In the last decade, the public’s demand for cosmetic dentistry has
increased dramatically, and savvy dentists are taking advantage of this
trend by offering more comprehensive aesthetic treatments. Rapidly
evolving technology has made more advanced materials and equipment
available to dentists. By employing these newer modalities into their
practices, many dentists have been able to explore a new dimension in
the way they practice dentistry. This has allowed them, in many
circumstances, to substantially increase their revenue, decrease their
patient volume, and remove themselves from third-party insurance.
However, in order to use these new modalities successfully, the dentist
needs to go through a proper learning curve to avoid becoming frustrated
or disillusioned. In order to create the beautiful smile that patients
desire, it is essential for the dentist to design an accurate
“blueprint” from which to work. This is similar to how an
architect/builder will design and build a structure to the desired
requirements and specifications of the client. It is only logical to
assume that if the digital blueprint, which in this case is a computer
simulation of the teeth, is correct and accurate from the beginning,
then the chances for a successful aesthetic outcome and satisfied
patient will be far more predictable.
With advances in computer technology, dentists can now more easily
design a smile using computer simulation. Computer simulation is digital
image enhancement/modification utilizing a graphical editor for image
pixel manipulation. It is now possible to alter an image digitally to
present, in an extremely realistic manner, a preview for the patient,
dentist, and laboratory technicians of the desired smile prior to the
start of any actual treatment.
However, many dentists are reluctant to use computer simulation due to a
concern that they will be inviting lawsuits from unhappy patients if
they are unable to match the simulated image. True, there is always a
risk with nearly everything we do in dentistry—we just need to be
prudent and use new technology wisely. On the plus side, consider the
improved patient satisfaction when the patient can see what it is that
you are talking about. Visual images overcome barriers that exist due to
language differences, patients’ lack of understanding of dental
terminology, and perhaps most importantly, unrealistic expectations. If
the patient cannot afford a top-end smile, then it is important to show
him or her what a lesser improvement might look like. And from another
perspective, consider the effect on patient satisfaction when you do not
use computer simulation and the patient is unpleasantly surprised by
unexpected results. What is the cost of this to your practice?
But don’t many dentists already use Adobe Photoshop (Adobe Systems) to
alter digital images? Yes, but this is not what we are talking about in
this article. Most dentists use Photoshop to modify the entire image at
one time using tools like rotate, flip, crop, compress, color balance,
etc. Most dentists do not use Photoshop for simulation because using
Photoshop to modify just part of an image at the pixel level is just too
complex and time consuming.
There are two basic approaches to dental simulation. The first is the
process of placing a smile chosen from a library of digital smiles
directly over the patient’s existing smile. The new smile is digitally
cropped, rotated, and stretched to fit within the confines of the lips.
This method can be inaccurate and misleading; placing the new smile does
not take into account where the patient’s roots are in the bone and what
the true gingival architecture is. Consequently, it may be impossible to
come close to the simulated smile. The second approach, to which this
author subscribes, is the actual digital manipulation of each individual
tooth and, if necessary, the gingival architecture, so as to achieve as
accurate a result as possible. But obtaining an acceptable result
requires more time and training in utilizing a graphical editor for
pixel manipulation.
This article will discuss the things you need to consider in order to
introduce computer simulation successfully into your practice, and will
provide an example of how a simulation program especially designed for
dentists can be used.
REQUIREMENTS FOR COMPUTER SIMULATION
Specific requirements for creating an accurate and realistic
digitally enhanced smile image include the following:
Determine What the Patient Wants
Get accurate and detailed information from the patient as to what his
or her expectations for a new smile may be. Discussing and showing
examples of different tooth colors and shapes will aid in ascertaining
from patients their likes and dislikes. This information will be the
basis for the actual computer simulation.
A Good Digital Image
Get a high quality, high resolution image of the patient, preferably
a headshot showing the entire face with the patient smiling in a large
natural smile so as to reveal as many teeth as possible. The impact is
most powerful for the patient when the before-and-after simulation is
viewed from a full-face shot. But since a full-face shot will make it
necessary to zoom in to make adjustments to the teeth, you need as much
detail in the digital image as possible. To maximize the image detail,
keep these important factors in mind:
If you choose to photograph only the teeth and not the entire face,
you can get away with less resolution and more image compression. In any
case, it is very important that you understand how to set up your camera
for maximum sharpness.
Move Images From Camera to Computer
The operator needs to be able to transfer the digital images easily
and quickly from the camera to the computer. The camera-to-computer
connection is accomplished either by connecting the camera directly to
the computer using the USB cable that came with your camera, or by
taking the memory card (a digital camera’s “film”) from the camera and
inserting it into the computer’s memory card reader (which is either
connected to or is part of the computer). The memory card method is
usually quicker for image transfer.
Keeping Track of Your Images
Typically, you move the images from the camera to a folder on the
hard drive of either the computer simulation computer or a network file
server. Take care to choose folder names carefully and arrange the
folders so that you can find what you are looking for months or even
years after taking the image. Ask your computer support person for
assistance if necessary; this is a simple but necessary “housekeeping”
chore that should be done properly.
Alternatively, many dentists rely on a digital image database to help
them with this. You can choose from any of the many low cost digital
image databases sold in the digital photography market or one of the
much more expensive databases specifically designed for dentistry. A
low cost database will require you or your software support specialist
to set it up to meet your needs. A more expensive dental-specific
database typically includes setup in the purchase and support price.
Use Digital Image Manipulation Software (Graphics Editor)
You will need computer software to manipulate your digital images.
Software programs designed for modifying all or part of a digital image
are called graphics editors. You can choose from general purpose
graphics editors such as Adobe Photoshop, or graphics editors
specifically designed for dentists, such as AlterImage (Seattle Software
Design) or Vipersoft (DENTRIX).
Many dentists already use Photoshop or a simple graphics editor to
perform basic tasks on the overall image such as cropping, rotation,
color balance, etc. Although important, this should not be confused with
the much more sophisticated tasks of computer simulation, such as
repairing chips, closing diastemas, moving gumlines, etc. There is a
certain amount of overlap among the different kinds of graphics editors;
Photoshop will allow you to do nearly anything to a digital image (albeit
slowly and with lots of training), while dental-specific programs should
allow you to do basic, whole-image tasks such as cropping, rotating, and
color balance, too.
Computer Hardware
Fortunately, most modern computers already come with sufficient
computing power and the interfaces you need to get pictures from the
camera and manipulate the images. You may need to purchase an
inexpensive adapter to be able to read the memory cards. Also, digital
image manipulation of high resolution images is a very compute-intensive
task, so try to use one of your newer and faster computers for image
manipulation, and be sure you have plenty of RAM memory (at least 512
megabytes for Microsoft Windows XP). It is always a good idea to check
with your software vendor about any particular hardware requirements it
may have.
For image simulation, you will need a good “pointing” device. Don’t even
try to rely on the mouse pad or pointing “nub” that is part of your
laptop computer—you will not be happy with the results when doing
detailed simulation. Check with the software manufacturer to see if they
recommend a graphics tablet or an optical mouse.
Network Considerations
If you will be doing all of your work on a network, there are a
couple of considerations. First, you may want to store all of your
digital images on a central file server so they can be conveniently
accessed and regularly backed up. Any graphics program should be able to
access digital images from the file server just as conveniently as from
a local hard drive. But the downside is that you need to move some
images from the file server to your laptop if you want to work from home
or take your images to a meeting. Also, you need to consider where you
wish to perform computer simulation. If you want the flexibility to use
the simulation software on any computer on your network, then you can
buy a site license or multiple work station license from the vendor.
These can be expensive. A much less expensive alternative is to take
advantage of programs like Microsoft Remote Desktop that allow you to
install any expensive graphics program on one Windows XP Pro computer
and then “run” that application from any other computer (including
Macintosh computers) on the network. The graphics program actually
executes on the Windows XP Pro computer where it is installed, but all
the inputs (keystrokes and mouse movements) and outputs (window data)
are sent and received to and from other computers via the network. If
you choose this option, then make sure you have a high speed network and
install the graphics program on an otherwise unused computer with lots
of RAM. Do not install the graphics program on your file server or else
you may slow down everyone in the office each time you do a simulation.
Disclaimers
The actual outcome will almost always differ at least a little from a
simulation. For that reason, it is important to advise the patient of
this reality. Some dentists are comfortable advising their patients
verbally, while others feel more secure with a signed consent form. You
should discuss this with your attorney. The disclaimer is one area where
a graphics program specifically designed for dentists is superior to a
general purpose graphics program. The dental-specific program should
always display the message “Actual results may vary” or something
similar.
Should you give patients a printout of the simulation? Some dentists do
and some don’t; it is a personal decision. But if you do, the easiest
and safest way is to create a Microsoft Word template with your
letterhead, a standard message advising the patient that the results
will differ, a place where you can copy and paste the “pre” image and
the simulated image, and a place for the patient’s signature. Get your
attorney to help you with the text. And get the patient’s signature on
the sheet before you turn it over to the patient.
SOFTWARE ALTERNATIVES
Basically, you can choose from 3 types of software programs for
computer simulation. These include the following:
General Purpose Graphics Programs
General purpose graphics programs are designed to manipulate any type
of digital image, be it dental or otherwise. The most popular general
purpose graphics program dentists use is certainly Adobe Photoshop. But
Photoshop is very complicated and requires a lot of training and time in
order to achieve a natural-looking simulation. However, if one is very
skilled with computer graphics and is willing to devote a significant
amount of time manipulating the image, a very lifelike image can be
generated. Photoshop is relatively inexpensive with a list price of $649
for one workstation.
Graphics Modules for Practice Management Systems
Several practice management software systems offer dental cosmetic
imaging modules that you can add. An example of this is Vipersoft, which
works with practice management software such as Dentrix (DENTRIX).
Typically, one will already own the practice management software or else
will purchase one in order to utilize it in conjunction with the
graphics module. This combined package can be quite costly, considering
the purchase price and the ongoing required software maintenance fees.
Additional expenses arise if you want to install this software on more
than one computer. Graphics modules designed specifically for dental
simulation should be far simpler to use than Adobe Photoshop. Though the
results from these graphics modules are good, limitations exist that, in
my opinion, do not allow the operator to create as natural a simulation
as can be achieved using more sophisticated programs such as Adobe
Photoshop. I would not advise purchasing these combined systems solely
for the purpose of doing computer simulation.
Stand-Alone Graphics Programs for Dental Simulation
Stand-alone dental imaging programs such as AlterImage are designed
specifically for dentists to perform computer simulations. This kind of
program does not require any specific dental practice management
software program, but rather, with its industry-standard, nonproprietary
interfaces, can be used with any image management program (in the same
way Photoshop is used). And a program like AlterImage has been designed
to be relatively user friendly when compared to programs such as
Photoshop. Limitations with this software are fewer as compared to the
bundled cosmetic module programs, thus allowing the operator more
manipulation options to create the simulation without spending a
significant amount of time. The results achieved from this type of
program can be very realistic and natural, and they do not require an
extensive learning curve to master, as with programs like Photoshop. It
is relatively inexpensive at a cost of less than $1,000 (currently
$1,295).
If you are willing to move past Photoshop to a dentistry-specific
graphics program, there are some additional benefits. You will most
likely get a valuable disclaimer displayed on the screen at all times
saying, “Actual results will vary.” And some of these dental-specific
programs have excellent tutorials. For example, AlterImage includes a
built-in PowerPoint (Microsoft) tutorial that you can access from the
Help menu that provides visual examples on how to perform common dental
simulations.
ADDITIONAL FACTORS TO CONSIDER
When deciding which of the above simulation methods should be
employed in order to perform a computer simulation, three significant
factors need to be considered. These are as follows: the time required
to perform the simulation, the cost to obtain the image, and the quality
of the simulated image.
Time
Once the operator has become proficient in performing simulations, it
will become clear that the time spent performing the simulation will be
the major expense, far exceeding the cost of taking the digital
photograph or purchasing the software or hardware. For this reason, ease
of use is the most important factor to consider. The second most
important factor is a nonproprietary, industry standard interface,
because if it ever becomes desirable or necessary for you to change the
image management software, and you are using a graphics program with
nonproprietary interfaces, then there will not be a need to start over
again with a new graphics program.
Cost
If the dentist has no desire to perform computer simulations, then
another option is to use a dental computer imaging service (such as
Virtual-Smiles.com). These services can produce the image desired, but
three fundamental downsides need to be considered. First, the dentist
will not have the ability to sit with the patient and have him or her
watch and give input as the image is being modified. Second, it will
take some time from image capture, to the simulation company receiving
the image, then performing the simulation, and finally getting the
finished simulation back. This turnaround time is usually a few days,
but there can be delays if the image needs additional modifications.
Third, this service carries a fee in the $100 to $150 range per
simulation. The upside, however, is that the quality of these
simulations can be extremely realistic and natural in appearance.
On the other hand, if the dentist wants to perform the simulation
chairside with the patient and is capable and willing to learn how to
use the computer software, then employing either a bundled cosmetic
module (such as Vipersoft) or a stand-alone dental program (such as
AlterImage) should be considered. In either case, the cost to the
dentist will be determined by the amount of time devoted to creating the
image. This is not unlike the chair time costs a dentist incurs for
doing any other dental procedure.
Quality
The quality of the image is a very important factor. An accurate and
natural simulation is a very powerful tool when treatment planning a
cosmetic case with a patient. Case acceptance is significantly increased
when every patient desiring a new smile has the option to get a
realistic preview of what he or she may look like before beginning any
therapy. Needless to say, this will also greatly increase the dentist’s
ability to create a beautiful smile, and thus dramatically increase the
dentist’s practice revenue. Besides showing the dentist and patient what
the desired smile should be, it is also extremely helpful to the
laboratory technician in the fabrication of the restorations. But
remember that it would be detrimental for a dentist who is offering
cosmetic dentistry if the simulation is of such a poor quality that it
has little or no positive visual impact on the patient.
Therefore, it is imperative for the dentist to create a cost-effective
balance between the time that is spent generating the image versus the
quality of the final image. In saying this, it is logical to conclude
that utilizing a relatively user-friendly software program that can
generate a natural simulation would be the ideal way for a dentist to
create his or her own computer simulation chairside.
EXAMPLE OF A SIMULATION SESSION
Opening an Image File
You need to use a graphics editor to open a graphics file and make
changes to it. So the first step with any graphics editor is to open the
graphics file using any of the following methods:
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