Using 3D Fabrication to Improve Patient Outcomes

You're listening to the Phil Klein Dental Podcast. The dental profession is rapidly moving to a point where in-office design and fabrication of prosthetics, surgical guides, appliances, and orthodontic aligners will become commonplace. The time to learn about and plan for these amazing advancements is now. To tell us more about it and share his personal experiences with digital dentistry, the nuances of delegating digital tasks to his team, and many other aspects of digital dentistry, including 3D printing, is our guest, Dr. John Flucke. Dr. Flucke is Chief Dental Editor and Technology Editor for Dental Products Report Magazine and maintains a private practice in Lee's Summit, Missouri, which is a suburb of the greater Kansas City area. He works with manufacturers on cutting-edge product design and new clinical techniques. Dr. Flucke, welcome to the podcast. Thank you for having me. It's nice to be back. We're very happy to have you back on the show. It's interesting because I don't get to see you or talk to you too much, but having a podcast with you is renewing conversation, renewing our friendship. And that's a great gratifying part of my job is that I get to talk to... Very smart KOLs, key opinion leaders that have the experience, and they can share that experience with our audience, which is growing very rapidly. So it's a great way to disseminate information that helps the dental community. So we thank you for that. So let's get right into the topic we're talking about today, and that's technology. And the rate at which things are changing in our society due to innovation is really astonishing. I mean, if you asked very smart people 30 years ago about how technology would be changing the way we live, Most likely, only a few would have predicted the extent in which technology is running our lives at this point. And all of this, of course, affects the healthcare profession, including dentistry. So here's your chance, Dr. Flucke, to make your prediction. Where do you see the most impactful advancements in dentistry? Let's look at a timeframe of the next three to five years. I think dentistry, it started probably around 2008 or 2010 with... computing power just became massive. And that's when we first started to see the inroads of cone beam coming into dentistry. But that, the whole prospect 3D of everything we do now between cone beams and digital impressions, and then the ability to do in-office fabrication of all kinds, prosthetics and appliances. I think the two... big things that we're going to see in the next three to five years are a much greater increase in artificial intelligence in dentistry. And then the other thing I think we're going to see is just a huge impact on things moving into 3D. I've talked for a few years now about what I really envision in the not distant future is what I've been calling the continuously evolving 3D patient. And what I mean by that is, You know, it used to be that somebody came in GP's office and the first thing we did was take either an FMX or we would take a Pano and bite wings. And now a lot of us as part of the new patient, we're taking a low resolution cone beam. And then as part of the patient experience, we also bring people in to do scanning. So we'll do like a full mouth scan with some type of intraoral scanner. What we're going to see happening, I think, is a move to, and you can do it already, but it's kind of clumsy, but it's going to become incredibly efficient and common, is you'll be able to take those scans that you've done intra-orally, and those will merge into that cone beam. And so you'll be able to actually see this is what the patient looks like today. And then every time that a patient comes in, and whether it's just a routine re-care every six months, whether it's... you know, after appointment where they had a crown done or something, you'll get a new scan and that scan is going to drop into that cone beam and you'll be able to actually watch the patient over time evolve in total 3D. And that I think is going to make our treatment planning so much better. It's going to make our recommendations so much better. And the fact that a lot of this is visual and that you can then share that with the patients. My dad told me one time, my dad wasn't in healthcare. When I got my first intraoral camera, my dad was one of the big, I bought it. And he said, if people can understand what their problems are, they'll make better decisions about themselves. And so between the information that practitioners get from all this technology, I think one of the huge things is the ability to pull that up on a monitor right in front of the patient and share that with them. That I think is really going to be a phenomenal uptick in what we do. The quality of care is going to go up. I think the acceptance rate of treatment will go up because we've got so much data and yet we still have or are going to even have better ways of sharing that with patients to include them in the co-diagnosis and treatment plan. So there's no doubt that there's digital information. is a great way to communicate with the patient. They could see things that they've never seen before. It's easier to explain to them. You'll get greater case acceptance. But also what wasn't addressed, which I would love you to address, is how it benefits the laboratory. Because the laboratory, those that have all the digital equipment, can actually absorb all this digital information and kind of reproduce the patient in 3D. The face, the condyle, the whole occlusion, the profile. It's almost like they have the patient in the lab. And this should really ratchet up the kind of restorations we're getting back from the lab. I mean, literally, reproducing the patient in the laboratory is something that was not even a pipe dream, you know, 10 years ago. You know, that's a great point. When I first got into, I started with digital impressions in the late 90s. I actually had a CEREC-2 in my office. Believe it or not, we actually booted that with a floppy disk. That's how long ago it was. When I, in the late 2000s, when I started to do real true digital impressions and send those to a lab, in the old days of stone and pendexes and that sort of thing, there was a certain amount of play in those models. And the dyes were just a little tiny bit wobbly. And oftentimes you'd get a case, even just a single crown, you'd get it back from the lab. And the context wouldn't be right, or maybe the inclusion was just a little bit off. And one of the things that I didn't expect when I went totally digital for my prosthetics is how rare the need of adjustments is. In fact, I deal with a small lab just about, I don't know, five or 10 miles from my office. the, the guy that owns the lab, it's a real small lab. You have 10 employees. And we kind of have this joke now where we say it doesn't matter because it used to be that I would do a, an anterior case, maybe doing, you know, five through 12, six through 11 or whatever. And we used to have to be really careful. I would always talk to the lab tech and I would say, okay, what order to put these in? Because anybody that's done that has had those cases where you, you try them in and. Oh, I put in eight, then I've got to put in six and then I have to put in seven or they're not going to line up quite right. And a lot of that has to do with just the defects that we had in the analog way of doing things. And when we started doing it digitally, I would call the lab and I would say, OK, what's the order? And he would laugh and it doesn't matter. And I was like, really? He's like, yeah, it doesn't matter. They're all going to go in. And I was cautious at first, but now it really is true. If they fit the models when they come back from the lab, they go in the mouth exactly the same way. And so we'll do cases and we'll just joke to each other. It doesn't matter because you don't have to factor in all the what if and worst case scenarios. And you're right about sharing that information. I mean, there are systems that are coming to market. that have sensors that you actually attach to the patient's face and a camera that records those movements. And you can then integrate those 3D scans in the cone beam with this data. And it actually becomes a digital, fully functioning articulator. And we all know the benefits of an articulator if you're doing lots of restorative, especially full mouths or an entire arch. giving them all of that data. Here's exactly how the patient moves. Here's exactly how the teeth appear. Here's, you know, exactly how the joints respond when they go into excursions. That helps them so much. And of course it helps the doctor so much, but really the thing that I'm paying is helps the patients so much. My, my big deal is things that benefit patient outcomes and providing all of this. data easily and predictably to the lab just makes the clinical outcomes better for the patients. And plus it decreases stress. You know, I think if you've been practicing for a while, we've all had those situations where, you know, you're putting an anterior case together and you're bonding them in and you get to the last one, you're suddenly like, wait a minute, this doesn't fit. like it did a minute ago. Now you've got cement starting to set, bonded material starting to set. You're like, what's going on? Why is it not lining up quite right? That just doesn't really happen too much anymore. It's always great to plan for the worst case outcome, but those worst case outcomes are just really rare. Yeah. So typically, and this applies to just about anything, Dr. Flucke, when someone changes the way they've been doing something for many years, it can be a little frustrating and even painful. And doing something differently that you've done for so long can certainly hurt the flow of things, essentially disrupting what we call workflow. We've heard workflow in every CE course you take, you hear the term, you know, digital workflow. So how do you recommend handling this and overcoming the pain points during the transition period when you're moving away from analog dentistry and you're starting to enter into the world of digital dentistry? Well, I tell people all the time, I even tell people that aren't in dentistry, life is like orthodontics. If you make gradual changes, it's a lot easier and nobody really notices that much. But if you try to move teeth in a weekend, you know, the patient is going to be miserable, their body's going to be miserable, probably the results will be miserable. So the two things that I really think is important is number one, get your staff involved. You've got to have buy-in. They have to be all on board with it. Human beings are creatures of habit. And when you put a patient into that mix, we're performing, whether we're going to admit it or not. The way we respond to the good and the bad when we're with a patient. affects their perceptions of what we're doing and what the outcome is going to be. And nobody wants to struggle, especially in front of someone else. It's very similar to, you know, being on stage and suddenly the microphone doesn't work or one of the lights goes out. And it's important to get your team all in this. And so whenever we bring in a new technology, we always have a staff meeting. We always talk about it and we kind of gameplay it and strategize it, you know, okay. You know, I'll give a for instance on this is when we started doing full arch digital scans. Our patients, it was like, OK, where are the pain points? What's going to go on? And the hygienists were like, well, we're not really sure how to do that. We don't know how to run the equipment. So we said, OK, well, we'll set up training and we'll get everybody trained by a competent trainer and we'll get you all up to speed and going. And then after training, how do you feel now? We're good. We're ready to go. We understand. And then, you know, in the meeting, we talked with the entire team. And when the hygienist said, we don't really know how to do this, the assistants and said, well, what about us? What are we going to do? We've been scanning for a while and we know how to do it. But what do we do if we need to scan a crown case and we've got hygienists that needs to do a scan on another patient? We only have one scanner. What are we going to do? And so we role played that and kind of figured that out. And actually, long term, we ended up with two scanners in the office, which really decreased that. But I think it's important that the staff knows what to do and they have the buy in with that, because if a hygienist needs to take a scan, but the assistant. has the scanner, chances are the hygienist doesn't want to say, okay, well, we'll just run 15 minutes late. I'll make everybody else on my schedule, you know, wait longer. And I'll try and make conversational happy talk with you while we wait and nobody wants to wait. Chances are they'll say, you know what, we'll just do that next appointment. And then you don't get that date. So I think kind of... playing this from a strategy standpoint and figuring out, you know, what do we do if this happens? How do we handle it? You know, when these things go wrong, one of my mentors, who I thank every day for taking me under his wing, he wants, he's a surgeon and he once said, Flukie, if you prepare for an emergency, you cease to have one. And I thought that was so true because if you know what to do when things go wrong, then When things go right, it's that much easier. And so I think bringing the staff in on that is number one. And then the other thing that I think is really important is to realize, even as the doctors, you're probably going to struggle. Now, some of these technologies, you know, I don't take many cone beams. My staff does that. I don't scan very many patients for anything. My staff does that. But the doctor needs to be knowledgeable about it. The doctor needs to know the insets of it. So, Dr. Flucke, let's talk about the single unit crown. What kind of time allotment do you allocate for that in your practice? And how do you ensure that everything runs smoothly from start to finish? When we started doing digital scanning for about the first month, maybe two weeks, it wasn't a long time, but we said, okay, crown appointments are two hours. And the reason for that is... If we run over, we've got a cushion built in. If it takes us a little bit longer to do something, we're not all stressing. The people at the front aren't looking at patients that are tapping their feet and looking at them because that's stressful. And we're just in the back doing what we do and providing the good outcomes. So I think also realizing that when you first learn to do something. it can be intimidating. It can be a little difficult. And if you're really ready before you start, number one, and then number two, if you know you've got adequate time, then you don't want to go back to the old way. Because the easiest thing to do when things go wrong, humans are creatures of habit, is let's just do it the old way. Throw this out the window. Let's just do it the old way. Let's get back on track. And the problem with that is it's kind of like the smoker who says, I'm really stressed out. I'll just have one cigarette. And then that one leads to two and, and on down the road. And it's easy with technology to do that too. It was so much easier though, but let's just do it. We'll worry about that next week. And that's why things end up being coat racks or just being, you know, dead expenses at an office is you move away from it and then it just becomes that much easier to not use it. And so by looking at all the. The speed bumps that you may have and smoothing those speed bumps out before you start, you decrease your stress level, you increase the acceptance for yourself, the doctor, for the team, and for the patients. And that just makes the whole transition process that much easier. So I've talked to a lot of dentists about their journey into digital dentistry. And for those that have the intraoral scanner going and they're very comfortable with that, for them to integrate a 3D printer was rather easy. not a steep learning curve at all. The staff picked it up pretty quickly. The design software was very intuitive. And before they knew it, they were printing provisionals, appliances, and so forth, surgical guides. So tell us about 3D printing in your experience, what you're doing with it, how long you've had it in your practice, and is it at this point an indispensable tool for you regarding your workflow? 3D printing is really amazing. I'm not very good with numbers. When I went to dental school, when I was in high school, I went down to the dental school here in Kansas City, which is where I ended up being accepted. And I asked him, what courses do I need to be accepted from undergrad? And I thought for sure they'd say calculus one, calculus two. And at the end of the meeting, I asked the admissions lady, I kind of smiled. I said, how much math do I need? And she smiled back and she said, can you count to 32? And I said, yes, ma'am. And she said, that's pretty much all you need. And I was so grateful. And, you know, 3D printing is such mathematics in how it works. But thank goodness that I don't have to deal with that. It's just an amazing thing. So we've been printing now in the office for about five years. And we do surgical guides for implants. We do some temporaries occasionally, 3D printed. We don't do any fixed, permanent fixed with yet. I don't like to experiment on patients. So I'm kind of sitting on the sidelines and watching how that evolves. But there are a lot of things that you can do. I mean, mouth guards are huge, clue guards, full arch temporaries for seeing. With something like VOCO's V-Print CNB10, when you're doing a full arch, if you can print those temporaries, actually have them ready before the patient leaves with something that, you know, it's not going to stain, it's not going to break. And the great thing about 3D printing in those situations is if, heaven forbid, a patient's call and they say, you know, I broke one of the teeth, well, then, okay, do you have your phone? Yeah. Can you just take a picture and show us basically where in your mouth it broke? So, you know, if we're doing an upper arch and a patient says, one of my molars broke, well, that's kind of a diffused question. So if they can just take the phone and snap a picture, we can look and we're like, reprint number 14. And when they walk in the door, all you've got to do is take that temp off and put the fresh temp on because they're identical. And that's one of the great things about digital. is their, their ideal. One of the other great things about 3D printing is printing dentures. And I've got a friend of mine who actually goes so far as he actually prints two dentures because he knows they're going to fit well. And he actually tells the patient, I, you know, I'm going to give you this extra one, take it home. He gives it to him in a box bubble wrap. He's like, take this home. Put it somewhere where you know where it is. And heaven forbid you should drop it and your upper denture break in two or, you know, gosh, shatters. You've got one in the closet. And it's identical to one that we just made. So we know it's going to fit. We know, you know, we can get you taken care of. And if you want to have enough backup, just call us. If you've accidentally broken the normal one and you're wearing the backup and want that bolt and suspender to have another backup, just call us. We'll print it. And then when it's done, we'll call you. You can come by and pick it up and you can put that in the box. But we can agree, Dr. Flucke , that the 3D printed denture is not as strong and durable as the traditional denture that's fabricated through a heat pressured system. Correct? Not yet. Correct. Yeah. They're strong. But they're not as strong, I'll gladly say. Yeah, I mean, I know some dentists are using 3D printed dentures as interim dentures. These are dentures that are not designed to be a final denture for the patient. But in your practice, when you print 3D dentures, what are your expectations for that denture? I expect them to, now we haven't done a lot of them, but they've gone very, very well so far. Now, I think it's important that you tell the patient. You know, this is something new. It's not quite as strong. And we let them make that decision beforehand. You want to do it this way. It's faster. The fit may well be more accurate. But we do have some issues where there's potential strength issues. One of the reasons, you know, why the two is a good idea. And I like to get them involved. You know, a new material comes out, for instance, for Crown and Bridge. I always tell patients, don't have a long track record, but they're gorgeous. And I can tell you that I would put it in my mouth, but I want you to help me with this. I tell people kind of like a dental tour guide. I tell you what we can do, and you kind of tell them if that interests you. And I think, once again, the buy-in part of that is really big for patients. I think it's probably because we do a lot of tech in the office and people kind of expect that when they come in. But probably 75, 80 percent of the time, people are all in with doing it a new way. They kind of like being involved in the process. And, you know, when we started billing crowns in -house, we booked longer appointments and we told the patients, this is something new we're going to try. If it doesn't work out the way we want it to, we'll always go back to the old way. you know, and get the good result to be interested in letting us do this. And I've never had somebody say no. Usually people are like really excited about it. You know, it's like, yeah, I'm all in. I'll try it. In your opinion, how far are we away from printing crowns and bridges that can compete with the strength and durability of a milled product, chair side? Yeah, I think, you know, this is my own opinion. I think ways still. They're now, they have resins with glass in them. So you're getting the aesthetics, the polishability and that sort of thing. I have been stung a few times in my career by trying new materials and had them burn or had them debond on a regular basis. So I'm always a little... on the adoption curve when I'm putting something else in somebody's mouth. There are people printing and putting restorations in the mouth right now. And from what I've seen, they look good. But I want to sit on the guidelines for a little longer and just make absolutely sure. I think we're close. I think within five years, we'll probably be there. We're further along now in 2024. for as we're recording this than I thought we'd be in 2019, for instance. I think we've come a long way. And there are so many smart people in research and development and what we do. The chemists and the engineers are just brilliant. And we'll be there. Yeah, you mentioned VOCO as a company. They're very strong in R&D. They have a tremendous research and development team and laboratory and manufacturing plant in Germany. So the materials that you mentioned that you use from VOCO, are those materials specifically for provisionals, temporization? Yeah, it's a provisional material. There's a denture material. And also they make a really nice material for occlusal splints called B-splint comfort. That stuff is really amazing. Get it out of the machine. You polish it. No bad taste. And once again, if somebody should lose it or have a problem with it, call us. We'll just make you another one. So their temporary material is really good. Their denture-based material is really good. And I think their splint material is really good as well. And you're right. They do have incredible R&D arm. I'm lucky enough to actually take a tour of the factory in Germany last year. And, man, I'm telling you, it's too bad that the companies – and I get it because you don't want to be giving your secrets. But it would be so nice if they'd let me take some pictures. of some of the facilities I've visited because dentists would be amazed at the amount of science that goes into bringing a product to our patients. It is just mind-blowing. Yeah, and what VOCO is also good at is getting the opinion of key evaluators that are in the mouth all the time, like yourself. And talking to them and releasing products before they release it to the general dental population, professional population. And they'll ask, you know, Dr. Flucke, what do you think of this? Where's the weaknesses? You probably are an evaluator for them as well. I know they send their products out. And then they take that feedback and go back to the lab in Germany and tell their PhD people, hey, listen, this works great. But practically, this is where we need to improve it. And then before they release it to the dentist, it's been through several iterations of this, which. again, really make the product better. And that's, you know, as a dentist, as a practicing dentist, we have so many things to worry about. You know, let the company work out all the bugs first and then sell it to me. So in closing, Dr. Flucke , and you've come up with some really insightful narratives here about how to handle the transition into digital dentistry and where you delegate in your office, what you do yourself and what your staff does and some of the... things that you have to think about when having one scanner in the office and when the hygienist wants to use it and the assistant wants to use it. You know, how do we handle that? These are all things that, you know, you learn sometimes the hard way, unfortunately. But in wrapping this one up, tell us what you say to a dentist when they say, you know, I'm 57 years old. Maybe I'm close. Maybe I'm 60 years old. I've been practicing a long time. I've been doing it the traditional way. Do I need to get involved with digital dentistry? I'm not a practicing dentist right now. I'm a retired endodontist. But before you answer that, I would say one reason to get into digital dentistry and make that move is to get your practice into that workflow so that you have something more to sell if you're looking to exit. Because now you have a fully running digital practice that a younger doctor who's coming into the scene will say, hey, this is ready to go right out of the box. I can start working up to the gold standard of what I want to be producing in the office. What is your answer to that? When a doctor says, yeah, for me to learn all this stuff and how am I going to get a return on investment on this? What's your answer to that? I think what you said that Klein is prophetic because truly, you know, when I came out of school and I'm really going to date myself with this, but I didn't learn gold foil, but they taught us all about it. If I would have gone into an office and asked, where's the amalgam? And the doctor would have said, oh, well, all I do is go foil. My patients love it. It works so well. I would say I don't know how to do that. And that would have affected, even if it was the best office on earth, that would have affected my decision making. Same with film. Offices now, everybody's digital. And students aren't being trained on film and processing and all that sort of thing. There's been a real focus in education on moving into new innovation, new things. And new dentists that are coming out of school are super excited about doing things in a state-of-the-art way. If somebody says to me, my office is for sale, it's $100,000. I don't have a curing light, for instance, or I don't have digital radiography. The first thought is, okay, if I'm going to buy the office and I want to do digital radiography because I'm going to, what does that cost to me as the buyer? And so I say, well, gosh, you know, if that's going to be, I'm just making up a number, $20,000, well, then the office is no longer worth $100,000 to me. It's worth $80,000. And so if you want to be able to have people interested in your office. I think that you need to work in this direction. And there's two more points I want to make on that is that young doctors and new doctors want to do this. They really want to be difficult. The other thing is it's fun. We love learning things. But the third thing is the outcome for the patients. The outcomes for the patients with these types of digital systems are just so, so much better. what we've been able to do in the past. That I think we owe it to our patients to do that. And the other thing is too, I think as a doctor that's been at this a while, I got my dream. I owned my own office. I called my own shots. I did what I wanted to do. I lived my dream. But if I don't let other people live their dreams, if I... let this office close or sell the records. That's just one less young doctor who wants my dream, giving them a chance to get it. So I think we owe it to our patients. I think we owe it to the profession to be better and to pass the dream along to the next generation. Well said, Dr. Flucke. Appreciate all your insight. For those of you who are interested, Dr. Flucke has a webinar on demand on VivaLearning.com. It's titled Implementing 3D into Digital Workflow. So take a look at that when you get a chance. Thank you very much, Dr. Flucke. We appreciate your time. Thank you, Dr. Klein. It is always a pleasure to be here.