Inside Dental Technology
December 2012, Volume 3, Issue 11
Published by AEGIS Communications
Trends in Dentistry
Experts weigh in on the latest trends in the dental industry, and reflect on the impact these evolutions will have in 2013.
Like most areas of the healthcare industry, the field of dentistry is rapidly changing. New technologies and innovative materials are constantly impacting the work done by clinicians and laboratory technicians alike, making processes easier, making materials stronger and more esthetic, and deepening the relationship between all members of the dental team. Many factors have influenced recent trends seen in the dental industry, but for 2013, there seem to be three major factors that will continue to impact the dental team. The first is the mass digitization of dentistry. As more and more clinicians and laboratory technicians transition to digital processes and procedures, communication between everyone on the dental team will become faster and more critical, restorative outcomes more precise, and patient treatment more effective. The second is the state of the economy. The economic downturn has driven many patients and, in turn, their clinicians, and laboratories to seek restorative solutions more cost-effective than those of the past. Finally, the third component impacting the industry is the major shift of dental insurance companies to push the financial onus away from employers seeking ways to lower healthcare costs.
Inside Dental Technology sought the expertise of eight Key Opinion Leaders and asked them to discuss the major trends they have seen building in the dental industry in 2012, and where they believe these trends will lead in 2013. Covering topics ranging from the economy, to dentist/laboratory communication, to indirect restorative materials, to insurance, these KOLs provide a wealth of knowledge that will help keep you abreast of current and future trends impacting your clients. Inside Dental Technology sincerely hopes that this information proves of value to your business as you begin to strategize and position your laboratory for the new year.
The Economic Outlook
Roger P. Levin, DDS
According to Roger P. Levin, DDS, the economic outlook for the entire dental industry has been radically impacted by unprecedented competitive pressure, which has led to lower production in 75% of dental practices that are, on average, seeing 30% fewer new patients. This pressure, says Levin, whose Levin Group in Owing Mills, Maryland, consults with thousands of dentists and has a division that compiles data on the dental industry, stems from what he calls “eight permanent game-changers,” adding up to a kind of domino effect. They include the opening of 15 new dental schools at the same time a difficult economic environment, changing consumer buying habits, competition from national corporate dental centers (dental service organizations [DSOs]), and lower insurance reimbursement rates have led established dentists to postpone retirement for 8 to 10 years. With these dentists working longer and offering fewer associateship opportunities, it is an especially difficult time for new dental school graduates—who are struggling with a higher than ever amount of student debt—to enter the profession.
Combined, he says, these factors affect not only dentists, but also the entire dental team, including dental laboratories, manufacturers, and distributors.
While Levin expects the US economy to stabilize in another 5 to 7 years, he believes that dentistry in the United States is unlikely to ever again see a return to the pre-recession free-spending consumer days that were a product not only of prosperity but also of different attitudes, expectations, and shopping habits among patients who are now more health-aware, frugal, and internet-savvy.
With the return to stability, he expects the explosive growth of DSOs to slow down. “Our Levin Group Data Center data shows that they employed 4% of dentists 4 years ago just prior to the recession, and we believe that they are probably 9% today.” However, he expects they will increase to about 15% in the next 5 years largely due to the competitive pressures mentioned above, including the workforce created by the glut of young debt-ridden dentists. “They won’t take over dentistry anytime soon, but I could see a scenario where they are 20% to 25% of the profession over time.”
Changes to Come
Levin says dentists are being squeezed in all directions. While many continue to offer the same refined levels of treatment, their compensation is decreasing while their overhead remains the same. In addition, he says, a new 2.3% medical device tax will also likely add to their burden. “In the past you could raise your fees, but you can’t do that when fees are tied to the reimbursement rates of the insurance plans in which 80% of patients participate.”
The solution to this downward economic spiral, says Levin, is for dental practices to become well-run businesses by using proven methods to attract new patients and operate more efficiently, applying approaches such as those advocated by his systems-based consulting firm. “When we put systems into practices, they typically grow 30% to 50%.”
Doctors must provide outstanding patient care, while realizing their practice is also a business, contends Levin. “Excellent clinical care supported by strong business protocols is the best defense against a sluggish economy.” In response to this challenge faced by so many dentists, the Levin Group recently developed a new methodology called The 3-Step Method for Accelerated Production Growth. Step 1 is to set clear targets. Targets must then be communicated to all team members. Examples include collecting 99% of all money owed the practice and having 98% of all patients scheduled at all times. Step 2 is to design systems to achieve targets. When specific step-by-step systems to achieve these targets are in place, production increases while stress—especially financial stress—is greatly reduced, he explains. Step 3 involves implementing value-creation scripting for all team members to make systems run better. Effective, motivating scripts for scheduling, case presentation, customer service, and collections enrich systems to achieve desired targets, he says.
Naturally, dental practice growth benefits their laboratories. However, Levin stresses that laboratories, too, will need to change in keeping with new business realities. “While the main goal for laboratories is still to provide a quality result or product, that alone will no longer be enough. Like dental practices, laboratories will also need to adopt excellent business principles in a more challenging time.” This, says Levin, means that the lab needs to become more of a partner with the practice, to add more value to the relationship—for example, through education, case planning, and acting as a troubleshooter for problems with cases.
Speed will become a competitive advantage for both the dental practices and laboratories that meet that demand. Dentists seeking to complete cases more quickly will place more pressure on the labs.
Fortunately, Levin sees improvements in technology and materials that can help them meet these challenges. “Better diagnostic technologies, improved materials, and continual improvements in radiography—including 3D imaging—are now available. Using 3D imaging, laboratories can literally be looking at the placement of an implant or natural tooth to understand how to construct a final restoration.”
Levin, who is a 3rd generation dentist, concludes, “The business world has come to dentistry and those who do not run excellent businesses—both dental practices and labs—may struggle. Dentistry will be fine, but dentists and their dental laboratories will have to learn to run better practices.”
Roger P. Levin, DDS, is the chairman and CEO of Levin Group, in Owings Mills, Maryland.
Insurance Trends Forcing Downward Spiral
Dean Mersky, DDS
From all indications, the same downward pricing trend for dental insurance benefits will continue in 2013, according to Dean Mersky, DDS, founder of Opt-In Dental Laboratory Cooperative. The driving force, in part, generally comes from purchasers looking to lower healthcare expenses. Additional pressure comes from the fact that insurance companies compete mainly on price. They have found that the most expeditious ways to lower premiums and compete are to discourage patient utilization, shift costs more towards the patient, or lower fees and dentist reimbursement. Mersky believes this trend, which is exacerbated by the sluggish economy, will continue into the future.
In truth, dental benefits are far different than traditional insurance, and are, instead, capped subsidies. They will cover a set fee amount for dental procedures up to a limit, and that cap limit is generally around $1,000, which hasn’t changed in the past 30 years. Thirty years ago, a $1,000 cap limit was a great policy, but with our changing economy and applied dental fees, even the higher plans of $1,500 and $2,000 cover a small percentage of the dental care an individual may need. Additionally, industry statistics show the $1,000 limit has been growing as a percentage of overall dental benefit sales. The fact that dental plans have not kept pace with rising costs is a reflection of how plan purchasers and benefits companies are cutting expenses on the backs of the dental industry. This downward-pricing trend will continue to impact both the dental practice and the dental laboratory.
Today, cost shifting is creating a heightened cost awareness for each stakeholder in dental care. In some cases, employers are reducing their expenditures by shifting fiscal responsibility to the employee through higher deductibles and a higher portion of the co-pay. Other employers might provide the benefits but require employees to pay 100% of the premiums. Shifting risk cost and fiscal responsibility to the employee can affect the patient’s attitude toward care as well as his or her willingness to accept treatment options offered in the dental practice. Insurance company sales representatives have educated them that if they opt for lower-priced services or avoid services, their premiums will be reduced.
A new, albeit smaller, trend is that larger employers are moving into a self-funded role to reduce costs. In this model, the employer uses the insurance company or third parties only for administration. However, self-funded employers still use reduced dental fees, deductibles, and the co-pays of traditional dental benefits to lower their expenses. Employees with no employer-sponsored dental benefits plan might join discount groups. In these models, plan members pay a small fee to obtain access to dentists who belong to the discount group. Typically, the patient will have reduced or free preventative care and a fee reduction for other services. Regardless of the dental plan, each is designed to compress dental fees to even lower levels, which will continue to be felt downstream.
It is clear that the trend for dental laboratories is that owners will continue to be pressured by their dental clients for lower-cost products. Laboratory owners need to ask more questions and listen carefully because dental practices are now far more complex in their needs than at any time in history. It is important to attempt to discover concerns and needs, and where each customer or prospective customer sits in this market. In this unchartered territory, laboratory owners who continue to market themselves without flexibility and with limited services will find it increasingly difficult to survive. Now more than ever, laboratory owners need to be sensitive to where the market has gone and stay attuned to where it is headed.
In response, business-savvy laboratory owners have formed large purchasing groups, like the Dental Resource Alliance (DRA Group), TEREC Group, and the CNC Group to obtain discounted pricing on supplies and equipment. Private equity firms have also bound laboratories together such as Dental Services Group (DSG), Dental Technologies Inc. (DTI), and National Dentex Corporation (NDX) in hopes of increasing their value by transforming the dental laboratory industry to more efficient marketing and manufacturing models. Unfortunately, until recently, small independent laboratories lacking in business skills and resources, have been left behind. Opt-in Dental Laboratory Cooperative was recently launched to help small laboratory owners better compete. Aggregating into a single brand, small laboratories will be better positioned to lower their costs, acquire technology, and better market themselves to increase sales.
Business-astute laboratory owners will continue to change their business models in response to the changes wrought by outside forces. Increasing their efficiencies is one way today’s dental laboratory owners will better serve their customers during difficult times. To remain competitive, small business owners are advised to reflect on the new realities that change has brought, consider every possible option in response to the changes, develop a strategy to accommodate the new normal, and commit to adjusting laboratory operations and business direction.
The insurance industry and other players will continue to drive change and place laboratory owners who resist change at a disadvantage. Because change is inevitable, those who embrace it will be in a much better position to prosper from it.
Dean Mersky, DDS, is a business consultant in the dental industry, the founder of OPT-In Dental Laboratory Cooperative, and the president of Opt-In Management, LLC, in Doylestown, Pennsylvania.
Evolving Lab-Clinician Communication
Michael R. Sesemann, DDS
Recent leaps and bounds in e-communication have provided both dental laboratories and clinicians with unlimited opportunities to expand their relationship and enhance the work they do together. Geographical boundaries are no longer an impediment, and dentists and laboratories can now establish relationships regardless of the number of miles between them, and in turn, make those relationships just as successful as they would be if the laboratory and the office were in the same town. Michael R. Sesemann, DDS, is a general, comprehensive, and restorative dentist who has been in the dental industry for over 30 years, and he believes that enhanced communication between laboratories and clinicians can only further the field of dentistry, and help both parties perform best for their patients.
I consider the relationship between the dentist and the laboratory technician more critical now than at any time in the history of dentistry. The need for mutual respect is essential, as the dentist and the lab technician combine their intellect and expertise to find the best restorative solution for anygiven situation.
New technology has emerged to help clinicians and laboratories keep their lines of communication open. With the Internet, the flow of information is extremely fluid and the clinician and lab can do everything from exchanging digital photos to video chatting. Digital photography in particular has made huge improvements in the dental industry. Digital cameras are the best they’ve ever been, and in the future they can only get better. With the help of a digital grey card (WhiBal), we even have the capability to globally correct the color of an image in Photoshop® so that we can be sure that the images received by our laboratories accurately portray the colors and opacities the tooth presents with.
The breadth of e-communication has made it so that there no longer needs to be a back-and-forth aspect to dental lab work. Clinicians can send their measurements and intraoral photos to the laboratory electronically, the restoration can be designed virtually, and all questions can be answered through video chat. We are developing a business model where the only package being shipped will be the final restoration to the dental office.
One of the reasons there has been an explosion in lab-dentist communication in recent years is because until recently there were not as many material and technological options for the industry. There was a time when every indirect restorative unit was tooth-borne and it was either going to be a PFM or made of metal, period. The biggest decision to be made would be whether the metal was going to be precious, semi-precious, or a base metal. Now there are a multitude of restorative options that require that both the clinician and the laboratory technician make a number of decisions before either party can move forward. Things like whether the restoration will be PFM, all-metal, or all-ceramic are decisions that the lab and the clinician need to make. Then there are also numerous and varied ceramic options, like CAD/CAM versus pressed options; layered versus monolithic forms; and virtual models versus traditional models. And lastly, whether the restoration is going to be tooth-borne or implant-supported significantly affects all of the aforementioned factors.
All of these options have led the dental team and the laboratory team to form a synergistic relationship, creating a very collaborative environment. I rely heavily on my lab, which I visit at least once a year so that I can experience the dental industry from their point of view. As a dentist, I look at completely different restorative factors than they do. I’m focusing on biological perimeters, how the restoration will function, and whether or not I’ll be able to finish and polish it in the mouth. The lab is looking at its fabrication proprieties, how to make the restoration as strong and accurate as possible, and how to optimize the esthetics so that I can achieve what I want to achieve in the mouth. It’s a complicated process and it’s great to have a close relationship with the lab so that this process is as smooth as possible. I strongly believe that it is the collective intellect of both teams that will provide the best restorations of the patient.
Regardless of physical distance between the dental laboratory and the dentist’s office, there should be a commitment toward getting together and having face-to-face time to share philosophies and update each other on the recent advancements in both sides of the industry. I learn a lot when I go to visit my laboratory—eg, what’s new, what journals and literature they’re reading—and in turn, the lab learns a lot about what is going on in dentistry and what my needs are. It’s like any other relationship, it doesn’t just happen perfectly, it requires that both sides put in work.
The lab/dentist relationship has recently undergone a significant metamorphosis, and both parties are now more entrenched with each other than ever before. New technologies like e-communication and digital design allow clinicians and laboratories to easily work together even when they are miles apart. This synergistic relationship helps the lab and the dentist perform their best work because they have someone watching their back and helping them make the best decisions for the patient. In the future this relationship will continue to grow, and one can be sure that the more interaction there is between labs and clinicians, the better dentistry will become.
Michael R. Sesemann, DDS, is a general, comprehensive, and restorative dentist who has been in private practice since 1981.
Increased Durability and Esthetics in the Pipeline for Laboratory Materials
Ed MCLaren, DDS
According to Ed McLaren, DDS and director of UCLA’s Center for Esthetic Dentistry, there are four driving forces behind the development of materials for the dental laboratory, “Esthetics, economics, durability, and ease of use are all major factors in the development of new materials for the dental industry,” he says. Although they remain acceptable solutions, metal and porcelain-fused-to-metals (PFMs) are no longer the go-to materials for clinicians and dental laboratories, and there are a couple of reasons why the industry is moving in that direction. First, the cost of alloys around the world has skyrocketed, causing laboratories and their clinicians financial strain. Second, the dental industry is extremely esthetics-driven, and it is generally accepted that it is easier to achieve ideal esthetics with metal-free substrates.
The dental industry had been looking to move away from metal and PFMs for a long time, but clinicians and laboratory technicians had been hesitant to make the switch until fairly recently. This is because at the time of their introduction, these new materials could not guarantee the durability and ease-of-use of the metal restorations. That dynamic has been shifting, and now lithium disilicate and zirconia—two materials relatively new to the dental market—can, if used properly, perform just as well as metal and PFMs.
Zirconia, in particular, is a quickly evolving dental laboratory material. There are two types of zirconia available, monolithic and layered. Monolithic restorations such as BruxZir® (Glidewell Laboratories, www.glidewelldental.com), Zirlux™ FC (Zahn Dental, www.zahndental.com), and Cercon® ht (DENTSPLY Prosthetics, prosthetics.dentsply.com) to name a few, are more durable than layered, but is less esthetic. Monolithic zirconia can be used on molars and bicuspids, and theoretically, as newer more translucent versions become available, on anterior teeth as well. A trend that many materials companies are currently entrenched in is creating zirconias that are more and more translucent. The technology used to make the zirconia used in dentistry more translucent involves making the particles significantly smaller. When the grain size gets to be much closer to the wavelength of light, light bends less when it goes through the material, making it more translucent. I’ve actually seen zirconia in the pipeline that’s clear. There is very exciting progress being made in this field.
Lithium disilicate is another material that offers the user outstanding strength and esthetics, as well as one specific advantage over zirconia and metal ceramics—it is easily bondable. This easy bondability, combined with its strength, allows me to use it for procedures that I never thought I would be able to do in the past. I am one of a growing number of clinicians who practice minimalist dentistry, and as such, I like to do preparations as conservatively as possible. Because I want to minimize the removal of tooth structure, I’m constantly on the lookout for strong, esthetic materials that I can use pretty much anywhere in the mouth. The bonding capabilities of lithium disilicates, combined with their impressive strength, make them an ideal material for clinicians who are practicing minimalist dentistry, as it can be placed in the form of onlays, inlays, and supergingivally. In addition, a number of companies are looking to create their own ceramics to compete with Ivoclar Vivadent’s e.max® (www.ivoclarvivadent.com), the leading ceramic on the market. In the 5- to 10-year range, I can almost guarantee that many dental manufacturers will come out with their own form of e.max.
The trend toward non-metal restorations has gained so much speed that in the near future, 80% to 90% of all restorations will be non-metal.
Other trends in the dental industry can act as a catalyst for trends in dental materials. Pressed restorations versus machine-milled restorations is one area where this can be seen. Since many people in the dental industry are moving toward a digital workflow, machine-milled restorations are becoming popular, but they are not yet in a position to edge out the more traditional pressed restorations. This is related to cost. I do not see pressing disappearing until machining costs come drastically down. This will eventually happen when more clinicians move towards digital dentistry, incorporating digital impressioning and digital scanning into their workflow. But for now, it is simply not as cost effective as pressing.
Another trend that has led to innovations in dental materials was the interest the industry had in creating a ceramic/composite hybrid. In creating a hybrid, the dental industry could side step one of the major issues we have with composites, namely, that they wear much more quickly than we would like. 3M ESPE’s new Lava™ Ultimate is technically a composite, but the company has bonded nano-crystals in the resin, giving it wear properties closer to a ceramic, thus helping clinicians to solve the wear issue.
While dental technology is constantly offering clinicians and technicians innovations, it is safe to say that the trends in materials will remain consistent. Manufacturers will constantly be improving their materials’ esthetics and strength, as well as their ease and breadth of use, to ensure that dental offices and laboratories are able to offer their patients the best restorative options possible.
Ed McLaren, DDS, is a prosthodontist who specializes in esthetic dentistry. He is currently the director of UCLA’s Center for Esthetic Dentistry.
Major Players in Removable Prosthodontics
Three major factors will continue to dramatically impact the field of removable prosthodontics in 2013 says Dr. Lyndon Cooper, Director of Graduate Prosthodontics, University of North Carolina School of Dentistry. The major over-riding factor for next year will be the current and projected economic climate, which will continue to positively affect the removable market; second is the value recognition and growth of the implant market as it integrates in to removable treatment modalities; and third is the advent of digital technologies into the removable sector of dentistry.
Strength in the increased demand for removable solutions will continue in 2013 due to the impact the economic downturn has had on the restorative choices patients are now making. The change in patient demand has awakened astute dentists to the realization that there is a role for removable prosthetics in people’s lives and that their practice can provide the services their patients need. A removable solution can be temporary, often reversible, and can be a highly esthetic solution given the new high-end material choices on today’s market. The ability to offer patients a stabilized prosthesis by placing just two implants to eliminate the well-published problems of conventional mandibular dentures appeals to patients unable to afford more complex and often fixed solutions. Patients recognize the value proposition implants bring to the removable prosthetic and are much more likely to accept treatment. For some well-trained general practitioners the implant-supported partial and complete overdenture as opposed to a fixed solution is a growing area of practice. A limitation in growth remains in the perceived cost of therapy and components. While lower cost components and ‘simplified’ solutions have been brought to the market, the more traditional components and procedures offered by the industry leaders offer remarkable value. The larger, established implant companies bring incredible value to the majority of practicing dentists. These are dentists who were not exposed to implant education in dental school and who rely on the education and support offered. Paradoxically, as the focus of dental education changes, younger dentists who obtain increasingly detailed and excellent dental implant education, may require further training in removable prosthodontic techniques that are increasingly diminished in their curriculum
The new esthetic denture materials now being introduced will also help drive the removable market in the coming year. Now dentists have the opportunity offer their current denture wearers a new prosthesis that is vastly improved in terms of esthetics. Although we don’t know exactly how long patients keep their dentures before replacing them, the thinking is that many dentures are kept for more than 10 years of continuous use. Perhaps these new materials and denture teeth will help drive the market forward as patients become increasingly aware of the modern esthetic and the need and value for more frequent denture replacement.
The esthetic materials boom has also affected the flexible denture market. In the past five years the well-engineered, carefully planned conventional cast partial denture has disappeared in favor of nylon partial devices with tooth-colored clasps. This is a trend that may continue to increase in popularity primarily due to the reduced number of patient visits to the practice and perception by the patient that the removable flexi-denture solution is more esthetic. That said, the long-term data is not in on flexible partials in terms of their effectiveness, durability, and patient safety.
Digital technology continues to make in-roads to the removable market. From CAD designed and 3D printed wax partial frameworks to designed and milled titanium, chrome cobalt, or zirconia implant bars and now complete dentures, this is one area of the market that is in its infancy in terms of market share but will demonstrate incredible growth as it matures. Avadent has introduced the one-visit denture. The company has figured out a way to provide dentists with the tools needed for a single record-taking visit. Once the impressions and records are sent to the company, a software CAD designer processes and manufactures the prosthetic in a virtual environment, and delivers to the restoring dentist a final milled prosthesis with the midline, occlusal plane, and tooth display in the right place and the denture still in centric relation, all for $600 to $700. This is a remarkable achievement but one that still needs improvement in terms of technical challenges for the day-to-day dentist. Although it changes the number of visits for the dentist, the clinical technology and know-how for a novice practitioner could be very overwhelming.
There are limitations to the technology such as colorizing the denture base for the more discerning patient, revising the flanges, which currently are very thin and knife-edged, making them uncomfortable for the patient, and the lack of a post dam in the denture base, which may affect the ability of the denture’s stability in the mouth. Where digital dentures will really be of value in their current state is for the large denture chains such as Affordable Dentures. In the future, as laboratories gain access to the technology, the larger fixed laboratories that are challenged to find qualified denture technicians, but that have the CAD know-how, will be able to tap into this outsource center. I am waiting for someone to figure out how to mill the teeth in position on an arch out of plastic, mill the denture base, and then marry the two segments together.
One area of the CAD/CAM denture market that is exploding is the CAM milled implant bar market. No one in 2013 should be casting an implant supported overdenture bar. The advantages to the fit and precision of CAM milled titanium, chrome cobalt, or zirconia implant bars are remarkable.
Another area showing promise is in capturing information intraorally and computerizing it for design, manufacture, and duplication. We are not there yet. We still have problems when it comes to determining the finish line, the movability and nature of the tissue, and the position of the margins. But that will come. Today we can scan a dentate patient before extraction, print a model from the scan, and then the technician hand articulates the arches, removes the teeth from the model, and fabricates a conventional denture.
Lyndon Cooper DDS, PhD, is the Stallings Distinguished Professor of Dentistry of the Department of Prosthodontics at the University of North Carolina at Chapel Hill where he serves as director of Graduate Prosthodontics.
Digitally Planned, Site-Specific Implants
The placing of dental implants is one of the fastest-evolving fields in the dental industry, both for clinicians and the dental laboratory team. Implant restorations are becoming more reliable, easier to place, less expensive to produce, and with a wave of baby boomers reaching old age, they are becoming more and more in-demand. This demand drives change, and according to Jacinthe Paquette, DDS—a prosthodontist specializing in esthetic and implant dentistry, rehabilitative dentistry, and dental implantology—it is increasingly becoming a more simplified treatment approach with more predictable outcomes.
As technology advances, the steps involved in planning and placing implants have moved from traditional x-rays toward digital scanning and electronic planning. Computer-guided treatment is gaining popularity, encompassing the initial scans, the surgical planning and placement, and finally the laboratory fabrication of the final restorations. Almost everyone in the industry sees the move to digital as a positive step, as it consolidates all of the data and provides everyone on the treatment team—the dentist, the lab technologist, and the surgeon—
access to the information on the same platform. The consolidation of this data streamlines the process for better communication and precision among the team members.
Additionally, the efficiency of the digital workflow translates to a more economical approach to the patient’s treatment. Certainly, with the economy in its current questionable state, clinicians, dental laboratories, and patients alike will benefit from the improved productivity and potential cost-saving benefits of these technologies.
On the restorative side, the introduction of CAD/CAM implant abutments now provides a customized treatment approach to each individual patient in a mechanized system. These custom abutments can be designed to meet the specific contours and topography of the surrounding hard- and soft-tissue architecture of each implant site and can be defined as “site specific.” Historically, the custom-designed implant abutments required many hours of dedicated time from the laboratory technician for their fabrication. Now they can be created overnight for next-day delivery in many instances, which expedites treatment tremendously. It has revolutionized what we’re able to do.
The digital workflow of the CAD/CAM production processes, in conjunction with advances in the restorative materials, has provided the dental laboratory team with the necessary tools to create the final restoration—sometimes even before the actual surgical phase of treatment is initiated. These procedures can minimize the surgical requirements, more accurately plan for appropriate implant positioning, and significantly shorten the healing and restorative times.
This new era in dentistry has brought about a platform for an increasingly participative role of the dental laboratory team in the implant treatment process. Having the knowledge and experience of the laboratory team more integrally involved creates a powerful synergy for clinicians and laboratory technicians, providing a better communication partnership. The laboratory technician’s expertise and input before restorations are created is yet another trend that has emerged in dental implantology, and will only gain speed in coming years.
As CAD/CAM technology, digital implant planning, and implantology in general continue to evolve, we will see continued improvements in time-saving efficiency, greater levels of treatment accuracy, and the benefits of better communication among all treatment team members. The increased role of the laboratory, combined with the collaborative environment fostered by these technological advancements, ultimately serves the patient, who in turn will receive individualized, reliable, and predictable implants at a much lower cost than ever seen before.
Jacinthe Paquette, DDS, FACP, is a Board-Certified prosthodontist specializing in esthetic and implant dentistry and rehabilitative dentistry.
Trends in Technology
Paul Feuerstein, DMD
One of the biggest trends impacting the dental industry today is the myriad ways digital technologies are dramatically changing the relationship between dentists and dental laboratories. Paul Feuerstein, DMD, believes that trend will continue into 2013 and beyond. Feuerstein is an assistant professor at Tufts University of Dental Medicine and maintains a high-tech general practice in North Billerica, Massachusetts. He believes that the advent of digital impression devices, virtual implant-planning software, cloud-based Internet portals, and even consumer-based devices such as the iPhone and iPad are opening up a whole new world of communication and case collaboration for the dental team.
By mid-year next year, there will be 11 digital impression scanners on the market plus advancements in current technology. Sirona just released its new CEREC® Omnicam with redesigned handpiece and ColorStreaming technology. The biggest breakthrough for Sirona’s Omnicam is that dentists no longer have to use powder to capture intraoral details. That’s huge and brings this technology in line with the 3Shape Trios®. 3M ESPE also recently announced a reconfigured Lava™ COS, which has beem renamed the 3M™ True Definition Scanner. The scanning device or wand is completely revolutionary. It is small, lightweight, and mimics the look and feel of a dentist’s high-speed handpiece. The scan files are now in STL format for connection to any milling unit and are transmitted to the laboratory from the cloud-based connection center. These are major improvements for this technology sector and are forerunners of the future for these devices.
Look for a company called Atron to enter this space. Its small wand plugs into a computer USB port, which makes it very convenient to use. In the background is Lantis Laser with its Optical Coherence Technology (OCT), which is able to read hard and soft tissue.
As more new digital impression systems are introduced and the technology is better understood in terms of cost savings, dentists will become more intrigued with this technology. Competition in the field will also affect the pricing of these units, as it has in other arenas. But these devices are not magic wands. If the dentist doesn’t prep the tooth correctly or leave enough room for the restoration, there is no difference between this technology and the traditional impression. However, the ability of the dentist to take a scan and communicate with the laboratory through Internet portals such as gotomeeting.com for an interactive discussion is revolutionary and that trend will continue to grow. The speed of digital processing versus analog for the dentist will become more important as the value of faster turnaround, reduced shipping, and elimination of infection control procedures becomes more apparent.
One of the biggest areas of growth in 2013 will be in the implant arena. More and more general dentists are discovering guided surgery and are becoming less nervous about placing implants, which has always been in the realm of specialists. With the advent of cone beam technology and surgical guides for placement, general dentists feel much more comfortable about performing implant surgery. The increasing acceptance of cone beam technology in the practice is a growing trend, especially now with new systems that are less expensive and give off less radiation. These systems capture only a single quadrant rather than the whole head, making the scans easier for plugging into virtual implant-planning software for implant placement planning, surgical guide design, and patient-specific restorative solutions. Collaboration through online meetings or Internet portals such as BrightSquid, eDossea, Dental Sharing, and RecordLink, which are HIPPA compliant, allows the laboratory technician to take part as a consultant in the planning process with the implant team.
What will be an interesting trend to watch is the growth of technology adoption among the large dental practice groups. Dentistry is changing quickly, with more and more group practices forming in this country. Because dental students are graduating with double- and triple-digit debt, many are unable to financially afford to set up a private practice and jump-start their careers by either joining or buying into to one of these large group practices. And these group practices have the financial backing to purchase myriad technologies in order to increase efficiencies and profits. If a new graduate buys into Pacific Dental, for example, the operatory comes equipped with a CEREC chairside milling unit. And the younger generation of graduates understands digital forward and backward. They are in the demographic that lives electronically in most facets of life and expects the same in their practice. That will continue to increase the demand for intraoral impression devices and other technologies as these graduates move from group to private practice and move dentistry away from paper into an electronic communication era with e-mail, text messaging, Face-to-Face, and other electronic means of communication for instant case feedback.
As for the growth of chairside milling units, those dentists who jumped in first were the more tech-savvy dentists but more now are coming in. With the advances in design software, being tech-savvy is not necessary. However, these chairside mills are limited in the restorative material options they can deliver and demand that the user have a solid understanding of proper prep design. Although there is an attractive scenario presented by in-office mills, laboratories need not shudder at the prospect of their taking over the majority of indirect work on the market. In the future, they will become more intuitive. Glidewell is developing a chairside mill that offers the dentist tens of thousands of software design proposals for posterior teeth that will allow click-and-mill efficiency.
There is no doubt we are entering a new era of dental restoration technology. And as this technology further integrates into the practice and laboratory, the collaborative relationship between the dentist and technician will become much more critically important. If ever there was a time for both dentists and laboratory owners to refine existing knowledge and skills and learn new ones, it is now.
Paul Feuerstein, DMD, has a private practice in North Billerica, Massachusetts, and is an assistant professor at Tufts University of Dental Medicine.