Fundamentals of Treatment Planning. Lino Calvani
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Computerized chairside and laboratory technologies
It is possible to craft both analog and digital restorations in an excellent way. Indeed, human endeavor in terms of ‘collective intelligence’ and artistic ability has always been phenomenal. Yet, with the advent and rise of digital technology, this endeavor is rapidly and constantly progressing and improving as a new and broad range of digital dental technologies are increasingly being introduced. This is having an impact on the shape and performance of all areas of the dental medical profession, be it in dental hospitals, universities, dental offices, surgical theaters, operatories, and laboratories. Each day, the diagnostic dental medical devices and other objects and devices in our clinics and laboratories are becoming exponentially ‘smarter.’ This has resulted in a rapid change in our prosthodontic treatment possibilities and ‘tools’, a brief description of which is presented below.
Digital software treatment revolution
The progress in software development and marketing has implications for all areas of dentistry, including prosthodontics. For instance, clinicians today have the ability to access digital algorithms to rationalize workflows, to reduce the time of clinical intervention, to reduce operative costs, and to increase the predictability of results and therefore patient satisfaction.
● 3D high-definition (HD) magnifying visors allow us to see the smallest details that have until very recently been impossible to see even with magnifying lenses (which are today almost obsolete).
● 3D screens allow us to show patients detailed views of the operative field in order to better explain to them the reality of their oral situation.
● Improved multiple detectors in use with cone beam computed tomography (CBCT) are able to take a 3D HD radiographic scanned reproduction of a patient’s head and mouth by simply and quickly sliding only once from one side of the face to the other, dramatically reducing the amount of radiation exposure for the patient.
● Temporomandibular joint (TMJ) occlusal evaluators can tell us precisely what happens in a patient’s TMJs at rest and while speaking, chewing, and biting. Among other things, they provide information regarding invisible occlusal vectors in terms of timing, intensity, and direction of the applied chewing forces. Using precise algorithms, they allow us to study the occlusion during both the treatment planning and in the following clinical phases, according to important static and dynamic parameters now visible and measurable. This was impossible to achieve with the previous analog methods.
● 3D intraoral scanners progressively eliminate the use of trays and impression materials, recording at high magnification all possible details of our preparations and of the surrounding teeth and saving them in both dental imaging and communication in medicine (DICOM) and/or photographic files. This allows for fantastic magnified on-screen reproductions that are ready to be studied for the design and crafting of 3D-printed or milled prostheses.
Regarding treatment planning, increasingly perfected artificial narrow intelligence (ANI) algorithms allow for the planning of clinical cases by means of digital workflows and simplified procedures, creating with excellent approximation visual graphs that clearly show the clinician where and how to craft any fixed prostheses. This can be done without producing physical casts that are both costly and require storage space.
By means of digital communication media, clinicians and dental technicians are now able to easily communicate online and share information about the treatment on an ongoing basis. By DICOM and other dental medical data files over the internet, the milling or 3D printing of dental prosthesis can be activated remotely from anywhere in the world.
Computer-guided implant-positioning software and hardware
This allows the clinician to place virtual implants and teeth according to the underlying bone position as well as the future teeth. The use of this hardware and software has vastly improved the understanding and treatment planning of partially or completely edentulous cases.
These reproduce the best analog articulators. They are diagnostic tools able to study any prosthodontic case.
Clinicians at the chairside and technicians in their laboratories are now able to create digital dental guidelines and landmarks and show the patient a previewed 3D version of the virtual representation of the dentition and face, possible smile, and prosthetic outcome of the treatment plan. This is useful for discussions with the patient regarding possible present and future dental treatments and their economic implications. The information and patient preferences can be stored and saved for future reference.
Today’s technology also allows us to rapidly prototype, design, and tweak predictable provisional customized mock temporary restorations, digital RPD substructures, and digital CD prostheses. These files can then be saved on a dedicated database and be used to design, craft, and manufacture restorations using a broad range of digital milling or 3D printing machines in our offices.
Digitally created, usefully milled, and wearable pretreatment mock temporary restorations can currently be temporarily cemented and used without any tooth preparation. They enable the patient to try out the mock-up in vivo and also in their own environment once they leave our offices. This try-in gives patients a good approximation of the esthetics and functional aspect of the planned and proposed prosthetic outcome. If the patient is satisfied with the esthetics and function of the temporary restorations after the try-in, the digital image can be scanned in the mouth, mounted on virtual articulators, and used to produce a digital version of the final prosthesis. This is useful to either create minimally invasive prosthetic ceramic pieces to be bonded over the remaining dentition, or useful guides to prepare what remains and adapt it to the new identical final prostheses. The newest digital light processing machines and bioprinting machines will predictably one day be precise and powerful enough to recreate even sound brand-new teeth for implantation.
Computerized laboratory technologies
New laboratory ceramic materials increasingly resemble natural teeth in terms of their optical and physical properties. 3D milling and printing machines are increasingly changing the way the laboratory works and how it relates to the clinical office. Indeed, despite what the monumental Dr House wrote in 1937,113 these AI machines are becoming more and more able to create and craft artistically what we humans are able to do with our art and dexterity. We have been the masters up until now, but for how much longer?
This evident digitalized simplification of procedures means more ‘predictability,’ which consequently also means less undesirable posttreatment complications, including a decreased risk of possible working cross-contamination between the clinic, the laboratory, and the social environment.
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