Digital Workflow Across Multiple Practices Achieves Efficient and Esthetic Results
Laura Justice, DMD
Merriam-Webster's dictionary defines workflow as "the sequence of steps involved in moving from the beginning to the end of a working process."Workflows at dental offices are evaluated based essentially on two issues: whether the steps involved in the service/treatment are efficient and reasonably easy to deliver, and whether the service/treatment provides great value to the patient. For restorative dentistry, to make these determinations four factors need to be evaluated: form, fit, function, and financial. (1) Form: Does the design software create a robust automated design proposal with accurate anatomy and morphology that matches adjacent dentition? (2) Fit: Does the design software allow the clinician to read and mark the margins to ensure an excellent, precise fit? (3) Function: When put in the mouth does the restoration require little to no reduction? (4) Financial: Does the workflow save the practice money by reducing costs and increasing efficiency?
To assist clinicians in making these determinations, and to convey information needed to evaluate the benefit of adding a digital workflow system to any sized practice, whether a single practice or multiple offices, the author describes her "journey" to a successful digital workflow and presents a case study.
Lessons From the Journey
Wanting to be an early adopter of digital dentistry technology, I purchased the E4D CAD/CAM system (E4D Technologies) in 2008, visited the company's Dallas training facility to learn how to use the system, returned from training, and was excited to apply what I had learned. Unfortunately, obtaining an esthetic and precise-fitting restoration using the scanner and software proved to be difficult. I did not achieve the desired results and soon became disillusioned. My shortcomings with the system also hampered efficiencies. Trusting that some of my failings had to do with the user, I believed the technology would improve over time, so I held onto the scanner and mill and waited. Finally, in 2016, confident that the technology had improved significantly, I recommitted to the CAD/CAM system.
Planmeca (planmeca.com) had invested in E4D Technologies in 2013 and began co-developing CAD/CAM products under the Planmeca brand. One of the initial product launches was the Planmeca Emerald™ intraoral scanner, which had significant improvements in functionality and design over previous scanners, so I acquired one. The existing mill that I had been using worked well and efficiently, so I kept it despite its age. The key to restarting at this point was being able to depend on the scans. The scans with the Planmeca Emerald were much quicker than in the past and were in color, and the software was much more proficient and reliable. I also hired a nearby dental laboratory technician who was familiar with the CAD/CAM process to assist me in achieving faster restoration design (which, of course, is not necessary today because a dental auxiliary can easily be trained to scan and design). I was eager to offer same-day crowns in our practice and calculated that the production savings would more than pay for the use of the lab technician, who additionally could perform multiple other lab functions in our office that would create new efficiencies, such as the production of occlusal guard and other appliances, denture and partial denture repairs, wax-ups, model work, and so on.
We scaled up rapidly, and our practice has since fully integrated the complete Planmeca FIT® CAD/CAM system, which enables us to achieve most single- and many multiple-unit restorations in same-day visits. Most single-unit restorations are completed in a less-than 2-hour appointment. The flow works seamlessly: a staff member seats the patient (5 minutes); the doctor anesthetizes the patient and executes the preparation (20 to 30 minutes); a staff member performs the scanning process that includes three scans, the preparation scan, opposing scan, and bite scan (5 to 10 minutes). Once the scans are merged together, or "married," the design process begins using the Planmeca Romexis®software. Our dental lab technician is highly adept at CAD/CAM design and can create a beautiful, functional design in 5 to 10 minutes. The technician then exports the design to the mill, milling begins, and in 20 to 25 minutes a restoration is created. Our office typically uses lithium disilicate (IPS e.max® or IPS Empress®, Ivoclar Vivadent, ivoclarvivadent.com) for most restorations. Zirconia may also be used with a sintering oven.
The Planmeca FIT provides a complete digital workflow, from scanning, to designing, to milling, and has been an exceptional, cost-effective value. The easy-to-use system makes same-day workflow possible. Planmeca uses a fully open file system with a scanner that can be server based and communicate with a central database. This allows users to either complete the entire workflow or seamlessly delegate portions of it to other coworkers to implement in a multi-location practice, or outsource to a lab.
Improved Efficiencies, Decreased Costs
The past few years have brought on a changing climate for solo dental practices. A significant trend in dentistry today is the evolution of dental service organizations (DSOs)1 and some general practitioners opting to own multiple locations to compete.2 Concurrently, digital dentistry is experiencing a tremendous boom. This latter development may be favorable for dentists wanting to stave off the influx of "corporate" dentistry and utilize chairside CAD/CAM systems.
I never intended to purchase multiple practices; I was always content delivering high-quality dentistry keeping the patient at the forefront. But with the recent changing conditions, rather than letting large, non-dentist-run groups dominate the dental landscape in my town, I started buying practices and implementing systems that had worked well at my original site. I currently have two dentist associates with whom I have partnered not solely for financial gain, but also to keep dentists as owners, provide a caring environment for associate dentists, and perpetuate quality dentistry. Although dental conglomerates are not necessarily dispassionate about dentistry, our group is passionate about it and genuinely wants to care for patients and help them improve their oral health and smile. The financial profit is a by-product.
With growth comes some financial benefits, such as larger discounts with dental suppliers and, with the implementation of a digital workflow, savings on laboratory costs. We have basically mastered this process at our primary practice and are presently implementing it at our other four locations. Dental auxiliaries and hygienists are utilized to scan, and the scans are sent to our dental designer or design studio where the restoration is designed in a span of 5 to 10 minutes and then sent back to the office from whence it came. (For practices that are not confident designing their own restorations, outside labs are available to do the design work, offering practices the option of sending out the scan for design and having it sent back to the office for milling.) The same dental auxiliaries then place the selected material size and shade block into the mill, wait for milling, remove the restoration, de-sprue it, and then appropriately stain/glaze/crystallize it in a ceramic furnace.
When a practice uses its own dental design studio, timing and scheduling must be worked out in advance, similar to scheduling patients. With multiple practices there is the option of sending the scan to the practice's central milling location and then have a runner deliver the crown in the same day. This can save some initial expenses of buying mills for each location.
Regardless, this type of workflow can yield substantial benefits, including financial ones. Savings are gained by having a one-appointment visit instead of multiple appointments and eliminating the need for impressions, secondary impressions for temporary restorations, temporary restorations, temporary cement, and re-cement temporary appointments, all of which increase chair time and costs and decrease efficiency.
Laboratory cost savings are also garnered. The cost of the ceramic block and materials to create the crown is significantly less than using a lab. In the author's experience, a conventional impression/temporary/return visit type of scenario for a posterior single-unit crown has associated costs of about $75 for impression materials/stone/temporary material/supplies/dental chair time, including extra staff salary, and about $150 to $400 for an outside laboratory-fabricated restoration, depending on the laboratory. This is a total cost of between $225 to $475. An in-office restoration, however, costs about $40 for the ceramic block, putty, and stain; if the practice uses an outside lab for the design only or pays an in-house lab technician for the design, this will typically add an additional $25 to $50 to the cost. Thus, the savings per restoration is generally at least $125.
This clinical case demonstrates the use of a fine-tuned digital workflow and the value it can provide to both the practice and the patient. The patient was a practicing physician with a busy schedule and was enthusiastic about the possibility of having a dental quadrant treated and completed in the same day with no return visits.
Before the patient arrived for his appointment for dental work to be done in the mandibular right quadrant the staff and I created a workflow plan. Teeth Nos. 28, 29, and 31 needed porcelain coverage, and tooth No. 27 required a class V restoration. Tooth No. 30 had an existing porcelain crown restoration. Upon the patient's arrival a shade was taken prior to dehydration and isolation. A great benefit of a same-day in-office crown procedure is being able to match shade easily and see the micro-esthetic details that can be incorporated during the stain/glaze process (Figure 1).
The patient was anesthetized and the treatment area was isolated (Isolite®/Isovac® system, Zyris, zyris.com). Tooth No. 31 was prepared for a full-coverage lithium-disilicate (IPS e.max) restoration, retraction cord (Ultrapak™, Ultradent Products, Inc, ultradent.com) was placed, and our dental lab technician scanned the preparation of tooth No. 31 with a Planmeca Emerald. The timeline from anesthesia to preparation to scans usually takes approximately 20 to 40 minutes for a single tooth depending on the operator.
After attaining digital scans of the preparation arch, opposing arch, and bite scan, the Romexis software design began. The design process takes about 5 to 10 minutes. Once the scans were done on tooth No. 31, teeth Nos. 28 and 29 were prepared. While those teeth were being prepared, the dental lab technician designed the restoration for tooth No. 31 and sent the design to the Planmeca PlanMill® 40 chairside milling unit. The same preparation process that was done on tooth No. 31 was repeated for teeth Nos. 28 and 29 and retraction cord was placed (Figure 2).
The lab technician (or dental auxiliary) was now ready to scan teeth Nos. 28 and 29, and the scanning process was repeated. Using the Planmeca FIT software, the lab technician then seamlessly designed restorations for both of these teeth and sent the designs to the mill. The actual milling time for a crown is 20 to 30 minutes depending on its size. Once the restorations are removed from the mill they are still in the blue/purple phase, and the sprue then gets removed. At this point the stain and glaze were applied before the restorations were placed in a ceramic furnace (Programat® CS, Ivoclar Vivadent). After 10 to 15 minutes of staining/glazing and crystallization, the highly esthetic, precise-fitting restorations were ready to be seated.
Meanwhile, the restoration for tooth No. 31 was ready to seat. Again, the adjacent teeth were isolated and tooth No. 31 was prepared for cementation using a universal cleaning paste (Ivoclean, Ivoclar Vivadent), a 38% phosphoric acid etchant for 20 seconds (Etch-Rite™, Pulpdent, pulpdent.com), and a layer of dental adhesive (Scotchbond™ Universal Adhesive, 3M Oral Care, 3m.com), which was scrubbed for 20 to 30 seconds, air-thinned lightly, and light-cured. The internal surface of the restoration was prepared using a porcelain etchant (9% hydrofluoric acid) for 60 to 90 seconds and then cleaned well using a steam cleaner; a layer of the dental adhesive was then placed in the restoration and air-thinned. Finally, a resin cement (RelyX™ Ultimate Adhesive Resin Cement, 3M Oral Care) in a translucent shade was used to cement the restoration.
While the bicuspid restorations were being milled, stained, and glazed, the team was able to continue with the workflow and prepare and restore the class V restoration on tooth No. 27 with a dental resin (Filtek™ Ultra Supreme, A3 shade, 3M Oral Care).
When the milling of the restorations for teeth Nos. 28 and 29 was completed, they could be tried-in while in the blue/purple phase before staining/glazing to ensure excellent esthetics, marginal integrity, and good contacts. Once this was verified, the stain/glaze process was repeated as was the cementation process for both restorations. A post-cementation radiograph helps verify that well-fitting restorations have been maintained.
The entire workflow process was completed in 2.5 hours, and the patient was comfortable throughout the appointment. He was thrilled with the esthetic result (Figure 3) and the fact that the process was completed in one day. He even commented that the restorations actually matched his natural teeth better than his previous two-visit crown on tooth No. 30, which highlights the benefit of shade-matching in the dental office instead of sending photographs and shade mapping out to a laboratory. (Author's note: A video of this same-day procedure is available on Dr. Justice's YouTube channel under the title, "A Same Day Digital Workflow Experience to Achieve Efficient and Esthetic Restorative Results.")
When determining whether the delivery of service (the digital workflow) is efficient and esthetic, four factors may be evaluated: The design software should create a good automated design proposal that has excellent anatomy and morphology that matches adjacent dentition (form). The design software should allow the clinician to read and mark the margins to ensure a precise fit (fit). The restoration should require little to no reduction when placed (function). And, lastly, the workflow should save the practice money by reducing costs and increasing efficiency (financial). With the Planmeca FIT system, our practice has indeed witnessed these benefits. This workflow can aid any clinician who is willing to take the time to learn it, undergo training, and develop the teamwork within the practice to make it a success.
This article was commercially supported by Planmeca.
About the Author
Laura Justice, DMD
Private Practice, Lexington, Kentucky; Fellow, American Academy of Cosmetic Dentistry
1. Reich-Hale D. Changing demographics and economics are leading to a seismic shift in how dental practices operate, as fewer dentists run their own business. Group Dentistry Now website. May 30, 2018. https://groupdentistrynow.com/dso-group-blog/changing-demographics-and-economics-are-leading-to-a-seismic-shift-in-how-dental-practices-operate-as-fewer-dentists-run-their-own-business/. Accessed May 6, 2020.
2. Zlatin A. Taking on the world of corporate dentistry. Dentistry Todaywebsite. October 5, 2018. https://www.dentistrytoday.com/news/todays-dental-news/item/3883-taking-on-the-world-of-corporate-dentistry. Accessed May 6, 2020.