CBCT Feature: Building a Virtual Patient Wm. Randol Womack, DDS Editorial Director, Orthotown Magazine

New software and techniques designed by Anatomage, Inc., are allowing orthodontic specialists to collect specific data from their patients to create virtual patients – helping with overall treatment planning and actual treatment. Orthotown Magazine recently spent some time with Dr. Doug Chenin director of clinical affairs at Anatomage to learn more about how this technology is not only changing the faces of patients, but the face of the profession.

by Wm. Randol Womack, DDS, Editorial Director, Orthotown Magazine

Some of our readers might not be acquainted with Anatomage. Can you give us a little history?
Chenin: Anatomage is now five years old. We are a 3D imaging software company that is expanding the potential of 3D imaging in all fields of dentistry with cone beam computed tomography (CBCT). We are by definition a 3D CBCT software service and solutions company and our ultimate goal is to expand the potential as much as possible. The whole industry is pretty much focused only on implant planning, with little concern for other specialties or even inter-specialty communication. We were one of the first to branch out and get into orthodontic applications. We are not focused on just implants, but all dental specialties. Some of the new updates really bring home that we have the ability to do everything in the same platform; orthodontics, implants, periodontal assessment, TMJ assessment, 3D photography, hard- and soft-tissue simulations and more. It’s the most complete “virtual patient” available.

I understand you have some new developments in the works.
Chenin: We’ve launched the first next-generation of CBCT imaging, called Dynamic CBCT. It has the ability to simulate hard- and soft-tissue movements and also compares pre/post treatment results via superimposition. This was a huge developmental advancement from mere static CBCT imaging. We are now releasing another generation of digital imaging – Cosmetic CBCT – which has the ability to combine intraoral photography data, as well as a digital model data, into the patient’s scan. All three of those elements are combined on one platform, which is again, the CBCT scan, the patient digital model and intraoral photography. It brings cosmetics into the realm of radiology, which is very interesting and unique, and it advances computer-guided treatment to a whole new level. Having accurate information about gingival height, contour, health, color, and so on, can really help in treatment planning a case for implants or orthodontics, or a combination of the two.

Are you saying that you can actually see gingiva with CBCT and that you can actually define the gingival margins around teeth?
Chenin: Exactly! We will scan the digital model as well, and that gives us the data that was missing from the CBCT scan, which provides the patient’s hard tissues. CBCT shows internal soft tissue, but does not distinguish well between the gingiva, cheeks or tongue, nor does it show critical aspects like gingival margins. We have three elements, one is the cone beam data set – that is a rough outline of the soft tissue and a very good outline of the hard tissue, then the stone model scanned and the photo, which we add to provide us with color. So you really get the CT scan as the basis of everything. The stone model scans give you gingival data and the photo essentially gives you true patient colorization on it.

Are you are able to produce a virtual model that shows the gingival line around the teeth?
Chenin: Yes, as a result of the combination of these several data sets. We combine the CBCT scan of the patient, which is the platform for all the data, with a scan of the stone model of the patient and that is where the gingival data is brought in. Normally with a cone beam data set, the gingival lines are not distinct from the cheeks or the tongue. But with the incorporation of the model scan, the gingival line is very distinct and very clear. Also, the intraoral photos are fused to the model so we have the actual color and the actual intraoral photo in there as well. So, three unique data sets come together for the first time – the cone beam scan of the patient, the scanned stone model and the intraoral photography.

What is going to be the orthodontic benefit of this type of thing?
Chenin: Orthodontists are using cone beam as a record for treatment plans and having that gingival data from the start is a great initial record. I think it will also help as the case goes on as a record of where the gingival data is at the end. What is greatly enhanced is temporary anchorage device (TAD) treatment planning. With CBCT it is possible but previously, because we didn’t know where the gingiva was, it was hard to accurately place or see how it was going to appear. Now you can virtually place these TADs and know exactly how it is going to look from the gingiva, so you can plan more accurately how that is going to happen. In terms of the dental team quarterbacking with the surgeon or implantologist who is placing the implant, if you are doing the ortho first and the implant second you can take the gingival aesthetics into consideration as well. So rather than just using the hard tissue, we now have a complete cosmetic layer as well.

Will this enhance the application of this technology to creating bracket placements or doing Invisalign without PVS impressions?
Chenin: I believe so. Cone beam, in general, is going towards therapeutic devices such as indirect treatments, brackets and other aligners. One of the challenges of just pure CBCT data is you don’t have that gingival line, so our enhanced, cosmetic CBCT gives you those boundaries. If you are planning brackets, you would be able to plan them in consideration with the gingival line, which would be absolutely necessary. The last thing you want to do is place some brackets on the CBCT scan and then, when you get the patient in the chair, realize that you have placed those brackets on top of gingiva. The cosmetic model has the stone model scan fused to the CBCT scan so you can take both things into consideration. This is a procedural step that can help make that leap of orthodontic therapeutic devices from conebeam easier. So, in computer-guided orthodontic treatment this step can definitely help both the process and the treatment planning. This is all going back to the idea of the virtual patient; that the more complete our picture of the virtual patient is, the better all treatments will be. In some cases it is a necessity. I think this is the most complete virtual patient that is possible. Again, it has the 3D CBCT scan which has the soft and hard tissues (a scan of the stone model which has an accurate presentation of the gingival) and it has the intraoral photography fused to provide that as well.

If I wanted to use this service what would you need from my office to make this work?
Chenin: We would want a CBCT scan of the patient, a CBCT scan of the stone model and regular series intraoral photographs.

When you say a composite of the stone model if we were doing electronic models like OrthoCAD models, for example, would that digital information work for you?
Chenin: It would. However those companies have their own proprietary formats. If they had a non-proprietary format such as an STL file, it would work. There is just that proprietary barrier. If you have your own digital scanner, you can send us that data because it is non proprietary. The easiest way is to scan the model with your CBCT machine.

If we did a stone model in the office would it make any difference what kind of impression we would take?
Chenin: Definitely! The quality of the model is going to be a concern. We recommend PVS and good quality stone or good quality plaster – but you could use just regular stone. I think the higher grade you use, especially like PVS, it will definitely make an impact on the overall quality.

I’ve seen some studies showing that intraoral scans produce more detailed images than you could get from a PVS impression.
Chenin: We can also fuse intraoral scans with that data. The categories would be a CBCT scan, intraoral scan and then oral photography. It doesn’t necessarily have to be a stone model scan in a CBCT machine.

Once we can achieve a virtual patient that has all of the information including soft tissue, then this can be used for any specialty. This one data file can be shared by orthodontists, implant doctors, surgical doctors and anyone like that, is that correct?
Chenin: Yes, and that is the idea behind the virtual patient. Everybody should be on the same page. With this, you’re working with the same file that can be shared with anyone. The treatment planning is facilitated, the combination therapy is facilitated, communication is facilitated – everything. Records are simplified. The software allows you to press an upload button; the file is then uploaded to our secure server, where you can then share with whoever you then specify. It reduces the hassle of having to track down records from different offices. You can have the orthodontic simulation programmed into that file, the implant simulation programmed into it and everybody is using the same file.

Once this virtual patient data file is all put together, how would an orthodontist or oral surgeon look at this? Is that done through your Web site?
Chenin: Within the software there is a button that they can upload to our Web site, which has a secure sign-in and where the other collaborating doctors would access it. They can download that file and then open it up with 3D viewing software. Even if they don’t have the full version of the software, they will be provided with a free viewer. Essentially, any number of collaborators would have access to the file and the software to view it.

What can you tell us about the cost involved with doing this?
Chenin: It is less than $100 per case. You’re getting the ability to collaborate with your colleagues to a level that far exceeds anything that has come out before. On top of that, your diagnostic data is more sophisticated and exceeds anything that we have seen before. If you’re doing an orthodontic, orthognathic, implant case what is $75 - $100 to make sure everything is done right and everyone is on the same page.

What is the difference between a virtual patient and a cosmetic CBCT scan? Are they the same?
Chenin: Everybody has a piece of the virtual patient or a lot of companies try to portray a virtual patient. Something such as a digital stone model can be called essentially a virtual patient. But what the cosmetic CBCT does is to provide the most “complete” virtual patient. I think almost any type of digital file that is a patient record could be technically called a “virtual patient” but the real question is: how complete is it? I think our cosmetic CBCT is the most complete because it has the full 3D hard and soft tissue from the cone beam scan, it has the gingiva from the stone model and it has intraoral photography as well. In addition, it has everything that you can do with cone beam such as TMJ, airway, ortho, etc. So really, Cosmetic CBCT is really the next generation of CBCT and it is the most complete virtual patient.

Doug, thank you so much for this interesting and informative discussion of the next level of sophistication in the CBCT technology.
Sponsors
Townie® Poll
When did you last increase your fees?
  
Sally Gross, Member Services Specialist
Phone: +1-480-445-9710
Email: sally@farranmedia.com
©2025 Orthotown, a division of Farran Media • All Rights Reserved
9633 S. 48th Street Suite 200 • Phoenix, AZ 85044 • Phone:+1-480-598-0001 • Fax:+1-480-598-3450