K—By now you’ve probably heard of 3-D printing in dentistry. If not, please roll away the rock under which you live and step into the sunlight. 3-D printing, a once fledgling technology, has come into prominence in several industries, with dentistry being one of the most prolific. Although this article will talk a great deal about 3-D printing within dentistry, I come not to preach, but to evaluate its place within the average dental practice.
Let’s begin with the history of 3-D printing in my office. I practice in Richmond, Virginia, and have two very run-of-the-mill dental practices. We do fillings, crowns, cleanings, Invisalign, and all the typical fare that you’d find in most practices. I heard about 3-D printing several years ago and immediately realized that this was up my alley. (You can make cool things from thin air based on computer models? Sign me up!) I ran out and bought a filament printer (basically a hot glue gun that makes objects from building layers) and started printing small items. After buying the printer, I quickly learned that I would need some type of software to design these 3-D objects to print. Meshmixer became my tool of choice. It is a widely adopted free software that is still used by many dentists today.
As time went on, I began to learn more about 3-D printing and its uses in dentistry. I realized that I needed a more “professional” 3-D printer. My next printer was the Form 2 from Formlabs. It has stayed with me, and it is the 3-D printer that I use to this day . . . although I am developing an itch for a new printer. (More on that later.)
My story could be similar to many of yours out there. It could be quite groundbreaking. Or it could be quite sophomoric. Such is life in dentistry. My evolution to the technology has been partially bolstered by the amount of information that is available on social media and the internet. It’s also partially been about keeping up with the Joneses, or the Jones, DDSes, as it were. For as much as I have enjoyed the process of tinkering and learning, I have also come to the realization of where 3-D printing actually fits within my practice—and that it might be different than where I had thought it would be.
So here comes the confession part of the article. I love technology and toys in dentistry. Just as I give my wife grief for buying too many unnecessary things at Target, I do the same thing in dentistry. If it is shiny, cool, or different than what I currently have, it will be bought. It is a coping mechanism, I guess. As this pertains to my 3-D printer, it was a tool looking for a cause. Sure I could take impressions and pour them up, but now I could print them. I could design and print my own surgical guides for implants instead of paying for the completed project. I could print model series and then make my own aligners instead of sending them off to Invisalign. I could do lots of things. But over time, I found that I didn’t. How could this be? I watched all the videos, took all the online courses, and picked the brains of all the smart people in dentistry. Something just didn’t click. And, as time goes on, I am learning that this is OK.
You may have thought that this article was going to be a “rah rah rah” for 3-D printing, but as much as I love the idea of it, it may not be for everyone. I would like, instead, to present a rationalization of 3-D printing in dentistry and a practical guide for those who are just getting started.
So as we sit here in mid-2019, I 3-D print a few things in my office and use 3-D printed technology from other sources. Arches and models are my printer’s most common use. I have used the Trios from 3Shape as my intraoral scanner for several years now. I have found it to be quite fast and accurate. My patients definitely prefer it over conventional impressions. Now, these printed arches are used for just about everything in my office: bleaching trays, partials, occlusal guards, sleep apnea appliances, and clear aligner suckdowns. Once again, yes, I could take impressions and pour up these models, but hey, shiny new technology. Barring the glitz and glamour of it all, I find a few positives:
• Having endless copies of an arch—I can print off thousands of pristine copies of an arch if I desire.
• Printed models have some favorable properties over suckdown material. They don’t chip or crack as easily as stone. It usually comes off very clean.
• You can digitally modify the model to make life easy on yourself. Need to wax up a missing tooth for an Essix? Do it digitally and print out the results! Need to do staged treatment? Print off the stages as you go!
You may see some docs printing off dozens of models at a time. I have great aspirations to do this, but it has never really happened in my scope of practice. I am oftentimes printing off three or four models at a time. The economy of scale for 3-D printing may not exactly be in my favor for this. It may take 30 to 50 minutes for these to be printed in my office, so it is often not a “same visit” procedure.
The next thing that I print—and I find quite handy—involves dentures. Dentures will most likely be one of the biggest sectors of dentistry to benefit from 3-D printing. Imagine being able to digitize denture impressions, design a denture base and teeth digitally, then print the dentures for use. Changes or variations could be made in the computer. The methods to do so are improving rapidly, and companies like Blue Sky Bio are bringing user-friendly software solutions to market. These will be great solutions for offices that don’t mind the lab work and are willing to train team members to do a good portion of this.
Truthfully, I have become too lazy to try and make the dentures myself. What I have found quite helpful is a stripped-down version of the process. For patients currently wearing dentures, I will create a 3-D scan of their dentures. You can do this by using an intraoral scanner on the denture, and it is much more simple to use a tabletop scanner. I use a Shining 3D by Shining 3D Tech, which can create a digital copy of an existing denture in minutes. (Cory Glenn, DDS, has some great YouTube videos on this subject.) You can take the digital file of the denture to print out a copy. This copy can be used as a custom tray and an occlusal rim, which shaves a couple of appointments and some cost off of the job. Just this simple process alone may not be a complete digital denture process, but it does speed up the process for an otherwise analog office like mine. The digital scanner is also nice because we can scan almost all dentures and have backup digital copies if needed.
The third thing that I print in-office are implant surgical guides. These are often easy to design and print, and they are very accurate. Since starting to use these in implant surgery, my confidence has improved, and I have learned more about proper implant placement. I don’t use them for every case now, but they come in handy for tight spaces. The widespread implementation of these guides has also led to easily printed bone-reduction guides with complex implant placement, and even crown-lengthening guides. To me, these implant guides, which otherwise are expensive, are one of the biggest reasons to use a 3-D printer in-office.
One of the biggest internal struggles that I’ve had with regard to 3-D printing is printing models for aligners. At the outset, clear aligners proved to be a successful mode of moving teeth, but there is controversy surrounding the players in this game. Disappointed with the corporate decisions and costs of some of the big clear aligner providers, dentists are seeking to manufacture their own aligners in-house. There are several options. Blue Sky Bio has a robust program spearheaded by Baron Grutter, DDS. Companies such as Full Contour and iRok provide design services for you to print and produce aligners in-office. Both of these options still require a fair amount of in-office lab work. This option can be great for offices that can train team members to produce these outcomes.
On the contrary and much to our chagrin, public knowledge of clear aligner treatment is growing to an all-time high. Some think that the old guard of clear aligner treatment is ready for a renaissance. When faced with the extra labor and time expenditure, some doctors may still opt for using Invisalign or ClearCorrect. My recent purchase of an iTero (Align Technology) is something that I thought I would never do.
As you can see, incorporating 3-D printing may not be as cut-and-dried as you would think. Yes, you can benefit from the technology without having a printer. There are huge amounts of information out there about using the technology in the office. Watch some videos by Drs. Baron Grutter or Cory Glenn, or visit a 3-D printing party by August DeOlivera, DDS. Evaluate if you have the team that can take on the work associated with printing. Will you be learning and doing the design work, or will you be outsourcing it? What price point would make it worth it for you?
Printers can range from hundreds of dollars to tens of thousands of dollars. Much of this price range is based on speed, accuracy, size of the 3-D printing field (build plate), and materials used. My understanding is that NextDent resin can be used across several models of printers. These resins have varying costs depending on their use, but this should be figured into the overhead of the dental practice.
From my own observations, it seems that the two most common printers in the dental office are the Form 2 and the MoonRay from SprintRay. Both are midsize printers and both are in the $3,500 range. The Form 2 uses proprietary Formlabs resins with a limited catalog, while the MoonRay uses third-party resins, and more specifically NextDent resins. The NextDent resins have a wide variety of uses and configurations. You will probably hear arguments on both sides as to which is better. Who actually knows? Maybe Ford is better than Chevy. Both SprintRay and Formlabs have new models of printers that will be released by the time of this publication. Both are slightly more expensive than their predecessors, and both claim to be faster and more accurate. This is probably the part of the buying process that will mimic the release of the new iPhones. The current product is good, but I will wait for the next one to be better, and I will buy it then. The techology in these printers is being field-tested more and more, and advances will ultimately benefit us all. Personally, I would probably opt for the new SprintRay machine. My workflow (which is mine and mine alone) would benefit from a quick turnaround and more versatile resin selections. Yours may be better suited for other printers.
In the end, I hope not to sound too negative on the world of 3-D printing. There is a lot of great education out there and a lot of hype as well. Social media can be a great communication source, but it can also be a driver of practice overhead purchases when the dentist may not be ready.
Please take time to evaluate your workflow and where you can input 3-D printing technology seamlessly. Don’t feel pressured to incorporate technology—even though it is cool. There will be a time in the near future that it will work for you.
JASON LIPSCOMB, DDS, a general dentist, currently practices in his offices in Richmond, Virginia. In recent years, he has lectured on dental marketing and social media. He is the cohost of the Dental Hacks Podcast, which has recently reached the million mark for downloads and given rise to the Facebook group “Dental Hacks Nation.” Feel free to reach out to Dr. Lipscomb at [email protected].