Ep. 24: Implant Deep Dive Part 2 - Precision and Progress

Part 10:00

This is Beyond the Arches, where full-arch dentistry meets real talk. Let's get into it. 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, we've got Wes, and we've got Blake with us today. Welcome back, guys. Hello, hello. We went a long ways. I think we had one bathroom break, but... A couple waters. We're back putting a part two on our discussion just sort of about dentistry, the full-arch industry as a comprehensive look and sort of screw manufacturing and what an implant company sort of does and looks like. And we kind of put a pause in the last episode because I wanted to talk about more manufacturing data acquisition and what happens beyond the implant screws.

And so I felt like that was a good break because this is a whole other topic and category. ▶And having you on this, Patrick, is great because, like I said on the last episode, you've always been this all-in-one kind of pusher, right? You want the manufacturing side to be available and the data acquisition side and the implant screw to be proper. And that isn't just from a... Most of the time... Most of the time that feels disingenuous. Like when I'm looking at an implant company and they say, well, we're an all-in-one package, all-in-one solution, most of the time they're just picking up this piece and throwing it into the shopping cart and saying, well, this is available, whether or not they know how to use it or whether or not it's good for the actual practice.

And so what I like about you is you've always kind of come from this 360 perspective, which is necessary and the solution is important. But I feel like you've always done a good job sort of incorporating things into the solution. Yeah, absolutely. that are functional and that work, saying that, maybe you don't have a big push towards guys. Maybe you have a solution that's available, but it's not one of your big pushes, which is one of my deep convictions is if you have it, great. And if you don't, or if I don't need it, don't push it on me. I've determined that that's not what I want to do. That's not how I want to treat my patients. And so hearing you say that just sort of reaffirms what I'm saying, which is...

That all-in-one solution is important, but where it's not necessary, it's not like a push. You've never been like a pushy guy with this product or that product. And I think that that's important for us as clinicians making decisions for the patient, not getting sold on something that's sort of snake oil, if you will. Yeah. It's interesting because you're right. I'm not pushy about it. I hope we're not, our company's not pushy on anything. No. At the end of the day, we...

Blake and... Sorry. I don't think we talked about it, Blake. But with Wes, Wes and I were

Part 23:01

talking about this yesterday. The best way to describe what we... And this will kind of circle back to who we are, what we do, what we do, and to your point on the 360. ▶So Wes and I were chatting in the car ride over from Tampa, and it's who do... The best way to describe who we focus on is who we don't focus on. A general dentist coming out of school that wants to do their first single posterior implant, that is the furthest from a customer.

They don't even understand the problems our solutions address. For example, I mean, we have custom strategies in Hyperdent where we can actually bring in the XYZ coordinates from your photogrammetry file into the construction info and how that benefits your milling outcomes. You guys mill wet, I think you told me, right? Yes. I love that. That's cutting edge stuff. I mean, you have to have a dry cycle on your centering furnace. There's things you have to do to make sure the outcome is perfect, but it's...

It's the best way. It's the most high-end way of doing it. That's not revenue generating for us. It's also the cleanest. It's definitely the cleanest, but you have to be... What he's talking about is when you're cutting the teeth out, and we'll talk about additive and subtractive manufacturing, but when you cut the teeth out in a milling machine in zirconia or plastic, it creates a lot of dust. And you can either do it dry, which doesn't have cooling, or you can do it wet where it's producing...

You know, it's cooling the surface down. And so that's generally the better way to do it because you're not imparting stress of heat, et cetera, in the material. Sorry. And zirconia is a powder that's highly compressed into a 98-millimeter disc. So it's really a powder. So when you get it wet, it actually turns into concrete when it dries. So your team has to be meticulous about cleaning the machines, which clearly they are. That's the, now, my point here is that if you're a customer of ours and you're not milling wet and we go to you and say, here are the benefits of milling wet, here are the cons, you have to clean it, you have to be meticulous, otherwise you can freeze your spindle, you can have problems, that doesn't generate any revenue for us. But to your point back to the beginning, if we maintain integrity as a company or as a professional, as an individual, if we maintain integrity that our goal is to bring practices and optimize and live in that, yeah, it's the cutting edge. It's like, what's next? How can we optimize, level up one more? That doesn't generate revenue, but it's what's best for you and trickles down to being what's best for the patient. So that's what we thrive to achieve.

We even tell ourselves our goal is to have the best solution, comprehensive solution for full mouth rehabilitation. And if there's a better product out there, we can, we will still, market it, still support it because that's what's best. Even if we don't sell it and make money, even if we lose business, what's important is that we stay in what's relevant, where the technology is going. So let's get deep, man. I'm ready. Let's do it. So let's talk about manufacturing. Blake, let's, the two types of manufacturing mainly in make, actually, no, let's back up. Let's not talk about manufacturing. I wanted to talk about data acquisition. So Wes, why don't you give us a little bit of a insight on, when we're talking about data acquisition, there is a big component of scanning. Do you guys have a scanner, an internal scanner available? We sell Trios. We sell a number when we sell Shiny 3D, but anybody who asks us what we recommend, it's going to be Trios 6. Trios 5 is good too, but. I think, I don't, I think we have five. When did six come out? This year. Okay.

Then we have fives. Five is great. Amazing. It's the best internal scanner for capturing tissue, even in a bloody wet environment. It's going to give you, the best. Now, Wes could talk about this, but we also developed for those that do surgery day of surgery and they want to capture all the data right then and there, we developed the tissue mapper, which eliminates the need for an intraoral scanner postoperatively. You still need the intraoral scanner preoperatively, postoperatively. We can capture tissue using photogrammetry technology and it could be bloody, wet, doesn't matter. It's going to be a very accurate impression.

And so why don't we talk about, real quick. So in photogrammetry or not photogrammetry with intraoral scanners, there's, there's two big ways in tech and dental technology, speaking to soft tissue and implant position that we're acquiring the data on a patient, right? That is intraoral scanning and photogrammetry. So intraoral scanning is, is what Wes? Intraoral scanning. Intraoral scanning is you're taking, um, pictures and you're stitching those pictures together of the, uh, object that you're scanning.

Like four or five pictures or? Oh, 2000. Is it 2000? Yeah. It's usually 2000 is when it'll max out on it. 2000 what per, per what? It's 2000 total, total images. Okay. Yeah. So, and then photogrammetry is you're taking a image of the implant placement and it's giving you an X, Y, Z coordinates. So you're getting an X, Y, Z coordinate as Wes mentioned, but then you're getting the relationship to the one next to it, the one across the arch, the one in front of it to all the ones that have scan bodies and that are captured.

And a scan body is something that fits on top of the part that you're trying to capture the location of. And so a scan body for those that are listening at home, there's sort of, there are scan bodies that you can take intraoral scans of. That's what we primarily see for single implants because you can scan and stitch those pictures together enough and the technology or the design, um, the design file software knows enough to get it in a good position where it can then be 3d printed and a crown can be manufactured or such on it.

But with photogrammetry, you're getting a much more accurate. Decision on where that implant is correct because of the scanner and that scan isn't really capturing the gum tissue or the other teeth. ▶It's capturing exactly where that particular implant that you've asked it is relative to the other implants. And that accuracy, uh, is important when you're trying to, there's a lot of stuff on the market and maybe you can kind of give some insight. I personally feel like no matter how much you're stitching those pitches pictures together, they're not going to be as accurate.

There's going to be enough inaccuracy so far, or the piece that attaches to the implant has to be so big to get an accurate representation of where it is that is sort of non-functional to take a full arch intraoral scan with those scan bodies. You know, all of those different, um, components that are available. Do you like any of those? No, I think the, if, if I can just be transparent, the best, I mean, Wes could tell you this as well.

The best technology on the market. In photogrammetry, which is technology, that's basically taking a series of pictures with different cameras on one device at different distances. And it tells you the angles and everything. And, uh, and the algorithm puts those images together and basically coordinates, uh, uh, X, Y, Z coordinate for each scan body. So that's, there's, there's really two main technologies on the market that do that exceptionally. There's three, I would say there's micro mapper, I cam.

And pick there's other ones like two pole, but you've run into issues. If you have more than four implants, there's, um, there, the repeatability is not there. I mean, there's the, the quality is not there in my opinion. That's not just because we don't, we don't sell it, but there's, it's just not quite there, but you guys have, I cam, we used to, we were the number one distributor for I cam until we developed the micro mapper.

I cam is great. Micro mapper is the best all around because accuracy. I cam and micro mapper, you're going to be relatively similar and it's going to be in the neighborhood of say, call it, um, I mean, you can, we've gotten scans as low as like nine microns of accuracy across six implants, which is unheard of, but that's in a, like a, uh, that's on a model that's not on a patient. And then it'll go up to say 60 of scan bodies are used a lot with micro mapper or even I cam you're going to be in the sixties, but, uh, just the thickness of a piece of hair.

Is 50 microns. Yeah. So we can use that as a point of measurement. What Patrick's speaking. I didn't know that that was 50 microns. Yeah. It's we're talking, we're talking microns or so now just put it this way. If you want to, you know, you'll see claims that people have a photogrammetry devices or internal scanning, scan bodies that you can stitch together and scan and get within six microns. You cannot even calibrate a machine and tell me if something's in a certain position, like six microns.

Six microns of accuracy. It's, it's so hard. The only, and one of the things we've tried to do different there with micro mappers, we, there's a calibration device in Toronto at Clarinavs headquarters that manufactures the micro mapper. They have a big long granite slab table. That's huge. ▶And this is that prevents like heat change or temperature changes, which can throw off the scans and throw off the calibrations. So this is one of the most controlled environments and they can get it down to around six to eight routinely.

So that's just the test if something's within an accuracy specification. So it's hard to say it's impossible really for any other photogrammetry device to say, Hey, we're getting six microns of accuracy every time. That's just not happening. Right? Yeah, it's not. But yeah, so, so photogrammetry that's given us the XYZ coordinate as Wes mentioned, that gives us the implant position.

Part 313:21

The intraoral scanner is for those that aren't. In the industry or aren't clinical. It's the same as if you take a pano image on your phone and you know, you have that arrow in the middle, you have to keep in the middle. If you move too fast, it goes up. You have to slow down. You go too slow. It goes way down. So you have to have it just perfect. Intraoral scanning is the same. It is the same.

I never made that connection. It's the same exact thing. Yeah. Cause you're just stitching a bunch of images together. Yeah. So you think about the oral cavity, patients moving, assistants moving, tissue stretching, their saliva. There's blood in some cases, it's very difficult to use an intraoral scanner to capture implant positions more than one or two implants. Like you said, if it's for single implants, relatively, you can get it accurate enough. So it fits. It's not an issue.

It'll never be a problem. But when you go to a full arch cross arch stabilization of a, of a restoration that we'll talk about, whether it's milled or printed to get that to see perfectly, you need to have photogrammetry to have repeatability and predictability. And that, so to, to parlay on your pano, a panoramic image that you take on your iPhone, everyone can understand that when you're stitching, when that's stitching actively together, when something moves, you know, you have somebody that walks through the background, it gets all distorted.

Well, when that person, that person's image is what you're trying to get, be it your implant position and you're doing it with an intraoral scanner, it doesn't matter what it is. It's always going to look distorted. Yeah. To some degree, you're always going to have distortion. Like a lot of offices use bone fixation screws. You don't at Dun & One. If you use bone fixation screws, when you go to do the matching, the post-op, so you put fiducial markers, you put these bone screws in the midline of the palate, two on each retromolar pad, you'll do a pre-op scan and the proper vertical.

Then post-operatively, in theory, those screws have stayed the exact same place. In theory. In theory. In theory. In theory. In theory. All the way through the process, through the surgery, and if there's any movement, there's distortion, and the bite, midline, or can't is going to be off. ▶The implant position is never an issue because you're using photogrammetry, which doesn't care about the distortion because it's capturing a real-time XYZ coordinate up to, call it, 50 microns of accuracy.

Intraoral scanning is not near that accurate, and you get that distortion. So, yeah, you have to make some adjustments. Blake, have you ever done? Have you ever done a case with fiduciary markers and fixation screws as a reference point for before and after? Yeah, I've found workflows I've done before with intraoral scans, pre-op, like you talked about, putting it in the palate, retromolar pad, it works, but they can move. It's another area of discomfort for the patient, but it's a different protocol than we use.

I did it a bunch way back in the day. I think I even did a couple cases when you came and visited. One or two times. Beside the workflow interruption, which is I have to put it in, and then we have to wait for the scan, and then we have to come back, the fear as the person responsible for the care of the patient, the overwhelming or the overlooming fear of disrupting that fixation screw, I always felt like got in the way of clinical decisions.

I was not compromising my care, but I was making clinical decisions around these four. Four or three or five little screws, and that always felt very uncomfortable for me because you would get all the way to the end maybe, and it did move, and you can't do X, Y, Z that you were planning on. But not only that, the decisions were somewhat compromised because I'm altering what I'm doing based on that screw's in the way. Now I can't do this, and that was always very frustrating.

That was probably the number one reason why I started as a… All digital guy, all digital workflow, and then bounce back to being a mix of analog and digital is because that, to me, is not a solution. That's just introducing additional problems. That's just my take on it. No, no, no. I see it all the time where the distal sites on the mandibular arch, you would go to place your angulated distal implant, and your contralateral handpiece would hit those screws.

▶You'd have to change your insertion direction of your drills, which sets the tone of the implant position, the multi-units. And the teeth. It gives me palpitations to think about it, honestly. It scares me. One thing I wanted to ask you, Dan, is you've gone through all the workflows, analog, digital. When you switch from scan bodies to, let's call it flags or scan bodies for photogrammetry, what did you see the difference clinically for your patients? Well, I'll go back a little bit further.

So when I first started doing hybrids, we were not doing zirconia as the predominant restoration. We were doing… A cast bar with denture teeth on top. And that was before any of this real technology was available. So we would take a physical impression. We would take that physical impression, put it in and pour it up and turn it into the stone that everyone is used to seeing. And then you have to connect that with a very strong plastic bar, if you will.

The lab will make you a strong plastic bar. They cut it in a specific way where they're each individual. Give it back to you. You put it into the patient and you re-glue it back together inside that patient to re-insure. It's called a verification jig. You do the verification jig to make sure that those implants are exactly where your impression said it was. You then take an impression over that. You go and you… Well, you can take an impression over that.

But you would take that back to the model. You cut. You would look for any differences. You cut that out of the stone. Re-pour stone. Re-pour stone in that particular area just to… And you kind of would guess, right? Because if you did four implants and one was off, you had to have somebody that really knew what they were doing to tell which one was the one that was off. Because one is going to throw the whole system.

And you have to have that eye for really which one is the one that didn't make it correctly. But long story short, when you would finally get to the end, that was just done by hand and by stone. And stone expands and contracts and expands and contracts and has different… Levels of accuracy. And so the result wasn't that accurate. To the point that when we would do a zirconia off of that type of way, you almost had to wince and be a little bit concerned.

As you were tightening these screws in, there was a chance that they would be off enough that it would break the zirconia. And that's even with… And we still use titanium bases for a pretty specific reason. But that's even with titanium bases holding the screws in. Which gives you a little bit of play. That was… Isn't that the intention? That's the intention of the titanium bases was there's a metal piece that's touching the abutment. There's cement that's kind of your fudge factor.

And then there's this unforgiving zirconia. And the problem was even in the most controlled scenario, when you screw that in, there would be enough off that you could break that cement, which was better than breaking the teeth. But it would be broken loose and it would be floating. So then with the advent of photogrammetry, we were able to instantly have a digital file that gave us that really close estimate or that really close number of where that implant sat.

Which allows you to seat zirconia with repeatability and a peace of mind, etc. Passively. Have it fit passively. Yeah. And the analog way, too. If everything doesn't line up, not only can you fracture the zirconia, but your… You're putting stress on the implant as well for the longevity of it. Wonderful. And you're going to get bone loss. And that could be a whole other five-hour conversation, but that's the reason why I hate the zirconia bridges on top of the implants.

▶As you can impart internal stress into those bridges, into those teeth, into those implants, and get a killing of the bone because there's too much pressure in one direction or another, that ultimately the patient doesn't see until it's too late. And so, the reason why we're in hybrids and the reason why we do the cases with the gum tissue and all of that is because when you assemble it all and you assemble the machinery and you assemble the accuracy, you get that very repeatable good result that you don't have to wake up at night and think, oh, man, Mrs. Smith, I hope that her implants are okay.

You know that they're tied to that implant. When did you switch over to photogrammetry? So, that's part of the story as well. So, we got into zirconia. We started to switch over off of the analog into photogrammetry. We started in, I would say, 2017, 2018, right about when we met. And I remember I had negotiated a deal with ICAM, with Horace, for maybe three or four of them. We had three or four offices. And Dr. David, my business partner, was talking to Pick Dental.

And unbeknownst to me, when I showed up. I wanted to give him the numbers for the ICAM. I was all excited about it. And he said, oh, you owe me this much for the picks that I just ordered because we just bought four of them. So, that was already committed and down the road. So, we went down Pick. And this isn't to bash Pick, but their flags are made of plastic. And they're very, very big. So, it's really hard in surgery to get the pictures of them.

And you also can't determine whether or not they're deformed or not, truly. You kind of. You almost have to open a new package every time. But even then, patient accidentally bites down and deforms it. What are you going to do? You wouldn't be able to see it. And so, Pick, and it also has two cameras. Pick was really hard for acquisition. It was really hard on the patient. It was really hard for consumables and changing out those plastic pieces.

And so, I had a really, really bad first experience with photogrammetry. Such that, when I separated and moved on my own, you know, circa 2019, 2020. I didn't do any photogrammetry. We went back to verification jigs because I was convinced that photogrammetry didn't work because of my bad experience. And then, finally, over time, I forget what was the scenario. But that's when I went back into iPick. iCam. iCam. iPick is a movie theater right here. I went to the iCam because their flags are much more accurate.

But they're made of metal. They can be reused. They're not destroyed. They're not disturbed by patients. The acquisition is good. And maybe, in the future, we end up with a micron mapper. But it's one of those things that has a thousand different parts to it, right? Why we use it and what solution isn't always the answer. There's what goes into it for the patient's experience. What goes into it for the cost. What goes into it for the new computers you need to buy.

Does it fit into the software?

Part 424:49

There's a lot of the things that kind of go into that whole ecosystem. And part of dentistry, there are some places that sort of make it Apple where the ecosystem is on the iOS platform. And that's cool at first, but then you're limited. And so you want to grow out. Yeah, Zircon's on. And so, yeah, it's all fascinating stuff. And to go back before, since we're covering a little bit of history, there also was a period, and still some people do, if you don't have an intraoral scanner.

Or, say, don't want to invest in one or the lab, not every single location has an intraoral scanner. The lab will, the lab or the place that it gets scanned will have a tabletop scanner. And so that was basically like a standardized platform that had a series, a camera that had a series of views that it would take. And you would scan it and it would take five, ten, ten minutes. Yeah, they're relatively quick. Yeah, it was different data acquisition.

Yeah. Yeah. Relatively quick. And it manipulates it in a way in which it can turn that stone model into a digital representation. The problem with that is that it's only as good as your impression. It's only as good as the shrinkage of your stone. And so a lot of the streamlining of this digital world has been focused on how do we limit the data inaccuracy. So you can use a micron mapper at six microns. But if you're.

Milling machine, you're doing it dry and with a crappy, you know, really old version, maybe it only mills to, I don't know, 50 or I don't know what the tolerance would be for. So on milling machines, the tolerance, it's like for Imus I-Core, what we sell, arguably we view it as best in class. They're going to be with new burrs calibrated. You're going to be within around 20 microns of accuracy. ▶So to that point, the best, the best micron scan doesn't even matter.

Because you're only ever going to get within 20. It stacks actually. So your average scan, whether it's I-Cam or micro mapper, a good scan is going to be 20 microns of accuracy. So you got 20 on the photogram machine. Could be off a total deviation of 20 microns. Milling, say, could be off a total of 20 microns. There's 40. Then you've got centering, which there's some, the papers are very rough on that. We've done some studies. But so micro mapper has what's called fit check.

So you can take your zirconia. Restoration. You can screw on reverse scan bodies and scan that. And it'll tell you, it compare it to the actual patient scan. So you can tell exactly what's in the patient's mouth up to six microns. Then you can see exactly what the rest of the framework is and compare the difference of those two. That's the only way. Think about this. I know I'm going a little bit ahead here, but rewind back to 2017 when you guys are doing everything analog.

What was the tool that? Verified if something was off. The dentist. Well, the dentist. Yes, but there's a, what's the patient's mouth? How did you know? We didn't try to do it. Oh yeah, sure. Usually the verification jig. So in a fully digital world, what is the verification jig? If you need a check, say if you're a mass production lab or you're a big implant center, you guys do a lot of cases. How do you check that?

Really? It's, it's adding all of those equipment up to the zirconia and whether or not you're having issues. That's zirconia, which would be a negative because it's at the final, at the delivery. Exactly. So what we developed is the fit check and it's not for everybody, but those that understand what it can do. Like we, for example, there's a, there's an office, a good friend of mine. He gets everything from us. Milling machines, implants, you name it.

Photogrammetry. He called us and said, and he actually, before he had his milling machine from us, he got a, he had a zircons on and he's like, something's going on. I've had multiple. I've been using micromapper for a year now. No problems. Now I'm having arches that are not fitting and we're freaking out. We're like, Oh, what's going on? What could it be? Um, everything's digital. We're like, it's photogrammetry. It's gotta be active and passive unless maybe the scan bodies are off.

So we checked the scan bodies. That's fine. They're seating them all the way. We looked at the, you know, how they were seating them. Everything was going fine. Come to find out. He's like, listen, I want to buy a new milling machine. Maybe it's my mill. And we're like, uh, the sales seems like, all right, let's get this done. And I'm like, well, hold on. How could it be the million machine? I know zircons on well, it's not our product, but it's still a good mill.

It just takes four hours and the zirconia is through the roof expensive and it's a closed system. So I see the cons, but it's still a good milling machine. They still, I know, I know Enrico Steger. I have a lot of respect for them. It's good zirconia. And as long as they're centering it properly and milling it properly, it shouldn't be an issue. Come to find out that was the same month we released fit scam fit checkers.

Blake parachuted in. He's like, let me figure this out. I'm going to fish out exactly what's going on. So he basically took on all the scans of the patient. He compared them to the 3d prints. There's obviously 3d and proteins, not nearly as accurate as milling. So you're, you're, you're roughly a 60 to 80, maybe even 150 microns max off. Okay. Not, not terribly off, but this is consistently something's off. Went to the mill, milled out restorations, obviously, and zirconia it's milled at 20, roughly 20 to 30% larger.

Cause you got to shrink it when you bake it. That's when it turns into a metal. So we milled out some restorations and then fired them. And we come to find out his centering furnace was not calibrated. The zircons on had been calibrated in over a year. So it was distorting on the centering side. So he ended up buying the milling machine from us anyway. Uh, but we did surface the problem. It was a centering furnace with, in the new world of digital workflows.

There's no other way to verify is how can you pinpoint where the process is? Maybe they match the wrong exocad libraries. Maybe they put the wrong screw channel. I mean, there's so many different, so many parts. So anyway, this is, um, it's a tool that, yeah, it's a little bit of a, a plug for micromapper, but at the end of the day, I hope more companies develop these for their scanners. Because it's something that's, uh, a new, a needed tool in this new environment of digital.

Yeah. Cause you always want to know where your, your problem comes from, whether it be a business or manufacturing or whatever it is. Not only that, when the patient comes to receive their final teeth, you don't want them to be disappointed when they don't fit properly. And now you're back to the drawing board and you know, it's not a good day. Absolutely. Yeah. It's, it's funny. Cause we were talking last time about how exciting this is. Yeah.

For me, because it's putting all these pieces together allows for this whole new world and it's a stress, more stress-free and all of that. And it's very like peace of mind. And, uh, similarly you can do this the old way as much as you want and it works fine. You know, it's, it's within the boundaries of what works, but it's only really like possible with exceptional results. If you use good machines and you vet them out. And you make sure that they're all, you know, just as an example, you can't just buy the machine and think that you as a dentist are going to run it all by yourself because there's calibrations that need to happen.

There's, you know, the dry, the dry heating and the there's everything that goes into it, running the distilled water through to make sure that the machine is clean. So there's a lot that goes into it and it's a whole team that comes together to make this possible, but when it's possible, the, the accuracy and the results are so bulletproof that it's. It's just a very straightforward type of process. Yeah. And I think, I think with your culture and what you've done with your team, like many of your team members I've known since the beginning, since I met you, which is, which is, that's, that's what it takes a team that's close, that works together and you need people you can depend on to cover their end of the pie, so to speak.

And, uh, it's good to see that you guys are all still together. Yeah. We gotta be a, you gotta be a team to, to bring in those, those good results. We don't get to see Nick today, unfortunately. Well, he's probably working. He's probably working very, very hard. He's a, he's a busy bee, especially with Jacksonville opening. He's, he's a busy guy. So, um, parlaying into manufacturing more from the data acquisition into manufacturing, Blake, describe to us the different types of manufacturing that you can main manufacturing for dentistry.

Yeah. So we've thrown around a lot of words so far. We've talked about zirconia, we've talked about resins. So to kind of go from the beginning, um, you have additive and subtractive. So additive think you start with nothing and you're 3d printing something. So that's going to be your 3d printing, um, you know, anything that's going to be out of a resin, more of a temporary material, um, like night guards, uh, temps, acrylics, things like that. Um, subtractive, we're going to see this in full arch when we actually mill zirconia, that's going to come from a puck.

This is going to come from a substantial material and it's a different process. It's pre-manufactured prior to bringing in your dental. Uh, the file, if you will, versus sort of, like you said, comes out of nothing. It's manufactured with some sort of material. The material can be a goop with a light that comes from the bottom and it's not accurate enough, but the other type of additive manufacturing that's popular in printing is it's almost like a hot glue gun.

Um, that's what your main hobby ones are. And, um, there's a lot of advantages and disadvantages to different, the two different types of 3d printing, but the main advantage for dentistry and the reason why we use the ones with the vats of goop and the light that, that cures it is because of the accuracy mainly. Um, if we were able to ever get to an additive manufacturing where it was more like your hobby printers, it's, you know, a little bit more clean, it's a little faster, you know, you have a lot of, um, a lot more variety and material and material, um, um, mixing colors together.

And there's a, there's a couple of companies out there that, that are starting to kind of break that trend. Like. Um, but for the most part, it's a, it's a vat of sort of, um, you know, a matrix of goop is really the best way. Yeah. It's a resin, right. And, and the ones that you use obviously are all FD approved. So that's the other limiting factor is you need to have a medically approved, uh, restoration that way patients even, I mean, some of the, some of the materials even approved for long-term use, what they would call a final, not that I see it on every company.

But, um, yeah, you have to, it's a resin and what happens is there's a bill plate that comes down from the top, puts pressure on the goop as you're calling it, which is the liquid resin in a tray. And the tray is a transparent bottom that flashes a UV light in a certain shape. And that's, what's going to be, uh, cured on that one micro flash.

Part 536:18

And you get like a, a small layer. And most of these products, uh, are, are, are, are, are, are, are, are, are, are, are, are, are, are, are, are, are, are, are, are, are, are, are, are, are, are, are, are, are, are around 50 microns of accuracy. So it's a tiny 50 micron layer, uh, relatively. And there's just multiple layers. So by the time you're done with your print, if you look at it before you cure it, you can see the lines and the layers that were added on top of each other.

Yep. And it makes this as a little bit more solid too. When you're doing, I do a lot of like hobby printing. I have a couple of hobby printers at home and you can see the layer lines because they're not as accurate and they also don't seal together as well when you're doing that resin it has a tendency to seal in that whole structure that whole surface can you can you elaborate give us some ideas of what you've milled it or printed at home oh all kinds of stuff right now currently what i'm working on is um you know when you're fishing um you have uh different lures right and different lures will hit different fish at different times maybe it's light out and they want a darker they are starting to hit like dark purple or the white ones or whatever it may be right and so when you rig these up it kind of takes time to rig them up right well you want to be making any second that that loot and a lure is out and i do a lot of trolling so it's dragging dead bait if you will six of them at a time anytime that one of those rods is out of the water you're not fishing so i always struggle with preparing the right amount of bait and keeping all of the stuff organized and like the the line that's attached to the lure and so and you also usually put actual like ballyhoo or dead bait on it and so right now what i'm working on is uh i've prototyped the system that allows you to organize the lure in sort of like this shotgun kind of grab way so it's uh organized on the inside of a five gallon pile you're like man i shouldn't have asked this question keep going but it's unorganized it's organized in a five gallon pail and so it's it's essentially the top that holds the line of the lure and keeps it sort of pulled up with the bait and so the be the reason why it's in a five gallon pile is because you fill it with like ice water so that bait stays frozen and and brined but can also be like a quick switch out so you can switch out when your bait gets hit and you're not you have minimal downtime and so for well several hours and then you're ready to go to the next part which is the software so what software are you using then we can go into dental yeah so i use for the design you mean yeah so that's actually a genius little segue so there's always a design software the design software is what creates the cad program or the file that you're going to to be printing or manufacturing and that file is kind of similar to microsoft word or pages for apple so it can be a little bit specific between systems so i design my prototypes and things in a program called fusion 360 it's the design program that really is the main engine for the system so i design my prototypes and things in a program called if you're going to build the new ford engine and you're going to build a piece that fits onto a the lid of a of a cup or something it's one of the main design engines sort of across all industry platforms and then once you have that file made you then need to put it into the machine that you're going to make this file on so in additive printing you need to put it through a machine that's going to make this file on so in additive printing you need to put it through a machine that's going to slice it and you put it in what's called a slicing software and that slicing software and infusion has a built-in somewhat but it slices it to say it's really creating the the instructions on how to actually assemble and build it's kind of like the microsoft word when you go to prepare to print it's it's giving specific instructions on the printer of where everything needs to go it's not it can't just duplicate it out of the computer so there's two different really types of software which is similar to the way that we use in dentistry and then if you're going to do cad i also have a cad uh woodworking milling an acrylic milling machine at home and i can design infusion but it's a different type of software it's a different way to write the instructions and those are very different in additive and subtractive so it's computer-aided manufacturing so cam yeah exactly there you go yeah very similar to your milling machine at your lab but so you're you're doing subtractive and additive printing so you're doing subtractive and additive at home yes oh interesting yes it's a big hobby of mine that's why it's almost kind of i feel like that's why i kind of got into hybrid dentistry is because it really just like hit all of my favorite little hobbies and niches and what i love about it as a hobby just as a little side note is i love that for instance like we had the the tropical storm that rolled through here so there's a ton of rain we'll say on sunday right well i got to go play part of my hobby and even if i'm 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 put it in the machine actually make it or send it across the country to to be printed but what i love about it is it's a hobby that's sort of dependent independent of location and um weather you know so it's a it's a hobby that i can do i don't have to check the waves every day to see if i can go fishing or check the wind and see if i can golf you know so it's a hobby of mine that i can do in my idle time in a waiting room or whatnot yeah yeah yeah so with uh when it comes to dentistry we've got um exocad is the predominant cad software globally for full mouth rehabilitation three shape you can get through it um you'll have less hair than me which is not much if you stay in three shape um it's uh it's a great software for singles dentures a lot of other restorations but full arch fixed restorations using photograpsies and stitching meshes together exocad is by far the best no questions asked um we can you know wes asked me i think you asked me this yesterday as well what's the what's the latest with ai design as exocad um mentioned anything well the head of exocad was actually at our headquarters recently and then our team was on the phone with him in germany about uh about some of those advancements they already have ai design for single crowns meaning you upload that internal scan body from twirl scan that you did and within a few clicks you can have a crown generated and you can toggle back through different libraries for different morphology or shapes when it comes to full arch it's not there yet there's um we are working hand in hand with exocad to help support them as fast as they can uh there's another company that we're working very closely there's two other companies so it's not something we want to bring in house but it is something that uh if somebody comes out with it great we're gonna as long as it works we're gonna promote it even if we don't sell it it's uh it's something the market needs the patients need it'll increase that time and and result but uh exocad is what the what basically takes all your files your photogrammetry file your inter-oral file brings them in allows you to stitch a mesh which is a an inter-oral scan of a patient when you bring in an exocad it comes in the form of a mesh the implant position file is another mesh and you basically start stitching these together along with the teeth design and there's pre-fabricated libraries in exocad zircon zon's got a bunch of libraries there's a number of libraries out there you can import into exocad so then you adapt the teeth libraries which whatever design library you want and then you stitch that to soft tissue scan the implant position and the opposing arch and then you take that file you export it i'm simplifying this oh yeah yeah blake veroni exo he he runs our exocad team he was actually just at nova i think a week or two ago teaching them he was at unc last week teaching the process there on exocad he's arguably one of the most educated guys when it comes to exocad um globally that i know of but he could he'd probably uh slap me on the leg for for talking about exocad like this but the but that's a simply that's how i view it it's a file organization tool that allows you to customize make some designs and then you can and then export that stl to what you were talking about dan you can go to your 3d printer

Part 645:23

or you can go over to a milling machine so like to blake's point additive and subtractive yeah and and different materials have the different uses you know predominantly currently printing and additive manufacturing is used as a temporary prototype however you want to say whether it be for a crown or a full arch it's used as a definitive for uh night guards what else is it definitive for um single unit crowns single unit crowns we see that pretty common yeah not necessarily you're in the main aesthetic zones but um and then on aesthetic zones we do see those pretty common guides surgical guides surgical guides yeah model bases models yeah and then the um subtractive is generally what we're refining most of your final materials it takes a little bit it's a little bit more time intensive because you're taking the final material and cutting away from it and there's usually a little bit of post-processing because you can't do there's a little bit more post-processing because depending on the material or or how you're going to finish it can take a result so it's not as convenient as a temporary it's a little bit more expensive material materials and um yeah that it all works out pretty well in the end um but you know the the tech the tech has come a long long ways i mean oh yeah as i said here my career is not that long and i started with doing cast and cast bars were not even cut on a milling machine cast bars were you make it out of glue and sticks and super glue and and tape and then turn it into a metal version it's it was it's a pretty been a pretty wild career so far and it changes when you look at accuracy time and you know all those things i always say technology never has a bad day right it's not fight with its wife it's not a lack of sleep um it's going to be spot on every time where in the analog way there's human air that's involved all of those things that can change depending on the circumstances who hands whose hands it's in is you know it acts different where the technology is um you know it's repeatable and um you can rely on it to to do that every time you go to use it you're only as good as the machines you use and you're also only as good as the hands that are used in it as well so that the two combined can be a big problem or perfect result yeah yeah we see um so back when you first started with zircons on that was roughly three and a half three three hours 45 minutes to do a zirconia arch nowadays we've seen actually i just pulled up an image from last week like roni just sent the uh we're at one hour eight minutes for a full arch centering no no no milling milling milling that's great so timing is coming down now a lot of that has to do with the machines has to do with the hyperdent the cam software has to do with um finishing roughing burrs so now they're making a lot bigger burrs because full arch is becoming so popular they'll come through with a big four millimeter burr we have a 4.5 that's coming out that it goes through and just mows down all the excess zirconia so then the fine burrs can get in there and then you usually have what they call a c-clamp so on the subtractive manufacturing it'll allow the access of the burr to go directly on the front of the zirconia and then you can get in there and then you can get in there and then the tooth so you can get good details on those anterior as opposed to being all the way around the material yeah top and bottom only sure the as we kind of get to sort of towards the end um how do you think being that you guys are so exposed to other dentists and offices i mean patrick is one of the most prolific uh in terms of knowing people in the industry of full arch that i know of for sure might be number one in terms of person that also know that knows that many full arch people in america i think i mean can you think of anybody that knows more people and offices yeah i don't think so at any rate yeah i have a a random question for you so as the other night i was

Part 750:05

watching television and there was a very locally made uh television commercial that was a local office and of course you know they're touting their technology because they think that that's what all the old people want is just more to see more screens etc and so they're talking about super accurate printers and super accurate scanners and all of this and i'm looking at the equipment i'm like well that's not that accurate and that's terrible and i used that eight generations ago how do you think of an office differentiates itself because now the they it used to be you had a printer you were like one of the whole coast and then it was one of the state and then you know how do you think that there's how do you inform the public to discern a little bit into like what that that there's a differing level of quality between an office that is advertising for you know this scanner and this they have all of these pieces of equipment and maybe another one that has better equipment and better technology are we going to run into this scenario the way i think of it is my father is uh um in the printing industry and they print millions and millions of bibles per year and the printers that they that they buy come from a specific you know place in in europe and takes 10 years to end up getting and calibrating and perfecting right and and the bibles that they print on are the paper is so thin you wouldn't even be able to touch it without pulling it apart you wouldn't even be able to touch it without pulling it apart you wouldn't even be able to touch it without pulling it apart kind of thing, versus I have an inkjet printer at home.

I can advertise that I'm a printer and so can he. What's the scenario there? We can all think of like, okay, well, his is better because we can see it and it's better. Whereas as a person that's in the industry, it's hard for me to differentiate. Hey, I very much care about the accuracy. This guy just bought the one that was on the sales floor. How do you see the industry going in terms of technology and using that as a marketing sort of ploy?

It may not have an answer. It's tough because technology is only coming at us all faster and faster, not just in dentistry. But when it comes to full mouth rehabilitation, I wouldn't say it's – I mean, technology is just to be – they need to use certain technologies to have a certain level, kind of like your thresholds. You have certain thresholds, otherwise you won't even look at it. You won't even entertain it. Once those are met, after that, it's not more technology is equals better.

It's – so once you're using photogrammetry, once you're using CAD softwares, once you've eliminated the analog steps on the verification jag impressions to increase your accuracy, the next things are more the intangibles on like going to your assistant, asking her the questions. Because they're in for a consult or when they go to see the – the office or maybe if it's over the phone, it's asking the uncommon questions that you could probably find out the most for a practice.

For me, it would be I can learn so much about the employees of an operation. I can learn about – I'm sorry. I can learn so much about the clinician if I understand the employees, understand the culture, how they're treated, how educated they are, do they know what's going on. Like I can walk into any dentist's office in this neighborhood or any state anywhere and ask, okay, I need a crown. How much is a crown? How much time is it going to take?

And what steps are involved? Almost everybody, every front and back office can tell me. But if I'm a full mouth rehabilitation patient and I need a full mouth done, I can't go to every office. You can't – not everybody can answer those questions. So in your practice, I could go to any one of your assistants, PROS or surgical. I could go to your lab techs. I could go to your – I could go to your business partners.

I could go to – and everybody's on the same page. That's the big differentiator. So how a patient takes that and executes on that when they're in their journey for treatment, it's somewhere in that neighborhood. Because I think about it in other – I mean, if I have to go see a cardiologist, how do I translate what I know? It's very hard. I always tell patients I don't envy you having to make this choice. Yeah. And I think patients are smarter now than they've ever been because of the access of information at their fingertips to do their own research at home.

▶Not too often, probably when you see a patient, it's their first consult, right? So nowadays is different than what it used to be of putting all of the trust in the provider, the clinician, to kind of tell them, the ins and outs of the technology or how they go about stuff. I see now, especially in the younger generation, even the older generation, with the access that we have to the internet and AI and things like that, we can find out a lot of this information at home where now they're coming to you and they're having – they're asking you very educated questions.

And some of those educated questions revolve around products or this type of technology or different brands or things.

Part 855:43

Things like that. So it just goes to show the awareness that they have and the accessibility that they have to it. Absolutely. And that can be to the positive or to the detriment. 100%. Yeah. Sometimes they feel like they know too much and it's really not something that matters. And sometimes they don't know or they know just enough. Yeah. I'd say in general, though, I'm grateful for there being a company out there that's pushing the big marketing.

Because they're raising the awareness and they're where people go to for the first consult and they kind of give them that first tweak of maybe that's not the right place for me. Maybe I don't really want it to be so streamlined herding cattle kind of scenario or whatever it may be, but they're bringing up the awareness. And so is the technology. Even if it's to their detriment, that gives you an opportunity to educate them and say, no, that actually doesn't really matter and here's why.

So it's kind of nice. It's nice because you're on a limited platform of these are all the potential questions and education that you have to be down. But when I first started doing this, it was an hour and a half of discussing all the different options that might work for this person. And so they only get little tiny limited windows of each thing and maybe had never heard of it. And it was so hard to sell a case back in the day because there was just so much out, nothing out there, rather.

And educating from scratch. Yeah. Mm-hmm. And exciting. ▶Talking about experience and how long you've been in the game doing this and how you've seen the changes in the industry and how you've crafted your skills to adapt to the different changes in the technology and with the industry. I think from someone like myself, when I go to buy something and I see the experience the person has or the confidence I get of, oh, they've been doing this for a while and, you know, hey, you know, this is our lab that we have.

We do all of this in-house. You know, things like that that are really kind of like a wow factor. Like, this office knows what they're doing. They've been around the block a few times. And, you know, when it comes time for the surgery, they've probably seen every, you know, the things that can go wrong. They've probably seen them before. So now they know how to mitigate those or to kind of work around those things to get to the end point.

Yeah, absolutely. It's, I guess the best advice is keep your ears up. And if someone, you know, you know, you know, you know, you know, you know, you know, you know, you know, you know, if something feels kind of weird, maybe you should find someone somewhere else. Nothing wrong with a second opinion. Yeah, absolutely. Well, speaking of second opinion, I appreciate you guys coming in and giving me your second opinion. I've had a good time catching back up with you guys and conversing about some of my, this is sort of where my passion lies is in the manufacturing and the streamlining and just how that whole flow works.

So this has been fun discussing that and the macroscopic stuff with implants. And et cetera. So appreciate you guys. I know you got a flight. So if you're listening, watching this, like, subscribe, come on, join. We'll have a lot more episodes with a lot more content, a lot more visitors, just discussing kind of things with dentistry and patients and the good, the bad and the ugly. So we'll see you next time. Thank you. Thank you. Thank you.