonding trays are 3D printed, both OrthoSelect’s and SureSmile’s systems have 2 advantages over Great Lakes and Arcad – 1) There is a significant time savings on the lab side of things since there are no 3D printed models, only the indirect bonding trays are 3D printed and 2) There is no human error brought into production of the indirect bonding trays since they are 3D printed.

Our practices are now making the transition from conventional indirect bonding to 3D digital indirect bonding with SureSmile’s Elemetrix 3D printed indirect bonding tray system so I will give a brief overview of how we utilize this in our practices. We have a 3 Shape Trios 3 intraoral scanner at each practice location. With the “Insane Mode” of the Trios, we can intraoral scan 2 arches with a digital bite registration in a total of 1 minute. We then upload the intraoral scan through the cloud to SureSmile. SureSmile will then segment, clean up, and create the 3D digital model and we will receive the digital model back on our end in 1-2 business days. We then assign the virtual brackets (.018 American Empower stainless steel or clear) and virtually position them on the digital models. Upon final approval of the virtual bracket placements, we then order our SureSmile 3D printed indirect bonding trays. The indirect bonding trays are then 3D printed and then shipped to us. We currently schedule 15 days between the intraoral scan for indirect bonding and the full bonding appointment to allow time for setup and approval, 3D printing of the trays, and for shipment to us. In the future, I hope that we will have the capabilities to 3D print our own indirect bonding trays in house, which will give us the capabilities to have quicker turnaround time with the indirect bonding trays and we will not have to deal with any shipping issues. Because SureSmile’s 3D printed indirect bonding trays are rigid, there is also an added benefit with their indirect bonding trays as we do not have to worry about over seating or under seating of their trays as you do with conventional indirect bonding trays, which are softer, as a result of the silicone and polyvinyl siloxane materials which are used to make them. The total cost for a full indirect bonding case with SureSmile’s Elemetrix Indirect Bonding System is $105 which is very affordable and attractive to me especially considering the added benefits which I have stated above.

My personal opinion is that any of the 4 digital indirect bonding systems, which I have stated above, are a step above and are an improvement upon any conventional indirect bonding systems currently available. If you are currently utilizing conventional indirect bonding or are considering transitioning to indirect bonding in your practice, I would strongly encourage you to evaluate the digital indirect bonding systems which are currently available today. As with all other aspects of our lives, technology is changing the way we all live and is helping to improve how we do things in everyday life as well as with our practices.

eOrthodontics

By Dr. Anthony M. Puntillo, DDS, MSD

Dr.-Puntillo-PictureIt was not that long ago when we all relied upon our friendly postmen and postwomen for the delivery of our letters. Today the United States Postal service is scaling back mail operations in favor of package delivery, and the majority of our written communication is transmitted electronically. Is the delivery of healthcare, and particularly orthodontic care, headed for a similar fate? A Computerworld article, cited research by Deloitte, which projected 75 million of 600 million appointments in 2014 with general practitioners would involve electronic or eVisits¹. “Electronic visits or telemedicine are comprised of electronic document exchanges, telephone consultations, email or texting, and videoconferencing between physicians and patients. The vast majority of eVisits, according to Deloitte, are likely to focus on capturing patient information through electronic forms, questionnaires and photos.” In the state of Texas, new legislation has opened the door for physicians to be compensated for remotely providing care to children through a video connection to the school nurses’ office². Market forces including an expansion of access to care, increased efficiency, and financial incentives are driving all of these changes. Just as eMail though has not completely eliminated the need for our postal service, eVisits are not likely to eliminate the need for all direct patient to physician interaction. However, there can be no denying that technology is changing the manner in which healthcare is delivered and our specialty will not be immune.

It may be hard to conceive how we will remotely align teeth. However, the 1999 introduction of digitally created tooth moving clear aligners (Align Technology, Inc.) opened the door to the Orthodontic digital age and fortunately or unfortunately that door cannot be closed. Recently, while attending an orthodontic meeting overseas, I noticed a new company that seemed to be garnering a great deal of attention, Dental Monitoring (dental-monitoring.com). This company claims to be the “first monitoring solution in orthodontic care.” Patients capture their tooth movements with their smartphones and orthodontists can remotely monitor and direct treatment via an app. Whether or not this company is the first is irrelevant. It will certainly not be the last. The same efficiencies and cost advantages that eVisits offer physicians in the general practice of medicine also apply to orthodontic practices. To be clear, I am not advocating that remote care is better or even desirable. The purpose of this blog is to raise our members’ awareness and open discussions regarding technological changes in our profession. In the last 20 years, we have incorporated electronic patient records, CBCTs, intraoral scanners, and even 3D printing into our practices. As we all adapt to the expectations of the Millennial Generation what will our practices look like 20 years from now?

1. Almost one in six doctor visits will be virtual this year. Computerworld: Mearian, L. August 8, 2014.
2. Law could bring remote doctor visits to schools. The Texas Tribune: Rocha, A et. al., August 23, 2015.

Smartphone-based orthodontic monitoring: the big brother in our patient’s mouth

by Domenico Dalessandri, DDS, MS, PhD

Screen Shot 2016-03-11 at 11.06.09 AMNowadays almost all of us have a smartphone and we use it hundreds of times during the day checking incoming e-mails, surfing through the web and sharing our thoughts and pictures online within our social communities. This is the “permanently online” era and our patients ask for immediate information supply and assistance request satisfaction.

Since sometime orthodontists have used text messaging apps like WeChat or WhatsApp to communicate with their patients, to remind them the next visit, to solve an emergency or replying to a late doubt, or even checking the oral hygiene status or the cooperation level with removable appliances. There is a growing evidence in the literature showing the efficacy of these “App based” monitoring protocols in ameliorating oral hygiene and reducing treatment duration, bracket bond failure, and failed or late attendance [1-2].

Commercial interest regarding patient monitoring has also increased progressively and nowadays there are few apps especially designed for this purpose. In all these systems the orthodontist has his own dashboard on reserved area in the company website that can be used to invite patients to download the app in their smartphones and to visualize their smile pictures.

SmileTrackerTM (TP Orthodontics) also allows visualizing a time-lapse video, based on daily pictures taken by the patient during the monitoring, of the treatment progress. Furthermore this app has a rewards-based system in order to keep patients engaged throughout the monitoring and it also allows them to share their progresses through their own social profiles.

Dental Monitoring® allows patients to take smile pictures every 2 weeks in case of fixed orthodontic treatment or even every week for invisible aligners treatments. Doctors can also ask for a supplementary exam whenever they want, sending through their personal homepage a specific invitation that is forwarded by e-mail to the patient. This system requires doctors to send patient dental impressions before monitoring begins, because it utilizes a specific algorithm that allows calculating teeth movements based on pictures 3D matching and superimposition on the initial virtual models. For this reason patients are required to take 13 pictures for each exam from different angulations focusing on both single arches and on their position in occlusion. Three more pictures are required for patients treated with invisible aligners, in order to check each single aligner fit. This system, apart from calculating through the algorithm tooth by tooth displacement as mesial/distal, intrusion/extrusion, retraction/advancement, rotation, inclination and angulation variations, provides pictures observation by an orthodontist that looks at oral hygiene level, aligners fitting, possible presence of teeth abrasion, decays or brackets failure, sending a warning to the treating orthodontist in case of any unexpected event.

Could these systems become important tools allowing us to improve our treatments efficiency and quality? Is it credible that “virtual” appointments could in some occasions substitute the traditional “physical” appointments? Will our patients be available to be continuously controlled by this orthodontic “big brother”?

It is hard to foresee the future. The possibility for patients, especially if they live far from the orthodontic office, to save time and money by reducing the number of visits having the same, or even a better, accuracy in treatment progress control, can be universally recognized as positive factors fostering the diffusion of these systems.

Are we ready for this further step forward along the digitalization path of our beloved orthodontic specialty?

1: Zotti F, Dalessandri D, Salgarello S, Piancino M, Bonetti S, Visconti L, Paganelli C. Usefulness of an app in improving oral hygiene compliance in adolescent orthodontic patients. Angle Orthod. 2016;86:101-7.

2: Li X, Xu ZR, Tang N, Ye C, Zhu XL, Zhou T, Zhao ZH. Effect of intervention using a messaging app on compliance and duration of treatment in orthodontic patients. Clin Oral Investig. 2015 Dec 2. [Epub ahead of print]

Domenico Dalessandri qualified in Dentistry from the University of Brescia, Italy, where he received specialty training in Orthodontics. He obtained his PhD from the University of Torino discussing a thesis entitled “Cone Beam Computed Tomography: accuracy and reliability”. He received a research fellowship in “CBCT applications in Orthodontics” by the University of Trieste. Currently he is Adjunct Assistant Professor at the University of Brescia.

He has additional clinical research interests in: indirect bonding; self-ligating braces; use of mini implants and miniscrews; lingual orthodontics; Invisalign; cleft lip and palate; impacted teeth; 3D technology and virtual treatment planning; CAD-CAM; corticotomy and piezocision.

3D Printing and Orthodontics

By Dr. Christian Groth

As we move towards the 2015 AAO Annual Session in San Francisco many of us will be making check lists for items to investigate at the exhibition hall and lectures. Anybody who has attended recent meetings has seen that intraoral scanners are a hot topic. Every year new products are being released, or updates to current systems are offered. Intraoral scanning has opened the door for additional technologies within (and outside of) the orthodontic office. Dr. John White wrote a very informative blog post in February talking about the use of intraoral scanning for same day consultations (click here to read it). As more people are offering clear aligner therapy (including general dentists and the mail order aligner system that we all know about) it is time that we differentiate ourselves as orthodontic specialists. One way in which we can do this is to incorporate 3D printing into our daily practices.

3D printing, also known as additive manufacturing, is a process by which a physical object is created from a digital file (check out a video of 3D printed models here). There are several different types of 3D printers available that range in price from a few hundred dollars to almost one hundred thousand dollars. They all have one thing in common: they build models layer-by-layer with a build platform that moves vertically. The smaller the layer thickness the better looking the model will be. The four most popular types of printers are: Fused Deposition Modeling (FDM), Stereolithography (SLA), Digital Light Projector (DLP), and Polyjet Photopolymer (PP). Without getting too technical here is how each basically works. FDM involved heating up a thin strand of plastic resin that comes off of a spool and is deposited in layers as thin as 100 microns. SLA and DLP technologies are similar in that they utilize a vat of liquid, photosensitive resin. When the light hits the resin it is cured and platform moves to enable the next layer to be cured. The different between SLA and DLP is that SLA uses a single laser point to draw an image whereas DLP uses a projected image to cure a whole layer simultaneously, which allows the printing process to move faster (think of this as the difference between drawing a picture and stamping a picture). PP printers are probably the most popular in dentistry and use inkjet technology (yes, just like your desktop printer). Liquid resin is jetted out of nozzles in an extremely accurate fashion and cured by a UV. Layer thickness of SLA, DLP, and PP printers can be as low as 16 microns (for your reference the average piece of paper is 100 microns thick).

While the technologies differ between printers what truly sets them apart is the quality of the parts. Cheap printers are made from cheap parts that can degrade over time and result in inaccurate models. It is truly a case of you get what you pay for. So if you are in the market for a 3D printer to be used in your practice, buy the best one that you can afford.

3D printed models can be used for anything in the orthodontic office.   The most practical use is for retention and relapse treatment. A major downside to stone models is that they are often destroyed during the retainer fabrication process. 3D printed models do not get ruined and can be used as many times as necessary for retainer fabrication. Imagine being able to print a model, make a clear retainer, and mail it off to a patient who is away at college. What a service you have just provided to your patient and they never stepped foot in your office! Pairing 3D printing with one of several software programs available allows us to create sequential setups/models for minor tooth movement. By controlling the process we control the overhead and thus have the ability to pass these savings on to the patient. Another great service that we can offer our patients if they have a lapse in retainer wear.

Whatever your practice is like there is a place for 3D printed models in it. While you will pay a little bit more for the physical model, the longevity, versatility, patient excitement, and ability to virtually eliminate alginate impressions from your practice will pay off in the end!

The Digital Generations

By Anthony M. Puntillo DDS, MSD

Dr.-Puntillo-PictureThe majority of the U.S. Workforce today is comprised of three generations:  Boomers (1946-64), Xers (1965-80) and Millennials (1981-99), each generation with its own unique set of characteristics.  The American Association of Orthodontists (AAO) now reports that more than 51% of its membership is composed of Gen Xers and Millennials.  By virtue of their birth timing Xers and Millennials, including myself (1966), were the first generations to grow up with computers in their homes.  Although Gen Xers differ from Millennials in many ways, technology is now ingrained into nearly every part of both generations’ lives.  For those Xers and Millenials that also happen to be orthodontists, this attachment to technology includes not only their personal lives, but also their orthodontic practices.

Over the last few years, my blog posts have centered on the discussion of a “Digital Orthodontic Practice.”  A digital practice must include not only the management and record keeping aspects (paperless) of our offices, but also clinical diagnosis and tooth alignment functions.  In this post, I want to highlight the current opportunities for moving digital in the clinical portion of your practice.

Diagnosis:

The clinical care for most orthodontic patients begins with a diagnosis and a treatment plan.  Given that Kodak is now only a shell of the company that it once was, I think it is safe to say most orthodontic practices are now taking digital photographs, instead of film, as part of their diagnostic records.  The recent 2014 JCO study of Orthodontic Diagnosis and Treatment Procedures1 found that more than 91% of the respondents used digital radiography, 69% used CBCT either routinely or occasionally, 41% used digital models and 28% used intraoral digital scanners.  Additionally,  the American Board of Orthodontics (ABO) recently announced that all initial models for their exam must be submitted in a digital format.  While the JCO survey included a relatively low number of respondents (n=135), I believe the findings are indicative of the Electronic Health Record (EHR) movement in all of the health care profession.  This movement, aided by government mandates and subsidies, has now breached the threshold level.  The train has left the station.  If you and your practice intend to stay relevant over the next decade, you absolutely need to be utilizing digital diagnostic records.

Tooth Alignment:

As our profession transitions to a digital diagnostic record norm, some are looking to move beyond diagnosis to digitally construct tooth aligning appliances.  In 1999, Align Technology opened the door to digital orthodontic tooth alignment with the introduction of the Invisalign system.  The system at that time relied upon traditional dental impressions, but today intraoral scanners and 3D printing have allowed for the elimination of the impression procedure.  Whether it be Align, or any other current Clear Aligner option, a digital model (.STL) of a patient’s dentition can be captured with a scanner, the teeth can be aligned using computer software, and treatment appliances (clear aligners) can be fabricated by machines based off of the digital “plan”.  Furthermore, this process can now also be utilized for patients using traditional bonded brackets.  Custom brackets along with custom bracket placement jigs and custom wires digitally planned and robotically bent are possible.  In large part because of costs and the learning curve, the digitization of clinical orthodontic procedures has not yet been completely accepted.   However, as the techniques become more refined, we should expect the cost to include them into our practices to decrease and implementation by the tech savvy Xers and Millennials to accelerate.  If you are an Xer or a Millennial, and have not already incorporated digital tooth alignment into your practice, you should be planning to do so in the near future.  If you are a Boomer, and potentially less comfortable with technology, you need to consider if you can afford to ignore this change.

Creating an esthetically pleasing and stable smile, can be a bit like designing and constructing a building.  In a recent conversation with a Boomer architect friend of mine he described the digital changes his profession has undergone.  My friend reported that my office, built in the year 2000, was one of the last buildings he drew by hand.  All of his projects now are digitally designed using 3D CAD technology, allowing him to plan and visualize the end construction result more effectively.  The transition in the architectural profession took time and learning.  Change is never easy.  However, as my friend now approaches the end of his career, he finds the “old” way inefficient and less accurate.   Whatever generation you were been born into, I encourage you to embrace the digital change our profession is in the midst of.  I am certain a digital orthodontics will ultimately benefit you and your patients.

1Keim Et.Al. 2014 JCO Study of Orthodontic Diagnosis and Treatment Procedures, Part 1: Results and Trends Journal of Clinical Orthodontics 2014; 48:10 pages 607-630.

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.

What is “Big Data” and How Is It Related to the Practice of Orthodontics?

Dr.-Puntillo-PictureBy Anthony M. Puntillo DDS, MSD

Have you heard of the term “Big Data”?  My guess is that for many orthodontists the term is likely a bit like the term “The Cloud.”  They may have a general idea of the concept, but are not entirely sure how it is or will be important to them.  In fact, there is a strong relationship between the two terms that I will discuss later in this article.  First, however let’s look at “Big Data” by itself.  According to Wikipedia “Big data is a blanket term for any collection of data sets so large and complex that it becomes difficult to process using on-hand data management tools or traditional data processing applications.”

In 2009 the United States Congress passed the American Recovery and Reinvestment  Act (ARRA) which included the Health Information and Technology for Economic and Clinical Health Act (HITECH).  [For a detailed summary of this legislation please see Kirt Simmons blog posting from July 9, 2012 “The Electronic Patient Record: How it Affects the Private Practitioner”]. One of the requirements of HITECH is that full implementation of electronic health records (EHRs) for all patients is required by 2016.  The requirements of this act specifically pertain to healthcare providers who participate in the Medicare and Medicaid programs.  That means that currently few dentists are covered by this mandate.  However, this does not mean that we are not being affected.  Since 2009 doctors and hospitals across the country have spent billions of dollars, with the help of government subsidies, converting paper based systems to electronic digitally based health records.  These new digital systems are now collecting vast amounts of valuable data related to patient care.  Much of this information was collected before the legislation, but in a paper non-standardized format that was not easily aggregated and retrievable for meaningful analysis.  The value of all of this collected digital data is only beginning to be fully understood.  Big Data from all healthcare providers is being aggregated and programs to analyze the data are being used to improve the quality, safety, and efficiency patient care.  Hospitals are examining treatment protocols and doctors are making better informed treatment decisions based on the previous care of thousands of similar patients.

As I stated earlier, the EHR requirement of HITECH does not specifically pertain to most orthodontists so why is this important to us?  Many orthodontists have or are now also in the process of converting their practices to paperless systems (without the assistance of the government money).  Several of the orthodontic specific software vendors offer cloud based systems and here is where “Big Data” and “The Cloud” come together.  The aggregation of data from hundreds or thousands of individual private orthodontic practices into cloud servers is beginning to open the door for data analysis (mining).  Just think about how valuable that information can be to our patients and practices.  Most of the research studies published in our journals today involve treatment samples of less than one hundred.  The biannual Journal of Clinical Orthodontics Practice Study generally relies on the input for a few hundred survey responders (out of a possible pool of more than 8,000). Wouldn’t it be helpful for us to know the most efficient type of Class II corrector based on the actual metrics collected from the previous care of thousands of patients treated in practices all across the country or the globe?  Wouldn’t the knowledge that your treatment times/appointments vary significantly from the national or regional averages be useful? There is little question that access to “Big Data” analytics will offer our profession the opportunity to improve treatment quality, safety and efficiency for our patients just as it is beginning to do for the other fields of healthcare.