In-Office Milling: How to Transition to Single-Visit Dentistry

You're listening to the Phil Klein Dental Podcast In-office mills allow dental practices to offer crowns in a single visit. The mills are more efficient and reliable than they used to be, and the process typically starts with acquiring an intraoral scan. That scan is sent to a special design software, which is usually incorporated in the acquisition scanner. After the clinician traces the margins and designs the crown, the resulting file is sent to the in-house mill. followed by staining, glazing, and sintering. So that was obviously a very quick summary of what a milling machine does in the dental practice. But one of the key considerations is whether to purchase a closed or open milling system. The traditional closed system, meaning a proprietary system from one manufacturer, offers the advantages of having a more reliable workflow and easier access to customer support, meaning the dentist calls one place with any questions, whether it has to do with scanning, milling, software, or materials. In addition, a closed system is more expensive, and the practice is limited to the materials and equipment that come from that one manufacturer. On the flip side, an open system provides access to more materials and accommodates different kinds of equipment. But this also means contacting multiple call centers for support, which can be frustrating and time -consuming. To help us better understand all of this and make the right decisions in our digital dentistry journey is our guest, Dr. Anthony Mennito. He has been involved with digital workflow in the dental practice for almost 20 years. He is in private practice in South Carolina and is an adjunct faculty member at the Medical University of South Carolina. Dr. Mennito is also part of an excellent in-person CE program in Charleston, South Carolina. You can find more info on that at impresscourses.com, I-M-P-R-E-S, courses.com. We'll be talking to Dr. Mennito in a second, but first, are you looking for an air-driven handpiece that rivals the power and torque of electric? Well, I have good news. It's finally here. It's called the T-Mac Z and it's from NSK, a company we all know and trust as a world leader in dental handpieces. In addition to being lightweight and ergonomic, this revolutionary air-driven handpiece delivers unprecedented 44 watts of power, allowing it to cut through tough zirconia smoothly and quickly. In fact, the T-Mac Z reduces overall cutting time by 30%. That means less chair time, reducing the burden on you and your patient. Take a test drive of the TMAX Z air-driven handpiece from NSK. For a free 10-day trial, go to nskdental.com and find your local rep to inquire. Experience the power and excitement of the TMAX Z series. Dr. Menino, thanks for joining us on our show. Appreciate you having me, Phil. Yeah, so incorporating a CAD-CAM system into your practice, it's a pretty big decision. have to think about how much room we have in the office, how much money we have to spend on something like this. Tell us in your perspective, with your experience in digital workflow, what kind of practice and dentist is suited ideally for CAD CAM? Well, I think the first thing that you mentioned, the space within the office is a huge thing because that is something that you either have or you don't, right? And I will give our office as an example. We recently brought a CAD CAM system into... the existing practice that I joined. And it resides now in the doctor's office. So we sit in there and we fill out notes and we have the mill literally right next to where I sit. And the scanner lives in there as well. So it was enough of a priority for us that we decided it was worth obviously utilizing that space. But space is definitely something that you need to think about. From a clinical standpoint, I think the... The major advantage or one of the major advantages that I see with CAD CAM is it allows you to do more conservative dentistry a little more easily because, you know, it can be tough when you do conservative. preparations, these mostly enamel-based or really preparations that lack retention form to provisionalize those. And so dentists who are looking to utilize more conservative type preparations into their practice really find the use of a CAD CAM system beneficial. And I think that even if you aren't thinking along those lines, when you purchase a CAD CAM system, you begin to transition. in that direction because you find that it's far simpler for instance to scan a preparation that is completely supra gingival than it is if you go subgingival and you know with modern dental adhesives and our bondable ceramics it's really a good time to be thinking along those lines of being more conservative. You want a practice that does a fair amount and is able to do a fair amount of crown and bridge to make it economically viable, right? So I think there's a rule of thumb that if you do somewhere in the neighborhood of 17 to 20, crowns or onlays or things that are similar to crowns in your practice, that it's economically viable. So you can think about it along the lines of the return on investment as well. And nowadays, to be honest, for us, a big part of it is patient convenience. Our patients love not having to come back for that delivery visit. And so, you know, it just depends on the type of experience that you want to give your patients, right? That's a big part of it for us. Now, you mentioned 17 to 20 restorations. Is that per month? That is per month. Okay. You left that part out. I wasn't sure. I assumed it was per month. Yeah. So let's talk about looking for a CAD CAM system. Now, back in the day, we didn't have a lot of choices. CEREC was kind of the only one in town. That's not the case today. So what do you look for? in a contemporary CAD CAM system? Well, I think when you look at the market leader, CEREC is obviously still far and away the most popular option. And it's a very good option. Once again, we have one in our practice. We also have one of the competitor systems as well, the PlanMecca system in another practice that I work in. So I'm lucky that I'm able to utilize both. And I think the main difference, well, one is cost, right? So cost fluctuates from from dealer to dealer, but there's about a $50,000 difference between the two systems. So that's pretty significant. I will say that the CEREC system is a little more polished than the PlanMECA system, but you have this idea of an open versus closed system. And this is where practitioners really need to be educated about the benefits of these because CEREC is what we call a closed system, meaning you can't really move files in and out of that system very easily. CEREC kind of constrains you. So in other words, if you're going to use a CEREC milling system, you have to use their scanner and design software as well. The Plameca system is a more open system, meaning if you utilize their mill, you could literally use any intraoral scanner and you could use any design software as well. So the open milling It's beneficial in some ways, does kind of complicate things a little bit as well, right? Most people, especially if you're new to CAD CAM, you want a streamlined system. You want to keep things as simple as you can. And that's where the CEREC system kind of leads you. It's a little bit more streamlined. It's a little bit more polished from start to finish. And Plan Mecca offers a similar streamlined solution, but... If you don't like their intraoral scanner, you can certainly use a different one. So that's where the benefit is. So it's just a matter of educating yourself as a consumer to the pros and cons of each system. And once again, there is a cost difference and there is a usability difference there as well. The other thing that nowadays is becoming more and more popular is utilization of a lab software within. a clinical setting. So I myself utilize a software called Exocad. Exocad is utilized also by a lot of dental labs. It's a really powerful software that allows you to design just about anything that you want. In order to fabricate something out of Exocad, you have to have an open way of producing that so whether you're 3d printing or you're milling it has to be an open system so so this is where you know maybe when you're starting out you like that closed system is okay for you you're able to you know to mill your crowns you're able to follow that streamlined workflow but as you become a little bit more advanced in utilization of the technology it's nice to have options that the open systems give you so it's just a matter of educating yourself And maybe it depends on where you are in your digital journey. We'll be right back with Dr. Manito, and he's going to be talking about laboratories and the importance of choosing the right lab. But first, as dental professionals, we want our crowns and bridges to be strong and beautiful. But it seems we've always had to sacrifice one for the other, until now. With prime zirconia, you get a revolutionary material that provides the strength for splints and bridges and the superior aesthetics and translucency for anterior cases. Prime zirconia discs are made with a state-of-the-art gradient technology that creates Y3 strength where it's needed, as well as Y5 translucency for aesthetics. So thanks to Ivoclar, you can finally choose a material that offers the strength of zirconia and the aesthetics of lithium disilicate. That's why top clinicians around the world are prescribing prime zirconia to their labs. Your patients will be thrilled, and so will you. To learn more, visit Ivoclar.com, or to locate a lab near you, Check out the link in the description. Now, is it important to work with a particular lab that is really familiar with, obviously, if you're working with Exocad, you obviously have to work with a lab that works with Exocad. But generally speaking, if you're doing digital dentistry, is the investigation of your lab way more important than it used to be back in the day when everybody would just send in the impression tray and check off some boxes about porcelain fused to metal and that would be it? Oh, absolutely. And this is, I mean, this harkens back to our previous discussion on intraoral scanners a little bit in that some labs are more comfortable than others manipulating and dealing with digital files. Okay. And a lot of it can also depend on what you're asking the lab to create. So zirconia crown, for instance, a zirconia crown, that fabrication is completely digital process, right? Instead of ordering zirconia, if you order a gold crown, that is much more of an analog fabrication process. And so your lab may not be comfortable utilizing a digital impression to fabricate a analog gold crown. And I'm often surprised by what our labs are and are not comfortable with when it comes to digital files, because I've been doing this for so long that I feel like sometimes when I send a digital file, They they literally have no idea what to do with it. And so the restoration I get back, they won't call me necessarily and say, hey, Dr. Mennito, we're having an issue with this. We don't we're not really sure how to manage this. Instead, they try to kind of rig the workflow to make it work without really letting me know. But the restoration I get back is not what I was hoping for. Right. So absolutely knowing. that your lab is comfortable utilizing digital scans is incredibly important nowadays and most are to be honest but also thinking through how that restoration is ideally produced and giving the laboratory right whatever is going to make their job easiest Because in the end, that's going to help you, right? If you get a better fitting restoration, your job's going to be easier on the back end as well. So having a really good open communication with your lab is incredibly important anyway, whether you're analog or digital, but especially so if you're utilizing digital tools. So what does a single visit appointment look like as far as CAD CAM? What has it done for your practice, Dr. Mennito, as far as... transforming your practice as far as productivity, as far as marketing your practice to your patients that understand that they'll be out of there on one visit with their crown? And how much time do you typically allocate to that single CAD CAM appointment? It's a great, great question. And a very important question, I think, for everyone to hear. So and you'll hear different, you know, different people have a different way that they manage this. But for us, it's always a two hour appointment. And it doesn't necessarily always take two hours, but we allocate two hours for that either way because you just never really know. And I would say at the longer end of things, it is a two-hour appointment. At the shorter end of things, it's probably closer to 90 minutes. But what it's done for us is, once again, we're all about the patient experience in our practice and setting ourselves apart from our competition because We are a high-end practice. We are a little bit more expensive than the dental offices that are around us. And so it's important that we set ourselves apart. And one of the ways we do that is our utilization of technology. And that appointment looks like basically within the first hour, that tooth is prepped. The tooth has been scanned. And it is beginning to be milled, right, within that first hour. So the patient comes in, we get them numb, we get the tooth prepped, we get it scanned. And within an hour, the goal is that that crown is, or whatever the restoration is, is being milled. Now, in our office, the patient at this point is, they've got headphones on, they've got a warm neck wrap, they are watching Netflix. It's the middle of the day on a Wednesday. They're actually quite happy. Right. Because they're not at work. They're just chilling in the dental office. So it takes about 10, probably 15 minutes for me to design and mill that crown. And then we try, I usually try in the crown. I mill mostly Emax lithium disilicate in the office. We do occasional zirconia as well. But the workflow for those nowadays is about the same time, which is great. So it really doesn't make too much of a difference what material we're producing. I try in the restoration. I make any adjustments. And then I do a little bit of just basic staining and glazing of that restoration. And it goes into the oven. We have an Ivoclar CS6 oven, which is a brand new oven that allows us to crystallize Emax in about 11 minutes. So it's been absolutely great. Few minutes that you can save in that workflow is very helpful. And then we deliver that restoration. So once again, it usually is anywhere from 90 minutes to two hours, depending on the complexity of the case and the complexity of the patient, of course, that is a factor as well. But it is extremely rewarding. The patients are always happy that when they leave the office, the procedure is done, right? It's not halfway done. We don't have an additional step. That tooth is fixed. ready to go. And they love that they can go home and I don't have to tell them they can't eat something, right? They can eat whatever they want. So as far as building your practice as a technology-based practice that is conservative with tooth structure and that has same-day dentistry, there's a lot to say there. And this has probably been a great boom to your practice as far as spreading the word, right? Patients telling other patients saying, hey. go to this Dr. Mennito guy and he's going to do your crown in one visit and you got headphones on and a warm wrap and you're watching Netflix. Has that been a game changer for you because of CAD CAM? Oh, absolutely. Absolutely. And I've, you know, I've been doing, I've been doing CAD CAM for a long time, so I'm extremely comfortable with it. But I understand that the new users will have some hurdles. to get over. And so what I always tell new users is the first maybe 10 cases you do, just do them the way you've been doing them, meaning fabricate a provisional. You don't want the stress of having to design and mill with the patient in the chair waiting for you, right? So this is a way that you can kind of lower the stress level of adopting the new technology by just go ahead and provisionalize that patient and work on doing your design, learning design, learning staining and glazing without the stress of having the patient waiting there, even though they are potentially watching Netflix and just hanging out. So what I tell you for our practice is that for me, I have gleaned the most satisfaction from learning conservative dentistry over the course of the past 10 years that I've done this. And we really educate our patients on the benefits of this. In our hygiene room, I have 3D printed some models with different types of preparations on them so I can break them out as needed to talk about the difference between. an onlay, an occlusal overlay, and a traditional crown because patients nowadays are really very educated about these things. They don't want you grinding any additional two-structure that's necessary from them. So it's important that we educate our patients to the benefits that this technology brings them because they assume that all crowns are the same. right the crown that you would get from the laboratory that took them two visits is going to be the same and in many ways it is but but we're also able to do dentistry much more conservatively nowadays. And it's important that they understand the value of that because we're doing it for them, right? We're doing it for their oral health and for the future of their teeth. So it's important that we educate them to that. And I think you're right, Dr. Mennito. I think patients do know enough about their teeth to know that they shouldn't have them reduced or drilled down if in any way possible a dentist can do that more conservatively. So that's a big factor, and I think patients really appreciate that. And I think in a lot of cases where crowns were pretty much the default treatment, which would require tooth reduction, I think dentists are moving towards direct restoratives in some of these cases to preserve the tooth structure, especially because of our advanced materials and adhesive dentistry. So I couldn't agree with you more. Conservative dentistry is the way to go across the board. So to wrap up this podcast, Dr. Mennito, you gave us a really good recommendation about new dentists coming into CAD CAM, where they should extend that visit to two visits in the beginning, just to really get a good handle on design, glazing, and sintering. Can you make any other recommendations to our audience about incorporating CAD CAM into the office for new dentists that are doing this? When I started CAD CAM, the one thing that I really noticed was I needed my preparations to improve. Let's just face it. when you prep for the laboratory, I don't know that we scrutinize our preparations quite as much as if we're the ones who have to actually draw that finish line on the tooth. So one of the big benefits of CAD CAM is that you're forced, right? You're forced to scrutinize your dentistry. And so I think that really maybe either taking a course on how to prep for these materials or So really paying attention to your preparations a little bit more as you move forward in the learning curve or along the learning curve is really beneficial. And the main thing that you'll find is your preps just cannot have any sharp angles within them. So rounded and smooth is the name of the game when it comes to CAD CAM dentistry. you will find, right, over the course of your first 10, 20, 30 cases that when you do leave sharp angles, there are consequences for that, right? And sometimes those consequences can just be that the ceramic is a little thinner in those areas. But sometimes it can be worse than that, like the patient coming back and they have a fractured restoration. So it's important that you're paying attention to your preparations because they very much, they always matter. But now you're the lab technician or one of your team members might be the lab technician if you're training them as well. It's important that you're really paying attention to rounding and smoothing all those edges because when we're talking about milled restorations, that is vitally, vitally important for longevity. And actually on the show, Dr. Mennito, I've interviewed quite a few dentists who have said the same thing, that CAD CAM has really changed their mindset of how they prep teeth and their finish lines, because in the past it was to take impression off to the lab. And now when you're designing and you're looking at your own work, it changes things quite a bit. It changes your perception of yourself and your skill set of how you've got preps. And I will guarantee that I am a better dentist for having done CAD CAM for the past decade. because you're constantly scrutinizing your work and you can blow it up on that screen as big as you want, right? And so there's no doubt that getting that instant feedback to what your prep looks like is beneficial for us as clinicians. Dr. Mennito, thank you so much for your time on this podcast. We look forward to having you on future ones. Have a great evening. It's been a blast, Phil. Thanks for having me. If you're enjoying this 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.