Ep. 16: The Evolution of Full-Arch Materials

Part 10:00

This is Beyond the Arches, where full-arch dentistry meets real talk. Let's get into it. Hello and welcome to another episode of Beyond the Arches. I'm the host, Dr. Daniel Noorthoek. With me today I have Robert Odom. Hello, hello. Welcome back, Robert. Thank you. Today we have a very exciting topic. We're going to be talking through all the different materials that you can make hybrid dentures out of and what we've used before and how we're, maybe we see it in the future. And today we're going to do it a little bit differently. So we have in front of us a couple materials. We're going to kind of go off of sourced information in terms of specific numbers and such. And so typically we're more off the cuff and a little bit more informal, but I felt like today, especially as I work with you, that we should probably go through something that's a little bit more historic and linear in terms of what we use and what we don't use.

And what we've used in the past and what the problems were. And I'll throw in a bunch of stuff here and there and your two cents as well, but I thought it could be interesting to kind of walk through some stuff. And so we're going to talk about, ultimately we're going to talk about the history of how we got to this briefly. And then the material that sort of kind of started, kick-started everything, which was the denture teeth on top of a some sort of bar or denture teeth kind of based prosthesis. And then kind of go into some of the weird ones that we delved into for a while. Nano ceramics on titanium bars, peak is a material that we used to use a little bit. And then we'll kind of end up on zirconia and different ways that you can put it on a bar and compare some strengths and stuff. And hopefully we'll have a little bit of fun with it. Yeah. Love it. As, as a patient, I think this is one of the most talked about categories in, in this whole thing is, is materials and how they compare to each other and why people choose what they choose. So yeah, this would be a great topic to cover.

And just like when, you know, it's very understandable and relatable that when you're making a purchase that's this big, it's like going out and buying a car and what kind of options does it have on it? You don't want to buy the latest X, Y, Z that might have more chances of breaking. Just cause it's the latest, you know, you want something that's sort of tried and true and kind of in the middle has a track record, but also something that's on the cutting edge. So it's hard to balance that, especially when you're trying to explain to patients these kinds of things. So hopefully we can dispel some stuff in terms of materials and just experience with that. I think it's just like everything, everything has its pros and its cons. You, you know, absolutely weigh those options and figure out what's, what's best, what's best for each individual and that's what you can do.

Yeah. So, um, going off of our notes here, every podcast or every lecture that's ever been given on materials and how we got here, et cetera, always starts with the Egyptians and the wire, uh, the gold wire wrapped around a tooth. And then there's the one that's carved out of the seashell. And then there's a joke about George Washington having wooden teeth, et cetera. So the take home that I have for you is that you can buy a car and you can buy a car and you can buy a car and you can buy a car and you can buy a car and you can buy a car and you can buy a car and give as the history lesson is humans have been messing around with trying to replace teeth that have been missing for a really long time. And finally, after many, many, many years and many, many different attempts, we are at a position where we can talk about specific different materials rather than just, let's try this new thing and let's see if this works and let's add springs to it. Right? Right. So now we can actually, we're actually at a point in human history that we can make a comparison and can say, is this better or is this better, rather than just does it even work and how uncomfortable was it?

Yeah, yeah, what a time to be alive. Yeah, so we're not going to go through that part of the history because I feel like it's a really, really overdone trope, storyline. Sure. But likewise, if somebody would like us to go through all of that, we could do one that's specifically just on ancient sort of restorations and the weird stuff that was involved. Sure. And maybe that's just my bias from being in dentistry. I've heard that lecture. A million times.

Oh, a million times. Sure. So we're going to kind of start. The story kind of starts with cast iron or cast iron, cast bars that had denture teeth put on top of them. And that's really kind of, for the most part, there were some other stuff, things that came along before this, right? There's the advent of. There's a material called Vitalium and Palladium that kind of gave us the ability to make denture bases for partial dentures. When you make a full denture, it can be made out of plastic because it doesn't need to hold on to anything but gum tissue.

And so it doesn't have to be reinforced by anything. The force that you can put on is only as good as your gum tissue, right? So that generally doesn't need sort of a metal base. But when you're going to attach it to other teeth, it needs some sort of. Some sort of wiring and some sort of reinforcement to be able to grab onto other teeth. Right. And so that was probably the original drive to sort of add tooth-like plastic-y materials to metal, right?

Right. And so when you fast forward that to when dental implants are starting to be used, there were a lot of different types of implants. And that would be an interesting one to talk through, different subperiosteal implants, different types of implants that kind of came into vogue and fell out. Mm-hmm. Mm-hmm. Mm-hmm. Mm-hmm. Mm-hmm. Mm-hmm. The best way to describe them now just for patient education or people that are listening is we kind of refer to them as endosius dental implants.

So endosius means within the bone dental implants. So it's not like just sitting on the outside. It's a screw that goes on the inside of the bone. Right. So in all of that melee, I think it was around the 80s, somewhere in the 80s and 90s, they started to take these dental implants and started to try and figure out how to attach them with some sort of metal reinforcement because, again, now we have something to grab onto with that plastic that sort of represents teeth and can function as teeth.

Okay. And that lasted quite a while because if that was even, say, late 90s or mid-90s, we were still producing those and making them and delivering them. Right. Right. Right. And that started on the full arch scene, which would have been like 2010 to 2013, somewhere in there. Yeah. And for a long time, well, first we'll talk about the process. So do you know anything about the process in terms of making a cast bar? I don't. I've got so many questions.

Okay. So to start, when you would make a cast anything, you have to make sort of a duplicate version out of XYZ material. A lot of times we use a material called like Dirlon and there's different things that you can cast up, right? And so typical casting, you make this model or mold, wax, whatever the material is, and you put it in a furnace with it and it spins down and you melt the gold or whatever metal alloy you're going to melt down and it spins it into the cast, right?

It's in this huge spinning furnace, basically. Right. And so... The very, very first bars, we didn't have milling machines. We didn't have the computer power and all of that. And so a lot of our posts that we would put inside of teeth to reinforce for, say, root canal procedure, that's where casting kind of really began. And then they started casting... They used to make an abutment that would go inside of a single implant that was castable, right?

It had some sort of ability to be cast and make it so that it was a custom tooth that held on to. The crown on top. Okay. And so what we used to go through is these really longish procedures to get good impressions and such so that then the lab could then build and wax and mold your custom bar to then hold on to your implants. Okay. And so that was something that took time and it took some sort of artistic ability or some sort of hand skills.

Sure. On both the dentist and the lab side. And it was very time consuming because you can imagine when we take our information now, all of that information is just assumed that it's super accurate and it's perfect. Right. ▶So we can try in teeth right away. Even if the teeth aren't perfect, we can fix that file, but where the implants are is sort of assumed now. Sure. Right? Back in the day, we had to go through a process to make...

We had to make sure that those implants were exactly in the right position. Right. So when we would go through that, and I'll talk more... Because I came in really at the end of cast bars, and we did do a few, but more on the beginning of milled bars. That was actually like the hot, sexy topic. And I believe that the process to get the information is very similar. So if I'm wrong on a cast bar, I apologize.

But we'll assume... We'll assume that milled and cast is very similar in terms of the visits. Right. So your first visit was an impression to sort of get where everything was. Then you had another visit to get a more accurate version of where the implants were. Okay? Okay. And to do that, they would take your stone model of where these implants are, and they would put analogous pieces, analogs, in and essentially glue them together in some way.

You know, in our case, speaking almost to the end of when we were even doing those, it would be... They would send us back what's called a verification jig. And a verification jig took those analogs, and essentially they made essentially a plastic wire, if you would call it, band, or thick sort of like worm of material that went through all the implants. And then they would cut them all in between the implants. Why? Why? Well, stone, when it changes, when it...

When it hardens, kind of shrinks and deforms. Sure. So I can't take an impression of you, pour it up in stone, and have it be an exact perfect replica enough to put metal in your head. Right. Sure. So we would get... Your visit would have to be a verification jig. So you would try in each one of those parts, right? Because it's now segmented. And then we had to glue in every single one of those parts back together.

And what that would do is sort of accommodate for the shift, the shift in the stone. Okay. So when you would bring that verification back, that jig back to the lab, or put it back on the stone model, sometimes it wouldn't fit because it had been distorted in the transfer of the impression to the stone. Right. And so what you would then have to do is, this is real life, and it takes forever to work through it, and you can imagine, or talk through it, you can imagine in real person this takes forever.

So then what you would do is you would then cut the stone model all apart, and wherever it wasn't seated correctly, and re-fix it relative to the other ones. Now, I'm sure there were lots of lab guys that knew they could look at it and know exactly what needed to change. But you can imagine, even if you have three that are perfect, and say the fourth one isn't, it's very hard to figure out which one is the offender.

Right. You just know that it doesn't fit, right? Right. I never gained that eye because I would look at them if it was off and go, Oh. Oh, man, I think it's easier if we just start over again. Yeah, right. But there were guys out there that really knew what they were doing in terms of how to seat them. Sure. So once you would seat that, once that part was done, sort of simultaneously or separate to that, you would then start to create a model in wax of where you wanted the teeth.

Okay? Okay. So very similar to a denture. A denture, when you're fitting that for the teeth, you pick up the size, the color, the shape, you ask for it, and they'll send you to start, they'll send you a plastic base that's approximately what the patient looks like, and on it will have a block of wax. So you've seen those steps. So when that block of wax came in, you would shape it so that it would push their lip out properly and get the lip line properly, like the vertical dimension, right, how much tooth is showing, et cetera.

Yes. And so you would dial all that in. Then you would mark the midline. Okay? So that's another visit. Now we're like four or five visits in. Right. And the patient's already ready to, you know, go crazy in your office. Sure. So after that, they would send you back that same, go to the lab, they would put the teeth in, send that back to you, you would try that in the patient, and then you could actually, though a nice thing about doing it this old way, was if there was something just slightly off, you could kind of push the tooth because it was in wax.

Right, right. You could kind of alter things. Now the problem was by that time, generally, they've incorporated the bar, okay? So now you have the model that you're putting in or what you're putting into the patient is the now-made metal bar with where they think that the wax with the teeth needs to go. Right. Okay? When that would happen, generally, your bar would end up in a place that was sort of so bizarre relative to the teeth that we ended up with a lot of speech problems and complaints about my temporary is so much better because there wasn't so much material here.

That's kind of what we ran into quite a bit. That's where a lot of these sort of myths and problems come, and that's why I'm spending a lot of time on this part, this type of restoration, because it's probably the most widely, recognized and used with the exception of zirconia now. But up until now, this has been our historic work frame. Everything has kind of come out of that as a result of, let's just use this part and piece, or we don't like that so much, let's get away from it.

Right. That's kind of the two directions that have spurred on development. Sure. So when you would get that wax up with a bar, the worst and funniest thing, was if it was in the patient too long, like let's say you had to go to the waiting room and get approval from their mom, aunt, uncle, spouse, whatever it was, bring them back in. Sometimes it was in their mouth so long, it would start to melt the wax. Okay.

Yeah, sure. And so the tooth that you had just put in perfectly is now sort of like dripping off to the side, not dripping, but like kind of mushing off to the side. Or if they bit down too hard, and it was like, oh, my God, I'm going to die. If it was a little mushy, it would kind of distort everything. The pros and cons of wax. Which was the little cheat of getting a perfect bite. Ah.

Because if it was almost there and it was perfect, you're like, just bite it a little bit harder and then you just kind of settle it in. Sure. And of course, it's already melted a little bit, or softened rather, to the point that you would have to kind of keep a bowl of ice to the side, and you could take it out and put it back in occasionally. You had to remember to do that. So that funny scenario, was if you had kind of forgotten that or let it just go too long.

So after that was all done, you would have to wait for the lab to process it. And what happens is, essentially, I don't know the specifics, so nobody crucify me on this. I've never actually seen it really done. But I think what happens is they find a way, or they mount where your bar goes, and they essentially figure out or have a way to lock, essentially, where the teeth in, where it needs to go. And so now, you've got bar on one side and teeth on the other, okay?

And this like sort of puck. And just like when they're casting with metal, they essentially replace that wax, melt that wax out, burn it out, and replace it with vacuum pressure, under vacuum pressure, they replace it with acrylic, right? Like you would see for a denture. Sure. And in that way, that's how you end up fabricating that whole thing. Now, in addition to it being long, clunky, kind of keeping the patient, more or less, the patient was sort of blocked out of the decisions, right?

There's not a whole lot of changing that they are allowed to do. The biggest, or one of the biggest problems was now they're exhausted of the whole thing. But when you put it in, it always felt bulkier and worse than the temporary, because now, like I said earlier, you have the bar in, you have the teeth in there. Right. And that was always a problem for a clash. Sure. The other thing is too, long-term, these aren't, and we'll look at, I think that the numbers are in there for strength, but the long-term, it didn't hold up past 10 to 20 years, because you had a material that really wasn't intended, it's a plastic, wasn't really intended to hold the weight on the bearing of smashing sets of teeth together.

Right. With a metal, which of course is even stronger than our teeth. And those two things were mixed together in this amalgamation that wasn't really bonded or cemented together, right? And so you've got a lot of fracturing and de-bonding of either the teeth coming off of the pink plastic or the pink plastic totally fracturing on top of the bar. Right. Because as we'll talk about, there's a big problem in dentistry, where we want, you know, we want ideal rigidity and we want ideal flexure, right?

Where do you want flexure? Teeth. Where do you want rigidity? Kind of between the implants. Right. How do you push these two things together? Biomaterials is all about what's the ideal number, what's the sweet spot, or how do we take care of this? Because if you have too much flex on top of something that doesn't flex, of course it breaks. Right. Right. And so we saw that all the time on those. What's fun is seeing those from the nineties, occasionally, we get them.

I mean, I think we did one maybe a year or two ago, I think was the most recent one that we did, that wasn't a temporary, it was a final, that the lady had worn for 25, 30 years. Right. They held up pretty well. I mean, they can work. Right. I mean, it's not like we're doing this and they all failed and everyone was knocking on the door. Right. worked that's the reason why they're available and why that was so um it was a fascinating way and it's really what this whole niche of dentistry was really built on so you can't talk bad talk it too bad because it is what it was built on it got you through to here yeah yeah the last case that you saw that it had that done um you said maybe 25 years ago she'd got it done how were the the implants um with that kind of restoration attached the implants were pretty solid they had a little bit of bone loss yeah but at that point if if it's not a year out if it's not two years out if it's not five years out not that you're going to ignore it you still want to clean the surface etc but most of the time it's kind of gotten to a sweet spot that didn't happen overnight right and it's already been there for 30 years in my opinion we more or less address it when it becomes a dentistry it's a dentistry it's a dentistry it's a dentistry it's a dentistry it's a bigger problem which it probably won't right you know you more or less like don't mess with something that isn't broken yeah it's not broke don't fix it yeah i think we changed a couple of the parts that's another big thing is when you're changing out parts from an old version um with the acrylic denture teeth over top into a newer version of any type of material that you're going to use making sure that the parts are compatible right because they're pretty they're pretty industry standard now they weren't that wasn't always the case yeah you know we've taken apart some crazy stuff right and what's interesting this is a little tangent we were talking about the different types of implants so there was a type of uh implant that was not an endosteal implant it was called a subperiosteal implant okay and it was essentially just a piece of metal that's sat on top of your bone and it was we will go over those steps someday and they are crazy crazy wow to dissect them out in the surgery if they failed was crazy i've only seen it happen one time i've never done it personally i've taken out a piece of one and when i was in residency was sort of at their at that thing's 20 year mark 25 year mark somewhere in there right right around when you started to see them maybe fail or become problems or maybe they had been a small problem and they were a moderate problem that kind of thing yeah but when i was in school i was fearful that i would see those almost every day right because like old tech and it just needs to be re-updated and they were a nightmare and it made me nervous sure didn't keep me up at night made me nervous right again i told you i've taken out like one piece because what happens with old tech it ends up dying we're all humans and so the people sort of that just sort of kind of phased away to the point that if you saw one now it'd have to be in our hands right because if you don't have a process or if you don't have a a 100-year-old, 110-year-old kind of thing, right?

Sure. So there's also kind of something interesting that happens with dentistry. One that's happening right now is what is everyone's regular single crowns made out of? Not gold, zirconia, right? So we're starting to not see as much of the metal. When I'm taking out full sets of teeth, I'm not taking as many full gold crowns with porcelain on them. It's really funny to see that sort of phase away. Sure. Right? Because it just ends up sort of dying with that generation, and then there's the next generation of better materials.

Yeah, that's an interesting concept. You can kind of view the history of dentistry through people's mouth as they come in. That's pretty interesting. So that was sort of the time that we were – that's really when I started hybrid dentistry, and you could basically say that that was sort of the start of hybrid dentistry as we know it today, right? There are – and I'll briefly touch on it. Before that, what was available would have been a cast abutment, right?

And putting a bridge over top of it, like at that time would have been a PFM bridge, and doing enough implants. That you could get enough bridges in there. Well, there's a company that does that now, and they want you to make it – they want to make it seem like they came up with it. No. It's been around even before acrylic hybrids, right? And there's a lot of stuff that comes with that that I've done these cases personally.

They can turn into a big problem. It's not like the thing that you're going to notice in the first year, or in every single case. Mm-hmm. But run out against all the cases, they can really flush out to be a big problem. So there's a lot of different ways to perform on these and restore these. There's a lot of different materials out there, and I'm glad that it's probably the number one question because it is what people should be really looking at.

Right. You need to have a good surgeon. You need to have a good implant. You need to have a good set of teeth. You need to have a vetted set of teeth. And it's – again, I say, I say it all the time, but we don't envy the people that have to make the decision. Sure. Right? Sure. So then let's see if you know this. So we had milled bars, so we were able to start taking the information that we would get physically in a stone model, and we would be able to convert that digitally by taking an extra oil scanner.

So we'd still put it in stone, we'd put it in the scanner. Did you ever scan anything? Yeah. Yeah. So you know all about that. Yeah. So we would put the model in the scanner, and that would turn into a digital record of it. So that was kind of the first step. Yeah. Right. Towards – I believe so. Right. In my world, it was – The first usage of some kind of digital artifact to capture accurate records, an inch of oil scanner.

That's – No, extra – That was a tabletop scanner. Oh, tabletop, extra oil. Tabletop and intra-oil, I don't know the exact timing of when each one came on the scene. To me, it felt like they both came on the scene together. I was exposed to an intra-oil scanner in dental school. I was exposed to a tabletop scanner when I started – when we started switching over to milled bars. Right. But I don't know that one existed before the other.

I'm not totally clear on that. Gotcha. So we would scan those in and then we would digitally create the bar and then – or replicate the bar. So then you would still have a tech that would design that bar via physical world and then you scan it into the computer and then the computer essentially makes a Xerox copy of what you had created as the lab tech. Okay. But they were milled nonetheless out of one piece. Right.

That was a fun time because you started – you started to be able to get – your bars were less expensive. They were more comprehensively made. They were all milled out of one piece. And it was always really fun to watch the milling machine cut that metal. Sure. It's actually the thing that I – honestly, it's one of the things that I miss the most out of owning a lab. I really wish we cut metal bars still because they were really fun to watch.

Sure. ▶But then what we put on top of it changed because our abilities – to compute and manipulate digital teeth changed. And so we started – personally, we started putting PMMAs on top of titanium bars with the idea that the patient would come in – this is before Dun & One existed – that the idea was that the patient would come in and get a – we would call it like a retread. I never really fully understood why we called it a retread.

Yeah. But they would come in and get a retread. Meaning they would get it to – they would get a new set of teeth put on top of that bar. So your bar would be the thing that lasted the longest. And then you would cement a PMMA on top. At that time, we weren't able to really design the PMMA so that it fit over top of the bar very well. It did. But you had to make up for the slop with a different material.

Okay. So again, just like with traditional teeth with the denture, they weren't really that strong because you're dealing with unlike against like. You're dealing with different flexural strengths. And that was – it was a good restoration. It worked fine in terms of getting the result that you wanted, being able to be a little bit more custom with the teeth and all of that. But long-term, you had problems with bacteria collection and the porosity, which we didn't even talk about.

Yeah. Yeah. A lot of these, besides zirconia, a lot of these materials have some porosity to them and they can stink and they can create collections of bacteria and stain and cause all of the things that no dentist wants for their patient and no patient wants for their teeth. Right. So PMMA had some staining issues and it had some porosity and it had some plaque collection issues. So then we switched to nanoceramic. And I'm sure some breakage issues.

Some breakage issues as well. Some. There was almost – Or did that titanium bar really reinforce it to the point where breakage wasn't a concern? I'm not a biomaterials engineer, but there was enough – they did less than fracture. They became debonded. So more or less like the slot between the PMMA and the milled bar would sort of just become loose over time or they wouldn't hold over time. It would sort of kind of become loose. And you would end up having to make them a new one so that you could get it back together.

Before you get a chance to break, right? Yeah. Occasionally they broke. And that's probably because it was – at that time it was the first thing that we ever delivered that was monolithic. It was the only – it was the first sort of set of teeth that we would put in as made out of all one puck. Right. And PMMA is a material that you get in a puck. Right. When I say puck, you know this. Well, I'll let you explain.

Well, a puck is just a round – I guess it has different height, different thickness depending on how thick a patient's prosthesis needs to be. But it's a round cylindric piece of material that you use in a milling machine to etch out what you're going for. Etch out is what I was sort of looking for. Okay. So milling was sort of the first good, accurate thing that – tool that we had. And that's a subtractive process.

Right. You start with X material, X circle. You remove until you get that piece, and it stays intact as one piece. Right. Versus additive, which is printing. Yes. And although on the surface everyone flips them around and talks about them as if they're the same, they're vastly different processes. Polar opposites. Polar opposites. Couldn't be any more opposite. Right. You still end up with a product, but getting to it is totally different. Yeah. And there are some strengths that you get out of taking away from a solid material.

There's some cons to it. And then, of course, there's strengths and weaknesses in terms of when you're adding – or adding. When you're doing an additive process like printing. Right. So – So, PMMA was a very short stint. PMMA, I think, was maybe a maximum of a year. Probably in the 2014, 2015 category. When it was a popular material? When we did it, specifically. When you did it. Right, right, right, right. And it still works pretty well as its own temporary material.

It's approved FDA, I think, for two years as a temporary. Patient needs to know it's a – and people will be shady and sly with it and call it a permanent temporary. Right. Right. And they'll – I don't know. I even know what the – I'll see more on – I know that it's – the wording that they use is very shady. Mm-hmm. But I don't know what it is, and it boils my blood. But it's not meant to be absolutely permanent.

Sure. It's meant to be replaced. Totally. We use it, let's just say, for a patient that we don't love the idea of their implant stability. And we're concerned about the health of one. Or a patient comes in for, let's say, even two weeks, or they live close by, and they still can't make their decision. And we're getting to that two-week window of the safety of implants having screw threads in and out. Right. If neither of us want to make the commitment to the greater big goal of the zirconia, rather than all of us spend a whole bunch of money and risk implants, et cetera, we'll use it as a really, really nice temporary.

Same file, but same temporary.

Part 233:47

That's meant to last three months. Yeah. And I say that like we do it once a month. I can't remember the last time we did it. Yeah. We do buy it occasionally. We do it for some people here and there, but it's, can you think of? I can think of one lady that just came in with a PMMA, but we had delivered that a while back. Okay. It's very, very, very infrequent. We try not to. It is a fantastic material for that, though.

Right. Polishes nice, looks nice. It's not that porous. It's much better than a temporary. Right. So at that time, I was just along for the ride for all of this in terms of direction and making decisions. So we were on the ride for Nano Ceramic. My business partner at the time went to something and was sold on how Nano Ceramic was the greatest, best thing. The new. The newest and greatest. And the. The marketing pitch for the Nano Ceramic was it's the same as PMMA, essentially.

Right. In terms of it's a plastic. But in betwixt all of the particles of plastic are pieces and chunks and little micro parts filled with a ceramic. And the idea was that it could be more polished, stronger from the zirconia. Pieces being in there and less porous. Yeah. All of those things. It invented toasted bread. Right. I always got a kick out of the pitch of, you know, it's repairable chair side. Yes.

That's well, that's great. But I'd rather have something that didn't need to be repaired in the first place. Yeah. You know, it's funny. That was a big pitch for us for a long time. And I never really thought about the other side of that. Like, that's great. I don't want one that can be fixed. I don't want to have fix a flat in my car. When your car breaks down, it's very easy to repair. Can I just get a car that doesn't break down?

Do you have one of those? Yeah. So we went full bore into ceramics, Nano Ceramics. And Nano Ceramics were not strong enough to be their own piece. They definitely needed a bar underneath, just like the PMMA. Right. PMMA does not need a bar in the use as a temporary as we use it. It does need a bar if you were going to try to use it for two years and be shady about your marketing. Right. Nano Ceramic definitely needs a bar.

They tried for a little while to pitch that it didn't. It needs a bar. Right. And at the time, we were able, at that time, we had made enough advances in the computers and the designers and things that we had where we were able to design a fit, between the bar and the prosthesis, that was 20 microns or around 20 microns. Much more accurate. Much more accurate. Right. And that gave us, that was sort of the first real time of all of these processes.

That was one of the first real times I can remember when we would put the teeth in, there was almost no bite issue compared to before. Before, it could be a big thing where you're cutting half the tooth away, just to get that bite to fit. Right. Even through all those steps, there was enough slop and enough change and enough difference and things that could go happen where your bite would be off. Right. And the zirconia was also a problem at that time too, which we'll talk about in a few minutes.

▶But bites were always off. Always, always, always off from just the records that we took and the ability. And that was this sort of light bulb moment, Right. Right. where we, it changed our lives because we could kind of get this predictable bite in this material that was supposed to be magically strong. And I think, wasn't it pretty standard to use a Trilor bar with that too? Did that like help with occlusion? So that came further down the road.

Oh, did it? Yeah. Okay. I thought they came at the same time. Trilor and Nano Ceramic were kind of appeared on the scene together. The ceramics. Came on the scenes, according to this, mid-2000s to 2010. When we saw it in our world, it was, I'm going to guess 2016, 2017. Okay. Was when it really kind of came and gained real popularity. Right. Somebody figured out how to market it. To the point that you saw the rep and you knew who they were and you had a stake or whatnot with them.

Right. And according to this, as I was doing the preparation for this,

Part 338:45

▶I read that there were a lot of failures reported and seen at three to five years, two to three to four to five years, somewhere in there, two to five years. Okay. Which is totally tracks with us because when we started to see failures and there were a lot, you are instantly grabbing to, well, it can't be the material. What is it this? What is it that? And it can throw the whole system into disarray. Because now you've pot committed everything to that material.

Sure. And when you start to see those issues, it can be a big scramble to figure it out. Right. And just like anything in the world, you may not know the answer and the answer may not be obvious. Right. So our immediate, the industry, but also ours, was to switch the material that was the bar. The bar. Because the theory was that the titanium bar. The bar had no flexibility and was not giving as much as the nanoceramic, which was now more brittle because it had a ceramic in it.

Makes sense. Total sense. Right. I can, I will tell you, I wasn't in charge of teeth. I'm in charge of implant placement. I was not in charge of the business at the time. Right. It always made me feel really uncomfortable to start putting a flexible material within inflexible material and thinking. And that just because of its grip strength is so good that it's going to last forever. Sure. Did I believe in it enough to sell it and do it?

Yeah. That's what the industry was pushing on us. Right. That's what the owner of my practice was doing. Right. It is what it is, but we found big, big issues. And those big, big issues got answered with sort of the same. So we ended up starting to mill a Trilor bar and a nanoceramic. And the Trilor bar, you remember that when we would start, when we were milling and we're going to lump them in together, peak and Trilor kind of, you can kind of think of them very similar as a peak bar and a Trilor bar.

They're all sort of a plastic or a fiberglass or sort of this fiber reinforced plastic material. So I guess the theory on that was it's strong and it's fiberglass reinforced. It'll flex. Maybe it'll flex as much or as nicely. It'll flex as nicely as the nanoceramic. Right. The problem with that one though was the Trilor or the peak or whatever you're going to make this fiber reinforced bar with takes up so much room because it has to, it's a, there's a minimal amount for it to, to be strong.

Right. That the nanoceramic is now this thin little shell on top. Right, right, right. Remember that? Yeah, yeah. And when they would fracture, it would just be a devastating just explosion. Right. Very similar with the bar in very different ways. The bar was just the material difference. And I think that the Trilor was that you had this, maybe they were more similar, but now you have volume differences. Anytime you, you put and manufacture two materials together, they've got to really get along and really do their job really, really well.

Right. You can't just let it be glue that holds the two together. Sure. So Trilor. Trilor was tough and Trilor also was difficult and peak. Remember there was a whole conversation between, do you need to put the titanium bases in to hold onto the implants?

Part 442:25

Do you not? You were around for a lot of those discussions, right? Vaguely. Yeah. Didn't really know what we were talking about at the time. So that's a little blurry. Now you do. Yeah. The issue we always had with those is if you skip the metal, if you, if you do the metal, you've not added a step to your manufacturing. Right. So that takes more time and people and personnel. And now you're putting in another material. So now your two piece bridge becomes two piece with cement and more cement and the titanium insert.

Like it's, it's a whole thing. Sure. And then if you didn't do it, it would commonly sort of strip out over time when you put the screw in. I can see that. Sure. The material was really, it's a very, especially peak. Peak is a very weird feeling material. It's very, it's going to sound dumb, plasticky. Yeah. And it very, it's not brittle plastic. It's kind of like. Rubbery plastic. Yeah. You can feel like you can kind of smash it.

When you start to like screw in, you could feel it kind of give a little bit. Like there was like a rubberiness to it. Sure. That's a, thanks for giving that to me. So that was sort of a disaster. Just trying to figure that out. And at that time, this is still just before zirconia was really on the mainstream in terms of affordability and such and access to the, to the thicknesses and the look that we need.

Right. So again, we'll go back to nanostramic again real quick. The reason why there was such a hard press there and the PMMA was that both of those were, the teeth would give a lifelike appearance. They would have a translucency. They were able to take that plastic and that. Zirconia or ceramic rather mix and make it so that it was light to dark or, you know, see-through to not see-through. Right. Which is what our teeth look like.

And so you could give this patient a very natural look. The problem was over time with its porosity, it ended up looking too natural. Right. You could turn a bleach shade into a coffee smoker stained A1 real quick. Sure. But the, that was sort of why we were holding it. We were holding on to nanostramic. The, I've let it go a long time ago, but I'm going to say it one more time and maybe I'll never say it again before in my entire life.

Personally, we ended up having to replace all of these at our cost because they're under warranty. And of course we're trying to do good work. When, when I worked at that office, that was when I was in partnership with Dun & One or we had just started Dun & One, which we had a lot of those cases out as well. Yeah. Personally. I believe that. The number is well over $250,000. It's somewhere between $250,000 and $500,000 that came out of my pocket to replace those teeth.

So if you want anyone that hates nanostramic on this planet, I'm the guy. I'm the poster boy for hates nanostramic because you can't leave. It was supposed to be vetted. A lot of decisions, of course, in life, but also in dentistry, you're trying to make the best decision for your patient. I fully believe that that was what was the future and where we were going. It's what the reps told us to do. It's what the implant companies told us was great.

It's what my boss told us was great. Like everyone is saying this. It's what the designer said. It's what the lab work said. Everyone was saying it. And so you believe it because you see the successes. But over time, when the problems accumulate, you want that. You want that bread and butter, like tried and true. Yeah. I know. And so you have to stand behind that. So if there is a big problem and there is a big mess up, you got to stand behind that product.

▶Pretty much regardless of what the warranty says, right? The warranty very commonly for our warranty was always you have to get cleaned every year. I can tell you I paid for a lot of sets of teeth on people that didn't get cleaned because you want to stand behind the product no matter what. And unfortunately, the material company did not stand behind that. They didn't stand behind anything. They said, oh, we'll give you a 3% discount for every puck you claim broker.

I forget what the number was, but it was not enough. So I don't like nanoceramic. I will never be doing another one. So that's anecdotally. That's where I came in. Nanoceramic was what Dun & One was using at the time that we met and I had my procedure done. If there is somebody that dislikes nanoceramic as much as you, it might be me because I was told the same thing and not necessarily by you guys, but I didn't know what nanoceramic from concrete was before I had this done, but I like to research stuff.

So after I had it done, I started reading about it and confirmation about my... My biases were confirmed. This was the best material ever invented in the history of mankind. I thought it was so great. So when I started to have problems with it, I thought it was my fault. What am I doing wrong here? This is supposed to be stain resistant. Why is it staining? This is supposed to be chip and fracture resistant. Why is it chipping and fracturing?

And I think I had another set of nanoceramic made after the first time. And I remember like, okay. Whatever I did wrong the first time, I'm not going to do that again. So I'm going to be even more careful than I was the first time. Same result in the end. And I will say like psychologically, it really took a toll on me because I'm like, what am I doing wrong? I've omitted any kind of hard food from my diet just to be on the safe side.

And I'm still struggling with this material here. Come to find out it. Maybe it was still... It wasn't all my fault, but it wasn't all my fault. There should be a tolerable level with any material that goes in your mouth. There should be a tolerable level that can withstand whatever that part that is your fault. Right. And I think the second set that I had before I transitioned over to zirconia, I think I only had that second.

So the first set I had, I think for two years. And then I think the next set I only had for one year. And that's when we were starting to... Roll out the zirconia. If you're in nanoceramic, come back in. We'll take care of you. And, you know, world of difference. But even by the end of that one year that I was in the second set, it didn't even have 12 months worth of wear. And it was already staining.

I was already starting to see the beginning of the problems that I had with the first set. So I was like, oh, man, for a material that's supposed to last, you know, the duration of a procedure like this, and I'm seeing these issues at one year, you know, I don't know how anybody continues to use this material after this kind of, you know, feedback. What was the total time? I don't think we've let people know that you're in a hybrid before, but...

Oh, have we not? I don't think so. I am. We'll get into that story later. Sure. But in a different episode, but... That's the biggest thing I have to offer. No, it's not. That is a total lie. I couldn't... That Dun & One would not exist without Robert Odom. There are several people that Dun & One would not exist with without, and you're one for sure. The... How long... What period of time... I forget this. How long were you in a nanoceramic versus how long have you been in the zirconia now?

So I was in that first nanoceramic set for two years, and then I think I got a second set for about a year, and I'm rounding off to year increments. Yeah. ▶A total of three years for the nanoceramic, and then it's been about the same time, about three years in zirconia. And you've been in several sets of zirconia, not because they've broken, but because we've changed them on you. Yeah. You're sort of our... Do a little guinea pig style.

It's like the best kind of guinea pig, though, no? It is. It has to be.

Part 550:59

You've always said if one day you get hybrids, kind of have a different one for each day of the week, depending on what you're going out to do. Green ones, pink ones. Blue ones, blue ones, fang ones. Yeah. No, it's been cool to kind of watch the evolution and be able to, you know, if we want to try out something new, as far as design-wise or, you know, aesthetic-wise, to be able to be a part of that.

No, it's always been nice to be able to lean on you to... Also, your feedback is amazing, right? Because you do this, and you know what we... Have dealt with before, what we're dealing with now, and what we're going to deal with in the future, we'll say. And so you can put it through that lens. Yeah. So any sort of material we've ever tried to vet out, especially when it comes to the try-in material for the prototypes, you know, you were a big part in selecting that in terms of feel, cost, look, strength.

You know, because some of it, you don't want to overspend. And there's some materials that don't look very good, and they're supposed to last three months. Well, we want something that's going to look good and be a prototype for a day. Yeah. So that doesn't fit in our bill. So you vetting that out was really fun. Yeah, absolutely. So let's go back to... So we had Peak and Trilor Bar. Those were sort of a fad. There was also a fad that you could put on a regular crown on top of the Trilor Bar.

And we tried this a little bit. So you'd put a regular... Instead of putting that one full, a whole piece that would fracture the nanoceramic on top of the Trilor Peak Bar, you would then instead loot individual crowns onto this bar that was holding onto it, like individual teeth. And the idea there was that you could withstand that flex and not cause the break of the nanoceramic being too thin. And the problem with that was many-fold. It's very hard to make it look natural because it's now...

14, 15, 16, who knows? You're up in like almost the 20 parts and pieces coming together. It's really hard to make that look good. Sure. You do have movement between the crowns. And sort of the big pitch... We probably only did this once or twice to people that kind of knew they were experimental with this type of restoration. But the pitch was a little bit, hey, you're a business person. You want the best. Let's do this. Costs a lot of money.

To put all these pieces together, et cetera. Also, if a crown comes off at some point and you're in Chicago, you can go to a Chicago dentist and have it looted back in. Right. Well, nobody wants to touch it ever. Right. You know? And so they end up coming back and you have to loot it in for them. Now, it wasn't very hard, but the maintenance and the struggles were way too much given any sort of benefit.

And there really was no benefit to it. We also found that to... Personally, this is strictly personally, I'm sure that there's prosthodontists out there that do a much better job or have seen different lab people. They put the individual crowns on top of that individual bar as well. And we'll piece that all together so that it's more individualized, more characterized, and can be more expensive because of the individual crowns. Sort of the same problems. Stuff kind of gets stuck in between those individual crowns.

They can't smell it. Or they can't taste it. ▶They can't figure it out until it starts to smell because it's not like sticking in between your teeth, like your own teeth. And it was always really hard to hide that bar. It's really hard to wipe that bar out so that translucency doesn't necessarily translate as well. Those were the things that we came up against. So going into now, put all those old things away.

Part 655:00

Now we've been in zirconia pretty much full, full time since I would say 2019 or so. So six years ago, just personally. Yeah. And it's been around a lot longer than that. Yeah. The main reason why we waited, personally, to jump into zirconia was one, we were trying to figure out if nanoceramic could work in some way, fashion. ▶And second, so that zirconia, we were talking about this on the way in. I saw a video this week of the first zirconia we ever did in Jacksonville.

And I can't, almost can't even see the, watch the interview. I won't say his name because he's probably running on some ad somewhere or something. But I can barely tolerate looking at it because it literally looks like a piece of chalk. And why don't you explain to the listeners why that is? Because we talked about that a little bit on the way in. Yeah. From my understanding, the way that zirconia has changed in its formulation here kind of recently, has allowed it to offer some translucency like our natural teeth have.

And when you don't have that translucency, you just have a flat, white, lifeless looking teeth. So because here recently, they've been able to, I'm pretty sure it's a manufacturing process that has allowed this translucency to, to, to happen in zirconia. So it's a lot more lifelike now than it, than it was before. The possibilities are endless. And that typically happens when attention goes to something, right? When you get away from, you know, when we got away from flip phones, the smartphone market went crazy and I'm sure screen costs went down.

Everything went down because there's so many people jumping in and there's so much attraction to that. Right. of the industry. Likewise and similarly in zirconia, when that became a need and it kind of became the hot trend, our costs obviously came down some, but the manufacturer started spending more money on making the pucks thick enough was the main thing. The pucks that we could get that were thick enough didn't have the technology to have the translucency down at the bottom.

Right. And so you couldn't get any sort of translucency shades. You could only get these very, very opaque, chalky shades. Right. You could for crowns and there's some scientific specifics in terms of why the translucency works, but it is a manufacturing thing. And so now you can get very thick pucks that can handle almost anybody's height of teeth for a hybrid at an affordable cost with really good look. Right. So now you get the strength out of it.

The look out of it, the performance out of it, we're back to one piece. For us specifically, I was so,

Part 758:15

and there is a restoration in the world right now that's partially Vogue, we'll say. It's in Vogue. Okay. Titanium bar underneath the zirconia overlay. Right. Very similar to the nanoceramic. And that scares the absolute bejesus out of me. Because I was so burned on the nanoceramic world. Right. So we haven't gone in the foray of anything other than monolithic zirconia. I'm not saying it doesn't work. I haven't even done one because I got burned so badly on the nanoceramic.

Because again, you have inflexible brittle material on top of flexible metal. Obviously, it's not going to flex a lot, but you're still relying on cement. There's still materials that don't really go together. And they're still going to flex at different rates. And that scares the crap out of me as being a person that was burned by it. Yeah. In my opinion, and I'm not a professional, I'm a patient, but it's kind of another, if it's not broken, don't fix it things.

If monolithic works so well, what is the alleged benefit of combining two materials? Well, I have a personal opinion that the monolithic works so well, but the industry likes to do the titanium bar. For one, you can get away with some inaccuracies because they're all hooked together. So if they're a little bit less accurate, it doesn't transfer into the zirconia and fracture the zirconia, which we take care of in our scanners. So that's not a concern for us.

I also have a little bit of a theory that it's almost more cost effective to make a bar than it is to buy the little pieces that go into the zirconia, the inserts. And so you have this sort of cheap dentist doing cheap dentist things, trying to figure out what the best mode is a little bit. ▶But my theory is mostly that it allows for distribution of the force without directly transferring it into the zirconia through inaccuracies between the implants.

That's my biggest sort of theory. Because one of the first zirconias we ever put in in probably 20 years, 2016, 2017, in addition to it didn't look awesome, this might have been the second zirconia we ever did, was a lady from, she was going to Hawaii on business or something. She was some sort of traveling nurse. So this lady comes in and she's leaving for Hawaii that day, that afternoon actually, had been waiting for the zirconia forever, went through all the steps, all of that.

And we put it in. And as we put it in, something on the model must have been just a little bit off, tweaked a little bit off. And when we torqued it in, the thing shattered. And you can feel it when you're tightening it in, you can feel it when it happens. It just kind of like, it's almost like a, I've never had a bone broken, but it feels like what I would imagine, like breaking a bone feels.

This is like sinking gut feeling like that wasn't good. And so we broke it and she was very upset.

Part 861:35

But if you have inaccuracies in the implants, there, then you're going to have an issue with it seeding and going all the way and then also not fracturing as one piece. It doesn't tolerate it being anything other than perfect, which is why a lot of the industry, why we've all kind of gone to these scanners that get much more perfect data, is that perfect data then translates to better files, which translates to more accurate for the passive fit.

▶It's not just passive fit to, allow for the implants to heal well, it's also passive fit so that the actual set of teeth don't break on their own. So there's a lot, it goes on there. In terms of just comparing the materials, in terms of nano ceramic on top of a titanium bar, the flexural strength is pretty low. It's in the couple hundreds megapascals. that number doesn't really mean much to anyone except for when I tell you when a titanium bar comparatively with individualized zirconia the individual crowns is 900 to 1100 megapascals peak framework and the veneer that goes on top of nanoceramic veneer is 200 so the the peak with a veneer on top yeah 200 and a monolithic zirconia is 850 to 1100 megapascals so you can see you get a lot more strength and then you also don't have all of those parts and pieces sort of trying to be stacked on top of each other and all the it's not all about the bottom line in terms of personnel touching it it's about time efficiency and result if your result's the same which as you can see the difference is negligible right it was 900 to 1100 on the individual crowns versus 850 to 1100 on the monolithic right so if it doesn't have to be if if strength is comparable and man hours are greatly diminished and the look is almost the same if not better because you don't have to opaque it out and you don't have to have all those materials on hand that really improves your efficiency that really improves your predictability and you don't have to have all those materials on hand that really improves your predictability of the result that really improves the patient's experience that really improves their price it all just feeds into itself yeah and sort of part of this was a story of what are the materials that we used to do this on what is the comparative strength and how did we get to this but also at this point today it's great it is very strong it looks really good it's cheap enough to do in mass which passes on to the patient in our specific situation and it's a very strong in our specific example right without adding a lot of steps they can just get muddled along the way right so for for us zirconia has been a really nice good mainstay now the future is probably printing and man do i hope it's printing because then we can pass that that efficiency on to the patient even more right and mostly for sort of from a production standpoint from for zirconia we can produce a zirconia with a zirconia and we can produce a zirconia with a zirconia with a zirconia file in four hours i think is the time or we'll call it five or six it's just as fast as anybody that calls himself fast the problem is that you need the file and all of the stuff that goes in and everything has to go right if you want to go start to finish on that day yeah which is fine but imagine how much better it is when you can print it out and you can print it out and ship it and you know it's going to be the same file and it's going to be more accurate etc so additive i think that the future of additive manufacturing is bright subtractive manufacturing at some point will go out of the go out of vogue and not be so great probably the biggest problem is it's still made out of plastic currently right and so we've got uh porosity issue and the staining issue to some degree it's good but we've got some of those issues sort of still lingering and i think ultimately ultimately also as we look towards the future we'll call it five to ten years even though i'm hopeful that it will improve the the time and the look and all of these things one we kind of need to vet it out but i think that it's not going to really take our costs down ultimately because that full production when we're doing what we want to do the production of zirconia we've got down to a pretty low cost overall so i don't think it's going to be a big deal but i think it's going to be a cost-cutting thing to switch to plastic or to switch to a print or whatever the print may be made out of right but production time predictability and product that you give to the patient's going to be pretty sweet yeah you can see that 3d printing's come a long way i think one of the big factors um is also the waste with milling right i mean there's a lot there's and there's with printing there's zero well i don't want to say there's zero virtually zero virtually zero um so i can see you know as things progress uh climate you know whatever you think about we obviously need to take care of the planet everybody agrees on that but i feel like moving towards things that are less wasteful is probably something we're we're going to do going forward yeah and even if you don't care about something being wasteful for planet or whatnot being less wasteful means more efficiency and faster sure so even if you don't care about anything other than the parameters that reach you it will make it better absolutely i'm very very excited about that future because that's when and the tech is kind of coming around to where it's sort of all hopefully colliding in the same direction the right direction that makes it so accurate and so predictable and so beautiful that it's it's not even going to be a problem yeah you know if i if i don't have to hire a bunch of ceramics to do that and they can focus more on the teeth like making the teeth look nice and polishing those up we can see more cases and fix more and there's also the side of if you pay let's say you pay i think the going rate on the street is we'll say ten thousand dollars to have a prosthodontist put a zirconia and i think that is a really good idea i think that's a really good idea i think that's a really good idea relatively fair right sure it's probably even a little bit on the low end for us it's 7500 so we're in that ten thousand dollar range but how much would you rather pay for a subscription and every time you come in for a cleaning you get a new one right and again i don't think it's going to change the cost that it's going to arrive to done in one as an invoice of this is what this cost to make from a material standpoint but from a personnel boots on the ground i can't give you a zirconia every time you come in because it kind of just takes too much manpower to have enough boots on the ground to make one every time right it's much quicker to finish a plastic print yeah so that's where i think that the model will maybe ultimately end up and i don't i think that that's really cool as a patient because now you're talking about getting into a zone where hey i already have all the information did you like your teeth okay you want this change let's change this on the computer boop boop boop all right come back in two hours and we'll have your brand new teeth for the year yeah you may not want to change it okay no we don't have to change it i just think it's really cool to think about the teeth maybe i know we just talked about waste but maybe think of the teeth as a little bit more disposable if they can perform to the standards that we need them to perform right yeah i think from from a patient perspective i know we talked about you having this dream of like trying out different teeth and you know having a different smile depending on your teeth and you know having a different mood um but for me personally i mean yeah for you personally uh but i think there's another aspect um so as a dentist you know there are certain shapes of teeth that are supposed to represent youthfulness right and i i think and correct me if i'm wrong that if you have um let's say a more pointed canine that's supposed to be indicative of youthfulness because over the course wear down your natural teeth so then you have more of a squared look um so somebody who has this done when they're 30 out of out of necessity may want that youthful look and then you know 20 years down the road they might want a more natural looking older smile but and maybe not but to have that option is super cool i've never thought about it that way it is a fascinating yeah the the better we can put the tools in the hands or the tools can be put into the hands of the dentist and the patient together to work collaboratively on this to change and alter at a lower cost the better everyone will be right the my life has gotten so much better with the predictability of zirconia does it break yes it still is a material in this world it can still stain if you don't take any care of it it can also break if you bite into the wrong things or even if you don't sometimes things just happen there there can be craze lines in the zirconia when they're manufacturing we didn't even talk about that sure sure but that can happen and the way it is now it's a sort of it's not that big of a deal but it is a big deal it is a bigger deal than it will be for printing right the other thing and we'll kind of close on this i think if and when we get to zirconia or printing the well you and i 3d print on our own free time because we're weirdos right i also have the um wood milling machine yep cnc obviously we do this for a living and we're at the lab every week or twice a week or whatnot right so we mess around in this world the it's gonna be hard to explain but when you're milling something unless you have the most performance-based amazing milling machine you're going to have to do a lot of work to get it to the milling machine and you're going to have to do a lot of work to get it to the milling machine getting angles is very hard no matter how you can turn that puck and no matter how uniquely shaped that burr is and no matter how good your software is to do it right whereas with printing the world's your oyster i mean the easiest example would be if i design something complex and try to do it on the milling machine i can get something to look cool but i can't do internal lattices and different offsetting forces etc sort of shapes internally right that i can print in the milling machine second on my regular printer sure and that's what we get as sort of over-the-counter hobbyist consumers right with with a nice high-end printer i'm very excited to see the shapes and calculations and things that go inside of the hybrid to add strength and durability and longevity and transparency that's coming that's going to come absolutely it's not going to always be one solid block yep now if you're listening to this i can guarantee you if i had my hands in it i would tell you and if i had my hands in it it would be a couple years away or a year or two away it's not i don't we don't see many things there's rumblings every once in a while that there is but there really isn't anything that's going to change to zirconia the other encouragement is if we do end up with putting people in zirconia and then the next week change over into some sort of magical print we're going to make it a little bit more difficult to make it a little bit more difficult to make it a very very attractive switch over because the ideal would always be to have your patient base in matching stuff sure so i know that can be a concern when people are choosing things like well what's the next around the corner are you coming around with something next month i can guarantee you we're not something we're not close enough that we're even a year out from anything we don't have our hands anything i would love to you can tell i'm very excited about it i will hopefully be one of the first adopters i'm going to be one of the first adopters i'm going once it's verified and not a nano ceramic buckle but the what i'm most excited about is being able to then go back to our patient base and say hey there is something better and for 500 bucks you can get into it's not going to be anything crazy right it's going to be more kind of at cost shake hands high five we made it here yeah so as a patient that's exciting uh if there is a new thing that's tested and tried and done and it's going to be something that's going to be something true that uh you know switch over is not not a big issue yeah i feel very comfortable that zirconia is the sweet spot especially for us yeah it performs well it has some problems here and there like anything is going to have like we've already experienced in many many different ways different materials they're minimal people love it yeah it's a good it's a it's a good performing material it is but hopefully something will be better always something better always well with that i appreciate your uh time and uh conversation robert thanks for having me enjoyed having this conversation this is one of the things that i highly nerd out on much more than surgery even i probably shouldn't say that but i love this stuff right but um looking forward to many many of these in the future with you sir sounds good thanks for it thanks for coming on yes sir all right we'll see you guys next time see ya