If a practice already has an intraoral scanner, we look at what practices should consider when adding a mill to the workflow and how to avoid getting into trouble during implementation with this critical investment.
When practices are looking to add a mill to their digital workflow, the process can be a lot to, well, process. Also, integrating an existing intraoral scanner can change the focus of the search. We look at what practices should consider when adding a mill to the workflow and how to avoid getting into trouble with this critical investment.
What Are Your Goals for the Practice?
Practices should first set a goal and plan for what they want to accomplish by introducing a mill. Lisa Aguirre, Product Manager, Dental Solutions for Roland DGA, says that many of her conversations with clinicians start here.
"The first thing to understand is the why and what they're looking to do in their practice with a chairside milling solution," Aguirre says.
Gavin Sternberg, National Manager of CAD/CAM, Planmeca, agrees, adding that cost savings and new restorative opportunities have different effects on the bottom line. For example, a new practice that does fewer restorations may not have cost savings, but the mill's capabilities could boost word-of-mouth marketing about what's possible. On the other hand, established dental practices with many monthly restorations will reduce overhead.
"Once you hit a certain number of restorations—depending on what you are paying the lab—you are covering the cost of the machine. Everything above that is pure profit," Sternberg explains, estimating the break-even number for many practices at around 10-15 crowns a month.
Mohammed Soliman, CEO of vhf, Inc., adds that defining practice goals will help narrow the parameters for what the best solution may be regarding capabilities and sets the stage for implementation. Soliman sees a dental practice as a dental business, which requires attention to short- and long-term goals.
"Practices should evaluate both," Soliman says. "What can this mill do for me in the short term, and how will it pay back? In the long term, what could this do for my practice overall and, frankly, my life as a clinician?"
However, he warns against waiting for the perfect time to invest in new equipment. In his experience, most clinicians that invest in a mill as part of their chairside solution wish they would have done it sooner.
"Clinicians are always telling me, 'The effect it had on my practice, my patients, and ultimately my life was so great, and I saw such improvement, that I wish I would have done it sooner,'" Soliman says.
What Type of Architecture Does Your Mill Use?
After establishing goals, Aguirre says she turns the conversation to closed vs. open architecture systems. Aguirre favors open architecture because it allows clinicians to grow with the technology. While turnkey systems are great for when a clinician wants the whole workflow as a single piece, Aguirre says, it doesn't allow for room for digital workflow growth as technology advances.
In addition, open architecture systems allow clinicians to integrate existing equipment into their workflow. Aguirre says that getting into chairside milling with their existing scanner is often appealing to the practice as they are able make use of an existing asset.
"Open-architecture systems like the 42W [Roland DGA’s, DGSHAPE DWX-42W] allow a user to use their existing intraoral scanners," Aguirre explains, adding that it also lets you add different brand scanners to the workflow later. "With an open-architecture system, you could have 5 different brands of scanners if you wanted to, and you could integrate all of them into that same workflow. So, it provides a lot of flexibilityand versatility."
"As long as the practice can export that restoration file, we can import it and mill it. If they can only scan and don't have design software, we can bring it into our design software and design and mill that restoration," Sternberg says, regarding the Planmeca mills.
The integration of existing equipment is essential, Soliman agrees. Many offices do not consider a production workflow when purchasing acquisition software (scanner) or design software.Soliman says that vhf mills are designed to work with any open architecture scanners or software through STL export.EXOCAD and 3Shape users get an even bigger workflow advantage thanks to a trusted connection to the Z4 mill that streamlines the nesting process, he explains.The vhf line has several wet and dry milling machines, including the Z4 wet milling machine for same day dentistry applications, which are all open architecture. However, he thinks practices sometimes do not consider early enough in the process whether the mill they want to add to the workflow will fit in with this established system.
"You'd be surprised how far they go before they think about that," Soliman says.
How Much Do You Have in Your Budget?
Another important consideration is the price tag. Some mills decreased in price over the past decade, but some haven't and range from $150,000 to $160,000.
By contrast, Sternberg says the Planmeca FITÒ System which includes our PlanMill 35 for "bread-and-butter" restorations, e.g., crowns, inlays, inlays, veneers, and 3-unit bridges, starts at under $100,000. The more sophisticated mills cost more, but they do more, too, and reduce your costs per restoration, Sternberg explains. For example, at around $135,000, you can get the Planmeca FITÒ Plus which has our PlanMill 50 S allowing doctors to also mill splints, surgical guides, dentures, and full-roundhouse zirconia restorations.
"What kind of dentistry do you want to do: a general dentist who does crowns, inlays, onlays, and maybe a 3-unit bridge, or a general dentist who wants to expand the practice and do more in-house?" Sternberg says.
"Price is always a consideration," Soliman agrees, " Business decisions should always consider initial cost, operating cost, and ROI. Clinicians can get a plug and play, high quality vhf machine designed for same day dentistry for under $45,000.
“But that also goes back to the goals for your practice,” Soliman continues. “If you know your goals, you can determine what your mill requirements are.Machines such as our top-of-the-line R5, can produce almost any restoration you can think of and can even mill overnight thanks to a 10-disc changer.A $75,000 investment in an R5 can produce a massive return to the right practice.”
Aguirre agrees the ROI is a critical part of this decision process. Mills with a lower price point have an edge in this department, especially for practices with fewer milled restorations every month. Roland DGA’s DWX product line with a price tag of under $30,000 is a departure from their usual offering, which have been units exclusive to dental laboratory markets.
“Our products make same-day chairside restorative dentistry an affordable reality with ROI in less than 12-months of ownership,” Aguirre says.
Avoiding Common Pitfalls with Your Mill Investment
Some practices try to do too much too quickly. It is essential to have proper expectations for how long it will take to transition to the workflow. Sternberg recommends starting slow with a single unit crown. Then, graduate to more complex cases while getting used to the new workflow.
Training is essential, too. While most manufacturers have training that gets a practice started, additional training for the more complex restorations should follow.
Sternberg recommends investing time in a clinician-led advanced training course for smile design or denture classes. Planmeca partners with Modern Optimized Dentistry (MOD Institute) in South Carolina for its advanced training programs.
"There are reasons there are advanced classes so that clinicians can get the most out of their investment," Sternberg says. "The most successful docs take the time, do the classes, and work their way through the technology."
Aguirre agrees that change can't happen overnight, and most practices need about a month to be consistent in same-day restorative delivery. Gradually integrating the workflow in the office is essential.
"Start by scanning your patient and bring them back in a few days, or even the next day, instead of trying to do same-day dentistry right away," Aguirre says. "Then, little by little, start to integrate that same-day aspect as the clinician and team's technique gets better. Most practices that do that set themselves up for success."
Also, Aguirre says, pick your most easy-going patient with a straightforward posterior crown preparation for that first same-day case. Then, she recommends calling that patient beforehand and setting a proper time expectation for the appointment.
"You don't want your patient to expect that they'll be there for an hour and then be upset because it takes longer and they have somewhere else to be," Aguirre says.
Not having an implementation plan causes friction, too. For example, Soliman says, practices should consider which procedures they will produce in-house restorations for, who will design the case, who will operate the mill, and who will maintain the equipment.
“Even our chairside Z4 mill is capable of making inlays, onlays, temporary crowns, veneers, final crowns, short span bridges and titanium abutments.Implementing all of these workflows at once will create too much confusion in a practice,” Soliman says. “The business owners should decide which of these restorations they will bring in house first, train staff appropriately, and incorporate the workflow before expanding their capabilities.Some start with posterior crowns since they are less visible and then expand into more cosmetic anterior cases as they become confident and get better at making esthetic restorations.
“In the end, in-house milling is usually a good investment,” Soliman continues. "Most practices see reduced over-head, increased patient flow, reduced chair-time per patient, and a more profitable practice.”