The Technician's Palette
Enhancing the dental technician’s artistry with innovative technology
As technology has become an increasingly pervasive part of the modern world, it has entered into a strange relationship with artistry. At some times, technology may seem in direct opposition to a more freeform human creativity with its automation and algorithms, but at others it can open up entirely new avenues of expression and imagination. In the dental laboratory, great advances have been made in digitizing processes and workflows. While there are those who fear that increased automation could result in cookie-cutter cases and the loss of the human element, many others are convinced of the potential for artistry to be expanded through the use of technology. And as the technology improves, so too do the opportunities to use it artistically.
"Software is now the best it's ever been," says Jack Marrano, Director of Signature Prosthetics at Absolute Dental Services, Inc, in Durham, North Carolina. "We used to require so many workarounds and tricks to accomplish what we wanted within the framework of the system, but we don't need them anymore. We are really at the pinnacle of software performance."
Other advances in areas such as materials, milling, and 3D printing have given technicians many options for incorporating technology into their artistic process. And as each restoration is an individual work of art, each technician chooses to incorporate technology and artistry into different points in their preferred workflow.
The Finishing Touches
For many technicians, the opportunity to incorporate their own artistic touches comes primarily at the end of the fabrication process. The methods used to create artistry have not been digitized at this stage—porcelain layering, staining, and glazing are still analog processes—but technology has helped create the ideal canvas. The predictability, accuracy, and efficiency provided by new digital processes allow technicians to focus on the things that only they can do.
"I have never believed that technology takes artistry away from technicians," Marrano says. "I believe that it has supported me and given me more time to apply my artistry than I have ever had before."
That support begins with using the precision of CAD/CAM to provide a functionally sound starting point every time. For instance, with dentures, the ability to provide a try-in and then convert it into the final restoration with accuracy and predictability ensures the technician that the artistry they apply to the final restoration won't go to waste.
"In analog processes, every step was a guess, and when we finally reached the end and were ready to apply ceramics, it was still a guess," Marrano says. "No matter how many matrices were used, there was still no guarantee that it would fit when it got into the mouth. Now we can quickly print out a prototype and send it to the dentist to try it in. If you really commit to prototyping, it eliminates all the inaccuracies we saw previously. Our work is more predictable now than it has ever been—giving us more time to apply the artistry."
The accuracy afforded by prototyping is only the first step in creating a more efficient workflow through technology; design software, milling machines, and 3D printers can all play a role in expediting the process.
"Technology helps speed things up and get me to my goals faster," says Pheng Lor, owner of Dental Esthetics by Lor in Oakdale, Minnesota. "If I already have a diagnostic wax-up and photographs, I can probably use a library that I like to create something pretty close to what I want. Then I can either print it or mill it in wax instead of sitting there and creating it manually. I can cut out some of the labor, then come back to modify the details until it matches my final vision."
Marrano follows the same line of thinking. "Ceramists used to establish contacts and occlusion, and only after all that work was done could we move on to applying artistry to the restoration. But by the time you got to that stage, you were at the end of the line. You had very little time left for artistry," he says. "Now I am able to fast-forward through all of that because contacts and occlusion have already been placed for me. All I have to do is verify them, and I am left with more time than ever to focus on the artistic aspect."
Greater efficiency and more time for artistic touches place the laboratory in an advantageous position for scaling up their operations. With a streamlined workflow, not only is there more time to spend on artistry, but also on training and improving skills.
"Whether you are an owner, a manager, or a technician, the technology we have now gives us more time to train," Marrano says. "I'm not tied to the bench and can skip right to the end, to the last 10% to 15% of the process where I believe the majority of the artistry is applied. Because we are using modern technology and materials to their fullest advantage, I can spend more time with the other technicians in our laboratory, helping to train them and hone their skills. They have more time to really focus on the details, finesse what they are doing, and get better at it every day. Our technicians' work is better than it has ever been. They are producing more than ever before, and they aren't working long hours to do it."
Technology can help to create the ideal canvas for the finishing touches of a restoration—but how is that canvas crafted? Digital design can be an art form in itself, allowing the production of designs that are customized to the needs of each individual case.
"The wonderful thing about digital design is that you can put as much artistry into the occlusal design as you want, and you can make each design as detailed or plain as the customer wants. We try to individualize each denture for that dentist and that patient," says Rick Godair, CDT, TE, MICOI, Director of Technical Development at Edge Dental Solutions, LLC. "For example, a prison system is looking to take care of the basic needs of their patients and is looking for plain, functional dentures. On the other hand, we have other customers who are looking for very detailed work. They might request stippling, more root eminence, or more curve in the valley of the sulcus, and you can do all of that in the design process."
Not only can each restoration be customized to meet the specific needs of the dentist and patient, but each designer has an individual touch and style that affects the final restoration. It is important to remember that, in the end, digital design tools are just that—tools in the hands of an artist.
"Even if two laboratories both designed the same restoration with the same software, both used the same libraries, both milled it out of the same zirconia—believe it or not, you are still going to get a different result," Marrano says. "You still have the ability to apply artistic license."
Part of what makes digital design so powerful is the increased ability to communicate and collaborate. A designer may never hold the finished product in their hands, but will nevertheless play a significant part in translating the needs and wants of the dentist and patient into reality.
"Communication has always been the biggest part of any relationship between a dentist and a laboratory," Godair says. "Now, rather than needing to deliver a wax-up to the dentist, you can send a design, discuss their feedback, and make adjustments, all based on the screen. It's a very clean way of working."
There are many advantages to designing digitally. The designer is able to undo changes, try different approaches, and zoom in to get a better view of the details. However, when transitioning to digital design, there are some pitfalls to avoid.
"I have seen waxers do some very odd things when they first work with a digital design," admits Marrano. "They've never had the ability to zoom in before, so they will zoom in until they are looking at a molar preparation that is a foot tall on the computer screen, and then they will obsess over the margin line. Then when they zoom it out to actual size, you can't see any of their hard work, and it doesn't make a bit of difference."
"When I'm making dentures by hand, I have a rhythm," Godair says. "When I'm working digitally, it is much easier to get caught up in the details. If you're not paying attention, you can get lost and spend 45 minutes on something that should have taken 15. Digitally, you have to pay attention to every step."
Another form of artistry begins before any concrete steps are even taken on a case. A technician needs to have a vision of how they want the case to go before they can begin creating it.
"If you cannot picture how a case will look in your mind, then forget trying to create it on a computer. You will not be able to even pre-plan the case without that visualization," Lor says.
In order to have that vision of the case, the technician needs to have a solid understanding of all the steps involved and the technology and materials at their disposal. Just as an artist chooses the best medium to communicate their vision, a technician must choose the best materials and process to produce the most functional and esthetic restoration possible.
As a trained artist, Lor feels that the importance of medium cannot be overstated.
"An artist has to decide whether they're going to use pastels or colored pencils or some other medium before they begin to draw," Lor says. "A technician has to decide what materials they will use on the final restoration. As a type of artist, a technician has to understand the mediums available and the type of canvas they will be working with, whether it's lithium disilicate or zirconia. You can't just wing it; there must be purpose behind the choice."
Another way to aid in the conceptual stage of cases is through digital mockups. Dwight Rickert, CDT, FAACD, owner of Preferred Dental Ceramics in Indianapolis, Indiana, and past president of the American Academy of Cosmetic Dentistry (AACD), sees great potential in digital processes for case planning.
"If we get the right type of photography from the dentist, we can create a mockup of how we think the patient wants their smile to look. Then we can show it to the dentist and the patient," Rickert says. This allows for early feedback and for the technician to get a very clear idea of their objective in the case, thus allowing them to make the best choices in materials and processes.
Initial Clinical Stages
If a restoration is a piece of art, the oral environment is the gallery in which is it displayed. In order to create a really esthetic, artistic end result, clinical steps can be used to prepare the oral environment for the restoration. The dentist's diagnostic data and preparation design give the technician a strong starting point, allowing both the clinical side and the laboratory to work together toward a harmonious result that considers the requirements of both the restoration and the patient's natural dentition, soft tissue, and bone structure. In complex cases, the artistry often begins long before the restoration is placed in the mouth with orthodontic treatment to create optimal conditions.
"We work a lot with full-mouth rehabilitations centered around implants," says Martha Miqueo, DDS, co-founder and vice president of VIZSTARA in Englewood Cliffs, New Jersey. "We start with an orthodontic evaluation to be sure that we can move bone as necessary with orthodontics so that we can create a better form, a better implant placement, and a more esthetic result."
In order to best prepare the oral environment for implant placement, Miqueo considers cone beam computed tomography (CBCT) to be an essential technology. The 3D images of soft tissues, nerve paths, and bone provided by CBCT scans allow for thorough planning and customization. Miqueo also makes use of technologies like intraoral scanning.
"We have much more information with all these tools. The CBCT shows you 3-dimensional views and the entire facial of the cranium. The more information you have, the more predictable and esthetic results you can achieve," Miqueo says. "Every case is individual. Nothing is cookie-cutter."
Miqueo also hopes that technology will have an effect on patient acceptance of orthodontic treatments as part of complex restorative plans in the future. After all, the most esthetic result cannot be achieved if the patient can't visualize the difference and refuses treatment.
"One of the setbacks of orthodontics is that it takes so much time," Miqueo says. "As the technology evolves, we will be able to show a patient the before and after, not just in terms of teeth, but also in terms of bone results and root placements and so forth. That will help patients make a decision about orthodontics."
The Importance of Fundamentals
Technology can do a lot to enhance artistry and to improve efficiency, but it can't replace a solid understanding of the fundamentals. A streamlined digital workflow can provide advantages, but it can't replace a technician's expert knowledge.
"At one point, it was thought that no strong understanding of esthetics, function, or morphology would be needed when digital took over. I heard people saying that you could take someone off the street, and they would be making crowns by the end of the day," Marrano says. "I can tell you that it's absolutely not true. If I had to choose between someone off the street and an experienced waxer and then sit them down at a CAD/CAM system, I would take the waxer. They understand tooth form, contour, function, and occlusion. All of the basics will carry through to digital design."
"When it comes to moving from the analog world to digital, I would prefer somebody who has experience," agrees Rickert. "Their understanding of morphology is better than somebody who is coming in blindly and does not really understand the shape of the tooth or where it belongs in the mouth."
Even when hiring people without laboratory experience, Godair prefers that they learn analog processes first. "We have partner laboratories where we can bring new people in, give them bench time and training, and let them see what the physical part of the process is like. That gives them a baseline to work from," he says. "After a number of months building that knowledge base, we can get into their computer skills, which is really the easier part of it."
Lor also stresses analog skills in his laboratory. "As a purist, I still feel you need to do the grunt work," he says. "If you do not understand the very basics of pouring up a model, you will not appreciate a 3D printed model. If you skip analog work and just go digital, you don't gain the same understanding of the foundation of dental laboratory work. In my laboratory, I expect any trainees to do the grunt work so that they can gain that knowledge and apply it to digital."
In the end, it is the technicians, not the technology, who create the restorations and incorporate their artistic touch into each tooth.
"I do a lot of photography," Lor says. "I have a 3D printer, mill, scanners—but they're all just tools. If you do not have a dental laboratory background and an understanding of the clinical fundamentals, all of these digital tools are useless."
Looking to the Future
New and fascinating technology is looming on the horizon for the dental laboratory. There are new face scanning technologies, increased applications for artificial intelligence in digital design, and new materials and methods for 3D printed restorations. Each advancement gives the knowledgeable technician more tools with which to practice their craft and more avenues for artistic expression at numerous points throughout their workflow. Advancing technology offers options; it is up to the technician to choose the options that work best for them and for their laboratory. After all, technology is only a tool, albeit an extremely useful one; it is nothing without the guiding hand of the artist behind it.