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A few years ago, the burning question in our industry was if laboratories should get involved in CAD/CAM technology. Today, with zirconia and digital manufacturing taking the industry by storm, the question has become not if, but how should laboratories get involved.
Given the high costs of the systems, rate at which technology is advancing and desire to keep operations simple, the answer for many laboratory owners is outsourcing their CAD/CAM copings and frameworks to another laboratory. "Since I don't own a system, am I going to tell my clients to send their work to some other lab? No--I'll outsource it and doing so allows me to compete with anybody," says Evan Penrod, owner of Crown Laboratories, Sandy, Utah.
While outsourcing is not new to our industry, CAD/CAM has brought it to a whole new level: Of the respondents to a recent LMT e-survey, 83% offer CAD/CAM-fabricated restorations and nearly 60% of that group have the understructures fabricated by an outside lab.
Although CAD/CAM technology offers an automated manufacturing process, the results depend largely on the skill of the technician designing the restoration on screen once it's scanned. "As great as CAD/CAM technology is, we're the ones running the computers and virtually designing the restorations, so there's still so much in the hands of the technician," says Peter Pizzi, owner of Pizzi Dental Studio, Staten Island, New York. Understanding ceramics and tooth morphology is key to designing a good CAD/CAM coping or framework."
As a result, laboratories that are outsourcing quickly realize that getting the results they want requires proactive communication. Mark Tillman, who began outsourcing about four years ago, knows this firsthand. "It didn't take too many cases for me to figure out that if I didn't give the laboratory any information, the technician would mill the coping following the contours of the prep," says Tillman, partner, Spectrum Dental Lab, Santa Ana, California. "Even if the coping needed to reach 3-4mm to get an ideal contoured crown, I was getting copings that wouldn't support the porcelain."
To address this problem, Tillman implemented a protocol to clearly illustrate his expectations: he sends an illustration, including specific measurements, that shows the technician exactly how the coping should be designed; the prep is drawn in one color and the coping in another. Since implementing this strategy, Tillman only has to slightly reshape about one out of every 20 copings he receives.
While users know they could gain total control of the design process by purchasing an in-house scanner and designing the restorations themselves, some aren't ready to make this investment or take on the additional production time. So, like Tillman, they're implementing a variety of strategies to get the results they want, including:
Pouring up two models. Many labs keep one model and send the other to the outside lab so they can communicate over the phone and both be looking at the same thing.
Blocking out or modifying the die, if necessary, before it's scanned. For example, if a case needs more support because the adjacent tooth is too far away, Penrod manually waxes out the die before sending it to the laboratory to be scanned to be sure the milled coping will adequately support the porcelain. "If I relied on my lab to create the distal contact, there's no guarantee it would digitally design the coping the way I want," he says.
Reviewing the final design of large cases. For larger cases, like bridges, where remaking an already-milled framework would be especially costly and inconvenient, Pizzi asks to see a scan of the design before it's milled. He now receives a JPEG of the framework via e-mail, and if the design needs to be tweaked, the lab fixes it and sends him a second image to approve.
Photographing problems. If you receive an overextended coping, photograph it before making your adjustments, then send the laboratory the before and after shots so it can see what you're looking for.
Requesting a remake. In situations where you can't live with the work, send it back. "It doesn't happen very often, but if a substructure isn't to my liking, I'll mark the deficient area, take a picture and e-mail it to the other lab so they can see the problem," says Mike Williams, co-owner, Arlington Dental lab, Indianapolis, Indiana. "In most cases, they'll redo the case at no charge."
A successful partnership
As with any outsourced work, a good way to gauge whether or not a laboratory can deliver your desired level of quality is to send some test cases before you start offering the restorations to your dentist-clients. For instance, Penrod found three potential candidates, then sent cases to each and compared the work--as well as the service he received. "It's kind of like hiring an employee where you do several 'interviews' to find the one you like best," he says. "The lab I chose had technicians who were easy to talk with, dealt with problems immediately, and did a bit of handwork on the coping before it was sintered to be sure the margins were where they belonged. The staff really showed that it was paying attention to the details."
It's also important that the outsourcer's product offerings match your needs. If, for example, your clients are asking for a range of brands, be sure you're working with a lab that offers them all, or be prepared to work with more than one laboratory. Click here for a comprehensive chart of features and indications.
Like everything in dentistry, successfully outsourcing your CAD/CAM restorations to another laboratory is about good communication and if you take the time to establish a good foundation, you're more likely to be happy with the results. Most of the respondents to LMT's e-survey are: nearly 90% report being satisfied or very satisfied with the quality of the copings and frameworks fabricated by their partner laboratory, and more than half of the respondents say they plan to continue the arrangement over the next five years.
And once users find a lab they like, they stick with it. "I've been dealing with our lab for years and it makes sure we get what we need," says Williams. "I might be able to get less expensive work somewhere else, but for us that's not part of the equation. I want loyal clients and I want to be a loyal client, too."
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