April 12, 2021
by Susan McMahon, DMD, AAACD; Alexis Kuzemchak, Dental Student Class of 2025
Increasingly, more dental professionals are embracing digital dentistry and the technologies that accompany it. Pivoting to digital dentistry streamlines many processes while increasing convenience, comfort, and creating better clinical outcomes for patients and practitioners alike. With the inevitable march of dental technologies, restorations and dental procedures are being completed rapidly and efficiently, without middlemen nor jeopardizing quality. The integration of the digital workflow in dentistry allows for better, faster diagnoses, efficient and reliable record keeping, and better treatment planning and acceptance.
According to analysis by Reports and Data, a market research and consulting company, the compound annual growth rate for intraoral scanners globally is predicted to be 10.6% by 2026.1 Meaning, more dentists are turning to digital impressions versus taking manual impressions. With the standard becoming every patient gets digitally scanned upon arrival into the practice, their impressions can be summoned in the future, if the need arises. In the event that a patient requires treatments, these digital impressions and images can be outsourced to a laboratory or company for fabrication of dental appliances such as clear aligners, occlusal guards, and periodontal trays. Outsourcing comes at a fee for patients and also increases the timeline of treatment. It is estimated that dentists can incur a $100-200 fee when an occlusal guard is fabricated at a laboratory.2
With the help of a three-dimensional (3D) printer or milling machine, dental appliances like occlusal guards, surgical stents, aligners, provisionals, and permanent crowns and bridges can be made in office. Thus, cutting down number of appointments, shaving down treatment plan from weeks to days, and most importantly, making dental treatments more convenient for patients. As dentistry sees more and more patients of younger generations, convenience and time effective treatments are imperative.
Three-dimensional printing technology was created almost four decades ago, but it was not until recently that the technology has caught the attention of the public and the dental community. 3D printing is an additive manufacturing method in which a three-dimensional object is created via laying down successive layers of material.3 Similar to how a regular inkjet printer works, 3D printers essentially give life to computer-generated/ digital files. With seemingly endless and ambitious possibilities, this technology may seem daunting to implement, but ultimately creates better outcomes in minimal time for patients.
Approximately 15% of adults suffer from sleep bruxism, often times treated with an occlusal guard.4 Before the application of 3D printing into dentistry, something as simple as an occlusal guard was labor intensive, time consuming, and unpleasant to make in-office. First, an impression is to be taken on the patient, then a stone cast of the arch is made from that impression. The thermoplastic sheet is then heated and vacuumed over the cast. After cooling, the guard is cut off of the stone cast. Next, the guard can be perfected through trimming and polishing. All of these steps require manual labor and supervision, taking approximately three hours.
Conversely, making an occlusal guard with a 3D printer requires fewer, simpler steps. Firstly, the digital impression must be linked to a designing software. Once the guard is designed, it can be uploaded to the 3D printer. Designing and uploading can occur remotely at the convenience of the dentist. The 3D printer then creates the occlusal guard in approximately 2 hours, without any manual assistance. Once the printer has finished, the guard can then be washed, cured and lightly polished. Compared to traditional fabrication, a 3D printed guard requires minimal manual time and effort. The fit is excellent and the guard delivered to the patient very quickly. It is also important to note that the design file can be saved and reprinted in the event that the patient loses or damages their guard. Additionally, many dental 3D printers have the capabilities to make numerous guards at once, maximizing efficiency.
When an occlusal guard is made in office, aided by a 3D printer, the dentist is saved from labor costs and laboratory fees. Custom, well-fitting occlusal guards typically cost anywhere from $400-$800 without consideration for outsourcing fees.5 The average 3D printer costs around $6,000 plus the cost of materials.6 Return on investment can happen quite rapidly, for simplicity’s sake, after approximately 10 occlusal guards are created, the printer cost can be justified.
In the following case, a 3D printer was used to expedite treatment by fabricating a surgical stent to guide restorative/implant treatment without referring to specialists or outsourcing to laboratories and a provisional was printed.
The scope of 3D printing in dentistry is quite expansive. In addition to making occlusal guards, a 3D printer can create surgical guides for restoratively driven implant treatment. In this case, a young patient was missing several permanent teeth. He had a Class III occlusion, which complicated his restorative plan. Figs. 1,2. More often than not, clinicians will use their knowledge and experience to estimate the proper location for implantation. Using imaging from a cone-beam computed tomography (CBCT) scan critical anatomical boundaries were identified and then merged with an intra-oral scan. Figs. 3,4. This imaging data can then be uploaded into a software that can design a surgical stent to guide implantation. This clinician consults with a design company to merge this data and determine implant position. Fig. 5. After it is designed, the stl file is sent to the 3D printer to be fabricated in house.
16-year-old patient missing right lateral incisor, canine and first bicuspid. Class three malocclusion complicating restorative plan.
Images from Prexion Excelsior CBCT machine used to access ideal implant placement.
Itero scan merged with CBCT images and digital mockup.
Surgical guide design file alignment with Preform software on FormLabs 3D printer.
Fig. 6. From a workflow perspective, intraoral and CBCT scans are taken at theconsultation appointment. The surgical stent is designed and fabricated immediately and the surgical appointment is scheduled within days instead of weeks or longer. Fig. 7. The implant placement is precise leading toward a predictable and desirable outcome. In this case, the digital mockup model was also printed and used to fabricate a provisional appliance. Fig. 8. With digital help, the general practitioner is able to be at the forefront of patient service and clinical care.
Fabrication of surgical guide on FormLabs Form 3 3D Printer: Printed, Rinsed and Cured. After curing, guide sleeves are placed in the implant guide holes.
Guide in place for implant placement surgery.
The printed model of the digital mockup. The provisional appliance was made in-office on the model.
Final restoration in place. Restoration is simplified by lab using digital mockup as guide for fabrication. Digital planning and implementation make for predictable and consistent results.
As more dentists are turning to the digital workflow, the next logical step for practitioners is to fabricate dental appliances themselves, in office. With the investment in a 3D printer, the general practitioner has the ability to create occlusal guards, surgical stents, and more, in minimal time with maximum confidence. By eliminating the need for outsourcing and referrals, the presence of a 3D printer effectively speeds up treatment and gives more control to the general practitioner. By keeping more cases and treatments in house, practitioners are able to capitalize on their patients’ need for convenience and provide better clinical outcomes in a fraction of the time.
Oral Health welcomes this original article.
About the Author
Susan McMahon, accredited cosmetic dentist, dental educator, advocate for conservative, beautiful, cosmetic dentistry . As a graduate of the University of Pittsburgh, School of Dental Medicine, Dr. McMahon enjoys one of the largest cosmetic dental practices in Western Pennsylvania. She is accredited by the American Academy of Cosmetic Dentistry, and an invited Fellow of the prestigious American Society for Dental Aesthetics. She frequently lectures across the United States on minimally invasive dentistry and conservative cosmetic dentistry for teenagers and young adults.
Alexis Kuzemchak is a recent graduate of the University of Pittsburgh. She majored in Natural Sciences and will be attending dental school in the fall of 2021.
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