Ryan Hamm is the former Editorial Director for Dental Products Report and Digital Esthetics.

Ryan Hamm

	Here at Digital Esthetics, step-by-step techniques are our bread and butter. We think there's no better way to showcase all of the technology and trends we cover than to see how real dental professionals are working day-to-day.

So with that in mind, we compiled this list of the 10 most-viewed how-tos we ran this year. Our readers (in other words: you!) have shown us that there's a real hunger for technique showing how all of this technology can actually be put into every day uses. In this list, you'll see techniques involving implants, 3D printers, temporary materials, technology that allows work across continents and more. 

	Above all, you'll see how technology is truly changing and innovating the dental workflow. These shifts aren't just designed to make things more automated-they're designed to make your jobs easier, your workflow more efficient and your patient care even better.

	Click the next button to see the list! 

	Technique: An alternative approach to long-term temporaries

	Our case study involves a female patient who was missing her lateral teeth, numbers 7 and 10. An implant had been placed on number 10 because the patient sought longevity in the treatment plan. She also wanted esthetically pleasing provisionals for cosmetic reasons since she would be wearing the restorations long-term-for six-to-nine months.

Must-read: Understanding the reality of the digital workflow

	Our purpose for this article is to demonstrate the best method for fabricating this type of excellent long-term temporization. This type of work is done through the fixed department and is cosmetic in nature. 

Check out the whole case by clicking here.

	Technique: Using a 3D printer for model work

	Dental laboratory techniques are changing, growing more digital and moving toward the electronic age at a rapid pace, as most technicians know. Everything happens at a lightning-fast pace and it can be overwhelming and hard to keep up.

Related technique: An integrated surgical guide step-by-step

	How do we decide what to do? How much money should we spend on the equipment? What should we buy first?

	The author will, in this case study, demonstrate the value he has found in one such piece of equipment and the benefits he believes all dental technicians would reap from purchase of the same. It’s a good value for the money.   

	Step-by-step: How to digitally plan implants and design surgical guides

By Bob Cohen CDT, Information provided by CAP

	Like many new technologies introduced into the dental market, guided implant surgery has been slow to catch on. The reasons are many: cost, learning curve of complex software and time to do the virtual plan, to name a few. More recently, placing implants using a surgical guide has become much more popular. We now have faster, more powerful computers, better software and an increased number of CBCT scanners in dental offices. As a result, guided implant placement is more viable and economically feasible than ever before.   

Technique: An alternative approach to long-term temporaries

	Recently, 3Shape launched a new software module called Implant Studio. This end-to-end solution is built for guided surgery, merging surface scans and CBCT (or CT) scans. Subsequent digital CAD design of the final restoration follows by planning implant placement. Utilizing the combination of the design of the final restoration, the CBCT and surface scans enable a best-in-class plan. This top-down digital workflow is both simple and precise and eliminates the need for manufacturing an appliance prior to and solely for use for the CBCT scan.  

	Step-by-step: Fabricating temporaries with PMMA material

	We used to fabricate our temporaries with acrylic by hand, and, for higher end long-term bridges, we would often use composite. This particular case study will explain what PMMA (defined by webopedia.com as “short for polymethylmethacrylate or, more correctly, Poly (methyl methacrylate), PMMA is a clear plastic acrylic material that can be used as a replacement for glass”) is and how we can successfully use the material in the dental world. 

	We can utilize technology, especially for implants, to create long-term temporaries through the use of a CAD/CAM machine. A good example of what we can use the material for is with a full-mouth implant case scanned and then copy scanned with a wax try-in already set up.

To check out the full workflow, click here.

	Step-by-step: A better screw-retained zirconia prosthesis

	For some time now, we have been fabricating screw-retained dentures with great success for the dentist and the patient alike. Using the All-on-4 technique and placement of four-to-six implants, we've created a new and better solution for edentulous patients in need of a denture. 

	There are two types of restorations we can generate for our patients in need of such service: Traditional Denture or Zirconia Prosthesis. Below we will discuss the pros and cons of the two solutions. 

Learn how this prosthesis was created by clicking here.

	Technique: How going digital can revolutionize esthetics

	We rely on digital advancements and technology as an integral part of our own day-to-day lives, and the rapid advancement of digital technology for the dental industry means that we can’t ignore it in our professional lives either. 

	Since our lab began accepting digital scan files more than six years ago, we have seen firsthand how digital scan files can improve dentist/lab communication, contribute to overall increases in efficiency, and enable better accuracy. More and more dentists are beginning to adopt digital scanning technology, and the results we’ve seen in our lab make it clear that this is a technology that has numerous benefits to dentists, labs and patients. At D&S Dental Laboratory, the integration of digital technology is key to our success. It enables easier client communication, more efficient workflows and better overall results. 

Find out how going digital helped one lab.

	Technique: Creating an immediate load denture using digital tools

By Tra’ Chambers Owner of Express Dental Laboratory and Dr. Steven Park

	The dental industry is currently experiencing a major revolutionary shift in the laboratory design process, slowly but surely transitioning from the traditional physical model to a new age of digital design.

	At Express Dental Laboratory, we pride ourselves on being an industry leader by utilizing many innovative new technologies available from Dentsply Sirona in order to manage our workload more efficiently and, in turn, providing our dental partners with a streamlined process of communication and superior deliverables.

Related step-by-step: Using inLab for great results

	A recent case that we prepared for Dr. Steven Park showcases the true power and potential of digital design and communication. To better understand the endless potential benefits of available digital technologies, we will take an in-depth look at this particular denture case, and how a seamless digital workflow is changing the landscape of communication between dentists and labs while producing truly superior results in regards to form, function and esthetics.

Check out a whole case showcasing the digital workflow. 

	Technique: Using digital dentistry for esthetic implant work

	Our latest techniques in digital dentistry are getting faster and better. We have so many options available to us that we did not in years past and our esthetics and overall case design have been greatly improved as well because of these streamlined processes.

Related reading: Smoothing out CAD/CAM with software

	The purpose of this article is to explain digital workflow to create zirconia porcelain layering for a screw retained unit to a full mouth case. There are considerations to look into when fabricating the final restorations securely, such as path of insertion for the implant crown. We also have to look at how deep the implant level is since this will have a major effect on the framework design.

	Before we can have a basis for our frame design, we have to have a step-by-step plan from both the doctor’s and the lab’s side of the case.

Click here to check out the full technique.

	Step-by-step: Providing immediate esthetics for implant cases

By Chris Halke CAD/CAM Supervisor Albensi Dental Laboratory and Dr. Michael Pikus Director of Clinical Education Albensi Dental Laboratory

	Today, immediate implant placement after extraction and immediate temporization is becoming an increasingly popular option for many clinicians.

	Implants have revolutionized dentistry and are allowing patients whose only hope 40 years ago would have been to get complete dentures to now be able to have an esthetic and functional fixed prosthetic. Initially, dental implants were placed by oral surgeons, and their restorations were almost entirely undertaken by a prosthodontist. As implant science improved with different surface treatments and an increased scientific body of knowledge about the process of osseointegration, more clinicians started to delve into implant placement and prosthetics.

	Immediate placement of dental implants after extraction and the patient’s need to have an immediate fixed restoration of dental implants have pushed many clinicians into providing this service to their patients. One way dentists are able to offer patients quick, accurate, esthetic, long-lasting and functional restorations is for the clinician to utilize a dental laboratory with a digital workflow. 

Check out this cutting-edge step-by-step. 

Articles

Digital Esthetics looks at the top 10 most-viewed step-by-step technique articles of 2016.

The Top 10 techniques of 2016

	This year, Digital Esthetics heads to the Big Apple to help dental technicians and lab owners understand the new digital reality of dentistry-and thrive in that new context! We’re teaming up with the Greater New York Dental Meeting to showcase the latest advances in dental technology, and we want you to join us.

	Join us in one of our four live panels as we explore new workflows and possibilities alongside some of the industry’s premier experts and voices. Each session will be a panel format, so come ready to learn and to ask questions. No questions are off limits-our goal is to help each dental professional walk away from the Greater New York Dental Meeting (GNYDM) equipped with the knowledge to help your lab become more successful than ever.

 or click the links below. The panel themes are below, and panel times are in parentheses. CE credit will be awarded by the GNYDM.

Futurecasting the digital workflow (Sunday, Nov. 27, 2:00-5:00 pm)

 This panel will explore the current status of the digital dental workflow, where they see it going and both challenges and opportunities they see. From CAD/CAM to CBCT to digital material advances, this panel is open to any and all innovations in the world of digital dentistry. This highly interactive session will begin with a moderated discussion followed by a Q&A session.

Understanding the new implant workflow (Monday, Nov. 28, 9:45 am-12:45 pm)

: Implants are big business for the entire dental world, but now that they’ve gone digital and can be placed into CAD software, the methodology for both labs and dentists is completely changing. Together, we’ll discuss how the workflow has changed and where it can end up, along with information for labs about FDA guidelines and how they need to protect their abutment and crown work.

3D printing updates (Tuesday, November 29, 9:45 am-12:45 pm)

 How is 3D printing is currently revolutionizing implant work? What business opportunities does 3D printing present, both now and in the future? How will 3D printing change what is possible in dentistry? This program will explore all of those questions and more.

ne case, multiple workflows (Tuesday, Nov. 29, 2:00-5:00 pm)

 This highly interactive format will show a single case and then track it through two-three completely different workflows. Technicians and dentists will be able to watch the workflow ecosystem they’ve chosen and see how it differs from other popular digital option on the market. We’ll look at how it’s possible to make a beautiful restoration with those tools, albeit in different ways. 

	We hope you'll join us and contribute to the conversation. 

Want to know how your dental lab can thrive using a digital workflow? Join Digital Esthetics at the Greater New York Dental Meeting and you'll learn about all the latest innovations in 3D printing, dental implants, CAD/CAM and more.

Join Digital Esthetics at the Greater New York Dental Meeting

	Ashkan Afghan is the owner of Creative Image Dental Lab in Southern California. Creative Image is a small, family-owned dental lab specializing in all-ceramic crowns and implant cases. In addition to Ashkan, the lab employs three employees.

	Ashkan is in charge of digital production, and recently made the decision to purchase a 3D printer to streamline his digital workflow and model production process. We recently spoke to him to find out how the 3D printer has changed his capabilities, how his dental clients have benefitted and how a printer fit into his existing digital workflow. 

Tell me a little bit about yourself and your lab.

 We are a small, family-owned dental lab. I was a dental assistant for about 10 years, and then I switched to working for a large dental lab and then finally opened up my own dental lab in 2010-2011. I’ve been in this business since 1991.

What kind of digital set-up do you have at your lab? What components does it have?

 system, which is made up of the inEos X5 scanner, and I have the inLab MC X5 milling, and then use the 

 for 3D printing. A large portion of our intraoral scans come through Sirona Connect, and I’ve also been getting a lot of Carestream [files], but I can accept any STL files.

How did a 3D printer fit into your digital priorities?

 Prior to purchasing the Dental Prime printer, we got the [CAD/CAM] system, and we were a traditional lab with in-house milling capabilities. For us to gain access to the Sirona Connect doctors, getting the files was not feasible for us because you have to send out the models to be printed, which can be expensive. Getting a 3D printer has not only opened us up to accepting more digital files, it has also replaced our model room, because I can scan the impression directly from the impression trays we get from the dentist, and we can work off the scan, and then we can print the model and mill the final restoration. While we scan it, it produces a file that we can print out. And it’s the complete cycle-from scans, to milling, to 3D printing. The printer also allows me to print out surgical guides from BlueSkyBio.

Related: 10 things you need to know about 3D printing

What do you primarily use the Objet30 Dental Prime 3D printer for in your lab?

 As a model printer, mainly. We can get the models printed out overnight, so it’s not a labor intensive thing, and I can have 20-25 models ready to go the next day; that’s one of the advantages. It’s accurate, and it comes right off the digital scan. And there’s always a cost factor-those three things are the main things. For sure, it’s made our redo rate lower, everything fits better and is more accurate and has made my life easier as a lab technician.	 

How have dentists and patients benefitted from the 3D printed models?

 They mostly see the printed models and they understand they’re dealing with a higher echelon of lab, and then they already know that we use a full-scale digital production with digital model work. For them, it’s an interesting thing to see the technology being used. For the patient, they often get to keep the 3D printed model as a souvenir.

	It’s definitely a value-add to our clients. Our number one reason for having this printer in house is to eliminate our model work, which saves time and money, and now we can accept digital and intraoral scans which before we couldn’t accept.

What are your future plans for your Objet30 Dental Prime 3D printer?

 I am planning to tap into the orthodontics world and do orthodontic retainers. Also I’m planning to contact other business/manufacturers, that would benefit from using a 3D printer. It’s not just confined to dentistry. A lot of manufacturers would like to see parts or prototypes. This is a very accurate printer, and I’ve contacted other manufacturers to print out prototypes for them. And obviously they would be charged for the prototypes we print. They don’t know the dental field is using very accurate 3D printers.

Are you excited about more materials being available? What opportunities does that open to your lab?

 So far the material I’m using is for the model and surgical guides. I know there is one that is a clear one, if you want to print out the clear one. I haven’t had a chance to use the other materials but I’m sure I will definitely order some in the future.

What was the learning curve for working with the printer? How did ETI Digital Technology help with that?

 I think having a background in and comfort with using CAD software helped, and it gave me a feeling for how the 3D model would work. I use 

 to create the models, and then Stratasys software to nest the files.

	It was pretty seamless to integrate with our workflow because it was the missing part of the technology. My whole lab was built on digital technology-the printer was the missing part of the puzzle, and so when it came in, it closed the loop.

ETI Digital Technology came to our lab for the installation and start-up training for the printer. They have a very knowledgeable technical support team, three of whom are Certified Stratasys Application Engineers. The installation and training of the printer went smoothly. ETI continues to to provide me with ongoing support and service. From a technical standpoint, they have been great. In addition to providing technical support, ETI provides back-up printing for their customers if a machine happens to go down. In fact, we now order all of our printing materials directly from ETI, as they keep an inventory of the build and support resins.

Watch: Going digital with a little help from ETI digital technology

 The reason I chose Stratasys is that they are one of the leaders in additive manufacturing and have been for some time. The reason I went with the Objet30 Dental Prime is that, with anything digital, I like to get the newest and the best in the market and this is the newest right now. It would also do what we needed to do for speed and productivity, and it was right in our budget in terms of price. For our production volume and lab size, this was the one that I wanted. 

A lab technician tells how using the Stratasys Objet30 Dental Prime 3D printer has improved his efficiency.

How 3D printing streamlines your workflow

3D printing is changing-and disrupting-all kinds of dental workflows. Here are five dental processes that have been revolutionized by 3D printing possibilities:

	This is the most common use (so far) for 3D printing. Whereas models used to require time to mix stone and then careful set up, models can now be printed using the same CAD file used to create the restoration. It’s an easy way to naturally fit 3D printing into a digital workflow. Plus, it provides a great visual aid for dentists-and a bonus technological marvel for patients to take home!

Take our quiz: 5 surprising facts about 3D printing

	Using wax and burning it out has been a tried-and-true prosthetic and restorative method for many labs for decades. But it’s also time consuming, and due to the materials used, is prone to annoying failures-plus, it can be boring to do! 

	While “printing” metal isn’t really possible, there is laser technology that “builds” metal frameworks or pieces, and usually this technology (SLM or SLA) is grouped in with 3D printers. This technology has allowed dentists and dental technicians who prefer to work with PFMs an option to retain that method while going to a more digital process. Plus, there are several outsourcing partners out there who can “print” straight from an STL file and provide dental professionals with frameworks for a variety of indications.

	As more materials are approved by the FDA for in-mouth use, it’s becoming increasingly possible to provide instantaneous temporary solutions for patients. This can allow immediate smile esthetics while patients are healing or waiting for restorations/prostheses, and can help patients visualize what the final results will look like.

Test your knowledge: Do you know these facts about 3D printing materials? 

	Surgery for dental implants can often be “free-handed” when drilling, but some implant cases require precision and accuracy. An excellent way to ensure that kind of care is through a 

. And now, thanks to the combination of CBCT scans overlaid with digital mouth/teeth scans, it’s possible to create a custom surgical guide for each implant case that takes into account bone level, tooth/root placement and nerve locations. A surgical guide can be used during the implant workflow to ensure successful osseointegration and a much better patient experience.

Digital Esthetics looks at how 3D printing is disrupting five dental workflows.

5 workflows changed by 3D printing

	Earlier this year, 3Shape released Dental System™ 2016, the latest version of its CAD software for dental professionals.

Dental System™ 2016 introduces new and improved applications and workflows as well as a completely rewritten software for impression scanning to eliminate steps in the dental lab workflow. Dental System 2016 is also designed to save time for lab technicians by making designing faster and more intuitive for simpler to more advanced cases as well as increasing software reliability.

Step-by-step: Providing immediate esthetics for implant cases

	Dental System 2016 introduced features like impression scanning. The 2016 version of the impression scanning application eliminates a dental lab’s need for pouring gypsum models and other manual steps in the workflow.

	All 3Shape dental lab scanners can now scan analog impressions and skip directly to CAD design: a workflow step-saver that can reduce crown turnaround time by nearly one day. The 3Shape D2000 and D1000 lab scanner models additionally feature multi-line scanning technology for a more detailed and optimal impression scanning.

	3Shape includes LABcare™ with all Dental System subscriptions. LABcare ensures that 3Shape users can continuously receive the latest technology through annual software releases such as Dental System 2016. In addition to upgrades, LABcare includes access to the 3Shape support network, as well as training channels such as webinars, videos and more. 

Updated impression scanning software-scan each side of a triple tray in less than 30 seconds and single trays in 75 seconds

New functionality accelerates 3Shape D500, D1000 and D2000 lab scanners’ performance and speed	

Increased stability for large cases such as implant bridges 

Robust crown design engine for fast and intuitive design

Easily work on advanced cases such as RPDs and full dentures

This tech brief provides a look at the features and advantages of 3Shape's Dental System 2016 software.

Understanding the new features of 3Shape Dental System 2016

	Over the past decade, dental professionals have watched their industry shift rapidly from traditional to digital. From chairside technology to lab-side digital design and manufactuering, digital tools have caused huge disruption in every workflow.

	We were curious how that kind of seismic change plays out in labs that do production work each and every day, so we turned to a member of our Editorial Advisory Board, 

The industry is changing really quickly from analog to digital. How did you make the change? 

 At Keating, we saw the writing on the wall early on as more and more of our doctors began requesting for us to accept digital files. From our start with 

 up to today, our manufacture partnerships and industry thought leaders have provided us with great information on current trends. 

	As more and more dental offices buy into digital technology, the need for the laboratory to transition into these systems is paramount. It is interesting that everyone has been talking about the digital solutions for several years, and only recently, with the price points of some of these systems coming down, have dentists become increasingly interested in getting into the game. 

	Basically, we work with all the systems at Keating. Open-architecture STL file formats are allowing us to work with 

 and several other in-lab software’s to fulfill these digital work orders coming in from the scanners in the dental office. 

11 ways to get great esthetics in your dental lab

How can labs keep their commitment to esthetics even as they go more digital?

 I see labs trying to go the cheapest route on labor and getting it out so they can sell it for a cheap price, where we totally do the opposite. We’ve kept all our technicians, many of whom are Certified Dental Technicians. We really take pride in that. We’re cross-training them from ceramists that have been stacking from the ground up, to ceramists that provide contour and final stain/glaze to the product. They have the training and eye for detail; we just changed the material and process. All my PFM techs have now converted over to our Bruxer-type restorations. So it’s not about letting go your commitment to esthetics-it’s how to incorporate the materials effectively into the lab by training the team on the new process and procedures. 

It seems like “going digital” makes people think they’re going to lose control to computers. How is that not the case? 

 I think it gives us more control. We have dentists working with us digitally. Digital doesn’t lie. We can get parameters on a crown, how it fits. We can add cement spacer for the dentist. We can wax things a little differently. I can go from 60 microns to 100 microns of gap space for cement. I can build connectors, the right 3x3 or 4x4 depending on where it’s at. I can build marginal ridges up to support within 2 mm. If I’m doing a stack-on type like a 

, I can build my ZR substrates exactly where I want support in the software. 

Related: What dentists REALLY want labs to know

	It’s much more consistent and accurate by going digital. Yet with all of us here at Keating, we’ve got that aspect that we love but we also keep improving on how we interact with the doctors personally. We still have all the people on the phones. We still have every case that a doctor can call on and go over it hand-by-hand with us and we can program or we can do it by hand. 

How can these new tools be used more effectively to maintain desired esthetics? 

 No one likes change. There are still people in my laboratory that are fighting it a little bit, but they’re kind of dinosaurs and they like their ways-but they’re seeing the writing on the wall. As more and more crowns go into this digital format and less is being done by hand, they have to adapt and change or retire. A lot of my people don’t want to retire. It’s a happy place to work here. They like working here but we have to give them all the tools we can to help teach them and not just throw them in blindly. We want to get the best educators here, to help us with the change.

Must-read: 7 ways to make your lab a successful business

	Every other week we have someone in here trying to help us improve on our technology. You’re always going to have to be on that cutting edge of learning and accepting that change is good. That’s the way it’s going in digital dentistry.

Shaun Keating talks to Digital Esthetics about his efforts to take Keating Dental Arts from a traditional dental lab to a fully digital solution.

What the digital transition means for the dental team

	For the past decade, IPS e.max from Ivoclar Vivadent has been one of the most-prescribed materials for restorative dentistry. And for a long time, the ability to mill it was mostly restricted to chairside options. But Ivoclar Vivadent announced the Zenotec select hybrid mill in 2014, a mill specifically designed for the dental laboratory that would mill IPS e.max CAD. Since then, Ivoclar Vivadent has released several updates to the e.max line, providing additional esthetics and strength. 

	To find out how the addition of the Zenotec select and updated materials has changed the digital workflow, we spoke to Chris Roman, a dental technician who works with a 

. We also spoke with Trey Wilcox, DDS, a dentist who works closely with Roman’s lab on a variety of restorations, including restorations made with a digital workflow using the Zenotec select and e.max materials. Here’s what they had to say about how the digital workflow really works in the context of a busy lab, and how patients are responding to digital restorations. 

Q&A: Sarah Anders, COO of Ivoclar Vivadent North America, explains what "Being Digital" really means

What are your roles on the dental team? Tell us about your laboratory and practice, respectively.

Oak View Dental Laboratory located in Washington, Pennsylvania

 and the head technician of the lab along with two other technicians. Our lab has taken a role of working with around 25 doctors, who value the collaborative team approach and enjoy the ability to have a consistent quality product. Currently our lab specializes in crown and bridge and implant restorations with an emphasis on treatment planning to help our clinicians build confidence though education.

 I am a general practitioner with a patient pool estimate of around 1,400 patients. I run a five-operatory practice, with two hygiene chairs and three restorative chairs. During a typical week, I switch between two restorative operatories, and leave the third open for emergency appointments. I usually see between 100-120 patients a month on the operative side of dentistry.

Chris, what’s the workflow been like with IPS e.max?

 We started doing e.max shortly after our lab was founded in 2006. As we all know by now, lithium disilicate has changed our industry dramatically over the last several years. The versatility of this material had given us an arsenal of products that best suit our clients’ needs. We can create everything from single unit anteriors for the most esthetically demanding patients, to our daily “production” singe unit posteriors. Currently, we are also utilizing CAD-ON bridges, bonded bridges and implant retained units.

Related: New bur units expand capabilities of Zenotec select hybrid mill

You also have the Zenotec select hybrid mill. How does that fit into your workflow? 

 The mill not only fit seamlessly into the workflow of our laboratory, but almost completely changed our production setup, while making us more efficient and keeping to our standards of a quality product. We have our CAD/CAM system setup with a 

 as our server system. We have the ability to work as a client on the server when our case load reaches a certain level. Our designs are then sent to the Wieland software for nesting and CAM simulations before being sent to the Zenotec select hybrid mill.

Dr. Wilcox, what’s the workflow look like when working with a digital lab like Oak View?

 Since I began sending my cases to Oak View, workflow has much improved on my side of the practice. Crown seat appointmentss take less time, with minimal adjustments at most-crowns usually drop into place with invisible margins. I am seriously considering shortening my crown seat appointment times now.

	Next page: How the mill was incorporated into an existing workflow ...

Chris, what features made the Zenotec select hybrid the right mill for your needs? What was it like incorporating it into your CAD/CAM workflow? 

 Our lab has transitioned to only offering all-ceramic restorations this year, giving us the ability to optimally take advantage of all of the available features of the system. We chose this system for not just its current versatility but also for the future of the next generation of materials and processes. 

 by itself in 2011 and sent all of the designed units to different outsourcing labs depending on what restorations were being produced. When we decided to purchase the Zenotec select, one of our concerns was, how will this system integrate into our workflow? It turns out that after we had the system setup and running (it takes some time to tweak your fits to meet your standards) we realized that we needed to change our workflow to keep up with what this piece of equipment can do daily.

How does the combination of e.max and the Zenotec select hybrid mill work for your lab?

 IPS e.max has become our first choice for restorative units due to the versatility of esthetic options. Add to that the excellent margin adaptation and the fact that it can be bonded, it has been a workhorse for us. Since our work load is approximately 60 percent e.max, it was a no-brainer for us to utilize the Zenotec select. The combination of this mill and the material developed from the same company gives us the peace of mind we need to make sure that we can confidently produce a consistent quality restoration every day.

How is the fit for e.max restorations made with the Zenotec select? 

 We have found that our best fit for e.max has been all anterior restorations up to three-unit bridges, full contour posteriors and in the esthetically demanding cases, micro layering of the buccal of posteriors for strength and beauty.

 The results of the digital workflow have been outstanding. I have used multiple labs in my seven years of private practice, and the crowns I receive from Oak View are the best fitting crowns I have come across. Patients leave impressed, usually with the response of “it was that easy?!” Patients are happy when they can be in and out in under 30 minutes with a high-quality crown.

Related reading: Ivoclar Vivadent's new shades for e.max CAD

Anything else either of you would like to add? 

 While we have only talked about the machine and the materials used with it, I also think a major influence for us was the quality of support we received from Ivoclar Vivadent. They have been there for us for the simple “duh” questions and have really exceeded expectations with the most complex problems!

 I am thoroughly impressed with the quality and fit of the work from Oak View Dental Lab. Results are consistent, of the highest quality, and Chris and his staff are a treat to deal with!

Top photo: Courtesy of Chris Roman, Oak View Dental Laboratory

We spoke to a dentist and a dental technician to find out how the Zenotec select hybrid mill and e.max (both from Ivoclar Vivadent) can work to create better restorative workflows and patient outcomes.

How digital milling can improve outcomes and streamline processes

	Imagine you're an average patient who's just gone in for a fairly standard procedure-maybe you got a new crown, or a small bridge. Your dentist placed a crown made of zirconia instead of gold, and you're happy about it-it's much cheaper than a gold restoration would have been, and your dentist explained how strong it is and how long it will last. Plus, it looks great.

	You head home, and in the next few days, you start to get headaches. You feel run down, and you're not really sure what the problem is. You wonder if you could be having a reaction to something you ate, or something you were exposed to. You trace back the last few days to see if anything had changed in your diet or activities. Nothing comes to mind, however, except … you just got a crown made of zirconia. And you wonder:

	This story might sound far-fetched, but in fact the possibility for it to happen might be more common than you think, at least according to many of the sources 

 spoke to for this article. The reason it's a possibility is because of materials, equipment and dental supplies that enter the United States by skirting around regulatory, market and governmental standards. This shadowy availability of goods outside the normal modes of commerce describe something called the gray market. And all-too-often, dentists and dental technicians can be seduced by the low prices and false promises of the gray market.

Related: 4 things to know about gray market products

	The gray market can be tough to accurately define, but, generally, in a dental context, it refers to any dental goods, products, supplies or equipment that somehow avoid the regulatory process. "When we talk about the gray market, we are talking about products sold through an unsecured supply chain," explains Simon Hearne, Vice President of International Business, 

 "There are three main categories these fall into:

	"1. Products that are diverted from an authorized channel: These products often don’t comply with local laws and may have compromised quality due to improper handling or storage conditions;

	"2. Repackaged or relabeled products: This practice often happens with products nearing the end of their shelf life. Gray market dealers may change or remove the expiration date and repackage the product in order to sell it to unsuspecting buyers. In some cases products may be sold years past their expiration date, which can lead to problems like improper curing or bonding;

	"3. Counterfeit goods: These are fake products designed (with varying levels of competence) to look like the real thing. This category is the least common but should be of the highest concern for the industry, as it poses the greatest risk to safety."

	The gray market increases the likelihood that unsafe products or materials can make their way to patients. "When customers buy gray market products, they have no guarantee that the products have been shipped or stored correctly, or that their labels have not been falsified to conceal an expiration date or important safety data," Hearne explains. "In addition to the risks posed by improper handling and storage, the formulation or labeling of these products may not comply with U.S. laws. Any of these factors can compromise product efficacy and patient safety. Furthermore, many channels that are providing gray market products also sell products that are counterfeit. Counterfeit products are of the highest concern because of the safety risk associated with buying a product with a truly unknown composition."

	Incorporating a gray market product into just one part of the workflow can compromise the entire restorative process. "Using a gray market component invokes several short- and long-term risks to consider," says Paul Patella, Director of Key Accounts, Lab Division, Straumann North America. "[Dental technicians face:] paying out-of-pocket on a case redo because many of these gray market companies offer no reimbursement for failed products [or the] potential for legal action; the loss of the referring clinician; and of greatest importance, the patient’s situation is now quite compromised and the laboratory can be at a significant legal risk." 

	Plus, there are the financial ramifications of buying from shadowy sources. "Lab owners should care, because if they purchase products from unauthorized distributors, they may not be getting what they paid for," says Wayne O. Ledford, CDT, Vice President of Sales at 

. "Furthermore, if there’s ever a problem with the product in the lab or in the mouth, where does the lab turn to for support? Finally, there’s the issue of fraud. We have seen cases of customers who purchase a piece of equipment online from a seller who quotes prices much lower than the market, only to find out that the website is a shell and has no product to sell. By the time that’s discovered, the site is down and the customer has lost his money."

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	In the United States, usually gray market goods are sold or shipped so as to somehow avoid the notice of the regulatory body, the Food and Drug Administration (FDA). The FDA is responsible for keeping out harmful medical supplies of the U.S., and for making sure the materials and products used in patients' mouths are safe for both the dental team and for patients. Generally, that means the FDA has to approve of everything that would go into a patient's mouth, including dental materials. So how would something unapproved be able to make it through to final consumers?

	Well, first of all, an unapproved seller could just skip the FDA process entirely. "If the distributor is selling a product intended for a foreign market, it may not meet the requirements of US regulators," Ledford notes. "[Plus,] labs cannot [tell if a product comes from the gray market]. That's part of the problem. Counterfeit products and counterfeit packaging are also very prevalent in today’s global markets. The only way the lab can be sure that what they purchase is legitimate is to buy from an authorized source." It's remarkably easy to go buy a variety of dental products from eBay or third-party Amazon sellers, and really have no idea where they came from or if they are approved by the FDA.

	In addition to methods that completely skirt around regulatory bodies, some materials also may be taking advantage of the FDA's so-called 510(k) process, or "premarket notification." Essentially, this process allows manufacturers to acquire FDA approval by demonstrating their product is "substantially equivalent" to another product on the market that already has been approved by the FDA. But some observers of the dental market say this process could provide openings for companies to bring harmful products into the United States, where unwitting dental labs and dentists could purchase them. "The FDA takes data from a prospective supplier [and] data about the product they’re going after approval for," explains Jay Thomas, Product Manager, Ceramics at 

. Tosoh produces much of the zirconia powder used in the production of zirconia discs and blocks, which means Thomas has a keen awareness of the specifics of the zirconia market.

	"To the best of my knowledge, the FDA does question these submissions, where the submitter has to answer questions to the FDA’s satisfaction in order to ultimately get the 510k approval," Thomas continues. "But what we are seeing is any company can introduce a disc or block with this data, and essentially say, 'my product is significantly equivalent to that of another company who already has 510k approval.' As a result, the FDA grants approval to the submitter because the FDA is satisfied with the other company’s data and answers.

	"The FDA does not have the resources to follow up on every single one of these products [requesting 510(k) approval]," he says. "[Observers] can see who has 510K approval and who doesn’t, and many of the products come from overseas. And if the FDA is not going to, for example, China to inspect them, that is cause for concern. It has to be tightened up somehow."

	This obviously has significant consequences for the safety of dental products. When asked to comment on the clearance of zirconia, and on the 510(k) approval process specifically, the FDA said in an emailed statement, "The FDA is concerned about the gray market sale of legally-marketed dental products. We have been working with certain dental product resale websites to help identify any illegally marketed devices that are on the site for resale so they can remove them from their sites. We also encourage manufacturers and medical professionals to report to the FDA any instances of device sales that appear to be illegally marketed without appropriate FDA review. It’s important to note that while the FDA regulates dental devices for safety and effectiveness by premarket review and clearance or approval of medical devices to be legally marketed, it does not regulate the practice of dentistry. All dental device applications that come to the FDA through the 510(k) pathway receive a thorough review to establish substantial equivalence."	 

	So if these products are getting into the United States, either around regulations or through other means, how can dentists and dental technicians be sure they're not buying gray market products and hurting patients-and opening their businesses up to liability? Well, the first step is to practice common sense when making purchases.

	"Dentists should remember that if a deal seems too good to be true, it probably is," Hearne says. "Gray market distributors purchase and sell products well below the wholesale cost set by authorized distributors. For a dental business trying to watch pennies, this difference can be tempting. But make no mistake: the risks far outweigh the rewards.

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	"The first thing you can do is check for obvious and observable characteristics that may constitute a counterfeit or gray market product," he continues. "This includes smeared, irregular, uneven or otherwise low-quality printing, out-of-date product name, a blocked barcode, text like 'for export only' or 'not registered for sale in the European Union or United States' or an expiration date that appears to have been changed. If the packaging doesn’t send up any red flags and appears identical to the official company packaging, you can consider the pricing structure. If the price of a product is significantly below standard pricing, the product may be gray market or counterfeit. Another tip-off is if you’ve purchased the product from any party other than the manufacturer’s authorized distribution channels. If you’re unsure which distributors are approved, check the manufacturer’s website or contact their customer service team to find out."






Digital Esthetics magazine explores the shadowy world of the gray market, where people can buy unverified dental products for cheap-and possibly endanger patients in the process.