9 things you REALLY need to know about digital imaging

April 8, 2015

The first time you bought a computer, terms like server, gigabyte and RAM (among others) were probably somewhat befuddling. Every technological thingamajig has its own vocabulary and concepts, which can be confusing to those new to the device.

The first time you bought a computer, terms like server, gigabyte and RAM (among others) were probably somewhat befuddling. Every technological thingamajig has its own vocabulary and concepts, which can be confusing to those new to the device. Dental imaging has its own terms and concepts that might be stumbling blocks for those considering a foray into the world of CAD/CAM.

The first time you bought a computer, terms like server, gigabyte and RAM (among others) were probably somewhat befuddling. Every technological thingamajig has its own vocabulary and concepts, which can be confusing to those new to the device. Dental imaging has its own terms and concepts that might be stumbling blocks for those considering a foray into the world of CAD/CAM.

Dental imaging is the first stop in a CAD/CAM solution-it is the place where the dental anatomy is captured by a scanner-either directly from the patient’s mouth by the dentist or from a model in the lab-and put into the computer for manipulation by design software, ultimately to be manufactured on a mill or 3D printer.

But once you understand the terminology and the concepts, the world of dental imaging is not quite as daunting.

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Closed Systems

There are some CAD/CAM components that must all be purchased from the same manufacturer in order to function. When that ecosystem exists, the system is said to be “closed”.

For some systems, being closed can present unique features and capabilities. For instance, there’s no doubt that every component of a closed system will “play” together. But by and large, the current movement is to try and stay away from the limitations imposed by closed systems.

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“I’m under the personal opinion that nobody should really get into closed architect scanners because you become restricted as to where you can send work and you are restricted as to what types of products you can get based on what they happen to manufacture,” says Bob Cohen, president of Custom Automated Prosthetics in Stoneham, Mass.

Buying closed systems is less and less of an occurrence as it was more common with early adopters.

“A lot of people who originally delved into it got closed systems,” says Alex Thomas, general manager of DAL DT Technologies in Davenport, Iowa. “I would say that if anybody is looking to get it for the first time, open versus closed is almost a non-issue. You’re getting an open system no matter what.”

Using a closed system can limit the lab in the variety of cases it can produce.

“The biggest problem is on the back end if any of the laboratory’s accounts that they have-or want to get-move into intraoral scanners,” Thomas says. “With a closed system, you have everything you need, but there is limited availability for what that closed system can take on. It’s much more difficult to be a versatile laboratory with a closed system. And by versatile, I mean where you can send, who you can send to, who you can receive from and what doctors you can and can’t take on.”

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The notion of a system being “closed” is not necessarily a black-and-white issue, however. There are varying degrees of whether a system is closed. For instance, while a given system’s scanner might require the CAD component from the same manufacturer, in many cases the final file can still be output in an open format. Ultimately, it comes down to which manufacturer you and your client doctors elect to work with.

“Sirona lab software allows for the STL import of scan files,” says Norbert Ulmer, director of laboratory CAD/CAM at Sirona Dental. “And since all the other systems on the market are providing STL exports, these are scans that can be imported into the Sirona software, and, therefore, this makes Sirona the only system-the only lab software-that can accommodate any DI [digital impression] solution out there.”

Open Systems

Scanning devices that can exchange information freely with other components are said to be “open”. This functionality allows a scanner to be purchased from one manufacturer and the case data sent to another.

The industry seems to be moving toward more openness, and Cody Coonradt, global product manager, 3M Connection Center at 3M ESPE Dental in St. Paul, Minn., expects the future of open systems to follow a path similar to the current state of social media.

“In the future, we’re going to have workflows that function like photo sharing does today,” Coonradt says. “I can take a photo on my phone. I can put it on Instagram, and then I can ask Instagram to share it on Facebook and Twitter and maybe my GoPro account. All of the information, and all the architecture behind the scenes to make that ecosystem work, has all been put in place by various companies-oftentimes competitors in one sense or another. We believe that the development of digital dentistry will be similar; we’ll see the ecosystem of companies develop that have to learn to talk to each other. And what that means for customers, especially in the lab, is that we’ve seen that they may have to learn to work with a wide variety of scanners in a wide variety of CAD software packages."

Next page: Are these solutions "plug and play"?

Plug and Play

Some might be attracted to closed systems because they are perceived to be more plug and play than open systems. That is, since the components are all designed to work together, they should be quickly and easily connected with feature-rich capabilities.

Cohen says whether the system is open or closed doesn’t really matter. It’s a matter of which vendor provided the system.

“It depends on where you buy the system,” Cohen says. “If you’re working with a distributor that has integrated the products well, there’s really not much difference between closed and open other than the benefits of having an open system.”

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While devices being plug and play is appealing for the lab that wants to get up and running with a CAD/CAM solution or add a new component to its existing system, John Just, director of technical support at ETI Digital Technology in Placentia, Calif., warns that simply buying capable equipment does not necessarily make for a capable lab.

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“We’ve gone through an evolution,” Just says. “When CAD/CAM first came out, the whole idea was for the dentist to be able to produce a crown while the patient was still in the chair, and it really didn’t matter what it looked like because it was mostly posterior crowns. Today, it’s a different story because everybody can create that crown. They need to know function because as soon as they get off a single crown, they’re into a three-unit bridge, and that’s a totally different animal.”

Software

Like your computer, dental scanners require two components: hardware and software. The two have a symbiotic relationship-each needs the other to do its job.

“It’s like Apple,” observes Tony Ly, CAD/CAM manager at Keating Dental Arts in Irvine, Calif. “The hardware and the software have to be integrated perfectly. The hardware needs to be reliable; the software needs to be user-friendly. The hardware has to be accurate. The software has to be able to stitch all the scans together. The two have to work together perfectly for that to happen.”

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“You have to look at the system as a whole because manufacturers are becoming more and more open to where the files can be created,” adds Mark Ferguson, assistant manager at Core3dcentres in Las Vegas. “As systems have gotten more open, they’re starting to look at the system as a whole. Is this scanner accurate enough? Is this design software easy to  use? Is the design software open enough that I can do what I want with it? Because some of the closed systems may not allow you to be able to do certain indications because they’re just not in the software.”

Thanks to ever-evolving design software, more complex cases can be created.

“You can use this technology for crown and bridge work-just simple things,” says Alessandro Cucchiaro, CMDT, MDT, general manager of Zirkonzahn USA. “You don’t need a very sophisticated system to perform these types of restorations. But when you get into something more complicated, like full-arch, screw-retained bridges, this type of technology turns out to be absolutely unique because besides constructing the bridge itself, I use it personally as an amazing diagnostic tool.”

Design software is where new features and functions of scanning systems will show the greatest development and evolution.

“What’s the most important in all of this is how advanced the software is because then it’s about how much time it’s going to take the technician to design a case and then the quality of the design,” Cohen says. “From my perspective, the CAD is just as important, or more important, than the physical scanner the laboratory purchases. The vast majority of scanners available on the dental market today are adequately accurate for more than 99 percent of the cases we do.”

For instance, Just notes that Dental Wings provides the capability of changing workflows midstream-an ability that is especially appealing to dental labs.

“If you tell a lab at the beginning that you’re going to do a crown and, before you get all the way through the design, the doctor calls the lab and says, ‘Oh, by way, I’m not going to do a crown; I’d much rather you did a layered zirconia crown,’ you have to go back and rescan it,” Just says. “You can’t change that midstream because it looks at it totally differently. Dental Wings looks at it as, ‘This is a scan, and, before shipping it off to the CAD software, we’re going to have you determine the path of insertion, the margins and all the other goodies.’ It’s still an STL file, but now it’s an STL file that has the landmarks and information that Dental Wings is looking for.”

Next page: STL files and how to handle them.

STL Files

In order for open systems to share information, they must utilize understandable file formats. For instance, the de facto word processing document is the .docx format. In the CAD/CAM world, it is currently the STL file.

“That open standard is really critical to allow all of this interoperability,” Coonradt says. “The labs we talk to tell us that it can be a real challenge to have a closed CAD system, whether that’s an intraoral scanner or a benchtop scanner, because they often can’t take a certain file through their preferred workflow.”

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While the STL file format allows communication between different vendors’ devices, it is not perfect. The STL format is used for most CAD/CAM files, regardless of the industry. Many in the industry are pushing for an open format unique to dental work. Coonradt notes that 3M is supporting the development of the UDX standard, a standard being developed by the Open Exchange Dental Interoperability Group (OXDIG). Ultimately, Coonradt says he believes interoperability is inevitable.

“We’re going to see some phases in this transition like we’ve seen in other industries,” Coonradt says. “First of all, we’ll see silos of information crop up, and it’s very much on the consumer, in this case, the lab, to try and get those silos to talk to each other. 3M is pushing toward the second phase; we’re working together with other manufacturers to get these isolated silos of data to talk to each other. We call these Trusted Connections. This phase often requires a great degree of technical work to get the different systems communicating reliably. We’re looking forward toward the third phase-more of a standards-based approach-where interoperability becomes easier because everyone’s systems are essentially speaking the same language.”

Portals

Once scanned, the file might have to be transferred between partners-for example, from the doctor’s office to the lab or from the lab to a milling center. To accommodate this, vendors have set up “portals,” which allow the information to be shared securely and compliantly. Portals can also offer added features, like communication tools.

“When it comes to Sirona, we do everything through Sirona Connect,” Ulmer says. “And Sirona Connect does not require any licensing fees, neither for the doctor nor for the laboratory. There are no licensing fees; there are no data plans or anything associated with it. In addition to the connection between dentist and laboratory, we also add chat and Skype functionality to that portal to enhance communication between dentist and laboratory.”

Some portals also allow conversion to different file formats. For instance, the 3M Connection Center offers such ability.

“We can also transmit case status and alerts to the lab and to the doctor’s office from the Connection Center,” Coonradt says. “Our portal also allows us to convert our files to different export formats. We can export an exocad-compatible file. We can export a 3Shape-compatible file. We can export a Dental Wings-compatible file. We can export a UDX-compatible file and then we also have access for the labs to download that open STL file.”

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In order to get the most out of these portals, and depending on the lab and how deeply they want to invest in their CAD/CAM solution, it might make financial sense to partner with a milling center.

“Most intraoral scanners have portals like that to get their scans to the lab,” Ferguson says. “Some of the labs might have to buy additional software to receive it. A company like Carestream, which is really open, has Carestream Connect. They make the STL files available to the lab, and the lab can just bring in the STL files and use them however they want. 3Shape has Communicate, in which case the doctor can just send the files, but the lab has to have software in order to accept those files, and that’s where partnering with companies can really help and save a few bucks until they can actually see a return on investment.”

Next page: What about fees and updates?

Updates and Fees

Like your computer, scanner and CAD software is regularly updated, and it is in the best interests of labs to stay current with those updates. As such, oftentimes labs will have to pay a monthly or yearly fee or subscription. The fees associated with ongoing maintenance are used to fuel innovation in scanner and CAD software.

3Shape charges an annual fee to every laboratory that has a 3Shape system-it’ll depend on how many licenses you have, and then what software you have,” Cohen says. “That fee enables 3Shape to employ about 200 full-time engineers to continually develop products.”

Not every vendor requires an annual fee, and some have been able to offer a different business model because of it.

“Because of [3Shape’s] fee, it’s given exocad inroads to the marketplace because a lot of lab owners don’t want to pay the annual fee,” Cohen notes. “With exocad, if you want an upgrade, there is a fee, but it’s not mandatory that you pay. With 3Shape, you actually get shut down if you don’t pay it. Whereas exocad, if you buy it this year, you have 2015 software. If you want to operate on 2015 software for the next 10 years, you can do that. You [just] won’t get any other new features.”

In the exocad model, labs don’t have to stay current. However, if there comes a time they want to upgrade to the latest version of the software, whichever years were skipped between the last version that was paid for and the current version must be made up.

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“What I recommend to everybody for updates is once your one-year warranty is up, just immediately pay for another year,” Thomas advises. “It’s going to be the least expensive option to pay up front, as every month you miss, every year you miss, you have to go back and pay for those years.”

Some vendors’ fees are part of ongoing maintenance programs.

“The fees that are involved are related to the maintenance fees,” Cucchiaro says. “It’s helping the technician in learning how to utilize the system. If there’s anything wrong with the system itself, we’ll be able to intervene and help him out with any type of issue that he is encountering. It’s not a mandatory fee, but we recommend it for the first year.”

Labs should take a look at the fine print regarding fees before they sign on to any system.

“You have to be careful because, oftentimes, the ongoing fees are not well communicated to their customers until very late in the contract process,” Coonradt says. “We’ve taken a deliberate practice to be very transparent in our pricing. We give the device and data package pricing right up front.”

Support

What’s the most important consideration in buying a scanner?

“The top three things they should be looking for are support, support and support,” Ferguson says. “Every system has a learning curve. Does the company that they’re purchasing from have the know-how for how they want to use it? I’ve seen people buy systems to save a few bucks from a vendor that may not train on the more advanced type of cases, and then they’re left trying to figure out on their own how to do it or they’re paying more in the end to get trained somewhere else. I can’t emphasize enough the support aspect of who you buy from.”

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Support goes beyond understanding the basic capabilities of the scanner-it’s necessary to get all the functionality out of the device.

“The laboratory wants to have something where it is easy for them to understand the workflow, and for those doctors who want to go more in-depth, it’s good to know that there is an infrastructure on the education side, whether it’s on a local level, through online-based training classes and so on,” Ulmer says.

Cohen compares the intricacies of CAD software to those of Photoshop. However, CAD software is even more complex, and, for lab technicians, time is a precious commodity.

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“The thing with Photoshop is if you don’t know how to do something, you play, you play, you play, you play, but, with these technicians, they have work to do. They want to get home,” Cohen says. “When you have a problem and you can’t figure it out, you should be able to pick up the phone and reach a technical support person to help you through that problem. That’s probably one of the most important things in purchasing a scanner.”

Next page: In conclusion? Best practices.

Best Practices

The acquisition of a scanner is not a small investment, and labs should get the most out of the purchase that they can.

“The main thing typically is how committed is the laboratory to digital impressioning, and I would say the majority of labs today are not committed yet,” Ulmer says. “It’s still a relatively small percentage. The majority of labs have not invested into impressioning units yet.”

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While newer lab technicians understand computers and might need a better understanding of dentistry, it works the other way around-especially for older lab techs.

“It also depends on the age of the people who are looking to get involved in this technology,” Cucchiaro says. “I am a 52-year-old dental technician who has been working at the bench for 35 years, and my impact by this technology was terrible. I’m not a computer person. Guys who are in my age range are very frightened because they’re not used to this technology. They’re not used to this terminology, but they see the benefits of what it can be. So they need a little bit of patience, and they need a little bit of time to be able to acquire as much knowledge as they can to be able to use it.”

Communication with client doctors is critical; especially in terms of education about scanners.

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“As digital impressioning becomes more prevalent on the doctor side, it would be really good for the labs to pay attention to see what’s out there with intraoral scanners, having an understanding of the positive and negative points of each of the different scanners and then price points, so that if their doctor calls, they can have an intelligent conversation about it,” Ferguson observes. “The last thing they need is for their doctor to want to go digital and they’re not prepared with the information. Be aware of what’s out there on the doctor side. If you’re outsourcing, make sure you communicate with your outsourcing center so they understand the types of cases that you’re going to send and that they’ll be able to handle them as well.”

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Labs also need to spend a little time getting to know the system and what it can and cannot do.

“They tend to have problems if they don’t nail down the parameters, the contacts, the occlusions,” Ly says. “You really need to nail that down to do the digital impression because you don’t have the model. Most labs do not lock down those parameters. Just do R&D. If you get a digital impression, you must have a model printer to print the model. Then you check the parameters and try to drop the crown in. If it’s too tight, you reduce the contacts on the software design.”

Labs that might be waiting for scanners to mature need not wait any longer. Their capabilities are in a great place.

“I think that scanners are already at a great level,” Cucchiaro says. “The accuracy is amazing. The speed, to my point of view, is acceptable. They are scanning in a couple of seconds. I don’t know where else we want to go.” 

Top photo: GeorgeManga/Getty Images; Rakdee/Getty Images

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