Restorative Digital Dentistry, Part 3: Integration of Technology Into the Clinical Practice

This is the final article in a 3-part series. Part 1 was published in the October 2016 issue and part 2 was published in the January 2017 issue of Dentistry Today.

INTRODUCTION
Recap of Parts 1 and 2

In “Restorative Digital Dentistry, Part 1: The Journey to New Paradigms” (Dentistry Today, October 2016), topics included the implications of technological advancements, emerging restorative digital dentistry (RDD) workflows, and the best practices in adapting those changes. The RDD workflows were classified into 2 groups. Those involving the physical impressions are considered partially digital while those that have no physical impression in the workflow are labeled totally digital. Attention was given to 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 proper utilization of the technology.

In “Restorative Digital Dentistry, Part 2: Choosing the Right Digital Dentistry Strategy” (Dentistry Today, January 2017), the New York Center for Digital Dentistry (NYCDD) system was described, along with tools for managing the changes at each stage of the RDD journey, as well as the building blocks of success. These included the following:

  • Setting your objectives and choosing the right digital dentistry strategy, manufacturers, and partners
  • Planning the installation and implementation of new systems with your team and vendors
  • Providing the management and leadership to keep on track and to achieve your professional and team objectives, maximizing your return on investment
  • Aligning your lab relationships in the changing digital dentistry world.

In this last piece of the series, I will look more carefully at pitfalls and success factors from my own personal experience in Kaye Dentistry, as well as in NYCDD consulting and training.

THE FUTURE IS HERE
I believe that the number of practices switching to digital scanning will continue to grow, perhaps with even more momentum than the profession has seen up until now. Digital scanning can provide the fastest mode through which to become a better dentist; it allows us to see the details of tooth preparations at a much greater degree of magnification, achieving new levels of precision and accuracy from the simplest to the most complex restorations and prosthetics. Dentistry is seeing new ecosystems forming between dentists and innovative labs, with the labs providing breakthrough restorative solutions, knowledge, and technology centers that enable advanced workflow solutions and unprecedented dental competencies.

Implementation of in-office CAD/CAM systems allowing clinicians to provide same-day dentistry also continues to grow. Guided surgical implant planning using precise CBCT and STL file integration has improved the success in implant-driven restorative dentistry. Implant surgical guides can be designed and milled, allowing for predictable placement.

Figure 1. Full-arch mandibular scan (True Definition Scanner [3M]).
Figure 2. Full-arch maxillary color scan (3Shape Scanner). Figure 3. Full-arch maxillary color scan (Planscan [Planmeca]) with chairside milling unit (PlanMill [Planmeca]).

Today’s RDD systems are trending more and more toward open architecture, utilizing STL file integration. RDD systems can be combined to create optimal workflow solutions and protocols for better diagnostics; to allow for improved communication between the dentist and the dental laboratory; and give us the ability to control aesthetic, occlusal, and functional parameters in our restorative cases (Figures 1 to 3).

Design of PMMA and Restoration Try-in
It is now routine in our practice to collaborate with our dental lab technicians during the design and modification phases of the restorations. We are able to view a digital (virtual) wax-up and to provide vital input before the restoration is fabricated. In many cases, the lab team will fabricate the restoration in a polymethyl methacrylate (PMMA) material, giving us the ability to try-in an exact replica of the final restoration and allowing for simple and convenient modifications. We usually have the patient wear the PMMA restoration for a few days or even weeks. Once we are satisfied with the result, we simply scan the PMMA restoration and then copy it precisely in the appropriate long-term material of choice. In the event that no adjustments to the PMMA restoration are required, it is not necessary to rescan the restoration. The exact digital file that was used to fabricate the PMMA restoration can produce the final prosthesis.

Why Is RDD So Important?
The advances in RDD are as follows:

  • Significantly improving the quality of our patient care
  • Increasing our operational efficiency and effectiveness
  • Redefining our practice organization, focus, and scope
  • Helping us comply with federal and state regulations
  • Opening doors to maximize current and future revenues of our practices.

Fundamentally, RDD is elevating our professional standards of care and, with time, our patients will gravitate to those dentists who provide it. We repeatedly see that the emotional “wow” factor following the implementation of RDD is real. A dissatisfied customer will tell between 9 and 15 people about their experience, while about 13% of dissatisfied customers tell more than 20 people, according to the White House Office of Consumer Affairs. The patient experience of a digital scan compared to a physical impression is a good example of this. Patients in our practices have overwhelmingly expressed how much easier the experience of a digital scan is compared to an impression. While most of our patients can tolerate an impression, there are many aspects of it that are not pleasant, such as gagging, the bad taste, claustrophobia, and the sensation of choking. The negative perception of dentistry has always been a barrier to proper oral healthcare. RDD helps to minimize this.

Figure 4. People and technology management skills are at the heart of success.

What Do Successful RDD Projects Look Like?
Part of the answer is that the installation of the RDD system occurs as scheduled, within budget, and that it does what it is supposed to do on every technical level.

However, success is fundamentally based on your team’s ability to reliably and accurately complete the workflows as expected when the system was purchased. This means that your implementation has achieved the business and clinical goals that you set and that everyone on the team has mastered the required new knowledge, competencies, and skills. Defining success properly is a crucial part of successful projects and, when we adopt technology, we track the progress very carefully using our 100-day tracking system as discussed in part 2 of this series. This helps the team, in general, as well as each individual member, stay on track.

Figure 5. Average employees versus great employees.
Figure 6. Coach your practice to “learn RDD together.”
Figure 7. Learning curve.

Reality Check
While installation is usually straightforward, implementation success is not. Perhaps only 30% to 40% of projects achieve full implementation success.

Practices often get off to an enthusiastic start in their RDD journey. However, the technology has a certain degree of complexity and there are potential problem areas and risks that need to be managed. In the various stages of the CAD/CAM journey, these include the following:

  • Installation road bumps
  • Inconsistent technical support and training
  • Extended times for scanning and designing crowns and inlays/onlays
  • Slow transition to crowns produced using CAD/CAM
  • Tackling complex cases too quickly
  • Difficulties synchronizing patient scheduling with CAD/CAM
  • Poor understanding of impact on the practice workflows, productivity, and economics
  • Muted patient reactions
  • Slow transition to same-day dentistry
  • Team members with low levels of IT experience and knowledge
  • Difficulties training uninterested fellow dentists and assistants
  • Cost and hassle of keeping up to date on latest software versions
  • Preparation design and technical knowledge of CAD/CAM materials
  • Labs and dental practices not set up to send and receive STL files and partner effectively (many labs still have no digital scanning, design, milling, or 3-D printing equipment and, therefore, are unable to be an effective partner for more complex RDD cases).

Adopting RDD is a journey, and is often well worth the reward. We have to manage both the purchase and the implementation project and treat them equally. All too often practice owners fail to realize that once they have made the decision to purchase RDD equipment, they have to get started on implementing their new technologies. The vast amount of work lies in making sure that process goes smoothly.

Let’s look at some of the RDD key success factors that can help us prepare to succeed.

Align and Engage Your Team
We consistently find that the practice management challenges that arise from RDD adoption are more complex than most other types of changes that occur in our practices. The required professional and team leadership journey is not trivial!

We know that team members with “high engagement” help to accelerate successful adoption of new technologies, and the leadership skills of the dentist can help make the difference (Figure 4). I have seen this firsthand. When CAD/CAM was first introduced into the practice, the entire process—from setting up the computer, scanning the patient, designing the restorations, to milling and finishing (stain and glazing)—needed to be planned and controlled. The success with this technology accelerated when the assistant and the other team members got involved in the process. Their success contributes to their own engagement, which in turn contributes to the success cycle (Figure 5).

Leadership includes the following:

  • Making sure that there is a clear and aligned definition of the competencies, skills, and workflows required in connection with the new technology, and that everybody on the team understands what they need to do
  • Maintaining visible and personal commitment to the changes that are needed and ensuring that we model our willingness to change in our own professional behaviors
  • Developing meaningful reinforcements that provide daily positive consequences for the new behaviors we seek to see as part of the change, as well as negative consequences to discourage continuation of old behaviors
  • Giving our team members the opportunity to be proud of their work.

Team Learning
When it comes to the team learning curve, dentists, as leaders, can’t just hit people over the head with new concepts and hope that they get it. Educating, communicating, and implementing these changes together is imperative to achieving mastery of the new skills (Figure 6). It is also vital to the workflow as a whole.

We must also keep in mind the typical learning curve that people go through (Figure 7). It is not a linear process; there are the inevitable phases when hopes, fears, confidence, and competencies ebb and flow.

Think Workflow Solutions, Not RDD Products
Best-in-class RDD implementation is now focused around the mastery of workflows, including the partnership with digital labs and restorative solutions providers. The ecosystem within which our practices function is changing. RDD is opening up closer connectivity and synergy with labs through STL file transmission networks such as Digital Dental Exchange (DDX [Henry Schein]), specialists, vendors, and distributors.

CLOSING COMMENTS
RDD can be complicated. It can be frustrating, demanding, confusing, and exhausing; however, is can also be extremely rewarding. It can enhance and revolutionize our patient experience, our office professionalism, and our profits.

It requires us to make smart choices about strategy, about manufacturers, and about giving of ourselves; to learn and exchange information and ideas; to share knowledge and experience; all so that we can better serve our patients.


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 26, 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 26, 2016.
Kaye G. Keep score and win with technology! Sidekick Dental. Winter 2012. sidekickmag.com/dental-technology/keep-score-and-win-with-technology. Accessed September 26, 2016.
Kaye G. Restorative digital dentistry, part 1: The journey to new paradigms. Dent Today. Oct 2016;35:22-27.
Kaye G. Restorative digital dentistry, part 2: Choosing the right digital dentistry strategy. Dent Today. Jan 2017;36:20,22-24.
New York Center for Digital Dentistry online resources are available at nycdd-resources.org.


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 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, Texas. 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, is the 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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