Digital Smile Design - Sep 2, 2020

The integration of restorative digital workflows with DSD and iTero

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In June 2020, Dr Karla Soto, renowned Align Faculty Member and Invisalign Consultant, DSD KOL and Clinic owner, and AACA KOL, teamed up with Align Technology® in a webinar titled: ‘Integration of Restorative Digital Workflows with DSD and iTero’.

In a detailed hour-long presentation, she explained how working with Digital Smile Design® and iTero® intraoral scanners in digital workflows has allowed her to elevate her practice and her skills. Using examples from her own clinical work at her practice, she examined how integrating DSD and intraoral scanning in restorative digital workflows can bring predictability, efficiency and productivity to everyday dental practices.

Head over to our YouTube channel to watch the full webinar, or read the full transcript below.


Dr Karla Soto:

Today we are going to talk about the integration of restorative digital workflows with both DSD and iTero intraoral scanners. I have so much to cover, so I might be talking a little bit quick. It's a little bit also like my journey in the last two years; my practice was completely transformed from the moment I started implementing digital workflows, and it's been really transformational. So the very first thing that I want you guys, everybody to know, is that I'm a normal dentist just like everyone in this call, in a small three-operatory practice. I always like to say that because people always think I have this huge practice and I'm doing all of these cosmetic-only cases and it's totally not true. I have a totally normal dental practice and I happen to do some really cool cases too.

The integration of restorative digital workflows with DSD and iTeroThe truth is that since graduation, I have always had a belief in changing the way people experienced dentistry and patients perceived our field. If you're here, I am assuming you do too. So in this next hour, I might open a little bit of a little window onto all the things that are really, really cool for our patients, but even cooler for us. So, a lot has happened since the moment I decided to jump into full-on digital – and I really did take a full dive. It was like, "No looking back." These are some of my disclosures. I am a DSD KOL, I am an Invisalign, Align faculty and I'm an Invisalign consultant. I am a DSD Clinic and AACA KOL. So all of these things, all of this happened after jumping and being able to establish all of these concepts together.

So additionally, I feel like I need to say that every single patient featured in this presentation is mine. I always feel silly and I always say this in my lectures, but there's zero acting or staging in any of my videos or pictures. Another big disclosure is that all the photography that you're going to see in my presentation is iPhone photography. I know some of my friends are joining today's webinar and they're professional photographers. It's something that I never really got to do. It's definitely on my to-do list. Everything keeps evolving, but everything that I have so far it's on an iPhone. So I don't want anyone to think that these things are not possible if you don't know how to take professional pictures.

Two more disclaimers, every case here was done with an iTero intraoral scanner and digital technology that you see here. And a big disclaimer is that all the cases that you'll see here, it's a combination of things. You'll see cases from a local technician, a total artist, high-end technician, you'll see cases from the DSD Lab® from Brazil, but you'll even see cases from Glidewell. So the point is that really, once you get comfortable in the realm of digital dentistry and you plan your ideal designs and your DSD cases based on natural anatomy - which is really the point, right? To be natural and in harmony with the face - you really can choose any lab that suits the situation.

In the last two years, I had the privilege - it's a true privilege - to be able to beta test that connection of facially generated treatment planning and ClinCheck®. That comprehensive platform has really made a huge difference in the way I practice. That connection of introducing fully digital workflows, and it allowed me to visualize outcomes and really elevate not only the way I practice, but the way that I communicate with my patients in a real, real, emotional way. Today I won't get a chance to explore that part of what I do, which is one of my favorite things, but the exciting thing is that we're just getting started. And even the fact that soon everyone's going to be able to see facial integration on their ClinCheck has to do with all of this. So it's really cool and exciting, and I'm proud to be part of that.The integration of restorative digital workflows with DSD and iTero

Dr Karla Soto’s Continuing Education pathway

So I want to show you a little bit of my CE path. I usually have a little bit more time to go through this. I won't today, but I do want you guys to understand that digital is a tool, it's an instrument, and you have to understand the analog world, you have to understand dentistry, you have to make sure that you have training in occlusion and all of that. I haven't finished my path, I did all of Spear curriculum and I'm starting... well, I was supposed to start Kois in May and then COVID happened. But all of this knowledge and being able to diagnose really allowed a crazy growth in not only my practice, but in my Invisalign cases. This was all, the only change was buying an iTero intraoral scanner and doing DSD. I'm not about numbers, it's not what the lecture is about, but I really want you to understand the kind of changes that can happen in your practice. This was no marketing, three ops, very established practice, nothing else had changed. So that's a little bit of the proof of what can happen with digital dentistry. 

But today we're going to focus on the predictability that digital dentistry can bring us, and that comes with efficiency and productivity for the everyday practice like mine and yours. So like I said, I'm going to focus more on the technical part. I will talk a little bit about how the philosophy of jumping into all these platforms really helps us connect and bring the human side to dentistry. But I really want you to understand that you can really, completely change the way that people experience dentistry, be it by scanning all of your brand-new patients and giving them that experience. Still to this day, even after owning an iTero for more than two and a half years, it's a surprising thing. Everyone gets excited about it, and most people have never seen it. So you can still be that practice that gives the patients that first experience. The integration of restorative digital workflows with DSD and iTero
I'll show you how I made it work for me, but most importantly, for our patients. To be able to turn a first appointment into something cool – taking pictures and having fun, that's very easy. I mean, so easy that my patient is with a baby and my assistant is scanning her. You could not do this with regular impressions. And then to be able to go from that first appointment to a second appointment that is like this life-changing experience with showing a patient their possibilities and showing a mock up or a ‘test drive’ of what's possible in terms of designing their smile.

I can't really focus too much on mock ups. Today it's all about iTero intraoral scanning and restorative dentistry, but I want you to understand that this is a key moment in the cornerstone of the DSD concept. And whenever you see something like this, no treatment has been done, unless I say we finished the treatment. No treatment has been done and this is just like a visual illusion. We put the ‘test drive’ in their mouth and then we take the videos of the before and after. 

The integration of restorative digital workflows with DSD and iTero


Single Crown

So today, jumping right to the part of the restorative, I really want to start with the simplest indication for restorative, which would be crown and bridge. I wanted to play a game. I had some like polls ready and everything, but maybe you guys can use the chat if you want.

I wanted to know if you guys could tell me which one of these crowns was made using an iTero. Now, this is a long-time patient of mine. I actually did all of those three crowns, number three, number four, number five. But only one of those crowns was done with a digital scan with the iTero. Now, of course, it's very difficult to tell what crown was done. There's no way. I mean, a crown cementation doesn't really tell you if it was a traditional impression or a scan, but I think it's really interesting. And unfortunately, I can't play the game and I can't have the full ... but fortunately, we can tell that it's number four. So when we go back to the x-ray it's tooth number four. There's really no difference in the quality of the crown. You just have to know when you can scan and when you know what to look for and what to do. So that was crown number four. 

The scan, when you scan, it gives you the range of colors in terms of depth. So you can prep and you can scan, and then you confirm that you have the right occlusal clearance that you need. Let's say you scan and you still need more occlusal clearance for the kind of material that you're going to use. Let's say it's an eMax, let's say it's zirconia, then you can very simply just go back, prep your occlusal, and then just scan only that occlusal part on your scan. 

So some people that are really just traditionalists, they really want to stick to PVS for crown and bridge, it's really interesting, they'll say that a scan takes too long. It really doesn't, especially not with the new 5D. But if you really think about long term, it takes so much less because let's say you took a PVS impression, you didn't realize your clearance was wrong, and then you either have to bring the patient back or prep, or you have to do the opposite, you have to adjust it. I mean, it's just cumbersome. This is so much more predictable.

My other favorite thing about this is how cool it is that your assistants can be such a big part of impression taking. Part of the big headache in the dental field - and I'm not saying this for me, I'm saying it from everyone - is always complaining about how hard it is to find really, truly experienced people. And taking a crown and bridge impression, it has to be you if you want to make sure that it's good quality. I'm a huge delegator. With somebody with experience, I'll delegate. But with scans, you can delegate almost a whole thing. So I love this part and if you don't have to delegate, I will confess that it's so much more fun to take a scan, and so much faster for me than taking a PVS impression.

Pre-restorative Invisalign

So a big use for the iTero intraoral scanner for restorative dentistry, for me and the way that I practice, is doing pre-restorative Invisalign treatment. I am aligning prior to restoring, and I do that all the time. If you know me, I'm a huge proponent of that. So let's talk about this. Why Invisalign? And you can see that this person has beautiful teeth. You can see there's a little bit of occlusal, of trauma. You can see, especially when I go to the lowers, there's some periodontal problems, there's a tooth size discrepancy. But this is a perfect kind of case for some simple Invisalign and then some simple conservative restorative. I did not use Go for this particular case, but this could potentially be an Invisalign Go® case. 

So very simple alignment and very simple restorative because there is a tooth size discrepancy. You can see it on the bottom. Those are really skinny canines, and we want to make sure that we have nice occlusion as well, so what I did was I moved them mesially so that area, the distal, the canines, I left that space on purpose so that I could restore that. I literally used no prep, distal wedge, let's call them veneers. I didn't prep anything. I didn't touch anything and we're able to go from after the alignment, getting that space distal to the canines, to restoring and super conservative. Now on these pictures, you can't even really see where the margins of this is. And remember, this is no prep. You just scan, send to the lab, and then you get your little ... of course, not wedges. Of course, it needs to be a lab that knows exactly what you want, but still, it's very interesting things that you can do.

And then talking about interdisciplinary dentistry, which is a big part of my philosophy as well. Of course, we know that the next thing here is in the soft tissue grafting on that number 14, which is jumping at me and kind of bugging me. I prepped it like that on purpose to stay supra-gingival margin, and then we would graft. But anyway, it's really important staying to those canines and the restorative in those canines. 


Single Implant Crown

Another huge modality for the iTero intraoral scanner is this patient number 13 - or 25 for Canadian or international friends. This patient, I've been talking to her about alignment for so long and she just keeps breaking her teeth. And that implant on number 14, it's an implant that I placed I don't know how many years ago, probably a little while ago, because it was a tissue-level implant, but she just keeps breaking her teeth.

So she's always said that she's not ready for alignment because of her financial situation, but truthfully, I mean, she keeps doing that and she could have fixed the core of the problem. So I always tell my patients, it's so much cheaper to fix the origin of the problem than to keep replacing teeth. So anyway, she came in and her tooth had broken, and she had a wedding the next week, and she's like, "I just really need to do something about that." So the initial presentations, the broken tooth, we placed that immediate implant. And you can see here, I mean, you can see the occlusal DCs, there's a deep bite. We have a narrow arch, almost like Omega shaped. And once again, this is when you discuss with your patients how much money they could be saving if they fixed the core of the problem, instead of continuing to fix little fires here.

So, after eight weeks we take a scan body. We take an impression with the iTero intraoral scanner and we have the initial, we have the immediate implant, and now we have our restoration placed. Now it's interesting always when you're looking at your work bag, because I have different materials and different kinds of implants, but they're both clinically stable at this point. I'm pretty sure I did on a screw retainer on number 13. 

The integration of restorative digital workflows with DSD and iTero

iTero for Bridges

Another modality, iTero scanning for bridges. I don't really do that many bridges. I love placing implants, to me it’s the gold standard, so whenever I can replace an edentulous space with an implant, I will. I don't like doing bridges that much, but I love this kind of bridges for many, many reasons. So let me just show you this particular case. This was the presentation and this was before Invisalign treatment. You can notice how that bicuspid is all the way distal in the molar position. And you can see some discrepancies. So I asked him, and I definitely was not going to move that bicuspid all the way to its position, but I could do some pre-restorative alignments. So I closed that space mesial to that 28, and then you can see here, they have the arch after the alignment and then we have the preparation. You see that we closed this space. And then you also see that this is a bicuspid, so we had to get a little bit creative here in my preparation for that bicuspid to look like a molar and a little bit creative as well in the restoration design, but... I mean, this is the reason why I love iTero scanning for bridges.

I want you to notice a few things here. So the whole occlusal clearance situation, you can see that you can actually change the numbers on your iTero depending on what material you're going to use. But you just follow those colors and then you see what your clearance looks like. And it looks like I have pretty good clearance and the tightest spots are still about 2.1 millimeters, which is plenty for most materials that we'll use. 

The main reason why I love to scan bridges with an iTero intraoral scanner is because of the path of draw. This is a difficult path of draw situation. I mean, it's a long-span bridge and sometimes you can see it with a big mirror intraorally, but how cool is it to just take a quick scan. Even if you're not taking your final impression with an intraoral scanner, with your iTero scanner, you can still benefit from scanning because you can just quickly scan as an I record and just see on the big screen your path of draw, if you have any undercuts or anything like that. So that's my favorite thing and why I like using the iTero scanning for bridges.

In this particular case, I actually did use the iTero Element 5D® as my final scan. And you can see all of the margins and you can see the path of draw. I remember it being hard to get. So then you have from the initial, to that creative preparation design, to my restoration. You can see you have good adaptations, very creative restorative design, happy patient. Remember I said you'll see cases from all kinds of labs. This is a patient with some financial trouble. I have to get creative and I have to make sure that I still deliver good quality, clinically acceptable ... So this is zirconia, this is a zirconia bridge right here. On the lower left side she's still saving money to see what we can do about that.

Multiple Modalities - One Scan

This one is fun because it's not only about the individual things that I can do with my iTero scanner, a single crown, or another case for like a single implant or multiple implants, but how I can use multiple modalities in that one scan. So let me show you. Not only, of course, for Invisalign, right? Because that's what most people think, it's the iTero system from Invisalign. Not only did I use it when I did Invisalign on this patient – and I really actually haven't finished this case yet, but I thought it would be fun to show you guys everything that we're able to do just not only with scanning, but in one scan. So, of course, for Invisalign, for a single crown, you can see it on number 21. For an implant crown, you can see it on the lower left. You can also see that it was used for a bridge, and not only was it used for all of those things, but at the same time on this patient I'm doing DSD direct, which is an injectable composite technique.

So, to view it a little bit better, to show you where I'll be doing the injectable composite, and so that you understand, I sent this scan to the Digital Smile Design Planning Center with my instructions. These are the teeth that need the crown; this tooth needs the bridge; this tooth, it's the implant; but I'm also doing injectable composite on some of the other teeth. Now this is totally thinking outside the box. This is a patient that has very, very limited finances, and I'm still trying to give her the best that I can. So we're increasing the vertical dimension, not only with the porcelain, but also with the injectable composite.

This is what the DSD Planning Center sends me back. So my plan is to increase the vertical dimension with a combination of all of the modalities that I just told you guys. And look, I am not saying this is like textbook dentistry, but we really need to think outside the box for our patients and really meet them in the middle. And as long as there's clear expectations and clear communication of what composite is, what porcelain is, what the pros are, what the cons are, especially now. I mean, I have so many patients that were doing Invisalign, we were going to do full-mouth reconstructions, and some people have lost their jobs. Some of the full-mouth reconstructions became only six crowns. How can I still keep that original design and do a transitional thing with composite? I really think it's really important for us to stop being so strict and start thinking outside the box as long as, of course, you're honest and communicate the expectations really well.


iTero Element 5D

So actually, this was not part of my presentation. I'm actually planning a new iTero Element 5D presentation, but I couldn't help myself because I am totally obsessed with this imaging system from Align, and I am totally squeezing this part in the presentation so it breaks the flow a little bit. But I am really loving it, just improving the way that we're communicating with patients, and having them part of their own diagnosis, and playing with this super high quality, super high image quality. And we've never been so close to diagnosing so much with something that only took us a few minutes. So I know this is a restorative webinar and I am going to stick to restorative. There's so much more to it. I actually made a video of my favorite iTero Element 5D things on my Instagram, on my IGTV, you guys can check it out. I can't really go into details right now. And then I'm going to make a longer version with details on YouTube, so stay tuned.The integration of restorative digital workflows with DSD and iTero
But this is why I love it so much. I mean, you can have real discussions on your findings. In this particular case, you can show not only the extent of the lesion, not only that there's interproximal decay because this is ... I know I don't need the iTero Element 5D to diagnose that, I can clinically see that distal, that bicuspid, it needs a little bit of help. But how cool is it to show the depth, because you can't see that clinically and x-rays sometimes for patients are a little bit hard to read. So look at the extent of this lesion. Now with the iTero Element 5D, just to be clear - and it took me a minute to get used to it - it's almost like the opposite of x-rays. X-rays we see the radiolucency and that's where the lesion is. NIRI shows it as a bright spot. So you can see that brightness almost half way to this bicuspid, so it's just really cool to be able to have that conversation with the patients. 

Another really, really cool way to have communication and improve the way that we're showing patients things is not only the actual scan and the actual picture that the scan takes, because now I've eliminated intraoral cameras from my new patient exam. But look at those crack lines. It's incredible. I mean, I was very surprised to see how detailed that looked on NIRI (Near Infrared Imaging). But when I started playing with it, I was a little bit skeptical because I was like, "I have DEXIS. I have really good, high-quality x-rays and I don't really need this to diagnose." But I've been very surprised at how bright and how obvious it shows – way more than on the x-rays.

And guys, if you have any questions, just type them and I'll definitely make time for the Q and A, because I would love to know what you guys think about this. So, for example, let's look at it in this particular situation, is this a real lesion? When you're looking at this number 12 distal, this little bright lesion that's there, would you say that this is a real lesion? Because there was nothing on the x-ray. And then because this patient had other lesions and I knew he was high caries risk, so I actually did open a very conservative slot just to see what it looked like and make sure that I would manage it. He's a very young patient. He shouldn't be having these interproximal lesions and I don't want them to get bigger. I'm very conservative, but I had been seeing lesions with the iTero Element 5D and improving, it’s like crazy clinically.

So then I decided to go ahead and open it. And once I finished the practice at the beginning of the prep, I wanted to take a picture, it had definitely extended into dentin. So a true story on this particular case, I knew I had this lecture coming, so I wanted to gather some information, and that's why I wanted to take a picture of this. Now I was going to use my intraoral camera real quick, plug it, like, "Let's do it." And it wasn't working. So I was like, "You know what? I'll just take a quick scan." Because the quality of the intraoral picture is amazing. 


Fully Edentulous

So another fun thing, we've talked about some of the really simple restorative things, but let's talk about fully edentulous because I want us to switch gears and I want you guys to be aware and understand that scanning edentulous areas, it's a known limitation for scanners.

It does take a little bit to get used to that, but I'd almost dare say that iTero system is the best scanner for fully edentulous cases. And my lab technician, who's been doing these hybrids with me, he goes to different offices and we're also doing precise implant capture and PIC and all of that. He told me, he's like, "The iTero is the best one to do the fully edentulous." So I really wanted to give you a quick taste of the range of digital workflows, not only for a single crown, but then we're also talking about like full mouth reconstructions and edentulous spaces. So it's not only what digital has allowed me to do, but to the patients as well. And this is Todd and he was always hiding his smile.

He told me that he would leave his mustache long. This is the mock up. Remember this is a test drive. He accepted treatment on the spot for full hybrid top and bottom. Big case. That's a lot for some people. The cool thing about this is that digital workflows allow me to do my very first full implant case where I placed the implants fully guided. And now all the planning and the guides were based on that original setup and done by the DSD Planning Center. But to be able to do something like this and the patient leaves with that provisional that same day, to have something this powerful, unpredictable in your toolbox, it's just very cool. Yeah, I had done hybrids before and then the deliveries 24 hours after and things like that and the workflows were just not predictable.

The integration of restorative digital workflows with DSD and iTero

So this is definitely something that I'm excited about, to be able to give this to my patients. And it's that great example of that continuity and predictability from the beginning to the end. And you can see from before, to the mock up, to the provisional. That provisional video is just a few days after surgery. So that's just really cool. He looks great. Not only was he my first fully guided everything, but it was also very cool that we used the precise implant capture to go full, full, full digital workflows. No impressions were taken on this patient, everything completely digital. This just shows a little bit of the iTero scan with the very accurate correlation.

And then this is just after he was temporized for a while and we were ready to move on to the final hybrid. We had a PMMA milled from that prototype just to make sure that everything was smooth and seamless. I mean, for a temporary, this looks amazing. And the patient was very, very happy. But it removes from the equation doing these kinds of cases that are just sometimes very, very frustrating. So this is not an iPhone picture. This was a picture that my lab ... that Rafa took. But it's just very cool to see how natural and how happy he looks, especially from the beginning. So we go from the initial to that final prototype. This was taken last week. He is the best patient ever. So it's not only about those big things it's also about the little things that can make a world of a difference. 

Lite Dentistry

I do want to take a minute to talk about Lite Dentistry®. I mean, I did a full presentation last week at the Align Growth Summit about it, and there's so much to talk about.

But because we're all restorative dentists, I do want you guys to take away that misconception that DSD and digital workflows is only for wealthy practices and wealthy patients. It couldn't be further from the truth. It's really, really a cool concept and modality to, like I said before, meet our patients in the middle. The integration of restorative digital workflows with DSD and iTeroSo Lite Dentistry is basically simple alignment, maybe gingivectomy, and just very conservative, simple injectable composites. In this particular patient - I'll go very quick - it was easy to convince her to do some alignment. You can see the crown and you can see that there's some wear. But once we were done, I wanted to show her some options. I wanted to show her two ‘test drives’, take her on, let's call it a smile shopping experience. 

And we were playing with maybe just replacing the incisal edges, which is what you can see on the left, or maybe just giving a little bit more facial volume. So we went from here to choosing this model that she wanted, which was a full facial, to delivering and doing the injectable composite all on the same day. We are restorative dentists. We are made for this kind of thing, to be able to help our patients, to be able to do this. I mean, this is our every day. So just to get a text message like that, and to get messages like that from your patients from something so simple and so predictable. So taking advantage of everything that technology has to offer so that we can really focus on delivering beautiful smiles and life changing experiences.

Dr Karla Soto: “Here you see what your ideal smile is.”

Patient 1: “There's no way. Wow!”

Dr Karla Soto: “That's a smile.”

Patient 2: “Oh, I have all my teeth. Oh, my God. Oh, I love it. Oh, I love it so much.”

Dr Karla Soto: “Oh, I love it too.”

Patient 2: “Oh, thank you.”

Dr Karla Soto: “My pleasure.”

Patient 2: “Thank you so much.”

Patient 3: “Oh, my God.”

Dr Karla Soto: “Me vas a hacer llorar a mí también.”

Dr Karla Soto:

So those moments are my absolute favorite moments and that's my passion. And to be able to have all this technology, to be able to deliver that makes my day and your patient's day. 

Smile design app and veneers

So I have another cool case with an iTero intraoral scanner, and this is planned with the smile design app and then we did veneers. I'm going to be speaking very fast because I want to make sure that we go through all the cases, but this mindset of planning and looking at the smile doesn't always have to be at the very beginning. Ideally it happens at the very beginning, but some of you guys might have some Invisalign cases that you’re just finishing and you can see that you're catching some things in the middle and it could be something that you could improve on.

So this particular patient after alignment, I was like, "I think there's something we can do to improve this smile." So we had just finished Invisalign on this patient and here you can see him with a mock up of only the four front teeth. And before the alignment, you can see how narrow the arch was. You can really see on those lower ... I mean, that box at number 27, I mean really, really crazy narrow arch. And then after nine months, we were able to round everything off and make it so much better and much, much more ideal occlusion, especially if we're going to restore. Now, I don't know if you can see, but he had some large composites on eight and nine. So you're going to see in my prep, you'll see that a little bit more aggressive because of that. But with just this view, it's very evident that we only need to restore four teeth, very conservative. That will improve the smile curve, it’s very predictable as well. 

And you can see that the left smile is a really nice smile, but when you see that mock up - and this is the digital, this is not the actual mock up - but when you can see that it only involves four veneers and it makes a world of difference. So the narrow arch is really evident in that before picture. And then after the alignments, you can see that he looks really good, but then when you see him with the actual mock up, it's like, "Wow, that's a really cool improvement on the smile." So he loved that and he wanted to take a look at what it would be. And then we had some fun and we took some portraits, and we just made it a really cool experience. It's his moment. And this close-up shows a harmony with this smile and this same smile design will serve as my mock up. It will also serve as my prep guide. It will also serve as my temp guide and it will be my final restoration tesguide.

The integration of restorative digital workflows with DSD and iTero

And in this particular case I was using the DSD Natural Restorations, which is with the DSD lab, but like I said, you could use this same file, this design. You send the STL file of the design to whatever lab you choose as long as they're familiar and comfortable with digital workflows. And here's a progress photo. So nine months of Invisalign, I mean, you can see that box out of 27, it's completely up. And you can see that there's a lot of improvement in the bite, but then when we're able to restore, which is four porcelain veneers and nine months of Invisalign, that's really not much of a huge change.

Go Beyond

You can see here that I actually use that iTero for my preps, and notice how there's really no difference in the anatomy between that mock up and the final. It's copy, paste. So there are just so many different ways to implement. And the point is if you're taking this webinar, it means that you're hungry to go beyond and to learn. I really think our role is to gather all of these amazing options and platforms, and just really put your personal spin on what you like. If you like surgery, maybe use it for implants. If you love composites, then maybe use it for restorative dentistry. And the best part of 2020 - there are some good things to 2020 - now the dental community is closer than ever. So we can really help each other, and kudos to Align for showcasing regular dentists like me doing regular dentistry as well, and doing the best that we can with the tools that they provide us with.


Going to our last case. This last case is the perfect example of that interdisciplinary and the best that we can do and all the options that we can do that digital brings to us. And another myth about scanners and iTero systems is that they can't do full mouth scans. I already showed you multiple units where I scanned only with iTero intraoral scanners, but this next case you will see the use of the iTero scanner for every single step of this interdisciplinary case. Believe it or not, I still fight it sometimes. And like Christian Coachman, DSD founder, says: "Digital won't make sense if you're just dabbling in it here and there. It will only make sense if you just fully jump, you have to just not look back." So if you've seen me lecture before, especially for Align, you're probably very familiar with this case. This time I will not be showing the emotional presentation, which is one of my favorite moments. It's a really powerful, very cool video. But I’d rather focus on the technical aspects that made this case possible.

Dr Karla Soto: “I know that you already told me, but I'd like to know what your definition of a beautiful smile that you want for yourself is.”

Patient: “I just want to be able to just laugh and not have to cover my face or take pictures... I'm tired of people asking me, why do I look so sad in pictures and why don't I smile. I'm just very insecure about my teeth. My brothers used to call me ‘Vampire girl’ growing up because of the two teeth, and the staining…”


Dr Karla Soto:

It's hard to watch that, I've watched that probably a thousand times at this point, and my hands can do something about this. So you've met her already and you've heard some of her goals. And taking the DSD product, going and taking some of the portraits, taking the smile picture was impossible. She's like, "My muscles don't know how to smile." So the part that's really interesting about this case is how nothing would have been possible without showing her the possibilities. And here you see a mock up. This was a girl that said my muscles don't know how to smile. She just learned, she was really glowing. So Reyna works at a pet store. She's a single mom of a 16-year-old boy, she wants to buy a house. She has dreams just like everyone else does. But like she said in that video, she's just very self conscious and she just does not want to smile.

She's told me, "I've never smiled in a picture. I just can't smile." And you can see that she has a beautiful soul. So it's kind of heartbreaking for somebody not to have the freedom of smiling. So we jumped into Invisalign. We started doing Invisalign clear aligner treatment. In the middle of a treatment she sends me this picture. She's like, "I've never smiled. This is the very first picture ever that I smiled." You can even see her little avatar picture on the message where she's not smiling, but you can see that full picture where she's smiling. So it's very special to be part of something like this, for somebody to send you the first picture where they've ever smiled and to get such a beautiful message like that. It's just very touching. So the beauty of DSD and Invisalign collaboration, it's not only that we're able to visualize goals and move towards them, but it's also being able to connect with our patients and what their goals are.

So here we see a little bit of the actual final, ideal design, and we can also see some of the movements that were needed in this tooth movement table. And you can see those crazy rotations in those laterals. We know that laterals are tough. So this was a little bit of a challenge or so I thought, because you can see with this progress assessment how well we're doing and how well those laterals were doing at that point. This showcases a little bit more of the iTero scanning power, because it's not only a digital scanner, but most importantly - and I think this is really important - it's not about having a digital scanner. If that's what you want, there's plenty in the market, but it's a scanner that allows you to have all of these powerful applications and platforms and connections with other things.

So in this particular case, we see that green in the progress assessment, we are tracking well. And with that alignment that we achieved, now we're ready for restorative. So on the top you can see a scan of the technical mock up. I'm done with the alignment. I have my ideal smile design, and I try it on to make sure that we're on the same page, to make sure that I like everything, to make sure that the occlusion is good. I try to tweak everything at this moment before I've prepped, before I temp. And on the bottom, you can see my prep. So the combination of the technical mock up and then my preparations. Now, there's a really fun story about this case, which I'll tell you in a little bit, but just notice that I use my iTero system for all the scans. This was like a second bicuspid to second bicuspid full on smile design. So 10 preps right there.

And how cool is this? So the beauty of the iTero scanner too, is you can do a pre-op scan. And on my pre-op, scan I took a scan of my technical mock up, and then I can take my preps and I can overlap everything and see where I'm at. This is just crazy because I can see everything. I can see that I have the correct preparation space for this design. I know that I have the ideal room for the type of ceramic that I want to use. eMax was my personal choice, so there's just so much more than you can see, yet there's no way to do this a traditional PVS way. So we go from technical mock up to provisionals, all digitally guided, and again, predictability. My technical mock up and my temporaries should look basically the same.

I did not mention, but I also used digital. DSD prepared a guide for crown lengthening for me for those areas. So here's the story. When you think about it, it's crazy because we're doing all of this work and all of this dentistry. The original design was made in Madrid by the DSD Planning Center. And then we were ready to restore. We have a bit of friendly competition between the DSD Lab in Madrid and my local lab in Miami. So DSD lab with all the digital planning, all of the files get transferred to both labs.

The little competition or the point of it was we were going to actually test both. We were going to test my local technician, and we were going to test DSD Natural Restorations Center, and we were just going to have the patient choose which ones she liked. Unfortunately, the ones from Brazil did not arrive in time for our appointment because they got held in customs and I was heartbroken because I was so excited to take pictures and to show her and actually give her a choice. Next time. 

This is super cool. This is CAD wax. So Rafa mailed this so that we would be able to confirm adaptation and everything from that design. And you can see how nicely adapted this is to our preps. So eight months of Invisalign, ten eMax veneers, give us a very happy patient. So a lot of sacrifice went in for this case to happen. Financially I helped her out too, but there's a lot of sacrifices that went in from this patient.

So now we had just one more hurdle because that lower right area was killing me. That fact that she has that beautiful smile and now we're still missing a tooth. So we still used our digital platforms to be able to help her with that. But I wanted to show you a few pictures that Rafa took with this SLR just to show you a little bit of those DSD Natural Restorations, and that anatomy, and how this was all, remember, designed originally from Natural Restorations and very little work needs to be done. If you work with a technician that's very familiar with digital workflows, they'll adapt that to your preps. So that's just really cool. So when we go back to that idea of that lower right area, then it's like, "Okay. So if I scan this, and I send it to DSD, and I send my CT scan, then this is full-on digital workflow inside an app."

So this is another DSD solution to help us be very predictable and very, very, very profitable when you think about placing an implant in five minutes, and I've been placing implants for over 13, 14 years. This is a very, very easy implant to place. But when you're looking at doing an implant like this, perfectly centered, in less than five minutes - I mean, this video right here is a 2.5 minute video and that was all my osteotomies when I was placing this implant. So was this an easy implant that I could have placed without scanning and having a guide? Yeah, absolutely. But if this implant placement took five minutes, what do you think it does for the experience of the patients coming to you, for the reputation of what getting an implant is, and for your productivity at the end of the day as well?

So, then we remember that financially she's really making sacrifices. So what we did was we took an iTero impression with a scan body for a temporary. When you're taking an impression for a temporary or for a crown, you want to make sure that you get those interproximal areas of the adjacent teeth. That's really key when you're scanning for restorative because if you miss those areas, then you're going to have problems with the interproximal area. But it's very, very easy to scan for implants.The integration of restorative digital workflows with DSD and iTeroSo that's the beauty of digital again. Not what it allows us to do, not even your mindset, what is huge is that it allows us to focus on what really matters, which is the empathy, that connection, that basic human need. This particular picture was taken a few months ago. Reyna is as happy as can be and now known at work. She sent me a text message. I am known at work as ‘the girl with a pretty smile’. This was the girl that couldn't smile. Now she's known for a pretty smile. So she had this tattoo and I wanted to take a picture because I thought it was interesting, based especially on what I'm talking to you guys about, let your faith be bigger than your fears.

The integration of restorative digital workflows with DSD and iTero

I'm not trying to make a religious statement or anything like that, but the message still stands. Don't let your fear of something new and unknown keep you from full-on jumping into this paradigm shift of digital dentistry. So I want to end today by telling you guys, have at your forefront your ‘why’, and once you understand your ‘why’, jumping into the unknown becomes a little bit easier. This is my family, and this is my ‘why’. So thank you so much for allowing me to be in your homes and allowing me to share my message and my passion for digital dentistry and for improving the dental experience for our patients. 

Karla Soto

Remember to head over to our YouTube channel where you can replay the entire webinar as well as the Q and A session with Dr Karla Soto.

the content of this webinar is shared by Digital Smile Design with permission from Align Technology

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