Advancing Dentistry: Technology and Patient Care

Teaser:
You are saving on time. Again, time comes back to time. That’s important, how you want approach it. What’s the best way for you for your personal preference as a dentist? So like, cost doesn’t, so they do a lot of IM sort of stuff. And I’m part of that group and I see people just pumping out like beautiful stuff for me.

For me, I like it, but it is very hard for me as though I just don’t see the benefit for me personally, because I would rather just mill it or print it and it makes my life easier. It’s just that the problem with all these really fast growing industries is that you don’t have long-term studies.

You don’t know for sure how long things are gonna last. You could spend 12 grand than pay like thousand pounds for each bottle of resin and then you’re like, okay, I’m gonna replace all these things in two years. Then what’s the point of that? Like, you’ve lost that money and then you’ve lost more money and you’ve lost time as well.

Jaz’s Introduction:
Protruserati, I don’t know about you guys, but I am a noob when it comes to 3D printing, milling, and my limit of digital dentistry at the moment is my scanner. Right? My intraoral scanner is great. I’ve been using it for several years. Absolutely hate taking impressions now, obviously, but when it comes to this whole other world of actually production, right?

Printing stuff, milling stuff, man, I have no idea. And so I am so, so pleased to share this episode with you today. I have Dr. Rustom Moopen, who not only is one of the biggest geeks you’ll ever meet, but he’s a geek in a way that he’s not gonna lose you, right? He’s not gonna talk about like, molecule size of resin and different chips that you need for different printers and processing speeds and that kind of stuff.

In this episode, he will legit tell you why he thinks milling is better than 3D printing. But of course, what is the limit of 3D printing? What can be done with milling and how’s actual software and design part work as part of the workflow. Of course, you’d be wondering how much does this all cost? ‘Cause it doesn’t sound cheap and it isn’t, but it may work out more cost effective for your clinic.

There’s a few things I love about our guest, Rustom and I mentioned it right at the beginning of our chat. You know how I’ve shattered him in the past and saw the CEREC in action, how he really inspired me. I never really then got into the CEREC, but you could see him absolutely flying and he just gets a huge kick of having all these toys.

And importantly, with all these toys and different brands of toys he has, he’s not sleeping with anyone. He’s very unbiased. He’s very real talk and he’s just genuinely helpful. A really good argument Rustom makes in this podcast episode is that when it comes to his sphere of digital dentistry, printing, milling, a lot of people are very secretive about their knowledge.

They put up barriers so that then you have to do these curriculums and courses to be able to gain what he thinks is very basic knowledge. So I’m really hoping that this is the episode that finally brings it all together, and you’ll be amazed with everything that Rustom shares. It just makes so much sense, and he just gives it all away. And that’s just the kind of guy he is. He’s not only a phenomenal clinician, but he’s really, really caring and giving, and that shines through this episode.

Dental Pearl
Of course, I give you a Protrusive Dental Pearl, and I’m proud today to give you one from our community. Our community is called protrusive Guidance. There’s over 3000 of the nicest and geekiest dentists in the world, and what I like to do is I like to keep it as a little family, right? I don’t try and invite every single dentist I have ever met onto the community.

I actually want you guys to self-select yourselves. If you identify yourself as nice and geeky, and you crave this forum and this chat group in this lovely app that we have on iOS and Android, and of course on the laptop, you go to wwww.protrusive.app, you can access our entire web app, which is very powerful.

Then it’s like a treasure trove of all the content we made over the years. Our special webinars that we have, our paid masterclasses, everything is on there, but the magic of people and the magic of the Protruserati is what I love the most about it.

Now we get loads of questions every day from you guys on the chat group and on the main feed. And one question that Dr. Kang posted in the chat was about the clamps that I use for rubber dam, the Kerr soft clamps. Kerr is a company, K-E-R-R. I think those are the same guys that make OptiBond FL, et cetera. So very reputable company and they make this really nice rubber dam clamps. Now I know Celine Higton, who was a previous guest of the show, she’s not a huge fan of them, but I actually use this clamp for 80% of all my cases.

And the reason I like the soft clamp is because it’s soft, right? Compared to metal, it’s much kinder to the tooth and much kinder to the gingiva. And so whenever I’m doing a quadrant isolation, I don’t need to give a supplemental, palatal anesthesia for the upper, nor do I need to give anything lingual for the lower. The soft clamp is very comfortable.

Now while we are discussing in the chat group, Dr. Joe Cape came with his absolute gem, which actually makes a lot of sense. Now I’m wondering why have I never come across this before? And it’s basically if you want to achieve the same effect but with a metal clamp that you probably already have, then to avoid a potentially painful palatal injection or to give supplemental anesthesia, what you could do is you can actually rub some topical anesthetic into the palatal or lingual gingiva or anywhere you want.

So what Joe does is he gets a cotton bud with topical on it and he just spreads it on the gingiva that you want to clamp and just leaves it for a minute. And he swears by this. And so that just makes a lot of sense. And I told Joe on the Protrusive Guidance app that I’m gonna feature this as a Protrusive Pearl.

So thank you Joe. You saved me a lot of anxiety. I always get a lot of anxiety before, thinking of the Protrusive Dental Pearl about 300 episodes ago, it was easy to think of a pearl. I’m kind of running out of Protrusive Pearls now, so it’s great to collect them wherever I can and share them. So thanks so much Joe, and I hope you guys enjoy that one.

Anyway, let’s join the main episode. You’re gonna absolutely love it. And oh my goodness, this could have been a two part, right? This is a long one. This is like one of those the equivalent of a Joe Rogan three four hour marathon, but for dentistry. I find the sweet spot is about 40 minutes and I try and keep our episodes 40 minutes.

This one I was really debating whether I should make it a two part, but I ended up going with one part. It’s just one that you may need to revisit again and like continue the second half. But I promise you it is so worth it if this is a big problem for you and you dunno where to start with printing and milling, man, you’re gonna love this. Please let me know if you do like hit that thumbs up button, comment below and I’ll catch you in the outro.

Main Episode:
Rustom Moopen, the famous Rustom Moopen. Welcome to Protrusive Dental Podcast my friend. Honestly, it’s been a long time I’ve been waiting to to host you man. ‘Cause I wanna just give a little background about you before we formally introduce you.

You are the guy I once shadowed and I just saw like, wow, this guy’s a GDP and like for me. Like, I still think this now anyway, but to me at the time what was going through my head is like, wow, this guy’s a GDP and he’s operating at a specialist level. You were doing a mixed practice and you gave me this iPad and you were showing me the scope footage as you were treating it, and you have no idea how much you inspired me that day.

You showed me the CEREC. I didn’t go down that route, but just seeing your passion and your technology and how tech-y you are. And then you took me for a lunch date to KFC. So that was the best shadowing experience I’ve had in my life. And so I’m so glad that years later we can meet like this and geek out. So Rustom quite an introduction there. Tell all the listeners and watchers about you, mate. 

[Rustom]
That’s a tricky one. I remember that day when you came in for me, like sharing is fun. It’s like, you get to show people what you do and inspire them like you said, but there’s nothing really special about me like dentistry.

If you enjoy it, you enjoy it. If you don’t, then you don’t, and that’s fair, but it’s a good enough job that you get to do what you want to do. And be who you want to be in dentistry. My story is really this, like, people ask me this all the time, like you do a lot of stuff, but I’ll tell you what happened to me.

Back in the day when I first started, I used to work in the same practice that you came visit me in and it’s mostly NHS, mostly NHS. And I put up a case once, it was just a composite. I was trying to stain and glaze, not stay in glaze. So, um, just to put some stain in and stuff and make it look good.

[Jaz]
You’re such in lab mode that you had to, you’re just always like in the CEREC mode that it just came out of your mouth. 

[Rustom]
Pretty much. Yeah. But, so I put this case up on Facebook and back then I was working by myself. I didn’t have any associates. And you’re working by yourself. You don’t know if you’re doing good or bad, you just have no idea, but you wanna find out.

So I put this case up on Facebook and I said, look, I’ve done this seven and it looks horrible. Okay? People are like, oh, it’s amazing. I would have that in my math. And one guy messaged me, right? And he messaged me and he said, the reason it looks crap is because teeth don’t look like that. Okay? There’s no point in putting stain in stuff if you’ve just made a hot cross bun and the guy’s name was Govinda Perth, you know, Govinda, right? 

[Jaz]
Of course, man. 

[Rustom]
So I messaged him, I said, look, can you help me get better? So he said, fine. Like, just send me some cases. So I’d send him cases every day, like two, three cases a day. I’m like, what do you think about this? And he’d be like, look, if you want me to look at your photos, you got to take proper photos. So I start taking proper photos and he is like, fine. Like your photos are good now, but if you’re gonna put isolation on like rubber dam, then you gotta do it properly.

That’s leaking there. That’s a mess there. You gotta sort that out. So I started doing rubber dam and then he started looking at my competency. He said, look, morphology, you have to look at it like this. This is what teeth look like, right? You can’t just make up stuff in your head and do it. And just ’cause you put some stain in there.

People will think that it looks good because it looks better than what they can see, but that’s not really the truth. That’s not what teeth look like. And I got better and better and I remember it took me a year, right? And he used to just rip the piss outta me every time, but in a good way, not in a bad way.

And I got better and better ’cause he did that. And one day, a year later, it was literally a year and a couple of days and he said to me, you know what? That’s really good. That’s really good. And I said to him, are you taking a piss? Like, like you’ve ripped the piss at me every single day. And he is like, yeah, but let me ask you a few questions.

I was like, cool. He’s like, do you think about your photos now? How you’re lying them, how you take them? No. Okay. Do you think about your rubber dam? No. Do you think about your composites now? I was like, yeah, a little bit, but I don’t think about too much. But that’s the thing, like, ’cause someone’s mentored me through that.

Like it helps. That’s all it is. And I think in today’s world there’s always a lot of people who will really say, that’s great, that’s fantastic, but they don’t really mean it. Right? But with him, he helped me out by saying, look, this is how it needs to be. So you just get better and better. 

[Jaz]
I mean, that’s a powerful mentorship story, which is so crucial. And I’ve seen your Facebook post buddy, you do actively talk about the power of mentorship and that being more important than courses. And that’s a testament to what your, that experience you have with Gov, who’s a real ballbuster for all the right reasons. And an absolute legend.

And a master is craft. When I speak to my guest, and something I just wanna point out is usually when I have a guest on, on a certain topic, I have enough background knowledge about what we’re talking about that I can navigate. And this one is like uncharted territory for me. So I’m actually nervous, excited for how the rest of this chat’s gonna go.

‘Cause there’s so much I’m gonna ask you about milling, printing, and you must get inundated with messages because this is like, there’s so much out there already. So it’s not like it’s a new field, people doing it for quite a while, but it’s a territory that a lot of dentists like fair enough, a lot of dentists have now got scanners, now they’ve got the iTero or the 3shape, whatever. But this next step of milling and printing is almost a bridge too far for whatever reason. But how did you become an early adopter? 

[Rustom]
So when I graduated I heard about the CEREC thing and I saw it like I went to IDS and I saw it and I was just like, this is amazing. The fact that you can actually make your crowns in-house.

You get to control the design and do everything yourself, right? So, I said to myself like, it is the future so I wanna buy it. And loads of people are like, don’t buy it because it’s basically a really expensive door stop. And I thought about it and I realized what happens is that we as dentists, like when we do preps and stuff, we don’t measure, right?

We don’t measure, right? We just do a goal prep and we think that’s fantastic. We turn off the lab and they’ll make it fit, right? But the moment you start measuring things and doing things the same way, then you know it’s gonna work. It actually doesn’t matter further than that. And I’m a big fan of Attiq, I did a Attiq’s first course and the biggest thing I learned that day was like, measure.

Measure. Because you want to know how thick your ceramics gonna be. And I’ve done CEREC for like 12 years now, and I have cases going back all those 12 years, and I’ve had like fractures here or there, but I’ll count ’em on two hands at most. But success is, it’s immense, but also if something goes wrong, it’s your fault, right? It’s no one else’s fault. So I enjoyed the fact that I’ll take a punt and it was really expensive. So I paid about 90 grand, I bought it from sident. 

[Jaz]
Wow. 

[Rustom]
And it was on finance, right? Five years of finance. But once you realize that, okay, think about this. The advantage of this is you do an Emax or porcelain for a patient and you’re wired.

If it doesn’t fit, if it breaks, if your impression’s crap, then you’ve gotta send it back and it’s time. Okay? And everyone thinks that money’s important, but time is more important, right? But the moment you realize that none of these things matter, you are making them in-house, it costs you far less, okay?

Obviously you have to pay for the system and stuff, but if you can keep doing it. Like if you do something and it breaks and you’re like, look, I’m really sorry it happened to you, but we’ll make you a new one and it won’t cost you any more money. It’ll take you some time. That’s true. But money wise, no. So it was a bit of a journey, like, I just thought it was a future, so I bought it.

And like a punt. And sometimes whenever you buy something, like for example, like you wanna talk about printing and milling, I think the important thing is that every time that you decide you wanna take a journey or a step forward, you have to have a vision of what is gonna fit into your practice. And if you can make it work, then the money will be paid off in no time. But if you can’t make it work and you’re doing it for fun, then it’s just the hobby. And that’s fun too. 

[Jaz]
There’s a saying that people pay attention to what they pay for. So when you paid for it, what you did was you leaned in, like you were like determined, like, okay, I’m gonna make this work no matter what.

I’ve just spent an eye watering amount. It’s gonna work. Okay. And you made it work. And then through that you learn so much. It’d be also express your inner geek. And I can just totally see that from the way you talked, the way you when I was there, shadowing you. You love it and it brings you joy, which is great.

And I think there is a measurable return on investment, ROI here, because when you buy a scope, which you also have, when you buy a scope, there’s no ROI that’s really like you do it for yourself ’cause you want to just feel like you’re seeing more, you’re treating more and also posture and ergonomics and stuff.

But the CEREC, although it’s an investment, it is exactly that, it does have an ROI. Do you think looking back now, it has had a positive ROI? Look, counting all the repairs and maintenance and everything? 

[Rustom]
Yes, there’s a measurable ROI and you think about it like it makes you money. It makes you money, and it makes you better because you’re making your own work. So your preps get better straight away ’cause you are designing everything, you understand things better and you also gotta think that immeasurably because you are faster and everything ’cause you’re doing things the same way, then you’re getting paid more to do the same thing. You are saving on time, again, time it comes back to time.

That’s important. But yeah, easily like, and not just that, I paid it off five years ago. So I updated my omnicam to a prime scan and I paid another 28 K for that or the trade-in. But literally every crown I mill now, like the other day, one of the reps, he gave me two sets of blocks. So there’s 10 blocks, right? And I’m like, this guy doesn’t realize, but he’s basically giving me 8,000 pounds. 

[Jaz]
So how much does it cost you? I mean, obviously not including software and that kind of stuff, just the milling fee itself of one Emax. How much does it cost you? So let’s say my lab charges me 170 pounds, let’s say, and 300 bucks, whatever. How much does that unit costing you? 

[Rustom]
So, a block of Emax. So there’s chairside milling and there’s lab side milling, okay? And so if you buy a chairside unit, everything you buy is gonna cost you like roughly five to 10 times more. So if I mill a block of Emax, then it costs me about 30 quid.

But if I mill a puck of zirconias, you get these discs of zirconia, the premium five axis or whatever, right? That puck is about 90 quid and I get about 16 registrations out of it, and I have to central overnight and stuff. But you gotta really think, like, it doesn’t cost a lot of money to do. And if you’re doing bigger cases, like for me, I do a lot of indirect. And if I outsource a lab, like it would cost me easily, like 20, 30 grand a year. Like easily. 

[Jaz]
Tell me that, that is clear. That is a measurable ROI there. The thing that just already confused me, Rustom, if you don’t mind, is people will be thinking, well, Rustom said that it saves you time. But surely, totally.

It costs you time in the sense that, okay, not only the training you have to do additionally, which, okay, once you’ve trained you’ve got it. I understand that. So training maybe is an important step, but once you’ve got it, you’ve got it. But in terms of, you are now doing the lab work, doesn’t that take time? Doesn’t that actually steal time rather than give you time? How did you work that equation? 

[Rustom]
Okay. Let me ask you something. So you do a lot of onlay preps now, right? Like, I watch your podcast about onlays and stuff like that. And when you first started doing onlays, how long did it take you to prep in onlay?

[Jaz]
Probably when I first started doing it, it would take me like an hour and 40. An hour and 45. 

[Rustom]
And how long does it take you now? 

[Jaz]
Takes you about an hour and 20. So it’s still a long time. I’m slow, I’m slow. 

[Rustom]
Oh, that’s fine. That’s fine. Probably a bad example, but in reality, when I first started out, I used to book like an hour and a half. But my prepping now, if I was gonna prep an onlay and stuff, and you just have to see what’s gonna happen before it starts, but it’ll take me about 20 minutes, 20 minutes, I’m done. That’s it. 

[Jaz]
Like bird to tooth time. The prep itself, and what I’m including is removing the entire amalgam, doing the IDS and making the temp and all that kind of stuff. All that time in total is what I’m including. Is that the appointment time? Yeah. 

[Rustom]
No, I get in total, what I mean is, I’d like to break things up. So I believe in mental fatigue, like, okay, so if you start a case and you get tired, like in about 30 minutes, your concentration’s gone. So what I do is if someone comes in to have a massive amalgam, I’ll take it all out and I’ll do composite.

And also come back for your current prep. I break it down to stages. It just makes life manageable for me. So I never have really, really long appointments unless I absolutely have to. If I’m doing six anteriors or five to five, then I have long appointments. But other than that, I don’t believe in long appointments. I try and finish everything up within 45 to one hour at most. 

[Jaz]
Okay. So we’re the opposite in that. So just give you a flavor. We’re an opposite. And then that’s cool. Like the fewer patients I see in one day, the happier I am. That’s me. 

[Rustom]
No, no, but it comes back to the same thing I said again, like dentistry, you have so many flavors, like you get to pick your flavor, what you wanna do.

[Jaz]
Like you said, you get to choose. 

[Rustom]
So think about this, the most stuff that you’ll do in practice, the stuff that makes the most money easily, is always gonna be posterior. It’s always gonna be posteriors, right? Unless you are doing the aesthetic cosmetic stuff, fine. But like, I like being a general dentist, but to do a posterior, you do the design and it takes me like three, four minutes.

If you prep it properly, you have enough space, the software makes it in no time. And what I’ll do is I’ll send you a video of me just designing crap, okay? And then you can put it up at some point. And once you put the settings in, your settings, it takes nothing. The software does it for you more or less. Very little work to do. 

[Jaz]
So essentially the time you’d have taken to make a temp, you’ve just done the design then and that right? Does it? 

[Rustom]
I’ll mill it, I’ll mill it. Milling will take about between eight to 12 minutes, depending on if it’s a premolar or molar. And then I’ll put in the furnace, furnaces now take about 11 minutes, but it has to cool down, right?

The stain and glaze itself if you want to, and you don’t have to. Sometimes people just polish, and that’s okay too. But if you stand and glaze and you have a good system, you look at the photo or you just remember what the tooth looks like. It takes you literally two or three minutes at most. If it takes me more than a minute and a half, then I’d be surprised.

I think it’s important that I show you what I do and you can’t believe it till I show you. Obviously I can video the prep, that’s a different thing entirely, but it’s more the design stage to the finish stage. And I’ll send you across some videos so that you fully understand how much time it takes.

And it’s really simple. If you’re doing posteriors, you are looking at basically a little bit of morphology, putting some grooves in and putting your brown in just for depth, right? Like people complain about in-house stuff ’cause it has no depth. It’s monolithic, but you’re not creating real depth.

You’re creating the illusion of death and you put a little bit of brown in straight away, like you are giving someone what their tooth looks like or should look like. And some people say, no, I don’t want that. And you have to do what’s right for your patient. Some patients be like, I want a brand new tooth.

You’re like, fine. I said, but it doesn’t take time. And I agree with you that there is a cost to training, there’s a cost of practice. These are all immeasurable costs again, right. But once you get there, like it’s totally worth it. And if you really think about it, like, okay, you look at countries like Canada, Mexico, America, Australia, the most practices have in-house milling.

We are the ones falling behind. And why is that? It’s just market forces. NHS market forces. You don’t get paid enough to buy a system like that. And then if you buy it, then you’re like, why should I do this work on the NHS? Because I don’t get paid enough to, I choose to do it because I’m like, I believe in volume experience, do more. Get better, right? Then you’ll just grow like insanely. That’s the whole point of it. But yeah, there you go. 

[Jaz]
I remember you talking about this exactly when I came to shadow actually. Now let’s talk about an appointment. Now, let’s say you’re doing a lower first molar Emax chair side milling, staining, the whole shebang. Now I know that you’ve done your IDS and composite buildup already at this point. So how long is that appointment taking you in total? 

[Rustom]
I book in one hour and 10 minutes. Okay. So patient comes in, it’s literally a prep, and you have to break down preps into the constituent parts, and that’s what I learned from Attiq. So the first thing is you look at a tooth and you say, I need to make space for my ceramic. Okay. So how tick is your Emax is that you want? 

[Jaz]
I aim for 1.5 to sometimes two, but more often 1.5 monolithic. 

[Rustom]
Yeah, and that’s a good point. It depends on how deep the amalgam is that you’re taking out or whatever. And you know that the walls are thin, so you may have two millimeters or one millimeter or whatever it is, but straight away you get a bear out and you take a millimeter off. Okay. And that’s an easy prep. Like you take, you go sideways, you know the depth you go into and you just go. Back and forth, back and forth.

You leave the contacts ’cause you don’t wanna hit the next tooth, hopefully. And then as soon as you’ve done that, now you take your other bur, like a chamfer bur or a needle, and you break the contacts and you don’t go straight down. You kind of angle it slightly and you just keep going and you leave a little lip so that that’ll break off.

And you can see air or gum. Really, doesn’t take you long. Okay, then you just take your refining bow. I use Shofu Ultrafine , so the yellow bands beautiful, right? And you just polish everything up so everything is smooth and you are done. That’s your prep done. Like, once they’re numb, they’ll take you 15, 20 minutes at most, right?

Like, if it’s a harder case you’re getting sub gingival, then that’s a different thing entirely. And sometimes there I’ll be like, look, I will make a temporary and I’ll leave that in for a while before I’ll come back and take a new impression. But those are rare. Like, I see the same patients year in, year out.

I see some new patients. And then when you stabilize, I tend to put temps on for long term. I don’t say I’m gonna give you a crown straight away. I’ll be like, I’m gonna remove all the decay. I’m gonna make a temporary crown. I’m gonna leave that influx. Three months, six months, they don’t come back and do.

And when you take that off, you know it’s gonna be like nice and easy. But once you do your prep, then you scan, like I use a prime scan and it is beautiful. Like it’s beautiful. 

[Jaz]
And you’re scanning under rubber dam? 

[Rustom]
No, I don’t scan under rubber dam. I don’t really believe in it because I’ve already done my core and stuff. I don’t need isolation when I prep. 

[Jaz]
For me, the reason I’m doing it on the dam is ’cause I’m doing my IDS at the same time. So for me it makes sense to get the isolation. But for you, I appreciate you’ve done your adhesive part already, the prep. I appreciate that. Yeah, you can be quicker because you don’t need the dam anymore.

You can go straight in when the patient’s numb. So that totally makes sense to me. And then one question I was gonna ask you is once you’ve done your prime scan and you’re doing all the bits to design and mill and stain and glaze, what’s the patient doing? Are they having a coffee? Have you got like some sort of system?

[Rustom]
It’s different for different patients. If I like ’em, then I’ll just chat them and it’s nice ’cause you get to know ’em. Right. If I don’t like them, then I’ll make a way outside. It’s a bit of a tough one, like some people are really high maintenance, so it ties you out talking to them, and some people are not, and you enjoy their stories and their lives and whatnot, and that’s cool. But a big part of what I do with cerec is simply that I get that time with a patient and 90% of people, I will stay there and I’ll talk to them and yeah, it doesn’t make me any money, but I know that the next time they come in.

They’d be like, yeah, I want the same thing again, Rustom. And it happens to me time and time again. And the other thing is that if they do leave me and they go somewhere else because they’ve moved away or they decided they don’t like me or whatever, they’ll go somewhere else and they won’t have that same experience.

And that’s important. So yeah, like it’s your personal choice, like what you wanna do in that time. Some people like to go into other surgeries and start doing a scale and polish, but in the name of efficiency, like there’s lots of things that they can have done. So sometimes if I do a CEREC, I know they need a filling and they need a clean, I’ll be like, look, while I’m doing your CEREC, I’m not gonna do a clean today.

When you come back and I’m doing a CEREC, I’ll do it while the crown’s being made. And it just means that your ROI increases in that period of time. But if not, just have a good chat. Like that’s probably worth more than anything else. 

[Jaz]
I like that. I can imagine all my American colleagues, like, what? You don’t do a hygiene check? Like what about the poor other operatories? Sorry about my weird Texan. I don’t know what, what that was. So a sincere apologies to the Yanks who, who join us. So anyway, probably pissed off the entire nation there. I love you guys really. Anyway, so look, I really like this intro, but I need to get to the meat and potatoes of it, right? So printing, milling, right? Let’s start with the very basics. What is printing? What is milling? What is the difference? 

[Rustom]
So by definition, printing is an additive manufacturing process. So you have a vat of resin, your printer comes down, your bill plate comes down and they shine the light and wherever you want things to be built up, it gets cured and it lifts up.

It comes down. You make models from it. You can make splints. You can make veneers, you can do whatever you want with it, but you effectively working with resin, you can print like stuff like zirconia metal, but that’s not something you would do as a dentist. That’s something you’d leave to the labs.

Printing is really cool. It’s the fastest growing industry in dentistry. Okay. It is the fastest growing like amount of money and time people spend in it. Like, it’s amazing. Like you think Invisalign has a d and d, is it r and d? Yeah. Research development.

[Jaz]
Research development, yeah. 

[Rustom]
Yeah, like millions. Millions. And printing. If you look at the whole industry, I’d probably say it’s more like easily, but if you think about it, Invisalign is about printing and thermoforming as well, so it’s amazing. The only thing I’d probably say about printing is that I would probably still say that it’s early days. Okay.

Like milling’s been here for a long time. It’s a subtractive process. You are taking a monolithic block and you’re cutting away. Like, you’ve seen that, is it DaVinci who takes the block of stone, Michelangelo, where he cuts away everything and he just says like, I’m just taking away whatever I don’t see in my vision, right? And that’s kind of what milling is. So you have a block or a puck and your machine. Is taking away whatever’s not your design around it as is. 

[Jaz]
Another good comparison is, people’s styles of working with composite. So there are printers and there are millers when you work with composite. So I am a miller. Now I’ll build this big ugly block of composite and then I’ll take away to leave me behind a kind of cut it back.

Whereas other people, they like to layer so precisely that they’re pretty much done by the time they’ve done their final cure. And so I like that way of thinking as well. But I think the uses and the indications of printing and milling are very different, right. Like you said with printing you do resin, so you do like splints. You mentioned veneer, so that’s like temporary veneers? 

[Rustom]
No, so if you look at, I think in America there’s got, there’s a guy named Wally Renne so he does, and if you go on YouTube you can search up his videos. So he does a lot of like printed veneers and stuff. Like, it is pretty cool because it is effectively resin, they have higher levels of polymerization than layering it. You’re controlling it outside of the mouth. So what he is doing is really cool. Okay. 

[Jaz]
So it’s essentially indirect composite veneers then, right? In a way? 

[Rustom]
Yeah. Pretty much. And he does it really well. He makes it look really good. And I’ve done a few, and I find it, it’s not that easy, like he’s been doing it for a long time and he makes dentures, he makes splints, he does pretty much everything with printing. Yeah, it’s pretty cool.

I think that for me, it’s not really there yet. But people make the mistake of comparing printing and milling. It’s not the case. They both work together and that’s when the magic really happens, right? Say for example, that you need to do six composites. Okay, let’s stick with composite. So say for example, someone comes in and they says, look, I want to get composite bonding done.

Alright, so you could say to them, okay, so you’ve come to me through Instagram, you like my vision, so I’m gonna draw on this iPad for you and show you what it looks like. Okay? But that’s a 2D picture with just basically, frames, wire frames, okay? It doesn’t really mean anything. You could do your composite, layer it beautifully, whatever, polish it, and then they’ll turn around and say to you, well, I don’t like it.

Take it off. And you’ve lost a lot of time and money, right? But what you could do instead is you could print a mockup up. And then you can put it in their mouth and show them this is what it’s gonna look like. Are you happy with that? And if they say, yeah, I’m happy, then you know that you can go ahead, you can get it signed off by the patient and that’s important. Then you could also say, I want a minimum, and that’s fine.

[Jaz]
So let’s just pause there. Just on the printing point actually. So let’s say you print the mockup, what you are printing here, ’cause there’s a couple ways to do it. You can be printing the Exocad design of the future model and then take like a putty of that and then transfer the bisacryl to the mouth. Or are you talking about printing the actual composite itself that they just like a snap on smile. What are you talking about there? 

[Rustom]
That’s the thing you could do either. You could do either. 

[Jaz]
What do you do? 

[Rustom]
I tend to print the model, I print the model. And I show ’em in the mouth with bisacryl. I have done shells, but I prefer shells for when I raise the OVD. It’s easier. In those cases, easier. They both work. But the beauty of having the stuff at your fingertips. Is that you can decide in this case how you want to approach it. What’s the best way for you for your personal preference as a dentist? So like, you know, Kostas, and so they do a lot of IM sort of stuff.

Okay. And I’m part of that group and I see people just pumping out like beautiful stuff for me, I like it, but it is very hard for me to do. I just don’t see the benefit for me personally, because I would rather just mill it or print it and it makes my life easier. For me, it’s about chairside time.

Like I told you about mental fatigue. If they come in and say you come in with a wear case, and I need palatal veneers to raise the OVD and then buccal veneers later, it’s easier for me to break it down into everything else. So I’ll be like, okay, you come in, I’ve done a scan, I’ve found what OVD want you to do.

It reads to, and I’ll mill everything before they come back. So I’ve spent maybe what, half an hour doing my consultation. Then they come back and they’ll spend half an hour to 45 minutes just getting those veneer cemented. Literally, it’s like, tak-tak-tak. You’re done, cured, go away. Then they’ll get some time to get used to it. Then they come back and they do the press. 

[Jaz]
What material is that though? What material would that be? 

[Rustom]
Again, it’s choice, right? Like I prefer to mill. So I will mill composite if I know my raised OVD, and then if I’m gonna convert to crowns, then I’ll mill ceramic later. Okay. You just have so many options, it’s your choice.

For me personally, I like to do palatal veneers in composite first, simply ’cause if I need to do any adjustments. So what you can’t really account for in the software is any mandibular deviations and stuff like that. So you can raise your OVD, you put stuff in, but if their joint deviates like this, you can’t predict that.

So you put it in and then you adjust everything, so it works. At that point, they’re comfortable and when they’re comfortable, you are comfortable. So now okay, I can move on to my bigger procedures. Like I’ve made a rehab into basically multiple steps where I’m doing the OVD raises and there’s no patient fatigue.

There’s no mental fatigue for me. I get that done, then they come back in and I do my next step for the aesthetics. So you’re breaking it down. It’s like Vailati’s protocol, but it’s just breaking things down to manageable bites. 

[Jaz]
It totally makes sense to do in composite. So you have that freedom to adjust easier and get refine the occlusion, get it right, and then copy that into the future.

[Rustom]
You said the word copied. So here’s the thing with the software, now you can copy the palatal surface exactly after your thing. So you have so much control and you have so many options. That’s the whole point of it. 

[Jaz]
And then that’s the real power of it. But again, going back to printing, milling, right? You said you like mill composite, but we kind of said that you can actually kind of print composite as well. You can print resin. So what’s superior about the mill composite compared to the printed version? 

[Rustom]
It goes back to the thing that, like how long millings existed for and how long printing’s existed for. Printing’s not been around for a long time, and I’m not really an early adopter. Okay. I like to wait and see what happens and I decide if it works for me or not. So the thing about printing composites simply that there’s a lot of materials, like for example, Flexer and stuff. You know, people did a lot of veneers or crowns and stuff, and they just melt away. They melted away, and now you have alveolar compensation, your case becomes that much harder a year or two later.

But at the same time, milled composites has been around for a long, long time. I have literally a 12 year recall where I’ve done a milled composite and the amount of wear I’ve seen is like, it’s there. It’s there. And that’s why prefer ceramic over composite, but there is a little bit of alveolar compensation, but it’s still okay. It could be worse. 

[Jaz]
Compared to direct. Like had you done that case in direct composite, how is the toughness or the wear resistance compared to direct composite versus what you mill? 

[Rustom]
Okay, so again, that’s an interesting thing. So, the first case that I used to post with composite, so I used to do a lot of composite I used to do. I love composites. But the thing is simply that the bigger the composite gets, okay, then you are fighting. You’re losing a battle. You’ve put it in and it’s too big. You now you have to control your contact point. You have to control the wear. You have to control how it looks.

You have to control where your occlusion and margin is. All these things make it harder, then you’ve gotta layer it and then you’ve gotta think about all the stresses you’re building and as you build it up and those stresses will just stay locked in and you’ll pay the price later when you start seeing chipping of the margins, ditching these sort of things.

And same thing again with direct, I have a really good track record, but what I think is simply this, do I want to spend an hour and a half doing a really complex composite or could I just mill it in like eight minutes and call it a day? So sometimes I’ll do composites indirectly and just mill it and I’ll just charge ’em a little bit more.

[Jaz]
But that mill composite, is, in my mind, it’s superior mechanically because it is like a fully, like a super cured block. That’s like the strongest you’re gonna get, right? 

[Rustom]
Pretty much. And there’s no stresses. So the only stress will be a cement layer. There won’t be any stresses ’cause you’ve layered in the shrinkage and expansion, you get what? As soon as you put it in, you get the shrinkage from curing, then it absorbs water and expands again. So it’s one of those things like, you take all the hot stuff out of it, take all the unpredictable factors out, and it makes your life easier. 

[Jaz]
Let’s pivot to splint. ‘Cause something that’s piqued my interest. One of the reasons I use my lab for splints is because I. I have this potentially misconception, correct me that the printed splints are not there yet because I get referral cases, I get the strongest bruxers in the country come to me. And I’ll show you b splints with cracks right down the middle.

I have colleagues who got like lab made acrylic splints with multiple crackings. And so my worry is if I was to switch to, ’cause I do enough lab work to warrant buying a printer or a miller, I dunno which, you know how it works with the splints, but my worry is it’s not gonna be strong enough.

[Rustom]
So I started doing printed splints about three or four years ago and I’ve replaced all of them. They last for about a year. They start breaking down, chipping, wearing. And the thing is that like when we do splints, it’s not an easy thing. Like, it takes a lot of time. You’re treating the full mouth and you’re not treating one tooth.

It is a different thing entirely. What I’ve realized is simply that it is just not worth it ’cause you are redoing it. Like you’ll charge less for a printed splint, right? So I charge like 400 quid for a printed splint, and then when it breaks, you gotta redo it with an acrylic. But they were like, well, I already paid for it.

Why should I pay more? And they have a fair point. So I mail my splints now and they work really well. I would put it like this, printing splints in America, they tend to print like six. Because you can print them all at the same time and they’re all identical, so you give six of ’em to the patient.

But it doesn’t really work like that for us because we are geeky and we understand that when things start chipping or breaking or wearing, then the bite’s changing. And then you are kind of going here and then doing this up and down again. Every time their splint changes and it doesn’t really work. I have a lot of success with mill and you gotta really understand your sort of process of how your lab makes your correct splints.

It’s usually a heat cured or whatever, like in a flask and there’s always some expansion. So, you put it on and they have to adjust it and the articulator and stuff, but whatever they design and wax is not what they have before it’s processed. It’s not the same. So then that’s why they put an article and adjust it.

Whereas if you mill it, you already know that this is exactly what it’s gonna be like. Right? So you mill it and then you can do a little bit of work. So you are taking on the job of doing it yourself, right? Adjusting the math, which you’ll have to do anyway, but as long as you can get 90% there before you fit in the patient’s math, then it helps you for time and effort.

But the thing is this, if you want to mill a splint, then you need a five access mill. You need a five access mill, and you need a pucks, you need like, I use ProArt CAD from Ivoclar. It’s really nice and I get about two michigans per and I can squeeze in like one SCI or something like that.

But also it has so much more utility. So I can make jigs if I want to reline, say if I’m doing a three to three case for efficiency, I want to take the crowns off, but I don’t, you know, I wanna make shells anyway. So I’ll mill like, one to three shells on either side, and I’ll make a acrylic sort of splint from the four to four just to seat it with PMMA so I can realign it.

So it is just about minimizing chairside time and being efficient. So if you plan ahead and you get everything done, and I fully understand what you’re saying, like a lot of us don’t have the time, we don’t have the time to be like, I wanna sit down and design this myself or mill it myself, and I totally get that. But that’s the thing. So you pass it on to lab and that’s fine. I do have the time, and for me it’s like a hobby. So I’m like, yeah, I’ll make the time for this. 

[Jaz]
I think that’s an important point that I think people need to internalize is that because if you invest in milling and then you wanna design it as well, you are then taking on the role of a technician in terms of design.

And if you enjoy it, then this is like a playground for you, right? Then this is great, you save the lab fee, but now you’re just paying yourself in a way to have fun on the computer if that’s your idea of fun. Now, if you absolutely detest that and outsource it, then maybe it’s not no point for that individual to get the milling unit and the design stuff. Would you agree with that? 

[Rustom]
Yeah. Again, it’s personal choice, right? So there’s so many flow charts available. So straight away, let’s take it from, you’ve done a scan, okay? You’ve done a scan of a tooth, like a lower right six, like you said earlier. So you have the choice that one, you can design it yourself.

Or you can send it off to someone to design it and they wouldn’t charge you that much. I think there’s a lot of AI now. They’ll design a crown for you for literally three pounds or something like that. And then you now have a choice. Do you want to mill it yourself or do you want someone else to mill it or do you wanna print it?

So you could outsource all of these things. So you could send it to a milling center. So if you wanna do Emax, you can send it to a milling center and they will mill it for you for 30 quid or 40 quid or whatever ’cause they work in bulk. 

[Jaz]
Isn’t that what your lab is doing though, when I’m sending an iTero scan, that’s what the lab is doing.

[Rustom]
Yeah. So there’s a lot of labs. Now we should like, it is one person lab, or two person lab. So they will design for you and they’ll outsource the milling. And then it comes back and they’ll put the stain and glaze in. So straight away, think about this. You do the prep, okay? You either do the design or you don’t.

And then you either mill it yourself or you don’t. And then you either stain and glaze it yourself. Or you don’t. But if you go this side of the chart, then you’re paying more and more and more. Whereas if you go this side of the chart, it’s gonna cost you more and more time. Does that make sense? That’s all it is. 

[Jaz]
So essentially you get to choose where you draw the line, what you wanna do, what you don’t wanna do. And the more you do, the more money you save, the more you time you invest. But the more you outsource, it’s like, okay, just go to the lab and like the usual workflow you’re sending to a lab and you get it back. It’s like done for you kind of service. So, okay. I like this way of thinking. You mentioned five axis, I think. Does that mean five burs? 

[Rustom]
No, no. Five axis is it’s simply, four axis is like you have a block and you have two burs or one bur, and the block moves around. So there’s four axis available to milling. Five axis almost like printing that the puck or whatever moves around enough or the block moves right enough that your bur can hit it from pretty much any angle. So if you get milling by five axis, it takes a lot more time, but it’s more precise, more accurate, but it’s a lot slower. That’s the trade up.

[Jaz]
And it sounds like, like a milling is faster superior than printing, but if someone were to dip their toe into it, ’cause there’s still a lot to discuss here, but someone went to dip their toe into it. I imagine printing is much cheaper, the setup costs and the running costs. Is that right? 

[Rustom]
Pretty much. You could buy like any Anycubic, Elegoo or whatever it is, four or 500 quid. There’s a Facebook group run by a guy named, I think it’s a Rick Ferguson, it’s called literally 3D Printing Group. And he uses the frozen printers. The frozen printers, you get the mini 4K, mini 8K or whatever it is. But he’s already validated a bunch of resins. So you just plug and play, you plug and play for literally nothing.

And there’s a whole group of people who use his cheap printers and his settings and they will achieve the same things that people do with the big ones. So if you wanna dip into it, don’t spend too much money. Printing is very labor intensive. It’s not like you just print something and you’re like, yeah, this is great ’cause you’ve gotta print it thing, open the IPA wash for 30 minutes or 10 minutes or whatever it is, and then you gotta then cure it for a while. And it’s messy. It smells, it’s horrible. Like, it’s one of those things I don’t let- 

[Jaz]
You need space for it. Right? You need the real estate for it. 

[Rustom]
Not too much. The milling takes up more space for sure. Printing, if you have a small table, you’ll fit your printer. You’re washing a cure on it and that’s fine. It doesn’t cost them much energy either. You don’t need a compressor or anything. Like, it’s fairly straightforward, but printing fails, okay? If you mill something 90% of the time you know that there’s gonna be no issues. The burs may break or the block may fall off, but that’s fixable.

It’s very reliable. Whereas you could print and your print could fail and it could fail again, and it could fail again. And then if you have someone in the chair, you can’t really rely on that. Like you’re just like, oh, I’m gonna have to come, get you back in tomorrow. And then what if your print fails again tomorrow? That’s why I don’t like printing. 

[Jaz]
You didn’t mention SprintRay, is that one of the top brands, right? Well-known brands of printing? I imagine they come as a premium dental price to it compared to the Ferguson one you mentioned? 

[Rustom]
Yeah. You’d spend about, at least about 12 grand for a SprintRay. Like it’s a lot of money. It’s a lot of money and you have to make it work. And a lot of people love it. And I agree with that. It’s fine. Like I have a D 4K Pro, okay, it costs me about nine, 10 grand and it’s nice. It’s very reliable in that if you get the print going and it works, like it’s bang on.

Like, so if I’m doing a big case, I’ll never do it in the mouth. I’d always get a printed model and I fit it on there and do my adjustments and whatnot, but for single cases, it’s not really worth it. I started doing my first splints and stuff on that, but it’s just slow and just sometimes, like if you have someone in the chair and you want that model, and if it doesn’t turn out, then you have to start from scratch again and it pisses you off.

It really pisses you off. You’re like, I’m relying on this. But that’s the difference between printing and milling. It’s just the reliability is an issue, and I think you are a lot like me. For me, it’s about really about stability like you want to know exactly what you’re gonna get. And that’s why I rely on milling more than printing.

And also, you gotta think about what you’re gonna put in someone’s mouth. Okay? If you’re gonna print something and put in someone’s mouth, or if you’re gonna mill something and put in someone’s mouth. So all the stuff I don’t put in people’s mouths, like models and stuff, or you know those I will print. If I wanna put something in someone’s mouth, I’d rather have something that’s safe. That’s all. 

[Jaz]
I love that. So I was literally just gonna ask you, ’cause there are so many claimed applications of printing and so many claimed applications of milling. But someone who’s got both like you, you are then choosing to get the best outta your printers.

You just answered it right? Something you don’t put in the mouth. Okay. You’re gonna choose the printer. Something that you’re gonna put in the mouth, you’re gonna choose the milling. Now, if you only have a hammer and everything looks like a nail, i.e., if you only have a printer, okay, and you’re working with that, what are the applications of printing that you think general dentists can start using in the early stage of printing?

[Rustom]
So first thing is that if you’re gonna buy a printer, you gotta think who’s gonna design it for you? Are you gonna design it yourself or are you gonna either lab to design it and at that point for them to design it, they’re gonna charge you per tooth wax up or whatever it is, right? So you paid more for the design than the actual print. They’ll charge you 40 quid for the print. Who cares? 

[Jaz]
For the design or the print? Sorry? 

[Rustom]
For the print, they’ll charge you 40 quid for the model, but for each tooth, they’ll charge you 20 or 40 pounds anyway. So what’s the benefit to your printing? Why spend your day, wading through resin and then dipping it in like 99% alcohol?

And then curing it and then being like, oh, this is not quite right. Or the model looks a bit shit, or it’s warped. What’s the point of that? Like, at that point it’s not worth it. Now, if you are designing yourself, then it makes a difference, okay? Because then you can be like, okay, look, I have some free time during my lunch.

I can quit, do a quick design. Someone walks in, they’ve broken a tooth or something. You’d be like, I’ll do a quick wax up. So for me, again, if I do any direct composites like anteriorly, I don’t tend to freehand it. I don’t believe in it. There’s loads of people are great, but what I tend to do is either if I don’t have time, then I’ll do it in the mouth with composite and I’ll take a putty stent of it so I can do the palatal and build it up.

I don’t tend to freehand the whole surface. It just doesn’t work in my hands. I’m not Govinda Perth or Andrew Chandrapal or Dipesh Parmar. I’m just rusting it. So what I’ll tend to do is I like a scaffold to build on. So I’ll do a scan, I’ll print it and by the time they come back after lunch, I’ve got something to build my palatal shell on and it works up to me.

[Jaz]
Just says, clear to me what you are printing to help you with- 

[Rustom]
That is a model. 

[Jaz]
Yeah, digital wax up, exocad, you print the model and now you make a putty on that model and then you transfer it to the patient’s mouth. 

[Rustom]
Yes, pretty much. But also I do the design, right, so it’s easy for me. But now if you have to sign the lab, you can’t do it on the same day. So you have to really decide how you’re gonna get into this. And it comes down to that flow chart again. But my point being is simply that you can pick and choose whatever you wanna do, but there’s no benefit to dipping your toes unless you’re designing and printing, or you do everything or you do nothing.

The reason I like things is simply that I have control over my stuff. Like, when I was younger, I used to send stuff to the lab, put on a Facebow, they articulated it and I realized that I’ve sent my Facebow and they’ve chucked it somewhere. They’ve just put the teeth together, or they tell you, I think your bite’s wrong.

And you’re like, what are you talking about? You know, am I the clinician? Are you the clinician? Like, and there’s a point at which, I have a friend, Shai, saying, he said something to me that made me laugh because he asked me the same question you did. He’s like, why did you get into this stuff?

I remember, like, I ordered a crown from a lab, really well known lab, and it came in. I looked at him and I was like, well, this stains a bit shit, isn’t it? So I called him up and I said, did you do the stain and glaze? He’s like, yeah, I did. Did you like it? And I was like, no. I could literally do my, better myself.

So Shai said to me, that’s your origin story. Like, you’re a villain now. But it is what it is. Like, then you start controlling your stuff. You just enjoy it. You have more fun. But in dentistry, like I said earlier, is so beautiful that you can pick and choose exactly what and when you want to do it, but everything costs money.

That’s the problem. And then even if you get the money, like, because printing and milling is so, like you said, like, you know not a lot about it. And you’ve been in this industry for a long time. You spoken into all the big people in this industry. You had their views on it. But why is it that you don’t have this knowledge?

People gate keep this stuff, there’s a lot of money involved ’cause it’s growing so fast. You are being like, not being told everything. Like, because people don’t want you to know. Every time you wanna learn something everyone’s like, oh come on my course, you pay like two grand, three grand.

But why? Like, this is all information that’s out there. We should all share it freely. Like that’s fun, right? Like it’s fun, like- 

[Jaz]
Not everyone’s a saint like you man. I honestly appreciate it so much, but okay, we’re gonna keep going ’cause I’m really enjoy, I’m learning a lot here, like you said that unless you are designing and that makes sense to me. There’s no point. So if you’d like to design Exo cad, learn it and that kind of stuff, how much is the software fee to actually, you get Exo cad. I’m sure there’s no bloody Pirate Bay version that you can just like copy and hack. 

[Rustom]
I think that things are getting easier now ’cause there’s a lot of AI stuff coming in. So Medit used to be free and it was very good, but they’ve made it not free anymore. So you’ve tested, everyone’s tested Medit for them for basically free and given feedback for years and years and years. And now they’ve basically said, okay, we’re gonna make it paid for. 

[Jaz]
Reasonable, fair. 

[Rustom]
It is, it is. I mean, you don’t get a free lunch, like, it is one of those things, but you had a free lunch for a while now they took it away and that’s fine. But if you buy Exocad, it’ll cost you between six or nine grand. But you can pick and choose what modules you want. 

[Jaz]
Is that a lifetime license or something? Or? 

[Rustom]
There’s two options. You can get a lifetime license. It’s called Perpetual. So you pay more initially but you don’t pay anything after. But you won’t get updates- 

[Jaz]
That’s six, nine grand. I’m hoping that’s bloody forever. 

[Rustom]
Yeah, it’ll last you forever and then you know you’re done. You don’t pay anymore, but you won’t get any more updates. Okay. And you gotta think again, the design thing is a very fast growing industry as well. It gets better and better every year. For me, I have Exocad and I also have in lab. CEREC InLab. So I have the 22, which is the latest one, and I paid six grand for that. And it’s a lifetime buy. Like you don’t have to buy it again.

But cerec is clunky. Like if you’re doing big cases, like it doesn’t have the freedom of Exocad. I know that a lot of people use Trios as well. Trios Studio is quite nice. I use it for my aligner stuff, but I just didn’t like the look of it, like, it’s your personal sort of flavors of how things look sort of thing. But it works really well. I think there’s Douglas , he does a lot of Trios stuff and he’s really one of the pioneers for that sort of thing. And he loves 3Shape. 

[Jaz]
And that comes and you buy a 3shape scan and that comes with a software? Or is that gonna- 

[Rustom]
No, no. So all the big companies, like all the companies worth buying from, they wanna lock you in. They wanna lock you in for their stuff. So people complain about CEREC or Trios or whatever saying that you’re locked into a system. You don’t have to be. But it just costs you more to not be, not to be, to tap. 

[Jaz]
The freedom costs you more. 

[Rustom]
Pretty much. So like now I have Exocad, so I can’t take my STL from exocad and mill it on my CEREC. I’ll need in lab cam, that’s the computer aided manufacture section to put that STL in and then CEREC can mill it for me.

So I paid for the cam. I was like, yeah, it’s fine. Like, but also you have to really think about this. So, when I say nine grand for the software, it’s nine grand. It’s a lot of money. It’s true. But at the same time, if you’re doing that sort of work, all the time. What is nine grand? It’s nothing. You do two big cases and it’s paid off.

So as long as you do enough, you’re fine. But then I would also say if you are good at the sort of stuff, like if someone comes in and they’ve got a class one to class three palatal, wear erosion posteriorly, I’m gonna raise your OVD. I can finish the whole case in a day. Like in a day, right? I can do it in a day and you’ll get paid well for it. Like it’ll pay off all this stuff and if you get enough of them. But the problem is that you don’t get those cases walking in every day, right? Like, you have to do all this. 

[Jaz]
It’s the same thing I speak about when I speak to prosthodontists. I say, you know, why don’t you have a module? I’m like, okay, look, if you like that kind of stuff and you are going to the module is awesome.

And prosthodontist who’s doing full mouth rehabs all day long for the general dentist, how can general dentist is doing? They can’t justify it, but just like you’re right. If you’re doing enough cases, enough volume, then yeah, the design element, the software pays for itself. But then of course there’s training as well.

So you’ve gotta then invest time to actually learn how to use a software, which I’m sure scares a lot of people, right? To have to learn Exocad I’m sure is scary for a lot of dentists. 

[Rustom]
It is, it is. I think the first time I go Exocad, I really struggled with it. Like the problem is having too many options, having too much freedom is just as hard as having new options, right?

Exocad is so powerful that you have to just take your time and learn with it. But sometimes what I do is like if I really wanna learn something and we make the mistake of asking other dentists for help, and if you wanna learn lab software or lab software. Ask a lab tech. So I hire like this Lino Adolf.

He has a lab in Cambridge, not too far from my house. And when I wanted to learn Stain and Glaze, I asked him, bro, like, can you come help me out? And he’s like, yeah, I’m gonna charge you 1100 quid. I was like, that’s pretty cheap for what you’re gonna give me. And he spent the whole day with me. You shoot me loads of stuff.

Like if you look at my cerec journey, like I did a lot of posteriors and I did them well. But then when I jumped to anterior, it’s very recent. I was scared to do anteriors for a long time, but now I’m pretty happy. 

[Jaz]
Oh, your anteriors. I mean, for those who haven’t seen it, and a supposed killer cases, just phenomenal, honestly. I mean, all of that. So, you know, you can see how far you’ve come in this space, man, that what you’re pumping out now is truly aesthetic. So, hats off man, obviously people listening to you now, they’ve seen the investment in education and time and mentorship that you put in. So, hats off to you for doing that.

But people need to realize that you, they will also need to do that if they want to get the kind of results that you’re getting. It’s not just, I got a printer, I can now do everything. You gotta learn the design, you gotta get the training in. But in terms of just finishing off, rounding off the printing, the applications.

I know you use it for study models and it just makes sense to me something that doesn’t go in the mouth. You use printing ’cause you have access to a mill, but if someone’s only gonna go for the cheaper option, which they might do ’cause they’re dipping their toes into it and they get a printer first, then they wanna use it for everything they wanna use it for.

Then they get as much out of it as possible. And so, you can do aligners, right? You can do splints. Although we said like they’re wear away. Okay, you can do veneers, so what can you do with printing? 

[Rustom]
You can do everything, but it’s just- 

[Jaz]
But you can’t do Emax. I know it’s a stupid thing to say, but for the young dentist listening, they’re like, oh, I didn’t know. There’s some things that they haven’t learned yet. So yeah. What can you do? 

[Rustom]
It’s just resin based. Everything is resin based. And people will say stuff to you like, okay, we are going to print this crown for you in a 70% ceramic filler. What does that mean? It doesn’t really matter. It’s still a resin matrix.

It doesn’t matter. I mean, there was a thing a while ago where people used to mill a lot of composite crowns on the CEREC, and they have debonding because there’s too much flex. That material isn’t rigid enough at the margins. You make a thin margin, it’s gonna flex, and then your semi will tear off and the whole thing pops off.

So you have to understand where you need rigidity and where you don’t. And that’s really the click to it. But you can print whatever you want, it’s fine, but don’t tell people that this is. The same as a crown. It’s not the same as a crown, like an Emax crown. 

[Jaz]
So a good for a provisional. 

[Rustom]
Yeah. You can even do it as a permanent, but as long as you’re managing the occlusion everywhere else. So if you’re doing an inlay or doing one cusp coverage, but you have multi tooth contact in the same tooth, then it doesn’t matter what you put in there. Even if it’s GIC, the rest of the tooth will hold it up. But, so it doesn’t matter too much. But now if you’re doing a full coverage, fine, okay?

The 70% filler might wear at less rates than pure resin and stuff. But what would you want to do? Again, it’s your personal flavor of how you look at dentistry. Do you wanna do it once and then just say, you know, I’ll it done. Or you wanna be like, okay, you’re not paying too much, so I’m gonna give you this.

And in a couple of years you might have to replace it because that could happen. And it is just that the problem with all these really fast growing industries is that you don’t have long-term studies. You don’t know for sure how long things are gonna last. You could spend 12 grand, then pay like a thousand pounds for each bottle of resin, you know?

Then you’re like, okay, I’m gonna replace all these things in two years, then what’s the point of that? Like, you’ve lost that money and then you’ve lost more money and you’ve lost time as well. So, and you gotta really think about what your budget is. Say you have 20 grand to spend, okay? And you already have a scanner.

A lot of people have scanners now, what, 20 grand. You could buy a five access mill, like an, I think it’s called an E5, like VHF. They do some really nice mills and they’re pretty cheap. They are pretty cheap, right? You could buy a chairside mill for the same price and you could buy a hobby printer. You could buy a hobby printer for 500 quids, and you make your models, but you mill, so printing’s always about volume.

So you can put like six, seven prints down. So if you wanna make 10 veneers, it’ll and times important. So if I had to mill 10 veneers, it’ll take me like an hour, hour and a half. But if I had to print 10 veneers, you could print them all at the same time, as long as they fit on the build platform. 

[Jaz]
And so how long would that take to to print?

[Rustom]
Nowadays, like with the printers we have these days, it could take you like six minutes to 10 minutes. So times there’s Midas, I think a SprintRay, I put Midas out now. It’s like a printer where they push the resin and they cure it while they’re pushing it up. So in eight minutes you could print three veneers from one capsule. So that capsule costs. It could probably cost you about 20 to 30 quid or whatever.

I don’t know, I didn’t really feel like I wanted to invest in it, but at the same time, you could do a full mouth case in resin printed resin. You could print all of all of those in 10 minutes and then wash ’em and cure ’em in another three minutes and you’re good to go. And that’s pretty cool. It is really cool. But at the same time, it is still resin, it’s not ceramics. So it’s a different thing. 

[Jaz]
And but like you said, that you’re still using resin from the mill, the very superior mechanical properties. 

[Rustom]
Absolutely. And I think printing will get better. I just think that I’d probably just wait for one another year or two before I really start putting stuff into the mouth from there. ‘Cause I wanna see long term stuff, that’s all. 

[Jaz]
Rustom, it sounds like, because you have access to both and you’ve done so much of your homework and you are very much invested in it. I think the key recommendation I can extract from this is really, when you have the choice of milling and printing, milling is superior, it’s more expensive as well, but the main application of printing at this moment in time with what you’ve seen for the highest quality is the models and not so much what you put into patient’s mouth.

I’ve had that loud and clear, but any deviations from that. For example, if the associate wants to dip in and sounds like, it’s a lower margin of entry, like it’s much cheaper to enter into this space and you know that young dentist has got like a desire to learn Exocad and maybe they can use someone else’s software license or whatever, then printing to dip their toe into it, it might be a way to go. 

[Rustom]
Yeah. I think if you’re doing big cases, you’ve been on the same dental journey that I’ve been on, you start out, you start doing single tooth dentistry, then you start moving into full mouth dentistry and it’s scary. Like the first step is scary.

It’s really scary. The first time you wanna prep like six teeth or raise your OVD, like you have to wake yourself up and just slap yourself. Be like, yeah, do it today. You have to do it. In those cases, yeah. It’s perfectly accessable. I think that you should do those things where you can print them, try things in, adjust things, and it works really well.

Because the benefit is not really for you, it’s for the patient, right? Like, if you can help them get to a better state where they’re stable and you’re helping ’em out, fine, do it. It doesn’t matter what the cost is, but you have to price appropriately. The issue I take with things is that when you are doing printing, but then you’re charging ceramic rates, that’s a different thing entirely.

But what you’re saying is, right, if someone’s young, they want to get into this sort of stuff. It’s not really the application of printing, but it’s what you’re using it for. That’s important, right? As long as you’re providing a benefit, then yeah, fully get into it, that’s fine. But as long as people realize that they are printed materials, they’re not ceramic or long, long, long term dentistry.

[Jaz]
So maybe as like, to models and also provisionals for like maybe six months, nine months before you then have tested the occluding scheme and think, okay, you know what? Now we can go to ceramic. That might be a good indication. 

[Rustom]
It’s a good shout. And also if you’re doing a rehab and stuff and you’re controlling the occlusion and stuff, then it helps because ever since we’re at the same rate, right? I think it’s one of those things that you have to find where you are comfortable doing this thing as long as you inform the patient. Look, it’s not the same as us doing a ceramic rehab and stuff, but yeah, absolutely. I think it to help you along your journey is worth it. 

[Jaz]
But don’t you think a printed result versus a direct composite, let’s say a posterior, let’s say you do a wear case and you do like posterior injection moulding using gaenial universal injectable, right?

Anterior, posterior. So you’ve got a full mouth of resin, upper palatals, lower molars and upper molars, occlusal surfaces. You’ve got resin wear case, erosive case, let’s say, right? Is the printed solution mechanically superior than the direct injection molded solution? 

[Rustom]
No. I’d probably say the neck and neck, but what is easy is convenient. Okay? So you do, IM for like 20 teeth. I’m sure you’ve done this is the pain. And sometimes a resin goes, yeah, it goes there. The composite goes there and you’ve gotta clear all the contacts and all this stuff. But if you’re printing them, suddenly you can get them in. You put your rubber dam on and you fit four other posteriors, you cure it, it’s very easy.

Tuck your cleanup, it takes you less time. And the thing is that your dentistry isn’t really about the materials, it’s your dentistry that’s important, right? So if you’re good at what you do, then everything works, right? If you’re not good at what you do, then nothing works. But the take home point is that if you make things more easy and more predictable, then it is more likely to succeed.

[Jaz]
Okay, great. And so there’s this thing I read on Facebook whereby people say that if you start milling or printing, if you start making crowns, you start making this, you’re doing lab work and therefore you need to register as a lab. Am I naughty if I buy a printer and I’m printing models and doing that kind of stuff and I don’t register as a lab?

[Rustom]
MHRA thing is a bit of a tricky one. Like I’ve got my MHRA stuff already sorted at some point. I do wanna do lab work for other people as well ’cause I enjoy it. But it really depends again, like whatever lab work you do, is it going in someone’s mouth or not? If you’re making a study model that’s just a study model, like you’re not directly responsible for putting in someone’s mouth.

I’m not a hundred percent sure about this, but if you’re making stuff in-house and you’re not putting it on the open market, you might not need MHRA, but I would get it anyway. It’s just, it’s not hard. If you use the MHR website, it’s a pain in the ass, right? Like it makes no sense. But sometimes the best thing to do is just reach out to your friendly lab tech and be like, mate, can you help me with this?

I did it for one of my friends did it for me, and he just sat down with me, just went through the whole thing. He literally took like about an hour or two and I just paid him like a hundred credit and he was like, happy to do it. And once you set it up and you get the paperwork in place, it’s actually pretty straightforward.

And it just goes on like, you don’t have to keep renew, like you renew it, but you don’t have to keep changing things. You just add everything in and call it a day. 

[Jaz]
So those doing CEREC, by definition, they would be registered as a lab I guess? 

[Rustom]
Yes. You would get MHRA, you have to get MHRA for doing CEREC and you also have to, so when you do your own CEREC, you have to put a prescription in for yourself. You have to say, okay, shade A3 brown fissure stain. So I just put that in my notes. That’s my prescription. Pretty much. And, on dently, I just make a little format where I just fill everything in. There’s a little blurb at the end, say my inventory number and stuff like that. So it’s easy enough. All these things, once you set it up, it’s easy to run. Setting up is the hard part. 

[Jaz]
Totally, and then, so with the milling, let’s move on to milling away from printing, which is really what you think is a superior. The number one question you probably get is, how much is this all gonna cost me? So, which milling units do you recommend for like, beginner, intermediate, advance? How do you even tackle like the market for milling, like I’ve heard of Roland CEREC MC/MC X or whatever they are basically there’s so many different. 

[Rustom]
Yeah, it’s a bit of a tough question. What I would say is this, like the CEREC mills unknown because they’re basically bulletproof. Okay? If you go on the secondhand market, you could pick up a mill for like from two grand right up to six grand.

Okay? And some people will find 70, but 12 or 13 grand for something that’s 10, 20 years old. And you’re like, no, that’s a bit too much. But if you wanna buy a secondhand mill, like it is totally worth it. But then you have to really think, what software do you need to run your mill? So straight away you go back to the software question, okay, whatcha you gonna design on?

Does that design software communicate with your mill? If it doesn’t, you’ll need another software to bridge the gap. So if you get Exocad, for example, works well at VHF, you won’t need additional software. Okay? If you buy a CEREC mill, then you need the in-lab cam to let your design talk to the mill or you need search software to design.

So it’s a bit of a loaded question in terms of that, there’s more to it than it’s obvious. But if you wanna start milling, it’s actually not that expensive to get into milling. You could buy a old omnicam and a mill for like nine grand. Literally. And you can do your scan, you can upload them to DS core and design on DS core.

Nowadays, if you have an iTero, loads of people have iTeros, you get the free online Exocad software where you can design a cram and then you can take it from there and put it through your VHF mill that you’ve bought for like 10 grand or 20 grand or whatever. So it’s becoming more and more accessible. So when I bought my CEREC like, you gotta think 90 grand is a lot of money, right?

Nowadays that the entry level, it’s not like that. It’s much lower, but it’s still scary. Like, and the problem again is that the knowledge is very much put away. Like you have to pay to access it. So that’s the hard part. So I’ve been through this journey where I’ve literally bought stuff and I’d be like, this doesn’t work for me.

And then you have to resell it and you’ve made it lost. But it’s just a journey, like once you get there, like you have to share it with other people. So I always tell people like, if you wanna ask me anything, just message me. Like for me, like there’s nothing I enjoy more than like just geeking out having a conversation about this stuff. So, yeah, like, just enjoy it. Like, if you’re really looking into that, I’m happy to help anyone. It’s a simple thing. 

[Jaz]
Who’s the ideal candidate or ideal practice that their business model would suit milling or generally that is worthwhile investment for them, because like I said, yes, investment of time, money. Equipment maintenance, training of the nurse, training of the dentist. It’s no easy first step to take, I guess. So who is the ideal individual principal or practice? 

[Rustom]
So, it’s actually a really good question, and you gotta think that I have a mixed practice and I still do a lot of NHS work. Okay. I do a lot of NHS work, so I do a lot of composite on laser my cerec for the NHS patients. And you gotta really think about that if someone comes in, if I’m doing 1, 2, 3 onlays, my time that I spend is very little. So I’ll get them in and out to do a composite only in 45 minutes. In most cases, it’s done.

[Jaz]
And does that still count as 12 UDAs? 

[Rustom]
Yes. 12 UDAs. Yeah. It comes as 12 UDAs in directs, even minor rehabs. I’m happy to do ’em. I think it’s just a bit of fun. And once you do something with someone, they’re your patient for a long time and if they’re happy what you do, then they’re always happy to pay more later.

It doesn’t really bother me too much, like, but you can fit this into any model. The problem is that if you’re an associate, then it becomes harder. ‘Cause who’s gonna buy it? Okay, you’re gonna spend 20, 30 grand, like you know, and then you have to now take time outta your day to learn how to do it. And you’re gonna have failures earlier on.

You have failures, your design’s not gonna work properly, your milling is gonna fail or something debonds bonds. So this is a risk that you have to take, but in any model as a practice, it works. You have in-house milling, like specialist level practices. You have it in implant practices, you have it in NHS practices, not so much because that’s more market forces where they just don’t make enough money to pay for the system.

But once you get it. Then your lab fees are like very little and your time saved is so much. So it’ll work anywhere, but you just have to be clever about how you approach it. Like if I had a NHS practice, fully NHS practice, would I buy a CEREC? Absolutely, I would. I would. And I would buy a good scanner.

Okay. Where I can take four scans and I can make my night guards or whatever off that, and I’d buy a secondhand mill and that’s me done. Like, I would spend under 30 grand for it, like, but you will think your lab fees will drop, through the floor. Truth is that you’ve saved so much time and then you also have predictability.

So you know that when you do your CEREC it’s gonna fit every single time. And when they come back, they have no issues. There’s no like, oh, there’s a cement gap there, or all those things. So I believe in predictably of anything else. 

[Jaz]
I think though, from listening to you today, that I think you need to have that inner geek in you to just get involved with this stuff. Like, if it doesn’t excite you, like if there’s people who be like, listen, this is the last thing I wanna do, sod this, but there’s some people who you know who listen to this and you know what? That is so cool. Like, they listen thinking that is so cool. I think really you need to have that drive and to lean in to make it all worth it, and then you will make it work.

[Rustom]
Absolutely. You are a hundred percent right. You’re absolutely right. 

[Jaz]
And so the last question I wanna ask you mate, is, we’ve had this chat, I now understand a lot more. Like big time printing versus milling ideal indications. I know the printing manufacturers will tell you the indications are so vast, but really you gotta look at the quality and how long it’s been around for.

So you’ve been really good to dispel those myths. But you still, if I wanted to get into this, I would still want to go in some course learn about the software and like when you’re learning implant stuff, if I was to go into that. You get a mentor, you do everything by the book. So it’s a journey you go on. So where should one get their training? We have an international audience listening. What would you say to, ’cause again, people ask you all the time, I guess, what are you telling people? Where should they train? 

[Rustom]
It depends on what you wanna do. I think if you start with design software, it’s always a big plus. I learned all the stuff I do from this American guy named James Klim. He’s been around for a long time and he runs a website called cadstar.org. And the beautiful thing is like, no one wants to sit there and watch something for an hour and you’re trying to find little bits that you wanna do.

So he makes his videos like really short, really sweet. And he just gets to the point. He just gets point and you look at his work, like this guy was doing stuff that was so ahead of his time. Like stuff he was doing 10, 20 years ago is still as good as stuff like I’m doing now. And I respect that guy so much.

But the way I looked at his stuff for the, and it’s a very CEREC orientated stuff and he’s doing some extra kind stuff now, but it made my life easy. And you listen to him talk and you realize this guy’s a geek as well. And yeah, I would recommend if someone wants to get into like that sort of stuff, especially cerec James Klim cadstar org is the one, but other than that, he has a lot of YouTube videos as well.

It’s for free. You can watch pretty much anything you want on YouTube these days. Like there’s a lot of people putting stuff out, and if you just wanna have a taste, just go look at it. There’s nothing more to it. If I wanna buy something, I will do like a lot of research. I’ll find videos, I’ll speak to people, I’ll ask my friends, what do you think about this?

What do you think about that? And I’ll give them my vision of what I think is gonna fit in, like my practice or whatever I do. But you have to just talk. Like, dentistry is a very isolated sort of field, but at least nowadays we have social media, we make a lot more friends, and it’s just about sharing and just keeping everything going because when everyone else benefits you benefit too. That’s the best way to look at it. 

[Jaz]
Do you do any teaching lesson? ‘Cause you are so knowledgeable now you’ve got some experience. If you don’t, man, you should because you had the experience, you should share it. I mean, do you do anything like that? 

[Rustom]
I used to help Attiq on his courses for the prep courses and stuff. The thing is, it’s funny you said this because I put up a post yesterday just saying that like, I want to run like a course for charity. It is just about stain and glaze and it’s interesting for me because I get to meet people like me who are geeky, right? It’s a very niche sort of thing. But I also realized that I didn’t enjoy teaching when I was younger because it wasn’t anything else, but I wasn’t mature enough for it.

I think you have to get to a point in your life where you are mature enough that you enjoy it and make the most of it. And I just wasn’t there back then. I enjoyed working with Attiq but I was always very comfortable that I was working under his umbrella. So, it’s a safe space, right? And that was important for me. But yeah, like will I get into it? Maybe at some point, but it’s one of those things where I think there’s more important things. 

[Jaz]
I like your no BS approach and I think we need more of that. And it didn’t sound like you were in bed with any companies, which is cool. And it was just nice to hear your real approach. So, keep it up, man. More power to you. 

[Rustom]
Thanks, man. I appreciate it. Like, hearing that from me, that’s cool. It’s actually a real honor to be on here, right? I still remember, like we met at BACD and someone was talking to you and I said, you know this guy, he’s gonna be someone one day like really soon.

[Jaz]
Please man, what you’re pumping out there into the universe is amazing. Helping a lot of people, big time, especially with today, a lot of people will be inspired to do that. But just like you inspired me over that KFC stroke shadowing session, it’s amazing what you do. I hope you are colleagues and associates realize how lucky they are. Rustom, thanks so much for spending time with me today. I really appreciate you making printing and milling tangible to, we actually know, okay, where is the foundations of it. So thank you. 

[Rustom]
No, no worries man. Happy to be here. Thank you. Thank you for everything. Thank you buddy.

Jaz’s Outro:
Well, there we have it guys. Thank you so much for listening all the way to the end. What did I tell you, right? He is so like direct and he tells it how it is and he made it tangible. I’m hoping he’s give you an idea whether it is the right thing and the right stage of your career or your practice to start thinking about implementing these technologies.

For many practice, it’s a big no, but if you are in a geek who loves the toys and you want to kind of play the role of lab tech, then it can actually bring a layer of joy that you can only see on Rustin’s face. If you watch the video version of this. His passion and enthusiasm for this was just absolutely shining through. I hope you all agree.

Now you can get CPD and CE credits for this episode like most of our episodes. So if you are a regular listener, then you could be easily racking up, you know, 40, 50 hours of CPD just from these episodes every year. These are new episodes we make every year, let alone going back in time and claiming CPD for those and our masterclasses on the Protrusive Guidance app, including premium clinical videos like through the loop views and stuff.

Some of the walkthroughs we do, our best content is on the app. So do check out protrusive.app. It’s also how you support Team Protrusive so we can keep doing what we’re doing. If you’re watching this on the app, scroll below, answer the quiz, get 80% and you add some reflections in because this is what form as part of your PDPU and your certificate will have that in.

Right? And so Mari, our CPD CE Queen, she will sort you out. I wanna thank Gian for editing this episode, Krissel and Nav for the premium notes, and Erika for helping me with publishing. Thank you so much again guys, and catch you same time. Same place next week. Bye for now.