My digital journey – by Dr Giovanna Perrotti

2021 is Planmeca’s 50th anniversary. As part of the milestone year, we are publishing a series of articles written by our own specialists and by dental experts from around the world. In this article, Dr Giovanna Perrotti, CEO of the Lake Como Institute, recounts how CBCT imaging took over in dentistry and paved the way for the digital revolution.

My first encounter with the third dimension was in the second half of the 1980s when we timidly began to use multi-slice CT images to diagnose impacted canines. To my eyes, 3D images were like an anatomy atlas or dissection table, and since then my vision has always gone beyond the limits of the bi-dimensional.

Computed tomography was introduced in the 1970s. X-ray analyses of tissue layers were finally reconstructed as three-dimensional images. Its evolution, the CT scan (Computerised Axial Tomography), was developed in the early 80s. In dentistry it found an application in the specific Dental Scan exam, which has been fundamental both to the diagnostics and planning of implant-prosthetic cases since the dawn of implantology.

The main problem of the CT Dental Scan, characterised by great precision and detail in its contrast, has historically been the relevant dose of radiation delivered during the examination.

In the mid-1980s, cone beam computed tomography (CBCT) was introduced. It is an imaging technique where the beams of the X-rays used in the survey have a conical shape. In the dento-maxillofacial field, CBCT imaging was proposed and developed in the mid-90s by Italian researchers at the University of Verona.

In the year 2000, the United States Food and Drug Administration (FDA), a central control authority in the medical and health fields, recognised the validity of this Italian research and elected CBCT as a recommended examination for three-dimensional diagnoses in dentistry – particularly for preliminary pre-implant evaluations. This is because CBCT imaging emits 3 to 8 times less radiation than a traditional dental scan.

The concept of DICOM (Digital Imaging and Communication in Medicine) has advanced relentlessly and revolutionised diagnostics in all sectors of medicine.

In dentistry, CBCT marked a great turning point for diagnostics. In fact, in the field of orthodontics the multi-slice CT scan was prescribed only in very select cases. This was due to its very high impact, in terms of ionising radiation absorbed. Hence, any research project was unsustainable.

CBCT imaging immediately reduced the radiogenic load considerably and, in the meantime, provided high quality exams that met the needs of dentists and maxillofacial surgeons.

Image processing software opens new doors

Nowadays, we have extremely sophisticated machinery available that can modulate both the absorbed dose and the exposure field.

Therefore, the diagnostic process has become more and more customised towards real diagnostic objectives. However, I believe that the other diagnostic component that has revolutionised evaluation and study is the use of image processing software. This is where my personal story with the third dimension begins.

In 2006, I started a research project at the University of Milan called IRCSS GALEAZZI. The aim was to find a cephalometric method that is compatible with a three-dimensional reconstruction of the skull.

Image processing software allowed me to develop 3D multiplanar cephalometry analyses. Utilising information available in the literature at that time – mainly research carried out by R. Jacobson (1) and G.R. J. Swennen (2) – I built a novel 3D cephalometric multiplanar module named Total Face Approach (3,4).

In the following years, I developed an educational model regarding the use of 3D cephalometry in orthodontics and orthognathic surgery.

At the same time, we developed a multidisciplinary project with the University of Milan’s Department of Implantology, directed by Prof. Tiziano Testori, that correlates information coming from 3D cephalometry with implant-prosthetic planning of edentulous and post-traumatic cases.In 2015, the efforts of our team were collected into a book that was published by Quintessence International (5).

Collaboration with Planmeca

In 2018, I had a meeting with Planmeca.

Professionals and academics who work with digital technologies in the medical field know well that the union between clinics and industry must be transparent and synergistic. My personal experiences with the digital industry have always been constructive and positive. Still, I must admit that as a company Planmeca has shown the difference people make.

I was given a unique opportunity to use my scientific results to create a 3D cephalometry module within the Planmeca Romexis® software. In digital dentistry, even the best idea cannot be developed without a specific tool.

The recent remarkable expansion of digital technology – in terms of software, scanners and digital manufacturing capabilities – has led to a real revolution and paradigm shift in all aspects of dentistry. Today, digital radiography is a routine practice at dental clinics, along with virtual treatment planning and CAD/CAM techniques.

Digital impressions, digitally made prostheses and virtual patients have become a reality that is within the reach of every professional. A new discipline, digital dentistry, has been born – fully integrating into clinical practice and academic curricula.

The growing power of digital dentistry

Digital dentistry is not a fad and it is not even the idle whim of a dentist who wants to flaunt technology or wealth. Rather, it is a question of understanding that epochal changes in every area of knowledge always occur at the expense of our most consolidated paradigms.

In the current evolutionary context, there will be two different competitions between dentists. On the one hand, successful and digitised practices will compete for the best positions on the market. On the other hand, declining practices that did not invest in technology will experience a residual economy of mere subsistence.

Dental practices that digitise clinical and extra-clinical processes are on average much more successful than others. Digitalisation has penetrated even more into clinical practice, supplanting the mix of craftsmanship and intuition that was the pride of many clinicians.

Digital dentistry is the most powerful booster of a dental practice’s success. We could define it as an incremental and democratic catalyst. Incremental because it allows a gradual introduction into individual processes (clinical and extra-clinical) – postponing any integration of the processes in the digital ecosystem to be set up at the appropriate time. Democratic because it lends itself to anyone.

The digital dentist is an evolution of the species. Digital dentists took their first steps in the extra-clinical area in the 1990s. The first digital workflows in the clinical field appeared in the first decade of the new millennium. Traditional dentists have long since begun their metamorphosis into digital dentists.

The unstoppable revolution

The dental clinic has been literally transformed by the advent of digital workflows in all (or almost all) its disciplines – with prosthodontics, orthodontics, periodontology and surgery undoubtedly leading the way.

Digital workflows are increasingly used for production (or rather, in the execution of therapies): intraoral scanners for taking impressions, CAD/CAM tools for manufacturing prosthetic products, digital systems for producing orthodontic appliances, and digital models of surgical and implant planning integrated with other production systems.

This digital revolution in the field of dentistry was able to take place thanks to encouragement by an industry that offered new working models. Dentists are increasingly adapting to clinical workflows that use digital technologies. It is a new alphabet that we must learn to know and use.

The task of the industry is to make these paths user-friendly through information that is open and easy to understand – and above all can be integrated.

Digital dentistry is now an unstoppable phenomenon and new generations are ready to face the challenge.

Dr Giovanna Perrotti is an acclaimed author, lecturer, orthodontist and dental software developer. Currently, she is the CEO of the Lake Como Institute – a training center for advanced studies in implantology, oral surgery and digital dentistry. Dr Perrotti is an active member in the Digital Dentistry Society (DDS) and serves on the scientific committee of Dental Cadmos.

References

(1) Jacobson A, Jacobson R. L.Radiographic Cephalometry: From Basics to 3-D Imaging. Quintessence Publishing Co, Inc, 2006.

(2) SwennenG. R. J, Schutyser F, Hausamen J. E. Three-Dimensional Cephalometry. Springer Verlag Berlin Heidelberg 2006

(3) Perrotti G, De Vecchi L, Ferrario S, Politi M, Weinstein R. L. Basic knowledge and guidelines for the right prescription of cone-beam computerized tomography in orthodontics. Mondo Ortodontico2012, Volume37, 5, S1.

(4) Perrotti G, Baccaglione G, Clauser T, Testarelli L, Del Fabbro M, Testori T. Total Face Approach (TFA): a novel 3D cephalometric analisys for skeletal classification and relative normal values. Methods Protoc2021 Feb 20;4(1):15.

(5) Perrotti G, Testori T, Politi M. 3D Imaging and Dentistry: From MultiplanarCephalometry to Guided Navigation in Implantology. Quintessence Publishing Co, Inc, 2016.

Planmeca Oy and Planmeca Group
Planmeca Oy is one of the world's leading dental equipment manufacturers with a product range covering digital dental units, CAD/CAM solutions, world-class 2D and 3D imaging devices and comprehensive software solutions. Headquartered in Helsinki, Finland, Planmeca’s products are distributed in over 120 countries worldwide. With a strong commitment to pioneering innovations and design, it is the largest privately held company in its field. Planmeca Oy is part of the Finnish Planmeca Group, which operates in the field of healthcare technology. The Group's turnover in 2020 was MEUR 764, and it employs nearly 2,900 people worldwide.
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