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The CAD/CAM Chorus

Issue 2

February 2011 | Dental Products Report clinical 360: The Cad/cam chorus The take-aways Digital dental technologies of today work and provide clinicians with choices in how they want to practice. These technologies will continue to increase in efficiency and cost-effectiveness as systems are improved and refined. The CAD/CAM Chorus

February 2011 | Dental Products Report
clinical 360: The Cad/cam chorus

The take-aways

  • Digital dental technologies of today work and provide clinicians with choices in how they want to practice.

  • These technologies will continue to increase in efficiency and
    cost-effectiveness as systems are improved and refined.

The CAD/CAM Chorus

A range of voices from around the industry weigh in on the promise, potential and pitfalls of these gamechanging technologies.

by Noah Levine, Sr. Editor

Successfully testing the waters

Dr. Bret Jacobson, General Dentist, Federal Way, Wash.

Full-arch scans are one of the many expanded capabilities Dr. Jacobson has experienced during his time as a beta tester for Cadent’s iTero.

Many digital impression proponents like to promote the technology as a way to create a closer working relationship between dentist and lab technician, but Dr. Bret Jacobson actually got involved with the technology because of his already strong ties to his lab.

When Cadent was launching its iTero digital impression system in 2006, Dr. Jacobson was brought in to be a beta tester because of connections between his lab technician, Dave Nakinishi, and the manufacturer. He’s still not exactly sure what made his practice in Federal Way, Wash., a good place for testing the system, but he’s been thrilled by the opportunity and can’t imagine going back to the days before his impressions were captured digitally.

“I still once in a while take a (physical) impression for an implant, and when I do that, I hate it,” Dr. Jacobson said. “It’s a bad day when I take a (physical) impression. For routine crown and bridge I haven’t taken an impression for years.”

Improvements over time
Unfortunately, that wasn’t quite the case when Dr. Jacobson was first putting the iTero system to the test. Initially, his beta testing involved taking both physical and digital impressions with every crown or bridge case to provide data and feedback to Cadent. He was able to see right away that the system worked well back then, and the technology has continued to improve over the years.

The current iTero unit is both smaller and faster to use than the initial system he tested, and that’s not just because he no longer needs to take a corresponding physical impression every time he powers up the unit. The software has gotten faster at processing the data, and the faster-loading preview images are clearer than before.

The system also has expanded its capabilities to allow for scanning of full-arch impressions, for use in implant cases, and coming in Q2 2011, clinicians will be able to send a digital impression to Align for Invisalign patients. From the software to the design of the scan head, everything has evolved to be easier to use, and Dr. Jacobson said it wasn’t a difficult endeavor even in the beginning.

“It was basically like using an intraoral camera, which I do all the time,” he said. “It wasn’t real hard to get the hang of it right off the bat, and it just gets better and better as far as being streamlined and easier to use.”

Impact on the practice
Being a part of watching the technology evolve has been rewarding to Dr. Jacobson, but not as rewarding as seeing the many ways digital impressions have helped his practice on a day-to-day basis. Right away, the technology made a positive impact on his patients by removing some of the discomfort of a dental visit and serving as a valuable tool for communication about their treatment plans.

“It’s also a nice tool to have to open up a conversation because they can see their tooth on the screen in real time,” he said.

And while Dr. Jacobson already enjoyed a solid relationship with his lab before adding the iTero to his practice, communicating with digital patient information has helped improve those interactions with the benefits being realized by the lab, the practice and most importantly the patients. Working with the lab is now a streamlined process with cases only being shipped one way from the lab to the practice when the restoration is completed, and because the lab receives the scans right after they are captured, they can bring up any questions about the case immediately.

The iTero software allows him to track a case as it is being processed by the lab, so he always knows when a crown or bridge will be back at his practice, and when they arrive, he is confident in the fit he is going to get. The restorations fabricated from the digital impressions just seem to be more accurate, and Dr. Jacobson said he now spends less time on seating appointments.

“I don’t have remakes anymore, so that’s a huge thing. I don’t have to send crowns back,” he said.

Those benefits are huge for his practice, but Dr. Jacobson said working with digital impressions also has been beneficial on a personal level. Seeing his prep work magnified on screen has helped him refine his skills and improve his technique at creating the margins needed to complete a case, but it hasn’t changed his approach in terms of the decisions about what type of restoration will work best in a specific situation. Because the iTero scans are used to create a model that is sent to his lab, Dr. Jacobson can use a digital impression as the basis for a restoration from any material, and his lab is able to use the technique they prefer to fabricate the crown or bridge.

“One of the nice things about it is you don’t have a specific prep design you have to create, you can do any type of restoration you want,” he said.

Changes still to come
Being a beta tester for iTero is still an ongoing process at his practice, and Dr. Jacobson has been able to see a few sneak peaks at some of the innovations on the way to the digital dental world. He recently helped out with a case that tested the viability of milling a restoration based on just a virtual model.

The case was scanned and then a crown was designed and milled based on the iTero model, another based on just the virtual model and a final crown was pressed from the same data. Dr. Jacobson said the fit of the crown milled from just the virtual model was impressive enough to convince him that some labs may very soon be ready to do their work without producing any physical models, thus saving time and resources.

Those types of innovations and increased efficiencies are exciting, but Dr. Jacobson does not see much allure in getting in on that design-and-milling process himself. While he sees the advantages some dentists gain from using chairside milling systems, he believes the precision of dental restorations is better achieved when restorations are milled on the commercial-grade systems large labs have available rather than on a smaller unit that can fit in an operatory.

“I’m a dentist and not a lab technician, and I don’t want to spend time staining and glazing and doing those kind of things,” he said. “I want to spend time with my patients. That’s where I’m most productive. For my practice, I still want my laboratory making my restorations.”

That doesn’t mean he never sees potential of having a mill in his office. If he had a small system designed for the production of temporary restorations, that might make sense as an in-office innovation. Dr. Jacobson said he has no doubt digital impressions are going to be a big part of the future of dentistry because the industry continues to take advantage of the efficiencies of computerization.

“That is ultimately where it’s going to go,” he said. “Dental offices are going paperless, and we have digital X-rays so we don’t have film anymore. It’s going to be the same thing with impressions. The things you can do with the digital files now are just amazing.”

Staying ahead of the game

Dr. Fred Peck – General Dentist, Cincinnati

Photo: Submitted by Ms. Dickerson

Adding technological innovations is nothing new for Dr. Fred Peck. His Cincinnati practice is equipped with digital X-rays, lasers for diagnostics and treatment, computerized patient education and treatment planning, and for almost two years now 3M ESPE’s Lava™ Chairside Oral Scanner C.O.S. digital replication platform.

Dr. Peck’s motivation to add digital impression technology to his armamentarium was not at all complex.

“I didn’t want to get behind,” he explained.
Finding the right fit

But staying up with the latest innovations requires some research, and Dr. Peck made sure he did his homework before adding the digital replication platform to his practice. The first part of the decision process involved ruling out full chairside CAD/CAM systems because Dr. Peck said he thought about it for a moment but realized staining and glazing chairside milled restorations was not something he had any interest in doing.

With a focus on digital systems, Dr. Peck evaluated Cadent’s iTero and Sirona’s CEREC AC along with the Lava C.O.S. His research involved talking with friends who had worked with the systems at dental schools, and his search finally zeroed in on the Lava C.O.S. because he liked the video impression acquisition technology it employed and the way the system can be used to send cases to any lab he wants to work with.

“One of the things I liked about what I purchased was it didn’t matter what equipment they have in the lab,” he said.

Technological integration
Moving the system into the office was not a difficult process for Dr. Peck. He prepared his staff for the transition, and they responded positively, as have his patients.

For him personally, the transition has been just what he had hoped in that he has not had to adapt his preparations or his treatment plans to take the digital impressions into account. Being able to continue to practice the way he had before while using the system as often as possible was a big factor in his decision to invest in digital impression technology.

“I like the fact that it didn’t change the way I can practice. I didn’t want it to,” he said while noting that in less than two years he has transitioned to digital impressions for just about every crown or bridge case he treats.

Immediate advantages
In fact, the Lava C.O.S. has even allowed him to provide treatment to some patients who he could not easily treat without it. With some patients who presented a severe gag reflex, he could not take an accurate physical impression, but has been able to capture their intraoral anatomy digitally to provide treatment such as crowns and diagnostic models. Previously, he had to work with an oral surgeon to sedate those patients to take a physical impression, so the digital process is easier for everyone involved.

The results he is getting back from his lab have also improved since he switched to digital impressions. Crowns produced from the digital scans are seating better, and he described their occlusal accuracy as “phenomenal.” He’s even timed himself taking a digital impression and a physical impression to compare them, and for a single crown he saves more than two minutes by going digital. Those time savings only grow when he uses the C.O.S. system for larger cases because he no longer has to take repeat impressions to avoid air bubbles and other issues.

While those benefits make his work easier, the bottom line of adding technology like this is to improve things for the patients. Dr. Peck said not only do his existing patients know and appreciate the fact that he invests in new technologies to improve their dental experience, but promoting his practices’ technological investments also helps attract new patients.

“I do get a lot of patients who prior to becoming new patients look at my credentials and look at the technologies I use in the office, and they come in to the office with a level of trust that I don’t think they would have had otherwise,” he said.

Looking ahead
For the time being, Dr. Peck said he is very happy with his decision to move to a digital impression environment. However, he knows technologies will continue to evolve and improve, and he plans to stay on top of things to be ready when something new is proven both clinically and economically.
Whether it’s CAD/CAM with chairside milling or just in-office digital replication systems, he fully expects a more digital form of dentistry to be the norm while he is still practicing. Just like with lasers, which have become more widely used as they have become more affordable, Dr. Peck said even a dentist like him who has little interest in performing lab processes chairside could make use of a mill if the price were right.

“I don’t think I would use it all the time, but there might be times when it would be useful for a patient,” he said. “I wouldn’t feel bad if a piece of technology collects dust for a day or a week if it’s not that much money. But for $100,000, you want to be using that thing every day.”

My mail standard

Dr. John Cranham, Cosmetic Dentist, Chesapeake, Va.

Dr. John Cranham

The promise of CAD/CAM technology is something Dr. John Cranham has been fascinated by for most of his career. He recalls being amazed by what the CEREC 1 could do when he saw it while in dental school, but still being a bit confused by the complex line drawings of the CEREC 2’s interface. However, when CEREC 3D was released with its intuitive graphics and easy-to-use interface he got really excited because finally, “I don’t have to be a rocket scientist to design a crown.”

But, it isn’t just chairside CAD/CAM that has interested Dr. Cranham. He also recalls the introduction of milled zirconia to the dental lab market as another innovation that fascinated him. With esthetics a big part of his practice, the idea of milling restorations from an extremely strong monolithic white material was very appealing.

“We were all looking for something that would be a little more contemporary and a little more esthetic than porcelain-fused-to-metal,” he said.

Material advantages
The initial excitement was tempered a bit, as Dr. Cranham notes that early zirconia restorations were too bright. Still, the industry quickly figured out how to take advantage of the material’s best qualities to achieve both durability and esthetics. And this was just the start.

While he still sees great advantages of zirconia frameworks for larger cases, as an experienced chairside CAD/CAM user, he’s followed the continuing development of both chairside systems as well as the materials they can mill. His practice is now equipped with D4D Technologies’ E4D system, and when it’s time to choose a material for fabricating a single posterior crown, Ivoclar Vivadent’s e.max CAD is his “main standard.”

“I use it probably 95% of the time,” he said. “For crowns, the science behind e.max is kind of irrefutable, and I find it to work extremely well.”

While he said he was at first a little thrown off by the material’s blue hue in its unfired state, he’s never been left unhappy working with it, and once properly finished, the e.max crowns provide him with the qualities he needs to give his patients the results they’re looking for.

“We handle a lot of complex functional problems. When I deal with bruxers and people who clench their teeth, I need to have strength. I need to find the best-looking material that is naturally strong. Right now that’s e.max for me,” he said. “It’s the combination of having something so strong in a monolithic form, and it’s easy to make it beautiful. That combination is what I was looking for.”

Where it works
Some of those complex functional problems are cases Dr. Cranham handles in collaboration with a lab, but for cases that involve just a couple posterior units and no major changes to the patient’s bite, he prefers to create the crowns with his chairside system. This gives him full control over the case and allows him to deliver the results to his patients in less time.

But while he uses his system as part of his everyday practice, Dr. Cranham uses the technology in a way that is comfortable for him while delivering the esthetics his patients expect. This means he rarely creates same-day crowns, but rather prefers to scan his prep and design the crown while an assistant fabricates a temporary so he can dismiss the patient and finish fabricating the crown later in the day.

“We sort of do a two-day crown rather than a one-appointment crown. I find by doing that I still get the benefits of a decreased lab bill, I have all the benefits of new materials and control, but I don’t have the pressure of having the patient waiting and having to disrupt my workflow,” he said.

He also doesn’t use his chairside system when a case requires anterior crowns. Dr. Cranham said he believes the technology is capable of producing restorations for the esthetic zone, but it requires a lot more effort from the clinician in terms of finishing the crown with the esthetic touches required for something so visible.

“I just think you have to decide as a clinician how far into it you want to go on the lab end of it,” he said. “There is something to say for the artistry that a really skilled ceramist can add to a case.”
Still, from the pre-molars back, Dr. Cranham said he prefers to handle the work himself and he’s confident about using e.max on all those cases. He can’t imagine practicing today without being able to offer his patients the material advantages and timesavings of chairside CAD/CAM. Besides, the technology makes his work a bit more interesting and enjoyable.

“For my everyday nuts-and-bolts practice when I’m doing one or two units, it’s such an unbelievable adjunct in terms of telling patients they can get their restorations faster and for me to have control over some of the design,” he said. “There’s no question that the ability to make a crown chairside is something that any doctor could learn to do really quickly. The machines are intuitive, and it’s something fun to do.”

Ever better
He’s pretty sure more and more clinicians will be joining him in that fun in the future, because the CAD/CAM systems continue to get easier to use while producing higher-quality results. Chairside milling and finishing the milled restorations might not be something every dentist wants to do, but Dr. Cranham said he believes digital impressions will be standard in just about every practice before the end of his career.

The more people who buy into the technology the more affordable it is likely to become, and the business models supporting adoption of the technology will become more evident to people considering the move, he said. One of the best things about the current CAD/CAM and digital impression markets is the fact that multiple companies are trying to outdo each other with technological innovations.

“I think they push each other, which is a good thing,” he said.

He’s excited about the continued development of the systems and looks forward to more and more integration of 3D dental technologies into more powerful diagnostic and case planning tools. Dr. Cranham said virtual articulation is a powerful tool he’d like to have available. He’s also keeping a close eye on the development of materials, because if a truly functional polychromatic milling block comes along, he could even see adding anterior crowns to his chairside milling repertoire.

Standing apart: Not all labs are going digital

Joshua Polansky – Owner, Niche Dental Studio

For lab technician Joshua Polanksy who prefers hand fabrication to CAD/CAM processes, frame design comes from seeing, feeling and knowing the final outcome. He believes this holds true in any profession and creating work by hand guarantees that luxury.

As a relatively young dental technician, Joshua Polansky’s approach to CAD/CAM technology surprises many people in the industry. Because of his age, people tend to assume he’s a digital devotee, but that couldn’t be further from the truth.
The 31-year-old studied under master technician Olivier Tric and with Dr. Ed McLaren at the UCLA Center for Esthetic Dentistry and now owns and runs Niche Dental Studio in Cherry Hill, N.J. While he isn’t against CAD/CAM and technological developments, he’s chosen to take an analogue approach to his career as a dental technician. It’s something he views as a lifelong journey and never-ending educational process, one that he finds extremely rewarding.

“It’s not like I’m a purist who is trying to make a stand,” he said. “With the proper education and the proper foundation, I think that you can really get the result that you would want to look for without using a computer.”

The power of education
That education goes beyond learning the techniques and processes required to produce dental prostheses. It includes a dive into understanding the anatomy, morphology and function of the teeth being reproduced prosthetically. It’s this knowledge that he sees being lost when CAD/CAM systems are relied on too heavily, and he doesn’t think there will ever be a day when high-end dentistry can be achieved with just the press of a button.

“I’m not against CAD/CAM. With the foundation you can get by going through higher education, you can utilize CAD/CAM to your advantage,” he said. “But I don’t want a computer doing work for me. My doctors don’t work with a computer. They work with me for the things that my brain can do. A computer is only great if it’s guided by somebody with education.”

Still, Polansky chooses to work with wax and layered ceramics for most cases and is constantly striving to create restorations that truly mimic the natural world. While he sees the efficiencies and speed of CAD/CAM production, he also sees what those restorations are often missing, and that’s the nuance that makes things lifelike.

Lifelong process
Overreliance on technology can lead to an institutional erosion of knowledge as more and more critical steps are computerized and new technicians learn on digital systems without ever beginning a case in a physical environment. He worries that the focus on cheaper, faster and easier production systems boosts the business side of the industry, but at the detriment of the people receiving the end results.

“We’re going away from the basics, and if you go away from the foundation, from the basics, we’re kind of in trouble,” he said. “It’s disappointing because in this field we’re all working toward one thing, the end user. Everyone seems to think that end user is their account or their doctor, when in actuality the end user is our patient. And the patient has no idea what they’re getting.”

He admits that most patients don’t know or truly appreciate what goes into creating a natural-looking crown, but just like there are still craftsmen cobbling shoes and tailoring suits by hand, there will always be a place for the high-end, hand-crafted dental restoration.

Creating those restorations is something he views as an ongoing quest for knowledge, and just because he chooses to work in a mostly physical, rather than digital, environment, doesn’t mean Polansky eschews innovation. In fact, he finds the processes and materials with which he works so intriguing that he regularly spends his extra time experimenting with new ideas and new ways to approach the techniques and processes he puts to use every day.

Where technology helps
While Polansky is not sold on CAD/CAM as ready to outdo what a skilled technician can do in other ways, he is a strong believer in the power of computers, and namely the Internet, as a big part of how dental labs like his can remain viable in the industry. With the Internet connecting everyone to all manner of information, he and other technicians are able to share high-quality images of their work, discuss materials and techniques, and most importantly make themselves accessible directly to patients.

“The Internet to me is a game changer. Lab technicians used to be in the closet, nobody knew they existed. Today we’re out there,” he said.

Patients now are seeking him directly, and then asking their dentist to send their case to him, even when they know the fee might be higher than using another lab. Because patients and dentists looking for people like him can just push a few buttons to find him online, Polansky feels secure that even as the industry continues to embrace CAD/CAM ever more tightly, there will always be a place for him and others with similar outlooks.

“The satisfaction for me comes from the work,” he said. “I think it’s a great field, a great craft. I’m fighting to keep this section of the field alive.”


Not looking back

Dr. Bill Busch – General Dentist and DPR Clinical 360 Technology Team Member

Dr. Bill Busch

Leveraging technology to provide the best care for his patients is somewhat ingrained for Dr. Bill Busch, so it should come as no surprise that the DPR Clinical 360 Technology Team member has both Sirona’s CEREC and D4D Technologies’ E4D chairside CAD/CAM systems in his North Kansas City, Mo., practice.

The busy practice is doing enough same-day crowns to make use of two complete systems. For Dr. Busch, it simply comes down to making sure the practice is prepared to meet his patients’ dental care needs, whatever those needs may be.

“If you have an emergency, and you have a broken tooth that needs a crown, well we’re going to do it that day,” he said.

Evolving the CAD/CAM practice
This treatment model is nothing new for his practice where he has been providing CAD/CAM dentistry for close to a decade. Dr. Busch always has been attracted to technological innovations, and said he’s been intrigued by CAD/CAM since he graduated from dental school in 1989.

He finally decided the technology was ready for him to bring on board when CEREC 3D launched. He added his first CEREC system in 2001, and said he hasn’t looked back since. Even back then, Dr. Busch found the technology amazing and was pleased with what his financial and professional investment in the technology allowed him to do.

“It’s like GPS,” he said. “You can’t really believe it when you first got it, but you trust that it knows what it should do.”

Dr. Busch’s move into the dental CAD/CAM arena was about adjusting to patient desires. While he was looking to practice quadrant dentistry, his patients were more budget-minded and often wanted single crowns. By adding the CEREC to his practice, he could give these patients what they wanted, and he could do it far more quickly than they expected.

“It just made sense to me that it’s the perfect technology for our practice in doing a couple restorations in a single visit,” he said.

By 2008, the practice was busy enough to need more in-house CAD/CAM capacity, and Dr. Busch went looking for another system. He decided to add the E4D rather than a second CEREC because he felt it did some things better and thus made his practice even more versatile when it comes to offering CAD/CAM services to patients.

Just recently, he added Soredex’s Scanora 3D cone beam system to the practice because it can be paired with the E4D system’s forthcoming Compass software for advanced implant treatment planning. Each technological addition has made the practice more capable and added to the options Dr. Busch is able to provide for patients.

“I’ve kind of done it in steps,” he said. “These technologies are reliable, a blessing for the patient and profitable for the practice.”

Turning technology into action
Because he sees how each new addition to his practice provides new benefits for both patients and clinicians, Dr. Busch is always a little surprised that innovations in dental technologies are embraced by the industry at a slow pace. He is especially surprised that CAD/CAM systems are not more popular and more common because the benefits are numerous.

For him one of the biggest factors that should motivate dentists to get involved with CAD/CAM is the fact that so many labs are using the technology. It’s likely labs receiving physical impressions are scanning it on their end, so Dr. Busch said it makes sense for dentists to start the process digitally themselves.

Going to digital processes has not only been profitable for his practice, but Dr. Busch said it also has helped his practice become a greener business. Digital impressions save a truck from having to drive the impression to the lab, and when a chairside mill fabricates the restoration, no delivery trips are needed at all. This can provide a reduction in carbon footprint while increasing profits, but still Dr. Busch finds the clinical advantages of CAD/CAM provide the largest boost to his bottom line.

“The biggest impact is time savings. We’re probably saving 16 clinical hours per month in patients who don’t have to return for a second visit,” he said. “Today, people just want to get things generally fixed. That’s where CAD/CAM comes in because you’re able to produce it in the office in one visit. We’ve got it down to 90 minutes.”

The time savings also come into play for Dr. Busch. He has found he can do other work in a patient’s mouth or provide care to another patient while a crown is milled.

He also finds he can use the technology in creative ways to provide optimized care for his patients. If a patient with a partial denture presents with decay at the base of a tooth supporting that partial, he can scan the supporting tooth, digitally clone it and create an exact replica crown. Then after he removes the decay, the milled crown will be able to support the same partial denture, saving the patient both time and money.

“I think you can do more and have more control over the entire case from start to finish,” he said.

Crown versus crown
Having both the CEREC and E4D systems in his practice has allowed Dr. Busch to really put them through their paces to see each system’s strengths and weaknesses.

While he finds they both can produce high-quality restorations, he thinks the E4D is the better of the two systems right now. This is because the software is easier to use, and the E4D mill produces a smoother restoration than what he gets out of his CEREC mill.

Right now Dr. Busch feels the E4D system is better equipped to produce restorations for use in the anterior region, but both of his systems are in constant use.
“We use them both all the time, and sometimes I’ll use them both on the same mouth,” he said.

Wishlist for the future
The quality of the CAD/CAM restorations Dr. Busch is able to produce chairside today is vastly improved from what he could do back in 2001, and it is much easier to produce them today. He expects that to continue and is excited by the prospect of adding additional capabilities to his CAD/CAM systems.

He hopes to be able to use his chairside mill to produce surgical stents, custom implant abutments and 3-unit bridges, something he called “the holy grail” of chairside CAD/CAM. Other innovations such as accurate virtual articulation and the ability for him to send digital impressions from his systems off to a lab for design work that can then be sent back for milling in his practice are on his wishlist.

Overall, he sees an extremely bright future for chairside CAD/CAM technologies. With dental schools producing a crop of computer-savvy dentists, Dr. Busch believes demand for the technology will continue to grow, and this will help speed up the already rapid pace of innovation. Eventually, he expects the digital impression to be the standard starting point for every restoration with labs doing some design and other crowns being completely handled chairside. Dr. Busch will be very excited when he can use the same system for every case he treats.

“I do think they have to work out the kinks on being able to do it for every situation,” he said. “I want one machine that does it all.”

A logical progression

Roddy MacLeod – Vice President of CAD/CAM, Sirona

Roddy MacLeod

If you ask Roddy MacLeod, Vice President of CAD/CAM for Sirona, the industry’s transition to digital dentistry didn’t begin with the invention of the first CEREC chairside CAD/CAM system 25 years ago. That technological breakthrough would lead to many more critical developments, but change in the industry really started in the administrative areas of dental practices.

MacLeod said the introduction of computers for record keeping and submitting insurance claims kicked off the digitization of dentistry, and since that time, there has been a natural progression of different areas of dentistry moving from analogue to digital formats and workflows. Information was the first thing to be widely digitized and diagnostics began heading down the digital path next.
“Nowadays, it’s pretty rare to go into an operatory and not see a computer and a monitor,” MacLeod said. “Once you’ve got a computer chairside, it makes sense to look at the radiograph right there on the monitor.”

Where we are
From there, the next logical step has been to digitize the impression process that is the jumping off point for many dental treatments. While the technology is there and working to capture digital impressions both intraorally and via benchtop scanners in the lab, MacLeod said the industry is just now turning the corner as digital diagnostics are becoming the norm and the digitization of treatment is emerging.

“Treatment starts with an impression, so that’s the next logical thing to be digitized at a high level, and that’s exactly where we are,” he said.

Those digital impressions are allowing both dentists and patients new ways to see things, and this is beneficial to everyone. The digital impressions captured by the CEREC system provide 3D up to 30X magnification. This lets dentists see their work more closely than previously possible and lets patients see the details that help them understand their cases.

“When patients can see as big as their fist their tooth on the screen, they get a much better idea and the dentist is better able to communicate the value of their treatment,” MacLeod said. “The digitization story is all about seeing more, doing more, and in the case when you get to mill at chairside, doing it better because you have full control of the entire process.”

A chairside CAD/CAM system such as Sirona’s CEREC is able to take the fully digital diagnostic and treatment planning capabilities of the digital impression and use them to fabricate a final restoration almost immediately. MacLeod said this is the way the dental industry is headed because whether the work is done by a lab technician or at chairside by a dentist, the digital technologies allow it to be done both better and faster.

Where we’re headed
MacLeod said working in a digital environment offers numerous advantages for everyone involved with it, even as new technologies change the way everyone works. When dentists adopt digital impressions and work with labs ready to receive digital files rather than physical impressions or models, the interaction between clinician and technicians can happen from the very start of a case and problems can be averted. Other dentists will embrace chairside milling and become directly involved with some of their restoration design.

Either way, dentists will be working with digital patient information, and when this information is digitized, it becomes far more useful than that same information recorded in a physical impression. Just like digital radiographs that can be shared with colleagues and sent to insurance companies, digital patient information from intraoral scans and cone beam systems can be used for design of implant drill guides, orthodontic case planning and other uses. MacLeod said versatility is one of the biggest benefits of dentistry taking a digital path.

“That’s why things become digitized, because you can just do so much more with it,” he said. “We want dentists to do more dentistry than they’re doing today. We get from here to there by making the workflows in the practice more efficient and more profitable, and that allows the dentist to grow.”

MacLeod said the digital dentistry story is really about a slow transition that leads to providing better patient care more efficiently. Technology is providing clinicians with more detailed information about their patients and automating fabrication of restorations to achieve that goal.

“The digitization of the practice and the lab is a process,” he said. “It had a beginning 25 years ago, not just in CAD/CAM, but in the introduction of the computer to the practice and the lab, and that digitization follows a nice logical path that starts with the digitization of the information and the diagnostics of the patient, and flows naturally into the impression, which starts off the restorative process. It’s an exciting time, and of course at Sirona we are excited by that because we helped create this part of the industry.”

Calling the plays

Dr. Gary Severance – Vice President of Marketing and Clinical Affairs, D4D Technologies

While D4D’s chairside system started out with a focus on CAD/CAM, the company is now working on implementing technologies that can expand the system’s diagnostic applications.

Right from the start, Dr. Gary Severance, D4D Technologies’ Vice President for Marketing and Clinical Affairs, felt this article had the wrong headline. Sure he believes strongly in the potential of CAD/CAM to continue as a growing force in both the laboratory and operatory, but he thinks that term is a bit too limiting when it comes to describing the possibilities these new dental technologies are creating.

The way he sees it, Digital Dentistry is a better way of describing the potential digital impression, intraoral scanning, networked treatment planning and computerized milling technologies have to revolutionize the care and treatment planning of dental patients. Dr. Severance believes it’s only a matter of time before the industry embraces these technologies because CAD/CAM systems of today are capable of delivering better results for patients, and the pace of technological development is not likely to slow down.

“If we break down all the perceptions and the barriers and what we thought we knew and look at it fresh, we’re at a pretty good point where our (E4D Chairside) system is not a compromise at all to what conventional dentistry has offered, and it’s only going to get better from this point on,” he said.

The next steps
The ability to digitally design and automate the manufacture of dental restorations is here today and continues to be refined. However, Dr. Severance said the exciting direction for this technology is in expanded diagnostic capabilities from better use of intraoral scan data and ever more powerful intraoral scanning technologies. These technologies could help shift the dental profession from a restorative model to a more preventive model where disease can be diagnosed earlier than ever and the healing process can be tracked.

“Our goal is really to digitize that patient from first to last and allow us to watch that progression,” Dr. Severance said. “Diagnosis is key and treatment planning from that is the foundation.”

Of course change such as that takes time, and imaging technologies required to accomplish this are still being developed, but the existing technologies already allow for advanced implant treatment planning, same-day crowns and other new ways of delivering care. This means some change in the way certain types of cases are handled and the work done by dentists, dental assistants and dental lab technicians, but Dr. Severance believes everyone will continue to be vital parts of the team while working together more closely via the technology.

“It’s going to bring everybody closer,” he said. “It’s going to redefine people’s roles, but there’s always going to be a need to create something to either stop the disease or prevent a disease.”

Directing the action
Regardless of the technological developments, Dr. Severance said the dentist will always be the quarterback of the treatment team, assessing the situation and making the final call on what play will be run to provide the patient with the best possible care. But while technology may allow a patient to receive a final restoration in just a few hours, the dentist doesn’t have to be the one to perform every step in the process.

“It’s really all about delegation. We like to say dentistry’s a team sport,” Dr. Severance said. “Too often, dentists do the quarterback sneak when they should have utilized the people around them that have expertise.”

D4D believes strongly in empowering dental assistants by training them to use the company’s E4D systems to design restorations, freeing up dentists to see other patients. But just because restorations can be milled chairside doesn’t mean dental labs will no longer be necessary. Dr. Severance said the skills and knowledge dental technicians bring to the industry will not be something a computer can replace, and complex cases will always benefit from the involvement of a trained technician. However, sending a case out to the lab may be a bit different with technicians being able to apply their skills designing restorations in a digital environment and then sending their designs to be milled on a chairside unit in the dentist’s office to be finished by the dentist’s assistant.

“On a case that can be completed in the same day or in the office, we really encourage dentists to hand off to their assistants, or if it’s more complex or needs more attention, pass it off to their technician,” Dr. Severance said. “It’s the same ball. The benefit is we’re still trying to go to the same place, which is give the patient the care that they deserve.”

Heading down a one-way street

Dr. Richard Sullivan – Vice President, Clinical Technologies for Nobel Biocare North America

Digital treatment planning facilitates precise implant placement, which allows the use of screw-retained prosthetics in more cases.
Lab work by Jack Edwards, MDT

Dr. Richard Sullivan can’t imagine there are many clinicians who want to go back to handling implant cases the way they’ve done them before after experiencing what CAD/CAM and digital dental technologies can offer to both clinicians and patients.

As both Vice President of Clinical Technologies for Nobel Biocare North America and in his private implant practice in Southern California, Dr. Sullivan has been involved with implant-related digital technologies and CAD/CAM processes for more than 20 years. The benefits were apparent from the start, and over time technological advancements have made implants more accessible to both clinicians and patients.

“I really do make it a point to always look for the fastest, easiest, most predictable way to do things on behalf of the patient,” he said. “When you have years of doing castings you have certain expectations, and then when you change, it’s so dramatic. I don’t know anyone who’s moved over to computer-milled implant frameworks that’s gone back to casting. It’s so remarkable that it’s only a one-way street. You make the change going to CAD, I don’t think that you go back.”

Better materials, better results
Dr. Sullivan said the draw of using more biocompatible materials for implant abutments and crowns first attracted him to the potential of CAD/CAM technologies. Titanium and ceramic materials have shown better soft-tissue response than gold, and computer-milled bars for implant-retained restorations provide a more precise fit than those produced via other techniques.

When he started with CAD/CAM restorations, the bars were created by copymilling individual components that were then laser welded together. Those were still capable of providing a great deal of precision, but have been greatly surpassed by the precision possible from today’s systems where implant bars can be milled from solid blocks of titanium.

“There really is no comparison in the precision of fit, and they’re more biocompatible,” Dr. Sullivan said. “It’s rare that you get the opportunity to get something that has advantages in fit and biocompatibility, but that’s where we’re at.”

Better information, better plans
But the better material options and more precise fit were just the beginning of the ways digital dental technologies are improving implant outcomes. Today, the biggest advantage of the technology may come not from what the machines produce, but from the wealth of digital data that can be used to diagnose the patient and plan the treatment, Dr. Sullivan said.

With cone beam imaging and computer-based treatment planning, clinicians can design the ideal restoration for function and esthetics first and then plan implants to provide optimal support for the restorative plan. Surgical templates can then be fabricated to guide predictable implant placement.
“It’s changed things from my point of view from being able to place implants that are clinically acceptable, to ones that are perfect,” Dr. Sullivan said. “You’re able to deliver the restoration you’d like to do without any compromise.”

Knowing more details about the patient’s individual anatomy opens more options to clinicians such as the use of less invasive screw-retained or one-piece implants. Dr. Sullivan said this can make management of cement around gingival margins a non-issue and lower patient risk before treatment begins. This benefits everyone because it allows for a simpler, less expensive and more biocompatible restoration.

“What I see happening is, because of this CAD/CAM diagnostic ability, we will be able to do more optimal screw-retained restorations on a regular basis,” he said. “What I think the future should be is at least half of them should be restored this way. There’s no reason not to.”

Untapped potential
While the technology is certainly not new, Dr. Sullivan believes more clinicians should be using advanced treatment planning capabilities and CAD/CAM fabrication technologies for their implant cases. Besides providing better fit and more accurate pre-treatment planning, the technology also allows restorative dentists, surgical specialists and lab technicians to work as a true collaborative team rather than work in a sequential process that hands things from one person to another with little interaction.

The technologies in this arena are likely to continue their development and might someday yield even more precise results from even less invasive surgeries, but Dr. Sullivan said clinicians should not be waiting for that day. Instead they should be availing themselves of the untapped potential of today’s technologies, because they work and can lead to enhanced patient outcomes right now.

Just like with anything new, there always will be a learning curve associated with new technologies and updated techniques, but when it comes to implants the benefits of digital case planning and CAD/CAM fabrication are already too significant to ignore.

“There’s a fork in the road here where people who are going on this digital path keep expanding and evolving and getting further away from the people who have not got on it,” Dr. Sullivan said. “It’s inefficient to start, but once you get used to it, it’s more efficient. It’s the same going from a typewriter to a computer, it’s probably inefficient initially, but ultimately you would never go back.” 

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