Opportunities and Challenges with 3-D Printing

I had bought a closed system printer before because, you know, the sales pitch, you could do everything with this, but very disenchanted with the materials. They were either cloudy, they didn't hold up well, they just weren't satisfying my needs. I'm like, well, what good does this do if I'm locked into the materials that I have to use? Welcome to the Phil Klein Dental Podcast. We're all hearing about 3D printing, not only in dentistry, but everywhere. I recently saw an ad for a company that actually 3D prints single-family homes. Essentially, this technology continues to evolve and has infinite possibilities. But for this episode, we'll be focusing on how 3D printing can be an invaluable tool to help us fabricate the appliances we need for our patients. We'll be talking about the machine itself, as well as the materials that go into them. So if you're thinking about incorporating 3D printing into your practice, stay tuned for a very interesting episode. Our guest is Dr. Jeffrey Horowitz. a seasoned clinician and educator who is passionate about dentists seeing themselves as oral and facial health care physicians rather than tooth mechanics. By embracing digital technologies, Dr. Horowitz has improved the quality of care for his patients while increasing efficiency and reducing the costs to provide these much-needed services. He believes that within 10 years, almost every GP will have a CBCT, an intraoral scanner, and 3D printer in their office or within walking distance from their office. Dr. Horowitz, thanks for joining us on our show. Phil, it is great to hear and see you again. Yeah, it's been a long time. We saw each other in Scottsdale, Arizona for a program in the past with some key opinion leaders, which was a great program. I think it was at the Spears Center, and we actually did a live podcast from there, but it was great. Yeah, great seeing you there with all the other KOLs, and I'm glad we get a chance to kind of regroup a little bit here on this podcast. So tell us to begin about your dental practices. Now, we're going to be focusing on 3D printing, but I just want to give the audience a background about your dental practices and tell us why you felt the need to incorporate 3D printing into your workflow. Yeah, no, I think that's a great question. So I started out with a restorative practice, did a lot of... orthodontics did a lot of tmj work in my restorative practice in conway but really began to focus my practice more into functional dentistry into all the things that make dentistry fail not addressing the bite not addressing a tmj problem not addressing sleep apnea problems and so as i began that real focused learning track. I ended up developing another practice called advanced sleep and TMJ centers, where I only focused on that, opened up a satellite for that, which then ended up growing into another restorative practice, totally going the wrong way at my age, just ramping up. But where my primary interest is in functional dentistry and the problems of the past with traditional functional dentistry is there's just this huge lag time where you couldn't really do anything for patients right away. You couldn't make them a good quick splint. You know, you had to get to mounted models on an articulator. You had to get to, okay, now I've got the mounted models. Now I've got. to first design what i'm going to make for them what's the diagnosis and then you have to first get it to a lab and then there's that two to three week lag time there so there's always been a need for for more immediate treatment and what i believe is now more accurate treatment so now i've got these separate practices and i have a lot of need for for immediate and and high quality treatment for my patients. Now, did your desire to get into this kind of dentistry come first? And then when the digital aspect became available for the efficiency that you're talking about to expedite these appliances to treat these patients, then you said, okay, I'm going in on this. Now I've got what I need. Or did the digital technology with maybe some interest in, for instance, airway services then drive you to do this? No, it was the prior. It was that I've always had an interest in this type of work. I've always been into technology. So, you know, I was an early adopter of CEREC and 3D printing technologies. And I loved what that was able to afford, especially once I saw that the quality was not going to suffer, but that. In fact, we could make the quality improved with more immediate results, less time for patients to have micro leakage, no temporary, less emergency visits. And so this was really exactly what you had mentioned, where before it was so painstaking to take a patient from diagnosis to therapeutics. The time lag was horrible, and I felt so bad for these patients. And what do you do when you have that lag time? You end up using pharmaceuticals to try to mask the problem that really you want to address as quickly as possible. Yeah, and I think what you're addressing, especially with airway issues, is just so critically important in dentistry. And I think we're moving more towards that, where more dental clinicians are getting into airway services. They're becoming airway-centric, they call themselves, which is very, very important considering the percentage of people that have maybe not full-blown obstructive sleep apnea, but they have... issues that could obviously preclude successful restorative dentistry long-term when you are breathing through your mouth at night. Most of our audience understands why. So you're in this infinite loop of dental restorative care with the lifespan of a crown being much shorter than it otherwise would be if you weren't breathing through your mouth, among other issues that, of course, mouth breathers and snores. have problems with their relationships and everything else. But it's becoming much more popular than in the past, this kind of focusing on error-centric and the kind of things you're talking about. And 3D printing is certainly coming to save us from the aggravation, like you said, the painstaking aggravation that all this entails, doing it the old -fashioned way. Obviously, you've been in the world of digital workflow, as you said, for a while. But if you could, in your memory, go back to the earlier days, Dr. Horowitz, tell us how difficult it was, if it was difficult, to move from traditional workflow, analog workflow, to digital scanning, and then more specifically, 3D printing. Great point, first of all, about sleep apnea, because one third of the patients going through any dental practice are going to have the signs or symptoms of sleep apnea. And we know, as you said, gastroesophageal reflux. We know clenching, grinding. We know narrow arches, malocclusions. There's just so many things that come with that. Dentists really all need to at least have a basic understanding of this topic, even if they decide that they're not going to treat it. But going back to your question of the typical workflow. Let's take it from a TMJ patient standpoint. So the first part of that was always a detailed examination. We didn't have CBCT in the past. We actually used something called an axiotome, where rather than the computer making the images in three dimensions, we actually moved the patient instead of the computer making the slices. We actually moved the patient to make the slices. So just getting the x-rays was one thing. But now we would also have to take digital images of the teeth because the occlusion tells us so much about what's going on. If it's a foundationally based problem, if it's an occlusal muscle driven problem. And so what did that involve? That involved. alginate impressions or maybe a pvs substitute more recently than having somebody pour that up doing some kind of a face bow transfer um getting the case mounted and then being able to bring the patient back to review that diagnosis and try to show them on this you know, articulator, not the easiest thing in the world. So now we move to scanning technologies where we can show them the signs of bruxism. We can show them, you know, the fractured teeth. We're getting the images of the teeth as well. So it's your intraoral photography. It's your models. And now we have the ability to mount that on a virtual articulator right there on the screen. And so we can begin to really get to diagnosis faster, which then allows us to get to treatment. So where before it was one appointment to capture data, one appointment to bring them back and discuss. diagnosis, then potentially a new set of impressions and bites to go to whatever therapeutic modality that we want to implement, and then bringing them back three weeks later. Now at that first visit, we scan them. We have our images. We have our CBCT. I can couple those things together. If the patient says yes that day, I don't need another scan. I don't need to report any models. I might just take a different bite registration, something to hold them in the place where I want, scan them, and then make them something that they can have in their hands the following morning. And there are some things that I still 3D print. There are some dicetyl resin. appliances that I make that still need to be 3D, excuse me, not printed. They need to be milled actually. And it's just the type of milling machine you need for a full arch mill like that is just beyond what I can have in the office. But most of the solutions are really printable. Right here in my office. And I don't even do that. I mean, I walk out of the room and Cindy has something for me if it's the morning, potentially by the end of the day, or if it's the evening by the next morning. And even if I have to have a lab processed therapeutic model, then I still have something to give them right away. So the patient communication aspect of this is a game changer compared to the past, right? Just getting case acceptance, just getting them through case acceptance so that they can visualize and understand what your plan is. Well, you get it, Phil. I mean, you've been in the profession for a long time and patients get burnt out. It's like I'm on my fifth visit. Nothing has happened. Right. Right. So, you know, whatever we're going to do, whether it be a neuromuscular appliance like a deprogrammer, we can 3D print that. right away, whether it's just, you know, going to a full arch splint situation for neuromuscular or for TMJ internal derangement discrepancy. Again, I can take this, even if I'm not the one designing it, I can still get it done typically within 24 hours. You know, there are three specific steps that everyone has to understand. There's data capture. Then there's design, and then there's print. And so most dentists don't want to spend their time in the world of design. Now, I've become an ExoCAD user just because it's hard to, when you want things as specific as I do, it's hard to do that with the laboratory. But there are times where I don't have the time to design a splint, and my lab knows what I like. and i can send it over to them and within a couple of hours they've got an exocad designed for me to review and then boom it goes straight to my printer from there and how much work do you have to do once it's printed how much like what we call in the editing business post-production post -production right so for cine there there's typically a polymerization Cindy is my TMJ assistant and does all of our 3D printing. I'd love to tell you that I know all the numbers and settings and all that. That's a podcast for you and Cindy, actually. I understand the science and I understand the basic principles, but most of the post-production and the nuances of printing, she is just amazing at. But typically... know 30 minutes um once it's out and you know depending on what it is you're printing and depending on how many so sometimes we'll have three or four splints that are being printed at one time and of course the print time is going to be a little bit longer for that um sometimes we're we're printing one and you know within you know within a couple of hours we have our finished product now do you think uh dentists that are using 3d printing are getting their staff trained under the design work end of it so the dentist doesn't have to get involved with that. And eventually the staff becomes very, very competent at designing most of these appliances. Or do you think, is that something that's becoming more common? So I have not done that. The thing is, so when it comes to like 3D milling, I did have my staff very involved in that. When it comes to 3D printing, Design can be a little bit more nuanced. There's a lot to it. And so typically I'm either designing it or the lab technician and a very specific lab technician that I've worked with, he will design it because he already knows all of the idiosyncrasies that I want fulfilled in whatever appliance it is that I make. But with that said, once that design is done, that design goes right to Cindy. She puts it in the nesting software and she handles everything from nesting the design that was done to printing it to the post-production work and polymerization. So let me ask you this, Dr. Horowitz. What are some of the bigger challenges that our audience should be aware of and possibly anticipate? when it comes to actually making that transition from analog dentistry to digital. And usually the process is they get a scanner. The next move is to get a printer. And those are the first two basic things. And, you know, tell us that journey. Like, what are they? looking at as far as kind of pain points in the early stages of that transition. You know, so one of the biggest disconnects that I have seen has been in getting dentists to understand everyone was out there talking about digital. Oh, look what I can do. I can take a patient from A to Z and I can do that in, you know, less than 12 hours like I'm talking about now. But no one, there was very little education about how you go from data capture to design. to nesting, to printing or milling. And I've got to tip my hat to VOCO for this because... Voco is a company that I've worked with because of their dental materials for a long time, the excellence in dental materials. And they actually offered me the opportunity because I was going down this path of 3D printing and I didn't want to get pigeonholed into having to use one specific printer that only allowed. for certain materials, in other words, a closed system. So VOCO offered me this opportunity to come out to Kuxhaven, Germany, where their plant is, and I got a full guided tour filled. blown away blown away at the r d and i mean literally you could eat off the floor and by the way i did eat off their floor because yeah they did serve me a bratwurst that fell on the ground i'm like this place is clean enough right i'm eating it yeah i'm not here that often to let this thing go in the garbage so it's actually very interesting though for a clinician who's in the operatory to have the opportunity to go to germany in this case for voco And I am familiar with Voco and they have a phenomenal R&D department. But to actually see what goes on there, the amount of work and then they it's just amazing. It's really amazing. And you had that opportunity. So what did you get out of that trip? How did that help you clinically? Oh, this this actually solidified my 3D printing journey because. i had bought a closed system printer before because you know the sales pitch you could do everything with this but very disenchanted with the materials and you know they were either cloudy they didn't hold up well they just weren't satisfying my needs i'm like well what good does this do if i'm locked into the materials that i have to use And so my goal for going out there was to really press the scientists who know way more than I do about the nuances of design printing and certainly about materials was to say, OK, let's take this from the standpoint of what are the ideal materials for each given situation? And what do you have? And then. with those materials, what options do I have to print those? And so this is what blew me away was, and I wasn't even really familiar with a lot of VOCO's 3D printing materials, but they literally have a printing material for just about every single option. And here's the other thing is their scientists have figured out a way to not have a lot of sediment. in these printing liquids i don't know how they do it because in almost every printing system they tell first thing you have to do you have to shake the bottle up right and and because there's going to be a lot of sediment and god forbid if you don't then you have inclusions in your appliances and the strength is gone um So, you know, that was the first thing was going, okay, Voco's got some pretty amazing 3D printing materials, but then came out a question, can I use this in my closed printer system? And the answer was no, because company X just wants to sell company X's. That's a typical business move. I mean, that's nothing new. But it's not really best for the patient, not really best for the practitioner. So I took it from that standpoint. And then I said, OK, they said, you can use our materials in any open printing system. And I said, all right, well, you know, what would you recommend then? You know, you are working on these. What are the machines that you have sitting in your laboratories? Because I'm listening to you. You know, you're the guy with the fancy hat and the mask on and and with the calculators and everything. And and so the thing that came across from that was Voco had actually developed their own 3D printing system, but was always. uh intent on keeping that an open system because they didn't want to be seen as that company you have to use our materials we want you to use our materials because of how great they are not because we're making you use them and so they offer an option for their uh you know people who are just very devout to to voco um they have a a machine called the soul flex which is a very nice printer But the other printer that kept coming up was a SIGA, which is not a very well-known name in dental offices, but almost every dental laboratory has one of them in. Where's that made? Where is a SIGA made? Australia, I believe. I believe it's made in Australia. But we do have an SIGA distributor here in America. And so I said, okay, good enough for the scientists. good enough for me, actually approached Asiga and told them that I was really off on this mission to kind of simplify the whole 3D imaging to diagnosis to 3D printed solutions. And I would love to get one of their machines in to sample and then purchase if it worked out well, because I really want to preach about open systems and using the highest quality materials. You did buy that machine and it's worked out really well. I ended up buying the Asiga and I, you know, listen, I still have my old closed system, which we'll use for some simpler modalities. But when it comes to the high strength that I need for a deprogrammer, for a TMJ splint, or for a temporary airway device, I'm going to go with these V-print materials, which are made by VOCO. And again, I don't want this to sound like a commercial. I'm just telling you my experience with the VOCO materials. And there are other good materials out there. You don't have to use it. My suggestion and my message to everyone is... Find the best materials for the job and then make sure that they can be used in whatever system you have. Don't get locked in by one particular manufacturer to say you've got to use these materials. Right. But in order to know that the material is what you want, you have to use it, which is much different than doing a direct restorative where you don't need a printer. So in this case, you actually should start with an open type of system for your printing. Just for that reason is a really cool thing, too. And this is, you know, you could say kind of I had a little honeymoon with them because of everything that they offered, because, you know, again, my mission is not to go out there and be a spokesperson for any one company. is to make dentistry simpler for patients and more effective, you know, simpler for dentists and more effective for my patients. And so, but part of that honeymoon was like, okay, you want us to print you something? We'll print it. They actually have it on their website, Phil, where you can go on and they will print you from any of their materials so you can feel and hold it. All you have to do is, you know, send them the information. The other thing that they've done too, which, you know, again, this is kind of going above and beyond, is they've put an ROI calculator on their site as well to show dentists, look, even if you don't want to get into TMJ or sleep like I do, If you're just finding the bruxism and doing occlusal splints and guards for kids and things like that, you can really make 3D printing pay in absolutely zero time. But the open system is just paramount. So for a second, Dr. Horowitz, let's pivot to the general practice who is not invested in digital dentistry at this time. They're primarily analog. They may use a lab that has digital tools, of course, but in their office themselves, they're pretty much analog. Talk about the three main digital tools that you would recommend for a GP to invest in and integrate into their workflow and prioritize them, not only for their practical use, but also for their return on investment. technology items that we can have in a dental practice one is cone beam imaging two was having a good quality scanner um the cost savings there on everything you can do with that the roi on that is right there and then three is a printer now notice i didn't say milling even though i said i was an early and i did get an roi on that and i still do to this day but if you think about what a mill machine does is it pretty much does one thing it makes crowns for us right right and outside of that and there still has to be a design process in the office if you want to get it to the patient that same day so there was really even though there is an roi with with milling and and i certainly found it I don't think investing $20,000 or $30,000 in that for someone who may be far along in the game makes much sense. With 3D printers coming on the market at most under $10,000, and think about what you can do with these you can make splints you can make surgical guides you can make temporaries you can make dentures denture bases custom trays literally anything and you know the the problem with same day dentistry with milling was that do we want dentists using their most valuable commodity which is time to be in their designing It's great if you can get an assistant to learn that or you can train them to do that. But there was definitely a back and forth, you know, kind of a dance that you had to learn to do that. In this case, with 3D printing, because of all of these different procedures, and we're not saying it has to be done within the hour. We're just saying... know in a more condensed amount of time and at a much much much lower price point and and if we can do that and not have to be forced into doing our own design listen i'm just doing that because i'm a nerd and and i'm a control freak but you don't have to do that yeah and i think that design that design component scares some dentists away i think they're a little yeah Yeah, we went to school not to be CAD designers. We went to school to do dentistry. Although the new crop of dentists in 10 years from now, Dr. Horowitz, you may not be able to say that. They could be just designers. But yeah, finding that relationship, and there are more and more labs out there now that are saying, listen, we're great. We don't have to make your appliance. We don't let us do the design for you. you know, 25, 30 bucks, I'll have a design back to you in an hour. You can give me feedback. And I still do that sometimes when I don't have the time. My time is the most important thing. So I'm not going to take patient time away to go design a case that might take me an hour. I'm going to send that one away if I need it tomorrow or if I have the weekend, maybe I will do the design. I'm glad you mentioned CBCT as an inodontist myself. But I think CBCT, as much as it costs, I think it is the number one technology also. I agree with you 100%. In fact, I'm doing some podcasts coming up with Bruno Azevedo, Dr. Azevedo. I don't know if you know him. He's a board certified radiologist. He just finished his endo program in Philly down the road from where I went to endo. He's doing some podcasts with me about the use of... of CBCT for the general practitioner, even if you don't do implants. So for you to say, well, I don't do implants. I don't need a CBCT. It's $80,000. But that machine, man, that machine is a game changer for GPs. You know, the more I see the different types of things that that does and how that sets the treatment plan correctly is just mind boggling. If you took CBCT away from me, I would not want to practice. You're an amazing guy, Dr. Horowitz, because you embrace this stuff, you know, full force ahead. You weren't afraid of it. You have more practices than I can count on one hand. And you're opening new ones and you're using a lot of technology to make this all grow. Do you wish you were 30 years old again? Yeah. And for a lot of reasons. OK, let's focus on it. Let's focus on the dental reason. Yeah. Yeah. It's a dental podcast. It's rated GP. Yeah. OK. No pun intended. Yeah, I do. I think this is the single most exciting time in my career. And I say that because what and I also believe that those three technologies. The ones we mentioned, CBCT, scanning and printing, I believe will be in 95% of all practices by the end of this decade. And they should be. And they should be. When I lecture, I don't want to see any dental practice that does not have at least access within walking distance of a CBCT machine because you just need it for diagnosis. Scanning technology allows us to not only get impressions that are more accurate, but get impressions that we can keep forever. in the cloud or or just to always have them and to be able to compare and to be able to diagnose from our from our desk without having to run to a lab and then finally 3d printing is the answer that that milling wasn't so as i said milling was for a very specific group of dentists and i loved it i love being able to offer a one to one hour and 15 minute crown that I could rest behind and feel great about. Again, I put some control in my hands, which, you know, said control-free. But 3D printing, the amount... procedures that can take the bottom line of a dental practice and revolutionize it while also doing a positive service for the patient for under $10,000. I just don't see it. And the printers are getting cheaper. So I really believe that by the end of the decade, it's going to be the real outlier that doesn't have these 3D printing solutions in their practice. They just need to replace their fax machine with a 3D printer. That's all. Then they'll be right up to speed. All right. Well, listen, Dr. Horowitz, you've been amazing as usual. I miss you now more because we had this great discussion back in Scottsdale, I don't know how many years ago. We were sitting there having hors d'oeuvres at the bar with a bunch of other KOLs that were rambling around, but it was a great time and it reminds me that... so nice to speak to someone who really appreciates the technology of dentistry, knows how to apply it, knows how to teach it. And my last question is, where do you teach right now? Yeah, interesting. So I'm working with Dr. Brian Shaw, TMJ surgeon down in St. Pete. He purchased the Piper Clinic. I actually had learned under Dr. Piper. So we're doing some courses together. As you know, I'm part of a group called Dentists in the Know, and we do hosting and teaching for the American Independent Dental Alliance, which is a group of distributorships, dental companies that have helped dentists come together for... reasonably priced, solid education. And that's where my efforts are primarily, but little secret in our new building that we are moving into, we do have a teaching center. So I'm hoping not to be on as many airplanes coming up. Power to you. You've got a very active, busy life in dentistry, and it's keeping you young, and it's keeping you on top of things, which is just amazing. Thanks so much, Dr. Horowitz, for your time. Great discussion, great podcast, and hope to have you back again soon. Thanks so much, Phil. Always a pleasure to see you.