Digital orthodontics

Digital Orthodontics: Technological invention, clear aligners therapy, robotics, tele-orthodontics, laser orthodontics, artificial intelligence, Digital impression , intra oral scanners, CAD-CAM

1. DIGITAL ORTHODONTICS DR. OLARINMOYE OLUWATOBI JOHN

2. Outlines INTRODUCTION REGISTRATION AND HISTORY TAKING CLINICAL PHOTOGRAPHS STUDY MODELS DIGITAL IMAGING TREATMENT PLAN AND OPTIONS TELE-ORTHODONTICS LASER ORTHODONTICS ROLE OF ARTIFICIAL INTELLIGENCE AND ROBOTICS IN ORTHODONTICS SUMMARY CONCLUSION REFERENCES

3. Orthodontics is a specialty of dentistry that deals with the diagnosis, prevention and correction of malpositioned teeth and jaws. Digital Orthodontics involve the use of advancements in technology in orthodontic treatment. Orthodontic departments have been using “computer technology” for decades now. INTRODUCTION

4. Gradually, and almost consecutively, digitalization has been adopted in the three major steps of the conventional patient workflow, resulting in three distinct processes : 1. Digital patient: the acquisition of patient data is digitized (clinical information, x-ray based information or casts) and can now be stored or archived in the patient’s digital records 2. Virtual patient: mental planning of the patient’s rehabilitation can now be assisted with a digital treatment planning and on-screen simulation (computer-aided design or CAD ).

5. 3. Real patient: treatment procedures may be assisted with computer-aided manufactured (CAM) devices using milling or 3D printing technology

6. Picture source: Google

7. Digital orthodontics was implemented in the treatment process, through which we could create a virtual patient from 3-D data , simulate a treatment plan, and design and manufacture tailored appliances . These capabilities are still employed by the minority of orthodontists. However, digital orthodontics embraces the full digital patient process, which is far more than a single digital treatment process resulting in a bracket system or a specific appliance. It incorporates an ecosystem that is far more complex and includes 3-D image acquisition; registration of different image sets and formats; segmentation of the anatomic structure of interest; simulation of bracket placement, occlusion, function and smile; online monitoring of the treatment course and hygiene; and design and manufacture of appliances. In essence, digital orthodontics is a matter of communication, using and transferring information.

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9. REGISTRATION AND HISTORY TAKING There are different softwares now used to register patients instead of the old method of opening a folder and giving a card number Now, registration number and log in details are ascribed to your name and can be accessed by the dentist anywhere with a PC and data network This saves from the stress of looking for case notes and also reduce patient waiting time.

10. SOFTWARES OR APPLICATIONS mAPP eRegister Google form and cloud storage, etc.

11. DIGITAL TECHNOLOGY AS A CLINICAL AID TO DENTAL EXAMINATION AND DIAGNOSIS The new patient visit includes examination, diagnosis and establishment of a treatment plan. There are equipments that help out in the processes of charting the teeth, evaluating occlusion , TMJ and the Jaw These Biometric aids include T-scan, BioJVA , JT-3D, These hardwares help out in the digital examination of dental patients

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13. Clinical photographs and study model Dental Photographs are vital in communicating with patients the outward view of their smile. Imperfections that are not readily visible to the patient will be apparent in still photographs. Thus , dental photography allows the patient to visualize his or her smile and oral condition with the same acute perspective as the dentist, which helps the patient understand the rationale for recommended treatment. Whether the use of dental photography is solely for documentation or other purposes (social media or marketing ,), take steps to protect patient confidentiality .   .

14. Devices that can be used Digital cameras with single lens reflex ( eg . Nikon and canon cameras) Dental camera and monitor mounted on dental chair External storage device Other accessories needed are cheek retractors. Buccal and occlusal mirrors Images can be stored in JPEG or RAW formats which allow for future processing of the image.

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16. The re are at least 5 intra-oral photos that should be made: frontal photo, right and left buccal, upper and lower occlusal photos. Extra-oral photos are relatively easier made than intra-oral photos. The important thing is position of the patient and the clinician. Four extra-oral photos are face-frontal with lips relaxed and smiling, profile and 45 o   profile.

17. Picture source: Google

18. INTRA-ORAL SCANNERS,DIGITAL IMPRESSION AND DIGITAL MODEL Intraoral scanners (IOS) are devices for capturing direct optical impressions in dentistry .  Similar to other three-dimensional (3D) scanners, they project a light source (laser, or more recently, structured light) onto the object to be scanned, in this case the dental arches, The images of the dentogingival tissues captured by imaging sensors are processed by the scanning software, which generates point clouds .  These point clouds are then triangulated by the same software, creating a 3D surface model (mesh )  The 3D surface models of the dentogingival tissues are the result of the optical impression and are the 'virtual' alternative to traditional plaster models .

19. Intra-oral scanners are a viable alternative for practices that wish to provide their patients with the highest level of care. Some of the benefits of using intra-oral scanners are : Less trauma, especially in cases of gag reflex and special needs patients. Wow factor, patients notice and appreciate the ‘tech feel” of an intra-oral scanner. Accuracy; no need to call your patient back due to a distorted impression or broken model No mess, no alginate, no plaster, no trays, no model trimmer. No shipping out : digital impressions are sent through the cloud

20. Examples of intra-oral scanners Picture source: Google

21. Multiple angles of a digital impression Picture source: Google

22. Although plaster study models have undeniable benefits, digital model has become a viable alternative for practices that are running out space to store plaster models or find storage inconvenient and impractical. Some of the benefits of digital study model are: NO physical storage , information is safely stored in the cloud. Information is easily accessed and sort through so you can locate patient files quickly. Can access the records from anywhere as long as you have an internet connection. In case of transfers, the files can be  3D printed . Collaborate and share information with colleagues.

23. Digital model. Picture source: Google

24. 5 basic techniques for producing digital models Stereophotogrammetry Laser scanning Non-destructive imaging White light scanning CT Scanning

25. 3d digital model using stereophotogrammetry Picture source: Slideshare

26. Applications or softwares used Carestream dental software Cerec 3shape eModel Dental studio Etc…

27. Digital Imaging. Digital imaging was first introduced to the dental profession in the late 1980s. Since that time technology has evolved, allowing new types of imaging, e.g., cone-beam computed tomography to become more common in all areas of dentistry. Digital imaging is reliable and consistent, providing dentists with more radiographic options to diagnose disease, anomalies, and other conditions . The production of digital images requires a process called Analog to Digital Conversion (ADC). Digital imaging is a radiographic technique that utilizes a wired or wireless hard sensor or phosphor plate sensors known as a receptor, instead of film.  In digital imaging, the x-ray machine is still used, but the image is converted from analog to digital. When the photons from the x-ray tubehead strike the sensor, the analog image is converted to a digital image and then transferred to the digital imaging software 

28. Digital imaging requires an x-ray unit, sensors to capture the images, computer hardware and software to view, store, and transfer images, and if an indirect digital system, a scanning device . Dental Digital Imagings can be taken INTRA ORALLY OR EXTRA ORALLY It can also be Direct and Indirect Digital Imaging

29. INDIRECT DIGITAL IMAGING This means digitising a conventional radiograph using a CCD scanner. T he term is used for images acquired using a photostimulable phosphor plate (PSP ). Charge-coupled device ( CCD ) detectors are used in INDIRECT digital  radiography  for the indirect conversion of  x-ray  photons into an electric charge Simply involves the use of xray films

30. Picture source: Google

31. DIRECT DIGITAL IMAGING The essential components of this system include: Xray machine, an intra-oral sensor /intra-oral sensor receptor and computer monitor The sensor is placed and exposed to radiation, it captures the image and then sends to a computer monitor. A software is then used to view, enhance and store the image.

32. Picture source: Google

33. Advantages of DI Time saving and patient experience Patients safety Environment  – elimination of radiographic supplies, such as radiographic film and processing solutions. Digital imaging is also beneficial to reduce hazardous waste materials, such as lead foil and silver salts 3D Reconstruction Tele-radiology Storage Contrast enhancement

34. DISADVANTAGES OF DI Cost Technique sensitive Patient Comfort – direct sensors are hard and not flexible like film.  Medico-legal  – concerns regarding manipulating images have been addressed by manufacturers. Dental software has warning features if the enhanced image does not match the original image. It is recommended copies of the original images be stored on the computer or network server. Researchers in the area of fraudulent digital dental records recommend digital content have attached metadata. In forensic dentistry metadata and watermarking is added to discourage tampering documents.

35. SOFTWARES FOR DIGITAL IMAGING

36. Digital processes in treament planning and options In the past 20 years, changes in orthodontic treatment philosophy, treatment modalities , and new appliances have been enormous. These have included the move from extraction to non-extraction therapy, reduced friction brackets and space-age wires, appliances that make mandibles grow. O pportunities to overcome anchorage limitations with skeletal temporary anchorage devices (TADs ), and more recently, the extraordinary growth in clear aligner appliances made from three dimensional (3D) printed models.

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38. The latest technological advancements (e.g., computer-aided design (CAD); computer-assisted manufacturing (CAM); finite element models (FEM) software; rapid prototyping (RP) techniques) enabled the company to digitize conventional aligner fabrication processes, including making a series of impressions and hand-made laboratory setups. This introduced a new generation of orthodontic appliances, playing a crucial role in the evolution of digital orthodontics . Currently several corporations offer similar technology to dentists and orthodontists worldwide.

39. Virtual treatment planning The CAD-CAM CAD/CAM (Computer Aided Design/Computer Aided Manufacturing) technology has been used in dentistry-in tooth restoration and reconstruction, implants and by dental technicians. In Orthodontics, CAD/CAM technology is less commonly used despite the advancement of the technology. In recent years, CAD/CAM is used to manufacture transparent aligners and custom made brackets.

40. Digital Orthodontic Aligner Processes The digital aligner treatment process begins by creating a digital model after the clinician develops the diagnosis and treatment plan. After the orthodontic treatment goals are well established, a computerized model is created by a reverse-engineering process using CAD, either directly from the patient’s mouth using an intraoral scanner (IOS), by scanning a plaster model of the teeth created from impressions (e.g., polyvinyl siloxane) of the patient’s mouth , or by scanning the dental impressions.

41. The CAD software converts the clinical tooth misalignments into a 3D digital image in the most common file format (i.e., Standard Tessellation Language [STL]). Subsequently, the graphic representation of the dental models can be manipulated by human hands using FEM software to simulate how the teeth will move throughout the treatment according to the orthodontist’s plan. On the virtual planning software, the dentist dictates how and when each tooth movement should occur, plans if any tooth should remain stationary, decides on incisor proclination or anterior dental arch constriction, dictates the amount of dental distalization , extrusion or intrusion, and anything else necessary for achieving the orthodontic treatment goals.

42. The dentist can either manipulate the software to visualize the dental movements required, or have it manipulated by the company’s technicians . The ability to convert images or impressions of the patient’s teeth into a computerized malocclusion in order to virtually plan orthodontic movements allows patients to visualize how their teeth will move throughout treatment, before it even starts, which can be motivating. It is also more efficacious in terms of legal issues, since the 3D treatment plan can be shown, if necessary, as proof of the plan originally agreed to by the patient. The FEM (Finite Element Model) software then calculates the amount of aligners needed for each type of dental movement requested, as each aligner can produce an average 0.2 mm inclination and/or one degree rotation per tooth.

43. However, the clinical predictability of dental movements programed using the FEM software is strongly influenced by the amount of movement planned per tooth on the vertical, sagittal, and transverse planes . Another key factor for predictable dental movements with aligners is reducing the staging (i.e., amount of movement/rotation per aligner). The staging protocol should not exceed a rate of 0.25 mm per aligner

44. 3D Printing(CAM) and Aligner materials An aligner is then fabricated for each single movement outlined in the virtual plan based on its corresponding printed dental model, which are manufactured today via CAM methods. This process (i.e., a 3D printer creates the physical dental model) is an example of a rapid prototyping (RP)technique, which plays a key role in automating aligner fabrication while incorporating a construction process that utilizes additive layer manufacturing technology. Fused Deposition Model(FDM ) technology is also used to produce clear aligners. 3D printing has become a well-established aligner fabrication method, and in comparison to hand-made setups fabricated with plaster, 3D printing is less time-consuming and a much cleaner and more accurate technology.

45. Picture source: Google

46. What is Rapid Prototyping? RP is a type of computer-aided manufacturing (CAM) and is one of the components of rapid manufacturing. It is a technology that is capable of making physical objects directly from 3D computer data by adding a layer-upon-layer .  First, slicing of the digital model is done, and then through an automated process of layer by layer construction, transverse sections are physically produced. These 3D physical structures are known as rapid prototypes . Rapid prototypes contain mobile parts with complex geometry that is impossible to be made by other construction techniques . T his technique allows visualization and testing of objects, which reduces costs .

47. Classification of rapid prototyping Broadly rapid prototyping may be categorized into: 1) Additive method – which is widely used 2) Subtractive – less effective . The frequent technologies that are adopted in dental practice are: 1. Stereolithography is an additive manufacturing process which uses UV-Photopolymer curable resin and a UV laser to build layer by layer. It is the most widely used. 2. Selective laser sintering (SLS ) 3. Inkjet-based system (3D printers [3DP]) 4. Fused deposition modeling (FDM).

48. Aligner’s materials In order to exert the force required for orthodontic dental movements yet demonstrate sufficient elasticity to prevent distortion, aligners must be fabricated with material manifesting the appropriate rigidity and durability . The aligner’s plastic material must also demonstrate the capacity for retention to best fit the teeth, as well as be flexible for the patient’s insertion, removal and comfort. Numerous companies have developed aligners made from different polymers that present excellent modeling properties, all of which vary in terms of physical, chemical, and mechanical composition due to additives and reinforcements.

49. Since 2013, Invisalign has been fabricated with a 0.30 mm thick patented polyurethane material called SmartTrack ™ . The manufacturer states that it is made from “biocompatible medical grade thermoplastics” engineered for fitting more precisely to the tooth morphology, delivering more constant force due to higher elasticity and, therefore, providing better tooth movement control . A further claim is that the Invisalign design has higher flexibility and lower initial insertion force, which makes it easier for insertion and removal and improves patient comfort.

50. Scheu Dental GmbH (Iserlohn), a German aligner fabrication company, commercializes their Clear-Aligner in three different thicknesses (e.g., 0.5 mm, 0.625 mm, and 0.75 mm) for each stage of the treatment. They utilize a glycol-modified polyethylene terephthalate material to fabricate the aligners GeoTek Centre s.r.l . (Terni, Italy ) when fabricates their Nuvola aligners to self-adjust their thickness from 0.75 mm to 0.85 mm throughout the treatment phases. Clear Correct , LLC aligners are made from Zendura , a material described by the manufacturer as a “custom formulation of medical-grade polyurethane” created exclusively for Clear Correct by Bay Materials.

51. A ligner fabrication polymers should be O dorless , T asteless , “ F ood and drug administration”(FDA) approved, and N ontoxic (free of bisphenol -A and phthalates).

52. The patient wears a set of aligners for 22 hours a day, but they can be removed for eating, drinking, brushing, and flossing. During the following months, the dentist prepares the patient’s dental occlusion to receive successive pairs of aligners. The aligners are replaced every 2 weeks, or after 300 hours of use . It’s important to note that maximum patient compliance is essential for successful orthodontic movement with aligners. Further, patient refinements or mid-course corrections may be required to achieve the anticipated orthodontic goals.

53. With CAD/CAM produced clear aligners, patients have an orthodontic treatment alternative to conventionally fixed appliances with fewer negative impacts on their day-to-day lives . With minimal visibility, the aligner's transparency is a key benefit. However , more important is the fact that aligners enable unimpeded oral hygiene, which has been highlighted in studies evaluating the periodontal health of patients undergoing orthodontic treatment. Additionally , the patient’s comfort during CAT is improved, since aligners do not occupy excessive space in the mouth, leaving lips, cheeks, and tongue to move naturally . Damage to the mucosa typically caused by the irregular borders presented on the brackets and bands commonly used in traditional orthodontics, can also be prevented, and less time is spent on patient visits and emergency appointments for bracket re-bonding or repair.

54. CAD - CAM SYSTEM Picture source: Google

55. USES OF RP(CAD/CAM) IN ORTHODONTICS Diagnosis and treatment planning RP model can be used as a tool for diagnosis and treatment planning in orthodontics. These may include identifying the exact position of impacted canine , locating exact anatomical relationship between the impacted tooth and other teeth, serving as an aid in intraoperative navigation during surgery to expose the tooth and communicating with the patient. RP model can also be used for the fabrication of metal attachment for the canine traction.

56. Orthognathic surgery Cephalogram , dental study cast, and facial photos are traditional tools for diagnosis and treatment planning in orthognathic surgery. However , when analyzing the spatial relationships of bony structures, accurately, these have limitations especially when there is a facial asymmetry. Surgeons usually rely on subjective visual estimation and personal experience. Hence , fabrication of anatomical model with use of RP can help the surgeon to plan and perform the surgery in a better way and achieve better postoperative results . Discrepancies due to asymmetry can be measured directly on the model, and also manipulation can be made if required before the actual surgical procedure is performed . As a part of computer-assisted orthognathic surgery, SLA can also be used for making surgical splints .

57. Distraction osteogenesis osteogenic distraction of mandible in a patient with aglossia by fabrication of the mandibular symphysis distractor using RP model of the jaws. Lingual orthodontics RP is used in cases of lingual orthodontics (LOs) to produce customized lingual brackets .

58. TELE-ORTHODONTICS Tele-orthodontics is an area that dentists should be aware of. It's another innovation that's changing the marketplace and making it easier for dental services to reach patients . It is now possible for patients to realign their teeth at home, guided and cared for remotely by experienced dentists.   This is the future of orthodontics, giving patients control over their smiles in the safest, most convenient way possible . IT CAN BE SIMPLY TERMED ‘’ORTHODONTIC TREATMENT AT HOME’’

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60. LASER ORTHODONTICS Laser technique now is widely applied in orthodontic treatment and proved to have many benefits. Soft tissues laser can be used to perform gingivectomy , frenectomy and surgical exposure of tooth with less bleeding and swelling, improved precision, reduce pain and less wound contraction Other laser applications include enamel etching, bonding and bracket debonding. Lower level lasers have the potential effects of pain control and accelerating tooth movement. Clinicians must be aware of the safety issues and risks associated with laser and receive proper training before the laser treatment is started.

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62. Artificial Intelligence in orthodontics Artificial intelligence (AI) is a subfield of computer science concerned with developing computers and programs that have the ability to perceive information, reason, and ultimately convert that information into intelligent actions. AI as a science is very broad and encompasses various fields, including reasoning, natural language processing, planning, and machine learning (ML ). At present, ML is the most commonly used AI application in the medical and dental fields . This works based on ML Algorithms At present, dentists have more advanced ML systems available to them that can diagnose a broader range of orthodontic cases and determine treatment needs. Several advanced systems have been developed to help orthodontists diagnose, plan and evaluate treatment outcomes and growth . AI algorithm are being developed to analyze unknown cephalometric X‑rays at almost the same quality level as experienced human examiners (current gold standard).

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64. ROBOTIC-ORTHODONTICS This is currently widely used in wire bending . THIS IS THE FUTURE OF ORTHODONTICS Picture source: Google

65. Benefits of Digital Orthodontics Improved Accuracy New advancements in computerized imaging has greatly improved the ability of oral health professionals to diagnose and treat various conditions that occur within the teeth; these highly-detailed images are able to capture contours within the teeth that are traditionally difficult to view with detailed accuracy. This improved accuracy has a trickle-down effect of sorts across other areas of orthodontic treatment; misdiagnosis could soon become a thing of the past, and rare conditions can be spotted and immediately, allowing treatment to begin before the condition is allowed to worsen .

66. Increased Patient Comfort The great news is that there’s nothing invasive whatsoever about computerized image processing; no putty, and other types of foul-tasting contrast agents necessary! Patients can sit back and relax while the computerized images are taken, and then move on with their appointment. More Customizable Care Digital Orthodontic Technologies further allow oral health professionals to create even more personalized plans for those with specific conditions; both doctors and patients can better track their treatment and stay even more organized!

67. SUMMARY The introduction of modern digital technology to dentistry brought about precision , speed of action and computing capabilities which provide dentists and their patients with a new dimension of treatment. It is obvious that no digital technologies can function without human supervision , in this case, an experienced dentist; and they allow him to use solutions that are not available in a traditional manner. Many orthodontists treat their patients using such systems as INVISALIGN or INCOGNITO, which were created thanks to modern, digital solutions, and are highly valued around the world. Orthodontics is one of those fields of dentistry, which in terms of modern, digital solutions has been recently given a lot of attention by manufacturers.

68. Such devices as CT scans, digital panoramic radiography, intraoral dental scanners, and specialist software for analysis and design of patients’ smiles are used in many clinics around the world on a daily basis . Orthodontists who have access to such advanced technologies can, e.g. cover a patient’s tomography (made using a CT scan) with a digital scan of teeth (made using an intraoral dental scanner), and thus they can perform a simulation of effects of treatment in a given patient.

69. CONCLUSION Tele-orthodontics, AI or ML and Robotic orthodontics are all forms of Digital Orthodontics. New technologies are being invented and improved on Digital orthodontics is the future of orthodontics!

70. REFERENCES   Kravitz ND, Burris B, Butler D, Dabney CW. Teledentistry , Do-It-Yourself Orthodontics, and Remote Treatment Monitoring.  Journal of Clinical Orthodontics  2016:50(12);718-726. 2. Bauer JC, Brown, WT. The Digital Transformation of Oral Health Care: Teledentistry and Electronic Commerce.  Journal of the American Dental Association  2001:132(2);204-209 . Treatment outcomeand efficacy of an aligner technique—regarding incisor torque, premolarderotation and molar distalization . BMC Oral Health. 2014 Jun 11; 14: 68.Westerlund A, Tancredi W, Ransjo M, Bresin A, Psonis S, Torgersson O.Digital casts in orthodontics: A comparison of 4 software systems. Am J Orthod Dentofacial Orthop . 2015; 147: 509–16 . www.google.com www.slideshare.com Clinical pocket dentistry dictionary American Journal of orthodontics

71. Thank You!