Taking It In-House by Dr. Joe Westbury

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Taking it In-house 

This Townie’s post about his digital dentistry setup has earned nearly 7,000 views on Dentaltown’s members-only message boards. We asked him to discuss what inspired him to create his own lab, how he set it up, what he’s been able to create with it, and why he believes it’s worth the purchase price


by Dr. Joe Westbury


Most of us have experienced it before: poor-fitting crowns, wrong shades, open contacts. (If you haven’t, you should hug your lab technicians and tell them how much you appreciate them.) For most of my dental career, I’ve struggled with lab inconsistency, but I’ll admit that I was always trying to walk that fine line of quality versus cost.

I’ve owned three practices, all in working-class communities, and my fees were such that I couldn’t afford the higher costs associated with a top-tier dental lab. So I tried a lot of different labs over the years, and most of those relationships frustrated me. I eventually settled in with a local lab I worked with for nearly 15 years. The last few years of that relationship were plagued with frequent open contacts, poor-fitting crowns and mismatched shades. I also never knew the quality of material the lab was using. Every crown-seating appointment was stressful. On most appointments, I’d have to add a contact or alter the shade to match. With my small office, this would consistently wreck my schedule.

Finding inspiration on Dentaltown

Frustrated, I began to look for alternatives. I researched the Cerec, introral scanners and CAD/CAM forums on Dentaltown, where threads by Townies “jaymsn2004” and “Guerrilla Dental” caught my attention. Both had purchased five-axis mills, were making their own crowns and had developed digital workflows that worked for them.

Convinced that I had found a solution to my lab issues, I started researching mills. My main criteria was simple: I needed to be able to mill zirconia crowns, bridges and hybrid cases. I also wanted to be able to mill custom titanium abutments—anything else the system could do would be a bonus.
I wanted the scanner, mill and sintering oven to be manufactured by the same company, so the CAD/CAM and milling would be fully integrated. I also wanted an open system instead of a closed one; I knew that I could mix and match different component brands to save money, but that could come with its own set of problems if the equipment didn’t integrate nicely with each other. Plus, I wanted continuity of support if something were to go wrong.

The particulars of my specific setup

I eventually settled on Amann Girrbach (AG) for my mill, computer, desktop scanner, sintering oven and design software.

The company also manufactures its own high-quality zirconia and the equipment is set up to seamlessly integrate the zirconia pucks into the software. AG provides a handheld scanner that plugs into the computer’s USB port, which allows the scanning of a unique barcode on the company’s zirconia puck and seamlessly auto-imports specific information about the puck—including height, shrinkage factor, shade, lot number and material—into the software database. This saves time and creates less room for error. The scanner works only for Amann Girrbach materials and this is a great example of what integration of a system gives you (Fig. 1).

My five-axis mill (Fig. 2) is capable of milling crowns, bridges, All-on-4s, dentures, partials, nightguards, and can handle titanium, PEEK, PMMA, wax, acrylic and more. It can mill either wet or dry, and it’s simple and quick to switch between the wet and dry modes. It’s a remarkable machine that I know I won’t outgrow anytime soon. My mill is designed to be upgraded as newer materials are introduced into the market by simply changing out the material holder arm (Fig. 3).

In-house dental lab
Fig. 1
In-house dental lab
Fig. 2
In-house dental lab
Fig. 3


One thing to be aware of is that depending on what you want your machine to do, you’ll need to purchase an Exocad software module for whatever you plan to mill. For example, I purchased the implant module, which allows me to design a screw-retained bridge or hybrid along with the gingival design (think “All-on-4” cases). I also bought an advanced tooth library, which gave me access to different tooth shapes and the ability to perform cut-backs if I so desire.

Be prepared to spend some money on the software: It isn’t cheap and will need to be renewed annually if you want to stay current on any updates. My scanner (Fig. 4) is a high-speed desktop scanner that is super-accurate to 4 microns and scans fast. Because my lab is at my home and I’m not doing same-day crowns, I bought a traditional sinter oven (Fig. 5). It was important for me to be able to sinter long-span bridges and hybrid cases, and a fully programmable oven will allow me to do this. My sintering programs are as short as six hours for single units and as long as 14 hours for hybrids or long-span bridges. I rounded out my large equipment purchases with a Whipmix Pro200 porcelain oven (Fig. 6), which I use to stain and glaze my work.

In-house dental lab
Fig.4
In-house dental lab
Fig.5
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Fig.6


Additional considerations

If you’re considering an in-office mill, be aware that you’ll need a 220-volt outlet and a source of clean, dry air—ideally different from your operatory air, unless you’ve got a high-capacity compressor. If during milling your air pressure drops below the required pressure, the mill may throw an error code.

Plan carefully where you decide to place your mill and equipment. You don’t need a lot of space—my lab (Fig. 7) is 12 by 24 feet, which is plenty of room—but you do need some sort of dust collection. Dry milling is messy; I’m constantly cleaning up the fine layer of white zirconia dust that settles everywhere.

Also, there will be a bunch of ancillary equipment that you may or may not have already. In my opinion, necessary things needed to be able to set up an in-office mill are: a desktop sandblaster; a high-quality electric lab handpiece; a dust-collection system for when you are cleaning up your crowns in the green state; an assortment of lab rotary burs; a model trimmer; and the ability to pour models. Don’t forget a comfortable chair for when you’re designing cases. You’ll need it!

As someone new to this whole crown-making process, there have been a couple of things that have been critical to my success and made my life easier. They are the Miyo stain and glaze system from Jensen Dental (Fig. 8), and titanium bases, scan bodies, multiunit abutments and the corresponding library for these parts and pieces from Dess USA.

The Miyo system will allow even amateurs to create crowns that look incredible in a short period of time. The company provides excellent support with a series of YouTube tutorials on how to use its product. In fact, by not having its product, you take away one of the big advantages of having an in-office mill, which is to be able to do tough, cosmetically challenging anterior crowns—in particular, the always-difficult single anterior crown. I like to say my worst single anterior crown is better than anything I’ve received back from my old lab.

In-house dental lab
Fig.7
In-house dental lab
Fig.8


Finished case examples

You may be asking what makes doing these types of cases easier with your own mill. Over the next two pages, I’ll share few of my case examples.

I recently had a patient fracture a lower single endodontically treated tooth (Fig. 9). He brought in his fractured natural tooth and we took an impression of the arch with the broken tooth. After pouring up the model, I glued the broken tooth back onto the model to closely represent what it looked like before breaking. After doing a cast post and core on the fractured tooth, I prepped and took an impression. I scanned in the “before” model, then the prepped model, and superimposed the “before” model onto the prep model and generated a crown that was almost exactly the same size, shape and position of the patient’s natural tooth (Fig. 10). After milling, it became a simple matter of staining it to match his existing dentition (Fig. 11).

In-house dental lab
Fig.9
In-house dental lab
Fig.10
In-house dental lab
Fig.11


This extremely difficult case involved a single crown on tooth #8 that replaced a 30-year-old PFM (Fig. 12). I simply used the mirroring feature in the design software and mirrored the contralateral natural tooth, #9 (Fig. 13). I milled out five different crowns using a high-translucency zirconia, all in different Vita shades, then did shade variations for each crown using the Miyo system (Fig. 14). Did it turn out perfect? No, but it’s far better than anything I used to get from my old lab (Fig. 15).

In-house dental lab
Fig. 12
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Fig.13
In-house dental lab
Fig.14
In-house dental lab
Fig.15


This case involved making crowns on teeth #7 and #9 on an older gentleman who in the 1970s was a California light heavyweight boxing champion. Making the crowns without all of the cracks and chips would have never looked normal. I was able to match closely not only the color but also the cracks and chips he incurred during his professional boxing career (Figs. 16 and 17).

In-house dental lab
Fig. 16
In-house dental lab
Fig.17


Another case was on a 96-year-old man. His lower four anterior teeth were hopeless because of periodontal disease. I took an impression before extraction, then removed the four teeth. We ended up prepping #22 and #27 for a six-unit bridge. I was then able to scan the “before” model and superimpose it over the prepped model to match what the existing teeth looked like before extraction (Figs. 18 and 19).

In-house dental lab
Fig. 18
In-house dental lab
Fig.19


This case was a simple screw-retained implant crown on tooth #8. I used the “mirror” software feature to mirror and duplicate tooth #9. I milled the crown, then stained and glazed with the Miyo system (Figs. 20 and 21). These sorts of things can really simplify and improve your clinical cases.

In-house dental lab
Fig.20
In-house dental lab
Fig.21


Titanium specifics

Another piece of the in-office milling puzzle is which manufacturer of titanium bases, angled titanium bases and multiunit abutments you’ll be using. If you stick with one manufacturer, you won’t need to carry scan bodies for every manufacturer, and it’s nice to only have to become familiar with one library.

As mentioned earlier, I use Dess USA components. The company carries parts and pieces for several different implant manufacturers; everything is FDA 510(k)-approved and is of exceptional quality and very reasonably priced. Plus, I can get something overnighted for around $20.

I do a lot of single-implant crowns using titanium bases and, frankly, it may be the easiest thing I do with my mill and saves me a ton of money. I get to control the emergence profile and individualize the overall shape of the crown. If the implant angle is off, I simply use an angled Ti base, which allows me to correct the screw hole angulation up to 25 degrees during the crown design stage (Figs. 22–24).
In-house dental lab
Fig.22
In-house dental lab
Fig. 23
In-house dental lab
Fig.24


All of Dess’s Ti base chimneys come robotically pre-sandblasted from the factory. I have yet to see another manufacturer do this and I believe it contributes to a consistent fit.

I use Panavia V to cement my implant crowns to my Ti bases and after two years and a bunch of crowns, I have yet to experience a single failure. I make sure that I purchase the Panavia V opaque to mask the Ti base and prevent it from possibly altering the shade.

The financial equations

Why get a mill and start making your crowns in-house? The obvious answer is saving money. I used to spend around $50,000 annually on my lab bill, excluding removables. Crowns averaged about $180. They now cost me about $12. I was paying $400 for a zirconia crown on a Ti base; I’m now able to make the exact thing for $55.

Obviously, this doesn’t factor in my time or the initial cost of the equipment, but I look at it this way: If it takes me less than an hour to make one screw-retained implant crown, after expenses that’s about $350 an hour saved. That’s making good money while I kick back, listen to music or a podcast, hang out with my dog and make crowns.

In reality, saving money is just one reason to start utilizing this technology. The ability to control everything from start to finish is priceless. I can now control the consistency, fit, aesthetics, materials, timing and process of every restoration I do. Plus, I get the creative satisfaction that comes with making my own crowns.

There’s also the marketing effect that it can have on your office! Dentists market their use of Cerec, microscopes, etc.—why not a mill? I casually let every patient know that I’ve made their crown from start to finish. I tell them about my equipment, what it can do and how it’s part of the future of dentistry. Patients are genuinely interested and impressed!

I’m convinced that in the future, every dental office will have these machines. Over time, the process will continue to get easier, more streamlined and faster.

Buying a mill and all that it entails is a commitment. But it’s a commitment that I find is worth it.

Watch the buildout—and see more cases—online

In his post on Dentaltown’s online message boards, Dr. Joe Westbury walked Townies
through the entire process of building a new room to house his digital setup, and
has shared tons of cases he’s used it to treat. Click here to check out the thread.


Author Bio
Joe-Westbury After graduating from the University of Missouri–Kansas City School of Dentistry in 1989, Dr. Joe Westbury practiced dentistry in South San Francisco and was a clinical professor at the University of the Pacific. Westbury, who has been in private practice for 32 years, currently practices in Oak View, California.

 

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