Case Study: Digital Dentistry with Ricardo Brito
In my task to explore the benefits that 3D printing provides in applications, not only for engineering but also in other fields such as dentistry, I decided to visit a dental office to see it for myself. As a result, …
In my task to explore the benefits that 3D printing provides in applications, not only for engineering but also in other fields such as dentistry, I decided to visit a dental office to see it for myself. As a result, I am pleased to have contacted Dr Ricardo Brito, whom I thank for giving me his space and time to share this experience with you.
Ricardo Brito graduated from the UCV (Universidad Central de Venezuela) in 2008 with a postgraduate degree in oral rehabilitation from Javeriana University. Ricardo has explored various criteria in several countries worldwide, mainly throughout Europe, Latin America and the USA, to develop his personal work philosophy within his practice. Ricardo is also a scientific advisor to two commercial houses, Ivoclar Vivadent and Digital Smile Design (DSD), with whom he has lectured on digital dentistry worldwide since 2012.
For the past four years, Ricardo has been using Formlabs Dental technology in his practice as a fundamental part of his workflows. Upon entering his office, I was able to witness a place fully equipped with digital systems. I also had the pleasure of meeting his assistants working with the resin printed dental models. As there was work to do in his office, Ricardo gave me the interview in his uncle’s office, located in the same clinic. The contrast was impressive; this office, unlike the previous one, had a vintage style; it didn’t even have a single computer. This simple change made me think of the digital changes that have happened at an abysmal pace in just one generation, and, with this idea in mind, the interview begins.
The Transition from Analog to Digital
What was it like, in your personal experience, that transition between traditional and digital?
It is trending in dentistry, and it is equipment modernisation, as easy as that. One thing leads you to the other. However, not necessarily having the latest technology makes you a better dentist; the most important thing is to have the concept clear, but modernisation forces you to do processes with a slightly different curve, a digital curve.
For many years, 3D printing for dental uses has been in existence, with a learning curve much longer than I have directly felt. I personally worked with this technology long before I bought it. The first case was addressed in 2014 at the headquarters of Digital Smile Design in Madrid. Then when I saw enough precision and an affordable price range, I started using it in my office.
What is the key factor that forced you to adapt to that digital curve?
Precision, I specifically addressed it for precision. Because when you do it analogically, you depend 100% on your skill. Did I like the results I had? Yes. But the problem is that I had to spend too much time on that critical point that was the lab. So, when you start to enter the digital world and when you see that you take less time on the computer to make that same result; Well, obviously, you no longer need your hand ability, you just press play, and you are 100% sure that the printer will replicate what you did on the computer.
What did you use before to make the models? A resin? A mould?
Exactly, I used a silicone material mould to duplicate what I did. But, as I say, what is the point of that duplication issue if now I have a machine? In the end, I won’t claim back the human time it would take me to do that; it’s not operational for me. It’s a time where the machine works alone. When a workday is over, I start the printer, and it’s like having a person in the office working at a time when nobody works.
And, as for the separate lab you mentioned, with all its specialised machines, how high are the additional upfront and maintenance costs?
Notice that the cost of, for example, a product such as a milling machine is diametrically opposed to a printer. A dental milling machine, the cheapest, is available on the market for $50000, the cheapest. On the other hand, a printer of an excellent and professional range, such as Formlabs, is between $3000-$4000.
The New Digital Modality
So isn’t the milling machine going to be needed anymore? Is this a complete transition from subtractive to additive?
We are just around the corner from not needing a milling machine anymore as printing technologies are doing it in a much more efficient way, faster, and not only that but also with fewer problems and with less material expenditure. Because, here, you only print what you want, while the milling machine acts backwards, you have a block-mill, and so much material is lost in the process. Previously, the depreciation of the material was huge. I mean, you lost almost 70% of the block.
The implication it has is absurd. So, it is practically impossible for a mill to make certain angles, while in 3D printing, there are no position restrictions. If you want to make a geometry within another geometry with a milling machine, it is impossible. In contrast, there are very few limitations on the printer.
Of course, the milling machine still has a range of gain. With the same file, the milling machine can make a definitive material, while with the resins, we’re not quite there yet; but we are getting there soon. The use of resins with ceramics suspensions is entering the market; it simply needs a lost-wax technique where the particles agglutinate to generate the definitive ceramic piece. It’s going to be achieved, it’s a chemical thing, it’s purely engineering.
Another vital thing we are seeing is that we can bring splendid dentistry to the masses. Before you could not do that, before you paid a lot for an elite technician, now we can lower the costs of those technicians who have these technologies and thus massify the matter a little more.
However, isn’t this a problem for technicians, given that dentists can now solve in-house?
No, on the contrary, what it does is that it makes the process easier for them. That generated a huge controversy in the dental world four years ago. No, we need the technicians, but imagine how a good technician could be enhanced with good technology. You’re going to significantly increase the excellence factor, which is what we’re looking for. And, the technician who maybe didn’t have that manual virtue can now take it to an optimal level.
So, now, I guess the technician can concentrate more on the details and become less saturated with the demand.
Exactly, then you generate a much better market, you cover much more, you give a better service, everything improves, everything has to improve, and it will improve. From the first moment I saw the 3D printing matter, I said that it has to go to my office, yes and yes. And in our dental courses and conferences, we say that dentists who don’t have a printer in their office right now are practically crazy to us. How are you not going to have it?
In what specific case has the geometric freedom you mention helped you?
You can simply see it with all the provisional prostheses that one places; it is freedom, plenty. After you scan the patient, you already get a file, which is a very fast result. Having a temporary tooth for a patient after 45 minutes is a great thing.
What is the current issue like regarding regulations, health standards in the world of dental printing?
Look, the most important point is that we live off biocompatibility and sterilisation. We must sterilise our materials and use autoclave ovens for this purpose. The good thing is that we have no problem with that, available resins can withstand these high-temperature cycles. Also, of course, they meet the purpose of biocompatibility by not generating negative responses in tissues. These processes are already governed by the American Dental Association (ADA), an entity with a very high-quality standard, which we follow in our procedures.
Ricardo’s Dental Workflow
In this section, Ricardo briefly shares with us all the steps he follows with his patients and how digital technology is involved in every aspect of this workflow. He started by telling me about the importance of the DSD Planning Center digital platform in his daily workflow and that of his colleagues.
We are part of a global planning centre called Digital Smile Design (DSD) Planning Center, set in Madrid. They have a place full of programmers, all under this dental philosophy. So, you send your case there, they analyse, they print, they mill, they simulate, and they guide you; it’s straightforward. It’s impressive, I don’t even need to send my file to manufacture there; they send it to me to print it here since I have exactly the same printer calibration they have there. In fact, I have the same software as them. We were part of that learning curve during its development, and for that reason, I belong to their organisation; also, my laboratory is certified by them.
What I’m saying is that we dentists are trained to care for patients in a chair. Well, let’s give the chair time, an effective time, that’s the most important thing.
And, in what cases would you have to send something to another lab?
The only cases I have sent to other labs is when surgical plannings are too extensive, and although I can deal with it myself, I have a family, I have a life, so I prefer to leave it with them. I just do as an orchestral conductor, and when it’s ready, I approve the treatment plan. For approval, they send me the file to print. In fact, they send a box which is called The Magic Box. They send everything from surgical guides, bone reduction guides, implant placement guides, prosthetics guides, everything. Every guide has the perfect ring for the implants to enter in the right position and height. I mean, it’s like playing Lego. Now we are playing Lego in dentistry.
In general, how are your workflows?
We say that in the courses as well. There are some dynamics in the first and second consultations. The dynamics of the first consultation is: The patient arrives and makes his story, enters the office and takes his photographs. Then moves on to the dental chair, where you do the scanning. Then, he goes home quietly, but you already have the necessary information: Photographs, scans and what you saw at the time of the dental consultation. If you have a supplemental exam like a CT scan or some x-ray study, you attach it, but those are complementary studies. Once you have that information, it is processed within a planning centre where the ideal treatment is generated. Then, one validates it as a dentist.
And do they do it manually from the centre, or do they rely more on automated algorithms?
That’s manual and within the software capabilities. Since they have a learning curve already set, the team at the planning centre know precisely where they are going. They’ve seen so many repeated cases that it’s something like having an algorithm generated.
We cross different files. First, we cross an STL file with a CT scan and, apart from that CT scan, with a photograph or face scan. So we have an overlay of images that provides me with outstanding accuracy. Face scanning can be done with photogrammetric cameras to get a good mapping, but there are several other techniques. You cross that with the scanning of the jaw, and with a tomography, here practically everything you need is noted.
I’m getting more technical here. From the periodontal point of view, crown or teeth enlargements were exceedingly manual in the past. When the dentist worked and made good precision work, you said, “Hey, yes, I like it”; the aesthetic aspect of the dentist had to be there. Not now, design workflows generate a restrictive guide where you simply have a single cutting position. You no longer need that ultra-delicacy of that dentist wizard; now you already know what you want. The same program sets limits, and your software workflow becomes 100% restrictive.
The software works with a mesh crossing between each element. Then you go with the first mesh, which is the bone, and on top goes what the gums and teeth would be, then the other elements to add. When the software captures it, you decide what to do, and it generates almost everything for you, which is the most exciting thing about it. There is no ideal software for me, several companies are coming up to create them as ideal as possible, but there is no ideal software. What I do is I have three favourite software programs, Nemo, Blue Sky and Exocad, and I cross information between them. So, it opens up an excellent range of possibilities.
Once we have studied the patient’s case, then comes the second consultation dynamic. We generate a review, and additionally, we can have a printed mockup model to present the ideal treatment. Then, we show the project in images, and, after approval, we proceed to the dental chair to place the model in the patient’s mouth as a test.
Which resins do you use for these mockups? Is it biocompatible?
Yes, those specific resins are biocompatible. But, in this case, it is for temporary use; we place it so that the patient can see it. For this, I use Formlab’s temporary tooth colour resin in its various colours, A1, A2, A3. In the end, the idea with the mockup is that you see what you could do in the future. It’s a functional biological prototype you use before producing the final one. With flows just like those of architecture or engineering: 2D Planification, 3D, testing model and definitive. Before, in dentistry, many tests were made: Material testing, ceramic testing, dimensional testing. Now the printer provides me with a fidelity of 30 microns, is there something more faithful than that? The truth is I’m hardly testing anymore.
Once the project is approved, you start executing the protocol. For each tooth, whatever that is needed: “This tooth needs inlays, this tooth needs a mask, this tooth needs an implant.” You’re going to execute the treatment plan you defined from the ground up.
And, what can you tell me about the lost wax process?
Previously, it was the lost wax technique, and now it is a lost resin technique (More on this process here). Already we generate definitive results, and we can use the model we print in a refractory investment casting process. Here the oven is calibrated specifically so the model can be removed entirely, without any residue, and then the ceramic is injected.
Some resins already come suspended with ceramics, for instance, the one offered by BEGO (A Formlabs Dental partner). From the software, you calculate the redistribution level of the ceramic material. It is like, for example, zirconium; this material comes oversized. When sintering, the molecules bind together, and that is already calibrated to achieve the intended scales. The same goes for these resins, you just have to calculate the shrinkage percentage, and you’re done.
Ricardo’s experience with Formlabs Dental
You already have a learning curve of several years with 3D printing. How do you feel it has evolved throughout time?
Like any other learning process, you have to focus on the specific software you use; the printer is just: Log and play. The learning curve of printers is not that complex, and machines do practically everything for you. You have to place the initial setting, but, in many cases, commercial houses, such as Formlabs, give you an instruction on how to place those parameters. Formlabs interfaces are highly intuitive because they have already done such a nice learning curve that they know very well how to adapt it to your dental workflow quickly.
How is your experience in terms of calibrations and maintenance? Do you consider Formlabs printers to be robust systems?
Look, compared to other systems, the Formlabs equipment is quite stable and doesn’t need much calibration. We do quarterly calibrations. In fact, Formlabs printers, which is the thing I like the most, yield a result after calibration, thus making sure everything is fine. That’s because it’s Formlabs and its array of sensors. With other brands that do not exist, you have to do it all manually.
We know they have a useful life, and equipment depreciation. So, we do calibration to see how the machine is doing; though we know that Formlabs does it digitally, we do it manually just to be sure. After that, we’re ready to work and print.
The most important thing I can tell you is that you should have dedicated tanks. I personally have tanks for each resin, all stored, sealed and protected against light. Otherwise, you would have to be constantly emptying and cleaning, which I don’t recommend.
How do you handle slicer parameters?
Everything is already preset. The only thing you have to do in Preform is to choose the layer height: You want 25 microns, 50 or 100 microns?
On what basis do you decide which resolution to use?
There are cases where we always need to have a very high resolution for a definitive work. When it comes to mockups, where not so much detail is needed, printing is much faster. We are not interested in taking four hours on a model when it can be done in 45 minutes and still with an excellent resolution. You need it to work fast, and the machine must be useful for any task it takes. For example, a full-mouth model with an accuracy of 25 microns can take about 4 hours, while the same model with 100 microns can take 1 hour. A 100-micron resolution is enough to be within the tolerance range we need for a test sample.
Since you told me that you leave the machine alone in your office, what can you tell us about the Formlabs monitoring system?
I go home, and just by checking the Formlabs website, I can know in real-time how the process is going, the level of the tank, the depreciation of the equipment, what error is happening, everything. Besides, you also have stats. For example, you can see how much resin you spent in a month and, with that, you can generate your own accounting. The same platform tells you, “Look, the resin tank will run out soon. Do you want to place a new order?” Of all the brands I’ve worked with, I’ve only seen this management level with Formlabs.
So what would be the main factor that drove you to choose Formlabs?
It is an earnest company that can always take, maybe, a little longer than other commercial houses to get their products out. But, the product that comes out has such a good accuracy that users don’t really need a learning curve. The commercial house is already doing that learning curve, and it is sending you an elite product to your office; this must be said.
Another thing that surprises me a lot about Formlabs, is their technical support. It’s one of the best tech supports I’ve ever had in my life. On your page, you have a Formbot that says: “Hi Ricardo, what do you need?” and then you write your problem. For example, “I am generating x error when I try to print” or “The tank has x issue”. For any issue, it gives you detailed instructions with everything you need to do. The communication is super fast, super effective, and everything is nicely documented. They are constantly innovating, always doing forums, they always send videos on how to make improvements to your equipment in order to have the best and most precise final process. While other brands tell you, “Well, here’s the stuff, get beaten up”, Formlabs takes you by the hand like a child.
The Digital Future in Dentistry
With all these benefits, why don’t you convince your uncle to adopt this technology?
He doesn’t need to; he has me. In fact, in this clinic, everyone has me. So he always comes to me and says, “Hey Ricardo, can we print?” everyone in this clinic uses it.
Of course! It should not be easy for everyone to adapt to digital dynamics; it is like learning a whole new language. That is entirely understandable.
Exactly. It’s, as I say, a learning curve. You have to be clear from the start that there must be a considerable studying process until, suddenly, you are already an expert in the field, and everything becomes easier. It’s like when we transitioned from discs to MP3. One said then, how do 1000 discs fit into this device when a thousand discs occupy an entire piece of furniture? (He points out his uncle’s record furniture), it’s the reality of life, and that’s where we go. That’s why I consider myself an early adopter, and I try to adapt as soon as possible.
And, beyond 3D printing, what other technologies do you see filling your ecosystem?
What I see is that we’re going to have more AI technology. We will configure a program’s settings to do what we do routinely; for me, that is AI. Instead of a radiologist reading an x-ray, this time, the machine will do it. For example, machines detecting cavities and bone densities for us, the criterion of whether an implant is going to be needed or not, everything is going to be decided by the AI and that’s what’s going to happen in dentistry. So, all of these digital protocols will be standardised by a machine. We depend 100% on our brain, but we can redirect that energy for more enjoyment if we release a little bit of the tension we have at work.
Now, going back to 3D printing, what expectations do you have regarding 3D printing for the future? What’s missing? What future development can we expect?
I would say that definitive materials for dentistry is the next stage of development. And, I tell you, that’s just around the corner. Now we are still printing resins to transform them into something else, as it happens with the lost resin technique. Then the technology points towards the definitive product coming out of the printer quickly, and with fewer post-processing times, all is reduced to shortening processes and improving materials. We already have the fidelity of the machines, and now we only have to make sure that the same fidelity happens with the materials. Therefore, I see that there will be no clinic without a 3D printer. It has to happen.
Finally. What recommendations can you share with those who want to enter a digital modality in the world of dentistry?
First of all, it is already a reality; You can’t cover the sun with a finger. Digital dentistry is happening and is here to stay. Digitisation is already a reality that we see on a daily basis, and the most important thing is to take the first step, to act. “Don’t worry, take care of doing it yourself first, and then you’ll see how it goes”; that’s what we always say in our courses. I am already doing 100% digital dentistry since 2012, and I’m convinced I will never go back to classic dentistry. Now my hands sting if something doesn’t go into the digital stream because I know that doing it this way, I work with more precision, I’m freer, and I can offer a better service.
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