Something for everyone

You probably can’t do everything all by yourself, and you might not want to even if you could. The good news is there are plenty of outsource laboratories-right here in the U.S.-willing and able to help you. Some can help with everything, while others specialize in helping with certain case types or with manufacturing all, or just part, of the restorations you need.

But the bottom line is, there are plenty of options out there. Here three experienced laboratory industry leaders share their stories and discuss some of the many services offered by their large facilities-Dave Lesh, CDT, President of Dale Dental; Mike Girard, RDT, President and CEO of Diadem Digital Solutions Inc; and Bob Miller, CDT, President of Custom Milling Center (CMC)-but these are just some of the many outsource opportunities available that you, as a lab owner, may want to consider.

If you’re working with traditional models and impressions, there are outsource facilities ready to take your models and offer up a wide variety of milling and manufacturing options. If you’ve invested in a scanner already, the technology advances you can take advantage of can lead to reduced labor on your end, reduced or entirely eliminated shipping costs, quicker turnaround, and most importantly of all, the opportunity to offer your clients every type of material and restoration on the market.

“At the end of the day, the way I have always looked at Dale is as an enabler for all labs. We make it possible for labs of all sizes to compete effectively and to offer every restoration they need to offer their dentists,” Lesh said.

Sometimes, all of these decisions regarding outsourcing options and technology purchases can be a little overwhelming in terms of what to do and when. But that’s no reason not to get on board, not with digital technology changing the way we do things on a daily basis.

“I think this is the most amazing time in the dental lab space but it’s probably for many labs the scariest,” Girard said. “Even so, I think there’s no better time to embrace digital.”

No scanner, no problem

Extraoral scanners and intraoral digital impression taking devices have made an impact with both laboratories and practices in the last few years. Even so, the majority of laboratories still ship models to their outsource partners so large milling facilities have to be ready and able to handle all types of requests.

Miller said one of CMC’s business models is positioned to meet the outsource needs of laboratories that have not yet purchased an open scanner/software to send STL files electronically.

“For these laboratories that send us the models and dies, we can scan, design, mill, sinter and return a finished substructure that exhibits exceptional marginal integrity,” he said.

Miller said employing experienced technicians and design personnel allows CMC to serve as the laboratories’ partner, helping to reduce their labor costs, and at the same time, broadening the range of products to which they can add their signature touch. “They can stain or layer the restoration before returning it to their doctor.”

Systems presently used at CMC include 5-axis milling machines, the envisionTEC DDP rapid prototyping printer that prints bridge frameworks to full anatomical crowns, a Haas Mill for milling Cadent iTero models, along with Dental Wings, 3Shape, Lava, and E4D systems for various substructures or crowns.

Miller’s facility, which is adjacent to Henry Schein’s laboratory division, Zahn Dental, provides interactive training with the Dental Wings software, and offers non-precious restorations (chromium cobalt) and Ivoclar’s e.max CAD or Press along with other products and related services listed on the CMC website.

Miller and Lesh both pointed out that laboratories working with outsourcers benefit tremendously by being able to offer everything to their customers including products they themselves either cannot or do not want to fabricate themselves.

Lesh, whose Dale Dental facility serves more than 3,500 U.S. labs and was the first exclusively for other labs and does not compete for dentist customers, works with many technicians who still pour models the traditional way. “There are a lot of labs that have yet to get scanners. In fact, the majority of labs still don’t have scanners,” he said.

Those on board

The laboratories that have gotten involved with the scanning portion of today’s technology can benefit from increased speed, consistency, efficiency and turnaround, not to mention reduced labor expenses and mess when compared with traditional methods.

Lesh, Miller and Girard all believe labs should get their hands on a scanner to at least get their foot in the door of the industry’s ever-evolving technology. “If they scan themselves, they have the benefit of being able to design the case and then they send it to someone else to mill,” Lesh said. “They don’t have to maintain and buy all of this equipment.”

“To me it’s a no brainer,” Miller added. “Laboratories that don’t see the opportunity that’s being presented to them and embrace our digital world is somewhat frustrating to me because to keep our laboratories relevant, they really need to at least purchase or lease an open-architecture scanner. When the laboratory owns a scanner, the benefits are many. They are in charge of their design, they don’t incur any shipping charges, as the data is being sent electronically, and CMC pays for shipping for them to the lab. Since the laboratory is providing CMC with a design, another benefit is a lower per-unit cost as well as a faster 24-hour turnaround time.”

Diadem, which boasts state-of-the-art learning centers in both Windsor, Ont., and Troy, Mich., uses the Roeders industrial precision milling system with RC3 robotic automation to supply laboratories with precise restorations including copings and frameworks, one-piece crowns and anatomical patterns. Following the 2008-2009 meltdown of the automotive business in the Detroit area, Girard was able to hire some extremely talented engineers who manage and operate his facility, which runs on a simple business model.

“We are NOT a lab!” Girard said. “The lab technicians should own the scan and design, do the final esthetic finishing-the ‘artwork’-and they should own the relationship with the dentist. Diadem will buy the machines, run the machines and maintain them, and most importantly buy new ones when the existing equipment becomes outdated.”

The company prefers not to accept models, but it has several incentive programs to make entry into the digital world financially painless for lab owners, Girard explained.

“Digital impression technology is slowly being adopted, and labs need to get ready. When your dentist calls and says ‘I’m sending you some impression data,’ the days of getting out a rubber bowl and plaster to start the restoration are over, or will be soon,” he said while stressing the importance for today’s laboratories to get on board with digital technology. “So for anybody with software and maybe a desktop scanning device, the world is at your feet now.”

This is not to say, however, that laboratories will need to work any less with their dentists in terms of communicating and sharing ideas.

“I believe this is still very much a relationship business, and the digital world will enable labs in ways they never thought possible,” Girard said. “There has never been a better opportunity for small lab owners to get their head up off their bench and become a good concierge to their dentists. Own the scanner and design at the front end; own the relationship with the dentist and work hard at that. I believe in my heart that the world is going to change.”

Many of our readers also expect change. In Dental Lab Products’ January 2010 Online Poll, 82.3% of lab owners and managers said they believe fabrication processes will be more digitally controlled in the future. Additionally, 58.2% of respondents feel intraoral digital impression capture technology is one that will have a great impact on their business in the future.

Advice offered

Laboratories may want to do a little homework before choosing just any outsourcing partner, and Lesh advised one prerequisite is to make sure the lab you plan to work with is FDA compliant.

“FDA requires that if you’re outsourcing, even completely within U.S. boarders, that you outsource to only FDA GMP-compliant labs. So, labs should make sure they’re working with labs they are legally allowed to work with” said Lesh, whose Dale Dental facility was the first lab in the U.S. to become ISO third-party certified compliant (ISO addresses the FDA GMP requirements). Dale also provides its customers with a certificate of its compliance to use in the event the customer gets inspected by the FDA. There seems to be a lot of confusion around the issue, but the lab customer is in violation of the FDA’s GMP requirement if they use an outsourcing lab that is not in compliance.

Next, you’ll want to make sure your partner can handle all of your requests in a timely fashion. Some large outsourcers serve as exclusive distributors in the U.S., while some also are certified to deliver specific products manufactured by other companies. Dale Dental, for example, became the exclusive distributor for BioCad (by Noble Procera) and DENTSPLY’s ISUS CAD/CAM implant bars and is certified in the other 15 brands of the restorations they offer including Lava, Captek and Straumann.

CMC offers numerous zirconia choices, Noritake’s Katana and Lava, but also has branded its own Pearl Zirconia, which is manufactured to ISO standards and certified with IdentCeram.

Miller said the results with CMC’s own zirconia brand have been strong. “Pearl Zirconia is actually made to our specifications by a USA materials company excelling in the manufacturing of ceramics,” he said. “Pearl Zirconia is milled from a shaded disc which exhibits exceptional translucency that we’ve had excellent success with, from single copings, full contour Zirconia to a 14-unit bridge. With improved software and 5-axis milling, what we deliver is a phenomenal product.”

When designing and sending STL files, a quick turnaround is an added bonus. “Using Monday as an example, if the laboratory technician scans and designs zirconia units, and we receive that file by 2 p.m. Mountain Time, CMC has the substructure back to them by Wednesday a.m., ready for them to begin the final process,” he  said. “It’s a fast turn time, no shipping charges, lower units cost, and the laboratory is in control of their own design.”

Primarily focused on milling IPS e.max “monolithic” material, Diadem was the first facility in the world to be validated by Ivoclar Vivadent for industrial milling of IPS e.max CAD. Now Nobel Biocare and Straumann join Diadem, but they are the only three facilities in the world validated by Ivoclar. Girard said he hopes to build relationships with a few hundred labs milling 2,000 units of IPS e.max per day at scale.

The way Lesh sees things, some labs make the mistake of getting too involved in milling when they might be better off leaving that to larger labs while concentrating on delivering the more value-added parts of the restorations.

“What a lot of labs do is they become a milling center, not so much by design, but they go ahead and buy a milling system because they’ve reached their critical threshold at which point it makes sense,” Lesh said. “It might be five or 10 units a day depending on the system.”

Lesh said a common mistake that often follows is taking on more milling jobs just to fill idle capacity, when doing so might take the technician away from more profitable functions.

“They buy a CAD/CAM system and decide to get into the lab-to-lab outsourcing, in addition to working with dentists to fill up the extra 20 or so units the machine can make a day. That’s typically how it starts. But at the end of the day, it can be a money loser,” he said. “Why would you use your capacity, and even buy more capacity, to sell copings for $70, when you can put ceramics on it and sell the same coping for $180?”

Once again, here is where doing a little extra homework can be a big help. There are an awful lot of options available today-it just may take a little research and planning to find out what’s best for your business.

What’s next?

It is an exciting but challenging time, and it is taking some labs awhile to adapt to this rapidly changing dental technology world, Girard said.

Prior to joining the Nobel Biocare team in 1997, Girard worked with a large lab group for nearly 20 years wearing a number of hats. “I thought I could become the traffic controller, but in those days it was a difficult task to get lab managers to share work back and forth,” he said. “When I helped launch the Procera Division in 1997, the word ‘outsourcing’ didn’t exist. Nonetheless, with a small but passionate team we built a pretty good business for Nobel. Some say Procera paved a new road for many of the centralized milling facilities that exist today. The Procera outsource business model was a pretty large leap of faith for laboratories at that time.”

Despite the initial obstacles involved with some major changes in the way technicians and lab owners think and operate, the concept caught on and has since proven to be a good way of doing business for many.

“In those early Procera start-up days I felt like a pioneer,” Girard said. “It was certainly a new trend recruiting labs to send data from a scanner to Stockholm. Then in addition we asked them to let us make half the crown and we made the understructure out of aluminum oxide, not metal. It was quite a paradigm shift!”

In 2004, Girard left Nobel and moved to Boston. He joined two young Harvard Business School grads who founded Brontes Technology. He helped them build the company that was acquired in 2006 by 3M ESPE, which soon after launched the product as the 3M Lava C.O.S. digital impression device.

With Cadent’s iTero, the 3M ESPE Lava C.O.S., E4D’s system and Sirona’s CEREC AC digital impression systems soon to be joined by several competitors, Girard expects digital impressions to have a great impact on the industry in the near future.

“It’s my opinion that two years from now, we’re going to look back and it’s going to be like 35mm film. We’re going to say, ‘Where’s the impression material?’” Girard said.

Lab owners are getting bombarded with new technology, especially in the CAD/CAM arena. The recent estimate is that there are about 180 systems on the market. “I’m afraid many of those companies won’t be around in five years. Where does that leave the owners of the system?” Girard said. “Even outsiders to our industry are watching dental technology. The last cottage industry will continue to go through some incredible transformation in the next few years.”

But for now, there’s no question every lab should at least investigate the variety of their possible options of working with an outsource partner.

“Outsourcing makes it possible to move the small at-home lab business from the garage or basement, to the living room,” Lesh said. “That’s the big game changer. You’re not slinging metal in a casting machine, grinding metal and making a mess. Now you can sit at a desk in a nice room, send out your impressions or models, or even design restorations on a screen, and have someone like us mill it, send you back the parts and pieces. You paint them up and sell them.

“That’s the best model. The dentist maintains the local lab relationship they prefer, and the lab has access to all the restoration types they need to offer to the dentist. Through technology, one technician in a room can offer the same restorations and more than even the biggest labs in the world. The difference is, that guy is local. And the dentists tell you they want to work with a smaller local lab,” Lesh said.

And labs don’t need to rush into CAD/CAM right away. “My point is, they don’t have to jump in with both feet. They can do it in segments. They can start by outsourcing through sending models and impressions, then buy a scanner, and if their demand continues to grow, they can get a printer or a milling machine and have it all in-house. It’s a changing field, but it’s exciting. The ones that are embracing this technology are realizing what the advantages can be.”

“The funny thing was, 10-15 years ago everybody thought technology was going to kill the small lab. But it’s just the opposite,” Lesh added. “Through companies like Dale, it’s enabling the small lab.”

He said domestic outsourcing and technology is not only great for labs of all sizes, but also is an ally in battling offshore labs. “Our equipment is not nearly as big a part of the manufacturing cost as the labor costs it saves. Those efficiencies are what will help domestic labs keep their prices competitive with the rest of the world whether we’re making all ceramic or conventional PFM restorations. It’s win, win, win on a lot of levels."