P a n a y i D e s Nearchos C. Panayi, dds, dorth, morth, is an orthodontist i g based in Limassol, Cyprus, and is currently a PhD can- n didate in the Experimental Surgery Department at the DIY I National and Kapodistrian University of Athens Medical t Y School (Greece). He studied dentistry at Athens Dental o School (1992–1997) and orthodontics at Tel Aviv Universi- u ty (1998–2001) before building his private practice, which r has grown into two fully digital orthodontic offices in Li- s Design It e massol and Larnaca, Cyprus. His passion for digital tech- l f nology encouraged him to use it in orthodontics, and as a huge fan of the in-house 3D designing Yourself O and printing concept in orthodontics, Dr Panayi has helped develop concepts, ideas, and meth- r ods that will transform traditional orthodontics to customized-centered digital orthodontics. t h He is the inventor of the orthodontic CAD software UBrackets for in-house designing of cus- o tomized fixed orthodontic appliances, and he introduced the use of general-purpose CAD soft- d Orthodontics o ware in orthodontics for orthodontic appliance design. Dr Panayi is also a researcher for direct n aligner printing. He is married and has six children. t i c s Nearchos C. Panayi, , , Edited by dds dorth morth ISBN 978-1-64724-051-6 90000> 9 781647240516 DIY Orthodontics: Design It Yourself Library of Congress Cataloging-in-Publication Data Names: Panayi, Nearchos C., editor. Title: DIY orthodontics : design it yourself / edited by Nearchos C. Panayi. Description: Batavia, IL : Quintessence Publishing, [2021] | Includes bibliographical references and index. | Summary: “This book describes the current digital technology that is used in orthodontics, including volume and surface scanning, 3D printing, CAD software, and artificial intelligence, before delving into a “design it yourself” guide presenting the application of this technology in all aspects of orthodontic treatment”-- Provided by publisher. Identifiers: LCCN 2021005696 | ISBN 9781647240516 (hardcover) Subjects: MESH: Orthodontic Appliances | Equipment Design | Digital Technology | Computer-Aided Design | Orthodontics--methods Classification: LCC RK521 | NLM WU 426 | DDC 617.6/43--dc23 LC record available at https://lccn.loc.gov/2021005696 A CIP record for this book is available from the British Library. ISBN: 9781647240516 © 2021 Quintessence Publishing Co, Inc Quintessence Publishing Co, Inc 411 N Raddant Road Batavia, IL 60510 www.quintpub.com 5 4 3 2 1 All rights reserved. This book or any part thereof may not be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, or otherwise, without prior written permission of the publisher. Editor: Leah Huffman Design: Sue Zubek Production: Sarah Minor Printed in Croatia DIY Design It Yourself Orthodontics Nearchos C. Panayi, , , Edited by dds dorth morth PhD Candidate Athens Medical School National and Kapodistrian University of Athens Athens, Greece Private Practice Limassol, Cyprus With translation support from Moshe Davidovitch, DDS, MMSc Contents Foreword vi Preface viii Acknowledgments x Dedication x Contributors xi 1 Introduction 1 Rafi Romano I 3D Technology in Orthodontics 2 CBCT in Orthodontics 3 Apostolos I. Tsolakis, Christos Angelopoulos, Nearchos C. Panayi, Kostas Tsiklakis 3 Surface Scanning 17 George Michelinakis 4 Additive Manufacturing 31 Nearchos C. Panayi, Ioannis Gkiaouris, Spyridonas Efstathiou 5 Orthodontic Office Digital Workflow 43 Moshe Davidovitch, Nearchos C. Panayi II 3D Applications in Orthodontics 6 In-House Custom Appliance Design 55 Nearchos C. Panayi, Apostolos I. Tsolakis 7 Custom Appliance Design Using Dedicated Orthodontic Software 85 Santiago Isaza, Stefano Negrini 8 In-House Customized Orthodontic Brackets: UBrackets Software 97 Nearchos C. Panayi 9 In-House Customized Lingual Orthodontic Appliances 119 Chris Riolo 10In-House Clear Aligners 129 Nearchos C. Panayi, Manolis Mavrikis, Evangelos Akli 11 In-House Digital Indirect Bonding 155 Nearchos C. Panayi, Moshe Davidovitch, Riccardo Nucera 12 In-House Orthognathic Surgical Splints 179 Federico Hernández Alfaro, Adaia Valls Ontañón 13 In-House Orthodontic Archwire-Bending Robots 195 Alfredo Gilbert 14 Artificial Intelligence and Machine Learning in Orthodontics 205 Rosalia Leonardi, Cristina Grippaudo, Silvia Allegrini, Ambrosina Michelotti Index 213 Foreword with a glimpse into the analog past, information available in a digital format. And digitalization the transforming present, is the next step to develop the appropriate tools to manage and the digital future the digitized information. The “digital transformation” is the integration of digital data with digital tools into all This book opens the “digital pathway” to 3D success aspects of any enterprise. The fact that many technologies, for the orthodontic clinical practice. It is a successful such as modern design and manufacturing, utilize digital demonstration on how digitization of patient infor- information and rely on computational procedures leads us mation and digitalization of clinical procedures can lead to consider ourselves under the “digital umbrella” as well. to a digital orthodontic transformation for the design and It is very important though to mention that a successful manufacturing of patient-specific devices—and in turn to digital transformation is not just about the technology. It considerable benefits for clinicians and patients. fundamentally changes how an organization operates in Many years ago, I had the opportunity to propose the order to deliver the potential benefits. It requires a cultural use of computer-aided engineering as a potential clini- change with new and different ways of thinking. It is a cal tool for preoperative planning, surgical practice, and constantly evolving situation that requires experimenta- customization of medical devices. However, the efficient tion for the implementation of novel processes that are integration of medical imaging with design, simulation, frequently radical and challenge analog routines. In health and rapid manufacturing was a long, challenging, and care, the order always used to be disease, medicine, and demanding task. It could take weeks or even months to then patient. However, a digital health care transformation coordinate just the export of images from medical scanners. puts the patient at the center of medical care, affecting how Specific knowledge and equipment were also necessary to people access or even define health care. transfer image data to a computer. Extra effort was required What does a potential “digital health care transforma- to decode and read the “native” formats utilized by those tion” really mean? It is estimated by IBM Watson that each closed systems. Overall, too much effort, too many projects, person can generate enough health data in their lifetime to extensive scientific work, and numerous clinical cases and fill 300 million books. More medical data has been created patient stories have been required in order to prove the in the past 2 years than in the entirety of human history, value of a digital engineering approach in clinical practice. and this is predicted to double every 73 days. Most data By the turn of the millennium, the underlying engineer- though are unstructured and stored in hundreds of forms ing technologies, as well as the relevant digital 3D workflow, such as lab results, images, and medical transcripts. It is were fully established. Computer-guided implantology was called Big Data because it is voluminous and complex. the first concrete example of a successful digital process Traditional processing software was inadequate to deal in dentistry. During the following years, a considerable with it, but now there are the technical capabilities to moni- simplification and automatization of the procedures was tor, collect, and process this scale of information. Big Data achieved, mainly due to considerable software develop- can be analyzed by intelligent systems that can imitate ments but also hardware improvements and increasing human learning and reasoning, otherwise called artifi- computer power. Nevertheless, it took decades to garner cial intelligence (AI). AI has the capability to sift through widespread recognition for the apparent benefits of engi- billions of pieces of unstructured information and “inves- neering approaches in dentistry and medicine, as well as tigate” millions of patient cases in order to find patient- the potential of a generalized digital transformation in relevant information, sort its importance, make necessary health care. Today, everyone wants to “go digital,” even connections, and summarize conclusions in a predictive when it is often unclear what that even means. way. In addition, such digital processes can employ “cogni- Strictly, the term digital refers to the management of digi- tive computing” techniques to simulate human thought tal information. Digitization is the initial step to make all by learning how to recognize and use the data. The rele- vi vant technology platforms can encompass reasoning, a “virtual human” model for the British MOD and NATO. speech, and object recognition, language processing, and It took a record time of a few months to generate a whole human-computer interaction. Doctors can interact directly human anatomy for the first time in an STL format. Today, through dialogue, discussing various proposals. Through such a model could act as an input for AI and cognitive “machine learning” (ML), digital systems can also be auto- computing systems to analyze, study, and predict human matically trained and keep learning from any mistakes as anatomy physiologic functions and responses. In the future, well as successes to adapt and become “specialists” in a such virtual patients or otherwise “digital human twins” range of disciplines. As such, a potential digital health will become a common practice for studying every pathol- care transformation can help clinicians to make informed ogy and treatment. From diagnosis to treatment, digital decisions regarding diagnosis and treatment options. It tools are about to change the way every health care profes- is also possible to obtain insights on outcomes of vari- sional works. Prior to embracing the forthcoming digital ous treatment options, to better understand which ther- era, however, we should keep in mind that the success of apy may be suitable for which patients, and in general to “going digital” relies on the way we think, approach, and identify information for optimizing therapy approaches use the relevant technologies. As it is demonstrated by the and improving clinical guidelines. It is important to note prominent authors of this book, the future orthodontic though that such intelligent systems are only assistants practice is not that far away. that support human experts. Doctors and nurses make This book represents the future digital transformation of decisions that are best for their patients, and they must orthodontics. It is an illustration of future digital orthodontic always have the last word. Computers cannot replace the workflows but also provides the reader the opportunity to emotional and social side of people. adopt and apply this already today. A digital roadmap is A key aspect for the success of a digital health care trans- provided for orthodontists who wish to provide care for their formation is that humans remain in control. For that purpose, patients in a personalized 3D way. I would like to express an interdisciplinary approach is necessary. Convergence my great appreciation to Dr Nearchos Panayi for his enthu- among various disciplines such as mathematics, physics, siasm and commitment to adopt digital engineering in his chemistry, biology, engineering, and medicine is imperative. daily orthodontic routine. His passion to share the digi- An appropriate understanding of the background technolo- tal knowledge and experience that he has accumulated gies and training of medics for the ideal application of digital during the last few years is admirable. I would also like to processes in clinical practice is also necessary. Certainly, extend my gratitude to all the authors of DIY Orthodontics. the application of automated methods does not mean over- This book is a significant recognition for all those pioneers, simplification of clinical procedures or reduced experience. engineers, and clinicians who believed, developed, and Systematic clinical training as well continuous collaboration introduced digital approaches in medicine. It proves that with experienced technology experts is mandatory. The computer-aided engineering techniques are applicable to all development of relevant technical and clinical standards is clinical fields, as it was once thought and hoped. However, a key element in establishing this digital health care trans- we are still in the beginning of exploring the many possibil- formation. “Certified” procedures and products are manda- ities that 3D engineering technology can offer in medicine. tory in order to protect public health, preserve quality, and We are entering a new universe in clinical practice, and it is promote safety for all concerned. For that purpose, develop- a learning process for all involved. Knowledge, experience, ing and implementing regulatory strategies and policies for as well as guidance and training on best practices are critical. digital health technologies is imperative. The most important Unrealistic expectations only lead to disappointment, but consideration in adapting digital procedures should be the when we work together—researchers, scientists, engineers, optimal results for patient well-being. No one should forget and clinicians—we can get this right! Until then, by reading that health care is about caring for people, and ethics should and applying DIY Orthodontics: Design It Yourself, you can be a key aspect during any digital transformation. already immerse yourself in tomorrow’s 3D world. A “digital future” presents possibilities for our life, but it depends on whether we can really embrace and make Panos Diamantopoulos, DPhil, Dr Eng them happen. Twenty years ago, I was tasked to produce President, Computer Aided Implantology Academy vii Preface Γηράσκω δ’ αεί πολλά διδασκόμενος Automatic integration of a volume and a surface scan is I’m getting older while being taught all the time. also available with certain software. 3D printing or milling — Solon, 630–560 bc, Ancient Athenian legislator & is another form of automation where 3D images are trans- philosopher ferred to dedicated machines and output as real objects following several automation steps. Other such examples I n 1957, the Canadian philosopher Marshall McLuhan are CAD software that performs teeth segmentation and stated that “As technology advances, it reverses the virtual bracket positioning for indirect bonding proce- characteristics of every situation again and again. The dures, which are semiautomation processes. Furthermore, age of automation is going to be the age of ‘do it yourself.’” artificial intelligence is being developed to “trace” cepha- This proactive statement has come to be realized in our lograms with remarkable accuracy or convert DICOM files time. into an STL printable format. The progressive nature of technology has given it a pres- Another example of automation in orthodontics is CAD ence in modern orthodontics since its recognition as the software that performs automatic procedures to help the first specialty of dentistry, as established by Dr Edward operator design almost all kinds of appliances, which are H. Angle. Its influence has been continuously evolving then printed or milled in special machines. Aligner 3D and altering the way orthodontics is practiced. The reality printing is in its initial steps but certainly will be the next is that new materials, techniques, bracket designs and big step in aligner treatment. Recently, in-house or labo- prescriptions, appliances, and software, together with ratory wire-bending robots have been developed to manu- advances in the field of biology, have influenced many facture patient-specific archwires. Artificial intelligence is aspects of orthodontic treatment. However, most of these also used by aligner companies to gather data from ortho- advances have been within the confines of traditional clin- dontists in order to provide assistance for future aligner ical practice workflows, with a dependence on an ortho- treatments. Blockchain, although initially developed for dontic laboratory and orthodontic material companies for use with cryptocurrency (ie, Bitcoin), has also found use in the necessary appliances and auxiliaries to be used for medicine. The ability to automatically share medical data treatment. The advancement of automation, however, is a without any central server using only peripheral computers departure from that workflow entirely. is a promising technology that could also be used between Automation implies self-regulation or acting inde- orthodontists for treatment and research purposes. pendently with limited to no human intervention. This term Customized orthodontic brackets manufactured by is rooted in the Greek word automatos, which means acting companies for individualized orthodontic treatments is an by itself, or by its own will, or spontaneously. Automation, important recent step in the direction of personalized medi- as alluded to by McLuhan, has been incorporated into cine within orthodontics, which has mainly occurred out medicine as a whole, and modern dentistry specifically, of necessity in lingual orthodontics. Nevertheless, bracket but to a lesser degree in orthodontics. customization manufacturing is currently available from Automation can mean fully automatic or semiautomatic a small number of companies also in labial orthodontics. devices or systems where human input has a minor role. A Despite this customization evolution, the relatively high modern CBCT, for instance, is a tomograph that can acquire cost of such treatment currently deters the mass of patients images in three dimensions only by setting the necessary from availing themselves tο such systems. The present book parameters in a semiautomatic configuration. An intraoral describes a new CAD software called UBrackets, which may scanner delivers colored accurate surface 3D images by place fixed appliance customization within the grasp of the automatically matching different angle scans of points of majority of orthodontists and their patients. This tool gives interest (POIs). Recently, color matching for restorations the orthodontist the ability to design the specific patient’s is also available or even functions for caries detection. tailor-made fixed orthodontic appliances. This has led to viii the start of a project to create the technology for in-house The goal of this book is to provide the modern orthodon- fixed appliance printing. tic clinician a description of the current digital technology Creekmore, in his article “Straight wire: The next genera- that is used in orthodontics, including volume and surface tion,” lists five reasons why current preadjusted appliances scanning, 3D printing, CAD software, and artificial intelli- cannot achieve ideal positions: inaccurate bracket place- gence, and to speculate as to the future developments that ment, variations in tooth structure, variations in the verti- can be expected. The former will be summarized within cal and anteroposterior jaw relationships, tissue rebound, a single chapter in an effort to indicate the directions and orthodontic appliance mechanical deficiencies. More- expected of the latter to describe the future integration over, he states that even with the preadjusted appliances, of digital technology and its use within the workflow of a first-, second-, and third-order bends have to be made to completely digital orthodontic office. The second section move the teeth in the desired positions. Perhaps the use of of the book is a “design it yourself” guide presenting the digital technologies will satisfy these conditions. application of this technology in all aspects of orthodontic It was the Greek philosopher Heraklitos (544–484 bc) who treatment. Almost every chapter of this book is a separate stated that “the only constant is change,” or put differently, subject that should be analyzed, studied, and evolved “nothing endures but change.” Within the changes brought more by researchers and orthodontic companies in order on by the digital revolution and the effect of automation to create a state-of-the-art orthodontic technology. processes is the continuous change of human roles. Thus, The book describes all the necessary technologic ingre- the whole complex of the contributing factors in practicing dients to be used in a self-sufficient digital orthodontic orthodontics is continuously changing due to technologic clinic. It focuses on the in-house design and production of advancements driven by automation. The consequence of tailor-made appliances by digitally diagnosing and evalu- automation, as previously stated, is the “do it yourself” ating the virtual patient and by creating an individualized concept. It is evident that the concentration of all the digi- treatment plan. Moreover, the book describes the concept of tal records of a patient in a computer allows for a global a future network connecting orthodontic offices (globally) view of the patient, or the virtual patient. Moreover, this to a central artificial intelligence server and to a noncor- facilitates in-house designing and printing of the majority porate orthodontic blockchain network. This will connect of orthodontic appliances, as foretold by McLuhan. Thus, all orthodontists in such a manner so as to create a “super technologic advances directly influence the role of the study club” for case sharing and research purposes using orthodontist or orthodontic clinic by bestowing on its tradi- cryptography. tional laboratory tasks without the intermediary steps with Whenever we talk about technology and digital advance- their inherent lost time and material requirements. This ments, it is essential to understand that digital technology now includes obtaining the patient-specific fixed appliance can make a good orthodontist better, but it will not trans- brackets as the result of an in-house customized bracket form a bad orthodontist into a good one. Furthermore, as design and printing process. it is described in these pages, automation is not to be the Companies will strive to manufacture new 3D printers substitution of human error with mechanical error. Mini- with higher capability for accurately printing small objects mization of such errors is dependent on the changing but like brackets at an affordable cost. Moreover, they will turn ever-present involvement of the human interlocutor. The their interest to creating reinforced resins or other materials symbiosis of human experience and knowledge, together that could be used for bracket printing and whose printing with digitized technology, can be honed to better serve our result will resemble the material quality and properties of patients and humanity. the currently used metallic or ceramic brackets. ix