New study investigates 3D-printing use in dental practice / Wanted: Research on 3D-printed zirconia restorations / “When it comes to 3D printing, it is the innovative character and attractiveness of the technology that counts”
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DTMEA_No.1. Vol.14_LT.indd
PUBLISHED IN DUBAI
www.dental-tribune.me
Vol. 14, No. 1
New study investigates
3D-printing use in dental practice
By Iveta Ramonaite, Dental
Tribune International
A recent survey conducted by
the American Dental Association
(ADA) investigated the prevalence,
applications and user experience of
3D printing in dentistry. It found that,
although the use of 3D printing in
dental practice is currently low, those
who adopted it reported improved
efficiency and reduced cost. The aim
of the study is to inform current users
about other users’ experiences and
to advise nonusers about the potential benefits of the technology.
The survey report considered
the responses of 277 members of the
ADA Clinical Evaluators Panel. It
found that only 17% of the participating dentists currently use a 3D
printer in their practice, of which 67%
have been using it for less than two
years.
“Although this survey found that
3D printer use in private practices is
currently low, it is growing due to
workflow efficiencies and expanded
applications associated with continuing developments and progress
with these technologies,” co-authors
Dr Kevin Frazier, vice dean and professor of restorative sciences at the
Dental College of Georgia at
Augusta University in the US, and
Dr Marta Revilla-León, director of research and digital dentistry at the
Kois Center in the US, said in a press
release. “Non-users should continue
to monitor these trends for adding
3D printing in their own practices.”
The most common uses for a 3D
printer were to complement or enhance other digital technologies,
control workflows, improve efficiency, use existing digital skills or
procedures, and reduce cost or manufacturing time.
Regarding usage, nearly half of
the users said that they use a 3D
printer for 25% of their cases per
month, mainly for diagnostic models
(62%), followed by splints and occlusal devices (50%) and then surgical
guides (48%). The most common
problems experienced with 3D printing involved software and printing
failure.
Among the 83% respondents
who do not use 3D printers, 44%
cited using a laboratory, 39% high financial investment and 34% lack of
perceived benefit as their reasons for
not using 3D printing.
Among non-users, 21% were
considering investing in a 3D printer
and 35% were considering undergoing training.
“3D printing was chosen for this
survey because it was one of the top
four topics on several ‘hot’ or ‘emerging’ trends in dentistry lists, and we
(Image: sapc/Freepik)
wanted to know how our colleagues
were responding to the advances in
3D-printing technology that have
led to expanded applications for
practice,” Drs Frazier and Revilla-León noted.
Japanese professor makes
learning about AI in dentistry
easy with published overview
By Anisha Hall Hoppe, Dental
Tribune International
For a clinician to be able to implement a responsible roll-out of 3D
printing technology in clinical practice or through an outside lab, it can
be incredibly useful to understand
the associated artificial intelligence
(AI) concepts that bring many 3D
printing solutions to life. Prof. Akitoshi Katsumata, chair of the Department of Oral Radiology at the Asahi
University dental school in Gifu, has
provided a clear overview of AI applications in dental diagnostic imaging.
The following article is a brief summation of Prof. Katsumata’s explanations.
Machine learning and other AI
have found significant applications
in dental diagnostic imaging since
the early twenty-first century. Digital
radiography and CBCT have reshaped dentistry, leading to the de-
velopment of computer-aided detection and diagnosis systems. These
advancements have enabled dentists to identify various conditions,
including maxillary sinus lesions, osteoporosis-related mandibular bone
changes and carotid artery calcifications, with remarkable precision.
Early detection and diagnosis
systems relied on human-crafted
rules and knowledge to make specific X-ray findings. However, since
the early 2010s, machine learning,
particularly deep learning (DL), has
gained prominence in detection and
diagnosis systems. DL leverages
neural networks inspired by the
human brain’s structure, enabling it
to excel in image analysis, natural
language processing, predictive analytics and machine system control.
In dental diagnostic imaging, AI applications have steadily advanced
across various modalities, such as intra-oral radiography, panoramic ra-
diography and CBCT. The classification task plays a pivotal role in identifying tooth locations on periapical
radiographs, where distinguishing
between maxilla and mandible and
left and right sides can be challenging. DL offers a precise solution for
tooth identification. Importantly,
user-friendly graphical interfaces
have made DL accessible to dentists
without programming expertise.
The accuracy of the initial classification labels assigned by humans is
crucial for supervised classification
tasks, where a machine learning
model is trained to classify data into
predefined categories. For instance,
DL can accurately identify impacted
supernumerary teeth based on clear
criteria. Conversely, diagnosing
mandibular cortex morphology indicating osteoporosis may require expert observation. Identifying periapical lesions, like radicular cysts,
presents further challenges.
Region detection tasks in DL involve AI learning from expert-annotated regions of interest to automatically define rectangular regions of
interest in images. This is essential
for classifying positive and negative
radiographic findings.
Automatic tooth detection in
panoramic radiography is a significant breakthrough. This technique
not only aids in diagnosing dental
diseases but also assists in postmortem identification after natural disasters. However, overlapping teeth in
panoramic images can complicate
the identification process.
The segmentation task in DL divides an image into distinct segments, distinguishing objects from
the background. Semantic segmentation uses colours to separate objects, and instance segmentation
identifies individual instances of the
same class. Segmentation tasks
complement region detection and
are essential for accurately tracing
the outline of target structures and
lesions. Examples include mandibular canal and maxillary sinus extraction in panoramic radiographs
and segmentation of periapical lesions. Generative AI encompasses
creating new content, such as text
and images, through DL models.
These models have been used to reduce image noise and refine dental
images, improving interpretation
and diagnosis. Additionally, generative AI aids in creating patient-specific dental and facial features, assisting in treatment explanations and
CAD.
Editorial note: The study, titled “Deep
learning and artificial intelligence in
dental diagnostic imaging”, was published in the December 2023 issue of the
Japanese Dental Science Review.
[2] =>
DTMEA_No.1. Vol.14_LT.indd
LAB TRIBUNE
B2
Lab Tribune Middle East & Africa Edition | 01/2024
Wanted: Research on
3D-printed zirconia restorations
By Dental Tribune
International
Zirconia-based restorations, renowned for their durability and aesthetics resembling natural teeth,
have gained popularity over the past
20 years and are increasingly being
produced using CAD/CAM. A recent
systematic review and meta-analysis
comparing milled versus 3D-printed
zirconia prostheses has found continual gaps in the research, including
biases, and potential under-representation of the performance capabilities of 3D-printed restorations. A
complete lack of clinical studies on
the efficacy of 3D-printed zirconia
crowns and fixed dental prostheses
(FDPs) also highlights how far research into zirconia crown fabrication has yet to go.
Zirconia, dubbed “ceramic steel”
for its robustness, is a preferred
choice for various dental restorations
owing to its high strength and biocompatibility, among other attributes. The introduction of CAD/CAM
technologies has enhanced the precision of manufacture of zirconia restorations by minimising human error.
There are two main fabrication
methods: subtractive (milling) and
additive (3D printing). Each technique has its advantages. Milling is
cost-effective and less sensitive to
minor design imperfections, while
printing offers more design flexibility
and efficiency in intricate structures.
While 3D printing of dental resto-
There is great need for research when it comes to zirconia restorations, regardless of the manufacturing process.
(Image: Freepik)
rations is nascent, studies comparing
the effectiveness of milled versus
printed zirconia are scarce.
The present review was conducted in an effort to bridge this
knowledge gap by seeking to determine whether the performance of
zirconia crowns and FDPs produced
by both methods compares favourably with that of conventionally pro-
duced ones. The review included various in vitro studies, necessary in lieu
of any available clinical studies on
3D-printed zirconia restorations, and
the results are intended to guide cli-
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— international magazine of
digital dentistry
nicians in selecting the best method
for creating crowns and FDPs. The included articles were published from
2004 to November 2022 and reported on the placement of over
1,500 zirconia restorations, predominantly in the posterior regions. The
studies involved a variety of clinical
designs, and most patients were followed for over a year.
Clinically, zirconia crowns and
FDPs showed impressive biological
and physical properties, with few reported is sues. The meta-analysis revealed that, regardless of variables
like age, glazing/staining, location
and marginal integrity, the pooled
survival rate of these crowns and
FDPs was consistently high, at 100%.
In the context of in vitro studies comparing 3D-printed and milled zirconia crowns and FDPs, findings suggested that both methods offered
comparable accuracy, adaptability
and strength, positioning 3D printing as a viable option for clinical use.
The main biological outcome
observed across the board was
bleeding on probing. Technical issues, such as crown fractures, were
noted, one study recording a survival
rate of 91.5 %. Proper polishing was
found to reduce the chance of crown
fracture. Other key findings in the review were that patients with bruxism
should be treated with zirconia
crowns and FDPs with great caution
and adjustments might be needed
after crown placement owing to occlusal issues or pain. The average
preservation of marginal integrity
was high, but varied depending on
the study. Zirconia was found to
cause wear on opposing teeth, but
less so than other ceramics.
There is limited literature on zirconia’s aesthetic aspects, especially
concerning colour. The review faced
challenges like technique variability
and limited patient sample size. Conclusively, zirconia crowns and FDPs,
whether 3D-printed or milled, are
promising but require more extensive research, especially long-term
studies, to validate their benefits
over traditionally produced prostheses. Although in some cases the literature suggests that milled crowns
and FDPs are superior to 3D-printed
ones, there were no identified direct
comparisons performed in any studies. The lack of research into
3D-printed crowns and FDPs may
have contributed to this result.
Editorial note: The study, titled “Clinical
effectiveness of 3D-milled and 3D-printed zirconia prosthesis—a systematic
review and meta-analysis”, was published on 27 August 2023 in Biomimetics.
[3] =>
DTMEA_No.1. Vol.14_LT.indd
LAB TRIBUNE
B3
Lab Tribune Middle East & Africa Edition | 01/2024
“When it comes to 3D printing, it is the
innovative character and attractiveness
of the technology that counts”
An interview with Dr Przemysław Kustra, Poland
1
Fig. 1: Dr Przemysław Kustra.
By Anisha Hall Hoppe, Dental
Tribune International
Dr Przemysław Kustra has spent
decades not only in honing his craft
as an endodontic specialist but also
in perfecting the art of teaching.
Specically, Dr Kustra has used his research in endodontics as a portal to
explore ways to improve didactics,
abandoning traditional methods and
replacing them with insight into advances in additive manufacturing
that give his students the opportunity for deeper learning on
3D-printed teeth and dental structures that exactly match those featured in complicated casework.
Dr Kustra spoke with Dental Tribune
International about how he has used
technology to advance teaching.
Dr Kustra, could you share
with our readers how you identied
the need for researching the use of
3D models in endodontics?
Thanks to my almost 20 years of
working as a researcher and teacher
in the Department of Conservative
Dentistry and Endodontics at the
Jagiellonian University Medical
College in Kraków in Poland, and because of my PhD in endodontics, I
have a clearer and deeper understanding of certain aspects of teaching, and I take the transfer of knowledge very seriously.
I remember, while still a student
at my rst international conferences,
watching examples of beautifully executed root canal treatments, including extremely difficult clinical cases
with successful outcomes. I learned
that even the most difcult clinical
cases could be dealt with through
the use of good models. Such models would require the new technology that began to appear in those
years. Specialist equipment, working
techniques and the development of
effective treatment methods were
what drove me on because I was very
interested in the effective treatment
of dental diseases. I decided that, as
a teacher, I would conscientiously
pass on the skills and knowledge entrusted to me by previous generations.
I realised an additional teaching
approach was necessary, one which
would accelerate the acquisition of
clinical experience while enabling
the student to gain self-condence in
performing clinical procedures effectively. An example would be the
clinical rinsing of a root canal, during
which an assistant demonstrates the
procedure and the student observes
the technique via a separate monitor,
after which I perform the procedure
myself. At a later stage, a surgical microscope is used to demonstrate the
root canal rinsing procedure, so that
the student can clearly see how re-
sulting dentine chips are successfully
removed and rinsed away. When a
microscope is used in work from the
beginning, the effects of the procedure can be viewed directly. Usually,
root canal rinsing is moderately effective in removing impurities, but
the technique can be quickly improved and corrected. For the casual
observer, nothing changes at all, as
the rinsing operation looks unchanged, but something subtle and
yet sufciently effective must have
happened so that the canal is now
rinsed and cleaned properly. When
we have the opportunity to see our
work, we can immediately correct it
by means of our working technique.
A valuable teaching technique
is the use of a copied tooth by a
student or clinician to create a realistic clinical situation that will give
the student the opportunity to gain
experience in performing the procedure effectively and with condence. This removes the need of
the help of an assistant who normally helps students from start to
nish, from the opening of the tooth
chamber, right through to the task
of root canal sealing.
Using 3D printing allows students to work with multiple exact
copies of teeth for specic clinical
situations. A teaching assistant
presents the procedure using the
first model, then, on the next
model, the students can perform
the procedure on their own, improving their working techniques
until they are sure that they will be
able to perform the procedure on
the patient’s tooth from beginning
to end.
What suggestions could you
offer to clinicians who have been
practising for a long time but who
are not yet comfortable with incorporating more digital processes into their workow?
3D printing itself is interesting
and the ability to create draws you
in. We can plan, create and print
real models that improve treatment outcomes and present patients with real visuals.
“When we have the opportunity to see our
work, we can immediately correct it by
means of our working technique.”
2
3
Fig. 2: Example of 3D scan provided by Dr Kustra of his own face. Taken with a
Siemens Somatom Sensation Cardiac 64 spiral CT scanner, such images are useful for virtual endoscopy planning. Fig. 3: Dr Kustra demonstrating the use of a
Leica HM500 digital microscope for his students.
The basis of a doctor’s thinking
is to nd a way of treating diseases
in a satisfactory way. This always
leads to caution when applying
new techniques, specically concerning the materials or devices
used. When it comes to devices, it
is always a question of whether the
cost of the device will actually improve the health of my patients.
Were there any results that
surprised you, or additional areas
of research that you identied?
When it comes to 3D printing, it
is the innovative character and attractiveness of the technology that
counts. I noticed that students like
new technologies, and this was a
factor that stimulated their desire
to study. Everyone wanted to be in
the group doing research involving
3D printing, to the point that additional research groups had to be
organised.
The use of 3D printing also
presents the opportunity for colleagues to help one another in a
given eld. For example, a dentist in
possession of a patient’s radiograph could bring a printed tooth
to a conference or to a specialist
and could, together with others,
develop a technique for the procedure before commencing clinical
work. This is most likely to happen
in complicated cases.
While working with 3D-printed
models, I found that students did
surprisingly better when working
with premolars than with molars or
incisors.
Where would you direct clinicians who want to learn more
about the topics of bioprinting
and virtual endoscopy?
There are many 3D dental atlases available today, and their databases are constantly being improved. You can familiarise yourself
with the available programs for vir-
� Page B4
[4] =>
DTMEA_No.1. Vol.14_LT.indd
LAB TRIBUNE
B4
Lab Tribune Middle East & Africa Edition | 01/2024
� Page B3
How has training for students
changed in the last ten years, and
what do you predict dental and
endodontic training will look like
in the future?
5
4
Fig. 4: A 3D-printed molar as viewed by a student under a clinical microscope. Fig. 5: A digital model being prepared for a virtual endoscopy.
6
7
Fig. 6: A 3D-printed lower incisor used in instruction.
Fig. 7: A tooth about to be inserted into a Nanotom scanner for radioisotope
thermoelectric generator (RTG) scanning.
8
Fig. 8: The Nanotom scanner, running radioisotope thermoelectric generator (RTG) scans on a single tooth. With the scans, a digitial model can be made and the data
generated can be further used for other purposes such as bioprinting. (All images: © Dr Przemysław Kustra)
“Our students are our future.”
tual endoscopy on medical industry websites. Medical physics departments also deal with this topic
in the context of engineer training.
One example of open-source software is InVesalius.
In addition, studying 3D bioprinting is worthwhile. This is a
technique mainly associated with
reconstructive surgery techniques,
and is the future for personalised
oral soft-tissue regeneration. It is
also designed to deal with challenges involved in regenerative
dentistry by fabricating 3D tissue
structures with a customised complex architecture. CELLINK and
Fluicell are fairly well-known educational platforms as is the edX
platform, which has courses in subjects such as biomaterials and biofabrication.
Our students are our future.
Practice, practice, and even more
practice makes perfect. Habits established early may last for years
so, it is good to start with the best
ones. If the teacher is very skilled,
it’s more likely that the student will
also become very skilled.
The changes in training come
down to the amount of time allocated to theoretical and practical
learning. I have also noted that
there is a signicant need for practical classes in order to acquire manual skills.
With these classes, there has
been a shift from block classes to
year-round classes. Constant practice is important, as is the ability to
make positive demands and reduce
routine. These changes have been
followed by the implementation of
machine working techniques, together with the implementation of
electronic measurement and root
canal lling devices. We have worked
to make seminars more interactive
with open discussion of problems
and the differences of perspective
between authors.
Additionally, even though disease is objectied in instruction, it is
important to be sensitive to the
views of others in order to avoid
treating a person as an object.
In the future, we may become
aware of the strengths and weaknesses of the use of articial intelligence in procedures. As an example, a clinician with extensive clinical experience working with an
endodontic motor equipped with
articial intelligence can, during the
mechanical preparation of a root
canal, “teach” the system. The dexterity gained by that clinician over
the years in his or her hands
through manual work can be digitally transferred to the program.
For the dentist who uses this device, it will be easier to perform
subsequent treatments.
Such devices would have to be
equipped with an endometer that
continuously measures the working length of the root canal. The
data obtained could be shared with
other clinicians who would be able
to download this data to their endodontic motors. This would allow
even novice dentists to be able to
treat patients more effectively.
There will still be some instances where, even with the use of
technology during the teaching
process, manual precision will be
required, as well as time to create
neural connections in the brain of
the learner. Just as in sports we witness that, through continuous exercise, the athlete achieves better
and better results. We may perform
more poorly as we initially form
and restructure neural connections, but being aware of that fact
will help us better understand it,
and this will benet everyone. Understanding the learning process
ourselves helps us teach others
how to learn properly.
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[cover] => ![Lab Tribune Middle East & Africa No.1, 2024]()
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[title] => New study investigates 3D-printing use in dental practice
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[title] => Wanted: Research on 3D-printed zirconia restorations
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[toc_titles] => New study investigates 3D-printing use in dental practice
/ Wanted: Research on 3D-printed zirconia restorations
/ “When it comes to 3D printing, it is the innovative character and attractiveness of the technology that counts”
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