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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.
Can dental labs achieve a true a balance between the 2?
On August 7, 1974, acrobat Philippe Petit stared death square in the eye while crossing a high-wire strung 1,312-feet in the air between the World Trade Center towers in lower Manhattan. The feat required teamwork (the night before, two crews covertly placed the wire);tools (including a 30-foot balancing pole and a crossbow to fire an arrow with the wire attached); and skill (from a young age, Petit honed his acrobatic skills as a street performer in France). Ultimately, he strode back-and-forth between the Twin Towers eight times in just 45 minutes.
Such a feat, obviously, requires exceptional balance. And, while dental labs aren’t performing anything quite so audaciously spectacular, they do need to find a certain element of balance between speed and quality, not only for the sake of making their clients happy, but also to remain successful.
Striking a Balance
Where the fulcrum of the balance between speed and quality lies really depends on the lab and its technicians.
“Some people, naturally, are better at that than others,” Patrick Bever of Workhorse Dental Technologies observes. “Some are able to look at both better than those who might focus on one more than the other. When I was in training, years ago, I had an instructor tell us that while you’re gaining experience and working in different labs, it’d be best if you worked at both kinds of labs—a big lab that does high volume and a small lab that does less volume. His reasoning was that when you worked for a big lab, you’ll actually learn how to do things really quickly and efficiently. I think that, maybe, what he was saying is that there’s sort of always two sides to that. One side is that you need to be able to do things quickly and efficiently in order to be profitable, but you also need to have high quality, because your reputation depends on it. That always has to be there to try to do things, learn anytime something goes wrong, and to learn from your mistakes and always do better.”
Achieving that balance can be an ongoing quest. Tom Zaleske, owner of Matrix Dental Laboratory and Consulting, has learned important lessons during his decades-long career.
“For 34 years I’ve been fighting that battle,” he says. “I realized, early on, that quality dictates time, and time does not dictate quality. In other words, if I shorten my time, the quality goes away. If I get enough time, and I know how to use that time correctly, I can add more time in order to maintain a certain level of quality. There’s a give-and-take, and your attention to detail erodes as you shorten the amount of time that you give yourself to do something.”
Laboratories, he says, are waging war on two fronts—business and time.
“In laboratories, of course, we’re always fighting the timeline that the doctors establish with the patient, but as a manufacturer, I understand that we have to be able to accommodate schedules,” he continues. “Dental laboratories pretty much cut their nose off to spite their face. They want to compete, so they think that, ‘Well, if I shorten the time to a certain level, this will garner new accounts, keep accounts, maintain accounts’, but we’re in a production setting.”
CAD/CAM promises to help labs with both speed and efficiency. That is, allowing the technology to take over the heavy lifting streamlines workflows while providing predictable, repeatable quality.
“3D printing, in theory, is a pretty simple technology to understand,” Sam Wainwright, Dental Product Manager at Formlabs, says. “It’s really a symphony between software, photopolymers, and the hardware. And there are certain ways to get both speed and quality, but it typically means more expensive solutions or paying more or getting into systems that might not make sense otherwise.”
But CAD/CAM shouldn’t be expected to do everything.
“Advances in technology, specifically in the digital realm, have improved efficiency, as well as predictability of fit, form, and function,” Jeff Smith,Director of Technical and Digital Service at Ivoclar Vivadent, adds. “It should be noted, however, that simply integrating a scanner along with a mill or 3D printer, does not guarantee improvements in either speed or quality. As has always been the case in dental technology, the quality of the input in terms of preparation, impression, bite registration, etc., is key in realizing predictable outcomes. Additionally, there is no digital system available, regardless of the quality of the input, that in and of itself produces a high-quality finished restoration. The goal is rather to create a more efficient method of achieving a good foundation for the dental technician to employ his or her skills and knowledge in completing the restoration. Ultimately the skill of the operator still determines the quality of the restoration.”
Cases will only be as good as their critical components. That is, unless all steps in the process are properly performed, the end result will be less than desirable.
“The single biggest obstacle lies in the quality of the input,” Smith says. “Simply integrating a newer technology does not make a poor prep, impression, or bite registration magically good. As an example, if a bridge preparation does not have a common path of insertion amongst the abutment teeth, there will be seating/fit issues, regardless of whether the bridge is produced traditionally or digitally.”
There’s an old saying, “The cheap comes out expensive,” meaning, when one tries to cut corners, it can deliver poor results. Such is true with CAD/CAM.
“Sometimes, in an effort try to save money, someone might choose a product that they’re going to invest in, whether it be a piece of equipment, or maybe they’re going to digitize a part of the process and buy some software, or something like that,” Bever says. “So maybe they just look at price alone and say, ‘Well, this one’s cheaper than that one. Why would I buy that one?’ And if you’re only looking at it that way, and are not looking at the big picture, I think there’s a lot of other things that have sort of come back to bite me when I tried to save a buck.
“It’s not so much that spending more money on a product or a service is the answer,” he continues. “It’s to have more of a comprehensive look at your pros and cons lists when you’re trying to choose something. A lot of times, it’s the old adage where you get what you pay for.”
Wainwright observes that the best results from CAD/CAM are achieved when hardware, software, and materials work in symphony.
“If the hardware isn’t moving the correct way, or if it’s not built to the specs required for the material, then you get some wonky stuff going on,” Wainwright says. “Or if you have software that is built to work with a specific material or a photopolymer, and it’s not to the correct manufacturing spec, that can have bad prints, low accuracy, or failures. We really pride ourselves in the validation that we do. We run all of our print settings before they’re seen by the public through 20-plus Form 3Bs and Form 2s, so we make sure that the majority of our resins are still able to use the previous generation printer.”
Achieving that equilibrium can be elusive for the laboratory, largely because of avoidable missteps.
“Most laboratories, in their early steps in a digital journey, make the mistake of expecting their newly acquired technology to compensate for inadequacies in either the incoming quality or their skillset within the lab,” Smith says. “At the end of the day, these technologies are simply a tool to facilitate the fabrication sequence. The ultimate quality requires a human element to evaluate the output from a mill or printer, make quality decisions on next steps, and ultimately finish a restoration using traditional ceramic, alloy or resin processes.”
It shouldn’t come as a surprise that time management can be a hurdle.
“What happens is, ultimately, labs have timeframes built in,” Zaleske says. “Most people have a pretty good idea of what it takes to get something done, but then something will arise. For example, I’m in removable prosthetics, so all of a sudden, in comes a reline out of the clear blue. Many labs will take that and then try to hit the date that they had to have it by. And, generally speaking, a reline is a real schedule killer. It’s a real production killer, because you have to move your time over to get that done. I started to realize there were some things that I was going to have to implement in order to keep me from killing my quality, because I’m trying to do everything, and one of them was that I insist on a preschedule. In other words, if the patient’s in the chair, it’s nothing more than either the front desk or the doctor, themselves, calling me to quickly to say, ‘Hey, I would like to schedule a reline for tomorrow or the next day,’ just to let me know so that I can get it into my schedule.”
It may be tempting to want to be a hero for client doctors and deliver cases ahead of schedule, but Zaleske warns that actually sends a bad message.
“Never get a case done early and send it earlier than you promised,” he advises. “The reason being is, and it’s just human nature, that if you send the case in earlier than you said you needed to have it done, it starts to set a precedent, and pretty soon they’re thinking to themselves that you can get everything done quicker. Everybody wants to be able to help their customers out and, let’s face it, human nature is such that a person waits for a wedding or a graduation or whatever. And then, all of a sudden, they want to get all of the work done in a certain amount of time—quick, quick, quick.”
Helping Achieve Balance
How can labs better achieve that balance? Wainwright says that embracing CAD/CAM technologies can also help level the scales.
“Labs are on the cutting edge of these technologies,” Wainwright observes. “And with the advent of desktop, 3D scanners, CAD software, dental being majorly adopted over the past 10 years, and desktop milling machines becoming affordable enough so many can get into those technologies; a lot of those workflow changes are quite different, opposed to analog, of course. Those same lessons learned in that ramp up, and adoption of those technologies, can be applied to 3D printing, because it’s not just a step, but it’s actually a complete workflow. Underestimating the complexity of 3D printing and that workflow, and really understanding how much space you need and what that employee does, is really critical to making a successful and cost-effective production center for dental laboratories.”
But the quality and efficiency afforded by CAD/CAM technology isn’t just the purview of the lab. Ideally, clinicians will have the best components, as well.
“Intraoral scanners can mitigate some of the biggest problem areas on the front end of the process,” Smith says. “First, they eliminate common accuracy issues arising from traditional impressions and model production, including impression tears, pulls, voids, etc., as well as stone bubbles, inaccurate water/powder measuring, and a myriad of other pain points. Also, digital transfer of information opens the possibility of better communication between clinician and laboratory relative to the quality of the data including prep, occlusal clearance, path of draw, etc.”
CAD/CAM is built of different components and as any one is optimized, the overall workflow improves.
“The one thing, overall, is that the processes continue to get better,” Bever observes. “Specifically, the software versions always seem to be a little more user-friendly and have more freedom to be able to do more variations on a single thing. And so, there’s ongoing improvement that that’s always happening. The materials, especially, have just gotten so much better over the years, and in a very short time. I kind of feel like that curve is going to continue, where these materials that we have to choose from, there’s going to be more choices to fit all of these different custom things that we have to do. The more choices the better. And as we get these better and better materials to use, and as the software that we use gets more features and they improve it and get the bugs out of it, there’s always improvement as the years go by with these digital processes.”
Because there are so many moving parts in CAD/CAM, Bever points out just how important it is to have robust support.
“It’s important when it comes to having a partner for that support, whether it be maintenance or the tech support on the software side,” Bever says. “It happens quite often with all these new versions of software, that something you were doing before doesn’t play well with the new version of software, because they’re not compatible with each other, and different updates have to be done, or sometimes that stuff gets pretty high-tech and complicated. So, having a partner that you buy your software from, that gives you the best support, that’s something that I can never emphasize enough when someone’s asking me about a recommendation on something that they’re thinking of buying.”
On the analog side, Zaleske optimizes his workflow via a process called “Regi-Tray”. It helps speed up the process while delivering ideal results.
Related Reading: Save Time, Get Higher-Quality Dental Impressions With Regi-Tray
“The sequence for removable prosthetics is: The patient comes in; the doctor takes a preliminary impression with a stock tray; then that goes to the lab; the lab fabricates a model from that preliminary impression; and makes a preliminary model,” Zaleske says. “And then on the preliminary model is made a custom tray that takes in all the borders and the refinement of a good impression. Then, that goes to the lab and then the lab fabricates a base plate with a wax rim, which then goes back to the doctor, and then they take a bite registration in the patient’s mouth to establish their bite and where the teeth should go. So I’ll do a Regi-Tray. It’s a custom tray with a rim on it, and when I send that back, now they can eliminate one appointment, because they’re going to take the final impression inside of the registration tray, and they’re going to take the bite registration at the same time. So they’re going to get two things—the impression and a registration. That takes a whole appointment out of the sequence.”
Like anything, quality and efficiency haven’t peaked, and they likely never will. There’s always room for improvement.
“The entire ecosystem—the chemistry, the technology—will continue to evolve and become better,” Wainwright anticipates. “Even if you look back 5, 10 years ago, 3D printing was only accessible to the largest dental businesses, laboratories and milling centers. We’ve just seen a boom of other 3D printing companies and new companies bringing products to market that are more affordable, easier to use and sort of getting to the sort of same vision that anybody can do this, and anybody can make these high-quality dental parts. That’s just a really good direction for the industry, generally. As it evolves, it becomes easier, more accessible, and more affordable.”
For some, future improvements can be discovered by looking to the past.
“I’m big on old texts,” Zaleske says. “I read stuff that was published in the 40s, 50s, 60s and 70s. I don’t care how old it is. If there’s a pearl to be had, I’ll grab it.”
Both dental labs and Philippe Petit have a few things in common—committed teams, technology, and the skills necessary to pull off spectacular balancing acts.