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SOUTHERN IMPLANTS: DESIGNING AND MANUFACTURING DENTAL
IMPLANTS TO THE WORLD

Amy Moore and Marianne Matthee wrote this case solely to provide material for class discussion. The authors do not intend to illustrate
either effective or ineffective handling of a managerial situation. The authors may have disguised certain names and other identifying
information to protect confidentiality.

This publication may not be transmitted, photocopied, digitized, or otherwise reproduced in any form or by any means without the
permission of the copyright holder. Reproduction of this material is not covered under authorization by any reproduction rights
organization. To order copies or request permission to reproduce materials, contact Ivey Publishing, Ivey Business School, Western
University, London, Ontario, Canada, N6G 0N1; (t) 519.661.3208; (e) cases@ivey.ca; www.iveycases.com. Our goal is to publish
materials of the highest quality; submit any errata to publishcases@ivey.ca.

Copyright © 2020, Ivey Business School Foundation Version: 2020-10-30

On November 23, 2019 Graham Blackbeard, the founder and managing director of Southern Implants, was
driving to the company’s office in Pretoria, South Africa. The company had been successful and over the
last 30 years had positioned itself globally as one of the pre-eminent specialty dental implant manufacturers.
With growth had come a variety of risks that the company had tried to diversify against. These risks related
to national, industrial, customer, and organizational considerations as well as currency and political risks,
regulations, customer diversification, upskilling, and quality manufacturing tools and processes which
Blackbeard had tried to mitigate against since the founding of Southern Implants.

Blackbeard’s foremost concern within Southern Implants was packaging; while the company had four
machine shops across South Africa, the final stages of production involved all items coming back to Southern
Implants to be cleaned, sterilized, and packed. The danger at these final stages was that if the company had a
non-compliant audit, the reputational risk plus delay in production could render Southern Implants bankrupt.
Another competitor had faced an import ban on one of its products over 10 years earlier, and the resultant 18-
month delay in production had a direct impact on sales and overall organizational value. 1

To diversify this risk, Blackbeard was considering setting up another processing cleaning plant abroad.
However, he wondered where he could do this. The United States was quickly becoming the largest
Southern Implants market, but the labour costs were high. Europe was another option, especially Portugal
which was considered to have an investor-friendly economic environment with no discrimination between
domestic and foreign investors.2 What were the organizational and managerial risks that needed to be
considered before making the decision?

THE GLOBAL DENTAL IMPLANT MARKET

Dental implants were classified as a medical device designed to act as an artificial root inserted into the
jawbone, acting as the replacement for the root of the natural tooth. Through a surgical procedure, an

1 Sven Egenter, “UPDATE 1–Straumann Says US Lifts Ban on Biora Products,” Reuters, August 5, 2008, accessed February 4,
2020, www.reuters.com/article/straumann/update-1-straumann-says-us-lifts-ban-on-biora-products-idUSL573365320080805.
2 “Invest in Portugal,” Invest in EU, accessed February 16, 2020, www.investineu.com/content/invest-portugal. D

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artificial replacement tooth would then be attached to the implant.3 Different options were available to
replace teeth that were missing, but dental implants were one of the most commonly used biomaterials.4

The global dental implants market was projected to grow from US$3 billion5 in 2018 to $5 billion in 2025.6

This increase was driven by a constantly growing aging population, the corresponding dental diseases, an
increasing acceptance of dental cosmetic surgery, and a growing number of dentists trained to perform this
procedure.7 In 2018, Europe dominated market share of global implants partially due to favourable
reimbursement policies.8 Germany, the Netherlands, France, Spain, and Italy were among the top importers
of dental fittings in the world.9 North America was projected to place first in the dental implants market
share and become the top importer of dental fittings.10 The US Centers for Disease Control and Prevention
(CDC) projected that one quarter of Americans 65 years or older would lose a tooth. Further, two thirds of
patients would choose to treat tooth decay, possibly spurred by the scientifically established link between
cardiovascular disease and poor dental health.11

The titanium implants segment represented the majority of dental implant materials. The material was
known for its suitability, biocompatibility, and non-allergenic nature for the majority of procedures. That
segment was expected to expand rapidly and achieve dominance by the end of 2026. Other materials used
in dental implants included zirconium and a lower grade of titanium, such as alloys mixed with titanium.12

DEVELOPMENT OF SOUTHERN IMPLANTS

Blackbeard studied engineering at the University of Cape Town (UCT); however, his first exposure to
precision manufacturing came during his second year of military service when he spent time in gun design,
working on the development of a G6 artillery gun.13 Following the end of his military service in 1982,
Blackbeard received a Rotary scholarship to study biomedical engineering at the University of Utah.14

During his time there, he was impressed with the department’s focus on translating biomedical technology
into applications for biomedical science and the private sector.

In the United States, Blackbeard had the opportunity to work with Dr. Willem Johan Kolff, who was known
as the “Father of Artificial Organs.” Kolff first invented dialysis and then the totally artificial heart in 1957.

3 “Dental Implants—Replacing Missing Teeth,” Canada Dental Association, accessed February 5, 2020, www.cda-
adc.ca/en/oral_health/procedures/dental_implants/.
4 B. Guillaume, “Dental Implants: A Review,” Morphology 100, no. 331 (2016): 189–198, accessed February 5, 2020,
www.sciencedirect.com/science/article/abs/pii/S1286011516000291?via%3Dihub.
5 All currency amounts are in US$ unless otherwise specified.
6 “Dental Implants Market Size by Products (Tapered Implants, Parallel Walled Implants), By Material (Titanium, Zirconium), By End-
Use (Hospitals, Dental Clinics), Industry Analysis Report, Regional Outlook, Application Potential, Competitive Market Share &
Forecast, 2019–2025,” Market Research.com—Knowledge. Identified & Delivered, October 2019, accessed March 3, 2020,
www.marketresearch.com/One-Off-Global-Market-Insights-v4130/Dental-Implants-Size-Products-Tapered-12746909.
7 Ibid.
8 “Dental Implants Market Size, Share and Industry Analysis by Material (Titanium Implants, Zirconium Implants), By Type
(Endosteal Implants, Subperiosteal Implants, Transosteal Implants), By Design (Tapered Implants, Parallel Implants), By End-
User (Hospitals, Dental Clinics, Academic & Research Institutes) and Regional Forecast, 2019–2026,” Fortune Business Insights,
June 2019, accessed February 2, 2020, www.fortunebusinessinsights.com/industry-reports/dental-implants-market-100443.
9 “Trade Statistics for International Business Development,” ITC [International Trade Center] Trade Map, accessed February 25,
2020, www.trademap.org/.
10 Ibid.
11 “Dental Implants Market—Growth, Trends, and Forecast (2020–2025),” Mordor Intelligence, accessed February 16, 2020,
www.mordorintelligence.com/industry-reports/dental-implants-market.
12 “Dental Implants Market Size, Share and Industry Analysis,” op. cit.
13 The Denel D6 was a self-propelled artillery vehicle produced in South Africa.
14 “Recent News from the Department of Biomedical Engineering,” Department of Biomedical Engineering, College of
Engineering, University of Utah, accessed February 2, 2020, www.bme.utah.edu. D

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He moved to the University of Utah in 1967 to direct the Division of Artificial Organs and the Institute for
Biomedical Engineering.15 Blackbeard worked on a section of Kolff’s research involving the artificial heart,
in particular the stabilizing titanium rings that were manufactured to support the heart valves. Blackbeard
learned about the principles of precision engineering and upon returning to South Africa in 1986 knew he
wanted to build a career in the field of biomedical engineering.

In 1987, Blackbeard registered his first company—Cardiac Devices of South Africa. At first, he wanted to
specialize in heart valves building on his studies at the University of Utah and using a technology called
fluidized bed technology. However, a key resource decided to emigrate to Boston, Massachusetts, United
States, and, with his departure, Blackbeard did not have the right partnership to move the project forward.
At the same time, Blackbeard was approached separately by the heads of dentistry at both the University
of Witwatersrand and the University of Pretoria. They had heard of Blackbeard’s exposure to precision
manufacturing with titanium at the University of Utah, and each asked if he could make dental implants
from titanium since South Africa had no existing dental implant manufacturers. Blackbeard partnered with
his army sergeant major whom he worked with on the G6 artillery gun, and through a process of trial and
error reverse-engineered the implant design in Pretoria. Realizing the local market opportunity, Blackbeard
rented space in Pretoria and started manufacturing.

In 1992, Southern Implants was registered as a new company. Blackbeard told others that the company
wanted to be proud of its South African heritage and reflect that in its name. Five years later, the company
purchased the land and buildings associated with the former Irene Film Laboratory in Pretoria; initially
Southern Implants used only the space it needed and rented out unused buildings. Blackbeard firmly
believed in the importance of company growth but in a steady, sustainable, and affordable way. On
principle, he never took in external capital; profits were used to fund all physical expansion, machinery,
marketing, and research and development (R&D). Despite several offers over the years from international
companies to purchase Southern Implants, the company remained privately owned.

RELATIONSHIPS AND PRODUCT RANGE WITHIN FIVE CORE AREAS

While some other dental implant companies focused on a small range of products, Southern Implants grew
its R&D and over time could be categorized into five different areas: (1) anterior aesthetics, (2) full-arch
rehabilitation, (3) molar tooth replacement, (4) craniofacial rehabilitation, and (5) peri-implantitis. These
core areas were refined after developing relationships with specialists (in particular maxillofacial and
craniofacial surgeons, prosthodontists, and periodontists) through conferences, personal visits, and
conversations to learn what their needs were.

Blackbeard’s focus was on innovative solutions that enabled the advanced implant clinician to effectively
and efficiently treat challenging cases.16 Being the only board member in this privately owned company,
Blackbeard believed Southern Implants was more nimble and able to respond to clinicians’ needs as he
could direct immediate funds and energy into development of products that he thought would add value.
For example, drills to install the implants were initially bought from overseas but were now made in-house.
Quality and control were ensured through making everything in-house. Drills were also made of titanium
which, Blackbeard believed, had a smoother feel than many of his competitors’ drills that were made from
lower quality materials.

15 “All U Need,” J. Willard Marriott Library, The University of Utah, accessed February 2, 2020, www.lib.utah.edu.
16 “Southern Implants Finds Growth with Innovative Treatment Solutions for Optimal Patient Outcomes,” Inside Dentistry 15,
no. 5 (2019), accessed February 3, 2020, www.aegisdentalnetwork.com/id/2019/05/southern-implants-finds-growth-with-
innovative-treatment-solutions-for-optimal-patient-outcomes. D

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The focus on relationships with clinicians was deliberate and took time to develop. In 2019, Stuart
Blackbeard, the founder’s son and the company’s sales engineering manager, estimated that Southern
Implants had formal relationships with 1,200 specialists in South Africa and 10,000 worldwide. He thought
it took two years to get a new customer on board—a long sales cycle. Perhaps as the company’s reputation
grew, the cycle would get shorter. Doctors were comfortable with what they were seeing, with what they
were experiencing, and with what the clinical trials were saying. Southern Implants wanted to sell to
customers who would place orders for more than 100 implants a year—the company felt those people knew
what they were doing and could be trusted with the company’s products.

Relationships were also fostered through money and time spent on research. The company partnered with
clinicians around the world for both new implant design and clinical trials. Greg Boyes-Varley, a
maxillofacial specialist based in Johannesburg echoed this partnership, indicating that Southern Implants
worked directly with key opinion makers with biomedical backgrounds to solve patient issues.17 A
significant “moonshot” of collaboration, according to Stuart Blackbeard, was the Co-Axis® developed in
2002 together with Professor Dale Howes. “Co-Axis® is the first threaded dental implant with an angled
prosthetic platform correction . . . [which] allows oral surgeons . . . to utilize existing bone while maintaining
the restorative platform at an angle that ensures an optimal esthetic result.”18 In 2008, a molar implant
design was created that brought the patient recovery process down from 12 months to 4 months; in 2017,
the Inverta implant was developed with Dr. Stephen Chu, the head of prosthetic dentistry and a prosthetic
expert at New York University. This latest design optimized patient anatomy and enabled surgeons to use
standard prosthetic components in both internal and external connections.

In 2019, Southern Implants had 64 concurrent clinical trials, which Blackbeard thought was unheard of for
a company the size of Southern Implants; companies 10 times larger could have 30–40 concurrent clinical
trials. The company had also recently hired an individual to head up all the clinical research and liaise
directly with top academics. Blackbeard believed that other competitor companies did not operate at this
scientific level, which meant that the top academics loved interacting with his company. Blackbeard felt
that one of the major issues for his organization was “what not to do,” rather than “what to do.”

QUALITY MANUFACTURING

Blackbeard believed in quality manufacturing, especially in buying titanium needed for the implants. While
South Africa had some of the largest reserves of titanium-bearing minerals and was a global producer of
titanium-bearing slag,19 the country had no processes for refining titanium. After considerable research
exploring options of purchasing titanium from different countries ranging from Russia to Korea, the
company reached an agreement with Perryman Company, in Houston, Pennsylvania. Perryman Company
provided a fully integrated process—from receiving the raw materials through to the blending process,
melting, blooming, billeting, rolling, finishing, heat treating, testing, and shipping. Blackbeard chose
Perryman Company because of this integrated process and the purity of the product—the ultimate product
was a grade 4 pure titanium, with a tensile strength of 920 megapascals that complied with the American
Society for Testing and Materials F167.20 Grade 5 titanium, which was less expensive and had a lower
fatigue life, was used by some competitors.21

17 Greg Boyes-Varley, interview by Amy Moore, January 6, 2020.
18 “Co-Axis® Implants: Built-in Angle Correction Reducing Cost and Complexity of Treatments,” Southern Implants, accessed
February 16, 2020, https://southernimplants.com/solutions/innovative-products/co-axis-implants/.
19 “Titanium Pilot Plant,” CSIR: Our Future through Science, accessed February 5, 2020, www.csir.co.za/titanium-pilot-plant.
20 Titanium ranged between grades 1–4, with grade 4 considered to have the highest exhibited strength when fatigue tests
were measured against the Vickers hardness measurement—a test to measure a product’s surface hardness.
21 Xiaotian Liu, Shuyang Chen, James K. H. Tsoi, and Jukka Pekka Matinlinna, “Binary Titanium Alloys as Dental Implant
Materials—A Review,” Regen Biomater 4, no. 5 (2017): 315–323, accessed February 2, 2020,
https://pubmed.ncbi.nlm.nih.gov/29026646/. D

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Southern Bioprecision was a separate company set up to machine the implants. Four machine shops were
started across the country—three in Gauteng and one in Cape Town—each run as a different company but
helping each other as necessary and competing against each other. The philosophy was that competing on
delivery times, reject rates, and new quote pricing raised standards. Their inspection process had three steps
as described by Mark Freddi, a Southern Bioprecision manager—every machinist checked the parts that
were made by him, then the team checked them, then Southern Implants checked them. Freddi believed
Southern Implants was the only company in the world that had those three steps. He thought all other
companies had machines running like robots with machinists collecting the parts, performing a quick
manual inspection, and disposing of parts that were not up to standard. Freddi’s machinists checked and
made small adjustments constantly. As the cutting tools wore, the company wanted to ensure that they were
at the middle of their tolerance; Southern Bioprecision worked to a two microns machine tolerancing, unlike
close competitors who worked to four microns.

Freddi further indicated that the company’s scrap was minimal, at approximately 2 per cent. Operators on
every machine used an oil-based lubricant, which was smoother and allowed for better cutting. But,
according to Freddi, the problem with oil was that it could catch alight if a tool broke. However, operators
were vigilant so risk was minimal; competitors used water-based lubricants, which did not have as high a
cutting quality. Southern Bioprecision also maintained its own machines, some of which were 14 years old.

Alex Masembu, the machine shop trainer, had been a petrol attendant (or gas station attendant) before
joining Southern Bioprecision, but had taken the opportunity to move up in the company. He knew that
everyone learned and moved at a different pace, which was accepted in the company. The company paid
for individual studies if they were linked to work at the company, and Masembu believed that culture was
also important and needed to be observed through small details such as wearing branded shirts, finishing at
12 p.m. to have a braai,22 or watching South Africa play in the Rugby World Cup tournament.

A DIFFERENT LEADERSHIP STYLE

Blackbeard thought the growth of the company stemmed from a few core principles and crucial elements—
being an early entrant into a new market, focusing on relationships and understanding the need of clients,
showing leadership by setting the standard of working hard, and showing what he was prepared to do.
Keeping costs down was also essential; Blackbeard tried to emulate that point by not flying business class,
despite traveling abroad as often as twice a month. He wanted people to be free to leave the company if
they wanted, but to stay because of the culture. Consequently, he paid staff at or below market value— he
wanted them to stay because they enjoyed the work and the caring environment of the company, not because
they were paid above market value.

Policies were not drawn up in a sophisticated human resources manual; most divisions did not have specific
targets or budgets. Blackbeard thought that he might focus on this aspect of the company in future. His
subsidiaries had budgets, but Southern Implants did not. He treated staff fairly and equally, but approve of
unions because he felt they pitted workers against management.

We try to create a solid team here, where we take care of our employees. We help staff build houses
and get motor cars, that sort of thing. One of our long-term employees died of acquired
immunodeficiency syndrome [AIDS] and we paid for his children’s schooling for years thereafter.

22 A braai is a South African term for barbecue.

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Blackbeard thought his general philosophy was working. He hoped his employees’ children would
eventually work at Southern Implants. The company had several staff who were approaching their 25-year
anniversary—many of them had worked with the company over 20 years.

TAKING EVERYTHING IN-HOUSE

Over time, Blackbeard tried to bring as many processes in-house as possible to give Southern Implants
control as well as agility. If Southern Implants developed a new product (e.g., in 2019, the company offered
3,000 different parts with 700 new products developed in that year), it did not need an external packaging
company—the in-house team just developed the new packaging. Products could also be made in smaller
quantities while they were being established with specialists.

Regulation conformance increasingly occupied the team’s time. Products sold in the United States had to
comply with the Food and Drug Administration (FDA) standards; in the United Kingdom and Europe,
products complied with the British Standards Institute and the CE mark (declaration of conformity) for
medical devices sold in the European Economic area; in Canada, products complied with Health Canada
standards; and in Australia, products complied with the Canadian Standards Association standards. In the
United States, regulatory consultants were initially hired as liaison for submissions to the FDA. But
Blackbeard discovered that these consultants caused delays. He found that the company did all the work
and gave it to the consultants, who simply repackaged it slightly differently—which was sometimes not
what the FDA wanted. The result was that time and great amounts of money were lost. Therefore, Southern
Implants decided to deal directly with the FDA and other governing bodies. From Blackbeard’s perspective,
the process was much faster, from design to clinical trials to selling new products. The regulatory team
within the company was headed up by a microbiologist (with a law degree) and two other microbiologists.

Another example of in-house processes was the company’s clean rooms—one of the last stages of
production. The products were made in one of the four different machining plants, but everything came
back to Southern Implants to be cleaned, sterilized, and packed. The process was essential to regulatory
conformance. Blackbeard knew that if things went wrong here, the company would be out of business.
However, he was confident that the company would do everything right. But the audit had a human element.
If the company received a bad certificate and was told to stop manufacturing, the company would need
about two years to get back on track. The company could not survive two years without sales, and by then
it would be bankrupt. But in the last few years, the results from companies validating the clean rooms were
unreliable, with occasional incorrect calibrations. The current plan, Blackbeard believed, was for Southern
Implants to buy the equipment, train the staff, and develop its own ability to certify work areas.

SUSTAINABLE GROWTH WITH INTERNATIONAL PRESENCE

The company was always focused on sustainable growth while being responsive to new opportunities.
While some competitors had grown through buying cheap manufacturing plants and focusing on both ends
of the markets, Southern Implants had not approached growth that way. Initial international presence started
with a distributor in the United Kingdom in 1992, but Blackbeard never wanted the company to formally
open an office abroad until it had the capital to do so.

Expansion abroad progressed steadily and gradually. In 2004, following the retirement of the distributor in
the United Kingdom, an office was opened in Chiswick, London. The Australian subsidiary was established
in 2013, and in the United States, an office in Jupiter, Florida was opened in 2016. The company’s presence
in Europe was deepened with the opening of an office in Barcelona, Spain in 2019. Entrance into Spain was D

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particularly convenient for Southern Implants because the bank that the company opened an account with had
a branch in Johannesburg and the branch manager was able to meet with Southern Implants staff in Pretoria.
Other geographical areas, such as Benelux, France, Germany, Greece, Italy, Namibia, New Zealand, Portugal,
Russia, Scandinavia, Turkey, and the United Arab Emirates, were serviced by distributors. Asia was currently
not a core distribution focus, given the language barriers and complicated regulations.

Year-over-year growth ranged between 15–20 per cent, and in 2019, Southern Implants’ market share was
about 0.37 per cent globally, with volumes of 100,000 implants sold. The United Kingdom and North
America represented the highest growth in 2019 at 12 per cent and 64 per cent, respectively (see Exhibit
1). This financial growth allowed the company to expand abroad, without having the initial cost of
establishing a processing plant as a primary consideration.

Considerations for expansion also included economic, political, and currency stability; reliable
infrastructure; leverage of existing networks; and often, as Blackbeard noted, simply finding the right
people in the right countries. The “right” people had the skill set that Southern Implants was looking for
and a positive attitude, with the right economic climate and relationships (or potential relationships) with
customers. An investment climate analysis (based on the competitiveness landscape, ease of doing business,
and a summary of investment climate) was sometimes used as a framework for expansion decisions (see
Exhibits 2 and 3); that framework was a consideration point for the processing plant decision. The United
States had represented a significant growth opportunity, with limited language barriers. However, wages
were much higher than those in Europe and health insurance costs were exorbitant. Portugal had a more
manageable time zone in relation to South Africa for operational efficiency, and the European market
generally offered expansion opportunities. The tax incentives that Portugal offered for business investment
were particularly attractive.

International agreements affected Southern Implants’ ability to be flexible and perhaps competitive in the long
term. Transferring staff to the American office in Florida had proved to be difficult, as Blackbeard commented:

It had been virtually impossible to transfer people from here. We managed one person—but it was
because he had a U.K. passport. In addition, the international trade landscape is changing with countries,
especially the United States becoming more protectionist, which is significant for our future.

The African Growth and Opportunity Act (AGOA) benefited Southern Implants in terms of duty-free access
to the U.S. market.23 However, the AGOA was set to expire in 2025.24

CHALLENGES FROM SOUTH AFRICA

One of the challenges of basing the company in South Africa was the lack of infrastructure for medical
device manufacturers. The lack of specialized auditor experience meant that auditors needed to be flown in
from abroad, which resulted in invoices of R840,00025—the equivalent of a new machine. That amount was
prohibitive for a new entrant into the market, and therefore prevented local competition. Local laboratories
might not conform to international standards, so products either had to be sent overseas, or testing, such as
the validation of the clean rooms, had to be completed by the company.

23 “AGOA Eligible Products,” AGOA.info: African Growth and Opportunity Act, accessed February 28, 2020,
https://agoa.info/about-agoa/products.html?resetfilters=0&clearordering=0&clearfilters=0.
24 “H.R.1295—Trade Preferences Extension Act of 2015 (AGOA 2015–2025 Renewal Legislation–Became Public Law 114-
27,” AGOA.info: African Growth and Opportunity Act, June 30, 2015, accessed February 28, 2020,
https://agoa.info/downloads/legal/5695.html.
25 R = ZAR = South Africa rand; US$1 = R14.7 on November 23, 2019. D

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Another challenge for the company in South Africa, according to Blackbeard, was broad-based Black
economic empowerment (B-BBEE).26 Southern Implants was non-compliant in the B-BBEE score, which
rendered Southern Implants unqualified for tenders at local hospitals and government agencies in general.
Blackbeard thought that the company was perceived as not being compliant because it was from a
developing country.

The company also had many issues that European manufacturers did not have, such as customs problems.
Customs clearance was unreliable and required labelling in the language of the receiving country. For
example, some products that were shipped to Italy were blocked because the Italian word for implant (i.e.,
implante) was required, and were sent back for repacking and relabelling before they could be accepted.
Blackbeard did not believe that his European competitors had the same customs issues.

Customs clearance could take only a few days or as much as several weeks. Blackbeard brainstormed with
his colleagues to resolve these customs issues. Distributors could choose products from Southern Implants
or from European competitors, but erratic delivery times caused by customs clearance would mean keeping
much more stock on hand. If clearance took only a few days, only a low amount of stock was needed, which
could come from the home company. However, because the timing was uncertain, Southern Implants had
to keep higher stock levels, which affected its competitiveness.

DIVERSIFICATION OF RISK

Thinking back to the late 1980s, Blackbeard felt that he had discovered a great business opportunity. The
dental implant market was a relatively new market then, and Blackbeard seized the opportunity. He knew
that mature markets were more difficult to penetrate because of many more competitors. Southern Implants
initially served a local need, which helped the company grow to its current size, with many clinical trials.
Blackbeard thought the company could compete against any international organization.

Blackbeard had taken significant steps over the years to address risks associated with growth and expansion.
One particularly significant step was bringing resources in-house—everything from general precision
manufacturing to regulatory and compliance expertise. However, with just one cleaning-processing plant
based in South Africa, Blackbeard thought the company’s current risk profile was high. Increasingly
opportunities abroad represented growth for the company, and a recent analysis indicated that some qualified
specialists in Japan and Singapore recognized the quality of Southern Implants products. While South Africa
was still the most profitable market, the American market represented an annual growth rate of 60 per cent
for the company, partially because the United States had so many specialists and hospitals focusing on implant
procedures. In addition, some European countries had established markets for dental implants and Portugal’s
policies for tax incentives presented a significant incentive for businesses to invest there.

Blackbeard knew he had to make a decision about a new processing plant. He firmly believed investment
abroad was the right strategy, but where should the processing cleaning plant be based—in Portugal or the
United States? The short-term cost of establishing the plant was not his primary consideration. How could
he balance and prioritize the other decision dimensions?

26 B-BBEE legislation was aimed at advancing economic transformation and enhancing the economic participation of black
people in the South African economy; “Acquisition of Black Ownership and Method of Funding Are Critical in Transforming the
Economy,” the dtic: Department Trade, Industry and Competition, Republic of South Africa, August 6, 2020, accessed August
30, 2020, www.thedtic.gov.za/acquisition-of-black-ownership-and-method-of-funding-are-critical-in-transforming-the-
economy/?hilite=%27B-BBEE%27%2C%27legislation%27. D

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Page 9 9B20M190

EXHIBIT 1: LIST OF IMPORTERS FOR DENTAL FITTINGS—EXCLUDING ARTIFICIAL TEETH
(IN US$ ‘000)

Importers Imported Value
2016

Imported Value
2017

Imported Value
2018

World 2,665,393 2,944,255 3,215,504
United States 300,058 367,640 440,432
China 209,700 264,703 327,624
Germany 263,421 273,973 287,452
Netherlands 275,891 289,820 278,522
France 269,386 282,973 263,769
Spain 110,256 112,637 133,138
Italy 106,085 85,520 107,099
Japan 106,647 107,267 101,875
Russia 74,692 92,277 96,331
Turkey 63,175 67,290 74,554
Canada 66,912 73,553 73,287
Switzerland 45,686 52,799 66,118
Australia 61,222 61,159 58,787
Republic of Korea 59,545 56,925 58,725
Taipei 43,342 51,029 55,051
Hong Kong 40,859 44,866 51,809
Iran 26,569 38,276 42,842
Belgium 38,002 40,751 41,591
United Kingdom 51,793 52,019 38,928
India 27,238 36,229 33,208
Portugal 19,464 28,623 32,869
Austria 28,422 27,233 29,003
Poland 15,324 20,721 25,294
Nigeria 60 6,448 23,187
Sweden 22,757 21,950 22,186

Note: The world aggregation represents the sum of reporting and non-reporting countries.
Source: “Trade Statistics for International Business Development,” ITC [International Trade Center] Trade Map, accessed February
25, 2020, www.trademap.org; “Comtrade Access,” UN Comrade, accessed February 2, 2020,
https://comtrade.un.org/db/syslogin.aspx?ReturnUrl=%2fdb%2fmr%2frfCommoditiesList.aspx%3fpx%3dHS%26cc%3d9021
&px=HS&cc=9021 [ITC calculations based on UN Comtrade and ITC statistics].

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Page 10 9B20M190

EXHIBIT 2: GLOBAL COMPETITIVENESS INDEX (2019)

Portugal United States South Africa
Index Component Rank Rank Rank

Value Value Value
/141* /141 /141

Overall institutions (security, social capital, checks and balances,
public-sector performance, transparency, property rights, corporate — 30 — 20 — 55
governance, and future orientation of government)

Overall security (crime, homicides, terrorism, and reliability of police
— 14 — 64 — 135

services)
Judicial independence: 1–7 (7 = highest) 4.5 43 5.2 25 5.0 33

Efficiency of legal framework in challenging regulations:
3.1 83 5.0 8 4.0 40

1–7 (7 = highest)
Efficiency of legal framework in settling disputes:

3.0 113 5.3 11 4.6 31
1–7 (7 = highest)

Burden of government regulation: 1–7 (7 = highest) 3.1 96 4.5 14 3.0 101
Incidence of corruption: 1–100 (100 = best) 64.0 28 71.0 22 43.0 62

Property rights: 1–7 (7 = highest) 4.9 44 5.6 22 4.1 89
Intellectual property protection: 1–7 (7 = highest) 5.1 32 5.7 12 4.7 46

Quality of land administration: 1–30 (30 = best) 20.0 47 17.6 58 15.0 74
Overall corporate governance (auditing and reporting standards,

— 77 — 31 — 26
conflict of interest regulation, shareholder governance)

Government ensuring policy stability: 1–7 (7 = highest) 4.0 63 5.3 16 3.3 108
Government’s responsiveness to change:

3.9 57 5.1 11 3.0 110
1–7 (7 = highest)

Domestic credit to private sector (% of GDP) 111.9 23 190.2 3 146.5 10
Financing of SMEs: 1–7 (7 = highest) 3.9 77 5.5 2 3.6 96

Venture capital availability: 1–7 (7 = highest) 3.4 50 5.2 1 3.1 77
Overall transport infrastructure (road, liner shipping and air

connectivity, quality of road infrastructure, railroad density, efficiency of — 21 — 12 — 45
air transport, train and seaport services)

Overall utility infrastructure (electricity access, electricity supply quality,
— 25 — 23 — 92

exposure to unsafe drinking water, reliability of water supply)
Overall macroeconomic stability (inflation and debt dynamics) — 62 — 37 — 59
Extent of staff training: 1–7 (7 = highest) 4.1 62 5.3 6 4.5 40

Quality of vocational training: 1–7 (7 = highest) 4.3 53 5.2 8 3.5 119
Skillset of graduates: 1–7 (7 = highest) 4.8 27 5.3 5 3.7 102

Ease of finding skilled employees: 1–7 (7 = highest) 4.6 44 5.3 1 3.9 98
Overall trade openness (non-tariff barriers, tariffs, complexity of tariffs,

— 39 — 14 — 77
border clearance efficiency)
Hiring and firing practices: 1–7 (7 = highest) 3.1 121 5.3 5 2.9 129

Flexibility of wage determination 4.6 98 5.7 18 3.5 134
Ease of hiring foreign labour: 1–7 (7 = highest) 4.9 13 4.6 31 3.4 123

Overall market size (GDP, PPP, imports of goods and services) — 51 — 2 — 35
Cost of starting a business (% of GNI per capita) 2.0 43 1.0 24 0.2 4

Time to start a business (days) 6.5 39 5.6 31 40.0 129
Attitudes towards entrepreneurial risk: 1–7 (7 = highest) 3.8 87 5.6 2 4.3 46

Growth of innovative companies 4.4 43 5.6 2 4.4 44
International co-inventions (per million population) 1.55 38 12.39 19 0.31 65
R&D expenditures (% of GDP) 0.07 27 2.7 11 0.8 45

Buyer sophistication: 1–7 (7 = highest) 3.9 47 5.1 4 3.8 50
Trademark applications (per million population) 6,121.03 19 2,947.15 32 504.69 73

Overall ranking — 34 — 2 — 60

Note: *141 refers to the total number of economies included in this index; GDP = gross domestic product; PPP = purchasing
power parity; GNI = gross national income; R&D = research and development.
Source: Adapted from World Economic Forum, The Global Competitiveness Report 2019, 2019, accessed February 2, 2020,
www3.weforum.org/docs/WEF_TheGlobalCompetitivenessReport2019 . D

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Page 11 9B20M190

EXHIBIT 3: EASE OF DOING BUSINESS INDICATORS, INWARD FOREIGN DIRECT INVESTMENT
FLOWS, AND CORPORATE TAX RATES (2019)

Economy Portugal United States South Africa
Rank (out of 190) 39 6 84
Starting a Business 63 55 139
Dealing with Construction Permits 60 24 98
Getting Electricity 52 64 114
Registering Property 35 39 108
Getting Credit 119 4 80
Protecting Minority Investors 61 36 13
Paying Taxes 43 25 54
Trading across Borders 1 39 145
Enforcing Contracts 38 17 102
Resolving Insolvency 15 2 68
Five-Year Average FDI Inward Flow (% of GDP)* 2.8% 1.8% 1%
Corporate Tax Rate** 21% 21% 28%

Note: FDI = foreign direct investment; GDP = gross domestic product.
Source: *Adapted from the World Economic Forum, The Global Competitiveness Report 2019, 2019, accessed February 2,
2020, www3.weforum.org/docs/WEF_TheGlobalCompetitivenessReport2019 ; **adapted from “Portugal Corporate Tax
Rate,” Trading Economics, accessed March 2, 2020, https://tradingeconomics.com/portugal/corporate-tax-rate; “United States
Federal Corporate Tax Rate,” Trading Economics, accessed March 2, 2020, https://tradingeconomics.com/united-
states/corporate-tax-rate; “South Africa Corporate Tax Rate,” Trading Economics, accessed March 2, 2020,
https://tradingeconomics.com/south-africa/corporate-tax-rate; adapted from “Doing Business 2020,” The World Bank,
accessed February 2, 2020, www.doingbusiness.org; a lower ranking indicates that the regulatory environment is encouraging
in the start-up and advantageous to the operation of a local firm.

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  • SOUTHERN IMPLANTS: DESIGNING AND MANUFACTURING DENTAL IMPLANTS TO THE WORLD
  • THE GLOBAL DENTAL IMPLANT MARKET
    DEVELOPMENT OF SOUTHERN IMPLANTS
    RELATIONSHIPS AND PRODUCT RANGE WITHIN FIVE CORE AREAS
    QUALITY MANUFACTURING
    A DIFFERENT LEADERSHIP STYLE
    TAKING EVERYTHING IN-HOUSE
    SUSTAINABLE GROWTH WITH INTERNATIONAL PRESENCE
    CHALLENGES FROM SOUTH AFRICA
    DIVERSIFICATION OF RISK
    EXHIBIT 1: LIST OF IMPORTERS FOR DENTAL FITTINGS—EXCLUDING ARTIFICIAL TEETH (IN US$ ‘000)
    EXHIBIT 2: GLOBAL COMPETITIVENESS INDEX (2019)
    EXHIBIT 3: EASE OF DOING BUSINESS INDICATORS, INWARD FOREIGN DIRECT INVESTMENT FLOWS, AND CORPORATE TAX RATES (2019)

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