The Rise of Digital Design Services and What It Means for Chairside Digital Dentistry

The first CAD/CAM system made its commercial debut in the dental practice in 1985, and the profession has never looked back. Since that first initial indirect restoration, the chairside digital workflow has expanded to include an exponential number of milling machines, intraoral scanners, 3D printers, and other technologies that allow dentists to handle restorations in-house. Over time, the software has become faster, more user-friendly, and increasingly accessible, resulting in a renaissance of digital design.

“Access to digital design has flipped dentistry on its head,” Austin Vetter, DDS, a private-practice clinician in Fargo, North Dakota, says. “The way the iPhone changed the photography world is the same as how digital dentistry has changed dentistry. We can take records, design, edentulate a patient, and deliver a patient’s denture all in 1 day. This was never possible years ago, but we are seeing this more and more every day. After having these technologies, I can’t imagine going back.”

And there is no going back. The changes CAD/CAM and chairside dentistry has brought to the industry have indelibly altered how clinicians view restoration fabrication. “The introduction of digital CAD/CAM to chairside made way for more precise and faster treatment,” Hakwan Kim, director of business strategy at Imagoworks Inc, says. “Previously, patient’s impressions had to be taken to the dental laboratory in order to make the prosthodontics needed for treatment. However, chairside digital dentistry enabled clinics to supervise all the required processes, such as intraoral scanning, design, and manufacturing. This led to the flourishing of 1-day crown and bridges, which continues to evolve in both speed and accuracy.”

Accessibility

A big factor in the increase of chairside dentistry—in addition to the allure of same-day dentistry—has been increased accessibility. Not only is the necessary technology less expensive than it was in years past, but it’s also now more compatible. As open architecture increases, more dentists can afford digital solutions.

“It’s not like the old turnkey systems of the past, where you had to buy 1 big, expensive system,” Lisa Aguirre, dental marketing manager at Roland DGA Corporation, says. “We’ve now evolved to open architecture solutions, which opens up a lot more possibilities. When you match open architecture, design options, material capabilities, and milling solutions together, it opens the doors to get away from cookie-cutter dentistry. It allows clinicians to provide more individualized, customized treatments for their patients.”

A roadblock for many clinicians has been matching the technologies. If they already own a scanner by one company, but the design software they want is by a different company, then they’re stuck. Buying a new scanner to match the software is a hefty investment. Similarly, purchasing software that doesn’t meet your needs is a fool’s errand. Open architecture systems ensure clinicians aren’t pigeonholed into 1 company’s software and hardware, allowing them to select the technology that works best for them, their skill level, and their desired uses.

“Open architecture systems are now being designed for users of every level,” Aguirre says. “It could be an experienced user, it could be a beginner level, it could be a middle of the road, or it might even be the clinician’s assistant performing that duty. It’s designed so anyone [in the practice] can use it, which is a big step in the right direction.”

Much of the technology that’s making chairside digital dentistry more accessible to clinicians of varying design experience or skill levels is already in the practice. A 2021 survey by the American Dental Association found that half of the respondents reported using an intraoral scanner in their practice.¹ Many clinicians deterred by the perceived investment costs of chairside dentistry may already have an intraoral scanner, which is the first piece of the pie. This brings them 1 step closer to being able to provide chairside services.

“Once clinicians realize they’re already a step of the way there and they’ve mastered that part of it, that’s when they start to dive into the next part of it and that’s where they have options,” Aguirre says. “They can go full-fledged and purchase design software, or they could just purchase a mill and use a design service. There are a lot of different ways to go [about] it. Because of this, it’s going to keep growing. I think we’re going to see the number of clinicians transitioning to in-house increase.”

This introduction of multiple options for design workflows has opened the doors even wider. Practices now have choices and can make decisions that meet their needs and practice flow. “The best workflow will win,” Rob Laizure Jr, CEO, FullContour by 3Shape, says. “Whatever workflow is most advantageous is what will be adopted in the long run. The digital workflow is everything.”

In-house Artificial Intelligence Design

As technology becomes more attainable, it lays the groundwork for dentists to branch out even further into chairside digital dentistry. Coupled with the advent of artificial intelligence (AI), this accessibility has opened doors for dentists who want to do more than just scan and send it off to the lab. Now dentists can more easily tackle the design workflow—a task that was often cumbersome and challenging to justify completing in-house.

However, AI isn’t foolproof; bringing design in-house can be a challenging and often eye-opening process for clinicians. After all, when in-house designs don’t work out, there’s no one to blame but yourself. “Design is often one of the biggest hurdles in chairside dentistry,” Aguirre says. “Clinicians learn very quickly how good their preps are—or are not. When they start doing chairside dentistry and start designing their own stuff, and the software is telling them again and again that there are issues with the design, it’s a real eye-opener. [However], I think it makes clinicians much better [with designing] at that point.”

For some, it has been much better. Dr Vetter is one clinician who has found success designing and producing restorations in-house with the assistance of AI. Originally, he simply wanted to fabricate restorations in-house but later felt the workflow of other systems would slow down his efficiency and produce lower-quality restorations. However, once he found a 5-axis lab mill and a speed oven that could produce zirconia in a single day, he chose to start practicing same-day digital dentistry, establishing a solid workflow with help from AI design.

“We scan and then send it to 3Shape Automate, an AI cloud program that draws the margin and designs of the crown in 5 minutes, without any human interaction,” Dr Vetter says. “This allows me to maintain a control on the design of my restorations and gives peace of mind to my assistants who are in charge of this workflow. AI has brought a predictability to dentistry that I never knew I needed. It’s like having a calculator. Sure, you can do mental math, but why not get the correct answer every time?”

This AI “calculator” has played a big part in digital dental design assistance well beyond just Dr Vetter’s practice, particularly when it comes to the design process in CAD. In addition to making chairside dentistry more accessible, thanks to AI support, it also cuts down on the time it takes to put together a design. Without AI, the dentist or technician is forced to design dental crowns with countless time-consuming mouse clicks. “AI technology, on the other hand, solves all these problems,” Kim says. “Many of the work processes in CAD can be simplified through technology, which can greatly shorten lead time.”

For example, clinicians using Imagoworks’ Dentbird cloud upload the patient’s 3D scan to the software. The program’s AI automatically classifies the data, and the crown design only requires a few extra clicks to be done. The AI then automatically detects teeth that need to be filled, determines the tooth number for each tooth, scans the margin lines, and designs the crowns based on the information. The software designs a crown that is the best fit for the oral structure, particularly in terms of occlusions with surrounding teeth, leaving little for dentists to modify when it comes to final rendering. The rendered crown can then be downloaded and milled or 3D printed.

“In a clinic furnished with the right digital equipment, such as a chairside intraoral scanner, dentists [can] complete prosthodontic treatment much faster, alongside chairside design services,” Kim says. “This leads to better profitability as well, because more patients receive treatment during limited business hours.”

Although the lure of speeding up production and avoiding lab fees can be tempting, bringing digital design in-house may not always be the best decision financially for a practice. Although digital design eliminates the need for a third party in the design and fabrication process, it also eats up time—a lot of time. And as they say, time is money.

“I believe we’ll see many more doctors getting involved in chairside design and printing,” Laizure says. “[However], the caveat is the value of a doctor’s time and [their] earning potential with that time. [The] bottom line is that a doctor’s time is valuable. Some doctors will find [that] design and production ends up being too expensive, but some doctors will embrace it. Maybe they’ll hire a technician to manage the workflow, and if they do that, they could be successful and profitable.”

This means that diving in without a plan can be a big mistake. “If a doctor called me today and said they wanted to do an in-house workflow and wanted help with design, I’d ask them to talk me through their strategy,” Laizure says. “What kind of mill do you have? What kind of printer? Who will be running your workflow? If they can’t answer that, I’d tell them they need answers to those important questions. Yes, we will design for you, but the doctor needs a good repeatable strategy and a solid workflow to get a successful outcome. Without that, they might not be successful and they may drown themselves in work.”

As a huge advocate for digital dentistry, Dr Vetter has a few words of advice for clinicians who are considering embracing their own design workflow: Do your homework, stay up to speed, and most importantly, delegate. “Research systems and ask questions online,” he says. “There are a few mainstream systems that are great at producing same-day restorations. If you have some tech savviness, you can really take your restorations to the lab-quality level while also performing the services same-day. I would also highly recommend championing one of your team members to be your lab technician.”

Outsourcing to Design Experts

Although delegating design and production work to an in-house technician can be a valuable strategy, it’s just not feasible for some practices and may not be a financially sound solution. Additionally, not every clinician is interested in managing the design process in-house, even with the support of AI. “Not every clinician wants to have control of design,” Aguirre says. “Some clinicians just want to provide same-day dentistry, but they don’t necessarily feel the need to design their case from A to Z. They’re happy to have someone else do it.”

For clinicians in this camp, outsourcing to a digital design service can be a practical solution. Design services take scans and design the restoration, submitting the final designs back to the clinician to mill or print in-house. This takes a lot of the legwork out of the dentist’s workflow while still allowing them to provide chairside dentistry. “Design services and outsourcing options are a great tool for clinicians [who] are trying to bypass the big learning curves of design,” Aguirre says. “It is an easy way for faster integration. Plus, a lot of these services are very inexpensive, so it makes an easy [and] affordable way for clinicians to bypass the design step.”

Aguirre also notes that outsourcing design can help practices that are short-staffed or are trying to reduce overhead. When practices outsource to design services, it eliminates the need to hire another staff member or an additional assistant to help with design. “Outsourcing is a great option for a clinician [who] may be trying to dabble in chairside milling without making a great investment or adding additional team members, or they just want to reduce that learning curve,” Aguirre says. “It’s a quick and affordable way for them to turn these things around.”

Design services also provide support to clinicians (or labs using design services), acting as a resource and guiding the workflow. “Our job is to provide value to labs and the practices, meaning we want to make their life better off by using us as a service vs them doing it all themselves,” Laizure says. “Small labs, medium labs, and large labs make a choice to use us as a service provider, because we help them achieve and accomplish more than they could without us. The same holds true for practices.”

Some companies, such as Laizure’s 3Shape Design Services, offer both AI solutions with 3Shape Automate and personalized design support from design professionals to meet the unique needs of a practice, giving a clinician flexibility in how they want to manage their chairside workflow. “We have both AI and design-professional solutions,” Laizure says. “We have advanced AI algorithms that can design prosthetics in as fast as 5 minutes, and we have design professionals [who] can customize their design however they want.”

Visions of the Future

Digital design has already dramatically changed chairside digital dentistry, but it’s not done yet. “The digital workflow has grown exponentially,” Laizure says. “Taking a scan is relatively user-friendly. There are AI tools that really help, and there’s a strong business case for scanning. But what do you do after you scan? As that part of the workflow gets better and [more] simple, I think doctors will do more. It’s less about the cost of the printer or the materials and more about the workflow.”

As the workflow improves and simplifies, so will adoption. Although digital dentistry has already eliminated many inconveniences that relied on manual work, there is still much to come. However, it’s possible that we aren’t far from a future where AI will complete the entire process of scanning, prosthetic design, and production at an unprecedented speed. For example, imagine a 3D-printing machine that functions like a Keurig. You walk over to your 3D printer, drop in a cup of resin, input your scan, and then it spits out an AI design in seconds. You then simply hit print, and voilà. You’re done.

“If the doctor can go from scan to print in 3 mouse clicks and it’s fully integrated, I think that will drive a lot of adoption,” Laizure says. “But that has nothing to do with the cost of the printer or [the] materials and [has] everything to do with the workflow. Nevertheless, I believe most doctors will maintain a vibrant and regular relationship with a dental lab, because they’re going to need them to do so many things—bridges, abutments, dentures, hybrids, inlays and onlays, and other indications that perhaps AI design is not addressing.”

Dr Vetter agrees that AI will be a big component of streamlining workflows and chairside dentistry. “I see AI having its hand in all aspects of the process,” Dr Vetter says. “Someday you will scan the patient and once that data is collected, it will go to AI, which will design the restoration and nest it for you as well as start the mill and choose the right shade of the material to be used. That workflow isn’t too far away and would be really easy for a company to implement.”

As chairside dentistry and digital design continue to grow, dental practices will see a shift in their relationships with the laboratories. After all, a practice that can design and mill all their restorations in-house will have significantly less work to outsource to labs. This means that as the industry shifts, labs must also adjust if they want to stay relevant.

“I think the smart labs out there will get involved, embrace the innovation, and [will] say, ‘How can I get behind this and support my doctors, so that if a couple of those doctors buy printers, I can figure out how to still be a part of that,’” Laizure says. “Maybe the lab can support them with designs and critical steps or…by selling [them] resin, [providing] printer support, or being backup production if the doctor’s printer goes down. I think there will be labs that embrace innovation like this and [will] just drive it and leverage it. Those are the smart labs.”

Ultimately, the growth of both supportive AI technologies and digital design services are making chairside dentistry a more realistic goal for many practices. Whether they want to have a hand in design themselves or want to simply mill in-house, practices are facing an increasing and exciting number of new options.

“I think you’re going to see more and more clinicians adapt to the technology,” Aguirre says. “It amazes me how rapidly things have changed over the past 5 years. Five years ago, a small percentage of clinicians had chairside intraoral scanners. Now those numbers have more than doubled. It’s said that approximately 75% of all dentists now have at least [1] intraoral scanner in their office. Now it’s just a matter of taking it to the next level.”

The bottom line is: The industry is shifting. And to some, the possibilities are endless. “Digital dentistry will escalate you to places you never thought you would reach,” Dr Vetter says. “It is the key to the profitable dental practice from 2023 and on.”

Reference

1. Revilla-Leon M, Frazier K, da Costa JB, et al. Intraoral scanners: an American Dental Association Clinical Evaluators Panel survey. J Am Dent Assoc. 2021;152(8):669-670.e2. doi:10.1016/j.adaj.2021.05.018