Denture Revolution

“My father had the foresight to understand that in the not-so-distant future, the industry would be facing a shortage of highly qualified removable technicians and instinctively knew that if I mastered the technical and clinical knowledge as well as the technical skills, I would be in a unique position within the profession,” says Carson. He threw himself into courses, learning and researching everything he could about denture mechanics and philosophy. He obtained his CDT in removable prosthetics and began searching out top removable technicians worldwide to take his knowledge and skills to new levels. He became immersed in the esthetic movement and sought out products around the world from Schottlander’s Enigma (www.americandentalsupply.net) denture system to Willie Geller’s CeraPearl (www.jensendental.com) denture teeth that would give him the results he knew he could achieve. Today, all of his hard work has paid off. He opened his own removable laboratory in 2003 as well as has an office in Raleigh with an implant dentist, and he continues to further his education and search out a variety of products wherever he can find them to improve the precision and esthetics of his work. He commands a dollar amount well above the national average for his services.

However, Carson is one of the exceptions in the field of removable prosthetics. As he points out, the future his father envisioned is now here, and the number of removable technicians in the United States with the same deep understanding of the clinical and technical philosophies and mechanics involved in manufacturing complex removable constructions is in danger as the old guard ages and retires and few young removable technicians wait in line to take their place.

For full-service laboratories like Dental Prosthetic Services (DPS) in Cedar Rapids, Iowa, an 80-employee full-service laboratory owned and operated by Kris Van Cleve, the rapid decline of removable technicians has resulted in an increase in business. In the past year, the removable segment of her business experienced an 8.5% uptick in volume and sales, despite a price increase. “Dentists are suddenly finding that their experienced denture technician has passed away or retired, and they are looking for another laboratory partner to work with,” says Van Cleve. She also attributes the economic downturn as playing a role in the increased volume. “Patients today are more willing to have a less expensive partial placed than a more costly fixed 3-unit bridge,” she says. “When the economy slows down, typically the removable side of the business picks up.”

Patients choosing a removable versus fixed solution have put pressure on general practitioners, who traditionally would refer their removable patients, to think again about letting those patients walk out the door and losing that revenue. Many, whether they have the skills or not, are opting to offer services never before considered because they are seeing fewer patients and the once highly profitable elective cases have disappeared. “I have clients who 10 years ago, when I was cold calling to drum up business, would turn me away because they believed dentures were an antiquated treatment option and no longer needed,” says Carson. “Today, those same dentists are contacting me to advise them on removable techniques and procedures because their $20,000 veneer cases have dried up.”

Ken Shaull, CDT, TE, and special care coordinator at the University of Iowa College of Dentistry, is in a unique position to view and comment on what he sees as an impending dilemma. He teaches senior dental students at the undergraduate level, supports the faculty within the department of family dentistry, and assists other collegiate departments regarding removable prosthetics. He also is an adjunct faculty member for the dental technology program at Kirkwood Community College. “We have older technicians, who are knowledgeable about denture principles, retiring; few of our dental technology graduates are choosing to enter the removable field; and dental schools continue to reduce removable curriculum, especially teaching denture basics, to make room for new programs such as implants to keep abreast of changes in the industry,” said Shaull. In his opinion, this is creating a vacuum of knowledge and skills at a time in history when they will be needed most. As in his state of Iowa, the largest population base of patients in the United States is rapidly graying, as the 79 million Baby Boomers, who are determined to hold on to their youthful appearance, marches into old age.

The convergence of these two factors—combined with the imprecise nature of removable materials and the handwork involved in the manufacture of removable prostheses, as well as the prolonged five-to-six-appointment process—set Andy Jakson, CDT, president of Evolution Dental Science laboratory and chief technician Global Dental Science LLC, and his partners at Avadent (www.avadent.com) on a course to find a digital solution. “This is a segment of the industry that in terms of material and production processing has gone unchanged for 80 years,” he says. “We saw the need to eliminate the imperfections in the manufacture of dentures by incorporating computer-aided technologies.” And he and his company are not the only entries launching a new age of digital solutions.

The demographic bulge of the 79 million Baby Boomers has driven US economic and market trends in each decade since World War II. The ever-expanding graying shadow heading into retirement age is providing an attractive market for companies and entrepreneurs eager to capitalize on their “forever young” mindset. According to the research firm Global Industry Analysts, the desire to retain a youthful appearance and remain vitally active alone will push the US market for anti-aging products from its current $80 billion to $114 billion by 2005.¹

And, unlike their parents before them, this generation has a different set of expectations from their healthcare and dental providers when it comes to maintaining function and esthetics. These expectations have not gone unnoticed by the dental community. New advancements in technologies, materials, and treatment options for removable prosthetics have fostered a revitalization of the removable market. For a segment of the dental technology industry once considered to offer a relatively lower profit margin compared to crown and bridge, removable prosthetic products now can command four- or even five-figure billable dollars, especially when implants are involved. “With implants, you are seeing a lot of combination cases, and those require removable knowledge as well as command a large price tag,” said Shaull. “Well-educated removable technicians are in a good position to get paid a higher fee for their services and that will continue as the field contracts.”

Manufacturers have been quick to react to the projected higher patient expectations as well as the increased production demand on laboratories with new, highly esthetic denture-base materials that resist color degradation and denture teeth that mimic the translucency of natural teeth, or quick and easy set-up tools for streamlining production efficiencies when placing denture teeth. The introduction of technologies such as CAD-designed and CAM-milled titanium and zirconia implant bars for prosthetic retention has eliminated the uncertainties and increased the precision of conventionally hand cast metal bars, while CAD design and 3D printing of partial frameworks in wax for traditional casting not only helps speed up production but also reduces a significant portion of the cost in labor.

Removable technicians steeped in clinical and technical knowledge and able to communicate with their clients on that level have been able to capitalize on that knowledge by consulting with and assisting those dentists who want to take on removable patients but are not well versed in removable or implant procedures. With their loyal patient base aging and choosing less expensive removable solutions over higher-priced fixed options, these practitioners are seeking out knowledgeable laboratory partners for guidance to help them capture those dollars and deliver a successful removable prosthetic.

This is particularly true for laboratories serving the younger generation of dentists, Van Cleve says. “There is a big gap in the knowledge base of the younger-generation dentists. When they get a patient needing a complex solution or it is an odd case, they are uncertain how to proceed and lean on us heavily to help them work through the case.” Van Cleve and her team partner with various organizations and vendors to provide CE courses on removable prosthodontics for those clients who want to learn more and employ managers on site to consult and troubleshoot over the phone. “Many of our clients have expressed interest in learning more about the removable side of dentistry, particularly implant-supported dentures.”

Shaull sees these types of educational efforts and reliance on the commercial laboratory as consultant, educator, and advisor expanding in the future, which means technicians will need to address case solutions in the clinical language the practitioner understands. “Removable technologists will need to expand their knowledge on the clinical aspects of prosthodontics more than ever before because of the fact they will be relied on more heavily to provide advice. This is even truer when you enter the realm of implant-supported prosthetics such as implant-retained dentures or CAM-milled bars or retro-fitting existing conventional dentures to implant-retained,” he says.

Carson agrees. His concern is that a majority of the technicians currently working in the field were bench-trained rather than formerly educated and may not understand the best-practices principles, axioms, and mechanics behind delivering a successful removable prosthetic. “Most were taught by experienced denture technicians, which may work for the more simplistic cases,” he says. “But they were never exposed to the removable principles of Pound, Frush, and Gerber, which have been in place now for more than 4⁰ to 60 years, on obtaining proper centric relation and identifying vertical dimension or the use of a Gothic Tracer. If they do not know those principles, then they can’t bring them to the attention of their clients, and that’s why both patients and their dentists are many times disappointed in the final outcome.” It is true, Carson admits, that some dentists shy away from using tools such as the Gothic Tracer because it takes extra time, but when he explains that they won’t have a disappointed patient or one who has to come back for two resets if they use it, that usually gets them hooked. His clients who do use the Tracer have never had a reset, and the occlusion has always been spot on at the wax try-in.

At his level in the profession, Carson is in a position to ask that his clients use a Gothic Arch Tracer to lock in centric relation, a papillimeter to establish the low lip line and length of the upper lip, and an Alma gauge to measure the vertical and horizontal distances between the papilla and the upper anterior incisal edges. He often recommends that his clients purchase Ivoclar Vivadent’s Smile Design Kit (www.ivoclarvivadent.com), which includes everything needed to work through a case. When his clients send him the conventional impression, he insists that photographs of the patient accompany it. “Several of my clients e-mail a photo of the patient smiling with the papillimeter in place. I will fabricate the bite rim to that image and send everything back.” For out-of town clients who want or need consultations, Carson schedules a video chat via Skype. His newest communication tool is the FaceTime feature on his iPhone 4.0. “Several times I have been able to talk to the patient using this feature,” he says. “That way patients can communicate to me exactly what their restorative expectations are.”

For Carson, each case presents the opportunity to open clients’ and patients’ eyes to the esthetic possibilities of a denture product. “Neither the consumer nor the dentist know what they can have in a removable product,” he says. “There is a certain perception and low expectation about the esthetics and fit of a denture. That opens the door for the experienced removable technician to create his or her own individual style to replicate nature much like the ceramists did in the 1970s and 1980s.”

For the next two decades, as the carefully preserved dentition of aging Baby Boomers begins to break down and requires restorative solutions beyond a crown or bridge, the removable prosthodontics side of dentistry will be expected to step up to meet the demand as well as the high functional and esthetic expectations of patients. Will there be the manpower as well as the clinical and technical knowledge base to meet the demand?

Some believe the answer to that question is no. The current protocols for treatment planning, manufacturing, and supplying a removable product have remained virtually unchanged for the last eight decades. Tediously labor intensive both clinically and technically, removable prosthetics remains fraught with inconsistencies and imperfections directly related to manual manufacturing processes and material inconsistencies. Add to that the five-to-six-appointment protocol for patients who have become increasingly impatient and today expect in-and-out procedures that allow them to get back to busy lives.

“Today we have computer-aided technologies that can shorten the protocol to two visits, eliminate the manufacturing imperfections, and deliver a product that is precision engineered to custom fit the patient and provide them the function and esthetics they demand,” says Jakson. Launched 8 months ago, Avadent (www.avadent.com), located in Scottsdale, Arizona, offers dentists a clinical protocol based on best practices for removable dentistry. The information- gathering process requires traditional information gathered through revamped and simplified record-taking procedures to acquire the proper information for supplying a functional and esthetic set of dentures. “We created what we call an Anatomical Measuring Device (AMD), which allows the clinician to gather all the clinical information needed using a single device intraorally,” says Jakson. “The system includes a mandibular and maxillary tray with a Gothic Arch Tracer built inside so that the clinician can lock in vertical and occlusal dimension as well as centric relation in that first appointment.”

Dr. Mark Kraver, who owns Cape Dental Care (www.capedental.com) in Cape Coral, Florida, has been using Avadent’s record-taking system and removable services for his edentulous patients. “One of the big advantages to this system is that you are getting a Gothic Arch tracing for centric relation in the jaw, which is difficult using conventional methods,” says Kraver. “There is, however, a learning curve that must be overcome.” An alumnus of the Pankey Institute, Dawson Academy, and Hornbrook Group, among others, Kraver admits one of the reasons the Avadent process appealed to him was because he has found it increasingly difficult to find a laboratory that recognizes the value and understands the methodology behind these record-taking procedures.

Once the information is gathered and the impression is taken, it is sent off to Avadent for digitizing and processing. The company has developed powerful proprietary software that virtually designs the denture base and automatically calculates which tooth molds best fit the patient. Approximately 170 Dentsply and Ivoclar tooth molds are built into the program, which automatically calculates the most appropriate tooth size and shape for the patient, even taking into consideration the sex and age, to give the clinician a choice of three or four molds that will best fit the case.

The denture base is then CAM-milled from a patented pressurized material that Jakson says is much like Dentsply’s Lucitone 199 (prosthetics.dentsply.com) but stronger and color-stable for up to 5 years. The denture teeth are then glued to the base, and the denture is delivered. On the second patient appointment, the completed and delivered denture is seated.

“A great deal of very good thought has gone into developing this system,” says Kraver. “The acrylic is amazing and so much stronger than conventional denture materials. But most importantly, these dentures fit precisely and the occlusion is fantastic.” If the clinician should want a try-in to confirm fit, phonetics, and esthetics, Avadent now provides a precision-milled acrylic base, complete with modified tooth pockets to allow for necessary functional and esthetic changes.

The one lament that Kraver expresses is not having the technology available to the laboratory community. “I’m hoping in the future they find a way to move this technology into the laboratory,” says Kraver. “I like my denture team close by so that I can visit the laboratory and consult with the technician.”

Jakson says that the team at Avadent is aware that their clients are many times more comfortable working with their technician partners and have developed a business model that will provide laboratories access to the technology. “As of October 1st, we are releasing a business model for dental laboratories to access the Avadent technology and be in control of the artistic production of their clients’ removable products,” says Jakson.

Avadent is not the only player in the digital denture market. Two other solutions have surfaced in the past year. DENTCA (www.dentca.com), based out of Los Angeles, California, uses patented trays to capture the impression, vertical dimension, and centric relations in one patient visit. The accuracy of the final dentures is calculated using multiple anatomical landmarks captured in the impression. DENTCA’s trays have detachable posteriors that enable capturing the vertical dimension of occlusion (VDO) and CD with the bite registration.

This system includes a 3D-printed prototype (try-in) denture. “If dentists request it, we print a 3D try-in using a proprietary semi-clear white material that can be either used as a try-in or surgical guide for the final version,” says Jay Kim, sales director. “The 3D-printed try-in is then converted to the final denture using proprietary methods.” The benefits of using DENTCA’s CAD/CAM dentures multiply over time, notes Kim. “The cost of producing DENTCA dentures is three times less than standard dentures and more than two times faster due to reduced chairtime needed for the procedure,” says Kim. “DENTCA’s system enables doctors to deliver final dentures in just two visits and 2 hours of chairtime.”

A third digital method for producing a denture was previewed at the Chicago Midwinter Meeting in February 2012 by EnvisionTec (www.envisontec.de), whose products are distributed in the United States by Zahn Dental. This 3D-printing process is strictly a laboratory-driven production process. The denture base material possesses similar mechanical properties to that of the Valplast flexible partial material (www.valplast.com), says EnvisionTec’s CEO, Al Siblani, and can be printed using either the company’s Ultra² or Perfactory DDP4 printers. The denture teeth are printed separately using the company’s new E-dent 100 composite material and glued into the base with a lock-in mechanism. “The laboratory can start the design and print process with either an intraoral scan or a model scan,” says Siblani. “From the scan, you can CAD-design the denture bases and print the upper and lower arch in approximately 90 minutes, or print out 12 bases in a little over 2 hours.” The cost in material and labor for a full denture with teeth will average $30. Siblani hopes to have FDA approval on the base material in the next 18 months or perhaps as early as the first quarter of 2013, and he is working with dental-design software companies to develop the CAD design software. By reducing the labor cost involved in full-denture fabrication, his goal is to ensure the industry does not lose business to cheap labor markets and keep manufacturing on US shores.

Capturing a digital record of the patient offers dentistry endless advantages, says Jakson. Digital records of the edentulous patient will allow clinicians to duplicate and rapidly replace a prosthetic should the patient lose the denture or damage it. In time, when the ridge resorbs, the clinician can do a soft or functional reline, send that to Avadent, where the digital files are merged and a new denture is milled. Perhaps, he speculates, the company would offer an insurance plan the patient would pay on a monthly basis for unlimited denture replacement. “When you have that digital record, it offers a completely different way of looking at how dentistry is delivered,” says Jakson.