Digital Dentistry: The New State of The Art - Is It Disruptive or Destructive?

DENTAL-3419; No.
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Available online at www.sciencedirect.com
ScienceDirect
journal homepage: www.intl.elsevierhealth.com/journals/dema
Digital dentistry: The new state of the art — Is it

disruptive or destructive?
E. Dianne Rekow
King’s College London, 5 Hellyer Road, Tenants Harbor, Maine 04860, USA
a r t i c l e i n f o a b s t r a c t
Article history: Objective. Summarizing the new state of the art of digital dentistry, opens exploration of
Available online xxx the type and extent of innovations and technological advances that have impacted – and
improved – dentistry. The objective is to describe advances and innovations, the breadth
Keywords: of their impact, disruptions and advantages they produce, and opportunities created for
Digital dentistry material scientists.
Intraoral scanner Methods. On-line data bases, web searches, and discussions with industry experts, clini-
Additive manufacturing cians, and dental researchers informed the content. Emphasis for inclusion was on most
CAD/CAM recent publications along with innovations presented at trade shows, in press releases, and
Virtual patient discovered through discussions leading to web searches for new products.
Robots Results. Digital dentistry has caused disruption on many fronts, bringing new techniques,
Scaffold systems, and interactions that have improved dentistry. Innovation has spurred opportuni-
Smart devices ties for material scientists’ future research.
Telehealth Significance. With disruptions intrinsic in digital dentistry’s new state of the art, patient expe-
Dental materials rience has improved. More restoration options are available delivering longer lifetimes, and
better esthetics. Fresh approaches are bringing greater efficiency and accuracy, capitalizing
on the interest, capabilities, and skills of those involved. New ways for effective and effi-
cient inter-professional and clinician-patient interactions have evolved. Data can be more
efficiently mined for forensic and epidemiological uses. Students have fresh ways of learn-
ing. New, often unexpected, partnerships have formed bringing further disruption — and
novel advantages. Yes, digital dentistry has been disruptive, but the abundance of positive
outcomes argues strongly that it has not been destructive.
© 2019 The Academy of Dental Materials. Published by Elsevier Inc. All rights reserved.
language into different languages, comparing product brands

1. Introduction for you, and much more [2]. Beds can automatically adjust
your position if you snore [3]. Sensors in babies’ diapers can
Digital systems are ubiquitous in our lives. Interconnectivity
track babies’ activities to alert you when the diaper needs to
has increased 1125% since 2000; in June 2019, 57.3% of the
be changed [4]. Nearly every device in your home, from win-
world’s population owned a cell phone with ownership reach-
dow shades to pet feeders, can be controlled digitally with a
ing over 80% in Europe, and North America [1]. With digital
push of button or voice control [5]. It is no surprise, then, that
assistants, your voice is their command; answering questions,
digital systems are becoming more and more commonplace
ordering food, arranging a car to drive you, translating spoken
in dentistry.
E-mail address: edr1@nyu.edu

https://doi.org/10.1016/j.dental.2019.08.103
0109-5641/© 2019 The Academy of Dental Materials. Published by Elsevier Inc. All rights reserved.
Please cite this article in press as: E.D. Rekow. Digital dentistry: The new state of the art — Is it disruptive or destructive? Dent Mater (2019),
DENTAL-3419; No. of Pages 16
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3.1.1. Intraoral scanners

2. Early drivers of digital dentistry With on-screen images, explaining treatment opportunities
to patients is simplified. Patients appreciate the more com-
Historically, digital advances had three foci: CAD/CAM sys- fortable data-acquisition process. Space-demanding plaster
tems, imaging, and practice/patient management systems. casts/models are replaced by easily archived digital files. Data
CERECTM , the first commercially available in-office CAD/CAM can be replayed at any time for a host of different reasons.
system, made possible delivery of same-day restorations [6]. A Drawing from comprehensive data for the 11 intraoral
laboratory-based system, ProceraTM , was introduced at about scanners featured at the 2017 International Dental Show and
the same time [7]. Together, these systems catalyzed both evo- available updated information from suppliers, scanner fea-
lution of new materials [8] and development of multiple other tures are summarized below [13–27]:
CAD/CAM systems [9].
Early drivers in imaging include both the intra-oral imag-
ing systems integral to the CERECTM system and evolutions • Time required to scan one full arch: 1–10 min (with the
in digital radiography. First introduced in the late 1980s, dig- majority at 1–3 min)
ital radiography has transformed the field, enhancing image • Tooth coating necessary: not needed for 8 of 11
quality, evolving from phosphor plates to solid state detectors, • Capture of occlusion possible: all systems
cone beam computed tomography (CBCT) and new genera- • Capture images in color: 4 of the 11 capture in color; 7 cap-
tions of intra-oral scanners [10]. ture only in black and white
Practice management software makes possible capture of • Enable shade selection: possible for 3 of the 11; 6 include
patient demographics, scheduling appointments, interaction color capture of image
with insurance companies, initiating and tracking billing, and • Scanner wand weight: 2.5–17.6 ounces; 6 of the 11 are under
generating reports. In parallel, electronic patient records, a 10 ounces
digital version of patient-centered clinically-oriented infor- • Scanner dimensions: 0.4–2.9 square inch in the tip area;
mation, motivated changes in tracking patients’ health, 8–10-in. length
facilitating quality of care assessments, and mining data for • Depth of field: direct contact to 15−18 mm; one images from
research, including evaluation of efficiency and efficacy of 7 to 22 mm.
clinical procedures [11]. • System configuration: carts, portable (hand-held/tablet),
In parallel, other technologies influenced and enabled integrated into the dental chair; multiple configurations are
innovations in digital dentistry, often at a remarkable available from most manufacturers
pace. While not a comprehensive list, these technologies • Wireless connection: available in most
undoubtedly include sensor miniaturization, artificial intel- • Open/closed architecture: all systems have open architec-
ligence, augmented and virtual reality, robotics, 3D printing, ture; 2 also offer closed architecture
telehealth, big data, interoperability, internet of things, nano-
technology, quantum computing, biomedical engineering, Accuracy and trueness between scanned data and refer-
cost of data storage, connectivity, and others. Many are tech- ence data have been comprehensively studied. Results, even
nologies we never imagined and words we didn’t even know with scanners that are earlier designs, show small differences
20 years ago. between intraoral scanned data, extraoral scan data, and data
from conventional impressions/models though all are within
acceptable limits for clinical use [28–31]. Not unexpectedly,
sharp corners, powder coating, and long cross-arch spans can
3. State of the art of digital dentistry — now influence the accuracy [32]. Scan pattern may influence accu-
and in the near future racy [33] or not [34], depending on study design and which
scanners were used.
Unquestionably, dentistry today is changing. To some degree, The major concern, however, is whether or not the restora-
digital systems permeate and/or enable almost every- tions produced based on intraoral scan data are equal to
thing in dentistry (Fig. 1). Modern systems are user- and those produced from conventional impressions. Most stud-
patient-friendly, versatile, and clinical assets [12]. While ies found no difference in margin fit of restorations produced
the scope of digital systems is immense, those discussed by these two approaches to data acquisition [35–43]. Preci-
below focus primarily on those that have implications and sions of internal fit of conventionally and digitally imaged
opportunities for developments and innovations in material cross-arch prosthesis were slightly worse for the digitally pro-
science. duced but still were deemed to be ‘not beyond the range of
clinical prestige’ [44]. At least one investigation reports bet-
ter marginal fit with digital scans although the differences
3.1. Scanners are both within conventionally acceptable limits [45]. Digitally
fabricated 3-unit ceramic frameworks fit better than conven-
Today’s scanners, both intraoral and laboratory-based, trans- tionally fabricated metal framework [46].
formed restorative dentistry. Real-time imaging proves Unfortunately, it is difficult to definitively compare results
on-screen digital images of single or multiple teeth, whole across different studies. Between April and July 2017, 2093
arches, opposition arches, occlusion, and surrounding soft tis- publications appeared in peer- and non-peer reviewed
sue. sources. Of these, 183 had full text and only 34 contained
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Fig. 1 – The reach of digital dentistry.
sufficient detail for in-depth review of accuracy of digital tech- plinary restorations. It enables and facilitates communication
nologies for scanning facial, skeletal and intraoral tissues between clinicians and the laboratory. Importantly, it also is
[47]. Testing and evaluation standards, or at least agreement critically important in pretreatment discussions with patients,
between major institutions, are needed. involving them in choices that affect esthetics and estab-
lishing realistic expectations the patient has for treatment
3.1.2. Laboratory scanners outcomes [54–58]. Interestingly, some investigators report that
At least 20 laboratory-based scanners are currently available, other general-use image-processing software, not integrated
capable of scanning either stone casts or impressions. All have into CAD packages, yield similar or more comprehensive smile
accuracies of at least 15 ␮m and are widely used in office- analysis [59,60].
laboratory workflow [48–52]. Tooth form libraries provide general tooth form and propor-
tions, enabling partial automation of restoration design and
3.2. CAD/CAM systems speeding digital ‘waxing’ [61]. Both tooth form and color are
critical to patient satisfaction. Digital photographs can be cal-
CAD/CAM systems revolutionized designing and fabricating ibrated for color and white balance and then mapped onto the
restorations, models, and other appliances. Pioneering efforts virtual image obtained by intraoral scans [62,63]. Virtual teeth
of the early systems could fabricate only inlays. Now, there models with more detailed photograph-based color informa-
seems to be no limit in the types of restorations that can be tion facilitates shade matching and enables patient-clinician
produced, ranging from simple inlays to digitally designed co-decision making about the final restoration [62]. The impact
and fabricated full dentures, orthodontic appliances, study on final shade selection of intraoral scans captured in color
models, implant-related components, and both simple and may be able to eliminate the integration of photographic infor-
complex surgical guides [9]. Introduction of open architecture mation, but this has yet to be widely reported. It is unclear that
has redefined how and where data flows to design to fabrica- CAD software can automatically compensate for shade varia-
tion, creating ingenious pathways (discussed below). In 2019, tions caused by manufacturing processes, cement choices, or
there were 252 CAD/CAM related exhibitors at the IDS meeting underlying tooth structure.
[53]! This precludes creating a comprehensive list of CAD/CAM Occlusion is a critical factor in restoration design and
systems. Instead, innovation in design prowess and shift from longevity as well as patient satisfaction. Jaw dynamics cap-
subtractive to additive manufacturing is the focus of the fol- tured by cone beam computed tomography (CBCT) or an
lowing discussion. intraoral scanner create a virtual articulator [64,65]. Captur-
ing the full range of static and dynamic jaw movements
3.2.1. CAD/Design software enhancements and occlusion, the data can be integrated with smile design,
Integration of data from multiple sources in combination with computer-assisted implant planning, and digital maxillofa-
improved user-interface and CAD software capabilities has cial surgery planning [65]. Unfortunately, integrating the data
opened important options. Software modules now include from multiple sources is not yet completely seamless, requir-
robust esthetic enhancements, including smile design, tooth ing interactive transfer of files between systems along with
form libraries, color matching, and tooth placement for den- user-interactions for superimpositions [65].
tures. Other enrichments integrate jaw tacking to improve and
automate components of dynamic occlusion [9]. 3.2.2. Additive manufacturing
Digital smile design integrates digital photographs of the Additive manufacturing, commonly referred to as 3D printing
face and software analysis to assist practitioners and lab- (3DP) is now a completely integrated option in CAM hardware,
oratory technicians in creating and planning a course of providing an alternative to subtractive machining (milling).
treatment, providing a virtual simulation of the final esthetic The most unique factor in additive machining is the flexi-
results. This is particularly valuable in complex, multidisci- bility of design. No longer must a solid block be the starting
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point for fabrication. Instead products are created layer-by- rication of dental implants by additive manufacturing found
layer, enabling a high degree of geometric complexity. Now, 1322 relevant papers but only 13 ‘qualified’ for the system-
products can be built with different internal geometries as atic review. One could conclude that a standard methodology
well as the desired topographic geometry. It is not yet clear for evaluating efficacy of additive manufacturing is clearly
that innovation in design of dental prostheses is capitalizing needed.
on this opportunity [66].
Although 7 different 3DP technologies are available [67–70],
four are most commonly used in dentistry: stereolithogra-
3.2.3. Workflow with CAD/CAM
phy (SLA), digital light processing (DLP), material jetting (MJ)
While the functional components of data acquisition, design,
and material extrusion (MD) although others are also being
and fabrication have not changed with modern CAD/CAM
explored [69,71,72]. InvisalignTM was one of the first to lever-
systems, the choices in how work flows through the pro-
age 3DP printing models with successive tooth positions upon
cess has changed dramatically. Open architecture of digital
which orthodontic aligners were fabricated [73]. Today, 3DP
systems created new opportunities. Rather than closed sys-
can deliver an exceptionally broad range of dental ‘parts’,
tems where all the functional components were incorporated
including everything from simple models, wax forms, tooth
into a CAD/CAM system, now functional components from
colored temporaries and surgical guides, to more complex
different manufacturers can be selected and linked by the
long-term metal and ceramic prostheses and digitally man-
user. This permits the processes of creating restorations to
ufactured full dentures [9,74]. Depending on the system,
be distributed to best meet the interest, capabilities, and
material choices include glass ceramics, cobalt chromium,
skills of those contributing to fabricating dental components.
composites, PMMA, Resin/polymers, wax, titanium, zirconia,
Fig. 2 demonstrates how work may flow through different
with ever more choices becoming available with new material
channels, each of which is capable of producing high qual-
innovation [9,71].
ity restorations/prostheses. Digital workflow has shown that
The quality of 3DP products is at least equivalent to those
the time from data acquisition to final product is shortened
produced by more conventional methods [75,76]. Among a
with digital workflow with greatest savings in laboratory time
host of specific studies, 3DP interim crowns fit better [75,76],
[88,89].
drill guides are accurate to within 0.25◦ of planned implants
[77], occlusal splints had comparable polished surface and
similar wear [78]. Trueness of external surface, intaglio sur-
face, marginal area, and intaglio occlusal surface of 3D zirconia
printed crowns was ‘no worse than the corresponding milled 4. The digital virtual patient as an enabler
crowns’ [79]. Custom-made templates and craniofacial pros-
theses yield good esthetics and better prosthesis fit than The integration of data from multiple digital technologies
traditional methods [80]. changes the scope of what is possible. The digital patient data
One particularly interesting in-vivo study reports degree of is vital in computer-assisted surgery/dynamic surgical navi-
comfort and satisfaction for twelve patients given two sets gation, robots performing dental procedures, CAD/CAM and
of removal full dentures fabricated with CoCr bases, one 3D new approaches to one-appointment restorations, and tissue
printed and one fabricated with conventional methods [81]. engineered scaffolds.
The patients rotated wearing the dentures. At the end of the The digital patient is created by integration of facial data
study, only one patient preferred the conventional denture from photographs or various 3D tracking devices, radiographic
and three had no preference. The 3DP denture bases, though information, intraoral image data, as well as other digital
identical in material and design, were harder, denser, and data that may be appropriate (e.g., CBCT scans, etc.). Using
had better microstructural organization. They had better clasp the virtual patient as a platform, enables development of a
retention and denture stability due to higher yield strength digital treatment plan, on-screen design and simulation of
and ultimate tensile strength. procedures such as design of restorations, surgical navigation
3DP plays an essential role in diagnostics and treatment for implant placement or craniofacial (and other) surgeries,
planning as well as enhancing patient communication, skills and virtual models for education and communication with
training, and maxillofacial surgery [82,83]. Low-cost printers a patient [90–93]. Creating the virtual patient reduces errors
may be a realistic alternative for in-house production. They that can be introduced when using conventional approaches,
can produce clinically acceptable provisional crown and bridge decreases time required for planning, and increases intuitive-
restorations [84], full arch models [85] and digital copies of ness [91,94]. In addition, the virtual patient permits clinicians
plaster orthodontic models [86]. These create realistic models and technicians to digitally model and evaluate multiple con-
with sufficient dimensional integrity for various applications figurations and solutions more easily than with conventional
[82]. They are also successful in creating face masks for face approaches which may introduce damage to models, have
transplant, assuring donor resemblance without risk to the limited breadth of 3D data available, and require tedious man-
allograft [87]. ual manipulations. In orthognathic surgeries, for instance,
Importantly, adding 3DP to digital dentistry opened the planning with the virtual patient allows high precision and
door to new material innovations. To date, after a comprehen- optimization of each treatment phase resulting in more accu-
sive review by Galante et al., it can be argued that additive rate orthognathic results [95,96]. If desired, CAD/CAM systems
manufacturing of ceramics for dental applications remains can directly design and fabricate prostheses, surgical guides,
understudied [71]. Another reviewer’s search relating to fab- models, or other structures.
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Fig. 2 – Workflow for modern, open-architectures CAD/CAM systems.
4.1. Computer-assisted surgery/dynamic surgical more accurate, minimizing surgical injury, especially in deep
navigation anatomical areas [99,100].
A logical extension to dynamic surgical navigation is made
Computer assisted surgery is yet another of the remark- possible with mixed reality, integrating aspects of both vir-
able opportunities enabled by digital technology. With this tual and augmented reality technologies, further enhancing
approach, a navigation system, similar to global positioning human visualization. Virtual reality makes images seem real,
systems, tracks the position of a surgical device in real time even though the environment is synthetic, created through
(e.g., endodontic file, implant placement, scalpel). The device the combination of virtual reality equipment (e.g., Google
position is projecting onto the digital image of the anatomic Glasses; https://vr.google.com/) and a computer. Mixed real-
area of interest, providing guidance to the clinician/surgeon, ity integrates the real environment int the virtual space, fusing
helping him/her in real-time to follow the anticipated path- the two [105]. One demonstration of this approach is described
ways and recognize possible interference with tissue adjacent in detail by Kubota and Yoshimoto [105] and can be viewed at
to the treatment area. Today’s most commonly used optical https://www.youtube.com/watch?v=EGhq WRbj-w.
tracking systems are based on capturing the position of a
series of light emitting diodes mounted on a surgical device.
In 2017, the United States’ Food and Drug Administration
approved a computerized navigation system (YOMITM ) which 4.2. Robots already in dentistry
provides robotic guidance to augment clinician’s skill and pre-
cision for implant surgery [97]. Non-dental proliferation of robots has been astounding. They
Details of using dynamic surgical navigation dental pro- autonomously deliver packages [106], perform a host of func-
cedures, including trauma and facial reconstruction, have tions in manufacturing and research, and a pair of robots have
been described by Landaeta-Quinones, et al. [98]. Site-specific been shown to assemble flat-pack furniture in less time (and
cranial-facial surgeries have been detailed by Guo and Cai et al. with no arguments) faster than humans [107]. Elementary-
[99,100]. and middle-school aged children build and compete with
In a systematic review, positioning accuracy of both dental LEGOTM -built robots [108].
implant horizontal apical and angular deviation was shown Robotics have been adjuncts in medicine since 1992. One
to improve with surgical navigation [101]. Augmented reality major company shipped 5770 robotic surgery systems in 2017
navigation results in smaller horizontal, vertical and angular [109]. In 2017, an estimated 877,000 robot surgical procedures
errors in central incisors and canines than was achieved with were performed [109]. In addition to surgical support, robots
traditional 2D image-guided navigation [102]. In endodon- also serve medicine as physician assistants, provide a telep-
tics, surgical navigation is safe, minimally invasive for root resence as well as aiding in rehabilitation robots and medical
canal location and prevention of technical failure, espe- transport, sanitation and disinfection, and prescription dis-
cially in anterior teeth with pulp canal calcifications [103]. pensing systems [110].
In computer-assisted maxillofacial surgery, positioning accu- Robotics utilization in dental applications have been less
racies have been reported to be <1 mm in an ideal setting prolific in dentistry. In 2001, a remotely located but human-
and between 2 and 4 mm in a real-life surgical setting [104]. controlled robot removed caries, completed a crown and
Serendipitously, dental implant placement surgery was also bridge preparation, and performed endodontic therapy [111].
faster [102]. In craniofacial surgery, using a navigation sys- Robots’ tooth preparation skills have been tested, showing
tem makes the surgery not only faster but also safer and that a robot’s laminate veneer preparations and crowns are as
accurate as those of human clinicians [112–114]. However, the
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crown preparation was done with lasers that required unreal- While already used in an array of applications, scaffold
istic cutting times [113,114]. use has recently also focused on inter-dental scaffolds. Vas-
Wire-bending robots for orthodontic wires were introduced culogenesis in root canals is successful, even fabricated with
around the turn of the century [115]. Recently, a mobile a hand-held bioprinting system [126]. Micro-patterns of the
wire-bending machine was introduced [116]. Using intraoral human dentin-pulp complex have achieved more than 88%
scan data, this mobile system can create a fixed orthodontic viability [127,128].
retainer wire in only four minutes. The YOMITM robot for guid- Bio-inks, making it possible to integrate live cells and
ing implant surgery (described above) was approved for use in temperature-dependent pharmaceutical agents into scaf-
2017 [97]. In 2017 a robot dentist in China inserted two den- folds, have been demonstrated [129–131]. An enlighten-
tal implants to an accuracy of 0.2–0.3 mm in a live patient with ing summary discussing biocompatibility, printability, and
human supervision but with no intervention [117]. mechanical properties of extrusion-based bio-ink-printed
scaffolds is given by You et al. [132]. Zhu et al. describe
advances and challenges in inkjet dispensing technology
4.3. A different approach to one-visit crowns and
related to drug discovery [133]. While much has been done,
bridges
there is still much to learn about printing structures that
induce tissue and organ regeneration [134].
One of the advantages first described for CAD/CAM systems
It is impossible within the constraints of this manuscript
was chair-side one-visit restorations. CAD/CAM-produced in-
to give a complete summary of developments in this exciting
house can deliver a restoration in a single visit but doing so
field. Already in the first half of 2019, 49 articles referenced in
with ‘traditional’ CAD/CAM systems usually requires a rela-
PubMed focused on creating scaffolds and tissue engineering
tively long appointment awaiting design and fabrication of a
for teeth. Digital dentistry’s influence on scaffolds and tissue
final restoration. In 2017, a new approach was introduced that
engineering cannot be overlooked. Unquestionably it is a ripe
shortens appointment time while still delivering crowns and
field for material science.
bridges from the diversity of existing materials [118]. With this
FIRSTFITTM approach, digital impressions and bite registration
are sent to a laboratory along with shade and characteriza- 5. Other digitally enabled applications
tion descriptions — before the tooth or teeth are prepared influencing dentistry
for a restoration. Laboratory-based CAD software designs the
preparation and then designs and prints three sets of 3D sur- Other digitally enabled applications influence dentistry
gical guides for preparing the tooth (one guide each for buccal, include innovations in technology-enabled health monitoring
lingual, and occlusal surfaces). At the same time, the definitive and care; telehealth; the confluence of forensics, epidemiology
crown or bridge is designed and printed (usually from zirco- and artificial intelligence; and evolution of and innovation in
nia). Only then are the guides, a unique burr, and the final dental education. Often overlooked, these are likely to have a
restoration sent to the dentist who prepares the patients tooth profound effect on the future of dentistry and on us personally.
by sequentially placing the guides on the tooth/teeth, running
the burr through grooves in each of the three guides, and then
5.1. Technology-enabled health monitoring and care
immediately seats a finished/final restoration. In case a clin-
ician is skeptical about the design and/or restoration fit, the
Modern devices track activity, health, fitness, and environ-
laboratory also sends a stone model of the patient’s dentition
mental factors continuously, without interrupting daily life.
so that he/she can practice the technique and confirm that
And they are becoming increasing more sophisticated and
the intra-oral preparation meets their demands and expec-
popular. The extraordinary evolution and proliferation of
tations. One must wonder what influence this may have for
wearable devices has been enabled by advances in minia-
the future. How will unanticipated intracoronal pathologies be
turization of flexible electronics, electrochemical biosensors,
managed? Will preparations be completed by assistants and
microfluids, and artificial algorithms [135]. Already by 2014,
only confirmed as acceptable by a dentist?
over 100,000 health apps were available for IOS and Android
software [136]. Globally in 2018, 172 million devices were
4.4. Scaffolds and tissue engineering shipped. Of these, 53 million were smart watches 2018 [137].
The diversity in types and capabilities of devices in
Data acquired by cone beam computed tomography (CBCT) remarkable. Devices can extract data from contact with epi-
and other digital imaging techniques married with 3D print- dermal, ocular, intracochlear and dental surfaces [135]. Many
ing has significantly influenced tissue engineering [119–121]. capitalize on artificial intelligence to offer real-time micro-
Transforming craniofacial reconstruction over the last two interventions to minimize or preclude disease. By way of
decades, this integration has open new options for complex examples, consider the following. At least one wearable gar-
craniofacial reconstruction through personalized scaffolding ment, that is washable, can track ECG and heartbeat, stress,
constructs based on individual patient-specific anatomical fatigue, QRS events, heart rate recovery, breathing rate, ven-
data [121,122]. Site-specific topographic and internal geome- tilation, activity intensity, peak acceleration, steps, cadence,
try, interconnected pore structure as well as mesoscopic and positions, and best sleep [138]. Contact lenses monitor glucose
macroscopic porosity, can all be tailored to patient/application levels, smart pills monitor medication intake behaviors and
needs [123,124]. Scaffold properties, such as stiffness, can be body responses; wrist bands monitor heart rate, blood pres-
tuned to site-specific requirements [125]. sure, calories burned; insole sensors measure weight bearing,
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balance and temperature [139–144]. A wearable ECG moni- the need of health care of people in care homes and in prison
tor, embedded in clothing, can record over 20 million data [157,158]. In 2017, the American Dental Association added tele-
points each day, giving a medically accurate electrocardio- dentistry codes to codes used for billing procedures [159].
graph trace and shares data directly with your doctor [145]. Clearly digital systems have had an impact. Patients and
Smart tooth brushes monitor and report effectiveness of clinicians both find advantages with telehealth. Telehealth
brushing and include games and feedback to teach children brings health to patients rather than requiring patients to
how to brush properly [146]. Smart spoon offsets hand tremors move to health centers for care – a critically important adjunct
(interchangeable spoon, fork, and key) [147]. for those where otherwise care would not be possible. In
underserved areas, it promises possibilities for care to be deliv-
5.2. Telehealth ered by an array of different health care providers who can be
meaningfully informed by experts at remote locations.
Telehealth Data from smart digital health devices can
be reported directly to clinicians/health care providers. 5.3. Forensics, epidemiology, and artificial intelligence
Not surprisingly telehealth is expanding rapidly. Telehealth
empowers patient-health care delivery, communications with The wealth of data contained in the digital data set is a gold-
both patients and for consultations with other professionals mine for both forensics and epidemiology. In forensics, it is
and brings health care into underserved areas and to people vital in assisting investigators in providing information that
with difficulty traveling to health care facilities. Additionally, it helps identify victims or perpetrators in natural and manmade
facilitates distance learning. In a word, telehealth dramatically disaster situations [160,161].
expands point-of-care options and diagnosis. Tracking prevalence and distribution of oral diseases can be
As with other digital areas, innovations in sensors, com- enabled by mining electronic patient records [162,163]. Prop-
puter prowess, and data acquisition are integrated into erly applied artificial intelligence, especially when combined
highly instrumented devices that open new pathways for with deep learning, can remove monotonous repetitive tasks
individual-health care provider communication. Because they from humans and do them quickly. As an example, IBM’s Wat-
can transmit high quality, high resolution data, realistic on- son can read 500,000 medical research papers in 15 s and, with
demand physical examinations and interface with a physician deep learning, can recommend diagnoses and most promising
virtually has become possible — and popular. As early as 2013, treatment options [164]. This is particularly valuable in tasks
a major health insurance company with 3.4 million members like interpreting radiographs and especially CBCT’s multiple
in its system, reported 10.5 million virtual visits [144]. image slices, caries detection, early detection and progres-
One handheld examination kit includes an examina- sion of various disease states, and a host of other questions of
tion camera, basal thermometer, otoscope, stethoscope, and epidemiological interest [165].
tongue depressor. An associated app provides a link for dialog
with a health care provider. The kit and app are commercially 5.4. Education
available for a cost of under $300 [148]. Charges for the video
consultation are usually lower than in-office visits. So, the Digital haptic and simulation systems have become important
patient doesn’t have to leave home to have an examination adjuncts in teaching dentally-related skills [166]. The real-time
and the cost of the ‘appointment’ with the physician is lower feedback through tactile sensation has been applied to locat-
than an in-person visit. ing carious tissue and injection technique [167,168], teaching
Other mobile systems integrate communication software insight into dynamic occlusion [169], locating cephalomet-
with real-time active input of patient clinical data. One, a ric landmarks [170], tissue compliance in surgery [171],
carry-on suitcase size mobile system, creates the ultimate and drilling for implant placement [172]. As schools strug-
portable practice, offering a breadth of diagnostic features gle with falling numbers of instructors, haptic systems
and capabilities including weight and height, stethoscope, become increasingly valuable by reducing faculty supervision
general exam camera, EKG, spirometry, vision, retinopathy, demands [173]. While valuable, learning is best optimized
hearing screener, ultrasound, portable X-ray, bone dentistry, through a combination of instructor and virtual-reality feed-
PACS (storage and access to images from multiple modalities), back, rather than one substituting for the other [174–176].
ABI (for diagnosis of peripheral vascular disease), colposcope, Second Life, an online virtual world with a social envi-
concussion testing, and dental examination. Incorporated ronment, can be considered as a learning supplement for
algorithms provide real-time language translation. With this pre-clinical teaching methods. Using 3D models virtual
dramatic array of compact mobile technology complete exam- models, students can more easily understand anatomical
ination capabilities are brought to the patient [149]. interactions that are difficult to observe in real life and it
In dentistry, telehealth has been used for a host of condi- appeals to digitally-savvy students [177].
tions/situations. These include remote screening, oral lesion Robot-based simulation systems programmed to simulate
diagnosis, management of dental emergencies for French a host of physiological conditions are useful in teaching dental
sailors [150], cephalometric analysis via smart phone [151], techniques as well as patient management [178]. One particu-
monitoring orthodontic treatment [152], screening of poten- larly interesting robot is SimroidTM [179,180]. It/she looks like
tially malignant oral disorders [153], diagnosis and treatment a petite woman in a pink sweater. Its teeth are fitted with
planning in mixed dentition [154], screening children in sensors and it cries out when a vital nerve is touched, gri-
underserved areas [155], providing support for dental health maces to show pain, and moves its/her hands and eyes to say
clinicians in rural or isolated locations [156], and screening for that ‘it hurts’. This robot simulates patient reactions and acci-
ARTICLE IN PRESS
dents during treatment, including reaction to pain, coughing, dropped from 25 min [187] to fractions of seconds, determined
vomiting reflex, irregular pulse, and irregular movements. by dosage calculations. Flat-plane images have been comple-
mented by intraoral scans, 3D CBCT, intra-oral scanning, plus,
in special situations, PET, MRI, and other imaging modalities
6. Digital technology can create strange
[10]. Drills/handpieces have morphed from flint tips found in
bedfellows
7500 to 9000 year old teeth [188] to bows operated by crafts-
6.1. Telehealth and Uber men [189] from foot-powered slow speed in 1864, when the
clock-work drill was invented to pedal-operated burr drill in
Three telehealth vendors have teamed up with Uber to give 1871, ultimately to air turbine high speed water cooled drills
hospitals and health systems a new way to deliver health care. first patented in 1949 [190,191]. Gloves for clinical procedures
In March 2018, Uber introduced UberHealth, a new business were not mandatory before the mid-1980, largely in response
line that provides a ride-hailing platform available specifically to HIV/AIDS epidemic, despite the fact that clinicians were
to healthcare providers [181]. Now, Uber Health and three tele- well aware of disease transmission long before that date [192].
health companies have joined to create a program whereby Materials and approaches to dental restorations have
care providers can arrange to have a telehealth kit delivered to changed dramatically over time as is well known to most read-
a remote patient or bring the patient to a local clinic that has ers of this journal. A broken tooth 6500 years ago was ‘restored’
telehealth capabilities [182,183]. Besides the obvious groups with a simple wax cap, the oldest recorded dental filling [188].
that can capitalize on this arrangement, it could be extremely A book with systematic description of dental diseases and
valuable during natural disasters, accidents and battlefields. their treatment existed in Roman Imperial times between
25 BC and 50 AD [193]. Missing Roman teeth were restored
6.2. ‘Do-it-yourself’ orthodontics and pharmacies with gold wire supporting a replacement human tooth with
evidence that both steel and ivory were also used. There
Driven by digital information and computational prowess, have been remarkable improvements in material choices and
digital photography, intraoral scanners and additive manu- techniques over time. Perhaps the three most revolutionary
facturing, ‘do-it-yourself’ orthodontics is an alternative for modern advances are Buonocore’s 1955 introduction to the
working adults and those living in underserved communities feasibility of adhesive dentistry [194–196], Bowen’s resin-based
[184]. In many respects, it is an extension of telehealth. For composites [197,198], and Branemark’s understanding of the
this alternative, a patient’s intraoral scan is sent to a company induction and management of osseointegration [199,200].
that makes a series of aligners, step-wise moving teeth to the Throughout the ages, dentistry has survived and flourished
most ideal position. (It should be noted that the patient is also despite all these changes. Care and longevity of the teeth and
given the option of taking their own conventional impressions the oral-facial complex has improved. Digital dentistry has
by themselves with company-provided materials.) Some com- changed how dentists think and function. It has improved
panies have created their own scan shops or studios designed the patient’s experience. It has created a distributed work-
specifically for capturing intra-oral scans. One has established flow to capitalize on the best expertise for different functions.
relationships with two pharmacy companies in a host of major Unquestionably, the impact of digital dentistry is disruptive —
cities where intraoral scans can be captured [185]. but in no way is it destructive.
7. Digital dentistry — is it disruptive or 8. Opinions on digital dentistry’s

destructive? opportunities for material scientists
Change is accelerating. The transfer of narrative to hand- Digital Dentistry’s opportunities for material scientists are
written information lasted for 200,000 years. Handwritten extensive and far reaching. They range from capitalizing on
to printing lasted 4800 years, analog to digital lasted 540 additive manufacturing for developing new materials, devel-
years until the World Wide Web was invented in 1989/90. opments to improve and simplify restoration with implants
Now, a mere 30 years later, transformation to artificial intel- and innovations in scaffold materials and fabrication tech-
ligence and advances in neural networks is underway [186]. niques. Complementing these is the need for standardization
This latest transformation is fueled, in part, by the EU- of testing methods.
sponsored Human Brain Project’s $5.4 billion of funding to
“accelerate development and application of innovative tech-
8.1. Capitalizing on additive manufacturing
nologies to revolutionize our understanding of the human
brain, including development of humanoid robots equipped
Without question, the introduction of CAD/CAM systems has
with biotechnical neural artificial intelligence” [186].
greatly expanded material choices for dentistry. Additive man-
Dentistry has changed and will continue to change. Among
ufacturing has further broadened choices. Nevertheless, there
some previous disruptive changes, consider the following. Few
are areas that promise ever expanding opportunities.
clinicians would consider using cocaine toothache drops or
alcohol for anesthesia and now researchers are experiment-
ing with nanobots control nerve-impulse traffic, eliminating 1 Unquestionably, ceramics have become the patient’s choice.
sensations [179]. Since its discovery in 1895 and the first Currently, the monolithic color of ceramic blocks demands
dental application in 1896, radiography exposure times have technician-delivered esthetic artistry. In the future, additive
ARTICLE IN PRESS
manufacturing should make it easier to locally vary color for

esthetics and characterization.
9. Summary
2 Strength and fracture resistance of layered brittle materi-
als can be improved with introducing functional gradients Digital systems are pervasive in our personal and professional
[201]. Additive manufacturing offers the potential for intro- lives. In dentistry, a core digital data set of patient records,
ducing functional gradients into restorations as part of the radiographs, photographs, and intraoral scans is the platform
normal fabrication process. revolutionizing clinical activities, enriching patient-clinician
3 Prosthesis design remains unchanged from conventional and interprofessional interactions, transforming education,
designs controlled by subtractive manufacturing. Inno- and enhancing practice management. An exponential rate of
vations in the internal geometry, possible with additive innovation has and will continue to deliver technologies we
manufacturing should be considered and tested. never dreamed of. As lines between physical, digital, and bio-
logical spheres blur, collaborations of computational design,
additive manufacturing, materials science, and synthetic biol-
8.2. Implant materials, design, and surface
ogy will unquestionably help shape the future. Opportunities
for evolution and innovation in material science are excep-
Dental implants have a long history of success, though that
tional.
success is often affected by unacceptable loading conditions,
Digital innovations have unquestionably disrupted den-
insufficient bone, and disease processes. Areas for potential
tistry. With these innovations, patient experience has
investigation may include:
improved. More restoration options are available delivering
longer lifetimes, and better esthetics. Fresh approaches are
1 Miniaturization of sensors may make if feasible to integrate bringing greater efficiency and accuracy, capitalizing on the
sensors into an implant that could report over-load condi- interest, capabilities, and skills of those involved. New ways
tions or other factors that might affect implant longevity. for effective and efficient interprofessional and clinician-
2 With additive manufacturing, it may be conceivable that patient interactions have evolved. Data can be more efficiently
implants should no longer be solid but instead be more mined for forensic and epidemiological uses. Students have
nearly like a scaffold, permitting ingrowth of tissues into the fresh ways of learning. New, often unexpected, partnerships
boney supported area of the implant itself as a component have formed bringing further disruption — and novel advan-
of osseointegration. tages.
3 New materials and/or surface features may be appropriate Is digital dentistry disruptive? Absolutely. Is it destructive?
for implants, further optimizing the human-implant inter- Absolutely not!
face.
8.3. Scaffolds Funding
Much has been done and is understood about materials This work did not receive any specific grant from funding
and tissue response across length scales. New fabrication agencies in the public, commercial, or not-for-profit sectors.
approaches might expand their applications, leveraging what
we already know to create new opportunities.
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Digital Dentistry: The New State of The Art - Is It Disruptive or Destructive?

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Digital Dentistry: The New State of The Art - Is It Disruptive or Destructive?

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DENTAL-3419; No.

Available online at www.sciencedirect.com

journal homepage: www.intl.elsevierhealth.com/journals/dema

Digital dentistry: The new state of the art — Is it

language into different languages, comparing product brands

E-mail address: edr1@nyu.edu

3.1.1. Intraoral scanners

Fig. 1 – The reach of digital dentistry.

Fig. 2 – Workflow for modern, open-architectures CAD/CAM systems.

7. Digital dentistry — is it disruptive or 8. Opinions on digital dentistry’s

manufacturing should make it easier to locally vary color for

8.3. Scaffolds Funding

Med 2016;13:612–21, https://www.medgadget.com/2018/02/liftwares-smart-

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