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Robert Elsenpeter is a freelance writer and frequent contributor to Dental Products Report and Digital Esthetics. He is also the author of 18 technology books, including the award-winning Green IT: Reduce Your Information System's Environmental Impact While Adding to the Bottom Line. As such, he’s particularly interested in the technological side of dentistry.
In this cover story for Dental Lab Products, six leading lab voices explain 7 ways you can take your dental laboratory business to the next level.
There are a lot of variables involved in building your laboratory into a successful business. Not only do you need staff that knows how to produce quality restorations, you also need to know how to market the business; how to keep up with changes in the craft; and know which equipment is the most utilitarian. We talked to six lab owners who shared their picks on equipment and practices that can help your lab balance the variables you need for success.
Using CAD/CAM for all its worth
Computer Aided Design/Computer Aided Manufacturing (CAD/CAM) technology is one that every lab should consider adopting, if they haven’t already. While start-up costs can be expensive for smaller labs, the return in investment is worth it.
“In this day and age, the labs that have not gotten invested into a scanner and design station are really shooting themselves in the foot,” observes Mark Ferguson, Assistant Manager at Core3dcentres in Las Vegas.
In spite of the initial cost, CAD/CAM can be an especially useful addition for small labs.
“Smaller labs need it to be a little more competitive with the mid- to large-size labs,” says Shane Palm of Palm Dental Solutions in Colorado Springs, Colo. “They may not be able to compete with price all the time, but they can offer their clients the same products and services. One employee can run the CAD/CAM. Once they get fully trained and used to it, they can do the work of two to three lab technicians.”
Palm recommends 3Shape and CEREC systems for labs new to CAD/CAM.
CAD/CAM newcomers might be overwhelmed by the sheer amount of systems available, not to mention understanding their use. Bob Cohen, President and Co-Founder of Custom Automated Prosthetics in Stoneham, Mass., offers some tips on getting started.
“From a digital perspective, it all starts with an open architecture scanner, and a best-in-class CAD software,” Cohen says. “There are numerous CAD systems, and there are numerous different choices in this marketplace today. Recently, we started looking at different open-architecture scanners and found that there are about 30 in the marketplace, which is an enormous selection. Primarily, it looks to me today as though there are two primary open CAD design systems: 3Shape and exocad. I think both of those work quite well.”
CAD/CAM is lauded for a number of benefits, including accuracy, quality, speed and consistency.
“They actually aid significantly in the efficiency of our dental laboratory,” Cohen notes. “For some time we had people designing restorations, and it would take a long time with hand-waxing. Now, automating things takes just a few minutes.”
Next page: The advantages of a CAD Verification Bridge ...
CAD/CAM can be a benefit to any size lab. The only difference between the operation of small labs and large labs is the sheer amount or work going through the machines.
“There’s really no difference for the smaller labs, other than the fact that they may not get the same utilization from a piece of equipment,” Cohen says. “What’s important for the small lab is that, prior to purchase, they evaluate the purchase for return on investment, so they make sure that, economically, it’s a viable investment for them. For larger laboratories, most of these machines work quite well from an ROI perspective. If you’re small, make sure that you have enough work so that it is viable in your environment.”
Labs adding CAD/CAM should also be aware that they would have to change some of their work practices.
“From a workflow perspective, it does change the workflow in your laboratory considerably,” Cohen says. “So whatever size lab you have, you have to be open to the concept of reorganizing the workflow and your whole manufacturing process. In the end, you will be more successful and more profitable.”
Another benefit of CAD/CAM is that it also expands product offerings, leading to more opportunities for profit.
“CAD/CAM has the unique ability to not only increase your bottom line, but due to the vast amount of products that you can manufacture with CAD/CAM, you can increase your top line as well, so there are more products you can now sell that we can’t manufacture on an analog basis,” Cohen adds.
Take advantage of CVB
CAD/CAM also affords the lab an opportunity to easily check work before the final product is manufactured.
“CAD/CAM allows a CVB-a CAD Verification Bridge,” Cohen explains. “On all of our comprehensive cases, or our full-arch cases, what we do is go through our entire design process, and rather than milling in our final restorative material, we mill it in PMMA, which is acrylic, and in doing so, what we do is give the dentist and the patient the opportunity to try our design. We can get all the critical feedback from the dentist and the patient and make sure everything is correct.”
CVBs allow the lab to test numerous variables critical to the restoration’s success.
“We can determine hygiene, esthetics, occlusion-all the functional parameters of a case before we do the final case,” Cohen says. “Very often, dentists and laboratories struggle with final restorations, going back and forth because they’re really developing a treatment plan for the final restoration through the manufacturing process of the final restoration. With the advent of the CAD Verification Bridge, we now have the ability to send out a plastic try-in bridge first, go through the intraoral processes of trying it and evaluating it, prior to fabrication of the final restoration. That’s something that can be done very simply. Once that’s tried-in and confirmed that it’s correct or needs minor changes, the minor changes are noted, we bring the file back up on our computer, make the small changes requested by the dentist, and go ahead and mill it in the final material.”
Next page: How to leverage imaging ...
Scanners are a very important component of a CAD/CAM system for Keating Dental Arts President and CEO Shaun Keating. They have allowed him to keep staffing levels low, while also offering consistent accuracy and quality.
“With CAD/CAM scanners, we went from having 45 waxer/finishers to about 10, because we can scan all our PFMs if we want to, and send them off to the wax printer,” Keating says. “The scanners have just been a godsend, because they’re so darn accurate. Designing crowns with right emergence profiles, the contact circles being perfect on the computer. With a technician, it took years to get that dialed-in. I remember it was always the toughest thing in the world to find full-crown waxers. I’ve got a lot of waxer/metal finishers that would just do copings and substructures for frames. And now, with these scanners, you can have a 30-year-veteran with the expertise of contours and morphology on a scanner, and then I can use that in a bunch of different departments from designing implant abutments and bars, which is one of our fastest growing areas.”
Scanners offer a level of accuracy and consistency that can be hard to come by when done by hand.
“Sometimes you get the feeling that today is Monday, and working with silly humans, sometimes you don’t get the ‘A’ performance every time, and that’s important,” Keating says. “It’s like a football team: You’ve got to keep your players motivated and on top of their game, and some days you don’t. With the machines, they don’t ever call in sick; they don’t ever complain about this case being tougher than the other ones; and they’re pretty darn consistent and pretty darn accurate. The consistency, the accuracy and the quality is second to none. They’re not going to diverge from the proper emergence profile or the proper curve of spee or the arch or the buccal contour or the buccal corridors to make sure you’ve got full, proper contours on the facial aspects. You just dial it in to the scanners and design it perfectly.”
Next page: Manage what the output of your scanner is ...
In addition to scanners, there are other products useful to input that can benefit a laboratory. John Orfandis, Owner of Orfan Dental Laboratory in Boston, recommends MC Dental Articulators model systems. Designed with digital in mind, it helps keep scans clean of obstruction.
“There is a model system that I like a lot, and it’s great for digital,” Orfandis says. “And the reason that it’s great for digital is that the articulator slides off the model, so there are no articulator areas inside the scanner. They don’t get blocked by the scanner’s view. It’s very efficient. It gets out of the way of the scanner. Obviously, we’re doing a lot of digital stuff, so when you get in to that level where all your work is going through digital, you want to make sure nothing is hindering that process.”
Manage your output
Once a case has been scanned into and designed on the computer, it is sent to an output device-like a mill or a 3D printer-to achieve its physical incarnation. Mills are the primary means of producing a restoration.
“The most commonly used product in dental laboratories today is the milling machine,” Cohen says. “The milling machine has undergone dramatic improvements to dental laboratories over the last several years. We now have mills being manufactured that are product specific. In other words, mill manufacturers will look at something like a lithium disilicate block, and saying, ‘What exactly do I need to mill a lithium disilicate block?’ and then getting exactly what’s needed-no more, no less. It’s the same thing for milling zirconia or milling metals and custom abutments.”
Alongside the mill are 3D printers, which make it possible to create something out of nothing. Advancements in 3D printing technology put them well within reach of even small dental laboratories. They are not only affordable, but provide the quality that labs need.
“For a long time, 3D printers have really only been a viable product for the larger laboratories, as the cost of 3D printing has been very, very expensive,” Cohen observes. “More recently, 3D printing systems have launched-for instance the ProJet 1200, which is a very affordable, sub-$10,000 printer-that print wax patterns for both pressing and casting. These printers will produce about 10 units every hour, so it’s a very efficient, accurate system. The parts retain their shape long-term, so it’s not something where we’re working with a material that has difficulties, because it changes shape after printing. In addition, the whole process is super cost-effective. It really streamlines operations in the casting and pressing area. That’s another product that will see growth in the near future.”
Next page: How to choose the software that's right for your lab ...
Choosing the right software
Like any other industry, computers are crucial to dental labs, and they aren’t just used for the production of cases. The software used on front and back office computers should get attention, too.
“You need a solid lab management program,” Palm says. “Evident has one of the better ones out there.”
Palm says that Evident’s cloud-based lab management applications are useful for any sized lab-and can even be customized for labs of different sizes with different needs.
“Earlier this year they launched their lite solution, which is a scaled down version that’d probably be for smaller, four- to six-person labs,” Palm says. “It’s very user friendly. They have different sizes and modules, things that you can add on, rather than spend a lot of money on a full-blown product that you’ll probably never use all of the functions on. Also, it’s cloud-based, so you have access to your information all the time.”
Being cloud-based, the application is available to different users, no matter their location or role.
“They have a great way of tracking cases, and assigning work to individual technicians,” notes Palm. “A manager, even if he or she is on vacation, can pull it up. They have an online portal, so dentists can check on their cases to see where they’re at. So the lab’s front office people aren’t always being bombarded with ‘Where is this case at?’ ”
For CAD/CAM systems, the obvious place where software is involved is in the design phase. However, once the restoration is moved to the manufacturing stage, software is also involved, and is easily overlooked.
“CAM software is becoming really important to have in a lab to help labs have their signature on their work, instead of outsourcing everything,” Ferguson says. “CAM software is the least appreciated, but most important part when people bring the whole system into their lab. 3Shape is still the leader in terms of having the complete package, but I think exocad is also fantastic software. Those are the two that are leading the way for everybody else to try and catch up to.”
Next page: How to get into the implants market the right way ...
Pursuing dental implants
Implants present exciting opportunities to dental labs, as well as technical and artistic challenges. But advances continue to occur that make implants more functional, esthetic, and easy to create.
One such development was created by CAP with its Izir Bridge.
“The Izir [uses] full-contour Zirconia, and it is screw-retained,” Cohen notes. “Most of these cases are full-arch cases. We see it as a replacement to conventional, hybrid restorations.”
The Izir Bridge builds on the conventional method of denture creation with sturdier, more robust materials and methods.
“A hybrid restoration, generally, has a cast metal frame, or a milled metal frame, where you go ahead and process denture teeth to it with denture acrylics,” Cohen says. “Denture acrylics and denture teeth work fine as dentures, but problems and breakage occurs when we create a screw-retained denture. It’s more than it should be. The numbers of failures and breakage in these cases are really not acceptable; especially when you look at how much money a patient spends. So we now have replaced all these acrylics and these acrylic materials that have a flexural strength of about 100 megapascals with zirconia. The zirconia has a flexural strength of about 1,100 megapascals, so we’ve now far exceeded the biting loads of patients.”
The quality is improved over prior restorations, and the production method is simplified by using CAD/CAM equipment.
“It’s also really nice in that it’s not only stronger, but it’s 95 percent automatable, so the amount of labor that we put into an Izir Bridge is dramatically reduced from the competitive type products that have been around in the past,” Cohen says. “In addition to that, because it’s made from a digital process, in the event of a problem, in the event of a remake, because we own the digital file to the case, a remake is really quite simple. We just pull up the old file, remill it, resinter it, and send it off to be replaced. It’s good all the way around: It’s good for the patient and it’s good for us.”
Custom abutments have also revolutionized the implant process.
“Today, I think buying gold cylinders from implant manufacturers and adding wax to them, casting, having two different metals in them, and milling them out, has been replaced with CAD/CAM custom abutments,” Cohen notes. “We can scan a model in about five minutes or less. We can design a custom abutment in less than five minutes. We put a pre-machined blank in the mill. The mill time is probably 20 minutes. There’s a little bit of post-processing, and our custom abutments are done.”
The ability to create single implants is a good product for labs to offer, not only because of the demand, but because of the opportunity to turn a profit.
“Screw-retained, single tooth replacements are becoming more popular,” Cohen observes. “Recent studies have indicated that the number one failure in implant dentistry is due to cement left behind when we cement a crown on top of an abutment. By transitioning back to screw-retained restorations, this eliminates the intraoral cementing, which eliminates the number one cause of implant failure. When we do a CAD/CAM single-tooth, screw-retained zirconia crown, it’s done very efficiently, very cost effectively. It can also be an enormous profit center for a dental laboratory. So those three products, when automated, are wonderful additions to product lines.”
Next page: Choosing the right implant system for the job ...
At Core3Dcentres, Ferguson says that their solution provides the tools necessary to deliver implants that matches the original tooth as closely as possible.
“The Core3D digital implant solution is the most complete solution available right now,” Ferguson says. “We have scan bodies the doctors can take intraoral scans with, and then we can produce a model from that intraoral scan with a lab analog in the model, so the lab has the best representation of what’s in the mouth that they’re actually working on, and then they’re working on the actual custom abutment.”
Ferguson notes the ability to make such implants is an opportunity for growth, because not many dental labs offer them.
“There aren’t many people who have that,” Ferguson says. “I think there are more people who are starting to incorporate a workflow like that, but that complete intraoral scan solution is coming up, and we’ve had it at Core3D for four years.”
As with many other parts of dental lab work, many of the advances in implant work are being realized thanks to CAD/CAM. For labs that can’t mill implants themselves, they can be outsourced to a milling center, like DENTSPLY Implants’ ATLANTIS.
“It ties in with CAD/CAM,” Palm says, “whether you mill the implants in-house or scan them and send them off to ATLANTIS. To me, it’s just a lot better to scan all the custom abutments, send them out to ATLANTIS and have them mill it-or any milling center.”
Smaller labs might have difficulty getting started manufacturing implants. In his case, Keating says outsourcing the work to ATLANTIS was a smart move and helped his business grow.
“It was tough to do custom abutments when we were growing, and hard to get the technicians with the experience, until we hooked up with ATLANTIS,” Keating says. “ATLANTIS is second to none when it comes to succeeding in my implant department. We use a lot of Straumann stuff, but ATLANTIS is one of our biggest-we’re probably one of ATLANTIS’s biggest customers. When we started, we were just small-we did five or 10 a week, and now we’re doing hundreds, and it’s just amazing what they can do.”
Next page: A surprisingly powerful tool you probably already own ...
Make use of an unconventional tool
Some pieces of equipment useful for a dental lab aren’t even conventionally identified with lab work. Tom Zaleske, owner of Matrix Dental Laboratory and Consulting in Crown Point, Ind. uses digital photography to help ensure the quality and craftsmanship of his cases.
“When I first started using digital photography, it was over 10 years ago,” Zaleske remembers. “I used to literally send the doctors a camera, because most doctors didn’t have a camera. Of course, now things have changed, and now everybody has a phone with a camera.”
Zaleske uses what are known as “speaking distance” photos to get the results he needs.
“In removable prosthetics, we don’t need to put a shade tab next to a tooth or go inside the mouth, intraorally,” Zaleske says. “What we need to see is what it looks like from a speaking distance, because we build our prosthetics based on a certain distance from a person talking.”
But using a digital camera goes beyond pointing it at the patient’s mouth and taking a snapshot. Zaleske points out that dentists need to take the right pictures so that they are useful for the lab.
“When I started, the problem was they were taking every photo that I didn’t need, and very few photos that I did need,” Zaleske recalls.
The digital camera can be used for other applications within the lab beyond production duties.
“Right now, it’s very popular to track our manufacturing practices,” Zaleske says. “But I have been using photography in my laboratory well before any of this digital photography came on to track when an impression came in, or when it didn’t look right. I was able to take a picture, and I was able to communicate back to my doctor, ‘Here’s a situation I have, and I need you to remedy it.’ ”
Digital photography allows for more effective, efficient communication between labs and doctors to help produce the desired restorations. It’s a practice from which other labs would benefit.
“In the past, before I introduced photography, it was a matter of me convincing him that something was wrong,” Zaleske says. “I have good communication skills, but for someone who doesn’t have good communication skills, it becomes an argument, almost. Because, you say, ‘I see something’ and they say, ‘No, I didn’t send it like that,’ and you go back and forth. But if you have a picture, you are able to use that as a tracking mechanism.”
Whether yours is a small or large laboratory, the products available to you for success continue to grow and evolve. Labs still need to evaluate what their workflows and needs are, but there are no lack of tools that can help ensure success.