Annals and Essences of Dentistry
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Digital Orthodontics- A Technology in Modern Practice, Present Scenario with Clinical Implications

Abhinav Bhardwaj^{* *}Correspondence: Abhinav Bhardwaj, Department of Clinical Informatics, Indian Institute of Science, Karnatak, India, Tel: 8130211237, Email:

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Introduction

The integration of modern technology is essential for the success of an orthodontic practice by increasing efficiency and communication thereby enhancing the ability of the orthodontist to diagnose and plan cases using the high resolution graphics. Globalization in the field of orthodontics, allows us to have access to the best available resources so that we can deliver high quality orthodontic treatment to our patients. Orthodontic treatment starts with diagnosis which includes patient or parent’s chief complaint, clinical examination and diagnostic records. Since orthodontic treatment is based on the accurate diagnosis followed by an ideal treatment planning. So it is necessary to understand all diagnostic aids for planning orthodontic treatment. Diagnostic aids include essential and supplement diagnostic aids. Essential aids are dental and medical history, extra oral and intraoral examination, study models, intraoral and facial photographs, radiographs [1].

Orthodontic diagnosis includes 3 components, skeletal, facial and dental. The prime role of an orthodontist is to realign different craniofacial components in anatomical and dynamic balance position so as to make them aesthetically pleasing. However for achieving this process we need information regarding relationship of all these components of the craniofacial complex in three spatial planes. Most of the available conventional diagnostic aids provide only a 2-dimensional representation of patient. Advanced technology gives high quality diagnostic information in three planes to the orthodontist which helps in designing the most ideal treatment plan for the patients [2].

Digital technology started to make its way into dental and orthodontic offices with the introduction of computers in the era of 70’s and over the last three decades digital photography and radiography and technological advancements such as digitized dental models, have replaced their analogue counterparts and paved way for alternative options for patient documentation and facilitated imitation of the prognosis of orthodontic treatment. However, two-dimensional (2D) records are still in use, but new technologies have led to a more efficient orthodontic diagnosis and treatment planning. It is now a common place to perform virtual treatment planning as well as translate the plans into treatment execution with digitally driven appliances. Furthermore it is also becoming possible to remotely monitor treatment and control it [3].

Present Scenario-of Orthodontic Digitization

Digital study models: Study models are essential component of orthodontic diagnosis which provides record of malocclusion before treatment, during treatment and at the end of treatment. As per consumer Protection Act 1987 it is mandatory to retain all records of patient for at least 11 years. For orthodontist, study models are essential but it comes with number of limitations such as storage, durability and transportability. With the modernization of computer technology, digital study models provide an alternative to plaster study models, with lots of advantages over plaster models such as: no requirement of storage, negligible laboratory work, fast and easy data retrieval and easy transportability [4-6].These days impressions and study casts have been replaced by Intra oral scanners as they are considered more comfortable for patients reduced gag reflex and more accurate than plaster models.

However, few limitations of digital study models are that it lacks tactile sensitivity, not cost effective and can’t be mounted on articulator for fabrication of appliances. So, orthodontists cannot rely on them completely. However, measurements taken from these models like tooth size, arch length and width, space analysis, molar and canine relationship, make them valid for clinical use [7-8]. Furthermore virtual treatment planning can be done using various orthodontic software within minutes which facilitate better communication with patients allows them to visualize outcome of the treatment and easily simulate the treatment process compared to diagnostic setups which is cumbersome and time consuming [9].

Dentascan: Introduced in the mid-1980s, Dentascan is a computed tomography (CT) software program which provides images of maxilla and mandible in three planes - axial, panoramic and cross-sectional. It provides better evaluation of osseous maxilla and mandible useful in head and neck surgery [10-12]. It is simple and painless procedure with effective dose of DentaScan Protocol around 8.16 mSv. Patient is asked to remove any dentures, jewellery, hair accessories and hearing equipment’s. The mandible of patient is maintained in fixed position on a Styrofoam surface, attached to head holder of CT machine for patient’s right position having mandibular base perpendicular to horizontal plane. Axial slices of 1.5mm thickness with 1mm slice interval, 120 kVp, 120 ma are used for CT examination. This Axial CT data send to a workplace, reformatted by Dentascan and paraxial and panoramic images are produced and printed on films. Denta scan resulted in reduced total radiation dose from 120 KV to 80 KV without relevant loss of contrast and resolution of images. 80 KV allow good quality of images for orthodontics diagnosis and treatment.

Dentascan is an accurate and very precise method of measuring the intrusion and up righting of teeth where the pre and post treatment study models are taken and converted into three dimensional digital models using Dentascan software. On these digital models measurements are done using certain reference points and lines. For assessment of impacted maxillary canines or incisors, supernumeraries teeth, odontomes, trauma and orthopaedic treatment in routine orthodontic practice conventional X ray techniques are not sufficient so three-dimensional investigations are mandatory as Dentascan provides detailed information of bone morphology in all three dimensions. However, it has a few limitations such as greater exposure to radiation and it is expensive. So, case selection for Dentascan use is very important [13-14].

Sure smile: A new approach in orthodontic treatment with recent technological advancement in 3-dimensional imaging of the dentition along with manipulation of complex 3-dimensional data, and robotics have resulted in complete transition of orthodontic practice to a digital platform. It is used for diagnosis, visualizing alternative treatment plan and helps to plan more aesthetics smile for patient. Sure smile provides multiple treatment options with end result of the treatment which is more accurate than conventional methods and final treatment plan can be decided after discussion with patient. Sure Smile process has given a futuristic tool in hand of orthodontist, which incorporates technologies designed to provide high-quality and efficient treatment [15].

Procedure: Dentition is prepared and scanned and images are then processed in OraScanner image processing software to create an accurate, three dimensional display of dentition for sure smile work station. The final treatment plan is presented in three dimensional digital diagnostic setup. Using most common bracket types and prescription from a digital library Bracket positions are determined which facilitate automatic generation of geometry of arch wire in three dimensions for the finalized bracket positions on arches. So the end result is a digital prescription of customized bracket positions on images of malaligned teeth with arch wire designs[16]. So orthodontist can use Sure smile for treatment surveillance and monitoring of the treatment progresses. These enhancements have led to increased efficiency of orthodontic care, and has decreased the treatment duration and the travel distances of teeth.

RAPID PROTOTYPING

Rapid prototyping (RP) basically means fabrication of a model in 3D using a computer aided design (CAD) which was traditionally built by layering process [17]. The technology was first introduced in mechanical engineering, prototype includes number of steps before the 3D model is fabricated and is mainly used to evaluate the ease of assembly and manufacture of designed products before actual production. “3D” printers allow the designers to quickly create prototypes designs of their choice, rather than just two-dimensional photographs. Frequent technologies of RP are stereo lithography (SLA); inkjet- based system, selective laser sintering (SLS), and fused deposition modeling (FDM) [18].

Prototype models have various advantages such as it facilitates rapid fabrication of models with minimal time involved, better visualization and without much hassle. For communicating ideas to patients they are an excellent visual aid. Alongwith repeated verification, and the prototype design can also be reused. However, major drawback is that it is too expensive and clinician final decision still remains mandatory.

It can be used for assessment of an impacted maxillary canine as it provides exact anatomical relationship of impacted tooth with other teeth and can be used as visual aids for patient communication [19] .Various other uses of RP models include fabrication of surgical template for TAD’s placement, splints fabrication for orthognathic surgery using stereo lithography[20-21]. Pessa revealed the potential use of a high-resolution stereo lithography for the study of facial aging and in preoperative planning of complex dentofacial anomalies [22].

Clinical implications of digital orthodontics

With growing chains of private entrepreneurs in the field of dentistry and opening of clinics at multiple locations, a unique clinical problem faced was of handwritten treatment cards. Patients would frequently tend to visit in offices other than the location where their treatment card was stored. So it used to create lot of hassle and clinician had to spend a great deal of time in faxing copies of treatment cards to outlying locations. But with the perfect marriage between orthodontic and computer technology helped provide us with electronic treatment cards ultimately simplifying our clinical activities by making the patient aware of the next appointment, timings, medications which solved the for problems faced by patient and the doctor.

However this “simplification,” posed its own set of problems which required computer terminals needed to be installed at each chair. In addition, there was requirement of high-speed networks to allow patient treatment information to be viewed at any location. A network of computers allowed for easy viewing of photos and radiographs that have been transferred quickly and in a cost-effective manner. Best part of it was patients were impressed with high-tech offices. However all connections to the Internet are susceptible to hackers, so care must be taken to safeguard programs and patient records. The transmission and reception of digital orthodontic records presented the profession with a unique opportunity as diagnostic information is always available on a “real-time” basis. Records taken in one place can be viewed in different locations. Second opinions and diagnostic help are easily facilitated. Databases may be established and can be used for teaching and clinical support. The opportunities are unlimited and, I believe, it will provide a portal to the new millennium.

CONCLUSION

Digital records provide assessment of patient’s dentofacial morphology in three dimensional which is required for orthodontic diagnosis and treatment planning these days. Digital records have helped to improve storage, easy access, of data and further communication with patient .But there are still few limitations. So for an orthodontist it is necessary that they should be well aware of indications, benefits and potential hazards while using these digital diagnostic aids. Thus future of orthodontics looks more promising if these advanced techniques are used innovatively.

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