Ep. 47: Refresh Cases: A Second Chance at Full-Arch — Part 1

Part 10:00

▶This is Beyond the Arches, where full-arch dentistry meets real talk. Let's get into it. Hello and welcome back to Beyond the Arches. Today I am going to be your host, Erica, and I am joined by two of my favorite physicians. So I have Dr. Sarah Laks. I was almost going to say Dr. Dan first, but I have Dr. Sarah Laks. Hello. Hello. And then I have Dr. Daniel Noorthoek. Howdy, howdy. Hi. So today we're going to be starting off a series and it's going to have to do with our refresh cases. This is something a little bit different, something kind of new that we've incorporated. And what a refresh case is essentially is when we're having a patient start to finish from consultation to end result in a zirconia case, they have had their surgery done somewhere else, could be here, could be overseas, could be another local place that for several different reasons, either they're just not happy with it or they're just not happy with it. So we're going to be talking about that.

their case or there's something going on that just doesn't feel quite right, where we're actually taking them in as our own and kind of helping them find a solution to what's going on. And there's a lot of different protocols that we've had to set in place. So we're just going to be reviewing some of those. Yeah. I think it's such an interesting kind of field to dive into because just thinking about it from a patient perspective, these people are coming in thinking that they already solved their problems.

▶And now they're dealing with, you know, issues again. So it's, you know, diving into that investigative work and trying to get to a solution for these people. Yeah, absolutely. Like I said, these are just cases that could be coming in from America, could be coming in from South America, could be coming in from Turkey. We've seen a few of the crazy cases that have gone on. And it can definitely be a challenge on our end having a solution for these people just because of the type of implants that are placed or the placement of the implants themselves. So that's kind of where you guys come in and come up with a new treatment plan and we find a solution.

Yeah. And I think we're going to do a couple episodes on this. So we'll do a little mini series as it were to maybe two, maybe three episodes where we focus on how we get to the position that we do and what really this service is, what it fits and how it works. So today's just a general overview of... What it is, sort of an announcement, if you will. And then we'll dive into the nitty gritty of like kind of how it works. But what I can say is, if a person is out there, the reason why we came out with this is because there's a lot of patients that are out there stuck in a temporary lost confidence with their office. Maybe it's too expensive at the office that they were going to go to. Maybe it's too expensive at the office that they were going to go to. Maybe it's too expensive

Part 23:03

for their zirconia, their final. Maybe they didn't know they needed to go to a final and now it's just this huge expense on the other side. They don't like their originals. Maybe they've already had a hybrid. The patient base of this is actually a lot bigger than you would think. Yeah. We've seen several cases at this point and it's been very interesting. Everyone comes in with a different story. They're at different stages in their journey. Some have been in their finals for a while. Some, it could be very recent that, you know, they've been dealing with issues. So it's a very cool, you know, topic to start kind of diving into and learning about.

▶Absolutely. The exciting part for Erica, Erica's our coordinator, if you will, our quarterback of the lifetime warranty. And what's really cool about the refresh is once a patient is through the refresh, they then qualify. And we will cover the implant replacement that we didn't even do. And so essentially you're able to get that, that access. Yeah, absolutely. It kind of feels like a saving grace at the end of the day because you have that peace of mind that, you know, that your new prosthesis that you once again had to pay for it, it does cost a little bit of money. But it's something that you're now proud to wear instead of embarrassed to wear, or like you've mentioned a possible temporary as well.

And you know that you have somewhere to, you have an office who feels comfortable working with you and working on your parts that you have. So it's very beneficial that you're, you're allowed access to, once you've passed the clinicians kind of go ahead, you're, you're allowed access to our lifetime warranty program and you have coverage for cleanings, you know, assessments, x-rays, like I said, just most, most importantly is an office that feels confident kind of going in there and fixing up whatever was done. And so it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it, ▶I think that can be one of the most challenging parts of living with a full arch hybrid is that they're, even though there are clinics that say that they are comfortable with that, if your implants were done in another country, they may not be.

Yeah. And full arch is all about longevity. We want these to last for as long as possible. And so there's many levels to that. You know, sometimes it's an implant issue, but sometimes implants fail, not only because of biologics, reasons you can dive into that a little bit more but sometimes it's biomechanical so it's you know kind of a balance between the implants the um the cleansability how people are able to clean their teeth and the functionability how the teeth are actually designed yeah absolutely when i think about it i get so jazzed for the patients i don't even have a hybrid and i get jazzed about it because i just put myself in their shoes and if you're stuck in between a couple offices or you're frustrated with the one office you have whatever the scenario may be you have an old version to be able to get updated for a reasonable fee and then get pulled in and get coverage on the old implants with the assessment is kind of bananas and it's exciting for us it's we've clearly done the math and it does fine uh but um to be able to get that peace of mind is just it's one of the more exciting i always talk to um the team about the lifetime warranty and this program and i always say it's the most exciting thing i feel like i've helped bring to the table in dentistry just to be able to have that peace of mind to

Part 36:57

for the patient is pretty awesome yeah um and we had to do the the lifetime warranty came first because we we even though we did a bunch of these cases we didn't have an answer or solution to them like many places hey if we do your teeth and your implant fails like you're gonna have to pay us again or whatnot so coming up the step one was lifetime warranty now this is sort of a little bit of more icing on the top because now we can take those patients in because we're going to be have that sort of avenue etc yeah it goes hand in hand because i mean we're kind of restoring these patients faith in dentistry because these people went through it and now they're you know at their last you know the last chance they just want to get a final solution so it's cool to be a part of that yeah it's fun to be a part of the final win yeah like we did it yeah it's very hard to lose on one of these cases i've found yes so um before you know we're going to dive into it and then next this is just more of a hip hip hooray to begin with and introduce the series but um doc you've done a bunch of these with me the what's interesting is for for you on a on a case that went to a local big box chain or a local chain or a local office for the most part we're going to be able to identify the implants and go straight into where it's almost a better version of doing what you do day to day anyway you know what you do from normal pass off is you do the consultation you pass them off to me and they come back to you you know beat up with surgery and you have to work around that and work your magic around that yeah but um these cases are cool because you get to do the same exact work the amount the same amount of work on a patient who it's very hard to lose on it's a big win and they're not beat up from surgery so from that side it's easier but we've done a bunch of these where sometimes those parts don't fit and then you're so it can either be 10 times not 10 times two times easier or 50 times harder it's really wherever that it's where the energy is going into yeah so we don't have to deal with you know the post-surgery experience but we have to start our you know turn our on our investigative brains and start diving into like the mystery of what we're you know what we're dealing with and sometimes we see parts and pieces uh from companies that don't even exist anymore and sometimes we have to you know kind of think of other options and work our way from the ground up it can get wild yeah it's wild what are these parts and pieces that you guys are referring to just so everybody knows so perfect question i'm gonna start it and then i'm gonna have dr lax finish it okay so

Part 49:59

▶prior to i'll say 2015 mid-2010s or or early 2010s there wasn't a decisive piece that was

how we built it it was how we built it it was how we built it it was how we built it it was how we built what we build a hybrid on so the abutment that goes into the implant had sort of the concept there but it was independent of the manufacturer to decide on what that geometry looked like or how it was attached etc and so there wasn't really an industry standard so each person did it their own way because of xyz company made it made the parts that they liked but and it was a little bit of a free-for-all so it was a little bit of a free-for-all so it was a little bit of a free-for-all but then over time it has sort of become a very factory piece a very accepted piece of the of the pie it's almost a the design is almost like a commodity yeah yeah that's way better than commodity universal design and most slash all of our equipment and all of our process is built on the assumption that you have those pieces so once you have those pieces and the implants okay we can make you a free-for-all and then we can make you a free-for-all and then we can make you a free-for-all million sets of teeth once we have that design we can make you a million sets of teeth that's why we can do the lifetime warranties we have to get to that i always when i when we're working together and we're trying to figure out the parts and pieces i'm always referring to that it's called a multi-unit abutment but i'm always referring to that multi-unit multi-unit abutment as sort of like the translation piece or you could think of it as like the rosetta stone it's the way that we get to everything so if a person can make a free-for-all and they can make a free-for-all comes in with something that's a little bit off or you know a different brand or an old school brand or like dr lax was saying sometimes they don't even make those parts if a person comes in with those we have to figure out the way the best way to get them the rosetta stone so that then they're in our system and so i'll let you kind of high level kind of explain a little bit more about choosing those abutments and maybe um some examples of some you know they are difficult so so some difficulties you can run into because you can't just look at an x-ray and say oh that's what it is necessarily yeah you can sometimes sometimes you can sometimes you can't and sometimes the only way to know is to go in there and start looking when you're in the mouth um but i feel like it's it's a good a good way to go about this is to break it up into like three categories where you have to zoom out a little bit first you have to look at the implants the condition of the implants because this is all related to restorative you know categories so we have to make sure that the foundation is solid and yes sometimes these parts and pieces are not made anymore and that's okay but first we have to make sure that we're solid on the foundation and then we have to keep in mind that the parts and pieces that we do implement um they're all related to the restorative success so um these pieces have different heights uh different angles and so we need to keep in mind that it's all kind of harmonious and they all work together different positions positions so the angle of the implant and the available angles of this rosetta stone the multi-unit abutment that are available all have to line up in a way that makes it so that it's safe and good for dr lax not only to put in the mouth so that there isn't holes in or in the wrong position but also so that it's going to last a long time as well so yeah and we don't know all of the multi-units that are angled and they're not just straight coming out of it um they all come with a part that is essentially they call it the timing so it's it's like uh six positions and sometimes dentists when they're putting in an implant don't think of it the same way that we do and so it's like degrees off of where we would well that's kind of there is no real good solution so taking it apart is one of the most informative longest in terms of the appointment visit but can also be sort of one of the most daunting because there's a lot that you or i or restorative assistant have going on to sort of calculate and figure out longevity and such for them yeah and a big part of this also is having the confidence of just getting in there and you know trying out different things like you said sometimes the angle can be a little bit off and so you know try to correct it see if we can achieve a solution with that um and so it gets very uh deep i would say but it's fun it's fun i i imagine it's fun those are fun cases for you as well because it's something that's a little bit different and it's a different challenge and so it kind of it's a little bit of a challenge gives a little bit of variability in there right and i think there was a case not too long ago patient came in their implants ended up being you know looking good solid the abutments also you know looked pretty good good condition more recent you know brand all that but we ended up getting in there and noticed that the they were just too tall right the height was way off and so it gave us less space less restorative space to work with and so you know sometimes just modifying of that it can make a huge difference in the end huge oh yeah there was another one where um in jacksonville we ended up seeing them and they had way too many implants but we because of the way that they were put in there weren't there really wasn't a good one to skip because they were all kind of in important positions they were just in the wrong important positions and there wasn't like a good one to skip and that one was kind of crazy also because we could only get the the one angle not the other and so fixing it kind of was it was difficult and the one thing i'll say about these is no matter when we're describing difficulty we always kind of when when we're working with these patients for a refresh you know if it may be you want to come in and and give us an x-ray and and have us give you a quarter or whatnot we're probably not going to be able to do that because we're pretty simple to work with when it comes to um giving you pretty straightforward pricing which we're also very transparent if you and i think that it might be difficult to find those parts and pieces we'll a know that ahead of time b let the patient know that ahead of time so erica's working with a patient in terms of letting them know you may have a day where you go back home with that same set of teeth because we kind of have to overnight new parts or whatnot but when they get there it works out pretty smooth because they understand that there's a little bit of work to be done so you don't have surgery but you're going to probably have a long visit where we're trying to figure out the best way to get you to that rosetta stone and once we're past that portion it's a breeze yeah so um and at that point i feel like the confidence is already there the relationship is already there again these patients are coming in you know looking for something right we're trying to help them and so we're just really in this together and you can feel that with these cases and so taking a little bit more time to dive into it making sure that the things that we you know order that we need are correct for them they usually appreciate that so it's it's a really cool fun it's always been a really fun service to offer um and then of course when once that's done like you're saying it's very straightforward now you're coming in and you're like oh my god i'm so excited i'm so excited i'm so excited i'm so excited i'm so excited i'm so excited i'm so excited i'm so excited i'm so excited i'm so excited the warranty if we have parts go that'd be a problem where that implant becomes a problem we're going to replace it with our own brand that we feel comfortable with and incorporate it into the files so we have those files on hand for any type of emergency so yeah it might be a little bit of work to figure out the parts and pieces but after that you now have a home-based file that we can make you an emergency version or a zirconia or you can lose an implant we still have a basis so that's always kind of fun like to your point the only hill that we have to cross is just a little bit of work and then once that hill's

Part 518:56

crossed it's kind of all downhill yeah exactly so i have a question for you doc so when if you were to sort of imagine a patient that comes in with one of the ones that have come in in the past old final or temporary well let's let's exclude the temporaries because those are always way off an old final and they get a new final how much would you say just i'm just curious how much would you say it it ends up being super similar just a nicer version of what they came in with or like do they end up coming in with like do they end up walking out with like a totally different smile than maybe they assumed or um i think it's 50 50 okay yeah sometimes uh the patient has no complaints about the aesthetics you know how the teeth look and it's really just you know something's hurting me something is cracked you know there's a big issue at hand and yeah sometimes you know we veer off from what they started with and we totally change up you know everything and so i would say it's 50 50 but it's both really exciting both really the same process you know whether we want to change up the design a little bit that's you know it's pretty easy for us to do that so um yeah 50 50 that's pretty awesome or it's a temporary just waiting for a final right i the you would think that since we have the scan of their original let's say that they come in with a correct multi-unit since you have the scan of the original and then their their information on the implant and the gum tissue you would think that they would make it that that would make it pretty easy for some cases because they really just want a new version of it but then you would also say well maybe it was a really built very well so you know so i i can see 50 50 yeah and it's it could be confusing for these patients sometimes in the beginning because they think everything's fine and then we dive deeper and we notice that your issues are being you know they're caused by the foundation right the implants for example and so sometimes the kindest treatment is to start over and we're not really starting over we're refreshing them but that emotion can sometimes be it's just you know take a minute and you know you're like oh my god i'm like oh my god i'm like oh my god i'm like oh kind of review all the information because it's a lot of information that's being thrown at them at once and they're just looking for answers and so just taking it one step at a time explaining everything from the get-go and then it's sailing from there yeah yeah refresh is such like a appropriate term and i have no idea where it even really came from it we i can tell you that when we were talking at a high level like after lifetime warranty this is where we're going to go it's just one of those things where like in the meeting we just sort of casually started calling it refresh and then that's really what it became because it's such an appropriate thing like you're saying you know refresh meaning it could be refreshing because you have a new set of teeth and a new peace of mind a new outlook on hybrid dentistry it can be refreshing because like a refresh of the old that you have that is now old and dilapidated it's better or a refresh of something that was a

Part 622:14

little bit of a mess where you had an implant that was bad etc yeah we see it's pretty fun mm-hmm the one case that always comes to mind when i'm thinking of the refresh cases is the there was a patient who went out of the country they were originally potentially going to come see us it was sisters and they sent us the x-ray from their original surgery but there was a miscommunication that that was was not entirely recent yes and so we had already created the space to say if you need an implant that's going to be xyz to replace etc but that was a pretty wild one to change up on because when they came in the x-ray that they had given us was right after surgery yes and the x-ray that we took was not after surgery so we ended up replacing a few it ended up working fine but that was another case that you and i worked very hand in hand on because the remember the the brand was bizarre so this was this was a case that also came from overseas so i believe that when the clinical notes and information was sent it was sent in another language so we weren't able to that's correct i know the properties are sometimes flipped yeah month and day or yeah so and the brand was pretty unrecognizable we actually ended up finding correct me if i'm wrong the design from that implant brand was wrong for the multi-unit it looked like a multi-unit but it was not appropriate to the to the ubiquitous one and we ended up finding another brand that had the same internals to it correct that had the ubiquitous multi-unit on top and that's where it gets very interesting in my opinion because it's very interesting to me because it's very interesting to me because it's very interesting complex and you have to be comfortable with knowing the mechanics of everything the shapes and what fits into what it's a puzzle really there's a puzzle and also correct me if i'm wrong i mean we ended up replacing a couple implants with our own so we had those parts obviously but correct me if i'm wrong the the change up on the parts we had already done enough work ahead of time that we knew what we were faced in terms of the brand and how to switch it over but was it a puzzle or was it a puzzle i don't know i don't know i don't know i don't know i don't know i don't know i don't know i don't know i don't know i don't know i don't know i don't know wasn't there an issue or something with the the timing and the screw channel and the and the angles like we talked about yeah we had to order them on the fly yeah but also correct me if i'm wrong it didn't cost any extra time no no extra time which is great but as long as you're able to catch these things during the process the timeline doesn't really change much you know yeah so yeah what i would say is every case we're making a really good case that this is really complex and really tough and yeah you know we're making a good case that this could be a really good case disaster there they can be a ton of work for the exercise of using the tools at hand to make it happen but it always happens yeah and in smoothly exactly i think i'm sorry now go for it i was going to say i think it was also relayed very very clearly at the time of the consultation to have these expectations because of the x-ray that we had we knew it was completed overseas at least we didn't know when that x-ray was taken but we did know it wasn't um the parts that we are are accustomed to um so i think that these two women were very well prepared on their end to have these expectations coming into the appointments yeah and i was going to say it just gives you like an extra appreciation for when full arch does go well right you know that there are places out there and people out there that are dealing with issues and it could go wrong there there's a million things that can go wrong at every moment and so it just gives that you know appreciation to all of this yeah i think i have probably two favorite cases i'll just say one one of my favorite cases was um a woman from tampa who had gotten sir who had received surgery and had a temporary it was just a single arch it was just an upper and she received her temporary and basically decided at that moment like i've made a grave mistake this is terrible i don't want to do this i don't want to do this i don't want to do this i don't want to live in these for three months found us we essentially put her in this program it wasn't really a program at the time but like essentially did it the same way we would do it now shirley came with the multi-units and had her she was right at the right at the limit of where we feel comfortable taking the teeth in and out after surgery to let them heal and we got it in in time she came over we got it fixed it was kind of cool to look at the original temporary versus the final and how she was in a final she healed fine she's in the wife's on warranty now all of that is cool but it was kind of cool to see the drastic difference she just saved herself two and a half months of discomfort frustration plus all of the other appointments after that to make the finals but it was really cool to see hand in hand what she had just kind of swerved away from yeah or or got the traffic jam she got herself out of it's a good example of

Part 727:40

sometimes the solution is right there and it's pretty simple it's a simple fix you know you just have to know where to go right tools right place right people exactly yeah it's always really interesting to me too because i've only ever known done in one as our lab as our office whenever we see other cases that come in that sometimes aren't finished or are finished differently it's really interesting too to see like this is a plastic how are you supposed to heal in this like it makes me concerned and almost you know sorry for the patients that have to heal in such an uncomfortable way converted dentures into temporary hybrids are really that's not there's plenty of places that do them really well they're really hard to do perfectly and right that also sets you up for future success and patient happiness it's i won't say impossible because there's lots of people that pull it off yeah but as a person that did it for a long time it's almost impossible to do it it's so frustrating yeah um and so you know we've kind of had them all we've had the really old style they just wanted something updated we did a woman that was now that we're talking through it we've done a lot of these cases yeah uh we had a woman who had who had implants for 35 years and just wanted new teeth they were falling apart because it was a really old school and she was maybe a matter of three visits and done yeah pretty awesome that's easy peasy how do you decide when what how do you decide when you can refresh and restore on top of existing implants versus when you cannot i think dr likes kind of covered a little bit of that in the beginning where we have to make sure that the foundation is good we have to make sure that the implant is intact and fine that it hasn't stripped out too much um that would be in like the clinical like taking it apart portion of the exam that the multi-unit is the the the the the the the the the the the the the the the the the the the the ubiquitous one if it's not dr lax and i work together how do we fix that how do we not how do we fix that how do we get them converted over how do we get the new parts where are they coming coming from etc and then it's just a matter of sort of executing it in the end finding the missing puzzle pieces putting it together the typically you'll show me an x-ray and typically we can identify through them their phone conversation and the x-ray combined that clinical history plus the x-ray combined will give us a really good idea of whether or not we need to replace yeah and sometimes i mean materials can be a whole hour-long conversation probably more but sometimes even a strong material can't withstand just a weak type of implant setup you know angle position bone level cleansability all these things are kind of all related to each other yeah i think so we'll kind of end with the two with a couple little things here the um dr lax brings up a good point because at in this world we're sort of accepting anything from anyone and in addition to if it's even possible is the separate question which really is first is is it a good idea so we have to overcome that and the the hardest part about overcoming that is sometimes these people have had surgery in the last two months or two weeks even in that one scenario um maybe they've even had them for 15 years if we don't like something genuinely about an implant we may have to leave ourselves some space that we have some work to do um and i would say correct me if i'm wrong 90 85 of people are amenable to that and are very easy to work with when it comes to that and i think that's a really good point and i think that's a really good point um there have been one or two that don't give us that space and they almost kind of hold it on us that if the implant is wrong or not going to be good for them in the future that we're kind of in cahoots with the person that or you know that we're just um we're part of the the negative side of the situation that they're trying to get out of um when we're just trying to to fix it for them so it can be that you do it and you have to do it and you have to do it with these cases we need a little bit of a level of understanding not like we're going to put you through this i need you to understand that i'm going to hurt you it's not that you need to understand this going to be a lot more expensive no it's not going to be that we need the understanding of we're working through a problem that's very complex that we will find a solution for but here's all the things that we're looking at etc so sometimes we end up place replacing implants sometimes we end up not but giving them a little bit of a warning exactly yeah i think it

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takes a lot to build trust between these type of patients in our office just because it is something they've gone through before and it's obviously not a decision that they are either happy with or they thought that it would last them longer they would they would be in a different position than they are currently um so i think it's it's a lot of trust between the patient and the office this is not a patient seeing their first try-in for the first time ever this is something that they've lived with that they've coexisted with for who knows how long and obviously they've decided to go in another direction we've been testing this out for quite a long time and doing these cases just as they come through the the world but now that we're launching it is really like a product and a thing that we do i'm really excited to see how that community appreciates or doesn't appreciate well you know how they enjoy having that peace of mind and how they react to everything long term as a group that you can identify and keep kind of like as a uh quantifiable group rather and hopefully we can have some patients on the podcast yeah talk about their experiences i like that idea there you go we have a couple local refresh podcast refresh and really dive into it that would be awesome i love it okay it's about it that's all i got we're gonna get into we're gonna dive deeper yeah we'll um we'll do uh you know two or three episodes on it and that's where i'd like to really get into the what is a multi-unit and those kind of things we really haven't done that yet but this would be a good time to explain why that piece is important yeah why it's ubiquitous all of that yeah that's good the more knowledge the better yeah absolutely all right well thanks guys for joining us today and we'll be back with the rest of our series soon love it thanks everybody