Predictable and Profitable Bread & Butter Dentistry

You're listening to The Dr. Phil Klein Dental Podcast from Viva Learning.com. Welcome to the show. I'm Dr. Phil Klein. Today we'll be discussing the importance of managing your time through scheduling and workflow, along with the use of predictable and reliable materials. According to our guest, Dr. Daniel Butterman, this is the key to running a smooth and profitable practice. Dr. Butterman maintains a general practice in Centennial, Colorado, with an emphasis on implant and digital dentistry. He is an advanced CEREC trainer and resident faculty at cdocs.com. Dr. Butterman, it's a pleasure to have you on Dental Talk. Thanks, Phil. I'm happy to be here. Yeah. So I was just talking to you offline and the facility at Spear is really beautiful. I was in there in Scottsdale, Arizona for a program and it must be very enjoyable to teach there. Great training facility. Fantastic setup over there. So hats off to you for participating in that great program. Thanks. We kind of consider it dental Disneyland there. Yeah, it was quite busy. A lot going on. So to begin, let me ask you this question. Tell us how your office schedules patient appointments to optimize profitability and efficiency in your practice. And at the same time, how do you use CAD CAM and related materials to help raise your production? I think CAD CAM and technology in general is something that's really huge for allowing us to be efficient and allowing us to be more productive in our practices. It's something that I not only teach, but I live every day in my private practice. And it's kind of one of those things that we understand that patients really need efficiency as far as their crowns being done in a single appointment. In this day and age of COVID, having multiple appointments just isn't going to work for a lot of people. So we really need to be very efficient with our patients' time. And then, of course, ourselves for our practice, for our productivity, we need to be efficient as well. So having CAD CAM allows me to eliminate a lot of the analog steps that I used to do before. And quite honestly, Although analog dentistry has been around forever and we know that it works, it's just not the most efficient way to do things. So if I can replace a physical impression with just a few seconds of a digital scan to capture everything that I need, if I can design and manufacture my crown within minutes to an hour as opposed to weeks as we used to do, well, that becomes much more efficient. It allows me to schedule many, many more procedures because we don't just... worry about individual steps and procedures with patients. We worry about the entire digital workflow, and that allows us to just be much more efficient. So when you started in digital dentistry, did you start one step at a time where you started scanning digitally and you obviated the need for typical impression materials and the trays and so forth, or did you go straight into this full force? You know, it's funny because I understand the desire for a lot of people to take it one step at a time and maybe start with digital imaging. But for me, the whole idea of digital dentistry meant that I can now do something today that I couldn't do before. And that's where manufacturing comes in. So I jumped in with both feet and I felt that it was critical, not just a digital image, but to be able to manufacture as well. Did you practice with the traditional materials before? Or I don't know when you started practicing. You look like a young guy. They can't see you. It's a podcast, but I could see you. So I don't know when you started practicing, but you did one time in your practice work with conventional impression materials, right? Yeah, I appreciate it. I'm going to say there's probably something wrong with your camera because I haven't practiced for almost 28 years now. Oh, wow, okay. That must have been the podcast before that I had the young guy. Okay. Yeah, my eyes are open. So, okay, so that's the big thing with you is you could see a dramatic difference in the way things work having lived both sides. Absolutely. Absolutely. So for literally the first half of my career, I did things traditionally with analog dentistry, traditional crown and bridge with physical impressions, using a laboratory for all the steps that are ordinarily done. And switching to digital, probably the thing that changed the most for me was predictability. I knew exactly how everything was going to go every single time. There was no chance that something was going to be late from a lab or potentially not fit or we have a missed impression. Because I can see everything. When you capture a digital image, you have immediate feedback. When you mill and design a restoration, try it and you have immediate feedback and you know exactly how it's going to go. So it's really that predictability that created efficiency, if you will. Sure, sure. So tell us about your workflow and your typical bread and butter restorations and what products and techniques do you utilize daily within this workflow? The biggest part of the workflow and the reason that it goes so smoothly for me is because I delegate a lot of it. And that comes from training. It comes from practice. It comes from having a good team. Because if you can't delegate some of the procedures, then you're never going to be ultimately efficient. But it starts with capturing a good image. So we've prepped our tooth, as we would traditionally. And then I capture a very quick, good image, which I'll use my prime scan in order to do that. At that point, I can turn it over to my assistant, who can, in a few clicks, design my restoration. Once that restoration is designed, we're going to send it to our milling machine. And in my case, I'm going to use a prime mill. Probably my go-to block for most of my posterior restorations right now is going to be a Katana block. Karari makes it. And the reason I like it is because we've got high strength, we've got good aesthetics. And with my prime mill, I can mill that restoration in about four and a half or five minutes on super fast. So the manufacturing process is really, that's come down a lot. And that's kind of huge because it's kind of interesting when you can become more efficient, you can become faster, not actually by doing anything different or having even more training, but simply by having different materials or different equipment. You mentioned your staff does the designing. Doesn't that require someone who's super skilled as far as an assistant to do that? And is that type of assistant available to most dentists where they can actually design that prep through the software program? You know, it's interesting that you say that because I would say a lot of dentists would probably have their assistant designing a temporary crown for them or making a temporary crown for them in their practice. What are the steps involved in making a temporary crown? You're looking at margins. You're looking at contours, contacts, and occlusion. We're really doing the same thing digitally. And with the chair side software with CEREC, it's very intuitive and the steps are quite easy. So really, yes, of course, there's a learning curve. And yes, there is a requirement to train your team members to be able to do it. but it's not a steep one. And they can become very quick and very efficient with this. And you mentioned the Katana block. That's a Zirconia block. Correct. Yeah. So if you could share with us some of those advantages, because I know there's speed centering and the shade system is really innovative with the different layers of the block. the graduated layers, if you can cover some of that, because that really does feed into efficiency, doesn't it? Right. There's really three main points for me when I choose, and I test a lot of materials. I look at a lot of different blocks that are out there. And the three things that need to happen for me to at least be interested in it, number one, it needs to be strong enough. Number two, we need to have appropriate aesthetics for the type of restoration that we want. And then the actual manufacturing workflow needs to be a reasonable amount of time. Now, for me, when I say a reasonable amount of time, anywhere from 20 to 30 minutes, from when we design a restoration until we have it in our hands ready to place in the patient's mouth, longer than 20 to 30 minutes, and it no longer easily fits into a single visit or same-day workflow. So that's where Katana comes in nice and works so well here because we have the aesthetics, we have the strength, and we have the ability to mill it quickly and center it quickly. So it really fulfills all of those requirements that I need in a block. And I think a lot of your listeners will probably agree, zirconia has really come a long way. It's changed a lot from the original opaque zirconia. that used to come on the market that we used it because it was super strong, but we just didn't love the aesthetics of it. Now we're kind of at a point where we can have the aesthetics and the strength together. Now with this particular block, you can manufacture, as you say, the restoration relatively thin, right? Which adds to the translucency effect. Is that super innovative to a company like Curare where they could create a zirconia material where you can mill it so thin? Absolutely. And if you have a material that you can have relatively thin, it fulfills a couple of requirements. One is aesthetics. Yes, of course, we have more translucency built in, but also preps become easier. We don't have to reduce as much from the tooth. We can be a little bit more conservative with our preparations as well because we know we're going to have the strength that's going to be there. I'd say the aesthetic comes in from translucency, but it also comes into the fact that we have a multi-layered block. So we have a block that's going to have more chroma at the gingival third, and it's going to have more translucency or less chroma as we move up. So it'll give the illusion that we have more translucency in a material that historically has been considered very opaque. And how does it help you with getting the shade right using the STML versus the glazing? There's two different workflows that I would probably do. With an average posterior crown, where we just want things to match relatively well, I'm probably going to do a polish-only restoration, meaning that... After I've milled my restoration, I'll polish it in the green state before we center it while it's relatively soft because with zirconia, and we all know that this can be a material if it's not handled properly, if it's not polished properly, then it can cause damage to the antagonist tooth, but a properly polished zirconia is going to be incredibly kind. So I'll pre-polish my zirconia, I'll center it, and then I'll just do a quick polish after it comes out of the oven and it's ready to go in. That's going to be the bulk of my posterior restorations. And quite honestly, It never really occurred to me until recently to start using zirconia in anterior restorations, but I've started using it for some anterior cases, anterior bridges as well, and the aesthetics are quite good. I probably wouldn't do a polish only for that. I'm going to use maybe a CZR staining glaze paste where we'll put some color and a glaze on top of it in addition to polishing and restoration. So I really have both workflows depending. on the level of aesthetics that I need to create. In the workshops that I teach, I always ask the attendees what materials they're using. Everybody's using Emacs in the interior. As they go posterior, they're using zirconia. And most of the time, the zirconia is katana. Well, yeah, if you start moving that, and I have to say, as much as I, and Emacs is a fantastic material. I've used it for many, many years. But once you start moving into zirconia in the interior, you have a couple of advantages. One, when you design something in the software, meaning putting specific certain anatomy into it, the manufacturing of the material is actually going to happen, meaning that the tools or the burrs that are used to manufacture zirconia are much smaller than the burrs that are used to mill glass ceramics. So you can create that fine level of detail, and you've got a much more finished look when you mill out a zirconia restoration for the anterior as opposed to an Emax or a glass ceramic restoration. So you can capture a lot of that detail. So yeah, I've started to move more of my anterior restorations to this for sure. So in closing, what general advice can you give all of us regarding materials and technology that will help us achieve highly predictable clinic results with our bridges and advanced CAD CAM cases? Yeah, I think that we all want the same thing. Whether you have a single doctor practice or a large group practice, we all want the same thing. We want success with the materials and the procedures that we use. and we want efficiency and predictability. It really doesn't matter what type of practice you're in. Those three things are going to be key because if you have those three things, then you're also going to have profitability, which quite honestly is what's the point without that? We make a big investment in technology. We need to be profitable with it. So as you start moving into more advanced restorations, Training becomes important. None of this stuff is completely intuitive. And certainly having the education, not just spending money for technology, but spending money for education is going to be useful to understand what the software can do. Understanding that you don't have to own every single block on the market. Having a material like Katana that can be used posteriorly and anteriorly can be used as a polish for a posterior crown. stain and glaze for a more aesthetic anterior restoration, having cements that are easy, you know, because none of these restorations are going to be super useful for any of us, whether they're larger cases or smaller cases, if they don't stay bonded into place or if your patients are having sensitivity. One of my go-to these days is Panavia SA for self-adhesive universal. These kind of cements become very easy because they contain MDP that's going to be able to bond to the zirconia restorations as well. So we don't have multiple steps and multiple room for error with our restorations. So we need to simplify it. And that's really, in a nutshell, in order to be successful with single unit, full arch cases, anterior cases, implant restorations, we need to simplify it. Meaning we can't have multiple different materials that nobody knows how to use. multiple different cements and bonding systems. So I would encourage you to find a system that you like, find something that is intuitive and relatively easy to use, and find something that's going to work the same way every single time. And that's why a lot of the Karari materials speak to me in that regard. Whether it's the Katana zirconia blocks or the Panavia SA universal adhesives and cements, these things fulfill a lot of those requirements. Yeah, and you have a tremendous amount of experience, not only in your own practice, but also through teaching. As I mentioned, you talk to so many different dentists, and you are a discerning clinician when it comes to these materials. So you've probably tried a few in your day to come up with Curare's system where you feel satisfied that it's going to give you the highest clinical results. I have, and to be totally clear with that, I mean, there is no one block, there is no one cement that this is the one, everything else is bad, and you must use this material. In teaching a lot of people and working with a lot of people, we want to find materials that most people are going to be successful. Because at the end of the day, I haven't done my job if I can't send you back to your office and let you be successful with the materials that you're using. Yeah, last question. I know we're running out of time. Do you think Zirconia is the material of the future with CAD CAM? Is this here to stay? Well, I mean, you never know. But I'd say that the big push is Zirconia because it has a lot of properties that we like. The fit is incredible versus glass ceramics, again, because we're able to mill it predictably. We're able to use finer instruments, and then it shrinks 25%, so we get that beautiful fit. I think the big push is going to be increased strength, increased translucency, and a reduction in manufacture time. So I think we still have a number of years to come through. We're going to see a big push in those areas unless the next material comes and knocks it off the block. Exactly. Listen, we really want to hear from you more, Dr. Butterman, as these innovations come to market, because our audience really depends on these types of venues to keep up with the new materials and what doctors like you who are teaching this stuff. And also, you're one of the... evaluators for a lot of these companies. So you have that experience that we can learn from. So we hope to have you on future podcasts and webinars for Viva Learning. Thank you very much and Happy New Year. Happy New Year to you too, Phil. My pleasure and really happy to be here. Thank you.