Jason Lipscomb, DDS
When Dr. Chris Salierno approached me about writing an article on 3-D printing and digital dentistry, I became quite nervous. Digital dentistry is layered with many tiers of difficulty and requires in-depth study to fully grasp—and certainly more knowledge than I would have to share in a single article. It then occurred to me that the current movement in digital dentistry is toward everyday dentists, just like me.
Digital dentistry is an atmosphere of fast-paced development and discovery happening more rapidly than ever before. It is a groundswell that is involving new players in an old game and turning the dental world on its ear. The old guard is still plugging along, but the disruption is real. It is time to get on this bus. Five years ago, a 3-D printer would have been a novelty at a dental conference or show. The chairside milling workflow had long been in place in many dental offices around the country. Things have definitely changed. This year, you will probably see more 3-D printers on display at dental trade shows than ever before. The current zeitgeist of digital dentistry may require you to step out of your comfort zone, but the possibilities are endless.
Open versus closed systems
One of the first things that you will notice about today’s digital dentistry is the push for an “open system.” Many of us who owned a chairside milling system in the past are accustomed to a closed system—that is, a system contained within the confines of one company, one software, and a limited array of peripherals such as mills and blocks. In an open system, one can utilize a stand-alone design software, such as exocad, then pair it with a mill from any company, or use a 3-D printer from a nondental company. Some of these pairings come at a much-reduced cost over those offered by dental companies and allow access to technological advances that are showing up at an amazing clip. These advances are possible when the world at large works together to find new solutions to old problems. This is happening right now in 3-D printing. Engineers and tinkerers are creating innovations at an astonishing rate, and it is trickling down to the dental community. Actually, that trickle will soon feel more like Niagara Falls!
These open systems offer such a variety of combinations that it has begun a veritable war of who will come out as the “expert” in the field. Many educators in the field are trying to top one another with innovations in the field of 3-D printing, design, materials, and even milling. Some of these experts include Cory Glenn, DDS, and Baron Grutter, DDS, with Blue Sky Bio; Jonathan Abenaim, DMD, with Smile Syllabus; August de Oliveira, DDS, with Digital Enamel; Michael Scherer, DMD; and others. All of them are making great advances with digital design, digital implant planning, digital orthodontics, digital dentures, and improved digital workflows. Many of them disagree with one another on what the best products may be, but it makes for great entertainment and learning. In my opinion, Facebook is the best way to catch up with all of these enlightened gentlemen, and their thought processes may just blow your mind.
Within these circles there is a strong sentiment against closed-system technology. Many docs are becoming frustrated with high recurring fees and large entry costs to enter the digital realm. In alignment with this trend, large Facebook groups designed to help doctors enter the digital realm for a greatly reduced price are popping up. One example is the Blue Sky Bio Facebook group. It has many threads teaching doctors to virtually place implants and create their own surgical implant guides via the use of an affordable desktop 3-D printer.
Another option is a software such as Meshmixer, which has hours of free training on YouTube. Meshmixer is a powerful 3-D design software that you can use to take a scan from your 3M scanner, Trios, or CEREC, and create 3-D models, wax-ups, occlusal splints, or even dentures in the 3-D space. For those who don’t want to print their own, Barry Voltz from 3-D Digiworks offers a great, inexpensive service.
In addition to the free software, some paid software programs are coming into the spotlight. Exocad, formally a lab tech software, is becoming a darling of the daring dental tinkerers. This extensive dental design software will give you the capability to design almost anything digitally—crowns, bridges, custom abutments, you name it. During the writing of this article, I learned that exocad will be coming out with a chairside software that may accompany the iTero intraoral scanner. I would speculate that this will be used to design chairside crowns for milling in any open source mill out there.
The 3-D printing frontier
For many engaged dentists, 3-D printing is the new shiny object. I have become entranced with the thought of 3-D printing and own a Form 2 3-D printer. My orthodontist friend actually called me the other day and said, “I was told that I need a 3-D printer.” He asked questions about the cost, speed, and materials. At the end of the conversation, he realized that a 3-D printer is not magic and wouldn’t fit his needs and time constraints.
I would be cautious of the “gotta have” feeling and evaluate whether the technology is the right fit for your office. For now—and this will definitely change—there are limited applications for 3-D printing in the dental office. Approved options for the under $5k printers are: model production, surgical implant guides, occlusal splints, temporary restorative production, and coming soon—digital dentures. More expensive printers can provide these options more predictably. These printers will usually cost more than $50k. Bear in mind that the capabilities of affordable 3-D printers will most definitely improve over time. 3-D printer manufacturers, such as Formlabs, have embraced the dental community and offer new developments on a quarterly basis.
The Form 2 and Moonray printers seem to be the most popular options among the doctors whom I observe. They are under $4k, which is manageable for most offices. These printers currently have limitations in materials, but that is sure to change in the near future. The Form 2 is known to have great accuracy, but is limited to the Formlabs resin. Their resin library is limited at the time, but it will continue to expand. The Moonray can use NextDent resin, which is approved for many applications in dentistry, but some question its accuracy compared to the Form 2. Both are great for printing models, short-term orthodontics, implant guides, some temporaries, and bite splints. Look for denture functionality very soon. 3-D printers used by dental labs have much-improved speed and functionality, but they will run more than $20k to $50k and sometimes north of $200k.
Milling isn’t dead
These great advancements in 3-D printing may lead you to believe that milling is passé. Why would we mill when we can create something from almost nothing, right? We are actually in the midst of a milling renaissance. More companies are bringing their mills to market that could fit within the confines of a general dental office. Today’s mills have more robust capabilities than those in the past. The concurrent growth of 3-D design software also allows the general dentist to create a wider array of “millworthy” items within the office. Utilizing design CAD software and third-party milling CAM software frees up the dentist to mill a wide variety of products, including acrylic, wax, zirconia, lithium disilicate, and titanium, among others.
These are things that a dental printer just can’t do right now. With a mill like this, a general dentist can reliably and efficiently mill out 15 zirconia crowns from a block just like a lab. I know that I am making this sound remarkably easy, but it won’t be long before this is relatively common. But before you decide it’s time to invest in all of this technology, it’s worth remembering that sending an impression to your lab—that likely has invested in these technologies on your behalf—still works as well.
Your first steps into the digital world
With all the options that I have thrown out there, let’s think about how to fit this into your practice. If you’re going to use a digital workflow, you will need a way to make a digital impression. You will need a 3-D scanner—either intraoral or desktop. We are all pretty familiar with the intraoral scanners by now. 3M and iTero offer some great lower-cost options, and other open-source options include 3Shape, Carestream, and Planmeca. A desktop scanner might even offer a better solution for some docs or may add another option for those who are already using an intraoral scanner. 3Shape has several options, but also check out some models from Evolution Dental or Blue Sky Bio. These desktop scanners are an easy way to go digital by scanning impressions and digitizing them. They often come in handy by scanning dentures and prostheses.
Once you have a digital impression, you could use one or more of the many aforementioned software to design. Meshmixer is a great place to get started, and there are many educational videos out there from the likes of Drs. Baron Grutter, Cory Glenn, and Michael Scherer. The Blue Sky Bio software is a great way to plan surgical implant guides, create your own short-term ortho, and design digital dentures (coming soon). Some doctors also use the service iRock DDS to design digital ortho solutions in-office. Of course, exocad should also be on your radar. The software ranges from $4k to $10k depending on your add-ons, but it has many useful modules. Of course, the big chairside guys are options too.
This is just a mere summary of what is happening in the world of digital dentistry right now. Technology moves very quickly, and I expect some of this to be outdated very soon. Get started by using some of the free software that’s available, and maybe try an inexpensive 3-D printer. The muscle memory that you will build will make it easier to move forward in the future. Remember to have fun and innovate!
Jason Lipscomb, DDS, a general dentist, currently practices in his three offices in Richmond, Virginia. In recent years, he has lectured on dental marketing and social media. He is currently the cohost of the Dental Hacks Podcast, which has recently reached the million mark for downloads and has given way to the popular Facebook group “Dental Hacks Nation.” Feel free to reach out to Dr. Lipscomb at [email protected].