Read the audio transcript below:
Dr. Luisa Schuldt (LS): Hi everyone. Welcome to Brush Up, presented by Oral Health Group, the dental podcast where we speak with industry experts to discuss a variety of topics such as technology, finance and practice management. I’m your host, Dr. Luisa Schuldt, a prosthodontist and periodontist based out of Font Hill, Ontario. Today we’re discussing 3D printing with George Freedman. Dr. George Freedman is a founder and past president of the American Academy of Cosmetic Dentistry, co-founder of the Canadian Academy for Aesthetic Dentistry, Regent and Fellow of the International Academy for Dental Facial Esthetics, and a Diplomate and Chair of the American Board of Aesthetic Dentistry. He is an Adjunct Professor of Dental Medicine, at Western University, Pomona, California. He is the author of 14 textbooks, more than 900 dental articles, and numerous webinars and an internationally renowned lecture on aesthetic restorative adhesion, implants, veneers, 3D printing and dental technologies. Welcome, Dr Freedman.
Dr. George Freedman (GF): Thank you very much, Luisa. How are you?
LS: I’m doing great. I’m really excited to hear about the information you’re going to be sharing with us today. 3D technology and 3D printing is really something new. It’s hitting the market strong. It’s changing how we practise dentistry, for the clinical dentist. What is the most important thing that we should learn about dental 3D printing?
GF: Well, this is an area of dentistry that 10 years ago would have been science fiction. And today it’s something that you can get over the counter almost anywhere. So, let’s take a look at the most important features with respect to the clinical dentists, the cost, the speed, the learning curve, maintenance, and the effects on the laboratory relationship. First of all, cost. Printers are roughly one-tenth of the cost or price of milling units. So, if you take $100,000 milling unit, which is about the entry level cost, a similarly high-end printer will be under $10,000. More about that later. The resin printing materials are one-fiftieth the cost of the milling blocks. When you get a block, it’s about $50, give or take or more. And the resin printing materials costs about a dollar. So, it’s a major, major difference in cost. One of the questions is, should I buy an expensive printer? The answer is probably not. Number one: You basically need a printer that prints a fairly accurate crown or denture or whatever you happen to be printing, and they don’t have to be expensive. Nowadays they’re also going to change very rapidly. The evolution, the change, the new generations of printers are coming out all the time. So, you don’t want to get logged in pricewise into a system that you are reluctant to leave because there was so much investment. Get an inexpensive printer that works for you, whichever one it is. Now, what about high-quality resin materials for printing? Well, here I would definitely spend as much as you need to get the best material you possibly can, because the best material is going to cost 20 cents more at most for a single crown restoration than a poor material. So why not get the best? It means absolutely nothing in terms of the overall cost of the restoration. Now speed. Similar for printing, similar to milling unit, about 10 minutes for a single unit. The difference with printing is that when you put a stronger computer behind the printer, you can usually speed up the printing. So, this is something you can watch for in the future. In fact, if you’re printing an entire denture, it takes approximately an hour or less to do that. Learning curve. Very rapid uptake. There’s a lot of complicated technology, but we don’t have to worry about that. We just have to worry about the one button that we have to touch to start the process because everything else is taken care of by the technologists and most aspects of the printing process can be delegated to staff. Because they are extraoral, maintenance is relatively simple. Maintenance on a milling unit is expensive. It’s problematic. You often have to ship the whole unit back to the manufacturer or to the dealer. But with the printer it’s minimal. There are virtually no moving parts, so there’s nothing to wear out. A replacement of the unit due to a breakdown or obsolescence is much easier to bear. It’s much easier to replace a $5000 printer unit than it is to replace a $100,000 milling unit. Now the effect on the dentist laboratory relationship is going to be significant because most procedures can be done quickly, chair side, in office. You don’t need a lab, no lab fees, no transportation costs back and forth to the lab. Effectively same day, same appointment, serve.
LS: It’s amazing. It really does change how we provide our clinical care. The versatility of these units. You’re mentioning the comparison with the milling units and they have some of the same functions. But they also have additional functions that we can have in our printers. So, I think it’s just amazing the way it is changing the way we do our dentistry. How do you see all these options and things that we’ll be able to do with it affecting the way we work on a day-to-day? As dentists or staff or patients?
GF: The only way you can sort of summarize it is to say that 3D printing has arrived in dentistry. As with the other great paradigm shifts of the past 50 years in the profession, such as cosmetics, implants, diagnostics, major advances are very apparent on the near horizon. The needs are many, technologies are numerous, the applications almost unlimited, and the potential in this grade is open-ended. Consider, for a moment, cosmetic materials and techniques, firmly entrenched aesthetic restored dentistry in the hands of every practitioner just 40 years ago. Now, 3D printing brings the functional and artistic control of the restorative process into the chair side setting. The digital transformation of dentistry, including cone beam computerized demography, intraoral and external scanning, ceramic and composite milling, and robotic implant placement, among others, is well established. 3D dental printing is part and parcel of this evolutionary trend. Stereolithography, first used in the 1980s, was soon followed by additive manufacturing, the deposition of materials and increments. So, here’s a good spot to mention the difference between milling and printing. Milling: you take a block, and you remove structure to create a crown, for example. In 3D printing, you take a blank plate, and you use the theoretical shape of the crown to lay it down in increments, layer by layer, basically additive. So milling is subtractive, printing is additive. Dental applications are more recent than the medical applications. 3D printing has been utilized for rapid prototyping and modeling for more than a decade. The size and cost of earlier printers meant that they were really limited to larger laboratories. The more recent desktop printers have a much smaller footprint, are easily affordable for the single practitioner. They communicate with existing software platforms and offer high levels of precision with a wide range of materials. Current 3D printers are fully capable of managing the great demand for temporary, transitional, and permanent restorations and appliances, and achieving the clinical excellence required by the dental profession. Within the profession, there’s a great acceptance of this transformative technology. 3D printing is seen as an industry game changer and a prediction of the dental practice of the future. 3D printing techniques include stereo lithography, fused deposition modeling, subjective laser sintering, photopolymer jetting, electron beam melting and direct light processing. But before you get confused by all of these terms and products, you don’t have to know the difference. All you have to know is when you choose the appropriate printer for your practice, you press a button on the computer to begin its printing process. The currently use 3D printing applications can be grouped by treatment categories. In fixed spots dontics, you have permanent, provisional, indirect restorations, crowns, onlays, inlays, bridges and permanent monoblock direct restorations, all custom fabricated chair side within minutes of scanning the preparation. This is where the science fiction comes in. Removable prosthodontics, both full and partial dentures, including digital occlusal design. Patient comes in without teeth at 9:00 in the morning. By noon, they’re leaving with a fully articulated upper and lower full prosthesis. Just incredible. Implant dentistry: 3D printing of surgical guides has facilitated ideal implant positioning and biomimetic custom 3D printed bone implants replace missing segments, minimizing stress transferred to the remaining bone. In orthodontics, aligners are 3D printed with CBCT data and artificial intelligence is extrapolation of tooth movement over time. Endodontics: 3D printed endodontic access guides translate pre surgical planning into clinical success. In periodontics: 3D printed guides relieve and retract gingival margins, offering aesthetic gingival corrections, but soft tissue printing is currently in the research phase. Imagine if you can print missing soft tissues. That’s just incredible.
LS: Also scaffolds for bone. Are in the process of being designed.
GF: And maxillofacial surgery. Thank you for anticipating. Maxillofacial surgery: Custom-designed 3D printed bone grafts, which is the scaffolding that you’re talking about, and fixation plates expedite both the surgical procedure and the healing process. 3D printed techniques and procedures are high quality, high precision, accurate, and significantly lower in cost than conventional treatment options. Then to save money, many desktop printers cost between 3 and 10,000 dollars. 3D printing materials cost pennies per tooth. As a result, patients save money by the elimination of intermediate procedures and transportation costs. Treatment is faster. Typically, same day services. 3D printing is really the future of dentistry for every level, except perhaps lab technicians.
LS: And it’s really amazing. You mentioned earlier how affordable it is. And I also see the great advantage from the footprint. When we are milling material, we are discarding so much excess material that you know is not used. And when printing, you just make it the size you need. There might be some trimming and polishing, but we’re just using the material that is required. So, the footprint from the green perspective and trying to be gentle with nature in our environment, it’s a really great advantage as well.
GF: And the extra material that you don’t use, that you have to remove in printing, can be recycled.
LS: That is true. Yeah, very, very good point. The design tools coming up as well with AI integrating into this to make it easy to design those chair side and rapid prosthesis is just amazing. But all this is done with, I would assume, some standards for the material, standards for the printers. Who is developing all of these standards for us?
GF: 3D printing is in its formative stages. The major distinction between the comparable developments of cosmetics and implants is that printing is progressing much more rapidly, much more internationally and far more open source as an environment. The exciting expectation is that 3D printing promises to bring the functional and artistic control of the restorative process back into the chair side setting, but the daunting concern is that the extremely broad spread of research and multiple technical development alliance will lead to mutually incompatible nomenclatures and technologies. The digital transformation of dentistry is firmly established. It promises to transform the practice and delivery of dentistry within a decade or two. To me, it is essential that dentists and the dental industry continue to develop a setting where communication is enabled by corresponding software platforms, technologies that have both backwards and forwards flexibility. And most importantly, a research and development space where the terminology is standardized and mutually comprehensible. Current 3D printers can manage the increasing demand for temporary, transitional, and permanent restorations and appliances. They can decrease delivery costs for these services, enhancing patient accessibility and dentist practice viability. To speed the general practitioner acceptance worldwide, there must be a defined set of clinical standards that ensure treatment, predictability and success, and a suitable lexicon of readily understood terms for this innovative area of dentistry. At the level of researchers, developers, and manufacturers, this requires the establishment of a broadly recognized and accepted framework of measurements, standards, and guidelines. These paradigms must encompass most of the existing leadership of 3D printing at various levels, serving to delineate a basis for compatibility with adequate space for flexibility and growth that can reasonably accommodate foreseeable and perhaps unforeseen upcoming development. These foundational definitions will establish the future guidelines for applications that are yet to be developed and will institute continuity between the present and the future. For the practising dentist, 3D dental printing is a wonderful addition to the clinical armamentarium. It is also something new, something different, something with its own vocabulary. Most important step to achieving universal chair side acceptance of this technology is to make it easier to understand. Every technology brings its own word list, and every new technology has many competing word lists that only serve to confuse the practitioner. It is impossible to explore innovative treatments without innovative words and meanings. We must attempt, at the very least, however, to standardize these new terms and meanings, to minimize the confusion as much as possible. The recently formed International Academy for Dental 3D Printing is working to create 3D dental printing standards groups for defining a set of clinical research, development and manufacturing guidelines, and a set of standardized nomenclature and terminology. 3D printing is the future of dentistry. We are beginning by creating the proper foundations.
LS: You clearly speak from experience with all the time and hours you’ve invested in all the associations and academies you’ve formed an important part of. Each of these have nomenclatures that are commonly used and that they promote through their journals, through their lecturing, and I can see that that is what should be happening with 3D printing as well. You mentioned an association. Is that where we should be looking for leadership or are there some other options for us to look at for guidance or learning opportunities and leadership in the area of 3D printing? Dental 3D printing to be more precise.
GF: That question has sort of answered itself by the initiative of a number of people who’ve been involved in this over the past few years. There are few problems here. 3D dental printing is harmonious with the continuing positive evolution of dentistry. As a field of study and practice, it is clearly distinct from prior dental technologies and techniques. Yet at the same time, totally in sync with the arc of dental development. The rapid acceptance and uptake of 3D printing technologies in a wide range of dental procedures points to the need for an organizational structure to set manufacturing, oratory, and clinical standards, and to begin the formulation of a comprehensive educational platform that will serve to train dentists and technicians worldwide. So here, we’re not only add nomenclature and standards, we’re adding education because we need to have some foundation for that. Because 3D dental printing is so innovative, so promising and so destructive, it is unlikely to find a truly accommodating niche, one that would nurture its growth and progress with an existing and necessarily competitive dental organizations. For the very same reason that cosmetic dentistry could not have flourished as it did within the confines of prosthodontics or traditional restorative dentistry 40 years ago, 3D printing must engage open minds and imaginative spirits and empower science-based risk takers who will challenge conventional wisdom and established practice. Thus, it is essential that a new organization, one that has dedicated solely and exclusively through 3D dental printing, take the lead in shaping this nascent dental field. Ideally this must be an organization that offers an open forum for free discussion and timely presentation of new ideas, even if they seem far fetched, and open membership that is affordable and one that will not only attract and collect information and clinical feedback, but will effectively disseminate the accumulated knowledge base around the globe. The parameters of this group of professionals who have actually laid the International Academy of Dental 3D Printing, who have laid the foundation for the next major leap and dentistry, covered the following ranges of crucial expertise: Hardware experts, who develop the printing technologies and devices; software experts, who drive the hardware and link clinicians, lab techs and patients; technicians, who use the technology to turn raw materials into restorations; and dental professionals, who diagnose, treatment plan, and deliver restorations to patients. Therefore, it was very appropriate to have the convening meeting of the IAD3DP at the International Dental Salon in Cologne, where so many of the world’s experts in the above mentioned fields were gathered in March of 2023. The IDS was celebrating its 100th anniversary and it was very fitting to initiate the IDS’s second century by inaugurating this most fundamental transformation of the dental profession 3D printing.
LS: That’s quite a unique world with so many different groups of knowledgeable people coming together to make this truly work. In our dental setting, does the future look different for the dentists who have already grasped and truly engaged with this technology versus those who haven’t? Are they better positioned for the future?
GF: Let’s take a look at the global picture. The year 2023 has brought new promise and fresh hope. The world has passed through the dark clouds of pandemic and uncertainty, and a bright future beckons. We have lost much family, friends, time, opportunity – most of all confidence. Whereas we were once certain that our established knowledge, techniques, and experience could deal with anything that might be thrown at us, we have clearly seen that the keys to survival and future success typically involve radically disruptive concepts and non direct approaches. From a historical perspective, the dental professional experiences a major directional shift every 20 years or so, roughly once in a generation. In the 1960s, the high-speed handpiece mainstreamed dental access by leveraging productivity. In the 1980s, bonding and composite materials awakened the public interest in appearance. And cosmetic aesthetic dentistry made dental care desirable, very desirable, and highly popular. The 2000s ushered in the routine delivery of implants and implant bone restorations, providing full function and form to those who had no teeth to restore. The 2020s herald the advent of chair side, 3D-printed rehabilitation under the continuous and comprehensive management of the dental practitioner, encompassing virtually every dental treatment and material. The wide range of clinical 3D printing applications can be grouped according to the treatment category, as mentioned before. Fixed prosthodontics, removable prosthodontics, restorative dentistry, implant dentistry, orthodontics, maxillofacial surgery, and periodontics. It is reasonable to forecast that the 3D printing dental revolution will be significantly more transformative than the other paradigm shifts of the past century. Each of the earlier developments affected a small portion of existing procedures, relatively minor number of dental practitioners, or it initiated innovative new ones. Additive 3D dentistry effects and enhances every dental procedure. In fact, it’s easy to envision that in the very near future, the standard direct restoration will be printed extra orally and then bonded into the prepared tooth rather than being inserted in situ by relatively unpredictable tooth 3 millimeter layer of composite. 3D printing is typically the same day service, eliminating patient waiting time and laboratory transportation costs. 3D printers are generally all very high quality, high precision, accurate, and significantly lower in cost than conventional treatment options readily affordable for the single practitioner. That in itself will drive their mainstream adoption by their profession. The vast potential of dental 3D printing provides the impetus for its role in serving as the key ingredient for dentistry’s currently occurring paradigm. Shift 3D printing creates and embraces the future of dentistry, the future of our practices, and the best for our patients by offering clinical solutions that are better, faster and easier.
LS: It’s just amazing – everything that we will see in the next few years and in the way this technology is going to impact almost every aspect of what dentists do on a day-to-day basis. Thank you so much for joining us and sharing the experience you have. And it looks like you’re just as excited as I am to see where this technology takes us in dentistry. I’d like to thank our listeners. Thank you so much for joining us and listening in. Be sure to subscribe on Spotify and follow us on social media to be notified every time we post a new episode. Keep brushing up! Thank you.