The New Orthodontic Lab
Foreword
My Mom told people for 25 years that I make teeth. I would like to point out that I don’t. I did not make teeth in the old orthodontic lab and I do not make teeth in the new orthodontic lab.
I would also like to point out that I did not want any parts of the new orthodontic lab. I am there, but I still don’t want any parts of it.
Aye, I was happy. I bought my lab in 2005 and my three year plan stretched into ten years, but I was finally there. I had the right people in the right places doing the right things. I had my flat screen television, my Netflix and I was even chasing 90 on the golf course—without cheating.
My bills were paid, I was looking to add a sixth member to my small operation, and it was even looking like I could pay off my business loan and finally give myself a raise.
All that went to hell at the end of 2014.
Nothing like this has ever occurred in this industry. The only thing that comes close was over thirty years ago. I saw the tail end of it while puttering around as a child in my uncle’s lab. That was the “ancient” orthodontic lab, where over half of a lab’s output was making bands for braces.
I remember—I think it was Bee—bending over the welding machine, wrapping band material around teeth she had cut, folding it over, and then spot welding the bands and brackets.
When pre-formed bands came out, entire departments disappeared as they became Hawley and Hyrax labs. The loss of revenue was too much for some. It was either adapt and expand or go find a new line of work.
The new orthodontic lab is a completely different kind of animal. It is learning new technology and incorporating it into the business model as opposed to refocusing on other aspects. It is also occurring at the worst of times.
The new technology can be big money. As a small lab, a micro lab, I am used to seeing bills for hundreds of dollars, maybe a thousand here and there. If a piece of equipment went down, it might be a few thousand. Now, we are potentially talking tens of thousands.
At the same time, we are losing revenue. I would hazard a guess that 65%-70% of my income is from Hawley Retainers. With the growing popularity of invisible retainers and clear aligner treatment, I have seen a 30-60% drop across the board. So, at the same time I am losing money and scrambling for new sources of revenue, I need to spend tens of thousands of dollars.
One loan gets paid off to make room for another loan.
There is not only the necessary cash investment, but there is also the time investment. Learning the new technology is like going back to college–but without all of the beer. It is time consuming, challenging, and a general pain in the ass.
But what are you going to do? At 46, it was not like I was going to start putting out resumes. It is a well known fact that I don’t make a very good employee. I really never have. So, I embraced the new orthodontic lab and made it a reality in my tiny 500 sqft of shabby space with four dysfunctional employees.
This is how I did it.
Chapter 1: The Old Orthodontic Lab
I was there in an orthodontist’s office while the fancy wand salesperson was giving his schpiel. It was cool. I immediately grasped how it could benefit the doctor and the lab. No more bad impressions? No more remakes? Better communication and appliances with an ideal fit? Yeah!
Then, however, the sales guy started telling lies.
“It is going to make appliances cheaper and faster to get,” he was saying.
I went from nodding my head to shaking it. Violently. –I think I hurt myself. The sales person noticed my seizure and caught up to me afterwards.
“I noticed we were not on the same page in there,” he said.
“No,” I replied. “Faster and cheaper? You are setting up the orthodontist to be either pissed off at you or pissed off at me, and if he is pissed off at me I’ll make damn sure he is more pissed off at you.”
“I’m missing something, aren’t I,” he asked.
He was trying to be honest, so I replied, “You have no idea what goes on in the lab, do you?”
“No.”
So I invited him to stop by and see for himself. Since then, I have had a half dozen sales reps stopping by my tiny little lab.
My mom never really understood what I did in my lab. More importantly, though, salespeople for the new technology, and orthodontists, have no idea how a lab operates, so I thought I would explain a little bit about our average day. Even if you have owned a lab for decades, this might prove useful as I feel we need to look at our lab differently.
An orthodontic lab is different from a dental lab. A micro lab is different from a small to medium lab.
I think a problem is that the technology is essentially coming from the dental side of the industry and migrating towards orthodontics. The salespeople are as well. We are not a dental lab. I have no idea what a partial is, let alone how to make a denture or crown or bridge.
For the most part, we make retainers. And we have to make a lot of them.
Another problem is that we are not small or medium labs for the most part. We’re micro labs. The government defines a small business as less than 100 people. Most of the lab owners I have spoken to are like myself, 5-6 people or less. The sales people, and the tech, seem to be concentrating on the larger labs.
I think a part of our problem is with the perception of an orthodontic lab itself. Orthodontic laboratory is not really the right designation. A more proper designation would be light manufacturing facility for orthodontic appliances—and I tried my best to switch that around to get the right acronym but I couldn’t, so I’ll make it up as it is my clinic: LMFAO.
With the new technology, we need to redefine the lab into a manufacturing facility. We need to treat it as a manufacturing facility and we need to plan for the needs of a manufacturing facility entering the new industrial revolution.
I have been in a half dozen different labs and I think it is safe to assume that all labs will essentially be the same.
All of my work comes into my shipping and receiving department, where it is unpacked and each individual case is dated and designed. After the casts are cleaned, they go to the appropriate department, whether it is fixed appliances, removable appliances, repairs, or nightguards/splints.
The wire benders and waxers do what they do, and then the fixed appliances go the welding/soldering station while the removable appliances go to the pouring station.
After they are processed, welded and/or poured, they go to the finishing station. There, they are trimmed, cut, pumiced and polished. After final checks and adjustments, they are back on the shipping and receiving table to be packaged and sent out.
That is not a laboratory. That is a light manufacturing facility. And the new technology screws up everything.
Cheaper and faster? Are you kidding me? It slows things down, makes everything more expensive, massively cuts into our already small profit margins, and creates pressure from the larger labs that have the deeper pockets.
What is a micro lab owner to do?
You jump in.
Chapter 2: Scanners: It’s All about the Software.
Technically, you don’t need a scanner. You really only need the ability to get scans to the 3D printer. There is even free software to do that. If funds are very limited, your best bet might be to just buy something like Mesh Mixer or NetFabb. Personally, I recommend going the route that I did: 3Shape. Give it a look. And then a second look after seeing the price tag, and I’ll explain why.
This is where we need to start expanding our scope and services. This is where we need to start looking long term and thinking about where things are heading.
For decades, even with the pain in the ass doctors, the badly set bands, and the awful impressions, we have had it easy. We really haven’t had to be business owners. We could just be lab techs or lab managers with a bookkeeper that came in once a month. The prescriptions for Hawleys and Hyraxes flowed in, and we got them out. Now, we have to start learning the things that a first year business major learns. One of the most important was thrown at me a year ago and I had no idea what it meant.
ROI
Return on investment.
I’m going to take it back to where I was before. This new technology is an entirely different animal. It is not like a shipment of plaster or acrylic. It’s not wire or bands or even a new lathe. We know what the ROI on that is: it’s a Hawley or Hyrax and an invoice.
What is the ROI on a $40,000 printer? A $20,000 scanner? $10,000 in software? This laptop? I owned one of the very first laptops computers and I still hate the damn things. I prefer desktops. But it is kind of hard to bring one into a doctor’s office to show him something.
ROI
I was lucky. I had accounts that were sending impressions out of state to be digitized and stored. They told me if I bought a scanner, they would send them to me. It was a no brainer at that point: the volume of the digital study models would easily pay for the loan on the 3Shape R500. It did the trick. The R500 was paid for in about 9 months. The R2000 a year after that.
It is about the bigger picture. I knew one lab owner that was far ahead of me. He had a scanner, a printer, and was doing tons of printed models and trays. But he wasn’t doing study models. After I told him about what I was doing, he picked up a huge account converting a warehouse full of plaster models to digital.
But there is a catch. Something I told my partner AFTER I bought the scanner. Study models, like lab made bands, are a dying source of revenue. With the intraoral scanners becoming more popular, they will be extinct soon, as doctors will be able to scan their own and even covert their plaster ones.
But it is still all about the software. And, long range, I think you will still need to scan models as I will get into in a later chapter. Unlike lab made bands, digital study models can become a future source of revenue that I will get into later.
For me, choosing a scanner and software was like choosing between Betamax and VHS—or, for you younger people, Blueray vs HD DVD. A technology will win out. I remember a lot of people who had massive Betamax tape collections, with nothing to play them on.
This is where I need to start talking about a main concept of working with the new technologies: the path of least resistance.
In our decision making process, we encounter it every day. And every day, enterprising companies seek to give us the easiest way to get the things we want and need. As a lab owner, I know that I do this. Cost and quality are two main selling points, but convenience is a big one as well. Why go through all of the trouble of packaging and mailing out a case to Lab X half a continent away when I can stop by and pick it up on my way into work? It is the same with the new technology.
Dealing with a lack of time, as all micro and small lab owners must deal with, I went down the path of least resistance when it came to the scanner and software: I called Great Lakes. I got a lot of my supplies from them, they had scanners, so I walked down that path and encountered 3Shape and Maestro.
Something to keep in mind though is a simple fact I have discovered in my life: the path of least resistance tends to have the highest tolls. The decision we have to make is are the tolls worth it?
Maestro is still going strong. I even looked into Motion View but just could never get enough information from them. Just last week, I learned about a new player in the orthodontic market: Orchestrate.
But where does the best ROI lie? 3Shape was not the cheapest. And I hated the idea of yearly fees. But it is the path that I went. I liked the company. I liked where they were heading, investing millions into R&D, and ramping up their training and support.
NetFabb will cost you about $1,000. Meshmixer is free. 3D builder, just to get the scans to the printer, is also free.
But what does tomorrow hold? I actually had an entire other section here but then 3Shape unveiled a whole new line, that the software comes with, in Chicago a couple months ago. What happens at the AAO in two weeks? In six months?
The landscape is rapidly changing. My best advice is to get something. Now. There is a learning curve and anything that you get now will allow you to start learning what you need to know for the new orthodontic lab.
[3Shape]
[Maestro]
[Motion View]
3d Builder
Orchestrate
Chapter 3: 3D Printers and the lies that Sales People Tell
The sales people are lying to you. Sorry, but they are. Microns? Materials? Speed? Support?
Okay, maybe “lying” is a bit harsh. But they are not telling you the entire truth. Each company is essentially providing you the path of least resistance, showing you the scenery along the path. But they aren’t telling you about the tolls. Or the shortcomings.
If you talk to a 3D printing expert, as I have, they will tell you what they told me: the technology really isn’t there yet. And it definitely isn’t really there for the small and micro labs. If you ever get the opportunity, I highly recommend getting drunk with mechanical engineers. The alcohol will deaden the pain of the information they pound into your head, and I even got an entire workbench built in my garage.
But it is what it is. The doctors are there, they are digital or are going digital, so we have to be there as well. And that means investing in the best we can. Even more so than with scanners and software, this is really where the path of least resistance comes into play and can make or break a lab, or scare them away entirely.
I went back to Great Lakes when it was time to start looking at printers. That meant the Stratsys Objet. On that path of least resistance, though, there was a big detour sign. The damn thing would not fit into my lab!
How is your lab set up? Mine is a shabby little space in a basement. I have always told my partner that though we look like a Mom and Pop shop, we need to portray ourselves as something bigger. Perception meets reality when trying to fit new equipment into a small lab.
Since the path of least resistance was denied me, I had to go stumbling through the forest, and this is what I came up.
There are a bunch of 3D printing technologies. Nine I think. But we can concentrate on two. One is represented by the Objet, and the other by Envisontec.
I’m not going to hurt your brain the way mine was hurt. Basically, the Objet works on the same principal as a dot matrix printer. Print heads move across the printing surface depositing droplets of resin which is then cured by a UV light into the hard plastic we have all come to know and hate. Envisontec uses another additive printing process, –DLP or SLA if your brain doesn’t hurt too much–where it shoots UV light into a reservoir of resin, building the models in layers.
Both have their benefits and drawbacks. Price and size were main considerations for me. Did I really need a $40,000 printer?
And this is where things really get tricky. Objet. Envisontec. The path of least resistance? What are the tolls? How fast do they build? How much is the resin? What are the maintenance costs? You know you will get excellent support, but what do you really need, what can you afford, and, perhaps most importantly, what is going to be available in six months as more companies start to compete for the market share?
The Formlabs printer is becoming an excellent entry level printer to get you started. At under $4,000, it is something we can swallow as we jump in. Personally, I went with the Juell for $13,000. It had a bigger plate and printed much faster—I can print 8-10 models in about two hours.
My next printer, though, will be coming from outside of the box. Though it is a huge player in the 3D printing world, it is virtually unknown in our circle. The ProJet. It offers full color printing—though has monochrome models– and is mainly marketed to architecture firms and for people to build prototypes. I like it because it prints as fast as the Juell, has almost no waste, and, the most important factor: it prints in gypsum. Plaster.
Yes, it prints in plaster. Did I mention it prints in plaster? Good old hand carvable, seperatable, soakable, disposable, grayish white, beautiful, solderable plaster.
Did I mention it prints in plaster?
When Cade asked me to come here and give a clinic, he asked me to cover digital printing. I could have bored the hell out of you but the simple fact was that I really don’t know enough about it. I know it is changing rapidly as new companies form. I know that you have to talk to a lot of people as I did about what is out there now. And I know you really need to look into the drawbacks and benefits of each printer. But without my drunken engineer friends, the best I can really do is tell you there are many paths out of this forest, you need to get out of this forest, and you have to consider what is best for your lab.
— The Juell experiment—I was the beta tester.
And I will be updating this so stay tuned.
[3D printing technologies]
[The players in the Ortho 3D printing world]
[Benefits and drawbacks]
[Separators]
Chapter 4: The New Department; You Need a “Bob.”
I have found that most small lab owners are thinking of the new technology as merely a new way to receive models, that instead of sending a driver to an office or the post office, you are receiving a scan via the internet. Yes and no.
I hired Bob. He is a lousy technician, but he is my daughter’s friend and needed a job after graduating college so I hired him to do deliveries. After two years, he still cannot notch out for an Adams clasp but he is now my network supervisor and makes as much as a technician. You need a Bob.
When I bought my lab in 2005, I think the previous owner had one dinosaur of a computer, just to do invoicing. My sales have not gone up by that much that I need multiple bookkeepers –I wish– but I now own 5 computers and 4 monitors and even have everything networked together. I am not quite there to the point—yet—where I need an IT person, but I definitely need a Bob, a network manager that could control the workflow and help integrate it into the lab’s workflow.
The new technology requires a new department. Pouring, finishing, bending and, now, tech.
Even if you are able to follow the path of least resistance, give Great Lakes a call, or a similar company, and say “give me everything that you have and put me on the payment plan,” what are you going to do with it all?
The sales people keep saying that all of this will lead to a better and quicker work flow. No. It doesn’t. It never will. I challenge any and all salespeople to prove this assertion. I’ll put my annual salary against their annual salary as a bet.
We go from a simple process of picking up a model or having it dropped off –see old orthodontic lab– to this entirely different workflow. I show the people that stop by my lab the old and new work flows. If necessary, I can have a rush done in –what—30 minutes using the old way with about 5 cents worth of plaster to pour the model? – and that includes the cigarette break.
The new orthodontic lab makes this impossible.
[From scan to finished model, pre-processing and post-processing]
And then you run into the fact that you are not dealing with simple things. You are dealing with technology. And the tech gods hate me. Nobody will run into as many problems as I have run into, but you will run into problems. Every new piece of tech that I purchase, I have problems with that nobody else encounters. My 3Shape scanner and computer had more air miles than I have, with replacements and loaners coming from New York, New Jersey, Copenhagen and I think Poland. My experience with my printer has been about the same.
Aye, it’s new tech. Tech hates me. I have learned to live with that. But as a small lab owner, I can’t handle it. And my wife handles it even worse. Getting home at 2 or 3 am gets old soon if you are not coming from a bar.
But that is why you need a Bob. ROI? At this point, it can be about staying in business. That’s the return. But the future, I think, will open up a lot more oppurtunities.
[Maintaining the Tech]
[Learning the Tech]
[Organizing the work flow]
Chapter 5: Soldering vs. Laser Welders vs. Pulse Arc Welders
I am still pissed off at the salesman who promised me you could solder on his resin models. I guess that you can, with the proper hazmat gear. My first try put me on my butt and took five years off my life from the noxious fumes.
So, you either need to buy the gypsum printer or you need to explore laser or pulse arc welding, both of which can be done on resin models. Or, you have to duplicate everything that needs to be soldered.
For this, I was exhausted, my credit was still good, I just couldn’t do any more research, so I followed the path of least resistance, paid the tolls, and bought myself what all of the big labs are using: the Laser Star welder.
Pulse arc welding is a bit different, but much cheaper. I think I was looking at the top of the line pulse arc welder from Orion for about $8,000 but went with the Laser Star for $19,000. What’s the difference? At this point in time, I have no idea. But both Chistian Saurman of NEO labs and Don Inman of Inman labs told me to go with a Laser Star, so I did.
I can say that the pulse arc technology has advance rapidly in the last few years and there are many labs that swear by the PUK or Orion pulse arc welders. It can’t do everything that a laser welder can do, and I believe that it adds material as opposed to just fusing two metals together, but I haven’t seen an application yet in a lab that could not be handled by both. With the price difference, it is definitely something to look into and consider.
Orion
PUK
[Laser Welders]
[Pulse Arc Welders]
[Traditional Soldering]
Chapter 6: Expanding on the Technology
This is where Bob makes his money. And where I hope to make my money. This is where ROI and the path of least resistance really comes into play.
3D printing is a necessary evil, an expensive investment in time and money that you will never see a return on aside from keeping your accounts that are going digital. At $15 per model extra, with resin as much as $200 per pound (roughly), with maintenance costs, printer head replacements, and the extra time involved in pre and post processing, and the initial outlay of cash from $4,000 to $40,000, you will never see a return on this investment, aside from staying in business. It is the price tag of staying in business in the new orthodontic lab.
Or is it?
This is where I was getting to when talking about the software, 3Shape and limiting costs while you wait and see what comes next. There are essentially two paths you can go down from here. One is much easier, but with far less potential ROI. The other is much harder. The easier path is what I talked about earlier, how all that you really need is software to get the scan to the printer. The other path? Taking advantage of the technology that the more advanced and industry specific software allows.
A periodontist who I did not know blew into my office the other day. All in one sentence, in one breath I think, the initial greeting went like this:
“I’ve never used you before but I’ve know about you and I need guides and sometimes need other things and is this price schedule still accurate and give me a pen and some prescription slips and do I need to fill out all of this for every one and what numbering system do you use?”
And then she stopped, turned, and said more slowly: “I should be using you more, doing more orthodontics. Everybody else is.”
So the easier path is simply doing what we do with a new work flow and expensive equipment to integrate into our labs.
The harder path, the more lucrative one, is teaching orthodontists about the potential of the technology and also teaching non-orthodontists orthodontics. It is also about waiting out the eventual reckoning that the orthodontic industry will have to face. It might just be wishful thinking, but I do believe that eventually we will start seeing an upswing again in Hawleys, but until then, play the game.
With my sales dropping the way that they have, I went scrambling. I’m researching this new tech, learning the new tech, looking for new accounts, and looking for new sources of revenue. I’ve been like one of the arguably greatest scrambling quarterbacks of all time: The Philadelphia Eagles Randall Cunningham. [Pause for boos.]
I advertise more to dentists than orthodontists, trying to teach them about nightguards, replacement retainers, and aligner sets for minor corrections. I’m seeing far more relapse cases than I ever have before—we can do something about that—with the right software.
I’ll be honest. In the past two years, I’ve lost over 20% of my annual income in Hawley sales, while spending a lot of friggin money. But, also honestly, I’m making a little bit more money this year than I have in the past two, while now spending less money.
It is about positioning for the future. The orthodontists don’t want to care about post treatment? It should be in the hands of the GP anyway.
I’d recommend checking out my website. I thought my way through a lot of things and this is what I came up with: www.brynmawrortholab.com.
[Retainer replacement]
[Aligner sets for minor corrections]
[Treating Relapse]
Chapter 7: Marketing
From 2005 to 2014, I spent about $500 total on marketing. I think I purchased business cards. Since 2014, I spent about $20,000.
I upgraded my website, created mailers, folders, info packets and am now expanding it even further.
The truth is that doctors really don’t understand what they have yet. You not only have to tell them you are 100% digital capable, but also get them to spend more money on what this technology is really capable of.
Chapter 8: Networking—The Lost Boys
If you are reading this, or listening to me, then you understand the importance of learning more. A lot of people don’t, and never will. I am where I am at in part due to excellent advice and lectures from various lab owners and experts. I tip my hat to Priscilla, Don Inman, Christian Saurman, Phil Pelligree, Michael Wright and the dozens of other lab owners I have encountered in the Association for Orthodontic Labs Facebook page.
Networking is not always about getting new accounts. As much I hope for it, I have yet to run into an orthodontist on a golf course.
Our industry is changing radically and quickly. 3D printing and scanning technology is changing almost as fast as computer technology was in the early 2000’s. There is a good chance anything you buy today will be obsolete in a year. But, again: what can you do?
I have always felt that orthodontic labs were the unwanted step child of the dental profession. We need a Peter Pan to band us misfits together. We’re working on it.
Until then, I strongly encourage you to check out the resources out there. An excellent place to start is Facebook, with the association of orthodontic labs. I’m now a moderator. Study groups, through Facebook, are springing up left and right. I started one for 3Shape Ortho a year ago and have over 600 members. Joe Tortilinni just started one for the Formlabs printer and it is growing in leap and bounds. There has been very little for us up until now, but I think the tides are changing, the salespeople are coming around, and everybody is realizing that orthodontic labs are an important –and lucrative—aspect of the industry.
Association of Orthodontic Labs on Facebook
[Push for National Association of Orthodontic Labs]
Chapter 9: Chasing 90
Get the hell out of the lab! I plan on it. I’ve hit 90 twice—without cheating. I will break 90 this year.
The new technologies, and the new bills, can be overwhelming. While my friends were making excuses to sneak out to the bar, I was making excuses to sneak into work. All joking aside, I personally almost lost my marriage.
There is time, slow down, relax, hire a Bob, and remember the old adage about taking care of yourself first.
