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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.
It should come as no surprise that the dental lab industry has-and continues to-grow and evolve. From George Washington’s ivory dentures (despite what you heard on the elementary school playground, they were not wooden) to porcelain-fused to metal crowns to today’s all-digital, full-arch cases, the way we do things has constantly grown. Even within the modern CAD/CAM systems, progress continues.
Times, They Are A-Changin’
While current, modern systems seem to be the peak of technological advancement, CAD/CAM systems are still developing and will continue to do so.
“CAD/CAM is in its infancy right now,” says Mark Ferguson, assistant manager at Core3dcentres in Las Vegas. “Ten years ago, we thought, ‘We have to do these manual processes before we get to be able to do the next part.’ Now, it’s all digital, and we can change paths midway through a case. Manually, if I’m waxing a case, and now they say they want e.max, and I change my coping wax up to a full contour, that’s been a problem. In CAD/CAM, you might have to restart the case. That’s not the situation anymore. Now you can change paths midstream.”
It isn’t just the design software that is changing. Hardware must also keep pace with advancements.
“The bigger part of it is not just the software; it’s also that the hardware of the computers is able to handle all the data,” Ferguson says. “When you look at the shape of a tooth versus the shape of a house, there are a lot of straight lines-doors and stairs, whatever. It doesn’t have the intricacies and the detail that you have when you’re designing a tooth. The tooth takes more processing power of the CAD station even than designing a house, even though the house is obviously much bigger. Hardware is catching up and becoming more and more affordable. Software’s pushing the limits of that at all times.”
Advancing on Different Fronts
The equipment, products and materials of dental labs are improving but not all at once and not evenly.
“If you break down the evolution of the industry, I think it breaks down into advances in scanning technology and then advances in design technology and then advances in fabrication technology,” observes Larry Bodony, president of exocad in Woburn, Mass.
Each of the three is dependent on the others for success, and it all starts with scanning.
“Without a decent scan, the rest of it doesn’t make any difference,” Bodony says. “What we’re seeing, especially in the last two years, is the rapid evolution of so-called white light scanners, which look like they’re the leading dental lab scanner type right now. These replaced the old laser scanners. They’re faster and they have generally better accuracy.”
One of the key areas in which scanning technology has improved is its speed.
"The algorithms and the computers got faster enough to make some really sophisticated processing happen in real-time,” Bodony says. “The time to scan something has gone down dramatically in the last two or three years to the point now where high-volume labs can basically put junior people on scanning and crank out more than 100 cases a day.”
Once the scan moves to the design stage, technicians can do much more now than they could even a couple of years ago.
From the CAD standpoint, what’s expanded has primarily been the breadth of restorations that you can design,” Bodony says. “Pretty much everyone started out with single crowns, inlays, onlays and things like that. Recently, what we’re seeing is an advance in other types of restorations-from bite splints to bars. Now, full-denture design systems are starting to make their appearance.”
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And when it’s time to make the physical product, innovation in materials and equipment are responsible for better restorations.
“It’s been in increasing material innovations and machining innovations that have led to all kinds of interesting breakthroughs, like being able to mill pre-sintered zirconia-even though the milling was fast, the sintering took forever,” Bodony says. “It’s all about
getting productivity and good value on the restoration and good biological characteristics. On the fabrication side, now you hear a lot of innovation happening with 3D printers. Mills are pretty well understood, but, still, there are better and better mills every day that can mill harder substances and do it faster and more accurately.”
Rob Nazzal, CEO of Custom Automated Prosthetics in Stoneham, Mass., compares one of the earliest CAM mills, which was the size of a refrigerator and cost a quarter of a million dollars, to a present-day table holding five desktop printer-sized mills.
“These five machines don’t even add up to a quarter million dollars, and these machines can run circles around that old mill,” Nazzal says. “These things can do much more than that big refrigerator could do.”
While some of the advancement comes by sheer virtue of technological advancements, Nazzal attributes some of that advancement to older machines having to perform manufacturing tasks for a broad range of industries. Manufacturers are making the machines specifically for dental applications.
"Now that zirconia has taken off and manufacturers recognized dental as a market, they are making purpose-built mills for dental,” Nazzal says. “That’s why you see things that are the right size, have the right features and are just right for dental, and that’s why the price got to be into the right range.”
Labs need and want different things from their machines, so there can’t be a one-size-fits-all mindset guiding their development.
“We have very open machines with very often software feeding the machines,” Ferguson says. “Not every machine is great for everything, so we have certain machines we dedicate for wet milling of glass ceramic and then we have another one for metal and then we have other machines that don’t wet mill at all for where we mill our zirconia or our PMMA.”
No matter where labs are now-or where the equipment progresses-it will never be in its final form.
“I think it will always be evolving and changing, because what’s perfect for one person is not going to be perfect for another,” Ferguson says. “I can say, ‘Is there a perfect-looking woman?’ And you can get a group of 100 different guys, and they’re going to have 10,000 different women that they think would be perfect, and they won’t look alike.”
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Advancements in the realm of manufacturing are not just limited to the machines. Materials have evolved and continue to be more useful within the world of CAD/CAM.
“Ten years ago, when we first started milling zirconia for example, at that time it was just white zirconia,” says Ryan Faufau, director of CAD/CAM rvesources at Custom Milling Center in Arvada, Colo. “KATANA was a pre-shaded zirconia. They were actually one of the first pre-shaded materials on the market, but the translucency, the lifelike look of the actual material itself wasn’t there. Back then, I wouldn’t have done a full contour with the material composition of the time.”
The improvement of materials makes CAD/CAM a more complete solution.
“With more translucent zirconia today, with multilayer products where it actually has that transitional blend from the gingival to the incisal, really kind of simplifies the process. The materials are really driving this digital era that we’re encountering,” Faufau says.
That growth in materials has changed the applications for which materials are used.
“We had the substructure first, then we got the full-contour zirconia and now are branching out into some of these more advanced things,” Nazzal says. “There are all kinds of materials on the market, like implant components, and all kinds of things that you can do in-house now.”
“The biggest change has been the availability of materials,” Ferguson adds. “That’s helped the dental labs, but it’s also hurt the dental labs. When we started milling in our dental lab, we had a couple different zirconias that we could choose from, maybe mill some wax or some PMMA, but now with all the glass ceramics and new materials coming out, whether they be VITA or DENTSPLY to compete with e.max, the material manufacturers are really working to make the materials themselves more processable, where you can click a button and let the machine do some work and you don’t have to sit there babysitting a burn out oven. It’s more about letting machines do the work while saving labor time so you can get more work through the lab.”
Materials are better for end results but also in terms of the demands on lab technicians.
A lot of the newer materials are more user-friendly material in its milled version than in its pressed version,” Ferguson says. “One of the things we started to do in our lab pretty quickly was stop pressing e.max and start milling it. It’s simply made it easier on the ceramists.”
Working and Playing Well Together
When dental CAD/CAM systems first came to market, they were closed, proprietary systems, meaning that the scan, design and milling components were all made and sold by the same manufacturer. Over time, the industry has moved toward so-called “open standards,”-specifically the STL file format-which allows work to be performed on any machine, no matter who manufactured it, as long as the machine can work with open standard files.
“It has to do with not creating proprietary, closed standards,” Bodony says. “The reason [companies make closed systems] is pretty obvious. They want to sell everything as possible in the food chain. The benefit is that it tends to be better-engineered because they control the source and destination of every piece of data. The difficulty for the purchaser is that once you commit to one piece of that puzzle, maybe it’s intraoral scanning for the design, you can only get things from that system and send things to that system because it’s closed.”
CAD/CAM was available in other industries before it came to dental, and the appeal of open systems was first evident in those applications.
While the STL format is utilitarian enough in its capabilities, dental still requires a better standard.
“The piece that’s missing in our standards today is a layer of metadata, which is data about the data,” Nazzal says. “That has to do with things like if you needed to pass on information about where the margin line is on the design file. Or, ‘What is the insertion direction of this STL file?’ Or, ‘What is the patient information for this file?’ There’s no sort of envelope for information that’s included to tell us anything meaningful about that data. There’s no real standard for that right now.”
For that standard to become a reality, it will necessitate a body to make those definitions.
“At some point, they’ll get forced to interoperate,” Nazzal observes. “The market is going to demand that it goes open and that these standards make it even easier to transfer information between these systems. There’s not a lot of motivation between the players to make it happen yet. As more cases become digital and more systems require interoperability, we’re going to see more of these standards evolve.”
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Making the change
Labs considering the move from analog to digital (or at least adding digital to their offerings) must be aware that there is a different workflow involved.
"Changing is very difficult,” Faufau says. “I’ve consulted with a lot of laboratories about how they’re going to integrate the new process of doing production from the conventional methods. It gets to the point where I think that most laboratories are under the belief that you can hire a gamer or somebody that’s good with the computer and end up with the same result. I haven’t found that to be true. What you see on the screen is different than what you physically see in your hand.”
Faufau gives new designers a hands-on demonstration of the difference between reality and virtuality.
“One of the things that I do when I have a new designer on staff is let them design, and then I go ahead and we mill the design out of wax,” Faufau says. “Then we actually place that on a model and let the technician look at the difference between what they’ve actually designed physically and what’s on the screen. It’s a good tool because it allows them to see, physically what they’ve done virtually.”
Nazzal favors a teamwork approach, pairing those who are technologically inclined with those who are dentally inclined.
“See if you can find someone in your group; don’t just take your best ceramist and put them on the computer,” Nazzal advises. “They may not be interested in doing these things. It can be very frustrating for them. See who gravitates toward the computer. You might have somebody who always fixes your front desk computer or somebody who is interested in doing the next cool thing in the company and will work to help make that happen. They just need to be sitting next to somebody with dental knowledge.”
Using a computer to make dental restorations has certainly made the process easier, but there is still something to be said for the knowledge and skill required making restorations by hand.
"In a lot of ways, becoming a good manual technician is harder than becoming a good digital technician,” Bodony says. “Not only do you have to have good conceptual knowledge of what you’re trying to do, but you also have to be mechanically very adept at waxing and cutting and grinding and polishing and all the things that techs traditionally had to do.”
While the field used to call for special people with the unique ability to work in both fields, those workers are becoming less and less rare.
“The idea is you had to create your unicorns,” Nazzal notes. “There are more unicorns out there though. A lot of these unicorns have been grown because there’s so much digital out there in our industry, and it’s not as much of the unicorn as it was because there are thousands of scanners and there are thousands of mills out there now. A lot of technicians have touched these.”
Can You Still Do It All By Hand?
There is still a place for labs that do everything by hand, but those days may be coming to a close.
"It’s a little like the fish in the pond, and that is drying up,” Bodony observes. “It’s not going to happen all at once. You can have a couple of good dentists who are happy to send you restorations and happy to get the thing back. You can ignore it for a while, but the number of them is going to go down. There’s no question about it. Between the advances in intraoral scanning, CT scanning, implants, planning and all of that, the number of cases that are going to come in analog is going to decrease over time. When the exact point is when more cases are done digitally than analog is anyone’s guess because it’s impossible to gather the data. Everyone seems to agree that it’s happening, and it’s happening rather rapidly right now. The dentists I know who are using intraoral scanners are very happy with them, and they’re getting the results they want. They certainly don’t mind saving all the money in impression material and getting more reliable results.”
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Dentists are becoming more comfortable with CAD/CAM systems so the workflow is changing right from the earliest stages of restoration making.
If you’re going to stay relevant to the industry, you have to adapt to technology,” Faufau says. “I’m seeing more and more younger clinicians-doctors being trained in utilizing chairside scanning at universities. One of the first things they want to do is continue to use that technology once they graduate and open up their own practice. In order to work with these doctors, you’re going to have to have a way to accept data from them. I think technology is definitely the driver of the industry at this point, and if you haven’t adapted to it and you may be left behind.”
Many older labs may stick with traditional methods simply because they specialize and might be near retirement, but those labs would be wise to consider their exit strategy.
“I think there are always going to be processes that will be done by hand, at least for the foreseeable future,” Ferguson says. “But I know some labs that are small, boutique labs that are one- or two-man labs. They charge whatever they want to charge. They are at the absolute highest end. They will probably be able to make it through to retirement. I think there will always be a place for that. It also matters what they want to do with their lab when they’re ready to retire. When I look at a small lab that has CAD/CAM in its facility already, that’s something that you can sell. But when I look at a lab with one ultra high-end ceramist who wants to retire, that lab has nothing to sell at the end. As a business plan, I think what CAD/CAM does is it allows you to maintain the same quality more predictively, more streamlined, more efficiently and more quickly. Smaller labs mostly have older technicians thinking of an exit strategy. If you have a five-man lab that’s doing everything by hand, your exit strategy is to sell off your accounts and maybe some equipment, but it’s not really as much as when you bring in CAD/CAM.”
Making the Move
Deciding to embrace digital technology is the first step. But once that decision is made, the move shouldn’t be made carelessly or without solid planning.
“The biggest problem that I see is the up-front investment that you have with technology, and then obviously not knowing if that return on investment is going to come back at a fast rate and what the laboratory is expecting when they integrated,” Faufau notes.
CAD/CAM systems require more than a passing bit of education.
“Most laboratories can’t just go to a seminar to learn it,” Faufau says. “They need chairtime. You need time with the software. You have to get familiar with the tools that the software offers, and a lot of that you just need to put in the time to learn it.”
Ferguson advises not just looking at the price tag on a new machine but also knowing about the company supporting it.
“The biggest thing is to research the support that you’re getting with whatever system you choose,” Ferguson says. “There are a few major systems out there, and may be bought from any number of different people. Use 3Shape, for example. It’s the same system shipping from 3Shape, but how was the company you bought it from supporting you? That makes more of a difference than a thousand dollars on the purchase of a scanner. You can easily lose five to ten times that amount in trying to figure out that the system didn’t come with the proper support and training. It doesn’t matter the system: 3Shape, Dental Wings, exocad, whatever. Especially for technicians who haven’t dipped their foot into CAD/CAM, that training and support is going to be their lifeblood in how they incorporate their manual workflow digitally.”
The industry is firmly on the track to embrace digital, and it’s something labs that aren’t incorporating it should.
“If you look through the vendors who are involved with some of these [trade]shows today, the focus is digital,” Faufau says. “If you’re not digital today, I don’t know what you’re going to the show for.”
Nazzal recommends making sure you’re not going to digital just for the sake of going to digital. There needs to be some justification for it.
“For instance, zirconia is the fastest-growing restoration, and it’s best made using digital processes,” he says. “If you’re getting lots of orders for zirconia and you’re outsourcing those orders, it might make sense to bring that technology in-house. But there are certain times when you shouldn’t do it. If you’re only doing two or two or three zirconia units a day, it might not make sense to bring some of the stuff in house.”
There has been a lot of evolution in dental lab technologies, and that growth hasn’t ended yet. Make sure you’re prepared to make the leap to the future, and you’re doing so in ways that will make your lab last into the future.