Making the Leap: How to Set Yourself up for Best Outcomes with Scanning, Milling and Printing

You're listening to the Phil Klein Dental Podcast Thanks for joining us. I'm Dr. Phil Klein. There are many benefits to transitioning from traditional impression-based indirect restorations to digitally scanned and fabricated crowns, bridges, onlays, and veneers. To name a few, convenience for patients, increased productivity, increased accuracy and efficiency, and elevated patient experience, which leads to increased referrals. Proved to be true by many dental offices, modernizing your practice directly will increase your bottom line revenue. To tell us more about making the leap into digital dentistry is our guest, Dr. Susan McMahon. She not only owns and practices in the largest cosmetic dental practice in Western Pennsylvania, she's also an author, educator, and internationally recognized KOL. Dr. McMahon has devoted her professional career to the pursuit of advanced technologies in cosmetic and minimally invasive dentistry. She 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. Oh, it's a pleasure for me to be here, Phil. Yeah. So thanks very much. And I know you're a busy person in Pittsburgh. And as we talked offline, I wish you the best with the Steelers this year. Pittsburgh's really into their football teams. So let's root for the Steelers. I do like this. I'm in Austin, Texas, but I do like the Steelers. So let's talk digital dentistry. The whole digital dental practice discussion can be somewhat overwhelming for many dentists, especially for those that have been out of dental school for many years. So what's a good way to start? implementing digital workflow in an analog office where the practice doesn't bite off more than they can chew. Right. Well, I was one of those dentists that's been out of dental school for quite a while. I first started, I was at a meeting in Italy. doing some composite training with the style Italian folks. And I was in a class and I was the only American there and everybody else was Eastern European and European. And they were all doing digital dentistry. Every single one of them had a mill. Everyone had a scanner. And I was the only one that was like, what? I'm still prepping and impressing the old fashioned way. So when I got home, I sort of realized I've got to kind of jump on the bandwagon and really move ahead. For me, I started with an intraoral scanner. And I think that changed everything. It was a great place to start. It's easy to upload that. It's easy to train the staff. And there's so much production that can come out of it. Yeah, it seems like the momentum right now with intraoral scanners is just off the charts. Like I've been doing these podcasts since 2018. And when we first started and I interviewed dentists that were using intraoral scanners, it was like kind of a novelty. a real change. We're hitting that part of the curve where I really see momentum moving towards digital scanning because I think dentists are beginning to understand that they don't need to purchase everything to get the digital workflow started. They could scan and then proceed with everything they were doing before. Is that right? Yeah, I see the same thing. Like when I'm out lecturing, I used to always ask, hey, how many people in the room have a scanner, digital scanner? And like you said, maybe four years ago, five years ago, it would be like a smattering. And now when you ask, it's 60, 70% of the room has scanners. So people are really embracing now. And I think I'm really seeing the benefit of it. So when it comes to using a digital scanner, Dr. McMahon, what does the clinician need to keep in mind regarding tooth preparation? as compared to when tooth preparation was followed by traditional impression taking? I think the thing that was really surprising to me when I started scanning and kind of evaluating my scans and marking my own margins and then eventually milling and printing was there were two things. First of all, you have to be cognizant of how digital restorations are fabricated, right? They're fabricated on mills. They're no longer hand waxed or hand designed like that. And the mills have to have no sharp angles anywhere. So everything has to be really smooth on your prep. And you'll see a lot of preps now, like on all my preps, after I prep my teeth, I go back and polish them with a rubber wheel. to really make them smooth. But I think one of the shocking things was looking at my margins when I was marking my margins after I scanned preps, because I used to think, oh, I've been doing this a long time. I used to think I'm kind of good at this. And when I saw my margins digitally reproduced, it really, really made me focus on that a little bit more. And I think it's made me a much better clinician, frankly. What did you see on that 3D model that surprised you? Oh, my gosh, they were not smooth and certainly not as smooth as I thought they were, even though I was working under magnification. And sometimes even I work under with a microscope. But when you see what your prep looks like from blown up like that, it's humbling, right? You're like, oh, my goodness. I think I need to pay way more attention to how smooth my margins needs to be. And, you know, and I think that was part of part of that was I transitioned from the kind of hand pieces I had to electric hand pieces. And I think I found a huge difference in the smoothness of my preps and certainly the smoothness of my margins. And sort of when I look back at some of. The restorations I may have placed years ago, you know, those patients that you see for many, many, many years. And I'll look at crown margins. And if they're like a little short or a little open, and you know what we all used to say, that's that lab. Why can't they ever get that right? I sent them a beautiful impression. And turns out, it really is probably never the lab. It's us as operators. Yeah, so there's several factors involved, right? I mean, you have to have... tissue retraction and isolation, right? In order to get those, if you're sub-G and you want to get those perfect margins, which you needed anyway in the traditional way of taking impressions, you still needed to do that. But particularly in digital scanning, what I hear is if you can't see it, then you won't be able to scan it, right? So it has to be visually apparent, those margins for the scanning to pick it up. So you're absolutely right about you have to see the margins in order to scan them. And when we're taking impressions, you know, sometimes we'd lean into the impression material to push tissue off and you could still get a decent impression without like the best tissue retraction. But with digital, you absolutely have to have precise tissue retraction. Now, I thought it was interesting you mentioned electric handpieces. to do your tooth preparation. Is there any particular electric handpiece you like and why electric handpieces? As far as margins go and smooth this, you know, when you're cutting with air-driven handpieces, it's the nature of the air-driven handpiece is that you're sort of feathering on and off and there's always a little inherent chatter in the burr. So you're getting a little wobbling in the burr, especially if your handpieces are, you know, more than five minutes old. You're getting a little chattering, but electric handpieces operate differently. So they're... Once that you fire your rheostat, you're getting a torque on there and that torque remains constant the whole time you're on the rheostat. So you're not feathering on and off. It's more like a precise milling. And there's also very little chatter in the burrs. I've been using NSKs for a while, probably. five six years now and they're my favorite ones for a couple of reasons they're like workhorses they're super powerful but they're also light and nimble and a lot of people kind of hesitate to go to electrics because they can be they can be kind of clunky and they can be heavy and you know you can get hand fatigue from them but nsk makes a beautiful light model and they have even have a mini that's great for um i i only i only work in the minis i just love how little those heads are where you can get in anywhere in anybody's mouth and i was going to ask you about the ergonomics of the electric handpiece because that's you know electric handpieces were around when i practiced um a long time ago but they were like you mentioned they were heavy they were big tough to get in the back of the mouth especially doing molar root canal access on number two or 15 or whatever. But now they've changed that. They've developed these electric hand pieces with ergonomics like you described that are much more handy in constricted spaces and lighter, which is a big thing too. Yeah, it is a big thing. They're really nice. And I had several different brands of electric, changed my whole operatories, all my operatories to NSKs like five years ago. And they just came out with a new air-driven one for like the people that aren't ready to switch to electrics or aren't ready to kind of make that investment into electrics. NSK has like a super powerful air -driven one that feels very similar to an electric handpiece. It's powerful. but small and nimble. And I think it just launched last month. I just had my hands on one about three weeks ago. And I was like, is this electric? The handpiece companies are, I know NSK is ahead of the game on a lot of this, but they all are upping their game with air-driven where it's getting close now between electric and air-driven. But dentists generally like air-driven. They're used to it. They trained on it in dental school. perceive them as being smaller and lighter, more ergonomic. So the manufacturers are actually succeeding in equaling the playing field between air-driven and electric to some extent. So you mentioned that you mill, but talk about the transition from buying a digital scanner, which a lot of dentists are feeling that's the first thing they should buy when they're moving into the digital workflow. When did you start getting into milling? and or printing. And when does that transition take place, if at all, for some dentists? I think scanning is a great place to start and you can do so much production off that scanner. And I went to a mill next and I have a mill in the office and we mill, we pretty much mill all our single units in the office, the zirconia units. And we also do a lot of milling of lithium to silicate, some anteriors. And I do a lot of like, if I have replacement veneers, I'll mill those in the office too. And I think that it was sort of driven by patient demand. Patients were saying, hey, I heard you can get a crown the same day. Why am I in a provisional? Why am I waiting two weeks to get it? And then I thought, yeah, why are you? So we invested in the mill. So that's becoming really kind of a necessary digital component in order to meet patients' needs. And it's also a big practice builder. You certainly don't want patients talking about the doctor down the block who has all this. And they're asking you why you don't have it. You don't want attrition from your patient base based on the doctor down the block who has all these interesting contraptions that do all these great things like one day dentistry. But you still have to be set up for milling, right? It has to work for the office. Right. You have to adjust your schedule in a way that works for everybody. And I think it's really important to have your team on board with you because it's a big shift in your workflow. It's a big change. And for us, we offset our milling cases. So we prep, scan, and then I like to design my own. So I go in the back and design while we're setting up our next patient, then anesthesia, then we're milling, I'm doing the next patient. And we leave the patient in the chair during that 45 minutes or so while their case is milling. And and then I finished my second patient, go back to the first one. And it's it's been working really well in our office. And for us, we you know, we even charge a premium for to have it done the same day. It costs a little bit more to have it done the same day. And people are willing to pay it. And like you said, I know that. patients are leaving their dentist's office because they're turning up in my office because we have same-day milling. So I know before I had it, they were leaving my practice and going somewhere else. Where did you get the training to be so proficient in digital dentistry, starting with the digital scanner? And the second part of that question is, what was the timeframe between purchasing the digital scanner and then integrating the milling into the whole process? Yeah, we were about a year. We had a scanner for about a year before we bought the mill. And now I have two 3D printers in my office, which... I might even purchase before I got a mill because you can print so much stuff on it. You can print provisionals, you can print prototypes. There are pretty soon you'll be able to, and we have been doing it, print ceramic resin blend restoration. So I'm printing inlay onlays and you can print 20 of them in 15 minutes. So I love it. We were about a year with our scanners and it took about that long to get everyone on the team comfortable scanning. my whole office scans from my front desk to hygienist to the assistants, but everybody had to get on board with that. Your staff does the scanning also. Everybody scans, every new patient gets scanned before I didn't see them. And if it's restorative scanning, I'm actually doing the restorative preps myself, but they're scanning the opposing arch and the rest of the arch and the bite. You mentioned you really love 3D printing. Did that come on at the same time as the milling machine arrived or did that come on before? Yeah, it actually came after. We milled for probably three years before I got a printer and we got sort of a big... clunky printer and started just printing models. So we didn't pour models anymore. And I do a lot of cosmetic work. So we were doing a smile design and printing those models and using them to make stents for provisionals and things like that. What about surgical guides? Do you do any implants at all in your practice? The more we scan people, the more we diagnosed and the more procedures we were doing and the more elective procedures we were doing. So we started doing a lot of implants and now. I have a periodontist that comes to my office twice a month and puts the implants in. So it helped us grow that whole area. And we now print our own surgical guides. So I actually outsource the design for those. But I'm training. I'm learning how to design those myself. But, you know, it's a process, right? So we design our own. crowns, we design our own onlays, we design occlusal guards, but the implant planning, I'm still outsourcing and like the all on X restorations, I'm still outsourcing those prototype designs. And then we get the design back and we'll do the printing ourselves and the staining and glazing. So it's definitely been a process. I think the printing has been like very easy to adapt. And the milling, like learning how to design restorations, it took me a little bit of time to do that. So it's interesting because I recently did a podcast with a dentist who actually delegates out the design work to his staff, to his assistant who was trained in this. who was trained in this particular software, where she designs the restoration after the dentist preps the tooth. She also scans the preparation. So she scans and designs and sends it off to the lab. So basically, his job is to cut the prep. Do you see yourself doing that down the road? Or are you going to keep control over that process? No, I'm sort of like, I got to do it myself. I'm sort of control. I've got control issues. What can I say about how I want those preps, those restorations to look? But I lean on my staff a lot for designing. designing all of the occlusal guards. They're printing all the occlusal guards. They're doing all of the retainers. And I definitely... I think if you had the right person, yeah, you could absolutely lean on them and let them do the design. And frankly, there's so much AI in the design now. It takes so little time. I see myself and then we do this now. I'll have them design. I come tweak, tweak, tweak, three clicks, and then it's off to the mill. So it seems to me we're approaching a time or we may already be in a time where it's really important for dentists to consider updating their practice with some form of digital workflow. And as many dentists are doing, starting with the intraoral scanner. And it's also important that the patients see that because they're seeing other dentists through their marketing and word of mouth that do have maybe same day dentistry or no more goop in trays and gagging. So they're appreciating that type of digital service. So the question is, if a dentist wants to make the move to start digitizing their workflow, where is the best place for them to get the training so they make the right purchasing decisions and integrate this equipment properly? Yeah, there's a couple of things I'd recommend. But I completely agree with you that convenience is the number one commodity for every patient these days. And they're educated and they know that same-day dentistry is out there and they know that they don't have to have impressions anymore. So people, you don't even have to explain it to them. They come in knowing that already. But as far as training goes, I think that where you buy your device can offer some really great training depending on what device you buy. There's also like the big major labs are doing some selling devices. They're selling scanners and printers and mills. And they offer kind of a really nice support system, some of them. If you get stuck, you can log right in and someone jumps on your computer and helps you design whatever you need. keep moving forward with production. Depending on the system and how much you want to invest in it and how quickly you want to be in, like, do you want to buy just a scanner and learn how to do that? The scanning companies can teach you how to scan really well. You just have to commit your whole staff to it, I think. Everybody has to learn and then they get excited about it. Exactly. The whole point is having the team on board. And it's an exciting thing for the team because they want to come to work and use digital technology that's cutting edge. And I wouldn't say it's standard of care now to use some of these machines because, you know, you can still do good dentistry without it. But one day it might be looked at as a digital scanner. It might prove to be so much more accurate and efficient. It might become standard of care. And that's more of a legal term. But to wrap up this podcast, and it's been very interesting, Dr. McMahon, you've covered a lot of interesting practical. concepts that go on in a dental office and the whole idea of moving into a dental practice a digital dental practice let's talk about the possibility of digital printing teeth that are as strong as possibly zirconia one day and where we won't need to mill anymore is that something you see happening down the road Zirconia is already being printed in other parts of the world, and I think we'll see it here very quickly as well. I don't know that it'll completely replace the mills. Will we be able to get strong enough zirconia out of a printer? That's yet to be seen. But I'm really comfortable placing the ceramic blend inlay onlays now that come out of my printer. A lot of great information, Dr. McMahon. Thank you very much for your time. I think our listeners appreciate your experience. and your advice. And we are definitely moving into the world of digital dentistry. It's exciting, exciting time to be a dentist. And we look forward to having you on future podcasts and webinars soon. Thank you so much for your time. It was great to talk to you too, Phil. Thank you. If you're enjoying our podcast, please leave a review or follow us on your favorite podcast platform. It's a great way to support our program and spread the word to others. Thanks so much for listening. See you in the next episode.