Automation is changing the way labs work and the restorative services they offer their dentist-clients. In Part I of our series on the digital revolution, LMT attends the 2nd annual DLOAC CAD/CAM Technology Symposium and Expo in California to get a first-hand look at the technology, how far it's come in a few short years, where it's going and why it's hot.
What's the future of C&B restorations? In a word, "zirconia," according to the majority of attendees and exhibitors at the DLOAC's 2nd annual CAD/CAM Technology Symposium and Expo on October 28 and 29. This strong, biocompatible, esthetic, radiopaque, cementable material is being embraced by dentists and it's driving the demand for CAD/CAM systems used to mill and fabricate zirconia (as well as other understructure materials).
"The quality of the product is why I got involved with CAD/CAM," said Stan Okon, owner of Okon Dental Laboratory and Stanley Okon Milling Center, Laguna Woods, California. "When you're done making the crown, the only thing that matters is the quality of what you're holding in your hand. With CAD/CAM, that means I have an esthetic, tooth-colored zirconia restoration that's stronger than metal and that my clients can cement. You can't make that without CAD/CAM."
Five years ago there was one CAD/CAM system on the market; at the DLOAC meeting, nine different systems were on display in the exhibit hall. Key CAD/CAM players--including both established manufacturers and new companies in the marketplace, laboratory users and dedicated CAD/CAM outsourcing labs--gathered under one roof at the elegant Ritz Carlton in Pasadena, California. More than 200 laboratory owners and managers attended and if you weren't one of them, you missed out on a valuable learning opportunity. This was more than a regional show--owners and managers from across the country attended--and while only a few were southern California surfers, all of them are excited about riding the wave of this new technology.
They're eager to tap into the market potential of metal-free restorations. "In the global market, there are 110 million replaced teeth: 35% are PFM bridges, 50% are PFM crowns and 12-15% are all-ceramic. We view that 85% PFM market as our main competition and we want to bite into that market," said Nobel Biocare exhibitor Jeff McMann during the manufacturer presentations.
In addition to the material advantages, the automated manufacturing process affords an efficient, consistent method of production because it eliminates a number of steps that are subject to human error and can cause distortion. The software also allows you to store the restoration's information, so both the temporary and final restoration will have an identical fit.
Another offshoot of the CAD/CAM explosion is the growth in the laboratory outsourcing market. About 25% of the exhibitors at the DLOAC meeting were laboratories promoting their CAD/CAM outsourcing services. The lab-to-lab business expansion is helping them to defray the costs of their systems and opening doors to new business.
Users tell all
Five CAD/CAM users participated in a lively panel discussion sharing their experiences with the technology; Dave Lesh, owner, Dale Dental, a Richardson, Texas lab that outsources exclusively to other laboratories, moderated the discussion.
Most of the panelists tested the CAD/CAM waters by outsourcing at first, giving them a chance to evaluate different systems and see what worked best in their labs. "We went through an extensive decision-making process and tried four or five systems before picking one," explained Charles Wheeler, general manager of Perfect Smile Dental Ceramics, San Diego, California. "We went with the last system we tried and when we bought it, it was the cream of the crop and had all the latest bells and whistles."
Other panelists placed an emphasis on the versatility of the systems or on the manufacturer's reputation and marketing efforts. "We chose a well-established manufacturer that offered good service and had brand recognition in the marketplace. The wave the manufacturer had created was especially important to us. Rising tide raises all ships," said Steve Killian, CDT, partner, Killian Dental Ceramics, Irvine, California.
While panelists agreed that you can train an inexperienced person to handle the scanning, they also concurred that the greater the skill of the technician, the better the final product, especially for full contour restorations. "Manipulating the software is like manipulating the wax; the better you are, the better the restoration so you want a good technician running the machine," said Killian.
Okon has had good luck with hiring college graduates to operate his scanners. "Every prep is different. A good waxer can fudge and that same mentality is required when scanning. Given the material costs, remakes are very costly so the scanner operator has to be a problem solver and must be thinking all the time," he said.
Regardless of whether or not you have an experienced technician operating the system, keep in mind the implementation challenges. "You have to properly manage your expectations," agreed Bill Pilmer, owner, R Dental Ceramics, Solana Beach, California, whose workload is 60-70% metal-free restorations. "There is definitely a learning curve with CAD/CAM technology." The consensus among panelists was that it takes two to four months to learn the "ins and outs" of the system, how to tweak it and get it operating effectively.
On top of the cost of the systems--which range from about $12,000 to more than $200,000--you need to consider the cost of implementation, which Lesh said is approximately 15% of the cost of the system. So, for example, if you're looking at a $100,000 system, your implementation cost will be $15,000 to cover changes to facilities, including air, electric, plumbing or IT and the cost of technical training, testing and wasted material usage while learning how to operate it.
When asked what developments they would like to see in the future, "even more translucent zirconia," was the unanimous answer from the panelists. Previously, technicians used an exterior opaque or shade stains to colorize the white zirconia core after sintering; however, new techniques enable the zirconia core to be colorized before sintering. The colorant liquids come in five to 10 shades depending on the manufacturer and because the liquid soaks through the pre-sintered zirconia, the final core is both color correct and translucent. Although panelists acknowledge that progress has been made, they'd still like to see less reflective zirconia, especially when contending with underprepped teeth.
Panelist Kristie Rocco, CDT, owner of Rocco's Dental Studio in Escondido, California, is also excited by the prospect of the next generation of CAD/CAM--immediate prototyping for the automated production of alloy substructures. Instead of milling down a block of material, this new technology will create copings and frameworks by adding powdered material in layers and then bonding them together. This additive process doesn't result in material waste because the unused powders can simply be recycled.
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