Expanders

By Alison Werner There is no doubt that digital orthodontics is reshaping orthodontic treatment. Many practices have already made the switch to intraoral scanners. But that’s just one piece in the digital orthodontics puzzle. In-house 3D printers are the other. With prices ranging from a few thousand dollars to $100,000, the decision to bring a 3D printer into your practice is not one to be taken lightly. Orthodontic Products talked to two practices about their decision to bring a 3D printer in house. We wanted to know what went into their decision, what the reality has been, and what advice they would offer their peers who are considering a purchase. If there is a lesson to be learned from their experiences, it’s that this purchase decision requires flexibility and pragmatism. Be Flexible. Ken Dillehay, DDS, MS, of Wichita, Kan, spent a year researching the right 3D printer for his practice, eventually settling on a model from Detroit-based EnvisionTec (distributed by 365 Printing), which he introduced into his practice in February 2014. As an early adopter of the iTero® intraoral scanner from Align Technology Inc, and a member of the team that did the early testing of OrthoCAD® to get FDA approval for full arch intraoral scans, Dillehay saw an in-house 3D printer as the next logical step in taking his practice completely digital. Initially he intended to use the printer to make resin or printed models and eliminate stone models for indirect bonding (IDB). However, Dillehay ran into problems. He found it difficult to separate the brackets from the model consistently and successfully. While the practice still tries to find a reliable method for IDB, the machine’s use has evolved. Today the practice uses it mainly for tooth movement with in-office made aligners. “Sometimes I look back at that decision [to bring in a 3D printer] and I don’t think it was the best decision since we struggled so much with the original intent of using the 3D printer for indirect bonding. But now that we’ve somewhat repurposed the equipment for in-office aligners, I think it’s more cost-effective, more timely, and we have more control of the process. So, it is working out well, but we had to get to that point where we found a different use for it,” says Dillehay. Dillehay opted for the largest printer model available from EnvisionTec, one used by commercial labs. Depending on the dental arch, he says, the machine can print 12 to 15 arches per printing session. And that’s just what he wanted for his five office practice—all of which would share this one printer. “We wanted to be able to print several models at one time, and the [smaller] units only printed three to five arches. We wanted to print them overnight and come in the next morning and have a dozen models. A [smaller unit] would be hard to fit into our schedule,” he says. And while Dillehay is glad he made the purchase, bringing it in wasn’t simple. At the time of his purchase, Dillehay’s office was about 30 years old, and he’d planned to put the refrigerator-sized printer into the existing lab space. But there was a problem. First, the space lacked a dedicated electrical circuit for the printer, and then all those models, retainers, and aligners being fabricated in the lab meant dust, and most of these printers need a dust-free environment. What’s more, the machine needed to be vented, as there is an odor when it’s in use. Dillehay didn’t find out about the space and infrastructure needs of the machine until a team came to install it. But fortunately he had plans for a new office, which included a dedicated room off the lab, with independent heating, cooling, and ventilation, as well as a concrete floor and sealed door. “It’s worked out very well,” he says. Dillehay is quick to forgive the fact that he wasn’t made aware of the infrastructure needs at the time of purchase. “I think [the sales team] was learning as we were learning. I don’t think they intentionally didn’t tell me,” he says. Last February, a year after his purchase, Dillehay reflected on the decision to bring a 3D printer in house. He looked at the value the machine brought to the practice and whether or not they should sell the machine and opt for a commercial lab instead. Dillehay admits his practice has a lot of money tied into the printer—after all, the costs don’t stop with the purchase; there are the continuing costs of maintenance, software, and materials. And at that 1-year mark, he admits they weren’t using the machine to its fullest extent. But now, 2 years later, he says he feels more confident about his purchase. As for advice to those considering a 3D printer, Dillehay has a couple of tips. First, decide what you’re going to use it for, and then be flexible. And second, visit a commercial laboratory. “See what it’s going to cost you to produce on an annual basis [with a commercial lab]. Then look at the cost of the machine and the operational costs of maintaining and operating it. Unless you are going to use [the printer] a lot, it’s going to be more economical to do that with a commercial lab than owning it. I think it really boils down to how much you’re going to use the machine,” says Dillehay. “3D printing is cool, but there are a lot of other things where we can do the same thing.” Be Pragmatic. Christian Groth, DDS, MS, and John Dumas, DDS, of Michigan-based TDR Orthodontics, got their start with 3D printing over 3 years ago when they were approached by suresmile (OraMetrix Inc) to help develop the company’s clear aligner module. Soon, everything in their practice, from expanders to retainers, was done on 3D printed models, although they were relying on a commercial lab for their 3D printing. After a year, the practice decided to purchase a 3D printer and bring the work in house. “It got to the point where we were doing so much [3D printing] that the timeline for getting models back from the lab was starting to get a bit frustrating—even though the lab was only 45 minutes away. At that point, it made sense for us to have our own printer,” says Groth. Groth and Dumas spearheaded the project for the practice and looked at 10 different printers, ranging in price from a couple thousand dollars up to $100,000. They debated whether they wanted several smaller printers or one large commercial-sized printer. In the end they opted for the commercial-lab sized Objet Eden printer from Stratasys because it checked all the boxes on their list of priorities, including upkeep, reliability, and safety. “I’m not going to put anything in a patient’s mouth that’s been made on a model where the material hasn’t been vetted, especially in light of some research that came out recently from UC Riverside showing there are toxic materials that are uncured in the cheaper printer models,” say Groth, referencing a study titled “Assessing and Reducing the Toxicity of 3D-Printed Parts,” published in Environmental Science & Technology Letters last November. As to the reliability issue, Dumas and Groth wanted to make sure the printer they chose could stand up to daily use, especially since they planned to buy only one printer. And as Dumas says, you get what you pay for. “There are a lot of people thinking, I’m not going to spend $100,000 on a printer. I’m going to spend $2,000 on a MakerBot, and I’m going to put this into my practice and it’s going to solve all my problems. But the reality is there is no way to run a busy orthodontic practice on a low-cost, small footprint, slow printer. Now the gap is getting smaller. Printers are starting to get faster. But the point is, as the price comes down, something has to give.” And as far as Groth or Dumas are concerned, those lower prices often mean cheaper parts and questionable reliability. As for upkeep, Groth warns that those costs can be pretty significant. “It’s not something that’s talked about a lot. There’s daily, weekly, and monthly maintenance. And when things go wrong, the prices can add up. So we wanted something where the upkeep was something we can handle,” says Groth. “For the most part, we’ve had very few issues. But we didn’t want to get to a point where we were shut down because of a major issue.” For those who fret about the financial plunge into 3D printing, Dumas points out that the cost of a 3D printed model should be viewed in terms of the time savings when compared to alginate models. “People haven’t quite realized that when you have an orthodontic patient that finishes with treatment and you’re doing an old alginate impression to make their retainers, you get one retainer for one impression. And if they need to have another retainer made, they have to come back into the office and you have to take another. People don’t appreciate how expensive their chair time is,” says Dumas. “For us, each chair should be making $300/hour, at least. If it’s taking 20 minutes to clean and set up the chair, take the alginate, break down the chair, and clean it for the next patient, we’re losing money. People lament the fact that I’m going to spend $12 on a printed model, but what they don’t realize is that it’s so much more cost beneficial to do that.” What’s more, having a 3D printer in house allows Groth and Dumas to streamline retention. When a patient loses a retainer, the practice can easily print off a new model from the existing patient scan to create a replacement retainer—all without the patient returning to the office. In addition, the practice utilizes the in-house printing capability to do minor tooth movement, printing their own aligners, and expects to start IDB in the next month. The practice decided early on that it wanted to use this printer to set up its own commercial lab. Today Motor City Lab Works serves about 60 offices nationwide, and prints about 100 models a day. But setting up the lab meant creating the infrastructure to house the printer. “That’s really the big thing no one tells you when you are getting into this. No company is going to...