Digital Trailblazers
How laboratories are leading the way in the dental industry
Ellen Meyer, MBA
Do you view your laboratory as a valuable resource and partner or merely as a vendor who provides a means to an end? Most dentists, if they were being honest, would probably answer the latter. Considering the industry changes that are already in motion at the bench and in the operatory, it’s time to reevaluate that position. Laboratories are ahead of the curve in terms of their adoption of technology and understanding of new materials. In many ways, laboratories today are leading the way, and dentists who don’t take advantage of these partnerships will miss out.
Being a laboratory technician in the current economic climate is not easy. According to Inside Dental Technology Editor-in-Chief Pam Johnson, the challenges facing a constricting laboratory industry today and in the future will largely boil down to the high cost of investing in and maintaining production technologies that can keep pace with the escalating demand for dental services.
“The US population is growing exponentially while the number of dental laboratories in the United States is shrinking. The dynamics of supply and demand will necessitate that laboratories transform their businesses to automated production processes in order to meet the needs of an ever expanding patient base,” she explains.
Indeed, Johnson expects that the pressure to meet future demands may transform the face of the industry beyond recognition—including how the players interact with one another. By necessity, laboratories have stepped up to become modern manufacturing facilities. Their transformation, Johnson points out, was largely due to the advent of zirconia, which required milling technology. “When zirconia came on the market and challenged the strength and biocompatibility of gold at a time when the price of gold was skyrocketing, dentists jumped on the bandwagon and created a demand so great that laboratories either had to access the material through milling centers or invest large sums of capital in milling technology to bring production in-house,” she explains.
The Laboratory–Clinician Technology Gap
Although the laboratory industry has responded to shifting dynamics and evolving technologies by changing radically in a short time, this has generally not been the case on the clinical side. David Hornbrook, DDS, is well acquainted with both sides of the industry, maintaining a private dental practice in San Diego, California, and serving as clinical director of education and technology at Keating Dental Arts in Irvine, California. Although he recognizes that technicians had no choice but to embrace technology, he is frustrated that dentists are lagging behind to such an extent. Hornbrook notes “a huge disconnect” between the labs, who want digital impressions, and dentists, who continue to send traditional ones. Results from a survey he conducted of 45 dental labs a year ago corroborate what is true of the 500 or so dentists served by Keating Dental Arts: only about 5% of dentists are providing digital impressions on a routine basis.
Mike Cash, CDT, director of sales and marketing at Glidewell Laboratories, says that interest in intraoral scanning seems to be on the rise, but the rates of adoption are still increasing rather slowly. "We see 9% of BruxZir crowns and 12.7% of BruxZir bridges being done from digital impressions, but it's not growing very fast," he says.
“Clinicians need to realize with many of the new dental materials used today in the dental lab, these traditional polyvinyl impressions are poured up as stone models in the lab and then scanned and digitized,” Hornbrook says. “Most laboratory technicians believe that a digital scan directly from the mouth is more accurate than the lab’s digitized version of the model poured from doctors’ PVS impressions. Clinicians need to understand why a digital impression is better than a scanned model that is subsequently digitized. Just as in photography, it’s always best to use the original, not a copy.
Proper technique is important to ensure that digital impressions are in fact advantageous to the laboratory. "If an office can't get good conventional impressions, going digital will not fix that problem, and it could make it worse," Cash says. He notes that the adoption of digital intraoral scanning means a huge change to office workflow that requires a serious commitment in terms of time and money.
Hornbrook agrees that cost is a major barrier to adoption of digital impressioning. Dentists may not be aware that scanners have decreased significantly in price. “Scanners now are small, lightweight, and affordable—the 3M scanner is about $16,000.” He suggests cost-conscious practitioners factor in the cost of shipping and impression material into the cost of delivering a crown to make a fair comparison between analog impressions and purchasing a scanner.
“Digital impressions also allow for many of our restorations to be fabricated without any models, which further reduces the cost to the dentist and decreases the time needed to fabricate the restorations,” Hornbrook says. “At Keating, with the accuracy of the digital scans, coupled with the ease of use of the imaging (CAD/CAM) software and the precise mills available, modeless crowns fit well and reduce adjustment time in the mouth.”
Material Matters
Hornbrook points out another area of disconnect—awareness of material technology. “Technicians in dental labs are very proactive on materials because they are barraged with information by reps who don’t deal with dentists. Because companies often have separate sales teams for dental technicians and clinicians, the dentists are targeted for purchases of cements, bonding agents, and impression material, while the lab technicians are pitched new ceramics or changes in ceramics.”
“For the general dentist, it can be challenging to stay up on advances in restorative material options,” notes Brian P. LeSage, DDS. LeSage maintains a private practice in Beverly Hills, California, founded and directs the UCLA Aesthetic Continuum, and is the preclinical director of CAD/CAM at UCLA School of Dentistry. When it comes to discussing materials, he says everyone—including the patient—needs to be aware of the tradeoffs between esthetics and strength. “The rapidly evolving science behind material selection has allowed us to achieve better strength and less compromise on esthetics, but there is generally an inverse relationship between material esthetics potential and strength”—a gap that can be narrowed by talented ceramists with the ability to layer the highest strength milled ceramics to meet the greatest esthetic expectations
For this reason, LeSage suggests doctors ask patients one question to guide their decision-making in terms of material choices: What is more important to you, esthetics or longevity? Armed with this information and the patient’s clinical scenario, LeSage likes to discuss with the technician issues such as the types of restoration to fabricate and how to handle esthetic challenges such as material choice when there is a dark stump. Ultimately, on the issue of esthetics, he believes, “Dentists are only as good as their ceramist.”
R. Scott Clark, president of Dental Arts Laboratories, Inc. (DAL), in Peoria, Illinois, says DAL does presentations to dental groups to help educate them about material makeup, indications/contraindications, treatment planning, preparation requirements, cementation recommendations, and delivery/adjustment/polishing recommendations. To support this information, customers also receive a six-page material selection guide.
Clark emphasizes that advising and educating practitioners on material selection for different indications should not be viewed as a threat to dentists. “Most of us depend upon experts in each facet of life to guide or recommend the best path or solution for us to follow—for our health, finances, and spiritual life. Patients rely on their dentists to help them make the best choices and, in turn, dentists should be able to rely on their laboratory to help them choose the right materials. I look at our role as the expert on whom a dentist can rely when it comes to material selection. We work with many materials in the beta stage, and we will see more cases in 1 day than most dentists see over a long period of time. Thus, we have the benefit of measuring how each of these materials performs in various indications, designs, and load-bearing applications. We simply wish to share this perspective with our customers in the hope that we can direct them to the most predictable end result.”
Partners in Technology
Some dentists are progressive when it comes to technology, and those clinicians are more likely to be receptive to the adoption of new approaches and forming laboratory partnerships. Given Hornbrook’s findings about the majority of practices, however, he believes it is largely up to the labs to educate and push their dentist partners into the digital age. “The world of CAD/CAM and digital dentistry will be lab-driven. Technicians can let dentists know that digital impressions result in better dentistry—faster, less expensive, and more accurate due to certain advantages, including better marginal integrity and occlusion.”
Clark says DAL takes educating dentists about the digital workflow very seriously. “We do this via lecturing to dental societies, study groups, and dental meetings, and with conversations regarding case planning and material selection on an everyday basis.”
Like other lab owners, Clark knows this is a win-win situation. “It is imperative that each member of the clinical/laboratory team understands each step of the process—from scanning to CAD design to the final milled restoration—in order to maximize the predictability of the end result, which is the delivery of a premium restoration that meets both the dentist’s and the patient’s specifications and desire.”
Clark is anxious to speed up practitioners’ adoption of digital impressioning, and his laboratory’s efforts now go beyond education. “We are experiencing a lot of success with all of the current intraoral scanners, including Carestream Dental, 3Shape Trios, and iTero. In fact, we have partnered with Carestream Dental to present our customers with a very aggressive plan to cost effectively move into digital intraoral impressions.” This partnership, he says, provides “an easy segue into digital impression technology” with either a purchase program that requires a $5,000 down payment and a commitment to restorative work with DAL or a leasing program. “This progressive program is focused on eliminating the initial cost outlay and providing an easy entry into the many benefits of digital impressioning—reduced costs, faster case turnaround, improved treatment results, decreased chairtime, and—most important—increased patient satisfaction.”
Ensuring Quality Control
Peter Pizzi, CDT, MDT, owner of Pizzi Dental Studio Inc., in Staten Island, New York, urges caution when it comes to balancing efficiency and quality.
“It’s easy to say that because we can make it faster and cheaper through automated processes, more people can have dentistry,” Pizzi continues. “The problem is if the dentistry we’re giving them is challenging their health.” For example, he explains it is typical to find that 1 to 3 years after a lower first molar is placed, that patient will nearly always need a contralateral restoration as a direct result of the first restoration. “This could be due to flaw in the system. Perhaps the occlusion was too high or too light, or it shifted so the jaw has to move differently to close into that position.”
Pizzi’s point is that doctors sometimes need to consider the ultimate cost of the faster, cheaper option. “While it’s important to make things affordable for patients, we have to be educated enough to be able to substantiate what is right for the patient.”
That said, Pizzi is a great proponent of technology when used correctly by well-educated providers. “Computers only do what we tell them to do—so we have to have the basic knowledge of contour and form, function, and biomechanical capability of the patient before we can just grab a tooth from the library and mill it out in a material.”
“I think technology is fabulous and that every lab today must incorporate some type of technology—whether in basic form or advanced sintering and printing. The challenge is the education that comes with that process. In reality, you need more skills to transfer the information into the computer system than the other way around. However, I find that many of the technicians who are using this technology do not have the understanding to didactically work through a case,” says Pizzi.
Technology Changes to Come
Sometimes challenges with technology stem not from the user, but from the hardware or software itself. A significant barrier for dentists and laboratories wanting to embrace the digital workflow concept has been that the myriad technologies on the market can’t always “talk” to one another optimally. Even with “open” systems, unless labs and dentists have the same software program, data sharing can be imperfect.
Johnson says, “There is currently not the seamless free exchange of information and digital data due to the significant amount of proprietary software that hinders those communication lines. So, if the dentist owns Brand A digital impression scanner, he or she can’t just simply send that capture data in a usable format to any laboratory he or she chooses.”
However, a change is in the works. As reported in a recent issue of Inside Dental Technology, Mike Selberis, chief information officer at Glidewell Laboratories, and Andy Stark, general manager, Jenmar International, envisioned a software platform that would enable dentists to send digital impressions to whatever laboratory they choose using a standard language that wouldn’t require the use of complementary software. Universal dental exchange (UDX), the standard language created by their Open Exchange Dental Interoperability Group, was designed to convey data, “in a way that if one system exported a digital file, another could import it and would know what to do with all the meta data contained in the file,” Selberis explained. UDX was submitted to the ADA Standards Committee on Dental Products, which had been searching for a universal file format. The committee, which functions as the US representative for the International Organization for Standardization (ISO), then created a version largely based on UDX for consideration and possible adoption as an ISO-certified standard. The universal language is still under global review, Johnson notes. “It must go through a total of five international audit, review, and feedback meetings to get approved and put into a final format that everyone agrees on, at which point it becomes the ISO standard. Equipment manufacturers then may or may not choose to comply with the ISO standard in developing their technology.”
Another major development for the industry is that robotic processes once considered to be especially futuristic are now available in dentistry. According to a case presented on its website (www.universal-robots.com), Glidewell Laboratories is using robotics to increase production and save time. The company set the goal of a 10-minute milling cycle, which made operator-manned stations unfeasible. In the new process, the crowns are manually inserted in batches of 15 every 2 hours. The UR5 robot is programmed to take a milling blank from the dispensers, place it in the milling lathe, remove the milled crown, and place it on a conveyor after the 10-minute milling cycle is complete. According to the report, the robots cut production-cycle time from 27 to 18 hours, enabling employees to turn their attention to more complex tasks, which ultimately helps to improve the quality of the product.
Evolving Roles and Relationships
As the industry evolves, both Johnson and Hornbrook expect the friendly but rigid demarcation of roles between the dentist and laboratory to change. Hornbrook recognizes that bridging the divide requires better communication, as well as recognition on the part of doctors that they need to be open to a different relationship with their laboratory. “Traditionally dentists did not rely on their labs for information or advice, expecting them to follow their prescriptions,” he explains.
Restorations based on collaboration with laboratory technicians, including ceramists, enhance the longevity, esthetics, and function of restorative cases, LeSage says. Collaboration should involve all players—dentist, patient, and ceramist. He further suggests that doctors and technicians make a point of meeting regularly—every 3 to 6 months—“to discuss, explore, and integrate the various material options.”
This can lead to the development of a true partnership, which is happening already in many cases where dentists recognize technicians’ specific expertise and often superior ability to leverage technology. “In these cases, the laboratory is no longer acting as a mere vendor of products and services, but rather as a consultant, one that may offer dentists technical knowledge and insight and take on a significantly expanded role in the treatment and care of the patient,” says Johnson.
“I think the best technicians now and in the future are those who can didactically work through a diagnostic process with their dental partner, not just mill out a molar from a machine,” adds Pizzi. He sees a proliferation of highly trained and talented young technicians on the horizon.
Johnson sees two extremes evolving in clinician–laboratory relationships—for large and complex cases, close communications will exist between team members, whereas routine cases (eg, single crowns and three unit bridges) will be handled impersonally by larger labs that have transformed themselves into digital production centers.
As for the future of milled restorations, LeSage is emphatic: “CAD/CAM is here to stay.” He expects more restorative work to be done chairside and that many impression materials will “become extinct.” Johnson adds that she has concerns about new zirconia formulations that make it possible for dentists to mill the material chairside and deliver a full-contour zirconia crown in an hour, and the impact this may have on the laboratory industry in the future. This concern may seem premature in light of Hornbrook’s findings about the low adoption of digital impressions. He does not expect most dentists to clamor to purchase mills any time soon, given their steep prices.
Pizzi is encouraged by the simultaneous rise of technicians and dentists striving for growth and excellence, but he recognizes a laboratory industry phenomenon that mirrors the current American socioeconomic environment: “The upper and lower classes are growing and the middle is disappearing. They have to decide whether to work harder to become more educated and more viable in this environment—or give into temptation to sell things cheaper and faster.”
A Case Study in Lab Ownership
The story of Joshua Polansky, owner and operator of Niche Dental Studio in Cherry Hill, New Jersey, perfectly illustrates the pressures facing laboratory owners today. The son of a dentist, he found his calling in a dental lab. He pursued dental technician training at the highest levels in Europe and at UCLA School for Esthetic Dental Design and set up his own solo laboratory.
Although he initially struggled financially, he quickly developed a reputation for excellence and relationship building. Although many laboratory owners are experiencing contraction in business, Polansky’s “problem” is of a different nature. “I know most labs are going out of business and complaining about lack of work, but the fact is, we are full—very full.”
Under pressure from clients, Polansky felt compelled to invest in CAD/CAM. “There was demand from doctors wanting to work with us for their everyday insurance-based crown, but not at the fees charged for custom work. They said they didn’t need layered crowns for the back; they just needed a competitive price and a good restoration. So I restructured my fee schedule so we have two price points for two types of restorations.”
It was not an easy decision. “I was concerned first of all about my reputation, having begun as ‘a handmade guy,’ and the majority of my clients were using me only for those cases. But, ultimately, it’s a relationship business—less about my artistic skill and more about serving a need for the clients we had—and they wanted me to do their everyday work.”
Polansky did eventually invest in the technology, ultimately choosing Zirkonzahn because the developer of the machine and owner of the company is a technician whom he knows and respects.
“I went down to a competitive price point that was still a little more than other labs, but our product is not the same as the 60-person lab that charges $25 less. We just use CAD/CAM as a tool. We still touch it with our hands after the CAD does 80% of the work, which enables us to focus our energy on that 20%.”
CAD/CAM is “the best employee ever—it doesn’t complain, it does exactly what you tell it to do, and it works 24 hours a day,” Polanksy says. He chose his system carefully, spending $80,000. “It’s mostly about saving time, not getting ‘paid back’ for purchasing it. It’s a crazy situation that my three-person lab can compete with a 50-to-60-person lab.”
Ultimately, even with the technology, it’s still about personal relationships. “The advice I give everyone who will listen is this: It’s not just about teeth. It’s also about running a business, getting people to come. Ours is a tiny hidden little lab without even a sign out front, and we’re full because of the relationships we’ve formed with these doctors.”
