Tech Census 2011

The potential for new design and production technologies to reshape the dental laboratory industry is certainly real. When combined with developments in materials, new technologies can be leveraged to increase capacity, achieve efficiencies and even increase the accuracy of the restorations fabricated by American dental laboratories.

But just because things can be done in new ways with new tools, doesn’t mean people want or need to make those changes. With the 2011 Tech Census, Dental Lab Products took a look beyond what technologies are available for dental labs today to ask lab owners and technicians about which technologies they’re actually using and what they see as the most helpful to their business.

The results show an industry interested in the benefits technology can bring, but one moving slowly along the path toward greater automation and computer-driven production. The reasons for this are many, but the experts who shared their thoughts for this story all agreed that labs of all sizes get the most out of technology when they take a deliberate approach to integrating it into their workflows and business models. The high-tech dental lab that’s often talked and written about is still hanging out on the horizon, but based on the survey results, for most of the industry, it remains some distance away.

“Right now it’s like the wild west. It’s a shoot out with everyone throwing time money and energy at these new ideas,” said Dave Lesh, CDT, founder of Dale Dental. “But when you look at the proliferation, what’s actually making its way to the street and how people are using it, I think the reality falls short of what the expectations are.”

Are we high-tech yet?

That same sentiment is shared by Lee Culp, CDT, Chief Technology Officer for DTI. He said the industry is “not even in the ballpark” of having shifted to technology-based manufacturing, and the slow pace of adoption was part of what led him to move from developing CAD/CAM systems for companies such as D4D Technologies to his current role implementing and managing technologies for a network of labs. 

While working for D4D he heard from one lab owner who was happy with his new system, but just using a fraction of its capacity and capabilities. When asked why he wasn’t using it more, Culp said the lab owner replied, “if I did any more my waxers wouldn’t have anything to do.” This showed him that while people want new technologies the commitment to them isn’t always there, and developing technologies that weren’t being used was less fun than putting those systems to work himself.

In his current position, Culp is able to help CAD/CAM and digital production technologies become more than just a department for DTI labs, but an integral part of how the labs work. He said for technology in the industry to ever take off in a big way labs must not only dip a toe into digital systems, but must actually make it a key part of everything they do.

“Are they using it? Have they fully integrated it into their laboratory? Is it a major part of what they do every day? Not even close,” he said.

The Tech Census bears this out. While CAD/CAM systems have made gains in the industry, they are far from being the norm. Just 39% of the survey respondents have invested in a 3D scanner and 28% have a mill for in-lab fabrication of the digital designs, (see “Technology in use”). Even more telling are the statistics showing 20% of labs have no interest in purchasing a scanner and more than a third of respondents said they don’t plan to purchase a mill.

Does it work?

For labs that have not only purchased these systems but successfully integrated them into their business, the investments have been worthwhile. As Lab Manager at Ziemek Aesthetic Dental Lab, which has handled more than 10,000 digital impression files from dentists using 3M ESPE’s Lava C.O.S., and other digital scanners on the market, Jamie Stover, CDT, said adopting and integrating the Lava system along with technologies from 3Shape, Sirona, Dental Wings, and other companies has been very good for his lab.

“Digital impression technology definitely works, and we utilize it in our lab every day. I feel we’ve only scratched the surface of that technology. It’s just going to get more accurate, more affordable, and faster,” he said.

This is a point on which Culp agrees. The technology currently available has the potential to change the industry because of the efficiencies it can bring. Both in his work at technology companies and in his work at DTI, Culp said he has seen a range of economic measurements that always show the benefits of CAD/CAM.

“There’s no question that going digital is a better business model for profitability, efficiency in production, turnaround time and everything you could possibly put a stick to and measure,” he said.

Still labs aren’t yet racing to snatch up systems, Lesh said. While the technology provides a better way to accomplish many tasks labs do every day, it doesn’t provide a better outcome in every single task. Labs evaluating new technologies must be careful to assess where, how and why the investment will benefit the bottom line, and figuring out not just what type of technology will provide the biggest benefit, but what exact system is the best fit for a particular lab. That can be a confusing and time consuming process.

Slow rate of adoption

Labs evaluating scanners and mills aren’t all that different than a consumer looking to buy a new smartphone or an iPad. The rate at which new and improved systems appear can make it difficult to feel good about making an investment, and once a lab does sign the check it has to be ready to stay on top of the system upgrades that will arrive sooner or later.

Lesh said it can be especially difficult for smaller labs to make sure the rewards of the technology will be greater than the financial risks of the purchase. With improvements happening so fast, a lab investing significant capital in something ideal for their business today, might soon find themselves behind the technology curve.

“You’re always chasing the flavor of the month. Now it just becomes a question of how much money you’re going to spend to chase it,” Lesh said. “I think it’s always going to be a problem.”

Waiting for the technology to reach a level where it will be a good fit for the lab is very important, Stover said. While Ziemek is a high-tech operation, the lab hasn’t yet invested in a wax printer or an in-lab model production solution because the available technologies in those areas cannot produce higher quality work, faster and at a lower cost than the technicians on his staff. Until he sees a system that can accomplish that, he’s happy with the way his lab operates today.

For it to be a successful investment, adding a new technology needs to involve more than just finding something that adds efficiencies, plugging it in and powering it up. It needs to be a commitment from the whole lab to doing things in a new way, and that involves business planning, training and a commitment to the transformation.

The new attitude required to succeed with technology needs to be in place before a new system, Culp said. At this point he doesn’t see the shift in mindset happening throughout the industry, and is thus not surprised that technological adoption hasn’t happened at a faster pace.

“We know the technology works, but the biggest changes are not technological. What it really takes is the cultural change and the people change and the philosophical change of moving the manufacturing platform and a full and total commitment of putting every model through that scanner,” he said. “As an industry, we have not made that cultural change.”

Approaching technology

While the industry might not be ready to completely embrace every new technological solution today, there does seem to be plenty of interest in the high-tech options on the market. Just 13% of Tech Census respondents said they have little interest in adding new technologies to their labs, (see “Technology profiles”).

Instead most lab owners expressed interest, but a cautious approach to adopting new ways of producing restorations via technology. More than half of the respondents said they need to see a technology working for themselves along with other evidence of its capabilities before adopting a system. An additional 25% said they focus their attention on the potential for a new technology to improve their lab’s bottom line before making an investment.

Those two approaches sound about right to Stover, who said Ziemek’s approach to evaluating new systems begins with an internal investigation of the lab’s current operations. Once logjams and inefficiencies have been identified, the lab sets out to see if there is a system available to address those issues. Stover said the people who work in the lab are always more important than the technology, so he’s looking for systems that make his technicians’ jobs easier so they can accomplish more.

“We evaluate what the technology is and exactly what it can do for us today as well as its future potential,” he said. “The technology is very good now but in most cases it can’t replace a technician at a high-quality lab.”

Tech considerations

In fact, Stover said it is his technicians who help his lab stay up to date on all the high-tech options available in the industry. Keeping the lab on the cutting edge means technicians are encouraged to be proactive in looking at what’s available by reading industry publications, searching the Internet and talking with colleagues at other labs.  The technicians are proactive because they have seen first hand the benefits of using these technologies in the lab every day.

“Nobody is going to take you by the hand and show you all the new technology available, itemizing exactly what it can and can’t do in your lab. You have to go out and look for it,” he said.

Knowing what ‘s out there is important, but knowing why you want to invest in a technology and how you plan to use it is just as critical. While some Tech Census respondents said they invest in technology because it helps them compete with labs in their area or offshore labs, Stover said being able to meet the requests of your dentists should be the biggest motivation.

“Investing capital in technology for the sole purpose of competing with a lab across town is a risky strategy. Every lab has different technicians, different approaches to creating restorations, different profit margins,” he said. “A lot of labs that buy with this reason as their motivating factor won’t be happy with the ROI.”

Putting a system to use is very important, but trying to shoehorn every prescription through the scanner a lab invested in to make the payments on the system is not going to lead to the best results for the lab, the dentist and most importantly the patients. Listening to dentist requests and investing in the technologies they want their lab to be using, and at the same time informing them of the latest restorative materials available, can be important parts of retaining their business.

Stover said Ziemek not only asks dentists what types of restorations and materials they want to use, but why they want them. If a lab has a lot of accounts restoring implant cases with implants from Nobel Biocare or Straumann, it might make sense to invest in the CAD/CAM systems produced by those companies. This way, the lab is able to provide genuine parts to match those implant systems while having control of the design process.

“Some dentists are more particular about the parts they’re placing, if they have a Nobel (implant), they want to get a Nobel screw and a Nobel custom abutment,” Stover said. “If they have a Straumann implant then they feel more comfortable about getting Straumann genuine parts.”

Stepping outside

Of course not every lab can afford to invest in a scanner from a specific company to offer parts from that company, and this is where outsourcing can be a valuable resource. Whether sending a case to a milling center, or to a manufacturer providing production services such as Nobel Biocare or DENTSPLY Prosthetics, labs have a range of options for producing restorations via materials, processes and technologies they cannot afford to work with completely in house.

Lesh’s Dale Dental was a pioneer in the outsourcing business model and he has made it his business to not only stay up to date on available production systems, materials and fabrication technologies, but also to form strategic partnerships with manufacturers including Straumann, Nobel Biocare, DENTSPLY Prosthetics and others that enable Dale to produce genuine parts that match their products.

Lesh described it as being akin to a pharmacy where dental labs can go to get whatever they need to fill the prescription sent in by the dentist. He wants to make it easy for labs with minimal investment technology to access the latest production methods and materials.

“Our commitment to our customers is always to have all the restorations that they need,” he said. “Ultimately, everyone will need a product that they can’t make.”

Even a lab chain such as DTI with its own industrial scale milling capabilities uses an outsourcing model for CAD/CAM production. When Culp began in his new position with the company, one of his first moves was to move the CAD/CAM technicians out of their own department so that the digital processes would be integrated into the overall workflow of the lab. However, this was just for the design of the restorations. The production technologies were moved to one department and now all DTI labs outsource to their in-network production facility that can operate with the efficiencies of working on a larger scale.

Operating the systems

The majority of the people designing the cases sent to that in-network production center are not formally trained dental lab technicians, but designers who have learned the process starting with a computer design station. Culp said he stresses training to make sure his digital designers have a handle on the core dental knowledge required to produce a good restoration, but the technology can shorten the learning curve significantly.

“This digital does not take away education. It’s just something else to hold in your hand to make a tooth,” he said. “We’re just farther along so I don’t have to teach people basic tooth shape. Where you put that cusp tip, where the other cusp tip goes, how all the other teeth are going to relate to each other, the esthetics out of the mill, all those things are still extremely important.”

While Stover agreed that digital technology can make it easier to train people recently hired to work in a lab, he isn’t looking at the technology as a path to replacing his current staff. In fact training his staff to be experts on the new systems is a big part of the Ziemek business model, and getting buy in from the technicians working in the department most affected by the new systems is critical for it to be a successful addition to the lab.

Stover said he prefers for his technicians to become the lab’s experts on the systems automating the areas of production they’d worked in before the technology arrived, so their expertise can be leveraged into the efficiencies he hopes to achieve through the technology. As good as the systems become, he doesn’t know if they’ll  ever be able to create a high-quality crown by feeding in an impression and pushing a button. Because of this, designers trained just on CAD-and without a solid lab background-will only be able to do so much in the industry.

“It’s more difficult to take a CAD designer and turn them into a lab tech,” he said. “It’s easier to take a lab tech with a good lab skill set and understanding of form and function, and especially with the software these days, train them on CAD design.”

As much as his business is built on a foundation of technology, Lesh said he worries about its impact on the level of expertise to be found in the dental lab industry. People off the street might be able to use the software to design a crown, but without knowledge of form, function, occlusion and other principles at the heart of the work produced in dental labs, those people are completely at the mercy of the machines.

Lesh pointed out that when CAD technology moved into the architecture industry it didn’t lower the educational standards for architects, and the dental lab industry shouldn’t be any different. Putting someone who lacks training as a technician but is good with computers in charge of these systems may be the easier route for people to take when adopting new technologies, but that doesn’t make it right. Lesh said labs need to remember that their work ends up in the mouths of real people, and those people deserve a fully-functional prosthetic rather than a space-filler.

“You still need an architect who understands design and structure and support. You didn’t create an opportunity to replace them with somebody who has no skills, but knows how to work the keyboard,” he said. “CAD didn’t replace architects, why on earth would anyone think CAD would replace dental technicians, but yet people do it.”

Business machines

This same mindset of taking the quickest path to producing restorations via technology also can lead labs down the wrong path when purchasing a system, Lesh added. New technologies can seem like a wonderful quick fix to boost efficiency in a lab, but spending the money to invest in technology requires a solid, long-term plan for how that system will increase a business’ bottom line.

Lesh said it’s important to start with examining the products the lab produces and those it wants to use technology to produce. However, factoring in the lifespan of the technology and how long it will be useful in manufacturing the restorations a lab’s dental clients are prescribing is an important step. Investing in a system that makes a restoration that happens to the flavor of the moment may seem great, but if the system isn’t adaptable, it could quickly be useless when the next big thing hits the industry.

It’s for this very reason that Stover is a big proponent of open-architecture technologies that allow a system to work with data from other systems, and to send designs for production on a range of mills and printers. Closed systems might work for a lab with business built around one niche product, but for most labs being able to handle a variety of materials and workflows is the only way for the product to fit into a realistic business model.

Coming up with that business model before the purchase is an absolute necessity. Stover said if a lab is profitable doing things the way it has been, it should have a solid plan for how the technology investment will increase those profits, or purchasing that system just doesn’t make any sense.
Currently there is no single system that can handle all materials and all restoration types for in-lab design and production. For this reason, Culp said small labs need to approach a big investment with caution. While certain products, such as full contour posterior crowns, lend themselves to CAD/CAM, a small lab that dedicates all its resources to one system needs to have a plan in place in case that system breaks down.

“It’s like a baby. You need to take care of that baby daily. If that baby gets sick you have a problem,” he said.

Large operations such as DTI are able to invest in extra production capacity so all is not lost if a mill goes down and needs repairs. However, if a lab cannot afford redundant technologies-and few small labs can-those that find digital production to be financially beneficial might be in even better shape by investing in just a scanner and a design station with outsourced production figured into the new costs of doing business.

Lesh founded his business on this outsource production model based on his strong belief that this is the best way for these new technologies to be implemented in the dental lab industry. Operations working on the scale of a Dale Dental can afford to make the large investments in expensive production technologies. This gives labs with or without in-lab scanning and design systems access to any product a dentist could request, and this means labs don’t need to go high-tech to provide restorations produced by the latest systems.

“I think it’s a good thing and I think that is the future,” Lesh said. “I still think labs are underestimating what’s involved with getting into scanning itself.”

What adoption takes

But while technology might not be a great fit for every lab, many labs of all sizes are still finding that technology can lead to increased revenues. Labs looking to add new systems need to be committed to using the technology as much as possible, and Stover said arranging for a hands-on trial of a new system is a great way to get an idea of how realistic a plan actually is.

Many companies will allow a lab to spend some time using a new scanner or testing out new design software to see if it will work for that specific business. Stover said an in-lab trial period, “gives you a great idea of what you’re getting yourself into, and if the product lives up to the hype” and lets the staff members gain an understanding of how the new system might change the lab’s workflow and their individual responsibilities.

This also can provide a lab with a jumpstart on the training process, something else Stover said is key. Investing in new technology is about more than just purchasing a fancy new system, it’s also about investing in the technicians who will be using it, so getting them excited about being the expert on something new can go a long way toward successful integration.

“You need one person who is proficient with the particular technology, understands its benefits and limitations, and can then train others to be up to speed,” Stover said. “You need to put faith and trust into the technicians that you’re making that investment in, and then let them loose.”

Of course all the staff enthusiasm possible won’t help a lab be successful with a new system if that technology doesn’t either add new capabilities or improve on something the lab already does. If a lab doesn’t know how much it costs to pour a model by hand, there will be no way for the lab to know if adding a CAD/CAM model production technology will be a profitable move.

If a technology is going to be successfully integrated into a lab’s operations, the lab really needs to have a plan in place to use as much of that system’s capabilities as possible. Culp said labs should know how many years they expect a system to work and be confident the products that system produces will be in demand throughout that lifespan. Then it comes down to being dedicated to using that technology as much as possible.

“It’s a massive commitment and it has to be thought of that way,” he said. “Otherwise you’re just buying a toy.”

Looking ahead

Despite all the words of caution, it seems clear to Lesh, Culp and Stover that technological and materials developments will continue to change the way restorations are created and alter the way labs do business.

At Ziemek Lab they are already producing some crowns without ever creating a physical model. For straightforward posterior cases that begin with a digital impression, this model-free workflow is proving to be an efficient solution for some dentists, but Stover said he doesn’t think this will become the process for all restorations, and models will still be a key component of complex cases.

While he hopes to someday have an open-architecture system capable of producing any type of restoration at his disposal, he knows change doesn’t happen in an instant and technology needs to produce a better end result, not just a faster one, before it will truly take over the industry.

“I’m a believer that PFMs will be around for a long, long time,” he said. “We do a ton of e.max and all-ceramic, but there are things you can do with a porcelain-fused-to-metal restoration that you still can’t get with an all-ceramic.”

Culp said he firmly believes in CAD/CAM, and he thinks the computerization of restoration design offers a range of benefits to labs of all sizes. However, he is less certain that the CAM part of the equation will look the same in even a few years.

Milling might be the state-of-the-art today, but as soon as there are additive processes for working with the materials labs use, those technologies will go by the wayside. Culp said printed zirconia is in the works and when it and other printable full-contour materials arrive, mills will no longer be in demand.

“Milling is not the best way to do things. It wastes time, it wastes materials, it’s not really efficient, it’s just what we have the ability to do now,” he said. “I know you’ll see more additive technologies in the future.”

Lesh also isn’t convinced the CAD/CAM of today will be around for the long haul. He noted that if an esthetic material came along that could be shaped by hand and hardened to a state where it functions beautifully in a patient’s mouth, scanners and mills wouldn’t be necessary. For this reason, labs need to be sure they stay abreast of what innovations are coming to the industry, so they don’t get caught behind the times when investing in a new way of doing things.

“It’s a materials game. It’s always been,” he said. “People go with CAD/CAM because of the efficiency, but at the end of the day CAD/CAM may not always be the best option in terms of the materials the customers are looking for.”

Whatever the next big thing may be, at their core, dental labs are businesses and it’s clear from both industry experts and the results of the DLP Tech Census that a measured approach to technology is warranted, but missing out on opportunities to improve the efficiencies of a lab’s operations can be just as harmful as not keeping up with the developments making their way through the industry.