The Evolution of Digital Dentures
Where are we on the adoption curve?
Daniel Alter, MSc, MDT, CDT
There is no doubt that digital dentures have captured the attention of many in the restorative dentistry profession, both clinically and in the laboratory, and now patients are noticing too. As multiple solutions have become available, it has been fascinating to witness the progress of the adoption curve. Often, both laboratories and people in general fear change because they cannot clearly anticipate the benefits and are not willing to make mistakes. However, as Lao Tzu said, "If you do not change direction, you may end up where you are heading," and resisting change won't turn the outcome in your favor. Multiple dental professionals who work with diverse laboratory sizes and locales, and who deploy differing levels of adoption for digital dentures, share their perspectives and journeys with IDT on this evolving technology.
Success with Digital Dentures
Changing from a long-used process never comes easily. Marc Wagenseil, RDT, a VITA Global Trainer and owner of Heritage Denture Centre in Edmonton, Alberta, likens it to when Henry Ford changed his manufacturing process for the automobile. "Identifying efficiencies, integrating the new technologies of the time, and streamlining those efficiencies to produce a high-quality product for the end user are key." However, he continues, the road to technological fluency in digital dentures is not necessarily a straight line or even a one-way road. "There is some wiggle room and interpretation of the process," he says, "and each laboratory will have a slightly different interpretation, different ways to get to the end result. But that's what makes us stand out to our clients who keep coming back for our services."
This means that different laboratories could find a variety of challenges, whether or not they're using the same digital denture system. "I started to look at digital dentures as a means to be more efficient," says Esther Schwenning, RD-DD, of Northern Lights Denture Clinic in Prince George, British Columbia. "A little over 2 years ago, we took every course and lecture that had the word digital in it and completely jumped in. I originally started with an outsource digital denture service, which was fantastic, but I wanted to control more of the outcomes in-house."
Laboratories just getting started with digital dentures may be attracted to such outsourcing options because only a computer screen is needed to view the proposed designs, says Andre Theberge, RDT, CDT, LVI, AACD, from Drake Precision Dental Laboratory of Charlotte, North Carolina. "Outsource providers have some really cool innovations with implants and integrate them really well," Theberge says. "But sometimes we prefer to use ‘all in-house solutions,' mainly because of the turnaround time, expense, and control, and that's why we have our own printers. We do a lot of all-on-X hybrid implant prosthetics, implant surgical guides, and digital dentures, and now we are getting more into printed night guards, so we use our printers regularly and actually need more. Our primary goal right now, especially on the removable side, is to eliminate as much analog as we can and perform more of the tasks digitally."
William Berlin, CDT, of Hudson Valley Dental Lab in Wappingers Falls, New York, has taken a different route and has stopped short. "We purchased our 3D printer with the intention of making more digital dentures, but we still mainly do traditional dentures," Berlin says. "The design process was the biggest hurdle for us. Now, I use the printer primarily for evaluating full-mouth implant cases. We print a preliminary denture so that we can evaluate the bite, fit, and so on."
The Adoption Curve
New innovations, workflow solutions, and products typically go through an adoption curve, which consists of three phases. First is the concept and innovation phase, when developers make their vision work. Second, the early adopters work with the new product or system and figure out the bugs, face challenges, and help find solutions. These are then communicated to the solution provider so that future renditions can reflect the feedback. It is then further pushed out to the market with information regarding the successes and challenges experienced by the pioneers in Phase Two. Once the market is satisfied with the outcomes by the early adopters, Phase Three emerges. This is the mass market adoption of the product or solution. Many believe that 2020 is the year that digital dentures will mature to Phase Three and the entire profession will begin to engage in these workflows. However, statistics show that the adoption of digital denture fabrication processes accounts for approximately 1% of the industry.
The rates of digital denture adoption may jump when intraoral scanning of the edentulous arch has been perfected; then it will be possible to perform everything digitally—no more messy, gag-inducing impression material for patients. As with dental implants, the mainstream media will discuss digital dentures more; patients will become aware and start requesting them. That is when this process will really take off, Wagenseil believes. However, he cautions that this is the outlook on digital dentures today; it could be very different only a year or two from now.
Fixed dental laboratories are often quicker to adopt digital dentures because those laboratories already have most of the necessary equipment and only need to add a module and learn the workflow. They are also in a position to slowly launch digital dentures because they have a lower case volume and can contend with the challenges of the learning curve. "We were utilizing CAD software," Berlin says, "so all we needed to do was add a module and pick up a printer to start to learn this process better."
Theberge, on the other hand, feels that moving into digital dentures has been more challenging than transitioning to digital for fixed prosthetics. "Integrating digital into fixed seemed and felt easier because there were fewer parts and our clients would not know the difference," he says. "But with digital dentures, our clients need to do things differently, and we here at the laboratory do, too. Anytime you introduce something new and clinicians need to change their protocols, you are going to get some pushback. Some clinicians don't necessarily like the monochromatic printed try-in and prefer to have a wax try-in. We can do that!"
Client preferences will always influence laboratory processes. "I don't envision us ever going out of analog completely," Theberge continues. "We haven't seen that on the fixed side, and I don't foresee that on the removable side either. We'll still be doing some analog in our lifetime." However, being able to offer both manufacturing options will come at a cost. "If we follow the clinician's preference and it costs more, we need to charge for that," Theberge says. "Laboratories shouldn't have to absorb those expenses."
Nonetheless, Theberge believes that the most critical factor is to assure clinicians that they do not need to change their routine. Ultimately, the clinician wants an appliance that functions well, fits well, and looks good; how the laboratory manufactures it is really not so much of a factor. The key, Theberge says, is providing "predictable, repeatable results that satisfy the clinician's needs and their patient's requirements."
Another concern that could impede the adoption curve for digital dentures is their newness. Paul Edwards, CDT, owner of Paul Edwards Dental Studio in Stockton, New Jersey, worries about the rapid release of these solutions that have not been vetted for the long haul; how will they hold up over time? The FDA's interest in additive technology in the dental field can also be a deterrent. Theberge suggests that any laboratory interested in removable digital dentures should ensure they use only FDA-cleared materials. He urges laboratories using digital denture workflows to realize that if they sell appliances that are not FDA-cleared, they could face serious repercussions. "A laboratory must make sure they have all their materials, processes, and equipment validated to avoid getting into hot water," Theberge says. "As digital dentures move toward a mass adoption curve, the FDA is going to start scrutinizing laboratories more closely and may consider digital dentures as a Class II medical device, meaning even more FDA involvement, no matter the size of the laboratory."
The decision to adopt or not to adopt digital denture workflows, then, lies with each laboratory. More and more are moving to this process for greater efficiency and profitability. The laboratory is able to better allocate its resources. "Our experience over the years is that milling dentures doesn't make sense in our business model," Theberge says. "Printing six to eight bases in an hour and a half—that makes a lot more sense." Berlin reinforces these sentiments; he would rather mill fixed prosthetics, which are more profitable for his laboratory. Another more personal reason is saving technicians' time. Edwards particularly likes the idea of achieving a better work-life balance, where he would work fewer hours and allow the systems to do much of the time-consuming work. "That is a big motivator," he says.
Benefits of Digital Dentures
Many laboratories that have adopted digital denture workflows have seen the benefits they bring to the technicians, dentists, and patients. "The office is so much quieter, more organized, and much cleaner, with no plaster, wax, and stone everywhere," Schwenning says. "The patients are also so interested in how we invest and manage the technology that they get excited to participate." Recently, Schwenning compared the past year that she's been completely digital with the prior years. She was pleasantly surprised to realize that since fully implementing digital dentures, her business has reaped the benefits from an over 80% reduction in patient adjustments. "Numbers don't lie," she says. "It is a huge benefit to the business and patients alike."
Schwenning's experience supports Theberge's. "Our clinicians are just amazed with the fit of digital dentures," Theberge says. "In fact, most of the time, they are in awe of how well even the try-in fits." When the try-in fits so well, the final denture will, too, Schwenning says, and patients are much more confident with the end result and the dentist's service since the process appears significantly smoother, avoiding the back-and-forth required for adjusting traditionally made dentures. "Turnaround times in analog, specifically for the patient, always concerned me," says Edwards. "Digital can certainly help with that and that is what I am most excited about—time."
"Regardless of the system, any time you use digital, you reclaim variables for a better process in consistency, repeatability, and efficiency," Theberge says. Being able to save the case files to reproduce a lost or broken denture easily and cheaply is another big advantage.
"Benefits are truly realized in the engagement and complete compliance from patients," Schwenning says, "mainly due to technology, especially with dental-phobic patients. Technology is a huge selling point because the overall patient experience is so much better. They don't need goop in their mouth; rather, a camera is used to scan where we can stop at any time and continue whenever they are ready to continue. That immediately reduces the anxiety and is very compelling to those with phobia." Wagenseil agrees that, "The patients are preferring the digital dentures for fit. Plus, it allows you to have a digital record of the scans and bite."
For esthetic finishing, Theberge feels that the work is significantly less cumbersome and actually relaxing. "It allows our technicians to do higher-quality work," he says. While Edwards says he is not concerned about competition when it comes to quality, he certainly is concerned with competitors able to provide a faster realized digital denture. "That's something a small laboratory cannot ignore."
File Management
Being able to store and retrieve design files has become instrumental for many offering digital dentures. Schwenning needed to replace three patients' dentures recently due to a variety of reasons—a house fire, the denture becoming a chew toy for a dog, and domestic violence. All the dentures were remanufactured easily because the laboratory maintained the files and stored them on its server. These files can be used for rebasing and making new dentures alike down the road for their patients. Wagenseil cautions the profession and dentists, though, against committing to this model before truly evaluating the options. There is the potential for a patient insisting on a lower fee for a remake because it requires less work now that the scanning and design stages are already completed.
There are great benefits in maintaining design files for the patient, because it becomes very easy to reproduce the denture if it is damaged or lost. However, that presents other considerations for the laboratory: Where are the files stored, how long are they kept, and who carries the burden of costs associated with storage? These are all questions without clear solutions yet. Drake Laboratory, for example, currently maintains files on its server for 3 months and then offloads them to a cloud-based service to maintain for a longer term. Regardless of the location, digital storage costs money. Does the laboratory absorb it, or do they bill it to the clinician, who then presents it as a service charge to the patient? Laboratories are looking at this business decision very closely. Theberge is uncertain if the industry should offer a product like "file storage," which could prove to be a financial and administrative burden for the foreseeable future.
Education
Seasoned technicians approach digital dentures with varying amounts of excitement and trepidation. On one hand, new technology can be energizing to some, especially those who are newer to removables. For others, the prospect of changing their trusted workflow can be daunting. "Change is difficult for many because it relies on us changing the way we normally do things," Wagenseil says. "For my laboratory, it was more challenging because we were learning this while still doing things the old way." Having analog know-how and being able to visualize the end product certainly helps in the learning curve, but it can also make the overall education take longer since old habits need to be broken or replaced. "Even though some experts claim it requires 21 days to form a habit," he says, "I believe it is closer to 90 days because we also do so many other types of work on a daily basis."
Taking some regular time to focus on learning and integrating this new technology has been Wagenseil's method. "It is challenging. My experience has been that you need to slow down. I allocate ‘digital afternoons' where I take the time to learn the digital makeup and software," he says.
New technicians who do not know how to fabricate a conventional denture may be attracted to the new technology but also find digital dentures challenging in different ways. Most younger dental technicians are quite computer savvy and can grasp the CAD elements easier, but "they need to be educated on the prosthetic components and fundamental denture and anatomy landmarks," Berlin says. "There is so much education these days for advanced dental technicians, but there is nothing for the entry-level technicians, and that is something we desperately need," he continues. "We as an industry really need to look at our educational process or we'll be in big trouble. It's a completely different workflow than we have been doing for 100 years, and it requires some education and experience."
Business knowledge is similarly important when a laboratory is exploring its options in digital dentures. Edwards has been engaged in this quest mindfully and deliberately. "If I am not very careful in my choice of how to invest in this new line of business, it could lead my laboratory to financial ruin," he says. "So it needs to be implemented carefully and with a great deal of financial clarity." Whether equipment is bought or leased, each laboratory must identify its best source of funding and evaluate how each choice affects its bottom line when calculating tax base reductions and depreciations. A trusted financial advisor and the business's CPA should look at the numbers and make recommendations on what moves could yield the best outcomes.
Conclusion
To those wanting to integrate a digital denture workflow in their laboratory, Theberge recommends "researching and seeing which system allows for the least amount of difference with respect to your clients' protocols." This would make it significantly easier to implement and succeed with digital dentures. Schwenning adds a note of caution to those who want to adopt a digital denture workflow: "Do not purchase or commit to any specific digital denture solution until you have tried it in your environment to ensure that it works well and helps you meet the goals of your laboratory." She further recommends speaking with current users of the systems to hear about their experiences.
Like with all significant purchases and process changes, each laboratory must do its proper due diligence and complete the appropriate education to make the right choice for its specific needs. "It is a journey. It's not better or worse—just different," adds Wagenseil. "Everyone is going to have a different experience and will have to figure out what works for their individual laboratory and clients."
