June, 2001
Our Digital Model Experience: A Six-Month Orthoca User Report
Tom Marcel, DDS
Plaster casts are one of the most fundamental tools in orthodontics. The fond tradition of “passing plaster” around a residency conference table, a Monday evening study club, or an early morning treatment planning (with fresh coffee) to work up cases before the barrage of staff and patients arrive all come to mind. With the computer revolution, however, instead of “passing the plaster,” I am now “passing on plaster” as often as I can.
Pros and Cons of Plaster
Plaster casts are used routinely for diagnosis and treatment planning, progress assessment, and post-treatment evaluation. Several features in particular have contributed to their usefulness:
- Production is routine and predictable;
- They are relatively easy and inexpensive to produce;
- They are easy to examine and measure;
- They can be mounted to simulate articulation; and
- until recently, casts have been the only 3D medium available to accurately represent malocclusion.
On the other hand, plaster models present a storage dilemma because of their size and weight. They require labor intensive cataloguing and retrieval and lawyers refuse to tell us how long to keep them — even after retirement. In most cases, casts are rarely consulted after the original diagnosis. They can be lost or damaged and are troublesome to reproduce and transfer.
As our office has adopted digital technologies, these constraints have become even more glaring. We employ Ortho II™ and Dolphin™ for practice management and imaging software, respectively; and maintain digital charts, radiographs, and photographic images for each patient. We have networked chairside laptops to enable full access by the operating staff. By virtue of their physical properties, plaster models cannot be integrated into either system. As a consequence, we have had to manage two records systems: one computerized for digital charts and images, the other manual for study models.
With the emergence of an interdisciplinary approach in dentistry, especially in adult or complex cases, we have seen a growing number of occasions where we have increasingly had to duplicate casts and to send out to other specialists. Last but not least, severe staff shortages in the Bay Area have led to rising salaries, increasing the cost of labor related tasks, such as generating, storing, and retrieving study models.
A Diagnostically Superior Alternative
We have found that OrthoCad offers a diagnostically superior and cost effective alternative to plaster casts. Fortunately, the OrthoCad developers have chosen not to reinvent the wheel, focusing instead on preserving the unique look and feel that have made plaster models so popular over the years. You don’t need any special materials or methods. To obtain 3D models, we overnight our normal impressions and wax bites to the OrthoCad service center in New Jersey. Within one week, our models are downloaded on the office computer via the Internet. We then use the OrthoCad software, in essence a 3D browser, to store, present, and diagnose cases on screen.
Getting Started
To get started, three components must be in place: a) a download utility installed on an Internet ready PC to serve as a gateway; b) a designated computer folder for the incoming 3D models; and c) the OrthoCad 3D software. In our office, both the download utility and storage folder are located on the Dolphin imaging server. Once received, we can view the OrthoCad models on the server as well as on each of the chair side laptops.
An average OrthoCad file is 3MB, so you can store close to 10,000 cases on a typical $200, 30-GB hard drive. With hard drive retail prices constantly dropping, the lifetime storage cost for each model is negligible. Similar costs apply for burning finished cases onto CDs or DVDs, which frees up hard drive space. However, I prefer hard drive storage because it is easier to retrieve records.
To download models we use a DSL (Digital Subscriber Line) Internet connection. Downloading is totally automatic and usually takes place at night. In the few instances where we’ve operated in the manual download mode, it took less than 20 seconds for a file to reach the server. The OrthoCad center is equipped with a dedicated T-1 line and communication is therefore instantaneous. According to OrthoCad’s tech support team, downloading times for the more widespread 56K dial-up connection ranges between 8 and11 minutes.
Figure. A Positive Experience
Having used OrthoCad for six months, the experience has been extremely positive. The following are my impressions after using OrthoCad for six months:
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Getting Started: Orthocad provides the software, user key, manuals, and shipping supplies. Three days later, the tech support desk calls to assist with the installation, which we found to be quite elementary. We didn’t experience any glitches so the only other time we had to contact the support desk was to complete the integration with Dolphin. This was carried out fairly easily. OrthoCad also integrates with Ortho II but we chose to have the files displayed adjacent to the X-ray and photos. On both occasions the help staff was attentive and knowledgeable.
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Simplicity: There is no need to adopt new procedures or new materials. We use exactly the same types of impressions, wax bites, and trays, which means there is no learning curve for the office staff. We must relinquish our trays, but OrthoCad sends them back once they’re done. In addition, all shipping materials are provided in advance. We just need to obtain the impressions and call UPS to overnight the package.
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Convenience: In addition to the impression shipping procedure, the download utility really does a good job in getting the digital models to the office. Unlike in the case of an e-mail protocol where somebody has to actively initiate the communication and wait for the data, the 3D cases are automatically downloaded directly to our computer from an FTP (Internet) site. As part of the OrthoCad installation, our server was programmed to contact the FTP at night and download our finished models. When done, the connection is terminated and an accompanying and detailed message appears—or we are advised that no new models were found.
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Service: Quality of service has recently become a familiar term with the growth of mission specific service providers in our lives. As far as delivery goes, OrthoCad is fulfilling their promise. We receive the images within six business days. In addition, the 3D information is detailed, accurate, and reproduces very clearly on our monitors.
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Efficiency: The magic words here are “information sharing.” The same 3D file can be diagnosed by the orthodontist, presented by treatment coordinators, and used by the chairside assistant—all at the same time. A “digital case” can also be sent to other dental specialists, insurance companies, GP’s, or even to the patient’s family with the click of a mouse. Instead of taking an hour long lunch with a dental colleague to discuss a case, we now simply send them the file electronically. We can discuss a case over the telephone while sitting in our respective offices viewing the same images on our monitors. Notes on particular teeth can easily be made on the screen. And, we can calculate a Bolton analysis in nanoseconds.
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Value: OrthoCad charges a fixed price of $35/case (upper and lower). They cover unlimited software licensing, tech support fees, and UPS PRACTICE MANAGEMENT DIARY overnight shipping costs, as well as digital backup of the information. In fact, at your request, they will send your colleagues free copies of the 3D browser. There is no limit to the number of cases you can send so there are no contracts or minimum quantity commitments. If needed, casts can be fabricated for your study club for an additional fee.
Limitations
There are some potential hurdles, however. First, one must learn to analyze study casts on a computer screen. It is possible to view the casts from a myriad of angles, but comfortable manipulation takes some practice. Second, large practices must ensure plenty of available computer memory. Third, to date it is not possible to relate the casts to the hinge axis. And, lastly, Orthocad is currently working with the ABO to approve digital casts as acceptable records for review.
Final Thoughts
For our office, OrthoCad offers an elegant solution for our storage problems. It also eliminates the staff time required to pour up, trim, polish, and archive the models. Our lab technician now has time to fabricate more appliances so fewer casts must be sent to the lab. Our models are always accessible and reproducible. Duplicating merely requires emailing a copy or printing a 1:1 scale on a laser printer. We can use this printed record to size/ customize quad helixes to form archwires and lingual arches.
In return for a small premium over the market price for plaster casts (typically $20–$25), we have gained significant improvements in productivity and profitability. I am interested to see how our specialty will accept this technology. So far, my experience with the Orthocad system has been very promising.
Reprinted with permission from the Pacific Coast Society of Orthodontists Bulletin, Vol. 73, No. 2, Summer 2001
Contributed by:
Tom Marcel, DDS
Dr. Marcel lives in Livermore California.
