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Robert Elsenpeter is a freelance writer and frequent contributor to Dental Products Report and Dental Lab Products. 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.
3D printing is playing a bigger and bigger role in digital dental workflows, and lower costs and higher capabilities mean the technology will only grow in popularity.
A million and a half years ago, Grog the Caveman watched with envy as his neighbor, Atouk, learned how to harness fire. Of course, fire stopped being a novelty long ago and became a necessity.In 1886, Carl Benz patented the first automobile.1 Like Atouk’s fire, no one at the time needed one. Now, it’s hard to imagine life without it.And, 29 years ago, the smartphone started with little fanfare, but now most of us do, indeed, need one.2
Any technological advance seems to start as a novelty, something that people simply want. But, over time, that piece of technology can become a need. Dental lab advances are no different. Some labs rely on CAD/CAM. A popular technology augmenting those workflows is 3D printing. But, it begs the question, does every lab need a 3D printer?
The answer to that question, is that it depends on who you ask.
Jesse Flor, CDT, owner of Great Smiles Dental Services, Inc., is no stranger to 3D printing, and he’s still not ready to make the blanket statement that everyone needs a printer.
“Honestly, no,” Flor says. “And I say this having had at least 10 to 15 printers in the 10 years that I’ve been doing digital dentistry.”
Tom Zaleske, owner of Matrix Dental Laboratory and Consulting, has made custom removable prosthetics for more than 35 years. He stands by the quality he achieves in the analog workflow.
“There are a ton of things that a 3D printer can do, but you can still do in your laboratory without a 3D printer,” Zaleske says. “It really boils down to labor—how trained the technicians are in the laboratory; how entrenched the clinical side, your customers, are with the technology. It really comes down to, they say, ‘Well, we can duplicate such and such a thing with a printer.’ I can duplicate things using products here, and I can do them rather quickly, and I can do them very accurately.”
Andrew Kissin, Director of Marketing, Zahn Dental, observes that such choice depends on the lab’s business position.
“I think that’s a decision each lab needs to make on their own based on their business goals and plans,” he says. “Of course, in my opinion digital dentistry is right for every lab and is a tool to assist in optimizing a lab’s workflow. First things first though, start with a scanner and see where your digital journey goes from there. Do you have the right technicians on site to use a 3D printer, what applications would you print today and what might you print tomorrow? All good considerations.”
Jamie Stover, CDT,Senior Manager of Dental Lab Applications at Carbon, Inc., says that the times are changing and 3D printing is becoming more of a necessity.
“If you would’ve asked me this question a few years ago, I would’ve most likely said, ‘No’,” he observes. “Because, in those days, the applications available for labs to print were really limited and 3D-printing models in-house for cases received from intraoral scanners was how the majority of labs substantiated the investment in a 3D printer. But, since then, the global additive manufacturing landscape has dramatically changed and we have seen many industries making the shift to additive manufacturing. Material development has rapidly expanded the number of applications that can be fabricated with the 3D printers in the dental industry, and increased the number of labs for which a 3D printer now makes sense.”
Deciding whether or not a lab needs a printer is going to depend on a number of variables, including how entrenched they are in the digital workflow.
“Labs are about to have a very heavy digital presence,” Flor says. “Because, if you look at it, the numbers may be only 15 to 20 percent of the dental workforce has visual imagers. Those labs definitely have to have an investment. Almost 90 percent of my work is all-digital. No stone models, really, come in, and even if any do, we digitize those as quickly as possible. Where 3D printing comes in is I can present a 3D-printed denture. I can do a partial. I can do teeth.”
“It’s not an intuitive answer,” Stover adds. “You would think that the answer, right off the bat, would be, ‘Yes, in order to be successful with a 3D printer, a lab needs to have CAD/CAM workflows firmly established and have very experienced digital technicians.’ But, honestly, the answer to that question really depends on how we’re measuring success. In other words, if we’re measuring success by the speed at which a lab gets up and running with the 3D printed workflow, or how efficiently they transition their technicians from the bench to the printed production? Or, perhaps it is measured on how well they market and educate their clients on the printed products to drive prescriptions. The reality is when you’re moving these products and fabrication from an analog process to a printer, there is education and communication with your dental clients required for them to understand the benefits for their workflow and the benefits for the patient so they are incentivized and motivated to prescribe them.
“In my experience, a lab needs to do all three of these things very effectively to be successful with the 3D printer,” he continues. “And I measure 3D printing success by how much profitability a printer yields, both from reducing the amount of hands-on labor required to fabricate the restorations and how much a lab can grow their business by increasing the number of restorations they fabricate, as well as the efficiency it provides our dental clients and the benefits of the printed restorations for patients. Every lab has to start somewhere with a transition into the digital workflow, and years ago milling was where they had to start. Today, because of the number of available 3D printed applications on the market even smaller labs without years of digital experience can incorporate printing right out of the gate and experience success.”
Another consideration is whether or not their client doctors are willing to be part of that workflow.
“I see big contenders, like Asiga, the little cheap ANYCUBIC Photons,” Flor says. “I see a lot of doctors buying those for their own offices, just because it’s affordable and also allows them to work through the challenges of dialing in the settings. But once they do, they have a 3D printer in their office that doesn’t break the bank. And then I see big, huge corporations, or even bigger labs, they’re getting like Carbon. So, I think in mass-produced dentures, it’s almost like niche operations going with 3D printers. It’s a neat tool to use, and you see big corporations going for the full-scale product for the ability and volume production models. But, in other ways, not everyone is in that mentality.”
One of the knocks against digital dentistry is that while 3D lab output is faster, more reliable, and more reproducible, an element of personalization is lost. 3D printing doesn’t really do anything to change that.
“This isn’t a widget – it’s not like a coat hanger where everything’s the same,” Zaleske observes. “Every patient has their own nuances and challenges. And that’s what makes it such a great profession, because we’re doing one-off dentistry. If you don’t understand dentistry, if you don’t understand how anatomy, function, phonetics all coordinate toward a successful conclusion, then there is a whole lot to not get right.”
It’s not just technicians, he observes, that have less knowledge about how to achieve successful removable treatment, but is a sign of the times.
“You’ve got dentists coming out of school with less removable technical education, less emphasis on hand skills like impressions and bite registrations,” Zaleske says. “Then, the battle cry that I always hear out there is, ‘Well, that’s what the patient wanted.’ You know, that’s kind of like an excuse now.”
Even though he hasn’t, personally, seen much demand for digital dentistry, Zaleske
anticipates that to change—both because of trends in labs and clinics.
“Unless there’s a huge surge in formally trained dental technicians and better trained dentists, I don’t see that train stopping,” Zaleske says. “I really don’t. I just see more and more people adopting it, only because—and remember this is not a slam to dental technology—but by-and-large, dental technicians are reactive, not proactive. So, if a doctor asks for something, they get it. Even if they do or do not agree with it, they get it because somebody is asking them to do it.”
Like any technological advancement, with 3D printers, the entry point tends to be initially very expensive. But, as time goes on, costs come down and become more accessible to the masses.
“If you look at it from a 1,000-foot view, you can see that, as with most technology in our lives, the cost is coming down,” Stover says. “We know that many years ago a Lava mill for Zirconia crowns cost around $300,000, and now, for around $20,000, you can purchase a mill that is far superior as a result of technology improving. Affordability and price are really a conversation about your ROI and about the perception of what ownership actually means. The majority of dental labs purchase more expensive hardware with capital equipment loans—they don’t pay cash, and that means that they are making monthly payments on this equipment for 3 to 5 years. Making payments on these machines is not ownership, the lender owns the machines until the loan is paid off. The reality is that the majority of this hardware is depreciating on day one and on a road to obsolescence in 2 to 3 years, either by the parts wearing out or it not being compatible with the new materials that are developed. By the time a lab pays off the loan, they need a new printer, and the cycle just continues. Also, labs need to factor in the amount of hidden costs associated with most 3D printers, such as the unplanned downtime when they break down and the disruption it causes in workflow, the technician time to calibrate, tinker and repair the printers when they go down, the annual service fees and often, high resin prices.”
Stover says that Carbon ameliorates this with its subscription model.
“Our subscription model replaces the monthly loan payments with a model of comprehensive support, including proactive monitoring of all the printer’s components to virtually eliminate unplanned downtime. Our printers are smart hardware, and the performance continuously improves over time with automatic software updates,” he says. “So, a Carbon printer installed today will actually perform better a year later. You eliminate that race to get your ROI before the printer’s performance depreciates and the technology becomes obsolete.”
Labs, and clinicians, can find even more affordable options to dip their toes into the 3D printing waters.
“It’s definitely going well,” Flor says. “My first Stratasys was $160,000. This year I bought a ANYCUBIC Photon for around $350. You can get a really good chairside printer, like a SprintRay. They’re a little finicky. They still need some dialing in, but they’re getting better, but that’s about $6,000. You could also send this on like a FormLabs 3B, which is specifically for dental. And those are maybe $3,500. Those things are reliable workhorses. They just really very rarely go down. So anyone can really use them. You see all these different price lines. It just depends on what you want. If you want speed, you’re definitely going to have to buy one of the more Lamborghini-type printers. If you just want reliability or versatility, you can go with these affordable, slower printers and it still works pretty good.”
“Today, labs can get into 3D printing for a few thousand dollars, assuming they already have a scanner,” Kissin adds. “Of course each lab should do their due diligence on the printer specs and ultimately what they are going to use it for. Just because you buy a 3D printer doesn’t mean you’re going to be able to churn out 50 models a print or you’re printing with the most accuracy. Every lab should look at what their main indications will be to start and select what’s right for their budget and workflow.”
But it isn’t just the cost of the printer that labs must consider. The printer needs other components or work.
“There’s a substantial investment,” Zaleske says. “They’ll say, ‘It’s not that much,’ but it is. You have a substantial investment in a printer, but you also have to have a scanner to go along with the printer. You can’t just buy a printer and say, ‘I’m printing’. There’s ancillary education that goes along with that. You have to learn how to use it. You have to be able to implement it. There are a lot of different things that go into that mix besides just buying the equipment. And then you have to look at your clientele base.”
He hasn’t seen a lot of demand from his client doctors, but it is out there.
“I had one person who asked to do that. It wasn’t a deal killer with my business,” Zaleske says. “They were more curious about it and wanted to get involved in it. It’s this funny thing. Before you pick up the shiny objects, you ought to investigate the ones with fingerprints over them. Everybody wants to jump forward with this stuff super quick, and it seems like an, ‘If you’ve got a hammer, everything looks like a nail,’ kind of thing. Well, if you got a printer, everything looks like it’s going to print. Everything looks like we should be doing it with that, and that’s not necessarily always true.”
Room For Improvement
In order for 3D printing to be a critical component in the dental lab, some prerequisites must first be met.
“A lab that already has adopted a scanner is obviously in the right place to add to their workflow,” Kissin says. “Over the past few years, we’ve seen major advancements in the software and technology so it isn’t just for crown and bridge labs anymore. We are seeing more and more removable labs start to add to their digital ecosystem as opportunities for both additive and subtractive workflows evolve they are able to replace very manual and labor-intensive processes with digital.”
The materials used for 3-D printing continue to evolve and are, somewhat, the technology’s Holy Grail. The field is improving, but not there, quite yet.
“On the materials side, we’ve come a long way very quickly,” Stover says. “When looking at the number of applications a lab can now produce on a printer, they have dramatically increased. Lucitone Digital Print dentures and KeySplint Soft Clear night guards are examples of game-changing products that have become available just in the last couple of years. There will, no doubt, be other really impactful applications that are going to become available to print as the focus on material development continues for the dental industry.”
Cost isn’t the only barrier to entry—3D printers must also be easy to use.
“Those cheap little printers are cheap, because it’s just the basic technology has been put in,” Flor says. “You have to really know how to dial it in and work in a collaborative group to get the settings right. The company doesn’t do that for you. Products like Asiga, they make it a big deal where they kind of validate workflows for you. If you print out dentures, they really kind of do the backing into it. And then they provide you with that information. It makes it easier to integrate. But honestly, the biggest limitation, is printed materials. BEGO has their resin print material that allows doctors to print out a supposedly permanent crown for about $2 in resin materials. But the problem is, we still don’t know long-term durability and versatility. Can it really handle the chewing cycles of what people put it through? What we’re all looking for with toughness and materials and resistance to impact that we use, which is like 90 percent of what we have to do in any type of dental products.”
Out With the Old?
3D-printing is an output device for a CAD/CAM solution, one currently widely filled by milling. But, is 3D-printing poised to replace milling, or is there a place for both?
“I think at some point yes, 3D printing will reign supreme,” Kissin says. “By default when you manufacture with additive technologies you aren’t wasting materials. While dental techs have already become masters at nesting entire discs, there is always some residue. With 3D printing this should eliminate any leftover. I believe there will be a place for both in most every dental lab, however. Ultimately it’s going to depend on what each business decides is right for their workflow and products they offer their accounts. Not to mention, I don’t think anyone is printing zirconia but I’m sure that’s on the horizon.”
“They still have their place, but yes, within 5 years there definitely will be a supplantation of printing,” Flor adds. “The problem is when we first started with zirconia crowns, they were not very esthetic. They were very ungainly to look at. It’s going to be the same type of induction curve that’s going to come in, and you’re going to have early adopters really testing it out, seeing if the proof’s in them and then providing that feedback. And then resins and materials would catch up in translucency, durability, and affordability, in terms of systems. And then more and more adoption will kind of speed that along. But there will always be cases, just like today. There are some cases you cannot do in pure zirconia—you might have to do a PFM base and layer porcelain, just because the patient can’t handle that setup.”
“I think in the future there will be a 3D printer in every lab,” Stover adds. “And, eventually, the possibility exists that 3D printing will replace milling, but I think, for quite a while, they’re going to coexist. Milling and 3D printing are both very viable production methods for labs, and it really comes down to the material development for printing and the applications they make available, because there really isn’t an argument about which production method is more or less efficient. When we’re talking about milling, it’s reductive technology and it’s inherently wasteful, because you’re starting with a large mass of material, cutting out just the pieces that you need, and the rest is thrown away or perhaps a portion of it recycled. This being said, milling is, currently, the most efficient production method for restorations such as zirconia crowns and bridges. It’s also a very efficient way to fabricate products from alloy, such as milled implant custom abutments, implant bars, and even full gold crowns and frameworks for PFM bridges. But, for other types of restorations, especially what we’re seeing with the digital evolution of the removable segment of the industry for dentures and night guards, it’s much more efficient to print than to mill them, or to fabricate them by hand at the bench with traditional methods. I believe that milling and 3D printing are going to continue to coexist in the labs for some time to come, with mills handling the majority of the fixed digital workflow and printers producing the digital removable prostheses. We don’t yet have a printable material for final restorations. When that day arrives I think printing will become the way the majority of restorations are fabricated. I say, ‘Hold on tight, the evolution of our industry is going to happen faster than it has up to this point!’”
If 3D printing does become a necessity for dental labs, it certainly won’t take another million and a half years, a century, or even 3 decades. 3D printing is accessible right now, and it’s not too hard—or expensive—to get started.
“The biggest thing for anyone is that it’s better to get in and at least get your feet wet,” Flor says. “And, thankfully, there are a lot more affordable options that can teach you what 3D printing can and can’t do for your process. And, honestly, it’s better to at least know what’s coming down the road than to try to ignore what doesn’t exist.”