Dental professionals who will be leaders in years to come require an education that encompasses the techniques and technology that are on the verge of transforming the field. Enter the ever-growing advances in digital dentistry, and to that end, the School of Dental Medicine’s Digital Innovation Initiative, aimed at fully integrating the latest in digital dental technologies at almost every stage of education and patient care.
Two gleaming new spaces in the lower level of the school’s Thomas Evans Building opened earlier this year and mark an evolution toward embracing digital dentistry and workflow across the school. With state-of-the-art equipment, the new Digital Design and Milling Center and the Center for Virtual Treatment Planning, together with new staff and curriculum changes, open up possibilities for training students, conducting research and continuing education, and delivering seamless and cutting-edge patient care.
“The many types of digital technologies working together is the key to effective application and outcomes in patient care and education, and that is our goal,” says Markus Blatz, professor and chair of preventive and restorative sciences and assistant dean for digital innovation and professional development. Blatz has championed and leads the school’s Digital Innovation Initiative.
“Scanning teeth with optical scanners and fabricating dental restorations with digital technologies has become very common. Now, we have additional technologies, from electronic health records to face scans, that help us right from the beginning, with diagnostics, treatment planning, and restoration design,” he adds. “All this information interconnects, making it much easier to include all dental specialties and even artificial intelligence tools in the treatment planning process. This, I think, is one of the big advantages of digital dentistry.”
Building a digital design team
Ever since joining Penn Dental Medicine’s faculty in 2006, Blatz has worked to integrate digital technologies into many aspects of the school’s operations, notably in his areas of expertise: materials science, prosthodontics, and esthetic dentistry.
Recruiting expert faculty was a key part of this effort. In 2008, Michael Bergler, who trained in Germany, joined the school, bringing with him years of education and practice as a master dental technician with extensive experience in both traditional laboratory methods and computer aided-design and computer-aided manufacture (CAD/CAM) technology.
“My philosophy in life is that you can either go against the technology, and say, ‘I don’t want to have anything to do with it,’ or you can make yourself an expert and try to get as much knowledge as you can. This is what I did, because I saw such a big opportunity in doing so,” says Bergler, who is currently pursuing a master’s in digital technology at Germany’s University of Greifswald to stay on the top of the latest developments. “I’m highly motivated to share my experience with students and faculty.”
Together, Blatz and Bergler built the Penn Dental Medicine CAD/CAM Ceramic Center, formerly located on the third floor of the Evans Building, to enhance the school’s digital competencies in research, education, and clinical care. For the last dozen years, the facility has been involved in every level of digital technology development and a centerpiece of materials research, complex esthetic case design, and related software development. “This lab built the foundation for the new Center for Virtual Treatment Planning,” says Bergler, who directs that Center.
Meanwhile, five years ago, Blatz recruited Julián Conejo, a prosthodontist who had been using digital technologies in his own private practice since 2010, to continue to enhance the Penn Dental Medicine community’s digital expertise. Conejo, the clinical CAD/CAM director, has focused on furthering research, particularly in chairside CAD/CAM dentistry. With Blatz, he began a pilot study to test a fully digital workflow, using one intraoral scanner and one milling machine, Conejo personally assisting each student who wanted to complete a fully digital case. Quickly, the pilot proved to be a success.
“We were quickly able to ramp up that pilot study to a bigger scale,” says Conejo. “And now, it’s rewarding to see where we are today with intraoral scanners in all our clinics and the many resources of our new Digital Design and Milling Center.”
Upon arriving at Penn Dental Medicine in 2018, Morton Amsterdam Dean Mark Wolff also recognized the importance of training dental students in digital dentistry and embraced and bolstered their efforts to continue to move the school’s Digital Innovation Initiative forward, fast-tracking plans to create the new facilities.
New digital hubs
Those plans became a reality when the two adjacent spaces opened earlier this year: the Digital Design and Milling Center is focused on chairside CAD/CAM applications and headed by Conejo, and the Center for Virtual Treatment Planning is led by Bergler and addresses complex cases and full-mouth restorations. While the facilities were temporarily closed due to the COVID-19 pandemic, they are now back up and running, welcoming students to work in a socially distanced fashion. Both spaces are outfitted with state-of-the-art equipment and technology and came together in part through generous in-kind support from corporate partners.
The Digital Design and Milling Center features 12 computers/design PCs loaded with three types of software for different applications: one for designing and milling single-unit restorations like inlays, crowns, and veneers; another for implant-related restorations and surgical planning; and a third laboratory-oriented program for digital wax-ups, which are planning models for restorations. Students have been 3D-printing models from the digital wax-ups at Penn’s Biomedical Library free of charge. But recently, the school acquired new printers with 3D capabilities that can print up to 40 different materials.
In addition, 10 high-speed milling machines line one wall of the Center to produce restorations, and eight ceramic furnaces are used to fire and finish them.
Full-time dental technician Soo Ann, who joined the school in 2019, manages daily operations in the Center. Students are assigned a PC where they can pull up their patients’ digital scans, and Ann supervises the design and milling process. Second-year prosthodontics residents also do a rotation in the Center once a week, assisting dental students with their cases.
“The residents are a great asset,” says Conejo, “for they learn as well by teaching and getting more hands-on in the lab.”
Centralizing the entire design and production process in the Center, as opposed to dispersing design software and milling units across the school’s clinics, ensures better quality control and helps Conejo and others track trends, such as which types of cases clinicians are addressing digitally most often, and what materials are most popular.
A goal of Conejo’s is for the school to eventually be alginate-free, referring to the material typically used to make dental impressions. He explains that digital impressions have a host of benefits over traditional ones—and are more comfortable for patients, to boot. “The scanning process is fast, it provides files that can be easily shared among specialists or a dental lab, and if needed, part of the mouth can be quickly reimaged,” he says, “while if a portion of a traditional impression comes out faulty, the entire process needs to be repeated.”
With 17 intraoral optical scanners now dispersed throughout the school’s clinics, Penn Dental Medicine is moving in a digital direction. A top priority has been to significantly increase the number of scanners to ensure all students and faculty across clinical departments are able to apply the technology to patient care.
“Our faculty and students have been trained to use this technology,” says Conejo, “and I foresee that in the next couple of years we’ll be doing 100% digital impressions.”
Incorporating digital design files into a patient’s electronic health records also ensures that an identical restoration could be replicated in the future.
With the digital transformations, information technology needs are changing as well. Sam Bogharas was hired two years ago to ensure that IT issues were being met, including aspects related to patient privacy and adhering to best practices for digital storage. The Center is also reaching across clinical departments at the school. “Our goal is to strengthen and support all departments with digital cases and applications,” says Conejo, “and to use the resources of the Center to train other clinicians as well through hands-on continuing education.”
A new home for complex cases
For cases that require more complex care, next door is the Center for Virtual Treatment Planning. The vision for this facility is to educate, train, and support postdoctoral students in digital case set-up and give them the opportunity to use the latest software tools for virtual treatment planning. The Center’s six workstations are outfitted with a full spectrum of digital technology for planning implant- or tooth-supported restorations.
“We have a total of 24 licenses of professional 3D designing software,” says Bergler, “and each one has over 50 designing tools—from digital denture set-up and an implant planner to wax-up and model creators, just to name a few. It is important that residents understand how different digital tools interact with each other and see the impact they have on the success of a restoration.”
However, the focal point of the new center is the newly developed virtual treatment planning software—features of which were developed in conjunction with the school’s CAD/CAM Ceramic Center to establish digital wax-ups in a timely and predictable way. Bergler explains that files can easily be interchanged with other software for a smooth workflow. The software’s newly developed tools include digital tooth extraction and face morphing to simulate face and jaw movements in real time.
Bergler’s driving concept for the Center is focused on creating “a virtual patient.” “Based on the huge amount of data we can collect via an intraoral and/or laboratory scanner, a [cone beam tomography] scan, a face scan, we are able to create a virtual patient on screen,” he says. “Residents can basically superimpose all of these data sets, and then most importantly, simulate different treatment protocols for their particular cases.”
In addition to helping residents learn in a more comprehensive fashion, the sophisticated combination of technology helps patients directly, too. Clinicians can develop personalized approaches and show them to patients in advance, allowing them to offer feedback to shape the clinician’s vision.
“This can give the patient more security in going through the treatment,” says Bergler.
To execute treatment plans, the Center features four industrial five-axis machines that can mill a full spectrum of materials. The newest machine, added this summer, can mill four different materials in one cycle, increasing capacity and reducing production time. The specialized technology builds residents’ understanding of the milling process, as well.
The Center’s design and production capabilities also allow research to be conducted under controlled circumstances to evaluate a particular intervention and assess new materials and technologies. One area of recent research is 3D printed oxide ceramics, a technology Bergler believes could hold promise for the future. “We get very valuable data out of our work that we’re able to give back to industry,” Bergler says, “in order for them to make changes and improve CAD/CAM systems and materials for better patient care.”
An education for the future
While many long-established private dental practices may not yet embrace digital dentistry, it’s clear that it’s the way of the future, and as part of the Digital Innovation Initiative, both the predoctoral and postdoctoral curriculum have been adjusted to incorporate experience with CAD/CAM technology. Presently, dental students are required to do two completely digital cases, but Conejo anticipates that with the additional resources in the Digital Design and Milling Center, that may increase. Bergler’s changes for the curriculum aim to prepare the residents for an independent and confident handling of complex digital planning.
“We have seen students heavily engaged,” says Blatz. “They’re digital natives and are eager to engage with these new technologies.”
Even first- and second-year students are now learning to use intraoral scanners in the preclinical simulation labs, scanning mannequin mouths as they simulate procedures to begin refining their techniques before entering the clinic. By the time students reach their third and fourth years, they’ll be ready to apply these techniques in patient care. For postdoctoral students, digital design allows them to approach challenging cases in entirely new ways.
“Our Center for Virtual Treatment Planning has a huge effect on the quality of our teaching,” says Bergler. “Our residents are able to simulate a variety of treatment protocols without even touching a patient, which is giving them detailed impressions about the opportunities and impacts of digital technologies in dentistry. This is making their learning experience much greater.”
Conejo is also working on an e-book to serve as an on-the-go reference for students and faculty in their everyday patient care.
Students on the cusp of entering the workforce say they are gaining invaluable experience working in the Digital Design and Milling Center. Sivothayan Sevvanthiraja, an internationally trained dentist from Sri Lanka who came to Penn to further his education, is enthusiastic about the possibilities the Center provides. “When I describe it to patients,” he says, “they are very surprised about the quality of the results and the short time it can take for procedures.”
Sivothayan, a fourth-year student, has also appreciated the close working relationships he’s had with faculty members such as Conejo, Blatz, and Bergler. “The faculty are very welcoming to new ideas from the students.” He is currently pursuing a project in collaboration with Conejo and other faculty members to fabricate complete dentures for patients with a fully digital workflow.
“I’m really excited about the application of these digital technologies in patient care,” Sivothayan says. “So many people are not aware what we can do with digital technology in dentistry.”
Relentless improvement
As anyone who has owned a laptop or cell phone knows, digital technologies are not static; they’re constantly evolving. To ensure that Penn Dental Medicine’s technological resources and techniques are the finest available, faculty and students are engaged in research projects to identify best practices and provide feedback to industry partners to continue refining their products.
“We’re conducting numerous laboratory studies on the physical, optical, and biological properties of new CAD/CAM-milled materials and 3D-printed materials as well as clinical studies to see what is working best for our patients,” says Blatz. “We work across the board with dental manufacturers, because they trust us to give them unbiased feedback about their materials and equipment.”
In the future, faculty envision every patient coming through admissions will be scanned, and Blatz foresees a greater number of restorations being manufactured at Penn Dental Medicine.
“The vast majority of crowns and single-tooth indirect restorations are now being done in house,” Blatz says. “It’s far exceeded my expectations.”
And though some may believe that a greater use of technology means less personal care, Blatz underscores the opposite is the case.
“Some people think that with CAD/CAM technologies, everyone is getting the same smile, but in fact we can individualize care like never before. And by using scan files of natural dentition to design and restore teeth and smiles, the outcomes look and function in a truly natural manner,” he says. “With costs coming down and these technologies becoming more accessible, my hope is that ultimately, patients’ access to high-quality oral health care and customized dental restorations that look nice, that are well-fitting, and that have quality materials will be greatly improved. That is the goal.”
