Digital Dental Technology: Look How Far We've Come and Why You Should Look Again

Digital technology and CAD/CAM have come a long way for dentistry. There are myriad benefits of implementing digital technology. Looking back at a brief history of CAD/CAM, we can also dive deeper into today's digital scanning and CAD/CAM.

It All Starts with Scanning

Robert Mongrain, DMD, Director of Clinical Advocacy at Heartland Dental supporting Clinical Digital Technology Scanners & Labs, says clinicians always have opportunities to improve patient care, and technology can aid in that. However, whether it is materials technology or digital, clinicians that don't change and adopt new technology cannot continue to provide the best patient care and experiences. Striving for mastery though constant and never-ending improvement is a core value of Heartland Dental.

Dr Mongrain embraced those values even before joining the dental service organization (DSO), while leading his private practice, Berkshire Dental Group in Broken Arrow, Oklahoma, where he and his team took pride in providing world-class patient care.

"My primary job as a dentist is to help people do what they ought to do instead of what they want to do," Dr Mongrain says, referring to patients’ reluctance to treat their dental problems.

An early adopter of technology, Dr Mongrain had a CEREC 2 in 1998 and was one of the first eD4 users. He thinks using digital technology, specifically intraoral scanners, can improve patient care in several ways, including fewer remakes, faster turnaround time, and improved case acceptance rates. Moreover, he can see this in his current role at Heartland Dental, with data from 2,200 scanners and 2.5 million scans across 50,000 digital cases per month.

Scanning technology has improved communication in dentistry by helping people understand what's going on in their mouths. At Heartland, the teams do Wellness Scans to show patients their oral health progression.

Dr Mongrain also shares the impact of dental labs that are already digital. Nearly everything that the practice sends to the lab is either poured up and scanned or scanned directly using CT Scanning technology. This digitalization benefits the laboratory workflow, which indirectly helps the dental practice. However, the dental practice doesn't enjoy many direct benefits unless they implement digital technology in-house.

Dr Mongrain did approximately 4 occlusal guards a month at his practice before the implementation of scanning technology. After scanning and showing patients what was happening to their teeth, the number of occlusal guards they delivered jumped to around 12, triple what they were doing before.

"Those patients needed care before I had a scanner and more of them accepted care after I got a scanner. I didn't change my treatment planning," Dr Mongrain says. “Instead, the technology helped pain a clearer picture.”

Another area that digital technology is changing in dentistry is the ability to simulate outcomes. Dr Mongrain sees artificial intelligence (AI) assisted technologies that evaluate radiography and scans becoming more widespread in the next 24 to 36 months. He explains that these technologies will filter information and automate your charting, a considerable time saver for offices.

"But you have to have a digital scanner," Dr Mongrain says. "That's the entryway."

Heartland Dental uses training to leverage the most benefit from its scanning technology. Regular training programs broken down into 5 parts are offered continuously to improve the team's skills with the technology. The idea is that by developing these learning experiences, the scanner will never sit in the corner, unused. In addition, investing resources in training for the whole team builds confidence, which is essential to enhancing patient care and experiences.

"For a change management plan, you have a schedule of sequential learning experiences. Partner with the scanner company and your laboratories and develop these sequential learning experiences. Whatever you do, don't let it sit in the corner. If you have a problem, get some help to keep it going," Dr Mongrain says. "Mastery is not an event; it's a journey."

A Brief History of CAD/CAM

Something few people might know is that CAM preceded CAD, but both had their starts in the 1950s. CAD started with Douglas T. Ross, a researcher at the Massachusetts Institute of Technology (MIT), who was working on projects that pioneered the beginnings of the technology. Later, Patrick Hanratty, PhD, known as “The Father of CAD/CAM,” worked at the General Motors Research Laboratories, and added the use of software with CAD with his Design Automated by Computer (DAC), which used numerical control programming (PRONTO) that Hanratty developed in 1957. In the 1960s, Ivan Sutherland, PhD, developed Sketchpad, a design software that allowed designers to use a light pen to draw on the monitor.¹

CAM was also changing a lot in the 1950s. Computers were churning out G-code to make punch cards that controlled machines. Then the production of punch tapes using computer control increased the speed of making the instructions and the manufacturing process itself. The earliest commercial uses of CAM were in the automotive and aerospace industries.¹

CAD/CAM came together in the late 60s to help produce Renault cars in France. Then, in the early 70s, Hanratty founded Manufacturing and Consulting Services (MCS) in the US, where he created ADAM (Automated Drafting and Machinery). Most modern-day commercial drafting derives from ADAM. In 1982, John Walker introduced his CAD software AutoCAD for the PC. Ten years later, it was available for Windows, and by 2007, it became the industry leader.¹

An Even Briefer History of CAD/CAM in Dentistry

The 1970s was when CAD/CAM came to dentistry, introduced by the team of Bruce Altschuler, Francois Duret, Werner Mormann, and Marco Brandestini. Dr Duret took an optical impression and fabricated a crown using a numerically controlled machine. Later, in the mid-1980s, Mormann and Brandestini developed a commercially available system for dentistry and called it CEREC.² At the same time, Matts Andersson developed Procera (which is now NobelProcera, from Nobel Biocare), and then went on to be the first to manufacture composite veneered restorations.³

Later in 1994, Siemens introduced CEREC 2. Using two-dimensional concepts, the CEREC 2 could produce inlays, onlays, veneers, partial and complete crowns, and copings. In 2000, Sirona launched CEREC 3. Five years later, Sirona released a different version, which did everything CEREC 2 and CEREC 3 could, plus virtual automatic occlusal adjustment. The new CEREC 3 system also no longer used two-dimensional principles. 3 In 2008, D4D Technologies, LLC, launched the E4D Dental System, providing competition to CEREC.

Today, CAD/CAM enjoys widespread use globally. More than 30,000 dentists worldwide own scanning and milling machines, and dentists have delivered more than 15 million CEREC restorations.⁴ This market is growing—a recent market research report projected that the global Dental CAD/CAM Market Size will reach 4.94 Billion by 2029.⁵

Why Digital Technology and CAD/CAM Deserve a Second Look

Today's CAD/CAM systems deserve a second look, too. After all, they do not use two-dimensional principles, nor do they require producing punch cards. Things have come a long way, and it shows in what they make, John Flucke, DDS and Technology Editor for DPR, says.

"The restorations that come out of these machines are amazing," Dr Flucke says.

Dentists that invest in CAD/CAM have a lot to look forward to with the innovation in the space. There will be improved quality with the new version of the systems that have both extended uses and easier-to-use interfaces. Materials are also improving, with more of them providing wear that mimics enamel and is strong enough to withstand the forces imposed on full crowns and bridges. Moreover, the Journal of the Canadian Dental Association suggests that the automation the systems provide will likely produce changes we cannot predict today.⁶

Dr Flucke also thinks the increase in CAD/CAM providers changed the technology from closed systems to open architecture systems. Dentists have the option to mix and match with open systems to get what they want. Dr Flucke uses CAD/CAM for posterior restorations in his practice scanning with iTero, designing with exocad, and milling with a DGSHAPE mill from Roland.

"The other great part about it is if a company comes along next year with an incredible intraoral scanner, I can buy the new one, and it will interface with the pieces I already have. That is huge," Dr Flucke says. "The idea of open architecture and interchangeable is a big deal."

Per Dr Flucke, the quality of your work is much better today than it was in the past. He started using CAD/CAM back in the days of floppy discs in 1998 and recognizes that today's machines have bells and whistles that he wouldn't have imagined back then. The fit is more precise. Early critics of CEREC told Dr Flucke that an inlay is a piece of porcelain in a swimming pool of composite, which described how clinicians were cementing restorations with composite. Today, he says the restoration "looks like it grew there" with CAD/CAM-produced inlays, onlays, and crowns with marginal fit as good or better than what can be achieved with human hands.

There are many other practice benefits of using CAD/CAM, including:⁷

• Delivering treatment faster, meaning less chair time for restorative work
• Providing a more straightforward treatment, which provides a better experience for everyone involved
• Making treatment convenient and comfortable for the patient, which improves the patient experience and related word-of-mouth marketing
• Presenting a precise restoration, reducing, or eliminating the adjustments needed for a proper fit
• Producing the best esthetics with improved materials

Colgate details some additional patient benefits. Primarily, CAD/CAM provides the opportunity to deliver a finished restoration in a single visit. It also allows the team to take a digital impression, which is much better than the conventional way. In some cases, the cost of the restoration might be lower by eliminating outsourcing costs for the prosthetic.⁸

Another reason Dr Flucke thinks clinicians should reconsider their decision to avoid CAD/CAM is that it is more affordable than it used to be. In particular, the digital impression systems vary in price, depending upon the scanner you choose and the options. Plus, what you buy today can do so much more than what it used to provide. He compares it to buying a digital camera.

"The best cameras on the market are $2000 to $2500. You get the best camera Nikon or Canon makes when you buy that. However, the day you buy it, somewhere in the R&D department, they have a camera much better than the one you just bought. So, what's going to happen is next year, when the new camera is released, the one you have will drop in price, and the new one will be $2500," Dr Flucke says. "So, whenever you buy a high-end camera, you spend $2500, but it is exponentially better than the last time you spent it."

Dr Mongrain led Heartland's scanning implementation of iTero scanners around 7 years ago. He would encourage clinicians and practice stakeholders to view this purchase for their practice as an investment rather than an expense.

Dr Mongrain says delaying a purchase means missing out on the per-use opportunities, like saving lab shipping costs, ranging from $18-25 per case, or the ability to undertake clear aligner therapy (CAT) and digitally plan implant and restorative cases (when used with CBCT technology). Also, practices without scanning lose out on case acceptance for periodontal care, crown and bridge cases, and CAT opportunities.

"The last part of this second look relates to change management,” Dr Mongrain says. “If you are going to do it, now is the time. You do not want to be the last one to go digital."

References

1. Duncan G. The History of CAD/CAM - Computer Aided Design & Manufacturing. Technical Foam Services. May 5, 2020. Accessed August 9, 2022. https://www.technicalfoamservices.co.uk/blog/blog-history-of-cad-cam/

2. G. Uzun. An Overview of Dental CAD/CAM Systems. Biotechnology & Biotechnological Equipment. 2008;22(1):530-535. doi:10.1080/13102818.2008.10817506

3. The Use of CAD/CAM in Dentistry. Pocket Dentistry. October 29, 2016. Accessed August 9, 2022. https://pocketdentistry.com/the-use-of-cadcam-in-dentistry/

4. Irfan UB, Aslam K, Nadim R. A review on cad cam in dentistry. J Pak Dent Assoc 2015;24 (3):112-116.

5. Worldwide Demand For Dental CAD/CAM Market Is Growing At A CAGR of 8.9% By 2029 | 153 Report Pages.Digital Journal. July 18, 2022. Accessed August 9, 2022. https://www.digitaljournal.com/pr/worldwide-demand-for-dental-cad-cam-market-is-growing-at-a-cagr-of-8-9-by-2029-153-report-pages

6. Natalie A, Rhonda K. CAD/CAM Dentistry For Restorative Dentistry and Orthodontics. Dentaly.org. June 30, 2022. Accessed August 9, 2022. https://www.dentaly.org/us/restorative-dentistry/cad-cam-dentistry/

7. CAD/CAM Dentistry: What Is It? Colgate.com. February 3, 2022. Accessed August 9, 2022. https://www.colgate.com/en-us/oral-health/dental-visits/cad-cam-dentistry-what-is-it#

8. Rekow ED. CAD/CAM in dentistry: a historical perspective and view of the future. J Can Dent Assoc. 1992;58(4):283-288.