Private practice dentists often work in a microcosm of big business. They act as business managers, human resource managers, repairmen, IT administrators, counselors, and clinicians. It's not easy, but the rewards do outweigh the drawbacks.
However, working in a microcosm makes it difficult to see dentistry from a broader perspective and appreciate what is going on outside the practice. Dental laboratories are well suited to provide this valuable information because of their different perspectives on issues that profoundly affect the profession. With these thoughts in mind, hearing from some respected people within the lab profession can provide some benefit. For a broad perspective, I interviewed:
- A small lab owner: Chris Roman, CDT Owner, Oak View Dental Laboratory, from Washington, Pennsylvania
- A large lab owner: Don Albensi, General Manager of NDX Albensi, from Irwin, Pennsylvania
- A prosthodontist: Lt. Col. Sloan McLaughlin, D.M.D., who runs the U. S. Army Dental Laboratory at Fort Gordon, Georgia. (Lieutenant Colonel Sloan McLaughlin's opinions are his own and they do not represent official policy from the U.S. Department of Defense.)
Digital technology in dentistry is growing exponentially. Additionally, there is a large influx of knowledge regarding new materials and techniques. Do you have any strategies to keep your dentists abreast of advances in these areas?
Albensi: “We have many strong partnerships with our vendors and suppliers to lean on that assist us in educating and marketing to our clients and team members. Our large sales and marketing organization at NDX makes this job easier to execute.”
Roman: “The best way I have found for our laboratory is through constant communication with our clients. When we are in the treatment planning phase of communication, we bring up the latest techniques available and what materials are most appropriate for the situation.”
McLaughlin: “We publish monthly 'Tips to the Reader' as well as a biannual newsletter. These help to keep our providers aware of the capabilities we have and any new technology that has been brought on board. Our submission guidelines are also available and continually updated. These discuss what should be submitted (e.g., model, impression, etc.) for different types of cases and materials that we use.”
How do you communicate with your dental offices when you have questions about a submitted case?
Albensi: “For IOS cases we primarily communicate through email and occasionally include screenshots of the scans to identify areas in question or of concern, such as confirming a margin. We can use tools like Team Viewer as needed. We also have daily case email reports that go out each evening to our accounts notifying them of cases received that day, cases that were shipped with a tracking number, and cases on hold waiting for materials or questions to be answered. We also have a customer care team of seven to field all inbound calls and to transfer to an internal subject matter expert if it requires a highly technical person to answer their questions.”
Roman: “We have various methods of communication now. We utilize everything from traditional phone calls to texting, email, and even utilize the communication features included with some digital scanners. For most circumstances, we end up using multiple options together. Texting has been a valuable tool for us to utilize while in phone conversations.”
McLaughlin: “The software we use to track cases within our lab has a corresponding software, with which providers write their prescription. Within this software, there is a messaging capability that allows us to correspond with a provider and keep all correspondence bundled with the case. Additionally, we will send an email, as necessary. Phone calls are seldom used to contact providers due to the numerous time differences.”
We also have a customer care team of seven to field all inbound calls and to transfer to an internal subject matter expert if it requires a highly technical person to answer their questions. – Don Albensi
Do you have any opinion of the impact of chairside milling has had on the dental laboratory?
Albensi: “It is and will continue to be a viable option for an office to provide same-day crowns; however, we have seen a larger adaption of intraoral scanners used to send cases to our labs due to the use of these chairside systems.”
Roman: “It is a useful tool for practices that plan and utilize the system while understanding the limitations.”
Is there anything unique to dental service organizations (DSOs) regarding your relationship with them compared to your relationships with private practices?
Albensi: “We have a sales team dedicated to working with and servicing DSOs for NDX that make it easier for us and our sister labs to do business with them. We have found it to be beneficial when working with a dentist who may be having issues, as we are able to work with the DSO mentors and leaders to help provide training and support a dentist or office may need.”
You are a big proponent of prescription accuracy. How do you help your dentists improve their communication with you on prescriptions?
Albensi: “We encourage all of our accounts to fill out a client preference sheet that we load into our production management systems. If we have incomplete prescriptions, we can reference their preferences and eliminate a phone call or email, which will only delay the case getting into production. The preference sheets do not help in all situations and require our teams to make phone calls or send emails to consult with the offices.”
McLaughlin: “The software we use allows us to update, in near-live time, the products available for a provider to choose. If we bring on a new product or discontinue one, we can update it, so providers are aware. There are questions on our software to help prompt providers as to what other products they may need or clarify to the lab exactly what they are requesting. Additionally, on the printed prescription we will annotate any product choices that may have been omitted. Emails are sent when necessary to suggest alternative products and why we recommend a different product than chosen.”
What are some of the things you see in your lab that would help dentists have a more predictable and enjoyable experience through their insertion process?
Albensi: “Properly identifying paths of insertion in our 3Shape software for implant restorations particularly screw-retained restorations. In addition, the 3D printed abutment insertion guides for placing implant abutments have made life easier when inserting the final abutments and restorations.”
Roman: “Planning, planning, planning. I see a lot of the issues that arise with insertions trace back to the preplanning. Stopping and looking at how the situation got to the point of needing a restoration. Something as simple as stopping and looking at the adjacent contact points or looking at the opposing for over eruption. Checking the anterior envelope for freeway space when they are replacing the old crown because it chipped or fractured.”
McLaughlin: “The quality of models and impressions that are submitted could be improved in many cases. Often providers verify an encode or tooth preparation was captured accurately, but do not look at the contralateral side, which has a large void in the impression. Nodules and blebs on opposing models result in inaccurately mounted models, simply taking a minute to remove these could save a large amount of time chairside. Making an accurate final impression, digital or analog, is another area that could greatly decrease chair time.”
Do you see any differences in precision between cases submitted with physical impressions and those submitted with digital scans?
Albensi: “Absolutely. We have seen a significant decrease in our remake percentages on cases from IOS versus traditional impressions while reducing the turnaround times for delivery back to the office.”
Roman: “A few years ago, I would have said yes, across the board, with digital versus analog. Today, I would say the technology has advanced to the point we can comfortably know that the restoration leaving the lab is at or near the same precision we can obtain by analog fabrication. I attribute this to not only the advancements in technology on both the lab side and clinician side but also a better understanding from the clinician side of what a lab needs to make a restoration from a digital scan.”
McLaughlin: “We receive a much larger number of physical impressions than we do digital scans. I feel digital dentistry requires more attention to ensuring a dry field and having adequate retraction. More digital scans do seem to be less precise. The majority we receive have no retraction cord and a large amount of heme or tissue obscuring the impression. With a physical medium such as VPS this heme or tissue can often be moved, allowing the lab a more defined margin area.”
Do your dentists understand the concept of drill compensation through the milling process? How can you explain to them the importance of preparation design?
Roman: “Our clients do. They understand because we have educated them on the importance of minimizing and controlling these parameters. Preparation design is critical to the amount of drill compensation that is applied to each restoration, to minimize the compensation applied we recommend soft/rounded edges to preps with no sharp angles.”
McLaughlin: “A number of providers do not understand the concept of drill compensation. When I speak with other providers, I try to stress that nearly everything we fabricate has at least some portion of a CAD/CAM factor to its fabrication. Reinforcing smooth, rounded preps are key to having an adequate fitting restoration. Of those who do understand it, many do not realize the burs within one milling unit are different from others, and thus, a different milling strategy is used. This milling strategy may result in increased drill compensation for providers who design a prosthesis at their clinic.”
According to Lab Management Today's (LMT) “2019 Retrospective,” fully a quarter of the scans that labs receive are inadequate. How can you counsel your dentists to provide more accurate scans and minimize the risk of remakes?
Albensi: “We triage all questions on IOS scans through a team in our lab that communicates and consults with our clients about what we are seeing, what we can do together to improve the consistency and quality of our final restorations. If they are part of a DSO, we will get their lab support group and doctor mentors involved. Sometimes we will ask the scanner vendor to assist us by working with the doctor remotely or sending a trainer into that office to work with the doctor and team.”
Planning, planning, planning. I see a lot of the issues that arise with insertions trace back to the preplanning. Stopping and looking at how the situation got to the point of needing a restoration. Something as simple as stopping and looking at the adjacent contact points or looking at the opposing for over eruption. – Chris Roman
Roman: “We recommend they evaluate the scanned file the same way they would evaluate a traditional impression. One benefit they have with digital is the ability to look at the 3D rendered model before the case is submitted. Unlike traditional, they have the chance to see what we will be working with before it ever gets to us. As for the accuracy we recommend finding a technique that will allow them to replicate the scanning paths needed to capture all the required details.”
McLaughlin: “We stress retraction and digital dentistry is not a solution for average dentistry. When using digital scans, heme control and retraction are even more critical. Another area that is often easily missed or distorted on a digital scan is the adjacent interproximal areas.”
With your dentists' ability to utilize digital treatment planning that comes with their scanning systems, when should dentists do the restorative design and when should it be entrusted to the lab?
McLaughlin: “Much of this decision comes with the comfort and knowledge that a provider has with their preferred system. I recommend to our providers that unless they know the bur size used in our mill and can change the milling strategy that they send to the lab. The number of times designs take versus transferring the scans is a decision point.”
Most dental offices have budgets, which they try to abide to. If a dental office was interested in making a capital purchase of either a milling system or a 3D printer, which would you consider to be a more valued investment?
Albensi: “The most valued investment from my perspective would be obtaining an IOS scanner first, milling system second, printer third.”
Roman: “Milling system. 3D printer, in my opinion, is still a niche product/equipment for a dental practice. The limited materials that are available in my opinion would not justify the time/cost associated with printing. The milling machine would definitely give a practice more material options and be utilized in more productive ways than 3D printing can achieve right now.”
Do you have any preferences for open tray or closed tray impressions for implant restorations? Do you have any opinions on whether closed or open tray impressions are more accurate?
Roman: “I advocate for direct open tray impressions in every discussion about implant restorations. While there is a place for closed tray transfers, I feel direct impressions are far superior. Of the many reasons I feel that there is way too much room for error replacing these posts into polyvinyl and polyether impressions.”
McLaughlin: “Open tray impressions are my personal preference when I would train general dentists in a 12-month advanced education in a general dentistry program. Open tray is easier to retrieve if a resident were to have difficulties. Closed tray impressions have their place and I use them more often for single posterior restorations. Literature has shown open tray impressions are more accurate.”
Open tray impressions are my personal preference when I would train general dentists in a 12-month advanced education in a general dentistry program. Open tray is easier to retrieve if a resident were to have difficulties. – Lt. Col. Sloan McLaughlin
When you receive prescriptions for multiple restorations in the esthetic zone, what photographs are required by you to help ensure the patient is pleased with the final result?
McLaughlin: “For any case that crosses the midline we require some form of esthetic guidance. Whether that be a wax-up, cast of provisionals, photos, or a combination of these. My preference is to use a cast of provisionals that were tested in the mouth for a period of time and approved by the patient. The critical part is the incisal length that translates the esthetics/phonetics that are needed for the patient. Without this, technicians are left to their best guess and following the LAR (i.e., looks about right) principle. Full-face smiling and close-up smiles can be some of the best photos as these can sometimes be added to the CAD portion of fabrication to help design using the patient.”
How do you address unrealistic expectations from your dentists? For example, a dentist sends you an anterior triple tray prescription with multiple units without adequate documentation.
Albensi: “We will call and encourage them to obtain thorough records for large cases; however, if they continue to refuse, we do have to either proceed as best as we can with the office knowing we will not accept responsibility for any adjustments or remakes and unfortunately there are occasions where we will have to reject the case.”
McLaughlin: “We will email a provider and send out our newsletters or other tips we previously noted. Trying to clarify to a provider as to why the submission was not ideal and what could be improved upon in the future is what we strive to do.”
How do you help your dentist clients when one of their patients is disappointed in the final result?
Albensi: “If they are a local client, we will encourage the patient to come in for a no-cost shade and design consultation. If not, we will do all we can to remedy the issue for the patient in conjunction with their dentist, which may include a discount, gift card to the patient, or lunch for the office.”
Roman: “The first step we take is to find out what the patient's expectations are. What does the patient like/dislike about the current result? After we have this discussion, we regroup with the clinician and form a plan of how to proceed to exceed the patient's expectations on the next attempt.”
What benefits can dentists expect in the future from dental laboratory technology?
Albensi: “Increased predictability and consistency in the quality of the restorations delivered with materials designed to last a lifetime while achieving esthetics that we previously thought was not possible in a monolithic restoration with short turnaround delivery times and affordable costs.”
Roman: “I see more collaboration between dentists and technicians every day. Once the clinicians discover they have a unique tool to utilize in a lot of the treatment planning phases then the real benefits start to appear.”
McLaughlin: “Technology is continually improving and the products available and means to communicate more effectively with a lab are always increasing. The ability to send a clear scan and prescription is still a critical aspect of receiving a good product.”
Does your laboratory service all U.S. Army dentists?
McLaughlin: “We service all U.S Army providers throughout the world. We also provide a number of services to our Sister Services, the Air Force, and Navy.”
Edward J. Roman, D.D.S., (www.romanvaughan.com) is a dental laboratory owner who maintains a private practice in Washington, Pennsylvania. He is a member of Spear Visiting Faculty and a contributor to Spear Digest.