Transforming dentistry with ZBrush Dental innovator Dr. Paul Zhivago is revolutionizing his field using digital sculpting to bridge art and science.

Dentistry is not generally associated with the creative power of ZBrush but Paul Zhivago, a dental surgeon and clinical assistant professor in the Department of Prosthodontics at NYU College of Dentistry, is on a mission to change that.

A specialist in esthetic, restorative and implant dentistry, he is unique in his field for integrating ZBrush into dental workflows. And with multiple innovation awards to that effect, he lectures all over the world on the advantages and techniques of digital dentistry.

Zhivago, an enthusiastic artist since childhood, turned to 3D software to help him overcome complex perspective challenges in his artwork. Finding his way to ZBrush proved personally and professionally transformative. Today, his YouTube channel shares his techniques and workflow with students, professionals and patients alike. Wanting to learn more about how ZBrush supports Zhivago’s work, we caught up with him at his practice in New Jersey.

Zhivago: I was born in Germany and emigrated to the United States with my family. My father was a dentist, so I wanted to become a dentist too. As a kid I was always sketching and drawing but had trouble with perspective and eventually started using Maya and 3ds Max to help me with my art.

One day, I picked up a magazine about ZBrush and the level of finish was way beyond what I had been using, so I taught myself by following YouTube tutorials and had fun creating my personal art.

I began using ZBrush for my dental work as an undergraduate at New York University and more so during my post-grad studies in prosthodontics at NYU. I continued using it at Columbia University where I was a surgical and implant fellow, and I practiced in New York City for many years before opening a private practice.

It was an opportunity to build a practice the way I wanted, with a completely digital workflow and state-of-the-art technology that allows me give patients individualized care.

Zhivago: Prosthodontics is a specialist field that relates to all procedures that involve restoring, repairing or replacing teeth with prosthetics and esthetic dentistry. That includes things like dental crowns, veneers, bridges, implants and dentures that are 3D printed in resins or milled in porcelain.

Zhivago: When we first started sculpting teeth using traditional wax in class, I started modeling teeth using ZBrush to learn dental anatomy. I was inspired by articles I read about how the software is used by artists who create characters with incredibly accurate anatomical details for movies.

The combination of science and art felt intuitive, and I began to apply ZBrush to dental challenges more and more. It means there is no limit to my creativity, and I can customize to a very high level. To integrate ZBrush with my professional practice, I pioneered workflows that I now teach.

The workflows are used to sculpt digital impressions of patients' mouths, as well as to create and modify a 3D model of what a patient’s mouth, and ideal smile, will look like post-op. I can do that with them next to me in the chair, with their active involvement and feedback, and that really changes the doctor-patient dynamic, making the patient feel much more engaged in the process.

Beyond those specific workflows, I use ZBrush to create or remodel individual teeth, bridges, veneers, arches, crowns, implants and more. I use ZBrush routinely alongside specialized dental imaging software, including SmileCloud biometrics, exocad, Medit intraoral scanning technology, SprintRay and 3D printing technology.

Zhivago: I like creating teeth from scratch and modeling a full arch is a good example of how I do that. There are four stages to the process, and I use a lot of the same brushes throughout. My favorite brushes are the Standard brush with mask function, Move Topological to easily move teeth without affecting the mask, Clay and ClayBuildup with Smooth or Polish to refine forms and DamStandard for the detail.

I begin by designing rough anatomy and creating a series of spheres that I sculpt into individual teeth. I use the Transpose plugin to pose individual proxy models with a series of SubTools to allow for efficient positioning and alignment within the overall arch. I then use the Standard and Move Topological brushes to easily form the basic shapes and position the teeth. I also use ClayBuildup with Move Elastic to create individual forms.

The next stage is to fine-tune the anatomically correct details with the Clay and Smooth brushes, using DamStandard to create the sharp edges of cusps and pinched lines of the valleys typical of molars. Dynamesh Master is a really useful tool here to scale the SubTools up or down to make the workflow easier.

Once the arch is aligned, the final stage is to customize the arch and bite to the patient’s specifications. This stage finishes the model with specific alignment, sizing, shading and textures, as well as photo-real flesh, enamel tones and materials. Clay and ClayBuildup brushes with Move Elastic lets me sculpt individual details. The Smooth and Polish brushes ensure that hard surfaces or shell borders are smoothed before exporting as an .STL file ready for 3D printing.

Zhivago: As part of my digital workflow, ZBrush enables me to connect my vision with what the patient imagines so we can get an ideal result. I had experienced the benefits of this creative freedom and wanted to help others achieve that. NYU has always been open-minded, so I suggested teaching a course in ZBrush as part of a postgraduate in digital dentistry and I’ve been doing that since 2016.

Zhivago: Some years ago, I went to a 3D software convention in Los Angeles and met ZBrush artists who were really surprised that I used it for dentistry. For me, though, ZBrush is an intuitive fit and I share the approach used by artists like creature designer Dan Katcher who designed the dragons’ teeth for HBO’s “Game of Thrones.”

Having him lecture to my students was a fun way to get them to appreciate the creative power of ZBrush. He inspired them to combine creative vision with anatomical detail and realism to achieve beautiful, lifelike results.

Zhivago: Digital dentistry has really advanced in recent years, and I want the field to move to an open architecture sandbox approach that allows greater creative freedom, artistry and individualization. With digital workflows, 3D modeling and sculpting we can increase patient involvement, and create individualized treatment plans and options where we can be innovative while maintaining human creativity.