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

What to Consider Before Buying an Intraoral Scanner

By Anthony M. Puntillo DDS, MSD

Dr.-Puntillo-Picture

It is a New Year and I would guess that some of you may be considering new technology to add to your practice in 2014.  If you have read my previous posts, you know that an impressionless orthodontic practice is finally a reality.  The two pieces of equipment that are essential to achieve an impressionless practice are an intraoral scanner and a 3D printer.  I have been asked to discuss intraoral scanners at the upcoming AAO annual session in New Orleans.  As a prelude to that presentation, I thought I would highlight a few things to consider when deciding which scanning machine to purchase.  (To be clear I have no skin in this game.  I am not affiliated with or employed by any manufacture or supplier of these machines.  My practice began using a scanner more than 6 years ago.  We have used a few different models since that time and currently have three machines in use.)

The first major consideration before purchasing any machine is ACCURACY.  Before you buy any intraoral scanner you want to make sure that it will accurately capture the data you are looking to collect.  Some machines capture data by collecting still pictures and then use computer software to stitch the individual images together.  Other machines eliminate the computer ”guess work” involved with stitching and use real time streaming video feed technology to capture images.   Furthermore, some machines enable the user to select a high or low-resolution scan.  You should know that the method of data capture and scan resolution can have a direct affect on image accuracy as well the image capture time.

The second and seemingly most obvious consideration is PRICE.  I say seemingly obvious, because most of these machines have underlying costs associated with their purchase.  These “after sticker” expenses include support or warranty costs, supply costs (i.e. disposable wand tips), and costs to store your captured 3D models.  On the positive side, however, several of the companies also offer cost discounts or rebates on the use of associated products (i.e. clear aligners, orthodontic appliances, etc.).  Make sure to consider all of the costs, and discounts, before buying any machine.

The third and final thing to consider is EASE OF USE.  Ease of use actually is a broad term which includes several considerations such as: (1) Scan time- How long will it take for your assistants to capture an image? (2) File type- What type of file is created by the scan and is it a type that is accepted by the labs/companies you may want to send your scans to? (3) File storage and export – Are the scan files stored locally on your computers or in the cloud and how easy is it for your staff to transfer these files to a 3rd party for appliance fabrication? (4) Unit size and wand size- How portable is the unit? Can it be easily moved within an office or transported from office to office?  How heavy and or bulky is the scanning wand?  (5) Scanner software– Is the scanner software intuitive or will there be a significant learning curve for your staff? (6) Patient comfort- Does the machine require that the patients’ teeth be coated with a powder prior to scanning to improve accuracy?

In conclusion, the purchase of an intraoral scanner is a significant investment for most practices.  There are several things that should be considered when determining which machine is the right one for your practice.  I hope this quick review provides you with some insight that will be valuable in the consideration of your purchase.  If you would like to hear a more detailed discussion on this topic, I encourage you to attend my presentation in New Orleans and look forward to seeing you there.

The “Right” Time

By Anthony M. Puntillo DDS, MSD

Another annual meeting has come and gone.  If you attended the recent international gathering of orthodontists in Philadelphia, it would be hard to argue against the expanding influence of technology on our profession.  At this years’ meeting technology, as it has for the last several meetings, certainly played a prominent role on the convention floor.  Philadelphia, however, showcased more than the just the vendors selling their latest “must have” equipment or systems.  This year several of the lecture halls included significant discussions about the incorporation of technology into the clinical practice of orthodontics.  The CTech committee, in fact, had a room for an entire day dedicated to that exact topic.

On the convention floor, I am sure most noticed the proliferation of the intra-oral scanning options.  Only two years ago at the 2011 Chicago meeting, I can recall one company displaying an intraoral scanning machine.  This year there were at least a dozen vendors.  The effect of this increased competition has led to significant reductions in costs, improved technology, and increased acceptance of the machines into clinical practice.  As more of these machines are put to use and practices become more comfortable with them, there is a natural progression toward impression-less practices.

I incorporated intraoral scanning into my practice two years ago and attended this year’s meeting with the intent of investigating the offering of three-dimensional printers. The ability to print plastic models would not only eliminate impressions from my practice, but also plaster.  In Philadelphia, I found two such machines on display.  Both units were selling at the meeting for around $40,000.  As with any major investment, it is often difficult to know exactly when it is the “right” time to get in. Ultimately, the “right” technology decisions differ for each practice.  For now, I have decided to wait on the purchase of a 3D printer and plan for the immediate future to continue to outsource the printing of my .stl files.  You can bet, however, that I will be closely monitoring developments with these machines and when it is the “right” time for my practice I will be getting in.

Digital Retainers- Part II / Impression-Less Orthodontics

By Anthony M. Puntillo D.D.S., M.S.D.My last article received so many comments that I felt it warranted an extension of the discussion.  In the last twenty years of practicing orthodontics, our profession has gone paper-less, film-less, brace-less, wire-less, and coming soon….IMPRESSION –LESS.  Several companies now produce intraoral scanners and by all accounts they are selling them like hot cakes.  I want to reiterate that I have no financial interest in the sale of any of these machines.  However, if you have not bought one yet, my guess is most of you within the next five years will.  We would all love to eliminate our post-lunch gaggers.  But there are more tangible reasons why this trend is gaining momentum.

First and foremost the majority of our patients simply dislike having impressions taken.  Second, intraoral scans produce more accurate models for the fabrication of better fitting appliances. Third, intraoral scans eliminate the expense and wasted time associated with impression retakes and inaccurate model pours.  Fourth, intraoral scans allow for the elimination of alginate, PVS, and plaster expenses.  Finally, the move to digital patient records has been driven largely by the improved efficiency in handling, manipulating and transferring files, photos, and radiographs.  The same benefits also can be said for models.

Digital models have been around for several years.  I believe the recent mainstreaming of intraoral scanners and 3D printers has now pushed us to a “tipping point.”  Most orthodontists today using intraoral scanning, still digitally transfer their .stl files to the lab of their choice for fabrication of models or an appliance.  But what if you could simply hit “print” and create a bubble free model in your own lab?  The model could then be used to create an in-house retainer or indirect setup just as you would with a plaster model.   In fact, this is now possible.  Some may say that the costs of 3D model printers are too expensive.  Depending upon the size of their practice, you may currently be correct.  I say currently because most of us can remember the costs of color printers when they were first released.  Now they are very affordable and ubiquitous.  Why?  Because corporations such as Hewlett Packard discovered that they could sell the machines at a loss and make their profit on the sale of ink.  I submit to you it will not be long before the same dynamic occurs with 3D model printing.  And when this happens, we will all have one in our office and alginate and plaster will go the way of film-based photography.

Radiation Exposure as Low as XX μSv…

by Juan Martin Palomo DDS, MSD
With the advent of Cone Beam Computed Tomography (CBCT), the amount of radiation received by the patient became an issue of heated discussions and controversies.  Perhaps one of the most asked questions would be “How much radiation would the patient receive for a CBCT scan with this or that scanner, assigning radiation exposure to a scanner brand?”
This created a lot of confusion.  The amount of radiation that patient receives during a scan has to do with the same physics’ principles as any other radiograph, which are mA, kVp, amount of time the beam is on, and area irradiated (confined by collimation).  Any CBCT scanner would give several different combinations of the above variables, and would be able to create CBCT volumes using a wide range of radiation exposure.  So the answer can never be a single number.  But this is sometimes misrepresented as a single number, almost as the marketing trick used by retailers when they use phrases such as, “as low as $XX”, or “starting at $XX”.
Usually the item one likes is not at that starting price, is it?  Some scanners do have advantages over others, by providing what’s referred to a “pulse mode”, which means the beam would turn itself on and off while taking all the images necessary, reducing the amount of radiation received.  But many times, the settings used (mA and kVp) will determine both image quality and radiation received, and unfortunately, at this time, there is no consensus on settings to be used for specific protocols.
In medicine, one cannot answer with a single number the question of how much radiation is received when having a CT scan, but there are protocols in place for specific imaging, such as CT of the brain for example.  The protocols determine the recommended mA and kVp to be used, and those can be used independently of the CT scanner brand, and will be different from a CT of a different part of the body.
We do have protocols for periapical radiographs, but not yet for CBCT’s.  Orthodontic CBCT’s would probably use lower settings than CBCT’s used for pathologic examinations or implant placement.  If we have protocols, perhaps all scanner brands would offer the same options as far as settings, and patients would receive the same amount of radiation for the same procedure, independently of the scanner brand used, or the office they decide to go.  Right now this is not the case, and even though radiation exposures can be considered low, they are different in different offices, when used for the same purpose.
The advances in technology, through better software filters and hardware changes such as “pulse” are helping to reduce the amount of radiation received by the patient, but there are still options that the operator must choose, and these can make a big difference.

X-Rays: If You Take Them, Read Them!

By Dr. Greg Jorgensen
Rio Rancho, NM – www.gregjorgensen.com

Radiographs, whether the oldest film-based bitewing or the newest digital 3-D cone beam scan, are important diagnosis and treatment planning tools for orthodontists. They allow us to visualize anatomic structures and relationships that cannot be examined in any other way. The American Association of Orthodontists suggests that its members follow the ALARA principal (As Low As Reasonably Achievable) when it comes to the amount of radiation to which they expose their patients.

The value of radiographs as a diagnostic tool is indisputable. X-rays allow orthodontists to see pathology, monitor development, and diagnose skeletal and dental relationships that are at the root of malocclusion. Not a day goes by in my office where I don’t find something of importance in a radiograph that was not visible to me clinically. I believe that most orthodontists diligently read radiographs taken before treatment and between phases because they are in their “diagnostic mode.”

Dental radiographs are also essential to doctors during the treatment planning phase. The number, condition, and position of unerupted teeth affect the timing and scope of orthodontic treatment. The skeletal relationships revealed by lateral cephalograms help orthodontists select the appropriate treatment plan and biomechanics. While many orthodontists routinely evaluate radiographs taken specifically for treatment planning, others delegate the tracing of “cephs” to staff members who are not trained to recognize pathology. Many doctors study the results of the cephalometric analysis without actually seeing the film from which it was derived.

The data set created during a cone beam scan is useful not only for the evaluation of disease and the localization of important structures, it can also be used in the fabrication of orthodontic appliances before, during, and after orthodontic treatment. Examples of such appliances include digital models, indirect bonding set-ups, custom arch wires, and retainers. Some would argue that exposing patients to additional radiation solely to avoid taking alginate impressions is a clear violation of the ALARA principle. Some technology however uses the CBCT scan not only to fabricate an appliance, but also to visualize the current position of the roots in the alveolar bone and predict the effects that specific movements will have on the health of the teeth and the bone. That is revolutionary! Doctors using this technology would argue that this use of radiographs provides patients with the most accurate and healthy results currently available at a reasonably low radiation level.

Another timepoint just as important as before and during treatment is at the end of treatment. “Final records” are too often considered a mere legal record of what was accomplished during treatment. These records however also provide the orthodontist with information about wisdom teeth, changes in root length and bone support that occurred during treatment, as well as other non-treatment related pathologies that may arise while the braces were in place. Final records should be analyzed as carefully as initial ones.

Whether you take an x-ray to look at developing teeth, evaluate jaw growth, or as part of the diagnosis, treatment planning, and appliance fabrication process, you have a responsibility as a doctor to review all images and inform patients of any abnormalities present. A formal chart entry should always be made to document that you did review the radiographs taken whether or not you found anything out of the ordinary. While most of us are very comfortable evaluating routine panoramic and cephalometric films, today’s CBCT scans oft times include expanded field of views that include areas of the craniofacial complex with which we are not as familiar. The AAO’s Council on Insurance recommends that we seek the opinion of a qualified dental radiologist anytime we are not comfortable interpreting a diagnostic film.

Dental radiographs are important diagnostic tools. They not only help us diagnose and treatment plan orthodontic problems, they can also save teeth, bone, and even lives. They are useful however only if they are read. If you take an x-ray, make sure you read it!

Digital Retainers? Now at a Lab Near You

By Anthony M. Puntillo D.D.S., M.S.D.

It’s the middle of September and a patient you just debanded last month is enjoying her first year of college… and her new smile. After 24 months in orthodontic appliances, however, you are now both relying on her retainers to make sure her smile remains perfect. Unfortunately, her roommate has just accidentally stepped on that very same retainer and with campus 6 hours away from home she has no way of returning until Thanksgiving. Her parents assume that the impressions you took last month can be used to make a new retainer. Not wanting their orthodontic investment to be for naught, mom is calling your office requesting a new retainer with plans to ship it to her daughter. You are now in the unenviable position of delivering the bad news: the original model was damaged during the fabrication of the retainer and her daughter will need to return home for a new impression or attempt to schedule an appointment with an unfamiliar orthodontist closer to campus.

If you have been practicing orthodontics for any length of time, I have no doubt that the circumstances of this story sound familiar. The good news is that technology can now offer both you and your patients a better option. The increased movement toward digital models and intraoral scanners has not only improved our ability to store and manage our patients’ records, but it has also led several well-known commercial laboratories to add capabilities for processing these 3D digital files (STL- stereolithographic). Labs that have made the investment in the technology and equipment can now accept files over the internet and then use the digital data to create any number of well-fitting orthodontic appliances. Using STL files in this manner will save you the material, staff costs, and schedule constraints associated with taking a replacement impression. Furthermore, it saves the patient and parent the inconvenience of an additional trip to the office. So the next time a frantic parent calls requesting a replacement retainer ASAP, if you’re using digital models you can let them know you’ve got it handled. Simply forward the final records STL file to your favorite commercial lab and the replacement appliance will be on its way!

The Rise of Digital Orthodontics

By Anthony M. Puntillo D.D.S., M.S.D.

 

The Industrial Revolution of the mid seventeen hundreds to the mid eighteen hundreds ushered in numerous social, economic, and cultural improvements to the everyday lives of people of the day. Along with these improvements also came disruptive forces. Businesses had to adapt to the new way of doing things to stay competitive. The modern Technology Revolution is having similar beneficial and unsettling influences on our lives. Technology is being employed to improve the efficiency and effectiveness of virtually every aspect of our society. In the field of healthcare, we have seen the mapping of the human genome, improved medical imaging techniques, and robotic surgeries. Modern orthodontics has also incorporated digital technology to improve the accuracy of orthodontic diagnosis and treatment planning. As the quality of and methods for obtaining digital data have improved, so has the orthodontic specialist’s ability to use this data to improve the level of care he can provide his patients.
Two examples of recent technology that have changed the way orthodontists provide care are intraoral scanning devices and three-dimensional Cone Beam Computed Tomography or CBCT. There are several intraoral scanners currently available. These machines typically use visible light and an intraoral “wanding” procedure to create very accurate three-dimensional digital dental models. It is possible to use these 3D models not only to diagnose, but also to fabricate active clear plastic aligners and other treatment appliances. Invisalign, Insignia Clearguide, and ClearCorrect are examples of aligners systems created using digital models. SimpliClear is a digitally designed clear biomer wire fabricated with adjustments bends already in place. Insignia uses digital data obtained from an intraoral scan to create patient specific brackets and custom bracket placement jigs.

Patients can benefit from intraoral scanner technology by avoiding the impression procedure and by the improved accuracy of the appliances provided by their doctor. Orthodontists benefit by the elimination of costly impression materials and the improved efficiency of digital models. One shortcoming of intraoral scanners however is that the models they create are limited to supragingival tooth structures only.

Orthodontists are interested not only in the alignment of the crowns of the teeth, but also how the entire dentition (including the roots) are positioned relative to the supporting bone and facial structures. Using cone beam (CBCT) technology, orthodontists now have the tool they need to evaluate the alignment of the teeth in three dimensions. There are several CBCT machines and software programs currently available that enable orthodontists to view the teeth and supporting structures in all planes of space. This alone can improve orthodontists’ ability to diagnose and treatment plan to the benefit of their patients. There is now one system available (SureSmile) that incorporates the bone data from a CBCT scan into its digital 3D models. This allows orthodontists to make better treatment planning decisions regarding the roots of the teeth by revealing the limits of the supporting structures. The software can then follow the orthodontist’s “prescription” to robotically generate custom archwires containing every necessary tip, torque, and angulation needed to finish the treatment.
The rise of digital orthodontics has also spawned a resurgence in lingual orthodontics. The ability to digitally create custom brackets and wires (i.e. Harmony, Incognito, Suresmile QT, etc.) has made it easier for orthodontists to manage the intricacies of lingual treatment. Consequently, an increasing number of orthodontists are now offering lingual treatment options to their patients.
Technology has drastically increased the pace of change in our society. As orthodontists adapt and incorporate technology into their practices, their ability to provide better treatment for patients will also increase at an exponential rate. It is our challenge and obligation as orthodontic specialists to identify and evaluate new technologies, and when appropriate incorporate them into our patient care in a cost-effective manner.

Cone-Beam CT Dosimetry: Making Sense of it All

By Aaron Molen

There continues to be controversy inside and outside our profession on how much radiation exposure is justified in the pursuit of diagnostic information.  In the end there is no golden answer that will address every situation and ultimately I cannot tell you what’s appropriate in your office.  However, I can arm you with information that will enable you to make an educated decision regarding what’s best for your patients.

Effective Doses
There are many publications and websites that try to accurately compare effective radiation doses, but it’s not that simple.  For example, there are two ways to quantify effective radiation, the ICRP 1990 recommendations and the ICRP 2007 recommendations.  The 2007 recommendations give more weight to the salivary glands, skin, and other organs than before which results in effective doses being higher when measured using the 2007 recommendations. Most publications, though, use the 1990 recommendations which were written before the release of the 2007 recommendations.  Comparing 1990 to 2007 based doses is like comparing apples to oranges so you should double-check which method is being used.

Secondly, the absorbed dose of a CBCT system varies widely within the system itself based on the FOV, scan time, kVp, and mA settings used in the scan.  Recognizing this is important because sometimes CBCT manufacturers will report their scans with the lowest radiation dose and the scans of their competition with the largest radiation doses.  It’s paramount when comparing effective doses between different systems to standardize the previously mentioned settings as much as possible to create a fair comparison.

Finally, the radiation dose measurement depends on the phantom used by the company, or researcher, to measure the dose.  There are a number of different phantoms available that can have a varied number of sensors placed in them to measure the dose.

It’s for the above reasons that I will not be discussing specific radiation doses in this blog post since I believe with all these variables it can be like comparing apples to oranges.  Instead when the time comes to make your decision as to which machine to buy or use I would encourage you to use the information we’ve thus far discussed to filter through the always changing information available in peer-reviewed journals or in the published material from the manufacturers themselves.

Using Cone-Beam in Your Office
Each orthodontic practice has its own unique set of patients and each doctor uses their own personalized treatment approaches to delivering the best care possible to their patients.  Since each practice is unique, each practice will also use cone-beam differently.

In keeping with the ALARA principle I believe orthodontists should answer the following questions before taking a CBCT scan: (1) How does the dosage of this specific scan compare to my normal 2D radiographic series; (2) Does the additional 3D information have the potential to change my treatment plan; and (3) Does the additional 3D information have the potential to create a better treatment outcome for my patient?  How you answer these questions will determine for each patient whether taking a CBCT scan is warranted in their unique case.  Since each office has their own unique set of patients and uses their own unique treatment modalities, some orthodontic offices will take less scans than others.  In the end the goals of protecting our patients, while delivering the best treatment outcomes possible must be balanced by each orthodontist.  Hopefully with the information I’ve provided orthodontists can find that balance with more confidence.