Since 1983, DENTAL ADVISOR has been serving the dental profession by researching products and equipment with a scientific basis in mind and connecting data to clinical practice. DENTAL ADVISOR interacts with more than 300 dentists to gain insight on new and established dental products.

Dentistry Today, which has collaborated with DENTAL ADVISOR for more than a decade to bring product information and evaluations to its readers, recently had the opportunity to speak with the co-owners of DENTAL ADVISOR, Dr. Sabiha S. Bunek, DDS, CEO and editor-in-chief, and Dr. John Powers, PhD, president, about the company’s mission and vision both now and into the future.

We have great respect for the information DENTAL ADVISOR has provided to the dental community over the last 37 years. What is the mission of DENTAL ADVISOR? Has that changed over the years, and how does it benefit both manufacturers and doctors?

Dr. Bunek: We’re here to provide dentists with a quick, objective guide to the products that can help them perform at their best, which leads to improved patient care. That’s been the mission of our organization since it was founded in 1983. I think that, while the mission of DENTAL ADVISOR hasn’t changed over the years, our approach has evolved as we’ve grown in our knowledge, body of work, and outreach. In today’s world, we recognize the need to be vigilant about remaining authentic, reliable, and transparent as product reviewers for dentists. Our work also benefits manufacturers because we’re not only helping them to identify the features and benefits of their products out in the marketplace, but we’re also providing them with feedback from the evaluations so that they can make refinements or improvements in the product development phase. As advocates for good products, I like to think we are one of the factors pushing manufacturers to deliver great products for dentists and to continue to innovate.

Dr. Powers: Our core values at DENTAL ADVISOR have not changed since its inception. My background as a researcher, mentor, and educator has influenced the pages of every DENTAL ADVISOR issue. Knowing the importance of material performance and specifications, I have always seen it as critical to determining success or failure in the dental practice setting. Working side by side with Dr. Bunek and assessing needs is what I enjoy most. We are fortunate to have a small but very dynamic and strong team here at DENTAL ADVISOR that is committed to researching what information the dental industry needs and wants.

DENTAL ADVISOR has recently gone through ownership changes. Please tell us about your leadership team and other team members.

SB: Dr. Powers and I have traveled around the world presenting DENTAL ADVISOR information to clinicians and researchers in the industry for the last 10 years, so it was a natural transition for us to become co-owners of the company. We complement each other well. While our styles are very different, we respect and honor each other’s viewpoints. It’s a pleasure to be in business with someone like him, who is not only my business partner but also a dear friend and influencer in my life.

An extension of our leadership team is our executive director, Mary Yakas. Dr. Powers and I rely heavily on Mary to head up the daily operations and pull the balloon strings together to provide daily direction and future planning for our team. Within DENTAL ADVISOR, we have a diverse and dynamic team of researchers, creative and design specialists, clinical writers and editors, a clinical consultant advocate for our wonderful volunteers, and a team that works directly with our manufacturer customers.

We also have clinical consultants from more than 300 offices across the United States who volunteer their time to provide us feedback. Between our clinical consultants and our core team, we are well positioned to influence dentistry, and we have so much more to share. Each time our team is together, I am so impressed by what we can provide by simple conversation and how many different angles are considered.

DENTAL ADVISOR’s editorial board meets biweekly to review product evaluations, new products, and research.

In your opinions, what do you see as the most important considerations in product evaluation as they relate to product development and research?

JP: Over the years, we have developed relationships with large and small manufacturers to work on projects at the pre-market level, often helping with third-party validation and testing. It is important to look at potential issues prior to launch, outside of the confines of the company where it is developed, away from paid opinion leaders, and separate from any internal influence. We pride ourselves on being very thorough and honest with any manufacturer about its product.

SB: My view as a clinician varies slightly. I know how important laboratory and clinical research are to the success of a product; however, it is just as important to have a product work in a dental professional’s hands. We see amazing products come through the door that perform highly in the laboratory only to be very technique-sensitive and not necessarily clinically feasible. For me personally, I need to have a sound, scientific reason to change my methods, but it also needs to be easy to integrate the product into clinical practice for the team to buy in.

Over the last several months, we have seen change like never before in our profession. What is DENTAL ADVISOR doing to keep your readers informed and safe? What do you think the future holds for dentistry?

SB: Although COVID-19 brought out fear and doubt in clinicians about doing things the right way, I do believe our profession was well prepared for the change this pandemic brought upon us. Infection control techniques and protocols have always been at the forefront of our profession, and, although stressful, I’m happy to see how well everyone has been adapting to the changes that have been mandated.

While dental offices were shut down across the country, our team at DENTAL ADVISOR was busy delivering information to help clinicians and their teams navigate the new world of PPE and what products were going to be effective against the new virus. During this time, we have been lucky to have Dr. John Molinari (previously DENTAL ADVISOR’s director of infection control) and Dr. Fiona Collins as our infection control consultants to work with our team on microbiological testing to address the area of aerosol mitigation. We are actively working on quantitative data to present at several meetings, and it has been an area that is sorely lacking in research.

DENTAL ADVISOR tests hundreds of products annually in their biomaterials lab.	Dr. Powers, president; Jim Dombrowski, creative director; and Dr. Ona Erdt, clinical editor, discussing and debating DENTAL ADVISOR product research.

DENTAL ADVISOR’s motto is “Product Insights You Can Trust.” Tell me more about how that integrates into what is published and what information is provided from your research.

JP: Having a basis in science allows us to rely on scientific test results to help us assess a product’s claims. We help develop benchmarks and standards in conjunction with the ADA and follow established ISO and ASTM standards for testing. As new product categories are developed, we can take a 360° look at what the basis of the product is, how it should perform, and what we expect from test results in order for us to find something acceptable. The hallmarks of DENTAL ADVISOR are that we are trustworthy, we provide confidentiality, and we provide good research. I am proud to be a part of the product insights we provide.

SB: I agree completely. There is nothing that makes me prouder than sitting at an opinion leader meeting and having someone turn to me to ask what DENTAL ADVISOR found or what we think. It’s critical that we are honest and forthright in providing information and insights that are trustworthy. Anyone can endorse a product. Anyone can review a product. How do people know it is reliable and not a paid endorsement? I recently had a conversation with a manufacturer who mentioned that if we were really providing a service, we wouldn’t accept money. I find that disturbing. As much as I understand the need for charity, we know that the services of experienced professionals are just that: a service. We also need to clarify that although we offer paid services, not one person at DENTAL ADVISOR has ever accepted money for endorsement of a product. People do not buy their ratings or their scientific results. We do the work. We provide a service. Providing a service does not imply that we will find all products to be acceptable or ready for dental practice.

DENTAL ADVISOR is actively testing product efficacy related to infection control, with a particular focus on aerosol reduction.	Dr. Bunek is a regular contributor to major dental meetings as an educator and opinion leader.

That’s very interesting. So, have you seen products fail? Do you report on those?

JP: We have seen many products fail, both in the lab and clinically. We take pride in working with manufacturers to diagnose where the issues lie. They can be chemistry, shipping and receiving methods, a variation in instructions, and/or ease of use in a clinical setting.

SB: At DENTAL ADVISOR, we have the approach that no one wins, especially the patient, in promoting a product that can fail. It’s frustrating for dentists and their teams, and it can affect reputations as well as cause financial distress for manufacturers. Our goal is to identify any issues early on and work with the manufacturer to develop and possibly change the product, technique, instructions, etc. As our executive director, Mary, often tells manufacturers, “Our group is not afraid to tell you your baby is ugly.” As bad as that sounds, it’s the truth. As scientists develop products, it can sometimes be difficult to accept that their “babies” may have some issues. This is where we step in and do our best to back up our findings with research as to why something may fail in the dental marketplace. That is not information you will see publicly as we don’t find joy in in letting everyone know how smart we are and that we were able to uncover the shortcomings in a product. We would rather work with manufacturers and their researchers to improve their products for the betterment of the industry and, ultimately, the patient.

Executive director Mary Yakas, Creative Director Jim Dombrowski, CEO and editor-in-chief Dr. Bunek, and Dr. Bunek’s assistant Shelby collaborate daily on DENTAL ADVISOR projects.

If you had to predict what will disrupt the industry in 2020/2021, what would you say it might be?

JP: I believe digital dentistry will continue to shape the landscape. During the COVID-19 pandemic, we have seen 3-D printing companies change to accommodate shortages in PPE and testing equipment. We have seen typically innovative companies bring products back that were long ago introduced and revive them. Technology will continue to evolve, and machine learning will develop even further than before. The availability of Internet-based learning (and even saying the word “Zoom”) has drastically altered continuing education. It’s exciting to see. People are innovating and sending us products so that we can collaborate with them on ideas and make them a reality.

SB: This pandemic has certainly changed priorities for many, including what we had planned at DENTAL ADVISOR. Our publication schedule for the rest of the year, which had included updates on ceramics, composites, and other clinical-related topics, has already changed. We made the decision to completely shift gears and updated our main topic schedule to discuss and review products and equipment related to the pandemic. COVID-19 will affect our practices for years, and we will see many innovations in infection control as a result. Dentists have always been leaders in protecting our patients and our teams; however, I see dentistry taking a larger role in the future. With all the new infection control protocols changing the way we practice dentistry, we will continue to see new equipment innovations and products that fit better with the shifts and disruptions in practice.

Dr. Bunek, CEO and editor-in-chief of DENTAL ADVISOR, leads a seasoned team of researchers and clinicians in reporting evidence-based data relating to clinical and laboratory properties of dental products/equipment. She earned her DDS degree from the University of Michigan School of Dentistry and maintains a private practice in Ann Arbor, Mich. Her unique and multi-faceted career as a clinician and researcher provides a valuable vantage point to bridge the gap between science and real-world clinical applications. She has been nationally recognized as one of the Top 10 Young Educators in the US by Seattle Study Club and one of the Top 25 Women in Dentistry by Dental Products Report, a recipient of the Distinguished Service Award from the Dawson Academy, named a Top 40 Under 40 by Incisal Edge Magazine, and honored with the Lucy Hobbs Clinical Expertise Award by Benco Dental. Dr. Bunek is a sought-after national and international speaker offering a uniquely balanced program, bridging the gap between research and clinical dentistry. Her dual role as practice owner and CEO of DENTAL ADVISOR establishes her unique perspective as an educator. She has presented at the American Academy of Esthetic Dentistry, American Academy of Restorative Dentistry, Society for Color and Appearance in Dentistry (SCAD), and numerous other national and regional meetings. Her collaborative research has been published in several dental journals. She can be reached via email at drbunek@dentaladvisor.com.

Disclosure: Dr. Bunek is CEO and co-owner of Dental Consultants, Inc (DENTAL ADVISOR), and Bunek Dental Studio.

Dr. Powers graduated from the University of Michigan with a BS in chemistry in 1967 and a PhD in dental materials and mechanical engineering in 1972. He was a professor at the University of Michigan School of Dentistry from 1972 to 1988. He was a professor at the University of Texas Dental Branch at Houston from 1988 to 2005, where he is now Professor Emeritus. He founded the Houston Biomaterials Research Center and served as director from 1994 to 2005. From 2005 to 2018, he was clinical professor of oral biomaterials at the University of Texas School of Dentistry at Houston. He is also adjunct professor at the University of Michigan School of Dentistry, where he is a consultant to the Michigan Pittsburgh Wyss Regenerative Medicine Resource Center. Dr. Powers received an honorary PhD from Nippon Dental University in 2011. He was a founding member of the SCAD and received the E.B. Clark Award from SCAD in 2012. He received the 2013 International Association for Dental Research Distinguished Scientist—Wilmer Souder Award. He was named an American Association for Dental Research Fellow and an SCAD Fellow in 2016. Dr. Powers has authored more than 1,100 scientific articles, abstracts, books, and chapters. He is co-author of Dental Materials: Foundations and Applications and co-editor of Craig’s Restorative Dental Materials and Esthetic Color Training in Dentistry. He has served as dental materials section editor of the Journal of Esthetic and Restorative Dentistry since 2011. He can be reached at jpowers@dentaladvisor.com.

Disclosure: Dr. Powers is president and co-owner of DENTAL ADVISOR.

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Lori Trost, DMD, a well-known practitioner and lecturer, shares her experience, advice, and opinions related to choosing equipment and technologies to build a successful cosmetic dentistry practice with our editor-in-chief, Damon Adams, DDS.

You recently began a new practice. How did you arrive at that decision?

Dr. Trost: Once we successfully get past this crisis involving COVID-19, I feel that we will once again be able to say that there has never been a better time to practice dentistry! I decided to create a new practice after selling my former practice of many years and taking a sabbatical. Because I love dentistry, the patients, and the community, I really missed the day-to-day interaction, confirming that I was not ready to retire or take a back seat. The idea of starting over again initially seemed daunting, but the challenge of building a new practice based on experience gained over the years, clinical relevance, and practice management was intriguing and ultimately professionally satisfying.

Would you please tell us about your practice vision?

Dr. Trost: Much like we do in delivering quality clinical dentistry, a practice vision begins with the finish line in sight. So, just like a comprehensive treatment plan that fosters creativity, this process allowed me to explore and consider a variety of options from certain technologies to the look and feel of a space. However, at the core of the new practice process is understanding what type of patient you would like to serve/attract, the local demographics, and the procedures that will be offered. With that said, literally every decision, from inception to the finalized product, revolves around the goal to create a positive impact on each patient by utilizing the most advanced technology available. My vision was a practice space that offered clean lines, glass, and no clutter—a more intimate, high-tech, boutique-like practice. By keeping the patient at the center of the design effort, I became inspired to provide comfort, offer visual aids, and invoke a sense of the familiar with confident care.

Figure 1. Positioning a patient in the CBCT scanner (XMIND TRIUM [ACTEON North America]).	Figure 2. Curing a posterior composite using the SmartLite Pro (Dentsply Sirona).
Figure 3. Each operatory has comfortable seating for the patient and ergonomic access for the dentist, hygienist, or assistant (Midmark).	Figure 4. Capturing a periapical image using the NOMAD Pro 2 (KaVo Kerr) handheld radiograph unit.
Figure 5. Showing a patient her treatment plan on an operatory monitor.	Figure 6. Color-coded organizational tubs and trays (Zirc Dental Products).
Figure 7. Smartphone screenshot of our patient communication system, Weave.	Figure 8. Digital scanning a patient using the Omnicam (Dentsply Sirona).

Figure 9. Intraoral camera images (DEXIS DEXcam 4 HD [KaVo Kerr]).

How did you ensure that your vision became a reality?

Dr. Trost: Working with knowledgeable technology and equipment specialists is critical to turn a dream into reality. I was fortunate in partnering with Ryan Swift from my local Patterson branch, who listened to my ideas and was able to create an alliance between technology, equipment, and design. That is, of course, no small task!

Anyone who considers or builds a new practice must understand that this is a process that cannot be rushed. During this time, details matter! You must take into consideration workflow patterns, procedures, digital integration, and how patients enter and exit the operatories, along with infection control. I cannot begin to tell you how many times we used markers and tape to map movement and traffic patterns. We took into consideration the size and requirements for specific equipment/technologies, such as chair footprints, a 3-D imaging unit vs a panoramic unit, and even noise reduction from the compressor/vac room. We also considered possible additions and secured wiring and support backing for any possible future mounts or add-ons. During this phase, a “Master Dreams List” was compiled and prioritized. There is always a difference between practicality and a dream list, but the key is to strike a balance between the 2. In the modern world, it is so easy to get caught up with the newest, latest, and greatest products. However, like with everything else we want, I too had to come to the realization that every purchase decision had to be justified.

What specific equipment was at the top of your “must have” list?

Dr. Trost: Digital dentistry has transformed how we diagnose, plan, and choose treatments, all for the betterment of our patients. With that in mind, selecting and integrating a 3-D imaging unit was central to my practice goals and vision. Deciding what unit was the best fit for my practice required research. This also included talking to trusted colleagues and considering their recommendations.

I strongly believe a CBCT unit sets a high standard of care and creates predictability, especially when diagnosing and placing implants, doing endodontics, or treating growth and airway cases. Our unit, the XMIND TRIUM (ACTEON North America) is showcased in the heart of the office. This imaging unit offers incredible scan clarity, radiation dosage control, and predictable bone density, and it can easily be adjusted to patients, whether they are standing or sitting. I am confident in the XMIND TRIUM and how it provides a reliable assessment of bone quality, especially when I place implants. This technology ultimately increases the predictability of procedural and long-term clinical success.

Figure 11. Maxillary restoration finishing using an NLZ electric handpiece (NSK).	Figure 12. Prophy polishing a patient with the cordless AeroPro Cordless Prophy System (Premier Dental).

Restorative dentistry remains the “bread and butter” procedures of most practices. Ensuring the thorough light cure of any chosen composite restorative material, adhesive, or resin cement is critical. While there are many excellent curing lights on the market by a variety of quality manufacturers, for my new practice, I chose the SmartLite Pro (Dentsply Sirona). This curing light offers a small profile for direct access for tight spaces, has 2 interchangeable batteries so that the clinician is never without a charge, and also includes a transillumination tip for fracture/craze line identification.

Can you describe your operatories?

Dr. Trost: With the design framed around creating a positive patient experience and to create engagement, each operatory has been equipped with comfortable chairs (Midmark) and with operatory lights (Midmark) that have multiple exposure settings (low to high brightness), along with a resin filter to prevent the premature setting of composites. I also chose rear-delivery units from Midmark.

In keeping with the clean design, there are no x-ray units on the walls. Instead, we use a portable x-ray unit NOMAD Pro 2 (KaVo Kerr) with DEXIS sensors (KaVo Kerr).

Another key element in each operatory is a large monitor that is used for patient education and entertainment, as well as for practice marketing information. We use this space to not only inform and engage with patients but also to have fun with them through contests, random facts, and trivia!

Regarding sterilization, each procedure is color-coded by the use of cassettes and tub systems. These organizational products (Zirc Dental Products) have not only streamlined our procedures but have also reduced our stress levels. Because of this system, we can truly focus more on the patient.

What technology has been a real game changer in your new practice?

Dr. Trost: Our patient communication system, Weave (getweave.com), has laid the groundwork for a truly integrated patient journey. Their unique system allows for 2-way texting, patient appointment reminders, birthday wishes, and also a secure payment portal. Essentially, this system is like having an invisible employee working in the background 24/7! Weave has completely enhanced our patient experience. In a world of online reviews, we all can agree that it is crucial to capture positive patient experiences. Weave provides patients with an instant link to quickly access Facebook or Google. Without a doubt, my eyes have been opened to the importance of personally communicating with patients and having them truly feel that we are a patient-centered dental practice.

You mentioned that your new patient exam protocol has been elevated. What specific equipment or technologies compliment this, and how do they work?

Dr. Trost: More than ever before, patients are better educated about dentistry and want to be involved in their treatment. They also want to understand all their options. As dental professionals, we must show, tell, and engage them. However, we often do not know how to do this.

As a new patient enters any practice, he or she immediately begins to make comparisons regarding his or her own prior dental experiences. The key is to capitalize on using digital tools to create a customized diagnostic approach for the patient. In essence, the exam becomes the patient’s dental story. We start by digitally scanning (Omnicam [Dentsply Sirona]) each patient. It is easy to do, and patients are very impressed with this technology. Next, we use the DEXIS DEX and cam4 HD (KaVo Kerr) to capture a minimum of 5 standard images, along with any other areas of specific mention/concern. We then follow this with transillumination using the DEXIS CariVu system (KaVo Kerr). Finally, we take a 3-D image (XMIND TRIUM). All this information offers a complete diagnostic menu allowing the clinician and team to better understand the patient’s needs and wants. In addition, a uniquely customized treatment plan can then be developed for the patient. This protocol using these digital tools helps to elevate the patient’s perceived value and overall experience.

As dentists, we must realize that we have to become better communicators and to offer more value to create more treatment opportunities. With this in mind, the monitors in each operatory are invaluable and become the point of engagement. They help to tell each patient a story. Patients believe what they see, and, more importantly, they are more likely to remember and commit if you engage them and create a memorable interaction.

What product has delivered the most from a return on investment (ROI) standpoint?

Dr. Trost: I have been a big proponent of early caries detection and remineralization for many years. To date, challenges existed with various caries detection technologies, such as whether they utilized fluorescence or transillumination and how/if they could be quantified or integrated into a patient’s chart. Several colleagues shared their experiences with transillumination, and I ultimately purchased a DEXIS CariVu system. Interproximal surfaces that look pristine to the eye and are virtually absent on a magnified radiograph can be illuminated to show early changes in the enamel. For me, this radiation-free exam tool has been an eye-opener. Furthermore, the ROI has been multifold. More importantly, patients are benefitting from early caries detection that supports and reinforces a minimally invasive treatment approach. Once their pictures go up on the monitor, they already understand that something needs attention, and they want it addressed.

In what other ways have your choices of technology and equipment impacted your patients’ experience?

Dr. Trost: Whether it was choosing comfortable chairs or ensuring radiation reduction with the use of the CBCT scanner, the office was built through the eyes of the patient experience. I am not exaggerating when I say at least 4 patients per day walk in and mention how this dental office is unlike any other that they have visited.

We also utilize aromatherapy and have received an overwhelmingly positive response. Smell is the strongest and most memorable sense humans possess. To be able to create an immediate relaxing feeling vs the typical sterile office sets our practice apart. You will routinely smell blends of lavender or bergamot.

Another surprising element has been the older demographic of patients who are ready and want to improve their oral health. Again, demographics play an important role. Many of these edentulous patients want to secure their existing dentures with implants, and others are interested in updating their current care. Regardless, many of these patients remember their “typical” dental experience and truly welcome the modern change with technology that helps us discuss their care using pictures.

What specific technology has helped to increase your efficiency?

Dr. Trost: Digital scanning has brought a new level of efficiency and clinical excellence to the practice. Compared to traditional physical impressions, digital impressions reduce remakes, eliminate the need to pour models, and raise the level of accuracy. The ability to view the preparation, detail the margin, and ensure proper occlusion reduction is invaluable when doing all-ceramic restorations. I have been using an Omnicam for over 7 years now. The learning curve was minimal, and I have not looked back. Because of my practice schedule, I choose to scan and then send the scan to my lab team electronically for restoration design and milling. Our patients wear temporaries for 5 days at most. I would be remiss without saying that delivering the final restoration is also much easier due to the spatial accuracy.

Another key efficiency component of our paperless practice is the use of a cloud-based practice management system, Open Dental (opendental.com). This system not only integrates with the radiographs and imaging technologies but also updates seamlessly, has excellent customer service, and creates timely reports that are necessary for goal setting.

What specific equipment did you consider for improved ergonomics?

Dr. Trost: If you plan on practicing for any length of time, ergonomics have to be considered and not compromised. This is especially important to ensure hand and shoulder health. That being said, the workhorse of the practice—the high-speed handpiece—must be carefully considered. Handpieces are used every day, and we ask them to perform a wide variety of tasks on a broad range of materials and structures. I have used both air-driven and electric handpieces and, over time, have experienced their evolution. I use and recommend the NLZ electric handpiece (NSK). This lightweight handpiece is smaller than competitors’, balanced, and powerful. The beauty of electric handpieces is the improved control found in using presets for crown prepping, decay removal, polishing, margin placement, and cutting through incredibly hard zirconia materials. Gratefully, I have not had any hand health issues over my career, and I contribute much of that to proper handpiece selection.

Handpieces on the market today have truly evolved, and I really like the cordless, slow-speed units used for hygiene. We use the AeroPro Cordless Prophy System (Premier Dental) and like its portability; how it mandates an infection control standard; and its quiet operation, with 2 speeds from which to select. Also, patients routinely comment about not having cords drag across them during their cleanings. In addition, patients also appreciate the quieter operation found with this handpiece.

What advice do you offer to anyone who is considering a technology purchase?

Dr. Trost: Do your homework. Talk to colleagues. Visit other practices. Create your own compare-and-contrast worksheet. Get your team on board. Commit to learning and implementing the new technology or equipment. And, finally, showcase your decisions on social media.

What do you enjoy about most about your new office/practice?

Dr. Trost: Digital technology and its integration have made dentistry so much more predictable, interesting, and easier. The fun part for me is to see patient interactions, provide incredible accuracy, and witness the benefit found in developing an efficient workflow. All of these components add up to a new level of professional satisfaction. I have heard that if you love what you do, it is never work. It is true!

Dr. Trost received her dental degree from the Southern Illinois University School of Dental Medicine. She maintains a private practice in Red Bud, Ill. Dr. Trost offers postgraduate courses to dentists and their team members that draw from her extensive private practice experience and focus on restorative dentistry, digital technology, dental materials, orthodontics, business management, and patient communication. She is an author, clinical evaluator, and editorial board member and is listed as one of Dentistry Today’s Leaders in Continuing Education. She can be reached at trostdental.co or via email at trost@htc.net.

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Disclosure: Dr. Trost reports no disclosures.

Our editor-in-chief, Damon Adams, DDS, interviews Steven Barrett, DDS, a founding partner and the chief clinical officer at Greenberg Dental & Orthodontics, part of one of the largest privately owned group practices in the country with 92 offices in Florida, about his unique approach to doctor development for recent graduates as well as for doctors with many years of experience. With more than 30% of graduating students now choosing to start their career with a DSO—and many believe this will only increase—this in an important topic within our profession.

Dr. Barrett, you have been working with and training dentists for the past 25 years. Has working with young dentists today become easier or more complex?
Dr. Barrett: Twenty-five years ago, working with young doctors was much easier. I say that for many reasons. Today, a young graduating dentist is introduced to a broader range of dental topics during his or her 4 years. Twenty years ago, discussions on intraoral scanning, in-office milling, aligner therapy, and restoring or placing implants were not part of our training. Just as digital technology has influenced the way we practice, so has the ever-evolving choice in materials available. Also, there are now countless ways for doctors to get access to dental education. This is wonderful, and yet it can also be confusing to a new graduate. In addition to the clinical side of dentistry, today’s graduating dentists must navigate through the many different business models that make up the current dental landscape. Therefore, any training program must not only address current clinical issues but also highlight the strengths of its business model. I would say what has not changed and must remain constant is that any mentorship program needs to focus on clinical excellence above all else.

What are the current challenges you see as you work with this next generation of dentists?
Dr. Barrett: A big challenge is trying to distill current information and trends and then weave them into the information that our group has amassed over the last 42 years. The information needs to address the challenges that dentists face in their day-to-day practices and provide solutions to those challenges. Our goal is to reduce the learning curve for all our dentists and to help them achieve their desired levels of success sooner. School debt is a big issue, and doctors are looking for programs that can help them decrease that burden as quickly as possible. With that in mind, our focus is to help doctors strengthen the fundamental aspects of dentistry and to also help them predictably work through relatively complex dental diagnoses. Helping young dentists get up to speed faster not only helps them overcome the huge debt burden but, more importantly, also helps more patients experience the full potential of clinically excellent dentistry. This occurs not just from my own efforts but also in combination of working with other mentoring doctors and our in-house specialists.

I must also add that today’s dentists want answers quickly. It may be a chairside decision that needs to be addressed or a case planning discussion. In either situation, I truly believe that because we are a privately owned group that’s owned and operated by dentists, we understand this better than most. With no middle management layers, our doctors can communicate directly with one of the partners (who are all dentists) at any time.

Figure 1. Dr. Quyen Pham designs a crown using the glidewell.io system (Glidewell).	Figure 2. Periodontist Dr. Shalia Santana, working with Dr. Richard Collier, does surgery in the lower anterior while 2 other interested colleagues also observe (Altamonte Springs, Fla).
Figure 3. Dr. Barrett, working on an anterior case with periodontist Dr. Victor Yeung, Dr. Stephanie B. Chavez, and Dr. Ava Lee in Jacksonville, Fla.	Figure 4. Dr. Barrett, demonstrating photography skills while taking preoperative lateral photographs with studio lighting.
Figure 5. Hands-on photography course for the Pre-Dental ASDA (American Student Dental Association) Chapter at the University of South Florida in Tampa.	Figure 6. Dr. Barrett teaches an impression program at the University of South Florida for the Pre-Dental ASDA Chapter.

How would you describe the training program that you have created at Greenberg Dental?
Dr. Barrett: I have personally visited dental schools for the past 20 years, and each time I ask students what is most important to them after graduation. Is it location? Is it pay? Is it mentoring? Mentoring is always the No. 1 thing students are looking for. Based on that feedback, our Vision First program was developed. It is built around the philosophy that a dentist must first develop his or her mind’s eye, expand his or her vision, and learn to see what is possible. Taken one step further, the dentist must now create a shared vision for patients and for his or her practice and dental laboratory teams. And, most importantly, the dentist must learn how to communicate the vision. The Vision First process can help doctors at any point in their careers to learn how to achieve a predictable outcome by following an established set of protocols. Over the years, I have seen a decrease in the number of aesthetic procedures that dentists have an opportunity to do in schools before graduation. Prior to graduating, most students have done very few, if any, porcelain veneers, multi-unit ceramic crown cases, or implant restorations. In addition, many students are using cell phones as the standard for dental photography.

It sounds like aesthetics is a major part of your Vision First program, correct?
Dr. Barrett: We do focus a large portion of the program on aesthetics. The reality is that looking good never goes out of style, and more patients are looking for aesthetic dentistry, which is most often elective dentistry not covered by insurance, at an affordable fee. The Vision First program is first introduced to our doctors during a very intense 2-day orientation. Following the orientation, there are bi-monthly, 3-hour in-person doctor meetings in each region of Florida. During the meetings, we introduce the “Barrett Esthetic Protocols.” These protocols are geared to teaching how to diagnose, sequence, and treat aesthetic cases with better outcomes, less remakes, and a high degree of patient satisfaction. The protocols include learning how to incorporate motivational mock-ups, photography, video, and custom BioTemps Provisionals (Glidewell) into the daily practice. As doctors develop their minds’ eyes, their vision for how they see teeth and how teeth fit into the face becomes second nature. They then become more comfortable planning aesthetic and elective dental treatments.

In all of our meetings, we present case studies from patients we have treated within our group. Topics within our treatment planning discussion include the sequencing of treatment, restorative material options, insurance implications, and how to discuss patient financing. In addition, we have developed a diagnostic and treatment template that helps to guide doctors through these decisions.

What is the next step after you help doctors create a vision?
Dr. Barrett: Let me answer that in 2 parts. First off, after creating one’s vision, a dentist needs to learn how to influence patients to make good decisions for their own dental health. It is important to develop case presentation skills that address not only need-based concerns but also elective dental concerns. The case presentation must be non-confrontational, caring, and compassionate. It must always take into account the patient’s dental budget. This is something I learned a long time ago from one of my mentors, Dr. Paul Homoly, and it is still true today. We continually focus on being able to meet or exceed our patient’s expectations. Some patients just require routine dental treatment, but others require and expect a much higher level of care. We need to be able to deliver both types of experiences to our patients, especially the multidisciplinary cases that require coordinated care between a general dentist and specialist. We are uniquely able to take care of those patients with our integrated specialty care model.

Figure 7. (Figure 7a) Pre-op view. (Figure 7b) BioTemps Provisionals (Glidewell). (Figures 7c and 7d) Final lithium disilicate restorations (IPS e.max [Ivoclar Vivadent]) on teeth Nos. 7 to 10.

The second part of our program, chairside mentoring, is what I really think sets us apart. It is critical to accelerate young doctor development. In the first part of the Vision First program, we have helped doctors to create a vision, plan treatment, and discuss cases with their patients. Next, we need to help them chairside. We have developed a very intense one-on-one mentoring program. To demonstrate our commitment to the process, I personally work, on average, in more than 50 offices each year with more than 50 different doctors. Our doctors from all over Florida can schedule me to come to their offices to help them with a case. Often, I see the patient for the consultation and treatment planning appointment. From that initial appointment, I help the doctor through every step of the process. We document each case with photographs and video (part of the Barrett Protocols). When the case involves lab-fabricated restorations, I work with the doctors on proper communication with the dental laboratory team, seating of the final case, follow-up photographs, and video documentation. It is in these one-on-one treatment interactions where doctors learn how to put into practice those skills we learn about and discuss during our monthly meetings. In addition to me, mentoring doctors in each region follow my lead and support this unique aspect of our model. By working chairside with so many doctors, we have a real-world perspective and can better evaluate our doctors’ understanding and implementation of the protocols. Every dentist knows that each case has its own nuances, and helping doctors address those unique issues chairside is invaluable.

Let me add one more item that I think is very important to the overall success of our mentorship. Working with our lab partners and our in-house lab and clinical consultant (Nick Azzara, Dental Network Solutions), I gather current cases from our partner dental laboratories and, through a series of specific pictures, evaluate our doctors’ progress. During one-on-one consultations, I have an opportunity to encourage each doctor to self-evaluate his or her own cases. This also gives me the opportunity to reinforce our protocols and tailor my mentorship to be more impactful for our doctors.

Let me just highlight a few key metrics regarding the success of the Vision First program: There has been a 10% increase in all anterior restorations, a 20% growth in lower anterior restorations, and a 40% year-over-year growth in cosmetic restorations since 2017.

That sounds like a lot of work and traveling on your part.
Dr. Barrett: Yes, it is, but I love what I do and am still very passionate about being able to help change patients’ lives. With more dentists in our group accelerating their skills faster, we have more opportunities to help our patients. Dentists who have a clear vision and confidence are giving patients smiles that they never dreamed were possible. This is a major motivational factor for me, even today, because I personally visit the dental schools and share with them the great things dentistry has to offer. I interview and hire doctors, so I take the responsibility to help train them to heart. I don’t do this alone, however. Every year, more dentists complete the Vision First Mentoring Process, enabling us to develop regional mentoring doctors. These regional mentors share in the responsibilities and create a daily learning experience for young doctors. I refer to this as a “real-life GPR.”

Figure 8. Teeth Nos. 3 to 14 with individual single unit crowns. The lower arch with a bridge on Nos. 22 to 27 and single crowns on Nos. 19 to 21 and 28 to 30. This work provided a life-changing transformation for the patient. (Figures 8a and 8b) Pre-op photos. (Figures 8c and 8d) BioTemps Provisionals (Glidewell Dental Laboratories). (Figures 8e to 8h) The final zirconia restorations.

Many DSOs have training programs. So how do you measure that the training is translating into doctors becoming more confident and productive?
Dr. Barrett: Great question. It is important to understand that we have no quotas, but we do have expectations of our doctors. These expectations are based on 42 years of experience. Let me explain the difference and why working within a group owned and operated by dentists is so valuable. Our philosophy is built around always striving for clinical excellence. We teach doctors how to develop their vision, and we give them the tools to achieve this. We provide data to our dentists measuring their commitment to the fundamental elements of the Barrett Protocol. This data is shared with the doctors during our monthly meetings. From there, we can further evaluate the growth of each of our doctors based on other relevant metrics that are unique to them, such as office location, levels of experience, and the makeup of their staffs. All these things and much more help the owners, who are dentists, to evaluate each doctor’s individual circumstances and growth. We are committed to the process and believe that time should be spent developing better habits, not chasing better results. This is the essence of the Vision First program. This same process applies to dentists at any point in their careers. For me, it took 6 years in practice until I realized the full power of Visionary Dentistry and Esthetic Protocols. I did not know how to measure progress through conscious habit building. We are now seeing more of our experienced doctors taking this journey and wanting to get to their next levels faster.

For the past 3 years, I have had the honor of presenting and highlighting parts of our Vision First program during the Glidewell Annual Symposium. The topic “Provisional Restorations: Planning For Esthetic Success” is a key component of our Barrett Protocol. The use of BioTemps Provisionals is highlighted as a way to help achieve a predictable result by providing a preview of the final restorations. Our commitment to the use of BioTemps and helping our doctors to develop good habits has made us the largest user of BioTemps in the world. This is a key component of our Vision First program and is designed to help build a doctor’s confidence in his or her abilities sooner. This year, I will be adding a full-day continuing education course as part of the Glidewell education platform. The experience of teaching on a national stage and speaking directly to dentists from private practices, as well as other groups, has validated that our Vision First approach and direction have great merit.

Does outside CE play a role within your training?
Dr. Barrett: Partnerships are very important to us. Companies such as 3M, the Danaher Companies (Kerr, Orascoptic, Implant Direct), Dentsply Sirona, GC America, Geistlich, Ultradent Products, Ormco, Align Technology, GlaxoSmithKline, Ivoclar Vivadent, and Brasseler USA have all been highly engaged in our learning initiatives. We have found it more productive to match the information from each company and align it specifically to how we use their products and technologies in our offices. We vet each speaker, develop our own internal subject leaders, coordinate with our specialists, take our own procedural slides, and often present the information ourselves or co-present with the companies. In addition to our Vision First training and the manufacturer-supported initiatives, there is a $3,000 doctor benefit that goes to support any relevant outside CE. Doctors can also use their CE benefit to help them with the purchase of a quality DLSR Camera from Lester A. Dine (part of the Barrett Protocol). Our lab partners play a critical role as well. We bring all these critical partners together each year for a laboratory and manufacturer symposium. We present, collectively, to these partners our results from the previous year and lay out our clinical goals moving forward. The success of our doctors is due to this collective effort.

Figure 9. Dr. Barrett and Samantha Montenegro, implementation specialist, engineering & technology, Glidewell Labs, with the iTero Intraoral Scanner (Align Technology).	Figure 10. Dr. Antony, one of our mentoring doctors, hosts an overdenture live patient course for our doctors at the Greenberg Teaching Facility in Lake Mary, Fla.

Figure 11. This is a perfect example of how to use photography to highlight your patients. This patient did not have any dental work done, but these photos were taken to highlight the types of pictures you can do in the office with studio lighting.

Well, Steve, you have explained so well why your group is unique and so successful. Do you have any final thoughts?
Dr. Barrett: Dr. Adams, it has been my honor to participate in this dialogue with you and your readers, and to have the opportunity to share my thoughts on doctor development. Speaking on behalf of my partners, we could not be more excited about the accelerated development curves we have witnessed and are even more committed than ever to improving the Vision First mentor program. As a privately owned, multi-specialty, general dentist practice, we have all the components of a “real-life GPR” already in place within our model. This structure enables us to accelerate a young doctor’s career, as well as add new levels of motivation for experienced doctors. It is important to know that our dentists have autonomy in treatment decisions within the dental office and to direct the care of their patients. The Vision First program supports this philosophy. As dentists and owners, we encourage, support, and mentor our dentists to make decisions that are in the best interest of their patients.

I am very grateful to have had great mentors throughout my career including people like Andrew Greenberg, DDS, our co-founder. It is important for me to carry on this tradition. My partners and I have made the commitment to expand the Vision First philosophy to help future dentists create a clearer vision for their careers. I talk in depth on this topic during my visits to many different dental schools and through my involvement with undergraduate pre-dental societies. At the heart of it, I have exceeded my own expectations. It is now my chance to help others exceed their own expectations!

Dr. Barrett, after graduating from Case Western Dental School (1988), served in the Navy during Desert Shield and Desert Storm, for which he was awarded the Navy Achievement Medal. In 1991, Dr. Barrett joined Greenberg Dental & Orthodontics in Orlando and, now, as the clinical director, provides mentorship for 92 offices, 152 general dentists, and 58 specialists. Over 29 years, Dr. Barrett has developed novel clinical protocols for achieving predictable aesthetic outcomes in an affordability minded practice. Dr. Barrett co-treats patients and teaches, lectures, and writes extensively on restorative dentistry, practice management, and career development. He can be reached via email at drbarrett@greenbergdental.com, by phone at (321) 356-7951, and at the Instagram handle@stevebarrettdds.

Disclosure: Dr. Barrett has been a featured speaker at the Glidewell Symposium for the past few years.

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Kenneth A. Malament, DDS, MScD, discusses his professional expertise and candid perspectives related to all-ceramic dental material options.

Dr. Malament, in addition to your position as a clinical instructor at Tufts University School of Dental Medicine (TUSDM), and even more importantly to our GP readers, you are a busy clinician. How does being a practicing Board Certified Prosthodontist and postgraduate continuing education professor shape your view of dentistry?

Dr. Malament: I have been a clinical professor in the Department of Postgraduate Prosthodontics at TUSDM for more than 25 years and teach a course each week on the clinical management of simple and complex prosthodontic care. This course provides a significant exposure to modern material science, with an emphasis on dental ceramics. As a past president of the American Board of Prosthodontics, I have had the privilege of examining candidates since 2001 and learning from many of the most skilled and knowledgeable individual examiners in prosthodontics and dentistry. My mentors and professors always emphasized that continued learning and teaching was the most important part of a career. I have practiced prosthodontics since 1977 and created a full dental laboratory with master dental technologists, and I can clearly say that I have learned more from my dental laboratory team than I have taught them as a practitioner. One may believe that a specialist in dentistry should be an expert on the cutting edge of knowledge in materials and techniques; this thought would be incorrect. The graduate prosthodontic education taught and examined by the board is set by the ADA and is based on experienced, excellent clinical care. The education emphasizes treating patients with comprehensive care and with an interdisciplinary approach. We teach our residents the value of teamwork, and I believe prosthodontists everywhere are the most knowledgeable and talented dental professionals to consult and help guide GPs with complex care.

I created a database 36 years ago of more than 7,600 all-ceramic restorations with 27 different confounding variables. Besides writing papers on the survival of the different all-ceramic restorations, I learned from my own experience what may be successful and under what conditions the restorations may survive best. I also learned from Professor Sigmund Socransky that to develop meaningful information, one must study at least 500 restorations over 5 years to have reasonable statistical significance.

To further elaborate on what shapes my vision of care today and tomorrow, I should add that I attend many academy meetings where I learn much from my colleagues’ work and their observations. In my dental career, nothing has shaped me more than continuing education.

Figure 7. The patient presented unhappy with her aesthetic results and smile. Over the years, there had been loss of vertical dimension of occlusion (VDO) due to wear.

What are some of the clinically relevant trends that you are seeing related to current dental material options?

Dr. Malament: Today, there is more of an emphasis on ceramics than ever before, as they do not degrade over time in the same manner that resin restorations can. The ever-improving CAD/CAM technologies allow dentists to create restorations more quickly and with improving precision. Digital impressions are accurate, and the data has the potential to create a restoration that will fit more precisely than restorations made with any of the different impression materials, stone dies, investment materials, and casting techniques. As always, proper tooth preparations and any required tissue retraction must be acceptable. With each passing year, CAD/CAM technology is improving with the introduction of more precise milling machines that can self-calibrate and replace worn drill bits automatically. CAD/CAM restorations can be milled today in blocks or in discs where many restorations can be made, and the material costs are not significant. There is work being done now to develop a lithium disilicate disc, and, if this can be accomplished, the use of this excellent and etchable glass ceramic will have an even greater use in clinical dentistry. Removable, complete dentures are made today with CAD/CAM technology, as well as millable metals or forms that can be layered and sintered into metal. Since 3-D printing continues to develop, in time, this technology will allow for the creation of master casts and dies, wax patterns, resin restorations, and maybe even zirconia all-ceramic restorations. Great work is being done in this area. Today, most restorations are made in milling centers or by small labs that can afford the new and excellent CAM/CAM machines. It is important to remember that technology is improving in this field at a logarithmic rate and, due to wear, new machines are required to be purchased within only a few years. It must be remembered that great dentistry is about the dental materials applied more than it is about the technology that is used in the process. CAD/CAM or 3-D printing can make the process easier and faster, but there will always be the highest need for great technologists. These individuals will design restorations and custom finish them to the most optimal aesthetic results. Those results and the long-term survival of these restorations will always define “success.”

Figure 8. Maximum Interdigitation Position (centric occlusion) at a decreased VDO.

Figure 9. Laterotrusive (working) excursion. All the posterior teeth are hitting in all excursive movements.

Based upon your own clinical experience, in terms of long-term observations and data gathered in your own practice, can you please share your latest findings related to all-ceramics? What is the relevance of your latest findings to the everyday GP reading this interview?

Dr. Malament: As I have described, the database I created 36 years ago studying different all-ceramic restorations, and the effects that 27 different, confounding variables may have on long-term survival, have a profound impact on the way scientists and dentists understand how ceramics survive over a long time.^1-5 To date, the most successful ceramic is the IPS e.max lithium disilicate glass ceramic material (Ivoclar Vivadent). This glass ceramic is the most versatile and can function and survive even at thicknesses of 0.5 mm as a complete- or partial-coverage restoration. It has excellent light absorption and reflection properties that can be enhanced with fluorapatite veneering ceramics that are unlikely to chip in function. The ceramic can be translucent or more opaque, allowing technicians, if they desire, to stratify color to develop in depth color that is stable over time.

In an article in the Journal of Prosthetic Dentistry titled “Ten-Year Survival of 1960 Pressed e.max Lithium Disilicate Monolithic and Bilayered Complete Coverage Restorations,”⁵ it was concluded that e.max pressed lithium disilicate restorations can survive successfully: “Seven failures were recorded for the 1960…units placed, providing a [crude percent] failure estimate of 0.003. The 7 failures occurred during a cumulative monitoring period of [5,112.6] years, providing an estimated failure risk of 0.14% per year.”⁵ The e.max survival statistics clearly demonstrate there is minimal chance of fracture with restorations anterior to the bicuspids and that molars have a very low percentage of fracture as well. “The failure rate for complete coverage restorations for each tooth in both arches….[finds that] regardless of mandibular or maxillary placement, incisor restorations had no failures.”⁵ There was no statistically significant difference in the survival of acid-etched, pressed e. max restorations related to type of monolithic or bilayered physical structure, tooth position, sex, or age.⁵

The ceramic has a glassy component, allowing it to be etched and then silaned to create a good attachment between tooth structure and the ceramic. This is important because it limits micromotion that can break the seal and have a restoration come out and also minimizes crack growth that may fracture the ceramic.

Figure 10. Maxillary full-coverage tooth preparations.	Figure 11. A digital pantograph (Cadiax) was used to record the patient’s posterior determinants and to set a fully adjustable articulator. The registration allowed a visualization of the condylar movements and timing.
Figure 12. After the new VDO had been determined and captured in the full-mouth provisional restoration, the dimension was maintained using a leaf gauge. The guided centric relation (CR) was recorded.	Figure 13. A full white wax-up can either be made by hand or digitally fabricated. This is tried in to examine tooth position, shape, length, and occlusal planes. Most important is that this is tried in so that the patient can feel and preview the form to approve and give us permission to finish the work. Wax, as opposed to resin, can be very easily adjusted.

What is the importance of selecting the right dental material options and in understanding and perfecting the appropriate techniques (ie, preparation design, isolation, bonding-cementation, finishing-polishing, and occlusion) and skill levels to predictably achieve long-term clinical success with all-ceramic materials?

Dr. Malament: Each clinical condition requires different considerations as to what dental material will work best to provide structural support, aesthetics, and resistance to fracture and chipping. All dental restorations, whether gold, metal-ceramic (ie, PFM), or all-ceramic, need to be checked with a fit checker to ensure proper contact and marginal seal with the tooth. With individual crowns, lithium disilicate ceramics have become the standard of excellence as they resist fracture and are etchable and very aesthetic. Metal-ceramic crowns are more expensive and labor intensive. Depending on the level of artistic and technical ability, they may be aesthetically more unpredictable, and feldspathic porcelain has a clear history of chipping. Crowns made with zirconia have improved significantly, but its physical properties are dependent on the quality of the zirconia used. There are many off-label and poor-quality zirconia ceramics sold, chosen due to low prices, and these materials should not be used. Dentists should know who manufactured the zirconia that they will use and some of its physical properties. Quality zirconia disks are, by themselves, not expensive. Ceramics produced by isostatic pressing from major manufacturers should always be considered first, as these will perform significantly better. The color properties of the new generation zirconia ceramics (such as IPS e.max ZirCAD Prime [Ivoclar Vivadent]) have fused together 3Y-TZP that has high strength with 5Y-TZP that, although lower strength is more translucent, allows the production of an all-ceramic with excellent aesthetics and strength. The 5Y-TZP has 650 MPa strength and will resist fracture. By blending the 2 zirconia forms to create a more translucent form, the use of zirconia is more prevalent today than ever before. The problems remain that many restorations are coming out after cementation and, furthermore, the time to dislodgment is unpredictable.

Figure 14. Resin-bonded, individual full-coverage e.max restorations, principally monolithic with micro-layering done for aesthetic effects, in CR and in protrusive.

Figure 15. The completed restorations in CR.

With complex bridges and implant reconstructions, zirconia made with a CAD/CAM titanium substructure is an excellent and predictable restoration. Some laboratories cement implant components to zirconia frames, and, with this poor technique, there is a probability that they can be dislodged and the zirconia suprastructure can fracture. Metal ceramics with complex care may still be the standard of care.

Although it is desirable to use individual, all-ceramic crowns for aesthetic reasons, in some patients, contact areas open up, teeth continue to move down occlusally, and—in the worst scenario—individual teeth snap off at the gingiva. One of the tenets of placing a periodontal prosthesis is to splint together many, if not all, teeth together. This minimizes tooth mobility and many of the problems just stated. Understanding advanced prosthodontics and periodontics is most helpful in guiding the choice of dental materials.

Figure 16. The completed restorations in protrusive.

Figure 17. Maxillary and mandibular occlusal views of the final lithium disilicate full-coverage restorations.

When we observe preparations in dental laboratories, we are still not witnessing the expected growth in minimally invasive dentistry, despite the fact that quite a few modern composite and all-ceramic materials allow for more thoughtful prep design that saves tooth structure. Knowing that, along with placing a fairly high number of partial-coverage lithium disilicate restorations, what are your comments and recommendations to the majority of clinicians who seem to find it easier or “safer” to deliver full-crown restorations instead of more minimally invasive partial-coverage restorations? 

Dr. Malament: Minimally invasive dentistry has been around a very long time. For generations, the gold onlay was the ideal standard of care for most operative dentistry. A gold onlay strengthens a tooth and does not degrade over time, and it is an ideal restoration to improve occlusion. The ceramic veneer, assuming the bonding of the ceramic is mostly to enamel, has been a significant restoration since the 1970s. With the etchable lithium disilicate ceramic, partial-coverage restorations can more easily and predictably be a part of modern treatment.⁶ A great advantage of this type of restoration, because it is etchable, is that the bond and cement strength to both dentin and enamel is a significant improvement over zinc phosphate or conventional glass ionomer cements. These restorations reinforce the tooth complex without extensive occlusal coverage as was required for gold restorations. The survival statistics now being reviewed and processed for a new journal submission are excellent. Dental school faculties are not teaching the onlay preparation as effectively as was done in the past; therefore, clinicians are not comfortable doing them in their practices. Another point is that many teeth considered for minimally invasive dentistry already have large existing restorations and decay. Many of these teeth would be better treated with full-coverage restorations to minimize tooth fractures.

Dental technicians are perfecting the lithium disilicate veneer restoration to improve the color properties by building more translucency into a thin veneer. These veneers are being created using CAD/CAM technology. Lithium disilicate ceramic veneers are easier to fabricate for the technician, are etchable and significantly stronger than feldspathic ceramics, and are now becoming the standard.

With all the growth in materials, techniques, and evolving treatment modalities, we are expecting young dental graduates to learn so much more and in the same amount of time as we did 20 to 30 years ago. Is the time currently devoted to the average dental curriculum enough to adequately prepare to be a knowledgeable and high-quality dentist? What role could academia play in better preparing young graduates to take an evidence-based and more minimally invasive approach to dental care? Do you feel we may reach a point, as with physicians, that dental residencies become a required step in the dental career?

Dr. Malament: The undergraduate and graduate dental curricula are very challenged to provide the best and most meaningful education to our students. What is taught is set by an ADA Council and by the educators themselves. As so much is changing every year, and because new equipment is expensive and wears out with time, the challenge to educate students about cutting-edge technologies is nearly impossible. As I have previously mentioned, all educators today emphasize the importance of continuing education and finding mentors who can guide persons through all the many, and often complex, questions that will arise.

References

1. Malament KA, Socransky SS. Survival of Dicor glass-ceramic dental restorations over 14 years: Part I. Survival of Dicor complete coverage restorations and effect of internal surface acid etching, tooth position, gender, and age. J Prosthet Dent. 1999;81:23-32.
2. Malament KA, Socransky SS. Survival of Dicor glass-ceramic dental restorations over 14 years. Part II: effect of thickness of Dicor material and design of tooth preparation. J Prosthet Dent. 1999;81:662-667.
3. Malament KA, Socransky SS. Survival of Dicor glass-ceramic dental restorations over 16 years. Part III: effect of luting agent and tooth or tooth-substitute core structure. J Prosthet Dent. 2001;86:511-519.
4. Malament KA, Socransky SS. Survival of Dicor glass-ceramic dental restorations over 20 years: Part IV. The effects of combinations of variables. Int J Prosthodont. 2010;23:134-140.
5. Malament KA, Natto ZS, Thompson V, et al. Ten-year survival of pressed, acid-etched e.max lithium disilicate monolithic and bilayered complete-coverage restorations: performance and outcomes as a function of tooth position and age. J Prosthet Dent. 2019;121:782-790.
6. Malament KA, Margvelashvili M, Natto ZS, et al. Ten-year survival of pressed, acid-etched e.max lithium disilicate monolithic and bilayered partial coverage restorations: performance and outcomes as a function of tooth position. J Prosthet Dent. In press.

Dr. Malament received his DDS degree from the New York University College of Dentistry and a specialty certificate and Masters (MScD) degree from the Boston University Henry M. Goldman School of Dental Medicine. He has a full-time practice limited to prosthodontics in Boston that includes a dental laboratory with master dental technicians. Dr. Malament is past president of the American Board of Prosthodontics, a clinical professor at Tufts University, and a course director in Tufts University’s postgraduate department of prosthodontics. He is past president of the Academy of Prosthodontics, Greater NY Academy for Prosthodontics, and Northeastern Gnathological Society, and is currently the vice president of the American Academy of Esthetic Dentistry. He is a Fellow of the American College of Prosthodontists, the Academy of Prosthodontics, the Greater New York Academy of Prosthodontics, and the Northeastern Gnathological Society. He is also an active member of many dental organizations, including the International College of Prosthodontists, the American Academy of Fixed Prosthodontics, the American Academy of Esthetic Dentistry, the Academy of Osseointegration, the Northeastern Prosthodontic Society, and the American Equilibration Society. Dr. Malament was on the research and development teams for 2 well-known ceramic products and developed instrumentation used in clinical practice. He is a consultant to 3 journals, has published significantly in the dental literature, and has frequently lectured about prosthodontic topics involving ceramics, implants, and periodontics. He can be reached at kenmalament@mac.com.

Disclosure: Dr. Malament reports no disclosures.

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Damon Adams, DDS, editor-in-chief of Dentistry Today, speaks with Gary Kaye, DDS, MS, about how he got started in digital dentistry and briefly discusses, from Dr. Kaye’s own experience, some key points related to building a successful digitally based practice.

When did you start your involvement with digital dentistry?
Dr. Kaye: I first started on my journey in digital dentistry in 2001, when I acquired a CEREC 3D chairside CAD/CAM system (Dentsply Sirona) for my office.

What originally sparked your interest in technology and, specifically, digital dentistry?
Dr. Kaye: Prior to attending dental school, I had spent time in the medical technology industry working with ultrasonic imaging and early surgical laser devices. Within a few years of graduating from the Columbia College of Dental Medicine in 1993, I was able to observe one of the early CEREC machines in clinical use. I went to observe—over the shoulder—a single-visit ceramic inlay being designed, manufactured, and delivered to the patient. I was fascinated that everything we had learned to do by hand to create a restoration could be done by a machine. The procedure took more than a few hours, and the resulting restoration required a good amount of adjustment by hand at that time. I was amazed by the technology and immediately realized what the limitations were. At this stage of the development in this technology, the restoration was, in my opinion, sub-optimal. But I understood from seeing the all-around progress in technology that this would translate to a different way of practicing dentistry, and I knew that it would be just a matter of time until this is how dentistry is practiced.

At this time in my life, I had the benefit of being at the beginning of my career as a practicing dentist. As many of us do, I invested heavily in postdoctoral education and made it a priority to become a better dentist. As I evolved over the years, so did the technology. I’ve been fortunate that these 2 paths have run parallel, and, through my involvement in the digitization of dentistry, I am proud to have played even a small part in changing how the profession of dentistry is practiced.

At the outset, what strategies and which concepts interested you the most? Has that changed over the years as you’ve expanded your role in digital dentistry?
Dr. Kaye: Prior to attending dental school, I had seen technologies in medicine improve the diagnostic and therapeutic capabilities for both doctors and patients. On the diagnostic side, I had been involved in the early ultrasound imaging devices and in surgical laser technology. Coming straight from that environment, it was natural for me to think about how technology could be used in dentistry. In dental school, I explored how ultrasonic imaging could be used to measure periodontal bone loss. I also understood the challenges of taking an idea or concept and creating a viable, functionally useful product from it. Over the years I have—and continue to—worked with innovative companies in developing and refining their products. So the concept of taking advantage of technological innovations in clinical practice has always been the key for me. In particular, restorative digital dentistry seemed to me a logical progression of where the technology was going.

Since you took such an early interest in the emerging field, what were the primary limitations you encountered? You mentioned the viability and functionality of the budding digital dental technology. Could you expand on that?
Dr. Kaye: The challenges seemed to be focused primarily around the design (CAD) and manufacturing (CAM) of the restorations. The image capture or scanning process was restricted to just a few teeth—a quadrant at best—and the process was very technique-sensitive, requiring a thin layer of contrast medium on the teeth, often in the form of a powder. Since then, technology has advanced to the point that a full arch can now be scanned in about 1 to 2 minutes. In addition, the capture of the patient’s occlusion—the bite record—can be done very efficiently and with great precision. Next, there have been exciting advances in dental materials. The earlier all-ceramics, while useful in the development of CAD/CAM, lacked the appropriate properties for widespread use. It took some time, but now there are many options to choose from, including the highly touted lithium disilicate and zirconia materials.

As the years have passed, and those advancements have been made, how has your thinking about digital dentistry changed?
Dr. Kaye: At the outset, the technology was for single-tooth restorations done at the chair. As things continued to advance, we were eventually able to do multiple restorations with a single intraoral scan. As new materials became available, it expanded the kind of restorations that could be done. Once we are able to scan the dentition and send those virtual models to a laboratory team, it became apparent to me (and many others) that physical impressions would be giving way to digital scans, just like radiographic film gave way to digital radiographic sensors. And now I can’t imagine practicing any other way!

With all of these changes happening at such a rapid pace, has there been any noticeable impact on your patients? Do they accept or reject digital dentistry from your point of view?
Dr. Kaye: In general, I have noticed that our patients have accepted the technology. Many of them, particularly those who have grown up with high-speed computers and smartphones, tend to equate new technology with cleanliness and competency. It actually helps to put them more at ease seeing some of the things that we can do with intraoral scanning and 3-D capture technology.

What about your team? Has the evolution of digital dentistry posed any challenges from an organizational standpoint?
Dr. Kaye: Introducing new technology to the team often takes them out of their comfort zones, so I found resistance in the beginning. The way we got over that hurdle was to include the team in the buying and implementation discussions and decisions involving any new technology. Now, any time we look at a new piece of technology, we have the team involved in the research and justification to add it to the process. It makes a noticeable difference in morale and allows everyone to be included in the development and growth of the practice.

Were there any specific challenges that you found yourself confronting when adopting new technologies? If so, how did you manage to get through them?
Dr. Kaye: When I started, my goal was to do certain restorations in a single visit. I had to adapt the workflow to match that strategy. Appointments took longer, but there were fewer of them. Initially, I was the only one who could operate and maintain the equipment in my office. The efficiency that I gained from the technology was lost because I was doing tasks that did not require my expertise and training as a dentist. In addition, while the restoration was being designed or fabricated, the patients would have to sit and wait. Once I realized this, I started to train my auxiliary team members to understand the process from start to finish. That allowed us to approach the workflow in a more measured way and really take advantage of a proper routine. Also, and importantly, I could once again use my diagnostic expertise and clinical skills where they were needed most.

Given that you’ve gone through the technology adoption process numerous times, would you say that it’s important to think about the service and support available from the manufacturer?
Dr. Kaye: Yes, absolutely! I believe that this is one of the most overlooked aspects when dentists make buying decisions related to equipment, especially in the realm of digital dentistry. Focusing on pricing and features is obviously important, but considering the need for support after the purchase should never be overlooked. It should count for more in a buying decision than many clinicians realize. Scanners, mills, printers, and imaging devices are all run by very sophisticated computers, even though the user may only see a relatively straightforward interface. Such high levels of technology require professional, specialized experts, and, in the dental office setting, any fixes have to be done very promptly. The nightmare scenario of having a patient in the chair and a vital piece of technology shut down is one that we can all understand, so having the proper support to minimize downtime is absolutely vital. The best manufacturers provide the most expedient service and support to get us back up and running. Doing homework to figure out which purchases come with the best support is well worth the investment and the time. Consulting with experts, colleagues who have experience with different systems, and dental laboratory owners who work with different scanners and mills can be invaluable when adopting new technologies.

How did digital dentistry relate to the mission and values of your practice?
Dr. Kaye: Digital dentistry allows us to provide better care for our patients, which is in direct alignment with our primary mission and our core values. Our patients are the center of everything that we do, and, if we can see to them more accurately, more efficiently, and with less discomfort—then we have met our biggest goals. Overall, digital technologies make us much more efficient, whether through shorter treatment times, fewer remakes, or better-fitting restorations. We all tend to think of efficiency as a benefit to the clinician and practice, but the real beneficiary is the patient. Improving the patient experience is what we are always trying to achieve!

Do you think digital dentistry enables better functional and aesthetic results?
Dr. Kaye: There’s no question. In my practice, the whole digital restorative revolution has made my job easier when it comes to restoring form and function to our patients. The technology allows us to visualize the restorative outcomes before anything is even tried into the patient’s mouth. This has led to much more predictable outcomes, and it improves our ability to deliver better functional and aesthetic results.

Do you think that one ever stops learning when on the digital dentistry path?
Dr. Kaye: No, never! And that is what makes it so exciting! Technologies, materials, and science are advancing so rapidly that we are compelled to stay updated and find a way to implement relevant technologies into our practices. This holds true to dentistry in general. We were taught in dental school that our degrees were just the beginning of a lifelong commitment to learning, and this is just a facet of that now.

So, what do you see as the future of digital dentistry?
Dr. Kaye: I believe that more dentists will adopt the technology as companies continue to innovate and work on driving costs down with improved functionality. Cost has been a barrier to adoption for many practitioners. Dental schools, while slow to adopt some of the new advances, are starting to include them in their curricula. This will give the graduates the skills to enter into practice, where the technology is much more ubiquitous. Digital dentistry has improved immensely over the past 2 decades, and it continues to change the ways that dentists and lab teams collaborate. Ultimately, as digital dentistry takes hold, I think that it will allow clinicians to further leverage technology to improve efficiency and provide better patient outcomes.

Thanks for taking the time, Gary, to share your experience and expertise with us! And congratulations on now being Dentistry Today’s digital dentistry editor! I, and my editorial team, look forward to working with you!

Dr. Kaye graduated from the Columbia University School of Dental Medicine, where he received awards in endodontics, prosthodontics, and geriatric dentistry. He has practiced comprehensive dentistry since 1993 and has built successful multispecialty group practices in and around New York. He is a graduate of the Dawson Academy of Comprehensive Dentistry and has published and lectured on ceramics, occlusion, and the adoption of digital dentistry. He consults with dentists, dental schools, and manufacturers on all aspects of digital dentistry. He can be reached at drgarykaye@nycdd.org.

Disclosure: Dr. Kaye is a founding member of Biodental Sciences Laboratory.

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Dentistry Today’s editor-in-chief, Damon Adams, DDS, leads a discussion with Jihyon Kim, DDS, on why techniques for placing direct composites need to change.

What is injection molded composite?
Dr. Kim: Historically, many advances in science and technology have been spurred by perspectives gained from the cross-pollination of ideas across industries. A recent example might be the conceptualization of 3-D printing and its crossover from additive manufacturing to current uses in medicine and dentistry that has led to commercially successful products, such as TrueTooth from Dental Education Laboratories. Similarly, the concept of injection molding originates from a long-standing manufacturing process of injecting molten material into a mold to produce parts. Bioclear employed this concept as a solution to composite placement for direct restorations.

Figure 1. Four-year postoperative view of a midline diastema closure. Note the structural failure of the large direct posterior composite.

Figure 2. Two-year post-op view of tooth No. 7 peg lateral treatment. Clinical presentation does not reveal the subgingival ledges contributing to poor tissue health.

Figure 3. Tooth No. 7 peg lateral treatment. The preoperative and 8-year post-op views show the excellent color stability and integrity.

Figure 5. A Go/No-Go Probe (Bioclear) is used to measure depth of cure limits for the Filtek One Bulk Fill Restorative composite (3M). The green zone is within 4 mm. The yellow zone is within 5 mm. The red zone exceeds 5 mm. (Photo courtesy of Brandon Walker, third-year dental student, University of Washington.)

Legacy methods for direct composite resin restorations involve incremental placement techniques into traditional G.V. Black mechanically retentive cavity preparations. Composite resin is layered and hand manipulated for cavity adaptation, mitigation of C-factor concerns, and depth of cure. Layering techniques are also used in efforts to create polychromatic aesthetics in restorations. However, layering and hand manipulation of composite resins creates seams, gaps, and voids that may contribute to material weaknesses and early aesthetic failures (Figure 1). The use of a bulk-fill composite resin reduces the need for layering, but single incremental placement is still mired with issues from hand manipulation.

With indirect restorations, our profession is leaning toward the use of milled, monolithic restorations. Monolithic ceramic restorations have the advantage of increased strength over layered porcelain restorations. It would seem reasonable to infer that monolithic direct composite resin restorations might also be stronger than layered direct composite. What if we are able to create monolithic composite resin restorations directly in the mouth? That is the goal with injection molding of direct composite resin.

The injection molding method is a 3-step process following clinical total etching and immediate dentin sealing. Step one is the use of an adhesive (Scotchbond Universal [3M]) as a wetting agent, followed by aggressive air thinning. Scotchbond Universal, with its one-bottle system and self-etch/rinse-etch flexibility, is ideal for injection molding. Step 2 is placement of heated flowable composite. Step 3 is placement of heated regular composite resin. The 3 steps are done without curing in between. Injection molding of composite resin maximizes the material’s propensity to flow once heated, then captures and pressurizes it within a containment. The pressurization of composite within a containment creates shear thinning (thixotropic flow) that further encourages composite resin to flow like a liquid. Little to no hand manipulation minimizes the chance for internal defects that would otherwise contribute to structural weakness of the restoration. When done properly, injection molding and the Bioclear Method open up a third avenue of treatment possibilities. The options are no longer limited between temporary composite bonding vs irreversible, resective indirect restorations such as crowns. Injection molding offers advantages of both modalities: additive dentistry and preservation of tooth structure with strength, durability, and aesthetics.

What is the Bioclear Method, and how does injection molding fit in?
Dr. Kim: There are 4 cornerstones to the Bioclear Method: (1) biofilm disclosing and removal with aluminum trihydroxide to allow intentional excess of composite onto clean uncut enamel; (2) clear, anatomic Bioclear matrices capture and mold heated composite resin into monolithic shapes with mylar finishes in the inaccessible gingival and interproximal areas; (3) multi-viscosity composite resins are heated for better flow and adaptation; and (4) Bioclear’s trademark Rock Star polish—a simplified polishing method to create mylar finishes of the final restoration.

Figure 6a. Tooth No. 9 with deep caries, labial and palatal views. (Case courtesy of Dr. Reza Moezi, Vacaville, Calif.)

Figure 6b. Tooth No. 9 with caries removal. An A101 matrix (Bioclear) on the mesial and an A102 matrix (Bioclear) on the distal, ready for injection molding.

Figure 6c. Tooth No. 9 after injection molding and polishing, labial and palatal views.

The only similarity between conventional bonding techniques and the Bioclear Method is the use of composite resin. Typical outcomes of conventional bonding techniques that engage subgingival areas can appear clinically acceptable. The dirty little secret of a less-than-ideal subgingival outcome is revealed with a radiograph (Figure 2). Bioclear’s patented method and anatomic matrices for restoratively driven papilla regeneration and injection molding of composite are built for favorable subgingival adaptation and tissue responses. The resulting monolithic injection molded composite restoration with Rock Star polish has excellent color stability and stain and abrasion resistance (Figure 3).

There has been a steady increase in patients seeking treatment with the Bioclear Method. Both patients and well-meaning clinicians have been dissatisfied with the typical outcomes from traditional composite bonding techniques. Patients are also realizing the physiologic costs of indirect restorations and are no longer willing to sacrifice sound tooth structure for treatment. They are seeking a viable alternative, and Bioclear is satisfying the demand for porcelain-esque outcomes with minimal to no physiologic cost.

Why do you favor Filtek composites by 3M?
Dr. Kim: For more than a decade, we preferred using 3M Filtek composites because of the handling and optical qualities of the “body” shade that perfectly matches the corresponding flowable shade. The intimate and void-free adaptation of injection molded composite resin, along with the mirror finish achieved with the Rock Star polish, reveals the true optical and structural integrity of the composite. The resulting chameleon effect and enhanced photon penetration allows us to achieve a non-layered polychromatic effect by varying the facial thickness of composite.

Experimentation with heating of composite resins is not new. Numerous studies exist noting many advantages of heating (Figure 4). Although many composite resins are available, each resin may respond differently to heating. We are familiar with the handling of 3M composites and their responses to repeated cycles of prolonged heating times. 3M has been committed to testing the performance of their composites and documented that the heating of their composite resins does not affect safety or efficacy. They are the first in the industry to receive an FDA clearance for a heating claim.

The growing industry trend with bulk-fill composites also fits naturally with injection molding. The greater depth of cure with modern curing lights means that direct posterior composite restorations can be injected instead of layered. This simplifies the placement technique in difficult-to-access posterior areas. The typical 1.5- to 2.0-mm depth of cure requirement for most composite resins is challenging to consistently or predictably adhere to. The 4.0- to 5.0-mm depth of cure of bulk-fill composite resins facilitates single-increment monolithic injection molding of small- to moderately sized posterior restorations. Eliminating the technical challenge of layering may mitigate one of the most common failure points with Class II restorations, which is the structural failure of marginal ridges. According to the Department of Polymer Technology at the Royal Institute of Technology in Stockholm, knit lines in polymers (similar to seams in hand-manipulated composites) should be avoided as they can result in up to a 70% reduction in strength. This is analogous to structural concerns our profession has with layered cold composite resin restorations.

Figure 7a. Teeth Nos. 4 and 5 preoperatively with disclosing solution to reveal biofilm. (Case courtesy of Brandon Walker.)

Figure 7b. Selective caries removal and disease-driven cavity preparations. Preparations were cleaned and biofilm was removed with aluminum trihydroxide in a Bioclear Bioblaster. Bicuspids were matrixed with Bioclear Biofit HD Bicuspid matrices and wedged with a Bioclear Large Diamond Wedge (tooth No. 4, distal) and Medium Diamond Wedge (tooth No. 4, mesial). A Bioclear Molar Twin Ring Separator was placed on the distal of tooth No. 4 in preparation for injection molding of tooth No. 4.

Figure 7c. Post-op radiograph and photograph of injection molded teeth Nos. 4 and 5 with Rock Star (Bioclear) polish.

Despite their advantages, numerous biases exist against bulk-fill composite resins, including concerns with depth of cure, polymerization shrinkage stress, and aesthetics. Clear matrices reduce depth of cure concerns. After occlusal curing, metal matrices must be peeled back to complete buccal and lingual curing in order to achieve the 5-mm depth of cure. Clear matrices avoid the potential hazards of disrupting the resin prior to full curing. A greater concern is confirming the cavity preparation does not exceed the manufacturer-recommended depth for single-increment bulk filling. This can be overcome with the use of a depth gauge, such as Go/No-Go Probe (Bioclear) (Figure 5). The use of a high-quality curing light is critical and often underappreciated. All composite resins have volumetric polymerization shrinkage. The concern lies with the associated shrinkage stress, which can be mitigated with a good dentin bonding system and proper dentin surface cleaning.⁷ 3M’s proprietary monomers AUDMA and AFM help reduce the stiffness of Filtek One Bulk Fill (3M) while moderating volumetric shrinkage stress. Finally, Filtek One is as aesthetic as many aesthetic composite resins on the market.

What is the scope of treatment possibilities with injection molding and the Bioclear Method?
Dr. Kim: The patented method of injection molding composite resin around a tooth is the same regardless of the tooth. The scope of treatment can range from a single anterior or posterior tooth to the entire mouth (Figures 6 and 7). The additive nature of the method, combined with a lack of constraints for uniform thickness of restorative material, means ultimate flexibility. With indirect restorations, the tooth must be prepared to satisfy path of draw, path of insertion, and material thickness requirements. This often results in the sacrifice of sound tooth structure to accommodate material and technique requirements. With injection-molded restorations, the material is instead adapted to the tooth. Thus, sound tooth structure can be preserved while missing, diseased, or weak tooth structure is replaced or reinforced.

Many aesthetic concerns can be addressed with additive, instead of resective, methods (Figure 8). Teeth that were once thought hopeless can be restored to buy valuable time for the patient (Figure 9). Dentistry as a profession has made incredible strides in the last 60 years. Despite advances with composite resins, we still adhere to century-old cavity principles and designs that do not reflect sound engineering principles. With advances in implant options, we prematurely sacrifice existing tooth structure for replacement. Since the time of G.V. Black, the average lifespan of our patients has doubled. That fact needs to be an important decision factor in treatment planning. Injection molding as a third modality of treatment options opens up possibilities and impacts the algorithm for treatment decisions. We need to educate and involve patients regarding treatment options and let go of our professional biases for outcomes. The decision should be about patient-centered outcomes.

What do you mean by doctor/patient-centered outcomes?
Dr. Kim: Doctors have professional biases regarding aesthetics, acceptable physiologic cost, and treatment predictability. Our biases do not necessarily match our patients’ desires and are generally not evidence-based. While we strive for perfect replication of natural tooth contours and colors and orthodontic correction, there is a common patient aesthetic complaint in regard to incisal translucency and polychromaticity. Many patients prefer color-uniform teeth that are bright but believable. They are often seeking an improvement of their perception of nature, not our ideas about replication of nature. Clinicians pursue marks of good artisanship with no evidence that this is desired by patients. A simple example of this disconnect is the placement of occlusal stains on direct and indirect restorations. How often have we asked patients if they desire this or had patients ask if an occlusal stain was caries? We simply need to be aware that our professional aesthetic biases may not match that of our patients.

Figure 8. Pre- and post-op views of a severe periodontally compromised case. Black triangle treatment was done to improve smile aesthetics and reduce mobility. (Case courtesy of Dr. Charles Regalado, Spokane, Wash.)

There has been a significant increase in adult orthodontic treatment. However, orthodontic tooth movement in adults has a high probability of leading to open gingival embrasures, or “black triangles,” which are, ironically, a greater aesthetic dilemma for patients than crowded teeth.⁸ Clinicians were guilty of dismissing patients’ concerns regarding the aesthetic dilemma of black triangles, especially in the absence of disease. Before Bioclear, we had no conservative solutions for treating black triangles. In today’s youth culture, patients have strong negative reactions to presentations of “unfamiliar” negative space. High-contrast areas are more readily noticed than soft-color contrast areas. Thus, issues such as black triangles, uneven or harsh incisal embrasure spaces, dark restorative margins, dark caries, or occlusal staining are real aesthetic concerns for patients. We may be inadvertently heading into an informed consent crisis with orthodontic treatment by creating greater aesthetic concerns for the patient.

What advantages/disadvantages does injection molding and the Bioclear Method offer?
Dr. Kim: Significant advantages are the conservation of tooth structure, possibility of treatment reversal, and ability to maintain all treatment options with additive injection molding. With the increased lifespan, preservation of tooth structure should be a priority. Since everything has a limited lifespan, reliance on medical devices too early should be avoided.

Figure 9a. Pre-op photograph of rampant caries treatment. (Case courtesy of Dr. Les Miller, Lawrence, Kan.)	Figure 9b. Post-op view of injected molded teeth Nos. 6 to 9 and 22 to 27.

We cannot heal and “restore” diseased teeth to their virgin states. We can only “repair” teeth when treating caries or structural compromises. The manner in which we prepare teeth to retain a restoration will have a significant impact on the tooth’s longevity. The advent and improvement of composite resins relying on adhesion should reduce our dependence on G.V. Black cavity prep designs of mortice and tenon joints for mechanical retention with their specific internal prep designs, dimensions, and line angles. Instead, we should shift our focus to the removal of diseased tooth structure and preservation of sound tooth structure. Our first touch on a virgin tooth can impact how rapidly that tooth progresses through its life cycle. The disadvantage is a lack of training and the status quo maintaining our professional biases. Adoption of a new concept and achieving proficiency in it is always challenging. This can be ever more difficult with concepts that are yet in the early stages of general acceptance. We continue to work hard at the Bioclear Learning Center to share our philosophy of preservation and patient-centered care.

What are your goals for teaching at the Bioclear Learning Center?
Dr. Kim: With any new method, there is a unique learning curve for every clinician to reach basic proficiency, then mastery. Our goal with Bioclear was to create a system and a method to enable committed clinicians to predictably and consistently deliver results superior to their current methods. We share the excitement from clinicians when they express how the method makes sense and that they are eager to develop their skills. There is a strong fellowship of clinicians who are excited about doing the right thing for their patients. Furthermore, at the Bioclear Learning Center, we focus on teaching the Bioclear Method in its purity. We have had attendees with all levels of experience, from dental students to seasoned clinicians with more than 50 years of experience. We strive to help every attendee reach a basic comfort level so he or she can conquer his or her first case Monday morning. If we fail in this goal, then adoption and continued progression of skill will falter. Most of our attendees do begin cases right away, which is gratifying. More clinicians trained in the Bioclear Method gives more patients access to this third avenue of conservative treatment.

What thoughts do you have about the future?
Dr. Kim: With the current economics of dentistry, there is enormous pressure to provide billable procedures dictated by codes in an insurance plan rather than the right service directed by a patient’s wants and needs. Financial pressures are pushing for the delivery of easier procedures at a faster rate and lower cost. The change in the economic landscape is devaluing our skill and judgment and trading it for our ability to deliver a commodity. This will negatively impact the doctor/patient relationship and patient care and undermine even the most well-meaning clinician.

Bioclear began with a desire to provide better and more predictable outcomes for our patients in our practices. Bioclear is continually striving to make its systems more prescriptive, and our teaching at the Learning Center is intensively hands on. We can never underestimate the importance of clinical judgment, experience, a love of problem solving, and striving for excellence. We hope to teach a better way while fostering a learning environment of mutual inspiration.

We believe that injection molding is a better method for direct composite dentistry. We have been sharing the concept of injection molding with educators and institutions. Currently, injection molding and the Bioclear Method have been fully incorporated at the Roseman University of Health Sciences College of Dental Medicine in South Jordan, Utah. Roseman was the first school to spearhead the conversion of their preclinical and clinical curriculum. The University of Alberta’s GPR program has also adopted the method. The Loma Linda School of Dentistry is working to incorporate the method in the near future.

With the beginning of the adoption of injection molding and the Bioclear Method in our nation’s schools, we are excited for what the future holds. We want to contribute a positive impact to our profession. We are excited for the recent educational partnership formed between Bioclear and 3M to help introduce the Bioclear Method globally. We are committed to facilitate and support the learning of practicing clinicians, dental students, and study clubs throughout the country.

Many thanks, Jihyon, for taking the time to thoroughly discuss this exciting and revolutionary approach to composite resin restorations! Your passion, expertise, and dedication to teaching others about these novel techniques are obvious. We wish you all the best for continued success!

References

1. Lucey S, Lynch CD, Ray NJ, et al. Effect of pre-heating on the viscosity and microhardness of a resin composite. J Oral Rehabil. 2010;37:278-282.
2. da Costa J, McPharlin R, Hilton T, et al. Effect of heat on the flow of commercial composites. Am J Dent. 2009;22:92-96.
3. Mundim FM, Garcia Lda F, Cruvinel DR, et al. Color stability, opacity and degree of conversion of pre-heated composites. J Dent. 2011;39(suppl 1):e25-e29.
4. Dunbar T, Abuelyaman A, Phillips C, et al. Does preheating a dental composite degrade its post-cure properties? J Dent Res. 2016;95(special issue A). Abstract 0952.
5. Zimmerli B, Rickli C, Lussi A. Microhardness and marginal adaptation of pre-warmed composites. Poster presented at: Pan European Federation Meeting; September 15, 2006; Dublin, Ireland. Abstract 589.
6. Daronch M, Rueggeberg FA, Hall G, et al. Effect of composite temperature on in vitro intrapulpal temperature rise. Dent Mater. 2007;23:1283-1288.
7. Sherawat S, Tewari S, Duhan J, et al. Effect of rotary cutting instruments on the resin-tooth interfacial ultra structure: an in vivo study. J Clin Exp Dent. 2014;6:e467-e473.
8. Cunliffe J, Pretty I. Patients’ ranking of interdental “black triangles” against other common aesthetic problems. Eur J Prosthodont Restor Dent. 2009;17:177-181.

Dr. Kim is a full-time clinician in Bellevue and Tacoma, Wash. She also teaches and develops curricula as full faculty and co-director of the Bioclear Learning Center. Dr. Kim is creator of the Smile Design Gauge, a multifunction tool for chairside smile design. She can be reached at drkim@jihyonkimdds.com.

Disclosure: Dr. Kim is faculty and co-director of the Bioclear Learning Center and a consultant for 3M and has a financial interest in the Smile Design Gauge.

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Our implant editor, Michael Tischler, DDS, speaks with Scott D. Ganz, DMD, about cutting-edge technology for implant dentistry.

You have been involved with dental implants for many decades as a surgical prosthodontist, contributing to scientific literature and numerous textbook chapters, helping to run live surgical courses, and continuing to be in demand as a lecturer around the globe on a regular basis. What is your motivation?

Dr. Ganz: First, Michael, I want to thank Dentistry Today for the years of dedication to the dental industry in bringing such an array of educational articles from clinicians of all persuasions, specialists and GPs, auxiliaries, and other people from our profession to reach such a wide audience in a wonderful format. I am always honored to have been included in past publications, and in this current edition, as Dentistry Today has always chronicled the progress of modern-day dentistry. On that note, perhaps the publishing industry is one that has also gone through amazing transitions in moving from a fully analog publication into today’s digital world with an online presence. In my humble opinion, the digitization of dentistry has the potential of impacting how most clinicians address the needs of their patients. I say this having been there at the beginning, watching the evolution, and trying to stay one step ahead. The changes that we have witnessed, and are witnessing, provide plenty of motivation for me to continue to push the envelope.

Figure 1. A reconstructed panoramic image, revealing a periapical radiolucent area surrounding the mandibular right second molar tooth (red arrows). The path of the inferior alveolar nerve (IAN) is shown in orange. (Case submitted by Dr. Barry Kaplan, Morristown, NJ.)

What do you think of the progress that has been made since you placed your first implant?

Dr. Ganz: As you know, dental implants did not start with Dr. Brånemark. I always like to also give credit to those who risked and invested so much in paving the way to our modern world of dental implants with the blade implant, the subperiosteal implant, pterygoid implants, root form implants in various shapes and sizes, and even today’s zygomatic implants. Pioneers like Greenfield, Strock, Chercheve, Schroeder, Leonard Linkow, Hilt Tatum, Norm Cranin, Jack Hahn, Carl Misch, and so many more set the path for where we are today. So much has changed, and yet there are some things that should remain constant. In fact, some ideas become new again!

What do you mean that “some things should remain constant?”

Dr. Ganz: What should always remain constant is the concept that our patients come to us because they need teeth, not implants. It is our goal to deliver both function and aesthetics, whether for a single tooth or a full-mouth restoration. The foundational conventions of dentistry, such as occlusion, lip support, phonetics, centric relation position, the rule of golden proportions, etc, should be considered for either an analog or a digital workflow. It is my belief that today we finally have the appropriate tools to practice true “restoratively driven” dentistry, with the ability to place implants accurately into restorable positions based upon the needs of the patients and the limitations of the materials that currently exist.

Figure 2. The CBCT scan cross-sectional slice exhibits the path of the IAN in proximity to the molar tooth (lower arrow) and the fenestration of the lingual cortical plate (upper arrow).	Figure 3. The axial view shows the extent of the lesion as it pierces through the lingual cortical plate of the mandible (red arrows).
Figure 4a. Using advanced software segmentation, a 3-D volumetric rendering helps improve the diagnostic phase. The second molar tooth was digitally separated from the mandible (cyan color).	Figure 4b. Having the ability to separate and then move an object like the molar can be an invaluable diagnostic tool.
Figure 5a. The segmented mandible can then be exported as an STL file for 3-D printing of a solid model. The buccal view is seen here.	Figure 5b. The lingual view of the full-scale mandibular model provides excellent visualization of the cortical plate fenestration and position of the molar roots.

Which tools do you find to be most important? And please clarify how that applies to achieving the goal of restoratively driven dentistry.

Dr. Ganz: This relates back to where we are today, in terms of our progress in the dental industry. We have made great strides in creating implant designs that may have a greater than 95% success rate for more than 20 years. However, we often speak about the success of the osseointegration process and whether implants have been integrated to the bone without a perception of whether or not all the treatment goals were reached—including function and aesthetics. I do not judge success solely on integration, as there is so much more to consider! Although it is nice to say that clinicians are placing implants in the proper restorative positions, even today there are implants placed “where the bone is” and without careful appreciation of the restorative demands. Therefore, I believe that with all of the success that our industry has achieved, the weakest link is still in the first phase of treatment: the diagnosis and treatment planning steps. Therefore, the first most important tool that I will not practice without is computed tomography (CT), or today’s cone beam CT (CBCT). A 3-D image powered by today’s high-powered computers provides the clinician with an interactive environment to assess each patient’s unique and individual anatomical presentation. Michael, both you and I together, and individually, have contributed several articles on this concept within the pages of Dentistry Today and other publications in past years.

Figure 6. Using an in-house printer with a large enough print bed, it was possible to produce 2 full-scale mandibles, a bone reduction guide, and a surgical drill guide for implant placement (Form 2 [Formlabs]).

Okay, most clinicians have a clear understanding as to the importance of CBCT in the placement of implants, but what other tools are necessary?

Dr. Ganz: Well, actually, I’m not done with the first part—it’s too important. Even though we have this amazing tool, CBCT, many clinicians still have no real understanding of how to navigate through the software, or how to truly diagnose or treatment plan with or without regard to dental implants. Take, for example, a failing mandibular molar: Can a periapical radiograph reveal the extent of the pathology present? A reconstructed panoramic image reveals a periapical lesion (red arrows) surrounding a lower right second molar tooth (Figure 1). The orange line represents the path of the inferior alveolar nerve (IAN) in close proximity to the lesion. What would be the correct plan of treatment for this case? Do we have enough information from a view similar to a periapical radiograph? What other views would be most helpful?

The CBCT allows for a variety of different views, and each one is important. The cross-sectional view reveals a surprise: The periapical radiolucent area extended significantly through the lingual cortical plate (Figure 2). The upper red arrow points to the lingual aspect of the molar root, and the lower arrow points to the thin layer of cortical bone lingual to the IAN. The axial view shows the extent of the lesion from another perspective. The red arrows clearly show the break in the thick lingual cortical plate (Figure 3). Without 3-D diagnostic imaging, a proper treatment plan would have been, at best, difficult to determine, which could have led to uncontrolled bleeding and, potentially, a sublingual hematoma.

Figure 8a. The resin screw-retained mock-up aides in the assessment of fit, occlusion, emergence profile, lip support, midline, and aesthetics prior to the milling of a definitive monolithic zirconia prosthesis.	Figure 8b. The final restoration provides a natural and aesthetic solution for an implant-supported, fixed monolithic prosthesis.

Figure 10. Resonance Frequency Analysis (RFA) technology provides clinicians with a non-invasive, objective method to assess implant stability at the time of placement, at uncovering, or at any time when monitoring the health (integration) of the implant(s) (IDx [Osstell]).

That is significant! However, you did mention other tools. Can you please elaborate?

Dr. Ganz: Of course! Let’s continue on using this same case example. The first 3 images were taken from the CBCT dataset and represent individual slices in different planes. Many clinicians will still have trouble navigating between these images and may find it difficult to fully appreciate the information at hand. We can then further refine the CBCT data and convert the DICOM data to a 3-D volumetric rendering of the patient’s mandible and teeth through the process of segmentation (Figure 4). Using the density values within the scan data, objects can be created and separated to improve the diagnostic phase. The red arrows clearly point to the large bony lesion within the lingual concavity of the mandible (Figure 4a). The second molar tooth (cyan color) was digitally separated from the mandible based on its density values. These digital tools are becoming invaluable not only in dentistry but also in medicine, simulating anatomical structures and virtual surgical procedures. By separating the virtual molar from the mandible, it can be further manipulated to help determine the best surgical approach (Figure 4b). Finally, the next step in surgical simulation would be to have a physical model of the patient’s mandible in hand to closely examine (Figure 5a).

Advancements in 3-D imaging software allow for the creation of interactive 3-D models, as seen in Figures 4a and 4b. The data utilized for on-screen visualization and manipulation can be converted into STL (standard triangulation language) files for either milling or 3-D printing. The exported STL file of the mandible previously discussed was printed using the process known as stereolithography on an in-office printer (Form 2 [Formlabs]) (Figure 5a). The lateral view reveals the teeth, the mental foramen, and the ascending ramus. There is no evidence of any buccal fenestration, as also evidenced in the cross-sectional image in Figure 2. The lingual view reveals a full-scale representation of the defect as previously described (Figure 5b). The ability to visualize a 3-D printed model can be appreciated by the novice or expert as it represents a physical replica of the patient’s unique anatomy, open for examination.

Scott, that’s a great example of how diagnostic imaging can be used to the maximum. How important do you think in-office 3-D printing is today?

Dr. Ganz: Let’s go back in time for a moment. It was approximately 20 years ago that low-dose CBCT scan devices became available. During the 1990s, and through today, 3-D imaging devices became a major aid in diagnosis and treatment planning for dental implants and a catalyst for the development of guided dental implant surgery applications. The majority of surgical guides were fabricated by the process of stereolithography, or 3-D printing on devices that cost hundreds of thousands of dollars. It was a dream to think that, in my lifetime, 3-D printing would become available to the clinician or the dental laboratory technician for the in-house production of surgical guides or biomedical models as seen in Figures 5a and 5b. Three-dimensional printing has become a natural extension of today’s digital workflow—not just from DICOM CBCT data, but also from desktop and intraoral scanners—and an aid for general dental applications; orthodontic aligners; nightguards; crowns and bridgework; digital mock-ups; and much, much more.

By using an in-house printer with a large print bed, it is possible to print 2 mandibles, a bone reduction guide, and a surgical template for implant placement (Figure 6). To evaluate a full-arch monolithic zirconia prosthesis, an STL file is first created by lab-based tooth design software (exocad [exocad GmbH]) and then exported to a 3-D printer (Figure 7). Using a gray-colored resin, the mock-up can be evaluated in the mouth for emergence profile, tooth shape, bite, and lip support to be approved by the patient before the milled restoration is fabricated (Figure 8a). The final monolithic prosthesis can be delivered to the patient with confidence (Figure 8b). The new digital workflow allows for a complete and often seamless communication process between clinician, laboratory, and patient.

Whether they are single-tooth replacements or full-template guidance immediate load complete arches, we as clinicians need confidence that our cases will be successful. Using advanced 3-D planning concepts, we can plan for tooth extraction, bone reduction, implant placement, abutment connections, and transitional prosthetic restorations with a guided or non-guided approach. If true restoratively driven concepts are followed, anatomic landmarks are appreciated, and a partnership is in place with the dental laboratory team (Figure 9).

Is there any other technology that you find indispensable for dental implants today?

Dr. Ganz: Yes, there is. With the amazing diagnostic tools available for planning and placing implants, whether guided or non-guided, we still need information about every implant placed in terms of implant stability and whether an implant is integrated enough to load. While many clinicians believe that insertion torque is a reliable method to determine implant stability, this may be provide a false sense of security. Insertion torque is the frictional resistance of an implant as it is delivered to the osteotomy site at that moment in time, and often it is a subjective measurement. We need an objective, non-destructive measurement that can be documented at the time of implant placement, an hour later, 2 months later, at the time of uncovering, or at any time during the lifespan of the implant. This technology exists as resonance frequency analysis (RFA), which measures implant stability quotient (ISQ). I like the concept of being able to have an entry in the patient’s chart at the time of placement, providing me with critical information relating to when it is appropriate for loading (Figure 10).

Thanks so much for taking some of your valuable time to address some of these important topics related to successfully placing and restoring dental implants. You are a true leader in implant dentistry, Scott!

Dr. Ganz received his specialty certificate in Maxillofacial Prosthetics/Prosthodontics, which led to a focus on the surgical and restorative phases of implant dentistry and to contributing to 15 implant-related textbooks. He is a Fellow of the Academy of Osseointegration, a Diplomate of the International Congress of Oral Implantologists, president of the Digital Dentistry Society, and co-director of Advanced Implant Education. Dr. Ganz is on the faculty of the Rutgers School of Dental Medicine and maintains a private practice in Fort Lee, NJ. He can be reached at drganz@drganz.com.

Disclosure: Dr. Ganz reports no disclosures.

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Our editor-in-chief, Damon Adams, DDS, and our technology editor, Paul Feuerstein, DMD, recently discussed some of the trends in technology and their implications for the practitioner. Due to their respective connections with Dentistry Today, they find it fun once in a while to sit down over a glass of wine and dinner, catch up, and candidly talk about dentistry. In this case, they recorded their conversation for the benefit of our readers. Presented here are some salient portions of their discussion.

Paul, I bet our readers, especially the general practitioners (GPs), will be interested in hearing what you and your tech-loving peers are seeing and thinking in our rapidly changing world of dentistry.

Dr. Paul Feuerstein: GPs today are facing quite a bit of pressure to add several different technologies to their practices. Dental professionals are being bombarded with information coming from all sides: manufacturers, lecturers, authors, and academia. Furthermore, there is information crawling all over traditional and social media about new processes for instant crowns, instant smiles, and much more, while many dentists have been performing high-quality services for their patients with tried-and-true systems.

The most common comments we read are from practitioners who take “traditional” crown and bridge impressions and are receiving exceptional results from their dental laboratory teams. Are the new digital systems so far superior to well-taken physical impressions that there will be a dramatic difference in quality and fit of the restorations fabricated? How can a solo practitioner, or even a small group, justify a multi-thousand-dollar investment in, for example, a digital impression system and get a decent return on investment? How about adding in-office mills or 3-D printers, which now means someone has to design restorations and have patients waiting around for a finished product, and someone also has to be trained in machine maintenance? And what about 3-D digital radiography? Does the general practitioner really need all of that information that is available from the volume of data revealed when taking a CBCT scan? Maybe you have similar thoughts, Damon?

One can certainly argue that CBCT scans are immensely helpful in many different situations, such as in select endodontic and oral surgery cases, when treatment planning implants, for clinicians working in the arena of sleep disorders or diseases of the temporomandibular joints, and so much more. Although it represents a mesmerizing and almost “addictive” sort of go-to modern technology, dental professionals need to be thinking about the ways and reasons why one should be extremely selective over a patient’s lifetime in how and when this advanced technology is used and, above all, making sure it is employed only when the patient will benefit from its use and subsequent findings.

So, Paul, what is the driving force behind this situation where practitioners might feel a bit pressured to buy the latest technologies?

Dr. Feuerstein: Actually, although the dental consumers we serve are becoming savvier and asking for things like one-visit dentistry and “clear braces,” the real pressure is coming from the dental laboratories and their changing products and processes. New materials and manufacturing processes, like the choices in zirconia restorative materials (including the latest introduction of more aesthetic zirconia options by big players in the dental industry: IPS e.max ZirCAD Multi [Ivoclar Vivadent], Lava Esthetic [3M], ArgenZ [Argen], and BruxZir Anterior [Glidewell Laboratories], to name a few) that seem to be taking over much of the basic crown and bridge work, are created using computer-driven mills. Our laboratory teams can only create restorations from the latest materials using a digital workflow. The number of days left for plaster models, waxing, and casting grows shorter with every passing year. The new labs, even the smallest ones, have some sort of CAD/CAM system in place. There are a number of impression scanners that labs use to turn the traditional physical impressions taken, including any models sent, into digital files. If you think about this, scanning an impression or model is a secondary step, and this step can introduce miniscule errors into the process as opposed to scanning intraorally. So, even though many practitioners still prefer traditional physical impression techniques, the lab owners and their teams like, and many now prefer, to receive scans and to use digital files.

Of course, for those dentists who are staying with the tried-and-true gold, porcelain-fused-to-metal, conventional stacked porcelain, and other restorations, the advantage seems to wane—or does it? With new milling and 3-D printing of models, these more traditional restorations can also be done digitally and with the highest accuracy. And think of a small discrepancy in an impression or a stone model that was created with plaster that was not accurately weighed, with water not at the manufacturers’ recommended temperature and amount and not mixed properly for the precise length of time recommended. You have introduced discrepancies that are eliminated as possibilities in the digital workflow. In addition, there are economic advantages as there are no inbound shipping or pick-up fees and, in many cases, no model fees and a lower cost of the manufacturing and resultant lab fees charged to the practitioner.

This is all great, but if the clinician has been working for years with talented technicians in a smaller lab, and still wants that same high level of quality craftsmanship and especially, artisanship in the restorations created, moving away from this to in-office based technologies is a big and difficult decision. In my lectures, I often say that in committing to in-office CAD/CAM technologies, we are deciding to move beyond clinical work and into laboratory work as well. While this is definitely an exciting and appropriate choice for many dentists, it is not the easiest shift, nor is it always in the best interest of every clinician when all the implications are carefully considered. No matter how desirable it may be to have the latest and greatest technologies right at one’s fingertips, we have to realize that it may be a real challenge to afford the investment, implementation, training, and ongoing maintenance costs that are involved in owning in-office CAD/CAM and printing technologies. Furthermore, many recent graduates, who would otherwise likely be among the most aggressive of our colleagues in moving into the latest and greatest in-office equipment and digital workflow concepts, find themselves, on average, nearly $300,000 in debt coming out of their undergraduate degree and dental school. It is ironic, and frankly a bit discouraging, that this is the case at a time when we see such amazing technological innovations in dentistry for implementation in the dental office. How could this be changed to move technology forward? Perhaps even the educational model in the United States needs to be revisited and revamped?

Paul, what can you say to shed some light on this dilemma and possible solutions to the incorporation of more technology into the dental practice?

Dr. Feuerstein: Well, doctors can consider at least owning scanners. And to this point, many more dentists are sending in cases via scan files. However, the lab teams must have a method to at least receive and use these digital files. This does not mean that the lab must invest thousands of dollars in manufacturing machines. For example, there is a whole new group of labs doing work for other labs. Entrepreneurs have set up large design and milling centers that are exclusively available to dental labs—in effect, acting as subcontractors. This allows your favorite technician to have the latest technology and materials as available services while still controlling the design and finishing steps of the cases. There is a need for the technicians to learn how to virtually “wax-up” a case on the computer screen, but the learning curve is not steep. This software is more robust than what is commonly seen in a dental office; there are more design controls; and the technician, who has done many more crowns and bridges than the average practitioner, can spend more time tweaking the end result. Most labs use software with names that are now becoming familiar to dentists, such as 3Shape, Dental Wings (Straumann), and Exocad. This software can be found in most laboratories, and some dentists and their office teams are now learning how to use these as well. Also, when the cases come out of the commercial mills, the technicians have a large array of finishing, glazing, polishing, and tweaking tools. There are, of course, some practitioners who have done advanced studies and can create restorations equaling the technicians, but the majority of clinicians doing this don’t want to spend all of that time either learning or creating and will defer this work to their lab teams. Also, these companies are tweaking the lab software to make it a bit more user-friendly and offering it directly to the dentists. One example that comes to mind is the Exocad Chairside software that was recently released (exocad.com). As an aside, at a recent dental laboratory show, I came across a few companies, such as Full Contour (fullcontour.com), that allow busy labs to export cases to them and get the designs sent back for milling. This will soon be available to dental offices that have impression scanners and mills (and 3-D printers) but don’t want to spend the time designing. These companies are set up to receive your scan over the Internet, design the restoration for a small fee, and then export it directly to the office mill. Since this is all digital, and because there are facilities in many locations throughout the world, clinicians should be able to work virtually/digitally with a technician in an appropriate location in real time. Perhaps this the best of both worlds.

With this digital infrastructure and these new CAD/CAM materials, what should be we looking for?

Dr. Feuerstein: Well, as you know, there has been a huge push in the industry to get away from porcelain-fused-to-metal restorations, especially with single units, to zirconia and lithium disilicate restorations. We are being told, especially with zirconia, that these are almost indestructible. The compressive strength of zirconia is reported to be as high as 1,400 MPa. The recent introduction of aesthetic zirconia drops this down to the 700 to 800 MPa range, but it’s still very strong. However, in an earlier Focus On article in Dentistry Today (September 2016), Dr. Rella Christensen gave us some warnings and things to look out for when using some of the latest translucent zirconia materials. First of all, the research she has done shows that there can be inconsistency in the manufacturing, ingredients, and formulas for the zirconia blocks being sold and used. Not all manufacturers, nor dental labs, dealing with these products are created equal. For just a couple of examples, companies like Glidewell Laboratories (BruxZir and BruxZir Anterior) or Ivoclar Vivadent (IPS e.max ZirCAD and IPS e.max ZirCAD Multi) have amazing quality controls in place and work with a team of chemists and scientists to ensure that clinicians and patients are getting the excellence in product performance that is expected. Like anything else, there are both name brands and generics, so doctors need to know details about the dental material being prescribed and verify with the lab owner the source and exact makeup of the material being used to fabricate their restorations. In addition, Rella found that, although the aesthetic zirconia material had good strength values, improper occlusal adjustments and polishing techniques, as well as poor prep design, can lead to premature fractures. These materials also have different thickness requirements, so clinicians must be aware of this and make any needed adjustments in the preparation design for any given material and/or material usage.

Paul, you are spot on! By the way, beware gray market materials! Stick with quality materials from quality manufacturers and laboratories. An old cliché is relevant here: You get what you pay for. And gone are the days when one prepared a tooth and then thought about which material would be “the best one” to use. Thorough diagnosis and treatment planning, along with thoughtful material selection, is required before beginning the preparation of any tooth. Fortunately, when prepared in a minimally invasive way, the clinician now has aesthetic and conservative options to work with ever-improving direct composite resin choices, along with lithium disilicate and a variety of zirconia options, when required.

So Paul, you have been talking a bit here about the dental laboratories, but what is going on with in-office restoration design and creation?

Dr. Feuerstein: The terms “one-visit dentistry” and “crown in a day” are now a reality! CEREC (Dentsply Sirona) has been doing this for more than 30 years and leading the way, followed by E4D, now Planmeca, and others. The in-office design software and milling has become extremely accurate, with more materials available than ever before, including zirconia. The most confusing but exciting development, though, is having components from various manufacturers that can “talk” to each other. This is called having an “open” architecture. There are impression scanners, design software, mills, and 3-D printers available from a variety of manufacturers that seem to allow the office to pick, choose, and set up the same way you would buy stereo components. Of course, this is not just plug-and-play, but it is evolving and becoming more simplified quickly. There are also third-party distributors, including many of the existing ones, that will help the dentist pick and choose the components and then stitch them all together for the office. This is, of course, helpful when something goes wrong and the practitioner is not sure which component is responsible. Some of the scanner manufacturers also have relationships with software and milling manufacturers and can guide the office through the setup. Companies like Exocad have software that can work with all components and are even bundled in the scanner or mill software and work invisibly. Glidewell has created a complete system using the iTero scanner with its software and mill. We are, and will be, seeing more of this merging of systems and companies, which will allow the doctor to set up a system now and, when a new product comes into the marketplace, add only one piece to upgrade instead of changing the whole system.

OccluSense (Bausch)

The advent of 3-D printers, along with new materials, will also be a game changer. Damon, you will remember that my column in August 2018 touched on some of the advances in 3-D printing. Although we are not quite ready to print “permanent” crowns and bridges, this technology is advancing rapidly and should soon give us the ability to do so. For now, even though some of the current materials have been in the mouth for 5 years, the crowns are still classified as “provisionals.” Of course, using composite or polymethylmethacrylate, we can now print provisionals. The cost of printing is minimal—less than $10—but right now, the printing process takes at least 20 to 45 minutes. This is not practical for a single crown temporary. With digital case planning and clever use of the software prior to the patient visit, printing will allow practitioners to create long-term/long-span temporaries in the office at a great cost savings over lab-fabricated temps. Printing also covers a range of products, including models, retainers, mouthguards, surgical guides, and more. In fact, a couple of companies are now printing dentures. Dentca, for example, has an entire digital workflow once the edentulous impressions are scanned. Of course, we currently cannot scan a totally edentulous arch.

Using a Carbon printer (carbon3d.com), the denture base and the teeth are printed and then fused together. Materials and printers from 3DSystems/NextDent and EnvisionTEC are also printing dentures. If the clinician has an in-office printer, a patient can get a spare or duplicate if one is lost or damaged in less time and with less cost than when done by the dental lab team. Finally, we are seeing a proliferation of new digital orthodontic systems, such as SLX Clear Aligners (Henry Schein), Insignia Clearguide Express (Ormco Products), Clarity Aligners (3M), and Smart Moves (Great Lakes Orthodontics), following the lead of Invisalign and Clear Correct, of course.

Thinking ahead, with software and the ability to print all of the sequential models—or, soon, the actual aligners—these technologies will revolutionize this arena. As we continue in this exciting area, we are seeing that NextDent now has more than 40 materials allowing us to print many things, from models to night guards to provisional crowns. EnvisionTEC and VOCO have a barrage of materials that are coming out at a rapid pace. Other companies are in the hunt as well.

Speaking of interoperability, Paul, where does cone beam technology come into this picture, and how does it fit in the digital workflow?

Dr. Feuerstein: My answer to your questions could really be long if we had more time, so let me just make a brief few statements. I often get asked why a GP should consider cone beam in his or her office. I suppose (facetiously) if all you do is straight restorative, and never do endo, place or restore implants, treat periodontal disease, or perform any extractions, then I suppose there is limited value. The information obtained from a scan is not only a better diagnostic tool, but also a patient education system. Showing a patient periodontal bone loss on the scan is quite dramatic. A patient in pain, especially if there is previous endodontic treatment, can be diagnosed for fractures, additional canals, or apical lesions easily, and it can be demonstrative to the patient and doctor. As far as restorative, the impression scans can be superimposed on the cone beam for the diagnosis and treatment planning of many procedures, particularly implant placement. Even if the dentist does not place them, the position of the crown preoperatively could help determine where (and if) an implant should be placed for optimal physics. We have all experienced having to create an abutment and a crown on a strangely placed implant. This can be made more predictable, provided the anatomy and bone will allow it, with this merged technology. Adding 3-D printers to the mix, surgical guides can be created in the office for less than $10! And, with new software and tracking devices, occlusion can be determined using the patients’ own TMJ movements, creating virtual articulation. As an aside, the Bausch corporation has just launched a digital articulating paper called OccluSense (occlusense.com) that not only records the red marks on a patient’s teeth, but displays them on an iPad, showing the actual forces of each mark. There is also a short video that can be made showing the patient’s excursive movements.

Well, Damon, it has been great to discuss what’s going on with you again! We have focused on a small section of some of the new technologies now available. There are many new processes, computer programs, restorative materials, cements, practice management systems, and much more that have been developed with amazing technologies. It is so exciting to know that there is plenty of material for us to continue writing and lecturing about in this area without being repetitive. As you know, I spend a lot of my time going to meetings as an attendee and a lecturer, so I will always do my very best to keep you and our readers informed on many of the latest new innovations in dentistry.

Paul, as always, it has been an honor and pleasure to talk with you about even a small slice of the ever-changing world of dentistry. Thanks for taking the time! Be well, my friend, and travel safely!

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What do you think is the most important new technology clinicians should consider adopting right away?
Dr. Christensen: I would name cone beam radiology, because it can reveal conditions missed consistently in the patient’s past examinations. These formerly undetected conditions could be important to the patient’s health and treatment priorities. Today, dentists have options. They can purchase their own cone beam equipment, or they can gain access through traveling mobile units, radiology labs, or colleagues who are already using this technology. It is important to realize this is a developing technology with differences in equipment offered by different companies. In addition, the expertise of a certified radiologist is necessary to interpret these new images and clinicians must upgrade their knowledge through coursework. I think the best way to get started is to take a course and then talk to colleagues already using cone beam in their practices to gain perspective on the advantages and limitations of the technology. Currently, the primary uses of cone beam are in endodontics and oral surgery, particularly implant surgery. Cone beam technology has not been adapted yet for dental caries diagnosis, but, theoretically, the possibility exists. Cone beam could show not only the location of caries lesions, but also the extent of these lesions by “slicing through” them. Clinicians have never had such an opportunity before. The limitations of cone beam might be start-up cost, a lack of space in the office for the equipment, and the learning curve necessary to interpret the images. However, I believe cone beam technology is here to stay, and the sooner dental clinicians learn to use it well, the better it will be for patients.

Figure 1. Light polymerized materials and a cordless curing light in action.	Figure 2. A scanning electron microscope for study of the clinical performance of dental materials.
Figure 3. A clinical camera for recording and comparing the clinical performance of materials and treatments over time.	Figure 4. Instrumentation for measuring fluoride release from dental materials over time.

What do you consider the most interesting emerging technologies?
Dr. Christensen: Three-dimensional printing and intraoral scanning come to my mind immediately, but this is a personal opinion that could differ by clinician and specialty. Both printing and intraoral scanning are in current use in a growing number of dental practices and laboratories across the United States, and both have the potential to improve patient treatment by improving accuracy, consistency, and delivery times of provisional restorations, and, eventually, fixed and removable restorations. Our lab tested the practicality of intraoral scanning 15 years ago in a blind comparison of full-contour molar crowns where 2 crowns each were fabricated by the same lab for the same preparations in a group of patients treated by 5 dentists. The dentists then selected the blinded crown they preferred for fit, form, and function. Interestingly, in all cases except one, the dentist selected the crown fabricated from the intraoral scan in preference to the crown fabricated from the conventional physical impression that he made. Back in 2004, when we compiled the results of this research, in addition to the work we had in progress with CEREC (Dentsply Sirona) intraoral scanning, we became convinced that scanning was the future and aimed our clinical research at CAD/CAM-produced monolithic restorations. Many don’t realize that it was CEREC that brought intraoral scanning into restorative dentistry. Although CEREC’s combination of intraoral scanning and milling was accepted slowly at first using the in-office fabrication approach, once commercial laboratories adopted CAD/CAM fabrication, a virtual revolution in materials, fabrication methods, and business models of dental laboratories and dental practices occurred, and it continues to this day. I believe we will see a similar pattern with printing. Right now, we are in the cautious beginning of the curve, but I believe this will be followed soon by an explosion of activity as printing equipment, the printing process, and the materials printed are improved. Right now, we seek upgrades in accuracy, resolution of detail, and elimination of chemical residuals released from the plastics printed. But I believe all of these challenges are surmountable. Watch and see!

You mentioned CAD/CAM. What are your thoughts on the future of CAD/CAM in-office and in-laboratory technologies for restoration fabrication?
Dr. Christensen: Well, it is obvious that CAD/CAM technology used in-office by the dentist and staff, and especially that which is used in commercial laboratories, has swept through the profession worldwide and just about eliminated technologies that had been used for many, many years, such as all-metal and PFM fixed prosthesis technologies, including lost wax casting, hand layering of porcelains, metal soldering, etc. However, I don’t think we can rely forever on fabrication methods like milling that use subtractive technology, unless we can find ways to use the tons of sludge waste it now generates daily worldwide. I have friends who are already setting up businesses that recycle the zirconia sludge generated in dental laboratories. However, I think future methods will be developed to print or cast zirconia slurries or, perhaps, other similar tooth-colored materials not yet introduced. But for now, CAD/CAM-generated, zirconia-based materials have taken over and reign supreme! The rapid acceptance of these 2 concepts, CAD/CAM and zirconia, has caused clinicians and researchers to scramble to quickly learn more about the advantages and limitations of the various zirconia as clinical use outstrips the knowledge base. Consider these critical areas where essential information is lacking: (a) Today, clinicians cannot advise patients concerning how or when a CAD/CAM-produced zirconia restoration might fail because this information is not yet known; (b) as yet, no one knows the clinical implications of the various oxide and ion additives now placed in zirconia to influence its translucence, color, and physical properties, yet thousands of these clinically unvalidated zirconia formulations are seated every day worldwide; and (c) increased wear of opposing dentition by some of the newer zirconia formulations has been observed recently in our clinical studies, but we do not know yet why this is occurring. The original BruxZir formulation (Glidewell Laboratories) introduced in 2009 has not shown this problem clinically. Our lab now has 8 years of definitive data from controlled clinical practice-based studies of BruxZir original solid zirconia and IPS e.max CAD lithium disilicate (Ivoclar Vivadent) full-contour molar crowns showing 100% and 95% survival, respectively, at 8 years with no abrasive wear of the opposing dentition. Although we have identified these 2 CAD/CAM-produced monolithic crown materials as excellent performers clinically, the competitive marketplace is trying to push past these 2 well-proven products and the clinical research is not keeping up with the clinical use. This can cause dentists and their patients to experience unforeseen problems. So, while we love to see technology move forward in leaps and bounds, there is a need to look for proof that newer is better before rushing into the newest concepts.

Figure 5. An anaerobe chamber for the culturing of oral microbes associated with dental caries, periodontal disease, and oral pathologies.	Figure 6. High-resolution replicas, fabricated to study the clinical status of tooth-colored fixed prostheses over time.
Figure 7. Loupes and a head lamp, to enhance visual access necessary for precise work in treatment and research.	Figure 8. Soft-tissue and hard-tissue lasers, used for research of laser effects on tissues and microbes.

In your opinion, which technologies are responsible for the most significant improvements in everyday patient care?
Dr. Christensen: Everyday basics like radiographs, local anesthetics, air rotor and electric handpieces, magnification, and hand instruments of many designs most immediately come to mind. Although these technologies are taken for granted today, they represented huge leaps forward when they were introduced. Today, when most people hear the word “technology,” their thoughts jump to the automated and/or software-driven devices that are entering the market at an ever-increasing pace. In dentistry, these have also resulted in important improvements in care. Consider products such as the newest apex locators, automated endodontic handpieces, ultrasonic devices for cleaning and disinfection of root canals, soft- and hard-tissue lasers, and business software, to mention just a few. Then there are the technologies that help patients better understand their oral problems and treatments, such as intraoral cameras, caries detectors, and patient education videos. All of these things mentioned have greatly improved patient care. As stated in the beginning of this discussion, dental treatment absolutely depends on, and would be impossible today without, a whole list of instruments, devices, equipment, and materials that add up to a large array of dental technologies. Sure, we can deliver patient care without some things I listed, like magnification, but when we use it, we can do a much better job or even see something important we might otherwise have missed. This is a good example of the way technology can support and improve delivery of care. Clinicians who learn to use loupes and head lamps generally feel uncomfortable and insecure if forced to return to unaided vision during a procedure. In our research in dental materials and dental caries, we simply cannot operate without magnification that includes loupes, head lamps, and operating microscopes. In fact, magnification has become the norm in some clinical areas today—for example, operating microscopes in endodontics.

Do you think technology will replace people in dental treatments?
Dr. Christensen: This is a question in which I would never say “never!” However, in the foreseeable future, people are still absolutely necessary to control, maintain, and repair the technology used for patient care. But for routine tasks in dental laboratories and clerical tasks in dental clinics and dental laboratories, I see that people already have been, or are in the process of being, replaced. From a business point of view, people are the most valuable asset and the most frustrating liability—and generally the largest expense. So, it is easy to see why the crosshairs of technology are focused on the exclusion of as many people as possible from multistep processes. However, people are difficult to replace when judgments involving human health are concerned. Here, intelligence and clinical experience, along with abstract concepts like empathy and sympathy, come into play, and humans still have the advantage in these areas.

Are there some urgently needed technologies not yet present?
Dr. Christensen: Absolutely yes! For the clever and enterprising of the world, there is plenty of opportunity. Today, there is a push worldwide to find ways to treat everyone, not just those educated to seek dental treatment and with the resources to pay for it. Innovative technology and automation will be essential to address this challenge. Considering just the sheer number of people worldwide never touched by a dental clinician in the past gives some perspective on the need for new ways to address dental health worldwide. For more than 40 years, our lab has sought help from companies and individuals around the world to develop a technology we can place and leave in the oral cavity to regulate pH shifts that initiate demineralization of tooth structure. It is a simple idea, but it calls for a complex solution—and we have yet to find anything that truly addresses the challenge. But here are some other long-overdue needs begging for solutions: (a) restorative materials and cements that respond 1:1 with surrounding tooth structure and chemically seal at the material-tooth interface—and stay sealed; (b) technologies that measure and monitor inflammation to help achieve more effective treatment of periodontitis; (c) instruments that “see” and display the microbes involved in periodontal disease and dental caries, giving their locations, concentrations, and perhaps even their genus and species; and (d) digital impression technologies that “see through” tissue and blood with resolutions useable for milling subgingival margins. I could list many more theoretically solvable problems where new technologies could move treatment beyond where we are now. There’s no doubt about the fact that there are still numerous unmet clinical needs.

As dentistry moves into more complex computer-based technologies, how can clinicians keep up?
Dr. Christensen: Good question! It can seem overwhelming to take on the number of new technologies. Keeping up involves not only costs for purchasing and maintenance, but also on-site expertise to operate the technology and interpret the data produced. I believe the best approach, wherever possible, is to try to share purchase and upkeep costs with colleagues. In the past, dentists have been known for their strong desire to be independent, but it appears to me that the future will force the need to work, act, and own in groups. Young people in many disciplines are now trained and required to work in teams. I think the increasing costs and complexity of operating future technologies will push hard toward groups working together. The challenge is to find the people who blend into a well-oiled group called a team. I believe the best approach to keeping up with the constant upgrades in hardware and software is to delegate. Develop a team of staff who are “specialists” in various specific technologies. Make it each specialist’s responsibility to know how to operate, update, and maintain/repair his or her technology—and reinforce and inspire with monetary and verbal rewards. The main thing is to avoid withdrawing and hoping to retire before your patients begin to seek care elsewhere because they perceive you as being behind the times. I have just reluctantly changed my primary care physician for this reason after relying on him for 40 years. But, today, he is missing things, and I am getting older and cannot chance too many “missed things.” Plan to keep up by getting together with your staff and colleagues and carefully choose something new each year and embrace the challenge to learn it. Then let patients know you have something new at your office and how it can help them. The idea is to make the advancing technologies work for you!

Rella, thanks so much for taking the time for this excellent update on technology that is based upon many years of experience and research in the dental field. I am confident that our readers, as well as I, have learned important information and insights from sharing your thoughts and advice with us.

Dr. Christensen currently leads TRAC Research Laboratory, which is devoted to clinical research in oral microbiology and dental restorative concepts. TRAC Research is part of the nonprofit educational Clinicians Report Foundation (formerly CRA), which she directed for 27 years. Throughout her career, she has taught at the under- and postgraduate levels, authored many research abstracts and reports, and received numerous honors. She has performed research within the practices of hundreds of dentists and their teams seeking the best patient treatments. She can be reached via email at rella@tracresearch.org.

Disclosures: Dr. Christensen reports no disclosures.

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X-NAV was developed for implant surgery; however, Dr. Maupin and I immediately recognized this system as a perfect solution for guided endodontics (Figures 2 and 3) without the numerous difficulties encountered when using static drill guides for endodontic access.

Do all of you use this in your practices?
Dr. Khademi: Steve and Charles have been on the hunt for guided endodontics for many years, and they began using the X-NAV system shortly after it was released at the 2015 Academy of Osseointegration meeting. I’m the new guy to DG, and my first experience with it was last August when the 3 of us did a research study to determine the accuracy of seasoned and novice users. I was the novice in this research.

Figure 1. (a) An X-NAV (X-NAV Technologies) optical tracking system and (b) a computer displayed avatar of a drill, jaw, and a programmed drill path.

How did that go for you, John?
Dr. Khademi: Having known both of these guys and their skills for many years, I was really nervous about doing it for the first time in front of them—really nervous! Of course, I didn’t know the planning software, so Steve and Charles planned my first case (Figure 4). When I sat down to cut the access, I was astonished at how easy it was to follow the computer monitor that displayed the planned drill path overlaid on an avatar of the patient’s tooth. It sounds difficult to do a procedure without looking directly at the patient’s tooth, but it turns out that anyone who has played his or her fair share of computer video games has all the heads-up skills that are needed. I think that any endodontist who works using the microscope will readily pick up the needed skills within the first few cases.

Charles, how does this help dentists doing endodontic procedures? It requires a bit of preoperative setup, so there must be a compelling reason, right?
Dr. Maupin: The most obvious application is for the most difficult cases referred to endodontists: calcified pulp chambers and canals. The majority of endodontists have CBCT machines, making it a simple matter to treatment plan drill paths and to use guidance immediately. DG allows us, in a single visit, to confidently and precisely drill 8.0 to 12.0 mm through solid dentin roots, finding canals in the apical third (Figures 5 and 6), and done through minimally invasive openings 1.0-mm wide or smaller. In teeth without severe calcification, DG can be used to reduce structural weakening through minimally invasive endodontic (MIE) procedures.

John, I know that you and Dr. David Clark have written about MIE objectives for our readers in Dentistry Today. How helpful is DG in achieving MIE outcomes?
Dr. Khademi: The dentin preservation shift really started with Steve and his GT files, designed to have maximum flute diameter limitations to control coronal canal enlargement. David and I extended this basic idea of dentin preservation to the coronal portions of the tooth with endodontic access cavities. Before we had dynamically guided access (DGA), cutting dentin-preserving access cavities required a lot of skill, experience, and luck. While restorative dentists universally loved these ideas, these access cavities were difficult and error-prone in the best of hands. DGA makes performing these “conventional” and “traditional” kinds of dentin-preserving accesses both safe and predictable.

Dr. Buchanan: With DG, specialists can cut perfect MIE accesses right off the bat and, beyond that, DG is so precise that it allows us to think about planning and cutting unconventional access paths. If you can plan it, you can drill it!

Dr. Khademi: Steve showed me some wildly unconventional access designs several years ago that he was cutting in his TrueTooth replicas that had my head spinning (Figure 7). Up to this point, all existing access designs and thought have been limited by the technology that we have had available for access; instrumentation and obturation; and, probably most importantly, for vision. The sea change that Steve brings up involves a combination of the incredible precision of DGA and today’s very small, flexible heat-treated NiTi instruments. We will need an entire new body of research to help us figure out where to cut access when you don’t actually need to see what you’re doing but instead know what you’re doing by working off of a computer screen.

Figure 4. Dr. Khademi’s first X-NAV DG outcome. Guided by the X-NAV system, he drilled a minimally invasive endodontic (MIE) access opening through a TrueJaw tooth replica modeled without a pulp chamber, intersecting the canal exactly at the CEJ.

So, Steve, what makes DG for endo procedures superior to static traditional drill guidance?
Dr. Buchanan: The most profound advantage is the just-in-time nature of the DG treatment planning, allowing access to be cut in a difficult emergency case within 10 minutes of the CBCT capture. Even with static guides fabricated just in time with 3-D printers or milling machines, the 4-hour step of actually making the guide is obviated with DGA. In the same vein, the immediacy of this guidance method allows changes to be made in programmed drill paths literally during the procedure—for example, altering a drill path when faced with unexpected clinical difficulties. Also, DGA is done with the same lengths of access burs that would normally be used, unlike static drill guides that require drills 10 mm longer than usual, which makes static guidance an impossibility in posterior teeth. Finally, guide rings cannot be overlapped in static drill guides, requiring a separate guide for each canal, making it cost prohibitive.

Charles, how did you get the idea to apply dynamic navigation to endodontics?
Dr. Maupin: Implant surgery primarily deals in millimeters, while endodontics deals in fractions of a millimeter. Steve and I have done implant surgery in our practices for many years, and our endless drive for microscopic precision naturally led us to using guidance. As we moved into implant surgery, we wanted the same accuracy in our implant cases as we accomplished in our endodontic procedures. After performing several dynamic navigation implant cases with precision, the wheels started to turn on bringing this technology into endodontics. When the right case presented, I went for it and the rest is history. Implant dentistry has changed all fields of dentistry, so it’s not surprising to see this technology crossover being led by endodontists who place implants. For endodontists and GPs who perform both procedures, DG is a slam dunk.

John, you’re the imaging and probability expert in this crew; what can you tell us about the relative accuracies with DG?
Dr. Khademi: Damon, your reaction (“I am blown away!”) to the pictures that we first showed you probably captures it the best: We need one of those mind-blown emojis! Typical molar endodontic access cavities have 4.0- to 6.0-mm-width dimensions. When we started our pilot project, we went with 2.0-mm-diameter access plans. However, we quickly found out that even these were far too large, so we reduced them down to 0.5 mm. Our initial look at the data tells us that we can achieve accuracy within 0.5 to 0.25 mm of the planned target at full planned depth. All this comes from the exact 1:1 representation of our patient’s anatomy with CBCT.

Steve, as a really experienced endodontist, do you think DGA is an innovation that you even need, considering the thousands of root canal procedures you’ve done?
Dr. Buchanan: Despite performing root canal treatment (RCT) procedures since 1977, cutting perfect access cavities remains the most challenging thing I do. In teeth with pulp chambers still extant, I want to cut the least amount of dentin as possible yet still create an ideal file path into each canal. That is difficult, but not nearly as difficult as getting this outcome in teeth with totally calcified pulp chambers—the bane of every endodontist’s existence. Losing my fear of calcified teeth is the greatest gift I’ve experienced from using DG. I actually look forward to these cases now.

Charles, are there other endodontists who use X-NAV for access procedures, and are you planning to teach this to colleagues?
Dr. Maupin: You know that all 3 of us love to teach, so of course we will be sharing our knowledge with our peers. Steve and I have already spoken about DGA at a few meetings, and a handful of endodontists have purchased X-NAV systems, and many others have expressed an interest. The team at X-NAV Technologies is still working to provide the specific features that we have asked for since their machine was not originally designed for endodontics. We are hoping that functionality should be coded and delivered as an update by mid-2018.

Figure 7. TrueTooth with access paths cut to 4 canals from below the occlusal surface.

In a way, DG is more important for endo than it is for implant surgery, as static guides are an established alternative for implant surgery, but not for endo access. The endodontic application of DG may end up being used more for endo than implant procedures, both in the number of clinicians using it and in the number of procedures performed. Implant surgeons have other guidance methods they have learned to use successfully. Endodontists have no guidance but dynamic guidance.

Regarding our teaching efforts, Steve and I are doing a live demonstration of DG on a TrueJaw surgical training replica at the American Association of Endodontists Annual Meeting this month (April 25 to April 28) in Denver. It will be informative and fun, so maybe some of your interested readers will want to attend!

In closing, my dear colleagues, what you have introduced here is nothing short of incredible! From what you’ve told me, the digital revolution is supercharging endodontics just as it has re-energized prosthodontics and implant surgery. It looks like a brave new world for the field!

I want to take this opportunity to thank all of you for sharing this important, cutting-edge information on dynamic guidance with all of our Dentistry Today readers and me!

Dr. Buchanan owns a private practice limited to endodontics and implant surgery in Santa Barbara, Calif. He is the founder of Dental Education Laboratories, a hands-on training center serving general dentists and endodontists by upgrading their skills with new endodontic and implant technologies. Dr. Buchanan is a Diplomate of the American Board of Endodontics (ABE) and an assistant clinical professor at the postgraduate endodontic programs at the University of Southern California (USC) and the University of California, Los Angeles (UCLA). He can be reached via the website delendo.com or via email at info@endobuchanan.com.

Dr. Khademi received his DDS from the University of California, San Francisco (UCSF), while his certificate in endodontics and his MS in digital imaging are from at the University of Iowa. He has a full-time private practice in Durango, Colo. Dr. Khademi was an associate clinical professor in the department of maxillofacial imaging at USC and is an adjunct assistant professor at St. Louis University. As a Radiological Society of North America member for more than 20 years, his background in medical radiology allows him a perspective shared by few dental professionals. He can be reached via email at jakhademi@gmail.com.

Dr. Maupin owns a private practice called Maupin Endodontics in Lubbock, Texas. He received his DDS degree from the Baylor College of Dentistry. Following graduation, Dr. Maupin attended UCLA, where he served as chief resident and received his certificate in endodontics. He is a Diplomate of the ABE, making him the only board-certified endodontist in Lubbock. He is an active member of the American Association of Endodontists, the ADA, the Texas Dental Association, and the South Plains District Dental Society. He is a founding member of the International Academy of Endodontics and is excited to be at the forefront of revolutionizing endodontics. He can be reached at (806) 589-3390.

Disclosure: Drs. Buchanan, Maupin, and Khademi report no disclosures.

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