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ОглавлениеProsthodontic tools for treatment planning
How prosthodontists can help their patients
From the start of its existence in the USA at the beginning of the last century, the specialty of dental prosthodontics has involved the study of the art and science of restoring broken or decayed teeth and mouths in various states of edentulism. Much research as well as clinical and laboratory experience and verifiable procedures have resulted in the publication of numerous scientific articles, books, manuals, photographs, films, webinars, and online lectures on the topic of prosthodontics.
The Glossary of Prosthodontic Terms, an important and useful resource currently available as a free download from the Academy of Prosthodontics website, was created to define words and concepts necessary to clarify and share a common prosthodontic terminology for the practice and scientific reporting of the specialty.1-3
The outcome of all of this evidence-based science and practice is a number of clinical and laboratory therapeutic prosthodontic tools available on the market today. These tools are intended for practical therapeutic solutions capable of restoring oral esthetics and function in patients whose mouths are in need of restoration.
As it is impossible to outline here all the clinical and laboratory prosthodontic reconstructive tools and procedures in use today, this chapter looks at the main categories of tools currently available to show the most common prosthodontic esthetic and functional rehabilitative possibilities, as reported in the literature.
Aims and requirements of all prostheses
The following are the main rehabilitative goals of any prosthesis. It should:
● replace the lost dentition and improve on it as much as possible;
● satisfy the patient’s needs/desires/requests;
● guarantee the patient’s comfort;
● help to prevent further problems;
● improve the patient’s oral health;
● help to give the patient a better quality of life.
To achieve these goals, the prerequisite of all prostheses should be that they:
● are minimally invasive;
● protect the remaining dental and periodontal structures;
● are made from biocompatible materials;
● are esthetically, phonetically, and functionally effective;
● are accessible to excellent oral and dental hygiene;
● are simple and easily repairable;
● last as long as possible;
● cost the least amount of money.
Current main prosthodontic tools
Table 3-1 outlines the main categories of prosthodontic tools in use today. This should be seen in light of the recent progress that has taken place in the prosthodontic field due to the modern technological revolution.
Table 3-1 Outline of the most important prosthodontic tools currently in use today
Fixed restorations
1. Inlays, onlays
2. Veneers
3. Crown, bridges, post and cores
4. Full-arch fixed complete prostheses
Removable partial dentures
1. Tooth-borne prostheses
2. Tooth- to mucosa-borne prostheses
Complete dentures
1. Immediate prostheses
2. Final prostheses
Overdentures
1. On some remaining portion of roots
2. On well-positioned implant
Fixed implant-retained prostheses
1. Partial implant prostheses
2. Following the prolonged use of complete dentures (CDs)
3. Following extractions, immediate CDs, and delayed implant placement
4. Following extractions and immediate implant placement
Bioinformatics and digital prosthodontic tools
1. Computer-aided implantology
2. Computer-aided prosthetic designing and planning
3. Precise guided implant positioning
Fixed prostheses such as crowns and bridges are termed fixed partial dentures (FPDs) or fixed complete dentures (FCDs), depending on their extension and abutment involvement.2
Fixed prostheses are considered a dream tool for prosthodontists because they are the best and most natural restorations.3 The naturalness of the final result depends on a number of clinical and technical factors such as laboratory materials, technical possibilities, professional skills, and artistic dexterity.4-8 Fixed prostheses are used all over the world and are fabricated from various materials, including gold, depending on factors such as culture and esthetics.5,9 Their manufacture follows rules imposed by ongoing research, especially that which is occurring in the field of digital technology.
The use of fixed restorations for endodontically treated teeth depends on the amount of the remaining tooth structure and on well-established principles of tooth preparation.5,6,8,10-12,19 Even though great improvement has taken place in this respect with resin adhesive rehabilitations,11-13 cast post and cores still show superior physical and biomechanical capabilities to withstand vertical and lateral loads as well as decementation.5,6,8,12,14-25
Nowadays, other new fixed prosthodontic methods, born as a result of and crafted with the help of new digital technologies, are revolutionizing the clinic and laboratory. And this is just the beginning, as much more is expected with the current speed of exponential progress and growth in this field.26
Today, in the case of edentulism where there is one or more missing teeth, implants are usually considered as the first option during treatment planning for fixed restorations, unless physical, biological, biomechanical, psychologic or economic limitations and/or contraindications are present.27-33 Where implants are not indicated due to their negative biological, functional, and esthetic possibilities or the chance of predictable short- or long-term complications,34 tooth-borne FPDs and FCDs are considered the secondary restorative tool, with pontic elements replacing the edentulous areas.
Removable partial dentures (RPDs) are generally considered the third restorative option in the western world. However, in many other countries worldwide they are considered to be the first choice. RPDs can be very helpful in various partially edentulous cases, depending on the patient’s chief complaint, desire, and financial situation.35-37 The relatively lower cost of these prostheses is a major factor of choice, despite the difficulty in planning them biomechanically and the inevitable clinical limitations that their unnatural composite structure introduces into the masticatory environment.38-48 This fact should spur us on to deliver a biomechanically well-conceived project in order not to damage the remaining dentition and to preserve it for as long as possible.
Due to decades of success and their helpfulness in innumerable edentulous cases, CDs have been called the mother of all dental prostheses.49 According to studies on oral health in the USA, even though there has been a relative decline in complete edentulism over the past 30 years due to a corresponding decline in caries, the need for complete dentures to treat edentulism is still high due to the increase in the aging population.28,50 Furthermore, edentulism still depends on infectious disease conditions and related health problems that involve both the young and the elderly worldwide, even today.51
Although there is a large body of scientific literature about them, clinical experience shows that in many instances CDs still remain very difficult to create and craft properly. However, if the literature is carefully studied and scientific engineering rules are strictly followed, the construction of CDs can result in a successful restoration. Experience shows that the obvious weakness in these prostheses is their mobility.52,53 In this respect, they must necessarily rely on the remaining available maxillary and mandibular primary and secondary bearing areas and on the characteristics of the hard and soft tissue comprising these areas. Their success also relies on a number of other biological, physical, chemical, and subjective factors that have been widely described in the literature. Regardless of whether they are created in an analog or digital manner, the nature of CDs makes these prostheses biomechanically lacking in terms of stability, retention, and support compared with other fixed prostheses. Nevertheless, many patients lack the economic resources for fixed implant treatments, and many in fact do live with CDs satisfactorily and sometimes more than satisfactorily, which compensates for their biologic limitations.52-70
In cases where up-to-date, three-dimensional (3D) digital technologies can be used to virtually plan the rehabilitation of edentulous cases with immediate implant-supported fixed prostheses, CDs can be used as excellent interim prostheses, as useful verification jigs, and as surgical guides to position implants properly to recreate final full-arch implant restorations.
In fact, when all anatomical dental reference points are lost, CDs are a precious source of anatomical information and can be used to recover most of these points in any edentulous mouth. In these cases, lip and cheek support, dental esthetics, phonetic and functional landmarks, and all occlusal parameters necessary to properly guide the oral rehabilitation with excellent approximation can be retrieved both in the mouth and on the working casts. This also depends on the knowledge and clinical skills of the clinician and the laboratory technician to replace the lost dentition with final fixed implant-supported prostheses.
Indeed, the advent of implants helped to improve this unstable situation. However, if structurally valid roots still remain in strategic positions in the mandible (ie, canines or first premolars), they can be reconstructed and utilized to support, retain, and stabilize any complete denture prosthesis. This possibility is cheaper than the use of implants, and biomechanical improvement can be better achieved by means of fixed attachments, as they may limit the number of biomechanical degrees of freedom to the mobility of the overlying CDs both at rest and during function. Certainly, the choice to save and use the roots is limited by a number of structural and biomechanical parameters that must be carefully evaluated during the first visit and during treatment planning.71-82
Mandibular implant overdentures can be obtained with two implants positioned in strategic positions. In these cases, the further use of bars or attachments as a means of anchoring may greatly enhance the stability, retention, and support of these types of prostheses.83-94 This combination has been defined as optimal and as the standard of care for mandibular CDs.95-97
In the maxilla, usually the greater extension and the quality of the bearing surface guarantee better support, stability, and retention. However, in the following instances implants might also be proposed to create maxillary implant overdentures: when the amount of alveolar ridge bone is poor; when the palate is particularly flat and induces instability; when the posterior palatal seal cannot be properly achieved and is not enough to aid the retention; and when the patient is suffering from xerostomia, which induces instability, inflammation, and poor retention of the denture base.30
Full-arch implant-retained fixed prostheses
These prostheses can be optimal in the restoration of all partial and fully edentulous cases. Limiting factors to this prosthetic choice may be the patient’s chief complaint restrictions, specific negative general health conditions, predictable increased clinical and technical costs, and local limiting factors such as the possible moderate to severe bone conditions that may not withstand further long and complex bone regeneration and implant treatment procedures.31-33,49,98 For more than three decades, this prosthetic tool has become the primary prosthodontic treatment option, offering the best quasi-natural improved restoration of complete edentulous arches with various types of fixed prostheses with the highest degree of success. Certainly, the most important rule for success in implant therapy is the presence of highly qualified and proficient prosthodontists and clinical and laboratory staff who perform all phases of the restoration, from the initial treatment planning phase, in a scientifically correct way.27,99-101 This professionalism is an ethical and practical must, because the challenge to plan and create implant prostheses always contains a large number of variables that are not always easy to keep under control unless one is knowledgeable and highly experienced.31,102 To this end, a description of many limitations and prerequisites for implant choices useful for brainstorming purposes as well as for the practice of treatment planning are reported in Chapter 10.
Bioinformatics and the digital prosthodontics paradigm shift
In the present era of computers, all areas of our lives are constantly becoming more and more digitized. We can only imagine what the reality will look like in 10 years’ time in the medical and dental medical professions as we attempt to grasp day by day just a small part of what thousands of extremely gifted scientists are creating. There are many impressive bioinformatic possibilities at present to store data and exploit in-office computer processing capabilities. Large databases are immediately available on the internet for the easy retrieval of precise information. This is changing the face of the dental medical profession forever, which is true for all dental specialist fields but perhaps more so for prosthodontics. The following section elaborates on a topic that was outlined in Chapter 1 and which is continually developing. The recent growth in digital technologies has introduced computer-aided implantology that has allowed for computer-aided prosthetic designing and planning and precise guided implant positioning.14,26,101,103,112
Computerized chairside and laboratory technologies
It is possible to craft both analog and digital restorations in an excellent way. Indeed, human endeavor in terms of ‘collective intelligence’ and artistic ability has always been phenomenal. Yet, with the advent and rise of digital technology, this endeavor is rapidly and constantly progressing and improving as a new and broad range of digital dental technologies are increasingly being introduced. This is having an impact on the shape and performance of all areas of the dental medical profession, be it in dental hospitals, universities, dental offices, surgical theaters, operatories, and laboratories. Each day, the diagnostic dental medical devices and other objects and devices in our clinics and laboratories are becoming exponentially ‘smarter.’ This has resulted in a rapid change in our prosthodontic treatment possibilities and ‘tools’, a brief description of which is presented below.
Digital software treatment revolution
The progress in software development and marketing has implications for all areas of dentistry, including prosthodontics. For instance, clinicians today have the ability to access digital algorithms to rationalize workflows, to reduce the time of clinical intervention, to reduce operative costs, and to increase the predictability of results and therefore patient satisfaction.
● 3D high-definition (HD) magnifying visors allow us to see the smallest details that have until very recently been impossible to see even with magnifying lenses (which are today almost obsolete).
● 3D screens allow us to show patients detailed views of the operative field in order to better explain to them the reality of their oral situation.
● Improved multiple detectors in use with cone beam computed tomography (CBCT) are able to take a 3D HD radiographic scanned reproduction of a patient’s head and mouth by simply and quickly sliding only once from one side of the face to the other, dramatically reducing the amount of radiation exposure for the patient.
● Temporomandibular joint (TMJ) occlusal evaluators can tell us precisely what happens in a patient’s TMJs at rest and while speaking, chewing, and biting. Among other things, they provide information regarding invisible occlusal vectors in terms of timing, intensity, and direction of the applied chewing forces. Using precise algorithms, they allow us to study the occlusion during both the treatment planning and in the following clinical phases, according to important static and dynamic parameters now visible and measurable. This was impossible to achieve with the previous analog methods.
● 3D intraoral scanners progressively eliminate the use of trays and impression materials, recording at high magnification all possible details of our preparations and of the surrounding teeth and saving them in both dental imaging and communication in medicine (DICOM) and/or photographic files. This allows for fantastic magnified on-screen reproductions that are ready to be studied for the design and crafting of 3D-printed or milled prostheses.
Regarding treatment planning, increasingly perfected artificial narrow intelligence (ANI) algorithms allow for the planning of clinical cases by means of digital workflows and simplified procedures, creating with excellent approximation visual graphs that clearly show the clinician where and how to craft any fixed prostheses. This can be done without producing physical casts that are both costly and require storage space.
By means of digital communication media, clinicians and dental technicians are now able to easily communicate online and share information about the treatment on an ongoing basis. By DICOM and other dental medical data files over the internet, the milling or 3D printing of dental prosthesis can be activated remotely from anywhere in the world.
Computer-guided implant-positioning software and hardware
This allows the clinician to place virtual implants and teeth according to the underlying bone position as well as the future teeth. The use of this hardware and software has vastly improved the understanding and treatment planning of partially or completely edentulous cases.
These reproduce the best analog articulators. They are diagnostic tools able to study any prosthodontic case.
Clinicians at the chairside and technicians in their laboratories are now able to create digital dental guidelines and landmarks and show the patient a previewed 3D version of the virtual representation of the dentition and face, possible smile, and prosthetic outcome of the treatment plan. This is useful for discussions with the patient regarding possible present and future dental treatments and their economic implications. The information and patient preferences can be stored and saved for future reference.
Today’s technology also allows us to rapidly prototype, design, and tweak predictable provisional customized mock temporary restorations, digital RPD substructures, and digital CD prostheses. These files can then be saved on a dedicated database and be used to design, craft, and manufacture restorations using a broad range of digital milling or 3D printing machines in our offices.
Digitally created, usefully milled, and wearable pretreatment mock temporary restorations can currently be temporarily cemented and used without any tooth preparation. They enable the patient to try out the mock-up in vivo and also in their own environment once they leave our offices. This try-in gives patients a good approximation of the esthetics and functional aspect of the planned and proposed prosthetic outcome. If the patient is satisfied with the esthetics and function of the temporary restorations after the try-in, the digital image can be scanned in the mouth, mounted on virtual articulators, and used to produce a digital version of the final prosthesis. This is useful to either create minimally invasive prosthetic ceramic pieces to be bonded over the remaining dentition, or useful guides to prepare what remains and adapt it to the new identical final prostheses. The newest digital light processing machines and bioprinting machines will predictably one day be precise and powerful enough to recreate even sound brand-new teeth for implantation.
Computerized laboratory technologies
New laboratory ceramic materials increasingly resemble natural teeth in terms of their optical and physical properties. 3D milling and printing machines are increasingly changing the way the laboratory works and how it relates to the clinical office. Indeed, despite what the monumental Dr House wrote in 1937,113 these AI machines are becoming more and more able to create and craft artistically what we humans are able to do with our art and dexterity. We have been the masters up until now, but for how much longer?
This evident digitalized simplification of procedures means more ‘predictability,’ which consequently also means less undesirable posttreatment complications, including a decreased risk of possible working cross-contamination between the clinic, the laboratory, and the social environment.
HoloLens hands-on 2 is a brand new powerful mixed-/augmented-reality tool, interconnected by means of a mixed-reality app that allows us to see what we cannot see with the naked eye, and so to touch, move, increase, and decrease – in a very practical and ‘quasi-normal’ intuitive way – the size of holographic virtual objects that physically appear in front of or around us. Users move their hands in a close, dedicated 3D virtual world that allows them to see, interact with, and use all types of actual (real) analog devices that are connected to the system. This means that we do not physically touch the instruments but rather touch and work with them from a virtual remote. We then receive useful written information about these devices that ‘float in the air’ before us so we can know, analyze, plan, and better control our workflows.
This situation is very difficult to imagine and understand if you are not actually working with it. However, it is extremely useful and will soon dramatically change the way we live and work.
Apart from all that has been discussed in this chapter, it is not possible for us to actually foresee which prosthodontic tools we will use in the future. Although the organization of treatment planning will certainly change, the clinical rationale on which treatments are based will not change. Even if one day an artificial general intelligence (AGI) team takes the place of humans at the chairside, the step-by-step planning procedure is simplified and sped up by new diagnostic methods, and workflows change according to the capabilities of new diagnostic and treatment tools, the clinical rationale remains the same.
The rise of deep-learning and self-learning AI algorithms is currently turning the world upside down. Practically, computers program themselves instead of being programmed by humans, enabling the computers themselves to ‘learn’ how to perform useful assignments. Computer programs have taken over from the old analog rules and are performing assignments in the most useful way. Training data programmed into increasingly large artificial neural networks are being adjusted and reordered to obtain the desired result. Furthermore, these results show that a deep-learning system that has been well-trained enough may find indirect and precise repeatable abstract patterns in data. This technique is already being used to perform an increasing number of practical tasks, from face recognition to predicting diseases from medical images, just like human doctors do when they investigate their patients’ signs and symptoms in order to understand their ailments, diseases or illnesses.114 So, how long before these incredibly quick machines completely change medical and dental medical science? By means of DNA sequencing manipulation, it will also be possible to program the elimination of diseases, including caries, and align the position of the teeth from their eruption. And when it is not possible to change something in that way, it will be removed, terminated, and rebuilt by powerful physically and chemically instructed nanocarriers, nanorobots, and machines.
Indeed, the evidence shows that everything that has been imaginable and thinkable in science has more or less been achieved in practice, because humans have an infinite capacity for curiosity and imagination. Therefore, it is foreseeable that in a few decades from now, the speciality of prosthodontic treatment planning and its current tools will be radically changed.
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