Terri Lively

The Biomimetic Approach: Playing Copycat with Tooth Structure. Image courtesy of spf/stock.adobe.com. 

Dental composite restorative materials should respond to forces and changes in the oral environment the way a natural tooth does to preserve the longevity of restorations. We can explore the biomimetic approach to restorative dentistry, and what that means.

Matt Nejad, DDS, practices in Beverly Hills, CA, and teaches biomimetic dentistry through the Nejad Institute, including online courses and in-office mentoring. Some debate exists about the definition and usage of the term biomimetics. Some clinicians refer to specific techniques or materials, but Dr Nejad says it is a treatment approach built on 3 primary pillars:

1. Mimicking the structure and properties of natural teeth

2. Preserving intact tooth structure and pulp vitality

3. Restoring dentition's biomechanics conservatively

Practicing and teaching biomimetic dentistry for over 12 years, Dr Nejad has seen firsthand the success rate and longevity of biomimetic restorations. In addition, Dr Nejad studied under the mentorship of Pascal Magne, DMD, PhD, at the University of Southern California. As a result, Dr Nejad was selected for Dr Magne's advanced training program, where Dr Nejad realized his passion for the concepts and techniques of biomimetic dentistry.

His practice is built on the concept that many patients value the precision and benefits offered by the biomimetic approach. Dr Nejad says it never felt natural to do something faster or easier. Moreover, adhesive dentistry changed what is possible for restorative dentistry.

"The bonded era of dentistry completely transformed the treatment possibilities, and the benefits for patients are undeniable," Dr Nejad says.

Steve Schiffenhaus, DMD, MA, is the founder of The BAARD Institute (Biomimetic & Advanced Adhesive Restorative Design). This online platform provides clinicians comprehensive on-demand training in biomimetic principles and techniques, which he describes as a philosophical approach to adhesive dentistry. Dr Schiffenhaus says before defining biomimetics, clinicians must first define what ideal dentistry is, which is often what the clinician would want for themselves and the people they love.

"Therefore, for me, ideal dentistry is to treat the tooth in such a way to extend the restorative life cycle of the tooth as much as possible," Dr Schiffenhaus says. "We want restorations to last, but with the caveat that anytime it needs to be serviced or replaced, it has the least detrimental impact on the natural tooth, and extending the life of that tooth in the mouth as long as possible."

Restorative work in the mouth is rarely permanent, Dr Schiffenhaus explains. While some restorations can last 40 years, Dr Schiffenhaus often replaces failed dentistry in his day-to-day work. He approaches each case knowing nothing lasts forever and has a goal to design the restoration with the most minimal biological impact when it fails.

Dr Schiffenhaus says, to him, biomimetic dentistry is about 3 things:

1. Using the natural tooth as the model to restore.

2. Restoring in such a way to extend the restorative life cycle as long as possible

3. Approaching restorative dentistry in a minimally invasive manner with a deep love of conserving healthy tooth structure

"Simply, we are plugging these materials into a dynamic system," Dr Schiffenhaus explains. "If we don't place them into this system harmoniously, the restoration nor the surrounding tooth will survive long term."

The Biomimetic Approach Requires Understanding Tooth's Biomechanics

Clinicians who practice biomimetics are copying a biological structure of a tooth with materials, protocols, and techniques. Dr Nejad says this approach requires a firm grasp of the natural biomechanics of the intact natural tooth.

"The tooth's strength comes from the combination of enamel's natural properties and the whole structure of the tooth," Dr Nejad explains.

Clinicians who practice biomimetic dentistry use bonded materials. Dr Nejad says some materials are better than others for bonding.

"For example, Zirconia can be bonded, but not as well as e.Max or feldspathic ceramic materials because the structure limits the maximum potential bond. You can only get about half the bond strength achievable with other highly bondable materials, and that's a big difference," Dr Nejad explains. "In biomimetics, you want to use materials that mimic the physical properties of enamel, dentin, and the dentin-enamel junction."

Dr Nejad says that materials the clinicians choose must mimic these tooth layers and achieve solid adhesion to replicate the natural tooth biomechanics, fracture toughness, and strength.

"It's critical how well the material bonds to the underlying tooth structure," Dr Nejad says. "Technique drives much of the success in biomimetic dentistry, particularly regarding adhesive technique. Some adhesive systems perform better than others for biomimetic strategies, but any will do well if the clinician knows how to maximize the adhesive systems' properties."

Maximizing the adhesive systems' bond performance requires focusing on the details. Per Dr Nejad, controlling moisture, using proven gold-standard materials, and applying them with excellent techniques are necessary to optimize the bond strength. In addition, surface preparation, preparation design, cleaning the surface, and other surface priming also play a significant part.

"Biomimetics is not one procedure or technique. There is more than one way to do Biomimetic dentistry, but it's essential to understand the science and avoid following protocols and procedures blindly. The science supports certain materials and techniques, yet many continue to practice without understanding the procedures. Teaching these concepts and helping people understand is my primary mission for my courses," Dr Nejad says.

Dr Schiffenhaus agrees that using techniques that maximize modern materials' longevity and recreate the underlying tooth's natural structure can help meet these goals. Modern materials allow clinicians to "mimic" the tooth structure. However, he says these results require letting go of preps designed for the metal materials. Using an optimized prep design and bonding technique is essential to take advantage of the properties of new materials.

"We are restoring the tooth as close to its natural harmony, physically and biomechanically, before treatment," Dr Schiffenhaus says. "So, to achieve these lofty goals, proper techniques and materials are essential. Specifically, composites to help us replace dentin and ceramics to replace enamel, and good adhesives to retain these materials and allow them to function as one bonded unit in harmony with the rest of the tooth."

The materials dentists use for these restorations require specific characteristics for biomimetic techniques. For example, Nathaniel Lawson, DMD, PhD, Division Director, Division of Biomaterials at the UAB School of Dentistry, says biomimetic dentists like the following materials best:

 Based on systematic reviews of Class V clinical trials, a biomimetic dentist likes 2-bottle bonding agents to achieve the highest possible bond to dentin and enamel.

 Fibers can toughen a material by bridging cracks in restorative material. Fibers can also help reduce stress by preventing shrinkage in the plane in which the fiber is present.

 These composites have a slower polymerization, which a biomimetic dentist likes because these materials allow time for the relaxation of polymerization stress.

However, one material Dr Lawson says biomimetic dentists dislike are bulk-fill composites. Part of the reason is that bulk filling composite does not give the material the opportunity for stress relaxation at each new increment placed.

"Also, bulk-filled composites have a lower modulus than traditional composites. This means they are more flexible," Dr Lawson says. "If a composite is more flexible than the tooth, it may place stress at the interface between the tooth and the composite when the restoration is placed under loading."

Russ Perlman, Executive Director of Marketing & Communication, VOCO America Inc, agrees that materials should also provide tooth-like properties to increase the longevity of the restoration. Providing these tooth-like properties has been VOCO's focus for years with their GrandioSO product family.

For example, preserving the margin is always a concern for restorative dentistry over time. Restorative materials that mimic the surrounding natural tooth structure reduce the stress experienced at the margin and provide fewer opportunities to undermine the integrity of that interface.

Perlman says many fundamental restorative physical properties become essential here, including modulus of elasticity (the stiffness or rigidness of the material) and thermal cycling (the effects of temperature changes on the material's behavior, particularly regarding bond strength). In both cases, if the restorative material does not respond to the bite forces and temperature changes the same way the natural tooth structure surrounding it does, it causes stress at the margin and contributes to potential failure.

"When one goes from the hot coffee in their mug to the cold milk in their cereal, they put more potential strain on the marginal interface," Perlman says, adding that "thermal changes are repeated over and over again throughout the lifetime of the restoration compared to the 1-time initial occurrence of polymerization shrinkage or shrinkage stress."

"The same is true of compressive and flexural strength, too. When the material is not responding similarly to the tooth structure, there will be added stress on the margin—which allows for potential micro-leakage and incipient decay to work its way into it and shorten the life of the restoration," Perlman continues. "So, creating a restorative material that has the most tooth-like properties, so it has a greater ability to behave similarly to the material surrounding it, puts less pressure on that margin and gives it a better chance for extended longevity."

Having a great bond is also essential, Dr Schiffenhaus says. He likes Kuraray's CLEARFIL SE PROTECT. The CLEARFIL bonding agents have many products, with other curing properties, from dual cure to light and self-cure, chemical cure, and light cure bonding agents and systems. He also likes the CLEARFIL APX composite for its physical properties and e.Max (Ivoclar Vivadent) lithium disilicate for his ceramic restorations.

Whatever materials you choose, Dr Schiffenhaus says it is essential that the materials function harmoniously together for the restorations' longevity. In addition, clinicians should consider the tooth a natural model and restore it with a failsafe in mind so that it will break favorably. Finally, he recommends clinicians use the following 2 guiding principles to drive their actions in restorative dentistry:

 When a restoration with prep for a metal crown or deep metal post fails, the resulting damage often leaves the clinician with little or nothing to save because most of the tooth is destroyed.

 Traditional approaches seem to view the tooth as a static or straightforward object that you put any material into or on, Dr Schiffenhaus says. However, teeth experience a variety of loads, which both their macroscopic and microscopic structures handle dynamically. When studying the biological engineering of teeth, he says clinicians realize why enamel and dentin are present in their natural thickness, grading, and orientations; to work together as a system to handle loads that exceed the capacity of any constituent materials alone.

"When we put material into a tooth, we need to understand that system and plug that material in a way that works with tooth structure around it, not against it, which is much different from the traditional approach. The materials don't need to be that strong, hard, or thick if they are used in a systematic, dynamic way," Dr Schiffenhaus says.

Learning More about the Biomimetic Philosophical Approach

The Nejad Institute helps other clinicians learn and understand the biomimetic approach in their practices. Dr Nejad's courses help participants implement biomimetic dentistry confidently. Understanding the science and techniques makes dentists comfortable changing their practice, resulting in greater satisfaction and pride in their work.

"Preserving healthy tooth structure and providing quality always feels right," Dr Nejad says.

The Nejad Institute offers 3 levels of coursework that get progressively more in-depth and interactive. In Level I, he starts with the fundamental science and techniques of biomimetic dentistry. Level II includes a deeper dive into mastering and refining the approach, including more mentorship and guidance during the extended course duration. Finally, Level III allows in-office mentoring and shadowing to see procedures up close in real-time. In all the courses, there is a focus on a growth mindset and the power of continuous improvements to increase efficacy, known as Kaizen.

"There are always going to be excuses. It's natural for people to resist change, but I want to embrace change when needed and focus on continuous improvements. It's the best way for me to practice," Dr Nejad says.

Dr Schiffenhaus also teaches coursework on biomimetic dentistry through the BAARD Institute. There are several online courses available as well as live courses. From prep design to adhesion to isolation for direct and indirect restorations, Dr Schiffenhaus covers the techniques required to deliver biomimetic dentistry.

"These techniques often associated with Biomimetic Dentistry are just good adhesive dentistry and using materials in as idealized a way as possible. We want to maximize the longevity of both the restoration and the tooth as long as possible," Dr Schiffenhaus says. "We do that through the use of better materials and excellent technique."

Articles

Restorative materials must respond to forces and changes in the oral environment the way a natural tooth does to preserve your long-term restorative work. The biomimetic approach to restorative dentistry can protect the margins and promote the longevity of your composite restorations.

The Biomimetic Approach: Playing Copycat with Tooth Structure

Tim Bizga, DDS, practices general dentistry with his father in Cleveland, Ohio. Before that, he worked as a chairside assistant and a dental lab technician, and those experiences enhanced Bizga Dental, Inc. in many ways. Tim remembers tagging along to the office with his dad, Chester Bizga, DDS, as part of the latter’s attempt to raise a dentist from among his 6 children.

“I joke that Dad started to look at the older 3, and their gifts and talents, and decided that if he was going to get a dentist out of the lot, he needed to resort to brainwashing the most pliable,” Tim jokes. “My memories of the dental office were hanging out with my Dad and raiding the toy chest he had for his kid patients.”

At 16, Tim was no longer pilfering toys but seeking something more valuable. When he asked his father why he had become a dentist, Chester told him about the benefits of owning a business: flexible hours and the ability to provide a comfortable living for one’s family. As a boy in downtown Cleveland, Chester had seen a dentist roll by in a 2-seater convertible with a set of golf clubs in the passenger seat and immediately knew that dentistry was for him.

“My Dad’s vision of being a dentist was [that] he would drive cool cars and get to play golf—and he wanted to golf as much as he could,” Tim says, adding that as the fourth child, he saw the benefits of the hard work his father had put into building the practice and wanted the same benefits for his own wife and kids.

“One of the reasons that families tend to follow suit is that dentistry is a great career.…on the whole, you do very well.”

However, father and son both know that golf and fancy cars are not a given for any dentist. They are the result of sacrifices and putting a great deal of time and energy into taking care of patients. Tim’s older siblings jokingly complain that the younger kids had a far different childhood than theirs. But Tim believes that if children see that dentistry makes their parents happy, they will want to make it their career too.

Nevertheless, he doesn’t plan to push his children, who are still very young, into dentistry, feeling 

that the profession must be a good fit for any person who pursues it. He would love it if one of them did choose dentistry because it has much to offer, and still will in 15 or 20 years, but he won’t force the issue.

For the Kuseks, dentistry is even more of a family affair. Edward R. Kusek, DDS, and his daughter, Amanda Voegeli, RDH, work at Kusek Family & Implant Dentistry, in Sioux Falls, South Dakota. His son, Alex Kusek, DDS, also worked there but now practices in Mount Pleasant, South Carolina.

The elder Kusek used to take his kids to work when they were little, and Amanda would pretend to do dental work on her brother. Later, pretending became a reality and Alex became one of his sister’s first patients. And because Kusek’s patients knew Voegeli, they accepted her as soon as she began practicing. She’s also “very gentle, and patients like that,” Dr Kusek points out. “She has a better touch than me.” According to Voegeli, that’s down to Dad­—it’s “what happens when your dad’s a dentist, and you’re cleaning his teeth,” she says, laughing. “He’s telling you, ‘OK, gentle, gentler,’ every time. So, he trained me to be that way.”

Dr Kusek is also an author and speaker, a clinical instructor for various manufacturers, and an adjunct professor in the dental programs of the University of South Dakota and the University of Nebraska. Voegeli has been editing his papers and helping him with presentations for years. “I was always doing my PowerPoints,” he says, and “she would always see all this bloody stuff,” but it didn’t seem to bother her. “That’s why I am a hygienist,” Voegeli explains. “I don’t mind watching it, but I don’t want to be in it.”

The younger generation also kept the technology up to date. For example, Alex had his father upgrade to faster scanners and encouraged him to add a CBCT unit so that they could assess patient airways. And, encouraged by dad, Voegeli took a laser course.

It can, of course, be tricky to work together. As the liaison between her father and the staff, Voegeli has had many opportunities to hone her diplomatic skills, but the effort has been worth it, the duo agrees because the atmosphere is more fun for everyone. “I enjoy working with my daughter,” Dr Kusek says. “When my son was working with us, I enjoyed that, too.”

Charlie Culp, DMD, and his twin brother Alex Culp, DMD, also followed in the footsteps of their dentist father and hygienist mother. Alex is an orthodontist with multiple practices, and the brothers have patients in common. Charlie jokes that they used to think that what their parents did all day was spend time with each other—and with teeth. “When we were little, we always thought our parents were the coolest,” he says, adding that they would go to the practice and hang out with them. “Some people don’t appreciate their parents, but we thought they were neat people.”

The brothers never felt pressured to become dentists. Instead, it felt like a natural progression, Charlie says. When Alex decided to leave the family practice (Culp Dental, in Rock Hill, South Carolina) to pursue a specialty, it was hard for him to break the news. But the support was always there, and everyone was happy for Alex.

Like the Bizgas, Charlie believes dentistry often becomes the family profession because it allows practitioners to enjoy a flexible schedule and an excellent quality of life. They can spend more time with loved ones, form stronger emotional bonds, and have open and frank discussions about business. He looks back on his years working with his father and brother as the best of his career. “We always wanted it to be better and more fun, and all of us were in the office for 3 years. Not every day was the best day ever, but some [were]…the best times I’ve had for sure.”

Dawn Rockwell, DMD, and her husband, Alex Rockwell, DMD, are co-owners of Rockwell Dentistry, in Middletown and in Hamilton, New Jersey, and they are excited about their children joining them. Twins Eric and Natasha, are about to graduate from the Kornberg School of Dentistry at Temple University. “We are multigenerational now,” says Dawn Rockwell. “My husband and I have decades of knowledge and experience…to mentor them, and they are trained in the latest digital dentistry techniques, which will add a whole new facet to our practice.”

Dr Rockwell says her dad encouraged her entrepreneurial spirit and inspired her to “shoot for the stars.” She chose dentistry because it combines art and science and allows her to be her own boss and to build close professional relationships with patients. Dawn met Alex 30 years ago when, as recent grads, they were associates at the same dental office. Her husband, she explains, followed his mother into dentistry.

Born in Kyiv, Ukraine, where his mother was a dentist, Alex immigrated to the United States in 1976 with his family. It took his mother 2 years to graduate from NYU College of Dentistry and be licensed in New York, and she practiced there until her retirement in 2005. At age 

15, Alex began working as a dental assistant in her office during summer vacations, so dentistry was an easy career choice for him.

Rockwell Dentistry is not merely a dental dynasty, but a female dental dynasty. “While there are many mother-daughter dentists, I don’t know of any other grandmother-mother-daughter dentists,” Dawn says proudly. “I think it is a great profession for a woman. It easily allows…your professional and family life [to] coexist.”

In addition, having her children join the practice will guarantee continuity of care, she’s quick to note. “[M]any…patients…[come] to us because their previous dentist retired and they do not like the way…the new office is run.…that won’t happen here,” she says. When patients ask her about retirement, she responds, “No worries…I made 2 clones for you.” In turn, her patients—some of whom are second- and third-generation—can show her children “how interesting and rewarding dentistry is,” she concludes.

Rick Adelstein, DDS, practices with his father, Gerald Adelstein, DDS, at Obermeier, Adelstein, Lempel and Associates, Inc., which has offices in Beechwood and Medina, Ohio. His daughter, Melanie Adelstein, DMD, recently finished her general practice residency and joined the practice. Rick says that his parents actually discouraged him from becoming a dentist, but he always wanted to be one. Even if his father hadn’t been a dentist, he thinks he might have ended up in the field. “Ever since the middle of high school, I was…happy doing things with my hands and love[d] dealing with patients,” he says.

Melanie is no stranger to Obermeier, Adelstein, and Lempel, having worked there in various capacities before joining as a dentist. And she will also benefit from her surname: “When patients get used to dentists they’ve seen for 20 years, and then there’s someone new, they automatically connect the word new to ‘fresh out of school.’ Because [she]…is my daughter, most…patients will accept her…[more easily] than if…[she] wasn’t related,” Rick says.

He looks forward to continuing his father’s tradition of collaborating on decisions about the best course of action. Dr Gerald Adelstein used to ask others, including Rick, for their opinion, and Melanie will have a perspective that her own father wants to hear. For her part, she is eager to use the office equipment she hadn’t been able to touch while in school or residency. Rick also looks forward to the new services, like Botox treatments, his daughter will be offering: “She’s going to take some courses, and once she’s certified, she wants to do [Botox]. So that’s something that we wouldn’t have done,” he says.

Dental manufacturers, distributors, and service providers are also owned and operated by single families. One example is Benco Dental, founded in 1930 by Benjamin Cohen partly to avoid working in a sweatshop, according to his grandson Chuck Cohen, who is a co-managing director with his brother Rick. “I would call it a happy accident that we ended up in dental,” he says, “but I am so glad we did.” Their father, Larry Cohen, is the company’s chief customer advocate.

It was actually another family connection that led Benjamin Cohen to the industry. A distant cousin, Julius Charlestein, had founded Premier Dental Company in 1913, 17 years before Benco was founded. Benjamin started out selling Premier instruments door-to-door before opening his own dental depot in Northeastern Pennsylvania. “The business is still there today, although quite a bit larger than when he started it,” Chuck says.

According to Chuck, there are many benefits to being a family-owned firm. Dentistry is a relationship-oriented field, he points out, and dentists have long-term business relationships with people they know and like, which is why his father, Larry, created a customer-centric environment at Benco and is a fierce client advocate.

“Customers trust the service they get from a family like ours,” Chuck says. “Being family-owned allows us to be independent; to think in decades, not…quarters; and to have a more trusting relationship with our customers.”

Benco is one of the largest dental-only companies in the world because publicly traded companies tend to be in other verticals, Cohen explains. With 1500 employees who “think, eat, and breathe dental all the time,” Benco is able to focus on dental innovation in a way competitors can’t.

“Our mission statement is, ‘We drive dentistry forward through our innovative solutions and caring family culture,’” Cohen says. “Our goal is to be the most innovative player in the space, drive the industry forward, and…[have] a caring…attitude toward…customers.”

David Lang, president of Lang Dental Manufacturing Company, Inc., is the grandson of Samuel Lang, who founded the company in 1929 and sold materials to dentists in the Chicago area, later distributing them throughout the East Coast. Thanks to David’s father, who had a degree in chemical engineering, the company was able to develop quick-curing acrylics for use in prosthetic dentistry, which are still its focus.

Lang jokes that his mother made him join the firm in junior high to get him out of the house. At first, he filled bottles with acrylic, but after college and a brief stint as a teacher, he rejoined in 1977 and has been at the company ever since. Mostly retired today, he is surrounded by family members. His wife is the company’s quality director, and his children hold leadership positions in quality systems, regulatory, and sales.

No matter their title, however, all of them understand all aspects of the business: “Any of the people in management here could be president [and all] have a good understanding of the regulatory and quality assurance requirements, etc. So, we all wear many hats,” he says.

The company has grown considerably under their careful watch. It became a global company in the 1950s and branched out into other industries, but dental remains its main focus because of the consistent quality of its products and the family’s accessibility, Lang says.

“Every person in management here is intimately involved with the end users,” Lang explains. “We…can communicate with the people who use our products and understand their problems and the things they like…. If you can continue to do that, it helps you keep that mom-and-pop feel, even though you’re a much larger company.”

The family’s involvement with trade associations has put them in touch with other family-run businesses, many of which face challenges similar to those the Langs face. These connections have given Lang Dental access to resources that wouldn’t otherwise have been available to a company of its size.

Nicolle Campion, president of Zirc Dental Products, says the industry is amazing because everyone is passionate about what they do. A manufacturer that uses plastic injection molding, Zirc strives to be efficient by investing in capital equipment and controlling the supply chain so that it can compete with offshore corporations. And its efforts have paid off in recent years.

“It’s been important for us to continue manufacturing in the United States. Everything is made here at our Minnesota facility, so we can see it firsthand,” Campion says. “We want our team to be doing the…quality control and not…someone else.”

Campion also appreciates the stability of the dental industry. As the daughter of James Cam

pion, who started Zirc in 1967, she hopes that the next generation, which is still in school, will take over. And judging by her experience, they might. “Family-run or not, people create great bonds and friendships, and rarely does someone get into the industry and then leave[s],” she says.

Campion has been at Zirc for 22 years, learning different aspects of the business. The more time that passed, the more natural her transition to management became. At first, it was about doing the best she could and watching the company grow, she says.

Later, it was about shaping the company’s direction and working with customers and her team to develop ideas. She plans to use a similar approach with members of the next generation, the oldest of whom is a senior in high school.

“We haven’t quite reached that point of having someone in the third generation who is old enough to know if the family business will be a fit for them, but it would be wonderful if one or all want to join the business someday,” Campion says.

There are many benefits to product offerings when a company is family-run, she says, because there is less red tape to contend with. “When it comes to…product development and…what we’re doing out on the street, we can make a decision quickly,” Campion says. “A lot of the new product ideas we get are from clinicians. So the quicker we can act, the better.”

In addition to its simple but broad product line, Zirc focuses on efficiency and organization. And the gains it makes that way can significantly benefit clients. Zirc also offers consulting services and customizes solutions for dental practices.

“It’s about being organized, yes, but a lot goes behind it. It’s not just fun bins that we have; it’s the whole method behind what you do with the bins and how you use and store them,” Campion explains.

Shashikant Singhal, BDS, MS, director of education and professional services at Ivoclar USA, says that product families offer comprehensive solutions. In today’s fast-paced environment, “it is difficult for dental professionals to…[spend] time…finding products and technologies via multiple manufacturers,” Dr Singhal explains. To minimize the lack of compatibility and functionality that can compromise outcomes, manufacturers offer families of products with predictable results.

“If a dental professional uses products from one manufacturer, it is easier to provide support and troubleshoot issues. Therefore, a customer can rely on us and consider us a strong partner for their successful, hassle-free business operations,” Dr Singhal says. “Since all the products are tested extensively, we as a manufacturer can predict the outcome…in a clinical situation and guide dental professionals with a recommendation. This helps them provide better service to their patients.”

Benco sources its privately branded products from well-known manufacturers. Chuck Cohen describes the portfolio as a robust selection of the best products available, including the PRO-SYS® toothbrush line and natural extensions® personal protective equipment. Sourcing allows Benco to “offer some fabulous products and technologies at competitive pricing,” he says.

Abir Bou Khouzam, senior marketing manager at Tokuyama Dental America, Inc., believes that adding to a product family increases its usefulness because new components can address other needs. However, these components must have brand recognition for clinicians to trust them, she says. For example, OMNICHROMA’s initial success was partly due to the performance of Tokuyama’s previous composites.

After the launch of OMNICHROMA and OMNICHROMA BLOCKER, the team at Tokuyama introduced OMNICHROMA Flow and Blocker Flow formulations in response to specific clinical needs. By expanding the family, Tokuyama was able to offer other options that have the same predictability dentists have come to expect, Bou Khouzam says.

“The physician is satisfied, and the patient is satisfied,” she says, adding that products that rely on innovation and research must have excellent outcomes to survive and grow. “If OMNICHROMA…hadn’t been a success, the flowable and blocker wouldn’t have gone so well.”

Having more options is always better, but more options also mean more decisions, Bou Khouzam says. Therefore, the marketing team ensures customers are well informed and educated about products, all while building the family brand. Once clinicians are familiar with the products and satisfied with the outcomes, using the family becomes a habit that extends the use of the product and product family to multiple indications, she says.

“This can be a challenge and an opportunity,” Bou Khouzam continues. “Even if a better product comes to market, and this applies to everyone, it will be more challenging to change a clinician’s habits. You must be persistent and have a company and portfolio to back you up. The more [clinicians] see and read about [new] products, the more likely they will consider trying it.”

Russ Perlman, executive director of marketing and communication for North America at VOCO America, Inc., says the goal of product families is to develop trust. Most relationships are based on trust, and when a company develops a family of products, clinicians can be confident that the products will work together as expected.

By introducing a family of products, you’re indicating that they “are meant to work together—and will work together—well,” Perlman explains. “We know, based on science and chemistry, many of these products will work together even when they aren’t from the same brand family, but when we talk about a family of products, we’re talking about compatibility, working together, and trust.”

Perlman says that every practitioner should exercise due diligence and include only products they trust in their armamentarium. But obviously, anything VOCO can do beyond intensive testing and research can be helpful.

For example, products from VOCO’s GrandioSO line can be combined in different restorative procedures. The advantage for clinicians is that they can treat a wider range of problems with a single family of products. VOCO also offers CAD/CAM workflow options with their Grandio blocs.

One of the most significant benefits of product families is their consistency, Perlman explains. Working with products from the same family removes variables that could interfere with the intended outcome, leading to solutions that last.

On the other hand, if “you bring in products [from] outside the family, …there could be a small indication or application changes because of different chemistry or technology,” he says. “That’s where working with a family of products benefits the practice, as it helps to minimize variables.”

The concept of a product family also extends to workflow components. Alyssa Federico, marketing manager at DEXIS Imaging, says that doctors want a one-stop shop, not multiple companies with which to coordinate for workflow. However, by the time they add CBCT, they often already have other digital workflow components in place.

“Therefore, our ORTHOPANTOMOGRAPH® OP 3D CBCT scanner is an open system that…work[s] with just about anything a dental practice might already have or [with] a complete family of products,” Federico explains. “We like to say, ‘We integrate with just about everybody.’”

One of the main advantages of having a full suite of products, particularly with DEXIS technology, is the support available, Federico says. She considers investing in a family of products to be like investing in a relationship with the company. DEXIS Imaging takes that relationship seriously, ensuring that clients can reach representatives as quickly as possible when they need help. “You can call and talk to somebody or submit a request, and somebody will get back to you within a few hours, give or take,” she points out.

In addition, buying from a product family enables ease of use with a step-by-step workflow. Even if a dental office isn’t technologically savvy, she says, it’s easy to adapt when you have a workflow that works with you, not against you.

“If you are an orthodontist, [a] specialist, or [a] general dentist, you have a solution that will work for you, whether [you’re] completing your digital puzzle or starting your digital journey. We like to work with the customer on developing a digital roadmap,” Federico says. “This is the new dentistry. It’s amazing to have a one-stop shop for everything with the new dentistry.”

Children often follow their parents into the profession, the leadership of privately held dental companies is passed down from one generation to the next, and dental products are grouped under the same brand name. However you look at it, dentistry is often a family business. Let’s see why that is the case.

All in the Family: From Family-Owned Practices and Brands to Product Families, Dentistry is a Family Affair

Digital Technology: Look How Far We've Come and Why You Should Look Again. Photo courtesy of sunlight19/stock.adobe.com. 


Digital technology and CAD/CAM have come a long way for dentistry. There are myriad benefits of implementing digital technology. Looking back at a brief history of CAD/CAM, we can also dive deeper into today's digital scanning and CAD/CAM.

Robert Mongrain, DMD, Director of Clinical Advocacy at Heartland Dental supporting Clinical Digital Technology Scanners & Labs, says clinicians always have opportunities to improve patient care, and technology can aid in that. However, whether it is materials technology or digital, clinicians that don't change and adopt new technology cannot continue to provide the best patient care and experiences. Striving for mastery though constant and never-ending improvement is a core value of Heartland Dental.

Dr Mongrain embraced those values even before joining the dental service organization (DSO), while leading his private practice, Berkshire Dental Group in Broken Arrow, Oklahoma, where he and his team took pride in providing world-class patient care.

"My primary job as a dentist is to help people do what they ought to do instead of what they want to do," Dr Mongrain says, referring to patients’ reluctance to treat their dental problems.

An early adopter of technology, Dr Mongrain had a CEREC 2 in 1998 and was one of the first eD4 users. He thinks using digital technology, specifically intraoral scanners, can improve patient care in several ways, including fewer remakes, faster turnaround time, and improved case acceptance rates. Moreover, he can see this in his current role at Heartland Dental, with data from 2,200 scanners and 2.5 million scans across 50,000 digital cases per month.

Scanning technology has improved communication in dentistry by helping people understand what's going on in their mouths. At Heartland, the teams do Wellness Scans to show patients their oral health progression.

Dr Mongrain also shares the impact of dental labs that are already digital. Nearly everything that the practice sends to the lab is either poured up and scanned or scanned directly using CT Scanning technology. This digitalization benefits the laboratory workflow, which indirectly helps the dental practice. However, the dental practice doesn't enjoy many direct benefits unless they implement digital technology in-house.

Dr Mongrain did approximately 4 occlusal guards a month at his practice before the implementation of scanning technology. After scanning and showing patients what was happening to their teeth, the number of occlusal guards they delivered jumped to around 12, triple what they were doing before.

"Those patients needed care before I had a scanner and more of them accepted care after I got a scanner. I didn't change my treatment planning," Dr Mongrain says. “Instead, the technology helped pain a clearer picture.”

Another area that digital technology is changing in dentistry is the ability to simulate outcomes. Dr Mongrain sees artificial intelligence (AI) assisted technologies that evaluate radiography and scans becoming more widespread in the next 24 to 36 months. He explains that these technologies will filter information and automate your charting, a considerable time saver for offices.

"But you have to have a digital scanner," Dr Mongrain says. "That's the entryway."

Heartland Dental uses training to leverage the most benefit from its scanning technology. Regular training programs broken down into 5 parts are offered continuously to improve the team's skills with the technology. The idea is that by developing these learning experiences, the scanner will never sit in the corner, unused. In addition, investing resources in training for the whole team builds confidence, which is essential to enhancing patient care and experiences.

"For a change management plan, you have a schedule of sequential learning experiences. Partner with the scanner company and your laboratories and develop these sequential learning experiences. Whatever you do, don't let it sit in the corner. If you have a problem, get some help to keep it going," Dr Mongrain says. "Mastery is not an event; it's a journey."

Something few people might know is that CAM preceded CAD, but both had their starts in the 1950s. CAD started with Douglas T. Ross, a researcher at the Massachusetts Institute of Technology (MIT), who was working on projects that pioneered the beginnings of the technology. Later, Patrick Hanratty, PhD, known as “The Father of CAD/CAM,” worked at the General Motors Research Laboratories, and added the use of software with CAD with his Design Automated by Computer (DAC), which used numerical control programming (PRONTO) that Hanratty developed in 1957. In the 1960s, Ivan Sutherland, PhD, developed Sketchpad, a design software that allowed designers to use a light pen to draw on the monitor.

CAM was also changing a lot in the 1950s. Computers were churning out G-code to make punch cards that controlled machines. Then the production of punch tapes using computer control increased the speed of making the instructions and the manufacturing process itself. The earliest commercial uses of CAM were in the automotive and aerospace industries.

CAD/CAM came together in the late 60s to help produce Renault cars in France. Then, in the early 70s, Hanratty founded Manufacturing and Consulting Services (MCS) in the US, where he created ADAM (Automated Drafting and Machinery). Most modern-day commercial drafting derives from ADAM. In 1982, John Walker introduced his CAD software AutoCAD for the PC. Ten years later, it was available for Windows, and by 2007, it became the industry leader.

An Even Briefer History of CAD/CAM in Dentistry

The 1970s was when CAD/CAM came to dentistry, introduced by the team of Bruce Altschuler, Francois Duret, Werner Mormann, and Marco Brandestini. Dr Duret took an optical impression and fabricated a crown using a numerically controlled machine. Later, in the mid-1980s, Mormann and Brandestini developed a commercially available system for dentistry and called it CEREC.

 At the same time, Matts Andersson developed Procera (which is now NobelProcera, from Nobel Biocare), and then went on to be the first to manufacture composite veneered restorations.

Later in 1994, Siemens introduced CEREC 2. Using two-dimensional concepts, the CEREC 2 could produce inlays, onlays, veneers, partial and complete crowns, and copings. In 2000, Sirona launched CEREC 3. Five years later, Sirona released a different version, which did everything CEREC 2 and CEREC 3 could, plus virtual automatic occlusal adjustment. The new CEREC 3 system also no longer used two-dimensional principles. 3 In 2008, D4D Technologies, LLC, launched the E4D Dental System, providing competition to CEREC.

Today, CAD/CAM enjoys widespread use globally. More than 30,000 dentists worldwide own scanning and milling machines, and dentists have delivered more than 15 million CEREC restorations.

 This market is growing—a recent market research report projected that the global Dental CAD/CAM Market Size will reach 4.94 Billion by 2029.

Why Digital Technology and CAD/CAM Deserve a Second Look

Today's CAD/CAM systems deserve a second look, too. After all, they do not use two-dimensional principles, nor do they require producing punch cards. Things have come a long way, and it shows in what they make, John Flucke, DDS and Technology Editor for DPR, says.

"The restorations that come out of these machines are amazing," Dr Flucke says.

Dentists that invest in CAD/CAM have a lot to look forward to with the innovation in the space. There will be improved quality with the new version of the systems that have both extended uses and easier-to-use interfaces. Materials are also improving, with more of them providing wear that mimics enamel and is strong enough to withstand the forces imposed on full crowns and bridges. Moreover, the 

Journal of the Canadian Dental Association

 suggests that the automation the systems provide will likely produce changes we cannot predict today.

Dr Flucke also thinks the increase in CAD/CAM providers changed the technology from closed systems to open architecture systems. Dentists have the option to mix and match with open systems to get what they want. Dr Flucke uses CAD/CAM for posterior restorations in his practice scanning with iTero, designing with exocad, and milling with a DGSHAPE mill from Roland.

"The other great part about it is if a company comes along next year with an incredible intraoral scanner, I can buy the new one, and it will interface with the pieces I already have. That is huge," Dr Flucke says. "The idea of open architecture and interchangeable is a big deal."

Per Dr Flucke, the quality of your work is much better today than it was in the past. He started using CAD/CAM back in the days of floppy discs in 1998 and recognizes that today's machines have bells and whistles that he wouldn't have imagined back then. The fit is more precise. Early critics of CEREC told Dr Flucke that an inlay is a piece of porcelain in a swimming pool of composite, which described how clinicians were cementing restorations with composite. Today, he says the restoration "looks like it grew there" with CAD/CAM-produced inlays, onlays, and crowns with marginal fit as good or better than what can be achieved with human hands.

There are many other practice benefits of using CAD/CAM, including:

Delivering treatment faster, meaning less chair time for restorative work

Providing a more straightforward treatment, which provides a better experience for everyone involved

Making treatment convenient and comfortable for the patient, which improves the patient experience and related word-of-mouth marketing

Presenting a precise restoration, reducing, or eliminating the adjustments needed for a proper fit

Producing the best esthetics with improved materials

Colgate details some additional patient benefits. Primarily, CAD/CAM provides the opportunity to deliver a finished restoration in a single visit. It also allows the team to take a digital impression, which is much better than the conventional way. In some cases, the cost of the restoration might be lower by eliminating outsourcing costs for the prosthetic.

Another reason Dr Flucke thinks clinicians should reconsider their decision to avoid CAD/CAM is that it is more affordable than it used to be. In particular, the digital impression systems vary in price, depending upon the scanner you choose and the options. Plus, what you buy today can do so much more than what it used to provide. He compares it to buying a digital camera.

"The best cameras on the market are $2000 to $2500. You get the best camera Nikon or Canon makes when you buy that. However, the day you buy it, somewhere in the R&D department, they have a camera much better than the one you just bought. So, what's going to happen is next year, when the new camera is released, the one you have will drop in price, and the new one will be $2500," Dr Flucke says. "So, whenever you buy a high-end camera, you spend $2500, but it is exponentially better than the last time you spent it."

Dr Mongrain led Heartland's scanning implementation of iTero scanners around 7 years ago. He would encourage clinicians and practice stakeholders to view this purchase for their practice as an investment rather than an expense.

Dr Mongrain says delaying a purchase means missing out on the per-use opportunities, like saving lab shipping costs, ranging from $18-25 per case, or the ability to undertake clear aligner therapy (CAT) and digitally plan implant and restorative cases (when used with CBCT technology). Also, practices without scanning lose out on case acceptance for periodontal care, crown and bridge cases, and CAT opportunities.

"The last part of this second look relates to change management,” Dr Mongrain says. “If you are going to do it, now is the time. You do not want to be the last one to go digital."

Duncan G. The History of CAD/CAM - Computer Aided Design & Manufacturing. Technical Foam Services. May 5, 2020. Accessed August 9, 2022. https://www.technicalfoamservices.co.uk/blog/blog-history-of-cad-cam/

G. Uzun. An Overview of Dental CAD/CAM Systems. Biotechnology & Biotechnological Equipment. 2008;22(1):530-535. doi:10.1080/13102818.2008.10817506

The Use of CAD/CAM in Dentistry. Pocket Dentistry. October 29, 2016. Accessed August 9, 2022. https://pocketdentistry.com/the-use-of-cadcam-in-dentistry/

Irfan UB, Aslam K, Nadim R. A review on cad cam in dentistry. J Pak Dent Assoc 2015;24 (3):112-116.

Worldwide Demand For Dental CAD/CAM Market Is Growing At A CAGR of 8.9% By 2029 | 153 Report Pages.Digital Journal. July 18, 2022. Accessed August 9, 2022. https://www.digitaljournal.com/pr/worldwide-demand-for-dental-cad-cam-market-is-growing-at-a-cagr-of-8-9-by-2029-153-report-pages

Natalie A, Rhonda K. CAD/CAM Dentistry For Restorative Dentistry and Orthodontics. Dentaly.org. June 30, 2022. Accessed August 9, 2022. https://www.dentaly.org/us/restorative-dentistry/cad-cam-dentistry/

CAD/CAM Dentistry: What Is It? Colgate.com. February 3, 2022. Accessed August 9, 2022. https://www.colgate.com/en-us/oral-health/dental-visits/cad-cam-dentistry-what-is-it#

Rekow ED. CAD/CAM in dentistry: a historical perspective and view of the future. J Can Dent Assoc. 1992;58(4):283-288.

Digital technology and CAD/CAM have come a long way in dentistry. If you have previously passed on digital investment, we look at why today's digital technology deserves a fresh look. 

Digital Dental Technology: Look How Far We've Come and Why You Should Look Again

Optimizing Digital Communication Between the Dental Practice and the Dental Lab. Photo courtesy of BillionPhotos.com/stock.adobe.com.


Communication with your lab is critical for a quality patient experience and outcome for your restorative dentistry. What is the best way to find a communication style that works for everyone?

A foundational element to communication between a dental lab and a dental practice is standardized communication systems. On 3M's blog, 

, Hans-Jürgen Stecher, MDT, writes that standardized communication is essential for the dental practice and the lab. Standardizing how you communicate, from patient info to the treatment plan to desired materials, gives everyone access to relevant information about the case. It will also ensure everyone knows about decisions made along the way. Stecher also suggests standardized communication practices to demonstrate the next steps or tasks in the procedure, so everyone knows what they are doing.

Part of Stecher's communication standardization process is to use checklists. He writes that they give structure to the work processes that are easy to understand and that the clearly defined steps enable the team to work right away. Checklists also simplify delegation, ensure that the work gets done and no steps are left out, and increase the efficiency of procedures by facilitating solution suggestions for recurrent or potential problems.

In addition, Lumapps, an employee experience platform, suggests the following to improve digital communication:

 When managers send employees emails after work, it can make employees feel pressure to respond right away. The same goes for dentists emailing dental labs after hours. However, after-hours is when most dentists can send those communications. A good workaround is to draft emails and set reminders or schedule them to deliver during working hours. Or, if you know the lab well, ensure they know that you don't expect a reply until they are back in the lab.

 Things happen. Cases change or patients have emergencies. To accommodate for these inevitabilities, ensure that you have an established procedure for urgent messages, so they don't get missed. Lumapps recommends using a different channel, like voice or video calls, for these situations. The channel use will signal an urgency to the recipient.

Be open to regular feedback about changes needed in the system. 

Even though it is a client-supplier relationship, communication best practices go both ways. Regular feedback about what is working and what isn't in your digital communication system is essential. Not only will it improve the system, but it will also promote teamwork and problem-solving in your working relationship.

The website is helpful for labs to set up standardized communication with their customers. For example, DDS LAB has many ways for clinicians to communicate digitally with their lab, such as its customer portal where clinicians can log in and interact with them. DDS LAB also invested in a Digital Impression webpage that explains step-by-step how to upload scans from all compatible systems, followed by a detailed workflow description. They have a live chat option for additional customer support as needed, too.

The DDS LAB website also has a daily case summary update, so dentists know where the case is and a MyDDSLab App, which is designed to facilitate mobile case tracking and is available for clinicians registered through the customer portal.

However, this website-enabled digital communication functionality isn’t limited to extremely large dental labs. Small- to mid-sized labs can also leverage digital communication via their websites to enhance their customer experiences. Nick Azar, VP of Sales and Marketing at Keating Dental Lab in Irvine, California, says that communication is critical for any laboratory to give the best service to the dentist and their patients. The need for a digital communication option has been made even more apparent, Azar says, during the COVID-19 pandemic with a lot of unavailability-to-call in dental laboratories. Keating's customer portal helped set them apart, Azar says.

"We have a portal that we developed quite a few years ago, and it's that portal that allows the dentist to do everything they need to do without having to call the lab ever," Azar explains.

Keating's customer portal, developed years ago, has a lot of communication functionality such as its ability to keep track of the stages of their case. Clinicians can also send messages to the specific technician working on the case through the portal. Communication isn’t the only highlight of this platform. The Keating portal makes it possible to make payments, upload photos clinicians forgot to send, or update prescriptions. Dental practices can also order shipping material, schedule pickups through UPS, and do anything related to their case.

The portal is also helpful for clinician-facing communication. When the STL files dentists submit are insufficient for the case, or they didn't capture the bite or opposing dentition, Keating notifies them through the portal per their preferences. When UPS delivers a case, or the lab sends one out, Keating scans the tracking number in the portal, which notifies the doctor. Moreover, the portal is open 24 hours a day, 7 days a week, and even on holidays.

"During the pandemic, that became extremely valuable because we had very few people in here to answer all the calls and do everything a full-service lab can do," Azar says.

In addition to the communication, Keating logs all the phone calls and customer communications related to a case. That way, Azar explains, everyone can see the history and knows what is happening with the restorative case.

"Very rarely will we ever come across something where we don't remember what happened," Azar says.

Digital communication is also helping improve the digital impression process. Many times, scanners do not perform equally in different types of cases. Azar thinks the lab should understand the strengths and limitations of the scanner and help dental practices understand these too. Keating offers classes on-site at their training facility for dentists to come in and learn with the manufacturer. Keating also sends their technicians for training on the scanner technology so technicians can be a helpful resource for dental practices.

"So, when a dentist is not having good luck with what they are doing because they're new, the lab should be able to log on and see what the team is not doing that they should be and help them get that patient taken care of," Azar says. "I'm not saying we are technical advisors. The practice should call the manufacturer and schedule another training session for that. But today, the practice needs that answer to that question, which is important for us to answer."

Keating is celebrating its 20th anniversary this year, and part of that celebration is to establish themselves as the kind of lab where dental practices can learn about products and how to improve digital technology skills. With their 120 employees, they have combined experience of over 5000 years, Azar says, and Keating wants their customers to take advantage of it.

"We are on a trajectory to go there," Azar says.

Digital communication with labs also enhances marketing efforts for labs. For example, Keating invested in the HubSpot CRM platform for its internal marketing use. The platform reports customer history and what led them to the lab in the first place. Azar says that data helps Keating target customers and communicate about things they are interested in learning. Azar prefers this targeted approach instead of a general blast.

Communication with your lab is critical for a quality patient experience and outcome for your restorative dentistry. So, what is the best way to handle it that works for everyone? 