Hello and welcome to Beyond the Arches. I'm your host, Dr. Daniel Noorthoek. With me, I've got a part two. We've got Patrick, Wes, and Blake with us today. Welcome back, guys. We’ve gone a long way; I think we had one bathroom break and a couple of waters, but we’re back.

We are back for part two of our discussion about dentistry, the full arch industry as a comprehensive look, screw manufacturing, and what an implant company actually looks like. We put a pause in the last episode because I wanted to talk more about manufacturing, data acquisition, and what happens beyond the implant screws. This is a whole other category.

Having you on this, Patrick, is great because you've always been an "all-in-one" pusher. You want the manufacturing side, the data acquisition side, and the implant screw to be proper. Most of the time, when an implant company says they are an all-in-one solution, it feels disingenuous—like they are just throwing pieces into a shopping cart without knowing if it's actually good for the practice. I like that you come from this 360-degree perspective, incorporating things that are functional. For example, you don't have a big push toward guides. You have a solution available, but it’s not forced. One of my deep convictions is that if I don't need a product, don't push it on me. Hearing you say that reaffirms my approach; you’ve never been a pushy guy with "snake oil" products. That is important for us as clinicians making decisions for the patient.

It’s interesting because you're right. I hope our company is not pushy. At the end of the day, Wes and I were talking in the car on the way over from Tampa about who we focus on—or rather, who we don't focus on. The general dentist coming out of school who wants to do their first single posterior implant is the furthest thing from our customer. They don’t yet understand the problems our solutions address.

For example, we have custom strategies in Hyperdent where we can bring XYZ coordinates from your photogrammetry file into the construction info to benefit your milling outcomes. You guys mill wet, which is cutting-edge. You have to have a dry cycle on your centering furnace and take specific steps to make the outcome perfect, but it is the highest-end way of doing it.

It's also the cleanest. To explain for the listeners: when you are cutting teeth out of zirconia or plastic in a milling machine, it creates a lot of dust. You can either do it dry or wet. Wet milling uses cooling on the surface, which is generally better because you aren't imparting heat stress into the material.

Zirconia is a powder highly compressed into a 98mm disc. When it gets wet, it turns into concrete when it dries. Your team has to be meticulous about cleaning the machines, which they clearly are. If a customer of ours is not milling wet, we tell them the benefits and the cons—like the risk of freezing a spindle if you aren't meticulous. That advice doesn’t generate revenue for us, but if we maintain integrity as professionals, our goal is to bring value and optimize the practice. It’s about what is next and how we can level up. That trickles down to being what is best for the patient. We strive to have the best comprehensive solution for full-mouth rehabilitation. If there is a better product out there, we will still support it because that is what is best—even if we don't make money or if we lose business.

What’s important is that we stay relevant and focus on where the technology is going. Let’s get deep; I’m ready.

Let's do it. Let’s talk about data acquisition. Wes, why don't you give us some insight? When we're talking about data acquisition, there is a major component of scanning. Do you have an intraoral scanner available?

We sell Trios; we sell a number of them, including Shining 3D. But if anyone asks for a recommendation, it’s going to be the Trios 6.

Trios 5 is good, too. I think we have the 5. When did the 6 come out?

This year.

The 5 is great. It’s the best intraoral scanner for capturing tissue even in a bloody, wet environment. Now, for those who do surgery and want to capture all the data right then and there, we developed the Tissue Mapper. It eliminates the need for an intraoral scanner postoperatively. You still need the intraoral scanner preoperatively, but postoperatively we can capture tissue using photogrammetry technology. It doesn't matter if it's bloody or wet; it’s going to be a very accurate impression.

In dental technology, when speaking to soft tissue and implant position, there are two primary ways we acquire data: intraoral scanning and photogrammetry. With intraoral scanning, you are essentially taking thousands of images and stitching them together to create a 3D representation.

Photogrammetry is different. You’re taking an image of the implant placement, and it provides an XYZ coordinate of where those implants are located in relation to each other. You get the relationship of one implant to the one next to it, the one across the arch, and the one in front of it—provided they have scan bodies attached.

A scan body is a component that fits on top of the implant so the scanner can capture its location. We see these primarily with single implants because you can stitch those pictures together accurately enough for a 3D printer to manufacture a crown. But with photogrammetry, you’re getting a much more accurate reading for full arches. That scan isn't necessarily capturing the gum tissue or the other teeth; it’s capturing exactly where that specific implant is relative to the others.

I personally feel that no matter how much you stitch intraoral pictures together, there is too much room for inaccuracy across a full arch. The components needed to make an intraoral scan accurate for a full arch are often so large they become nonfunctional. Do you like any of those other systems?

To be transparent, there are really only two or three technologies on the market that do this exceptionally well: MicroMapper, iCam, and PIC. There are others like Tupel, but you run into repeatability and quality issues if you have more than four implants.

We were the number one distributor for iCam until we developed the MicroMapper. Accuracy-wise, iCam and MicroMapper are relatively similar. We’ve seen scans as low as nine microns of accuracy across six implants on a model—which is unheard of—though on a patient it might go up toward 60 microns.

The thickness of a piece of hair is about 50 microns, which serves as a helpful point of measurement for what we're discussing. We are talking about incredibly small tolerances. You will see claims from people saying they have photogrammetry devices or intraoral scan bodies that can stitch images together and get within six microns of accuracy. In reality, you cannot even calibrate a machine to tell you if something is in a certain position with six microns of accuracy in a clinical setting—it is extremely difficult.

At Claronav’s headquarters in Toronto, where they manufacture the MicroMapper, they use a massive granite slab table to prevent heat or temperature changes from throwing off the scans. In that highly controlled environment, they can routinely get accuracy down to around six to eight microns. That is used as a test to see if a device is within specification, but it is effectively impossible for any photogrammetry device to achieve six microns of accuracy on a live patient every single time.

As Wes mentioned, photogrammetry provides the XYZ coordinates for implant positions. Intraoral scanning, for those who aren't clinical, is very similar to taking a panoramic (pano) image on your phone. You have that arrow in the middle that you have to keep steady; if you move too fast or too slow, the image distorts. Intraoral scanning is exactly like that because you are stitching a bunch of images together.

When you think about the oral cavity—with patients moving, assistants moving, tissue stretching, saliva, and blood—it is very difficult to use an intraoral scanner to capture the positions of more than one or two implants accurately. For a single implant, it's fine. But for a full arch requiring cross-arch stabilization, you need photogrammetry for repeatability and predictability. Just like when someone walks through the background of your pano photo and it gets distorted, an intraoral scan of a full arch will always have some degree of distortion.

Many offices use bone fixation screws (fiducial markers) as reference points. They place these in the palate or the retromolar pad and do a pre-op scan. In theory, those screws stay in the exact same place throughout the surgery. If there is any movement, there is distortion, and your bite, midline, or "cant" (the tilt of the teeth) will be off. Photogrammetry doesn't care about that distortion because it captures a real-time XYZ coordinate.

Blake, have you ever done a case using fiducial markers or fixation screws as a reference point?

I have used workflows with intraoral scans where markers are placed in the palate. It works, but they can move, and it's another area of discomfort for the patient. It’s a different protocol than the one we use here.

I did it a lot back in the day. Beyond the workflow interruption of having to place them and wait for scans, as the person responsible for the patient's care, I had an overarching fear of disrupting those screws. I felt like it got in the way of clinical decisions. I wasn't compromising the quality of care, but I was making decisions around those tiny screws. If one moved, you might realize at the very end that you couldn't execute the plan you had. Altering what I'm doing because a screw is in the way was always very frustrating. That was the main reason I moved from being an "all-digital" guy back to a mix of analog and digital. To me, that wasn't a solution; it was just introducing additional problems.

I see it all the time where the distal sites on the mandibular arch cause issues. You go to place your angulated distal implant, and your contra-angle handpiece hits those fixation screws. You end up having to change your insertion direction, which sets the tone for the implant position, the multi-unit abutments, and ultimately the teeth. It gives me palpitations just thinking about it; it honestly scares me.

One thing I wanted to ask you, Dan: you’ve gone through all the workflows, analog and digital. When you switched from traditional scan bodies to photogrammetry flags, what clinical differences did you see for your patients?

I’ll go back a little further. When I first started doing hybrids, we weren't using zirconia as the predominant restoration. We were doing a cast bar with denture teeth on top, before this technology was truly available. We would take a physical impression, pour it up in stone, and then the lab would create a strong plastic bar. They would cut it into individual pieces and give it back to you. You would then place it into the patient and glue it back together inside their mouth. This is called a verification jig.

You did the verification jig to ensure the implants were exactly where your impression said they were. Then you would take another impression over that, go back to the model, and look for differences. If one implant was off, you had to have a very skilled technician determine which one was the outlier, because one error throws off the whole system.

The process was done by hand and with stone, which expands and contracts, leading to varying levels of accuracy. The result wasn't precise enough for zirconia. When we started doing zirconia off those analog models, you had to wince as you tightened the screws. There was a real risk that they were off enough to break the zirconia. We still use titanium bases today for a specific reason—they provide a little bit of "play."

That metal piece touches the abutment, and the cement acts as your "fudge factor" between the metal and the unforgiving zirconia. The problem was that even in a controlled scenario, the fit could be off enough to break that cement bond. The teeth wouldn't break, but they would be "floating" loose. With the advent of photogrammetry, we were able to instantly generate a digital file that gave us a precise location of where that implant sat. This allowed the zirconia to fit passively.

With the analog way, if everything doesn't line up, you aren't just risking a fracture in the zirconia; you're putting internal stress on the implant itself, which leads to bone loss. That’s a major reason why I used to be wary of zirconia bridges. You can impart pressure in a direction that ultimately kills the bone, and the patient doesn't realize it until it's too late. By using accurate machinery and photogrammetry, you get a repeatable result that lets you sleep at night. You know Mrs. Smith’s implants are actually healthy.

When did you switch over to photogrammetry?

We started switching from analog to photogrammetry around 2017 or 2018, right when we met. I remember I had negotiated a deal with iCam for three or four units for our offices. My business partner, Dr. David, had been talking to PIC dental. Unbeknownst to me, when I showed up on Monday to give him the iCam numbers, he told me he had already ordered four units from PIC.

So, we went down the PIC path. This isn't to bash them, but their "flags" (the components that attach to the implants) are made of plastic and are very large. In a surgical environment, it is incredibly difficult to get clear pictures of them. 

One major issue I had with systems like PIC was that the "flags" were made of plastic. If a patient accidentally bites down on one, it deforms, but you wouldn't necessarily be able to see that deformation. Since PIC uses a two-camera system, acquisition was tough on the patient, and the cost of consumables—replacing those plastic pieces—was high. I had such a bad first experience with photogrammetry that when I went out on my own around 2019, I went back to old-school verification jigs. I was convinced the technology just didn't work.

Eventually, I moved to iCam. Their flags are metal and much more accurate. They can be reused, they aren't disturbed if a patient bites them, and the data acquisition is excellent. Whether it’s an iCam or a MicroMapper, the solution depends on the whole ecosystem: the patient experience, the cost of new computers, and whether it fits your software. Some companies try to be like Apple, where everything is locked into their "iOS" platform, which is fine until you want to grow beyond their limitations.

Before intraoral scanners were common, labs used tabletop scanners. These were standardized platforms where you would place a stone model, and a series of cameras would take 5 to 10 minutes to turn that stone into a digital representation.

The problem is that a digital file is only as good as the physical impression it was based on. Stone shrinks and expands. The goal of the digital world is to limit data inaccuracy. If you have a MicroMapper scan accurate to six microns, but you are using an old milling machine that only has a tolerance of 50 microns, the scan accuracy is wasted.

On a best-in-class machine like an Ivoclar or a ZirkonZahn, a calibrated mill with new burs will get you within about 20 microns of accuracy. In reality, these errors stack. You might have a 20-micron deviation in the scan and another 20-micron deviation in the milling—now you’re at 40. Then you have the centering process for the zirconia, which adds more variables.

We developed something called "Fit Check" for the MicroMapper. You can take the finished zirconia restoration, screw on reverse scan bodies, and scan it. The software then compares that scan of the actual bridge to the original scan of the patient's mouth.

Back in 2017, the only way to verify a fit was the verification jig, and even then, the dentist's eyes and hands were the final check. In a fully digital world, Fit Check is the modern verification jig. It allows high-volume centers to ensure the framework is perfect before it ever reaches the patient's mouth.

I had a friend who used a MicroMapper for a year with no issues, and suddenly his arches stopped fitting. We were panicking—was it the photogrammetry? Was it the scan bodies? We had to check everything.

Everything looked fine initially—the scan bodies were seating properly and we didn't see any obvious errors in the acquisition. Come to find out, the dentist was ready to blame his milling machine and buy a new one. We knew he had a ZirkonZahn; while it's a closed system and expensive to run, it’s still a high-quality mill. Enrico Steiger and his team make great equipment. As long as you’re centering and milling properly, it shouldn't be an issue.

It just so happened that we had just released the "Fit Check" tool. Blake parachuted in to fish out exactly what was going wrong. He compared the patient scans to the 3D prints. Now, 3D printing is additive manufacturing, and it’s not nearly as accurate as milling; you can be anywhere from 60 to 150 microns off. He then moved to the milled restorations. In zirconia, the bridge is milled roughly 20% to 30% larger because it shrinks when you bake it in the furnace—that's the stage where it essentially turns into "metal."

We milled the restorations and fired them, and we discovered the problem: his centering furnace hadn't been calibrated in over a year. It was distorting the zirconia during the shrinking process. He ended up buying our mill anyway, but we surfaced the true problem. In this new digital world, there are so many parts—Exocad libraries, screw channels, software settings—that you need tools to pinpoint where the process is failing.

You always want to know where your problem is coming from. When the patient comes in for their final teeth, you don't want them to be disappointed by a poor fit that sends you back to the drawing board.

It’s about peace of mind. You can do things the old way and they work fine within certain boundaries, but exceptional results are only possible if you vet your machines. You can't just buy a machine and think you'll run it yourself without a team. There are calibrations, dry heating cycles, and distilled water flushes to keep it clean. It takes a dedicated team to make this level of accuracy bulletproof.

I’ve known many of your team members since the beginning, and that’s what it takes—a team that's close and can depend on each other to handle their piece of the pie. It's good to see you guys are still together.

We have to be a team to get these results. Nick is busy with the Jacksonville opening, so he couldn't be here today. Blake, why don't you describe the main types of manufacturing we use in dentistry?

We’ve used a lot of technical terms like zirconia and resins. Essentially, you have additive and subtractive manufacturing.

• Additive: Think of starting with nothing and building up. This is 3D printing, typically using a resin to create temporary materials like night guards, temporary bridges, or acrylics.
• Subtractive: This is what we see in full arch when we mill a restoration from a solid puck of zirconia. You start with a substantial, pre-manufactured block of material and the machine carves the dental file out of it.

Additive manufacturing can be a "goop" (liquid resin) cured by a light from the bottom, or it can be like a hot glue gun—which is how most hobbyist printers work. 

The main advantage for dentistry, and the reason why we use the ones with the vats of "goop" and the light that cures it, is primarily accuracy. If we were ever able to get to additive manufacturing that was more like your hobby printers, it would be a bit cleaner and faster, and you would have more variety in materials and the ability to mix colors. There are a couple of companies starting to break that trend, but for the most part, we use a resin matrix.

The materials you use are all FDA-approved, which is a limiting factor. You need medically approved restorations, some of which are even approved for long-term use as a "final" restoration. With these resin printers, a build plate comes down from the top and puts pressure on the liquid resin in a tray. The tray has a transparent bottom that flashes UV light in a specific shape, which cures that micro-flash into a small layer. Most of these printers have around 50 microns of accuracy. By the time the print is done, if you look at it before the final cure, you can actually see the lines and layers that were added on top of each other.

This process makes the structure more solid. I do a lot of hobby printing at home; with hobby printers, you can see the layer lines because they aren't as accurate and don't seal together as well. Resin has a tendency to seal the whole surface into one structure.

Can you elaborate on what you've printed at home?

Right now, I'm working on fishing lures. Different lures hit different fish depending on the light or color. When you're trolling, you're dragging bait—sometimes six lines at a time. Any second a lure is out of the water, you're not fishing. I struggle with keeping the gear organized and the bait fresh. I've prototyped a system in a five-gallon pail that organizes the lures in a "shotgun" grab-and-go way. The pail is filled with ice water so the bait stays frozen and brined. I've gone through about three prototypes. For about 50 or 60 cents a piece and three hours of printing, I can have them ready to go.

That brings us to the software. What are you using?

That’s a great segue. You always need design software to create the CAD file. It's similar to Microsoft Word or Apple Pages. I design my prototypes in a program called Fusion 360. It’s one of the main design engines used across all industries, whether you're building a new car engine or a lid for a cup.

Once you have that file, you need to put it into the machine. In additive printing, you use slicing software. This software essentially creates the instructions on how to actually assemble and build the object.

So, there are really two different types of software, similar to how we use them in dentistry. If you're going to do CAD, I also have a woodworking and acrylic milling machine at home. I can design in Fusion, but it’s a different type of software; it’s a different way to write the instructions, and those are very different for additive and subtractive manufacturing.

It’s computer-aided manufacturing—CAM. That’s exactly what it is. It's very similar to the milling machine at your lab, so you're doing both subtractive and additive at home. It’s a big hobby of mine. I feel like that’s why I got into hybrid dentistry, because it hit all of my favorite little niches. What I love about it as a hobby is that it's independent of location and weather. For instance, when that tropical storm rolled through on Sunday, I could still play with my hobby. Even on vacation, I can be designing something on my computer. I don’t have to make it right then; I can bring it home, put it on my slicer, and send it to the machine to be made. I don’t have to check the waves to go fishing or the wind to see if I can golf. I can do it in my idle time in a waiting room.

In dentistry, Exocad is the predominant CAD software globally for full-mouth rehabilitation. You can get through it with 3Shape, but you’ll have less hair than me if you stay in 3Shape. It’s a great software for singles, dentures, and many other restorations, but for full-arch fixed restorations using photogrammetry and stitching meshes together, Exocad is by far the best. No questions asked.

The head of Exocad was actually at our headquarters recently, and our team was on the phone with him in Germany regarding AI advancements. They already have AI-designed single crowns—meaning you upload that scan body from the intraoral scan and, within a few clicks, you have a generated crown. You can even toggle through different libraries for different morphology or shapes. When it comes to full arch, it’s not quite there yet. We are working hand-in-hand with Exocad to support them as fast as they can.

Exocad is what basically takes all your files—your photogrammetry file and your intraoral file—and allows you to stitch a "mesh." An intraoral scan of a patient comes into Exocad in the form of a mesh. The implant position file is another mesh, and you start stitching these together along with the teeth design. There are pre-fabricated libraries in Exocad, including Zirkonzahn libraries and many others. You adapt whichever design library you want and then stitch that to the soft tissue scan, the implant position, and the opposing arch. Then you take that file and export it.

I’m simplifying this, of course. Blake Veron, who runs our Exocad team, was just at Nova and UNC teaching the pros there. He’s arguably one of the most educated guys globally when it comes to Exocad. But simply put, it’s a file organization tool that allows you to customize designs and then export that STL file to either your 3D printer or your milling machine.

Different materials have different uses. Predominantly, additive manufacturing is used for temporary prototypes, whether for a crown or a full arch. It’s used as a definitive material for night guards, some single-unit crowns in non-aesthetic zones, surgical guides, and model bases. Subtractive manufacturing is generally where we find most of our final materials. It takes a little more time and is more intensive.

Subtractive manufacturing is more intensive because you’re taking the final material and cutting away from it. There’s also more post-processing involved depending on how you finish it. It isn’t as "convenient" as a temporary material and the pucks are more expensive, but the tech has come a long way. Early in my career, cast bars weren't even milled; we made them out of super glue, tape, and sticks before turning them into metal. Technology never has a bad day—it doesn't get into a fight with its spouse or suffer from a lack of sleep. It is repeatable and spot-on every time, whereas analog methods always involve human error.

You’re only as good as the machines you use, combined with the hands operating them. When I started, it took nearly four hours to mill a zirconia arch. Now, thanks to better CAM software like Hyperdent and advanced burrs, we can do it much faster. They are even making 4.5mm burrs that just mow down the excess zirconia so the fine burrs can get in quickly. We also use a C-clamp on our machines, which allows the burr to access the front of the tooth directly to get those crisp details on the anterior steps, rather than being limited to just top and bottom access.

Patrick, you are incredibly prolific in this industry. You probably know more full-arch practitioners in America than anyone else I know. I have a question for you: I was watching a local TV commercial for a dental office recently. They were touting their technology—super accurate printers and scanners—but I recognized the equipment and knew it was eight generations old and not actually that accurate.

How does an office differentiate itself now that everyone has a printer? How do we inform the public to discern the quality difference between an office with cutting-edge tech and one that just bought whatever was on the sales floor? It's like the printing industry; my father prints millions of Bibles on specialized European presses that take years to calibrate, whereas I have an inkjet printer at home. We can both call ourselves "printers," but the results aren't the same. How do you see the industry evolving in terms of using technology as a marketing ploy?

Technology moves faster every day, not just in dentistry but in the world at large. For me, there are certain thresholds a practice must meet; if they aren't using photogrammetry, CAD software, and digital workflows to eliminate analog error, I won't even entertain the conversation. Once those technical standards are met, however, "more technology" doesn't necessarily mean "better."

The real differentiator becomes the intangibles—the office culture and the education of the team. I can walk into any dental office and ask about the cost or process of a single crown, and almost anyone can answer. But full-mouth rehabilitation is different. If I ask a surgical assistant, a lab tech, or a business partner about the process and they aren't all on the same page, that’s a red flag. In our practice, everyone is aligned. That is the big differentiator for a patient on this journey.

I don't envy patients having to make these choices. Fortunately, patients are smarter now than they've ever been because they have access to information at their fingertips. It is rarely a patient’s first consultation anymore. In the past, patients put absolute trust in the clinician to explain the technology. Today, both younger and older generations use the internet and AI to research, so they arrive with highly educated questions about products, technology, and brands.

That awareness can be a positive or a detriment. Sometimes they feel they know a lot about things that don't actually matter, but it gives us an opportunity to educate them. I’m actually grateful for the big companies doing massive marketing because they raise awareness. Even if a patient’s first experience is a "herding cattle" scenario at a high-volume center, it brings them into the conversation. When I first started, I had to spend 90 minutes educating a patient from scratch because there was no information out there.

When I look for a service, I look for experience and confidence. Knowing an office has been around the block, has its own in-house lab, and has seen every complication imaginable is a huge "wow" factor. It means they know how to mitigate risks to reach the finish line. My best advice to a patient is to keep your ears up; if something feels weird, find a second opinion.

I appreciate you guys coming in and sharing your perspectives. My passion really lies in manufacturing, streamlining, and how the macroscopic design of implants fits into the clinical flow. This has been a great discussion. I know you have a flight to catch, so we’ll wrap it up here.

If you’re listening or watching, remember to like and subscribe. We’ll have many more episodes with visitors discussing the good, the bad, and the ugly of dentistry. We’ll see you next time.