3D Print Your Way to Superior Dental Provisionals

I realize when you look at the provisionals, oh, these are terrible. No wonder the patient has lost confidence kind of in what the final can be. And it's also not a prototype for the ceramics. He doesn't know what you want. You're like, make it better. Make this look great for the patient instead of here's specifically the size, shape, and color that I want. Make it just like this, but in a ceramic material. Welcome to the Phil Klein Dental Podcast. The fabrication of provisional restorations is a critical step in fixed prosthodontics. Traditionally, materials like bisacryls and bisgmas have been the go -to options. While these materials have served us well over the years, they come with inherent drawbacks. Working with them chair-side introduces numerous variables that can sometimes lead to poorly fitting and unesthetic temporaries. Fortunately, advancements in 3D printing and materials such as VOCO vPrint are revolutionizing this process. These 3D printed provisionals not only maintain form and function for extended periods, but also serve as a reliable communication tool with the lab. Moreover, they help set realistic expectations for patients about their final prosthesis. Our guest today is Dr. Susan McMahon. She's an expert in leveraging 3D printing technology in her practice. And she's going to tell us why she loves 3D printing for her provisional restorations and how it has transformed her workflow. Dr. McMahon leads the largest cosmetic dental practice in western Pennsylvania. She's not only a skilled clinician, but also an accomplished author, educator, and internationally recognized key opinion leader. She has been honored as a top U.S. dentist more than 20 times and has been voted by her peers as a top Pittsburgh dentist every year for over two decades. Dr. McMahon, it's a pleasure to have you back on the show. Hello, Phil. It's so great to be here. I always enjoy chatting with you about the newest stuff in dentistry. Yeah, and you've had some great podcast episodes, not only in content and what you're actually saying, and our discussions are pretty good, but the engagement in the thousands, absolute thousands. So our show has really taken off. I want to thank our audience for that because they're the ones that are making those numbers happen. A lot of dedicated follows on Spotify and Apple Podcasts, along with listening to it on VivaLearning.com. And of course, we want to thank our guests on the show as well for their incredible content. So provisionals, you know, we all have been doing these since dental school, right? We spent hours on our provisionals when we were in dental school. So where are we now with provisionals? In fact, let's backtrack. Talk about traditional methods. What did we do in the past? Review how this has all evolved. And then we'll get into what modern day dentistry is doing with provisionals and why you do them. Yeah. Well, you know, provisionals are really important, right? Like anytime you do any sort of indirect restoration, you have to protect the underlying tooth in the interim between prepping the restoration and having it fabricated or putting it in. Right. So, yeah. Oh, I remember back in dental school, powder liquid, powder liquid, making just really awful looking things. And now, you know, most of us are using things like this acrylics and this GMA. dual barrel syringe, mixed provisionals. And I've been successfully using those for most of my career, but they have limitations. And the alternative to those are maybe like a pre-made shell that you get done at the laboratory and then you reline it. And most of what I'm doing in my practice is anterior cosmetic work. So I'm working in provisionals every single day. We're prepping teeth and then provisionalizing and... need them for multiple reasons we've got to protect the teeth underneath of course we also want to protect the gingiva and make the gingiva sometimes develop the gingival architecture. And then we're using them as prototypes for our final restoration, kind of a preview for both the patient and for us. And then, of course, we are also using provisionals for single units. Not everybody's milling in their office now. Lots of us are still prepping crowns, prepping inlay-on-lays, and we have to provisionalize them with something before the finals can go in. Yeah, and what's remarkable is... how fast the actual abutment moves. It moves so quickly. I had a lower molar done. And for some reason, the orientation of the abutment was so screwed up that the assistant, as much as she tried, could not get that thing to fit well, the temporary. And it came off four times. And I kept putting it back on at home, you know, in my bathroom mirror. And then the margins broke. So for four days or five days, it wasn't on. And when I came back for the final crown, it was actually a gold crown. The dentist struggled to get this thing to fit, to go on until he found the orientation. He said, did you have your provisional on the whole? I said, it wasn't on for like a week. And he said, you know, as a dentist, these teeth move. And they did. Right. Oh, absolutely. Even like in 48 hours, it can move. It can super erupt a little bit. They measly tilt. You need a provisional to hold that space, right? I think we've all been in that position where we're super frustrated trying to insert something and have had a failed provisional along the way. So regarding provisionals, before we get into the technology side of how you've evolved from traditional methods to using your 3D printer, how much do you rely on provisionals with regard to getting feedback from your patients? while they're wearing their provisionals so that you can make those adjustments and then relay that information to the lab before you move to final fabrication Right. So pretty much any anterior case, we're putting our patients in a provisional prototype, sending them home and saying, you know, I kind of want to get a general feel. It's this kind of the way you like it, about the same size, about the shape. Because oftentimes, you know, we're fixing rotated teeth. We're changing length because people have wear. We're fixing spaces, changing spaces. So there's a lot of change that happens. Sometimes people come in and they're like, here's what I want to look like. I want square teeth and I want to look just like this. And it's all sort of verbal. And I'm trying to get a feel for what they want. And also, based on what I think will look good for them. And oftentimes on digital smile design, we're marrying all those things together and making a prototype. But what I think they want is not necessarily what they think. think they want and what they think they want may not be good for them. So all of those things together, we're able to put it in their mouth and say, go have a look, see how you do. And it's usually about a week for us. And when they come back, we can adjust it or modify it till we get it where they want it. And sometimes we send them home again, but I'd say like 90% of the time we're pretty close. But before we move to that next step to final restorations, we actually have them sign a consent that says, I like my, you know, essentially I like my provisionals and my finals are going to be based on these provisionals. And it, it gives us a really good framework to know that confidently those final restorations are going to be something that we all are pleased with. And it makes it so much easier on the ceramist, right? There's no more guesswork. It's like, this is the size and shape we want. And then we kind of tell them what shades we're looking for and they're able to deliver something that makes. insert and try and insert like a stress-free appointment. So in your career, you've placed tons of provisionals in with the traditional materials that many of us still use. What worried you the most about those provisionals? My concerns with those provisionals were always strength, if they have to stay in for a few weeks, color stabilization, because sometimes they would pick up color. They also lose their sheen a little bit. And I think the very biggest thing is marginal integrity. Even though there's a lot of great materials out there, and they've been better and better over the years, the margins of those are never quite 100% smooth or 100% accurate to the preps. digital technology lets us get more accurate in that department and that can make for even better gingiva, better health along the way. So we've talked a lot about 3D printing on previous podcast episodes with you. I've talked a lot about 3D printers with other dentists and most dentists really like them. There are some though that feel that it's not really helping them that much with workflow. There's actually a lot to do. after using a 3D printer. It's not like push the button and there's the appliance or there's the model, whatever they need to do. And I know you are just thrilled with them, especially for replacing the whole alginate deal with pouring up models in your office. Just that alone is worth its weight in gold to you. So what comes into your mind when a dentist says he or she is not particularly thrilled with a 3D printer? Why would that be when you love them so much? And then let's get into how you use 3D printing to really make high quality provisionals. Yeah, I hear that feedback too sometimes from dentists. And I think it's just a matter of, you know, diving in and really adopting it because, you know, we don't, like you said, we don't, we don't. pour up any more models anymore. There's no more plaster in our office. And it does take a little bit of time to get your team on board and get everybody sort of like focused on using the digital technology. But once they are, they're 100% behind that. So provisional specifically. I'm not sure that we're saving a lot of time at the beginning because there's a little bit of a learning curve to learn how to do it. So you've got to, you can, and this is how we would operate. We would do a smile design ahead of time. We have a design that we're looking for. Then we prep the teeth. And then I'm going to do the final scan on the teeth, a digital scan. And I'm going to take that scan and... my smile design on it and then design the provisionals from that scan. And that, depending on how many teeth, like I recently... did a webinar where I showed a two-tooth case. Designing those two teeth took maybe like less than five minutes to do that. And then that goes directly to the printer. And that's kind of when I'm out of the loop. As soon as it's designed, then my assistant takes over. She takes it from the design to the software, uploads it immediately with the supports on it. It's really simple. It's like a two-click situation. And then off to the printer. And depending on how, what printer you have is how long. it's going to take to print, but somewhere in the like maybe 15 minutes to print those restorations and then cure, rinse, cure, polish. So the total time might take 20 minutes to make those, but that's 20 minutes I'm not, I'm no longer involved with. If I'm going to be in the chair making those out of a bisacryl or a stent, that's me the whole time. And it might only take me 15 minutes to make them. So maybe five minutes longer to print them. But it's not my time. I'm off doing something else. I'm doing a smile consult. I'm doing whatever else I need to do, checking recalls, working on another patient. So there's, you know, it's a little bit of a change in the flow. So when making that transition, if an office has EFTAs that were normally doing the provisionals themselves, how does that work as far as the responsibility with the 3D printer, the design, and then going to the printer? I think many EFTAs are doing single units or bridges posteriorly. They could totally do the entire process. It's going to be a scan. That design is going to take them maybe a minute and a half because it's a library tooth right on there really quick. And I think they could get through the process in a really similar timeframe as it would be them sitting there. So the after you're a trained assistant. You know, the success of your provisional is all about the skill of the operator. And, you know, there's kind of a wide range of skills. And I have always done my own anterior provisionals. And I think a lot of us feel that way. So that's going to work the original workflow plan. But a posterior one, I think that's definitely an EFTA. They're going to get that whole provisional. scanned printed washed rinsed in the mouth within 10 minutes and the advantage to it is the margins are perfect it fits beautifully there's no occlusal adjustments the interproximal fits like a glove and they polish so much better and so much quicker so there's a lot of advantages to doing a printed restoration if you can work that into your workflow so when the printer finishes the actual fabrication of the provisional, and then it's washed and polished. Do you come back and put it in or does your staff actually cement it in and you just come in to take a quick look or you're done already once you finish the design and hand it off to your assistant? Posteriorly, assistant, they're going to finish that off. And to your case, I'm going to put it in myself. You mentioned how precise, accurate, and durable the margins are of 3D printed provisionals. Where do you typically end your margins? Just curious. I'm right equigingival. I'm right at the gingival margin. Pretty much all my restorations, anterior and posterior. I think it's marginal integrity. It's so much better in a printed restoration. But the aesthetics anteriorly are so much better as well because it's the digital design. It's just a better... aesthetic design restoration than you can do by your own hands, I think. And I've been doing it for a long time, and I always thought, oh, my provisionals look great. And then I started printing them, and I was like, wow, this is so much better. Better material, frankly, you know, it's a cured resin. So it's going to hold its shine. It's going to hold its color and no little voids. You know, when you use bisacryl, you get void sometimes or you'll get a little roughness in your surface or you get interproximately. Even if you finish beautifully with a disc, you'll still get a little bit of roughness in there. It's all gone. It's all really, really smooth and nice. So what kind of materials are you using now? And how did you decide on those materials? Yeah, I've been using a lot of the VOCO print crown and bridge temporary material. It has a couple of shades that I really, really like, and it prints beautifully every time. But it also works great for like longer term provisionals and a lot of these anterior cases that are working on. We're replacing older dentistry. Sometimes people are losing a tooth and, you know, we're going through a whole implant protocol where, you know. extraction, bone graft, implant, and later, they're four to six months before you can put anything on that. So we need a really good, stable, and aesthetic long-term provisional. And the VOCO material works so well for that. So in your past experience using traditional methods of making provisionals with bisacryls and bisgmas and all that, you couldn't go six months with those materials without having the patient come back and redoing it, right? Or could you? Oh, I don't think so at all. I think that that would be multiple restorations over time. Even the stronger materials, you know, there's some stronger, longer term provisional materials, but I have never had them hold up as far as like the glaze and the margins like a printed restoration. I'm always remaking those. And even if you get the ones pre-made at the lab, I think there's real limitations to that. I'm never like 100% satisfied with the aesthetics of those. because they tend to be sort of cookie-cuttery. And I also think that it's difficult to get really nice margins on those because you're relining those shells, and the shells don't always line up where you put your margins. Yeah, there's no question. There's so much more human error that goes into the equation when you're doing it the traditional way. So let me ask you this. For those that have intraoral scanners, obviously you need an eye. in order to have a 3D printer. And I assume most dentists are moving into intraoral scanners. And you could tell us yourself, because I know when you do your lectures, sometimes you ask for a raise of hands to find how many people are using 3D intraoral scanners. So I'll ask you for that number in a second. But assuming they have an intraoral scanner, what's the learning curve to move into 3D printing where they start moving from traditional ways of building, fabricating provisionals? to uh printing them yeah it's it's been interesting um now when i ask how many people how many people have a natural scanner i think we're like at 70 or higher like i'm really it's a huge difference five years ago it would be like a smattering so people lots of people have scanners now they're accessible that you know they're they're They're the right price point, and you can use them for so many things. So if you are scanning your restorative, moving to, so a lot of people are using their scanners just for diagnostics, for clear aligners. And then, of course, you can use them for all the other things we're using them for, like occlusal guards, surgical guides, perioprotect trays, things like that. But if you're already using your scanner for restorative, it's very easy to move into printed provisionals from that. So how simple is it to install the 3D printer and get it into workflow? I guess they just ship it to you and it's kind of like plug and play? Yeah, no, it comes in a box and you install it yourself. And I can tell you, I'm not like a Luddite or anything like that, but when I get a box in my office, I'm like, somebody else deal with this. I installed the printers myself. They're pretty easy to do. We have four of them in the office now. So I've got a lot of printers going on. But I installed all four of them myself. So super easy to do. So you get a printer and then you need, once your print comes out of the printer, it has to be washed because it has extra resin on it. And then it has to be cured. So there's always three steps, print, a wash and a cure. But it's really easy to get there. And I think it's probably the most exciting. of all the digital technology that we have. And I think it's the most versatile. Like, you know, we have a mill in our office too, and we're using our mill a lot for posterior single units. But I find us... gravitating toward our printers more and more and we're shifting because they're faster. I think they're really precise. The biggest hurdle I think for everybody is the design step. So it's easy to get the technology. It's easy to set the equipment up, but to go from your scanner to an actual print, you have to design a restoration in between. And some printers have design software included. in them. And they're pretty easy. It's a pretty easy thing. And others, you have to adapt a little bit. Like I do a lot of my design on my trios. So I scan on a trios, I have trios design, it designs really easily. And then that goes directly to our printers. You can use ExoCAD, which I find is very daunting for a lot of dentists. It seems like, ah, that's an open source. And yeah, so you're scanning with trios and using three shape. And of course, there are plenty of other options out there with printers and software. Yeah, there's other, of course, there's other options, but that's what we're doing it on. And it's pretty simple. So I'm scanning on my three shape and then my scan is going to go to my ceramist for the actual fabrication of my final restoration. But I'm using the same scan, doing a quick design and doing the provisional on that. Yeah. What made you... decide to buy more printers and why do you need so many printers? I know you have a pretty big practice in Western Pennsylvania, probably the biggest almost in the whole area, right? Well, we do a lot. I do a lot of cosmetics, right? So we have a very high production office, but I don't actually do a high volume of patients. We do sort of a low volume of patients, but high production. So we're doing a lot of big cases. I see. I see. Why did you need four printers? Because I think I might be a printer junkie. Okay, that's what I thought the answer was. I was just trying to find out what the reason. I didn't want our audience to think, okay, you start with one, but what good is one? You're going to end up buying four. But Dr. McMahon is a printer junkie. Yeah, I self-admitted. So you just feel like you need those printers, obviously. They're not all sitting there as doorstops, right? No, we have a couple. I have an Acureta Soul that's printing these provisionals. And it's a smaller platform printer. So it prints restorations and print really easily. We can print multiple restorations at a time, but you can't print a lot of models on that. So I have a bigger printer that has a bigger platform that we're printing a lot of models on because I'm doing a lot of, you know, we're doing a lot of smile consults and smile design. And we need like, I can print, I don't even know how many models at a time, maybe like 10 models at a time on the bigger printer. And then we're using the smaller ones for these restorations. So it sort of turned into an addiction for me. It used to be. shoes but now I'm into 3D printers yeah my wife isn't my wife's still into the shoes she's yeah I think I'd rather have her buy shoes and 3D printers what was really interesting was I went out to dinner with my wife the other night in a strip mall here in Austin Texas and there was a brand new store that had like 10 3D printing machines and you go in there and it was closed because it was like seven at night and I just looked at this place in amazement this is a probably a chain of 3D printing stores where you can go in and print whatever you want to print right there in the store. I've never seen anything like it. I don't remember the name of the store, but it was very beautifully decorated and very high-tech looking. It's certainly a new kind of business to be in a strip mall, and it just shows you how fast things are moving with technology. Really astonishing stuff. So getting back to provisionals, is there any benefit of printing? provisionals in your office using a 3d printer regarding the cementation of the final restoration yeah as far as like cementation goes i think it's always better margins less plaque gathering at them, less gingivitis. So you're always going to get a cleaner field to cement into if you have a 3D printed restoration, a 3D printed provisional as opposed to any other kind of hand fabricated provisional. So I really like that, especially when working in the anterior with all the, you know, you're putting everything in as being bonded in. So you need clean, dry fields and that really helps. And I want to ask you this question as well. Dentists are always trying to wow the patient. Do you think Printing the provisional with a 3D printer in the office wows the patient to the point where they're impressed and it helps market your practice, even through word of mouth. Because I do a lot of, you know, I've been like marketing for cosmetics for a long time in Pittsburgh. I see a lot of cases where people are getting their stuff replaced. Like they had something done years ago, a few years ago, sometimes right away. They don't like the way things look. And I talk to them about replacing it. And so many times I hear things like, oh, I. Don't want to do that before the holiday, before this wedding, before this, because I had such an awful temporary. It was yellow. It fell out. You had a falling out experience, right? Yes, I did. Yeah. So I love to be able to say to them confidently, I am going to make your provisional look beautiful. I send people to big events in these provisionals all the time. And I can confidently tell you, you will. Love your provisional and you're going to love your final restoration. It helps people move forward, helps them kind of forget about past experiences with ugly provisionals. Sometimes I get people that come to my office in provisionals that had some work done. They're in provisionals. They've had a couple of try-ins and there are doctors like just can't seem to get what they need. And, you know, and then I realized when you look at the provisionals, oh, these are terrible looking provisionals. No wonder the patient has lost confidence. kind of in what the final can be. And it's also not a prototype for the ceramics. He doesn't know what you want. You're like, make it better. Make this look great for the patient instead of here's specifically the size, shape, and color that I want. Make it just like this, but in a ceramic material. Where do you actually put your printers in your office? I was just wondering if it's visible to the patient because it is kind of a wow factor. Our printers are in a hallway. So everyone walks by them and sees them. And, you know, we talk them up all the time. Sorry, that's making so much noise, but we're printing something. Patients are sort of wowed by the technology. And sometimes they'll shoot a video and post it on their social media. And we get a little play out of it that way, too. So as we wrap up this podcast, Dr. McMahon, it's been very enlightening for sure. You mentioned you like vocal products, specifically vocal vPrint. Tell us why you like that and what benefits. Does that material bring to the table? And is that material accepted by most printers? Right. A lot of printers can utilize that material. Some printers are closed systems and they only have their own material. And some of those closed systems don't even have provisional material to work with yet. So I've been using Voco products for a long time and I really like a lot of their other printed material. So it was a no-brainer for me to try this. And I've been so successful with it that I really like it and use it all the time. And it comes to different shades? There's a couple of different shades. And then I also use OptiGlaze on it. So I'll stain and glaze with OptiGlaze to get it a little bit more lifelike. I'll put a little translucency on it. And I'll put a little bit of like warmth up near the tissue level sometimes. And that only takes... Oh my gosh, that's like a three minute situation. Dab, dab, dab. Pop it back in the curing unit for maybe like a minute and then you're good to go and it'll hold its color as well. You know, I've talked to several dentists about 3D printers, as I mentioned earlier on the show, and many of them love it. Some are not ready to adopt it at this point. They think it's too early or it doesn't. have the capabilities they're looking for. It doesn't save them enough time. But I don't think those dentists are seeing the value of a 3D printer from the perspective of fabricating these incredible provisionals that we talked about today from the standpoint of durability, tissue tolerance, aesthetics, communicating with the laboratory, and patient satisfaction, confidence. having the patient really understand what they should expect when they get the final restoration delivered. And I think it's a practice builder, and I think it's the right thing to do. If you can employ a printer into your workflow, I think most dentists would be thrilled with the results. Oh, completely. People, patients have a totally different expectation than they used to. They're not going to tolerate so-so looking provisionals. They're not going to tolerate provisionals falling out, breaking. They just don't have any... for that anymore at all. It's no longer like that. Just bear with me. We'll be, we'll get them in two weeks. They want results immediately. And I completely agree with you. It's all about confidence for them and confidence moving forward to forward treatment and during their treatment to feel good about it. And, and what kind of practice you want to build? It's the dentist is making a statement and saying, you know, to their staff, to their patients, to themselves. This is the kind of practice I want to build. And you'll get there when you have that kind of care that you're talking about doing these types of high-end provisionals, which you weren't able to do in the traditional days using bisacryl’s, bisgma’s, pre-made shells, and so forth. Great discussion, Dr. McMahon, as usual. You always have great stuff, and we love having you on, and hopefully we can do some more of these this year. Thank you so much, and we really appreciate it. Thank you so much. I enjoyed being here. Have a great rest of the day.