CAD/CAM: Having it all ... your way

Flucke ,John;

CAD/CAM: Having it all ... your way

March 19, 2015

Dental Products Report, Dental Products Report-2015-04-01, Issue 4

It’s all just ones and zeroes, off and on. It’s just that simple. It’s hard to believe that when a 25-year-old Texas Instruments engineer named Jack Kilby demonstrated the first integrated circuit, one person’s response was “But what is it good for?” That little integrated circuit, the off or on, the one or zero, gave birth to the digital revolution.

It’s all just ones and zeroes, off and on. It’s just that simple. It’s hard to believe that when a 25-year-old Texas Instruments engineer named Jack Kilby demonstrated the first integrated circuit, one person’s response was “But what is it good for?” That little integrated circuit, the off or on, the one or zero, gave birth to the digital revolution.

You may not be aware of it yet, but the subject of CAD/CAM in dentistry has seen some tremendous growth and change in the last few years. As a matter of fact, I think we need to have some more definitions in the category. It’s changed that much.

It used to be that when you talked about CAD/CAM in dentistry, you were talking about in-office milling. That meant you were basically talking about two companies. There was Sirona, makers of CEREC, and D4D, makers of the E4D system. Both companies sold acquisition units that acquired chairside digital information and allowed the office to design the restoration, which was then wirelessly transferred to a milling unit that took a block of material and created the restoration that had been designed.

One recent change in the industry and in this product category has been with the E4D. Recently, Planmeca made an investment into the company. While the technology, the people creating it and the trainers are the same, the name has changed due to this financial investment by Planmeca. The product is now called Planscan.

The Planscan device was previously called Nevo and is very easy to use. It is a truly portable scanning device because it has a USB and connects to a special laptop available from Planmeca. You can buy a laptop for each operatory that you work in and then move the Planscan and just plug it into the laptop. I got a chance to try it while it was still in beta, and I created a perfect scan with no training and no prior experience. It’s that easy.

The device has multiple size scanning tips to accommodate differences in patients. These tips contain some electronics that help track how long they have been used (so you don’t use them past their recommended lifespan) and yet they are autoclavable. The fact that they contain sensitive electronics and yet can be autoclaved … that technology alone makes my geek heart flutter! The system is also connected to Planmeca’s Romexis software and Romexis Cloud, which connects your Planscan to other parts of your office, such as internet-connected chairs, etc.

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While the early days of digital restorations sometimes yielded less-than-optimal results, the companies were constantly innovating, and now the restorations are equivalent with any that are human-fabricated. Labs have also embraced the digital philosophy and are often milling restorations as well.

Now, however, there’s been a seismic shift in the whole category. The shift started with the market introduction of digital impression systems. Devices such as the Cadent (now owned by Invisalign) iTero, 3M’s True Definition Scanner and the 3Shape TRIOS came to market and brought the concept of digital impressions to dentistry sans the milling unit.

This meant that for the first time, offices could truly create digital files of preparations and still use the dental lab for creation of the final prosthesis. This was groundbreaking in the profession. While in-office milling had proven itself, many offices still preferred to have laboratory-fabricated restorations for a number of reasons. This meant that there was a divide between digital impression offices and traditional impression offices. With the advent of devices that provided digital impression (acquisition) only, suddenly offices that understood the advantages of digital but did not want to mill had their solution. The market expanded substantially.

Video: Use iTero intraoral scanners with ATLANTIS abutments

From a personal standpoint, my office brought the iTero on board about five years ago. We rapidly embraced it and, within 30 days or so, were taking an average of one traditional impression per month.

Over these last few years, many offices that were hesitant about the process and/or the initial purchase price of in-office milling systems have seen the tremendous advantage of what the technology brings. For many of these practices, the question has now become “Should we now be milling many of these restorations ourselves? And, if so, how can we make that happen without a complete overhaul (both operationally and financially) of our current system?”

The answer to that all-important question is now a pretty simple one. Any of the acquisition units currently on the market (with the exception of CEREC) are open source. That term means simply that other devices can read the files created by the acquisition units. So the office that is currently taking digital impressions can easily move to milling. It’s important here to also make sure you understand that Planmeca’s Planscan is also open source. That means you can connect other acquisition units to the Planmeca mill or you can use a third-party mill with the Planscan acquisition unit.

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This is accomplished by purchasing a milling unit and getting the two devices to share information via a wireless network. The milling unit purchase also includes design software.
We are currently working with the Glidewell TS150 milling unit, sold by Benco. While I am always thrilled to test the newest, latest and greatest, this process has been a lot of fun for the entire team and the patients are enjoying it as well.

The process to do this is as follows: The company selling you the mill should perform a site survey to look for the proper location and also to identify any potential unique problems that the office may have. This will mainly have to do with assuring a reliable wireless connection. The acquisition unit should already be configured for your WiFi, but the mill will need to access your WiFi, as well. Good communication greatly helps the process.

The company that manufactured your acquisition unit will need to be notified that you are doing in-office milling. There may be some software they need to install, and there may be a monthly charge for the unit to connect to the in-office system. This is because part of the revenue model from the acquisition companies is charging for sending the info to the lab. In order to replace that, there will most likely be a monthly charge for access to the in-house system.

The mill is delivered and installed by the dental supply company (in my case, Benco). This involves getting it up and running from a physical standpoint as well as configuring it to your WiFi. There will also be design software included. In most cases, the purchase of the mill will include a computer to run the design software (which I recommend); however, you may be able to have the software installed on a computer in your office. The important piece of this is that the computer must be able to access your wireless network because it receives the digital impression data from your acquisition unit and then, after the design process, sends the restoration data to the milling unit.

Once the installation is complete and everything has been debugged, training on using the milling unit and training on the design software is done. I highly recommend allowing a full day for this with minimal interruptions. The design software that I have seen to this point does an incredible job and is fairly intuitive. However, no matter how easy a program is to use, if the team doesn’t have adequate time or is being constantly interrupted during training, the chance of the information being understood and retained drops greatly. When it comes to training, you will lose some production dollars for the day, but you will lose much more if the staff doesn’t “get it” after training is done.

Once everything is up to speed and working, the process is pretty simple. Our workflow really didn’t change all that much. We acquire the digital impression data from the iTero. Once your impression data is complete, acquisition units then need to know where to send the data. There is normally a dropdown menu that allows you to select the right data. In the case of milling, we just select the TS150 mill instead of the lab. The unit then wirelessly transfers the data to the computer that has the design software.

Video: Dr. John Flucke explains how and why DEXIS CariVu changed his practice for the better

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Once the data is transferred to the design computer, a team member will open the file and design the restoration. Some doctors prefer to do this themselves, but to me that is where the process can become expensive. I prefer to have the assistant that has been with me during the prep create the restoration while I continue to see patients. This keeps revenue generation from being interrupted, and I basically substitute an assistant for a laboratory technician. In a case where perhaps I’m doing a crown and some direct composites, I’ll have another assistant help with the operative while the assistant that helped with the crown preparation is designing.

Once the design is completed, I review and approve it, which is a minimal amount of doctor time, and the milling unit creates the restoration. While there is a small amount of “down time” for the patient while the mill runs, I feel I’m simply swapping the cement appointment for this “down time.” Actually, the mill and cement time is less than what we normally schedule for a lab-fabricated prosthesis so in reality we save about 10 minutes. We also don’t have the costs of setting up a room, the disposables, etc., from the second appointment. Granted, that isn’t a tremendous amount of overhead, but every little bit helps.

In our evaluation, we’ve found the restorations to be first rate with great margins and anatomy. Once the team got comfortable with the software, design time dropped and efficiency went up. I also like the ability to choose lab or mill. Depending on the case, the lab will always be an option for me. Having choices is a key component to this for me and I think most of you would probably agree on that point.

Video: How to optimize a team approach to digital dentistry and CAD/CAM

The really big key piece of this is the open source data. That allows an office to start slow if they choose to and then expand into in-office if they desire. I also think that not being tied down to one system is something the industry has needed. If a better mill comes along, I can sell the current one and get a new one without completely having to scratch all the hardware. The reverse is also true, meaning that if I’d like I can get a new acquisition unit or even add a new unit to my current configuration and have both open source acquisition units use the same open source TS150 mill.

As I said in the title, this is all about having it your way. The entire digital restorative process has evolved to the point that the doctor can now dictate to the technology instead of the other way around, which is wonderful for our profession and for our patients. I’m looking for even better things as the evolution continues. However, if this is of interest to you, I truly feel there is no need to wait and see where things go. This entire tech category is mature and producing great things. I feel the time to get involved with CAD/CAM is now! Enjoy the ride.

About the author

John Flucke, DDS, is technology editor for Dental Products Report and dentistry’s “technology evangelist.” He practices in Lee’s Summit, Mo., and has followed his passions for both dentistry and technology to become a respected speaker and clinical tester of the latest in dental technology, with a focus on things that provide better care and better experiences for patients. He blogs about technology and life at blog.denticle.com.