Why it's time to embrace the digital workflow

I think it is safe to say we have reached the tipping point of acceptance of digital dentistry across the dental industry. Just look at where we’ve been in this progression in the past 30 years. Patients received the first CAD/CAM restorations in 1985.

3D design software has been around since 2003. The technology has changed dramatically over that time and continues to evolve at an exponential rate when you consider that the level of precision we chase today involves mere microns. This is a level never considered, and perhaps even judged impossible to achieve, in an analog world. Dr. Bernard Jankelson said ,“If it can be measured, it is a fact. If it cannot, it is an opinion.” I might add to this: Just because something is a fact doesn’t mean it matters.

We can now scan, design and manufacture such a wide variety of indications and materials that the workflow has strayed far from what was originally envisioned as a straight line. For example, the workflow for a fixed hybrid denture is very different from that of a simple coping, and the difference in accuracy of the scan data required for these two procedures is also very different. In my experience, every scanner being used today, whether an intraoral or lab scanner, is accurate enough for crown and bridge.

However, and this is a key point you should always have in mind, only a few are accurate enough for multiple-implant screw-retained cases. The pain of accuracy in a scanner is often only judged as the difference in the initial purchase cost of the equipment. I suggest to you it goes much further if you are doing more complex cases. Consider the cost (dollars and time) of inaccuracy in poor fits, remakes and failures for all concerned: lab owner, technician, dentist and patient.  

Scanning is just one step of the CAD/CAM process. I often speak of clinical significance. Does the fact that one scanner is three microns more accurate make it better? Not necessarily! It depends on the use of the scanner, accuracy of the design software used to create the restoration and what you are going to use the system for. This question drives to the heart of the digital workflow. The next question is: Are your doctors using intraoral scanners? With the acceptance of intraoral scanning, scanners used by the dentist client have just as much of an impact. 

The most involved step for most labs is the design process. Depending on where the scan data comes from, the design process can change dramatically. Are models produced? Were models scanned? One nice thing about digital is that materials generally don’t matter. They are just data entered that might change some background functions. These should be imperceptible to the technician during the design phase. In effect, if the designer knows what a tooth should look like, he or she can design for all types of cases.

With the acceptance of intraoral impressions on the clinical side, labs today often scramble to find partners to help with aspects of their cases. This help can come in the form of model printing, education on the file quality or even data exchange. Most labs can’t be everything to everyone as this can be extremely expensive. That doesn’t mean they have to turn down cases. It may just mean they have to outsource a portion of the work.

The most often-overlooked portion of a CAD/CAM restoration is the CAM (or nesting) software. This vital piece of software controls the movements of the milling machine. I have visited many labs where they promote their “five-axis machine,” but it is actually being used as a three-axis or occasionally a 3+1 or two-axis machine. Why? Because the CAM software itself does not allow the five-axis movement of the machine. As this software is vital to the end result, creating the “finish” and accuracy on a restoration, we certainly want the package we purchase to utilize the machines’ capabilities to the fullest extent. Unfortunately, this software is often looked at as a throw-in in the total purchase and is more likely than not closed to the lab. Most of us are not machinists; we’re dental technicians. The fact that most CAM software is generally not fully open may be a good thing! 

As the complexity of the cases goes up, we see the traditional circle that starts and ends with a doctor and patient in the chair changing from that original digital workflow straight line to something that looks more like a spider web. However, the nice thing about a digital case is moving data around is now as simple as sending an email. This is where we revert back to the traditional basis of most dental transactions: relationships. Labs of all sizes seek to find partnerships. These partnerships come in the form of material companies, milling centers, educators and others. The areas of specialty are more and more focused. There are now companies that offer design services so if a small lab has a technician go on vacation, that department can be covered. Labs are using these services rather than hiring technicians. Are you? Who would have thought dental labs would outsource the contours of their restorations five or 10 years ago? The contour of our crowns was our signature as a technician. 

The proliferation of CAD/CAM has drastically changed the dental landscape. It has raised the quality of weaker technicians. Best of all, I have seen technicians embrace the technology and make the system into something as individual as they are. The possibilities are limitless. The technology is there to make almost anything happen.

Mark Ferguson graduated from the American Institute of Medical/Dental Technologies in 2001. He has worked with the Aurum Group in Las Vegas for the past 12 years with six years at Aurum Ceramic at LVI and six years with Core3dcentres. He recently accepted a position as GM of Vulcan Custom Dental in Birmingham, Ala.