Today we move between the digital and the analog world to accomplish the goals of aesthetic dentistry. A mock-up is a key tool in helping patients want aesthetic dentistry and visualizing what the changes will accomplish.

Lots of us have learned from masters like Dr. Susan Hollar how to hand-lay composite on the patient’s teeth so the patient can see their possible new smile. This trial smile technique is a fabulous way to motivate patients. It’s also a great way for us to learn what might be possible.

For many dentists, that technique is not natural for us, and it takes chair time. Another way we can model possible changes is through digital technology. In our office, we are using digital smile design as follows.

1. We do our initial records, which includes facial photos and an intraoral scan using our digital impressions intraoral scanning system.

2. Either on the software in our office or at the lab, a 3-D version can be designed of what the new smile approximately could look like.This doesn’t have to be a definitive wax-up. Remember, we call it a diagnostic work-up. In fact, this is oftentimes where we discover the need for gingival changes and/or orthodontic procedures in order to achieve the desired outcome. I find this extremely helpful in communicating with the patient as I can show them what the compromised outcome would be if they choose not to correct the gingival levels or align the teeth if that is in fact appropriate.

We’ve learned it is very efficient to collaborate with the lab, the lab creates the 3-D design, and the lab emails us the STL digital file of the design. Alternatively, the lab can send printed models, matrices, or even milled/printed PMMA shells of the design.

3. On the 3-D printer in our office, we print the model from the STL file.

4. We make a matrix from that, either in a suck down material or a putty matrix, and we take that to the mouth, fill it with our temporary material (usually bisacryl), and seat it right onto the teeth.

5. After letting it set, removing the matrix, and peeling off excess material, the patient is wearing their trial smile. This last step takes all of two minutes.

Using this process enables us to do the lab work between appointments, and when the patient returns, they can very quickly preview the possibilities.

It is a wonderful communication tool, because the patient can look in their own mouth, not at a picture of someone else, not at pictures of other shapes of teeth, and say, “I like that,” or “I thought they would be shorter (longer, fatter, narrower…).” You can go in with your handpiece and reshape the temporary material or add material with flowable to make something more pronounced.

Patient participation in the tweaking of the design draws the patient into deeper engagement with and commitment to the smile they want. Now, we can scan the corrected and approved trial smile while it is in their mouth and take photos to send to the lab to help them as we move into the definitive design phase, including working out the occlusion and function.

In my dental practice, we often use mounted models for diagnostics and restorative treatment planning. Three years ago, we began 3D printing these models.

One of the benefits of printed models is their higher durability compared to stone models. Also, long term, we do not need to save the printed models because we have the digital models saved in the patient’s file. But the greatest benefit has been the efficiency gained in mounting models on articulators. As a result, we have decreased our overhead and increased our mix of services.

What made this mounting efficiency possible is software called “Blue Sky Plan” from Blue Sky Bio. Blue Sky Plan is advanced dental treatment planning software used for milling and printing dental products. One of its applications is printing surgical implant guides, but it has many dental and medical applications for anatomical modeling, surface editing, and offsetting. It allows for CT scan importation and analysis, and export to STL format for 3D printing.

When dental models are printed, the interior can be hollow with a waffle pattern on the back that makes articulator mounting super easy. The process is as simple as opening the software, going to editing, importing your scan, and then selecting a hollow model with the waffle base. To print the waffle base on the model, you need to scan the entire pallet.

This blog is a precursor for the long lecture I will do on this topic at the 2021 Pankey Symposium.

Over the last decade, there have been major changes in how we do things in our laboratory (Niche Dental Studio), but from small cases to full mouth and hybrid cases, traditional Prosthodontic protocols still guide everything we do. These foundational processes provide a structural/philosophical approach for all our cases.

It’s a philosophical approach to diagnosis and treatment that you have been learning in your Pankey Institute courses. It’s an approach that extends from your dental practice into our lab, so our lab becomes part of your practice.

What are the key principles of this philosophy or approach?

• We will use optimal diagnostic protocols, communication, technology and methods to deliver custom prostheses as efficiently as possible while not compromising on the quality of the products.
• We will do our best to deliver products that meet or exceed your expectations for optimal function, comfort, and natural esthetics.

Here are some of the things that we do the same and some we do differently than we did ten years ago.

Feldspathic ceramics still produce the most natural appearance.

In the past everything we made was made by hand, and it was the prosthodontic protocols of this handwork that enabled us to have success using CADCAM technology today. And while today’s CADCAM dentistry is great, it does not replicate the results of restorations made by hand. A machine can’t mill “infinity margins.” Monolithic materials used in milling do not contain multiple levels of opacity.

To blend perfectly with Nature, restorations must still be made by hand, and in our laboratory, feldspathic veneers are still our “go to” type of restoration for central incisors. Layered feldspathic ceramics not only look the best but also are the best for marginal integrity. The restoration on number 8 below is an example.

For fit and finish, these types of anterior restorations are still the prosthodontic foundation of our Niche Dental Studio.

We still aim to replicate natural teeth.

Another foundational attribute of prosthodontic protocols is to replicate nature. Part of our success has been how much time and effort we have put into studying natural teeth and helping Pankey Institute trained dentists distinguish themselves by using restorations that are exquisitely made to appear natural and blend in the patient’s smile.

Today’s patients desire natural esthetics once they understand the elements of what makes teeth appear natural. If a patient seems stuck on a cosmetic dentistry meme of the past and requests whiter, brighter, straight teeth that will not blend in their smile, a conversation with your patient that illustrates tooth, smile, and facial esthetics will be appreciated by your patient and distinguish you as a caring, exacting dentist.

To create restorations that appear natural and don’t “jump out,” we do the following things:

• Increase the “value” of the color but not enough to create harsh contrast.
• Play with the levels of the incisal embrasures and the translucency.

These prosthodontic protocols can be implemented by you, too, while doing composite build-ups.

We use new technology to optimize communication.

From the ceramist’s perspective, I don’t want to see just close-up images of teeth. I want to see the patient. For many of our cases, we see the patient in our lab. Local patients come in for a consultation. We consult with other patients via Skype or Facetime. Seeing the entire smile, the entire face in natural interaction, aids us in doing our best.

 Modern 3D technology has changed how labs communicate visually with doctors and their patients. We’re constantly sending 3D screen shots back and forth with our doctors so they can check out the design and show them to a patient. An image like this one is confusing to patients. So, we’ve been able to integrate those screen shots into a photo of the patient to create a virtual image the patient grasps more easily.

CAD technology allows us to work more efficiently, but we still hand-finish restorations.

In our laboratory, we mill a lot of lithium disilicate crowns for clients. Prior to milling the lithium disilicate, we like to mill the restorations in wax. The milling quickly does 80% of the model creation and gives us the opportunity to hand finish the other 20% as we traditionally would. We can now put all our esthetic and creative efforts into finishing the case. We also mill temporary restorations from IOS data without hand modifying them.

Using IOS and CAD has made the lives of our clients much easier. For example, in the past, with full mouth cases, we did a lot of wax-ups when raising verticals. The doctors found working with matrixes too time consuming. They preferred working with eggshells and would reline them. Little problems would creep in when seating these eggshells. Perhaps, the cant was a little off or the vertical wasn’t raised accurately. With 3D imaging, it is far easier, because now we can do our full mouth wax-ups, scan them, and print the eggshells from scans with full palatal rest and retro-molar rest. There is now only one definitive way to seat the eggshells.

This is just a taste. There is so much to share.

To see how we do actual cases, in detail, go to the free Pankey Webinar: Prosthodontic Protocols for the Modern Dental Team. There you will see how our modernized approach, guided by traditional prosthodontic processes, becomes an extension of your treatment goals. I look forward to sharing more with you at the 2021 Pankey Symposium.

Around the world, people use AI-powered technology every single day. AI algorithms generate everything from Google search results to predictive text when writing emails to speech-to-text messages on smartphones. Every time you’re shopping and see “Recommended for you,” that’s based on AI data analysis, comparing your shopping habits to those of thousands of other people.

When I spoke at the annual Pankey meeting in New Orleans in 2015, my artificial intelligence software was just in its embryotic stage. Fast forward five years, and it is on the forefront of a technological revolution that improves the operations, ROI, and patient experience in dental practices of all sizes.

Data is hindsight. Intelligence is foresight.

Artificial intelligence programs are trained by using millions of data points that were categorized by humans already. AI software is taught to recognize the meaning of what it is seeing and/or hearing. Then, AI software programs extrapolate results and apply the information to predict behavior, coach behavior, command machines, and more.

9 Ways to Leverage AI in Dental Practice

Hygiene at home: Smart toothbrushes can record how patients are brushing their teeth and share that data with dentists, typically via an app. That allows dentists to identify bad habits and teach patients how to improve their at-home hygiene routine. Some apps even remind patients when it’s time to schedule their next dental appointment.

Voice-activated commands: In healthcare, medical and dental providers are already using voice-activated technology to dictate their notes into patient electronic medical records (EMR) and to access radiographs and other images hands-free. They are also using voice commands to research symptoms, diagnostics, and treatment options. This year will see an explosion of voice-activated commands in the workplace. Gartner, Inc, a world-renowned research and advisory company, predicts 25% of digital workers will use virtual employee assistants (VEAs) daily by the end of 2021. It also predicts that by 2023, 25% of employee interactions with applications will be via voice, up from just 3% in 2019.

Pathology identification: Computer vision AI analyzes radiographs in real time to detect pathologies and standardize quality of care. It provides confidence in the dentists’ diagnostics, and ensures problems are not missed. Companies like Pearl, Videa, and Overjet are successfully implementing computer vision AI in thousands of dental practices and improving diagnosis, case acceptance and ultimately patient outcomes.

Treatment planning: AI computing models are based on the treatment plans and outcomes of hundreds of thousands of patient records. Dentists can leverage AI to analyze different treatment possibilities and determine the potential for success, the length of the case, the materials that would be used, costs, and other considerations.

Treatment acceptance: Augmented reality isn’t just for kids’ games. Dentists use AI-powered augmented reality to generate smile designs in real time. When patients can see how the dental work will improve their appearance and restore function, they are more likely to start treatment.

Data analytics: At its most basic functionality, AI is big data computation. Its advanced algorithms predict future outcomes based on data patterns. Some dental support organizations around the country are already using AI to crunch numbers for predictive analysis designed to increase case acceptance, improve show rates, and optimize schedules.

Insurance reimbursement: For decades, insurance claims have been manually reviewed by dental professionals employed by the insurance carrier. AI can review claims, radiographs, and supporting documentation in seconds, generating approvals or identifying fraudulent claims much more quickly.

Elevated patient care: Technology has already revolutionized electronic health records. In this decade, AI will make it possible to closely tie oral health conditions to overall systemic health which will lead to better communication between providers and breakthroughs in both disease prevention and treatment.

Patient phone calls: Companies like Patient Prism leverage AI’s natural language processing algorithms and machine learning to quickly identify why patients called, the services they requested, the associated revenue, and whether the call ended in a booked appointment. Dentists use the data for everything from front office training to winning back unscheduled callers to determining whether their marketing efforts are driving the right kinds of calls.

Groups like the Artificial Intelligence Dental Council, a non-profit organization established by Pearl, are leading the way on the research and future applications. From helping patients at home to making it easier to book appointments to ensuring accuracy in diagnosis and treatment planning, AI is already revolutionizing dentistry. The future has arrived.

Over the years I have visited many offices and found every office has a special “hideaway” reserved for the new technology that the doctor is going to implement that never happens. I just looked over an article by Dr. Lou Shulman in Dental Products Report that reviews a multitude of technology options available to us. I was surprised to note the number of doctors who stated that they do not plan to purchase three specific tech areas that we have found to be significant in increasing our production, quality of care, and positive patient reaction. Based on our practice experience, these three items will very quickly provide a return on your investment when you integrate them into your practice.

Voice Activated Software

We have been using Dentrix VoicePro, a voice-activated perio charting and clinical note dictation, for over 15 years. Our hygiene staff would quit if we took it away. We do a full perio charting on every re-care appointment. This software makes it quick and easy, AND the patient hears the numbers and pays attention. There are numerous other features, but the perio charting is worth the price and learning curve. In today’s environment, the system eliminates the need for added staff as a recorder or the constant picking up and putting down of pens or probes.

Intraoral Scanner

We are using iTero and love it. We have had a CAD/CAM system for years and use it routinely. However, if you are doing any aligners or sleep appliances you will love the scanner. Your patients are so appreciative that you no longer have to have them sitting with “goo” in their mouths. There is a learning curve, but it is not too steep. The accuracy of the images is excellent. The unit will not let you send a poor impression to the lab. The cost of a scanner is far less than CAD/CAM. Your lab loves getting your impressions electronically. Your patients are fascinated by your ability to image their teeth with ease and accuracy. Our staff has quickly adapted to the use of the scanner and loves it.

Soft Tissue Laser

The price of soft tissue lasers has dropped dramatically. We were relatively early adopters of the soft tissue laser. We use ours for soft tissue shaping in crown and bridge, desensitization, and soft tissue periodontal procedures. We have had near-zero post-operative complaints in any of these procedures. The desensitization of teeth is amazingly quick and easy. All of our hygiene staff has been trained in laser use and feels that was worth the effort. Patient acceptance of soft tissue laser in hygiene/periodontal procedures is very high.

We try to be at or near the leading edge of the technology curve, not the “bleeding edge,” and we expect technology to have long term value as well as a rapid payback. These items have proven to be time savers, improve our quality of care, and are recognized by our patients as adding value to the experience in our office.

Sleep issues and sleep apnea is a very serious concern today for our patients’ health. I have been giving patients an Epworth sleepiness self-assessment for several years. It is a great way to find out if patients should pursue their sleep with a physician and inquire about having a sleep study.

Another incredible indicator of apnea is if someone else hears you stop breathing. Of course, there are challenges with this approach. First, there has to be someone near you when you sleep to hear what is happening. Second, someone has to be awake in order to listen and watch while you are sleeping. Third, someone has to interpret what is happening. I recommend the SnoreLab app that records and evaluates the sounds made while sleeping. It can even show you graphs of what was happening. Not only is this a great self-learning tool, but the recordings can be taken to the doctor as part of the information to determine if a sleep study is indicated. The product is available on the web and through the App Store.

Several of my patients have used the SnoreLab app and had follow-up studies in a sleep lab. Within my Glendale, AZ practice, I have a Dental Sleep Medicine practice and treat patients with sleep apnea appliances.

To serve patients to the best of their ability, I recommend general dentists learn how to competently develop a Sleep Dental Medicine niche within their practice. I can honestly and wholeheartedly say that The Pankey Institute’s 5-day immersion Dental Sleep Medicine course is one of the best programs in the nation. It is uniquely designed to give dentists the experience of being a sleep apnea patient themselves.

The dreaded single central crown… How many of us feel confident that we can deliver an acceptable restoration on the first try?

We even prepare our patients for the inevitable follow up appointments to “fine tune” the shade. Let’s not even start the discussion of how to charge for this. So, maybe we just veneer the other central for a better match, even if it didn’t need the restoration. If we are hoping to preserve as much natural tooth structure as possible, then obviously this is not ideal.

An Incredibly Technical Task

Shade matching in the anterior, especially for a single tooth, is one of the most difficult endeavors in dentistry. The level of accuracy has to be so high it can become frustrating for the dentist, ceramist and patient very quickly. The subjectivity of this incredibly technical task only serves to further complicate the results. If a picture is worth a thousand words, then it takes a novel to describe a single anterior tooth!

The eLab Alternative

What if we could quantify shade in a way that guided the technician in creating the restoration? What if we could perform a “digital try in” with a high level of accuracy? What if we could know with a higher level of certainty what truly isn’t right about the shade and make the correction in the lab? This is what the eLab protocol provides us: quantitative shade matching using calibrated polarized images, a digital try in and more success.

At the 2019 Annual Pankey Meeting in September, I will present the eLab protocol and describe image acquisition and calibration so the technician can use this information to aid in both fabrication and verification of the final restoration.

Wouldn’t you love to work more predictably with your technician, even when in different geographic locations? Join us from September 12-14 to see what’s possible!