The Role of High Technology in Maintaining Esthetic Restorations

J O U R N A I . OF E S T H E T I C D E N T I S T R Y

The Role of High Technology in Maintaining Esthetic Restorations

R O N A L D E . GOI.DSTEIN, DDS‘ MARILYN C . MILLER, DDS, FAGD’

wo of the major goals of T esthetics in restorative dentistry involve pleasing the patient and obtaining the longest possible life for esthetic restorations. It has become increasingly apparent that various areas of high technology have not only changed the way that we practice restorative dentistry, but also have a great deal to offer in helping obtain the goals of esthetic dentistry. This article addresses the basic forms of high technology that provide dentists a greater opportunity to render more efficient and longer-lasting service to patients who wish to have the ultimate in esthetic dentistry. Preston recently said, “The computer offers a knowledge and communication resource that sur- passes anything previously available. Its routine acceptance into the dental practice is inevitable.” The problem is that it has taken too long for dentistry to incorporate the various aspects of computerized technology, with the result that patients are not receiv- ing the quality of service that they otherwise might. Many esthetic failures can be prevented if various

aspects of the technology men- tioned in this article are used. It is, therefore, hoped that a review and suggested usage of various devices will enhance our ability to meet the goals of both esthetic and restorative dentistry.

I N’I’K A 0 R A I. C A M EK A S

To date, the intraoral camera is the clinical electronic device most widely accepted throughout dentistry. lntraoral cameras give patients a “tour” of their own mouths and a clearer understanding of any problems than can be achieved with radiographs, sketches, or casts. Although only about 25% of dental practices now have intraoral cameras, within the next few years that number should dramatically increase.

All intraoral cameras use a charged coupled device (CCD) chip to pro- duce an image. Cameras may be either analog (producing a continu- ous video signal that may be viewed on any television monitor) or digital (with a computer-processed signal that produces an image that must be viewed on a computer monitor).

Cameras may have a fixed focus or may be manually adjusted. If the depth of field is great enough, the camera will accommodate to differ- ent focal lengths without adjustment and may be referred to as “self-focusing.’’

Most cameras offer a 180-degree lens that is considered universal. Although such lenses suffice for many anterior images and open mouth occlusal views, they are usually augmented by a 90-degrec lens that allows close-up views of posterior teeth and palatal views. For maximum utility, a camera should be able to focus on a single tooth, as well as capture the entire arch.

Today, many camera systems provide a defogging air flow, whereas others rely on solutions for pre- warming. Most cameras have a fiber optic light source that trans- mits light to the area being imaged; others rely on external sources, such as the dental light. Computer storage of images is also possible with some systems. A color film printer is a desirable accessory,

‘Chical Professor of Oral Rehabilitation, School of Dentistry, Medical College of Georgia, Augusta, Georgia: Adjunct Clinical Professor of Prosthodontics, Coldman School of Graduate Dentistry, Boston University, Boston, Massachusetts; Visiting Professor of Oral and Maxillofacial Imaging and Continuing Education, School of Dentistv, University of Southern California, Los Angeles, California; Adjunct Professor o f Restorative Dentishy, University of Texas Health Science Center. Sun Antonio. Texas; and Private Practice, Atlanta, Georgia +Co-director, Center for Dental Information, Princeton, New Jersey

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since photographs can be produced for patients to take away as a reminder of what they must do to preserve their restorations.

Portability is another important consideration. Most camera systems are supplied with bulky carts; however, some are easily carried from room to room, providing greater flexibility of use. Still others offer the option of multi- operatory integration, with only a camera and monitor in each operatory and all peripheral devices housed in a central location.

The primary use of the intraoral camera is diagnostic. A secondary but no less important purpose is as a communication aid to patients regarding the diagnosis. The uses


of intraoral cameras for prevention and maintenance in esthetic dentistry are four-fold:

1. Following insertion of restorations, there is an advantage to being able to track any problems by periodic video examinations utilizing the intraoral camera. Visible and sometimes invisible potential marginal problems can be greatly enlarged. Certainly the ability to diagnose and treat a defective margin as early as possible can prolong both esthetic and functional life of restorations (Figure 1 ).

2. Patients cannot see for them- selves what we can see; thus, highly enlarged views made available by intraoral cameras enhance patient compliance in

Figure 1 . patient the existence o f both gingivitis and a defective crown margin caused mainly by inadequate home care.

This composite o f four intraoral pictures was used to show this

home care. Typically, patients wait until something is sensitive before seeking treatment. Periodic examinations utilizing the intraoral camera can play a significant role in prevention of inevitable esthetic failure due to marginal pathology.

Intraoral cameras can and should also be used to show patients areas of their mouths that lack proper hygiene maintenance. For example, enlarged lingual views give patients the opportunity to see the inside of their mouths like never before. Most systems can show both intraoral and angular viewing of the posterior and occlusal as well as the lingual, and some have a separate camera for the front view (Figure 2).

One of the most frequent causes of restoration failure is lack of gingival hygiene, with both flossing and brushing. When images of the mouth are magnified while the explorer is used to remove plaque from the sulcus, patients become visually aware of the importance of ongoing maintenance. Restoration longevity is nor- mally expressed in averages. For instance, as noted in “Change Your Smile,” the restoration life expectancy for full crowns is 5 to 15 years. However, a patient should be aware that not even the normal

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Figure 2 . Some intraoral systrms possrss two cameras, one for direct frontal cwws and another right-angle canera for posterior or lingual siews (insight Imaging System, Inc.. Sari Carlos, California).

baseline for assessing subse- quent staining or changes (Figures 3 and 4). It is easier and more dramatic to photograph microcracks with the intraoral camera than with standard 3.5 mm photography.

4. The intraoral camera can be used to magnify and photograph areas of obvious bruxism. Wear facets can and should be photographed and shown to thc patient with the patient duplicating the occlusal movements, especially in eccen- tric positions to demonstrate how the facet was produced (Figure 5 ) . Most patients deny tha t they clcnch or grind their tccth. Rather than argue with patients, which produces a negative response, it is far more effective to show them exactly

range of life expectancy will be achieved unless these gingival areas are maintained on a daily basis.

3. Intraoral cameras are also highly useful in showing patients existing microcracks. These microcracks can stain and cause other esthetic problems for patients. Photographs and permanent records of these microcracks can be of trernen- dous benefit to the patient in accident cases. Documentation of microcracks also provides a Figure .3.

microcracks in the central incisor. This full view intraoral image clearly reveals the presence of

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with manufacturers, each with its own advantages and disadvan- tages. System selection is usually based on individual preferences.

Most systems allow for image modification of almost any esthetic procedure. Examples include clos- ing diastemas, bleaching or veneering teeth, altering tooth form, or showing the patient the results of orthodontic treatment. Changes that are represented to the patient must be realistic, and it must be emphasized that the image is a goal, not an exact replication of treatment results.

Besides alleviating a patient’s apprehension about proposed

Figure 4 . The intraoral Camera is extremely useful both in diagnosing and in communicating to the patient who bas stain under a porcelain laminate emanating from a lingual margin.

how the facets occurred. Although study casts can

large amount of computer memory, often a gigabyte-size hard drive or

treatments, imaging technology has many other uses* Patients who

accomplish this, nothing com- pares to showing patients “up close,” in their own mouths,

an optical disk is necessary. Software for these systems varies

grind their teeth should be imaged and the proposed esthetic correction shown following cosmetic

exactly what is happening.

COMPUTER I M A G I N G

Before any treatment has begun, esthetic or computer imaging has made it possible to graphically dis- play how patients can appear after esthetic correction. It takes the intraoral camera one step further, from chronicling the current condition to giving patients a look into possible future outcomes.

Generally, imaging systems consist of a computer, video camera, “frame grabber” (imaging board), graphics tablet, monitor, and printer. Since images consume a

Figure 5. he was destroying his enamel cusps through bruxism.

These intraoral images demonstrated to the patient exactly how

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contouring or reshaping of the natural teeth. These images can be compared in the future to see if the patient is continuing the habit that caused the problem. Although a nightguard appliance can often be fabricated to control the problem, imaging can demonstrate whether or not the patient is actually wear- ing it. The best evidence that it is not being worn may well be imaging of the patient at a later time. This permits the patient to serve as “co-diagnostician,” which helps ensure that the patient will not only be pleased with the results, but will also play a greater role in maintaining those results.

Another use of esthetic imaging is to show patients the effects of their failure to maintain their new esthetic restorations (Figure 6) . A verbal warning usually is ignored. A photograph or illustration can go a long way in helping the patient visualize what can happen. However, nothing communicates more effectively than showing a patient images of his or her own mouth to illustrate the potential destruction that can result from bad habits.

The longevity of esthetic restorations depends on the maintenance of the soft tissues and bordering supporting structures. Computerized charting systems enhance the capabilities of the dental team to detect changes in

Figure 6 . possible unesthetic effects of their failure to maintain their new anterior restorations.

Esthetic imaging is especially helpful to shout patients the

the periodontium by facilitating the collection and storage of periodontal diagnostic data, producing comprehensive graphic and numeric charts, and enabling dental professionals to easily track the dental condition of patients. At the most basic level, information about the periodontium, such as pocket depth, bleeding, and plaque scores, can be entered manually into the computer. Although having to collect the information by hand and enter it into the computer is still labor intensive, available software allows for fast and accurate comparisons of data not possible with a totally manual system. Voice-activated systems, thus, save time by eliminating double data entry, while maintaining the chain of infection control.

With this technology, the computer is able to recognize a limited, though sufficient, vocabulary to complete a periodontal examination. The more sophisticated systems are preprogrammed to recognize a wider speech pattern range and can be used by multiple practitioners who speak with dif- ferent dialects. One commercially available example is the Victor Voice Chart (Pro-Dentec, Batesville, Arkansas) (Figure 7 ) . The user wears a lightweight microphone headset connected to a computer that records information about the patient during an examination.

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the distance from the base of the pocket to that landmark, and the measurement is recorded using a foot pedal. Since the same relative landmark is used at each site during all examinations, comparisons can be made of measurements from area to area within the mouth. This information can be displayed on a computer screen, printed out, or stored for future comparisons.

Figure 7. periodontal charting system (Victor Voice Chart, Pro-Dentec) helps to scientifically place the obligation of home care maintenance squarely in the patient k hands.

This printout from a voice-activated general dentistry and

This permits the practitioner to examine the patient and enter data simultaneously without either an assistant or the need to touch a pencil or computer keyboard.

The easy-to-read graphic charts produced from these systems enhance patient education and understanding. Using these charts, the dentist can readily point out changes that have occurred between examinations and more simply explain the need for additional treatment or preventive regimens. Patients who understand clearly the current condition of

their mouths may be more recep- tive to these recommendations and more motivated to follow through with home care instructions.

Electronic periodontal probing systems, which are essentially semi-automated, make use of an optical encoder to scan and record pocket depth. These systems not only measure pocket depth, but also record supplemental periodontal examination information, such as gingival bleeding, tooth mobility, plaque scores, and furcation involvement. To measure pocket depth, the practitioner directs the probe to touch a predetermined anatomic landmark on the tooth or tissue. The computer then measures

In addition to facilitating charting and storage of patient information, new computerized diagnostic devices provide adjunctive tools to identify pathologies that may inter- fere with the preservation of esthetic restorations. The PerioTemp (Abiodent, Danvers, Massachusetts) records pocket temperature of a spe- cific tooth and determines whether it is at, near, or above the temperature of a comparable, normal, healthy one. The Periotest (BiqResearch, Milwaukee, Wisconsin) provides objective data about tooth mobility and implant stability by determining the deceleration of a force applied to a tooth or implant. This deceleration is propor- tional to mobility and the amount of periodontal support or osseo- integration. Another diagnostic device, T-Scan (Tekscan, Boston, Massachusetts), records the timing, location, and intensity of occlusal contacts, allowing practitioners to measure the dynamics of occlusion rather than evaluate the static condition alone.

DIGITAL RA DIOGK A P H Y

One of the new technologies that opens many windows previously unavailable to practitioners is digital radiography. The recorded image is instantly viewed, making it possible to rapidly assess the need for any adjustments. Because the image is encoded digitally, it can be manipulated electronically in many ways. Dental professionals have the power to remove extra- neous information, adjust contrast and density, zoom in on one or more areas, and reverse black and white - all to enhance the image. Often color may also be used. Although it has not been deter- mined whether color improves diagnostic capability, the color pic- ture makes an impression on the patient and potentially can have a significant impact on oral hygiene compliance. Already availablc in Europe, a digitized, panoramic machine will also be available in the near future for use by dentists in the United States.

Perhaps the most important benefit of digital radiographs to patients is that, depending on the modality and the application of the device, reductions of ionizing radiation may be from 50 to 90%. This reduced radiation, together with the ability to manipulate images, makes filmless radiography particu- larly useful during the try-in stage.

Without causing potential patient apprehension over repeated expo- sure to radiation, the dentist can quickly and easily evaluate the fit of a restoration and adjust and recheck it as necessary. Inter- proximal margins, for cxample, can be checked easily using digital radiography. Images taken during the final visit also can help illus- tratc maintenancr measures that the patient must take to preserve thr restoration.

Once images are acquired, they may be filed electronically using the computer hard disk or other storage media, such as optical disks or CD-ROM. They can also be sent by modem to a consulting dentist, reducing the time involved and eliminating the ncrd for patients to transport films from one dcntal office to another. Ruth practitioners can look a t the same images simultaneously, facilitating complex treatment planning. Images may he filed chronologically, recalled, and compared side-by-side while viewed on the monitor.

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Increasingly, the opcratory monitor is being used as a method for con- veying information to patients about procedures, follow-up, and maintenance. Video or CD-ROM programs, about 2 to 5 minutes in length, may be viewed during “down” time, while the patient is in the dental chair between each phase of treatment. This enables the entire appointment time to be

utilized more efficiently. Similarly, monitors in thc reception area and consultation room can provide educational programming. Depending on the system, patients may be able to select topics that intcrcst them from an interactive menu. Hy integrating education throughout the treatment, rathcr than relegating it to the end of each visit when patients usually are tired and eager to Icave, there is a greater likclihood that patients will pay attention and absorb the material. It is hopcd that they will realize that their on-going home carc is an integral part of their treatment.

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(hmputcr tcchnology has revolu- tionized the way thc world does business, allowing us to work faster, smarter, and m w e efficiently than ever before. Within dentistry, that translates to x-rays that use significantly smaller amounts o f ionizing radiation, automated periodontal charting and storage devices, and imaging systems. Perhaps the greatest bottom-line benefit, especially in esthetic dentistry, is that these state-of-the-art developments enable dentists and hygienists to more effectively com- municate with patients. The future of any restoration is based on thc patient’s motivation and ability to

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maintain an efficient oral hygiene routine. Esthetic restorations demand more vigorous home care programs to maximize their esthetic and functional life expectancy. With computerized images on screen, patients can better visualize the treatment that has been done and come to a real- ization that the restoration’s success rests squarely on their shoulders.

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Reprint requests: M.C. Miller, DDS, Center for Dental Infomation, 32 Nassau St., Princeton, N] 08542 81 996 Decker Periodicals

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The Role of High Technology in Maintaining Esthetic Restorations