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Chairside CAD/CAM dentistry with Dr. Gary Severance

Feb. 1, 2008
Dr. Dalin: In this issue of Dental Economics®, we are going to talk with Dr.

Dr. Dalin: In this issue of Dental Economics®, we are going to talk with Dr. Gary Severance. Gary is a dentist who has worked with Ivoclar Vivadent and Implant Innovations. Most recently, he moved to D4D Technologies as vice president of marketing and clinical affairs. D4D manufactures and supports the E4D Dentist™ Chairside CAD/CAM restorative system. Gary, we have been awaiting this product’s release for a few years. Would you tell our readers about the system?

Dr. Severance: Thanks, Jeff. This is an exciting time in dentistry. For the first time in 20 years, we have added a viable alternative for chairside CAD/CAM dentistry – the E4D Dentist Chairside system. I think there are some distinct advantages to the system as compared to those of competitors. The ultimate goal of these systems is to produce clinically successful indirect restorations in one dental visit. I think we have made the process more efficient, intuitive, and easier. The E4D Dentist System is composed of an intraoral laser scanner, a mobile design center with DentaLogic™ software, a robust mill, and a mill server. Actually, the system has three powerful computers that work together.

To me, the most obvious difference in the system is the capturing of data – the digital impression. The E4D system utilizes laser technology to capture hundreds of thousands of data points with each scan. The system allows you to capture the clinical situation and the “real” image.

As a dental professional, the most exciting aspect for me is the ability to show the real image via the ICEverything (ICE™) Mode.

We don’t have to animate or translate the oral environment into a yellow stone model. For the first time, we can show a real 3-D model – one that can be rotated, zoomed, and used to identify differences in build-up materials, discolorations, and enamel vs. dentin. You see what’s really there. The system captures the entire “neighborhood” and all tooth contours so that a design library and Autogenesis™ process can adapt the selected library tooth to the patient’s existing dentition. This is a breakthrough in technology. The stone model look is always available, if and when, you want to view the oral environment in the conventional CAD/CAM manner.

The more you use the DentaLogic software, the more advantages become readily apparent. The software is designed specifically for ease of use. Icons are easy to identify and follow. There are simple tabs that let you know where you are in the design process. Margin tools – such as Paint and Lasso – and other colorful, descriptive, and logical icons make design easy and intuitive. You can automate as much as you want with the software and have the design process run through the entire design procedure automatically (Autogenesis, automatic occlusion, contacts, sprue placement, etc.). Or, at any stage, you can alter the design input with numerous intuitive tools, such as the Rubber Tooth Tool™.

Dr. Dalin: I know there was a delay in the system’s launch. Now that the system is available, how will it better our profession?

Dr. Severance: We have been asked about the “delay” in the product, and what was holding it from being released. It was simply a matter of not being ready for the market. Our focus is on releasing a system that will be productive and efficient at the outset and easy to integrate into a practice with minimal interruptions. We also needed time to build a high-quality dental infrastructure for the training and support necessary to ensure success. D4D Technologies and the E4D Dentist system have gone from inception to market-ready in just four years while still combining the latest in hardware, software, and material development.

We also know a successful entry into the marketplace will lend additional credibility to the CAD/CAM chairside field and push not only our company to evolve and improve, but also press other technologies to take steps to remain competitive. This is a great situation to have in dentistry – a “win-win” for dental professionals and patients.

Dr. Dalin: It is interesting that companies such as D4D Technologies can take technology not used in dentistry to develop products.

Dr. Severance: We are a different type of dental company. Through the years, I have developed close relationships with opinion leaders in dentistry. Today at D4D I am surrounded with some of the best people and minds in high technology and business. To unite these two groups with a common goal and focus is amazing. Dentistry sometimes keeps a sheltered vision of what “has always been” or what has not worked in the past. For the most part, we remain within the profession and our oral fixation. At D4D, I am amazed daily at the passion and innovation employees show toward making the E4D system a vital component of dentistry.

The dream started about five years ago when Mark and Henley Quadling developed projects that offered digitizing solutions for several different applications. Only one of their projects related to dentistry. They took their ideas to Basil Haymann, a Dallas entrepreneur. After reviewing the projects, Haymann had a keen interest in the Quadlings’ dental application: using a laser to scan a tooth, designing a restoration chairside using customized software, and then milling the restoration for delivery in the same appointment. Soon after, D4D Technologies was founded and the Quadlings started the design and development of their Dream. (By the way, the 4 “Ds” of D4D are Dream, Design Develop, and Deliver.) After four years, millions of lines of software code, and much milling, there is now a chairside CAD/CAM system for the future of dentistry.

Dr. Dalin: Your company is somewhat unusual since it is supported by a number of existing dental companies that work together. Would you tell us about this partnership?

Dr. Severance: Whether in daily practice with patients or working with team members or peers, dentistry is a relationship profession. The same is true with business partners in dentistry. D4D Technologies is fortunate to have the support and direction of the world’s largest dental distributor – Henry Schein – as well as the material, clinical and market expertise of 3M ESPE, Ivoclar Vivadent, and Premier. We work closely with our partners in every step of development, implementation, and validation. While 3M ESPE and Ivoclar Vivadent are competitors in many areas of dentistry, we have shared expertise, specified indications, and optimized milling performances to make the clinical applications and the ancillary products a cohesive and comprehensive part of the E4D system.

Dr. Dalin: Gary, please tell us about your journey from training in clinical dentistry through working with established dental companies, and now to a start-up company.

Dr. Severance: My dental journey has been less than conventional. Instead of following my father’s footsteps after graduating from the University of Minnesota School of Dentistry into private practice, I took a right turn and spent most of my professional life – combined with clinical applications – working for Ivoclar Vivadent and Implant Innovations. While at Ivoclar Vivadent, I worked within regulatory affairs, professional services, marketing, education, and clinical affairs. It was an unbelievable experience to be a part of the evolution of the “Esthetic Revolution” and part of the introduction of IPS Empress™. In addition, I became familiar with corporate and clinical dentistry from individuals like Dr. George Tysowsky and Bob Ganley. I then moved to Florida to work with Dr. Richard Lazzara, Keith Beaty, and Dr. Curtis Jansen of Implant Innovations. This was my first experience in the power of thinking “outside of dentistry” and bringing in expertise from other areas. I then returned to Ivoclar Vivadent to direct professional services and assist with special projects. This included education center initiatives, chairside CAD/CAM dentistry, and soft-tissue lasers. I first checked into D4D Technologies in November 2006. As soon as I met the people and saw the product and its potential, I knew the company and its technology were going to help shape dentistry in the future and I wanted to be a part of it.

Since then, I have primarily been focused on clinical relevance, efficiency of the process, and office productivity, as well as introducing new innovations into the system. I have attempted to combine the best in dentistry and technology.

Dr. Dalin: While a fan of technology, I also think it is important to make good business decisions. What ROI should be expected from owning an E4D system?

Dr. Severance: This is one of the most important areas to cover. It is critical that dentists making investments at this level not get caught up in promises or hype. They should look at their situations, capabilities and practice needs now and for the future. It is not as simple as plugging numbers into an ROI calculator and seeing how much money you can make with chairside CAD/CAM dentistry. You must be realistic and specific to your practice. Chairside dentistry is not an alternative to your laboratory, it is a supplement.

“Single tooth” or “single quadrant dentistry” – replacing one restoration or a quadrant of work at a time – is what most of today’s dentistry is. But it does not make business sense for the practice or the patient to treat one tooth over two appointments, especially when there is an alternative. Dentists should take a look at the number of cases in which they restore one tooth or one quadrant at a time, and consider the possibility of preparation and delivery of quality restorations during the same appointment. What would this mean for the office, for the team members, and more importantly, for the patient?

Ideally, it would be better to prep and deliver a final restoration on the same appointment. This would provide no chance of tooth movement during provisionalization, a reduction in exposure of a prepped tooth to the oral environment, less inconvenience to the patient in time, and lower overhead for the practice. These are the restorations that should be considered with chairside CAD/CAM dentistry. To me, this approach is what makes sense for practices and patients – one visit, one shot, a digital impression, a design, a mill, and the seating of the final restoration in the same appointment.

We also understand the value of the person “on the other side of the chair” in this process – the dental assistant. For this reason, we have one dental assistant attend basic training and offer assistants a Chairside Dental Designer (CDD) program. Utilizing properly trained dental assistants to their full capabilities can reduce chairtime and downtime for the dentist by 50 percent. This is another factor to consider in the ROI analysis.

There are other benefits to high-tech dentistry. I think high technology can help create a better dentist, whether it is using magnification, or in our case, zooming in to a preparation and viewing for the first time real images of a preparation from any angle. Doing this can improve clinical performance since dentists often have relied on talented laboratory technicians to “find” margins. With the ICEverything mode, you can identify how much of your margins are on enamel vs. dentin. This may lead you to a more educated selection of placement and cementation procedures. There are many future possibilities with this type of technology. It will be interesting to see how it evolves and becomes a part of dentistry.

Dr. Dalin: The learning curve and proper training can be a challenge that keeps users from fully utilizing what a new system or technology offers. How does D4D Technologies approach this?

Dr. Severance: Having only one competitive system on the market for a long time, and knowing that the system has captured a small percentage of the potential marketplace (6 percent), has allowed our company to analyze the system’s methods and possibly correct or supplement deficient areas or expand upon untapped areas.

One area we have addresssed is basic education. Instead of completing basic education in the field or through approved training centers, D4D believes it is important to have one message and one clear agenda for basic training. Everyone should hear, see, and experience the same information. That’s why we have the E4D University, located at our headquarters in Richardson, Texas. Everyone who purchases the E4D system will attend the university prior to receiving the system. There is no alternative. This is the only way to ensure a balanced and firm foundation of common knowledge for all users. It also allows students to see our complete manufacturing area (all components of the system are designed and assembled in Richardson), meet our customer support team, and interact with software engineers and university faculty.

As a vertically integrated company, our design, assembly, marketing, training, and support are all completed in our 60,000-square-foot facility in Richardson, a suburb of Dallas. This allows for comprehensive support in all areas.

In addition, we have remote access to our systems. Following invitation by an office, we can log in to that office’s system, watch scanning take place, and offer suggestions on design or feature utilization. Even more importantly, we can diagnose and troubleshoot potential issues with the cart, mill or server. Often this eliminates the need for a service call or more extensive diagnosis and repair. We call this support mechanism SOS™ – Support-On-Sight. SOS is an added benefit of working with D4D, Henry Schein, and other partners.

We also have sought support and input from experienced educators, opinion leaders, clinicians, and technicians in dentistry to make sure we incorporate all that we can into making an E4D experience successful.

Dr. Dalin: Gary, is there anything else you want to share?

Dr. Severance: I am excited about what we are doing at D4D. I think the E4D system is just the start of the utilization of this technology. We demonstrated some of the future possibilities at the annual ADA meeting in San Francisco. Dr. Jansen and Dr. Lee Walker used the system to scan, design, and restore an implant that had been placed into an extraction site. Systems that require a reflective agent to be applied cannot do this. Also, I am excited about the precision of the mill and milling accurately to 0.2 to 0.3 mm. Lee Culp, CDT, is exploring this capability with thin veneers, as well as milling with additional material options. It is difficult to describe all the unique capabilities in an interview, so I would encourage you to check our Web site at

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Dr. Gary Severance is a 1987 graduate of the University of Minnesota School of Dentistry. He is vice president of marketing and clinical affairs for D4D Technologies in Richardson, Texas. D4D Technologies is the developer of the chairside CAD/CAM restorative system E4D Dentist, which provides same-day dentistry for indirect restorations. Reach Dr. Severance via e-mail at [email protected].

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Jeffrey B. Dalin, DDS, FACD, FAGD, FICD, practices general dentistry in St. Louis. He is the editor of St. Louis Dentistry magazine, and spokesman and critical-issue-response-team chairman for the Greater St. Louis Dental Society. He is a co-founder of the Give Kids A Smile program. Contact him at [email protected].

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