Restorative Digital Dentistry, Part 2: Choosing the Right Digital Dental Strategy

This is the second in a 3-part article series. Part 1 was published in the October 2016 issue of Dentistry Today, and can be found in our archives HERE.

INTRODUCTION
The new paradigms for digital dentistry are transforming our profession and dental practices in fundamental ways. These changes are having a profound impact on many aspects of the way dentistry is practiced. They are having dramatic implications with regard to how we talk to our patients about dental care and the new patient service experience. There are also major effects related to the workflows for the clinician and team; in-office IT infrastructure and environments; professional skills and identities as dentists; the continually growing and long-term partnership with digital dentistry system manufacturers and suppliers; and, perhaps most importantly, the doctor-laboratory technician relationship. In the first part of this 3-part series, the implications of these technological advancements were discussed, and the restorative digital dentistry (RDD) workflows and best practices in managing the integration of these technologies into a practice were identified.

These RDD workflows were divided into 2 groups. Those involving the physical impressions were considered partially digital, while those that have no physical impression in the workflow were labeled totally digital. (Please consider reviewing part 1’s Figures 1 and 2, which ran in the October 2016 issue of Dentistry Today.) Great detail was included, discussing scanning techniques, materials, preparation, retraction, design, and finishing the restoration.

No matter which workflow clinicians choose, it is incumbent upon them to have a full understanding of the mechanisms and principles involved. This ensures the proper utilization of technology (Figure 1).

Figure 1a. Digital technician scanning, designing, and milling restorations in the laboratory. The 3Shape scanner and design software, Wieland Mill (Ivoclar Vivadent), and Roland Mill (Henry Schein) were used. Figure 1b. Chairside digital scanner and laptop (3Shape).
Figure 1c. Technician and dentist reviewing digital scan (True Definition Scanner [3M]).

At the New York Center for Digital Dentistry (NYCDD), a systematic approach to managing the changes in each stage of the digital dentistry journey has been developed. NYCDD’s mission is to help the profession adopt digital dentistry as effectively as possible. Throughout the years, NYCDD has supported many of the digital manufacturers from the stages of product development to evaluation and beta testing. Additionally, educational institutions, group practices, and individual dentists have also been offered support with the goal of seamlessly adopting digital dentistry. Three building blocks of success for each cycle in the journey have been identified, as follows.

1. Set Objectives and Choose the Right Manufacturers and Partners
The first step in the digital restorative process is scanning within the mouth. The information derived from that scan is used for diagnosis, treatment planning, and prosthesis design. The designed prosthesis is fabricated in a mill or 3-D printer, finished, and finally inserted in the patient’s mouth.

As discussed earlier, the technology is evolving in a way that allows us to complete the entire digital workflow locally in our offices or partner with a third-party laboratory. The dentist has to determine which of those steps will be done chairside and which will be sent to a digital laboratory. The laboratory, of course, can be either an in-house lab or an outside lab.

The author believes that a majority of dentists adopting this technology during the next few years will opt to do away with physical impressions and will purchase (or lease) a stand-alone intraoral scanner. The scans will then be sent electronically to a digital laboratory. We can refer to this strategy as scan only, as opposed to chairside (where the entire process is done in the office). If a dentist selects the scan-only strategy, then the next decision is which scanner/manufacturer to use.

Figure 2. The technology scorecard is a tool that allows dentists to evaluate new technology acquisitions. Figure 3. Checklist: Thinking Through Your 100-Day Plan and Engaging Your Team. The 100-day plan checklist for keeping track of technology integration can be dowloaded for free at nycdd.com.
Figure 4. Conventional physical impression received by laboratory.

At NYCDD, a technology scorecard has been developed to assist in the decision process for specific practice needs, taking into account any goals and factors that are important to the individual business. It is, in essence, an analytical tool that guides the clinician, as the practice owner, in decisions on when to adopt certain technologies from certain manufacturers (Figure 2).

2. Plan the Installation and Implementation of the New Systems With Team and Vendor Partners
Once the equipment is selected, the next step is to plan how it will be incorporated into the workflow of the practice. The manufacturer and vendor can usually provide many of the details, but it is up to us as dentists and practice owners to develop a roadmap and vision of how we plan to move the practice to RDD. New equipment and workflows bring a new dimension to the entire team. Assistants and hygienists can be utilized to set up and operate scanners in the same way that intraoral cameras are employed. In many offices, the dentist will control the entire process, ensuring that it can be done to his or her personal preference. As practice models evolve, they lean toward more “group type” settings with auxiliaries providing support, enabling the dentists to be more singularly focused on the patient and the dentistry while planning the team’s role in this implementation—something that is critical to success. An example may be that most of the scanners require periodic calibration in order to function and perform as specified; while any of these calibrations are performed by the manufacturer, it is the practice’s responsibility to make sure that it is done. Making the decision in advance, related to who on the team will own that responsibility, will serve to clarify roles and to ensure success.

3. Provide the Leadership to Stay on Track and Achieve Objectives
When dentists purchase an intraoral scanner or a complete CAD/CAM RDD system, they are often motivated to bring this technology to their practice and patients. Many of the team members will share that enthusiasm, but it may be challenging to those who have difficulties when presented with change. It is important to keep in mind that introducing any new technology can be disruptive to the norm, thus requiring a certain level of discipline and consistency to ensure that the transition is successful. Keeping track of those changes in order to achieve success requires that the clinician/owner leads and manages the changes. At the NYCDD, we use a 100-day checklist tool (Figure 3) to plan and monitor the progress on our RDD projects (Figures 4 and 5). (A free download of the checklist is available at nycdd.org.)

EFFECTS ON THE PRACTICE
Financial Aspects

As this technology has evolved, the costs have come down to a level where many clinicians can afford to own this equipment. However, there is still a significant financial commitment on the part of the practice. Probably the most important part of the decision is how it will affect the outcomes for patients, as well as how it will impact the clinician’s ability to deliver optimal care. For this reason, the financial health of the practice is as important as any other factor when considering this process. It is vital to look at what the effects will be on the overall financial health of the practice. Tools, such as those that determine return on investment (ROI), are available from most manufacturers and can be used to analyze the viability of going digital. Parameters that come into play in ROI include but are not limited to: savings in cost of impression material, fewer remakes, time saved, shorter appointments, and fewer visits.

Implication for the Team
For the team, the transition involves learning new workflows and skills. This impacts all team members (dentists, assistants, and hygienists) who are performing the new procedures, as well as the billing and scheduling teams. The whole spectrum of our conversations and communications with our patients is similarly affected. Success rests on the level of engagement of everyone in the office, and the sustained and visible commitment of the clinician(s) during the course of 3 to 6 months.

Ways to Increase Productivity and Professionalism
Once the learning curve has been mastered, the common outcome is an increased level of professional dental care that is based on superior diagnostic and treatment tools. The accuracy and precision granted can certainly make a sizable difference. Also, as we become familiar with the use of new technologies, we are empowered to increase our productivity. Improving the dentist’s productivity is pivotal so more results can be produced in shorter periods of time. Tasks such as scanning and design work can be delegated to team members. The dentist will see the best results when delegating most of the tasks that others can complete, leaving more time to focus on the high value work that only the clinician can undertake.

DIGITAL DENTISTRY RELATIONSHIPS
The Doctor-Technician Relationship

In order to provide successful prosthetic outcomes for our patients, the relationship we have with our laboratories and lab technicians is of paramount importance. As we move into the digital restorative process, this relationship becomes even more important. Our ability to communicate has an added dimension as we can collaborate in real time with our technician partners in every aspect of the process, from diagnosis to planning, critical evaluation of preparation results, and the sharing of design aspects as they are developed. We routinely look at design proposals from our technicians before fabrication. We are then able to communicate approvals and/or modifications prior to the fabrication of the prosthesis.

Relationship With the Lab as a Knowledge and Technology Partner
The partnership between the dental lab technician and the dentist with the traditional restorative techniques has been largely driven by the dentist’s clinical knowledge and experience, as well as the technician’s knowledge and experience with regard to materials and fabrication processes. As we move into digital processes, where the IT workflow provides both enhancements and limitations on what can be done, the dentist-technician partnership takes on a whole new dimension. Both parties need to have an understanding of what can be done and how it needs to be handled. All too often, the knowledge base may be uneven. Traditional dental laboratories, whose core competency may or may not include a strong technical component, often have to depend on a dentist partner’s strength in that area. Conversely, a dental laboratory can provide technical support to a dentist whose core competencies may not lie in technology. Through this symbiosis, the partnership takes on a new dimension. Digital restorative dentistry is bringing the doctor-technician partnership to an unprecedented level and is raising the bar on what can be delivered to patients.

Figure 5a. Scanning of stone models to create digital files. Figure 5b. Technician scanning the physical models.
Figure 5c. Digital model created from scan of physical models.
Figures 5d and 5e. Detail view of preparation and margins.
Figures 5f and 5g. Designed restoration or virtual wax-up.
Figure 6. PlanMill (Planmeca). Figure 7. TS150 (Glidewell Laboratories).
Figure 8. Chairside scanning PlanScan (Planmeca).

DIGITAL SERVICES
New Types of Services As Labs Are Transformed by Digital Dentistry and Advanced Material Science
Everywhere we are seeing how technology is changing industries, and clearly that is the case in dentistry. Manufacturers of CAD/CAM systems (such as Planmeca) offer online support and are starting to provide design services. Those services allow for a scan to be taken in the mouth, then the restoration is remotely designed and immediately sent back to the dentist for chairside fabrication on a milling unit (eg, PlanMill [Planmeca]) (Figure 6).

Dental laboratories (such as Glidewell Laboratories) are providing chairside milling units (eg, Glidewell TS150) which allow crowns to be milled in the office instead of in the laboratory (Figure 7).

The Importance of First-Class Internet Digital Connectivity
Digital files vary in size as to the amount of data they contain. The speed and reliability with which this data is transmitted over the Internet is dependent on the size of the file as well as the bandwidth of today’s connectivity. As we have seen in our office, the integrity of the connection is just as important as the bandwidth of that connection.

Most offices rely on a local Internet service provider (ISP) who offers different upload/download speeds. When selecting the type and level of service from an ISP, it is important to keep in mind how often and to what intensity you will use your bandwidth. In a busy office where many scans are sent back and forth, it is important to ensure that a sufficient program is in place. Most ISPs provide the opportunity to upgrade the service as needs grow.

What Are Some Emerging Services?
We are seeing the beginnings of new types of services for dentists that fall into the lab/dentist relationship. An example is the remote design services described previously. In some areas of the country, we are seeing mobile scanning services often provided by dental laboratories (Mark Hartslief, New York Center for Digital Restorative Solutions; nycdrs.org) where digitally trained personnel come into the office and provide the dentist with the scanner to take a scan of the patient. This is transmitted back to the laboratory for instant feedback to the dentist and subsequent manufacture of the finished unit. The finished unit is then delivered to the dentist’s office for final cementation; and, as with most digitally manufactured restorations, there is no or minimal adjustment at seating (Figure 8).

CLOSING COMMENTS
The right digital strategy is not the same for each dentist or practice. There are many parameters to consider. I hope that these insights help you choose the right strategy for you and your patients.

The ways in which digital dentistry is changing our practices is constantly growing, making this a great time to be practicing dentistry!


Next: The management and integration of new technology into the clinical practice, covering various pitfalls and success factors.

Suggested Reading
Battersby J. CAD/CAM—The end for dental labs or a new beginning? Dentistry iQ. May 6, 2014. dentistryiq.com/articles/2014/05/cad-cam-the-end-for-dental-labs-or-a-new-beginning.html. Accessed September 6, 2016.
Kaye G. The restorative digital dentistry puzzle: Including all of the necessary pieces. Dental Economics. November 20, 2014. dentaleconomics.com/articles/print/volume-104/issue-11/features/the-restorative-digital-dentistry-puzzle-including-all-of-the-necessary-pieces.html. Accessed September 6, 2016.
Kaye G. Keep score and win with technology! Sidekick Magazine. Winter 2012. sidekickmag.com/dental-technology/keep-score-and-win-with-technology. Accessed September 6, 2016.


Dr. Kaye completed his graduate dental school training at the Columbia School of Oral Medicine in New York City. He maintains a private practice in New York City and is the founder and principal of the New York Center for Digital Dentistry. He is a graduate of the Dawson Center for Advanced Dental Training and the Sirona Speakers’ Academy, and he is on the guest faculty for Planmeca University in Richardson, Tex. His lecture topics include ceramics, occlusion, and digital dentistry. He can be reached at This email address is being protected from spambots. You need JavaScript enabled to view it..

Disclosure: Dr. Kaye is a consultant to Henry Schein, owner of the New York Center for Digital Dentistry and Kaye Dentistry, and maintains an ownership interest in the New York Center for Digital Restorative Solutions.

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