November/December 2011, Volume 32, Issue 4
Published by AEGIS Communications
Incorporating New Technology in a Tough Economy
Like any other business, dentistry feels the effects of a recession. Not everyone handles a downturn in their practice in the same manner. Some will continue to do business as usual, hoping it will eventually get better, and some will downsize their expenses to weather declining revenues. Some, however, will view it as an opportunity. If dentists are not getting the results they expect, then maybe it’s time to make some changes.
It is difficult to deviate from a comfort zone and embrace change. However, that may be exactly what is needed in order to move forward, especially in a tough economy. It begins with time and dedication allotted to learning something new, finding ways to acquire the necessary tools, and ultimately implementing those tools into a practice’s routine. Dental technology falls into this category. Practitioners must realize that they can’t do everything, and do it well, without implementing new technology into their business. This may require a new mindset, with the understanding that doing something quickly and more efficiently does not necessarily equate to doing it poorly. Quality is quality no matter how it is achieved. Once this philosophy is accepted, then new technologies that can significantly impact a practice can be explored.
The dental industry is making quantum leaps employing technology-based systems, especially in the CAD/CAM arena. In the past 10 years, 39% of respondents to Dental Lab Products’ Tech Census have invested in a 3-dimensional (3-D) scanner, and 28% have a mill for in-house fabrications.1 That may not sound like much, but it is when considering the size of the industry and the time and money needed to take this initiative. Conversely, according to the same survey, just 20% of the industry expressed no desire to purchase a scanner at this time, while one-third had no plans to purchase a mill. It could be that these individuals have determined that their return on investment won’t pay off because of the volume and type of work they do, which may not utilize technology. Not everyone has the time or money to invest in a down economy. However, converting a dental practice to digital is a sound business model for profitability, efficiency and consistency in production, and turnaround times. The issues for practitioners are why, how, and when to go digital.
Today, there is no panacea when considering a CAD/CAM system. Any system inherently consists of components. A successful system requires an accurate acquisition device, software to interpret the data, and a machine capable of interpreting the information it receives to produce the desired result.
Currently, there are seven chairside acquisition systems that can be used to capture digital impressions.2 The advantage of a digital image over a conventional impression is accuracy. Once the scanning technique is learned, the risk for error is minimized.3 Today’s software can automatically find the correct bite when an image is acquired from the correct positions. With conventional techniques, an incorrect bite can lead to undesired results with the final restoration.
Intraoral scanners can record dentition and store it,4 eliminating unnecessary steps associated with conventional model-and-die methods. They can also fabricate models, be used to design restorations, and then be sent to an in-office milling unit or sent to an off-sight facility for fabrication. Table 1 lists available intraoral scanners, and the options for sending files to a laboratory. The laboratory then decides whether to finish the restoration in-house or send the design to a milling center for further fabrication.
Initially, early systems only offered single-crown dentistry out of limited feldspathic or polymethyl methacrylate (PMMA) material. A small range of shades coupled with only a number of different size milling blocks limited the use.5 This coupled with three-axis scans and mills produced inconsistent or poor fits—what used to be referred to as a “socks on a rooster” restoration fit. Now, with such new improvements as five or more axis capabilities, excellent results are achievable, with marginal integrity at 20 µm. Similar to the way a camera is only as good as the lens that is on it, a milling machine cannot mill what it cannot see or recognize. It is important to select an acquisition unit with an equally proficient milling unit.
There are many CAD/CAM systems to choose from with various features and benefits, thus it can be difficult for a dentist to determine which is best for his or her needs. The author advises trying some out, seeing what works best for specific needs, and determining whether the system is easy to use for those tasks. While today’s systems can do remarkable types of restorations, they may not be best suited for a particular, single task. Initially, most systems were closed systems. This enabled the vendor/manufacturer to more readily assist with any problems or situations that might arise. In short, the vendor knew everything about the components and software and could make them work together. Unfortunately, this type of system limited other opportunities that the user might have wanted to add later. For example, a user might want to try a specific new material on a recently purchased system only to find out the material is not compatible with the system. Closed systems dictate what material can be used. Open architecture, or open systems, allows more versatility but requires software permission to communicate with other components such as scanners, mills, and printers. The software file has to be changed in order to be recognized by different machines. This versatility is a huge benefit, since it can decrease initial entry-level expenses. It gives users the ability to “outsource” to off-sight companies for manufacturing, without purchasing the equipment.
Since all-ceramic and PMMA restorations require a shoulder or chamfer preparation, conventional preparations often do not lend themselves to what a CAD/CAM system can produce. Thus, a new relationship between older methods and new technology has to be established, and a new attitude
and philosophy is needed to successfully employ these systems. CAD/CAM presents dental practices a great opportunity and it is here to stay. As more and more computer-savvy people enter into dentistry, the goal should be to take skilled dental professionals and train them to be computer literate, or vice versa—train computer-savvy individuals in dentistry.
Training is most critical when delving into CAD/CAM technology. Without a good trainer or training program, it is highly likely the technology will not be used to its full potential, which would be a costly mistake. Most companies offer a basic training course and free telephone support with the purchase, but very few offer advanced training without additional fees. Training classes typically include the dentist and one or two assistants. The assistant usually becomes the primary operator, and the dentist checks and verifies the results before fabrication. The software is developed for easy adaptation and assimilation into the practice. Additional software upgrades typically range from $1,500 to $3,000, but some companies offer free software upgrades as part of the purchase. Warranties vary from 1 year to 5 years, but additional insurance can be purchased to safeguard against costly repairs. Dental meetings and conventions offer numerous possibilities to learn what is new and how to use it. More recently, the use of remote access support options such as TeamViewer (TeamViewer Inc., www.teamviewer.com) and S.O.S. Support on Sight (D4D Technologies, www.e4d.com) have made it less costly to train and assist without the need for a technician to come to the user’s office. However, some vendors will send a technician off-site to an office.
Digital dentistry has emerged in many large laboratories and represents their success in the future. Large laboratories such as Glidewell Laboratories, Dale Dental, Dental Technologies Inc. (DTI), Issaquah Dental Lab, Dental Crafters, Apex Dental Lab, and many others are blazing trails for many other smaller laboratories. Large laboratories can be a great resource for learning about the technology. Dentistry has progressed from single-crown restorations, to three-unit bridges, to roundhouses, and fabricating zirconia, titanium, and PMMA using CAD/CAM. More recently this technology has been expanded to fabricate custom abutments, overdenture bars, and accurate custom models. The digital model revolution is an important step in changing dentistry. Models are being fabricated from the digital image, are accurate, and save time compared to conventional techniques.6 As more companies enter the digital model arena, there is a possibility that it will replace traditional laboratory model-and-die. Some companies (eg, 3M ESPE, www.3MESPE.com; Sirona Dental Systems Inc., www.sirona.com; Cadent Inc., www.cadentinc.com) offer milled or stereolithography (SLA) models. (Sirona offers both options.) This increases choice and accentuates the versatility of the digital model.
The cost of implementing a digital solution into a dental practice is reasonable, and there are many different ways to get involved. The simplest purchase of an acquisition system ranges from about $16,000 to $25,000. As the practice grows, an in-house milling unit can be added for simple crowns and temporary bridges. The cost of adding a milling unit is an additional $60,000 to $80,000. If adding an in-house solution is not appealing, intraoral image files can be sent via the Internet to an off-site laboratory. The fee for this service will depend on where the files are sent and the complexity of the job. Each solution has its own advantages that can increase a dental practice’s productivity and profitability. Monthly payments can be easily managed with about 6 to 10 units per month. Practitioners can charge slightly higher prices than with traditional work due to the new technology. The price charged will depend on market conditions and what the patient will pay.
In conclusion, CAD/CAM solutions are becoming more popular due to ease of use and increased productivity. Dentistry is changing at a rapid pace. In the current economy, dentists can be resourceful and adapt to change or choose not to change. Many different choices make dentistry exciting. From intraoral images to overdenture bars and custom abutments, there are many materials and restorations that can be fabricated much easier than in the past. Adapting to something new takes patience, time, and the necessary training for success. With success dentists gain the confidence that they have become part of a progressive dental trend that is growing and will continue to advance. CAD/CAM technology is dynamic and will continue to offer the dental profession better alternatives while providing patients added benefits that will enhance their entire dental experience.
1. Levine, N. Tech Census 2011. Dental Lab Products. June 30, 2011. http://www.dentalproductsreport.com/lab/article/tech-census-2011. Accessed September 28, 2011.
2. Brown, C. Making a new impression. Inside Dental Technology. 2011;2(4):60-62.
3. Strietzel R, Lahl C. CAD/CAM Systems—Parts 1-4. Procedure: Principles and History. Spectrum Dialogue. 2010;9(4-7).
4. Jacob G. Digital scanning benefits for removable restorations. Journal of Dental Technology. 2010;27(8):10-12.
5. Giordano RA II. Building blocks—An overview of the various types of machinable blocks for laboratory-based CAD/CAM systems. Inside Dental Technology. 2011;2(5):46-50.
6. Ender A, Mehl A. Full arch scans: conventional versus digital impressions—an in vitro study. Int J Comput Dent. 2011;14(1):11-21.
About the Author
Ed Flocken, CDT
Owner and manager of a studio laboratory
Hendersonville, North Carolina