In an interview conducted by Dr. Damon Adams, Dentistry Today’s Editor-in-Chief, Drs. Frank Spear and Sameer Puri, and Mr. Imtiaz Manji discuss current and future CAD/CAM technology and how they might impact your practice. Dr. Spear is the Founder and Director of the Spear Institute for Advanced Dental Education. Dr. Puri is co-founder of the Web site cerecdoctors.com, and is a certified trainer and educator on CEREC proficiency. Mr. Manji is Founder and CEO of the Scottsdale Center for Dentistry.
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| Dr. Spear using the CEREC machine with a patient. |
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Figure 1. Full coverage all-ceramic crown created for tooth No. 19, using a feldspathic por-celain block (VITABLOCS Mark II [Ivoclar Vident]). |
Dr. Adams: For the practitioners who may be considering the purchase of an in-office CAD/CAM system, what advice can you give to help them in choosing a specific system?
Dr. Spear: I always select equipment based on a set of criteria that include technical and financial considerations. First and foremost, the restorations produced must fit an appropriately prepared tooth as well as, or better than, a laboratory-fabricated prosthesis. The system must be easy to use with a learning curve that permits its initial implementation quickly with minimal training and downtime. It must be backed by a company with an excellent track record for supporting the equipment, the software, and the doctor. There should be advanced training opportunities available so that the full capabilities of the system can be mastered once the basics have been learned. When the system meets all of these criteria it must then fit the financial model and plan for the business.
Dr. Adams: How can any dentist, including high-end clinicians such as yourself, fully benefit from CAD/CAM dentistry?
Dr. Spear: As I have observed the development of this technology, it has become very clear to me that impression materials will become one of those items that we talk about with young dentists who have never used it. The ability to capture and store what is essentially a permanent record of a preparation that can be used as many times as necessary is a fundamental change that all dentists will benefit from. Laboratories are already using computer-aided design (CAD) and computer-aided manufacturing (CAM) to create many laboratory-fabricated restorations, so the benefits are already being enjoyed by many who are unaware of it. The ability to quickly obtain a well-fitting ceramic restoration will permit dentists to offer patients a service that would have required multiple visits in a single one. For a large number of patients this makes the difference between yes and no, thank you.
With composite blocks available, operative restorations can be greatly improved with a minimum of time, and the creation of composite temporaries in a complex case can provide the time of service necessary to work out the variables that often mean the difference between success and failure. As we use this technology I am absolutely certain new uses will continue to be discovered. Even so, we need to recognize that one size doesn’t fit all, and all clinicians will continue to need a strong relationship with their dental laboratory technicians to support high level comprehensive care.
Dr. Adams: What do you think is the number one hurdle that clinicians face when trying to implement new techniques and technology such as CAD/CAM systems into their offices?
Dr. Spear: The number one hurdle to any new technique or technology is always a commitment to implementation. In the absence of a strong commitment to training and time in the operatory, frustration will cause you to set it aside in favor of your “tried and true.” In the learning curve, you must be willing to take more time with patients so that the new technology becomes seamlessly fused with the procedures in your office. It’s like a roller coaster ride. The energy you put in at the beginning is what powers the entire ride and then, it’s mostly downhill.
Dr. Adams: CEREC is now entering its 24th year of service very soon. As a practitioner, what have you been impressed by the most with that technology? In your opinion, what has impressed you the least, and what could be changed or developed further to address any current concerns with this system?
Dr. Spear: Again, as that observer of CAD/CAM mentioned above, I am most impressed by the fit of the restorations that I have seen and personally completed. This was not an attribute of those I saw several years ago. As I began to learn how to utilize the technology, I became tremendously impressed by the ease of use and a learning curve that was a small hill rather than a mountain.
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Figure 2. Full coverage all-ceramic crown created for teeth Nos. 30 and 31 using a lithium disilicate block (e.max CAD [Ivoclar Vivadent]). |
I have to search for what impresses me the least since I’m new to this technology, so I’ll answer that by addressing the final part of your question. Many dental offices will struggle to bring another rolling piece of equipment into the operatory where space is already at a premium. Development of a wireless camera for capturing the digital impression, combined with software that could be integrated into the office network would allow even space-challenged doctors and patients to benefit from this technology.
Dr. Adams: What are your suggestions for CEREC owners that want to get the most out of their system?
Dr. Spear: Never stop learning! Each time you learn something you are building on everything you’ve learned before. If it’s material that you have previously studied, I promise you are not hearing the same thing you heard before—because you are different. Seek out opportunities to learn more about your CEREC by attending courses and meeting with other users. In my teaching, I return to the same topics because repetition of concepts and skills are what create mastery. I am a student as much as I am a teacher. An ongoing commitment to learning is what will get you the most out of your CEREC, and out of your life.
Dr. Adams: Can you give some examples why it is important to have various materials available for use with the CEREC technology; concerning such issues as aesthetics and strength?
Dr. Puri: Unfortunately there is no magic bullet in dentistry with regards to materials. Each patient is unique and each clinical situation is unique. By having a multitude of materials to choose from, we can address the unique clinical challenges that each patient poses. Being limited to only one material is akin to sending a case to your laboratory and being only able to do cast gold for every tooth, regardless of the area of the mouth, or the patient’s aesthetic desires and needs.
With CEREC, when fabricating full-contour restorations, dentists have the ability to choose from a number of materials that include feldspathic porcelain, leucite-reinforced porcelain, lithium disilicate, and composite. For those dentists who choose to mill their own copings, a number of materials are available including zirconia.
Dr. Adams: What are the actual material benefits to the doctor and patient in having these materials fabricated into restorations via the CAD/CAM process versus being done conventionally at a dental laboratory?
Dr. Puri: A tremendous amount of research has been done on this, most notably by Dr. Rella Christensen of CLINICIANS REPORT, formerly known as Clinical Research Associates. To keep it as simple as possible, CEREC materials are homogenous—meaning no layers, voids, or porosities. These materials perform very well in the mouth. Because the final restorations are milled from a solid piece of porcelain or composite, any deficiencies inherent in the layering process are eliminated resulting in a stronger final restoration. Take composite for example—it is an excellent restorative material when placed properly. However, it is subject to operator error if it’s not placed in layers. More significant polymerization shrinkage can occur if large amounts of composite placed in bulk are cured all at once. This in turn results in increased internal stress. If we take the example of 3M ESPE’s composite blocks, all the polymerization has occurred already when the blocks are fabricated in the factory. Therefore, you end up with a stronger composite, easier placement for the clinician, and less variability in the final restoration.
The same occurs with porcelain. With the e.max CAD material, you have a homogeneous block of lithium disilicate and the properties are factory controlled. You do not have to worry that improper handling by the dental laboratory technicians will factor into causing deficiencies in the material. The consistency of homogenous materials is important and this results in highly successful restorations over time. These materials have performed extremely well clinically in my office.
Dr. Adams: In your opinion, as we move forward, will more restorative dental materials or new digital technology be developed and made available for use with CAD/CAM systems?
Dr. Puri: There is no doubt that we will continue to see innovations in both the materials and the equipment. Sirona recently launched their next generation CEREC camera and it is a major advancement allowing the clinician easier imaging and the fabrication of larger virtual models—even full arch models.
With continued development you will see the CAD/CAM systems become the central processing center in the office along with the integration of other technologies. CAD/CAM will be integrated with digital radiographic imaging allowing the clinician to expand the uses of the system by being able to preplan implant surgeries, plan abutment placement, and to use the CAD to mill out the abutment and the final restorations. Other uses may be to allow the fabrication of multiunit bridges at the operatory chair. While the software and hardware currently available is certainly capable of doing that today, we have a material limitation since currently there is no material available aesthetic and strong enough that can be milled to full contour chairside. Gold is not an option because it is simply not cost effective to mill gold blocks. Once a manufacturer can figure out a way to mill a porcelain to full contour that is both strong enough and aesthetic, the indications for chairside CAD/CAM will be expanded further.
No doubt, there will also be innovations that we cannot even anticipate until these systems have been in the field longer. While the future is bright for CAD/CAM, there is no doubt that today’s systems are very capable and are becoming an integral part of thousands of dental offices. With 23,000 CEREC users in the world currently, and other manufacturer’s technologies and machines coming on the market, this number will grow, not diminish.
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Figure 3. A large inlay created for tooth No. 2 using a composite block (Paradigm MZ100 [3M ESPE]). |
Dr. Adams: How high are the expectations that patients have these days for their dentist? Does CAD/CAM dentistry now play a role in some of those expectations?
Mr. Manji: Patients have always had high expectations for their dentist because, as a profession, they have set high expectations for themselves. With regard to integrity, safety, efficacy, durability, accessibility, prevention, aesthetics, and evidence-based care—dentistry has been ahead of the healthcare curve on all these aspects of care for the last 100 years. So, when we talk about patients having high expectations, it really is a compliment to the dental profession. Patients expect the best because they trust their dentist to act in their best interests.
Technology is no different. If it is worthwhile, patients expect to see it in their doctor’s offices before they see it anywhere else. Even so, patient expectations are accelerating and that is primarily being driven by the accessibility to information on the Internet. Twenty years ago, it was a safe bet that most patients had never seen the inside of a dental office other than their own doctor’s. Furthermore, they had no sources of education regarding their dental needs and treatment options—other than what was told to them in that one office. Today, the Internet has changed all of that. People are going online to find all sorts of information about dental conditions and care. They are using that information, often incorrectly, to identify their needs and treatment goals. Doctors need to become more aware of these behaviors and develop strategies in their patient experiences to better understand these self-taught expectations and gently course-correct them when needed.
For CAD/CAM, patient expectations are growing everyday because it offers a convenience factor that people crave. It’s no different than how iTunes changed the music business; people do not want to buy the whole album when all they want is one song. Why would someone want a 2-visit crown when they can get it all done in one visit? It really is quite extraordinary that patients want this kind of care so much that we receive several calls every month at the Scottsdale Center for Dentistry from patients who are looking for a CEREC dentist in their area. As more and more patients experience CAD/CAM, the tipping point will be reached and it will be universally expected by the majority of patients.
Dr. Adams: How does CAD/CAM play a significant role in patient loyalty?
Mr. Manji: The same forces that are changing patient expectations are re-engineering what patient loyalty means. Old-school loyalty was based on the fact that patients had no access to dental information besides our practice, and therefore they would come back to us because they knew us best. The new loyalty is reversed. It is not about how patients need us for their dental treatment; it’s about how we match the patient’s perceived needs and goals. The barriers to patients switching practices are dropping: patients can go online to another doctor’s Web site and in a few minutes of reading they may feel they know that doctor as well as you.
The world is smaller now and you’ve got to imagine all the dental practices in your area are lined up side-by-side practicing on the same street—kind of a dental version of the “auto mall.” When you understand this reality, then you will understand that loyalty has to be driven entirely by the experience you provide inside your practice. You have to ask what factors in your practice differentiate you from the dentist next door and help patients recognize that you are the best doctor for them.
Until it becomes ubiquitous in dentistry, CAD/CAM is going to be one of those key differentiating factors that signal to patients the uniqueness of their doctor. It is going to strongly enforce the loyalty of patients who are convenience-driven or technology-driven; or perhaps are younger patients who have grown up with advanced technology as part of everyday life. It is going to generally reinforce to all patients that you are on the leading edge of technology and committed to the best treatment choices offered in contemporary comprehensive dentistry.
Dr. Adams: Where does comprehensive dentistry rate with regards to commercial interests, and how can a dentist compete with that?
Mr. Manji: We’re living now in the bailout economy and so, even if someone’s income and lifestyle has not been affected, their mindset about their economics has. People are being protective, there is less credit available, and major purchases are being deferred. Comprehensive care competes directly against major consumer purchases ranging from new appliances to vacations to new cars. A car company has just announced that if you buy one of their cars and make at least 2 payments, then if you have a life changing event in the next 12 months (ie, your job is eliminated), you can return the car and be excused from your financial obligations. That kind of offer shows how intense the competition is for consumer spending choices and available credit.
The important factor to realize is that in any economy, there are businesses that succeed, and there are also businesses that fail. Therefore, the level of success a doctor can achieve is really a choice. In my experience, with some discipline to tighten up core practice systems, improve the clinical focus of the practice, and optimize techniques for creating value with patients, most practices can grow 20% to 30% in a normal economy. In this economy, that same effort is needed to protect the current practice’s economics. What will happen though, as the economy improves down the road, is that the growth will happen then and the practice will surge ahead. It’s never a bad time to improve your ability to diagnose and communicate the value of comprehensive care.
In terms of competing against other commercial choices for patients, we have to always remember that we are not selling a product with a limited shelf life. We’re offering the patient treatment choices that have a lifelong value to them. Doctors who master the ability to communicate lifelong value are not going to experience an economic downturn because they’re successfully connecting comprehensive care to patient needs that are innately more personal and important than any consumer product.
Dr. Adams: Where does in-office CAD/CAM stand in the new landscape of dentistry and how has CAD/CAM impacted dentistry? What do you see as we move 5 to 10 years in the future?
Mr. Manji: The wonderful aspect of any technology is that over time its capabilities improve and its costs go down, and the best example of that is the movie Star Wars from the late 1970s. The special effects that made it a hit can now be created by anyone on their home computer using almost free software. CAD/CAM is reshaping dentistry in the same way. Every evolution of it becomes more effective and more accessible. It’s going to become as fundamental to the delivery of dentistry as radiographs are for the diagnosis of dentistry.
The adoption of CAD/CAM is going to be huge. We have about 4,500 new dentists graduating each year. These young dentists have technology in their DNA. They think digitally and so CAD/CAM is extremely interesting to them because “digital” is a language they are fluent in. As these new doctors move into private practice, I can tell you that they are putting more value on associating in or purchasing practices that have CAD/CAM in place. In a little over 10 years, these young doctors will make up 35% of practicing dentists. So, in my opinion, in the next 5 to 10 years, the dental world will be divided into 2 camps: those utilizing CAD/CAM and the dwindling camp of those that do not. And this distinction will become even clearer in the minds of patients as well.
Dr. Spear is the Founder and Director of the Spear Institute for Advanced Dental Education. He continues to be recognized as one of the premier educators in aesthetic and restorative dentistry in the world today. He received his DDS degree from the University of Washington School of Dentistry in 1979 and an MSD in periodontal prosthodontics in 1982, also from the University of Washington. He can be reached at (888) 575-0370 or ksimon@seanet.com, or visit seattleinstitute.com.
Disclosure: Dr. Spear reports no conflict of interest.
Dr. Puri, co-founder of the Web site cerecdoctors.com, is a certified trainer and educator on CEREC proficiency. He also owns a successful private practice emphasizing aesthetic and reconstructive dentistry. After graduating from the University of Southern California School of Dentistry, he finished his AEGD residency at the University of Tennessee. Dr. Puri has been published in numerous professional journals and also serves as a consultant to various dental product manufacturers. He serves as the Director of CAD/CAM at the Scottsdale Center for Dentistry. He can be reached at drpuri@socalsmiles.com.
Disclosure: Dr. Puri receives financial compensation from the Sirona and Patterson companies for lectures and speaking engagements.
Mr. Manji is Founder and CEO of the Scottsdale Center for Dentistry, the continuation of his longtime goal to provide a world-class facility where dentists and teams can receive comprehensive, evidence-based, patient-centered learning. For more than 20 years, he has been educating and motivating dentists across North America. Mr. Manji’s newest workshops, Dental Office Design, BreakThrough Practice, and CEREC Experience, and his classics, Leadership & Team Alignment and Transitions & the Business of Dentistry, combine his endless energy and inimitable style with his practical teachings to make these programs a must-see. He can be reached at (866) 781-0072 or imtaz.manji@scottsdalecenter.com.
Disclosure: Mr. Manji reports no conflict of interest.
