First Look at the E4D Dental CAD/CAM System

Dr. Jonathan Bregman visits a practice and finds the reality matches the hype.

I vividly remember the first time I heard of CAD/CAM technology. What a concept! A dentist could mill a crown to fit a prepared tooth in one appointment. No impressions, no temporaries, no second appointment for crown delivery. To me, this was amazing.

As a dentist trained in the 1970s in the hallowed halls of Northwestern University Dental School, home of GV Black (the father of modern dentistry), what I saw was beyond belief. I dare say that the advent of this technology would definitely make GV jump up out of the depths and take notice.

Being an early adopter of technology, I closely assessed CAD/CAM in those early years. But I decided that I wanted to wait until the systems and machinery were more finely tuned. First out of the gate was CEREC by Sirona Dental Systems, which debuted more than 20 years ago and has enjoyed solo rule of the market. With steady improvements, culminating in the release of the MCXL, Sirona has made major improvements to the original model, culminating in CEREC MCXL milling system. The designers have boosted performance both in terms of quality of restoration and ease of use. And today, a new system has entered the market: D4D Technologies’ E4D Dentist Chairside CAD/CAM System.

Enter the E4D

When I heard about the E4D, I was thrilled that there was a new player in the mix. I took my questions to John Hinton, Regional Manager, E4D sales/distribution for Henry Schein for the Eastern United States and a dental colleague of more than 25 years. What he told me really excited me. When I was able to watch a demo at a local Henry Schein Dental High Tech Night, I was totally amazed.

Recently I went one step further. I had the opportunity to see the E4D in operation in a clinical setting. I visited the office of Dr. Edmond Suh in Wake Forest, N.C. and interviewed him and his team.

What moved Dr. Suh to purchase the E4D?

Within the first few moments of meeting Dr. Suh, he relayed this story. A few months ago, he accompanied Dr. Ross Nash on a visit to the Texas headquarters and training center for the E4D. His sole intention was to learn. He was so taken with what he saw, that he purchased the unit before he left Texas. After completing the necessary training in the Suburban Dallas training center, and after a little more than a month in his office, he has now successfully completed more than 40 units with his new E4D unit.

What were the biggest selling points for Dr. Suh?

1. Accurate Image: The E4D utilizes laser imaging to construct an accurate image of the prepared tooth from nine separate shots comprising more than 1 million data points. Dr. Suh has been extremely satisfied with the results.
2. No change to his tooth preparation: The imaging capacity of the E4D means that Dr. Suh has not had to develop a “CAD/CAM specific” prep style and has been able to maintain his normal way of preparation.
3. Immediate online support or SOS (Support on Sight): Technical support personnel can immediately log-in, if invited (HIPPA laws) to his in-operatory unit or the milling machine to directly address questions that arise, trouble shoot, or provide guidance.
4. Training: Dr. Suh says the onsite training center in Richardson is a top notch facility, well run with a consistency of message and support. Training plus travel/hotel for two to the training site are included in the purchase price.
5. Commitment to improvement and feedback: D4D Technologies, LLC, is a US based company that incorporates combined expertise of Ivoclar Vivadent, 3M ESPE, Premier Dental and Henry Schein. Each of these companies is an investor in D4D, creating a new type of manufacturing company in dentistry. Dr. Suh has found that any and all suggestions are taken very seriously and acted upon almost immediately. Glitches that occur are not only corrected but become incorporated into the software as updates within a very short time. There is an ongoing state of continual feedback and improvement.

The clinical and laboratory experience

Now, let me share with you what I saw in the operatory and laboratory that day.

In the operatory:

• Dr. Suh prepared a lower left first molar (#19).
• His assistant, Heather, having taken and successfully completed the required E4D training, took the eight laser images of the tooth after Dr. Suh took the initial occlusal view
  1. Mesio-lingual
  2. Disto-lingual
  3. Mid-lingual
  4. Mesio-facial
  5. Disto-facial
  6. Mid-facial
  7. Adjacent tooth Anterior
  8. Adjacent tooth Posterior
• Heather did a scan of the inter-occlusal record (bite registration).
• Dr. Suh returned to view the image that was created from the combined nine laser views, marked the margins, and designed the crown. He picked the block and shade and remotely set up the milling process from the operatory.

In the laboratory:

• Earlier, the milling machine (where the block of porcelain will be shaped into a crown) had been turned on, a solution of water and a lubricating solution was placed in the fluid tank of the E4D. That was all it took to set the machine for the week.
• Now, the doctor-prescribed block of porcelain, attached to a sprue, was placed inside of the machine.
• The milling machine, now ready to go, began to mill the crown over the next 17 minutes.

Back in the operatory:

• While the milling was taking place, a crown on the upper left first molar (#14) was being prepared, then images were created for the tooth and inter-occlusal record scanned. Margins were marked, crown designed, and the message sent to the milling machine for fabrication.
• The milled crown #19, now milled and cut off of the sprue, was tried in, adjusted, polished and cemented while the crown for #14 was being milled over the next 13 minutes in the laboratory.
• The crown on #14 when finished being milled, was tried in, adjusted and delivered.
• Final occlusal refinements were accomplished before the patient was dismissed.

What were my four most important clinical observations?

1. Tech support: At one point in the design of the crown on #19, Dr. Suh ran into a situation for which he needed advice. Within a few moments, he was speaking to the SOS technician with D4D in Texas. The SOS technician remotely ‘took over’ the control of the computer in the operatory and helped him to answer his question.
2. Efficiency: The entire procedure, after anesthesia and preparation, to completed delivery of the crown was only about 45 to 60 minutes.
3. Accuracy: Any adjustments that Dr. Suh made were minimal and merely a fine tuning of the end result. Margins, contour, contacts, emergence form, shade and occlusion were all perfect
4. Ease of use: The E4D milling machine is extremely simple to use and maintain. From dulled milling diamond burs to fluid levels, if anything changes, the unit will warn you.

The Patient experience

Isn’t the real purpose of all new technology to improve patient care and the patient experience? Of course it is. So, what did Dr. Suh’s patient, Linda, think of her experience?

After the preparation, the milling, and then placement of her two crowns (#19 and #14) her final statement to me was “This is great for the patient!!! And you can quote me on that.” She loved the facts that:

• in a very time effective manner, she could walk out with her beautiful new crowns in place;
• No return visit was needed; and
• No temporaries were placed that she needed to be concerned about.

The doctor and team experience

What does his amazing team think of it? They are excited not only with the technology but with what it does for patient care and office efficiency. April and Heather both have taken the entire training course in Texas and say they love every minute of working with the E4D. Dr. Suh said their skills are improving every day, which means his future involvement chairside will be less and less. Both assistants said they plan to take advanced coursework to become certified “Chairside Dental Designers,” through E4D Technologies

Interview with Dr. Gary Severance

A few days after my visit with Dr. Suh, I interviewed Dr. Gary Severance, E4D’s VP for Clinical Affairs and Marketing and a trainer in the Texas training center. Besides confirming what I learned from my visit from Dr. Suh, I asked him how he saw the primary advantages of same-day dentistry and the possibilities with this technology. His reply was simple.

1. When possible, ‘same day dentistry’ is better dentistry:
   1. Designing and fabricating a restoration equal in fit and function to what you would normally get back in two weeks from a laboratory (single units);
   2. Eliminating the bacterial bathing, potential tooth movement, and other stresses that are created when using a provisional crown; and
   3. The clinician and assistant are involved intimately in the entire process: locating margins, custom designing to ideal form and function, and customizing the shade.
2. Create better, more comfortable, and convenient care for the patient: Digital scans, one appointment, one injection, no temporaries, etc.
3. Improved economics: this technology can be more economical for an office when the dental assistant takes over a majority of the in operatory computer scanning, marking of margins, crown design, milling and finishing, leaving the dentist to be maximally effective with his/her time in the operatory.

Is it for me?

After spending the day with Dr. Suh, it became clear to me that he is a superb dentist who leads one of the most highly motivated, quality- and people-driven teams I have met. When considering adopting any new technology, he involves his team in the decision making and has them take the same training that he takes as a dentist. Through his leadership and involvement of the team, integrating the E4D has been and will continue to be a great success, I believe. We can all learn many lessons important lessons from him and his team. This technology works for them.

Every dentist and team must decide what technology makes the most sense for their practice. They have to make a decision to purchase then fully incorporate a new technology based on their own reasons – not mine, their friend’s or those of Dr. Suh.

• Is an E4D or one of the other Chairside CAD/CAM Restorationsthe right investment for you?
• Does it fit your long term personal and practice plan?
• Do the numbers work regarding rate of return and return on investment?
• Are you willing to make the investment of time and resources to maximize this significant investment?
• Is the physical plant capable of handling the additional space needed?

We are in a world of amazing and ever expanding technology. Decide what is right and what makes sense for you then go for it. It is your practice. It is your future.