The Rush to Digitize
New developments that will propel dentistry even farther on the digital highway.
By Pam Johnson
Digital technologies have spurred a fundamental and organic transformation within the dental industry. They are changing the ways in which dental professionals capture and transmit oral data, how they formulate diagnostics and treatment planning, and which materials and processes they use to produce their end products. With these new tools, industry manufacturers are also re-working their foundational structures and functions—ultimately, altering what they do and how they do it. As core competencies, systems, and processes become further integrated, they will create more streamlined solutions and open the door to possibilities that were once merely pipe dreams. And as digitization works its way into various processes in the operatory and laboratory, the links between the industry's manufacturing and service communities will evolve, crafting new processes and business models that will rev the economic engine for growth.
For laboratory owners, the digital invasion has revolutionized conventional thinking about production processes, material selection, and cost structures. What once was is no longer. Pressures within dental technology have forced the industry on the fast track to produce more with less manpower, with greater efficiency, and a lower price tag. For those business owners not yet engaged in the digital workflow, the explosion of new technologies, the rapid integration of digital platforms, and the advent of new restorative materials are breeding confusion, indecision, and, all too often, inaction. Meanwhile, the few early adopters who have automated their production processes are discovering promising new markets and business models, and are awaiting digital functionalities that will further change the nature of their businesses and nurture completely new types of business.
"It's taken 25 years," says Roddy MacLeod, vice president of CAD/CAM for Sirona Dental Systems. "But I think everyone would agree that today digital restorative dentistry is the future. Whether you are a dentist, laboratory owner, distributor, or manufacturer, you are looking for ways to cater products and services to that future."
Manufacturers are projecting optimism for the future as they see the market begin to loosen up and more laboratories seriously consider an entry point. Many believe the industry is right on the cusp of making the changeover from analog to digital. "Laboratory owners are beginning to unfreeze," says Mike Girard, RDT, president of Diadem Digital Solutions LLC, a large outsourcing facility in Troy, Michigan.
"They are ready to make that purchasing decision to find entry into the digital workflow," he continues. He believes manufacturers with existing digital impression scannerson the market are pushing that movement forward by using creative marketing channels to get their products in the hands of dentists and by lowering the price point to compete with the next generation of intraoral impression scanners. "Traditional impressions, like 35-mm film, will be gone," Girard suggests. "When general dentistry embraces digital impressioning, that will be the tipping point. Laboratories will have to be digitally ready to receive that file."
The rapid adoption of monolithic material solutions for restorative cases by dentists in the US serves as another impetus for laboratories to have, at minimum, digital scan and design capabilities in order to meet increased demand and expected shorter turnaround. "I think the monolithic solution is the product of the future—whether it is full-contour zirconia, full- contour ceramic, or another material, such as polymer," says Jan Slor, vice president and general manager of DENTSPLY Prosthetics. DENTSPLY just introduced its full-contour solution, but Slor believes newer restorative materials will soon be introduced that combine the strength of full-contour zirconia with the esthetics and translucency of a glass-ceramic into a single milling solution or one that can be conventionally pressed. Further down the development line, Slor foresees the capability for additive 3-D printing of ceramic materials trickling down to dentistry from other industries that have already adopted it.
However, Slor points out, nearly 75% of the industry is comprised of small one- to five-person laboratories, a majority of which are not invested in scanning, milling, or 3-D printing technologies and do not have access to capital to make that leap. That concern has some companies changing their business models to help educate laboratory owners and speed up the adoption process. "Our company is reinventing itself," says Kim Solomon, NobelProcera™ Product Manager North America. Adopting a business consultant view of the industry, Nobel Biocare has developed financial planning tools to help laboratories formulate a business plan that shows them the potential profits they could garner from investing in NobelProcera. "It is comprehensive and measurable," Solomon explains. "If they choose, they can even use these business plans when seeking funding from financial resources."
Todd Larson, president of Amann Girrbach America Inc., agrees that education is key to helping speed up adoption of digital technologies. "We want to educate rather than just sell a system," he explains. "We want to help laboratory owners ask the right questions and establish a long-term relationship with them."
Still other manufacturing leaders in the industry believe that market penetration of digital technologies will not make significant strides until the industry consolidates further. Stanley Maragos, general manager of Wieland Dental Systems Inc., thinks that smaller laboratories will find it challenging to compete against the aggressive industrial pricing structures of large production centers, as more outside capital filters into the industry and milling technology evolves for 24/7, "lights-out" operation. "Consolidation at any level exemplifies true capitalism," Maragos says. "Volume pricing structures, coupled with digital and mechanical precision are being deployed aggressively by big-box laboratories; brand value and the value proposition are going to be the key to smaller laboratories' success."
He suggests that 4 to 5 years ago, small boutique laboratories had an advantage over the quality and customized uniqueness of the restoration they could deliver versus what was being produced by scanning and milling technology. However, as advances in material science and production technology continue, that quality gap has become narrower than ever. "A consumer can expect consistent, microscopic precision out of machines similar to a highly skilled technician," Maragos says. "The emphasis now shifts from journeyman to the same expertise being translated into a digital platform."
Nonetheless, back-end industrial automated production still requires the dental technician's specialized knowledge and expertise in understanding how that restoration functions in the mouth and must appear esthetically, according to George Tysowsky, DDS, MPH, vice president of technology for Ivoclar Vivadent. "There is no doubt we are at a crossroads in the dental technology profession," he notes. His belief is that all laboratories will have to learn to embrace digital technologies. As they do, the industry will find a balance between the industrial approach and the specialty high-service laboratory. But there is no doubt in Tysowsky's mind that the laws of economics, coupled with the increased volume of indirect work in the future, will require more digitalized production centers and the consumables to feed them.
And that is why MacLeod says the industry is seeing companies, such as Argen, Whip Mix, Talladium, and Jensen, becoming a part of the digital story. "We are in the middle of the tornado of mass adoption," he says. "Everyone is focused on it. The next 5 years will be the most exciting period in digital dentistry."
In the rush to digitize the industry, corporate self-interest is definitely a piece of the pie. The flood of restorations going offshore has impacted their businesses in spite of the fact that many of these companies supply offshore laboratories with materials and equipment. MacLeod estimates that of the 50+ million restorations prescribed in the US annually, 15 million are being sent overseas for production, primarily because of price advantages. And that number is projected to grow if solutions are not found. Manufacturers believe that increased automated production, coupled with the use of new monolithic materials and the ability to deliver a model-less solution to the dentist and patient, can offer laboratories the advantages they need to compete with offshore pricing. "Glidewell, Trident, and other customers of ours are already doing this with monolithic IPS e.max® and full-contour zirconia products," MacLeod explains. "They are delivering crowns at a price point of $60 to $70 per unit, making them very competitive with China. If you need to compete on price for some customers, monolithic CAD/CAM restorations can be a game changer."
The model-less concept for single-unit restorations has been around for 25 years and adopted by chairside users of CEREC® (Sirona Dental Systems Inc., www.sirona.com) and E4D CAD/CAM units (D4D Technologies, www.e4d.com). Now laboratories are pressing forward with the concept, convincing clients to accept the accuracy of the impression scanning and milling technologies without the necessity for physically checking fit and occlusion. But for multi-unit and large reconstructive cases, the stone model is still the foundation on which the laboratory builds the proper restorative function, anatomy, and esthetics. It is a labor-intensive portion of the production chain that not only adds to turnaround time, but also to the cost of the final restoration and its price tag for the customer. If digital dentistry is to move forward, proponents say this is one of the production processes for which an automated solution must be found.
Several companies have addressed the problem on a semi-industrial level, developing CAM milling and 3-D model printing solutions. Beyond the financial means of most small and medium laboratories, these expensive, large model production units reside in the hands of manufacturers and must be accessed by the laboratory through outsourcing—again adding time as well as shipping and production costs to the equation.
However, with the introduction of the ZENOTEC T1 (Wieland Dental Systems Inc., www.wieland- dental-systems.com) in 2009 and a newly enhanced feature added to Sirona's inLab® MC XL desktop milling unit this year, in-house model milling is now within the reach of smaller businesses at a competitive price point. "The laboratory can now receive the impression scan from the operatory, design and mill the restoration, and then, as the framework is being sintered, crystallized, or fused, the laboratory can design and mill the model," MacLeod explains. "All parts of the restorative solution are completed within the same approximate timeframe and ready to deliver." Sirona is selling two model milling block sizes, both for less than $8. MacLeod estimates the in-house cost per model, including labor and block cost, amounts to about $10 to $15.
But what if the model could be eliminated completely from the chain of production, even for large cases? Slor says DENTSPLY is closely following research on technologies that industrially manufacture the framework, place a dentin ceramic layer on top of the framework, mill that dentin layer back, place the enamel layer, and then mill it back for the final restoration. The layers would be fused industrially to the framework as they move through production, using a heating process. Taking veneering ceramics out of the equation would eliminate the need for a physical model on any case. "There are also devices coming out of other industries that can print ceramics," Slor notes. "We've seen one development coming out of a technical university in the Netherlands that is capable of printing multiple layers and colors of ceramic material." Although the technology is not mature yet, Slor is confident 3-D printing of ceramics will find its way into dentistry. Dr. Tysowsky agrees. "Every major ceramic manufacturer is working on a deposition solution for manufacturing all-ceramic restorations, but that's far in the future," he says.
The digital revolution in dentistry is still in its infancy—but as it evolves, it is fundamentally changing the structure of businesses. Like other industries that have struggled with the challenges of digitizing, dentistry finds itself at a point where manufacturers and business owners alike must reinvent their business models in order to stay in the race. "It's amazing as technology takes hold how the industry gravitates toward it," Solomon says. "As that happens, new channels of opportunity open up for those who see the need and possibility."
Those new channels include helping smaller laboratories and general dentists get invested in the digital process. For example, two major industry manufacturers, 3M ESPE and Jensen Dental, recently joined forces, recognizing that the strengths of their core competencies could be optimized to further the adoption of digital solutions to both the laboratory and operatory. One company has the ability to develop new technologies and materials for the office and the laboratory, while the other provides equipment, education, and support services to its core customer—the small laboratory owner. Together, the two companies have created a new channel through which they can more rapidly bring better digital solutions to laboratory owners still seeking entry into the digital marketplace. "Partnerships between and among companies is not uncommon in industries undergoing transformation," says Joe Carofano, vice president of marketing for Jensen Dental. "I don't think our industry is unique. We have to acknowledge what we do best, identify where the gaps are, and then determine whether we are better off developing that capability or developing synergy with respected partners to complement what we do."
As the industry moves closer to a comprehensive digital platform, identifying the missing links and connecting them will be a springboard for new business models. Currently, one of the largest gaps in the industry is the absence of digital technology education. Not many dental technology programs have the equipment and curriculum to graduate technologically savvy dental technicians, and few post-graduate programs provide training on digital platforms. Most education is coming from the manufacturers themselves. But that could change soon. Plans are in the works for the first dental technology program in North America devoted to combining didactic education with a digital curriculum in the last year of a 2-year program. The goal is to produce 32 graduates a year, with a starting annual salary ranging from $30,000 to $50,000. The hope is that smaller laboratory operations would hire these graduates to provide the digital expertise they need to set up and access the digital workflow. "I think the education factor will be a huge component as more and more digital solutions roll out," Solomon says. And he believes that providing education in digital dental technologies will attract a new, younger generation to help fill the vacancies created by the multitude of technicians projected to leave or retire from the industry in the next 5 to 7 years.
The future dental technician will be a digital technician who possesses a deep understanding of computer technology, file format, milling configurations, and most importantly, the technical knowledge needed to design cases in CAD onscreen. Solomon envisions a new type of highly trained, hybrid technologist—much like a dental assistant—working chairside, especially on complicated implant cases. "They would take the digital impression, design the case in front of the patient, and push a button to send the case off to a production facility, then get it back in 24 to 48 hours for final customization and delivery," he says. "Tooth to root solutions would truly be point of service."
Along with dental IQ and expertise in oral morphology, the personalized service that laboratories provide to their customers will remain a foundational element in the industry as it reinvents itself to adjust to a digital landscape. "I think it is a matter of understanding how to bring digital technology into your laboratory, but yet maintain that excellence of service and quality by the individualized expertise you deliver to the clinician," Dr. Tysowsky says. "It's going to have to be a balance between digital production and providing the highest level of expertise and service to your customers."
But many believe achieving that balance will require laboratory owners to change their traditional approach to business and staffing. "Businessmen have to be smarter today," Maragos says. "You can no longer sit at the bench and just produce a crown." If this shift in thinking and production processes can be achieved, most manufacturers believe the smaller laboratories may have an advantage because they can more easily change direction, as the industry transforms and matures digitally. They do not have to make the same large capital investments in equipment that bigger operations do in order to grow their businesses. Yet, they will still have access to all the newest product and material offerings from a wide variety of big production centers through scanning technology. "That's why we opened a milling center as well as a zirconia milling block and ceramic manufacturing facility," explains Eddie Harms, CDT, senior vice president of operations at Talladium Inc. "We think it is important to provide our customers with digital solutions and consumable products that will keep them competitive in the market."
Small operations also have the advantage of close relationships with their clients. "They can still offer that personal attention and touch that dentists seek out from their laboratory partners," Larson says. And that is one aspect of dentistry that can never be wholly digitized, but in the future may be a premium service dentists will have to pay to get.
As quickly as the dental technology industry is witnessing the changeover from manual to digital industrial manufacturing, the end game is still far in the future. New millable material technologies, not based on ceramics or zirconia, will help dental professionals find better solutions for implant-supported restorations. New automated methods and materials for producing full and partial removable products are under development. Automated solutions for high-end anterior and large reconstructive cases are on the horizon. And new business opportunities continue to evolve and re-shape the industry. As Girard says, "This is a defining time in dentistry."