The Last Frontier

“So if we don’t offer dentists something such as chairside consulting, our survival is threatened. The last frontier we have as dental laboratories are the services we can provide.”

Nor is Wiand a lone crusader. Intent on honing their competitiveness and boosting their bottom line, dental laboratory owners across the country are adding chairside consulting to their repertoire. Their in-office assistance to dentists on esthetic and restorative procedures ranges from collaborating—defined as providing professional input on treatments—to guidance, as in the case of consulting with dentists and specialists on the placement of immediate-load implant procedures.

For some laboratory technologists, chairside consulting has become an integral component of their business model, either as an add-on value or a
specific billable service. And while their dentist-clients embrace laboratory technologists’ expanded services, some in the profession raise concerns about the role of technicians venturing too far into the clinical realm, citing their lack of formal dental education (see sidebar on page 30).

Yet there is no question that dentists have become increasingly reliant on the expertise of their laboratory partners, especially since dental schools have winnowed restorative procedures from their curricula. “In the late 1980s, we started seeing dental schools cut back on restorative dental laboratory procedures,” says Bennett Napier, executive director of the National Association of Dental Laboratories, in Tallahassee, Florida. “With all the subject matter that the schools needed to cover in four years, restorative dentistry just kept getting cut to the point where it’s become a miniscule part of their curriculum.”

The fabrication of crowns and inlays and other restorative devices largely has become the sole province of dental laboratory technologists. In turn, an increasing number of laboratory technicians today often serve as ad hoc educators to dentists on restorative dentistry fundamentals.

“The growth of chairside consulting seemed to start around 2002,” Napier continues. “That’s when we began to hear from laboratory technicians who said they were being called upon to be in dental offices for restorative procedures.”

Though NADL has no statistics on the number of laboratory technicians offering chairside services, Napier adds that it seems to have gained momentum during the last four years as more technicians have started helping dentists provide immediate-load implants.

To explore this in depth—to illustrate the various needs technicians fill today, how some of their in-office assistance has evolved, and the challenges they encounter—Inside Dental Technology spoke with five dental laboratory owners and managers who provide these services, along with their client dentists.

Leonard Marotta, CDT, PhD, finally decided that the only way to handle the mounting requests for chairside assistance would be to build operatories at his Marotta Dental Studio in Farmingdale, New York, so that dentists could bring their patients to him.

When Marotta opened his laboratory in 1980, which he co-owns with his brother-in-law, Steven Pigliacelli, CDT, much of his chairside advising focused on implants. “Doctors who needed help with implants would call me and say, ‘I don’t know some of the materials. I don’t know how I’m going to get the implant to fit or retrofitted. Can you come to my office?’ And that’s how it all started,” says Marotta, who also serves as a clinical professor in the departments of Implant Dentistry, Restorative and Prosthetic Science, and Biomaterials and Biomimetics at New York University College of Dentistry in New York City.

When calls for chairside help became overwhelming, Marotta knew he needed to act. “That’s when we decided to build two operatories in our facility,” he says. “Now about 75% of our chairside consulting, which we provide as an add-on value, is done in-house.”

“When the doctors come here, especially for immediate-load implants,” adds Pigliacelli, “they know that they have a full laboratory on the premises should anything go wrong. So we can always make the case work.”

“We do case-planning with the surgeon and provide a surgical guide for placing the implants,” says Pigliacelli. “I’ll suggest where they should go for the best restorative outcome.”

While the majority of Marotta Dental Studio’s chairside consulting initially centered on implants, that emphasis has shifted, continues Pigliacelli. “It seems dentists just out of school these days are asking more general questions about restorative dentistry,” he said. “They want to know how crowns are made, for example. Most of our consulting today focuses on restorative procedures.”

But chairside advising extends beyond filling the gaps in dentists’ educational curricula, points out Scott Holsinger, CDT, owner of Quartz Dental Laboratory in Centennial, Colorado. In-office assistance can also be essential to providing optimal dentistry, he says.

Holsinger cites the recent case of an inadequate veneer preparation for a woman in her 20s who had been treated for pulpitis and had history of trauma to tooth No. 8.

In early December 2011, as Dr. Brittany Bevis of nearby Larkspur devised her treatment plan for the patient, prime among her priorities was to salvage as much tooth structure as possible. “I didn’t want to do a full-coverage crown in case she needed endodontic treatment in the future,” Dr. Bevis explains. “I also wanted to keep her occlusion stable because she had had ortho and her smile was gorgeous. So I prepared tooth No. 8 for what I hoped would be a conservative veneer.”

She then sent the impression of the preparation to Holsinger, who immediately saw that it would not work. “I needed an additional 1 mm removed from the middle third of the tooth so that I could get my material in to block out discoloration and provide proper contour,” says Holsinger, a Master Technician at the Las Vegas Institute for Advanced Dental Studies.

Dr. Bevis recalls, “I then asked Scott to come in chairside with the patient so that he could see the case and I could explain my limitations as far as the patient’s age and pulp condition.” In the operatory, Holsinger underscored the need for re-preparing. “I asked Dr. Bevis to break contact on the mesial and distal and provide a little more room. Otherwise, the tooth would be a bit bulky and we’d probably have to schedule the patient for another appointment to remedy that.”

Dr. Bevis agreed to re-prepare, but held fast to removing minimal tooth structure. Instead of the 1 mm Holsinger requested, she shaved the facial just 0.5 mm.

“But that proved to be enough,” Holsinger recalls.

“That was the first time in the 10 years I’ve been practicing that I’ve had to re-prepare something, but it was for a valid reason,” Dr. Bevis says. “The patient and her mother were very excited with the result.”

Helping dentists provide optimal dentistry also is the focus of chairside consulting at Gagliano Dental Laboratory in Tampa, Florida. For about 20 years after he opened his laboratory, James Gagliano, CDT, handled the laboratory work for about 38 clients. Then in 1998, he decided to concentrate on providing only high-end restorative and esthetic devices and services, including consulting, for a client base of six general dentists also committed to using only highest-quality laboratory products available.

“I decided to promote my laboratory and my accounts as offices that provide the type of dentistry people don’t get anywhere else,” he says. “I’ve been successful with my approach; I haven’t had to worry about off-shore competition. And I’ve yet to see CAD/CAM technology match the quality of handmade products.”

Gagliano provides chairside consulting to his clients every day. Dentists call him in for all cases dealing with patients’ anterior teeth. “I may take a shade, visit a patient for the first time, or offer input on whether a patient is a candidate for restoring. Sometimes, for example, I might suggest that instead of restoring we provide a patient with Invisalign.”

When one of Gagliano’s clients refers a patient to a surgeon for implant placement, Gagliano also is present for the procedure. He says he typically consults with the surgeon on the optimal placement of the implant, then returns with the patient to the restorative dentist and advises on abutment selection.

Gagliano, who has continually taken continuing education courses on esthetic dentistry and dental materials, does not have a specific fee schedule for different consulting services. But he does justify the time spent at offices by increasing the price of his products.

However, that does not deter his dentist-clients. “Jim provides great treatment-planning advice from a prosthetics standpoint,” says Dr. Marc Tindell in North Tampa. “He’s very knowledgeable about crown-and-bridge, for instance, and can help determine whether a tooth is a good candidate for an abutment. Also, his interaction with patients helps him learn details about their case that we might not have picked up on. And he sometimes recommends procedures, such as whitening or another tooth restoration, that may extend treatment for patients.”

Jeff Stronk, CDT, owner of Treasure Dental Studio in Salt Lake City, Utah, has no doubt that his chairside consulting for implant cases has been key to his company remaining profitable during the recession. Specifically, he points out that consulting has distinguished his laboratory from that of his competition, while also allowing “us to keep our price points a little higher.”

Stronk began in-office advising on implants more than 20 years ago, just as the technology began making headway in the marketplace. Educated about implant dentistry through CE courses sponsored by DENTSPLY and Nobel Biocare CE courses, Stronk saw that with his knowledge of restorative fabrication and the prerequisites for a successful outcome could make him an important part of the implant team.

“I worked as a liaison between the surgeon and the restorative dentist to make sure the case went smoothly,” he said. “I would assist the surgeon chairside with case designs, advise on implant placement for the type of restoration that the restorative doctor was planning to use, and make sure they had the components they needed. A lot of implant representatives at that time knew all about the pieces and parts of implants, but didn’t know how to integrate it all into a final restoration. That’s where I stepped in.”

Two years ago, Stronk expanded his in-office consulting to include helping dentists provide immediate-load implants. He supplies surgeons with a surgical guide for implant placement, performs all necessary laboratory work in the operatory the day of surgery with his mobile laboratory kit, and consults with surgeons to ensure the procedure runs smoothly. He lists this service as “chairside transition” and charges $600.

“It’s very important to have Jeff available to handle any questions that come up,” says Dr. A. J. Stosich, an oral and maxillofacial surgeon in Salt Lake City. “I might ask, for example, whether a certain implant will work prosthetically, or whether he can use an abutment at a certain angle. Also, there are times when you might be planning to place an implant in a certain position, but because of poor bone quality or lack of bone, you have to change plans. In those instances it is very valuable to have him there to ask about an alternative placement site.” Dr. Stosich adds that if he is working with a restorative dentist that has new- to immediate-load implants, Stronk will help guide the dentist on attaining correct occlusion and seating the denture to the implant.

Stronk says the big challenge of advising on immediate-load implants is keeping up with the demand. When he started, he handled all of the consulting requests, but has since appointed two more staff members to share the workload. “Next week, the three of us actually have overlapping appointments,” he reported in late December.

Immediate-load implant consulting has proved a boon for Tom Wiand as well. He says that since he began in-office consultations four years ago, his bottom line has grown consistently, despite the recession. His chairside service consists of consulting with surgeons on implant placement and alignment and completing on-site laboratory work, ie, providing the provisional immediately after surgery and, later, the final prosthesis.

He attributes the growing demand for his services to the popularity of implant centers that promise patients new teeth in a single day. Local surgeons and restorative dentists aiming to compete with the implant centers needed laboratory technicians who could complete the requisite laboratory work in the operatory the day of surgery.

“When I started this, I had no interest in going to a dental office and providing assistance to doctors,” he said. “I thought the operatory was not the place for a technician. But I also knew that if I didn’t do it, other laboratories would. And that prediction proved correct—a few laboratories around here are now consulting as well.”

Patients pay between $25,000 to $30,000 per arch for the provisional, surgery, implant placement, and final restoration, says Wiand. He adds that his laboratory bill is about $5,000 (his consulting fee is part of the overall service charge). Because the surgeons and dentists typically are unfamiliar with the immediate-load procedures, they are naturally wary of making mistakes on such big-ticket procedures, and thus turn to him for guidance, Wiand says.

“The surgeon, of course, knows how to place implants conventionally, and the restorative dentist understands how to restore these final cases, which are basically implant-supported dentures,” Wiand emphasizes. “But they need someone to help them determine how much space will be needed to restore and then to do the actual conversion the day of surgery. There’s a certain amount of room we need to get in all the implant hardware as well as the prosthesis, and the surgeon has to create that space by reducing bone.”

Wiand supplies a surgical measuring guide used to ensure sufficient bone reduction. “After the surgeon performs the osteotomy, we use a drill guide to determine the location of the implant. At that point I might ask the doctor to move the implant more toward the palate or more distally. Of course, he might not be able to do that because a nerve may be present, so he makes the final decision. But I try to get everything in the ideal position for the restorative dentist.”

The major challenge of his chairside consulting, says Wiand, is to ensure surgeons accurately perform immediate-load procedures, which “are counterintuitive to how they traditionally provide implants.”

While conventional implant procedures stress bone preservation, he explains, the immediate-load devices require added interocclusal space to accommodate the fixed detachable hybrid. Removing added bone for immediate-load implants necessarily entails excising additional tissue, which surgeons aim to avoid during standard implant procedures.

Steps for placing immediate-load implants versus implants for crown-and-bridge restorations also differ significantly, explains Wiand, who received training on immediate-load implants from surgeons and at Nobel Biocare seminars. “During conventional implant placement, the surgeon places the implant into the extraction site, down in the long axis of the tooth apex,” he continues. “The implant engages the cortical bone in the socket. But if you were to use that same approach for the immediate-load implant, the implant would be in an undesirable esthetic position—the access hole would come out of the facial of the tooth. In order to get the hardware in the space we need to have the access hole in an ideal position, it has to be 5-mm to 7-mm lingual of the socket.”

Today, Wiand considers his chairside consulting on implants a major growth area for his laboratory. “Immediate-load implant procedures are still in their infancy,” he concludes. “With baby boomers’ increasing demand for the implants and the growing competition among surgeons wanting to handle these cases, we’re only at the tip of the iceberg.”