Effective Integration

Matt Roberts, CDT (MR): Design software. Digital technology has been around for many years, but it was not very fast, accurate, or esthetic—three strikes. The wrong materials were being used in the wrong places. Layered zirconia was phenomenally unsuccessful in that it fractured the layering porcelain off fairly regularly. What changed was the software.

Almost 10 years ago, I attended a lecture in Chicago and saw tooth shapes on the screen that actually looked like teeth, rather than like big chunks of poorly shaped material. We acquired a copy of that software and were able to start creating the tooth shapes that I needed to fit into a high-end reconstructive niche in the marketplace. We work at a very high level, and the effectiveness of our digital tools is validated by the fact that our clients are willing to pay our fees, which are two to five times more than the average. Our quality level actually has increased.

IDT: How has the evolution of digital technology changed not only your workflow but the way you do business overall?

MR: We first integrated CAD/CAM by scanning stone models, but with many dentists now using intraoral scanners and sending the data directly, many cool things can happen. We are not shipping models, so infection control is not an issue. We can start working on a case almost immediately after a dentist finishes taking the impression. With traditional analog technology, the impression was shipped to us and sent to the model department, removable dies were made, the dies were trimmed, and then we could finally start waxing the case. Now the workflow is almost the opposite: A digital scan is sent to us, and we load it into our software, we design the restoration and send it to the mill, and simultaneously the model is being printed. It compresses the working time in which we can turn a case around. We still preschedule our cases, but if a client needs something quickly, we have the flexibility to do that easily.

IDT: How has technology affected your career and your life?

MR: It has gotten me re-engaged in dentistry. This has been the most fun I have had in my entire career. We had a very predictable, productive analog workflow for high-end, esthetic dentistry, but the advent of several key pieces of software allowed us to not only replicate that workflow but exceed it. We now have slice tools to help us create milled restorations that are so accurate I can place a full arch on a model and not need to adjust contacts. We are copying provisional, in the design software, designing inside a shell of the provisional or literally doing a preoperative scan in the software. We can track cases, and there are many more analytical tools available to work with a diagnostic wax-up and translate that into preparation design and the interactive relationship between what we want to do esthetically and functionally for the patient. We can analyze where the teeth would ideally be and where they are currently by superimposing the scans in the software. We can literally build a virtual patient, insert a 3D design into the patient's face, develop their optimum esthetics, and look at options of how to get to this ideal position. Do we need to extrude or intrude teeth with orthodontics? Do we need to aggressively prepare teeth and place crowns or veneers over them? Can we avoid preparations and simply utilize additive veneer technology? We discuss all those options with the dentist. We also utilize a series of screenshots with the patient's existing dentition and the new design for cross-sectional analysis showing thicknesses of potential restorative materials vs initial tooth position, and then along with the dentist we deduce what we need for minimum preparation design, where we are going to prepare the teeth, and by how much.

IDT: What else do new software applications allow you to do that is above and beyond your previous capabilities?

MR: Being able to stack two or three scans on top of each other offers significant benefits in analyzing the accuracy of scans. When the dentist scans the patient's prepared teeth and the temporary models, we superimpose those two scans over each other, and if they do not fit seamlessly together then we know one of the two is somehow distorted and another impression is required. That way, we usually can stop a case before starting to fabricate it. The dentistry becomes much more accurate. There are fewer contact and occlusion adjustments. We are doing full-mouth reconstruction cases, and the dentists are saying they did not need to touch anything, which makes them happy.

Digital records have other benefits as well. Our shipping company recently lost a bag that had carried 13 boxes and approximately $35,000 worth of dentistry. For the patients whose appointments were before the bag was finally found, we were able to re-mill the designs, re-print the models, and finish the restorations in order to still deliver them on time.

Some of the new denture software is very exciting. We have always been a fixed laboratory, but having the ability to build a quick but esthetic temporary denture for a full-mouth implant reconstruction case is a significant benefit.

IDT: Was it difficult to get your high-end clientele to accept CAD/CAM work?

MR: If they were aware we were doing CAD/CAM work early on, that was always a question. Our position was that we produce a quality level of crown that is consistent, and we do not talk to our clients about how we produce it. Typically, the only thing our dentists noticed was that their cases were looking great and requiring much less adjustment. Contacts and occlusion were more consistent. Today, if we were to ever stop using CAD/CAM, we would probably see a negative impact.

IDT: For a laboratory looking to make purchasing decisions in 2019, what are the most important considerations?

MR: Software is the first step. Digital technology is not a fix that you can simply purchase and immediately integrate. You need to learn how to use it well, like a musical instrument or an art form. It takes time. Digital technology is nothing more than a tool that allows us to use our knowledge of shape, form, function, and esthetics in new ways. There are advantages when compared with the tools we had previously, but unless it is used well, it is not better. If it is used well, it can be much better and more productive. Technology needs to be well adopted and well understood in order to be used well.

IDT: What do you envision being the most impactful developments in the immediate and long-term future?

MR: Integrating and superimposing CT scans over optical scans for implant planning and other applications is currently impactful but not yet widely utilized. Short-term, simply absorbing the technology we have today likely will take 5 more years.

Printing is becoming much more sophisticated as manufacturers increase the speed of their machines and develop printers that can print multiple materials and multiple colors.

Some new mills make it possible to mill denture teeth and a denture base, and then put the two together. The next big milestone probably will be printing 3D color in layers and in different materials that are usable for permanent restorations in the mouth. Research is being done in those areas that will result in very interesting technologies.

Business models will continue to change. Many of our dentists are buying printers, so essentially we are selling electrons: We send them a design, they print it, and they save shipping time and shipping costs. We will continue seeing developments in business models based on the technology. We are still in the early phases of seeing how these new technologies will impact our profession.