By Robert Pauley Jr., DMD
The ability to perform onsite restorations for my patients has interested me for a number of years. By bringing this process in-house, I knew that I could not only control the quality of my dental work, but I could also set myself apart from other practices while improving patient care. In addition, I knew that doing the work in my office would allow me to save on lab fees and other expenses associated with setting up the operatory twice for the patient.
When I was deciding on a CAD/CAM restoration system, I sought the advice of my colleagues who were already using this technology. I also did a great deal of research online concerning prep design, bur selection, cementation materials and techniques, and ceramic block selection, as these techniques and materials differ from past conventional PFM and ceramic crown procedures.
With no previous CAD/CAM experience, I decided to incorporate CS Solutions (Carestream Dental) into my practice. This workflow includes an intraoral scanner, restoration design software, and a milling unit. The main draw for me with this system was the intraoral scanner. Unlike traditional scanners that require a trolley that must be pushed from room to room, this scanner was convenient to share between operatories by simply plugging it into any available USB.
Overcoming early challenges
One of my mentors, Dr. Edward Mills, has always emphasized that we, as clinicians, should avoid practicing as an island. I put this concept to use through my online research and by speaking with fellow dentists who had used other CAD/CAM units in their offices. They were able to guide me on how much time to allot, what to do and not to do, which burs to use, and the cementation process.
From my conversations with these colleagues, I ascertained that the learning curve was fairly high, and I would need to be patient while implementing the new system into my office. I made sure that I really took time with the first few patients, and booked a half-day so I wouldn't feel pressured as I was performing the procedure and using the equipment. I informed my early CAD/CAM patients that I was using new technology that would allow me to scan their tooth and mill their final crown, but, since this was a new procedure, they might leave with a temporary and return another day to have it cemented.
After four months of making CAD/CAM crowns, my patients are typically in the chair about three hours. I am chairside approximately the first 45 minutes, which includes prep, scanning, and designing. Then I'm free to see other patients while the restoration is being milled. The crown is then tried in, a bitewing radiograph taken to verify margins, and I supervise final stain and characterization prior to the glazing/characterization cycle. I'm now free again to see patients until the final try-in and cementation. We always take a postop radiograph to verify that all of the cement has been removed. Most of the ceramic blocks that I've used require staining and glazing prior to final delivery. I use the Programat CS Oven (Ivoclar Vivadent) to finalize the staining/glazing process. My assistants are improving daily in their skills of scanning the opposing arch, obtaining a bite registration, and assisting with the stain and glazing, which allows me more time to work with other patients, ultimately increasing my production and improving the office workflow.
Economic benefits of CAD/CAM
Cost and value are always concerns when bringing new technology into your office. CS Solutions clearly boosts our practice's bottom line with more time available on the schedule, less chair time for patients, more production time for me, and great word-of-mouth marketing by our satisfied patients. We are also saving money because we have lower lab fees and fewer impressions and temporaries to make. In fact, through calculating my net profit and cost savings, I've found that the system pays for itself if you perform just eight CAD/CAM restorations in-house each month.
One very important point is that, while I'm currently using the CAD/CAM milled crowns for premolars and molars, not every posterior tooth is a candidate for the CAD/CAM milling process. Dentists just need to incorporate the process into their existing armamentarium and use as the treatment plan allows.
While the financial advantages of performing CAD/CAM restorations are important to me as a small business owner, the improvements in patient care have been critical as a dental clinician. The CAD/CAM crowns were well received by patients. They were pleased that they did not have to get two injections at two separate appointments. One of our patients really liked not having those "messy" impressions. Patients have commented that they love the look of the CAD/CAM crowns because they do not have a metal lining or a gray line at the gum line.
Patients always seem intrigued rather than impatient with the procedure. We seek to make them a part of the process, which is a great marketing tool, giving them an iPad with the capability of watching during the design of the crown, and watching while the milling unit fabricates the crown.
Other advantages of performing crowns in-house
My staff is excited to be using the new CAD/CAM system. My assistants are eager to watch and learn the process and enjoy explaining the process to each patient so they can become active participants. They are also happy about not having to take so many alginate impressions on our patients. My front desk personnel are also pleased that they can add slots on the schedule that were previously not available.
My hygienists are eager to offer these new crowns to patients who are good candidates, and they've been thrilled with the resulting crowns -- not only because the patients are happy with the shorter process, but also because of the quality product. They've commented many times that the supragingival margins on these crown-prepped teeth are excellent and allow for easier cleaning. The crowns are smooth and do not accumulate plaque. They've also noticed a great reduction in the number of comments from patients regarding sensitivity with the new crowns, probably because of the smaller prep of tooth structure under the new crown.
My staff is very team oriented and cross-trained. We all work together to schedule patients for CAD/CAM crowns. When we first began to schedule CAD/CAM crowns, occasionally we would need an extended appointment because of a delay working through the process. Everyone worked together to make our schedule move as normally as possible. The best advice I can give to a dentist adding a CAD/CAM system is to get your staff motivated and encourage them to be patient and flexible the first six months. No one on my staff can imagine our office without the CAD/CAM system now.
Robert Pauley Jr., DMD, is a graduate of the University of Kentucky, College of Dentistry. Currently enrolled in the Advanced Dental Implant Studies, Dr. Pauley is an Associate Fellow of the American Academy of Implant Dentistry and a Fellow of the International Congress of Oral Implantologists. Contact him at email@example.com.
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