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Washington State Dental Association

Entering the digital age: Are you ready?

Innovations in technology are happening at a dizzying pace. We spoke with four reps who will be involved with the live demonstrations at the PNDC about the future of digital impressioning and CAD/CAM technology. Come see for yourself at the PNDC.

WSDA News: Tell us a little about your company’s vision for the future of either Digital Impressioning or CAD/CAM. If these technologies really are the future of dentistry, how soon before you feel they will be the only standard in the industry, versus an option?

Bill Neal, Patterson Dental Supply: Patterson Dental Supply has now sold more than 12,000 Cerec CAD/CAM units in North America, and more than 25,000 worldwide. We feel strongly that the technology will be adopted at an accelerated rate over the next 5-7 years, because the learning curve is diminishing. Materials developed by Ivoclar, Vident, Sirona, & 3M are of a very high quality in terms of wear ability and aesthetics.

Jeff Deney, Cadent:
At Cadent, we have processed more than 325,000 cases of Crown and Bridge – that’s 500,000 restorations walking around the world that originated from an iTero scan!  Our digital services have processed more than 2,500,000 cases.  With our connectivity to implants, orthodontics, Invisalign, and any type of crown and bridge we now are the “digital front end” to about 99% of what walks through the door of a dental practice.  We have over 2000 customers worldwide that know the future is now.  To our customers, conventional impressions are no longer an option.

Ron Brown, Henry Schein:
Digital impressioning, Cad/Cam dentistry will become a larger and larger part of our offering to our customers throughout the world. Currently we sell the E4D Cad/Cam system in the US, the E4D and Cerac system in other parts of the world and the 3M Lava COS digital impressioning system as well as the Cadent Itero product here in the US. A year ago, Gordon Christensen stated every office will be doing digital impressioning within the next five years. I think it might take a little longer, but not much.

Kevin Black, 3M ESPE: Digital intraoral capture has the potential to change the way  we practice dentistry. Imagine digital scanning becoming as routine as taking X-rays, and the diagnostic and treatment planning possibilities of comparing digital scans over a period of time. The information obtained will enable the doctor to track wear, recession, tooth movement and changes in occlusion, which can then be combined with sophisticated treatment software and have a positive impact on patient treatment.

WSDA News: Tell us a little about the technology and its results. How do they compare with more traditional methods? If not the present, when do you think they will eclipse the current standard?

Kevin Black, 3M ESPE:
A dental technician using traditional methods tries to achieve accuracy in the 60 – 100 micron range. Numerous studies suggest that 3M’s COS accuracy is in the 6 – 10 micron range. Seating times have been documented to be reduced by 44 percent. Recent CRA data from a double blind study showed that COS crowns were selected 83 percent of the time compared to traditional impressioning and 100 percent of the time in multiple unit cases.   

Bill Neal, Patterson Dental Supply: The clinical results that can be achieved with Cerec are very comparable to the results from a dental lab. The technology and materials have advanced to a point where the strength and esthetic results are very pleasing to the doctor and patient, with great results on both posterior and anterior teeth.
    Cerec now fully integrates via software with the Sirona Galileos, a cone-beam x-ray unit. The Galileos allows for precise planning of implant cases and the Cerec software integration allows the doctor to fully plan the restorative case with the implant placement. The ability to fully integrate and control the restorative process in the doctor’s office will continue to be a focus of Sirona’s.

Ron Brown, Henry Schein: The results we see with the digital impressioning systems and the E4D Cad/Cam are excellent. We see less remakes using either system and the Cad/Cam offering same day dentistry. For those using Cad/Cam and a staff member to make the crowns, onlays, veneers and then seat another day, the ability to control the making of the restoration has made for less adjustment time and less remakes.

Jeff Deney, Cadent: iTero utilizes a combination of laser and optics to capture both tooth structure and tissue without the use of powder ever!  Removing powder eliminates one of the last variables of digital dentistry, reduces the learning curve, creates a scanning protocol that allows the user to touch the teeth with the device, and generates a highly accurate scan. The scan data sent wirelessly via a “click of a mouse” where all subsequent processes are started.

WSDA News: How does the cost compare? How does the cost to the patient compare?

Ron Brown, Henry Schein:
For the doctor, the cost per restoration is substantially less than using a lab, however, they do have to make the initial investment. The cost to the patient for the restoration is the same, but in most cases they only have one appointment instead of two. Our research shows that 15 percent of patients would switch dentists if one offered one day appointments instead of the traditional two day appointment for this type of restoration.

Jeff Deney, Cadent: We all have to agree that a very sophisticated piece of technology is required which ultimately translates to a small capital expenditure.  iTero’s initial price is between $26,500 and $30,000. We now sell 90 percent of our scanners with unlimited scanning which creates an attractive ROI for any clinician that is doing in excess of 13 impressions per month.  I rarely say that this is a cheaper option compared to the conventional process if we look at hard dollars.  If we look at reduced chair time, enhanced quality of dentistry, enhanced patient experience, and overall “big picture”, iTero will win every time.

Kevin Black, 3M ESPE: Current 3M COS pricing, ($24,000) indicates that the break even point is 14 units per month when compared to traditional impressioning. Furthermore, if the practice selects a laboratory that offers lower digital pricing, (i.e., $50.00 a unit) your break even point is 12 units per month. Costs to the patient are typically the same as traditional impressioning.

Bill Neal, Patterson Dental Supply:
The cost to the patient is usually the same for a lab-produced restoration or a Cerec restoration produced in the office. The initial return on investment when purchasing a Cerec is positive after performing between 12-15 single unit restorations per month. After the Cerec is paid off the cost per unit for the doctor is reduced from a $200-$300 single unit lab fee to $25-$30 per unit with a Cerec. Most of our clients are paying off loans on their units in 30 months.
    Another benefit of Cerec is the ability to produce a restoration in one visit. There is no temporary or need for a second visit which saves cost incurred during the second patient visit.
    There are over 300 Cerec owners in the Puget Sound Region and many of them reported to us that Cerec was a saving grace during the difficult economy of the past two years.

WSDA News: What is re depreciation schedule? At what point do you envision this technology being obsolete – in terms of being replace by something even more advanced?

Jeff Deney, Cadent: We have iTero doctors who purchased their scanners in July of 2006. iTero technology uses a patented parallel confocal imaging technology that provides for our unique features and benefits compared to other systems. We do not envision digital impression technology becoming obsolete. Our vision is to provide a an open system that is currently capable of comprehensive restorative dentistry, orthodontics, and Implantology. With our patented technology, we envision the iTero system will continue to expand its functionality in the dental practice for years to come. We learn every day from our users and our R&D team is actively turning their vision into new functionality. 

Bill Neal, Patterson Dental Supply:
  Cerec can be depreciated fully under section 179 which allows for the accelerated depreciation of dental equipment in 2011. It can also be depreciated over five years.
     The current generation of Cerec technology is based on a platform that is being updated primarily by software enhancements. Past hardware enhancements have included a new high resolution camera and a higher speed and more accurate milling unit. Sirona and Patterson Dental Supply have a trade-in program for any older unit a doctor desired to replace with a more advanced one, a rarity in the dental industry. 

Ron Brown, Henry Schein: In today’s economy, the dentist can take advantage of the section 179 tax write off, which with an E4D could save $49,000 in taxes by writing off the purchase all at once. The technology should continue to advance for many years. Most upgrades are software driven, which is a continual process. Will there be something more advanced coming down the road? Absolutely. Technology keeps evolving, just look at your phone — what did it look like ten years ago? I know at E4D, the items in the works are phenomenal and the R&D being put into this technology will continue to bring it to a new level. I don’t see that slowing down anytime in the near future.

Kevin Black, 3M ESPE:
The biggest fear for most dentists considering digital impressioning is obsolescence. The break even numbers of 12 – 14 units per month include the cost of a maintenance – software upgrade agreement. As software is developed it is downloaded to the customer at no additional charge.
    3M’s latest software upgrade required a system computer with more horsepower and a camera change. These upgrades were covered under the service agreement and performed at no cost to the customer. Because of that, COS devices sold almost four years ago are as up-to-date as the machines sold today.

WSDA News: What are the pros and cons of your systems? What are the pros and cons of your competitor’s?

Kevin Black, 3M ESPE: The main technical feature that distinguishes the 3M COS from other systems is the patent on real-time 3D video. Instead of single click pictures that are stitched together, the 3M system takes 24 pictures per second. Having video capabilities allows full arch scanning in less than a minute, versus up to six to ten  minutes for single click systems. For those vacillating between a chair-side milling system or a digital impressioning system, 3M will add a chair-side mill this year than can be purchased separately. Other features that distinguish us include a touch screen interface and a camera that weighs only 14 ounces.
    Up until the most recent software upgrade the learning curve was a little steeper for our product than our main competitor’s. Software upgrades have improved user ability, and now the two digital impressioning devices are now equal.

Ron Brown, Henry Schein: E4D is a newer product, and lacks the historical advantage Cerac has. Although Henry Schein is the largest seller of Cerac, we can’t sell it in the US market. Because of that, we went to D4D Technologies to make the E4D, armed with a list of what we liked and disliked about Cerac — which we feel helped us make a better product. Additionally, 3M and Ivoclar joined forces with us in making of this machine. We use a patented laser scanner, so no powder is needed; instead of taking one picture of the tooth from the top down and having the computer produce an image for the new crown, we take actual scans of the entire tooth and build the new crown from the actual dimensions of the existing structure. Both are excellent machines and produce fine quality restorations.  We just go about it a little differently.

Bill Neal, Patterson Dental Supply: In 2010, Sirona and Patterson celebrated the 25th anniversary of Cerec in the United States. The total number of Cerec users vastly exceeds all of the competitive products combined. Sirona’s history of innovation and excellence in manufacturing are world class. There commitment to research and development is unmatched in the dental industry.
    Cerec continuing education opportunities provide a user with a great pathway to success. The quality and amount of Cerec CE courses are unmatched by any competitor. Local technical support for Cerec is a top priority for every local Patterson Dental Supply branch office.
    Sirona continues to develop new techniques which make the process of creating a quality restoration easier and predictable. Our material partners continue to develop stronger and more aesthetic materials.

WSDA News: What are the differences between digital impressions and elastic impressions? What are the differences between restorations produced via CAD/CAM technology and those made using standard laboratory techniques?

Ron Brown, Henry Schein: Digital impressions are not subject to variations in traditional impression materials. Heat, liquids, disinfectants, etc. never effect a digital impression. There are less remakes with digital impressioning, and if by some reason you would have to remake a Cad/Cam restoration, it can be done on the spot. The materials being used in Cad/Cam restorations are the same as used in a lab. With the new E-Max blocks, the strength of the restoration is not a factor and the same material as now being used by your local lab.

Kevin Black, 3M ESPE: Studies have suggested that up to 75 percent of impressions submitted to laboratories are flawed to the point where the defect will affect the final restoration. With 3M COS, a dentist can view their preparations in 3D at a magnification of 10X and have the information of a complete set of virtual articulated models while the patient is still in the chair. In the case of implant impressions, the 3M COS can take these implant scans at bone level, eliminating dozens of steps that contribute to error.
    Laboratories with digital capabilities can produce full contour restorations of any type that are so accurate that the value of a model for single units is now being questioned. Traditionally, if you poured two models from the same VPS impression, the crown made on one set of dyes would not exactly fit the second dye. The 3M COS System uses SLA model manufacturing technology, and ten sets of models could be made and the crown would fit each model identically. Any lab can use SLA models to build crowns and bridges in a traditional manner, but those with digital production capabilities have a significant advantage in the quality of the restorations they can produce.

Jeff Deney, Cadent: Digital with iTero has removed the variables of the conventional process. Tears, bubbles, voids, distortion, temperature, technique, time, people, materials, occlusal clearance tool, powder, stone models, chipping of stone models, bite registrations, articulation, and more have all been removed from the process.
    Regarding chair side milling and laboratory produced crowns, there are no differences in materials if you are willing to utilize all the commonly known all ceramic options. Chair side system’s #1 seller is a “one visit” crown appointment. That doesn’t mean the systems “shoot out” a lab quality restoration like a vending machine.    
    Quality crowns take time and resources whether they are fabricated in a lab or a dental office. Labs do this all day, they have advanced CAD/CAM systems, calibrated porcelain ovens, highly trained technicians, and systems in place.  

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