High-tech dentistry
One dentist finds that technology is the tool, not the answer.
Sharon Baerny
We not only have a new economy in the high-tech age, we have a new skill set. But just as new-economy businesses are learning they must stick to some old-economy ways, people are realizing that technology is a means, not an end. Old-fashioned skills and training are often required to most effectively use technology.
Bellevue dentist Neville Richter discovered this when he took the plunge into high-tech dentistry three years ago. Since his purchase of a CEREC system www.sirona.com, Richter can do faster and better tooth repairs. But without his old-fashioned skills and knowledge gained through years of experience, he wouldn't get as much out of the technology.
Changes in material and approach
CEREC, which stands for Chairside Economical Restoration of Esthetic Ceramics, was developed in the late 1980s in Switzerland. Based on new material and new attitudes towards dentistry, it enables dentists to make more conservative and durable repairs to damaged teeth.
In the past, dentists used silver fillings and composites. The amalgam used for silver fillings caused fractures in teeth, because the filling material expands and contracts with hot and cold. Richter compares using silver fillings to pouring concrete into a hole, because the amalgam doesn't bond with the tooth.
First developed in the 1970s, composite can bond with teeth and mimic enamel in appearance. The downside of composite is that a dentist can't replace large sections of tooth, so they have to use a crown. This means a more drastic repair because healthy parts of teeth must sometimes be removed to fit a crown. It's also a more labor-intensive repair because crowns are made by hand in a lab.
CEREC enables dentists to use ceramic for repairs. Ceramic can actually bond to the tooth and become part of the tooth. "The whole process is premised on bonding," says Richter, "in fact, dentistry is now premised on bonding."
With CEREC, a milling machine carves the repair from ceramic. CEREC is essentially a software program integrated with a milling machine and a digital camera. The first version was a crude machine that used a block of ceramic and diamond cutters and burrs to shape inlays and onlays.
Over 10 years later, version 3 is the latest and greatest. Sirona doesn't release a new version every six months. It waits for feedback from users, then improves the next version based on this feedback. Ten years passed between versions 1 and 2, and five years between 2 and 3. It's still a software program, camera and milling machine, but much improved, and version 3 has "lots of bells and whistles" that make it almost completely user-friendly, says Richter.
How it works
The CEREC setup is a stand-alone unit with a flat-panel screen, a built-in flat keyboard, and a trackball. The software runs on Windows NT, and the milling unit is remote radio controlled.
To use CEREC, Richter cuts a preparation in the tooth to make room for the repair, then inserts the wand-like camera into the patient's mouth. The camera takes two pictures, one looking straight down. Then a mirror inside the camera angles and it takes a second picture 1/40 second later to get the depth. Based on the images, the program constructs an internal wire frame model with x-, y-, and z-axes. A photo of the tooth and its immediate neighboring teeth appears on the screen. The program includes a database of what every tooth in an adult mouth looks like, and it makes recommendations for forming the repair based on the images in that database. Richter modifies the software's suggested repair using the trackball and arrow keys. He can adjust a line by just a pixel using the arrow keys on the built-in keyboard. "I can get outrageously accurate results," he says.
In addition to the black and white image on the screen, Richter can view graphs to the right. The graphs display the top and side views of how the repair piece will be shaped, so Richter can work with either the photo or the graphs, or both, to make his modifications.
When Richter is satisfied with the shape of the repair, he inserts a ceramic block into the milling machine and waits a few minutes while the repair is carved and shaped. "The milling machine is what's amazing," says Richter. Then he removes the shaped ceramic piece from the machine and pops the perfectly shaped piece into the hole cut into the patient's tooth.
The whole process takes one-and-a-half to two hours for a bonded ceramic restoration. It used to take two separate appointments, says Richter, because a dental lab made the repair. Now Richter is saving on time and he has eliminated the lab expense. It's also more reliable: Because the repair is made in-house, Richter doesn't have to rely on someone else reading his prep, he says.
And one final benefit: CEREC keeps Richter, who doesn't even use an assistant, close to his patients.
Taking the high-tech plunge
Perhaps the technology's most important benefit is that it enables dentists to make less drastic repairs. Using CEREC means Richter doesn't necessarily have to do a crown if a tooth is badly damaged. For example, if Richter finds a minute crack in the tooth after removing an old filling, he can do a much more conservative restoration with CEREC, actually bonding new material with the tooth, rather than putting a crown on the tooth.
Richter says he can "conserve huge amounts of tooth" rather than have to remove parts of it to make the repair. And the repair is more durable. Using the new material, the tooth will actually be stronger after the repair than before.
Richter has been practicing dentistry for 25 years, but he knew he needed to keep up with the technology. "I kind of saw dentistry changing, people changing their ideas about what they will accept in their mouths," says Richter. It's not just the software, digital camera and fine quality of the milling machine. The ceramic material is crucial because it not only looks like part of the tooth; it bonds with and becomes part of the tooth. "It's a finer kind of restorative care," he says.
"I could see this is the way dentistry will be done between now and when I retire," he says. Still, it was a huge jump for him to move into using a computer for dentistry. The computer was an administrative tool before, "and now I've got a dental tool."
Technology has its limits
Despite the amazing ability of the software and milling machine to create a life-like repair, the dentist's old-fashioned, hands-on skills are still the most important. Years of schooling and experience are necessary to get the most out of CEREC.
After the photograph is taken, Richter has to modify and adjust the proposed repair. The technology can only go so far, because a computer is still just a computer. The software makes the only recommendations it is programmed to make, and since all teeth and mouths are different, the dentist's subjective skill is imperative. "You need to know an enormous amount of dental anatomy to make this work for you, to know what you want it to look like," says Richter.
Richter's adaptation of technology in his practice epitomizes what technology can do, not what it will do. Technology is still just a tool. If we believe technology in and of itself holds all the answers and solves all the problems, we're wrong. We have to have the necessary skills, training and understanding to make the most of technology as a tool.
Data Basics
Company: Neville Richter, DDS, PS
Address: 10655 NE 4th St., Ste. 308, Bellevue, WA 98004
Phone: 425.637.1179
Web site: www.whatagreatsmile.com
Email: nrichterdds@earthlink.net
Copyright © 2001 KFH Publications, Inc.
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