Everyone would agree that the science of dentistry has moved forward at a quantum pace over the past few years, but what about the art of dentistry? Let’s face it (and smile, please) — most patients are more concerned about the appearance of their teeth than they are their oral health. And when procedures move beyond routine maintenance and into the realm of cosmetic dentistry, the profession has as much in common with Michelangelo as it does with Hippocrates and Pierre Fauchard.

Michelangelo’s David is an example of artistic perfection, but from a technical point of view, it is a miracle that the work is still around. Michelangelo chose a very poor quality marble for his sculpture, which today has forced restoration artists to go to progressively extreme efforts in an attempt to save and restore this important piece of art. As a metaphor, David demonstrates the importance of balancing the technical with the aesthetic — a strong argument for employing the best possible quality in both the science and the art of dentistry. At just 23 years of age, Jeff Paulen recognized this connection between dental art and dental science – when he opened New Image Dental Laboratory.

in 1984. “I started in dental materials at a very young age,” recalled Paulen, “when I was in high school and I did a research project at Emory University. I worked at Emory’s dental school from 1976 to 1978, and as I continued working in dental materials my interest in the industry just kept growing.” Then, at the urging of friends and associates, Paulen opened his own lab. “They said I needed to open a lab,” Paulen recalls. “They even said they’d work for me. So sure enough I came down here and built out a place and opened it six months later.”

SAME ARTIST – NEW MEDIUM
There was a compelling reason for a 23-year-old to venture into something as daring as opening his own dental lab — it would help fill a huge labor shortage that was plaguing the industry. “About 15 years ago there’d always been a shortage of technicians,” Paulen remembers. “That was a standard in our industry. Everybody was saying how they had plenty of work, but they couldn’t find enough good help. I went out and grew my own help, and that’s what made what we do so unique.

“Making teeth is an art,” Paulen says. “Every tooth is different; each person’s tooth has a unique shape, color and contour.” Paulen started by recruiting from outside the industry, looking more for talent than experience. “I looked outside of the dental community,” he adds. “Instead of advertising for technicians, we looked for people with art backgrounds. We interviewed people who were strictly painters and sculptors, guys who did bronzes, pencil sketches — all types of things.” Prehire testing included such things as dexterity and chalk carving. Paulen strongly believed that if he could find the right people who had a gift for art, and then properly trained them in the techniques and the science of creating dental products, they would simply apply their natural talents using these new tools. He was right. Instead of creating beautiful paintings, or sketches or sculptures, his new dental artisans began creating beautiful teeth — and crowns, and bridges, and virtually every kind of prosthetic restoration possible.

CERTIFIED ARTISTS WITH AN EYE FOR DETAIL It’s easy to find Paulen’s words in practice at New Image Dental Lab, perhaps the most progressive full service dental laboratory in the country. As an active member laboratory of TEREC — a consortium of independently owned regional dental labs focused on research and sharing of advancements in the dental profession — New Image is dedicated to the pursuit of continued research and development of dental prosthetics. The result is unwavering quality, the finest materials, and the most technologically advanced prosthetics available.

“We have a lot of certified dental technicians,” says Fay Ashley, New Image’s Customer Service Relations manager. “All of our departments are managed by CDTs, but we took it a step further.” New Image is actually a certified dental lab, and well on the way to getting their DAMAS — a level of certification very similar to ISO, where every aspect of the operation is documented. Ronald Banister is New Image’s director of Education, who is also spearheading the DAMAS certification process. According to Ron Banister, “DAMAS certification will give New Image customers assurance that the appliances they deliver are of the highest quality available.”

Even with the detailed technical quality control that comes from rigorous procedural controls, in cosmetic dentistry quality control is also an aesthetic process. No one knows this better than Florence Clements, one of many people responsible for Quality Control at New Image. Florence came to the company from the garment industry, where as a colorist, she would match fabrics for color and pattern consistency. That training gives Florence a better eye for evaluating how closely a prosthetic matches the organic color detail specified by the dentist.

As a TEREC member, New Image benefits from early access to many of tomorrow’s cutting-edge technologies. Paulen, who is the technical team leader for TEREC, acknowledges that the association is mutually advantageous. “We beta test new technologies and processes all the time,” says Paulen. “Partnering with companies like 3M/ESPE and Weiland, among others. This enables us to stay ahead of technology, so that when new materials and procedures are formally introduced, our technicians already know them and how to use them to get the best quality product.” One of Paulen’s TEREC assignments has been to keep up with all the CAD/CAM systems on the market. CAD/CAM in this instance refers to the computer-aided design and computer-aided milling of prosthetics. Other TEREC teams concentrate research efforts on other aspects of the laboratory business, such as management and marketing.

It is fitting that New Image has been charged with technical research for TEREC. “I just love technology,” says Paulen, who works hard to be the first to introduce new technological innovations to dentists. An example is Lava. “Lava by 3M/ESPE has been out there for three years, but we had it a good year before then,” he says. “We beta tested Lava, just like we’re beta testing a new machine right now called ZENO.” Made by Wieland, ZENO is a 3D CAD/CAM milling machine that shows tremendous potential for working with zirconia to cost-effectively build longer bridges (up to 14 units long). “We’ll be evaluating ZENO, working with it, and giving Wieland feedback prior to them releasing it for sale to other laboratories in the U.S.”

The ZENO system is one of many new technologies in various stages of testing and evaluation at New Image. “We’re looking at technologies right now,” says Paulen, “and we’re working with companies that are printing gold copings, another company that’s laser prototyping frameworks ... so we’re out there looking at all these technologies well before they even enter the market. Many of the technologies we’re working with now won’t be released for a year, two or even three years from now. It’s a big plus to be able to play with them now.”

“OVER THE SHOULDER” TRAINING IS OVER Over 15 years ago, New Image opened their own in-house school to provide continuous training and education for their artist/technicians, using a variety of systems, including Productivity Training Corporation’s PTC2000 training and verification system. This ensures that everyone who goes through the training program (and Paulen stresses that everyone means everyone) is certified in all facets of the procedures they will be performing to create their works of dental art. It also ensures that dentists receive a finished product with quality that is achieved, monitored and maintained consistently.

”The PTC program is but one part of an exhaustive training program at New Image’s school that every employee must go through — for a solid three months — before they ever pick up their first piece of work. After that, training is ongoing — a process that takes several years. This is why New Image is so selective upfront with their hiring. In an industry that complains of a shortage of labor, that New Image can be both so selective and retain employees for entire careers says something. For example, Steve Bates started as an apprentice in 1992, and is now manager of their Empress Department. Joel Yawn started his career at New Image in 1995 and is now manager of their Composite Department. At New Image, training equals longevity and a clear opportunity to climb to the top.

As a testament to New Image’s training regimen, several years ago a nearby university had approached Paulen about having him open a training program for their school — an offer he declined. “I refused because they wanted to create a program where they’d take just anyone who would pay the tuition to go through the class, where here I carefully choose people with the aptitude and talent, and then I pay them through their training period and they become a part of this team. There’s a big difference.”

The thoroughness of the training has enabled New Image to find — and hold on to — talent from all walks of life. “We have technicians — all ages — who worked as forklift drivers, or who came from manufacturing and from the food processing industries,” Paulen explains, “but they all have one thing in common — they are all phenomenal artists.”

GROWING TOGETHER
Continuing education is a primary component of anyone’s career in the medical professions. In the middle of the winter training season, Jeff Paulen attends several of the dental, implant and prosthodontic meetings held around the country, joining other laboratory owners and directors. Unlike many of his peers, however, Paulen brings with him an entourage of as many as a dozen technicians from his office.

“We do lots and lots of continuing education,” Paulen explains, “and not just for our doctors. We also do a ton for our staff.” Paulen truly sees his employees as members of a team, and believes in the importance of having them learn from these continuing education experiences first-hand. “People always look at us like we’re nuts, but they’re the ones at the bench who are actually doing the work. So when we go to our meetings we always go as a group.” A side benefit of this practice is a strong sense of camaraderie and loyalty in a laboratory whose employees stick around for decades, instead of months or a few years. “I just don’t have any attrition,” he remarks. “I don’t lose people. Even the people I brought in as apprentices, the sculptors have been with me 10 years, 12 years — we just kept growing. We all learn together, we all grow together. My fourth and fifth employees (Kenneth White, manager of Crown and Bridge, and David Cawthon, general manager) are now two of my key managers at New Image, and they are now celebrating their 20th anniversaries with the company.”

Having a staff that’s trained first-hand in the latest techniques frees up Paulen to focus on another of his passions — reaching out to share this information with dentists. “I spend much of my time case planning, guiding our dentists to the specific needs of their cases and occasionally will be chairside on the most challenging of cases,” he says. In addition to educating dentists one-on-one, Paulen is often found speaking at the industry’s major meetings, including the D.C. Dental and Hinman Dental meetings, and numerous study groups, as well as at Nova Southeastern University and the University of Florida.

THE ART AND SCIENCE OF CUSTOMER SERVICE
Jeff Paulen has found a way to blend the art and science of dentistry. His Customer Service Department, led by Fay Ashley, has refined both the art and science of ensuring a pleasant experience for dentists doing business with the New Image team.

“Working together as a team with New Image has made my practice more successful,” says Dr. Stanley Rye, a prosthodontist in Atlanta, GA. “Communication is the key to success between New Image and my practice. Case planning together with New Image has made my practice run very smoothly.”

Fay Ashley knows that testimonials like these are pretty commonplace. “Dentists should expect a personal touch from New Image,” she explains. “We’re one of the larger labs, but we’re not so large that a dentist can’t talk with the owner, or their ceramist or their technician,” added Ashley, who is also a dental assistant. “It is not uncommon for Jeff or me to assist our local dentists with difficult chairside procedures. We can help them choose the proper material or talk about prep design. Most labs don’t have that capability on staff.” New Image definitely sees customer service as a partnership to help dentists grow their practices. As an integral part of that partnership, territory managers Debbie Schmidt and Marjie Machado are always in the field introducing dentists to new products and materials.

“The relationship between a dentist and the laboratory is a crucial one,” stresses Ashley. “From the patient’s perspective, the lab is a choice made by the dentist, so naturally the quality and reliability of the work that comes out of that lab is a direct reflection on the quality and reliability of the dentist and his or her practice.”

A STEP AHEAD
Although every lab is quick at responding to customer requests for products, New Image tries to stay ahead of that curve, working hard to introduce dentists to new products, materials and procedures. Nellya Yultugriyeva, their Removable Prosthetic manager, has been trained in many of the newest products on the market. “We have a variety of products that are unique,” she explains, “such as the Ultraflex Nightguard from Astron, which is ideal for patients with allergies to certain materials. It also enables the patient to insert the nightguard into his mouth and self-adjust using his own body temperature.” New Image tries to be the industry leader in any and all new technology available. This creates an exciting atmosphere at the lab, but also proves to be invaluable for dentists and their patients.

“We were excited when we partnered with 3M/ESPE over three years ago to work with their Lava milling machines,” says Paulen. “We pioneered Lava introduction into the East Coast. U.S. Lava offers the superior strength of zirconia, with excellent aesthetics and translucency. Most of the dentists we work with are shifting to Lava crowns and bridges, and they’ve been extremely happy with the results ... as have their patients.” In addition to Lava, New Image has significant experience with other systems, including Everest. This is another exciting CAD/CAM system that has 5-axis milling technology that allows the restoration to have more exact contouring. They are also well versed in composites, including Cristobal+, BelleGlass and Sinfony. Implant technology is also an important part of New Image’s business, and their technicians are trained and certified in virtually every major implant system currently available.

THE FUTURE OF DENTAL ART
New Image’s love affair with new technology will no doubt mean that as the company continues to grow, it will maintain its position at the cutting edge of innovation, refining new products and techniques while others are just beginning to know they exist. “I’ve known Jeff for more than 15 years,” says Fay Ashley, “so I know he’s going to be there trying out everything that’s new and innovative, testing and evaluating these systems and if we like it, he will help dentists use it to grow their practice.” And while technology has and likely will continue to dramatically change the way we practice dentistry, the need for the artist will remain. “The art will always be there,” says Paulen, smiling. “I don’t see art being replaced by a machine for a long, long, long time.”

02/07/2006
A Dental Lab Products article in the January 2006 issue, titled "CAD/CAM: ARE YOU IN?" is definitely getting the Dentists' attention. The percentage of Dentist's prescribing lab-fabricated CAD/CAM crowns jumped from 18% to 27%, a 50% increase in 13 months. There is a definite market trend that is growing amongst dentists accepting CAD/CAM restorative options.

01/01/2005
Article: Moving away from Metal
by Jeff Paulen
Published in Dental Economics

Television programs such as “The Swan” and “Extreme Makeover” have brought cosmetic dentistry into the homes of millions of Americans, so it is no surprise that dental patients are becoming more concerned with the aesthetics of their dental work. In line with this trend, metal-free alternatives such as Zirconia (ZrO2) ceramic substrates are gaining in popularity for crown and bridgework. They offer superior aesthetics, as well as strength that is comparable, if not better than, traditional porcelain-fused-to-metal, or PFM, restorations. Preparation techniques for many all-ceramic systems are similar to traditional PFM crown and bridge techniques, so they are easy to incorporate into practice. Thus, clinicians are realizing benefi ts in both patient satisfaction and referrals.

The differences in appearance between traditional PFM restorations and all-ceramic crown and bridge systems are pronounced. Most people can recognize a PFM crown by the substructure that is often visible in the patient’s mouth, appearing as a thin, gray line at the margin of the crown. All-ceramic crowns offer excellent marginal fit and eliminate gray margins.

In addition, PFM crowns do not transmit light through the crown, resulting in a somewhat dull tooth appearance. Zirconia ceramic substrates, on the other hand, allow for light transmission, so the entire tooth and the surrounding tissue are illuminated and lifelike in appearance. For example, Lava™ crowns and bridges, an all-ceramic system from 3M ESPE that uses computer-aided design/computer-aided manufacturing, or CAD/CAM, technology, offers colorable frameworks in eight different shades for natural color matching.

Tissue response
Tissue sensitivity can be a common issue with PFM crowns and bridges. Base-metal crowns contain nickel, which can cause an allergic reaction in many people, especially women. Restorations that use non-precious metals can sometimes result in gum tissue that is purplish in appearance, and some patients experience irritation and/or gingival recession. Alternatively, zirconia is a biocompatible material and has been used with great success in other medical applications, for example, hip replacements, for the past 20 years. Similarly, zirconia results in excellent tissue response when used in the mouth — gum tissue appears healthy and is pink in color.Further, the tissue does not pull away from the material, which can occur with traditional PFM restorations.

Strength
Strength was a concern for earlier alternatives to PFM restorations. In the past, when most glass-containing, high-strength ceramics on the market were subjected to masticatory forces, normal oral moisture led to subcritical crack propagation. Strength problems are no longer an issue with current zirconia-based, all-ceramic crown and bridge systems. These new materials deliver strength and durability that rival many PFM restorations. The system we use features a high-strength ceramic core material that measures 1,272 Mpa. The benefit is that less tooth structure needs to be removed during clinical preparation. At 0.5 mm, the Lava system can mill a thin, yet strong substructure.

Cost considerations
While some dentists may shy away from using zirconiabased prosthetics because of initial fi nancial concerns, a look into average fees for the different types of restorations and typical insurance reimbursement structures shows that cost should not be a barrier to all-ceramic systems. Based on the ADA procedure codes, the national average fee for a crown using porcelain-fused-to-base metal is $856 (code #2751); the fee for a porcelain-fused-tonoble metal crown is $888 (code #2752); and the fee for a porcelain-fused-to-high noble metal is $973 (code #2750). At $1,018 (code #2740), the average fee for a crown with porcelain fused to a ceramic substrate is not significantly higher. When insurance reimbursement is based on a percentage of the reasonable and customary fee in an area as defined by its zip code, the porcelain fused to a ceramic substrate will result in a larger reimbursement

Other financial benefits of using all-ceramic materials for crown and bridgework include their accurate fit. The CAD/CAM technology used in our lab ensures an accurate fit the first time, virtually eliminating the need for costly remakes. Patient satisfaction with both the procedure and resulting aesthetics can have a significant
impact on repeat business and increased patient referrals.

Accessibility
In the past, advancements in technology required an investment in hardware and equipment by the dental laboratory, which limited accessibility for the dentist. This is changing. For example, our laboratory has become an Authorized Lava Milling Center, one of eight milling centers located across the country. This business model allows access for any doctor or laboratory to a high-quality crown and bridge system without expensive equipment investment.

Patients are becoming increasingly more demanding about the appearance of their smiles. All-ceramic crowns and bridges offer the high-appeal, aesthetic results patients desire without compromising strength and durability. When comparing appearance, tissue response, strength, cost considerations, and patient satisfaction, zirconia-based all-ceramic crowns and bridges offer a clear advantage in most cases over traditional PFM restorations.