(Dr. Hangorksy) Hello and welcome. One of the most exciting frontiers in innovations in dentistry has been the recent incorporation of computer controlled components in patients' diagnostic and clinical procedures. This computer- controlled approach to dental therapeutics is widely known as digital dentistry, and it has the potential to increase both the efficiency and effectiveness of clinical treatment resulting in better clinical outcomes. To explain this fascinating area in dentistry is Dr. Conejo, who is the Clinical CAD/CAM Director, the Department of Preventive and Restorative Sciences at the University of Pennsylvania school of Dental Medicine. He conducts research and has multiple publications in peer reviewed scientific journals on CAD/CAM technology, prosthodontics, and implant dentistry. Doctor Conejo has been the recipient of several awards in this field, including the international college of prosthodontist research fellowship in dental restorative materials in 2016 and has lectured in over 35 countries. Welcome Doctor Conejo. Well, Doctor Conejo, please tell us, what is CAD/CAM? (Dr. Conejo) Well, CAD/CAM means Computer-Aided Design, Computer-Aided Manufacturing. CAD/CAM dentistry started in the University of Zurich in Switzerland 35 years ago with Doctor Mormann and an engineer called Mr. Brandestini. They were able to develop the first same-day ceramic restoration. With this technology, we're able to take a digital impression directly from the patient's tooth or implant, then, in the software, design the restoration that is needed, and then in a milling machine, we will insert a block of different materials to create the final prosthesis. At Penn Dental Medicine, we have been working with chairside CAD/CAM dentistry since 2015. We have a dedicated lab called the Digital Design and Milling Center, where our students, residents, and faculty are able to design and mill out these prostheses for our patients. (Dr. Hangorsky) Can you please tell us what is innovative about this approach to clinical dentistry? (Dr. Conejo) Sure. There has been many changes in the world of CAD/CAM dentistry and digital dentistry, at least since the moment I started around 2010. At that time we were using the intraoral scanners already to make the final impressions to avoid the need of the conventional impression materials that are never attractive for patients. Once we scan, we were designing the restoration, whether it was a crown or a veneer, and then we were milling that restoration. CAD/CAM was something very related to prep, scan, design, mill, and deliver the restoration. Nowadays, the biggest development that I see is the integration of the technology from the intraoral scanners for diagnostic purposes. The latest iteration, intraoral scanners are able to help us diagnose caries, for example, and also we can track the changes in the patient's mouth through time. Let's say when we're trying to observe non-carious cervical lesions, where of the occlusal surfaces. Sometimes patients are not really understanding exactly those pathologies that take longer periods of time to really develop. This is also great that we can track through time overlapping the different scans. It's been a great use now, not only for production of restorations, but from the diagnosis point of view. Then the other concept that is growing a lot now is the aid of artificial intelligence. What we are being able to do now is not only digitize intraoral scans, but of course everything in the world of radiology where it's 2D or 3D images. We have the help of the same softwares providing us with very accurate information of different possible pathologies. Let's say I'm missing some interproximal decay, but the software is able to give me a warning and advice that there might be a pathology there, same in the periapical lesions. It's really amazing to see how it's come from just, let's say a restorative aspect to now a full integration in the different specialties of dentistry. (Dr. Hangorsky) Could you please tell us how this new technique will change and address the needs of the population? (Dr. Conejo) As I said this has been around for more than three decades now, and many patients that were in need of a single unit restorations - needed a crown, needed onlay - they were the group of patients, the population that were having the benefits. Nowadays with the possibilities of integrating these intraoral scans with for example implant planning softwares, now everyone in need to replace missing teeth are getting the benefit of this. Lately, we published with the team of radiology here at Penn on the digital clone and it's basically how we integrate the CBCT images with these STL files from the intraoral scans, even with a face scans, and then we can basically have a clone of our patient for better treatment planning. Now everything we do related on implant dentistry is with implementation of these tools that are very helpful to see better, to avoid or reduce the percentage of complications and they are great for patient communication because they are very visual. (Dr. Hangorsky) So I'm sure that the questions that many viewers would want to find out, is this technology very expensive? Will it be affordable to people who are seeking dental care? (Dr. Conejo) Yeah, I think that's a great question. It's very important to understand the costs and that will be one of the factors that will determine how a technology is really being implemented. I would say that for the first 15 to 20 years the CAD/CAM systems were very expensive. You would to have a very established practice with a high volume of indirect restorations per month to be able to acquire one of these CAD/CAM systems or the same for the laboratories. But nowadays, the technology is more open and there are very good competitors. Let's say it's more open for the clinicians to invest in what exactly they will be needing. Before, we had to invest on a scanner and a milling machine and a porcelain furnace because the systems were sold as one unit, which were very expensive. Now, let's say if you are in the world of Implantology and you would like to only get an intraoral scanner, and not being able to mill the crowns in house because that's not what you're doing, you can just invest on the intraoral scanner. Now we've trained from the early adopters to the late adopters, and we have more options so the costs are lower for the clinicians and for the dental laboratories as well. (Dr. Hangorsky) What are some of the therapeutic and scientific innovations which have been incorporated into this technology? What made this whole approach possible? (Dr. Conejo) Yeah. We were, at the beginning, being very effective on creating those final restorations in one appointment. We reduced the amount of times that the patient needed to come in for one procedure. When I started studying prosthodontics, to create a single crown, it was always maybe three to four appointments and nowadays with CAD/CAM technology and the improvements on the softwares we can scan, design and get those restorations in one appointment and that's something that we've been incorporating here at Penn Dental Medicine. With the support of our deans and department chairs, we were able to open the Digital Design and Milling Center. Now we have the infrastructure, we have the IT support, to be able to create those restorations in the same day. If we go back to the pandemic, it was of great help because patients didn't want to come so many times for one same procedure so we scheduled longer appointments, but we were able to complete the therapeutic needs in way less visits. That was something very nice to see - how these technologies help us go through these challenging times. Then, the other thing that has been very exciting is how we've been able to start collaborating with different departments. Let's say with a periodontics apartment and the restorative department, now we make intraoral scanners as initial impressions, replacing the use of the alginate impressions for the study models. And from there, we can create a digital wax up and that's what we share with the periodontal residents and faculty members, and that's where they start planning and discussing the possibility of implants or the need or not need of grafting. I think that has been something very positive. How we've integrated these technologies between the different departments as well. (Dr. Hangorsky) I'm sure you will have many dentists saying, "I get great outcomes with the techniques I have been practicing." Why should they invest in new technology and change it? Could you please tell us - Is there any improvement in the clinical outcome, in diagnostic outcome, if you use this technology? (Dr. Conejo) Sure. I've had this situation that many people have been doing conventional impressions for 20, 30 years and they're excellent at that, and that's great. What I really like about the possibility of making the digital impressions is that if I detect that there's an area on the preparation or in the margin around the soft tissue that is missing data, I can just dry the area, go back again, and scan for a few seconds, so I can correct or improve the impressions. As a prosthodontist, maybe you got a very nice impressions, but once in a while you can get a bubble or the material share. Then you had to repeat the whole impression. With digital technology, you can scan, evaluate it, and if you need a little more retraction or a little more detail in a specific area, you just go back and that's something that we see very, very useful, very helpful. We see it from the students, the residents, that makes it very, very attractive. Then other great advancement I see is that now we have the accuracy not only for single restorations or quadrant dentistry that we've been doing with CAD/CAM technology for many years. But now we have the possibility of scanning full arch digital impressions. Here we have another group, the edentulous patients, getting the benefits of this type of technology. We've been conducting research on full arch scanning on multiple implants, like the concept of All-on-4, All-on-5, All-on-6 implants. The latest research that we've been doing has shown that we are at a level of accuracy, even superior to the conventional open tray impression technique for full arches. That's very exciting and of course, we now need to keep training our colleagues and residents on perfecting the technique as everything in dentistry, we need to go through that learning curve. But the equipment, the technology is there right now. (Dr. Hangorsky) Do you find any improvements in also in diagnostic abilities? (Dr. Conejo) Yes. I was amazed when I had the chance to go to the IDS in Germany where they present the latest technologies, most of the different companies under scanners. Now, diagnostic is the big thing. Being able to view interproximal decay is something very useful. But of course, as clinicians, we always have more needs and always we want more. What I would like to see is to be able to have the possibility of scanning through the hard and soft tissues. Maybe in a few years we'll be talking that no more manual sounding and probing that we can, actually, with the scanner, implement some ultrasound technology and actually check the bone, check the ligament, and what we're not able to do at the moment. I think there's a lot of improvements to be made. That makes it pretty exciting. (Dr. Hangorsky) When you discuss the potential for future innovations, is there actually research being conducted in those domains? (Dr. Conejo) Yes, there is. We've had conversations here with the engineering department at Penn and Penn Medicine on what they are doing from the ultrasound technology. It's trying to be able to convert that into a smaller unit that can be used inside the patient's mouth. That's something I'm looking forward to be able to have these scanners replace the need of extraoral X-rays, of CBCT images, and just capture the data that you need, not only from the outside, but also from the inside that we need. (Dr. Hangorsky) Thank you, Dr. Conejo. This is very exciting. Thanks for coming here. (Dr. Conejo) Thank you, Dr. Hangorsky for having me.
