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Even labs that haven’t yet taken the first step in the process of “going digital” by investing in a scanner should be aware of the ways CAD/CAM can improve the efficiency of laboratory operation and how to get technicians on board and procedures in place to maximize advantages. Concrete steps can be taken to helping labs to increase the quality of the restorations they create by developing quality systems and checkpoints for production, improve lab efficiencies by streamlining workflow, and eliminating waste without compromising the end product.
Taking the Plunge
The three levels of CAD/CAM in the lab, are: having no CAD/CAM equipment in house, having just a scanner to create digital files that are sent to an outsource company for design and fabrication, and having a complete system to do scanning, design, and milling restorations in house. Laboratories generally evolve from one level to the next, investing in equipment and training as their business grows.
Level One—No CAD/CAM Equipment
Owners of small laboratories—particularly boutiques with a reputation for creating handcrafted high-quality restorations—may be reluctant to use digital design and manufacturing processes for fear that it will negatively impact the quality of their restorations. But with the technological advances seen over even the last 5 years, it may be time for even the smallest labs to consider incorporating digital technology into their fabrication process in some form, while continuing to provide the artistry their clients expect. Working with an outsourcing partner capable of machine fabrication with a validated manufacturing process can enable them to offer products that they previously could not provide accurately and consistently. Many outsource companies also offer the ability to preview design so technicians can verify their accuracy. This “first step” requires no purchase of new equipment or software and minimal training, but it does involve longer turnaround time due to transit, plus there will be shipping costs and outsourcing fees.
Level 2—Scanner Only
Lab owners who have already purchased a scanner can scan their models and send the digital file to an outsource partner for design and milling or printing; or they can design the case before sending that file to the outsource company for fabrication. The first scenario is advantageous for those labs that don’t have a design technician. They can leave the design process to the experts. The second scenario gives the laboratory complete control over the design of the restoration. Design software allows for flexibility; when a change needs to be made to the design, it’s easy to pull up the file and make the necessary adjustments. The software will also check the parameters of the product being designed to ensure adherence to the manufacturer’s specifications. With the ability to scan (or scan and design) and send, production levels usually increase, and less expensive technicians can be utilized to perform these tasks. Because the outsourcing partner receives the file instantly, the outsource company can get right to work; shipping costs are reduced because there are no heavy models, and turnaround time is halved.
The challenge most labs face when considering this level of digital technology is the expense of the equipment and the need for training. When deciding who should become a designer, dental IQ is more important than computer skill. The designer needs to understand tooth morphology and function if the CAD/CAM department is to be successful and productive. A dental technician who has been a waxer or ceramist and has computer know-how would be an ideal choice.
Level 3—Scanner and Mill/Printer
Level 3—scanner plus CAD/CAM—requires the greatest financial investment and represents the highest level of commitment to digital technology, but it also offers the greatest advantages when capabilities are maximized. With digital technology integrated into the laboratory, there is the ability to scan, design—performed by a trained technician—and mill, a mix, that creates a very efficient CAD/CAM workflow. As a result, the lab can expect accurate, consistent restorations, higher production levels from employees, lower labor costs, and increased laboratory capacity. There remains the option of outsourcing any or all of the process, but it isn’t required.
Given the expense, it is essential that the system purchase be justified by a return on investment (ROI) that factors in the cost of implementation and equipment maintenance costs, as well as purchase price.
Outsourcing
Outsourcing has made every type of product available to every lab. Despite the cost, many well equipped CAD/CAM laboratories choose to outsource a portion of their work—for example, long span zirconia bridges—to a partner more experienced in the “trickier” aspects of fitting such restorations or others they consider too time consuming or outside their realm of expertise. In this instance, the author recommends making an actual wax up of the design for the outsource company to copy, and also send the models along so that they can make sure the bridge will fit correctly after sintering.
No matter how much or little a laboratory works with an outsourcing laboratory, it is important to choose one that provides consistent and reliable results and makes a sincere effort to meet quality standards. Although it may require some adjustment on both sides to build a lasting relationship with a company that will be a true resource, expectations should be made clear at the outset. Desirable qualities in an outsourcing partner include easy telephone access, problem-solving focus, and providing staff training and technical support.
Digital vs. Analog Workflow
Why choose the digital way in terms of workflow? In many ways, the traditional analog method is faster and requires no expensive equipment. Calculating the time it takes to move a gold crown through the digital workflow must consider the following: design time, mill time, adjusting the wax unit to fit on the model, and then sealing the margins. Although digital designing, in terms of the technician’s hands-on time, is faster in most cases than hand waxing, it typically requires more time in the lab. A highly skilled crown-and-bridge technician can wax a gold crown and in a very short time, have it invested, while it takes two to three times as much time to get the digital unit invested.
However, digital workflow enables the lab to increase the capacity and the productivity of its most highly skilled and expensive hands-on techs, while less skilled techs with an adequate understanding of tooth morphology and function can do designing, which is faster than waxing. A good designer can produce up to 40 units of full contour design per day, whereas a fast hand waxer can do about 25; the milling requires no labor at all. One of the most important things to keep in mind when deciding which workflow to use is to maximize the productivity of the most highly skilled—ie, costly—technicians, and having less experienced techs doing the bulk work to support them. A digital workflow lends itself to this goal; when utilized properly, productivity and capacity rise and labor costs fall, compared to the analog workflow, which can be used, if necessary to complete a rush case in less time.
Integrating Digital into Analog Workflow
Integrating CAD/CAM into an analog workflow can be daunting for staff accustomed to a familiar way of doing things. The key to a successful CAD/CAM integration is getting the hands-on technicians to buy in to the whole digital concept in the first place. Right from the start, the emphasis should be on quality.
Designers should understand tooth morphology, esthetics, and function well enough to put the most beautiful tooth design into the system to achieve the level of precision and artistry the ceramists are expecting. It will make a difference to the crown and bridge staff that they be provided with machinable waxes that behave more like regular wax, so they are able to more easily deliver quality in keeping with their high standards; these products may be more expensive than those that mill well but are difficult to adjust, if necessary, after milling.
It’s important that technicians become accustomed to digital technology as part of the everyday production workflow and to understand that technology isn’t going to eliminate their jobs, but will make them easier. By automating as much of the process as possible, always without compromising quality, the hands-on techs have more time to do what only they know how to do, thereby increasing their productivity, increasing the capacity of their department, and as a result, saving labor dollars without negatively impacting the quality of the restoration. Digital technology also allows less skilled technicians to perform tasks that would be beyond their ability if they were to try to do them by hand.
Where Leadership Comes In
Probably the most important factor that affects all aspects of laboratory production is effective leadership. The goal of effective leadership is twofold: (1) to be able to say things only once and know repetition will not be necessary; (2) to be able to fix things only once and never have to fix them ever again
A strong leadership structure with very clear rules of engagement will lead to a very smooth, efficient, and more profitable production. Strategic planning and implementation will be more effective and more likely to be successful with leaders who follow through with the plan and report results to superiors. Morale will also improve with a clear line of communication for everyone in the lab, from the top down and from the bottom up. All department managers should be held accountable for their departments, reporting each day to their managers regarding the status of a task or project they are working on, the state of their department, and a report of the smaller decisions that were made throughout the workday. These managers are the eyes and ears of upper management. The goal for lab owners or general managers is to have confidence that their team has everything under control.
Plan to Succeed
Laboratory owners should plan to succeed first by building an organization chart that makes sense for their lab. Larger labs will probably want to have a more narrow span of control, or fewer direct reports per supervisor, whereas a smaller lab might be effectively led with a wider span of control or a larger number of direct reports supervised by one manager.
Based on the initial organization chart, the owner can determine the ideal organizational structure for the future of the lab, then begin filling the gaps. With growth, the owner should either promote from within or start recruiting those in key positions, who should be given the appropriate amount of authority and held accountable for results.
Conclusion
The optimal use of the CAD/CAM workflow can improve lab efficiencies by streamlining workflow and developing quality systems and checkpoints for production while at the same time increasing production and improving quality. However, there are many different ways to do things right. It all depends on what works for a given laboratory and its customers. Ultimately, their doctors let them know how well they are doing, either by sending them more of their cases or sending them somewhere else.
