	Combining the milling capabilities of the Roland DWX-51D five-axis mill with the advantages offered by UNIQUE CAM software, the SMARTMill51D system from ETI Digital Technology is designed to provide detailed and efficient milling solutions for every dental laboratory. 

	The SMART (which stands for Smart Manufacturing Adaptive & Reliable Technology) workflow provides milling capabilities for a large variety of indications, including partiatls, bite splints, surgical guides, crown and bridge models and more. The five-milling axes of the 

 allows for fine control over margins and results. The 10-station tool changer helps the mill achieve stunning detail, and the UNIQUE CAM software allows even greater control over tool choice. 

The other half of CAD/CAM: ETI Digital Technology's scanning solution

 is also designed to allow users to ensure they’re using every puck of digital material to its fullest extent. The purchase price of the system includes three years of software updates and maintenance, along with ETI Digital Technology’s customer service and support. For more information, visit 

		A vacuum and anti-static ionizer for better calibration and dust reduction

		Ability to interconnect as many items as can be placed on a disc

		PDF file for ease of locating cases post-milling

		Different milling strategies for different materials, designed to increase tool life

We are pleased with ETI Digital Technology’s overall customer service as purchasing our complete CAD/CAM system has been a life- and game-changer for us! We can literally mill everything we want in-house, everything from their Dental Wings 7Series Scanner to the Roland DWX-50 milling machine with Unique CAM software has been wonderful. We had been wanting to get into CAD/CAM for a long time and our purchase from ETI Digital Technology was one of the best decisions that we’ve made for our laboratory’s overall production and growth. We could not ask for more on the products that we had purchased and the continual customer support that we receive. ETI’s Technical Director, John Just, traveled to our laboratory and provided an excellent and thorough training session on the equipment and software that we purchased, which further supported our decision to purchase from ETI.” 

Owners of Main Street Dental Laboratory 

Articles

Digital Esthetics explores how the SMARTMill51D workflow from ETI Digital Technology improves dental milling and final outcomes.

How one workflow is improving dental milling

 was incorporated in 1962 by Murray Kaizer. The core of the business is in 

, but they do adjunct crown and bridge work, primarily in conjunction with removables.

They offer a full complement of CAD bars, all removable, along with fixed removables-from the simplest appliance to the most sophisticated hybrid. Murray Kaizer works closely with four of the leading 

 companies and handles approximately 500 private accounts and two dental schools across the United States. The lab prides itself on being painstaking in its commitment to doing the work correctly. They seek to have a dialogue with the doctor rather than risking a failed result. The lab does about 10,000 cases per year and has 16 technical people, seven CDTs-one in partials and six in full dentures-and then another eight people in more support/admin roles. 

Understanding-and flourishing in-today's digital workflow

 specializes in the designing and manufacturing of castable spherical attachments and implant overdenture abutments with a connecting nylon female component processed into the removable prosthetic device. Mr. Ezio Nardi, founder of the company, pioneered this simple concept of ball and cap connectors. Over the past 30 years, this technology has become a go-to solution for RPDs and overdenture prosthetic design, improving superior oral health, functionality, esthetics and patient comfort. Today, Rhein83 is recognized worldwide for its technical expertise in spherical and low profile dental attachments, superstructure frame designs and direct implant abutments with universal compatibility.

Murray Kaizer Dental Laboratory has been a long-time user of Rhein83 products. And not only has it been a long-time user-it’s also been a happy user. “We’ve used almost every Rhein83 product they’ve made over the years,” says Jerry Kaizer, CDT, owner of Murray Kaizer Dental Lab and son of its founder. “We’ve used them since the mid-80s. We’ve had great results. Rhein83 works better than many of the other systems.”

Read more about Rhein83's approach to attachments

Kaizer has been impressed with solutions offered by Rhein83, such as the 

 is a line of low profile castable, threaded components for bars and direct implant overdenture attachments, engineered to be the smallest attachment system on the market. “There’s nothing that’s 100 percent in this world, but in terms of strength and being forgiving, [the OT Equator system] seems to offer some advantages over some of its competitors,” Kaizer notes. “Most of the attachments that are currently made have a titanium nitride coating on them. It gives resistance but gives the doctor a visual cue-if he sees shiny spots on any of the male components in the mouth, he should know something’s wrong. So with the Equator attachments, we have seen the least amount of wear in that context. It’s the most forgiving system that we have worked with out of all of them. Additionally, we’ve done no less than 25 bars with Equators on them, and they’ve all been pretty much problem-free.”

Next page: How Rhein83 can prevent total implant losses ...

For Kaizer, one of the biggest attractions with Rhein83 isn’t necessarily with the products it makes-though those are great too. Kaizer says he is impressed by a specific service offered that sets Rhein83 apart from other options. “The one thing that Rhein83 has going for it that no other company has going for it: It will make any abutment for us up to 7 mm in cuff height for any manufacturer in the world as long as we can provide them with a thread pattern,” Kaizer says. “If I send a healing cap to Italy with a cuff height, I get an abutment. Whatever I want on top, they make for me. That has made it a much easier system to work with.”

Related: Using Rhein83's OT Equator in a technique

Todd Mercier, chief technology officer at Murray Kaizer Dental Laboratory, says recently, Rhein83 performed that exact service for them, helping them complete a particularly tricky case. “We just did a case this year, and a patient had four locators on a mandibular case,” he remembers. “The ones all the way back in the molar area were 6 mm diameter implants, but the company that made those only supplies abutments for a locator with a 4 mm abutment. When you looked at the X-ray, you saw a 4 mm abutment on a 6 mm implant, which was terrible for the patient. I called Rhein83, told them the cuff height and implant size and got back a custom abutment. Normally, that case would have lead to an implant having to be removed.

“Another nice feature is that Rhein83 makes a lot of components to rehabilitate cases,” Mercier continues. “There have been instances we’ve had an old CAD or cast bar and all of the old attachments were broken or worn out, and I’ve gotten attachments back from Rhein83 with a threaded sleeve for bonding so you can screw different sized Rhein83 balls into it and you can screw Equator into it. So you can take where the old attachment was threaded, ream it out, put in the pieces, cement it and you have a bar with brand new attachments.”

“There are a lot of old implants out there, and they need service from time to time, and they need attention,” Kaizer adds. “I’ve known [the people at Rhein83] for 35 years, and they’re some of the most customer-oriented people I’ve ever met. If there’s a problem they can take care of, they will, and if they can’t, they’ll direct you to somewhere that can.” 

Both Kaizer and Mercier are also filled with praise for the customer service and support provided by Rhein83-both stateside and from the headquarters in Bolgona, Italy. “They’re exceptional in terms of support,” Kaizer says. “They’ve actually helped us get a little smarter in what we do. They manufacture a 

-most dentists use a perio probe and it’s a guess, at best, but this tool is color-coded, and you hold it on there, and you place it on the top shoulder of the implant, and you screw it down until it touches tissue, and you use the color coding to see what the measurement is. The other suggestion they gave us is never take an order for an implant abutment over the phone but to always tell the doctor to send you the chart and sheets so you know you’re ordering the right part and it minimizes the risk you’ll take. It’s been exceptional. With other companies, sometimes you get a customer service person, and they’re wonderful, but they can’t answer your question. But with Rhein83, there’s someone where the buck stops, and if he can’t help you, then the product is not made.  He’s got the staff over there to help him. These guys are making it and selling it-not just selling something someone else made. It’s like having a valuable resource you know is always available to you.”

It’s high praise, but it’s echoed by Mercier. “ Every time I’ve worked with them, it’s always pleasant and positive,” he notes. “Most doctors want everything done as quickly as possible. But when we have situations where the abutments aren’t available or they’re just not made anymore, I tell them I have a resource in Rhein83 and give them the specs, and within two weeks, they’ll have a custom-made abutment that fits perfectly. They’re willing to wait that extra time and know it’s going to work.” 

“I’ve gone so far as to tell a doctor and say, ‘if you don’t like [the Rhein83 attachment system], we’ll eat the cost,’” Kaizer says with a laugh. “I haven’t eaten a case yet! I want my doctors to have a different tool in their toolbox. You can’t do projects with just two tools. If I can help an account of ours broaden its toolbox, that’s a home run, and that’s what Rhein83 has allowed us to do.”

This article originally appeared in the May 2015 issue of Dental Lab Products. For more great insights, make sure you're subscribed to DLP by 

 Murray Kaizer Dental Laboratory was incorporated in 1962 by Murray Kaizer. The core of the business is in removables, but they do adjunct crown and bridge work, primarily in conjunction with removables.

How one lab benefits from using Rhein83 as a partner

BEGO’s new Varseo 3D printing system offers eight different high performance resins that can be changed from one job to the next in less than 30 seconds.

Varseo is engineered to produce highly accurate splints, surgical guides, CAD/Cast partial frames and C&B patterns, as well as custom impression trays. Coming in 2015, indications will be expanded to include denture bases, models and temporary crowns and bridges. The printer accepts any STL file and comes standard with 

 CAMbridge software for support positioning and nesting. Varseo is said to feature excellent building speed, high accuracy, a user-friendly display and a cartridge system that allows the material to be changed in seconds.

		Created specifically for dental applications

		USP cartridge system reportedly allows material change within 30 seconds

		Ejector system is engineered to eliminate distortion

		Designed to provide the highest possible construction speed

For more information, contact BEGO by visiting 

 BEGO’s new Varseo 3D printing system offers eight different high performance resins that can be changed from one job to the next in less than 30 seconds.

A 3D printer designed for the dental lab

	When you think about it, the process of creating a restoration is sort of a miracle. The fact that a piece of human anatomy can be replicated quickly and at reasonable expense is nothing short of astounding.

But when you add new technology and materials-like CAD/CAM and monolithics-producing better, faster, cheaper restorations becomes even more impressive.

It’s not really a miracle, though. It’s hard work between the clinician and the laboratory. To optimize the endeavors of both parties, they must be able to work together smoothly.

Doctors say the same thing as lab owners when it comes to having a fruitful relationship-they want effective communication.

“Labs should be partners,” says Sheri B. Doniger, DDS, president of the 

. “They should expect definite communication regarding cases.”

“What I’m looking for in a lab is a partner,” says Dr. John Flucke, DDS, technology editor for Dental Products Report. “I’m a firm believer in relationships. What I want is a lab that knows what it’s doing, has good employees and then I can count on it to do the right thing and to help me.”

Staying on top of your working relationship is very important. You can learn what’s working and what needs to be worked on.

“The number one thing on the lab side would be to reach out,” says 

a. “If you’re not hearing anything and the cases keep coming, reach out anyway. Be proactive in talking to the doctor.”

“I would almost imagine that an average dentist is going to change labs probably between five and 20 times in his or her career,” says 

Dr. John Comisi, DDS, president and CEO of Dental Care With a Difference in Ithica, N.Y.

 “That happens for many different reasons; number one, of course, communication, is certainly a challenge. Sometimes what is communicated from the doctor to the lab and/or from the lab to the doctor can be paramount to a successful, long-term relationship.”

Another component of communication is checking in with your doctors from time to time. Even if every case sent back to the doctor is received and given to the patient without incident, the occasional call ensures you continue delivering what the doctor wants.

“Call every so often and just ask, ‘Hey, are the contacts too tight? Are they not tight enough? Is the occlusion off on a consistent basis? What are we learning?’” Dr. Mongrain notes. “In that case, you’re not going to have regular communication. It’s more like there’ll be periodic check-ins to see how things are going.”

More intricate cases will necessitate more interaction.

“It’s more of the bigger cases or something complex or you have a question about something-that’s where you would reach out to the lab and have a conversation,” Dr. Mongrain says. “That would just be occasionally, depending on the practice.”

The act of reaching out to doctors not only reveals problems but is also important in bolstering that relationship.

“If people are calling from the lab-which they should be-then the doctor sees the lab trying to reach out and do as good as they can,” says 

Shaun Keating, owner of Keating Dental Arts in Irvine, Calif

. “Doctors respect that, and I think they want to see that nowadays.”

Keating notes solid relationships are what keep dentists with their labs.

Exclusive video: What your lab needs to know in 2015

“We try to touch base with the doctors every two weeks minimum,” Keating says. “Those doctors are getting solicited 20 or 30 times a week from labs via email, mail and journals with print ads. There are lots of temptations for dentists that don’t really have that relationship with their labs. At the end of the day, we’re all sort of doing the same thing, so what sets you apart? Is it the low price? Is it the quality? Is it going to be the service? It’s a little bit of all of that, but, at the end of the day, the big thing is the relationship.”

Building a solid relationship also affords you a certain measure of protection if-and when-problems occur.

“That way, when you do screw up the case-mess it up bad-you won’t have a guy bouncing every week to another lab because there’s a relationship,” Keating observes.

Introducing a new product or material into the doctor/laboratory relationship can occur in several different ways. In some cases, the lab takes the lead.

“Generally, it’s the laboratory because it’s in its best interest to be able to continue to receive work from a doctor that’s made the switch to technology,” says Ryan Faufau, director of CAD/CAM Resources at Custom Milling Center in Arvada, Colo. “One of the fears I see with most labs is that everything’s going digital and doctors aren’t taking impressions today. How do [labs] maintain this working relationship with the clinician to continue to receive work and keep control of the account?”

Oftentimes, doctors are too busy to keep up with what’s new, so the lab brings it up.

“If the doctor is reading journals and literature, they’re going to be finding out about the new materials, but sometimes the day is too packed and crammed to know about all the different things that are out there,” Dr. Comisi says. “Many labs will send out brochures and leaflets regarding new techniques and materials that are available, and most of them say, ‘Call us to learn more about this material, how to work with it and what you can do.’ Technicians can give some great information. If the technicians are staying up  to date and they are trained on these things, you can’t get a better insight and a better team member.”

The opportunity for a new product or material often arises when the doctor is advised by his or her lab on improving a case.

“That’s when a lot of folks, including myself, get some insights into things,” Dr. Comisi says. “I talk to my lab on a regular basis. I say, ‘Can I use this material here?’ and they’re going to tell me yes or no and why one material might be better than another. Or, even better, they might suggest an alternative that I’m not even aware of. The more we talk, the more we will be able to learn and probably be able to do a better job as we go forward.”

“Our client services people may bring it up to an account,” adds Bob Savage, CFO at 

Drake Precision Dental Lab in Charlotte, N.C.

 “Our technical people, as they’re talking about a case, say maybe they’re having a problem on this case with a material and maybe this new material is a good option or, ‘Hey, maybe on your next case similar to this we have this XYZ product that may really fit into that particular modality of the case.’”

It isn’t always the lab taking the lead. Labs will often respond to their doctors’ inquiries about new products and materials.

“You have your clinicians that see a product and they want to try it or they have a case where it makes sense to try to use that product, so we get solicitations that way, as well as if we believe in the product,” Savage says. “Drake has always taken a proactive approach. We don’t want to take on products unless we feel they’re going to be good for our clients. We’re not always the early adopters sometimes because we want to do our due diligence on introducing new materials and new products into our market space.”

VIDEO bonus: How outsourcing can help your lab grow-and what you need to know

It is in the lab’s best interests to keep up on what is out there, so it can advise its clinicians appropriately.

“It’s really what the doctors are requesting, but our position is if we believe in a product, invest in the product and then educate, I think that’s really where Custom Milling Center takes a step forward and makes an initial investment and just makes our client base more aware of the direction of the industry and then also what new products have hit the market and the process of delivering the final restoration from that,” Faufau says.

Responding to the doctors’ inquiries can be beneficial for the lab because others may also be interested in the product.

“‘I heard about this e.max material. Do you guys do it?’” illustrates Jason Obrokta, director of technical marketing, fixed prosthetics at Ivoclar Vivadent. “The lab’ll say yes or no, and if it’s no, it’ll say, ‘Maybe I should look into this because my doctors are asking for it.’ Laboratories, by and large, tend to be very reactive to what the doctors are asking for, which is why we put a lot of emphasis on educating the doctor on material options.”

“What I see is primarily manufacturers and key opinion leader speakers that start talking about a new material and then the labs follow behind them to introduce them to use their clients,” Dr. Mongrain adds. “They’re usually talking to me before I’m talking to them.”

The type of product also is a factor in who introduces it into the relationship.

“In my case, when it’s a device like a scanner, I’ll often bring that to the attention of my lab,” Dr. Flucke says. “As far as materials, [the lab] will bring that to my attention because it is more versed in the materials than I am, but I’m a bit of an outlier from the device standpoint because I’m a gearhead and I’m always looking for gadgets and stuff to try.”

With new products and techniques, there are new ways to handle the workflow between doctor and laboratory.

“The expectation level changes a bit,” Savage says. “You used to box an impression up, and you get it the next day. With digital, I think there’s a growing expectation of immediate access. That impression is now in our hands. Is it good while the patient’s still in the chair? It sets a different expectation level for us. I don’t think the communication really changes, but I think it speeds it up, and I think it’s up to the lab to be responsive to that in understanding that, going forward, as more digital impressions and CAD/CAM type restorations enter into a lab, you have to be cognizant of that expectation change.”

Dr. Comisi has gone from traditional impression techniques to using a 3Shape scanner for an all-digital workflow.

“It’s made me, in my opinion, a better doctor overall simply because as I’m preparing, after I’ve scanned, I can really scrutinize,” Dr. Comisi says. “I can blow that picture up and see were my margin is, or even worse, not see where my margin is. And I can correct it before I send that off to the lab. Since I’ve gone digital, I’m just looking at this, and I say, ‘Oh my gosh, I see things that I wouldn’t have seen otherwise,’ and it’s really remarkable.”

And while scanning has been an aid for doctors, that doesn’t mean they can be sloppy.

“If you don’t scrutinize whatever type of impression or whatever type of work that you’ve done on the preparation for the laboratory case, and you don’t give yourself your own critique, the lab is going to have less of an ability to create something of value to you,” Dr. Comisi says.

The ability to send the case electronically helps not only in terms of speed and efficiency but also gives the lab a chance to look at it while the patient is still in the chair.

“The communication there is instantaneous,” Dr. Comisi says. “Once I send an STL file to the laboratory, it’s got it within minutes. The technicians who open up the file look at the case, and, shortly thereafter, I get a notification that the case has been accepted or not so I know right away if there’s a problem with my case. That’s great because I may have that notice before I dismiss the patient, and I can correct the problem. That’s really the great thing that goes on for most of these but especially with the mobile apps that are available with many of the systems. You get a notice on your telephone that something’s going on on the Trios app, and they look at it and say, ‘OK,’ and the lab has communicated with you. Then you type back and you tell it what you want or you ask it to clarify it more, or you just get on the horn and you talk.”

To facilitate that exchange of data, labs and doctors use online portals.

“If the doctor has a chairside scanner, how does he or she get that data submitted over to the laboratory, and how do we make this as easy as possible?” Faufau asks. “One of the things that we do at CMC is we help laboratories set up this workflow between the laboratory and the doctor. We use the program called DDX, which is Dentrix-it’s actually an online web-based program that enables the clinician to create an account through its website, and the laboratory would create account, and this is how they both would connect. The clinician would be able to simply pull up the web browser, attach the file and submit the case to the laboratory without purchasing additional software.”

Tools like DDX not only facilitate the exchange of information, they also ensure regulatory compliance.

“I think it’s becoming more common because one of the things we also have to look at when we’re sending Rx’s and patient information over the web is, ‘Is this HIPAA-compliant?’” Faufau says. “‘Is it following patient privacy?’ And DDX follows all those guidelines, which I think is something that might be [overlooked] in the industry today, especially when it comes to electronic submission.”

Taking advantage of the benefits afforded by digital dentistry can be a great opportunity for both doctors and labs.

“Right now, we are seeing a big influx of digital technology being put into the laboratories, and it’s taken a long time to get to this point,” Obrokta says. “But the labs are starting to realize, ‘I see the benefits now. It’s a reduction in my labor costs so it helps me to produce a more efficient and more reproducible restoration, and I can do it with a little bit less cost for my doctors. It’s something that will look nice, perform well and net me a little bit of extra money in the end.’”

CAD/CAM has really come into its own in recent years, and many labs have realized that.

“Most laboratories are of the mindset that if they’re not involved in some sort of digital technology, they should be,” Obrokta says. “As to whether or not they feel definitively that what’s out there today is going to be the answer in the future, I think there’s still some trepidation about that. A lot of labs are in that wait-and-see approach to see what technology is going to pan out to be the ultimate technology that everybody adopts.

 “Within the data acquisition part of it, they’re scanning models or they’re scanning representations of the patient’s mouth to go into the digital fabrication. That technology seems to have pretty well panned out. There’s one company that seems to have the bulk of the market right now, but even that adoption rate is not 100 percent. A lot of people are still saying, ‘I want to see what else this thing can do before I invest in it.’”

New materials require new cements for the proper application, and your doctors might not know that.

“In the past, you had to always do this bonding procedure that required a bunch of steps and was very easy to not get completely correct,” Obrokta says. “And if you didn’t get it right, then a restoration could fall out or fail because of that, so all ceramics were a bit limited in their exposure and their penetration into the dentist market because of that. Because doctors typically would just like to put some cement on the crown and stick it in place, and that’s been the procedure they’ve had for metal-based restorations forever. That was in the past. Now, with these stronger, all-ceramic materials like zirconia and lithium disilicate, there’s more flexibility in the cementation they can do. It becomes more application-based now versus just material-based.”

It is up to the lab, ultimately, to communicate correct usage.

“Some doctors know that and understand that,” Obrokta says. “Most doctors, I feel, don’t, so it’s up to the laboratory. What ends up happening a lot of times is a doctor will get a new crown of a new material type from a new laboratory, and they get that restoration, and they’ve got the patient and they go, ‘Let’s get the lab on the phone because I don’t know what to put this thing in with.’ To that end, we’ve also done a lot of work trying to educate the laboratories on cementation so they can answer those questions. Every time there is something different that’s offered to a dentist, the dentist will say, ‘Great. What am I supposed to cement this with?’ We’ve tried to educate the laboratories so they can be a better resource for their doctors.”

For the best working relationship-and for the best results-clinicians and their labs must work as a team. To smooth out complex cases, Dr. Flucke brings each member of the team together.

“What I’ve seen is the lab will call me and say, ‘You know, John, we’re going to have a hard time getting this the way you want it because the surgeon or the periodontist didn’t put these where they need to be for easy restorability or for angulation or whatever,’” Dr. Flucke says. “Unfortunately, in those situations, the general dentist becomes caught in the middle. So what I’ve started doing when we get complicated things-and this is something I would really advise with cases like this-if there is a chance that it could go haywire, have a meeting.”

That meeting can be done in person or even through conference calls or online. In Dr. Flucke’s case, he built a conference room in his building with a screen so he can host meetings. He brings in the lab tech and any specialists, and puts the case on the wall so they can all go over the details together.

“We can review the X-rays, photos, everything,” Dr. Flucke says. “We can all treatment plan the case together so that we all know the nuances of it. It’s nice to do that because you end up with a case that everybody is involved with from the ground floor. I have no problem with having a big meeting and getting everybody together and making the decisions together as a group so we all know where the limitations are with different potential stopping points.”

Realizing the skills and talents of the other members of your team will help you deliver the best for the patient.

“It’s definitely an interesting time, but, regardless of whether it’s CAD/CAM or whether it’s traditional impressions, communication is a very big piece to our business,” Savage says. “We have to communicate because I think both parties bring different talents and different experiences to the table. We learn from our clients, and I hope our clients learn from us because that’s the way it should be and can really build a synergistic relationship-not be just one-way communication.”

Ultimately, a solid relationship between the clinician and lab comes down to that vital quality of a great relationship: communication.

“At the end of the day, it’s just about talking,” Savage says. “It’s two people communicating. Whether it’s a lab and a doctor or two friends talking to each other. It’s about being respectful. It’s about being positive and really showing what the general intent is. Communication is difficult and easy at the same time. It sounds easy, but, as you get into it, you can’t be afraid to talk to your clients.”

Robert Elsenpeter is a contributing writer for Dental Lab Products and Dental Products Report.

 When you think about it, the process of creating a restoration is sort of a miracle. The fact that a piece of human anatomy can be replicated quickly and at reasonable expense is nothing short of astounding.

Dental Lab Products May 2015

How one workflow is improving dental milling

How one lab benefits from using Rhein83 as a partner

A 3D printer designed for the dental lab

What Dentists Want Labs to Know