Dental Lab Products 2023 Innovation Guide

Over the past decade, demand in the dental industry has driven digital design software development and become a mainstream solution. This drive to expand the functionality of design software platforms is fueled by the staggering disappearance of qualified technicians in the United States. At the same time, this design software evolution drove the development of the technologies necessary for the digital manufacturing of dental restorations, with both additive and reductive technologies proving to be effective.

The winner in the battle between additive and reductive processing is still undecided, but a definite move toward the cleaner and more accurate additive technology is starting to emerge. As these technologies evolve into more functional manufacturing platforms, the race to finding materials to support this digital world has become the new battleground.

When judging new product and technology innovations in the dental industry, there are many potential contenders. Determining the most influential material must be done by evaluating both the material properties and, more importantly, how that technology and material combination influences the broader industry.

The first material to be considered is undoubtedly high-strength, multilayer zirconia. Over the past few years, great advancements have been made in this industry-changing product. High-strength, multilayer zirconia is now not only a functional material, but also an esthetic material (Figure 1).

Through this material advancement, the industry finally has a solution capable of eradicating the need for the labor-intensive layered ceramic technique. Furthermore, monolithic zirconia offers a full digital workflow, making it a potential choice for the product of the year (Figure 2).

Figure 1: Monolithic high-strength multilayer zirconia on teeth Nos 7 & 10

Figure 2: A digital design for zirconia milling.

Figure 3: Reductive denture fabrication

Figure 4: A Lucitone 3D printed denture base with carded teeth.

Figure 5: A Flexcera denture base with printed teeth.

Figure 6: An Iintraoral scan of an existing denture for prototyping.

Figure 7: A digital diagnostic preview for the patient's review and approval.

Figure 8: Carbon additive processing of denture bases.

Figure 9: Digital archiving of design data allows for restorations to be replaced.

Figure 10: An example of a monolithic printed tooth structure.

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Although there are multiple other materials to consider, printable polymers for denture applications are arguably responsible for finally bringing denture fabrication into the 21st century. Even though reductive technology came to market first (Figure 3), the arduous and expensive nature of this processing technique quickly allowed additive technologies to become a favorite among laboratory owners. First-generation polymers were brittle, translucent, and offered very little strength, but with the launch of products such as Dentsply Sirona’s Lucitone Digital Print (Figure 4) and Desktop Metal’s Flexcera Smile, (Figure 5) an entire new world of predictable, efficient, and economical fabrication is a possibility for the dental laboratory.

The second reason this polymer material, and with it the additive processing technique, should be considered the innovation of the decade, is the way this material has influenced the clinical workflow.

For decades, denture fabrication was seen by dental laboratories as a low-profit product, with the potential of large numbers of postdelivery issues. With clinical issues, such as multiple try-ins and vertical dimension of occlusion discrepancies caused by bite rims, the road to satisfying patients’ esthetic demands and bite concerns was littered with landmines.

Today, clinical workflows are influenced by digitally driven chairside techniques, allowing the clinician to utilize the existing denture as a prototype starting point for gathering clinical data (Figure 6). In addition to this, smile pictures now allow for remote communication between the technician and the restorative team, and in some cases also involve the patient.

This digital design allows the restorative team to have input regarding the diagnostic design by super-imposing the design data into the patients’ smile pictures. This process is done through accurate STL model matching. This feature also allows patients to experience a digital try-in of the prosthetic device (Figure 7).

Many researchers point to the virtual eradication of postdelivery issues. High spots, bite changes due to processing errors and even base cracks, and teeth debonding have become rare with these new materials.

Design archiving of the patients’ final smiles gives the restorative team the ability to deliver future dentures without requiring additional try-ins. This also provides the option to remake a lost denture from the data without requiring any clinical chair time.

From a fabrication perspective, additive platforms, such as carbon printers, not only allow for scalable (Figure 8) and therefore cost-effective production, but also produce polymers exhibiting fracture resistance almost 3 times that of hand-processed, high-impact acrylics.

In the past, equipment costs were seen as the biggest expenses in prosthetic manufacturing; this was seen as a barrier to modernizing denture production. While traditional techniques require less expensive hardware, the least expensive platform is in many cases no longer the most economical option. The ability to purchase polymer in bulk drives the unit cost down and in some cases, this can even nullify the additional hardware cost of shifting to a digital platform. Consumable costs now have the largest influence on product pricing. It is important to not only consider the equipment cost, but also calculate how the material choice will affect the total unit production cost.

These second-generation polymer materials are ultimately the glue that binds digital design, clinical workflows, diagnostic planning, and communication with production that requires minimal hand processing.

The dental laboratory of the future will most likely continue to struggle with labor shortages, price pressure, and scalability demands. Unfortunately, employing today’s advanced technologies without functional and esthetic materials will not satisfy patient demands.

What was once an equipment and software evolution is now quickly becoming a materials race. Modern-day additive materials will continue to advance at an exponential rate and will undoubtedly continue to influence clinical workflows and processing techniques in a positive way (Figures 9 & 10).

Implementing and mastering the correct combination of these new-world technologies and materials will ultimately define the dental lab of the future.

Stef Vanneste, vice president and general manager of dental at 3D Systems

“The digital dental segment is growing rapidly. Oral specialists in segments such as orthodontics, prosthodontics, and implantology are increasingly embedding digital workflows in their daily practice. This year we have seen increased interest not only from dental labs, but also from clinics to invest in digital applications.

For 2023, we intend to build on our training and educational programs. Keeping this focus is key to ensuring better patient outcomes. With the introduction of new printers and new 3D printing materials on the horizon, we hope to enlarge the number of applications and further open up the field of digital dentistry.”

Kris Schermerhorn, CDT, owner of Northern Virginia Dental Laboratory

“In 2022, our industry has seen great advances in both materials and digital workflows. While the last 15 years of digital milling focused primarily on crown and bridge materials, I noted an increased focus on milling plastics and other polymethyl methacrylate (PMMA) applications in 2022. There is an increased demand for PMMA and other plastics for production of removable restorative solutions. While milling set the standard for digital production of removables, 3D printing has undoubtedly made some advances in the last year. However, it is still a somewhat new technology, and most clinicians or dental lab technicians are not willing to rely on 3D printing to fabricate permanent restorative solutions. Digital dental milling technology and millable materials have been used for many years by dental lab technicians and have a reputation for accurate and reliable restorative outcomes.

Looking forward, I expect we will continue to see positive expansion of millable materials and digital workflows. With innovative milling solutions like Roland DGA’s DGSHAPE DWX-53DC dry dental milling machine with automatic disc changer, laboratories can become more efficient and expand their production capabilities. The DWX-53DC’s combination of faster milling strategies and larger tooling make milling partials and dentures a smart and profitable choice for dental laboratories. Materials like PMMA, DuraFlex™ and Zirlux Acetal are being produced in puck form, and laboratories can complete digital workflows using materials proven reliable on the analog side.”

Stijn Hanssen, director of dental applications and business development at 3D Systems

“The trend of digitizing procedures and treatments in dentistry is continuing in full force. More and more practitioners are embracing digital technology in their practices, allowing an expanded scope of procedures to benefit from digital workflows. 3D printing is well established within dental laboratories, and dental offices are beginning to embrace it as well. With smaller, more affordable 3D printers, combined with improved materials, chairside printing for crowns and bridges is becoming more popular. Next year promises to be another very exciting year for digital dentistry and 3D printing in general. While hardware improvements seem to focus mainly on platform size, the material developments will be key in enabling the full integration of 3D printing in the dental office for long-term restorations.”

It’s been a year of ongoing challenges for laboratories, but a positive shift in the adoption rate of 3D-printed dentures provides the opportunity to solve some of those challenges. One of the most daunting challenges for labs continues to be the shortage of experienced technicians, especially experienced removable techs. 2022 NADL demographic data from Valmont Research shows that 60% of technicians are over the age of 55 and only 24% are listed as “most experienced” removable technicians.

Labs that are successfully overcoming the removable technician shortage are enacting strategies to simultaneously move experienced technicians out of analog production roles and train them on digital processes, such as denture design, while hiring less experienced technicians or even employees from outside our industry to perform the 3D-printed denture production steps. This strategy allows labs to develop internal training programs, overseen by experienced technicians, while eliminating many of the labor-intensive steps required to produce an analog denture.

Labs transitioning from analog to 3D-printed denture fabrication often struggle with the task of training technicians to design dentures. To help labs streamline and simplify this process, 3Shape and Carbon partnered to develop a comprehensive digital design training program, exclusively for Carbon customers, covering all aspects of digital denture and splint design from case entry to exporting designs to the Carbon printer. The modular educational platform tracks a technician’s progress in the program, tests their comprehension, and provides them with a certificate of completion. Technicians can complete the training from anywhere, eliminating the need to train during the workday, which prevents production bottlenecks, and they can also access live training and case design support from 3Shape experts at a reduced cost.

The other major trend, 3D-printed denture adoption, is growing due in part to new materials and available workflows, and studies and data show the fit of 3D-printed dentures is superior to milled.¹ In the past year, Dentsply Sirona has expanded the Lucitone Digital Print Denture™ System by releasing on-label workflows for printed and milled denture teeth, an economy and a premium tooth resin, and 4 additional digital tooth libraries, which have all contributed to the ability for labs to increase the conversion of analog cases to digital.

Focusing on the clinical side of the industry, the continued growth of the dental support organization (DSO) market is a trend labs should be aware of and should commit time and resources to developing a strategy for. Industry statistics show that in 2019, 10% of the dental workforce was affiliated with a DSO. That number has likely only continued to grow, especially considering 30% of dental students planned to join a DSO after graduating in 2020, and that number was only 12% in 2015.^2,3

When consulting with Carbon labs, I build simple yet effective strategies for competing in the DSO space, especially the small to emerging DSO segment, because these groups are in less organized structural phases and often place a higher value on customer service, training, education, and standardized digital products than more organized large DSO groups, who are more likely to leverage their high restorative volume to drive restoration prices low.

Overall, I expect this trend to continue. At some point in the future, all labs could have some volume of DSO customers of varying sizes. I highly recommend labs develop a DSO strategy. Start by working closely with your current accounts as they link up with other dentists, forming small groups to learn their needs, or initiating conversations with accounts who join existing groups to see what unique services you can provide.

References

1. 1. Grande F, Tesini F, Pozzan MC, Zamperoli EM, Carossa M, Catapano S. Comparison of the Accuracy between denture bases produced by subtractive and additive manufacturing methods: a pilot study. Prosthesis. 2022;4(2):151-159. https://doi.org/10.3390/prosthesis4020015
2. 2. How big are dental service organizations? American Dental Association Health Policy Institute. July 2020. Accessed November 14, 2022. https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/research/hpi/hpigraphic_0720_1.pdf
3. 3. Istrate EC, Slapar FJ, Mallarapu M, Stewart DCL, West, KP. Dentists of tomorrow 2020: An analysis of the results of the 2020 ADEA Survey of U.S. Dental School Seniors. J Dent Educ. 2021;85(3):427-440. doi:10.1002/jdd.12568

History is easy to write about. The future? A littler murkier. The dental laboratory industry has decreased from about 18,000 labs when I started in 1970 to about 4500 today. Meanwhile, the number of general dentistry offices has increased from roughly 100,000 to more than 150,000 today. Why the difference in growth rates?

In a word: consolidation.

The average number of lab employees 50 years ago was 2.7. Today, the average is closer to 10. Every indication is the overall lab count in the industry will continue to decrease to approximately 3500 over the next decade. Manufacturing equipment and automation processes will result in productivity gains for those who can afford the high entry costs, but squeeze out those who choose not to make the investment.

Adoption of digital dentistry surged during the COVID-19 pandemic. Intraoral scanners are more and more prevalent. It won’t be long before they supplant conventional impressions as the primary method. Even conventional impressions are being digitized directly upon receipt via purpose-built micro-CT scanning machines, instead of being used to pour and scan stone models (Figures 1 & 2). Why suffer the deficiencies of plaster when you can die trim at high magnification in a virtual “mistake-free” environment?

Increased automation should make offshore labs less attractive. Homegrown robotic production and 3D printing advances will make international sites such as China an unnecessary inconvenience for United States dentists. Some labs that outsource to China are looking for other low-cost labor markets. This is not only because the autocratic government can shut down an operation unexpectedly, but also because of rising labor costs in China.

Figure 1 : Custom impression scanner for enhanced efficiency.

Figure 2: Custom impression scanner for enhanced efficiency.

Figure 3: Custom automated production is the way of the future.

Figure 4: Custom automated production is the way of the future.

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The big challenge to our industry is not international production, but the rising strength of dental support organizations (DSOs). DSOs have Wall Street investors. Their insatiable demand for profits means they want you to make less. Their business managers demand low, low prices on all lab products. We have never been trained to properly price our products for this business model. Many labs are feeling the pain of discovering they accepted cut-rate pricing that negatively impacts their profitability.

DSOs don’t require that you stay in business, only that you supply low-cost products. If their present lab fails, they just go to the next lab in line, which is excited by the short-term prospect of increasing their sales volume. To what advantage is that increase if you can’t sustain it?

Before 3D printing, lithium silicate, and zirconia, one could make a fair living as a dental ceramist. If you’re like me, you were one of those. New materials made us irrelevant. Today we print models that were once made in our plaster department. Printing can process a full denture? How did that happen?

It’s not only the materials and equipment that changed us. It’s the development of software that makes designing patient-specific dental prostheses easier. We all go to a trade show and marvel at exciting advances being made. All increase our productivity while challenging our usual ways of making teeth, which costs some of our employees their careers. It’s progress, but on a personal level, it hurts.

The future? From this perspective, it seems like it will hold more hurt. Automated milling machines are taking over. If you are a ceramist, uninterested in reinventing yourself or investing in perpetually advancing technology, you’d better retire soon. Even CAD designers will be challenged by artificial intelligence (AI). AI replaces the human decision-making process with unvarying precision.

We are becoming less dental technicians and more business operators. We used to handcraft custom products. Now we are engineers learning to automate mass customization (Figures 3 & 4). Despite their unique nature, restorations will continue to become more like assembly line products—akin to packaged goods hanging in a store.

Let’s hope the patient benefits from this change. Ten years from now, another 30% of us will no longer be here.