The Tangibility Question: Can an All-Digital Lab Succeed Without Fabricating Physical Restorations?

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The introduction of digital technology begs many questions for dental labs today, like what defines a lab or a dental technician? What makes a lab a lab when production can be done anywhere based on designs that come from anywhere? Can an all-digital lab enjoy success without fabricating physical restorations?

The short answer to that question is no, says Rune Fisker, senior vice president of product strategy and product management for 3Shape. Profit isn’t in the design, at least not in North America and not for a single-unit crown.

“I don’t see an attractive business model in design services only,” Fisker says. “You need to capture the full value, which is producing the crown.”

Richard Jentsch, head of research and development at Opulent Digital Specialists, agrees that design-only isn’t a viable option for lab success, nor does he consider a design-only lab a full-service lab in the traditional sense. If the lab isn’t making tangible product, then he considers that a design center, a business model where competition is fierce.

“Design centers are everywhere, and they offer it dirt cheap,” Jentsch says.

The human element is essential to the restorative fabrication process, says Kenn Butler, director of lab research & development for Dandy. A patient’s teeth are crucial to get right, functionally correct, and attractive to the human eye. Design-only labs can work, Butler says, but they aren’t scalable. Instead, they are very small businesses driven by relationships with prosthodontists seeking a faster turnaround for the design of larger provisional restorations that the dentists produce in-house.

“An easier example would be a CEREC doctor that wants a very quick turnaround time, they know a guy who knows a guy that can design crowns the same day. There are a couple of these outfits that make a solid living doing that, but it’s very few and far between,” Butler says. “Fabrication is where the money is.”

The economies of scale that a lab can produce make those margins possible, Butler adds. Sure, a practice can produce crowns, bridges, and 3D-printed restorations, but a lab, even a mid-sized lab, can do several at a time. The dentist can’t have the same economies of scale, and therefore, not the same margin. So, design-only services are mostly niche businesses.

However, the economy of scale is only part of the reason fabrication is an essential part of the success of a lab; quality is the other, Butler says. A dental technician sees more restorations and only works on them all day. Dentists do a lot of things in a day, not only modifying adjusting, and characterizing crowns. One of the reasons dentists outsource to labs is not having to put their time into producing the restoration themselves, he says.

“You can make the argument that a dentist can spend more time on the unit and theoretically it could be better,” Butler explains,” but that is almost never the case. A master technician will always outclass even a really good prosthodontist when it comes to characterizing a restoration.”

What Design Only Can Do for a Lab

However, if the short answer to the tangibility question is no, the longer answer is more nuanced regarding the role of design in the dental lab. Jentsch and Fisker believe leveraging digital design as a competitive differentiator is a sound strategy for dental labs, particularly if you have knowledge in a unique area. For example, implant planning could be an area where design can strengthen an existing relationship or facilitate a new one, according to Jentsch.

Design-only projects could supplement other services labs provide, like designing a surgical guide the practice can print themselves, Fisker adds. The design of the guide might be a loss leader, but it could strengthen their relationship to earn more of their restorative production and prosthetic work.

Digital denture design has the potential to be an area where design-only projects work for a lab. Most designs take around 20-25 minutes to create, and labs could charge $20 to $30 for it. However, even at around $1 per minute, that design is not price-competitive with low-cost design centers in other countries.

That said, the design file could be for the try-in, which the dentist prints. If the lab prints the final, then the lab still captures the majority of the value, Fisker explains.

“But I don’t see any viable business model to design only in the US,” Fisker says.

It’s Not Only the Money That Doesn’t Work Here

Part of the problem with only designing a restoration is that the restorative process is collaborative between the dentist and the lab technician, says Travis Zick, co-founder and director of finance & acquisitions for Apex Dental Laboratory Group, and former president of the National Association of Dental Laboratories (NADL). When the lab technician isn’t the one manufacturing the final restoration a lot can be lost in translation.

However, some areas might work better than others. The success of design-only cases depends upon the treatment plan and the goals for the appliance. If it’s a simple design and treatment plan, then digital labs are having success there. For example, transactional procedures like single-unit posterior crowns, night guards, mouth guards, splints, and even simple oral appliances for sleep treatment might work.

Zick, who also was the president of a large, multi-location Midwest laboratory before his present position, says with complex restorative procedures, like implant-related restorations, full and partial dentures, complex, multi-unit bridges, and anterior crowns, it isn’t feasible to design the restoration and not fabricate it.

“So much of what we do is collaborative between the lab and the dental offices, and, frankly, that’s not feasible in the digital design only ‘lab,’ that’s not producing the restoration,” Zick says, “There is still a lot of work that the lab does on a single anterior crown or multi-unit bridge to make it fit, function and look good.”

Transparency is key with dental labs, no matter what business model they operate under, according to Zisk. Labs should always disclose the point of origin and materials composition of the restorations they deliver to dental practices, especially in the 11 states that mandate this disclosure by law.1 However, digital-only labs that outsource production are not disclosing that information. If practices without those disclosures in those states are audited, it could mean trouble for the dental practice’s license.

“There needs to be full transparency from the ‘lab’ to the doctor, and we’re not seeing that,” Zick says. “The doctors need to understand the disclosure requirement, and the labs certainly need to understand it. It’s a potential legal issue in 11 states currently, but labs have an ethical obligation everywhere to properly disclose who is making the product and where it is coming from.”

Designing the Role of Today’s Dental Technician

However, the relationship between dental labs and dental offices is not the only thing that has changed with technology. Digital design capabilities have also changed the role of dental technicians in recent years.

Zick says technology has improved communication between lab technicians and patients, too. Before digital models, lab technicians would create a physical model to demonstrate what the treatment plan would do for the patient’s smile. However, patients are still looking at a physical model of their teeth, which doesn’t tell patients the whole story. With the software today, patients can see what their faces will look like once the treatment plan has achieved its goals, which increases treatment plan acceptance.

“From a doctor-lab-patient collaborative perspective, it’s night and day,” Zick says.

The relationship between dental technicians and dentists has changed, too. Technicians see hundreds and thousands of restorations coming through the lab and Zick believes technicians should share their opinions on what they see. Part of the added service dental labs bring to the relationship is sharing information that makes dentists’ jobs easier.

For example, technicians might know which materials are best for various restorations or new treatment plan options, especially for larger cases and surgical procedures. Technicians should share information with dentists because dentists treat patients all day and can’t stay on top of it all.

“We’re usually the first line that learns about these things because it’s coming downstream from the vendors, suppliers, and materials manufacturers,” Zick says. “Part of our role is to share as much information as we can that’s unbiased.”

In addition, the restorative design and production process has changed the role of the experienced technician. The most experienced dental technicians leverage the advantages of CAD software to become more like a project manager than a technician at the bench.

Necessity drives this changing role in part because of the shortage of experienced talent in the lab space today, Zick explains. Digital design allows experienced techs to review the designs as they come through, as well as the other steps along the process to get to the final.

“The experienced technician, so to speak, isn’t just sitting at the back end of the bench in the lab anymore waiting for the copings or crowns to come to them to be finished. They’re more involved in the process from start to finish,” Zick says. “The final steps are much easier if the design is on point. We can leverage their knowledge more and spread them out a bit more this way instead of giving them 10 to 12 units a day to finish at the back end.”

Digital design also changes the skill development necessary. Dental technicians that work digitally are usually reading an intraoral scan. Butler says developing digital impression reading skills is crucial. Moreover, the analog impression skills won’t help; what makes a poor digital impression is not always the same as what makes for a poor analog impression.

“One of the muscles that you actually need to end up learning how to exercise more is reading a digital impression,” Butler says.

Software is changing the dental technician’s role in the collaborative process, as well. For example, 3Shape’s Dental System 2022 has several new features to enhance the design process between technicians and clinicians, including virtual preparation that allows technicians to recommend tooth prep designs digitally. It also introduces a new share feature making design review even easier for labs and dentists, according to Fisker. It allows web case 3D previews using URLs so dentists can view treatment proposals from any device.

“The digital design allows the dental technician to share much easier digitally and communicate with the dentist regarding the design and achieve clearly better results and satisfaction,” Fisker says. “We already see this happening today on advanced cases.”

Butler agrees that many tools exist that facilitate communication and collaboration with the dentist regarding the design files Dandy is doing it at scale with their dental technicians getting on video calls with the dentist to show them the design and collaborate on the finished product.

“Digital design fundamentally improves—or has the potential to improve—the standard of care for patients, particularly when it comes to fixed restorations,” Butler says, adding that the communication skills of digital native dental technicians facilitate that. “Digital technicians have been communicating digitally with doctors from day one. I find that they are also better communicators about cases because they're so used to it.”

If Design-Only Isn’t the Future, What Is?

It’s clear that the road to success for a dental lab does not include many design-only business models—at least not today. However, that doesn’t mean that digital design does not have some unique applications that can generate new revenue streams for labs that don’t require fabrication. If a lab has equipment that can help clinicians with treatment planning, labs could turn borrowing that equipment into a new service offering, Jentsch suggests.

For example, photogrammetry units can help with implant planning positioning and orientation. Photogrammetry uses math to get 3D-coordianates of different points (X, Y, Z) which come from comparing many pictures of the same object, but from different angles.2 Furthermore, research indicates it can be a way to digitalize dental models.2

These units are improving the multi-unit implant scanning process for patients by providing a more comfortable and streamlined patient experience than intraoral scanners and reducing chair time and material costs for implant impressions for dentists. Plus, it reduces the work for the lab and dental technicians by eliminating the need for model production and scanning complex implant models.

If a practice wanted to get those measurements and the lab had a unit, the lab could take the equipment to the practice and charge for the time. This service could be helpful to a dental practice that is just getting started in an area that could use this technology but isn’t ready to invest in it yet. The lab bringing it there gives dentists a way to use the technology without investing in it. It’s similar to renting, Jentsch explains.

In addition, design only could be a starting point for new technicians to introduce themselves to a market and establish relationships, Jentsch says. The overhead is relatively low as far as equipment and software. However, over time, he says anyone who is doing the design only and either outsourcing or surrendering the fabrication will realize that it is more profitable to produce the restorations.

“Down the road, everybody would come around and say, “Why am I giving this away?” Jentsch says.

Dandy has a unique approach to its business model today. They give the dental practice a scanner and set up a digital platform for them to collaborate with Dandy’s dental technicians for the restoration designs. Then, Dandy either fabricates the restoration in-house or with one of their partner labs. Differentiation like this is essential as the lab space adapts to digital workflows, Butler says.

In the future, Butler sees labs moving toward the extremes. He sees some going to boutique shops while others become large-scale mega-labs. Part of this split is because of digital design.

“Digital design inherently means that you can produce higher quality restorations with less effort. So, to differentiate yourself, you need to put in far more time into a case than the average technician or you try and win through scales,” Butler explains.

Butler also sees digital design driving more localized onshore production. Labor costs were the main driving force of offshore design and production. However, Butler says in the future when digital design allows labs to leverage AI to design the crown and the human moves the restoration between stages and then adds finishing touches at the end, the cost savings would make it cheaper to produce in the US rather than offshore.

“Plus, you get much faster turnaround times,” Butler says.

3D printing is a game changer for labs. It is more affordable than in-office milling and there is very little waste with materials, Zisk says. Also, 3D printing requires little time in post processing. He sees the future where these benefits impact dental labs. However, that future depends on improvements in materials for the printers. For example, once dentists can 3D print zirconia, single-tooth posterior crowns might no longer happen in labs.

“Down the road, as materials for 3D printing continue to evolve, it is going to impact what is made in a lab versus potentially chairside in office,” Zick says.

However, some of the future of labs is already here, he says. The dental lab of the future will be a collaborative partner and resource for dental offices. Some of that might involve doing design work for the dental offices where the practice then prints chairside on the simpler things. However, dental labs will always be a necessary part of the production process.

“Our role in the future is going to be much more of a partner in the entire collaborative process versus just a product maker,” Zick says. “We’ve already shifted that way quite a bit and it’s going to continue.”

References

1. National Association of Dental Laboratories. What’s in your mouth? State regulations. Updated March 2022. Accessed October 20, 2022. https://dentallabs.org/state-regulation/

2. Stuani VT, Ferreira R, Manfredi G, Cardoso M, Sant'Ana A. Photogrammetry as an alternative for acquiring digital dental models: A proof of concept. Medical Hypotheses. 2019; 128: 43-29. doi.org/10.1016/j.mehy.2019.05.015