Dr. Eugene L. Antenucci

	A dental practice in the United States is largely comprised of private practitioners whose attention given to mastering clinical skills often outweighs attention to mastering business skills.

	The in-roads being made in dentistry by corporate entities place a strong spotlight on the differences of approach in dental practice when the business of dentistry is given equal weight to clinical skills. Practices that place equal emphasis on business strength have a strong advantage in all areas of the dental marketplace-especially with respect to delivering higher levels of patient care.

	The long-time president, chairman and CEO of General Motors Corporation Alfred P. Sloan in his book My Years with General Motors wrote, “The big work behind business judgment is in finding and acknowledging the facts and circumstances concerning technology, the market and the like in their continuously changing forms. The rapidity of modern technological change makes the search for facts a permanently necessary feature.” 

	In 1999, Microsoft founder and CEO Bill Gates wrote his revolutionary book Business @ The Speed of Thought. In it he stated, “I have a simple but strong belief. The most meaningful way to differentiate your company from your competition, the best way to put distance between you and the crowd, is to do an outstanding job with information. How you gather, manage and use information will determine whether you win or lose.”

	If the words of these two giants in American business are true-that the continual search for advanced technology is key, and that the implementation of that technology is necessary to maintain competitive advantage - then it’s reasonable to assume that it would be important to understand the state of advanced technology in dentistry today by seeing what is not only possible but routine in technologically advanced dental practices.

	Patients routinely come to the office for consultations regarding the placement of dental implants for missing teeth. An ultra-low dose dental cone beam computed tomography image (ULD CBCT) is the only image taken during the consultation. The image shows all of the required information for answering the patient’s questions, for determining whether the patient is a candidate for implant placement and for virtually planning the implant.

	A 39-year-old female presented as a new patient for an implant consultation to replace missing tooth #30. A ULD CBCT (Figs. 1-2) was taken, and it was determined the patient was a candidate for implant placement.

	A review of the scan revealed no pathology. The bone appeared to be dense with adequate width. The mandibular nerve was drawn, showing the nerve and the foramen were safely inferior to any position the implant would be placed.

	Using Planmeca Romexis® software, the appropriate implant library was selected, and a Camlog iSY 4.4x13-mm implant was placed virtually, along with an abutment and library crown to help visualization of proper implant angulation.

	From this consultation, the patient agreed to treatment and became a patient of the practice. She scheduled a new patient examination and hygiene appointment and scheduled surgery for the implant placement.

Trending article: Using technology for better esthetic outcomes

	A surgical guide was printed from the implant scan. The Romexis cone beam study is transferred within Romexis to the Romexis Surgical Guide Module, where a surgical guide is designed for implant placement (Figs. 3-6). The stereolithography file (STL) for the design guide was then downloaded to 3D printer software to print the surgical guide in-house on the practice’s 3D printer.

	                                                                  Fig. 3                                                                                                          Fig. 4

	A day in the life of a digital dentist doesn’t pass without digital impressions utilizing a scanner and milled fabrication of restorations. Fabrication may be accomplished in-house in a single appointment or by a laboratory from the digital scan impression.

	Fig. 5                                                                                      Fig. 6

	The implant in the tooth #12 area on the 50-year-old female patient is ready for restoration. In this instance, a stock abutment was selected and prepared extraorally. The abutment was placed to 25 ncm torque.

	The PlanmecaFit with the Planmeca Emerald™ scanner (Figs. 7-8) was used to take a set of digital impressions, and the restoration was milled in the PlanMill

 40 S using an Ivoclar Vivadent IPS e.max block shade A1.

	The milled restoration (Fig. 9) was crystallized and glazed in an Ivoclar Vivadent Programat CS2 oven.

	The restoration was seated (Figs. 10-11), contacts and occlusion checked, and luted into place with Ivoclar Vivadent SpeedCem composite luting cement.

	Finally, a day in the life of a digital dentist isn’t complete without a same-day restorative case. Digitally scanned impressions allow for the consistent, accurate, comfortable and cost-effective production of restorations.

	A 46-year-old male patient presents with pain on tooth #6. He stated he was traveling overseas in four days for an extended period of time and would like treatment to be completed.

	A digital periapical X-ray (PA) (Fig. 12) was taken using Air Techniques ScanX phosphor plates. The PA revealed caries into the pulp. The tooth would require endodontic therapy, a post core and a crown.

	Fig. 12                                                     Fig. 13

	Root canal therapy was completed (Fig. 13).

	A carbon fiber post and composite core buildup was completed (Fig. 14), and a soft tissue crown lengthening was performed with a diode laser at a setting of 2W continuous pulse mode.


	Fig. 14                                                                                             Fig. 15

	A digital scan (Fig. 15) was taken using the Planmeca Emerald. The total scan time of the preparation, the upper arch and the lower arch was less than two minutes.

	An IPS e.max CAD block low translucency shade A2 was milled in the PlanMill 40 (Fig. 16). Milling time was 14 minutes.

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	The milled crown was tried in the patient’s mouth and contacts and occlusion were adjusted. The crown was cleansed and dried and prepared with e.max stains and glaze prior to an approximately 20-minute cycle in the Ivoclar Oven (Fig. 17).

	The final crown (Fig. 18) was seated and cemented with Ivoclar Vivadent SpeedCem cement. The total treatment time for this case was three-and-a-half hours from start to completion.

	A day in the life of a digital dentist is a fulfilling and satisfying day in terms of the high level, sophistication and variety of care that can be accomplished, not to mention the high degree of profitability afforded.

	The search for optimal advanced technology is a never-ending quest; however, it’s an essential ingredient that’s required for success in today’s economic and practice environment.

	To paraphrase Bill Gates, the most meaningful way to differentiate your practice from others in the eyes of your patients, and the best way to put distance between you and the crowd, is to do an outstanding job with advanced dental technology. How you use advanced technology to gather and manage information and to provide care will determine your level of success in this profession.

Articles

How to use digital technology to improve patient care

Practicing dentists are faced with daunting choices when it comes to incorporating advanced technologies – 

, implant surgical devices, 3D computed cone beam radiographic imaging and computer-based management, as well as educational, promotional, and diagnostic technologies lead the list in 2014. 

The purchasing decision-making process is difficult in and of itself; dentists have to balance perceived needs and benefits with the pull of strong, focused marketing information and hopefully a high level of business ROI analysis.

But once you make your new purchase, what then?

Here is some advice I have learned from working with other dentists and incorporating my 

 Invest in education for the dentist and staff to develop a working knowledge of CBCT for the entire team, which includes image acquisition, fluency with the imaging software, and a basic understanding of CBCT image interpretation. This will allow a practice to acquire images consistently and interpret the data quickly and accurately on command for optimal benefit.

 Develop a clearly defined practice protocol for when images are taken. CBCT is not designed to replace 2D panoramic images, but a CBCT study will provide information that 2D images cannot provide. A practice protocol or flow sheet will standardize the use of CBCT for maximum benefit.

  Every practice needs to have a concise understanding of the procedures for which that particular practice will utilize CBCT. Each practice will differ according to the procedures they perform. With this knowledge, the practice can analyze past need historically and use this information to develop ROI figures.

For devices such as the ProMax 3D by Planmeca, this would include the number of 2D Panorex images that would be taken. For example, three pans a week at $125 per image ($1,625/month), eight implant CBCT studies per month at $375 each ($3,000/month), five CBCT studies of impacted third molars at $200 each ($1,000), and five CBCT studies of endodontic cases at $200 each ($1,000).

This minimal use would generate $6,625 in revenues monthly, providing an excess of $4,000 in direct profits monthly or $48,000 annually, without consideration for production from procedures generated by the diagnostic information from the imaging.

Knowledge of the type and frequency of procedures performed on a monthly basis removes the guesswork from calculating and planning ROI.
	 

Dr. Eugene Antenucci’s expertise in the clinical integration and utilization of advanced dental technologies has assisted many dentists in making sound decisions in working with and profiting from technology in practice. As an international lecturer, his programs have provided hundreds of attendees with concrete and usable information on the practical applications of technologies such as digital impressioning, intra- and extraoral imaging, digital radiography, dental lasers, CBCT imaging and office automation, as well as the incorporation of social media and the internet in dental marketing in order to increase a practice’s visibility and flow of new patients.

Dr. Antenucci currently serves as a Clinical Assistant Professor at NYU College of Dentistry teaching implant surgical and prosthetic dentistry. He is a Diplomate of the International Congress of Oral Implantologists and a Fellow of the Academy of General Dentistry. Eugene has served in numerous leadership roles with the Academy of General Dentistry at both the State and National levels. He has many years of experience with chairside CAD/CAM and Cone Beam Imaging, and incorporated the Planmeca ProMax 3D in his practice in 2008.

Practicing dentists are faced with daunting choices when it comes to incorporating advanced technologies – CAD/CAM, lasers, digital radiography, implant surgical devices, 3D computed cone beam radiographic imaging and computer-based management, as well as educational, promotional, and diagnostic technologies lead the list in 2014. 

3 ways to improve your dental practice's ROI using CBCT

	In restorative dentistry, close attention must be paid not only to the restoration, but to the area surrounding the restoration as well. This type of thinking should be applied to provide the esthetics and functionality the patient seeks. Therefore, to provide the best in patient comfort and minimally invasive procedures, practitioners must maintain familiarity with the newest instruments and techniques available through innovation and product development.

	Of these new instruments, the soft-tissue diode is one that should be added to every restorative and esthetic dental practitioner’s arsenal. Soft-tissue diode laser techniques are proven to be more efficient and gentle when compared with previous procedures. These lasers also are much less traumatic to the surrounding areas and the patient.

	Soft-tissue diode lasers not only give practitioners the ability to precisely complete routine procedures performed in general practice, but also many procedures they previously would have referred to specialists. They are particularly useful for gingivectomies to facilitate caries removal and enhance a smile’s esthetics in a minimally invasive way. When used to create a trough around prepared teeth, these lasers also can improve the quality of daily impression taking, resulting in impressions that are cleaner and more accurate.

	Soft-tissue diode lasers use an energy wavelength of 810 to 980 nm, a level proven to demonstrate a high affinity for soft tissue.

 Diode lasers also demonstrate photo-thermal effects to ablate, or cut and seal, soft tissue through vaporization.

 As a result, patients tend to experience far less post-operative discomfort, as well as significantly less collateral damage to otherwise healthy surrounding tissue areas.

	Soft-tissue diode lasers also have the ability to achieve simultaneous cutting and coagulation.

 This advancement in laser technology provides an immediate hemostasis with far less tissue-charring and a reduction of bacteria that lessens the incidence of post-procedure bacterial and viral infections.

 In contrast, conventional methods and instruments, such as scalpels, contribute to patient discomfort because they involve steel, pressure and mechanical friction to cut soft tissue. These methods and instruments often result in excessive bleeding, swelling and discomfort, as well as a need for postsurgical dressings.

	Previous generations of soft-tissue diode lasers tended to be cumbersome and heavy, with fiber systems that were expensive and difficult to manage. Newer generations, such as 

’s Odyssey 2.4G laser, incorporate innovations that make the laser easier to handle. The Odyssey 2.4G laser features a retractable fiber management system to avoid costly fiber breakage, simplify use and reduce overall cost. The Odyssey Navigator is another soft-tissue diode laser model that features a compact size and disposable fiber tips that fit on the handpiece.

	These lasers are routinely used in a variety of surgical soft-tissue procedures. When used adjunctively with CAD/CAM procedures, the Odyssey lasers are proven to provide excellent hemostasis, create bloodless troughs before impressioning and promote a positive post-operative tissue response (Fig. 1).

 Note that for CAD/CAM procedures, the creation of a bloodless trough, which separates soft tissue from existing tooth structure, helps prevent the formation of a “powder bridge” during digital impressioning (Fig. 2).

	The Odyssey soft-tissue diode lasers are lightweight and can be easily transported from operatory to operatory, unlike past models. A docking cradle easily secures to a countertop, providing mobility and a charging base for the rechargeable lithium ion battery.

 Units such as these promote freedom of movement throughout the practice, enabling practitioners to use the laser wherever it is needed.

	In comparison, earlier soft-tissue laser models were bulky and difficult to use and relocate. Also, whereas previous generations of soft tissue lasers required cleaving and stripping of the fiber optic tip before operation, the Odyssey Navigator uses uni-dose fiber tips that are pre-stripped and cleaved, facilitating efficient, easy operation.

	The Odyssey Navigator soft-tissue diode laser features more than 30 pre-set clinical settings, which are factory-installed in its intuitive software.2 This software also enables dentists to create their own programs and settings.

 The technology, design and features of these lasers provide clinicians with greater ease of use and more flexibility than previously available.

	Each clinical situation is different, and appropriate power settings are determined primarily by the type of lesion, vascularity of the soft tissue (a more fibrous tissue may require a higher power setting), or the selected mode of operation, which can be continuous or pulsed.

	The cutting speed the dentist prefers also will determine the power intensity necessary. However, dentists should use the lowest power setting that will effectively modify the tissue while not charring the surrounding tissue.

	Soft-tissue diode lasers are useful when treatment planning calls for troughing around subgingival preparations, eliminating the need to purchase and place packing cords.

 By using lasers such as the Odyssey, troughing procedures are simple, and bleeding is often stopped or prevented completely. As a result, clinicians can capture an impression without the negative effects of blood, ensuring a predictable restoration every time.

 Gingival troughing using a soft-tissue diode laser can be initiated in the “Continuous Wave” mode with contact being made with the fiber optic tip, beginning at 0.8W2. The fiber is then angled against the tooth, with light pressure, during the lasing process.

	A patient presented with an existing crown on tooth No. 20, which needed replacement because of subgingival marginal caries (Fig. 3). Once the previous crown and caries were removed, the preparation presented subgingivally as expected. The soft tissue surrounding the preparation exhibited a moderate amount of bleeding, which needed to be controlled before powdering and optical impressioning (Fig. 4).

	An Odyssey Navigator diode laser was used to achieve hemostasis around the preparation, as well as to create a gingival trough. This was accomplished using a power setting of 1.5W for 30 seconds. The area was then cleansed with chlorhexidine using a cotton pellet, after which a light coating of powder was applied to the preparation. Once these steps were complete, bleeding was under control and an optical impression could be taken of the preparation (Fig. 5).

	Following the optical impression, an IPS Empress CAD LT crown in shade A3 was fabricated. The restoration was polished and seated using translucent Multilink adhesive resin cement (Fig. 6). The patient was pleased with the restoration’s esthetics and functionality.

They’ll be your practice’s workhorses

	Odyssey lasers provide dentists with a full range of settings and features that make them more user-friendly compared with the bulky laser units of the past. The operator can customize programs and settings, choose between pulse modes and continuous power settings, as well as aim the beam intensity. Because they are lightweight and portable, the easy-to-use units provide greater mobility. These lasers are considered durable workhorses that can be used in a variety of applications, and are backed by Ivoclar Vivadent’s service and support.

 In restorative dentistry, close attention must be paid not only to the restoration, but to the area surrounding the restoration as well. This type of thinking should be applied to provide the esthetics and functionality the patient seeks. Therefore, to provide the best in patient comfort and minimally invasive procedures, practitioners must maintain familiarity with the newest instruments and techniques available through innovation and product development.