by Jeffrey B. Dalin, DDS, FACD, FAGD, FICD
Dr. Dalin: When I first graduated from dental school and returned home to practice with my father, he told me that I should spend time with the lab technicians. Doing that gave me a huge appreciation of the work lab technicians, such as yourself, do. In fact, I received several tips that immediately made me a better practitioner. Technicians taught me how to tweak preparations in order to provide a better final result. During this time, I learned that lab technicians are equal partners in the equation of delivering top quality dental restorations.
Block: Jeff, your experience in the lab is obviously one of the keys to success in your practice. I think that any dentist who truly cares about the quality of his or her work should make it a point to spend some time at a dental laboratory. As you said, it is time well spent. There are many dentists who have no idea how a lab actually functions, and how those intricate restorations are produced. Believe it or not, laboratory technicians have great knowledge about restorative procedures, and know much about the best way to prepare a tooth. If the doctor has an open mind and is willing to have a frank discussion with the technician about different techniques, chances are that the doctor will gain a new perspective about the proper way to approach a preparation design. Furthermore, with all the outsourcing taking place, I see many dentists who are frustrated with the inconsistency and lack of quality they are receiving.
Dr. Dalin: Let’s talk lab communication. A few years ago, I wrote a column for Dental Economics® called Digital Diagnosis. A few columns dealt with some of the great tools we have at our disposal that help us communicate better with lab technicians. To me, digital photography has made communication with lab technicians a piece of cake. Nothing is left to the imagination. Whether using something simple like the new Kodak P712 system or something more sophisticated like a Canon 30D camera, we are now able to provide something that will make the technician think he or she is sitting across from a patient.
Block:Jeff, you hit the bull’s-eye regarding communication. The truly amazing thing today is that you really need to add the word “digital” to communication to make it “digital communication.” I don’t know how we did what we did without good photography and the advent of the Internet. My ability to give the doctor a result that the patient will love is based on three things: a great preparation, a great impression, and great digital photographs.
A qualified lab will be able to deliver a spectacular case if its technicians are technically and artistically talented. Once the lab has the physical models at hand, along with the digital photos, it has all the information needed to perform its “magic” at a level of excellence that a doctor and patient expect.
Dr. Dalin: I am a fan of the Kodak 300 dock dye sublimation printer. I think the prints from this printer allow me to transmit incredible reproductions of what I see. In addition, I could easily e-mail the image to the lab. Do you get much information by e-mail?
Block:Yes, I receive about 50 percent of my cases via e-mail. I love it. It gives me the ability to see a patient and his or her smile before and after the teeth are prepped. As you know, with today’s popularity of makeover shows, the demand for esthetic dental restorations has increased greatly. This demand is based on the amount of high-end veneer cases currently being done. There is no reason to believe this demand will diminish at all.
Dr. Dalin: David, what do you think of the digital shade selection systems? Would you talk about the simple, single-point systems, such as new Shade-X™ from x-rite and Easyshade® from Vident? How about the ShadeVision® system?
Block: In the past, dentists drew crude shade maps or gave technicians little detailed information about the esthetic desires of the patient. Today, effective communication between the clinical team and the laboratory is the cornerstone of a successful relationship. The accurate communication of detailed color is critical to the delivery of the single unit, as well as multiple anterior restorations. In my opinion, shading ranks behind form and function in importance, but it’s high on the list of causes for restoration failures. Therefore, assessing color has been one of the most difficult barriers to accurately communicate between the dentist and the laboratory.
I have found the ShadeVision is a comprehensive system that captures color information, communicates to the lab, and enables end-to-end quality control. It is a portable and cordless shade-taking system, designed to quickly and accurately measure shades. The instrument uses proprietary precision optical measurement technologies that respond to light similar to the human eye.
On the other hand, Easyshade is a simple-to-use, point-and-click system. It has a digital spectrophotometer that provides instant dental shade readouts regardless of the lighting conditions. The VITA Easyshade features separate menu settings for “single tooth” shades as well as “tooth area” settings for measuring cervical, mid-third, and enamel shades. A “verify restoration” setting allows labs to confirm their shaded restorations regardless of surface condition. From bisc bake to the glazed state - wet or dry - the Easyshade system provides an accurate reading and indicates where adjustments might be necessary. It has a setting to allow labs to confirm that their restoration matches a doctor’s prescribed shade. When a difficult shade is measured, the system will accurately prescribe an interpolated shade. This is easy for the lab to replicate.
From a doctor’s perspective, Easyshade measures a precise shade instantly, and prescribes the best VITA shade under any lighting conditions. It has a narrow tip for measuring shades almost anywhere in the mouth. It measures a basic overall tooth shade, or separates the tooth into cervical, middle, and incisal areas depending on one’s preference. New technology has dramatically enhanced the predictability of achieving an accurately matched restoration.
Dr. Dalin: In the December issue of Dental Economics, I interviewed Ed Narcisi. We discussed many of the new all-ceramic systems. What are the advantages and disadvantages of the new ceramic-zirconium systems?
Block:On the plus side, embracing the new CAD/CAM systems for the all-ceramic restorations has proven to be one of the most viable and popular techniques to come along in recent years. It is the direction our industry is heading.
In fact, we currently fabricate an average of 22 percent of our total caseload using CAD/CAM. My prediction is that percentage will increase to approximately 60 percent by 2011. I am excited about the technology because of its accuracy and precision, along with the positive impact on our lab’s production flow and the esthetic advantages of zirconium in the posterior region.
In addition, many think CAD/CAM will offer a viable solution to the chronic shortage of skilled technicians. It will allow the master technicians to focus on higher-skilled techniques like feldspathic restorations on the anteriors. It will open the floodgates to a new breed of newcomers to the industry. CAD/CAM could relieve the shortage of fixed lab technicians since there is a greater pool of people who have the computer skills required for its manufacturing process.
Zirconia is the strongest of the ceramic materials available today. I do not know of any other nonmetallic material that comes close in strength to zirconia. But keep in mind the traditional PFM (porcelain fused to metal) is still the strongest option. When it comes to the interproximal junction, which is the most common area of breakage, 3M ESPE’s Lava™ all-ceramic system permits movement electronically where the connectors will be. In addition, it allows one to calculate the connector cross section to ensure proper strength. This results in an esthetically pleasing restoration that will last a long time. This technology also enables the lab tech to design proper frameworks for effective crowns and bridges. Unlike other systems, the Lava system helps to pre-plan because lab technicians can make changes as they proceed. This system eliminates the wax-up and subsequent alterations. You finish with a better overall fit while matching form and function.
On the minus side, I would have to say that - after 34 years in the laboratory business - nothing comes close to the opalescence beauty of all-ceramic feldspathic crowns. In my opinion, if you have a core or any other substructure, it will deflect a monochromatic appearance. Some of the advantages of feldspathic or stacked porcelain include less tooth reduction (3 to 5 mm vs. 6 to 8 mm), masking out dark stump shades without a core by using an opacious dentin or masking agent, porcelain is the same as traditional PFM, more of a “contact lens” effect can be obtained in thin areas, and different levels of opacity can be placed by layering the restoration.
While either CAD/CAM or the feldspathic technique can be viable solutions for most cases, there are advantages and disadvantages to both. The real key to esthetic success still remains in the artistic ability of the laboratory you select. Systems, techniques, and materials work differently in different hands. Therefore, it is important to build a relationship with a laboratory that suits your needs so you can achieve the most natural-looking restorations. Remember, the lab goal is to mimic nature.
Dr. Dalin: Recently, we have heard stories about lab work being sent overseas - both knowingly and unknowingly. What are your thoughts on this trend?
Block:I have been in the laboratory business for more than 30 years, so this trend is not new at all. In fact, more than 20 years ago, one of the owners of a major overseas lab proposed this concept to me. There are many lab owners that consider this to be the biggest current challenge to the U.S. laboratory business. Needless to say, this is an emotionally based debate. When I was 20, I wanted to become a dentist. Unfortunately, my father died and I gave up my ambition of becoming a dentist simply because I had to take care of my mother and sister. Therefore, after two years in dental school, I decided to open a laboratory. I was fortunate to have had the opportunity to work with a great mentor, Dr. Peter K. Thomas from Beverly Hills. His knowledge, wisdom, and clinical skills, left an everlasting philosophical imprint on me: “If you focus on precision and individual quality of service, then no one can take that away from you.”
I have taken many classes in economics, and have flirted with the import/export market to see if we could improve our final product - our American product, which is produced by trustworthy employees who have been with me for more than 20 years. Our work consists of products that have FDA approval and I.S.O. certification. I could fire all my tax-paying employees, and send my work offshore to make my profit line fatter. But the bottom line is that I do not care about China and its explosive growth. I will never send my work outside the U.S. to increase my bottom line. Besides that, how can a doctor look at a patient and tell him or her that the person’s crown was made in China?
Dr. Dalin: Some dentists seem to get upset with $30 to $50 differences in lab fees, and will even change labs to save a seemingly small amount of money. I understand the need to keep overheads under control, but I also remember the lessons taught to me by my parents and grandparents that “you get what you pay for.” A dentist does not have to raise crown fees that much in order to make up for this difference in lab fees. How do you think dentists should view this issue?
Block: I am glad that you asked that question. Let me answer it with this story. I teach a seminar called “Total Veneer Experience” (www.totalveneerexperience.com), along with Dr. Alan Grodin, a well-known and well respected dentist. Through the years, Alan and I have become great friends. His clinical skills, with respect to porcelain veneers, is nothing short of amazing (thanks to the great courses that DE Editor Dr. Joe Blaes teaches). Alan tells me that he is probably the most expensive cosmetic dentist in his area. But I can attest to the fact that he does more veneer cases than virtually any dentist of whom I know. In fact, during a consultation, Alan tells his cosmetic patients that he is one of the most expensive dentists in town. Yet patients readily choose him to do a smile makeover. I believe the reason is because most people actually do care about quality. They are willing to pay more for something as important as having the best dentist work on them. The same is true for laboratory fees charged by certain “boutique labs.” Dr. Grodin and Dr. Blaes have never complained about the lab bills that we send them. Each knows he is paying for the quality work that each desires and expects for patients. Each knows that every case that is delivered successfully can easily lead to more cases. Isn’t that what we really want?
Dr. Dalin: The name of your laboratory is Aesthetic Porcelain Studios, Inc. With such a name, I would think you are intrigued and happy about the cosmetic revolution that is taking place in dentistry today. Any thoughts on this subject?Block:Yes, I love cosmetic dentistry! It is such a great thing for dentists, labs, and especially patients. It’s genuinely a win-win-win situation. I have heard from many dentists who are grateful that they now have the opportunity to perform “want-based” dentistry as opposed to the traditional “need-based” dentistry of which they have become tired. With the number of cases that come to my lab, I would recommend that any dentist who ventures into the cosmetic arena should take a course or two dedicated to cosmetics. Start out with a simple case and work up to the larger, more complex situations. I have seen a few dentists genuinely excel at cosmetics, and they are happy people!
David Block is the president and CEO of Aesthetic Porcelain Studios Inc., a full-service dental laboratory located in Universal City, Calif. Block founded the laboratory in 1974. Some of his products include E-Z Contact, Renew, Suction Cup dentures, the Block Inlay Bridges, and most recently, the PURRFECT MATCH kit. He has been featured in many publications, including Dental Economics. Block be reached at (800) 544-9605, or at [email protected]
Jeffrey B. Dalin, DDS, FACD, FAGD, FICD, practices general dentistry in St. Louis. He also 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 one of the co-founders of the Give Kids A Smile program. Contact him by e-mail at [email protected], by phone at (314) 567-5612, or by fax at (314) 567-9047.